Neuroimaging and clinical features in adults with a 22q11.2 deletion at risk of Parkinson's disease.

The recurrent 22q11.2 deletion is a genetic risk factor for early-onset Parkinson's disease. Adults with the associated 22q11.2 deletion syndrome (22q11.2DS) may exhibit phenotypes that could help identify those at highest risk and reveal disease trajectories. We investigated clinical and neuroimaging features relevant to Parkinson's disease in 26 adults: 13 with 22q11.2DS at genetic risk of Parkinson's disease (mean age = 41.5 years, standard deviation = 9.7), 12 healthy age and sex-matched controls, and a 22q11.2DS patient with l-DOPA-responsive early-onset Parkinson's disease. Neuroimaging included transcranial sonography and positron emission tomography using 11C-dihydrotetrabenazine (11C-DTBZ), a radioligand that binds to the presynaptic vesicular monoamine transporter. The 22q11.2DS group without Parkinson's disease demonstrated significant motor and olfactory deficits relative to controls. Eight (61.5%) were clinically classified with parkinsonism. Transcranial sonography showed a significantly larger mean area of substantia nigra echogenicity in the 22q11.2DS risk group compared with controls (P = 0.03). The 22q11.2DS patient with Parkinson's disease showed the expected pattern of severely reduced striatal 11C-DTBZ binding. The 22q11.2DS group without Parkinson's disease however showed significantly elevated striatal 11C-DTBZ binding relative to controls (∼33%; P < 0.01). Results were similar within the 22q11.2DS group for those with (n = 7) and without (n = 6) psychotic illness. These findings suggest that manifestations of parkinsonism and/or evolution to Parkinson's disease in this genetic at-risk population may include a hyperdopaminergic mechanism. Adequately powered longitudinal studies and animal models are needed to evaluate the relevance of the observed clinical and imaging phenotypes to Parkinson's disease and other disorders that are more prevalent in 22q11.2DS, such as schizophrenia.

A Remote Collaborative Care Program for Patients with Depression Living in Rural Areas: Open-Label Trial.

BACKGROUND: In the treatment of depression, primary care teams have an essential role, but they are most effective when inserted into a collaborative care model for disease management. In rural areas, the shortage of specialized mental health resources may hamper management of depressed patients. OBJECTIVE: The aim was to test the feasibility, acceptability, and effectiveness of a remote collaborative care program for patients with depression living in rural areas. METHODS: In a nonrandomized, open-label (blinded outcome assessor), two-arm clinical trial, physicians from 15 rural community hospitals recruited 250 patients aged 18 to 70 years with a major depressive episode (DSM-IV criteria). Patients were assigned to the remote collaborative care program (n=111) or to usual care (n=139). The remote collaborative care program used Web-based shared clinical records between rural primary care teams and a specialized/centralized mental health team, telephone monitoring of patients, and remote supervision by psychiatrists through the Web-based shared clinical records and/or telephone. Depressive symptoms, health-related quality of life, service use, and patient satisfaction were measured 3 and 6 months after baseline assessment. RESULTS: Six-month follow-up assessments were completed by 84.4% (221/250) of patients. The remote collaborative care program achieved higher user satisfaction (odds ratio [OR] 1.94, 95% CI 1.25-3.00) and better treatment adherence rates (OR 1.81, 95% CI 1.02-3.19) at 6 months compared to usual care. There were no statically significant differences in depressive symptoms between the remote collaborative care program and usual care. Significant differences between groups in favor of remote collaborative care program were observed at 3 months for mental health-related quality of life (beta 3.11, 95% CI 0.19-6.02). CONCLUSIONS: Higher rates of treatment adherence in the remote collaborative care program suggest that technology-assisted interventions may help rural primary care teams in the management of depressive patients. Future cost-effectiveness studies are needed. TRIAL REGISTRATION: Clinicaltrials.gov NCT02200367; https://clinicaltrials.gov/ct2/show/NCT02200367 (Archived by WebCite at http://www.webcitation.org/6xtZ7OijZ).

[Screening and barriers for treatment of postpartum depression in Chilean public primary health care centers]. / Depresión posparto: tamizaje, uso de servicios y barreras para su tratamiento en centros de atención primaria.

