João Mazzoncini de Azevedo-Marques

COOP/WONCA Charts as a Screen for Mental Disorders in Primary Care

PURPOSE Most people with mental disorders receive treatment in primary care. The charts developed by the Dartmouth Primary Care Cooperative Research Network (COOP) and the World Organization of National Colleges, Academies, and Academic Associations of General Practitioners/Family Physicians (WONCA) have not yet been evaluated as a screen for these disorders, using a structured psychiatric interview by an expert or considering diagnoses other than depression. We evaluated the validity and feasibility of the COOP/WONCA Charts as a mental disorders screen by comparing them both with other questionnaires previously validated and with the assessment of a mental health specialist using a structured diagnostic interview. METHODS We trained community health workers and nurse assistants working in a collaborative mental health care model to administer the COOP/WONCA Charts, the 20-item Self-Reporting Questionnaire (SRQ-20), and the World Health Organization–Five Well-Being Index (WHO-5) to 120 primary care patients. A psychiatrist blinded to the patients’ results on these questionnaires administered the SCID, or Structured Clinical Interview for the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). RESULTS The area under the receiver operating characteristic curve was at least 0.80 for single items, a 3-item combination, and the total score of the COOP/ WONCA Charts, as well as for the SRQ-20 and the WHO-5, for screening both for all mental disorders and for depressive disorders. The accuracy, sensitivity, specificity, and positive and negative predictive values of these measures ranged between 0.77 and 0.92. Community health workers and nurse assistants rated the understandability, ease of use, and clinical relevance of all 3 questionnaires as satisfactory. CONCLUSIONS One-time assessment of patients with the COOP/WONCA Charts is a valid and feasible option for screening for mental disorders by primary care teams.

A web-based information system for a regional public mental healthcare service network in Brazil

BackgroundRegional networking between services that provide mental health care in Brazil’s decentralized public health system is challenging, partly due to the simultaneous existence of services managed by municipal and state authorities and a lack of efficient and transparent mechanisms for continuous and updated communication between them. Since 2011, the Ribeirao Preto Medical School and the XIII Regional Health Department of the Sao Paulo state, Brazil, have been developing and implementing a web-based information system to facilitate an integrated care throughout a public regional mental health care network.Case presentationAfter a profound on-site analysis, the structure of the network was identified and a web-based information system for psychiatric admissions and discharges was developed and implemented using a socio-technical approach. An information technology team liaised with mental health professionals, health-service managers, municipal and state health secretariats and judicial authorities. Primary care, specialized community services, general emergency and psychiatric wards services, that comprise the regional mental healthcare network, were identified and the system flow was delineated. The web-based system overcame the fragmentation of the healthcare system and addressed service specific needs, enabling: detailed patient information sharing; active coordination of the processes of psychiatric admissions and discharges; real-time monitoring; the patients’ status reports; the evaluation of the performance of each service and the whole network. During a 2-year period of operation, it registered 137 services, 480 health care professionals and 4271 patients, with a mean number of 2835 accesses per month. To date the system is successfully operating and further expanding.ConclusionWe have successfully developed and implemented an acceptable, useful and transparent web-based information system for a regional mental healthcare service network in a medium-income country with a decentralized public health system. Systematic collaboration between an information technology team and a wide range of stakeholders is essential for the system development and implementation.

Diagnóstico diferencial de primeiro episódio psicótico: importância da abordagem otimizada nas emergências psiquiátricas

OBJECTIVE: To review the literature regarding the diagnosis of first episode psychosis in the context of emergency psychiatry. METHOD: Review of empirical and review articles selected by electronic search in the database PubMed. RESULTS: Specific features of emergency care - single, brief and cross section assessment, and with little information - may jeopardize the diagnostic process. These limitations can be circumvented by application of operational diagnostic criteria, the use of scales and structured interviews and a short period of observation, between 24-72 hours. Diagnoses of bipolar disorder, schizophrenia, psychotic depression and delusional disorder developed in the context of emergency have good stability, but not the diagnoses of brief psychotic disorder, schizophreniform disorder and schizoaffective disorder. First episode psychosis can occur in the course of the use of psychoactive substances, with relatively frequent maintenance of psychotic symptoms even after cessation of the use of the substance. The rational use of subsidiary tests may help the differential diagnosis of psychotic episodes due to general medical conditions. CONCLUSION: Diagnoses of first psychotic episode can be adequately performed during psychiatric emergencies, if routines are implemented based on scientific evidence.

