Miguel Roberto Jorge

WPA guidance on how to combat stigmatization of psychiatry and psychiatrists

In 2009 the WPA President established a Task Force that was to examine available evidence about the stigmatization of psychiatry and psychiatrists and to make recommendations about action that national psychiatric societies and psychiatrists as professionals could do to reduce or prevent the stigmatization of their discipline as well as to prevent its nefarious consequences. This paper presents a summary of the Task Forces findings and recommendations. The Task Force reviewed the literature concerning the image of psychiatry and psychiatrists in the media and the opinions about psychiatry and psychiatrists of the general public, of students of medicine, of health professionals other than psychiatrists and of persons with mental illness and their families. It also reviewed the evidence about the interventions that have been undertaken to combat stigma and consequent discrimination and made a series of recommendations to the national psychiatric societies and to individual psychiatrists. The Task Force laid emphasis on the formulation of best practices of psychiatry and their application in health services and on the revision of curricula for the training of health personnel. It also recommended that national psychiatric societies establish links with other professional associations, with organizations of patients and their relatives and with the media in order to approach the problems of stigma on a broad front. The Task Force also underlined the role that psychiatrists can play in the prevention of stigmatization of psychiatry, stressing the need to develop a respectful relationship with patients, to strictly observe ethical rules in the practice of psychiatry and to maintain professional competence.

The reliability of the Brazilian version of the Composite International Diagnostic Interview (CIDI 2.1)

The objective of the present study was to determine the reliability of the Brazilian version of the Composite International Diagnostic Interview 2.1 (CIDI 2.1) in clinical psychiatry. The CIDI 2.1 was translated into Portuguese using WHO guidelines and reliability was studied using the inter-rater reliability method. The study sample consisted of 186 subjects from psychiatric hospitals and clinics, primary care centers and community services. The interviewers consisted of a group of 13 lay and three non-lay interviewers submitted to the CIDI training. The average interview time was 2 h and 30 min. General reliability ranged from kappa 0.50 to 1. For lifetime diagnoses the reliability ranged from kappa 0.77 (Bipolar Affective Disorder) to 1 (Substance-Related Disorder, Alcohol-Related Disorder, Eating Disorders). Previous year reliability ranged from kappa 0.66 (Obsessive-Compulsive Disorder) to 1 (Dissociative Disorders, Maniac Disorders, Eating Disorders). The poorest reliability rate was found for Mild Depressive Episode (kappa = 0.50) during the previous year. Training proved to be a fundamental factor for maintaining good reliability. Technical knowledge of the questionnaire compensated for the lack of psychiatric knowledge of the lay personnel. Inter-rater reliability was good to excellent for persons in psychiatric practice.

THE LATIN AMERICAN GUIDE FOR PSYCHIATRIC DIAGNOSIS: A Cultural Overview

The ICD-10 Classification of Mental and Behavioral Disorders is being accepted by most countries and by the World Psychiatric Association as the international standard in the field for statistical reporting and for clinical care and research. Emerging now, however, is the need to harmonize international communication with recognition of cultural diversity and specific local requirements. Latin American psychiatrists hold a long-standing commitment to the formulation of a reliable and valid diagnostic system in international psychiatry. Examples of important Latin American contributions include the pioneering use of explicit operational criteria in diagnostic methodology by Horwitz and Marconi in Chile, and the proposal of a multiaxial diagnostic formulation by Leme-Lopes in Brazil. In recent times, two main Latin American efforts at developing diagnostic adaptations to the international classification in psychiatry have emerged. One is the Cuban Glossary of Psychiatry, already in its third edition, and the second is a more ambitious project to develop the Latin American Guide for Psychiatric Diagnosis (GLADP). Departing from the experience gained by the Cuban psychiatry and keeping ICD-10 as the basis for nosological organization of mental disorders, the GLADP is being developed with the contributions of psychiatrists and other mental health professionals from most countries in Latin America. The GLADP comprises 4 parts: (I) historical and cultural framework of Latin American psychiatry; (II) a comprehensive diagnostic process and formulation, (III) psychiatric nosology (including ICD-10 major classes of disorders and Latin American cultural syndromes); and (IV) appendixes (including, a lexicologic glossary, concepts and proposals for future study, and bibliography). This is an overview of the basic principles and dimensions for psychiatric diagnosis in Latin America, with an emphasis on its cultural framework.

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.

The accuracy of the Clinician-Administered PTSD Scale (CAPS) to identify PTSD cases in victims of urban violence

As a consequence of the increasing urban violence in Brazil, many cases of posttraumatic stress disorder (PTSD) are now seen in the community and clinical settings. The main aim of this article is to assess the psychometric properties of the Clinician-Administered PTSD Scale (CAPS) to study factors related to the etiology, prognosis, and efficacy of interventions of PTSD in civilian populations. PTSD outpatients from a program of victims of violence and subjects identified in an epidemiological survey conducted in the city of Sao Paulo completed a battery of validated instruments and the CAPS. Instrument reliability and validity were measured. The comparison between the CAPS scores and the Structured Clinical Interview for DSM IV (SCID) interview resulted in the following validity coefficients: sensitivity=90%, specificity=95%, and misclassification rate=7.1%. The area under the receiver operating characteristic (ROC) curve was 0.97. There was a positive correlation between CAPS scores with Beck Depression Inventory (BDI; 0.70) and Beck Anxiety Inventory (BAI; 0.76) scores. The Kappa coefficients were all higher than 0.63 for all CAPS items. The internal consistency for all CAPS items resulted in a Cronbachs alpha coefficient of 0.97. The CAPS showed to be both an accurate and a reliable research instrument to identify PTSD cases in a civilian population.

