Elie Valencia

Análise epidemiológica do suicídio no Brasil entre 1980 e 2006

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

A critical time intervention with mentally ill homeless men: impact on psychiatric symptoms.

We describe the impact of a psychosocial intervention, critical time intervention (CTI), on the cardinal symptom dimensions of schizophrenia, namely negative, positive, and general psychopathology. Ninety-six men with schizophrenia and other psychotic disorders who were discharged from a homeless shelter were randomly assigned to receive either CTI or usual services only. CTI is a time-limited intervention designed to enhance continuity of care during the transition from institution to community. Symptom severity at baseline and at 6 months was assessed using the Positive and Negative Syndrome Scale. Using data on 76 subjects for whom we have complete symptom data, we assessed the impact of CTI on change in symptoms. The results suggest that CTI was associated with a statistically significant decrease in negative symptoms at the 6-month follow-up, reflecting modest clinical improvement. There was no significant effect on positive or general psychopathology symptoms.

Critérios de admissão e continuidade de cuidados em centros de atenção psicossocial, Rio de Janeiro, RJ

OBJETIVO: Analisar os criterios de admissao, encaminhamento e continuidade de cuidado a pacientes utilizados pelas equipes dos centros de atencao psicossocial. METODOS: Pesquisa qualitativa com avaliacao participativa realizada em tres centros de atencao psicossocial do municipio do Rio de Janeiro (RJ) em 2006. Foram sorteados 15 casos admitidos e 15 casos encaminhados dentre os pacientes admitidos para tratamento nos seis meses anteriores ao inicio da pesquisa. Os criterios apontados pela equipe para a admissao do paciente para tratamento ou encaminhamento foram analisados a partir de um roteiro estruturado. A analise da continuidade de cuidados baseou-se em pesquisa em prontuario, informacoes da equipe e dos proprios pacientes e/ou familiares seis meses apos a absorcao ou encaminhamento do paciente. RESULTADOS: Os pacientes admitidos apresentavam diagnostico de psicose (esquizofrenia), historia de internacoes previas, funcionamento social pobre e rede de apoio pequena e os pacientes encaminhados apresentavam transtornos ansiosos e depressivos, boa adesao a tratamento ambulatorial, bom funcionamento social e presenca de rede social. Quanto a continuidade de cuidados, oito pacientes em 27 tiveram destino desconhecido. Quanto aos encaminhamentos, dos 13 pacientes encaminhados a ambulatorios da rede, sete permaneceram em tratamento, dois retornaram aos CAPS e quatro tiveram destino desconhecido. CONCLUSOES: Os centros admitem pacientes que se encaixam na definicao de um transtorno mental severo e persistente. A continuidade de cuidado foi apontada como problema, provavelmente devido a dificuldade de acompanhar os pacientes na comunidade.OBJECTIVE To analyze the criteria used by teams for admission, referral and continuity of care among patients of the Centros de Atenção Psicossocial (CAPS - Psychosocial Care Centers). METHODS A qualitative study with participatory evaluation was conducted in three psychosocial healthcare services of the city of Rio de Janeiro, Southeastern Brazil, in 2006. A total of 15 admitted cases and 15 referred cases were selected among the patients admitted for treatment during the six months that preceded the beginning of research. Criteria pointed out by the team to admit patients for treatment or referral were analyzed from structured guidelines. Analysis of continuity of care was based on medical records and information from the team and patients and/or family members themselves, six months after patients were admitted or referred. RESULTS Patients admitted had psychosis (schizophrenia), history of previous admissions, poor social functioning and a small support network, patients referred had anxiety and depressive disorders, a good level of adherence to outpatient treatment, good social functioning and presence of a social network. In terms of continuity of care, eight out of 27 patients had an unknown destination. In terms of referrals, of the 13 patients referred to the networks outpatient clinics, seven continued in treatment, two returned to the centers and four had an unknown destination. CONCLUSIONS The centers admit patients who fit into the definition of severe and persistent mental disorder. Continuity of care was pointed out as a problem, probably due to the difficulty in following patients.

