Liliane Vilete

The Impact of Epidemic Violence on the Prevalence of Psychiatric Disorders in Sao Paulo and Rio de Janeiro, Brazil

Background Violence and other traumatic events, as well as psychiatric disorders are frequent in developing countries, but there are few population studies to show the actual impact of traumatic events in the psychiatric morbidity in low and middle-income countries (LMIC). Aims To study the relationship between traumatic events and prevalence of mental disorders in São Paulo and Rio de Janeiro, Brazil. Methods Cross-sectional survey carried out in 2007–2008 with a probabilistic representative sample of 15- to 75-year-old residents in Sao Paulo and Rio de Janeiro, Brazil, using the Composite International Diagnostic Interview. Results The sample comprised 3744 interviews. Nearly 90% of participants faced lifetime traumatic events. Lifetime prevalence of any disorders was 44% in Sao Paulo and 42.1% in Rio de Janeiro. One-year estimates were 32.5% and 31.2%. One-year prevalence of traumatic events was higher in Rio de Janeiro than Sao Paulo (35.1 vs. 21.7; p<0.001). Participants from Rio de Janeiro were less likely to have alcohol dependence (OR = 0.55; p = 0.027), depression (OR = 0.6; p = 0.006) generalized anxiety (OR = 0.59; p = 0.021) and post-traumatic stress disorder (OR = 0.62; p = 0.027). Traumatic events correlated with all diagnoses – e.g. assaultive violence with alcohol dependence (OR = 5.7; p<0.001) and with depression (OR = 1.7; p = 0.001). Conclusion Our findings show that psychiatric disorders and traumatic events, especially violence, are extremely common in Sao Paulo and Rio de Janeiro, supporting the idea that neuropsychiatric disorders and external causes have become a major public health priority, as they are amongst the leading causes of burden of disease in low and middle-income countries. The comparison between the two cities regarding patterns of violence and psychiatric morbidity suggests that environmental factors may buffer the negative impacts of traumatic events. Identifying such factors might guide the implementation of interventions to improve mental health and quality of life in LMIC urban centers.

Violence and post-traumatic stress disorder in Sao Paulo and Rio de Janeiro, Brazil: the protocol for an epidemiological and genetic survey

Backgroundviolence is a public health major concern, and it is associated with post-traumatic stress disorder and other psychiatric outcomes. Brazil is one of the most violent countries in the world, and has an extreme social inequality. Research on the association between violence and mental health may support public health policy and thus reduce the burden of disease attributable to violence. The main objectives of this project were: to study the association between violence and mental disorders in the Brazilian population; to estimate the prevalence rates of exposure to violence, post-traumatic stress disorder, common metal disorder, and alcohol hazardous use and dependence: and to identify contextual and individual factors, including genetic factors, associated with the outcomes.Methods/designone phase cross-sectional survey carried out in Sao Paulo and Rio de Janeiro, Brazil. A multistage probability to size sampling scheme was performed in order to select the participants (3000 and 1500 respectively). The cities were stratified according to homicide rates, and in Sao Paulo the three most violent strata were oversampled. The measurements included exposure to traumatic events, psychiatric diagnoses (CIDI 2.1), contextual (homicide rates and social indicators), and individual factors, such as demographics, social capital, resilience, help seeking behaviours. The interviews were carried between June/2007 February/2008, by a team of lay interviewers. The statistical analyses will be weight-adjusted in order to take account of the design effects. Standardization will be used in order to compare the results between the two centres. Whole genome association analysis will be performed on the 1 million SNP (single nucleotide polymorphism) arrays, and additional association analysis will be performed on additional phenotypes. The Ethical Committee of the Federal University of Sao Paulo approved the study, and participants who matched diagnostic criteria have been offered a referral to outpatient clinics at the Federal University of Sao Paulo and Federal University of Rio de Janeiro.

