The influence of caregiver attitudes and socioeconomic group on formal and informal mental health service use among youth.

BACKGROUND: Young people can receive mental health care from many sources, from formal and informal sectors. Caregiver characteristics/experiences/beliefs may influence whether young people get help and the type of care or support used by their child. We investigate facilitators/barriers to receiving formal and/or informal care, particularly those related to the caregiver's profile. METHODS: We interviewed 1,400 Brazilian primary caregivers of young people (aged 10-19), participants of a high-risk cohort. Caregivers reported on young people's formal/informal mental health care utilization, and associated barriers and facilitators to care. Data were also collected on youth mental health and its impact on everyday life; and caregiver characteristics-education, socioeconomics, ethnicity, mental health, and stigma. Logistic regression models were used to examine the relationship between caregiver and young people characteristics with formal/informal care utilization. RESULTS: Persistence and greater impact of youth mental health conditions were associated with a higher likelihood of care, more clearly for formal care. Caregiver characteristics, however, also played a key role in whether young people received any care: lower parental stigma was associated with greater formal service use, and lower socioeconomic class showed higher odds of informal care (mainly from religious leaders). CONCLUSIONS: This study highlights the key role of the caregivers as gatekeepers to child treatment access, particularly parental stigma influencing whether young people received any mental health care, even in a low resource setting. These results help to map barriers for treatment access and delivery for young people, aiming to improve intervention efforts and mental health support.

The Child Mental Health Treatment Gap in an Urban Low-Income Setting: Multisectoral Service Use and Correlates.

OBJECTIVE: To efficiently target capacity-building efforts for child mental health services in low- and middle-income countries (LMICs), it is critical to define how care is structured across sectors and individual-level factors. METHODS: In a community-based sample of 1,408 children and adolescents (ages 6-15 years) from Itaboraí, Brazil, the authors assessed need and service use across four care systems (mental health specialty, health, welfare, and informal). Individual-level factors included child gender and age, maternal perception of child mental health need, paternal absence, maternal education, and maternal anxiety and depression. RESULTS: The mental health treatment gap was 88%, with only 12% of children with psychiatric problems using mental health services. Children with mental health problems were more likely than those without these problems to use health and other sectors of care and to use services in more than one sector of care. Overall, 46% of the children with any clinical mental health problems and 31% of those with only internalizing problems were identified by their mothers as having a mental health need. Among those with clinical mental health problems, factors associated with mental health service use were being a boy and paternal absence but not mental health problem type or maternal awareness. CONCLUSIONS: Closing the child mental health treatment gap in urban settings in LMICs where resources are scarce will likely require system-level changes, such as engagement of diverse service sectors of care. Interventions need to target increased maternal awareness about mental health problems and encourage provision of mental health services to girls.

Epidemiology of psychotropic drug use in Rio de Janeiro, Brazil: gaps in mental illness treatments.

OBJECTIVE: Estimate the prevalence of psychotropic drugs use in the city of Rio de Janeiro, Brazil, and establish its relationship with the presence of mental disorders. METHODS: A probabilistic sample of non-institutionalized individuals, from the general population of Rio de Janeiro (n = 1208;turn out:81%), 15 years or older, who were interviewed using the Composite International Diagnostic Interview 2.1 (depression, anxiety-phobia, OCD\PTSD, alcoholism sections), and asked about their psychotropic use during a 12 and one-month period before the interview. Data were collected between June/2007-February/2008.The prevalence was estimated with a confidence interval of 95%. The associations between psychotropics use and mental disorders were analyzed through a logistic regression model (Odds Ration - OR). RESULTS: The one-month prevalence of psychotropic drug use was 6.55%, 3.19% for men and 9.13% for women. Antidepressants were the most frequently used drug (2.78%), followed by anorectics (1.65%), tranquilizers (1.61%) and mood stabilizers (1.23%). General practitioners issued the highest number of prescriptions (46.3%), followed by psychiatrists (29.3%); 86.6% of the psychotropic drugs used were paid for by the patient himself. Individuals with increased likelihood of using psychotropic drugs were those that had received a psychiatric diagnosis during a one-month period before the study (OR:3.93), females (OR:1.82), separated/divorced (OR:2.23), of increased age (OR:1.03), with higher income (OR:2.96), and family history of mental disorder (OR:2.59); only 16% of the individuals with a current DSM IV diagnosis were using a psychotropic drug; 17% among individuals with a depression-related diagnosis and 8% with Phobic Anxiety Disorders-related diagnosis used psychotropics. CONCLUSION: Approximately 84% of individuals displaying some mental disorder did not use psychotropic drugs, which indicates an important gap between demand and access to treatment. A significant failure is evident in the health system for patients with mental disorders; this could be due to health workers' inability to recognize mental disorders among individuals.