Interventions for homeless men and women with mental illness : reducing sexual risk behaviours for HIV

In this paper, we describe an intervention to reduce sexual risk behaviours for HIV transmission among homeless men with mental illness. In some urban areas of North America, 10± 20% of homeless mentally ill men are infected with HIV1,2. Yet, HIV prevention has been neglected in this population. There have been only limited attempts to offer HIV prevention in the settings where these men reside; and research in this ® eld has been minimal. Available data indicate that sexual behaviours Ð as well as drug use behaviours Ð contribute to the contraction and transmission of HIV in this population. Our previous studies found that both were important factors in HIV contraction3,4. Because more men currently practice unsafe sex than inject drugs, unsafe sexual behaviour may be the most important factor leading to further HIV transmission. While the need for sexual risk reduction in this population is clear, it presents a daunting challenge. Little is known about the sexual lives of homeless mentally ill men. Methods for changing behaviour (of any kind) among the chronic mentally ill have yet to be fully developed and tested. Finally, virtually no research has been conducted on behaviour change among destitute mentally ill people who also drink and use drugs. The present intervention drew on available theories of behaviour change from the ® eld of HIV prevention and psychiatric rehabilitation5± 15. In addition, we relied heavily on our clinical experience14± 18. Thus, application of these theories was considerably adapted for homeless mentally ill men. Below we describe, ® rst, the setting in which the intervention was developed. Second, we provide an overview of the philosophy and approaches that guided the intervention. Third, we discuss some of our ongoing work in this ® eld. THE SETTING

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

OBJETIVO: Analisar os criterios de admissao, encaminhamento e continuidade de cuidado a pacientes utilizados pelas equipes dos centros de atencao psicossocial. METODOS: Pesquisa qualitativa com avaliacao participativa realizada em tres centros de atencao psicossocial do municipio do Rio de Janeiro (RJ) em 2006. Foram sorteados 15 casos admitidos e 15 casos encaminhados dentre os pacientes admitidos para tratamento nos seis meses anteriores ao inicio da pesquisa. Os criterios apontados pela equipe para a admissao do paciente para tratamento ou encaminhamento foram analisados a partir de um roteiro estruturado. A analise da continuidade de cuidados baseou-se em pesquisa em prontuario, informacoes da equipe e dos proprios pacientes e/ou familiares seis meses apos a absorcao ou encaminhamento do paciente. RESULTADOS: Os pacientes admitidos apresentavam diagnostico de psicose (esquizofrenia), historia de internacoes previas, funcionamento social pobre e rede de apoio pequena e os pacientes encaminhados apresentavam transtornos ansiosos e depressivos, boa adesao a tratamento ambulatorial, bom funcionamento social e presenca de rede social. Quanto a continuidade de cuidados, oito pacientes em 27 tiveram destino desconhecido. Quanto aos encaminhamentos, dos 13 pacientes encaminhados a ambulatorios da rede, sete permaneceram em tratamento, dois retornaram aos CAPS e quatro tiveram destino desconhecido. CONCLUSOES: Os centros admitem pacientes que se encaixam na definicao de um transtorno mental severo e persistente. A continuidade de cuidado foi apontada como problema, provavelmente devido a dificuldade de acompanhar os pacientes na comunidade.OBJECTIVE To analyze the criteria used by teams for admission, referral and continuity of care among patients of the Centros de Atenção Psicossocial (CAPS - Psychosocial Care Centers). METHODS A qualitative study with participatory evaluation was conducted in three psychosocial healthcare services of the city of Rio de Janeiro, Southeastern Brazil, in 2006. A total of 15 admitted cases and 15 referred cases were selected among the patients admitted for treatment during the six months that preceded the beginning of research. Criteria pointed out by the team to admit patients for treatment or referral were analyzed from structured guidelines. Analysis of continuity of care was based on medical records and information from the team and patients and/or family members themselves, six months after patients were admitted or referred. RESULTS Patients admitted had psychosis (schizophrenia), history of previous admissions, poor social functioning and a small support network, patients referred had anxiety and depressive disorders, a good level of adherence to outpatient treatment, good social functioning and presence of a social network. In terms of continuity of care, eight out of 27 patients had an unknown destination. In terms of referrals, of the 13 patients referred to the networks outpatient clinics, seven continued in treatment, two returned to the centers and four had an unknown destination. CONCLUSIONS The centers admit patients who fit into the definition of severe and persistent mental disorder. Continuity of care was pointed out as a problem, probably due to the difficulty in following patients.

