A theoretical and empirical framework for constructing culture-specific stigma instruments for Chile.

Different cultural contexts contribute to substantial variation in the stigma faced by people with psychosis globally. We propose a new formulation of how culture affects stigma to create psychometrically-validated tools to assess stigma's culture-specific effects. We propose to construct culture-specific stigma measures for the Chilean context via: 1) open-ended administration of 'universal' stigma scales to a sample of individuals with psychosis, relatives, and community respondents; 2) qualitative analyses to identify how culture shapes stigma and to derive initial 'culture-specific' stigma items; 3) construction and pilot-testing of final 'culture-specific' stigma measures; 4) initial psychometric validation among a sample of individuals with psychosis. We identify initial hypotheses for how stigma might threaten the capacities to participate in fundamental activities that 'matter most' in the Chilean context. These include mental illness stigma threatening the man's ability to protect the honor of the family, and the woman's ability to be a 'holy and pure' mother. Mental illness stigma may further endanger the ability of the family to uphold reciprocal obligations within their social network. Developing such measures promises to aid efforts to address culture-specific forms of stigma, and to facilitate implementation of community mental health services, in Chile and other Latin American contexts.

A theoretical and empirical framework for constructing culture-specific stigma instruments for Chile / Uma estrutura teórica e empírica para a construção de instrumentos de estigma específicos para a cultura chilena

Different cultural contexts contribute to substantial variation in the stigma faced by people with psychosis globally. We propose a new formulation of how culture affects stigma to create psychometrically-validated tools to assess stigma's culture-specific effects. We propose to construct culture-specific stigma measures for the Chilean context via: 1) open-ended administration of 'universal' stigma scales to a sample of individuals with psychosis, relatives, and community respondents; 2) qualitative analyses to identify how culture shapes stigma and to derive initial 'culture-specific' stigma items; 3) construction and pilot-testing of final 'culture-specific' stigma measures; 4) initial psychometric validation among a sample of individuals with psychosis. We identify initial hypotheses for how stigma might threaten the capacities to participate in fundamental activities that 'matter most' in the Chilean context. These include mental illness stigma threatening the man's ability to protect the honor of the family, and the woman's ability to be a 'holy and pure' mother. Mental illness stigma may further endanger the ability of the family to uphold reciprocal obligations within their social network. Developing such measures promises to aid efforts to address culture-specific forms of stigma, and to facilitate implementation of community mental health services, in Chile and other Latin American contexts.

Diferentes contextos culturais contribuem para a variação substancial do estigma enfrentado por pessoas com psicose globalmente. Nós propomos uma nova formulação de como a cultura afeta o estigma para criar instrumentos validados psicometricamente a fim de avaliar os efeitos específicos do estigma cultural. Propomos a construção de medidas específicas de estigma cultural no contexto chileno através de: 1) administração aberta de escalas "universais" de estigma em uma amostra de indivíduos com psicose, parentes e entrevistados da comunidade; 2) análise qualitativa para identificar as formas de estigma cultural e extrair itens específicos de stigma cultaral; 3) construção e testes-piloto de medidas finais específicos de estigma cultural; 4) validação psicométrica inicial entre uma amostra de indivíduos com psicose. Identificamos hipóteses iniciais de como o estigma pode ameaçar as capacidades de participar em atividades fundamentais mais importantes no contexto chileno. Estes incluem o estigma de a doença mental ameaçar a capacidade do homem para proteger a honra da família, e da capacidade da mulher para ser uma "santa e pura" mãe. O estigma da doença mental pode comprometer ainda mais a capacidade da família para sustentar as obrigações recíprocas dentro de sua rede social. Desenvolvimento de tais medidas promete ajudar os esforços para abordar formas específicas de estigma cultural, e para facilitar a implementação de serviços comunitários de saúde mental, no Chile e em outros contextos latino-americanos.

