Vaccines for preventing herpes zoster in older adults

BACKGROUND: Herpes zoster or, as it is commonly called, 'shingles' is a neurocutaneous disease characterised by the reactivation of varicella zoster virus (VZV), the virus that causes chickenpox, which is latent in the dorsal spinal ganglia when immunity to VZV declines. It is an extremely painful condition which can often last for many weeks or months, impairing the patient's quality of life. The natural aging process is associated with a reduction of cellular immunity which predisposes to herpes zoster. Vaccination with an attenuated form of VZV activates specific T cell production, therefore avoiding viral reactivation. A herpes zoster vaccine with an active virus has been approved for clinical use among older adults by the Food and Drug Administration and has been tested in large populations. OBJECTIVE: To evaluate the effectiveness and safety of vaccination for preventing herpes zoster in older adults. METHODS Search methods: We searched the following sources for relevant studies: CENTRAL 2012, Issue 7, MEDLINE (1948 to July week 1, 2012), EMBASE (2010 to July 2012), LILACS (1982 to July 2012) and CINAHL (1981 to July 2012). We also reviewed reference lists of identified trials and reviews for additional studies. Selection criteria: Randomised controlled trials (RCTs) or quasi-RCTs comparing zoster vaccine with placebo or no vaccine, to prevent herpes zoster in older adults (mean age > 60 years). Data collection and analysis: Two review authors independently collected and analysed data using a data extraction form. They also carried out an assessment of risk of bias. MAIN RESULTS: We identified eight RCTs with a total of 52,269 participants. Three studies were classified at low risk of bias. The main outcomes on effectiveness and safety were extracted from one clinical trial with a low risk of bias. Four studies compared zoster vaccine versus placebo; one study compared high-potency zoster vaccine versus low-potency ...

WITHDRAWN: Carbamazepine for cocaine dependence.

BACKGROUND: Cocaine dependence has become a public health problem, developing a significant number of medical, psychological and social problems. Although there is no consensus regarding how to treat cocaine dependence, effective pharmacotherapy has a potentially major role to play as part of a broader treatment milieu. The anti-convulsant carbamazepine, a tricyclic medication that is widely used to treat a variety of neurological and psychiatric disorders, has been used for treatment of cocaine dependence, although its effectiveness has not been established. OBJECTIVES: To determine whether carbamazepine is effective for the treatment of cocaine dependence. SEARCH STRATEGY: We searched: Cochrane Controlled Trials Register (Cochrane Library issue 1, 1999), MEDLINE (f1966 - October 1997), EMBASE (1980 - October 1997), PsycLIT (1974 - July 1997), Biological Abstracts and LILACS (1982 - 1997); scan of reference list of relevant articles; personal communication; conference abstracts; unpublished trials from pharmaceutical industry; book chapters on treatment of cocaine dependence. The specialised register of trials of Cochrane Group on Drugs and Alcohol until February 2003. SELECTION CRITERIA: All randomised controlled trials focused on the use of carbamazepine versus placebo on the treatment of cocaine dependence. Trials including patients with additional diagnosis such as opiate dependence were also eligible. DATA COLLECTION AND ANALYSIS: The reviewers extracted the data independently, Odds Ratios, weighted mean difference and number needed to treat were estimated. Qualitative assessments of the methodology of eligible studies were carried out using validated checklists. The reviewers assumed that people who died or dropped out had no improvement and tested the sensitivity of the final results to this assumption. Where possible analysis was carried out according to the "intention to treat" principles. MAIN RESULTS: 5 studies were included (455 participants). No differences regarding positive urine sample for cocaine metabolites. Scores on Spielberg State Anxiety Inventory slightly favoured carbamazepine, but not statistical significance. Dropouts were high in both groups, less dropout occurred in the carbamazepine group (RR 0.87 95%CI 0.71-1.06). When no retention in treatment was due to side effects no differences were found. The number of participants presenting at least one side effect, was higher in the carbamazepine group (RR 4.33 95% CI 1.45-12.91). AUTHORS' CONCLUSIONS: There is no current evidence supporting the clinical use of Carbamazepine in the treatment of cocaine dependence. Larger randomised investigation must be considered taking into account that these time-consuming efforts should be reserved for medications showing more relevant and promising evidence.