Depression During Pregnancy: Review of Epidemiological and Clinical Aspects in Developed and Developing Countries

Contrary to general belief, gestation is not always characterized by joy and accomplishments. Many women experience sadness or anxiety in these periods of their lives. Gestation and postpartum (puerperium) are periods of woman s life which involve many physical, hormonal, psychic and social insertion changes which can have a direct effect on her mental health (Camacho et al., 2006). The changes caused by the newborn arrival are not limited to psychological and biochemical variables but also involve socioeconomic factors, especially in societies in which women are active in the labor market, contributing to the family income, and pursuing diverse professional and social interests (Maldonado, 1997). The scientific literature indicates that in the gestational-postpartum period is the phase with the highest prevalence of mental disorders of women s life, particularly in the first and third quarters of gestation and during the first 30 days of postpartum (Botega & Dias, 2006). The intensity of these mental health alterations depend and are regulated by interaction of multiple factors, including organic, family, marital, social, cultural aspects and the pregnant woman’s personality (Falcone et al., 2005). Approximately one fifth of pregnant women and women in puerperium present symptoms of depression (Limlomwongse & Liabsuetrakul, 2006). Most of these women are not diagnosed neither adequately treated (Andersson et al, 2003). Depression is the most prevalent mental disorder during pregnancy and the puerperium period (Bennett et al., 2004) and is associated with risk factors such as a psychiatric history, financial hardships, low education level, teenage pregnancy, lack of social support, stressful events and a history of domestic violence. There is evidence that pre-natal depression is not only more common, but it constitutes the main risk factor for postpartum depression. Indeed, in many cases it is the continuation of the depression that started during pregnancy (Alami et al., 2006; Andersson et al., 2006; Da Costa et al., 2000; Heron et al., 2004; Josefsson et al., 2001; Lovisi et al., 2005; Patel et al., 2003; Rich-Edwards et al., 2006; Ryan et al., 2005). Current studies suggest that gestational depression needs to be addressed in a more consistent manner. Although there is a consensus that the factors that affect the relationship

RedeAmericas: building research capacity in young leaders for sustainable growth in community mental health services in Latin America

The purpose of this paper is to describe the development and initial accomplishments of a training program of young leaders in community mental health research as part of a Latin American initiative known as RedeAmericas. RedeAmericas was one of five regional ‘Hubs’ funded by the National Institute of Mental Health (NIMH) to improve community mental health care and build mental health research capacity in low- and middle-income countries. It included investigators in six Latin American cities – Santiago, Chile; Medellín, Colombia; Rio de Janeiro, Brazil; and Córdoba, Neuquén, and Buenos Aires in Argentina – working together with a team affiliated with the Global Mental Health program at Columbia University in New York City. One component of RedeAmericas was a capacity-building effort that included an Awardee program for early career researchers in the mental health field. We review the aims of this component, how it developed, and what was learned that would be useful for future capacity-building efforts, and also comment on future prospects for maintaining this type of effort.

Mental Illness stigma research in Argentina

Studies regarding stigma towards mental illness in Argentina blossomed after the first National Mental Health Law was passed in 2010. Methodological limitations and contradictory results regarding community perceptions of stigma hinder comparisons across domestic and international contexts but some lessons may still be gleaned. We examine this research and derive recommendations for future research and actions to reduce stigma. These include tackling culture-specific aspects of stigma, increasing education of the general population, making more community-based services available and exposing mental health professionals to people with mental illness who are on community paths to recovery.