Acompanhamento de pacientes do espectro esquizofrênico no território: adaptação da intervenção para períodos de transição ("Critical Time Intervention") para o contexto brasileiro em centros de atenção psicossocial do município do Rio de Janeiro / Monitoring of patients within the schizophrenia spectrum: adaptation of intervention for transition periods ("Critical Time Intervention") for the Brazilian context in psychosocial care centers in the city of Rio de Janeiro

A continuidade do cuidado de pacientes com transtornos mentais severos e persistentes depende da facilidade de acesso aos serviços. A noção de continuidade do cuidado implica também que os serviços sejam abrangentes, indicando a existência dos destinados à intervenção em crises; de residências terapêuticas; de diferentes dispositivos de tratamento; oportunidades de lazer e redes de suporte social; e oferta de transporte para o acesso físico aos serviços oferecidos. Estudos mostram que a boa continuidade de cuidados associa-se à melhor qualidade de vida, melhor funcionamento social, menor gravidade de sintomas e maior satisfação com o serviço. Neste artigo são apresentados os resultados do estudo piloto que visou adaptar para o contexto brasileiro a Critical Time Intervention (CTI) e testar sua viabilidade com pessoas com transtornos do espetro esquizofrênico em tratamento nos Centros de Atenção Psicossocial (CAPS) do município do Rio de Janeiro. O desenho da pesquisa incluiu três fases inter-relacionadas. O objetivo deste artigo é descrever o trabalho realizado na Fase 3 do estudo - implementação da intervenção - por meio dos resultados do acompanhamento de 20 pacientes esquizofrênicos em tratamento nos 4 CAPS do município do Rio de Janeiro a partir da análise dos focos definidos pela intervenção (CTI-Br).

The continuity of care for patients with severe and persistent mental disorders depends on the ease of access to services. The notion of continuity of care also implies that services indicate existence of comprehensive services for crisis intervention, residential treatment, different treatment devices, leisure opportunities and social support networks, and that they offer transportation for physical access services offered. Studies show that good continuity of care is associated with better quality of life, better social functioning, lower severity of symptoms and greater satisfaction with services. This article presents the results of the pilot study that aimed to adapt "Critical Time Intervention" (CTI) to the Brazilian context and tested its viability with people with schizophrenia spectrum disorders treated in Psychosocial Care Centers in the city of Rio de Janeiro. The research design included three interrelated phases. The aim of this paper is to describe the work done in Phase 3 - implementation of the intervention - by analyzing the results of the monitoring of 20 schizophrenic patients in four Rio de Janeiro Psychosocial Care Centers as part of CTI-Br.

Adaptação da "Critical Time Intervention" para o contexto brasileiro e sua implementação junto a usuários dos centros de atenção psicossocial do município do Rio de Janeiro / Adaptation of Critical Time Intervention for use in Brazil and its implementation among users of psychosocial service centers (CAPS) in the municipality of Rio de Janeiro

A Reforma Psiquiátrica Brasileira propõe um modelo de atenção baseado na implantação de uma rede comunitária no qual os Centros de Atenção Psicossocial (CAPS) detêm papel fundamental. Neste artigo são apresentados os resultados do estudo piloto que visou adaptar para o contexto brasileiro a "Critical Time Intervention" (CTI) e testar sua viabilidade com pessoas com transtornos do espetro esquizofrênico em tratamento nos CAPS do município do Rio de Janeiro. O desenho da pesquisa incluiu três fases inter-relacionadas. A primeira consistiu em trabalho de campo qualitativo e quantitativo. Esta fase incluiu o mapeamento das características sociodemográficas, clínicas e de utilização de serviços dos usuários dos CAPS, bem como conhecer as necessidades concretas dos participantes do estudo. A segunda fase consistiu na tradução do manual clinico da CTI para incluir as adaptações feitas para o seu uso no Brasil, oriundas dos dados coletados na primeira fase, bem como o treinamento de profissionais de nível médio para atuarem como agenciadores da CTI. A terceira fase consistiu na implementação da intervenção adaptada em um grupo de pacientes com transtornos do espectro esquizofrênicos matriculados nos CAPS, mas com dificuldade de se inserir no tratamento.

