Bayesian Networks for Prescreening in Depression: Algorithm Development and Validation.

BACKGROUND: Identifying individuals with depressive symptomatology (DS) promptly and effectively is of paramount importance for providing timely treatment. Machine learning models have shown promise in this area; however, studies often fall short in demonstrating the practical benefits of using these models and fail to provide tangible real-world applications. OBJECTIVE: This study aims to establish a novel methodology for identifying individuals likely to exhibit DS, identify the most influential features in a more explainable way via probabilistic measures, and propose tools that can be used in real-world applications. METHODS: The study used 3 data sets: PROACTIVE, the Brazilian National Health Survey (Pesquisa Nacional de Saúde [PNS]) 2013, and PNS 2019, comprising sociodemographic and health-related features. A Bayesian network was used for feature selection. Selected features were then used to train machine learning models to predict DS, operationalized as a score of ≥10 on the 9-item Patient Health Questionnaire. The study also analyzed the impact of varying sensitivity rates on the reduction of screening interviews compared to a random approach. RESULTS: The methodology allows the users to make an informed trade-off among sensitivity, specificity, and a reduction in the number of interviews. At the thresholds of 0.444, 0.412, and 0.472, determined by maximizing the Youden index, the models achieved sensitivities of 0.717, 0.741, and 0.718, and specificities of 0.644, 0.737, and 0.766 for PROACTIVE, PNS 2013, and PNS 2019, respectively. The area under the receiver operating characteristic curve was 0.736, 0.801, and 0.809 for these 3 data sets, respectively. For the PROACTIVE data set, the most influential features identified were postural balance, shortness of breath, and how old people feel they are. In the PNS 2013 data set, the features were the ability to do usual activities, chest pain, sleep problems, and chronic back problems. The PNS 2019 data set shared 3 of the most influential features with the PNS 2013 data set. However, the difference was the replacement of chronic back problems with verbal abuse. It is important to note that the features contained in the PNS data sets differ from those found in the PROACTIVE data set. An empirical analysis demonstrated that using the proposed model led to a potential reduction in screening interviews of up to 52% while maintaining a sensitivity of 0.80. CONCLUSIONS: This study developed a novel methodology for identifying individuals with DS, demonstrating the utility of using Bayesian networks to identify the most significant features. Moreover, this approach has the potential to substantially reduce the number of screening interviews while maintaining high sensitivity, thereby facilitating improved early identification and intervention strategies for individuals experiencing DS.

Self-help mobile messaging intervention for depression among older adults in resource-limited settings: a randomized controlled trial.

Scalable solutions to treat depression in older adults in low-resourced settings are urgently needed. The PRODIGITAL-D pragmatic, single-blind, two-arm, individually randomized controlled trial assessed the effectiveness of a mobile messaging psychosocial intervention in improving depressive symptomatology among older adults in socioeconomically deprived areas of Guarulhos, Brazil. Older adults (aged 60+ years) registered with 24 primary care clinics and identified with depressive symptomatology (9-item Patient Health Questionnaire (PHQ-9) scores ≥ 10) received the 6-week Viva Vida intervention based on psychoeducation and behavioral activation (n = 298) or a single message (n = 305). No health professional support was offered. The primary outcome was improvement from depressive symptomatology (PHQ-9 < 10) at 3 months. Of the 603 participants enrolled (mean age = 65.1 years; 451 (74.8%) women), 527 (87.4%) completed the follow-up assessment. In the intervention arm, 109 of 257 (42.4%) participants had an improved depressive symptomatology, compared with 87 of 270 (32.2%) participants in the control arm (adjusted odds ratio = 1.57; 95% confidence interval = 1.07-2.29; P = 0.019). No severe adverse events related to trial participation were observed. These results demonstrate the usefulness of a digital messaging psychosocial intervention in the short-term improvement from depressive symptomatology that can potentially be integrated into primary care programs for treating older adults with depression. Brazilian Registry of Clinical Trials registration: ReBEC ( RBR-4c94dtn ).

Patient Health Questionnaire-9 Item Pairing Predictiveness for Prescreening Depressive Symptomatology: Machine Learning Analysis.