BACKGROUND: Postpartum depression (PPD) is a public health issue, and appropriate screening may lead to clinical gains. AIM: To describe the screening for PPD, its relationship with the use of health care services, and treatment access barriers in Chilean public primary health care (PHC) centers. MATERIAL AND METHODS: Puerperal women attending PHC centers for a well-child check-up were assessed for the presence of PPD using the Edinburgh Postnatal Depression Scale and a structured psychiatric interview. PPD cases were assessed by telephone three months later. Also, women with PPD and PHC workers were interviewed to explore treatment barriers. RESULTS: Of the 305 women assessed, 21% met diagnostic criteria for PPD. Sixty five percent of assessed women were previously screened for PPD while attending well-child check-ups. The results of the screening were communicated to 60% of them and 28% received some management indication. After three months of follow up, 70% of PPD cases continued to be depressed, and two thirds of them did not consult a health care provider and most of them rejected psychotherapy or medical treatment. CONCLUSIONS: Management of postpartum depression should be substantially improved in public PHC from screening to treatment.

Marital Functioning in Couples Practicing Periodic Abstinence for Family Planning.

OBJECTIVE: To compare dyadic (marital) functioning between users of natural family planning (NFP) and users of artificial methods of contraception (AMC). METHOD: A cross-sectional study was conducted in healthy, over eighteen-year-old couples living in stable relationships recruited from primary and secondary health centers in Santiago, Chile. Participants were assessed using a structured interview on sociodemographic and sexual aspects. Primary outcome, marital functioning, was studied using the Dyadic Adjustment Scale (DAS). RESULTS: One hundred and thirty-eight couples were studied, sixty-nine in each user group. Both groups had a similar average time living together (124.3 vs. 126.9 months). DAS results were consistent with functional couples in both groups, but on average, the NFP group had a significantly higher DAS score than AMC. After controlling for age, socioeconomic status, time in the relationship, and religious commitment in multivariable analysis, the NFP group had a 47 percent (odds ratio = 1.47) greater possibility of having a functional marital score above the cutoff (DAS > 114) when compared with the AMC group. The AMC group reported more frequency of sexual intercourse but similar sexual satisfaction. Most (>60 percent) of the NFP couples mentioned that their methods improved their relationship. CONCLUSION: There are sociodemographic differences between both groups, explained partly by unequal access to NFP centers. Both groups have DAS scores within functional range, but NFP users have a higher probability of being in that functional range. This study of mentally and emotionally healthy couples highlights the importance of family planning methods on intimate relationships. Summary Marital functioning is affected by family planning methods. A structured interview and a specific inventory to address conjugal functioning were applied to a group of healthy couples who live in stable relationships and are users of natural family planning (NFP) or artificial methods of contraception (AMC). The results were consistent with functional couples in both groups, but on average, the NFP group had a significantly higher score than the AMC group. The use of NFP explained this difference. This study of mentally and emotionally healthy couples highlights the importance of family planning methods on intimate relationships.

[Comorbidity in people with depression seeking help at primary health care centers in Santiago, Chile]. / Comorbilidad en personas con depresión que consultan en centros de la atención primaria de salud en Santiago, Chile.

BACKGROUND: International evidence has shown the complex interaction between depression and chronic physical diseases. Depression in scenarios involving multiple comorbidities has not received enough attention in Chile. AIM: To characterize the depressed people who consult at Primary Health Care Centers (PHCCs), taking into account the presence of chronic physical or psychiatric comorbidity. MATERIALS AND METHODS: A secondary analysis of databases used in a clinical trial. Two hundred fifty six adults seeking professional help were recruited in four PHCCs located in the Metropolitan Region. These people had a major depressive episode, identified with a structured psychiatric interview (MINI), and gave their informed consent to participate. Socio-demographic information was collected, depressive symptomatology was measured with the patient health questionnaire 9 (PHQ-9), psychiatric morbidity was assessed using the Mini International Neuropsychiatric Interview (MINI), and chronic physical diseases were self-reported by the patients. Descriptive analyses of all the variables were conducted. RESULTS: Seventy percent of patients had a history of depression, with a median of two prior depressive episodes. Depressive symptoms were mostly considered as moderate to severe and severe and 31% of the patients had high suicide risk. Seventy eight percent displayed a physical or psychiatric comorbidity. Of these patients, 29% only had a chronic physical comorbidity, while 46% suffered from an additional psychiatric disorder. CONCLUSIONS: Depressed individuals who seek help at PHCCs constitute an especially complex population that must be treated taking into account multiple comorbidities.

