Cultural pathways to psychosis care: Patient and caregiver narratives from Puebla, Mexico.

The current study used the McGill Illness Narrative Interview (MINI) to explore patients' (n = 6) and caregivers' (n = 3) narratives about how they identified and sought care for psychosis. Participants were recruited from an outpatient clinic at the Hospital Psiquiátrico Dr. Rafael Serrano, a public psychiatric hospital in Puebla, Mexico. All participants consented to complete semi-structured interviews in Spanish. Thematic analyses were used to inductively identify common themes in participants' narratives. The results indicated that during the initial symptom onset, most participants noticed the presence of hallucinations but did not seek help for this hallmark symptom. Participants described seeking care only when they or their ill relative exhibited escalating aggressive behaviors or physical symptoms that were interpreted as common medical problems. As participants became connected to specialty mental health services, they began to develop a conceptualization of psychosis as a disorder of aggression. For some participants, this conceptualization of psychosis as an illness of aggression contributed to their ambivalence about the diagnosis. These results can be understood using a cultural scripts framework, which suggests that cultural norms are influenced by collective understandings of normalcy and valorization of behaviors. Implications for community campaigns are discussed.

Evaluation of quality of life and depression in patients with rheumatoid arthritis in a General Hospital / Evaluación de la calidad de vida y depresión en pacientes con artritis reumatoide en un hospital general

abstract Introduction: Rheumatoid arthritis (RA) is a chronic, inflammatory, and multisystemic disease that has an impact on the quality of life and is associated with depressive symptoms. Objectives: To evaluate the quality of life, overall health status, and depression in patients with RA. Patients and methods: A cross-sectional study was conducted in the outpatient Rheumatology Outpatient Department of a General Hospital in Mexico City. All patients met the criteria for rheumatoid arthritis according to the American Rheumatism Association, 1987. Clinical and sociodemographic characteristics were recorded. Four measurement tools were used: Arthritis Impact Measurement Scale (AIMS), Dunbar Questionnaire, a Visual Analog Scale, and the Beck Depression Inventory. Results: A total of 43 patients aged ≥ 18 years were evaluated. The highest AIMS scores were in social activity (6.49±1.93), pain (4.70±2.04), depression (4.70±2.23), and physical activity (4.03±2.10). The mean score with the Dunbar questionnaire was 6.48±1.87, the mean Visual Analog Scale score was 69.41±24.67, and the mean of the Beck inventory was 15.74±9.85. Conclusions: The presence of anxiety and depression has an impact on the quality of life of patients with RA, but not on the presence of comorbidity or disease activity. Depressive symptoms are common in patients with RA, and should therefore be considered when evaluating this rheumatological disease.

resumen Introducción: La artritis reumatoide (AR) es una enfermedad que afecta la calidad de vida de quienes la padecen y se asocia a sintomatologia depresiva. Objetivos: Evaluar la calidad de vida, el estado global de salud y depresión en pacientes con AR. Pacientes y métodos: Se trata de un estudio transversal y comparativo. Se incluyeron 43 adultos mayores, ≥ de 18 anos, con diagnóstico de AR según los criterios de la American Rheumatism Association de 1987, que acudían al servicio de consulta externa de Reumatologia de un hospital general en la ciudad de México. Se determinaron características clínicas y sociodemográficas. Se les aplicaron 4 índices: Escala de Medición del Impacto de la Artritis (AIMS), Cuestionario de Dunbar, Escala Análoga Visual y el Inventario de Depresión de Beck. Resultados: Se evaluaron 43 pacientes mayores de 18 anos, en su mayoría del sexo femenino. Para la AIMS, las puntuaciones más altas fueron en actividad social (6, 49 ± 1, 93), dolor (4,70 ± 2,04), depresión (4,70 ± 2,23) y actividad física (4,03 ± 2,10). Para el cuestionario de Dunbar la puntuación promedio fue de 6, 48 ± 1, 87, en la escala análoga visual la puntuación media fue de 69,41 ± 24,67, finalmente, en el inventario de Beck el promedio fue de 15,74 ±9,85. Conclusiones: La presencia de ansiedad y depresión se relacionan con la calidad de vida de los pacientes con AR mas no con la presencia de comorbilidad o actividad de la enfermedad. Los síntomas depresivos son comunes en pacientes con AR por lo que deben considerarse al evaluar esta enfermedad reumatológica.

Actitudes hacia la homoparentalidad: Validación psicométrica de dos escalas en una muestra de estudiantes mexicanos / Atitudes em relação à homoparentalidade: validação psicométrica de duas escalas numa amostra de estudantes mexicanos / Attitudes Towards Homoparentality: Psychometric Validation of two Scales in a Sample of Mexican Students

Introducción: La legalización del llamado matrimonio igualitario, y de la adopción de menores por parejas homosexuales, es un fenómeno reciente y que debe ser estudiado, para lo cual es necesario contar con medidas confiables que permitan dar cuenta de cómo la sociedad percibe esta nueva configuración familiar. Objetivo: Determinar las propiedades psicométricas de dos escalas: Actitudes frente a las familias Homoparentales (AFFH); y creencias acerca del ajuste de los niños de familias homoparentales (CANFH). Metodología: La AFFH, con 20 reactivos, fue diseñada para dar cuenta de las actitudes hacia las familias homoparentales. La CANFH tiene 14 reactivos organizados en las subescalas de oposición individual (OI) y oposición normativa (ON). Ambas escalas tienen afirmaciones que deben ser respondidas con opciones tipo Likert que van del 1 totalmente de acuerdo, al 5 totalmente en desacuerdo. La CANFH fue aplicada a 170 estudiantes universitarios (78 (46%) hombres, 92 (54%) mujeres. Media de edad: 18.4 DE+0.94), y la AFFH a 88 (35 (40%) hombres, 53 (60%) mujeres. Media de edad: 18.2 DE+0.84). Se determinaron las propiedades psicométricas por medio de análisis factorial y de consistencia interna. Resultados: La AFFH resultó con un α=0.91; los reactivos se organizaron en dos factores que explican 46.14% de la varianza. En el caso de la CANFH se confirmó la estructura factorial de dos subescalas explicativas de 65.49% de la varianza y con un α=0.94. Conclusiones: Los datos indican que ambas escalas poseen las propiedades psicométricas adecuadas para medir las actitudes de estudiantes mexicanos hacia las familias homoparentales y hacia los efectos que estas puedan tener en los menores adoptados...(AU)

Introduction: Same-sex marriage and adoption legalization constitute a growing and relatively new research field. Its study needs reliable and valid measures that allow to understand the society's perception about this new family order. Objective: Assess the psychometric properties of two scalesdevised to measure same-sex parenting attitudes: Attitudes toward Same-sex Families Scale (AFFH for its acronym in Spanish), and Scale on Beliefs about Children's Adjustment in Same-sex families (CANFH in Spanish). Methodology: AFFH scale is a 20-item measure designed to account for attitudes towards same-sex families. CANFH is a 14-item measure consisting of two scales, Individual Opposition (IO) and Normative Opposition (NO). Both are Likert scales with five response options (1. Strongly Agree to 5. Strongly Disagree). The CANFH was answered by 170 college students (78 (46%) males, 92 (54%) females; Average age: 18.4 SD 0.94), and the AFFH by 88 college students (35 (40%) males, 53 (60%) females, average age: 18.2 SD + 0.84). Results: AFFH items were organized into two factors that explained 46.14% of variance with a Cronbach's alpha of 0.91. CANFH items were grouped in a two factors structure that explained 65.49% of the variance (α = 0.94). Conclusions: CANFH and AFFH scales have adequate psychometric properties to measure Mexican college students' attitudes toward same-sex families and to assess the beliefs about children's adjustment in same-sex families...(AU)

