Suspension of social welfare services and mental health outcomes for women during the COVID-19 pandemic in a peripheral neighborhood in São Paulo, Brazil.

During the COVID-19 pandemic, Brazilian urban peripheries have been severely affected both by the spread of the virus and by social, political, and economical dynamics, raising concerns about the psychological wellbeing and mental health of the population living in these areas. The pandemic broke out in a context of reduced public spending in social and health policies as well as in a process of erosion of social rights, fostering processes of exclusion and highlighting the association between austerity, the increase in poverty and inequality as well as in health and mental health problems indicators. This article presents the results of a qualitative participatory research that investigated subjective experiences in a peripheral neighborhood of São Paulo, Brazil, aiming to understand how contextual dynamics played a role in shaping mental health experiences during the COVID-19 pandemic. A multidisciplinary team of researchers worked closely with local volunteers trained to provide emotional support calls to neighbors of the community who signed up for the project. This article presents three ethnographic cases of women who had their routines strongly affected by the suspension of public and social protection services for the containment of the SARS-CoV-2 pandemic, leading to psychological suffering due to the increased demand of "domestic circuits of care". We argue that within a context of austerity, the pandemic was remarkably harsh in urban peripheries and, specifically, for women with caring responsibilities. In addition to highlighting the pervasive "social protection gap", the cases presented in this paper also reveals the unequal dynamics of the social reproduction work in several layers, which falls mainly on women's shoulders. The "crisis of care", proposed by gender and feminist scholars, can contribute to understanding the psychological outcomes of the COVID-19 pandemic for these women.

Individual and population level estimates of work loss and related economic costs due to mental and substance use disorders in Metropolitan São Paulo, Brazil.

BACKGROUND: We estimate work loss and economic costs due to mental and substance use disorders in the economically active population of the São Paulo Metropolitan Area, Brazil. METHODS: The São Paulo Megacity Mental Health Survey assessed a population-based sample of 3,007 economically active residents using the Composite International Diagnostic Interview 3.0 and the World Health Organization Disability Assessment Schedule 2 to investigate, respectively, 12-month psychiatric disorders, work performance, and economic costs. RESULTS: Absenteeism over the past 12 months was reported by 12.6%, and presenteeism by 14.7% (qualitative loss) and 13.1% (quantitative loss). Having any mental disorder was associated with 17.6 days of absenteeism and 37.7 days of reduced-qualitative and/or quantitative functioning. Fourteen mental disorders were significantly associated with work loss, with odds ratios ranging from 2.3 for adult separation anxiety to 40.4 for oppositional defiant disorder. At a population-level, oppositional defiant disorder, panic disorder, attention deficit disorder, and dysthymia contributed to the largest costs. The total annual economic costs were USD $83.2 billion/year, representing 6.1% of Brazil's Gross Domestic Product in 2007. LIMITATIONS: Diagnosis of mental disorders was based on self-reported symptoms. Work loss assessment was restricted to 30 days before the interview and may not fully represents the annual real experience and symptoms of the respondents which would lead to an overestimation of the burden. CONCLUSIONS: Mental disorders impose a great negative impact on work performance and functioning, with a consequent high economic burden, pointing to the need of implementing cost-effective interventions to prevent work loss.

The relationship between neighborhood-level socioeconomic characteristics and individual mental disorders in five cities in Latin America: multilevel models from the World Mental Health Surveys.