Indicated school-based intervention to improve depressive symptoms among at risk Chilean adolescents: a randomized controlled trial.

BACKGROUND: Depression is a disabling condition affecting people of all ages, but generally starting during adolescence. Schools seem to be an excellent setting where preventive interventions may be delivered. This study aimed to test the effectiveness of an indicated school-based intervention to reduce depressive symptoms among at-risk adolescents from low-income families. METHODS: A two-arm, parallel, randomized controlled trial was conducted in 11 secondary schools in vulnerable socioeconomic areas in Santiago, Chile. High-risk students in year 10 (2° Medio) were invited to a baseline assessment (n = 1048). Those who scored ≥10 (boys) and ≥15 (girls) in the BDI-II were invited to the trial (n = 376). A total of 342 students consented and were randomly allocated into an intervention or a control arm in a ratio of 2:1. The intervention consisted of 8 group sessions of 45 min each, based on cognitive-behavioural models and delivered by two trained psychologists in the schools. Primary (BDI-II) and secondary outcomes (measures of anxiety, automatic thoughts and problem-solving skills) were administered before and at 3 months post intervention. The primary outcome was the recovery rate, defined as the proportion of participants who scored in the BDI-II <10 (among boys) and <15 (among girls) at 3 months after completing the intervention. RESULTS: There were 229 participants in the intervention group and 113 in the control group. At 3-month follow-up 81.4 % in the intervention and 81.7 % in the control group provided outcome data. The recovery rate was 10 % higher in the intervention (50.3 %) than in the control (40.2 %) group; with an adjusted OR = 1.62 (95 % CI: 0.95 to 2.77) (p = 0.08). No difference between groups was found in any of the secondary outcomes. Secondary analyses revealed an interaction between group and baseline BDI-II score. CONCLUSIONS: We found no clear evidence of the effectiveness of a brief, indicated school-based intervention based on cognitive-behavioural models on reducing depressive symptoms among Chilean adolescents from low-income families. More research is needed in order to find better solutions to prevent depression among adolescents. TRIAL REGISTRATION: Current Controlled Trials ISRCTN33871591 . Retrospectively registered 29 June 2011.

[Assessment of a distant collaborative program for the treatment of depression in primary care]. / Programa colaborativo a distancia para el tratamiento de la enfermedad depresiva.

BACKGROUND: In the treatment of depression, primary care teams play an important role, whose effectiveness improves when inserted into a collaborative model of disease management. AIM: To report the results of a clinical trial carried out to test the effectiveness of a collaborative program between primary health teams and specialists supported by an electronic platform. MATERIAL AND METHODS: Physicians from four community hospitals belonging to the Reloncavi Health Service network, recruited 81 patients with depression aged 37 to 43 years, 84% of whom were female. Participants were divided in an active group, which participated in the collaborative program and a control group, which received the usual care, according to the Ministry of Health'’s Guidelines for Depression. The main outcome was the Beck Depression Inventory (BDI-I) score at three months of intervention. RESULTS: Participants had an average of 29.6 points (95% CI: 27.6-31.6) in the BDI-I and 38% of them had a high suicide risk. There were no statistically significant baseline differences between active and control group. In the intervention group, the BDI-I score changed from 30.0 (95% CI 27.0 to 32.8) to 15.3 (95% CI 11.8 to 18.8). In the control group the score changed from 29.2 (95% CI: 26.4-31.9) points to 20.8 (95% CI 16.8 to 24.7). The decrease was significantly higher in the intervention groups. CONCLUSIONS: A program of this kind may be useful to assist primary care teams in remote areas of the country to improve treatment outcomes for depression.

Detecting depression among adolescents in Santiago, Chile: sex differences.