BACKGROUND: Anhedonia and depressed mood are considered the cardinal symptoms of major depressive disorder. These are the first 2 items of the Patient Health Questionnaire (PHQ)-9 and comprise the ultrabrief PHQ-2 used for prescreening depressive symptomatology. The prescreening performance of alternative PHQ-9 item pairings is rarely compared with that of the PHQ-2. OBJECTIVE: This study aims to use machine learning (ML) with the PHQ-9 items to identify and validate the most predictive 2-item depressive symptomatology ultrabrief questionnaire and to test the generalizability of the best pairings found on the primary data set, with 6 external data sets from different populations to validate their use as prescreening instruments. METHODS: All 36 possible PHQ-9 item pairings (each yielding scores of 0-6) were investigated using ML-based methods with logistic regression models. Their performances were evaluated based on the classification of depressive symptomatology, defined as PHQ-9 scores ≥10. This gave each pairing an equal opportunity and avoided any bias in item pairing selection. RESULTS: The ML-based PHQ-9 items 2 and 4 (phq2&4), the depressed mood and low-energy item pairing, and PHQ-9 items 2 and 8 (phq2&8), the depressed mood and psychomotor retardation or agitation item pairing, were found to be the best on the primary data set training split. They generalized well on the primary data set test split with area under the curves (AUCs) of 0.954 and 0.946, respectively, compared with an AUC of 0.942 for the PHQ-2. The phq2&4 had a higher AUC than the PHQ-2 on all 6 external data sets, and the phq2&8 had a higher AUC than the PHQ-2 on 3 data sets. The phq2&4 had the highest Youden index (an unweighted average of sensitivity and specificity) on 2 external data sets, and the phq2&8 had the highest Youden index on another 2. The PHQ-2≥2 cutoff also had the highest Youden index on 2 external data sets, joint highest with the phq2&4 on 1, but its performance fluctuated the most. The PHQ-2≥3 cutoff had the highest Youden index on 1 external data set. The sensitivity and specificity achieved by the phq2&4 and phq2&8 were more evenly balanced than the PHQ-2≥2 and ≥3 cutoffs. CONCLUSIONS: The PHQ-2 did not prove to be a more effective prescreening instrument when compared with other PHQ-9 item pairings. Evaluating all item pairings showed that, compared with alternative partner items, the anhedonia item underperformed alongside the depressed mood item. This suggests that the inclusion of anhedonia as a core symptom of depression and its presence in ultrabrief questionnaires may be incompatible with the empirical evidence. The use of the PHQ-2 to prescreen for depressive symptomatology could result in a greater number of misclassifications than alternative item pairings.

Use of WhatsApp by older adults screened for depression in socioeconomically deprived areas of Guarulhos, São Paulo State, Brazil: challenges and possibilities for telehealth.

This study aimed to investigate the relationship between sociodemographic characteristics, depressive symptomatology, mobile phone ownership, and different uses of WhatsApp among older adults enrolled in primary care clinics in Guarulhos, São Paulo State, Brazil. This is a secondary data analysis, using data collected in the screening of participants to be included in the PROACTIVE cluster randomized trial. Individuals aged ≥ 60 years, registered in primary care clinics in Guarulhos, were assessed for sociodemographic characteristics, depressive symptoms according to the PHQ-9, mobile phone ownership, and use of WhatsApp. We performed multiple logistic regression models to investigate characteristics of the potential users of digital interventions. Of 3,356 older adults screened for depression, 45.7% said they use WhatsApp to receive/send messages. In the subsample that presented depressive symptomatology (n = 1,020), 41.9% stated using WhatsApp. Younger older adults and those with better socioeconomic status used more WhatsApp and were more likely to own a mobile phone. Participants with higher levels of symptoms of depression were less likely to use WhatsApp. Gender, age, schooling level, income, and depressive symptomatology are variables associated with the possession of a cell phone and with the use of WhatsApp by the older adults of the sample. These findings can help to implement digital health programs better suited to disadvantaged populations in Brazil and other low- and middle-income countries through mental telehealth interventions using WhatsApp and mobile health services to the older people.

Digital psychosocial intervention for depression among older adults in socioeconomically deprived areas in Brazil (PRODIGITAL-D): protocol for an individually randomised controlled trial.