Epidemiology of multimorbidity within the Brazilian adult general population: Evidence from the 2013 National Health Survey (PNS 2013)

Middle-income countries are facing a growing challenge of adequate health care provision for people with multimorbidity. The objectives of this study were to explore the distribution of multimorbidity and to identify patterns of multimorbidity in the Brazilian general adult population. Data from 60202 adults, aged ≥18 years that completed the individual questionnaire of the National Health Survey 2013 (Portuguese: “Pesquisa Nacional de Saúde”–“PNS”) was used. We defined multimorbidity as the presence of two or more chronic conditions, including self-reported diagnoses and responses to the 9-item Patient Health Questionnaire for depression. Multivariate Poisson regression analyses were used to explore relationship between multimorbidity and demographic factors. Exploratory tetrachoric factor analysis was performed to identify multimorbidity patterns. 24.2% (95% CI 23.5–24.9) of the study population were multimorbid, with prevalence rate ratios being significantly higher in women, older people and those with lowest educational level. Multimorbidity occurred earlier in women than in men, with half of the women and men aged 55–59 years and 65–69 years, respectively, were multimorbid. The absolute number of people with multimorbidity was approximately 2.5-fold higher in people younger than 65 years than older counterparts (9920 vs 3945). Prevalence rate ratios of any mental health disorder significantly increased with the number of physical conditions. 46.7% of the persons were assigned to at least one of three identified patterns of multimorbidity, including: “cardio-metabolic”, “musculoskeletal-mental” and “respiratory” disorders. Multimorbidity in Brazil is as common as in more affluent countries. Women in Brazil develop diseases at younger ages than men. Our findings can inform a national action plan to prevent multimorbidity, reduce its burden and align health-care services more closely with patients’ needs.

Cultural adaptation and psychometric properties of the family questionnaire in a Brazilian sample of relatives of schizophrenia outpatients

AIMS AND OBJECTIVES To evaluate the internal reliability and validity of the Brazilian Portuguese version of the Family Questionnaire among families of schizophrenia outpatients. BACKGROUND The main studies about the family environment of schizophrenia patients are related to the concept of Expressed Emotion. There is currently no instrument to evaluate this concept in Brazil that is easily applicable and comparable with studies from other countries. DESIGN Methodological and cross-sectional research design. METHOD A convenience sample of 130 relatives of schizophrenia outpatients was selected. The translation and cultural adaptation of the instrument involved experts in mental health and experts in the German language and included back translation, semantic evaluation of items and pretesting of the instrument with 30 relatives of schizophrenia outpatients. The psychometric properties of the instrument were studied with another 100 relatives, which fulfilled the requirements for the Brazilian Portuguese version of the instrument. The psychometric properties of the instrument were assessed by construct validity (using an analysis of its key components, comparisons between distinct groups-convergent validity with the Antonovskys Sense of Coherence Scale) and reliability (checking the internal consistency of its items and its test-retest reproducibility). RESULTS The analysis of main components confirmed dimensionality patterns that were comparable between the original and adapted versions. In two domains of the instrument, critical comments and emotional over-involvement had moderate and significant correlations, respectively, with Antonovskys Sense of Coherence Scale, appropriate values of Cronbachs alpha and strong and significant correlations, respectively, in test-retest reproducibility. We observed significant differences between distinct groups of parents in the category of emotional over-involvement. CONCLUSION We conclude that the Portuguese-adapted version of the Family Questionnaire is valid and reliable for the study sample. RELEVANCE TO CLINICAL PRACTICE This study provided evidence that the Family Questionnaire is a reliable and valid instrument for assessing expressed emotion. It is easy and practical to use and is acceptable for use in a Brazilian cultural population.

eHealth-interop: an Interoperability Platform developed for Mental Care Integration (Preprint)

