Collaborative care for depression and suicide prevention: a feasible intervention within the Mexican health system.

Mexico faces an enormous challenge in attending mental health disorders with depression rising as one of the five main contributors to disability adjusted life years (DALYs) and increasing suicide rates. These challenges are coupled with a dearth of resources and an inefficient allocation of the meager funds. While no magical bullet is available to ameliorate this situation in the short term, here we discuss current concepts and experiences that could be used in Mexico to deliver better primary mental health care. We focus on depression and suicidal behavior and argue that collaborative care is a feasible and replicable model, emphasizing the importance of training non-specialized primary care personnel to become case managers and provide primary mental health care. Mexi-co is currently undergoing a process of changes, including the emergence of universal health care. The time seems right to make mental health care more transversal, widely available and scientifically proven.

Atención colaborativa para depresión y prevención de suicidio: una intervención viable en el sistema de salud mexicano / Collaborative care for depression and suicide prevention: a feasible intervention within the Mexican health system

Resumen: México enfrenta un enorme desafío para atender los trastornos mentales, con la depresión como uno de los principales contribuyentes a los años de vida ajustados por discapacidad (AVAD) y el aumento de las tasas de suicidio. Estos desafíos se combinan con la escasez de recursos y asignación ineficiente de fondos. Si bien no hay una solución mágica a corto plazo, discutimos experiencias actuales que podrían usarse para brindar una mejor atención primaria en salud mental. Nos centramos en depresión y conducta suicida argumentando que la atención colaborativa es un modelo factible y replicable, enfatizando la capacitación del personal no especializado para que se convierta en administrador de casos y brinde atención primaria en salud mental. México está experimentando un proceso de cambios, incluido el surgimiento de la atención médica universal, por lo que es el momento para que la atención en salud mental sea más transversal, disponible y científicamente probada.

Abstract: Mexico faces an enormous challenge in attending mental health disorders with depression rising as one of the five main contributors to disability adjusted life years (DALYs) and increasing suicide rates. These challenges are coupled with a dearth of resources and an inefficient allocation of the meager funds. While no magical bullet is available to ameliorate this situation in the short term, here we discuss current concepts and experiences that could be used in Mexico to deliver better primary mental health care. We focus on depression and suicidal behavior and argue that collaborative care is a feasible and replicable model, emphasizing the importance of training non-specialized primary care personnel to become case managers and provide primary mental health care. Mexico is currently undergoing a process of changes, including the emergence of universal health care. The time seems right to make mental health care more transversal, widely available and scientifically proven.

Factores Psicológicos y Relaciónales Asociados a Episodios de Embriaguez en Adolescentes Escolares de Guadalajara, México / Psychological and Related Factors Associated with Drunkenness Episodes in Adolescent Students in Guadalajara, Mexico / Fatores Psicológicos e Relações Associados a Episódios de Embriaguez em Adolescentes Escolares de Guadalajara, México

Resumen El objetivo de este estudio fue asociar factores psicológicos y relaciónales vinculados a episodios de embriaguez en 1134 adolescentes escolares de Guadalajara, México. Se evaluaron diez factores psicológicos y relacionales. La variable de desenlace fue episodios de embriaguez durante el último mes. Se encontró una prevalencia de embriaguez de 26.5% con mayor consumo en hombres. Después del análisis de regresión logística los factores asociados a embriaguez fueron tabaquismo, alta autoestima, alta impulsividad, bajo locus de control interno, la presencia de estrés cotidiano y relación distante con el padre. La investigación concluye que los factores psicológicos y relacionales asociados a episodios de embriaguez hicieron referencia a un perfil de omnipotencia altamente influenciable, y al desapego emocional, por lo que el consumo excesivo de alcohol parece perfilarse como una estrategia de seguridad.

Abstract The aim of this study was to identify psychological and related factors linked with drunkenness episodes in 1134 adolescent students in Guadalajara, Mexico. The study evaluated ten psychological and related factors. The outcome variable was the number of episodes of drunkenness in the last month. We found 26.5% more episodes of drunkenness in men. A logistic regression analysis indicated that factors associated with drunkenness were smoking, high self-esteem, high impulsiveness, low self-control, presence of daily stress and distant relationship with father. The study concluded that the psychological and related factors associated with drunkenness episodes were related to a highly impressionable omnipotence profile and emotional indifference, with excessive consumption of alcohol as a safety strategy.