BACKGROUND: Depression in older adults is a challenge for health systems in most low- and middle-income countries (LMICs). Digital strategies for the management of this condition have been emerging worldwide, but the effectiveness of most of them is still unclear, especially among older adults. Thus, we aim to assess the effectiveness and cost-effectiveness of a digital psychosocial intervention to treat depression among older adults living in socioeconomically deprived areas in Guarulhos, Brazil. METHODS: We will conduct a two-arm individually randomised controlled trial with 1:1 allocation ratio. Five hundred older adults aged 60 years or over with depressive symptomatology (9-item Patient Health Questionnaire score, PHQ-9 ≥ 10) and registered with one of the primary care clinics will be recruited to participate in this study. A 6-week digital psychosocial programme, named Viva Vida, will be delivered via WhatsApp to participants allocated to the intervention arm. The Viva Vida will send psychoeducational and behavioural activation audio and visual messages 4 days a week for 6 weeks. The control arm will only receive a single message with general information about depression. The primary outcome will be the proportion of depression recovery (PHQ-9 < 10) assessed at 3 months. The cost-effectiveness of the intervention will be assessed at 5 months. A detailed process evaluation will be used to explore context and important implementation outcomes. DISCUSSION: This programme was based on the PROACTIVE intervention and designed to be delivered without face-to-face contact. If effective, it could be a simple treatment option, appropriate not only when social distancing is required, but it could also be included as a regular public health programme to initiate depression treatment, particularly in LMICs where resources allocated to mental health are scarce. TRIAL REGISTRATION: Registro Brasileiro de Ensaios Clínicos (ReBEC), RBR-4c94dtn. Registered on 22 October 2021 (submitted on 03 August 2021).

Depressive and subthreshold depressive symptomatology among older adults in a socioeconomically deprived area in Brazil.

Depressive and subthreshold depressive symptomatology are common but often neglected in older adults. OBJECTIVE: This study aimed to assess rates of depressive and subthreshold depressive symptomatology, and the characteristics associated, among older adults living in a socioeconomically deprived area of Brazil. METHODS: This study is part of the PROACTIVE cluster randomised controlled trial. 3356 adults aged 60+ years and registered in 20 primary health clinics were screened for depressive symptomatology with the Patient Health Questionnaire-9 (PHQ-9). Depressive status was classified according to the total PHQ-9 score and the presence of core depressive symptoms (depressed mood and anhedonia) as follows: no depressive symptomatology (PHQ-9 score 0-4, or 5-9 but with no core depressive symptom); subthreshold depressive symptomatology (PHQ-9 score 5-9 and at least one core depressive symptom); and depressive symptomatology (PHQ-9 score ≥ 10). Sociodemographic information and self-reported chronic conditions were collected. Relative risk ratios and 95% CIs were obtained using a multinomial regression model. RESULTS: Depressive and subthreshold depressive symptomatology were present in 30% and 14% of the screened sample. Depressive symptomatology was associated with female gender, low socioeconomic conditions and presence of chronic conditions, whereas subthreshold depressive symptomatology was only associated with female gender and having hypertension. CONCLUSIONS: Depressive and subthreshold depressive symptomatology is highly prevalent in this population registered with primary care clinics. Strategies managed by primary care non-mental health specialists can be a first step for improving this alarming and neglected situation among older adults.

Use of WhatsApp by older adults screened for depression in socioeconomically deprived areas of Guarulhos, São Paulo State, Brazil: challenges and possibilities for telehealth / Uso do WhatsApp por idosos depressivos em áreas socioeconomicamente carentes de Guarulhos, São Paulo, Brasil: desafios e possibilidades para a telessaúde / Uso de WhatsApp por ancianos deprimidos en áreas desfavorecidas socioeconómicamente en Guarulhos, São Paulo, Brasil: retos y posibilidades de la telesalud

This study aimed to investigate the relationship between sociodemographic characteristics, depressive symptomatology, mobile phone ownership, and different uses of WhatsApp among older adults enrolled in primary care clinics in Guarulhos, São Paulo State, Brazil. This is a secondary data analysis, using data collected in the screening of participants to be included in the PROACTIVE cluster randomized trial. Individuals aged ≥ 60 years, registered in primary care clinics in Guarulhos, were assessed for sociodemographic characteristics, depressive symptoms according to the PHQ-9, mobile phone ownership, and use of WhatsApp. We performed multiple logistic regression models to investigate characteristics of the potential users of digital interventions. Of 3,356 older adults screened for depression, 45.7% said they use WhatsApp to receive/send messages. In the subsample that presented depressive symptomatology (n = 1,020), 41.9% stated using WhatsApp. Younger older adults and those with better socioeconomic status used more WhatsApp and were more likely to own a mobile phone. Participants with higher levels of symptoms of depression were less likely to use WhatsApp. Gender, age, schooling level, income, and depressive symptomatology are variables associated with the possession of a cell phone and with the use of WhatsApp by the older adults of the sample. These findings can help to implement digital health programs better suited to disadvantaged populations in Brazil and other low- and middle-income countries through mental telehealth interventions using WhatsApp and mobile health services to the older people.