PURPOSE: Our understanding of community-level predictors of individual mental disorders in large urban areas of lower income countries is limited. In particular, the proportion of migrant, unemployed, and poorly educated residents in neighborhoods of these urban areas may characterize group contexts and shape residents' health. METHODS: Cross-sectional household interviews of 7251 adults were completed across 83 neighborhoods of Buenos Aires, Argentina; Medellín, Colombia; São Paulo, Brazil; Lima, Peru; and Mexico City, Mexico as part of the World Mental Health Survey Initiative. Past-year internalizing and externalizing mental disorders were assessed, and multilevel models were used. RESULTS: Living in neighborhoods with either an above-average or below-average proportion of migrants and highly educated residents was associated with lower odds of any internalizing disorder (for proportion migrants: OR 0.75, 95% CI 0.62-0.91 for the bottom tertile and OR 0.79, 95% CI 0.67-0.94 for the top tertile compared to the middle tertile; for proportion highly educated: OR 0.76, 95% CI 0.64-0.90 for the bottom tertile and OR 0.58, 95% CI 0.37-0.90 for the top tertile compared to the middle tertile). Living in neighborhoods with an above-average proportion of unemployed individuals was associated with higher odds of having any internalizing disorder (OR 1.49, 95% CI 1.14-1.95 for the top tertile compared to the middle tertile). The proportion of highly educated residents was associated with lower odds of externalizing disorder (OR 0.54, 95% CI 0.31-0.93 for the top tertile compared to the middle tertile). CONCLUSIONS: The associations of neighborhood-level migration, unemployment, and education with individual-level odds of mental disorders highlight the importance of community context for understanding the burden of mental disorders among residents of rapidly urbanizing global settings.

Mental disorders and employment status in the São Paulo Metropolitan Area, Brazil: gender differences and use of health services / Transtornos mentais e situação laboral na Região Metropolitana de São Paulo, Brasil: diferenças de gênero e uso de serviços de saúde / Trastornos mentales y situación laboral en la zona metropolitana de São Paulo, Brasil: diferencias de género y uso de servicios de salud

Abstract: Mental disorders are associated with employment status as significant predictors and as consequences of unemployment and early retirement. This study describes the estimates and associations of 12-month DSM-IV prevalence rates of mental disorders and use of health services with employment status by gender in the São Paulo Metropolitan Area, Brazil. Data from the São Paulo Megacity Mental Health Survey was analyzed (n = 5,037). This is a population-based study assessing the prevalence and determinants of mental disorders among adults, using the Composite International Diagnostic Interview. The associations were estimated by odds ratios obtained through binomial and multinomial logistic regression. This study demonstrates that having mental disorders, especially mood disorders, is associated with being inactive or unemployed among men and inactive among women, but only having a substance use disorder is associated with being unemployed among women. Among those with mental disorders, seeking health care services is less frequent within unemployed.

Resumo: Os transtornos mentais estão associados à situação laboral enquanto preditores significativos e consequências do desemprego e da aposentadoria precoce. Este estudo estima as taxas de prevalência de transtornos mentais nos últimos 12 meses de acordo com o DSM-IV, além do uso de serviços de saúde e as associações com situação laboral de acordo com gênero na Região Metropolitana de São Paulo, Brasil. Foram analisados dados do São Paulo Megacity Mental Health Survey (n = 5.037), um estudo populacional que avalia a prevalência e determinantes dos transtornos mentais entre adultos, usando a Composite International Diagnostic Interview. As associações foram estimadas através de razões de prevalência, obtidas por regressão logística binomial e multinomial. O estudo mostra que os transtornos mentais, especialmente transtornos de humor estão associados à inatividade ou ao desemprego entre os homens e à inatividade entre as mulheres, com exceção aos transtornos devido ao uso de substâncias psicoativas que também estão associados ao desemprego em as mulheres. Entre os portadores de transtornos mentais, a busca de serviços de saúde é menos frequente entre os desempregados.

Resumen: Los trastornos mentales están asociados a la situación laboral, como predictores significativos por las consecuencias que provocan el desempleo y la jubilación precoz. Este estudio estima las tasas de prevalencia de trastornos mentales en 12 meses, de acuerdo con el DSM-IV, además del uso de servicios de salud y las asociaciones existentes con la situación laboral, de acuerdo con el género en el área metropolitana de São Paulo, Brasil. Se analizaron los datos del São Paulo Megacity Mental Health Survey (n = 5.037), un estudio poblacional que evalúa la prevalencia y determinantes de los trastornos mentales entre adultos, usando la Composite International Diagnostic Interview. Las asociaciones se estimaron con razones de prevalencia, obtenidas por la regresión logística binomial y multinomial. El estudio muestra que los trastornos mentales, especialmente los trastornos de humor, están asociados a la inactividad o al desempleo en hombres y a la inactividad en mujeres, pero que sólo el trastorno de consumo de sustancias está asociado al desempleo en mujeres. Entre los portadores de trastornos mentales, la búsqueda de servicios de salud es menos frecuente entre los desempleados.