Brazilian Psychiatric Reform proposes a mental healthcare model based on the implementation of a community-based service network, in which Psychosocial Service Centers (CAPS) play a fundamental role. The report presents the results of a pilot study which aimed to adapt Critical Time Intervention to the Brazilian context, and to test its feasibility to provide it to persons with schizophrenic spectrum disorders who are enrolled in CAPS of Rio de Janeiro. Methods: The research design included three inter-related phases. Phase one consisted in carrying out qualitative and quantitative field work. This phase included mapping out the socio-demographic, clinical and service utilization data of CAPS users, as well as assessing the mental health needs of participants in the study. The second phase consisted in translation of the CTI clinical manual to include the adaptations made for use in Brazil, which were based on data collected in the first phase, as well as training individuals with moderate education as CTI intervention workers. The third phase consisted of pilot implementation of the adapted intervention among a group of individuals with schizophrenia spectrum disorders enrolled in CAPS, but with difficulties in being included in treatment.

[Adaptation of critical time intervention for use in Brazil and its implementation among users of psychosocial service centers (CAPS) in the municipality of Rio de Janeiro]. / Adaptação da "Critical Time Intervention" para o contexto brasileiro e sua implementação junto a usuários dos centros de atenção psicossocial do município do Rio de Janeiro.

UNLABELLED: Brazilian Psychiatric Reform proposes a mental healthcare model based on the implementation of a community-based service network, in which Psychosocial Service Centers (CAPS) play a fundamental role. The report presents the results of a pilot study which aimed to adapt Critical Time Intervention to the Brazilian context, and to test its feasibility to provide it to persons with schizophrenic spectrum disorders who are enrolled in CAPS of Rio de Janeiro. METHODS: The research design included three inter-related phases. Phase one consisted in carrying out qualitative and quantitative field work. This phase included mapping out the socio-demographic, clinical and service utilization data of CAPS users, as well as assessing the mental health needs of participants in the study. The second phase consisted in translation of the CTI clinical manual to include the adaptations made for use in Brazil, which were based on data collected in the first phase, as well as training individuals with moderate education as CTI intervention workers. The third phase consisted of pilot implementation of the adapted intervention among a group of individuals with schizophrenia spectrum disorders enrolled in CAPS, but with difficulties in being included in treatment.

Saúde mental e a população de rua na cidade de Nova York: panorama de 1994-2006. / Homelessness and mental health in New York City: an overview 1994-2006.

This article provides an overview of homelessness and mental health in New York City (NYC) over a recent period spanning from 1994 to 2006. This research was based on analysis of the main reports and studies on NYC homelessness and mental health and NYC Shelter System Register data. In 2006, the NYC homeless population was estimated at about 40,000 for any single day. Between 1994-2004, NYC shelters provided services to 416,720 individuals, including 163,438 children. The majority came from impoverished NYC areas. Many came from incarceration, streets and hospitals. Most were minority, particularly African-American. Homelessness had a major impact on morbidity and mortality. For 2001-2003, the HIV/AIDS estimated prevalence of the shelter population was twice that of the NYC adult population, and TB rate was 11 times higher. Two out of three of their hospitalizations were due to substance and alcohol use or mental illness (MI). Between 40-50 percent of single adults users are estimated to have a MI, however, the incidence over several years is much lower. A considerable number had a co-occurring MI and substance abuse history. Their death rate was twice that of the NYC population. Their leading deaths causes were heart disease, cancer, HIV/AIDS and substance abuse. NYC has developed the most extensive shelter service system for homeless people in the world. However, a crisis management approach, rather that addressing the roots of homelessness, has characterized its overall policy. Currently, there is a shift to an approach which seeks to drastically reduce homelessness in the next decade.