Este estudo teve como objetivo investigar a relação entre características sociodemográficas, sintomatologia depressiva, posse de telefone celular e diferentes usos do WhatsApp entre idosos cadastrados em unidades básicas de saúde de Guarulhos, São Paulo, Brasil. Trata-se de uma análise de dados secundários com informações coletadas na triagem dos participantes a serem incluídos neste estudo randomizado em cluster PROATIVO. Indivíduos com 60 anos ou mais, cadastrados em unidades básicas de saúde de Guarulhos, foram avaliados quanto a características sociodemográficas, sintomas depressivos, de acordo com o PHQ-9, posse de telefone celular e uso do WhatsApp. Foram utilizados modelos de regressão logística múltipla para investigar as características dos potenciais usuários de intervenções digitais. Dos 3.356 idosos depressivos, 45,7% usavam o WhatsApp para receber/enviar mensagens. Na subamostra que apresentou sintomatologia depressiva (n = 1.020), 41,9% disseram usar o WhatsApp. Adultos mais jovens e com melhor status socioeconômico usavam mais o WhatsApp e eram mais propensos a possuir um telefone celular. Participantes com níveis mais altos de sintomas de depressão eram menos propensos a utilizar o WhatsApp. Sexo, idade, escolaridade, renda e sintomatologia depressiva são variáveis associadas à posse de telefone celular e ao uso do WhatsApp pelos idosos da população estudada. Esses achados podem ajudar a implementar programas de saúde digital mais adequados para populações desfavorecidas no Brasil e em outros países de baixa e média renda, principalmente intervenções de telessaúde mental que utilizem o WhatsApp e serviços móveis de saúde para idosos.

Este estudio tuvo como objetivo determinar la relación entre las características sociodemográficas, los síntomas depresivos, la tenencia de teléfono celular y los diferentes usos de WhatsApp entre los ancianos inscritos en unidades básicas de salud en Guarulhos, São Paulo, Brasil. Este es un análisis de datos secundarios, que recopiló la información del triaje de los participantes a ser incluidos en este estudio aleatorio en un clúster PROACTIVO. Se evaluaron las características sociodemográficas, los síntomas depresivos según el PHQ-9, la tenencia de celular y el uso de WhatsApp de los participantes de 60 años o más, registrados en unidades básicas de salud de Guarulhos. Se utilizaron los modelos de regresión logística múltiple para identificar las características de los potenciales usuarios de las intervenciones digitales. De los 3.356 ancianos deprimidos, el 45,7% utilizaba WhatsApp para recibir/enviar mensajes. En la submuestra que presentó síntomas depresivos (n = 1.020), el 41,9% dijo usar WhatsApp. Los adultos más jóvenes con mejor nivel socioeconómico usaban más WhatsApp y tenían más probabilidades de tener un teléfono celular. Los participantes con niveles más altos de síntomas de depresión tenían menos probabilidades de usar WhatsApp. El sexo, la edad, la educación, la renta y los síntomas depresivos fueron las variables asociadas a la tenencia de celular y al uso de WhatsApp por parte de los ancianos de la población estudiada. Estos hallazgos pueden ayudar a implementar programas de salud digital que sean más adecuados para las poblaciones desfavorecidas en Brasil y en otros países de bajos y medianos ingresos, en particular las intervenciones de telesalud mental que utilizan WhatsApp y servicios de salud móviles para ancianos.

Acceptability and fidelity of a psychosocial intervention (PROACTIVE) for older adults with depression in a basic health unit in São Paulo, Brazil: a qualitative study.

