[Reliability of diagnostic instruments: investigating the psychiatric DSM-III checklist applied to community samples]. / Confiabilidade de instrumentos diagnósticos: estudo do inventário de sintomas psiquiátricos do DSM-III aplicado em amostra populacional.

This study focused on the reliability of the DSM-III inventory of psychiatric symptoms in representative general population samples in three Brazilian cities. Reliability was assessed through two different designs: inter-rater reliability and internal consistency. Diagnosis of lifetime (k = 0.46) and same-year generalized anxiety (k = 1.00), lifetime depression (k = 0.77), and lifetime alcohol abuse and dependence (k = 1.00) was consistently reliable in the two methods. Lifetime diagnosis of agoraphobia (k = 1.00), simple phobia (k = 0.77), non-schizophrenic psychosis (k = 1.00), and psychological factors affecting physical health (1.00) showed excellent reliability as measured by the kappa coefficient. The main reliability problem in general population studies is the low prevalence of certain diagnoses, resulting in small variability in positive answers and hindering kappa estimation. Therefore it was only possible to examine 11 of 39 diagnoses in the inventory. We recommend test and re-test methods and a short time interval between interviews to decrease the errors due to such variations.

[Psychiatric cases identification by multi-step epidemiological studies: methods, problems and applicability]. / Identificação de casos psiquiátricos em estudos epidemiológicos multifásicos: métodos, problemas e aplicabilidade.

OBJECTIVE: To discuss methodological aspects of the two stages in the identification of psychiatric cases in epidemiological studies. METHODS: Analyze the methodology used in the Multicentric Psychiatric Morbidity Study, which was conducted in three Brazilian cities (São Paulo, Brasília and Porto Alegre). In the first stage of that study, a random sample (6,740 individuals) of the population was drawn and all the participants were screened with the Questionnaire of Psychiatric Morbidity of the Adult (QMPA). In the second stage, a sample (775 individuals) of this population was drawn and these individuals were submitted to the Inventory of Symptoms of DSM-III, carried out by psychiatrists and trained psychologists. RESULTS: The study procedure for estimating the prevalence is described in details, showing that though the screening scales are a weak tool, they don't interfere with the methodology. CONCLUSION: The advantage of this methodology is to correct any distortions caused by the current tools used in the identification of psychiatric cases.

Gender and minor psychiatric morbidity: results of a case-control study in a developing country.

OBJECTIVE: Women suffer from minor psychiatric disorders (MPM) more frequently than men. Most of the studies were conducted in England and in the United States and some reported the higher occurrence of MPM among women to be modified by marital status and others by sociodemographic variables. The present study intends to address this question in a developing country. METHOD: A population based case-control study was conducted in three important urban centers in Brazil. Two hundred seventy-six individuals diagnosed as new cases of MPM and 261 controls were selected to investigate the role of a set of sociodemographic variables in the association between gender and MPM using logistic regression models. RESULTS: Univariate analysis showed that women were more likely than men to suffer from MPM (OR = 3.34; 2.27-4.91). After controlling for other sociodemographic variables, female gender was still positively associated with MPM, but not in a homogeneous way. A multiplicative interaction of gender with age group was found (LRT = 6.01; 2 df; p = 0.05) suggesting an increment in the magnitude of the association among those older than thirty years. Odds-ratios were 2.33 (1.19-4.55), 6.85 (2.86-16.41), and 7.47 (2.90-19.22) for age groups of fourteen to twenty-nine; thirty to forty-four; forty-five or more, respectively. There was no evidence of interaction of gender with marital status or other sociodemographic variables. CONCLUSIONS: The findings are consistent with the modification of the association between gender and MPM being mediated by social factors.

[Collective health: a "new public health" or field open to new paradigms?]. / Saúde coletiva: uma "nova saúde pública" ou campo aberto a novos paradigmas?