Resumo O objetivo deste estudo foi associar fatores psicológico e relações vinculados a episódios de embriaguez em 1134 adolescentes escolares de Guadalajara, México. Avaliaram-se dez fatores psicológicos e relacionais. A variável de desenlace foi episódios de embriaguez de 26.5 % com maior consumo em homens. Depois da análise de regressão logística, os fatores associados à embriaguez foram tabaquismo, alta autoestima, alta impulsividade, baixo lócus de controle interno, presença de estresse cotidiano e relação distante com o pai. A pesquisa conclui que os fatores psicológicos e relacionais associados a episódios de embriaguez fizeram referência a um perfil de onipotência altamente influenciável e ao desapego emocional; nesse sentido, o consumo excessivo de álcool parece perfilar-se como uma estratégia de segurança.

[Strategies of adolescents according to gender to quit their smoking habit]. / Estrategias de adolescentes según género para cesar su hábito tabáquico.

Objective: to explore and analyze tobacco smoking cessation strategies and identify differences by gender in adolescents. Methods: exploratory study with 62 regular tobacco smoking students from a public high school University of Guadalajara. Free lists were used for data collection. Results: seventy-nine percent of the students had tried to quit tobacco-smoking. Strategies used were focused on volition (53.5 %), substitution (16.3 %), avoiding hanging with smokers (12.8 %), reflexive thinking (10.5 %) and a progressive reducing tobacco smoking (7 %). Differences were found in strategies used by men and women: while the women used a higher rate of reflexive thinking and substituted tobacco smoking by ingesting calories, men avoided hanging out with smokers and substituted tobacco smoking with burning energy strategy. Tobacco smoking reduction was reported as the most efficient strategy. Conclusions: tobacco smoking cessation strategies derived from a cultural notion of tobacco as a vice where the most important issue was making the decision and using one's own resources. To stop smoking tobacco came out as a health need which should be attended by health care services.

[Factors associated to tobacco-smoking pattern in school teenagers]. / Factores asociados a los patrones de consumo de tabaco en adolescentes escolares.

OBJECTIVE: to evaluate the association between tobacco-smoking patterns and family and school variables in school teenagers from Guadalajara, Mexico. METHODS: 556 high school students at the Universidad de Guadalajara participated in the study. The analysis included the following risk factors: parental, siblings and friends smoking habits, being employed while studying, being an irregular student, school shift (morning/evening), and history of rejection in their first application to enter high-school. RESULTS: 48.3 % of students smoked occasionally and 9.7 % smoked regularly. The logistic regression analysis showed that the covariate smoking peers was associated to occasional and regular consumption when compared to non-consumption. The covariates: smoking father, being an irregular student and history of rejection to the first application, were associated to regular consumption. Unexpectedly, smoking peers was a protective factor for progression from occasional to regular consumption. CONCLUSIONS: smoking peers was a risk factor associated to progress from non-smoking to occasional and to regular tobacco consumption. Parental smoking, being an irregular student, and being previously rejected to enter to the high school were identified as risk factors for progression from non-smoking to regular consumption.

Efecto de una intervención antitabaco en estudiantes de enseñanza media superior en Guadalajara, México / Effect of an anti-tobacco intervention in high school students from Guadalajara, Mexico