Physical therapy for Bell s palsy (idiopathic facial paralysis).

BACKGROUND: Bell's palsy (idiopathic facial paralysis) is commonly treated by physical therapy services with various therapeutic strategies and devices. There are many questions about their efficacy and effectiveness. OBJECTIVES: To evaluate the efficacy of physical therapies on the outcome of Bell's palsy. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Register (February 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2007), MEDLINE (January 1966 to February 2008), EMBASE (January 1980 to February 2008), LILACS (January 1982 to February 2008), PEDro (from 1929 to February 2008), and CINAHL (January 1982 to February 2008). SELECTION CRITERIA: We selected randomised or quasi-randomised controlled trials involving any physical therapy. We included participants of any age with a diagnosis of Bell's palsy and all degrees of severity. The outcome measures were: incomplete recovery six months after randomisation, motor synkinesis, crocodile tears or facial spasm six months after onset, incomplete recovery after one year and adverse effects attributable to the intervention. DATA COLLECTION AND ANALYSIS: Titles and abstracts identified from the register were scrutinized. The assessment of methodological quality took into account secure method of randomisation, allocation concealment, observer blinding, patient blinding, differences at baseline of the experimental groups, and completeness of follow-up. Data were extracted using a specially constructed data extraction form. Separate subgroup analyses of participants with more and less severe disability were undertaken. MAIN RESULTS: The search identified 45 potentially relevant articles. Six studies met the inclusion criteria. Three trials studied the efficacy of electrostimulation (294 participants) and three exercises (253 participants). Neither treatment produced significantly more improvement than the control treatment or no treatment. There was limited evidence that improvement began earlier in the exercise group. AUTHORS' CONCLUSIONS: There is no evidence of significant benefit or harm from any physical therapy for idiopathic facial paralysis. The possibility that facial exercise reduces time to recover and sequelae needs confirming with good quality randomised controlled trials.

A systematic review of the interventions to promote the wearing of hearing protection

CONTEXT AND OBJECTIVE: Noise-induced hearing loss can only be prevented by eliminating or lowering noise exposure levels. When the source of the noise cannot be eliminated, workers have to rely on hearing protection equipment. The aim here was to summarize the evidence for the effectiveness of interventions to enhance the wearing of hearing protection among workers exposed to noise in the workplace. DATA SOURCE: Studies with random assignment were identified by an electronic search of the medical literature up to 2005. Data were double-entered into the Review Manager software, version 4.2.5. DATA SYNTHESIS: Two studies were found. A computer-based intervention tailored to individual workers’ risks and lasting 30 minutes was not found to be more effective than a video providing general information for workers. A second randomized controlled trial evaluated the effect of a four-year school-based hearing loss prevention program among schoolchildren working on their parents’ farms. The intervention group was twice as likely to wear some kind of hearing protection as was the control group (which received only minimal intervention). REVIEWERS’ CONCLUSIONS: The limited evidence does not show whether tailored interventions are more or less effective than general interventions among workers, 80 percent of whom already use hearing protection. Long-lasting school-based interventions may increase the use of hearing protection substantially. Better interventions to enhance the use of hearing protection need to be developed and evaluated in order to increase the prevention of noise-induced hearing loss among workers.

CONTEXTO E OBJETIVO: Perda auditiva induzida por ruído pode apenas ser prevenida eliminando ou diminuindo os níveis de exposição sonora. Quando a fonte do ruído não pode ser eliminada, trabalhadores devem utilizar os equipamentos de proteção auditiva. O objetivo foi sumarizar as evidências sobre efetividade das intervenções para aumentar o uso de protetores auriculares entre trabalhadores expostos a ruídos. ESTRATÉGIA DE BUSCA: Estudos randomizados foram identificados por busca eletrônica na literatura médica até 2005. Os dados foram checados duplamente e inseridos no software Review Manager software, versão 4.2.5. RESULTADO PRINCIPAL: Dois estudos foram encontrados. Uma intervenção padronizada por computador em relação ao risco de um trabalhador individual durou 30 minutos e não foi mais efetiva do que um vídeo fornecendo informações gerais entre os trabalhadores. Um segundo ensaio clínico randomizado avaliou os efeitos de um programa de prevenção auditiva de quatro anos em uma escola onde jovens trabalhavam nas fazendas de seus pais. O grupo de intervenção foi duas vezes mais provável de usar algum tipo de protetor auricular do que o grupo controle, que recebeu mínima intervenção. CONCLUSÃO DOS REVISORES: Limitada evidência não demonstrou quando as intervenções padronizadas são mais ou menos efetivas do que intervenções gerais em trabalhadores, 80 por cento deles já utilizavam o protetor auricular. Intervenções longas em escolas podem aumentar substancialmente o uso de protetores auriculares. Melhores intervenções para aumentar o uso de Equipamentos de Proteção Individual (EPIs) devem ser desenvolvidas e avaliadas com intuito de aumentar a prevenção de perda auditiva induzida por ruído em trabalhadores.

