Rubén Alvarado

Evaluación del Programa para la Detección, Diagnóstico y Tratamiento Integral de la Depresión en atención primaria, en Chile

OBJETIVO: Realizar una evaluacion preliminar del Programa para la Deteccion, Diagnostico y Tratamiento Integral de la Depresion, instituido por el Ministerio de Salud de Chile. METODOS: Se realizo un seguimiento de tres meses de un grupo de mujeres que ingresaron en este programa en ocho centros de atencion primaria de tres regiones de Chile. La muestra inicial estuvo constituida por 229 personas, de las cuales 169 pudieron entrevistarse a los tres meses. Se estudiaron variables sociodemograficas, factores de riesgo psicosocial, sintomas ansiosos y somatomorfos y el grado de satisfaccion con la atencion recibida. El cuadro depresivo se evaluo con el Inventario de Depresion de Beck. Se analizaron los tratamientos e intervenciones prescritos a las mujeres. RESULTADOS: La decision de ingresar a las pacientes en el programa resulto pertinente, ya que 95,2% tenian un cuadro depresivo. La concordancia en cuanto a la gravedad del cuadro clinico fue cercana a 50%, con una tendencia a subestimarla. La tasa de abandono del programa fue de 19,5% a los tres meses de seguimiento. Las mujeres que se retiran tienden a presentar un cuadro clinico menos complejo (sintomas ansiosos y somatomorfos menos intensos), asi como un menor numero de factores de riesgo psicosocial y una menor satisfaccion con la atencion recibida. Entre las pacientes del programa se observo buena adherencia al tratamiento farmacologico (73,3%) y regular a la psicoterapia individual (47,4%) y a la intervencion grupal (37,8%). Se observo un descenso significativo en la intensidad de los sintomas depresivos a los tres meses, el cual fue mayor entre las que presentaban cuadros mas graves. Se encontro tambien un descenso significativo de los sintomas ansiosos y somatomorfos. CONCLUSION: La evaluacion preliminar indica que el programa esta cumpliendo con los objetivos propuestos, si bien parece necesario desarrollar estrategias especificas para mejorar la precision en el diagnostico clinico y el cumplimiento de los tratamientos ofrecidos.

Prevalence rates of mental disorders in Chilean prisons

Objective High rates of mental disorders have been reported for prison populations worldwide, particularly in low- and middle-income countries (LMICs). The present study aimed to establish prevalence rates of mental disorders in Chilean prisoners. Method A nationwide random sample of 1008 prisoners was assessed in 7 penal institutions throughout Chile. Twelve-month prevalence rates were established using the Composite International Diagnostic Interview (CIDI) and compared to the prevalence rates previously published for the general population. Results Prevalence rates were 12.2% (95% CI, 10.2-14.1) for any substance use disorder, 8.3% (6.6-10.0) for anxiety disorders, 8.1% (6.5-9.8) for affective disorders, 5.7% (4.4-7.1) for intermittent explosive disorders, 2.2% (1.4-3.2) for ADHD of the adult, and 0.8% (0.3-1.3) for non-affective psychoses. Significantly higher prevalence rates among prisoners as compared to the general population in Chile were seen for major depression (6.1% vs. 3.7% males, Z=2.58, p<0.05) and illicit drug use (3.3% vs. 0.6% males with drug abuse, Z=2.04, p<0.05; 2.6% vs. 0.1% females with drug abuse, Z=5.36, p<0.001; 3.4% vs. 1.1% males with drug dependence, Z=3.70; p<0.001). Dysthymia (6.5% vs. 15.6%, Z=-2.39, p<0.05), simple (3.3% vs. 11.5%, Z=-3.13, p<0.001) and social phobias (3.9% vs. 9.7%, Z=2.38, p<0.05) were significantly less frequent in the female prison population than in the general population. One-year prevalence rates of alcohol abuse (2.3% vs. 3.9%; Z=-2.04; p<0.05) and dependence (2.7% vs. 8.2%; Z=-5.24; p<0.001) were less prevalent in the male prison population than in the general population. Conclusions Service provision for prison populations in Chile should acknowledge high rates of depression and illicit drug use. Overall prevalence rates are lower than reported in other LMICs. Previous research in prison populations in LMICs might have overestimated prevalence rates of mental disorders.