Introdução: A legalização do chamado casamento do mesmo sexo e adoção de crianças por casais homossexuais, é um fenômeno recente, que deve ser estudado, para a qual é necessário ter medidas confiáveis que permitem ver como a sociedade percebe esta nova configuração familiar. Objetivo: determinar as propriedades psicométricas de duas escalas: Atitudes para com as famílias homoparentais (AFFH); e as crenças sobre o equilíbrio das crianças de famílias homoparentais. Metodologia: O AFFH, com 20 itens, foi projetado para explicar atitudes das famílias homoparentais. O CANFH tem 14 reagentes organizados em sub-escalas de oposição individual (OI) e oposição regulamentar (ON). Ambas as escalas são declarações que devem ser respondidas com opções de tipo Likert, entre 1 que significa estar de acordo e 5 que discorda totalmente (CANFH). O CANFH foi aplicado a 170 estudantes universitários (78 (46%) do sexo masculino, 92 (54%) mulheres com idade média: 18.4 + 0.94), e AFFH a 88 (35 (40%) do sexo masculino, 53 (60% ) mulheres média de idade. 18.2 + 0.84). Foram determinadas as propriedades psicométricas por meio de análise fatorial e consistência interna. Resultados: A AFFH foi α = 0.91 com reagentes foram organizados em dois fatores que explicam 46.14% da variância. No caso de a estrutura fatorial CANFH dois explicativa 65.49% da variância e um α = 0,94 subescalas foi confirmada. Conclusões: Os dados indicam que ambas as escalas têm o direito de medir as atitudes dos estudantes em relação homoparentais famílias mexicanas e para os efeitos que podem ter sobre as crianças adotadas propriedades psicométricas...(AU)

Toward the early recognition of psychosis among Spanish-speaking adults on both sides of the U.S.-Mexico border.

Lack of knowledge about psychosis, a condition oftentimes associated with serious mental illness, may contribute to disparities in mental health service use. Psychoeducational interventions aimed at improving psychosis literacy have attracted significant attention recently, but few have focused on the growing numbers of ethnic and linguistic minorities in countries with large immigrant populations, such as the United States. This paper reports on 2 studies designed to evaluate the effectiveness of a DVD version of La CLAve, a psychoeducational program that aims to increase psychosis literacy among Spanish-speaking Latinos. Study 1 is a randomized control study to test directly the efficacy of a DVD version of La CLAve for Spanish speakers across a range of educational backgrounds. Fifty-seven medical students and 68 community residents from Mexico were randomly assigned to view either La CLAve or a psychoeducational program of similar length regarding caregiving. Study 2 employed a single-subjects design to evaluate the effectiveness of the DVD presentation when administered by a community mental health educator. Ninety-three Spanish-speakers from San Diego, California completed assessments both before and after receiving the DVD training. Results from these 2 studies indicate that the DVD version of La CLAve is capable of producing a range of psychosis literacy gains for Spanish-speakers in both the United States and Mexico, even when administered by a community worker. Thus, it has potential for widespread dissemination and use among underserved communities of Spanish-speaking Latinos and for minimizing disparities in mental health service use, particularly as it relates to insufficient knowledge of psychosis.

Depression among diabetic women in urban centers in Mexico and the United States of America: a comparative study / Depresión en mujeres diabéticas de los centros urbanos de México y los Estados Unidos: un estudio comparativo

OBJECTIVE: To compare the prevalence and patterns of depressive symptoms among women with type 2 diabetes in Puebla, Mexico, and Chicago, United States. METHODS: Two cross-sectional studies were conducted independently, in Puebla (September 2010-March 2011) and in Chicago (January-July 2010). Depression symptomatology was evaluated in a random sample of 241 women self-reporting type 2 diabetes in Puebla and a convenience sample of 121 women of Mexican descent seeking care for type 2 diabetes in Chicago. Depressive symptomatology was measured by the Center for Epidemiologic Studies Depression Scale administered in either English or Spanish. Women were similarly socioeconomically disadvantaged with low education levels in both locations. RESULTS: The Chicago sample of women reported higher levels of depression than the Puebla sample (38% versus 17%, P < 0.0001). Among those with comorbid depression and diabetes in both sites, minimal variations in symptoms were observed. Depressive symptoms, specifically the subjective element (feeling sad) and symptoms associated with diabetes (fatigue and sleep problems) were heightened in both groups. More frequent reporting of "feeling fearful" was statistically significant in Puebla. CONCLUSIONS: Despite a higher prevalence of depression among Mexican immigrant women with diabetes in the United States compared to Mexico, there was little variation in their depressive symptoms, regardless of residence. However, women in Mexico did report a higher incidence of fear. Screening for depression in patients with diabetes should take into account symptoms of fatigue and sleep and the bi-directional relationship of depression and diabetes.

OBJETIVO: Comparar la prevalencia y las características de los síntomas depresivos en mujeres aquejadas de diabetes tipo 2 en Puebla (México) y Chicago (Estados Unidos). MÉTODOS: Se llevaron a cabo independientemente dos estudios transversales, en Puebla (de septiembre del 2010 a marzo del 2011) y en Chicago (de enero a julio del 2010). Se evaluó la sintomatología depresiva en una muestra aleatoria de 241 mujeres con diagnóstico de diabetes de tipo 2 en Puebla, y en una muestra de conveniencia de 121 mujeres de ascendencia mexicana que acudieron en busca de atención de su diabetes de tipo 2 en Chicago. La sintomatología depresiva se midió mediante la Escala de Depresión del Centro de Estudios Epidemiológicos, administrada ya fuera en inglés o en español. En ambas ubicaciones, las mujeres pertenecían a niveles socioeconómicos desfavorecidos de forma similar y sus niveles de educación eran bajos. RESULTADOS: Se notificaron niveles más altos de depresión en la muestra de mujeres de Chicago que en la muestra de Puebla (38 frente a 17%, P < 0,0001). En ambos sitios, se observaron variaciones mínimas en los síntomas de las mujeres que padecían depresión y diabetes de manera concomitante. Los síntomas depresivos, específicamente el elemento subjetivo (sentirse triste) y los síntomas asociados con la diabetes (cansancio y problemas de sueño), aparecían intensificados en ambos grupos. La mayor frecuencia de la notificación de "sentirse temerosa"encontrada en Puebla fue estadísticamente significativa. CONCLUSIONES: A pesar de una mayor prevalencia de depresión en las mujeres mexicanas con diabetes inmigrantes en los Estados Unidos, en comparación con las que vivían en México, hubo poca variación en los síntomas depresivos, independientemente de la residencia. Sin embargo, las mujeres residentes en México notificaron una mayor incidencia de temor. El tamizaje de la depresión en pacientes con diabetes debe tener en cuenta los síntomas de cansancio y de trastornos del sueño, y la relación bidireccional entre la depresión y la diabetes.