BACKGROUND: Depression among adolescents is common but most cases go undetected. Brief questionnaires offer an opportunity to identify probable cases but properly validated cut-off points are often unavailable, especially in non-western countries. Sex differences in the prevalence of depression become marked in adolescence and this needs to be accounted when establishing cut-off points. METHOD: This study involved adolescents attending secondary state schools in Santiago, Chile. We compared the self-reported Beck Depression Inventory-II with a psychiatric interview to ascertain diagnosis. General psychometric features were estimated before establishing the criterion validity of the BDI-II. RESULTS: The BDI-II showed good psychometric properties with good internal consistency, a clear unidimensional factorial structure, and good capacity to discriminate between cases and non-cases of depression. Optimal cut-off points to establish caseness for depression were much higher for girls than boys. Sex discrepancies were primarily explained by differences in scores among those with depression rather than among those without depression. CONCLUSIONS: It is essential to validate scales with the populations intended to be used with. Sex differences are often ignored when applying cut-off points, leading to substantial misclassification. Early detection of depression is essential if we think that early intervention is a clinically important goal.

[Feasibility of implementing tele-psychiatry in Chile]. / Telepsiquiatría: una revisión sistemática cualitativa.

The objective of this review was to search the literature on the use of telemedicine in mental health and evaluate if it can play a role in Chile. A systematic, qualitative review was carried out to compile systematic reviews, meta-analysis, and clinical controlled trials (CCT) that were in English or Spanish and that applied information technologies for the treatment of psychiatric diseases. Excluded from the review were articles without summaries or articles that included only the trial design, without results. The references of each selected article were critically evaluated. Of the 265 articles found, 224 were excluded for failing to comply with the inclusion criteria. Therefore, 41 articles were left for analysis, 30 reporting CCT and 11 systematic reviews. It is concluded that the use of information technologies to provide mental health care is widespread. It can be implemented in geographically remote places, without access to specialized mental health care and be a part of complex interventions that integrate several components.

[Suicidal ideation, self-directed violence and depression among Chilean school adolescents]. / Ideas autolíticas, violencia autoinfligida, y síntomas depresivos en escolares chilenos.

BACKGROUND: Suicidal behaviors and depression are prevalent phenomena among adolescents, and are considered a public health problem. AIM: To determine the prevalence of depressive symptoms and suicidal behaviors and the relationship between both phenomena, in a representative sample of students from ninth grade in Santiago, Chile. MATERIAL AND METHODS: We recruited a probability sample of 2,597 adolescents who answered a questionnaire with questions about suicidal behavior and the Beck Depression Inventory (BDI-II). RESULTS: The lifetime prevalence of suicidal ideation and planning was 21 and 14%, respectively. The prevalence for the past two weeks was 6.7 and 4.4% for suicidal ideation and planning, respectively. Autolytic behaviors, once in lifetime and in the past week were referred by 26 and 4% of respondents, respectively. In one third of these, self-harm coincided with recent suicide ideation or planning. All levels of suicidal behavior were more frequently reported by women. Clinically significant depressive symptoms were present in 23.5% of adolescents. Females doubled male rates. Severe depressive symptoms were present in 9.4% of the sample. A higher level of suicidal behavior correlated with more severe forms of depression. Sixty percent of adolescents who reported recent self-harm, had clinically relevant depressive symptoms. Two thirds of them had severe symptoms. CONCLUSIONS: Suicidal behavior in Chilean adolescents is prevalent, and there is an association between this behavior and the level of depression. The school is a good place to identify and develop preventive measures for teenagers.

[Association between drug consumption and depression among high school students]. / Consumo de sustancias y síntomas depresivos en escolares de liceos municipales de Santiago.

BACKGROUND: The presence of emotional problems may trigger drug abuse. AIM: To determine the association between illicit drug use and severity of depression symptoms among students of public secondary schools in Santiago, Chile. MATERIAL AND METHODS: A probabilistic sample of 2,597 adolescents aged between 12 and 18 years (45% women), attending first year in public high-schools in Santiago, answered self-report questionnaires about consumption, during the last 30 days ,of alcohol, tobacco and marihuana, and the Beck Depression Inventory - II. Logistic regression models were used to study the association between drug use and severity of depression symptoms, adjusting by sex. RESULTS: Tobacco and marihuana use was reported by 38 and 13% of students, respectively. Frequency of consumption was significantly higher among women. Mild, moderate or severe depressive symptoms were found among 16%, 14% and 9% of students, respectively. Depressive symptoms were more common among women. There was a significant association between drug use and severity of depression among participants of both genders. CONCLUSIONS: The association between depressive symptoms and drug use should be considered on the design of treatment guidelines for these health problems in Chile.

