Non-standard diagnostic assessment reliability in psychiatry: a study in a Brazilian outpatient setting using Kappa.

The use of Structured Diagnostic Assessments (SDAs) is a solution for unreliability in psychiatry and the gold standard for diagnosis. However, except for studies between the 50 s and 70 s, reliability without the use of Non-SDAs (NSDA) is seldom tested, especially in non-Western, Educated, Industrialized, Rich, and Democratic (WEIRD) countries. We aim to measure reliability between examiners with NSDAs for psychiatric disorders. We compared diagnostic agreement after clinician change, in an outpatient academic setting. We used inter-rater Kappa measuring 8 diagnostic groups: Depression (DD: F32, F33), Anxiety Related Disorders (ARD: F40-F49, F50-F59), Personality Disorders (PD: F60-F69), Bipolar Disorder (BD: F30, F31, F34.0, F38.1), Organic Mental Disorders (Org: F00-F09), Neurodevelopment Disorders (ND: F70-F99) and Schizophrenia Spectrum Disorders (SSD: F20-F29). Cohen's Kappa measured agreement between groups, and Baphkar's test assessed if any diagnostic group have a higher tendency to change after a new diagnostic assessment. We analyzed 739 reevaluation pairs, from 99 subjects who attended IPUB's outpatient clinic. Overall inter-rater Kappa was moderate, and none of the groups had a different tendency to change. NSDA evaluation was moderately reliable, but the lack of some prevalent hypothesis inside the pairs raised concerns about NSDA sensitivity to some diagnoses. Diagnostic momentum bias (that is, a tendency to keep the last diagnosis observed) may have inflated the observed agreement. This research was approved by IPUB's ethical committee, registered under the CAAE33603220.1.0000.5263, and the UTN-U1111-1260-1212.

Inter-Rater Reliability between Structured and Non-Structured Interviews Is Fair in Schizophrenia and Bipolar Disorders-A Systematic Review and Meta-Analysis.

We aimed to find agreement between diagnoses obtained through standardized (SDI) and non-standardized diagnostic interviews (NSDI) for schizophrenia and Bipolar Affective Disorder (BD). METHODS: A systematic review with meta-analysis was conducted. Publications from 2007 to 2020 comparing SDI and NSDI diagnoses in adults without neurological disorders were screened in MEDLINE, ISI Web of Science, and SCOPUS, following PROSPERO registration CRD42020187157, PRISMA guidelines, and quality assessment using QUADAS-2. RESULTS: From 54231 entries, 22 studies were analyzed, and 13 were included in the final meta-analysis of kappa agreement using a mixed-effects meta-regression model. A mean kappa of 0.41 (Fair agreement, 95% CI: 0.34 to 0.47) but high heterogeneity (Î2 = 92%) were calculated. Gender, mean age, NSDI setting (Inpatient vs. Outpatient; University vs. Non-university), and SDI informant (Self vs. Professional) were tested as predictors in meta-regression. Only SDI informant was relevant for the explanatory model, leaving 79% unexplained heterogeneity. Egger's test did not indicate significant bias, and QUADAS-2 resulted in "average" data quality. CONCLUSIONS: Most studies using SDIs do not report the original sample size, only the SDI-diagnosed patients. Kappa comparison resulted in high heterogeneity, which may reflect the influence of non-systematic bias in diagnostic processes. Although results were highly heterogeneous, we measured a fair agreement kappa between SDI and NSDI, implying clinicians might operate in scenarios not equivalent to psychiatry trials, where samples are filtered, and there may be more emphasis on maintaining reliability. The present study received no funding.

COVID-19 and Immunization: Reflections and Rationale on Why Child and Adolescent Psychiatry Should Help.

The COVID-19 pandemic has resulted in widespread reflection in medical communities about the role of professional stakeholders in public health interventions. Health professionals, including mental health clinicians, should question how, when, and why they should intervene to address the obstacles and objections to these interventions.