Este artigo forneceu uma visão geral da saúde mental da população de rua da cidade de Nova York (NY) no período de 1994 a 2006. O estudo baseou-se na análise dos principais relatórios e estudos sobre a saúde mental dessa população em NY, bem como o de sistemas de cadastro de abrigos da cidade. Em 2006, a população de rua atendida em abrigos de NY foi estimada em cerca de 40 mil pessoas em um único dia. Entre 1994-2004, tais abrigos prestaram serviços para 416.720 pessoas, destas, 163.438 eram crianças. A maioria da população era oriunda de áreas pobres, de encarceramento, de ruas e de hospitais; pertenciam principalmente a grupos de minorias étnicas como afrodescendentes. A população de rua representa um grande impacto na morbidade e mortalidade. Entre 2001-2003, a prevalência estimada do HIV/Aids na população dos abrigos e a taxa de tuberculose foram respectivamente o dobro e 11 vezes maior do que aquela encontrada na população adulta de NY. A maioria das internações nos abrigos (duas em cada três) decorreu do uso de substâncias, de álcool ou por doença mental; 40 a 50% são adultos solteiros e sofrem de transtorno mental. Um número considerável tinha uma comorbidade de transtorno mental e histórico de abuso de drogas. A taxa de mortalidade foi duas vezes maior que a taxa de mortalidade da população de NY. As principais causas de mortes foram: doenças cardíacas, câncer, HIV/Aids e abuso de substâncias. A cidade de Nova York desenvolveu um sistema de serviço de abrigo para moradores de rua mais amplo do mundo. Além de uma abordagem focada na gestão de crises que busca o enfrentamento das origens da falta de moradia, tem caracterizado a sua política geral com o objetivo de reduzir a população de rua na próxima década.

[Epidemiological analysis of suicide in Brazil from 1980 to 2006]. / Análise epidemiológica do suicídio no Brasil entre 1980 e 2006.

OBJECTIVE: The objective of this study was to carry out an epidemiological analysis of the suicide rates found in Brazilian regions and state capitals between 1980 and 2006. METHOD: Data on mortality rates due to suicide were collected from the Departamento de Informática do Sistema Unico de Saúde (Information Technology Department of the Brazilian Public Health System--DATASUS). RESULTS: A total of 158,952 suicide cases were registered between 1980 and 2006, excluding those cases in which the individual was less than 10 years old (n = 68). In the period under study, the total suicide rate in Brazil increased from 4.4 to 5.7 deaths per 100,000 inhabitants (29.5%). Higher average rates were found in the South (9.3) and Central-West (6.1) regions. Men were more likely to commit suicide. The highest suicide rates were found in the 70-years or above age range while the highest increases were found in the 20 to 59 year age bracket. The most dominant social-demographic characteristics of the persons who committed suicide in the period under study were low educational level and singlehood. The most common methods of suicide were hanging, fire arms and poisoning. CONCLUSION: Although in Brazil the rate increased 29.5% in 26 years, the national rate is still considered to be low when compared to worldwide suicide rates (average of 4.9 per 100,000 inhabitants). Suicide rates in Brazilian regions vary broadly, ranging from 2.7 to 9.3.

Análise epidemiológica do suicídio no Brasil entre 1980 e 2006 / Epidemiological analysis of suicide in Brazil from 1980 to 2006