The Portuguese version of the Clinical Global Impression-Schizophrenia Scale: validation study.

OBJECTIVES: The Clinical Global Impression-Schizophrenia Scale was designed to assess severity and treatment response in subjects with schizophrenia involved in naturalistic studies and daily clinical practice. The objective of this study is to validate the Portuguese version of the Clinical Global Impression-Schizophrenia Scale in Brazil by assessing its psychometric properties. METHOD: Cross-sectional validation study of the Portuguese version of the Clinical Global Impression-Schizophrenia Scale, tested in outpatients and inpatients with schizophrenia (DSM-IV, ICD-10) from 6 centers in Brazil. Concurrent validity and sensitivity to change were assessed by comparison with the Positive and Negative Syndrome Scale, which is considered the gold standard tool to evaluate patients with schizophrenia. Interrater reliability was evaluated by intraclass correlation coefficients (ICC) calculated based on the scoring of two concomitant raters. RESULTS: 70 inpatients and 70 outpatients were evaluated. Total Clinical Global Impression-Schizophrenia Scale and Positive and Negative Syndrome Scale scores were highly correlated (r=0.79; p<0.01). Positive (r=0.86), negative (r=0.79), depressive (r=0.66) and cognitive (r=0.75) symptoms subscale scores were also correlated between both scales (p<0.01). Sensitivity to change was significantly correlated between the Clinical Global Impression-Schizophrenia Scale and Positive and Negative Syndrome Scale (r=0.73; p<0.01). Interrater reliability was substantial for positive symptoms and total scores of the Clinical Global Impression-Schizophrenia Scale (ICC=0.81 and 0.73), and moderate for negative, depressive, and cognitive symptoms score (0.64, 0.67 and 0.63, respectively). CONCLUSIONS: The Brazilian version of the Clinical Global Impression-Schizophrenia Scale is a valid and reliable instrument for the assessment of severity and treatment response in schizophrenic inpatient and outpatients.

The Portuguese version of the Clinical Global Impression - Schizophrenia Scale: validation study

OBJECTIVES: The Clinical Global Impression - Schizophrenia Scale was designed to assess severity and treatment response in subjects with schizophrenia involved in naturalistic studies and daily clinical practice. The objective of this study is to validate the Portuguese version of the Clinical Global Impression - Schizophrenia Scale in Brazil by assessing its psychometric properties. METHOD: Cross-sectional validation study of the Portuguese version of the Clinical Global Impression - Schizophrenia Scale, tested in outpatients and inpatients with schizophrenia (DSM-IV, ICD-10) from 6 centers in Brazil. Concurrent validity and sensitivity to change were assessed by comparison with the Positive and Negative Syndrome Scale, which is considered the gold standard tool to evaluate patients with schizophrenia. Interrater reliability was evaluated by intraclass correlation coefficients (ICC) calculated based on the scoring of two concomitant raters. RESULTS: 70 inpatients and 70 outpatients were evaluated. Total Clinical Global Impression - Schizophrenia Scale and Positive and Negative Syndrome Scale scores were highly correlated (r = 0.79; p < 0.01). Positive (r = 0.86), negative (r = 0.79), depressive (r = 0.66) and cognitive (r = 0.75) symptoms subscale scores were also correlated between both scales (p < 0.01). Sensitivity to change was significantly correlated between the Clinical Global Impression - Schizophrenia Scale and Positive and Negative Syndrome Scale (r = 0.73; p < 0.01). Interrater reliability was substantial for positive symptoms and total scores of the Clinical Global Impression - Schizophrenia Scale (ICC = 0.81 and 0.73), and moderate for negative, depressive, and cognitive symptoms score (0.64, 0.67 and 0.63, respectively). CONCLUSIONS: The Brazilian version of the Clinical Global Impression - Schizophrenia Scale is a valid and reliable instrument for the assessment of severity and treatment response in schizophrenic inpatient...

