Is recession bad for your mental health? The answer could be complex: evidence from the 2008 crisis in Spain.

BACKGROUND: We explored the impact of 2008 recession on the prevalence of mental health problems in Spain. METHODS: Repeated cross-sectional survey design. Datasets from 2006 and 2011 were used, and temporal change was examined. The study was conducted on the economically active population (16-64 years old). The two surveys included 29,478 and 21,007 people, obtaining a 96 and 89.6% response rate, respectively. Multiple logistic regression models were adjusted to identify poor mental health risk factors. A standardisation analysis was performed to estimate the prevalence of people at risk of poor mental health (GHQ+). RESULTS: The prevalence of GHQ+ following the crisis increased in men and decreased in women. Two logistic regression analyses identified GHQ+ risk factors. From 2006 to 2011, unemployment rose and income fell for both men and women, and there was a decline in the prevalence of somatic illness and limitations, factors associated with a higher prevalence of GHQ+. After controlling for age, the change in employment and income among men prompted an increase in the prevalence of GHQ+, while the change in somatic illness and limitations tended to mitigate this effect. After the recession, unemployed men showed a better level of somatic health. The same effects were not detected in women. CONCLUSIONS: The economic recession exerted a complex effect on mental health problems in men. The reduction of prevalence in women was not associated with changes in socioeconomic factors related to the economic crisis nor with changes in somatic health.

How does family intervention improve the outcome of people with schizophrenia?

BACKGROUND: There is strong evidence of the efficacy of family psychosocial interventions for schizophrenia, but evidence of the role played by the attitudes of relatives in the therapeutic process is lacking. METHOD: To study the effect of a family intervention on family attitudes and to analyse their mediating role in the therapeutic process 50 patients with schizophrenia and their key relatives undergoing a trial on the efficacy of a family psychosocial intervention were studied by means of the Affective Style Coding System, the Scale of Empathy, and the Relational Control Coding System. Specific statistical methods were used to determine the nature of the relationship of the relatives' attitudes to the outcome of family intervention. RESULTS: Family psychosocial intervention was associated with a reduction in relatives' guilt induction and dominance and an improvement in empathy. Empathy and lack of dominance were identified as independent mediators of the effect of family psychosocial intervention. The change in empathy and dominance during the first 9 months of the intervention predicted the outcome in the following 15 months. CONCLUSION: Relatives' empathy and lack of dominance are mediators of the beneficial effect of family psychosocial intervention on patient's outcome.

Inverse and direct cancer comorbidity in people with central nervous system disorders: a meta-analysis of cancer incidence in 577,013 participants of 50 observational studies.

BACKGROUND: There is a lack of scientific consensus about cancer comorbidity in people with central nervous system (CNS) disorders. This study assesses the co-occurrence of cancers in patients with CNS disorders, including Alzheimer's disease (AD), amyotrophic lateral sclerosis (ALS), autism spectrum disorders, Down's syndrome (DS), Huntington's disease (HD), multiple sclerosis (MS), Parkinson's disease (PD) and schizophrenia (SCZ). METHOD: Comprehensive search in PubMed/MEDLINE, Scopus and ISI Web of Knowledge of the literature published before March 2013. We identified 51 relevant articles from 2,229 discrete references, 50 of which contained data suitable for quantitative synthesis (577,013 participants). Pooled effect sizes (ES) were calculated using multiple random-effects meta-analyses. Sources of heterogeneity and uncertainty were explored by means of subgroup and sensitivity analyses, respectively. RESULTS: The presence of CNS disorders was associated with a reduced co-occurrence of cancer (ES = 0.92; 95% confidence interval, CI: 0.87-0.98; I(2) = 94.5%). A consistently lower overall co-occurrence of cancer was detected in patients with neurodegenerative disorders (ES = 0.80; 95% CI: 0.75- 0.86; I(2) = 82.8%), and in those with AD (ES = 0.32; 95% CI: 0.22-0.46; I(2) = 0.0%), PD (ES = 0.83; 95% CI: 0.76-0.91; I(2) = 80.0%), MS (ES = 0.91; 95% CI: 0.87-0.95; I(2) = 30.3%) and HD (ES = 0.53; 95% CI: 0.42-0.67; I(2) = 56.4%). Patients with DS had a higher overall co-occurrence of cancer (ES = 1.46; 95% CI: 1.08-1.96; I(2) = 87.9%). No association was observed between cancer and ALS (ES = 0.97; 95% CI: 0.76-1.25; I(2) = 0.0%) or SCZ (ES = 0.98; 95% CI: 0.90-1.07; I(2) = 96.3%). Patients with PD, MS and SCZ showed (a) higher co-occurrence of some specific cancers (e.g. PD with melanoma, MS with brain cancers and SCZ with breast cancer), and (b) lower co-occurrence of other specific cancers (e.g. lung, prostate and colorectal cancers in PD; lung and prostate cancers in MS; and melanoma and prostate cancer in SCZ). CONCLUSION: Increased and decreased co-occurrence of cancer in patients with CNS disorders represents an opportunity to discover biological and non-biological connections between these complex disorders.