Report of the WPA Task Force on Brain Drain

The brain drain of health professionals is an issue of continuing interest and debate. The WPA set up a Task Force to examine the phenomenon as it relates specifically to mental health professionals. This report provides a description of the work of the Task Force and its recommendations in regard to how the WPA might act to help address the issue.

Natureza e magnitude do estresse na residência médica

The stressful nature of Residency training has been largely discussed in the literature. The aim of this paper is to present some data about the stress of training and its effects on residents and on the quality of patients care. The magnitude of stress results from the interaction of three categories of stresses: professional, situational and personal. The main behavioral disturbances and professional dysfunctions are described and the importance of these data for planning, organization and evaluation of Residency programs is emphasized.

The Posttraumatic Stress Disorder Project in Brazil: Neuropsychological, Structural and Molecular Neuroimaging Studies in Victims of Urban Violence

BackgroundLife trauma is highly prevalent in the general population and posttraumatic stress disorder is among the most prevalent psychiatric consequences of trauma exposure. Brazil has a unique environment to conduct translational research about psychological trauma and posttraumatic stress disorder, since urban violence became a Brazilian phenomenon, being particularly related to the rapid population growth of its cities. This research involves three case-control studies: a neuropsychological, a structural neuroimaging and a molecular neuroimaging study, each focusing on different objectives but providing complementary information. First, it aims to examine cognitive functioning of PTSD subjects and its relationships with symptomatology. The second objective is to evaluate neurostructural integrity of orbitofrontal cortex and hippocampus in PTSD subjects. The third aim is to evaluate if patients with PTSD have decreased dopamine transporter density in the basal ganglia as compared to resilient controls subjects. This paper shows the research rationale and design for these three case-control studies.Methods and designCases and controls will be identified through an epidemiologic survey conducted in the city of São Paulo. Subjects exposed to traumatic life experiences resulting in posttraumatic stress disorder (cases) will be compared to resilient victims of traumatic life experiences without PTSD (controls) aiming to identify biological variables that might protect or predispose to PTSD. In the neuropsychological case-control study, 100 patients with PTSD, will be compared with 100 victims of trauma without posttraumatic stress disorder, age- and sex-matched controls. Similarly, 50 cases and 50 controls will be enrolled for the structural study and 25 cases and 25 controls in the functional neuroimaging study. All individuals from the three studies will complete psychometrics and a structured clinical interview (the Structured Clinical Interview for DSM-IV and the Clinician-Administered PTSD Scale, Beck Anxiety Inventory, Beck Depression Inventory, Global Assessment of Function, The Social Adjustment Scale, Medical Outcomes Study 36-Item Short-Form Health Survey, Early Trauma Inventory, Clinical global Impressions, and Peritraumatic Dissociative Experiences Questionnaire). A broad neuropsychological battery will be administered for all participants of the neuropsychological study. Magnetic resonance scans will be performed to acquire structural neuroimaging data. Single photon emission computerized tomography with [(99m)Tc]-TRODAT-1 brain scans will be performed to evaluate dopamine transporters.DiscussionThis study protocol will be informative for researchers and clinicians interested in considering, designing and/or conducting translational research in the field of trauma and posttraumatic stress disorder.

RELIABILITY AND FACTOR STRUCTURE OF THE BRAZILIAN VERSION OF THE CENTER FOR EPIDEMIOLOGIC STUDIES-DEPRESSION '

The Center for Epidemiologic Studies-Depression scale is a screening test designed by the National Institute of Mental Health (USA) to screen for ‘depressed’ individuals in the community. It has been widely used in different settings and cultures displaying variable psychometric properties. The present article describes coefficients of internal consistency and factor analysis of the CES–Depression version adapted for use in Brazil. In a sample of 523 college students internal consistency measured by Cronbach alpha was .85. Structure analysis evidenced that two questions were poorly correlated with the remaining questions. Factor analysis resulted in a four-dimension solution accounting for 53.8% of the total item variance. The scale is adequate for use in this different cultural setting.

Structural validity and reliability of the Positive and Negative Affect Schedule (PANAS): Evidence from a large Brazilian community sample

OBJECTIVE Positive and negative affect are the two psychobiological-dispositional dimensions reflecting proneness to positive and negative activation that influence the extent to which individuals experience life events as joyful or as distressful. The Positive and Negative Affect Schedule (PANAS) is a structured questionnaire that provides independent indexes of positive and negative affect. This study aimed to validate a Brazilian interview-version of the PANAS by means of factor and internal consistency analysis. METHODS A representative community sample of 3,728 individuals residing in the cities of São Paulo and Rio de Janeiro, Brazil, voluntarily completed the PANAS. Exploratory structural equation model analysis was based on maximum likelihood estimation and reliability was calculated via Cronbachs alpha coefficient. RESULTS Our results provide support for the hypothesis that the PANAS reliably measures two distinct dimensions of positive and negative affect. CONCLUSION The structure and reliability of the Brazilian version of the PANAS are consistent with those of its original version. Taken together, these results attest the validity of the Brazilian adaptation of the instrument.