Depression and anxiety in a community sample with epilepsy in Brazil / Depressão e ansiedade na epilepsia: uma amostra da comunidade no Brasil

OBJECTIVE: To estimate the frequency of depression/anxiety and to establish the social, epilepsy and psychiatric characteristics in individuals with epilepsy. METHOD: A cross-sectional study was employed to evaluate 153 subjects with epilepsy who were identified in a previous community-based survey. First, a structured interview was conducted, followed by a psychiatric evaluation. Subjects with depression were compared to those without, and subjects with anxiety were compared to those without. RESULTS: The prevalence of anxiety and depression was 39.4 and 24.4 percent, respectively. Both were associated with low schooling (OR 3.8, 95 percent CI 1.6 to 9.0 and OR 2.8, 95 percent CI 1.2 to 6.5 for depression and anxiety, respectively), lifetime suicidal thoughts (OR 4.4, 95 percent CI 1.9 to 10.3 and OR 3.6, 95 percent CI 1.7 to 7.7) and lifetime suicide attempts (OR 9.3, 95 percent CI 2.6 to 32.8 and OR 6.9, 95 percent CI 1.8 to 26.4). CONCLUSION: The high rates of depression and anxiety reinforced the need for recognition and treatment of mental disorders in epilepsy.

OBJETIVO: Estimar a frequência de depressão/ansiedade em pessoas com epilepsia e estabelecer as características sociais, da epilepsia e psiquiátricas associadas. MÉTODO: Foi feito um estudo transversal para avaliar 153 sujeitos com epilepsia identificados em um levantamento prévio feito na comunidade. Primeiramente foi realizada uma entrevista estruturada, seguida de uma avaliação psiquiátrica. Os sujeitos deprimidos foram comparados com aqueles sem depressão e os sujeitos com ansiedade foram comparados com aqueles sem ela. RESULTADOS: A prevalência de ansiedade e depressão foi de 39,4 por cento e 24,4 por cento, respectivamente. Ambas foram associadas a baixa escolaridade (OR 3,8; IC95 por cento 1,6-9,0 e OR 2,8, IC95 por cento 1,2- 6,5 para depressão e ansiedade, respectivamente), ideação suicida (OR 4,4; IC95 por cento 1,9-10,3 e OR 3,6; IC95 por cento 1,7-7,7) e tentativa de suicídio (OR 9,3; IC95 por cento 2,6-32,8 e OR 6,9; IC95 por cento 1,8-26,4). CONCLUSÃO: As altas taxas de depressão e ansiedade reforçam a necessidade de reconhecimento e tratamento dos transtornos mentais na epilepsia.

The quality of life of HIV-infected women is associated with psychiatric morbidity.

This study evaluated the effect of clinical, demographic and psychiatric factors on the health-related quality of life of 76 women with HIV infection seen in two HIV reference centres in Brazil. The generic questionnaire for evaluation of Health-Related Quality of Life (SF-36), the Hospital Anxiety and Depression Scale (HAD) and the Clinical Interview Schedule (CIS-R) were used. The statistical tests included the covariance analysis. The patients' mean age was 37.4 years; 44.7% had less than 8 years of schooling. A total of 44.8% were asymptomatic, 28.9% symptomatic non-AIDS and 26.3% had AIDS. Most (77.6%) used two or three kinds of antiretrovirals; 36.8 and 30.3% achieved scores for anxiety and depression, respectively (HAD); and 48.7% for conspicuous psychiatric morbidity (CIS-R). The sub-group of the non-AIDS symptoms (clinical stage B) showed the worst quality of life. The variables which better explained the scoring variation on both the mental and physical components of the SF-36 were related to mental health. The more mental symptoms present, the worse the health-related quality of life. We must rethink care strategies in the area of mental health which are directed toward HIV+ patients, by virtue of the levels of mental symptoms found and the request for care which the research revealed.

Restructuring mental health: a South American survey.

BACKGROUND: There is little information available on the changes in mental health services in South American countries following the social and political upheavals of recent decades. METHODS: A postal survey was conducted of all South American countries (health ministries, national psychiatric associations and key informants) to assess the development of mental health programs and the organization of alternative psychiatric care centers such as the psychiatric units in general hospitals (PUGH). RESULTS: Most of the mental health programs were implemented during the 1980s and 1990s, and aimed at incorporating psychiatric care into primary health care, as well as relocating provision from large hospitals to decentralized services. Most of the countries surveyed have less than 0.5 psychiatric beds per 1000 inhabitants. This change reflects a tendency to reduce the total number of psychiatric beds and increase the number of PUGH. Over the last 10 years this increase was significant in some countries (50-75%), but was not reflected in the availability of adequate human and material resources. CONCLUSIONS: A transition from a system based on large mental hospitals to alternative service provision is on the way in South American countries. Intensive efforts have to be made to collect and disseminate information, as well as to monitor the development and outcome of the mental health programs in these countries.