Dream-Reality confusion: differential psychiatric diagnosis in narcoleptic subjects / Confusão sonho-realidade: diagnóstico psiquiátrico diferencial em narcolépticos

Dream-reality confusion (DRC) is the consequence of hypnagogic content confusion with real events and memories. Narcoleptic subjects eventually have DRC and can be misdiagnosed as schizophrenic or with another disorder with delusional or hallucinatory symptoms. Although dream-related experiences and hallucinatory perception share neurophysiological pathways, they are phenomenologically distinct. The lack of phenomenological intentionality in Dreamrelated perceptions, the different cognitive pathways for delusion generation, and other differences between mental disorders psychopathology, and DRC-related phenomena are here discussed. The lived world and awake experience interpretation, and dream neurobiology in narcoleptic subjects related to DRC, might indicate some hints for the mind-brain gap issue that still exists in neurology and psychiatry.

A confusão entre realidade e sonho (CRS) é a consequência da confusão do conteúdo hipnagógico com eventos e memórias reais. Sujeitos narcolépticos eventualmente têm CRS e podem ser diagnosticados erroneamente como esquizofrênicos ou com outro transtorno com sintomas delirantes ou alucinatórios. Embora as experiências relacionadas ao sonho e à percepção alucinatória compartilhem vias neurofisiológicas, elas são fenomenologicamente distintas. A falta de intencionalidade fenomenológica nas percepções relacionadas ao sonho, as diferentes vias cognitivas para a geração do delírio e outras diferenças entre a psicopatologia dos transtornos mentais e os fenômenos relacionados à CRS são discutidos aqui. A interpretação do mundo vivido e da experiência de vigília, e a neurobiologia dos sonhos em sujeitos narcolépticos relacionados à CRS, podem indicar algumas dicas para a questão do gap mente-cérebro que ainda existe na neurologia e na psiquiatria.

Patients and physician's self-assessment regarding clinical stability in severe mental disorders: a cross-sectional study / Autoavaliação de pacientes e médicos em relação à estabilidade clínica em transtornos mentais graves: um estudo transversal

OBJECTIVE: This study explores the relationship between patients' self-assessment and physicians' evaluation regarding clinical stability. METHODS: This cross-sectional study was carried out at the general outpatient clinic of the Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro (IPUB-UFRJ) in a large sample (1,447) of outpatients, of which 67.9% were patients with severe mental disorders (SMD). We collected information using a structured questionnaire developed for this purpose, filled in by the patient's physician. Clinical stability was assessed by means of five psychiatric instability criteria and by the physician's global clinical impression over the six previous months. The patients' self-assessment was based on a question about how they evaluated their health status: stable/better, worse, does not know. For the analyses, patients' self-evaluation was considered as our standard. RESULTS: The sample was composed of 824 (57%) women with an average age of 49 years. The most prevalent diagnoses within the SMD category corresponded to 937 patients, of whom 846 (90.3%) assessed themselves as stable/better. The physicians' evaluations agreed more with patients with bipolar disorders and less with schizophrenics regarding stability. As for patients with depressive disorder, physicians agreed more with them regarding instability. CONCLUSION: The data analysis confirms our hypothesis that the self- -assessment made by patients with SMD was accurate regarding their health condition, and that the self- -assessment made by patients who considered themselves stable agree with the physicians' evaluation.

OBJETIVO: Este estudo explora a relação entre a autoavaliação dos pacientes e a avaliação dos médicos quanto à estabilidade clínica. MÉTODOS: Trata-se de um estudo transversal realizado no ambulatório do Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro (IPUB-UFRJ) em uma ampla amostra de pacientes (1.447), dos quais 67,9% eram portadores de transtornos mentais graves (TMG). Coletamos informações por meio de um questionário estruturado desenvolvido para esse fim, preenchido pelo médico assistente. A estabilidade clínica foi avaliada por meio de cinco critérios de instabilidade psiquiátrica e pela impressão clínica global do médico, nos seis meses anteriores. A autoavaliação dos pacientes baseou-se em uma pergunta sobre como eles avaliavam seu estado de saúde: estável/melhor, pior, não sabe. Para as análises, a autoavaliação dos pacientes foi considerada como nosso padrão. RESULTADOS: A amostra foi composta por 824 (57%) mulheres, com idade média de 49 anos. Os diagnósticos mais prevalentes na categoria TMG corresponderam a 937 pacientes, dos quais 846 (90,3%) se avaliaram como estáveis/melhores. As avaliações dos médicos concordaram mais com pacientes portadores de transtorno bipolar e menos com esquizofrênicos em relação à estabilidade. Quanto aos pacientes com transtorno depressivo, os médicos concordaram mais com eles em relação à instabilidade. CONCLUSÃO: A análise dos dados confirma nossa hipótese de que a autoavaliação feita por pacientes com TMG foi precisa quanto à sua condição de saúde e que a autoavaliação feita por pacientes que se consideravam estáveis concorda com a avaliação dos médicos.