Psychometric behaviour of the strengths and difficulties questionnaire (SDQ) in the Spanish national health survey 2006.

BACKGROUND: The Strengths and Difficulties Questionnaire (SDQ) is a tool to measure the risk for mental disorders in children. The aim of this study is to describe the diagnostic efficiency and internal structure of the SDQ in the sample of children studied in the Spanish National Health Survey 2006. METHODS: A representative sample of 6,773 children aged 4 to 15 years was studied. The data were obtained using the Minors Questionnaire in the Spanish National Health Survey 2006. The ROC curve was constructed and calculations made of the area under the curve, sensitivity, specificity and the Youden J indices. The factorial structure was studied using models of exploratory factorial analysis (EFA) and confirmatory factorial analysis (CFA). RESULTS: The prevalence of behavioural disorders varied between 0.47% and 1.18% according to the requisites of the diagnostic definition. The area under the ROC curve varied from 0.84 to 0.91 according to the diagnosis. Factor models were cross-validated by means of two different random subsamples for EFA and CFA. An EFA suggested a three correlated factor model. CFA confirmed this model. A five-factor model according to EFA and the theoretical five-factor model described in the bibliography were also confirmed. The reliabilities of the factors of the different models were acceptable (>0.70, except for one factor with reliability 0.62). CONCLUSIONS: The diagnostic behaviour of the SDQ in the Spanish population is within the working limits described in other countries. According to the results obtained in this study, the diagnostic efficiency of the questionnaire is adequate to identify probable cases of psychiatric disorders in low prevalence populations. Regarding the factorial structure we found that both the five and the three factor models fit the data with acceptable goodness of fit indexes, the latter including an externalization and internalization dimension and perhaps a meaningful positive social dimension.Accordingly, we recommend studying whether these differences depend on sociocultural factors or are, in fact, due to methodological questions.

No paradox, no progress: inverse cancer comorbidity in people with other complex diseases.

In the past 5 years, several leading groups have attempted to explain why individuals with Down's syndrome have a reduced risk of many solid tumours and an increased risk of leukaemia and testicular cancer. Niels Bohr, the Danish physicist, noted that a paradox could initiate progress. We think that the paradox of a medical disorder protecting against cancer could be formalised in a new model of inverse cancer morbidity in people with other serious diseases. In this Personal View, we review evidence from epidemiological and clinical studies that supports a consistently lower than expected occurrence of cancer in patients with Down's syndrome, Parkinson's disease, schizophrenia, diabetes, Alzheimer's disease, multiple sclerosis, and anorexia nervosa. Intriguingly, most comorbidities are neuropsychiatric or CNS disorders. We provide a brief overview of evidence indicating genetic and molecular connections between cancer and these complex diseases. Inverse comorbidity could be a valuable model to investigate common or related pathways or processes and test new therapies, but, most importantly, to understand why certain people are protected from the malignancy.

The opinion of psychiatric residents on the training they receive.

The results of a survey carried out by the Spanish National Board for Psychiatric Training among psychiatric trainees in their third and fourth year of training are presented and discussed. The aim of the survey was to know the resident's opinion and level of satisfaction on the training they had received. The results indicate that the majority of residents had complied with the National Program for Psychiatric Training requirements and that their level of satisfaction was fair. However a small but substantial percentage did not comply adequately with the program, particularly in relation with the training in psychotherapy, research methodology, old age psychiatry, neurology and general medicine. Based on these results the National Board puts forward some recommendations meant for those involved in the training of psychiatrists in Spain.

The impact of the 2008 economic crisis on the increasing number of young psychiatric inpatients. / Impacto de la crisis económica del 2008 en el número de jóvenes hospitalizados por patología psiquiátrica.