The present essay is an exploratory study of the historical and institutional background of the so-called "crisis in public health", aimed at identifying the new trends and perspectives for the paradigmatic transformation of the health field in the context of the current international panorama of economic and cultural globalization. First, the rhetoric of health is analysed in historical perspective, briefly considering the main elements of the discourse of the ideological movements that historically built the social field of health. Medical Police, Social Medicine and Public Health are included as representative of such movements in 19th century Western Europe. After the Flexnerian turn, these movements were followed by Preventive Medicine, Community Health, Primary Health Care and Health Promotion, which dominated the scene particularly in the second half of the 20th century. The authors also summarise recent concerted PAHO efforts to debate the theory and practice of Public Health in the Americas, vis à vis the emerging demands of the economic, political and social context of Latin American countries. In this regard, the need for a common political agenda is emphasized, with the convergence of three topics-sectorial reform, "Renovation of Health for All" and the "new public health", covering the conceptual, methodological and operative domains. Secondly, a brief systematic account of the conceptual landmarks of the Collective Health movement, as carried through in the two last decades in Latin America, is presented, focusing more particularly on its potential for building up both a domain of transdisciplinary knowledge and a universe of practices. As a field of knowledge, it contributes to the study of health-disease phenomena in populations as a social process, investigating the production and distribution of disease in society as an aspect of social reproduction, and analysing health practices as a labor process integrated into the other social practices. As a universe of practices, Collective Health focuses on its models or action guidelines four objects of intervention: policies (forms of power distribution); practices (behavior modification; culture; institutions; knowledge production; institutional, professional and relational practices); technologies (organization and regulation of productive resources and processes; bodies/environments), and instruments (means of production of interventions). Finally, it is concluded that, although not being in itself a paradigm, Collective Health, as a movement committed to the social transformation of health, presents some possibilities of articulation with new scientific paradigms capable of approaching the health-disease-care object with due regard to its historicity and complexity.

[Proxy informant reliability and bias in epidemiological research: analysis of a screening questionnaire for mental disorders]. / Confiabilidade e viés do informante secundário na pesquisa epidemiológica: análise de questionário para triagem de transtornos mentais.

OBJECTIVES: To evaluate the reliability, magnitude and direction of the resulting bias in the application of a screening instrument for mental disorders by considering proxy informants in comparison to primary informants. METHODS: Data are taken from a general morbidity community-based survey carried out in 520 randomly selected households of an industrial area of the Metropolitan Region of Salvador, the capital of Bahia state, Brazil. During the pilot phase, the first 70 families of the total sample were asked to participate in the evaluation of research instruments. The Questionnaire of Adult Psychiatric Morbidity, QAPM, consists of 44 questions about psychiatric symptoms widely used in Brazil. The husbands and wives of the selected families answered QAPM questions regarding themselves and their respective partners. One family refused to participate. The Kappa index was estimated for each QAPM question. To assess the magnitude and direction of bias, the proportional variation of prevalence was estimated from proxy and primary respondents. Each informant was analyzed as a primary informant when answering about his/her own symptoms and as a proxy informant when answering those about his/her partner. RESULTS: Proxy informants as compared to primary informants show weak reliability, as measured by the Kappa Index, particularly when husbands reported on their wives' symptoms. An overall underestimation of prevalence estimates was found, which reveals the potential negative bias with the use of proxy informants for psychological symptoms. No bias was found for only two questions (lack of appetite and globus hystericus) when women were taken as proxy informants for their husbands. In addition, departures of proxy informants from primary informant-based estimates were greater among men than to women. CONCLUSIONS: Proxy informants underestimate the occurrence of psychological symptoms in this community-based study. When the feasibility of a research project, based on the QAPM depends on the use of proxies, wives may be recommended as better informants than their husbands.

Minor psychiatric morbidity and internal migration in Brazil.