Intra-rater Kappa Accuracy of Prototype and ICD-10 Operational Criteria-Based Diagnoses for Mental Disorders: A Brief Report of a Cross-Sectional Study in an Outpatient Setting.

Background and Objectives: The use of "operational criteria" is a solution for low reliability, contrasting with a prototypical classification that is used in clinics. We aim to measure the reliability of prototypical and ICD-10 diagnoses. Methods: This is a retrospective study, with a convenience sample of subjects treated in a university clinic. Residents reviewed their diagnosis using ICD-10 criteria, and Cohen's kappa statistic was performed on operational and prototype diagnoses. Results: Three out of 30 residents participated, reviewing 146 subjects under their care. Diagnoses were grouped in eight classes: organic (diagnoses from F00 to F09), substance disorders (F10-F19), schizophrenia spectrum disorders (F20-F29), bipolar affective disorder (F30, F31, F34.0, F38.1), depression (F32, F33), anxiety-related disorders (F40-F49), personality disorders (F60-F69), and neurodevelopmental disorders (F70-F99). Overall, agreement was high [K = 0.77, 95% confidence interval (CI) = 0.69-0.85], with a lower agreement related to personality disorders (K = 0.58, 95% CI = 0.38-0.76) and higher with schizophrenia spectrum disorders (K = 0.91, 95% CI = 0.82-0.99). Discussion: Use of ICD-10 criteria did not significantly increase the number of diagnoses. It changed few diagnoses, implying that operational criteria were irrelevant to clinical opinion. This suggests that reliability among interviewers is more related to information gathering than diagnostic definitions. Also, it suggests an incorporation of diagnostic criteria according to training, which then became part of the clinician's prototypes. Residents should be trained in the use of diagnostic categories, but presence/absence checking is not needed to achieve operational compatible diagnoses.

How to define today a medical disorder? Biological and psychosocial disadvantages as the paramount criteria.

BACKGROUND: The 20th century has seen great developments in the concept of disease. Marked by the biopsychosocial paradigm, several strategies for disease definition were added to previous descriptive organic views, but a final concept is still out of reach. METHOD: A critical review was carried out on thorough analysis of articles and textbooks to describe the main concepts and definitions of disease. RESULTS: The concept 'disease' is a pragmatic construct, not a natural kind. Three main ways to define disease were identified, and characterized: Biological (disease as a lesion, disadvantage/deviation from normal and dysfunction), Psychosocial (distress and disability, existential potentials, descriptive prototype, and prototype typification), and values-based definition. CONCLUSION: All the paradigms have advantages and flaws, but progressive use of all criteria in disease definition adds validity and reliability to diagnostic constructs. Such constructs must be, above all, useful for practice and research. Biological paradigm is relevant, but fails to cover all the complexity that involves human illness and the treatment process. An emphasis on distress, dysfunction, and carefully selected value-laden characteristics might be the right direction for useful diagnostic construct conceptions.

The Weekly Study Meeting in Psychiatry of the Institute of Psychiatry - Federal University of Rio de Janeiro: 70-years of culture and scientific dissemination / O Encontro Semanal do Centro de Estudos do Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro: 70 anos de divulgação cultural e científica

OBJECTIVE: To describe the history of creation, development, and topics covered by the Study Center of the Institute of Psychiatry of the Federal University of Rio de Janeiro (CE ­ IPUB/UFRJ) over its 70 years. METHODS: Research in newspapers of the Hemeroteca Brasileira Digital, internal documents of IPUB/UFRJ, and interviews with eyewitnesses of the functioning of the CE. RESULTS: The Study Center has been operating on an uninterrupted basis for 70 years, every week. 472 events have been identified since the founding of the CE, but numerous other meetings have taken place. The findings were described in three major groups: 1. Academic meetings in the first half of the 20th century and insertion of the CE in the history of IPUB; 2. Topics discussed and presentations; 3. Changes in periodicity and format. CONCLUSIONS: The CE produces cultural and scientific dissemination continuously since its foundation. The type and format of events have changed over time, adapting to the needs of their community, but always serving as an important beacon for the training of specialists in mental health, dissemination of research, and tendencies about psychiatry worldwide, Latin America, and Brazil.