Depression among diabetic women in urban centers in Mexico and the United States of America: a comparative study.

OBJECTIVE: To compare the prevalence and patterns of depressive symptoms among women with type 2 diabetes in Puebla, Mexico, and Chicago, United States. METHODS: Two cross-sectional studies were conducted independently, in Puebla (September 2010-March 2011) and in Chicago (January-July 2010). Depression symptomatology was evaluated in a random sample of 241 women self-reporting type 2 diabetes in Puebla and a convenience sample of 121 women of Mexican descent seeking care for type 2 diabetes in Chicago. Depressive symptomatology was measured by the Center for Epidemiologic Studies Depression Scale administered in either English or Spanish. Women were similarly socioeconomically disadvantaged with low education levels in both locations. RESULTS: The Chicago sample of women reported higher levels of depression than the Puebla sample (38% versus 17%, P < 0.0001). Among those with comorbid depression and diabetes in both sites, minimal variations in symptoms were observed. Depressive symptoms, specifically the subjective element (feeling sad) and symptoms associated with diabetes (fatigue and sleep problems) were heightened in both groups. More frequent reporting of "feeling fearful" was statistically significant in Puebla. CONCLUSIONS: Despite a higher prevalence of depression among Mexican immigrant women with diabetes in the United States compared to Mexico, there was little variation in their depressive symptoms, regardless of residence. However, women in Mexico did report a higher incidence of fear. Screening for depression in patients with diabetes should take into account symptoms of fatigue and sleep and the bi-directional relationship of depression and diabetes.

[Validity and consistency of a new scale (Faces Pain Scale) and of the Spanish version of the CHEOPS scale to evaluate postoperative pain in children]. / Validez y consistencia de una nueva escala (facial del dolor) y de la versión en español de la escala de CHEOPS para evaluar el dolor postoperatorio en niños.

BACKGROUND: one of the most used scales for the evaluation of children's pain is the CHEOPS. This is complex, reliable but not commonly used in spanish. We decided to create a new Pain Facial Scale to be considered to be used in spanish. OBJECTIVE: to compare the validity and consistency of two different scales for the evaluation of post-operative pain in children. METHODS: process, comparative, longitudinal, homodemic, and prolective study. It was elaborated a simple and easy scale, to evaluate the post-operative pain in children. 5 experts evaluated their appearance and content. The original version of CHEOPS was translated to the Spanish by an expert; later this version was corrected and re-translated by a native Anglo-Saxon speaker, the result submitted for evaluation by 5 experts. The validity and consistency of both scales were evaluated by two investigators in a blind way. We used Cronbach's α for the internal consistency of CHEOPS, coefficient of intraclass correlation for the external consistency (inter observer's variability), effect size for sensitivity to the change of category, change of status for internal validity and Spearman's correlation for the convergent analysis. RESULTS: there was great external consistency, and a good and high internal validity, for the Spanish version of the CHEOPS scale, and an excellent internal validity for the Facial Pain Scale, as well as an excellent internal validity for both scales. CONCLUSIONS: two scales can be used to evaluate the post-operative pain in children between 4 and 8 years old.

¿Cuántos somos? ¿Dónde estamos? ¿Dónde debemos estar? El papel del psiquiatra en México: Análisis preliminar / How many are we? Where are we? Where should we be? The psychiatrist's role in Mexico: Preliminar analysis

The recently modified General Law on Health (Ley General de Salud) establishes in article 74b, section VII, that any individual with mental or behavioral disorders will have <

Una de las limitantes más importantes que explican la diferencia entre las personas que necesitan servicios de salud mental y las que acceden a éstos, es el insuficiente número de psiquiatras. La media mundial de psiquiatras por cada 100 000 habitantes es de 3.96 (DE 5.94), la distribución de psiquiatras varía de una región a otra; existe un promedio de 0.06 en los países de bajos ingresos y de 9.0 en los de altos ingresos. La psiquiatría, como especialidad médica, es relativamente reciente. Es hasta el siglo XIX cuando el tratamiento de los trastornos mentales empieza a ser objeto de una especialidad médica. En México, la enseñanza de la psiquiatría como especialidad independiente se inicia en 1950. En 2010 se abrieron 137 plazas para la realización de la residencia en psiquiatría en diferentes partes de la República Mexicana. A pesar de esto, el número de psiquiatras es insuficiente además de que el ámbito de su actividad no corresponde a las recomendaciones de la Organización Mundial de la Salud. El objetivo del presente trabajo fue determinar el número y la distribución de los psiquiatras en la República Mexicana y proponer nuevos campos de acción del psiquiatra. Metodología Se realizó un estudio descriptivo, transversal, heterodémico. Se revisaron las siguientes fuentes de información: el Directorio de la Asociación Psiquiátrica Mexicana (APM) de 2008, el Directorio del Consejo Mexicano de Psiquiatría (CMP) de 2008, el Censo de 1990 y el II Conteo de Población y Vivienda 2005. Resultados En el Directorio de la Asociación Psiquiátrica Mexicana se encontraron 1 397 socios activos. En el Directorio del Consejo Mexicano de Psiquiatría están anotados 1430 psiquiatras certificados. En los últimos 20 años hubo un incremento de psiquiatras del 29%, pues pasaron de 1 108 a 1 430. Para el 2005 la población aumentó de 81.2 a 103.3 millones de personas, es decir hubo un incremento del 27%. Esto indica que la cantidad de psiquiatras se ha mantenido constante respecto al número de habitantes. Observamos que, en total, hay más psiquiatras certificados que miembros de la APM. En cuanto al segundo objetivo, a excepción del Distrito Federal, en el resto del país el número de psiquiatras por número de habitantes es notablemente inferior a la media mundial de 3.96/100 000 habitantes. En promedio, hay 1.3 psiquiatras/100 000 habitantes. En 22 Estados hay menos de un psiquiatra/100 000 habitantes. No se identificó ningún psiquiatra adscrito al primer nivel de atención y casi la mitad estaba adscrita a hospitales psiquiátricos. Conclusiones En México el número de psiquiatras es insuficiente para atender las necesidades de la población por lo que la opción es, como ha propuesto la OMS, reestructurar la atención a los trastornos mentales. En el modelo propuesto se establece un continuo desde la atención que se proporciona directamente en la comunidad, hasta la que se proporciona en los llamados centros de <

Vocabulario expresivo en una muestra de niños preescolares con trastornos psiquiátricos y un grupo con desarrollo típico / Expressive vocabulary in a sample of preschoolers with psychiatric disorders and a group of children with typical development