Studies of non-psychotic disorders in migrants have shown inconsistent results. This paper reports the findings of a case-control study carried out in three cities in Brazil to investigate the association between migration and minor psychiatric morbidity (MPM). Two hundred and seventy-six cases and 261 controls were selected from a survey of 6740 people aged 15 years or more. Diagnoses were made using the DSM-III Symptom Checklist. A statistically significant increase in risk of MPM in migrants was found by univariate analysis [odds ratio (OR) = 1.76; 95% confidence interval (CI) = 1.21-2.57. After controlling for gender, age, educational level, marital status, place of residence and position in the labour market, the overall increase in risk of MPM disappeared (OR = 1.02; 95% CI = 0.64-1.64), but a statistically significant increase in risk was present only in migrant unemployed women. This finding did not support models that explain risk in migrants by viewing migration as associated with cultural change and stressful life events. On the other hand, models based on the concept of selection- displacement from the labour market are more consistent with the present findings.

[The factor structure of the adult psychiatry morbidity questionnaire in a community sample of Brazilian cities]. / Estrutura fatorial do questionário de morbidade psiquiátrica de adultos aplicado em amostras populacionais de cidades brasileiras.

Principal Components Analysis is a multivariate statistical technique for the purpose of examining the interdependence among variables. The main characteristic of this technique is the ability to reduce data, and it is currently used as an adjunct for the development of psychiatric research tools and the classification of psychiatric disorders. It has been applied to the study of the Factorial Structure of a Brazilian screening questionnaire, the Adult Psychiatric Morbidity Questionnaire (QMPA). The questionnaire is made up of 45 yes/no items for the identification of psychiatric symptoms and the use of psychiatric services and psychotropic drugs. The questionnaire was applied to 6.470 subjects over 15 years old in representative samples from three urban areas: Brasília, Porto Alegre and S. Paulo. Seven factors were found to explain 42.7% of the total variance: Anxiety/Somatization (eigenvalue = 3.81, 10.9%); Irritability/Depression (eigenvalue = 2.41, 6.9%); Cognitive Impairment (eigenvalue = 2.01, 5.8%); Alcoholism (eigenvalue = 1.90, 5.4%); Mood Elation (eigenvalue = 1.62, 4.6%); Hallucinatory/Delusional Disorders (eigenvalue = 1.60, 4.6%); and Drug/Therapies (eigenvalue = 1.60, 4.5%). A similar pattern of results was found when the analysis was carried out in the three places. It is suggested, on the banis of these findings, that some questions should be modified and some excluded in any future version of the questionnaire.

[Prevalence of headache as an symptom in a urban area of Salvador, Bahia]. / Prevalência de cefaléia como sintoma em um setor urbano de Salvador, Bahia.

The prevalence of headache was studied as part of an epidemiologic survey of neuropsychiatric disorders carried out with an adult sample (N = 1,511) of an urban area of Salvador City, Bahia, Brazil. The overall prevalence of headache complaints was 14.8%, significantly higher among the eldest, female, less educated, migrants, unemployed, low SES and married/divorced. Stratified analysis for age and gender as confounders erased out the effect of marital status and socio-economic status indicators. The presence of psychiatric disorders was strongly, significantly associated with the prevalence of headache (odds ratio of 4.2). These results are compared to the international literature, emphasizing the extremely lower rates found as well as the profiles of risk factors completely distinct from those reported in other sociocultural realities.

Is there an epidemic of drug misuse in Brazil? A review of the epidemiologic evidence (1977-1988).

A critical review is presented of methods and findings of epidemiological studies on drug use carried out in Brazil. Studies of the first phase (1977-1986) suffered from serious flaws but tended to produce inflated rates, as compared to studies conducted after 1987, which used better case definition criteria and sampling strategies. Prevalence of consumption of legal substances was comparable to industrialized countries but lifetime use of illicit drugs in the country tended to be much lower. In conclusion, there is no support from epidemiologic studies for the hypothesis of an epidemic of drug addiction in Brazil nowadays.

Hypertension in Brazil: a review of the epidemiological evidence.