Do Childhood Adversities Predict Suicidality? Findings from the General Population of the Metropolitan Area of São Paulo, Brazil.

BACKGROUND: Childhood adversities have been associated with a number of medical and psychiatric outcomes. However, the reported effects that specific childhood adversities have on suicidality vary across studies. METHOD: This was a cross-sectional, stratified, multistage area probability investigation of a general population in Brazil, designated the São Paulo Megacity Mental Health Survey. The World Mental Health Composite International Diagnostic Interview was applied in 5037 individuals ≥ 18 years of age, in order to assess 12 different adversities occurring during childhood and/or adolescence, as well as to look for associations between those adversities and subsequent suicidality in different age strata. RESULTS: Over half of the respondents reported at least one childhood adversity. Only physical abuse was consistently associated with suicide attempts in all subsequent life stages (OR = 2.1). Among adults 20-29 years of age, the likelihood of a suicide attempt was correlated with parental divorce, whereas suicidal ideation was associated with prior sexual abuse. Among adults over 30 years of age, physical illness and economic adversity emerged as relevant childhood adversities associated with suicide attempts, whereas sexual abuse, family violence, and economic adversity were associated with suicidal ideation. CONCLUSION: Childhood adversities, especially physical abuse, are likely associated with unfavorable consequences in subsequent years. For suicidality across a lifespan, the role of different childhood adversities must be examined independently.

Incremental health expenditure and lost days of normal activity for individuals with mental disorders: results from the São Paulo Megacity Study.

BACKGROUND: With the recent increase in the prevalence of mental disorders in developing countries, there is a growing interest in the study of its consequences. We examined the association of depression, anxiety and any mental disorders with incremental health expenditure, i.e. the linear increase in health expenditure associated with mental disorders, and lost days of normal activity. METHODS: We analyzed the results from a representative sample survey of residents of the Metropolitan Region of São Paulo (n = 2,920; São Paulo Megacity Mental Health Survey), part of the World Mental Health (WMH) Survey Initiative, coordinated by the World Health Organization and performed in 28 countries. The instrument used for obtaining the individual results, including the assessment of mental disorders, was the WMH version of the Composite International Diagnostic Interview 3.0 (WMH-CIDI 3.0) that generates psychiatric diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. Statistical analyses were performed by multilevel generalized least squares (GLS) regression models. Sociodemographic determinants such as income, age, education and marital status were included as controls. RESULTS: Depression, anxiety and any mental disorders were consistently associated with both incremental health expenditure and missing days of normal activity. Depression was associated with an incremental annual expenditure of R$308.28 (95% CI: R$194.05-R$422.50), or US$252.48 in terms of purchasing power parity (PPP). Anxiety and any mental disorders were associated with a lower, but also statistically significant, incremental annual expenditure (R$177.82, 95% CI: 79.68-275.97; and R$180.52, 95% CI: 91.13-269.92, or US$145.64 and US$147.85 in terms of PPP, respectively). Most of the incremental health costs associated with mental disorders came from medications. Depression was independently associated with higher incremental health expenditure than the two most prevalent chronic diseases found by the study (hypertension and diabetes). CONCLUSIONS: The fact that individuals with mental disorders had a consistent higher health expenditure is notable given the fact that Brazil has a universal free-of-charge healthcare and medication system. The results highlight the growing importance of mental disorders as a public health issue for developing countries.