Introduction Expressive language problems are common amongst preschoolers both in the general population (15-20%) and in clinical settings (50-75%); furthermore, these problems are often not detected. Language problems require attention since they are associated with severe developmental disorders such as autism (Au), Asperger's syndrome (AS), attention-deficit hyperactivity disorder (ADHD) and mental retardation. In theory, language development, specifically expressive vocabulary, associated to psychiatric disorders could be identified with a scale that measures expressive language. Objectives 1. To determine the frequency of language delay in a sample of Mexican children with typical development in the community. 2. To determine the vocabulary level for autism, Asperger's syndrome, ADHD and other psychiatric disorders through the use of the Language Development Survey (LDS). 3. To analyze if differences in vocabulary ratings among the clinical subgroups can be detected with this instrument. Materials and methods The sample consisted of: A community group with typical development (TDG) (n=302) and a clinical group (CG) (n=55); both groups had an age range of 2-5 years. The clinical group was subdivided into 4 clinical subgroups based on DSM-IV criteria for: autism, Asperger's syndrome, ADHD and other psychiatric disorders (OPD) (enuresis, encopresis, separation anxiety). Exclusion criteria were: deafness, hypoacusia and other sensorial disorders and mental retardation. A semi-structured interview based on DSM-IV criteria was designed ad hoc to diagnose: autism, Asperger's syndrome, ADHD (inattentive, combined or hyperactive impulsive varieties), specific phobia disorder, tics (transitory, chronic and Tourette's syndrome), dysthymic disorder, depression, enuresis, separation anxiety disorder based on parent information. The clinical evaluation included a semi-structured play session with age-appropriate didactic material. Discrepancies in diagnosis were resolved by consensus. All interviews were conducted by an experienced clinician. The number of bulbs in the household was used to measure socioeconomic status (SES). The LDS is a list of words that explores children's vocabulary based upon parental report. The original survey has a Cronbach's alpha coefficient of 0.99, test-retest coefficient of 0.97-0.99, and a sensitivity and specificity of 86-90%. Language delay (LD) was defined as ≤50 words, as recommended by several researchers. All parents signed an informed consent form and answered the LDS. Statistical analysis. Categorical data was analyzed using a χ2 analysis; continuous data such as age, socioeconomic status, and LDS score, were analyzed using t-tests. To analytically compare the LDS group medians, a Kruskal-Wallis test was used, since the variable distribution violated the normality distribution requirements for parametric tests. For the post hoc tests, a Tamhane analysis was used for groups of different sizes. Differences were considered statistically significant if they had a p<0.05. Results The groups were similar for variables such as child's age, parents' age and the LDS median between the normal development group and the clinical group t(355)=1.12, p=.26. The proportion of male children was greater in the clinical group (CG) than in the TDG, 76.4% vs. 53%, χ2(1,N=357)=10.63, p<.001. SES was higher for the TDG (M=7.2, SD=4.2) than for the CG (M=5.8, SD=3), p<.005. The father's age (r=.15, p<.009), the mother's age (r=.16, p<.003) and the SES (r=.13, p<.01) were correlated to the LDS score. Additionally, father's and mother's age were strongly correlated (r=.72, p<.0001) and the mother's age showed small correlations with the socioeconomic status (r=.15, p<.004). The mother's age was correlated with the child's vocabulary for both sexes (males: r=.16, p<.04, females: r=.16, p<.02), and vocabulary was significantly correlated with the SES, only for the males. Language delay frequency in the TDG was 21.2%, and 23.6% for the CG, χ2(1,N=352)=1.03, p<0.59. By sex, males in both groups exhibited a greater frequency of LD [TDG: 21.6% males vs. 20.7% females, χ2(1,N=302)=.154, p<0.926; CG: 26.2% males vs. 15.4% females, χ2(1,N=55)=.642, p<0.423]. The autism subgroup had the lowest vocabulary rating (M=85, SD=78.68), followed by the OPD subgroup (M=149, SD=121), whose rating was very similar to the typically development group (M=179, SD=105). The Asperger group (M=259, SD=27) had a similar score to the ADHD group (M=286, SD=100.2), which had the highest vocabulary score of all. The Kruskal-Wallis test for median differences was significant [H(4)=17.47, p<.002]. Multiple contrast comparisons and Tamhane's post hoc analysis showed that only the contrast between the autism and the ADHD subgroups (means: 85 vs. 286, respectively) was significant (ANOVA Tamhane post hoc, p<.01).

Introducción Aun cuando los problemas de lenguaje expresivo son muy comunes tanto en la población general (15-20%) como en la clínica (50-75%), su detección es insuficiente. Los problemas de lenguaje requieren atención debido a su comorbilidad con problemas graves del desarrollo como el autismo, el trastorno de Asperger, el trastorno por déficit de la atención e hiperactividad (TDAH) y el retraso mental. En teoría, el vocabulario asociado a estos trastornos psiquiátricos podría identificarse con un instrumento que midiera el vocabulario expresivo. Objetivos 1. Determinar la frecuencia de atraso del lenguaje (AL) (SDL ≤50 palabras) en un grupo con desarrollo típico de la comunidad. 2. Determinar el nivel de vocabulario para los subgrupos de: autismo, trastorno de Asperger (TA), TDAH y otros trastornos psiquiátricos (OTP) por medio del sondeo del desarrollo del lenguaje (SDL). 3. Analizar si el SDL puede discriminar entre los subgrupos clínicos. Sujetos y método La muestra estuvo compuesta por: un grupo de la comunidad con desarrollo típico (GDT) (n=302), y un grupo clínico (GC) (n=55), con un rango de edad de 2-5 años. Se formaron cuatro subgrupos clínicos: autismo, trastorno de Asperger, TDAH y un grupo de OTP (enuresis, encopresis, ansiedad de separación). El SDL es una lista de palabras que identifica el padre sobre el vocabulario de los niños que tiene un coeficiente de alpha de Cronbach de (.99), un test-retest de .97 a .99 y una sensibilidad y especificidad de 86-90%. Se utilizó la definición de atraso de lenguaje (AL) basada en un punto de corte de ≤50 palabras. Análisis estadístico. Los datos categóricos fueron analizados mediante la prueba de chi-cuadrada y para las medidas continuas como la edad, el MSE y el puntaje del SDL se usaron pruebas t de Student. Para el análisis del contraste de las medianas del SDL de los grupos se aplicó una prueba de Kruskal-Wallis. Resultados Los grupos fueron semejantes para las variables como edad del niño, edad de los padres y la media del SDL. La frecuencia de AL (≤50 palabras) fue de 21.2% para el GDT y de 23.6% para la población clínica. Por sexo, los varones presentaron mayor frecuencia de atraso de lenguaje (GDT): 21.6% masculino vs. 20.7% femenino (p<0.926), GC: 26.2% masculino vs. 15.4% femenino (p<0.423). El vocabulario del grupo de autismo fue el menor de todos (Mdn=85, DE=78.68) seguido del grupo de OTP (Mdn=149, DE=121.0) que presentó un desempeño muy semejante al grupo de la comunidad (GDT) (Mdn=179, DE=105.0). El grupo de Asperger (Mdn=259, DE=127) tuvo un puntaje cercano al grupo de TDAH (Mdn=286, DE=100.25). La prueba de Kruskal-Wallis para la diferencia en las medianas fue significativa (p<.002) pero sólo el contraste entre el grupo de autismo y de TDAH (Mdn=85 vs. Mdn=286, p<.01) fue significativo. Discusión La frecuencia de AL para el GDT fue de 21.6% y para el GC fue de 23.6%. El SDL fue sensible en la detección del nivel de vocabulario entre los grupos y los resultados fueron congruentes con el desempeño esperado con algunas excepciones. Los niños con TDAH expresaron un mayor número de palabras comparados con el GDT. El único contraste significativo fue la comparación entre el grupo de TDAH y el autismo. El vocabulario del grupo de Asperger fue mejor que el de autismo, pero esta diferencia no alcanzó significancia estadística. Conclusiones La versión mexicana del SDL es un instrumento de tamizaje útil para identificar el atraso del lenguaje en los niños preescolares. Este estudio muestra que el atraso de lenguaje en un niño preescolar con TDAH es una indicación para profundizar en el diagnóstico del autismo. Tampoco deben pasarse por alto otros trastornos que pueden acompañar o no el TDAH como los trastornos del lenguaje específicos (pronunciación, expresión, comprensión). El SDL mide el vocabulario y no identifica alteraciones del lenguaje cualitativas más complejas asociadas al trastorno de Asperger.