[Exposure to violence and mental health problems in low and middle-income countries: a literature review]. / Exposição à violência e problemas de saúde mental em países em desenvolvimento: uma revisão da literatura.

OBJECTIVE: To study the epidemiological evidence on the prevalence of exposure to violence and its relationship with mental health problems in low and middle-income countries. METHOD: The search was based on cross-sectional and cohort studies available in electronic databases (Medline, Psycinfo, Embase, SciELO and Lilacs), through July 2009, using the key words: 'violence' and 'mental disorders'. RESULTS: The frequency of exposure to violence was shown to be very high and was significantly associated with mental health problems. Among children, the highest correlation was found to be of domestic violence with externalizing problems (OR = 9.5; 95% CI = 3.4-26.2), and suicidal ideation with sexual abuse (OR = 8.3; p < 0.05); among women, depression/anxiety symptoms correlated with intimate-partner psychological (OR = 3.2; 95% CI = 1.8-5.8) and sexual (OR = 9.7; 95% CI = 1.9-51.2) violence. In the general population, the highest prevalence rates of post-traumatic stress disorder were associated with sexual and domestic violence, kidnapping, and cumulative trauma exposure. Violence also correlated with common mental disorders. CONCLUSION: A substantial part of the mental health problems in low and middle-income countries can be attributed to violence. Thus, interventions directed to decrease violence in low and middle-income countries might have a major positive impact on the mental health of those living in these settings.

Exposição à violência e problemas de saúde mental em países em desenvolvimento: uma revisão da literatura / Exposure to violence and mental health problems in low and middle-income countries: a literature review

OBJETIVO: Estudar os achados epidemiológicos sobre a prevalência de exposição à violência e a associação entre exposição à violência e problemas de saúde mental em países em desenvolvimento. MÉTODO: A revisão foi baseada em estudos de corte transversal e de coorte encontrados em bases de dados eletrônicas (Medline, Psycinfo, Embase, SciELO e Lilacs) até o mês de julho de 2009. As palavras-chave utilizadas foram: "violência" e "transtornos mentais". RESULTADOS: Exposição à violência em países em desenvolvimento é bastante frequente e está significantemente associada a problemas de saúde mental. Em crianças, a maior associação encontrada foi entre violência doméstica e problemas de externalização (OR = 9,5; IC 95 por cento = 3,4-26,2), e entre ideação suicida e abuso sexual (OR = 8,3; p < 0,05); entre as mulheres, sintomas de depressão e ansiedade estão correlacionados com violência conjugal psicológica (OR = 3,2; IC 95 por cento = 1,8-5,8) e violência sexual (OR = 9,7; 95 por cento IC = 1,9-51,2). Na população geral, as maiores taxas de prevalência de transtorno de estresse pós-traumático estão associadas com violência sexual e doméstica, sequestro, e exposição a múltiplos eventos traumáticos. Violência também está associada com transtornos mentais comuns na população geral. CONCLUSÃO: uma parte importante dos problemas de saúde mental em países em desenvolvimento pode ser atribuída à violência. Portanto, intervenções voltadas para a redução da violência poderiam ter um impacto significativo na redução de problemas de saúde mental nesses países.