Use of psychotropic medications in São Paulo Metropolitan Area, Brazil: pattern of healthcare provision to general population.

PURPOSE: We estimate the proportion of psychotropic medication use (PMU) among adults in São Paulo Metropolitan Area, Brazil. We investigated whether socio-demographic factors, comorbidity, and disease severity influence PMU among individuals with psychiatric disorders. METHODS: Data are from the São Paulo Megacity Mental Health Survey, a cross-sectional, population-based study, the Brazilian branch of the World Mental Health Survey Initiative. Trained lay interviewers face-to-face assessed psychiatric disorders and PMU through the Composite International Diagnostic Interview. Respondents were asked about use of healthcare service and prescribed medications for mental disorders in the previous year. Information on PMU was collected for 2935 adult residents in the area and among those with disorders who received treatment. RESULTS: Around 6% of respondents reported PMU in the past year: hypnotics or sedatives were used by 3.7% and antidepressants by 3.5%. Among individuals with 12-month disorders, only 14% reported past year PMU. Gender, age, education, income, occupational status, comorbidity, and severity were significant predictors for PMU. Among those with 12-month DSM-IV disorders who obtained treatment in healthcare settings, almost 40% received medication only. Among those treated in specialty mental health service, around 23% received combination of medication and psychotherapy. CONCLUSION: Our study has pointed out that the recent trend of access to mental healthcare in Brazil depicts unmet needs, characterized by a low prevalence of PMU among individuals with psychiatric disorders. Policies that improve appropriate access to prescribed drugs for those most in need are urgent public health priority.

Determinants of the use of health care services: multilevel analysis in the Metropolitan Region of Sao Paulo.

OBJECTIVE To evaluate the individual and contextual determinants of the use of health care services in the metropolitan region of Sao Paulo. METHODS Data from the Sao Paulo Megacity study - the Brazilian version of the World Mental Health Survey multicenter study - were used. A total of 3,588 adults living in 69 neighborhoods in the metropolitan region of Sao Paulo, SP, Southeastern Brazil, including 38 municipalities and 31 neighboring districts, were selected using multistratified sampling of the non-institutionalized population. Multilevel Bayesian logistic models were adjusted to identify the individual and contextual determinants of the use of health care services in the past 12 months and presence of a regular physician for routine care. RESULTS The contextual characteristics of the place of residence (income inequality, violence, and median income) showed no significant correlation (p > 0.05) with the use of health care services or with the presence of a regular physician for routine care. The only exception was the negative correlation between living in areas with high income inequality and presence of a regular physician (OR: 0.77; 95%CI 0.60;0.99) after controlling for individual characteristics. The study revealed a strong and consistent correlation between individual characteristics (mainly education and possession of health insurance), use of health care services, and presence of a regular physician. Presence of chronic and mental illnesses was strongly correlated with the use of health care services in the past year (regardless of the individual characteristics) but not with the presence of a regular physician. CONCLUSIONS Individual characteristics including higher education and possession of health insurance were important determinants of the use of health care services in the metropolitan area of Sao Paulo. A better understanding of these determinants is essential for the development of public policies that promote equitable use of health care services.

Determinants of the use of health care services: multilevel analysis in the Metropolitan Region of Sao Paulo / Determinantes do uso de serviços de saúde: análise multinível da Região Metropolitana de São Paulo