[Psychiatric care policies and deinstitutionalization in South America]. / Las políticas de asistencia psiquiátrica y desinstitucionalización en América del Sur.

INTRODUCTION: The process of restructuring psychiatric care in South America began in the 80's and increased in the 90's. This process had its landmark in the Declaration of Caracas (1990), which reinforced the need for alternative services to the mental hospital. OBJECTIVES: to analyse the current situation of the psychiatric care in South America, with special emphasis on Psychiatric Units in General Hospitals (PUGHs). METHODS: Two mail surveys were carried out. Questionnaires were sent to all Ministries of Health, Psychiatric Societies and key informants. RESULTS: All countries were represented in the returned questionnaires. In 7 countries there is a mental health plan. Material and human resources are inadequate in most countries. There has been a decrease in the total number of psychiatric beds over the last tem years. PUGHs were created in all the countries surveyed. CONCLUSIONS: All South America countries have a mental health program. A higher percentage of the programs is devoid of an evaluation system and almost all the countries lack budget estimates for mental health care. It was observed that the total number of psychiatric beds has been decreasing in most countries, and that the PUGHs and other decentralized centers were adopted as an alternative to the mental hospital.

Physician-patient communication in the prevention of female reproductive tract infections: some limitations.

The objective of this study was to describe the information that women with tubal infertility recalled having received from physicians when they consulted for a reproductive tract infection (RTI) and the information physicians reported having provided to women consulting for RTIs. Interviews were conducted with 16 women presenting primary tubal infertility selected on the basis of purposeful sampling criteria. Also, 15 physicians working in the public health network in the city of Campinas, Brazil, were selected at random and interviewed. Analysis of the women's statements concerning previous RTI-related medical consultations showed that they did not recall having received any information on either prevention or the impact of RTI on their reproductive future. Analysis of interviews with physicians showed that the information they provided to women consulting for RTIs was incomplete and unclear. The information women recalled having received and that which physicians remembered having provided at the time of treating a patient with RTI was similar. In conclusion, these women lacked adequate or complete information and that it was probably not possible for them to adopt measures to avoid repetition of RTI and minimize risk of tubal infertility.

Las políticas de asistencia psiquiátrica y desinstitucionalización en América del Sur* / Psychiatric care policies and deinstitutionalization in South America

Introducción: La reestructura de la asistencia psiquiátrica en América del Sur comenzó en la década del ochenta, acentuándose en la del noventa. Los organismos internacionales, Organización Mundial de la Salud y Organización Panamericana de la Salud, tuvieron un papel importante. Los cambios se oficializaron en la Declaración de Caracas, Venezuela (1990), priorizando la descentralización del hospital psiquiátrico, y la creación de estructuras alternativas, entre ellas las Unidades Psiquiátricas en Hospitales Generales (UPHGs).Objetivos: Obtener información sobre la situación de la asistencia psiquiátrica y los modelos institucionales en el continente, con especial énfasis en la organización de las UPHGs. Metodología: Fueron utilizados dos cuestionarios postales, enviados a tres fuentes de información: Ministerios de Salud, Sociedades de Psiquiatría e Informantes clave. Resultados: Se obtuvo buen índice de respuestas. Se constató que siete países tienen los programas documentados oficialmente y que el sector médico participó en su elaboración. Los recursos materiales son insuficientes; en ocho países los recursos humanos, también, son insuficiente. En los últimos 10 años siete países disminuyeron el número de camas psiquiátricas en hospitales psiquiátricos, creándose UPHGs en la totalidad de los países. Conclusiones: Todos los países sudamericanos tienen programas de salud mental, algunos de ellos no son evaluados y tampoco tienen un presupuesto propio. Se presentó una tendencia a disminuir el número de camas psiquiátricas de los asilos, aumentando el número de camas en las UPHGs. (AU)

Quality of life after partial penectomy for penile carcinoma.

OBJECTIVES: To investigate the impact of partial penectomy on the quality of life of patients with carcinoma of the penis. METHODS: Fourteen patients who had undergone partial penectomy for penile cancer were studied. Their median age was 50.5 years and the median time of follow-up was 11.5 months. The quality of life was evaluated in three dimensions: social adjustment, sexuality, and emotional state. The patients underwent a semistructured interview and were asked to complete the Overall Sexual Functioning Questionnaire, the Social Problem Questionnaire, the General Health Questionnaire, and the Hospital Anxiety and Depression Scale. RESULTS: In 9 (64%) patients, the overall sexual function was normal or slightly decreased. Only 2 (14%) men had precarious or absent sexual function. The masculine self-image and the relationship with their partners remained practically unchanged in all the patients. Sexual interest and satisfaction remained normal or slightly reduced in 9 and 12 patients, respectively. The frequency of sexual intercourse was unchanged or slightly decreased in 9 patients. Three patients had no sexual intercourse after surgery. No significant levels of anxiety and depression were found. Within the areas of living conditions, family life, and interactions with other people, all the patients remained as they were before the surgery. CONCLUSIONS: Patients who undergo partial penectomy for penile cancer can maintain the quality of life (in social, psychological, and sexual terms) at levels similar to those that existed in the period before surgery.