Analysis of REM sleep without atonia in 22q11.2 deletion syndrome determined by domiciliary polysomnography: a cross sectional study.

STUDY OBJECTIVES: Our aim is to evaluate the presence of REM sleep without atonia (RWA), the objective hallmark of REM sleep Behaviour Disorder (RBD), as prodromal marker of Parkinson's disease (PD), in an adult cohort of 22q11.2 deletion syndrome (22qDS). METHODS: Sleep quality was assessed by means of Pittsburgh quality scale index (PSQI), and RBD symptoms by means of RBD questionnaire-Hong-Kong (RBDQ-HK). Attended domiciliary video-Polysomnography (v-PSG) were performed in 26 adults (18-51 years, 14 females) 22qDS patients. Electromyogram during REM sleep was analyzed by means of SINBAR procedure at 3-second time resolution (miniepochs). RESULTS: An overall poor sleep quality was observed in the cohort and high RBDQ-HK score in 7 of the 26 patients, two additional patients with positive dream enactment reported by close relatives had low score of RBDQ-HK. Nevertheless, SINBAR RWA scores were lower than cut-off threshold for RWA (mean 5.5%, range 0-12.2%). TST and the percentage of light sleep (N1) were increased, with preserved proportions of N2 and N3. Participants reported poor quality of sleep (mean PSQI > 5), with prolonged sleep latency in the v-PSG. No subjects exhibit evident dream enactment episodes during recording sessions. CONCLUSIONS: RWA was absent in the studied cohort of 22qDS adult volunteers according to validated polysomnographic criteria. High RBDQ-HK scores do not correlate with v-PSG results among 22qDS individuals.

Functional Dysconnectivity in Ventral Striatocortical Systems in 22q11.2 Deletion Syndrome.

22q11.2 deletion syndrome (22q11.2DS) is a genetic neurodevelopmental disorder that represents one of the greatest known risk factors for psychosis. Previous studies in psychotic subjects without the deletion have identified a dopaminergic dysfunction in striatal regions, and dysconnectivity of striatocortical systems, as an important mechanism in the emergence of psychosis. Here, we used resting-state functional MRI to examine striatocortical functional connectivity in 22q11.2DS patients. We used a 2 × 2 factorial design including 125 subjects (55 healthy controls, 28 22q11.2DS patients without a history of psychosis, 10 22q11.2DS patients with a history of psychosis, and 32 subjects with a history of psychosis without the deletion), allowing us to identify network effects related to the deletion and to the presence of psychosis. In line with previous results from psychotic patients without 22q11.2DS, we found that there was a dorsal to ventral gradient of hypo- to hyperstriatocortical connectivity related to psychosis across both patient groups. The 22q11.2DS was additionally associated with abnormal functional connectivity in ventral striatocortical networks, with no significant differences identified in the dorsal system. Abnormalities in the ventral striatocortical system observed in these individuals with high genetic risk to psychosis may thus reflect a marker of illness risk.

Serum brain-derived neurotrophic factor and glucocorticoid receptor levels in lymphocytes as markers of antidepressant response in major depressive patients: a pilot study.

Depressive patients often have altered cortisol secretion, an effect that likely derives from impaired activity of the glucocorticoid receptor (GR), the main regulator of the hypothalamus-pituitary-adrenal (HPA) axis. Glucocorticoids reduce the levels of brain-derived neurotrophic factor (BDNF), a downstream target of antidepressants. Antidepressants promote the transcriptional activity of cyclic adenosine monophosphate (cAMP) response element binding protein (CREB), a regulator of BDNF expression. To identify potential biomarkers for the onset of antidepressant action in depressive patients, GR and phospho-CREB (pCREB) levels in lymphocytes and serum BDNF levels were repeatedly measured during the course of antidepressant treatment. Thirty-four depressed outpatients (10 male and 24 female) were treated with venlafaxine (75mg/day), and individuals exhibiting a 50% reduction in their baseline 17-Item Hamilton Depression Rating Scale score by the 6th week of treatment were considered responders. Responders showed an early improvement in parallel with a rise in BDNF levels during the first two weeks of treatment. Non-responders showed increased GR levels by the third week and reduced serum BDNF by the sixth week of treatment. In contrast, venlafaxine did not affect levels of pCREB. We conclude that levels of BDNF in serum and GR levels in lymphocytes may represent biomarkers that could be used to predict responses to venlafaxine treatment.