OBJECTIVE: To study the epidemiological evidence on the prevalence of exposure to violence and its relationship with mental health problems in low and middle-income countries. METHOD: The search was based on cross-sectional and cohort studies available in electronic databases (Medline, Psycinfo, Embase, SciELO and Lilacs), through July 2009, using the key words: "violence" and "mental disorders". RESULTS: The frequency of exposure to violence was shown to be very high and was significantly associated with mental health problems. Among children, the highest correlation was found to be of domestic violence with externalizing problems (OR = 9.5; 95 percent CI = 3.4-26.2), and suicidal ideation with sexual abuse (OR = 8.3; p < 0.05); among women, depression/anxiety symptoms correlated with intimate-partner psychological (OR = 3.2; 95 percent CI = 1.8-5.8) and sexual (OR = 9.7; 95 percent CI = 1.9-51.2) violence. In the general population, the highest prevalence rates of post-traumatic stress disorder were associated with sexual and domestic violence, kidnapping, and cumulative trauma exposure. Violence also correlated with common mental disorders. CONCLUSION: A substantial part of the mental health problems in low and middle-income countries can be attributed to violence. Thus, interventions directed to decrease violence in low and middle-income countries might have a major positive impact on the mental health of those living in these settings.

The posttraumatic stress disorder project in Brazil: neuropsychological, structural and molecular neuroimaging studies in victims of urban violence.

BACKGROUND: Life trauma is highly prevalent in the general population and posttraumatic stress disorder is among the most prevalent psychiatric consequences of trauma exposure. Brazil has a unique environment to conduct translational research about psychological trauma and posttraumatic stress disorder, since urban violence became a Brazilian phenomenon, being particularly related to the rapid population growth of its cities. This research involves three case-control studies: a neuropsychological, a structural neuroimaging and a molecular neuroimaging study, each focusing on different objectives but providing complementary information. First, it aims to examine cognitive functioning of PTSD subjects and its relationships with symptomatology. The second objective is to evaluate neurostructural integrity of orbitofrontal cortex and hippocampus in PTSD subjects. The third aim is to evaluate if patients with PTSD have decreased dopamine transporter density in the basal ganglia as compared to resilient controls subjects. This paper shows the research rationale and design for these three case-control studies. METHODS AND DESIGN: Cases and controls will be identified through an epidemiologic survey conducted in the city of São Paulo. Subjects exposed to traumatic life experiences resulting in posttraumatic stress disorder (cases) will be compared to resilient victims of traumatic life experiences without PTSD (controls) aiming to identify biological variables that might protect or predispose to PTSD. In the neuropsychological case-control study, 100 patients with PTSD, will be compared with 100 victims of trauma without posttraumatic stress disorder, age- and sex-matched controls. Similarly, 50 cases and 50 controls will be enrolled for the structural study and 25 cases and 25 controls in the functional neuroimaging study. All individuals from the three studies will complete psychometrics and a structured clinical interview (the Structured Clinical Interview for DSM-IV and the Clinician-Administered PTSD Scale, Beck Anxiety Inventory, Beck Depression Inventory, Global Assessment of Function, The Social Adjustment Scale, Medical Outcomes Study 36-Item Short-Form Health Survey, Early Trauma Inventory, Clinical global Impressions, and Peritraumatic Dissociative Experiences Questionnaire). A broad neuropsychological battery will be administered for all participants of the neuropsychological study. Magnetic resonance scans will be performed to acquire structural neuroimaging data. Single photon emission computerized tomography with [(99m)Tc]-TRODAT-1 brain scans will be performed to evaluate dopamine transporters. DISCUSSION: This study protocol will be informative for researchers and clinicians interested in considering, designing and/or conducting translational research in the field of trauma and posttraumatic stress disorder.