[Referral to the psychiatrist in the general hospital: a psychodynamic approach]. / Derivaciones al psiquiatra en el hospital general: una visión psicodinámica.

INTRODUCTION: It is not clear as to the process by which the psychiatrist attracts referrals and the reasons and motivations that doctors have for referring or not. This study describes the modus operandi of referrals to the psychiatrist in the context of a university general hospital. METHOD: A semi-structured interview was carried out on 50 doctors (35 male, 15 female) from the teaching hospital of the Universidade Estadual de Campinas, Brazil. Data was analyzed qualitatively, by means of content analysis, according to the psychodynamic approach. RESULTS: Some referrals need to be worked through in order for the doctor to overcome his resistance. Others are automatic: because something moved him deeply, the doctor directs his anguish and responsibility outside himself, without realizing the motives that lead him to do so. CONCLUSION: Referral is used in a variety of ways and different things are expected of the psychiatrist, all influenced by unconscious aspects of the patient-doctor-specialist triad.

Attitudes of medical students to necropsy.

AIM: To compare the attitudes of students towards the necropsy at different stages of their undergraduate career. METHOD: Students in the first, fourth and sixth academic years (n = 283) were asked to respond anonymously to a questionnaire comprised of 26 attitude statements. These statements dealt with the importance of the necropsy in medicine, rapport with the bereaved family and emotional reactions to the necropsy. RESULTS: Of the students, 226 (80%) completed the questionnaire. Overall, the students agreed on/the importance of the necropsy. The three groups differed in 10 statements on the approach to the bereaved family and emotional reactions to the necropsy. First year students showed more personal involvement and would have more difficulties in approaching the family of the deceased as well as in attending a necropsy. These reactions were increasingly less noticeable with fourth and sixth year students. The latter group was also more inclined to accept cremation, organ donation and necropsy of their own corpses. CONCLUSION: The changes in attitudes towards the necropsy throughout undergraduate study may reflect both the influence of psychological defense mechanisms and the viewing of necropsy as a relevant tool in medical practice. Necropsy should be carefully and sensitively incorporated into programmes designed to teach students about death and dying. This might reduce both their reluctance to seek permission for necropsy and their difficulty in looking after the dying patient.

General practitioners attitudes towards depression: a study in primary care setting in Brazil.

A self-report instrument comprising twenty visual analogue scale statements about attitudes towards depression was sent to all 110 general practitioners working in primary health care centres in the city of Campinas, Brazil. The statements of the Depression Attitude Questionnaire (DAQ) cover three main areas: nature of depression, treatment preferences and professional reactions regarding depressed patients. Seventy-eight (71%) doctors returned the questionnaire. Forty-two percent of the doctors believe "it is difficult to differentiate whether patients are presenting with unhappiness or a clinical depressive disorder that needs treatment". Sixty-three percent believe that "antidepressants usually produce a satisfactory result in the treatment of depressed patients in general practice". However, most doctors would refer patients in need of anti-depressants (66%) or psychotherapy (60%) to a specialist. They also view the treatment of depression as "heavy going" (46%) and "unrewarding" (57%). These findings suggest a need for further education of general practitioners on the nature, diagnosis and management of depressive disorders.

[Mood disorders among inpatients in ambulatory and validation of the anxiety and depression scale HAD]. / Transtornos do humor em enfermaria de clínica médica e validação de escala de medida (HAD) de ansiedade e depressão.

The revised Clinical Interview Schedule (CIS-R) and the Hospital Anxiety and Depression (HAD) Scale were used to estimate the prevalence of mood disorders among 78 consecutive admissions to a general medical ward in a university general hospital in Brazil (43 males and 35 females; mean age = 43.2yr). Interviewers also completed a 5-point symptom severity scales for anxiety and depression. The definition of cases of anxiety [and depression] was based on two criteria: a. score > or = 2 on the CIS-R section of anxiety [> or = 4 on the CIS-R sections of depression and depressive ideas]; and b. score > or = 2 on the clinical severity scale for anxiety [score > or = 2 on the clinical severity scale for depression]. A 39% prevalence rate of affective disorders was found. Sixteen (20.5%) patients met criteria for anxiety, most of the disorders being of mild severity. Twenty-sic patients (33%) were depressed, 7 of them in a moderate degree. The HAD was easily understood by the patients. Anxiety and depression subscales had internal consistency of 0.68 and 0.77, respectively. At a cut-off point of 8/9 sensibility and specificity were 93.7% and 72.6% for anxiety, and 84.6% and 90.3% for depression. HAD items correlated positively with the respective subscales. To a lesser degree, they also correlated with the alternative subscale. Our findings confirm the high prevalence of mood disorders among medical in-patients. In clinical practice, the HAD may have a useful role in detecting those patients requiring further psychological care.