BACKGROUND: Depression is a common condition in older adults, being often detected and treated initially in primary care. Collaborative care models including, for example, task-shifting and stepped-care approaches have been investigated to overcome the current scarcity of strategies and trained mental health professionals to treat depression. The PROACTIVE study developed a psychosocial intervention, which makes extensive use of technology in an intervention delivered mainly by non-specialists to treat older adults with depression. The aim of this qualitative study is to assess: 1. Health workers' fidelity to the intervention protocol; 2. Acceptability of the psychosocial intervention from the viewpoint of older adult participants; and 3. Perceptions of the psychosocial intervention by the health workers. METHODS: Qualitative methods were used to achieve our aims. The sample included participants (N = 31) receiving the intervention in the pilot trial and health workers (N = 11) working in a Basic Health Unit in the northern area of São Paulo, Brazil. Focus group, non-participant observation and structured interviews were used. Data were analysed using a thematic analysis approach. RESULTS: 1. Health workers' fidelity to the intervention protocol: training, supervision and the structured intervention were crucial and guaranteed health workers' fidelity to the protocol. 2. Acceptability of the psychosocial intervention from the viewpoint of older adult participants: Collaborative care, task-shifting, and stepped-care approaches were well accepted. The structured protocol of the intervention including different activities and videos was important to adherence of older adult participants 3. Perceptions of the psychosocial intervention by the health workers: It was feasible to have the home psychosocial sessions conducted by health workers, who are non-mental health specialists and received 3-day training. Training and supervision were perceived as crucial to support health workers before and during the intervention. Technology served as a tool to structure the sessions, obtain and store patient data, present multi-media content, guarantee fidelity to the protocol and facilitate communication among members of the team. However, extra burden was mentioned by the health workers indicating the need of adjustments in their daily duties. CONCLUSIONS: The PROACTIVE intervention was demonstrated to be feasible and accepted by both health workers and older adult participants. The qualitative assessments suggested improvements in training and supervision to ensure fidelity to protocol. To assess effectiveness a randomised controlled trial of the intervention will be conducted with the addition of improvements suggested by this qualitative study. TRIAL REGISTRATION: The pilot study of which the present study gives support to was registered at the Brazilian Clinical Trials, UTN code: U1111-1218-6717 on 26/09/2018.

Watching TV and Cognition: The SPAH 2-Year Cohort Study of Older Adults Living in Low-Income Communities.

Watching TV is a highly prevalent leisure activity among older adults and, in many cases, the only leisure option of those living in low-income communities. While engaging in leisure activities have proven to protect older adults from cognitive decline, the effects of watching TV on cognition of this population is controversial in the literature. This study investigated the impact of watching TV on global cognitive function, immediate memory, verbal fluency, risk of dementia of amnestic mild cognitive impairment (aMCI) in a cohort of older adults residents of socioeconomically deprived areas of São Paulo, Brazil. We used data from the São Paulo Aging & Health Study (SPAH). Participants aged 65 years or over, with no dementia diagnosis at baseline and who completed the 2-year follow-up assessment were included in this study (n = 1,243). Multivariable linear regression models were performed to assess the effect of watching TV on global cognitive function, immediate memory and verbal fluency. Multivariable logistic regression models were used to evaluate the risk of developing dementia and aMCI. Models were controlled by cognitive performance at baseline, sociodemographic characteristics and functional status. Cognitive performance at baseline and follow-up were similar. Thirty-one participants were diagnosed with dementia, and 23 with aMCI 24 months after inclusion in the study. Watching TV did not show any positive or negative effect on global cognitive function, immediate memory, verbal fluency, risk of dementia and risk of aMCI. It is good news that watching TV did not predict the decline in cognition in elders. However, it is essential to increase opportunities for other leisure activities for low-income and low-educated older adults if we do consider that leisure activities protect cognition decline in older adults. In the coming decades, developing countries will experience the highest burden of dementia and more than fun, public policies to promote leisure activities might be a strategy to alleviate this burden shortly.

A collaborative care psychosocial intervention to improve late life depression in socioeconomically deprived areas of Guarulhos, Brazil: the PROACTIVE cluster randomised controlled trial protocol.