Introduction Recent data, both domestic and from the world over, have shown that the epidemiologic impact of tobacco consumption has a higher increase rate among adolescent population, particularly women, than in the general population. This has highlighted the need to implement preventive intervention programs focused on young people. The school environment seems to be the most adequate space to achieve such a goal. Most school intervention reports aimed at reducing tobacco consumption among students have been carried out in the United States and have both had a positive effect and proven to be cost-effective. In Mexico, there is only one antecedent of a successful prevention program conducted in an elementary school. Results from this suggest that behavioural abilities acquisition reduces the prevalence of tobacco experimentation and promotes cessation among those already using it. Given the lack of educational interventions and the fact that tobacco consumption tends to increase among Mexican high school students, we conducted this study aiming to implement an educational intervention on tobacco consumption among adolescent high school students from the Universidad de Guadalajara, Mexico. Later on we proceeded to evaluate its effect. Material and methods Based on a diagnostic and a literature review from successful anti-tobacco consumption programs, we devised a campaign called <>. This lasted for half a school year and included parents, teachers and non-smoking peers. Parents participated in five sessions aimed at promoting abstinence from tobacco consumption at home. Forty-two teachers, trained as campaign mediators, participated. A manual describing the contents from each session was elaborated for quality control purposes. Students themselves participated in four monthly sessions, were given anti-tobacco messages, watched anti-tobacco educational documentaries -under the supervision and discussion of a professor-, and exchanged cigarettes for chewing gum with non-smoking peers. In addition, a Tobacco Clinic was established, a mouth-teeth exam was carried out, and an anti-tobacco poster was displayed at the school. The poster message was changed each month. School measures regarding the ban on cigarettes sale on the school premises were likewise reinforced. Right before starting the campaign and immediately after finishing it, tobacco consumption rates, the type of consumption, the likelihood of using tobacco in the near future and the level of understanding as to the harmful effects on health of tobacco consumption were all evaluated using validated and standardized surveys. All measurements were carried out with an electronic questionnaire. The intervention effect evaluation was carried out with two independent samples: a base sample and a final sample before the campaign conclusion. Calculation of the sample size required for both surveys was based on data from a diagnostic study conducted at the same school. Participants were randomly selected. The project was approved by an Ethics and Research Committee from the Instituto Mexicano del Seguro Social (National Social Security Institute) and all the students participated in the educational intervention. Results Whereas 621 adolescents participated in the base evaluation, a total of 524 of them took part in the final evaluation. Parental attendance at the various sessions changed from 90% to 20%. A total of 2675 mouth-teeth exams were carried out. At these, tooth cavities decay, lack of dental hygiene and gengivitis were detected. In turn, this resulted in suggestions to attend regular health care services for treatment. At the Tobacco Clinic, a group of 20 family parents was formed for treatment. The once-in-a-lifetime, in the last 12 months, and in the last previous month tobacco consumption prevalence accounted to 43.6%, 23.0%, and 24.3%, respectively. Experimental versus regular tobacco consumption were 34.9% and 7.2%. Nonsmoking population was 57.8%. In the same base evaluation, 9.7% of the students considered it was very likely they would smoke in the future, 46.9% considered it barely likely, and 43.5% considered they would never smoke in the future. The positive effect of the campaign was reflected in the type of tobacco consumption as there was a reduction in the rate of experimental smokers, as well as an increase in the number of non-smokers in the final evaluation compared to the base one. The rate of regular smokers did not change from one evaluation to the other. The once-in-a-lifetime, in the last twelve months, and in the last month frequency of consumption, together with the likelihood of smoking in the near future, showed no changes in the final evaluation compared to the base one. In the base evaluation, a high level of understanding about the harmful effects of tobacco on the pulmonary system and a moderate level of understanding about the harmful effects of tobacco on the heart and the female reproductive system, as well as on the stomach and liver, were observed, while there was a low level of understanding about the harmful effects of tobacco on the rest of the organic systems. In the final evaluation, it was observed that the understanding level of organic systems about which it was moderate or high remained the same. In addition, a significant increase of the understanding about the harmful effects of tobacco on the ocular system and the urinary tracts was observed. The level of understanding about the harmful effects of tobacco on the rest of the organic system remained also the same.