Psychiatric morbidity among medical in-patients: a standardized assessment (GHQ-12 and CIS-R) using 'lay' interviewers in a Brazilian hospital.

The 12-item General Health Questionnaire (GHQ-12) and the revised Clinical Interview Schedule (CIS-R) were used to estimate the prevalence of psychiatric morbidity among 78 consecutive admissions to a general medical ward in a Brazilian university hospital (43 males and 35 females; mean age = 43.2 years). The CIS-R was administered by three 5th-year medical students after a brief training. A prevalence rate of 36% was found for psychiatric disorders. The most frequent symptoms were sleep disorders (48.7%), worry (35.9%), depression (28.2%) and anxiety (26.9%). The sensitivity and specificity of the GHQ-12 were 71% and 76%, respectively. The CIS-R was simple to administer and acceptable both to patients and interviewers. Misunderstanding was most likely to occur with the poorly educated (20% were illiterate) in questions involving time calculation. Alternative options might be used to specify the length of time in future studies. The findings support the feasibility of the CIS-R and the use of 'lay' interviewers to produce epidemiological information on psychiatric disorders in developing countries at lower costs.

Consultation-liaison psychiatry in Brazil. Psychiatric residency training.

A mailing survey assessed consultation-liaison (C-L) service delivery and training among all 23 approved psychiatric residency training programs throughout the country. Twenty questionnaires were returned. Outpatient, inpatient, emergency, and consultation services were present together in 35% of the academic hospitals where residency training took place. Consultation service was provided by 18 (90%) responding programs. Eleven of those reported C-L training as part of their general psychiatry rotation. Nevertheless, educational objectives, weekly case conferences, and didactic seminars were provided by only five of them. The training time varied from 40 to 560 hours, 190 hours on average. The same five programs offered an elective third-year residency training, including liaison with specific units. The results illustrate the migration of academic psychiatric departments from the psychiatric hospital to the general hospital as well as the beginning of C-L training programs in Brazil.

Ambulatório de psiquiatria em hospital geral: alguns dados de HC/Unicamp

A partir de um estudo retrospectivo de 507 pacientes adultos atendidos no Serviço de Triagem do Hospital das Clínicas da Unicamp, coletaram-se dados demográficos e de avaliaçäo e evoluçäo psiquiátricas. A maioria dos atendimentos (70%) foi para pacientes com menos de quarenta anos, de sexo feminino (60,7%), com baixa renda familiar, residentes em Campinas (48,7%) e cidades da regiäo. Foram selecionados para "casos novos" preferencialmente pacientes psicóticos, apesar do predomínio de distúrbios psiquiátricos menores (71,4%), notadamente neuróticos, altamente prevalentes na prática médica geral. Por falta de programas específicos, muitos desses pacientes näo foram, aceitos pelo nosso serviço, como também os casos de alcoolismo e dependência de drogas. Houve altas taxas de näo-comparecimento a primeira consulta (26,4%) e de abandono de tratamento (33,2%). Discute-se a inserçäo compromissada do hospital universitário na rede básica de saúde, bem como a necessidade de um diagnóstico das dificuldades e a baixa resolutividade da assistência psiquiátrica por ele prestada

Ambulatorio de Psiquiatria em hospital geral: alguns dados do HC/UNICAMP

A partir de um estudo retrospectivo de 507 pacientes adultos atendidos no Servico de Triagem do Hospital das Clinicas da Unicamp, coletaram-se dados demograficos e de avaliacao e evolucao psiquiatricas. A maioria dos atendimentos (70 por cento) foi para pacientes com menos de quarenta anos, de sexo feminino (60,7 por cento), com baixa renda familiar, residentes em Campinas (48,7 por cento) e cidades da regiao. Foram selecionados para 'casos novos' preferencialmente pacientes psicoticos, apesar do predominio de disturbios psiquiatricos menores (71,4 por cento), notadamente neuroticos, altamente prevalentes na pratica medica geral. Por falta de programas especificos, muitos desses pacientes nao foram aceitos pelo nosso servico, como tambem os casos de alcoolismo e dependencia de drogas. Houve altas taxas de nao-comparecimento a primeira consulta (26,4 por cento) e de abandono de tratamento (33,2 por cento). Discute-se a insercao compromissada do hospital universitario na rede basica de saude, bem como a necessidade de um diagnostico das dificuldades e a baixa resolutividade da assistencia psiquiatrica por ele prestada.