El Programa Nacional para el diagnóstico y tratamiento de depresión en Atención Primaria: una evaluación necesaria.

Background: Depression is highly prevalent among Chilean adults, therefore a primary care treatment program was devised. Aim: To evaluate the Program for detection, diagnosis and integral treatment of depression, implemented in Chilean Primary Health Care Centers. Material and Methods: A three and six months follow-up study was conducted among women admitted to the program at seven primary health care centers in two regions of Chile. Socio-demographic data, treatments provided and compliance with the program were assessed. A clinical standardized interview (with ICD-10) was carried out and the intensity of depressive symptoms was evaluated using Beck Depression Inventory (BDI). Results: The initial sample was composed by 201 women aged 25 to 65 years. At 6 months, 35% were lost from follow up. Depression was mild, moderate or severe in 12, 63 and 25% of women, respectively. The severity of depression was underestimated by primary care teams. Among women with regular and irregular attendance to medical appointments and those that abandoned treatment, BDIscore decreased by 35,37and 13%, respectively. Conclusions: This primary care program for depression was effective to reduce BDI scores. Diagnostic precision of primary care teams must be improved.

Lessons from scaling up a depression treatment program in primary care in Chile

In Chile, the National Depression Detection and Treatment Program (Programa Nacional de Diagnóstico y Tratamiento de la Depresión, PNDTD) in primary care is a rare example of an evidence-based mental health program that was scaled up to the national level in a low- or middle-income country. This retrospective qualitative study aimed to better understand how policymakers made the decision to scale up mental health services to the national level, and to explore the elements, contexts, and processes that facilitated the decision to implement and sustain PNDTD. In-depth semistructured interviews with six key informants selected through intentional sampling were conducted in August-December 2008. Interviewees were senior officers at the Ministry of Health who were directly involved in the decision to scale up the program. Results yielded four elements pivotal to the decisionmaking process: scientific evidence, teamwork and leadership, strategic alliances, and program institutionalization. Each element contributed to building consensus, securing funding, attracting resources, and gaining lasting support from policymakers. Additionally, a review of available documentation led the authors to consider sociopolitical context and use of the media to be important factors. While research evidence for the effectiveness of mental health services in the primary care setting continues to accumulate, low- and middle-income countries should get started on the lengthy process of scaling up by incorporating the elements that led to decisionmaking and implementation of the PNDTD in Chile.

Efficacy of Community Treatments for Schizophrenia and Other Psychotic Disorders: A Literature Review

Background: In Chile, the clinical guidelines “for the treatment of people from first episode of schizophrenia” aim to support individuals with schizophrenia to live independently, establishment occupational goals, and gain an adequate quality of life and social interaction. This requires the implementation of a treatment model that integrates psychosocial and pharmacological dimensions. Community intervention strategies ensure the achievement of these goals. Objectives: This study compiles and synthesizes available scientific evidence from the last 14 years on the effectiveness of community intervention strategies for schizophrenia and related psychotic disorders. Methodology: An electronic search was carried out using PUBMED, LILACS, and Science Direct as databases. Criteria of inclusion: (i) randomized clinical trials, (ii) Community-based interventions, (iii) diagnosis of schizophrenia or related psychotic disorder (section F2 of ICD-10). Exclusion Criteria: (i) treatments exclusively pharmacological, (ii) interventions carried out in inpatient settings, (iii) bipolar affective disorder or substance-induced psychosis (greater than 50% of sample). Results: Sixty-six articles were reviewed. Community strategies for integrated treatment from the first outbreak of schizophrenia significantly reduced negative and psychotic symptoms, days of hospitalization, and comorbidity with substance abuse and improved global functioning and adherence to treatment. In other stages, there were improved outcomes in negative and positive symptoms and general psychopathology. Psychoeducation for patients and families reduced the levels of self-stigma and domestic abuse, as well as improved knowledge of the disease and treatment adherence. Training focused on cognitive, social, and labor skills has been shown to improve yields in social functioning and employment status. Conclusion: Community-based intervention strategies are widely supported in the treatment of patients with schizophrenia.