OBJECTIVE To evaluate the individual and contextual determinants of the use of health care services in the metropolitan region of Sao Paulo. METHODS Data from the Sao Paulo Megacity study – the Brazilian version of the World Mental Health Survey multicenter study – were used. A total of 3,588 adults living in 69 neighborhoods in the metropolitan region of Sao Paulo, SP, Southeastern Brazil, including 38 municipalities and 31 neighboring districts, were selected using multistratified sampling of the non-institutionalized population. Multilevel Bayesian logistic models were adjusted to identify the individual and contextual determinants of the use of health care services in the past 12 months and presence of a regular physician for routine care. RESULTS The contextual characteristics of the place of residence (income inequality, violence, and median income) showed no significant correlation (p > 0.05) with the use of health care services or with the presence of a regular physician for routine care. The only exception was the negative correlation between living in areas with high income inequality and presence of a regular physician (OR: 0.77; 95%CI 0.60;0.99) after controlling for individual characteristics. The study revealed a strong and consistent correlation between individual characteristics (mainly education and possession of health insurance), use of health care services, and presence of a regular physician. Presence of chronic and mental illnesses was strongly correlated with the use of health care services in the past year (regardless of the individual characteristics) but not with the presence of a regular physician. CONCLUSIONS Individual characteristics including higher education and possession of health insurance were important determinants of the use of health care services in the metropolitan area of Sao Paulo. A better understanding of these determinants is essential for the development of public policies ...

OBJETIVO Analisar os determinantes individuais e contextuais do uso de serviços de saúde na Região Metropolitana de São Paulo. MÉTODOS Foram utilizados os dados do estudo São Paulo Megacity, a versão brasileira da pesquisa multicêntrica World Mental Health Survey. Foram analisados 3.588 indivíduos adultos residentes em 69 áreas da Região Metropolitana de São Paulo, SP (38 municípios adjacentes e 31 subprefeituras do município de São Paulo), selecionados por meio de amostragem multiestratificada da população não institucionalizada. Foram ajustados modelos multinível logísticos Bayesianos para identificar os determinantes individuais e contextuais do uso de serviços de saúde nos últimos 12 meses e a presença de médico de referência para cuidados de rotina. RESULTADOS As características contextuais do local de residência (desigualdade de renda, violência e renda mediana) não apresentaram associação significativa (p > 0,05) com o uso de serviços ou com a presença de médico de referência para cuidados de rotina. A única exceção foi a associação negativa entre residir em uma área com alta desigualdade de renda e a presença de médico de referência (OR 0,77; IC95% 0,60;0,99) após controle das características individuais. O estudo apontou uma forte e consistente associação entre algumas características individuais (principalmente escolaridade e presença de plano de saúde) com o uso de serviços de saúde e ter médico de referência. A presença de doenças crônicas e mentais associou-se fortemente com o uso de serviços no último ano (independentemente de características individuais), mas não com a presença de médico de referência. CONCLUSÕES Características individuais como maior escolaridade e ter plano de saúde foram determinantes importantes do uso de serviços de saúde na Região Metropolitana de São Paulo. A melhor compreensão desses determinantes é necessária para o desenvolvimento de políticas públicas que permitam o uso equitativo dos serviços ...

Does income inequality get under the skin? A multilevel analysis of depression, anxiety and mental disorders in Sao Paulo, Brazil.

OBJECTIVE: Test the original income inequality theory, by analysing its association with depression, anxiety and any mental disorders. METHODS: We analysed a sample of 3542 individuals aged 18 years and older selected through a stratified, multistage area probability sample of households from the São Paulo Metropolitan Area. Mental disorder symptoms were assessed using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. Bayesian multilevel logistic models were performed. RESULTS: Living in areas with medium and high-income inequality was statistically associated with increased risk of depression, relative to low-inequality areas (OR 1.76; 95% CI 1.21 to 2.55, and 1.53; 95% CI 1.07 to 2.19, respectively). The same was not true for anxiety (OR 1.25; 95% CI 0.90 to 1.73, and OR 1.07; 95% CI 0.79 to 1.46). In the case of any mental disorder, results were mixed. CONCLUSIONS: In general, our findings were consistent with the income inequality theory, that is, people living in places with higher income inequality had an overall higher odd of mental disorders, albeit not always statistically significant. The fact that depression, but not anxiety, was statistically significant could indicate a pathway by which inequality influences health.

An updated global picture of cigarette smoking persistence among adults.