OBJETIVOS: A Escala de Impressão Clínica Global - Esquizofrenia é um instrumento de aplicação simples e rápido, utilizado para avaliar a severidade de sintomas em pacientes com esquizofrenia. Pode ser aplicado em estudos naturalísticos e na prática clínica. O objetivo deste trabalho é estudar as propriedades psicométricas e validar a versão Brasileira da Escala de Impressão Clínica Global - Esquizofrenia em nosso meio. MÉTODO: Estudo transversal de validação da Escala de Impressão Clínica Global - Esquizofrenia, na versão em Português, em pacientes com esquizofrenia, hospitalizados e em tratamento ambulatorial (DSM-IV, ICD-10), selecionados em seis centros no Brasil. Validade concorrente e sensibilidade à mudança foram determinadas em comparação com a escala Positive and Negative Syndrome Scale, considerada padrão-ouro. Confiabilidade interavaliador foi determinada através de coeficientes de correlação intraclasse (ICC), calculados a partir das pontuações de dois avaliadores concomitantemente. RESULTADOS: Setenta pacientes hospitalizados e 70 em tratamento ambulatorial foram incluídos. Os coeficientes de correlação de Pearson entre Escala de Impressão Clínica Global - Esquizofrenia e Positive and Negative Syndrome Scale foram: pontuação total (0,79), sintomas positivos (r = 0,86), negativos (r = 0,79), depressivos (r = 0,66) e cognitivos (r = 0,75, todos com p < 0,01). A confiabilidade interavaliadores da Escala de Impressão Clínica Global - Esquizofrenia foi alta para sintomas positivos e pontuação total; e moderada para sintomas negativos, depressivos e cognitivos. A sensibilidade ao grau de mudança foi moderadamente e significativamente correlacionada entre as duas escalas (r = 0,73, p < 0,01). CONCLUSÕES: A Escala de Impressão Clínica Global - Esquizofrenia em Português é um instrumento de boa validade e confiabilidade na avaliação da evolução de pacientes com esquizofrenia no Brasil, tanto em tratamento ambulatorial como hospitalizados.

A systematic review of the interventions to promote the wearing of hearing protection.

CONTEXT AND OBJECTIVE: Noise-induced hearing loss can only be prevented by eliminating or lowering noise exposure levels. When the source of the noise cannot be eliminated, workers have to rely on hearing protection equipment. The aim here was to summarize the evidence for the effectiveness of interventions to enhance the wearing of hearing protection among workers exposed to noise in the workplace. DATA SOURCE: Studies with random assignment were identified by an electronic search of the medical literature up to 2005. Data were double-entered into the Review Manager software, version 4.2.5. DATA SYNTHESIS: Two studies were found. A computer-based intervention tailored to individual workers risks and lasting 30 minutes was not found to be more effective than a video providing general information for workers. A second randomized controlled trial evaluated the effect of a four-year school-based hearing loss prevention program among schoolchildren working on their parents farms. The intervention group was twice as likely to wear some kind of hearing protection as was the control group (which received only minimal intervention). REVIEWERS CONCLUSIONS: The limited evidence does not show whether tailored interventions are more or less effective than general interventions among workers, 80% of whom already use hearing protection. Long-lasting school-based interventions may increase the use of hearing protection substantially. Better interventions to enhance the use of hearing protection need to be developed and evaluated in order to increase the prevention of noise-induced hearing loss among workers.

Revisão sistemática, metanálise e medicina baseada em evidências: considerações clínicas / Systematic review, meta-analysis, and evidence-based medicine: conceptual issues

Os autores fazem uma revisão dos conceitos que definem revisão sistemática, metanálise e medicina baseada em evidências, dão uma descrição sucinta dos processos envolvidos em sua realização e discutem sua importância. São apontadas a variabilidade de acepções desses termos, verificada na literatura médica, assim como a eventual falta de rigor metodológico na elaboração de estudos que levam o nome de revisão sistemática e especialmente metanálise, acarretando confusões e desconfiança quanto a sua validade; por isso é salientada a necessidade de clareza do sentido desses termos quando são utilizados para qualificar um estudo ou prática científica. Quanto à medicina baseada em evidências, é destacado o fato de que, apesar de ser desejável que as decisões médicas sejam tomadas do modo mais objetivo possível, e que para isso sejam observadas as evidências produzidas por estudos de boa qualidade metodológica, também devem ser incluídas e valorizadas a experiência pessoal do médico e as peculiaridades do paciente.