OBJETIVO: Descrever a história da criação e do desenvolvimento e os temas abordados pelo Centro de Estudos do Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro (CE ­ IPUB/UFRJ) ao longo de seus 70 anos. MÉTODOS: Pesquisa em jornais da Hemeroteca Brasileira Digital, documentos internos do IPUB/UFRJ e entrevistas com testemunhas oculares do funcionamento do CE. RESULTADOS: O Centro de Estudos funciona de maneira ininterrupta há 70 anos, semanalmente. Desde sua fundação, 472 eventos foram identificados, mas outros inúmeros encontros ocorreram. Os achados foram divididos e descritos em três grandes grupos: 1. Encontros acadêmicos na primeira metade do século XX e inserção do CE na história do IPUB; 2. Temas debatidos e apresentações; 3. Mudanças de periodicidade e formato. CONCLUSÕES: O CE produz divulgação cultural e científica continuamente desde sua fundação. O tipo e o formato dos eventos mudaram ao longo do tempo, adaptando-se às necessidades de sua comunidade, mas sempre servindo como um importante farol para a formação de especialistas em saúde mental e divulgação de pesquisas, apresentando as tendências da psiquiatria mundial, latino-americana e brasileira.

Student's confidence in mental health practice before and after psychiatry rotation: a follow up study / Autoconfiança dos alunos para a prática em saúde mental antes e depois do internato em psiquiatria: um estudo de seguimento

ABSTRACT Objectives The primary objective was to measure the effect of psychiatry rotation in students self-confidence (SC) for managing mental health (MH) issues. Methods An eighteen questions version of "Preparation for Hospital Practice Questionnaire" (PHPQ) adapted for MH was applied before, after and six months later the psychiatry rotation. Sociodemographic and experience with mental illness was measured as confounding factors. Results Hundred and ten students were recruited and four factors were identified: "Diagnosis elaboration and basic care" (F1), "Crisis management and prevention" (F2), "External sickness determinants" (F3) and "Personal distress with clinics" (F4). Cronbach Alpha ranged from 0.71 to 0.90. Previous MH training were not frequent (9.09%), and associated with better SC in F2 (after p < 0.05, 6m p = 0.03). Previous mental disorder was frequent (42.16%), and associated with more SC on F2 (p < 0.01) and F3 (p = 0.03) before course, but only on F3 after (p < 0.01) and not 6 months later. Male gender had more SC in F4 (p < 0.01) before course, but after course and 6m later female gender became more SC in F1 (after p = 0.02, 6m p = 0.01) and equivalent in F4. All factors had higher scores after and 6 months later (p < 0.001). The class considered that an interview script is very important for their SC, and improves assistance (mean > 9.0/10.0). Conclusion Obligatory rotation in MH improved SC in students. Previous training and gender were related with long lasting effects in SC.

RESUMO Objetivos Avaliar os efeitos de empoderamento do internato em saúde mental (SM) na autoconfiança (AC) dos alunos de Medicina. Métodos Uma versão adaptada para a saúde mental do "Questionário de Preparação para Prática Hospitalar" foi aplicada antes, depois e seis meses após o internato. Resultados Cento e dez alunos participaram e quatro fatores foram extraídos: "Elaboração diagnóstica e cuidados básicos" (F1), "Gestão e prevenção de crise" (F2), "Determinantes externos de adoecimento" (F3) e "Sofrimento pessoal com a clínica" (F4). Treinamento prévio em SM é incomum (9,09%), mas foi associado com pontuações mais altas em F2 (p = 0,05 e 6m p = 0,03). Tratamento prévio em SM (42,16% dos alunos) foi associado a valores mais altos em F2 (p < 0,01) e F3 (p = 0,03) antes, mas apenas em F3 (p < 0,01) após o curso. O gênero masculino apresentou valores mais positivos que o feminino em F4 (p < 0,01) antes, mas não após o curso, quando apresentaram valores mais baixos em F1 (após p = 0,02, 6m p = 0,01). Todos os fatores apresentaram valores mais altos após o curso (p < 0,001). Os alunos consideraram o uso de uma entrevista estruturada muito importante para sua autoconfiança e qualidade da assistência (média > 9,0/10,0). Conclusão O internato em SM aumentou a AC nos alunos. Treinamento prévio e gênero estiveram associados com efeitos duradouros na AC.