Intervenciones no farmacológicas en el insomnio primario: la evidencia de los ensayos clínicos controlados en los últimos diez años (1998-2008) / Non-pharmacological interventions in primary insomnia: controlled clinical trial findings (1998-2008)

Introducción: El insomnio es un trastorno del sueño que afecta al 10% de la población general e impacta a quien lo padece emocional, física y socialmente, por lo que es importante su adecuado diagnóstico y tratamiento. Objetivo: Describir los principales hallazgos de las intervenciones no farmacológicas sobre insomnio primario según la metodología de ensayos clínicos controlados. Método: Revisión sistemática durante febrero del 2009 en la base de datos de Ensayos Clínicos Controlados de Cochrane. Se seleccionaron artículos escritos en inglés, portugués o español publicados entre 1998 y 2008. Las palabras clave utilizadas fueron: primary insomnia, management, treatment y non pharmacological. Se descartaron artículos sobre insomnio secundario, con sólo resultados preliminares y aquellos escritos en idioma diferente a los establecidos. Al final se analizaron 37 artículos. Resultados: La modalidad de intervención más usada fue la combinación de técnicas cognitivo-conductuales (TCC). De manera general, todas las intervenciones tuvieron resultados positivos en la calidad del sueño. Las mejorías fueron de moderadas a altas y se mantuvieron a través del seguimiento. Según lo obtenido, el mejor tratamiento para el insomnio es la TCC, aunque otras opciones, como la máscara de luz, presentan resultados alentadores. Conclusiones: Hay hallazgos ciertos sobre los beneficios de las intervenciones no farmacológicas en el insomnio primario, con más estudios referentes a la TCC. Se plantea la necesidad de realizar estudios que evalúen dosis respuesta y la costo-efectividad de estas intervenciones...

Introduction: Insomnia is the most common sleep disorder and it affects approximately 10% of the world’s population causing a negative impact on sufferers’ emotional, physical, and social wellbeing. Several non−pharmacological treatments have been developed that appear to be effective. Objective: To analyze the main findings on primary insomnia. Methodology: During February 2009, a systematic review was undertaken using the Cochrane Database of Controlled Clinical Trials. A selection was made of articles written in English, Portuguese, and Spanish published between 1998 and 2008. The key words used were: primary insomnia, management, treatment and non−pharmacological. An analysis was carried out on 37 articles. Results: In general, all interventions had positive effects on the quality of sleep. With most of the combined techniques, the improvements were moderate−to−high and they were maintained through follow-up. According to the evidence gathered, the best non−pharmacological treatment was Cognitive Behavioral Therapy (CBT) although other intervention options such as Light Exposure produced encouraging results. The non−pharmacological approach gave better long−term results than pharmacological treatments. Conclusions: There is evidence of the benefits of non−pharmacological interventions for primary insomnia. Further research is necessary to evaluate the dose−response ratio and the cost−effectiveness of treatments...

Estudio de costo-efectividad del tratamiento de la depresión en México / Cost-effectiveness study of depression management in Mexico

Introduction Depression is a public health problem that carries substantial costs for the individual and the society. In order to establish evidence-based priorities for resource allocation in mental health care, it is necessary to integrate the costs and effectiveness of interventions and specify the essential packages for their treatment. The following are pioneering studies of cost-effectiveness for the treatment of depression: 1. compared psychopharmacology options (fluoxetine, imipramine and desipramine) to found no difference between drugs in terms of clinical efficacy, effect on quality of life and costs, and 2. evaluated cost-effectiveness of collaborative program of stepped care in primary care of persistent depression, to demonstrate a substantial increase in the effectiveness and additional moderate cost increase in comparison with usual treatment. Recently, the World Health Organization convened the National Institute of Psychiatry Ramón de la Fuente, as a collaborating center, to participate in the <

Introducción La depresión es un problema de salud pública que conlleva costos importantes para el individuo y la sociedad. Con la finalidad de establecer prioridades basadas en evidencias para la asignación de recursos en el cuidado de la salud mental, es necesario integrar los costos y la efectividad de las intervenciones y especificar los paquetes esenciales para su tratamiento. En esta dirección, la Organización Mundial de la Salud convocó al Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, como centro colaborador, a participar en el proyecto <

Estudio de costo-efectividad del tratamiento de la esquizofrenia en México / Cost effectiveness study of schizophrenia a management in Mexico