Continuing medical education in Brazil: what about obstetricians and gynecologists?

CONTEXT: In Brazil, obstetricians and gynecologists are not required to submit to periodical evaluations to ascertain their professional competence in dealing with new concepts and therapies. OBJECTIVES: To evaluate the performance of a group of obstetricians and gynecologists on a written evidence-based obstetrics test and determine their opinions and use of systematic reviews. TYPE OF STUDY: Prospective cohort. SETTING: Brazilian Obstetrics and Gynecology Congress 2001. METHODS: 230 doctors agreed to participate in the study during a national obstetrics and gynecology congress. Participants took an individual anonymous written multiple-choice test with seven questions on clinical obstetrics, one question on the interpretation of a meta-analysis graph and two questions on their opinions and actual use of systematic reviews. Scores were analyzed and compared after grouping the participants according to year of graduation, residence training, doctoral program and faculty status. RESULTS: The general average score was 49.2 +/- 17.4. The scores tended to decline as the years since graduation advanced. Doctors who graduated in the last five years had higher scores than those who graduated over 25 years ago (52.2 versus 42.9). The performance did not vary according to medical residence, postgraduate program or teaching status. While 98.2% considered systematic reviews relevant, only 54.9% said that they routinely used this source of information. DISCUSSION: The participants' average score was low, even though they were highly qualified and trained. Despite the limitations of the study, the results are worrisome. If motivated physicians participating in a national congress obtained such low scores, we can speculate that the results might be even worse among other doctors that do not attend these events. CONCLUSIONS: These findings suggest that Brazilian obstetricians and gynecologists could benefit from continuing medical education and raise questions about the recycling methods currently available.

Continuing medical education in Brazil: what about obstetricians and gynecologists

CONTEXTO: A educação médica continuada definida de forma genérica como todas as formas pelas quais os médicos aprendem após a sua formação, é um assunto de interesse tanto dos médicos como dos pacientes em geral. No Brasil, os tocoginecologistas não são obrigados a se submeter a exames periódicos para certificar sua competência e atualização profissional, o que torna a educação médica continuada sujeita à de consciência pessoal. OBJETIVOS: Avaliar o desempenho de um grupo de tocoginecologistas em um teste escrito com perguntas sobre obstetrícia baseada em evidências e determinar sua opinião e uso regular de revisões sistemáticas. TIPO DE ESTUDO: Prospectivo de coorte. LOCAL DO ESTUDO: Congresso Brasileiro de Obstetrícia e Ginecologia 2001, em São Paulo. MÉTODOS: 230 médicos participaram voluntariamente do estudo durante o Congresso. Todos preencheram um questionário escrito, anônimo, individual com sete perguntas de múltipla escolha sobre condutas obstétricas clínicas baseadas em evidência, uma pergunta sobre interpretação de um gráfico de metanálise e duas perguntas sobre opinião e uso de revisões sistemáticas. Foi calculada a porcentagem de acerto de todos os participantes nas perguntas de múltipla escolha. Os resultados foram também analisados conforme o tempo de formado, residência, pós-graduação e docência. RESULTADOS: A média geral foi 49,2 + 17,4. As notas tenderam a cair com o tempo decorrido desde a formatura. Os médicos formados nos últimos cinco anos tiveram notas maiores que aqueles formados há mais de 25 anos (52,2 versus 42,9). O desempenho não variou significativamente conforme ter ou não residência, pós-graduação ou ser docente. Enquanto 98,2% consideravam as revisões sistemáticas relevantes, apenas 54,9% apontou o uso regular dessa fonte de informação médica. DISCUSSÃO: A nota média dos participantes foi baixa, apesar de sua boa formação e qualificação. Apesar das limitações deste estudo, os resultados são preocupantes. Se médicos motivados que participavam de um congresso nacional tiveram notas tão baixas, podemos especular que os resultados seriam ainda piores entre outros colegas que não participam desses eventos. CONCLUSÃO: Esses achados sugerem que os tocoginecologistas brasileiros poderiam se beneficiar com educação médica continuada e levanta questões acerca das formas atuais de reciclagem médica.