BACKGROUND: The elderly population has been growing in most low- and middle-income countries (LMIC), and depression is a common condition among these populations. The lack of integration between mental health and primary healthcare services and the shortage of mental health specialists in the public health system contribute to underdiagnosis and undertreatment of depression. One of the strategies to reduce this gap is task shifting and collaborative care treatments. This study therefore aims to evaluate the effectiveness and cost-effectiveness of a collaborative care psychosocial intervention to improve the clinical management of depression among elderly people in poor neighbourhoods in Guarulhos, Brazil. METHODS: Two-arm, cluster randomised controlled trial with Basic Health Units as the clusters and a 1:1 allocation ratio. Twenty Basic Health Units have been randomly selected and randomised to control or intervention arms. We aim to recruit 1440 adults (72 per cluster) aged 60 years or over identified with depression (9-item Patient Health Questionnaire (PHQ-9) score ≥ 10). The control arm participants will receive an enhanced usual care, while the intervention arm participants will receive an enhanced usual care and a 17-week psychosocial intervention programme delivered at home by community health workers with the help of an application installed on tablet computers. The primary outcome is the proportion with depression recovery (PHQ-9 < 10) at 8 months' follow-up. We will also assess the maintenance of any earlier clinical gains and the cost-effectiveness of the intervention at 12 months. DISCUSSION: This is the first randomised trial to investigate a collaborative care intervention to treat depression among poor elderly in LMIC/Latin America. This is a major public health problem worldwide, but in these countries, there are no locally tested, evidence-based interventions available to date. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number ISRCTN57805470 . Registered on 25 April 2019.

[Construction of the work process of the Family Health Support Nucleus: the experience of pharmacists in a city in the south of Brazil]. / A construção do processo de trabalho no Núcleo de Apoio à Saúde da Família: a experiência dos farmacêuticos em um município do sul do Brasil.

The Family Health Support Nucleus (NASF) was created in 2008 with the objective of broadening the range and scope of primary healthcare. The insertion of pharmacists in this multi-professional context represents an opportunity to enhance the working process and the rational access and use of medicines. The working processes of pharmacists in a city NASF was investigated. Field research was conducted using a qualitative approach with participant observation and semi-structured interviews. Two analytic dialectic categories emerged. The first was the pharmacists' dilemma in the construction of their working process as promoters of primary healthcare, while at the same time facing the need to deal with managerial functions mostly to cater to operational demand. The second was the reality experienced with guidelines and coordination of their work, where pharmacists can be free to structure their work as supporters, although at the same time it limits them due to lack of acknowledgment of their previously established working process. The lack of planning and a clear objective for work in the NASF, besides the deficiency of pharmaceutical services in primary healthcare make the development of any type of pharmacist activity important and essential even if it does not fully attend the NASF proposal.

A construção do processo de trabalho no Núcleo de Apoio à Saúde da Família: a experiência dos farmacêuticos em um município do sul do Brasil / Construction of the work process of the Family Health Support Nucleus: the experience of pharmacists in a city in the south of Brazil

Resumo Em 2008 foi criado o Núcleo de Apoio à Saúde da Família (NASF) com o objetivo de ampliar a abrangência e o escopo da atenção básica. A inserção do farmacêutico neste contexto multiprofissional representa uma oportunidade no seu processo de trabalho e no acesso e no uso racional de medicamentos. Investigou-se o desenvolvimento do processo de trabalho dos farmacêuticos nos NASF de um município. Foi realizada uma pesquisa de campo qualitativa por observação participante e entrevistas semiestruturadas. Duas categorias analíticas dialéticas emergiram: o dilema do farmacêutico na construção do processo de trabalho, como apoiador da atenção básica, mas que também lhe aprisiona em funções técnico-gerenciais atendendo as demandas operacionais; e outra representando a realidade vivenciada na sua relação com as diretrizes e a coordenação do trabalho, tendo ao mesmo tempo “liberdade” para estruturar as tarefas como apoiador, mas que impõe limitações pelo pouco reconhecimento do processo laboral construído. Conclui-se que a falta de planejamento e de objetivo claro para os NASF e a deficiência de serviços farmacêuticos na atenção básica tornam o desenvolvimento de qualquer atividade por este profissional importante e necessária, mesmo não atendendo integralmente a expectativa da proposta do programa.