BACKGROUND: Little is published about the impact of the 2008 economic crisis on mental health services in Spain. METHOD: An interrupted time series analysis was conducted to investigate a potential short-term association between the 2008 economic crisis and the number of psychiatric hospital admissions. The timing of the intervention (April 2008) was based on observed changes in Gross Domestic Product (GDP). Data on 1,152,880 psychiatric inpatients from the national Hospital Morbidity Survey, 69 months before and after the onset of the economic crisis (April 2008), were analyzed. RESULTS: Age-adjusted psychiatric (ICD9 290-319) hospital discharge rates significantly increased from April 2008, matching the onset of the crisis, especially for inpatients aged 15-24 years old and to a less extend for inpatients aged 25-34 years old. Other age groups were not affected. There was a significant increase in diagnoses for disturbance of conduct and emotions, depression, neurotic and personality disorders and alcohol and drug disorders; however, diagnoses for mental retardation and organic psychosis for 15-34 years old inpatients were unaffected. CONCLUSIONS: Psychiatric hospital admissions abruptly increased in April 2008, coinciding with the onset of the economic crisis. We identified age groups and diagnoses affected. Increased hospitalizations were found only at the age-ranges most affected by the rise in unemployment. The diagnoses affected were those most sensitive to environmental changes.

Neurocognitive and clinical predictors of functional outcome in patients with schizophrenia and bipolar I disorder at one-year follow-up.

OBJECTIVE: Many studies have reported that cognitive ability may be predictive of the functional outcome for patients with schizophrenia. However, no study has prospectively examined these aspects in schizophrenia and bipolar disorders simultaneously. The present study attempted to analyze if neurocognition and clinical status predicts the real-life functioning for patients with schizophrenia or bipolar I disorder, using a longitudinal design. METHOD: Forty-seven schizophrenic and 43 bipolar I outpatients were assessed twice with a neurocognitive battery (Executive Functions, Working Memory, Verbal Memory, Visual Memory, Visual-Motor Processing, Vigilance, Vocabulary and Motor Speed tasks), clinical scales (the Positive and Negative Symptom Scale, the Hamilton Rating Scale for Depression and the Clinician Administered Rating Scale for Mania) and functional outcome measures (the Global Assessment of Functioning Scale, the WHO's Disability Assessment Scale and occupational adaptation level) over a one-year follow-up period. The cognitive performance of the patients was compared, at baseline and one year later, with that of 25 healthy subjects. RESULTS: In schizophrenia patients, global functioning one year later was predicted by a composite neurocognitive score and three specific domain (verbal memory, motor speed, vocabulary). Symptoms appeared to explain less of the variance in functioning. In bipolar I patients, changes in the composite neurocognitive score over one year, deficits in the visual/motor processing domain, severity of symptoms (psychotic, excitatory and affective symptoms) and premorbid adjustment at the first assessment were the variables that better predicted functioning or disability changes over follow-up period. CONCLUSIONS: Although the relationships between cognition, symptoms and functional capacity differ for schizophrenia or bipolar I patients, neuropsychological performance seems to be a principal longitudinal predictor of functioning in both disorders. Baseline neurocognition and cognitive changes over 12 months predicted changes in functioning over the same period, but only in bipolar I patients. These cognitive domains could be potential neurocognitive endophenotypes (endophenocognitypes) with regard to bipolar I disorder.

Five Interpersonal Factors Are Predictive of the Response to Treatment of Major Depression With Antidepressants in Primary Care.

Introduction: Factors relating to the interpersonal relationship between the patient and their physician and social environment are important components, which contribute to their response to treatment for major depressive disorder. This study aimed to assess the influence of optimism, perfectionism, therapeutic alliance, empathy, social support, and adherence to medication regimen in the response to antidepressant treatments in the context of normal primary care clinical practice. Method: We conducted a prospective study in which 24 primary care physicians administered sertraline or escitalopram to 89 patients diagnosed with major depressive disorder. The response to treatment and remission of the episode was assessed at 4 and 12 weeks by Cox regression. The effect of adherence to the medication regimen was assessed by multiple regression statistical techniques. Results: Adherence to medication (HR = 0.262, 95% CI = 0.125-0.553, p < 0.001) and patient perfectionism (HR = 0.259, 95% CI = 0.017-0.624, p < 0.01) negatively predicted the initial response to treatment, whereas patient optimism (HR = 1.221, 95% CI = 1.080-1.380, p < 0.05) positively predicted it. Patient optimism (HR = 1.247, 95% CI = 1.1-1.4, p < 0.05), empathy perceived by the patient (HR = 1.01, 95% CI = 1001-1002, p < 0.05), and therapeutic alliance (HR = 1.02, 95% CI = 1001-1.04, p < 0.05) positively predicted episode remission, while patient perfectionism (HR = 0.219, 95% CI = 0.093-0.515, p < 0.001) and low adherence to the treatment regimen (HR = 0.293, 95% CI = 0.145-0.595, p < 0.001) negatively predicted it. Finally, social support (p < 0.01) and therapeutic alliance (p < 0.05) predicted adherence to the medication regimen. Conclusions: In addition to taking the antidepressant drug, other factors including the personal interactions between the patient with their primary care physician and with their social environment significantly influenced the patients' initial response and the final rate of episode remission.