Population-based studies of hypertension in Brazil were reviewed. Nineteen studies were identified, all employing cross-sectional study designs. The majority of these studies were conducted in the south and southeast regions of the country, although increasing mortality from cardiovascular diseases is now a nationwide problem in Brazil. Except for Amazonian Indians, age and blood pressure were positively correlated in the studies reviewed. Men generally had higher blood pressures than women up to age 50; studies consistently reported that blacks, or groups combining blacks and mulattoes, had higher blood pressures than whites. Methodological problems that characterize many of these studies were noted, and some suggestions for future research were offered.

[Socioeconomic variables, family milieu, and child mental health in an urban area of Salvador (Bahia), Brazil]. / Variables económicosociales, ambiente familiar y salud mental infantil en un área urbana de Salvador (Bahía), Brasil.

Seeking an association among SEVs, parent's mental health, early family milieu, and children's mental health through an epidemiological survey on a representative 545-child sample from low income squatter population of the city of Salvador was the author's hypothesis. QMPA and QMPI were used to assess the mental health status of parents and children, respectively. A specific questionnaire collected data on social-economic variables, and the HOME inventory was used to measure the quality of stimulation within home environment. For data analysis linear, and multiple regression techniques were resorted to, stratified by children's age and sex as well as parents' working position. In the multiple regression analysis, a strong, significant relationship was found between quality of family environment and indicators of child mental health, consistent throughout all strata analyzed--and even stronger among females involved. Results do not point out a direct influence of parents' mental health, except--in the second set of variables--through the influence of an early family environment.

Variables económicosociales, ambiente familiar y salud mental infantil en un área urbana de Salvador (Bahía), Brasil. / [Socioeconomic variables, family milieu, and child mental health in an urban area of Salvador (Bahia), Brazil]

Seeking an association among SEVs, parents mental health, early family milieu, and childrens mental health through an epidemiological survey on a representative 545-child sample from low income squatter population of the city of Salvador was the authors hypothesis. QMPA and QMPI were used to assess the mental health status of parents and children, respectively. A specific questionnaire collected data on social-economic variables, and the HOME inventory was used to measure the quality of stimulation within home environment. For data analysis linear, and multiple regression techniques were resorted to, stratified by childrens age and sex as well as parents working position. In the multiple regression analysis, a strong, significant relationship was found between quality of family environment and indicators of child mental health, consistent throughout all strata analyzed--and even stronger among females involved. Results do not point out a direct influence of parents mental health, except--in the second set of variables--through the influence of an early family environment.

Social epidemiology of mental disorders. A review of Latin-American studies.

This paper reviews the literature about the relationships between cultural change and psychopathology produced by Latin American researchers. With the analysis of 22 epidemiological studies, the author shows how culture has been traditionally viewed by social psychiatric research in Latin America as an independent variable associated with the prevalence of mental disorders. Two basic approaches have been analyzed: one of anthropological origin and the other based on sociological explanations. The hypotheses of cultural shock, stress of acculturation and cultural marginalization belong to the first approach, while the second one is manifested by the notions of urban stress, life change, social support and goal-striving stress. Methodological issues were brought about to evaluate the results on the association of cultural processes and psychopathology available in contemporary socio-psychiatric research in Latin America.

[Relation between the parents' mental health and the mental health of children in an urban population of Salvador-Bahia]. / Relacões entre a saúde mental dos pais e a saúde mental das crianças em uma populaçao urbana de Salvador-Bahia.

An epidemiological study of the correlation between parent's mental status and children's psychological health was completed in a representative sample of 1516 adults and 829 children, living in a low-income area of the City of Salvador, Bahia-Brazil. Trained interviewers applied a family questionnaire (20 items on demographic and socio-economic information) and screening symptom scales to all the families (493) in the sample. The survey employed the QMPA (Adult Psychiatric Morbidity Questionnaire) and the QMPI (Child Psychiatric Morbidity Questionnaire), as instruments developed and tested especially for studies in that sociocultural setting. A second step of the survey consisted of a psychiatric examination of all suspected cases, thus allowing for an assessment of validity and reliability of both questionnaires, that showed high sensitivity, specificity and adequate overall misclassification rates. A multiple regression analysis was performed on selected variables. Results showed that mother's scores, family size and child's age are the only variables that reach significance levels to enter the regression model. Father's score showed no isolated effect on children's mental health variation even in interaction with other covariates. However, all the fitted equation explain only 16 per cent of the total regression on the dependent variable.