[Mental disorders among immigrants in Chile]. / Trastornos mentales comunes y uso de servicios de salud en población inmigrante.

BACKGROUND: Chile is receiving immigrant populations coming from other Latin-American countries. AIM: To determine the prevalence of Common Mental Disorders (CMD) among immigrants who live in Independencia, a quarter in Santiago, Chile. MATERIAL AND METHODS: A cross sectional study was carried out in the primary health care clinic and in the state-funded school of Independencia. A representative sample of 282 adults and 341 children were interviewed. Mental disorders were diagnosed using CIS-R and MINI structured interviews. RESULTS: The interviewed immigrants came mostly from Peru. The prevalence of mental disorders in the adult population was 17.8% and among children, it was 29.3%. CONCLUSIONS: The adult immigrants have a lower prevalence of mental disorders than the Chilean population but it increases among children. Barriers of access to health services, that should be solved, were detected.

Abnormal nodal and global network organization in resting state functional MRI from subjects with the 22q11 deletion syndrome.

The 22q11 deletion syndrome is a genetic disorder associated with a high risk of developing psychosis, and is therefore considered a neurodevelopmental model for studying the pathogenesis of schizophrenia. Studies have shown that localized abnormal functional brain connectivity is present in 22q11 deletion syndrome like in schizophrenia. However, it is less clear whether these abnormal cortical interactions lead to global or regional network disorganization as seen in schizophrenia. We analyzed from a graph-theory perspective fMRI data from 40 22q11 deletion syndrome patients and 67 healthy controls, and reconstructed functional networks from 105 brain regions. Between-group differences were examined by evaluating edge-wise strength and graph theoretical metrics of local (weighted degree, nodal efficiency, nodal local efficiency) and global topological properties (modularity, local and global efficiency). Connectivity strength was globally reduced in patients, driven by a large network comprising 147 reduced connections. The 22q11 deletion syndrome network presented with abnormal local topological properties, with decreased local efficiency and reductions in weighted degree particularly in hub nodes. We found evidence for abnormal integration but intact segregation of the 22q11 deletion syndrome network. Results suggest that 22q11 deletion syndrome patients present with similar aberrant local network organization as seen in schizophrenia, and this network configuration might represent a vulnerability factor to psychosis.

Correction: Mental disorders and mental health symptoms during imprisonment: A three-year follow-up study.

[This corrects the article DOI: 10.1371/journal.pone.0213711.].

Mental disorders and mental health symptoms during imprisonment: A three-year follow-up study.

BACKGROUND: Data on the course of mental disorders during imprisonment are scarce. Longitudinal studies from high-income Western countries point to improvements of symptoms over time. The aim of the present study was to assess mental disorders and symptoms three years after baseline evaluation at imprisonment and to determine predictors of change in a South American prison context. METHODS: Consecutively admitted prisoners in Santiago de Chile were assessed at intake and reassessed after three years using the Mini International Neuropsychiatric Interview and the Symptom-Check-List 90 Revised (SCL-90-R). The global severity index (GSI) was calculated with standard deviations (SD) and compared using paired t-tests. The prevalence of mental disorders at baseline and at follow-up were compared using McNemar tests. Analyses of variance were conducted to evaluate whether prespecified socio-demographic variables and disorders at baseline predicted symptom change at follow-up. RESULTS: 73 (94%) out of 78 prisoners participated. The prevalence of major mental illnesses was lower at follow-up: 47 (64%) at intake vs. 23 (32%) at follow-up had major depression (p<0.001); 22 (30%) at intake vs. 10 (14%) at follow-up had psychosis (p = 0.008). The mean GSI improved from 1.97 (SD 0.65) at intake to 1.16 (SD 0.82) at follow-up (p<0.001). Depression at baseline (F = 9.39; [Formula: see text] = 0.137; ß = -0.67; p = 0.003) and working or studying during imprisonment (F = 10.61; [Formula: see text] = 0.152; ß = -0.71; p = 0.002) were associated with strong improvement of the GSI at follow-up, whereas psychosis at intake was associated with relatively small symptom improvement (F = 12.11; [Formula: see text] = 0.17; ß = 0.81; p = 0.001). CONCLUSIONS: In a resource poor prison context in South America, mental health symptoms and disorders improve considerably over three years during imprisonment. This applies especially to people with depression at intake. Offers to work or study during imprisonment may improve mental health outcomes.