Introduction Schizophrenia is a disorder that causes significant disability. In addition, its treatment is expensive because the increased prescription of atypical antipsychotics with associated high costs. In a recent 14-country study on disability associated with physical and mental conditions, active psychosis was ranked the third most disabling condition in general population, more than paraplegia and blindness. In the global burden of disease study, schizophrenia accounted for 1.1% of the total Disability-adjusted life years (DALYs) and 2.8% of Years of lived with disability (YLDs). The economic cost of schizophrenia for society is also high. The study of the burden of schizophrenia for society, whether expressed in epidemiological or costs terms, is an insufficient basis for setting priorities for resources allocation. Thus, increasingly sophisticated economic models have been developed. Such is the case of cost-effectiveness studies, which show the relationship between resources used (costs) and benefit achieved (effectiveness) of an intervention compared with others. In Mexico, there is only one study that evaluated the cost-effectiveness of different antipsychotics to treat schizophrenia, but it was a specific approach (not generalized), and did not include psychological interventions. The present study is part of a World Health Organization's initiative labeled WHO-CHOICE: CHOosing Interventions that are Cost-Effective. WHO-CHOICE methodology involves the evaluation of interventions based on a generalized measure: DALYs, which allows carrying out several and important comparisons. The main objective was to determine the cost-effectiveness of different interventions for the treatment of schizophrenia in Mexican communitarian settings. Method Schizophrenia was modeled as a serious chronic disorder with a high level of disability, excess mortality from natural and unnatural causes, and a low rate of remission. The incidence, prevalence, and the fatality rate were estimated based on the study of the Global Burden of Disease and a review of the epidemiological literature. As the first episode of schizophrenia is currently not preventable, the occurrence represents how the epidemiological situation would be without intervention. In relation to the referral and the fatality, we did not found evidence that these rates change by a specific effect of the treatment; thus, they were kept as constants for the scenarios with or without treatment. Community-level interventions assessed were: 1. typical traditional antipsychotics (haloperidol), 2. new atypical antipsychotics (risperidone), 3. traditional antipsychotics + psychosocial treatment (family therapy, social skills training and cognitive behavioral therapy), 4. new antipsychotics + psychosocial treatment, 5. traditional antipsychotics + psychosocial treatment + case management, and 6. new antipsychotics + psychosocial treatment + case management. The effectiveness of the treatments referred to the control of positive and negative symptoms and associated levels of disability. To calculate the improvement in disability compared with natural history (when the disease is not treated), the effect sizes reported in controlled clinical trials were converted to a weight change of disability. Efficacy and extrapyramidal effects of typical and atypical antipsychotics compared to placebo were estimated from the meta-analysis of controlled clinical trials, with the score of the BPRS severity scale and the need anti-Parkinson drugs as efficacy measures. From another meta-analysis we obtained an estimate of the magnitude of the effect by adding psychosocial interventions. As an ad hoc Cochrane systematic review that found case management did not had a significant impact on clinical or psychosocial outcomes, only a minimal addition effect size when added to the combination of pharmacologic-psychosocial treatment was observed. Costs included those of the patient, the program and the training required to implement the intervention. The provision of community-based services, daily administration of antipsychotics and anticholinergics, and laboratory tests were taken into account. For psychological interventions were envisaged from 6 to 12 sessions: in primary care from 6 to 12 visits, in outpatients services a visit per month for 20-50% of cases, and in day care communitarian attention from 1-2 times a week for 20-50% of cases. A 3% discount by the process of converting future values to present ones and an age adjustment giving less weight to year lived by young were included. Finally, the cost of DALYs averted for each intervention was estimated to determine their cost-effectiveness. Results The main findings of the study are, in relation to the costs of interventions: 1. the largest share corresponds to those generated by medication, 2. the current intervention is the cheapest, and 3. the combination of new atypical antipsychotics, psychological treatment and proactive case management is the most expensive intervention. Concerning the effectiveness of interventions, the one available today, with a coverage of 50%, prevents 68 222 DALYs. Increasing coverage to 80%, the number of DALYs averted is almost doubled with the use of typical antipsychotics. The effect of psychological interventions makes the number of DALYs averted three to four times higher. Finally, in regard to cost effectiveness, the combination of typical antipsychotics, psychosocial intervention and proactive case management was the treatment with the best relation. The cost per DALY averted was $390,892 Mexican pesos, which corresponds to one third of the cost of DALY averted in the current scenario ($1,313,120 Mexican pesos). Conclusions The resources for the attention of a public health issue involve a social investment rather than an expense budget, but they are also finite and must be chosen properly to be allocated. Cost-effectiveness studies of available interventions are an essential tool for making such important decisions. Our Mexican study of cost-effectiveness of interventions to treat schizophrenia in communitarian settings suggests, in general terms: 1. That while the current situation is the one with the lowest cost, it is the least efficient, 2. all alternatives involve an additional cost to the current situation because they assume an expansion of coverage; however, the extra cost in not excessive, and 3) that within a model of community-based care, the least expensive option is treatment with typical antipsychotics combined with psychological intervention. Thus, for a modest extra cost it is possible to yield a major impact on disability. Recently, the Mexican Federal Government has included schizophrenia in the catalog of diseases covered by the program called <>, that provides a health insurance to general population, especially to the poorest and unemployed ones. The planned actions include four specialty consultations in an interval of two months and annual psychopharmacological treatment. Clearly the addition of haloperidol, trifluoperazine and risperidone to the list of available medications should be considered a success. However, schizophrenia also requires a proactive case monitoring of long-term for best control of symptoms and a successful rehabilitation. Moreover, consistent with our findings, case management has proven to be cost-effective when compared with routine care in the community. Among the limitations of the study it is important to note that it was based on modeled parameters obtained from the international literature. In this sense, the challenge is the data generation directly from studies in Mexico.

Introducción La esquizofrenia es un trastorno que produce una importante discapacidad, y su costo para la sociedad es muy elevado. El estudio de la carga que impone la esquizofrenia sobre la sociedad, ya sea expresada en términos epidemiológicos o de costos, es una base insuficiente para establecer las prioridades para la asignación de recursos, por lo que se han desarrollado modelos económicos cada vez más elaborados. Tal es el caso de los estudios de costo-efectividad, que muestran la relación entre los recursos empleados (costos) y los beneficios logrados (efectividad) de una intervención comparada con otra(s). El presente trabajo forma parte de la iniciativa de la Organización Mundial de la Salud (OMS) para la elección basada en evidencia de intervenciones costo-efectivas denominada WHO-CHOICE, Choosing Interventions that are Cost-Effective, que implica la determinación de una medida general que posibilita comparaciones internacionales: los años de vida vividos con discapacidad (AVISAs o DALYs, de las siglas de Disability-adjusted life years). Objetivo Fue determinar la relación costo-efectividad en México de diferentes intervenciones que han demostrado ser efectivas para el tratamiento comunitario de la esquizofrenia. Método Se evaluaron las siguientes intervenciones: 1. Antipsicóticos tradicionales típicos (haloperidol), 2. Antipsicóticos nuevos atípicos (risperidona), 3. Antipsicóticos tradicionales + tratamiento psicosocial (terapia familiar, entrenamiento en habilidades sociales y terapia cognitivo conductual), 4. Antipsicóticos nuevos + tratamiento psicosocial, 5. Antipsicóticos tradicionales + tratamiento psicosocial + manejo de caso, y 6. Antipsicóticos nuevos + tratamiento psicosocial + manejo de caso. La efectividad relativa de los tratamientos se refirió al control tanto de los síntomas positivos y negativos así como de los niveles asociados de discapacidad. Se consideraron los costos del paciente, del programa y del entrenamiento, así como un descuento de 3% por el proceso de convertir valores futuros a presentes, y un ajuste de edad, otorgando menos peso a los años vividos por los jóvenes. Finalmente, se calculó el costo por AVISA evitado por cada intervención para determinar su costo-efectividad. Resultados Los principales hallazgos del estudio son, en relación con los costos de las intervenciones: 1. que la mayor proporción corresponde a los generados por los medicamentos; 2. que la intervención actual resulta la más barata; y 3. que la combinación de antipsicótico nuevo o atípico con intervención psicosocial y manejo proactivo de caso es la más cara. En cuanto a la efectividad de las intervenciones, la disponible en la actualidad, con cobertura de 50%, evita 68 222 AVISAs. Aumentando la cobertura a 80%, el número de AVISAs evitados casi se duplica con el empleo de antipsicóticos típicos. El efecto de las intervenciones psicosociales hace que el número de AVISAs evitados sea tres a cuatro veces mayor. Finalmente, en lo que respecta a costo-efectividad, la combinación de antipsicóticos típicos, intervención psicosocial y manejo proactivo de caso fue el tratamiento con la mejor relación. El costo por AVISA evitado fue de $390,892, que corresponde a un tercio del costo de AVISA evitado en el escenario actual ($1,313,120). Conclusiones Los hallazgos del estudio sugieren, en términos generales: 1. Que aunque la situación actual es la de menor costo, es la menos eficiente; 2. Que todas las alternativas implican un costo adicional a la situación actual porque asumen una ampliación de la cobertura, sin embargo, ese costo extra no es excesivo; y 3. Que dentro de un modelo de atención basado en la comunidad, la opción menos costosa es el tratamiento con antipsicóticos típicos combinados con intervención psicosocial. Por un costo extra modesto se obtendría un impacto importante en la discapacidad. Entre las limitaciones del estudio destaca que fue producto de un modelado con parámetros obtenidos de la bibliografía internacional. En este sentido, el reto es la generación de datos derivados directamente de estudios realizados en México.