Hormonal cryptorchidism therapy: systematic review with metanalysis of randomized clinical trials.

The importance of cryptorchidism treatment concerns the possibility of diminishing risk of malignant degeneration and improving fertility. Success rates of hormonal treatment vary: 0-55% with human chorionic gonadotropin (hCG) and 9-78% with gonadotropin-releasing hormone (GnRH). Due to uncertainties regarding the effectiveness of this treatment, a systematic review and meta-analysis of randomized controlled trials (RCTs) on hormonal cryptorchidism treatment was done using the methodology of Cochrane Collaboration. Two studies compared hCG with GnRH, with a testicular descent rate of 25% vs. 18%, respectively. Nine trials compared intranasal LHRH with placebo, with complete testicular descent rates of 19% vs. 5%. Two other studies comparing doses and administration intervals could not be pooled together due to heterogeneity. With the information analyzed until the present, the evidence for the use of hCG vs. GnRH shows advantages for hCG, and this review also shows that there is evidence that luteinizing hormone releasing hormone (LHRH) is more effective than placebo. But because this evidence is based on few trials, with small sample sizes and moderated risk of bias, this treatment cannot be recommended for everyone, and there is no evidence that supports hCG's use in larger doses and larger intervals. Results from this systematic review are important for developing better RCTs that may decrease the uncertainty of cryptorchidism treatment.

Mental health epidemiological research in South America: recent findings.

This paper aims to review the recent mental health epidemiological research conducted in South America. The Latin American and the Caribbean (LILACS) database was searched from 1999 to 2003 using a specific strategy for identification of cohort, case-control and cross-sectional population-based studies in South America. The authors screened references and identified relevant studies. Further studies were obtained contacting local experts in epidemiology. 140 references were identified, and 12 studies were selected. Most selected studies explored the prevalence and risk factors for common mental disorders, and several of them used sophisticated methods of sample selection and analysis. There is a need for improving the quality of psychiatric journals in Latin America, and for increasing the distribution and access to research data. Regionally relevant problems such as violence and substance abuse should be considered in designing future investigations in this area.

[Posttraumatic stress disorder: an evidence-based approach]. / Estresse pós-traumático: uma abordagem baseada em evidências.

The interventions used in the clinical management of posttraumatic stress disorder (PTSD) focus on: 1. Prevention of the development of the disorder, after a traumatic event 2. Treatment of the disorder, once it is already established, 3. Maintenance of long term functioning and quality of life. A variety of psychotherapies and pharmacological treatments have been proposed as therapeutic options in the treatment of PTSD. However, many of these treatment modalities lack scientific background. In this article authors present the treatment modalities of PTSD which are supported by scientific evidence and discuss its applications and drawbacks.

Estresse pós-traumático: uma abordagem baseada em evidências / Posttraumatic stress disorder: an evidence-based approach

As intervençöes usadas no manejo do transtorno do estresse pós-traumático (TEPT) focalizam-se em: (1) prevençäo do desenvolvimento da doença após um evento traumático, (2) tratamento do quadro já estabelecido e (3) manutençäo do funcionamento e da qualidade de vida em longo prazo. Uma variedade de tratamentos psicoterápicos e farmacológicos tem sido proposta para o tratamentos do TEPT. Entretanto, nem todas as modalidades de tratamento apresentam comprovaçäo científica. No presente artigo, os autores apresentam as modalidades de tratamentos do TEPT amparadas em evidências e discutem sua aplicabilidade e limitaçöes

Saude e doenca mental em Pelotas, RS: dados de um estudo populacional / Mental health in Pelotas, Southern Brazil: data from population-based cross-sectional survey

Em 1994, um estudo transversal de base populacional foi realizado para avaliar a prevalencia do consumo de psicofarmacos num periodo de duas semanas em Pelotas, cidade na regiao sul do Brasil, com 300 mil habitantes. A probabilidade de transtorno psiquiatrico menor (TPM) foi estimada pelo Self Reported Questionnaire (SRQ 20)...