Relacoes entre a saúde mental dos pais e a saúde mental das crianþas em uma populaþao urbana de Salvador-Bahia. / [Relation between the parents mental health and the mental health of children in an urban population of Salvador-Bahia]

An epidemiological study of the correlation between parents mental status and childrens psychological health was completed in a representative sample of 1516 adults and 829 children, living in a low-income area of the City of Salvador, Bahia-Brazil. Trained interviewers applied a family questionnaire (20 items on demographic and socio-economic information) and screening symptom scales to all the families (493) in the sample. The survey employed the QMPA (Adult Psychiatric Morbidity Questionnaire) and the QMPI (Child Psychiatric Morbidity Questionnaire), as instruments developed and tested especially for studies in that sociocultural setting. A second step of the survey consisted of a psychiatric examination of all suspected cases, thus allowing for an assessment of validity and reliability of both questionnaires, that showed high sensitivity, specificity and adequate overall misclassification rates. A multiple regression analysis was performed on selected variables. Results showed that mothers scores, family size and childs age are the only variables that reach significance levels to enter the regression model. Fathers score showed no isolated effect on childrens mental health variation even in interaction with other covariates. However, all the fitted equation explain only 16 per cent of the total regression on the dependent variable.

[Internal migration and mental disorders: new evidence for an old hypothesis]. / Migrações internas e desordens mentais: novas evidências para uma velha hipótese.

The relationships between migration and mental illness have been perhaps the most important research topic of Social Psychiatry. Studies on this issue conducted in Latin America have in general reached the conclusion that migration, and the experience of modernization related to it, is a major risk factor of emotional disturbance. This hypothesis was tested with data from a survey based on a representative sample of 1549 adults living in a low-income neighborhood in Bahia, Brazil. The survey employed the QMPA, a 43-item symptom scale which was developed and tested especially for studies in that sociocultural setting; it showed high sensitivity (.93) and specificity (.72) and adequate overall misclassification rate (.12). Seven trained interviewers applied a family questionnaire (20 items on demographic and socioeconomic information) and the QMPA to all the families (493) in the sample. Multiple classification analysis and covariance analysis were used to control for the effect of potential confounding factors. Crude analyses showed a statistically significant association between migration status and poor mental health. However, taking into account the combined effect of age, marital status and education as confounders resulted in non-significant levels for the association under study. Sex and economic position, despite being themselves related to emotional disturbances, did not appear as confounders or interaction terms in these analyses. The results on rural-urban origin did not provide any evidence in support to the modernization hypothesis.

Migraþoes internas e desordens mentais: novas evidÛncias para uma velha hipótese. / [Internal migration and mental disorders: new evidence for an old hypothesis]

The relationships between migration and mental illness have been perhaps the most important research topic of Social Psychiatry. Studies on this issue conducted in Latin America have in general reached the conclusion that migration, and the experience of modernization related to it, is a major risk factor of emotional disturbance. This hypothesis was tested with data from a survey based on a representative sample of 1549 adults living in a low-income neighborhood in Bahia, Brazil. The survey employed the QMPA, a 43-item symptom scale which was developed and tested especially for studies in that sociocultural setting; it showed high sensitivity (.93) and specificity (.72) and adequate overall misclassification rate (.12). Seven trained interviewers applied a family questionnaire (20 items on demographic and socioeconomic information) and the QMPA to all the families (493) in the sample. Multiple classification analysis and covariance analysis were used to control for the effect of potential confounding factors. Crude analyses showed a statistically significant association between migration status and poor mental health. However, taking into account the combined effect of age, marital status and education as confounders resulted in non-significant levels for the association under study. Sex and economic position, despite being themselves related to emotional disturbances, did not appear as confounders or interaction terms in these analyses. The results on rural-urban origin did not provide any evidence in support to the modernization hypothesis.