Social cost of mental disorders: Disability and work days lost. Results from the Mexican survey of psychiatric epidemiology / El costo social de los trastornos mentales. Discapacidad y días productivos perdidos. Resultados de la Encuesta Nacional de Epidemiología Psiquiátrica

Summary: Introduction. When the impact of illness is evaluated by indicators like mortality, mental illness has a less significant impact than other illnesses. As a result, the impact of mental disorders was underestimated until the last two decades of the previous century This perception began to change as a result of two factors: On the one hand, the study of the Global Burden of Disease reported by Murray and Lopez, and, on the other hand, the definition of mental disorders by the American Psychiatric Association. The common element shared by these two factors is the inclusion of the concept of disability. Disability is the deterioration of the expected functioning of a subject of a particular age and sex in a social context. It is a part of the social cost of illness. Objective. To assess the disability burden associated with depression, mania, agoraphobia, social phobia, general anxiety, panic disorder, and post-traumatic stress disorder (PTSD) according to the Mexican Psychiatric Survey and to compare results with the disability produced by some chronic non-psychiatric conditions. Method. This survey is based on a stratified, multistage area, probabilistic sample of adults living in urban areas of Mexico. The instrument used was the third version of the Composite International Diagnostic Interview. We report the 12-month prevalence of psychiatric disorders as defined by DSM-IV criteria. We also evaluated non-psychiatric chronic conditions like diabetes, arthritis, hypertension, backache, and other painful illnesses, identified in general as "chronic conditions". Indicators of disability were Sheehan's scale and number of work days lost. This is an easy and fast self reporting scale, which can be used both in the clinic or research. The sub-scales can be added or averaged to obtain a total score. The scale of responses is a horizontal line with numerals from 0 to 10 and five verbal descriptions, with the description "Not at all" corresponding to a value of 0; "Mild" rangimg from 1 to 3; "Moderate" from 4 to 6; "Severe" from 7 to 9; and "Very severe" corresponding to 10. Results. Close relationships and social life were the areas most deeply affected. The disorders found to produce the highest levels of disability were depression, social phobia, and PTSD. The lowest disability levels were observed in chronic conditions. On the total score of Sheehan's scale, disorders with the highest level of disability were PTSD (mean 5.35 ± 0.307) and depression (mean 4.72 ± 0.167). Depression and panic attacks were the disorders by which most days were lost on average in the previous year (25.51, CI95: 16.53-34.5; 20, CI95: 3.02-36.97). Days lost were lower in chronic conditions than in the seven mental disorders studied (6.89, CI95: 3.04-10.74). Discussion. This is the first paper to demonstrate the impact of mental disorders in Latin America evaluating the association of disability with common mental disorders. We have shown that mental disorders, especially depression, are associated with deficits in functioning and result in the loss of work days. We have also shown that persons with common mental disorders have, on average, higher levels of disability than those observed among persons with a wide range of chronic physical conditions. These results are consistent with prior studies in North America and Europe that have found that persons with common mental disorders experience substantial disability in social role functioning.

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An empirical study of defense mechanisms in panic disorder

Abstract: Panic disorder is present in 2.9% of females and 1.3% of males in the Mexican urban population; about two thirds of these patients have an associated depressive disorder. Genetics and psy-chosocial factors are intertwined in the etiology of this disorder. There are several studies related to the role of defense mechanisms in the pathogenesis of psychiatric disorders. Few studies of anxiety disorders have been conducted in Mexico, and there is little evidence about the importance of the defense mechanisms that are present in these disorders. In the DSM-IV-TR, defense mechanisms or coping styles are defined as "automatic psychological processes that protect the individual against anxiety and from the awareness of internal or external dangers or stressors. Individuals are often unaware of the processes as they operate". The purpose of the present research was to identify the differential use of the defense mechanisms in normal controls and in patients with panic disorder alone or complicated mainly with mood disorders, and the patients who responded or did not respond to psychopharmacological treatment. Method. The sample of this study comprised 48 consecutive outpatients with panic disorder from the Instituto Nacional de Psiquiatría, Ramón de la Fuente Muñiz. All of them were evaluated three times: first by a third grade psychiatry resident, in second place by a specialist in psychiatry and finally by one of the authors. After the patients agreed to participate, they completed a demographic questionnaire, the Hopkins Symptom Check List (SCL-90), and the Defense Style Questionnaire (DSQ, Spanish Version). To evaluate the intensity of anxiety and depression, the Anxiety Hamilton Scale and the Hamilton Scale for Depression were used in their first appointment. Patients were treated as usual with a tricyclic antidepressant, a benzodiazepine, or both, during an eight week period. Then they were evaluated again with the same instruments and scales. The Defense Style Questionnaire (DSQ) is a self-report instrument of common defense styles, which are empirically validated clusters of perceived defense mechanisms. Subjects rate their degree of agreement with 88 statements designed to tap defense or coping mechanisms on a ninepoint scale. The DSQ is a widely used measure of empirically derived groupings of defense mechanisms ranking an adaptive hierarchy. A review of published studies, indicates strong evidence that adaptiveness of defense style correlates with mental health, and that some diagnoses are correlated with specific defense patterns (borderline personality disorder correlates with greater use of both, maladaptive and image-distorting defenses, and less use of adaptive defenses). For other diagnoses, the pattern of defenses is less clear. The validity and the reliability of the DSQ Spanish Version were established before its application, in a sample of 261 psychiatric patients and controls. Two factors were obtained in the factor analysis. The first was denominated Mature Style. This category included: suppression, working orientation, sublimation, anticipation, affiliation, reactive formation, altruism, and humor. The Immature Style was the second factor; it included projection, acting out, repression, somatization, autistic fantasy, affective isolation and social withdrawal, inhibition, help rejection, splitting, undoing, consume, idealization, denial, projective identification, passive-aggression, and omnipotence. Higher mean scores indicated greater use of the individual defense mechanism and style. The mean scores for individual DSQ defense mechanisms and styles were calculated by adding and averaging the scores. The reliability calculated was .89 (Cronbach alpha) for the items cor-responding to the 25 defense mechanisms. Axis I was ascertained reliably with face-to-face interview and a list of the DSM-III-R criteria. This group had 32 patients with panic disorder and 16 patients with panic disorder associated to mood comorbidity or alcohol dependence, in persistent remission for at least one year; 32 subjects were included in the normal control group. Results. The comparison of patients with panic disorder, pa-tients with panic disorder associated to mood disorders and controls, showed that both groups of patients used more projection, regression, inhibition, acting out, fantasy, splitting, help rejection, undoing, and reactive formation (p<.01), than the control group. The patients with panic disorder alone, used more somatization and denial (p<.01) than controls, but not more than the group of patients with panic and mood disorders. They also used less humor and sublimation as defenses than the control group (p=.03). The defense mechanisms of the patients who responded to pharmacological treatment were similar to the defenses of patients who did not improve or deserted. The only defense used more by the patients who responded to treatment was undoing. Conclusions. Overall, the results of this study on panic disorder draw us to the conclusion that patients with this disorder make more use of immature and neurotic defenses than nonpatients. It is clear that maladaptive defenses, measured with this version of the DSQ, are related to mental illness and greater symptomatology, and adapative defenses are related to a better health. There was a clear difference in the use of defense mechanisms between the groups with illnesses and the control group. The clinical value of these observations depends on the relationship of the defenses with the symptoms. In this survey it is not possible to propose that defense mechanisms are the cause of the panic disorder, the reaction to the disease, or just a manifestation of the illness. The theory which establishes that the predominant use of certain defenses predisposes an individual to the development of specific illnesses, is attractive, but there is no evidence to support this hypothesis at present. In order to determine whether specific defenses or defense styles create vulnerability for the development of specific illnesses, the ideal study would be a prospective and longitudinal one; it would measure defenses in childhood, in adolescence, and at several points in adulthood, and would note whether there were significant correlations between preexisting defenses and specific illnesses. Such a study has yet to be under-taken. It is intriguing to speculate if an assessment of defenses could guide to treatment choices. Therapists do tend to consider diagnosis, ego strength, symptoms, behavior, and defenses when planning treatment, but a systematic assessment of defenses is not used as a basis for planning specific interventions. Although several studies have examined the relationship among defenses, alliance, therapist interventions, and outcome, more studies looking at a wider range of specific diagnoses are necessary.