SCHIZOPHRENIA, THE PREVENTION OF HOMELESSNESS, AND THE GLOBAL HEALTH MOVEMENT

Available evidence suggests that individuals with schizophrenia and other severe mental illnesses are at increased risk for homelessness in contemporary societies with diverse cultures and socioeconomic conditions. Yet the prevention of homelessness among individuals with mental illness has rarely been a focus of global health programs. We propose that it should be. In any given society, the overall risk of homelessness will reflect broad societal factors such as income inequality, housing, migration, economic conditions, and family ties. We strongly advocate for addressing these societal causes of homelessness. We also believe, however, that we need to develop special programs in parallel to prevent homelessness among individuals with severe mental illness. We use historical examples to draw attention to ways in which individuals with mental illness have been – and still are – explicitly excluded from societies. We suggest that this social exclusion requires us to take special measures to protect the rights of individuals with mental illness, and to develop programs to ensure they have access to basic necessities including a home. The form these measures take will of necessity vary widely according to local conditions. We describe mental health initiatives in two middle-income countries (Brazil and Argentina) which illustrate different approaches, and allude more briefly to efforts being made in other countries including low-income countries. Finally, we consider some of the efforts that are already being made by various international groups to further this agenda within the global health movement.

Criterios de admisión y continuidad de cuidados en centros de atención psicosocial, Rio de Janeiro, Sureste de Brasil

OBJETIVO: Analisar os criterios de admissao, encaminhamento e continuidade de cuidado a pacientes utilizados pelas equipes dos centros de atencao psicossocial. METODOS: Pesquisa qualitativa com avaliacao participativa realizada em tres centros de atencao psicossocial do municipio do Rio de Janeiro (RJ) em 2006. Foram sorteados 15 casos admitidos e 15 casos encaminhados dentre os pacientes admitidos para tratamento nos seis meses anteriores ao inicio da pesquisa. Os criterios apontados pela equipe para a admissao do paciente para tratamento ou encaminhamento foram analisados a partir de um roteiro estruturado. A analise da continuidade de cuidados baseou-se em pesquisa em prontuario, informacoes da equipe e dos proprios pacientes e/ou familiares seis meses apos a absorcao ou encaminhamento do paciente. RESULTADOS: Os pacientes admitidos apresentavam diagnostico de psicose (esquizofrenia), historia de internacoes previas, funcionamento social pobre e rede de apoio pequena e os pacientes encaminhados apresentavam transtornos ansiosos e depressivos, boa adesao a tratamento ambulatorial, bom funcionamento social e presenca de rede social. Quanto a continuidade de cuidados, oito pacientes em 27 tiveram destino desconhecido. Quanto aos encaminhamentos, dos 13 pacientes encaminhados a ambulatorios da rede, sete permaneceram em tratamento, dois retornaram aos CAPS e quatro tiveram destino desconhecido. CONCLUSOES: Os centros admitem pacientes que se encaixam na definicao de um transtorno mental severo e persistente. A continuidade de cuidado foi apontada como problema, provavelmente devido a dificuldade de acompanhar os pacientes na comunidade.OBJECTIVE To analyze the criteria used by teams for admission, referral and continuity of care among patients of the Centros de Atenção Psicossocial (CAPS - Psychosocial Care Centers). METHODS A qualitative study with participatory evaluation was conducted in three psychosocial healthcare services of the city of Rio de Janeiro, Southeastern Brazil, in 2006. A total of 15 admitted cases and 15 referred cases were selected among the patients admitted for treatment during the six months that preceded the beginning of research. Criteria pointed out by the team to admit patients for treatment or referral were analyzed from structured guidelines. Analysis of continuity of care was based on medical records and information from the team and patients and/or family members themselves, six months after patients were admitted or referred. RESULTS Patients admitted had psychosis (schizophrenia), history of previous admissions, poor social functioning and a small support network, patients referred had anxiety and depressive disorders, a good level of adherence to outpatient treatment, good social functioning and presence of a social network. In terms of continuity of care, eight out of 27 patients had an unknown destination. In terms of referrals, of the 13 patients referred to the networks outpatient clinics, seven continued in treatment, two returned to the centers and four had an unknown destination. CONCLUSIONS The centers admit patients who fit into the definition of severe and persistent mental disorder. Continuity of care was pointed out as a problem, probably due to the difficulty in following patients.