Adaptação transcultural para o português do Social Phobia Inventory (SPIN) para utilização entre estudantes adolescentes

ABSTRACT Introduction: There has been a growing interest in the study of social phobia, mainly among young people, which demands self-report instruments to identify the disorder. In this study a cross-cultural adaptation of the Social Phobia Inventory (SPIN) was carried out to be used with Brazilian adolescent students. Methods: The adaptation process was conducted in four stages: translation; back translation; critical appraisal of the versions to develop a consensual version; and commented pretest. Results: The results of the four stages and the final version are showed for each item of the instrument. Discussion: The use of more than one translation and back translation is important to allow the comparison of the items, detection of errors and thus choose more appropriate terms. The commented pretest performed in a group similar to the target population allows a better adequacy of the instrument to the population to which it will be applied. Conclusion: Instruments developed in a foreign language need a careful cross-cultural adaptation process in order to be used in a different reality.INTRODUCAO: E crescente o interesse em estudar a Fobia Social, sobretudo em faixas etarias jovens, requerendo instrumentos de autopreenchimento para identificacao do transtorno. Esse estudo consistiu na adaptacao transcultural do Social Phobia Inventory (SPIN) para sua utilizacao entre adolescentes estudantes brasileiros. METODOS: O processo de adaptacao envolveu quatro etapas: traducao; retroversao; apreciacao das versoes com elaboracao de uma versao de consenso; e pre-teste comentado. RESULTADOS: Para cada item do instrumento, sao apresentados os resultados das quatro etapas e a versao final do instrumento em portugues. DISCUSSAO: E importante a utilizacao de mais de uma traducao e retroversao para possibilitar a comparacao dos itens e a identificacao de erros e assim permitir a escolha dos termos mais adequados. A realizacao do pre-teste comentado em um grupo semelhante a populacao alvo possibilita a melhor adequacao do instrumento a populacao em que sera utilizado. CONCLUSAO: Instrumentos elaborados em lingua estrangeira necessitam de processo cuidadoso de adaptacao transcultural para sua utilizacao em uma realidade sociocultural distinta.

Building resilience for future adversity: a systematic review of interventions in non-clinical samples of adults

BackgroundPotentially traumatic events happen in people’s lives, leading to the risk of the development of posttraumatic stress disorder, depression and even suicide. Resilience is an individual’s ability to maintain or regain his/her mental health in the face of significant adversity or risk of death. The aim of this study was to conduct a systematic review of studies evaluating the effectiveness of resilience promotion interventions in adults.MethodsElectronic searches were conducted in databases ISI, PsycINFO and PubMed, including every language and every year until January 20, 2013. We selected studies with nonclinical samples of adults that evaluated the effectiveness of the intervention through randomized and non-randomized controlled trials and open-ended studies. We also considered valid constructs directly related to resilience, such as hardiness.ResultsAmong 2.337 studies, 13 were selected for the review, 5 through electronic databases and 8 through search in references or the “times cited list” (list of articles that cited the selected papers). Of these, 7 are randomized controlled trials, 5 non-randomized controlled trials, and one an open-ended trial. Most of the studies included reported some degree of improvement in resilience-like variables among those subjects exposed to resilience-promoting programs. Furthermore, positive findings were more consistent among randomized controlled trials - six out of the seven suggested efficacy.ConclusionThere is evidence pointing towards some degree of effectiveness of resilience promotion programs, despite the poor operationalization of the construct and great heterogeneity in the studies. Indeed, the analysis of the methodological quality of the selected studies was hampered by the poor quality of reporting. There were faults in reporting in most studies on almost all items (random sequence generation, allocation concealment, blinding of outcome assessment, incomplete outcome data, description of concurrent treatment and intent-to-treat analysis), except for the item “selective reporting”. Additional efforts should be made to determine the actual effect size of the interventions, since this is crucial for calculating the cost-effectiveness of resilience promotion strategies.

They know their trauma by heart: an assessment of psychophysiological failure to recover in PTSD.