Um estudo longitudinal sobre a influência do internato em saúde mental na redução de atitudes negativas de estudantes de Medicina em relação a portadores de transtornos mentais / A longitudinal study on the impact of mental health internship in reducing negative attitudes of medical students towards people with mental disorders

RESUMO Objetivo Avaliar o efeito do internato em saúde mental nas atitudes dos alunos de medicina quanto ao portador de transtorno mental (PTM). Métodos Atitudes foram avaliadas por questionário antes e depois do internato, por meio dos fatores: "aceitação social de PTM" (F1), "não acreditar em causas sobrenaturais para doença mental" (F2), "papéis sociais comuns para PTM" (F3), "acreditar em causas psicossociais para doença mental" (F4), "intimidade" (F5). Diferenças foram avaliadas por meio de testes t, fatores confundidores por ANOVA e correlações entre expectativa de melhora e fatores por Pearson. Resultados 74 de 85 alunos responderam ao questionário. Houve redução significativa em quatro fatores avaliados (F1, p < 0,001, F2, p = 0,002, F3, p = 0,04, F5, p < 0,001). Uma associação entre ter um amigo PTM e F3 foi identificada antes do curso (p = 0,04), porém não após (p = 0,13). Houve correlação positiva entre crenças de melhora e atitudes negativas com o F2 antes do curso (p = 0,01), mas não após. F5 esteve relacionado com a expectativa de melhora (p < 0,001) após o curso, indicando melhores atitudes quando melhor expectativa. Observou-se a melhora da expectativa quanto a resposta ao tratamento da esquizofrenia (p = 0,02), transtorno bipolar (p = 0,03) e transtorno de ansiedade (p = 0,03). Conclusões O internato esteve associado à redução de atitudes negativas com relação aos PTMs. O contato direto com o paciente parece ter influência direta nessa redução. Acreditamos que, mais importante do que possíveis efeitos de esclarecimento sobre causas do adoecimento, a desconstrução do mito sobre o louco violento é essencial para a melhora das atitudes. Estudos com populações de outras regiões do Brasil e voltadas para avaliação do medo de violência são necessários para a confirmação dessa hipótese e do efeito do internato sobre os alunos.

ABSTRACT Objective To evaluate and measure the effects of mental health internship on Medicine Students (MS) attitudes towards people with mental illness (PMI). Methods MS was submitted to an attitude questionnaire previously and after the mental health internship. Their attitudes were measured inside five factors: (F1) "social acceptance of PMI", (F2) "normalizing roles for PMI", (F3) "non-belief in supernatural causes for mental illness", (F4) "belief in bio-psychosocial causes for mental illness," and (F5) "near contact with PTM". T-tests were used to evaluate factor differences, confounding factor were analyzed by ANOVA and correlations through Pearson's correlation test. Results 74 of 85 students responded. There were a significant reduction in four factors (F1, p < 0.001, F2, p = 0.002, F3, p = 0.04, F5, p < 0.001). An association between having a PMI friend and F3 was identified before the course (p = 0.04), but not after (p = 0.13). A positive correlation was identified between belief in disease improvement and negative F2 attitudes before course (p = 0.01), but not after (0.40). F5 was related with disease improvement after course (p < 0.001), suggesting positive attitudes when improvement is expected. There were an increase in improvement expectations after course for schizophrenia (p = 0.02), bipolar disorder (p = 0.03) and anxiety (p = 0.03). Conclusions Mental health internship was related to a decrease in negative attitudes towards PMI. Personal contact seems to influence this improvement. We believe that the reduction of fear toward PMI is more powerful to reduce stigma than the acquisition of knowledge about its natural causes. More studies with a regionally distinct population in Brazil and aimed to measure the impact of fear are necessary to confirm this hypothesis.

Mental State Examination and Its Procedures-Narrative Review of Brazilian Descriptive Psychopathology.