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Consistencia y validez de las subescalas del cuestionario de Conners para la evaluaicón de psicopatología en niños - versión larga para padres / Reliability and validity of the subscales of Conners' parents rating scale-long version

Introducción. Por lo frecuente de los síntomas de psicopatología en niños se requiere de instrumentos para la detección y evaluación de la misma. Objetivo: determinar la validez y consistencia de las subescalas del Cuestionario Conners para la evaluación de psicopatología en niños, en su versión larga para padres. Este cuestionario se seleccionó porque es de los empleados con más frecuencia y porque incluye un espectro amplio de síntomas de psicopatología que se presentan en los niños. Consta de 93 reactivos agrupados en 8 subescalas. Material y métodos. Se evaluaron 745 escolares que asistían a una escuela primaria pública: 53 por ciento niños y 42 por ciento niñas (en 5 por ciento no se anotó el sexo), con edad promedio de 9.26 años. Utilizándose el alpha de Cronbach y haciendo un análisis de reactivos de la subescalas propuestas. Resultados. Mediante un análisis factorial con rotación varimax se obtuvo una estructura factorial muy similar a la de Conners, con 9 factores: trastornos de la conducta, antisocial, ansioso-depresivo, problemas escolares, síntomas psicosomáticos, obsesivo-compulsivo, inmadurez, tensión muscular y problemas de lenguaje. La estructura de 4 de los 9 fue casi idéntica a las de las subescalas correspondientes de Conners. Por medio del alpha de Cronbach y del análisis de reactivos se encontró que estos factores tienen una consistencia adecuada. Conclusión. Las escalas propuestas por Conners son válidas y confiables. Pueden ser empleadas en la forma descrita y pueden complementarse con las que se están proponiendo

¿La clinimetría o la psicometría? Medición en la práctica psiquiátrica / Clinimetry or psychometry? Measuring in psychiatric practice

La climetría, a diferencia de la psicometría, tiene una base estrictamente empírica. Los índices clinimétricos se han desarrollado a partir de la observación y de la entrevista con pacientes. En este artículo, después de algunas definiciones fundamentales, se revisan los principales índices clinimétricos en psiquiatría. A estos índices también se les han llamado "escalas de evaluación" y evalúan los síntomas de psicomovimientos anormales y las variables como la calidad de resumen los estudios metodológicos que se han realizado con estas escalas en nuestro país

Conceptualización y medición de la calidad de vida de pacientes con cáncer / Conceptualization and measurement of quality of life of cancer patients

En este artículo se revisan tres aspectos del concepto de calidad de vida de los pacientes con cáncer: la definición, los propósitos de medirla y los instrumentos que se emplean para este fin. A pesar de las diferencias aproximaciones en cuanto a la definición de la calidad de vida, existe cierto acuerdo en considerar que es la "evaluación subjetiva del carácter bueno o satisfactorio de la vida del paciente". Se propone que la calidad de vida se mida en los ensayos clínicos, principalmente cuando se trata de intervenciones paliativas, además de que puede ser útil como referencia en la toma de decisiones clínica y en la planeación de servicios de atención a los pacientes con cáncer. Finalmente, se hace una revisión crítica de los instrumentos con los que actualmente se evalúa la calidad de vida de pacientes con cáncer

Diferencias entre niveles nocturnos de melatonina y cortisol en pacientes deprimidos y sujetos voluntarios sanos / Differences between night levels of melatonin and cortisol in depressed and healthy volunteers

La producción de melatonina en la glándula pineal tiene un ritmo circadíano con un pico nocturno de secreción. Esta variación cronobiológica de sus niveles es regulada por receptores noradrenérgicos (alfa y beta), lo cual hace que ésta sea una estructura ideal para el estudio de la función noradrenérgica. En la depresión se han reportado diversas alteraciones de los ritmos neuroendócrinos, así como de los del sueño y de la temperatura. El cortisol plasmático ha sido constantemente descrito como elevado en este tipo de pacientes, mientras que se ha observado que la melatonina es baja. Se ha aducido que hay una relación inversa entre estas dos hormonas. El presente trabajo se realizó con el objeto de conocer la relación que hay entre estos dos sistemas hormonales. Se estudió a 10 pacientes con depresión mayor primaria y a 12 volumtarios sanos. Ambos grupos se estudiaron durante 3 noches en habituación y registró polisomnográfico basal, y la tercera noche se tomaron muestras sanguíneas nocturnas cada hora. Las concentraciones de melatonina y cortisol se midieron utilizando la técnica de RIA. En los resultados se observó que los enfermos deprimidos presentaban menor amplitud de melatonina en sus picos, que los voluntarios sanos. Los niveles de cortisol plasmático nocturno se encontraron elevados en los pacientes, mientras que la curva de los sujetos voluntarios sanos apenas muestra una elevación al final del registro. Nuestros resultados coinciden con el resto de los trabajos que estudian la relación que hay entre la melationina y el cortisol en los trastonos afectivos. Estos hallazgos pueden explicarse en función de las modificaciones a los receptores monoaminérgicos que han sido descritos en los trastornos afectivos

Efecto potenciador de la amitriptilina sobre los analgésicos en pacientes con dolor oncológico / Potenciator effect of amitriptyline on the analgesics in patients with oncological pain

Se evaluó la eficacia e un antidepresivo tricíclico (amitriptilina) como potenciador de analgésicos en pacientes oncológico terminales, con dolor resistente a tratamiento convencional. El estudio se realizó con un diseño doble ciego, controlado con placebo. El efecto del medicamento se determinó mediante tres índices: el dolor al momento de la entrevista, el dolor habitual y el peor dolor durante la última semana, que se calificaron numéricamente. Se definió como mejoría la reducción en por lo menos el 25% del dolor manifestado al inicio del tratamiento. Unicamente en el grupo recibiendo amitriptilina se observaron mejorías del 100%, aunque las diferencias entre ambos grupos no fueron significativas. Se comentan los resultados y los problemas en la realización de este tipo de estudios