Abstract The Family Health Support Nucleus (NASF) was created in 2008 with the objective of broadening the range and scope of primary healthcare. The insertion of pharmacists in this multi-professional context represents an opportunity to enhance the working process and the rational access and use of medicines. The working processes of pharmacists in a city NASF was investigated. Field research was conducted using a qualitative approach with participant observation and semi-structured interviews. Two analytic dialectic categories emerged. The first was the pharmacists’ dilemma in the construction of their working process as promoters of primary healthcare, while at the same time facing the need to deal with managerial functions mostly to cater to operational demand. The second was the reality experienced with guidelines and coordination of their work, where pharmacists can be free to structure their work as supporters, although at the same time it limits them due to lack of acknowledgment of their previously established working process. The lack of planning and a clear objective for work in the NASF, besides the deficiency of pharmaceutical services in primary healthcare make the development of any type of pharmacist activity important and essential even if it does not fully attend the NASF proposal.

Pharmaceutical services and health promotion: how far have we gone and how are we faring? Scientific output in pharmaceutical studies

The objective of this study was to investigate the scientific output on health promotion within the pharmaceutical field and its relation with the development of pharmaceutical services within health systems. A comprehensive review of published scientific articles from the Medline and Lilacs databases was carried out. The review comprised articles published until December 2011, and used combinations of the terms 'health promotion' or 'health education' and 'pharmacy', 'pharmacist' or 'pharmaceutical'. The articles were selected according to inclusion and exclusion criteria. A total of 170 full texts and 87 indexed abstracts were analyzed, evidencing that most described actions of health promotion in community pharmacies and other services. Following the Ottawa Charter, most of the studies dealt with new guidance of the service and the supply of pharmaceutical information and services. It was concluded that there is a lack of theoretical background on health promotion in the pharmaceutical field to sustain the professional education and practice required by the health system and the population.

O objetivo do estudo foi investigar a produção científica sobre o desenvolvimento teórico e prático da promoção da saúde na farmácia e sua relação com o desenvolvimento da área e dos serviços farmacêuticos. A revisão integrativa de artigos científicos foi realizada a partir das bases de dados Medline e Lilacs. Ela compreendeu os artigos publicados até dezembro de 2011, através da combinação dos termos 'promoção da saúde ou educação em saúde' e 'farmácia, farmacêutico ou farmacêutica'. Critérios de inclusão e exclusão definiram a seleção dos textos. Ao todo, 170 artigos e 87 resumos foram analisados, sendo a maioria identificada como trabalhos teóricos que relatam atividades descritas como de promoção da saúde em farmácias comunitárias ou outros serviços. Confrontando com o referencial da Carta de Ottawa, a maioria dos estudos revelou ter como campo de investigação principal alguma proposição de reorientação dos serviços de saúde e oferta de informações e práticas farmacêuticas. Conclui-se que há uma carência de embasamento teórico sobre promoção da saúde na área farmacêutica para sustentar a formação e prática profissional, conforme exigido pelo sistema de saúde e pela população.

Coadministration of cannabinoid CB1-receptor and adenosine A1-receptor antagonists improves the acquisition of spatial memory in mice: participation of glutamatergic neurotransmission.

The aim of this study was to characterize the interaction of adenosine A1-receptor and cannabinoid CB1-receptor antagonists in the water maze and object-location tasks, and to evaluate the participation of glutamatergic neurotransmission in the hippocampus in the learning enhancement induced by the coadministration of both antagonists. Our results show that coadministration of ineffective doses of DPCPX (8-cyclopentyl-1,3-dipropylxanthine) (an A1-receptor antagonist) and AM251 (N-(piperidin-1-yl)-5-(4-iodophenyl)-1-(2,4-dichlorophenyl)-4-methyl-1H-pyrazole-3-carboxamide) (a CB1-receptor antagonist) in different proportions enhanced the acquisition of spatial learning. N-methyl-D-aspartate receptor blockade disrupted the effects of the selected drug combination [AM251 0.25 mg/kg intraperitoneally (i.p.)+DPCPX 0.30 mg/kg i.p.] either in the water maze or in the object-location task. Moreover, this drug combination induced a significant ex-vivo enhancement in glutamate release into hippocampal slices. In addition, the blockade of N-methyl-D-aspartate receptors with MK-801 (0.25 µg/site) infused into the hippocampal CA1 area reversed the effects of coadministration, as evaluated in the object-location task. In conclusion, this is the first study to show that A1-receptor and CB1-receptor antagonists might interact on hippocampal neurons to enhance spatial memory in mice.