Treatment of postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile: a randomised controlled trial.

BACKGROUND: The optimum way to improve the recognition and treatment of postnatal depression in developing countries is uncertain. We compared the effectiveness of a multicomponent intervention with usual care to treat postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile. METHODS: 230 mothers with major depression attending postnatal clinics were randomly allocated to either a multicomponent intervention (n=114) or usual care (n=116). The multicomponent intervention involved a psychoeducational group, treatment adherence support, and pharmacotherapy if needed. Usual care included all services normally available in the clinics, including antidepressant drugs, brief psychotherapeutic interventions, medical consultations, or external referral for specialty treatment. The primary outcome measure was the Edinburgh postnatal depression scale (EPDS) score at 3 and 6 months after randomisation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00518830. FINDINGS: 208 (90%) of women randomly assigned to treatment groups completed assessments. The crude mean EPDS score was lower for the multicomponent intervention group than for the usual care group at 3 months (8.5 [95% CI 7.2-9.7] vs 12.8 [11.3-14.1]). Although these differences between groups decreased by 6 months, EPDS score remained better in multicomponent intervention group than in usual care group (10.9 [9.6-12.2] vs 12.5 [11.1-13.8]). The adjusted difference in mean EPDS between the two groups at 3 months was -4.5 (95% CI -6.3 to -2.7; p<0.0001). The decrease in the number of women taking antidepressants after 3 months was greater in the intervention group than in the usual care group (multicomponent intervention from 60/101 [59%; 95% CI 49-69%] to 38/106 [36%; 27-46%]; usual care from 18/108 [17%; 10-25%] to 11/102 [11%; 6-19%]). INTERPRETATION: Our findings suggest that low-income mothers with depression and who have newly born children could be effectively helped, even in low-income settings, through multicomponent interventions. Further refinements to this intervention are needed to ensure treatment compliance after the acute phase.

Association between School Membership and Substance Use among Adolescents.

BACKGROUND: Substance use among adolescents is a major problem worldwide, producing many health and economic consequences. Even though there are well-known personal, familial, and social factors associated with drug use, less is known about the effect of school-related factors. School membership is a recognized variable affecting academic performance among students; however, its effect on substance use is less understood. AIMS: The primary aim of this study was to explore the association between school membership and cigarette, alcohol, and cannabis use among a representative sample of secondary students from municipal state-funded schools in Santiago of Chile, and secondly, to test the hypothesis that depressive or anxiety symptoms mediate this association. METHODS: A total of 2,508 students from 22 state-funded schools in Santiago, Chile, answered a questionnaire. This instrument included an abbreviated version of the psychological sense of school membership (PSSM), questions regarding the use of alcohol, tobacco, and cannabis and scales of psychological functioning (depression, anxiety, self-concept, and problem-solving). The association analyses were performed using adjusted regression models for each outcome using all independent variables while controlling for gender and age. For the mediation effect, a combination of ordinary least square and logistic regression analyses was conducted. RESULTS: There was an association between a strong PSSM and low risk for smoking (OR 0.57; 95% CI 0.46-0.72), drinking (0.65; 95% CI: 0.51-0.83), and cannabis use (0.52; 95% CI 0.37-0.74). We also found that depressive and anxiety symptoms do not fully mediate the association between school membership and any substance use, and 73% of this effect in the case of smoking, 80% in the case of drinking, and 78.5% in the case of cannabis use, was direct. CONCLUSION: This is the first study in Latin America exploring the association between school membership and substance use among secondary students. School membership seems to be an important and independent factor to be included in preventive interventions. Therefore, these results support future research aiming to test interventions at increasing the sense of school membership to prevent substance use among adolescents. CLINICAL TRIAL REGISTRATION: ISRCTN19466209. Retrospectively registered.