OBJETIVO: O objetivo deste estudo foi realizar uma análise epidemiológica dos índices de suicídio registrados entre 1980 e 2006 nas regiões e capitais estaduais. MÉTODO: Dados referentes à taxa de mortalidade devido ao suicídio foram coletados do Departamento de Informática do Sistema Único de Saúde. RESULTADOS: Entre 1980 e 2006, foi registrado um total de 158.952 casos de suicídio, excluindo-se os casos nos quais os indivíduos tinham menos de 10 anos de idade (n = 68). No período estudado, o índice total de suicídio cresceu de 4,4 para 5,7 mortes por 100.000 habitantes (29,5 por cento). Os índices médios mais altos foram registrados nas regiões Sul (9,3) e Centro-Oeste (6,1). Os homens são os que têm a maior probabilidade de cometer suicídio. Os índices mais altos de suicídio foram registrados na faixa etária de 70 anos ou mais, enquanto que os maiores aumentos aconteceram na faixa etária dos 20 aos 59 anos. As principais características sociodemográficas das pessoas que cometeram suicídio durante o período estudado foram baixo nível educacional e estado civil solteiro. Os métodos mais comuns de suicídio foram por enforcamento, armas de fogo e envenenamento. CONCLUSÃO: Embora o índice brasileiro tenha crescido 29,5 por cento em 26 anos, o índice nacional ainda é considerado baixo se comparado aos índices de suicídio mundiais (média de 4,9 por 100.000 habitantes). Os índices de suicídio nas regiões brasileiras variam muito, ou seja, estão entre 2,7 e 9,3.

OBJECTIVE: The objective of this study was to carry out an epidemiological analysis of the suicide rates found in Brazilian regions and state capitals between 1980 and 2006. METHOD: Data on mortality rates due to suicide were collected from the Departamento de Informática do Sistema Único de Saúde (Information Technology Department of the Brazilian Public Health System - DATASUS). RESULTS: A total of 158,952 suicide cases were registered between 1980 and 2006, excluding those cases in which the individual was less than 10 years old (n = 68). In the period under study, the total suicide rate in Brazil increased from 4.4 to 5.7 deaths per 100,000 inhabitants (29.5 percent). Higher average rates were found in the South (9.3) and Central-West (6.1) regions. Men were more likely to commit suicide. The highest suicide rates were found in the 70-years or above age range while the highest increases were found in the 20 to 59 year age bracket. The most dominant social-demographic characteristics of the persons who committed suicide in the period under study were low educational level and singlehood. The most common methods of suicide were hanging, fire arms and poisoning. CONCLUSION: Although in Brazil the rate increased 29.5 percent in 26 years, the national rate is still considered to be low when compared to worldwide suicide rates (average of 4.9 per 100,000 inhabitants). Suicide rates in Brazilian regions vary broadly, ranging from 2.7 to 9.3.

Criteria for admission and continuity of health care in psychosocial healthcare services, City of Rio de Janeiro, Southeastern Brazil.

OBJECTIVE: To analyze the criteria used by teams for admission, referral and continuity of care among patients of the Centros de Atenção Psicossocial (CAPS - Psychosocial Care Centers). METHODS: A qualitative study with participatory evaluation was conducted in three psychosocial healthcare services of the city of Rio de Janeiro, Southeastern Brazil, in 2006. A total of 15 admitted cases and 15 referred cases were selected among the patients admitted for treatment during the six months that preceded the beginning of research. Criteria pointed out by the team to admit patients for treatment or referral were analyzed from structured guidelines. Analysis of continuity of care was based on medical records and information from the team and patients and/or family members themselves, six months after patients were admitted or referred. RESULTS: Patients admitted had psychosis (schizophrenia), history of previous admissions, poor social functioning and a small support network, patients referred had anxiety and depressive disorders, a good level of adherence to outpatient treatment, good social functioning and presence of a social network. In terms of continuity of care, eight out of 27 patients had an unknown destination. In terms of referrals, of the 13 patients referred to the network's outpatient clinics, seven continued in treatment, two returned to the centers and four had an unknown destination. CONCLUSIONS: The centers admit patients who fit into the definition of severe and persistent mental disorder. Continuity of care was pointed out as a problem, probably due to the difficulty in following patients.