Contribution of the Economic Crisis to the Risk Increase of Poor Mental Health in a Region of Spain.

Previous research suggests that the economic crisis can affect mental health. The purpose of this study was to analyse the association of risk of poor mental health with various socioeconomic, demographic, health, quality of life, and social support variables; and to evaluate the contribution of socioeconomic variables most affected by the beginning of the economic crisis (employment situation and income) on the changes in the prevalence of the risk of poor mental health between 2005 and 2010. A study of prevalence evolution in adult population residents of the Valencian Community in the Spanish Mediterranean was conducted. We studied 5781 subjects in 2005 and 3479 in 2010. Logistic regression models have been adjusted to analyse the association between variables. A standardisation procedure was carried out to evaluate which part of the changes in overall prevalence could be attributed to variations in the population structure by age, sex, employment status, and income between the years under study. The prevalence of GHQ+ increased from 2005 to 2010, in both men and women. Several variables were closely associated with the risk of poor mental health (sex, age, country of birth, number of nonmental chronic diseases, social support, disability, cohabitation in couple, employment status, and income). The changes produced as a result of the onset of the economic crisis in income and unemployment (increase in low income and in unemployment rates) contributed to the increase of poor mental health risk. This could confirm the sensitivity of mental health to the economic deterioration caused by the crisis.

Posttraumatic stress disorder in primary care with special reference to personality disorder comorbidity.

BACKGROUND: Posttraumatic stress disorder (PTSD) is a common and disabling disturbance in primary care. Few studies have been carried out in primary care samples and none have taken into consideration the association between PTSD and personality disorder. AIM: To describe prevalence and risk factors of PTSD and its comorbidity with personality disorder. SETTING: General practice centre in Valencia (Spain). METHOD: Patients who had experienced at least one traumatic event in their lives were selected from a random sample attending a primary healthcare centre in Valencia and blindly assessed by trained professionals. Patients suffering from PTSD were compared with those who were not. PTSD and personality disorder diagnoses were established using CIDI and SCID-II interviews respectively. Sex, age at the time of experiencing trauma, frequency, multiplicity and type of trauma, dissociative symptoms, personality disorder and severity of PTSD were subjected to multivariate analysis to estimate the probability of developing PTSD and its duration. RESULTS: Life prevalence rate was 14% and current prevalence 9%. Dissociative symptoms and personality disorder were significantly associated with PTSD. Cluster analysis based on age, frequency and type of trauma revealed the existence of one subgroup composed mainly of women who had experienced frequent body-contact trauma at an early age, developed severe PTSD and suffer from a variety of personality disorders, particularly paranoid personality disorder. Time to the complete disappearance of symptoms was only explained by the initial severity of PTSD. CONCLUSION: PTSD is a frequent disorder in general practice and it is often associated with personality disorder. Women who experienced high frequency body-contact traumatic events at an early age often suffer from personality disorder and present a particularly severe form of PTSD deserving referral to specialised care.

Discordance between two national health statistics sources (EMH and EESCRI, 1990-2009). Analysis of psychiatric morbidity.

INTRODUCTION: Two statistical sources provide data on hospital stays and discharges for all Spanish hospitals: Hospital Morbidity Survey (acronym in Spanish: EMH) and Statistics of Health Establishments providing Inpatient Care (acronym in Spanish: EESCRI). Our aim is to contrast these two statistical sources to define their accuracy and relevance in psychiatric epidemiology studies. MATERIAL AND METHODOLOGY: The analysis is based on two aspects: 1.- Compare the number of psychiatric stays and hospital discharges from 1990-2009, 2.- Analyze and compare how the average stay is provided. RESULTS: The differences between the two statistical sources are significant and increase over time. In 2005-2009 the EMH records 121% of hospitalizations (577,078 vs. 475,414) and 46% (14,239,527 vs. 30,821,412) of psychiatric stays, compared with EESCRI. Moreover, the average stay estimated by EESCRI shows serious methodological problems, particularly in settings of prolonged hospitalization (psychiatric hospitals); the estimations are potentially below the real value. CONCLUSIONS: Surprisingly, the questionnaires completed by hospitals to develop the EESCRI provide data on assisted morbidity quite different from that provided by the EMH, despite both statistical sources having the same inpatient records for data processing. It is difficult to attribute these differences to sampling error, as the EMH has a very high sampling fraction, which minimizes the sampling error. Given the mismatch between sources, we recommend using the EMH, as it offers more reliable data and allows an accurate determination of the length of stays.