Background: Mental State Examination (MSE) is compared with physical examination as a reliable method of objective data investigation. There is a growing concern with psychiatric clinics, nosology, and the reliability of diagnostic interview methods as a source of valid diagnostic strategy. Efforts to achieve an international diagnosis protocol have been unsuccessful or polemical. This paper focuses on psychopathology, MSE, and mental function development within Brazilian psychiatry over the last few decades. Methods: Searches, interviews, and narrative reviews were done to look for systematic ways in which to conduct MSE, mental functions, symptom clusters, orientations about data observation and records. Brazilian psychopathology textbooks were examined, if they provided access to consolidated knowledge on psychopathology examination. Results: Sixteen textbooks were selected from a 49 year span. Descriptive psychopathology with phenomenological orientation was the primary trend in the MSE. Concepts derived from different traditions, most lacking common terminology, suggested some divergence among authors. Recommendations for patient observation and how to collect objective data was clear, but MSE standardization efforts were missing. A detailed description of mental function abnormalities was the main MSE record strategy, without consensus about ways to summarize and record this data. In an examination summary, mental strata was divided into "mental functions," and MSE subsets were frequent. All authors considered the following mental functions: consciousness, perception, thought, memory, attention, orientation, and volition. Discussion: Psychiatric competence demands MSE proficiency. Official documents are not clear about performance and recording standards. MSE data was usually recorded through descriptive psychopathology. A shift from detailed descriptive findings, to an array of observed pathological elements, described through a mental function checklist was observed over time. Clinical practice and research guidelines should consider the development of reliable MSE practices; however, it has been neglected by modern psychiatry/neuroscience through the excessive emphasis on interview protocols. Better MSE practices, and the improvement of bedside skill in psychiatry are necessary and depend on the recovery of psychopathological debates and semiological reasoning, which will allow the return of phenomenology-oriented "observational" techniques.

Attitudes of Brazilian Medical Students Towards Psychiatric Patients and Mental Illness: A Quantitative Study Before and After Completing the Psychiatric Clerkship.

OBJECTIVE: The authors evaluated whether a psychiatric clerkship reduces stigmatized attitudes towards people with mental illness among medical students. METHODS: A 56-item questionnaire was used to assess the attitudes of medical students towards patients with mental illness and their beliefs about its causes before and after their participation in their psychiatric clerkship at a major medical school in Rio de Janeiro. Exploratory factor analysis identified four factors, reflecting "social acceptance of people with mental illness," "normalizing roles for people with mental illness in society," "non-belief in supernatural causes for mental illness," and "belief in bio-psychosocial causes for mental illness." Analysis of variance was used to evaluate changes in these factors before and after the clerkship. RESULTS: One significant difference was identified with a higher score on the factor representing social acceptance after as compared to before the clerkship (p = 0.0074). No significant differences were observed on the other factors. CONCLUSION: Participation in a psychiatric clerkship was associated with greater social acceptance but not with improvement on other attitudinal factors. This may reflect ceiling effects in responses before the clerkship concerning supernatural and bio-psychosocial beliefs about causes of mental illness that left little room for change.

Cross-National Analysis of Beliefs and Attitude Toward Mental Illness Among Medical Professionals From Five Countries.

This quantitative study sought to compare beliefs about the manifestation, causes and treatment of mental illness and attitudes toward people with mental illness among health professionals from five countries: the United States, Brazil, Ghana, Nigeria, and China. A total of 902 health professionals from the five countries were surveyed using a questionnaire addressing attitudes towards people with mental illness and beliefs about the causes of mental illness. Chi-square and analysis of covariance (ANCOVA) were used to compare age and gender of the samples. Confirmatory factor analysis was employed to confirm the structure and fit of the hypothesized model based on data from a previous study that identified four factors: socializing with people with mental illness (socializing), belief that people with mental illness should have normal roles in society (normalizing), non-belief in supernatural causes (witchcraft or curses), and belief in bio-psycho-social causes of mental illness (bio-psycho-social). Analysis of Covariance was used to compare four factor scores across countries adjusting for differences in age and gender. Scores on all four factors were highest among U.S. professionals. The Chinese sample showed lowest score on socializing and normalizing while the Nigerian and Ghanaian samples were lowest on non-belief in supernatural causes of mental illness. Responses from Brazil fell between those of the U.S. and the other countries. Although based on convenience samples of health professional robust differences in attitudes among health professionals between these five countries appear to reflect underlying socio-cultural differences affecting attitudes of professionals with the greater evidence of stigmatized attitudes in developing countries.