BACKGROUND Posttraumatic stress disorder (PTSD) develops following exposure to atraumatic event and is characterized by persistent intense reactivity to trauma related cues. Equally important, but less studied, is the failure to restore physiological homeostasis after these excessive reactions. This study investigates psychophysiological markers of sustained cardiac activity after exposure to reminders of traumatic event in PTSD patients. METHODS Participants passively listened to neutral and personal traumatic event while electrocardiogram was continuously recorded. Heart rate (HR) and heart rate variability (HRV) were analyzed in 19 PTSD patients and 16 trauma-exposed controls. RESULTS Both PTSD patients and trauma exposed controls exhibited a significant increase in HR to the exposure of their personal trauma. PTSD patients sustained the increase of HR while controls recovered to basal levels. In PTSD patients, sustained HR was positively associated with re-experiencing symptoms. The PTSD group also showed a reduced HRV (a measure of parasympathetic influence on the heart) during personal trauma exposure and lack of recovery. LIMITATIONS The sample size was small and PTSD patients were under medication. CONCLUSIONS Our findings provide an experimental account of the failure of PTSD patients to exhibit physiological recovery after exposure to trauma-related stimuli. PTSD patients exhibited a sustained tachycardia with attenuation of HRV that persisted even after cessation of the stressor. Re-experiencing symptoms facilitated engagement in the trauma cues, suggesting that, in their daily-life, patients most likely present repeated episodes of sustained over-reactivity, which may underpin the emotional dysregulation characteristic of PTSD.

Peritraumatic tonic immobility in a large representative sample of the general population: association with posttraumatic stress disorder and female gender

BACKGROUND Tonic immobility is an involuntary response to inescapable life-threatening events. Peritraumatic tonic immobility has been reported in convenience samples of female victims of sexual assault and in mixed-gender victims of different types of trauma. This study evaluated peritraumatic tonic immobility in a representative general population sample and its association with posttraumatic stress disorder (PTSD) and gender. METHODS 3231 victims of traumatic events aged 15-75 years responded to the Tonic Immobility Scale. PTSD and traumatic events were assessed using the Composite International Diagnostic Interview (CIDI 2.1). We calculated the means and the standard deviations of Tonic Immobility Scale scores stratified by PTSD and gender. The association between tonic immobility scores and gender was explored controlling for potential confounders through a multiple linear regression model. RESULTS Tonic immobility scores were more than double in those who met criteria for PTSD and were almost four points higher in women. Gender differences remained statistically significant even after adjustment for confounding variables. LIMITATIONS The cross-sectional and retrospective design may have given rise to recall bias. Results presented here may not apply to small and medium rural areas and the CIDI 2.1 can lead to a certain degree of misclassification. CONCLUSIONS We have expanded the scope of previous investigations on peritraumatic tonic immobility which were based on convenience samples only, showing its occurrence in victims of traumatic events using a large representative sample of the general population. Furthermore, we confirmed in an unbiased sample the association between peritraumatic tonic immobility and PTSD and female gender.

Conditional risk for posttraumatic stress disorder in an epidemiological study of a Brazilian urban population

INTRODUCTION Conditional risk for PTSD is the risk of developing PTSD after exposure to traumatic events. This epidemiological study of the general urban population from the two largest cities in Brazil reports exposure to traumatic events; conditional risk for PTSD; and proportion/estimated number of PTSD cases secondary to each type of traumatic event. METHOD Cross-sectional study of general population (15-75 y.o.) from Rio de Janeiro and São Paulo. PTSD was assessed through Composite International Diagnostic Interview 2.1. RESULTS Our main findings, from 3744 participants, were: 1) high prevalence of traumatic events (86%), urban violence being the most common; 2) conditional risk for PTSD was 11.1%; 3) women (15.9%) have overall conditional risk 3 times higher than men (5.1%); 4) war-related trauma (67.8%), childhood sexual abuse (49.1%) and adult sexual violence (44.1%) had the highest conditional risks; 5) 35% of PTSD cases (estimated 435,970 individuals) were secondary to sudden/unexpected death of a close person, and 40% secondary to interpersonal violence. CONCLUSIONS Brazilian urban population is highly exposed to urban violence, and overall conditional risk for PTSD was 11.1%. Violence prevention and enhancement of resilience should be part of public policies, and mental health sequelae of trauma should be better recognized and treated.

Resilience to trauma in the two largest cities of Brazil: a cross-sectional study