Abnormal motor asymmetry only during bimanual movement in schizophrenic patients compared with healthy subjects.

In schizophrenia, research on motor asymmetry has focused on the direction and the degree of handedness using unimanual motor tests and tasks. However, typically both hands collaborate in the production of most manual movements. This study explored motor asymmetry exhibited during unimanual and bimanual tasks in schizophrenic and healthy subjects using a new experimental motor battery. Specifically, the authors investigated the motor indices of laterality during finger-tapping and hand-turning tasks in four unimanual and four bimanual conditions in 84 schizophrenic and 31 healthy subjects, all right-handed. The schizophrenic patients showed reduced motor asymmetries only during bimanual tapping compared with healthy subjects due to reduction in right-hand performance. These results stress the importance of considering bimanual conditions in the assessment of motor asymmetries, and suggest that it is necessary to use bimanual tasks to test hypotheses about abnormal motor lateralization in schizophrenia.

Specific executive/attentional deficits in patients with schizophrenia or bipolar disorder who have a positive family history of psychosis.

Neurocognitive impairments are well documented in patients with schizophrenia and their healthy first-degree biological relatives. Less is known about neuropsychological performance in bipolar disorders, but some studies indicate that, compared to schizophrenia, bipolar disorder displays a similar profile pattern with less severe deficits. The genetic and environmental contributions to the development of neurocognitive deficits are also unclear. This study explored the effect of a family history (FH) of psychotic disorders in first-degree relatives on a variety of cognitive domains (abstraction and flexibility, verbal fluency, verbal memory, motor activity and visual-motor processing/attention) in 30 patients with schizophrenia, and 24 type I bipolar patients. After adjusting the results for age, gender, education level and pre-morbid intelligence, patients with schizophrenia or bipolar disorder with positive FH (n=18) performed significantly worse than patients with negative FH (n=36) on the visual-motor processing/attention domain. These findings were independent of the specific diagnosis. Moreover, when logistic regression analysis was performed, poor Digit Symbol performance was the only predictor of belonging to the positive FH group. Our results are compatible with the existence of some common genetic factors between the illnesses, as well as the involvement of identical, or at least similar, disordered brain systems in both disorders. These findings are discussed within the context of the continuum model of psychosis.

Efficacy of sildenafil citrate (Viagra) for the treatment of erectile dysfunction in men in remission from depression.

Erectile dysfunction (ED) and depression are highly prevalent and frequently comorbid. Sildenafil effectively treats ED in men with depression and in men taking antidepressants. We evaluated the efficacy of sildenafil in men with depression in remission and ED. Patients with a history of ED when major depressive disorder (MDD) was diagnosed, which persisted after MDD was treated to remission, were randomized to 12 weeks of treatment with sildenafil (50 mg, flexible) or placebo. Efficacy was assessed using intercourse success rates, a global efficacy question (Has treatment improved your erections?), the International Index of Erectile Function (IIEF) and Life Satisfaction Checklist (LSC). By week 12, intercourse success rates were significantly higher among sildenafil- (74%) compared to placebo-treated patients (29%; P=0.0001). About 83% and 34% of sildenafil- and placebo-treated patients, respectively, reported improved erections (odds ratio=9.4, P=0.0001). IIEF scores in the sildenafil group (n=83) were significantly improved compared to those in the placebo group (n=85; P <0.0001). LSC sexual life item improved significantly among sildenafil- versus placebo-treated patients. The most frequently reported adverse events were transient and mild-to-moderate. Sildenafil is an effective and well-tolerated treatment for ED in patients with a history of ED at the time of MDD diagnosis, and which persisted after the MDD was treated to remission.

[Gender and mental health in a changing world]. / Género y salud mental en un mundo cambiante.