BACKGROUND: Cross-national variance in smoking prevalence is relatively well documented. The aim of this study is to estimate levels of smoking persistence across 21 countries with a hypothesized inverse relationship between country income level and smoking persistence. METHODS: Data from the World Health Organization World Mental Health Survey Initiative were used to estimate cross-national differences in smoking persistence--the proportion of adults who started to smoke and persisted in smoking by the date of the survey. RESULTS: There is large variation in smoking persistence from 25% (Nigeria) to 85% (China), with a random-effects meta-analytic summary estimate of 55% with considerable cross-national variation. (Cochran's heterogeneity Q statistic = 6845; p < 0.001). Meta-regressions indicated that observed differences are not attributable to differences in country's income level, age distribution of smokers, or how recent the onset of smoking began within each country. CONCLUSION: While smoking should remain an important public health issue in any country where smokers are present, this report identifies several countries with higher levels of smoking persistence (namely, China and India).

Cross-national epidemiology of DSM-IV major depressive episode.

BACKGROUND: Major depression is one of the leading causes of disability worldwide, yet epidemiologic data are not available for many countries, particularly low- to middle-income countries. In this paper, we present data on the prevalence, impairment and demographic correlates of depression from 18 high and low- to middle-income countries in the World Mental Health Survey Initiative. METHODS: Major depressive episodes (MDE) as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DMS-IV) were evaluated in face-to-face interviews using the World Health Organization Composite International Diagnostic Interview (CIDI). Data from 18 countries were analyzed in this report (n = 89,037). All countries surveyed representative, population-based samples of adults. RESULTS: The average lifetime and 12-month prevalence estimates of DSM-IV MDE were 14.6% and 5.5% in the ten high-income and 11.1% and 5.9% in the eight low- to middle-income countries. The average age of onset ascertained retrospectively was 25.7 in the high-income and 24.0 in low- to middle-income countries. Functional impairment was associated with recency of MDE. The female: male ratio was about 2:1. In high-income countries, younger age was associated with higher 12-month prevalence; by contrast, in several low- to middle-income countries, older age was associated with greater likelihood of MDE. The strongest demographic correlate in high-income countries was being separated from a partner, and in low- to middle-income countries, was being divorced or widowed. CONCLUSIONS: MDE is a significant public-health concern across all regions of the world and is strongly linked to social conditions. Future research is needed to investigate the combination of demographic risk factors that are most strongly associated with MDE in the specific countries included in the WMH.

Sociodemographic correlates of transitions from alcohol use to disorders and remission in the São Paulo megacity mental health survey, Brazil.

AIMS: To evaluate sociodemographic correlates associated with transitions from alcohol use to disorders and remission in a Brazilian population. METHODS: Data are from a probabilistic, multi-stage clustered sample of adult household residents in the São Paulo Metropolitan Area. Alcohol use, regular use (at least 12 drinks/year), DSM-IV abuse and dependence and remission from alcohol use disorders (AUDs) were assessed with the World Mental Health version of the Composite International Diagnostic Interview. Age of onset (AOO) distributions of the cumulative lifetime probability of each alcohol use stage were prepared with data obtained from 5037 subjects. Correlates of transitions were obtained from a subsample of 2942 respondents, whose time-dependent sociodemographic data were available. RESULTS: Lifetime prevalences were 85.8% for alcohol use, 56.2% for regular use, 10.6% for abuse and 3.6% for dependence; 73.4 and 58.8% of respondents with lifetime abuse and dependence, respectively, had remitted. The number of sociodemographic correlates decreased from alcohol use to disorders. All transitions across alcohol use stages up to abuse were consistently associated with male gender, younger cohorts and lower education. Importantly, low education was a correlate for developing AUD and not remitting from dependence. Early AOO of first alcohol use was associated with the transition of regular use to abuse. CONCLUSION: The present study demonstrates that specific correlates differently contribute throughout alcohol use trajectory in a Brazilian population. It also reinforces the need of preventive programs focused on early initiation of alcohol use and high-risk individuals, in order to minimize the progression to dependence and improve remission from AUD.