Critérios de admissão e continuidade de cuidados em centros de atenção psicossocial, Rio de Janeiro, RJ / Criterios de admisión y continuidad de cuidados en centros de atención psicosocial, Rio de Janeiro, Sureste de Brasil / Criteria for admission and continuity of health care in psychosocial healthcare services, City of Rio de Janeiro, Southeastern Brazil

OBJETIVO: Analisar os critérios de admissão, encaminhamento e continuidade de cuidado a pacientes utilizados pelas equipes dos centros de atenção psicossocial. MÉTODOS: Pesquisa qualitativa com avaliação participativa realizada em três centros de atenção psicossocial do município do Rio de Janeiro (RJ) em 2006. Foram sorteados 15 casos admitidos e 15 casos encaminhados dentre os pacientes admitidos para tratamento nos seis meses anteriores ao início da pesquisa. Os critérios apontados pela equipe para a admissão do paciente para tratamento ou encaminhamento foram analisados a partir de um roteiro estruturado. A análise da continuidade de cuidados baseou-se em pesquisa em prontuário, informações da equipe e dos próprios pacientes e/ou familiares seis meses após a absorção ou encaminhamento do paciente. RESULTADOS: Os pacientes admitidos apresentavam diagnóstico de psicose (esquizofrenia), história de internações prévias, funcionamento social pobre e rede de apoio pequena e os pacientes encaminhados apresentavam transtornos ansiosos e depressivos, boa adesão a tratamento ambulatorial, bom funcionamento social e presença de rede social. Quanto à continuidade de cuidados, oito pacientes em 27 tiveram destino desconhecido. Quanto aos encaminhamentos, dos 13 pacientes encaminhados a ambulatórios da rede, sete permaneceram em tratamento, dois retornaram aos CAPS e quatro tiveram destino desconhecido. CONCLUSÕES: Os centros admitem pacientes que se encaixam na definição de um transtorno mental severo e persistente. A continuidade de cuidado foi apontada como problema, provavelmente devido à dificuldade de acompanhar os pacientes na comunidade.

Lessening Homelessness Among Persons with Mental Illness: A Comparison of Five Randomized Treatment Trials.

We evaluate the influence of housing, services, and individual characteristics on housing loss among formerly homeless mentally ill persons who participated in a five-site (4-city) study in the U.S. Housing and service availability were manipulated within randomized experimental designs and substance abuse and other covariates were measured with a common protocol. Findings indicate that housing availability was the primary predictor of subsequent ability to avoid homelessness, while enhanced services reduced the risk of homelessness if housing was also available. Substance abuse increased the risk of housing loss in some conditions in some projects, but specific findings differed between projects and with respect to time spent in shelters and on the streets. We identify implications for research on homeless persons with mental illness that spans different national and local contexts and involves diverse ethnic groups.

Cost-effectiveness of critical time intervention to reduce homelessness among persons with mental illness.

OBJECTIVES: Cost-effective programs are needed to assist homeless persons with severe mental illness in their transition from shelters to community living. The authors investigated the cost-effectiveness of the critical time intervention program, a time-limited adaptation of intensive case management, which has been shown to significantly reduce recurrent homelessness among men with severe mental illness. METHOD: S: Ninety-six study participants recruited from a psychiatric program in a men's public shelter from 1991 to 1993 were randomly assigned to the critical time intervention program or to usual services. Costs and housing outcomes for the two groups were examined over 18 months. RESULTS: Over the study period, the critical time intervention group and the usual services group incurred mean costs of 52,374 dollars and 51,649 dollars, respectively, for acute care services, outpatient services, housing and shelter services, criminal justice services, and transfer income. During the same period, the critical time intervention group experienced significantly fewer homeless nights than the usual care group (32 nights versus 90 nights). For each willingness-to-pay value--the additional price society is willing to spend for an additional nonhomeless night--greater than 152 dollars, the critical time intervention group exhibited a significantly greater net housing stability benefit, indicating cost-effectiveness, compared with usual care. CONCLUSION: S: Although difficult to conduct, studies of the cost-effectiveness of community mental health programs can yield rich information for policy makers and program planners. The critical time intervention program is not only an effective method to reduce recurrent homelessness among persons with severe mental illness but also represents a cost-effective alternative to the status quo.