Introducción La mayor parte de los reportes de intervenciones escolares para reducir el consumo de tabaco en estudiantes han sido realizados en Estados Unidos y han mostrado un impacto positivo además de que son costo/efectivas. En México solamente existe el antecedente de un estudio exitoso de un programa de prevención de tabaco realizado en primaria, cuyos resultados sugieren que el desarrollo de habilidades conductuales reduce la prevalencia de la experimentación de tabaco y promueve el cese en quienes ya lo consumen. Ante la falta de intervenciones educativas y la tendencia hacia el aumento del consumo de tabaco en adolescentes escolares de educación media superior en México, realizamos el presente estudio con el objetivo de implementar y evaluar el efecto de una intervención educativa sobre el consumo de tabaco en adolescentes de una preparatoria de la Universidad de Guadalajara, en la ciudad de Guadalajara, capital del Estado de Jalisco, México. Material y métodos Basándose en un diagnóstico previo se diseño una campaña antitabaco, dirigida a adolescentes fumadores, con una duración de un semestre escolar, que incluyó la participación de padres de familia, maestros y pares no fumadores. Antes del inicio e inmediatamente después de finalizar la campaña se evaluaron, mediante dos muestras independientes por medio de encuestas validadas y estandarizadas, la frecuencia de consumo de tabaco, el tipo de consumo, la probabilidad de consumir tabaco en un futuro cercano y el nivel de conocimientos sobre los efectos nocivos para la salud que produce su consumo. Resultados El efecto positivo de la campaña se apreció en el tipo de consumo de tabaco puesto que hubo una reducción de la proporción de fumadores leves así como un incremento del número de no fumadores en la evaluación final con respecto a la basal; la proporción de fumadores moderados no se modificó en ambas evaluaciones. La frecuencia de consumo una vez en la vida, en los últimos doce meses, en el último mes, así como la probabilidad de fumar en un futuro cercano no mostró modificaciones en la evaluación final con respecto a la basal. Discusión La intervención educativa antitabaco tuvo efectos positivos sobre el tipo de consumo de tabaco en los adolescentes de la escuela sede, que se evidenciaron en la disminución de la proporción de fumadores leves, en el incremento de no fumadores y en el incremento del nivel de conocimientos sobre los efectos nocivos del consumo de tabaco sobre la salud. Creemos que la explicación se vinculó a tres aspectos: 1) por haber diseñado la intervención a partir de un diagnóstico escolar, 2) por haber tomado en cuenta las diferentes influencias sociales al incorporar la participación de maestros, pares no fumadores y padres de familia, 3) por la inclusión de sugerencias de programas exitosos en la modificación actitudinal. La intervención implementada resultó ineficaz para fumadores moderados, por lo que se tendría mayor efecto preventivo si se aplicaran en estudiantes de educación básica y media básica, en quienes el consumo de tabaco aún tiene un impacto inicial. A partir de la falta de interés mostrado por los padres, hipotetizamos que en ellos parece prevalecer una actitud permisiva en el consumo de tabaco de sus hijos y parecen subestimar la posibilidad de influir en su consumo. Se considera que los padres representan un contexto preventivo importante en el tabaquismo del adolescente. A partir de esto se plantean hipótesis y nuevas preguntas para ser investigadas. El estudio presenta limitaciones al no haberse incluido un grupo control y por haber limitado la evaluación de la intervención al periodo inmediato posterior. Sin embargo, pensamos que a pesar de estas limitaciones la intervención educativa antitabaco es efectiva para la reducción del consumo de tabaco experimental y en el incremento del nivel de conocimientos de los efectos deletéreos sobre la salud.

La adicción ¿vicio o enfermedad? Imágenes y uso de servicios de salud en adolescentes usuarios y sus padres