BackgroundResilience is a dynamic process involving the interaction between intrapsychic and social factors of risk and protection. For resilience to be recognized there must be a significant threat to the individual, such as a traumatic event, and a good quality of adjustment. The aim of this study was to identify predisposing factors and possible mechanisms associated with resilience to traumatic events in the general population.MethodsWe conducted a cross-sectional study with a random sample, aged 15-75 years, living in the two largest cities in Brazil, who were exposed to trauma (N = 3,231). Positive adaptation to trauma was defined as the lifetime absence of anxiety (including posttraumatic stress disorder), depression and alcohol related disorders in the presence of at least one traumatic event. Logistic regression models predicting resilience were used to estimate the incidence density ratio. This measure expresses the extent to which the rate of resilience differs from the exposed group to the non-exposed group. Moreover, we explored the relationship between positive/negative affect and resilience, using linear regression models.ResultsMale gender was a predisposing factor to positive adaptation (incidence density ratio [IDR] = 1.34; p < 0.001). There was an inverse linear relationship between childhood violence and resilience (IDR = 0.67; 0.53; 0.19; p < 0.001). Our findings suggest that the absence of parental mental disease (IDR = 1.35; p = 0.07) also predisposes individuals to positive adaptation.ConclusionsThis study provides results that help to identify vulnerable groups and protective factors that may lead to a positive adaptation following traumatic experiences.

Sexual trauma is more strongly associated with tonic immobility than other types of trauma – A population based study

BACKGROUND Tonic immobility is an involuntary motor and vocal inhibition reaction, considered the last-ditch response of the defensive cascade model. It is elicited in context of inescapable threat and perception of entrapment. Our aim was to investigate the association between different traumatic events and peritraumatic tonic immobility (PTI) in a representative sample of the general population. METHODS This is a cross-sectional study of general population from Rio de Janeiro and São Paulo with 3231 victims of traumatic events aged 15-75 years who completed the Tonic Immobility Scale (TIS). We calculated the frequency of the different traumatic events and estimated the mean scores with 95% confidence intervals for each traumatic event, controlling for the potential confounders using multiple linear regression models. Finally, we calculated the proportion of individual scoring zero in TIS for the 16 traumatic events. RESULTS PTI scores in child sexual abuse and adult sexual violence were almost twice as high as in other types of traumatic events, even when controlled for gender and educational level. Torture and war also showed high PTI scores, but these were based on very small number of cases and need to be interpreted with caution. Furthermore, victims of sexual trauma had the lowest proportion of individuals with total absence of PTI symptoms. LIMITATIONS This is a cross-sectional study and causal inferences must be drawn with caution. CONCLUSIONS Peritraumatic tonic immobility is more strongly associated with sexual trauma, particularly in childhood, than to other types of trauma in the general population.

Portuguese-language cross-cultural adaptation of the Social Phobia Inventory (SPIN) to be used with adolescent students

ABSTRACT Introduction: There has been a growing interest in the study of social phobia, mainly among young people, which demands self-report instruments to identify the disorder. In this study a cross-cultural adaptation of the Social Phobia Inventory (SPIN) was carried out to be used with Brazilian adolescent students. Methods: The adaptation process was conducted in four stages: translation; back translation; critical appraisal of the versions to develop a consensual version; and commented pretest. Results: The results of the four stages and the final version are showed for each item of the instrument. Discussion: The use of more than one translation and back translation is important to allow the comparison of the items, detection of errors and thus choose more appropriate terms. The commented pretest performed in a group similar to the target population allows a better adequacy of the instrument to the population to which it will be applied. Conclusion: Instruments developed in a foreign language need a careful cross-cultural adaptation process in order to be used in a different reality.INTRODUCAO: E crescente o interesse em estudar a Fobia Social, sobretudo em faixas etarias jovens, requerendo instrumentos de autopreenchimento para identificacao do transtorno. Esse estudo consistiu na adaptacao transcultural do Social Phobia Inventory (SPIN) para sua utilizacao entre adolescentes estudantes brasileiros. METODOS: O processo de adaptacao envolveu quatro etapas: traducao; retroversao; apreciacao das versoes com elaboracao de uma versao de consenso; e pre-teste comentado. RESULTADOS: Para cada item do instrumento, sao apresentados os resultados das quatro etapas e a versao final do instrumento em portugues. DISCUSSAO: E importante a utilizacao de mais de uma traducao e retroversao para possibilitar a comparacao dos itens e a identificacao de erros e assim permitir a escolha dos termos mais adequados. A realizacao do pre-teste comentado em um grupo semelhante a populacao alvo possibilita a melhor adequacao do instrumento a populacao em que sera utilizado. CONCLUSAO: Instrumentos elaborados em lingua estrangeira necessitam de processo cuidadoso de adaptacao transcultural para sua utilizacao em uma realidade sociocultural distinta.