It is well established that human psychological development, violence and sexual abuse, the experience of reproduction and parenting, as well as psychopathology and psychiatric morbidity are different for men and women, both in quality and quantity. In this chapter some of these differences, including disability and the use of services in the Spanish population are described and analysed. Whether there is a need for a new discipline to study psychiatric illness and psychiatric treatment from the point of view of gender is discussed. There has been a deep process of transformation of gender roles in our society. In our opinion this calls for new research efforts aimed at estimating the rates of prevalence and associated risk factors in men and women at present. The results of such research will probably lead to the formulation of new and more relevant hypotheses, and to the development of new research strategies and more valid and reliable measuring instruments.

Unmet needs in the management of schizophrenia.

Studies on unmet needs during the last decades have played a significant role in the development and dissemination of evidence-based community practices for persistent schizophrenia and other severe mental disorders. This review has thoroughly considered several blocks of unmet needs, which are frequently related to schizophrenic disorders. Those related to health have been the first block to be considered, in which authors have examined the frequent complications and comorbidities found in schizophrenia, such as substance abuse and dual diagnosis. A second block has been devoted to psychosocial and economic needs, especially within the field of recovery of the persistently mentally ill. Within this block, the effects of the current economic difficulties shown in recent literature have been considered as well. Because no patient is static, a third block has reviewed evolving needs according to the clinical staging model. The fourth block has been dedicated to integrated evidence-based interventions to improve the quality of life of persons with schizophrenia. Consideration of community care for those reluctant to maintain contact with mental health services has constituted the fifth block. Finally, authors have aggregated their own reflections regarding future trends. The number of psychosocial unmet needs is extensive. Vast research efforts will be needed to find appropriate ways to meet them, particularly regarding so-called existential needs, but many needs could be met only by applying existing evidence-based interventions. Reinforcing research on the implementation strategies and capacity building of professionals working in community settings might address this problem. The final aim should be based on the collaborative model of care, which rests on the performance of a case manager responsible for monitoring patient progress, providing assertive follow-up, teaching self-help strategies, and facilitating communication among the patient, family doctor, mental health specialist, and other specialists.

A short message service (SMS)-based strategy for enhancing adherence to antipsychotic medication in schizophrenia.

BACKGROUND: The aim of this study was to assess the impact of a short message service (SMS)-based strategy on adherence to antipsychotic treatment. METHODS: A multicentre, randomised, open-label, controlled, 6-month study with clinically stabilised outpatients with schizophrenia was conducted. The patients assigned to the intervention received daily SMS reminders to take their medication for 3 months. Self-reported medication adherence was determined using the Morisky Green Adherence Questionnaire (MAQ). Secondary outcomes were severity of illness, attitude towards medication, insight into illness and health-related quality of life. RESULTS: A total of 254 patients were analysed. A significantly greater improvement in adherence was observed among patients receiving SMS text messages compared with the control group. The mean change in MAQ total score from baseline to month 3 was -1.0 (95% confidence interval (CI) -1.02, -0.98) and -0.7 (95%CI -0.72, -0.68), respectively (P=0.02). Greater improvement in negative, cognitive and global clinical symptoms at month 3 was observed. Attitude towards medication also significantly improved across the study in the intervention group versus the controls. CONCLUSIONS: An SMS-based intervention seems feasible and acceptable for enhancing medication adherence. Further studies are needed to confirm whether this kind of intervention could be a complementary strategy to optimise adherence in schizophrenia.

Standardised measures of needs, stigma and informal care in schizophrenia using a bottom-up, cross-cultural approach.

Background There is a lack of instruments to measure the needs, stigma and informal care of people with schizophrenia that take account of sociocultural variation and patients' and formal and informal carers' opinions and experiences. Aims To develop questionnaires to measure stigma, needs and informal (non-professional) care for people with schizophrenia. Method We undertook the study in seven countries and in English, Spanish and Portuguese. We first held focus group discussions with patients, formal carers (professionals) and informal carers (family and friends) in Spain, the UK, Argentina, Brazil, Chile and Venezuela to elicit the main dimensions of needs, stigma and informal care. We then held nominal group discussions about these dimensions with patients, family members and professionals in Spain, Portugal and the UK, to develop the instruments. Results Three hundred and three people participated in 46 focus groups and results were discussed in three nominal groups, each involving eight participants. Three instruments were developed in this iterative process: needs for care (46 items), stigma (38 items) and informal care (20 items). Conclusions These instruments are based on service users' and carers' views and experiences and have cross-cultural validity. They will have application in assessment of outcomes for people with schizophrenia and their families.