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Abstract: Introduction Through time, the concept underlying drug consumption has been a matter of much controversy in the health sciences field. Here, it has been referred to using different definitions, but society seems to perceive it mostly as a vice, associated to socially unacceptable behavior. The addiction-vice notion implies a moral concept which goes beyond health issues and induces affective reactions that seem to hinder the use of health care services. In contrast, when addiction is considered as a disease and the inability to control consumption is acknowledged, it all seems to lead to an intervention meant to solve the problem. Does the temí "addiction" -as used by drug users to refer either to a disease or vice- have any influence on stopping or promoting the use of health care services? And if so: Which are the cognitive processes supporting the images of addiction-vice and addiction-disease? Reports from different studies agree on the fact that adolescents and their parents only look for the help of health care services when they feel frustrated because they find themselves unable to control the drug use and feel at risk because of certain beliefs, attitudes or intentions. The study of images comes from the socalled "French social psychology", where Moscovici proposed using the concept of images to define a more complex and logical structure than that of attitudes and/or evaluation results. He considers images as an inner representation of an external reality, as constructions similar to visual experiences: a sort of mental sensations or impressions of objects and persons. According to him, images persist because they are lodged in the memory where they reinforce the sense of both a continuity of the environment and individual and collective experiences. From this theoretical perspective, the following were the aims of this study: to describe addiction-related images built both by adolescent users of illegal drugs, who were undergoing treatment at the time, and their parents. Method Based on the theory of social representation, a qualitative study was devised. The sample was composed by fifteen 13 to 19 year-old adolescents, who were users of multiple illegal drugs and were undergoing treatment in the Centros de Integración Juvenil in Guadalajara, Jalisco, Mexico, in 2002, together with their respective accompanying parents. The data were compiled using in-depth recorded interviews. The interpretations consisted of thematic encoding, classification and interpretative analyses. Ethical steps were taken in order to protect the participants' identity and to obtain their informed consent. Results In the accounts of both the adolescents and their parents, addiction was consistently referred to as a vice. Here, the voluntary use pathway put forward by the subjects' stood out; so, a voluntary decision would also be required to stop using drugs. In addition, parents perceived addiction as something wrong. Only when drug users started having drug consumption-related difficulties, was this redefined as a problem that they could not solve by their own means. It is worth mentioning here that adolescents did try to avoid the influence of friends and the environment when using drugs. Parents thought willpower alone would suffice to stop their offspring from using drugs. This was so because parents were not sensitive enough to the influence of tolerance and abstinence regarding the problem. Consequently, there were reasoning processes that redefined addiction as a problem needing the help of specialists. This cognitive re-definition turned the image of addiction-vice into that of addiction-disease. On the one hand, to look for help in the health care services under the stigma of the vice image meant to be openly recognized as a dissolute person and to be thus socially excluded. On the other, having a disease implied the possibility of solving the mistake of drug-taking and thus being rehabilitated and reinserted into a productive life. Nevertheless, in the addiction-disorder image, drug consumption-related problems still prevailed, such as the inability to control using drugs, together with family, school and work problems. Redefining addiction as a disease did not seem to be stable or permanent in their minds for there were still traces of the vice image. This finding suggests the disease image acted as a sort of link between addiction-vice and the access to treatment when trying to stop the use by their own means failed. Instead of rejecting the vice image, it seems that the subjects' appropriation of the disorder image represented by health care services in order to look for a specialized treatment was used as an important expectation. This was the case even when in their minds the use of drugs was a vice influenced by willpower and environment. Drugs and addiction-vice and addiction-disease are not antagonistic images in social reasoning, but are a part of a continuum where they coexist. Discussion Our findings show that the adolescents interviewed had in their minds an image of addiction-vice as a pathway to drug use. It was also an image where drug use-related problems appeared, and thus they defined addiction as a disease without completely disassociating it from the notion of vice. Although these findings agree partially with those reported on this matter, there is a more elaborated and useful construction giving the problem a continuance in society, and to which Moscovici referred to as "image". An image has three characteristics accounting for its stability, consistency and continuance in social groups: 1. marginal elements, such as beliefs, cognitions, and judgements, which act as safeguards to protect; 2. the key element of the image, which is in this case addiction as vice, and 3. the social function accomplished by the image. We believe that the latter is the most important characteristic, a feature which was also emphasized by Moscovici. According to the common sense of the adolescents and parents under study, the function of the addiction-vice image was to reject a behavior considered deviant from accepted social norms. On the other hand, we detected that the addiction-disease image was not stable in the social mind, because this was not an image made up by the population under study, but one that they had appropriated and where health services were included. It is a construction circulating outside these particular social actors, and which is appropriated to carry out the purpose of gaining access to treatment. The images composing the voluntary use pathway seem to be antagonistic and mutually excluding, and they seem to coexist in the mind's continuum when addiction is redefined as a problem deserving help. Consequently, using drugs can be at times viewed either as a vice or disease, or vicedisease, depending on the purpose it fulfills in a given situation. Only common sense can accept such exclusions and alternations, because the reasoning underlying it does not need any verifications regarding its validity. From this viewpoint, addiction represents a big challenge for health services because of the several elements it involves. Results from this study point out to the reasoning used to examine the ideas of both the adolescents and their parents and to explain decisions regarding drug use. The degree of knowledge about the way these individuals think, communicate and take decisions will enable health services professionals to develop more efficient interventions. To a certain extent, we believe the reasoning behind the vice image is accurate enough because, although the use pathway was voluntary, willpower is also important to stop consumption and look for help in the health care services. Finally, we think that it would be appropriate to study these images in populations from other regions in order to evaluate if the same or similar images prevail or not. Further research of these images would help to develop longitudinal studies which would also evaluate, on the one hand, the images through the therapeutic process and, on the other, their link with the effectiveness of any given treatment.