Background The electronic exchange of health-related data can support different professionals and services to act in a more coordinated and transparent manner and make the management of health service networks more efficient. Although mental health care is one of the areas that can benefit from a secure health information exchange (HIE), as it usually involves long-term and multiprofessional care, there are few published studies on this topic, particularly in low- and middle-income countries. Objective The aim of this study was to design, implement, and evaluate an electronic health (eHealth) platform that allows the technical and informational support of a Brazilian regional network of mental health care. This solution was to enable HIE, improve data quality, and identify and monitor patients over time and in different services. Methods The proposed platform is based on client-server architecture to be deployed on the Web following a Web services communication model. The interoperability information model was based on international and Brazilian health standards. To test platform usage, we have utilized the case of the mental health care network of the XIII Regional Health Department of the São Paulo state, Brazil. Data were extracted from 5 different sources, involving 26 municipalities, and included national demographic data, data from primary health care, data from requests for psychiatric hospitalizations performed by community services, and data obtained from 2 psychiatric hospitals about hospitalizations. Data quality metrics such as accuracy and completeness were evaluated to test the proposed solution. Results The eHealth-Interop integration platform was designed, developed, and tested. It contains a built-in terminology server and a record linkage module to support patients’ identification and deduplication. The proposed interoperability environment was able to integrate information in the mental health care network case with the support of 5 international and national terminologies. In total, 27,353 records containing demographic and clinical data were integrated into eHealth-Interop. Of these records, 34.91% (9548/27,353) were identified as patients who were present in more than 1 data source with different levels of accuracy and completeness. The data quality analysis was performed on 26 demographic attributes for each integrable patient record, totaling 248,248 comparisons. In general, it was possible to achieve an improvement of 18.40% (45,678/248,248) in completeness and 1.10% (2731/248,248) in syntactic accuracy over the test dataset after integration and deduplication. Conclusions The proposed platform established an eHealth solution to fill the gap in the availability and quality of information within a network of health services to improve the continuity of care and the health services management. It has been successfully applied in the context of mental health care and is flexible to be tested in other areas of care.

Predictive Validity of the Brazilian Portuguese Version of the Family Questionnaire for Relapse in Patients With Schizophrenia

Background and Purpose: The Family Questionnaire-Brazilian Portuguese Version (FQ-BPV) has been preliminarily validated in the Brazilian population. This study assessed the predictive validity of the FQ-BPV for relapse in patients with schizophrenia. Methods: Ninety-four dyads (patients with schizophrenia and their relatives) were recruited from three mental health clinics. Expressed emotion was assessed using the FQ-BPV. Presence of relapse was assessed at 6-, 9-, 12-, and 18-month follow-ups and analyzed through logistic regressions. Results: The critical comments (CC) domain of the FQ-BPV was statistically significant at 18 months. However, the model was not sufficiently robust to classify individuals correctly into relapse or no relapse categories. Conclusion: The FQ-BPV did not predict relapse well and we cannot recommend it for that purpose in Brazil without further studies.

Expressed emotion and family burden in relatives of patients in first-episode psychosis

BACKGROUND: Evidence suggests that expressed emotion (EE) and family burden (FB) are phenomena that interact, but there is a lack of studies that analyze this association in patients in first‐episode psychosis. AIM: This study evaluated the relationship between EE and FB in relatives of patients in first‐episode psychosis. METHOD: A convenience sample of 71 family members of patients being assisted in an outpatient care unit participated in the study. We used a form with sociodemographic and clinical variables of family members and patients, the Family Questionnaire‐Brazilian Portuguese Version and the Brazilian version of the Burden Interview. The data were obtained via semi‐structured interviews. Statistical analyses included Fishers exact tests, Mann Whitney tests, Spearman correlations, and Students t‐tests. RESULTS: Our results showed high levels of EE and its component emotional over‐involvement (EOI) among relatives, and a strong correlation between critical comments (CC) and EOI and FB measurements. In addition, family members with elevated EE levels showed higher means for FB and this difference was significant. CONCLUSIONS: Mental health nurses are expected to consider these concepts for proposing nursing interventions to first‐episode psychosis patients and their relatives. HIGHLIGHTSFirst‐episode psychosis (FEP) causes several changes in the family dynamics of the affected individualsFamily members of FEP patients with elevated Expressed Emotion (EE) levels showed higher means for family burdenHigh levels of EE and its component emotional over‐involvement among relatives of FEP patients in a Brazilian sample.