Stigma toward mental illness in Latin America and the Caribbean: a systematic review

Objective: Stigma toward individuals with mental disorders has been studied extensively. In the case of Latin America and the Caribbean, the past decade has been marked by a significant increase in information on stigma toward mental illness, but these findings have yet to be applied to mental health services in Latin America. The objective of this study was to conduct a systematic review of studies relating to stigma toward mental illness in Latin America and the Caribbean. The authors specifically considered differences in this region as compared with manifestations reported in Western European countries. Methods: A systematic search of scientific papers was conducted in the PubMed, MEDLINE, EBSCO, SciELO, LILACS, Imbiomed, and Bireme databases. The search included articles published from 2002 to 2014. Results: Twenty-six studies from seven countries in Latin America and the Caribbean were evaluated and arranged into the following categories: public stigma, consumer stigma, family stigma, and multiple stigmas. Conclusion: We identified some results similar to those reported in high-income settings. However, some noteworthy findings concerning public and family stigma differed from those reported in Western European countries. Interventions designed to reduce mental illness-related stigma in this region may benefit from considering cultural dynamics exhibited by the Latino population.

Validación de un cuestionario para evaluar riesgos psicosociales en el ambiente laboral en Chile

BACKGROUND The measurement of psychosocial risk among workers is becoming increasingly important. AIM To adapt, validate and standardize a questionnaire to measure psychosocial risks in the workplace. MATERIAL AND METHODS The Spanish version of the Copenhagen Psychosocial Questionnaire was adapted and evaluated. Its contents were first validated with a panel of experts. Afterwards a semantic adaptation of the questionnaires was carried out applying it to a pilot sample. Finally, it was applied to 1,557 workers (65% men). RESULTS A preliminary questionnaire containing 97 questions was constructed. A good item-test correlation was found, the factorial structure was similar to the original questionnaire and it had a good internal consistency, convergent validity with the Goldberg Health Questionnaire and test-retest correlation. Ranges for the different dimensions and sub-dimensions of psychosocial risk were calculated by tertiles. CONCLUSIONS The resulting questionnaire is useful for measuring psychosocial risk factors at work, with good psychometric properties.Background: The measurement of psychosocial risk among workers is becoming increasingly important. Aim: To adapt, validate and standardize a questionnaire to measure psychosocial risks in the workplace. Material and Methods: The Spanish version of the Copenhagen Psychosocial Questionnaire was adapted and evaluated. Its contents were first validated with a panel of experts. Afterwards a semantic adaptation of the questionnaires was carried out applying it to a pilot sample. Finally, it was applied to 1,557workers (65% men). Results: A preliminary questionnaire containing 97 questions was constructed. A good item-test correlation was found, the factorial structure was similar to the original questionnaire and it had a good internal consistency, convergent validity with the Goldberg Health Questionnaire and test-retest correlation. Ranges for the different dimensions and sub-dimensions of psychosocial risk were calculated by tertiles. Conclusions: The resulting questionnaire is useful for measuring psychosocial risk factors at work, with good psychometric properties.

Development of Community Care for People with Schizophrenia in Chile

Chile has greatly reformed its approach to psychiatric care in the last two decades, having transitioned from a model centered around a psychiatric hospital to one in which mental health care is based in the community. During this period, patients were moved from large psychiatric hospitals into ambulatory clinics, and the number of people who were in hospitals for extended periods decreased. At the same time, mental health service networks—consisting of ambulatory clinics, day hospitals, rehabilitation centers, and community group homes—were created, each responsible for a specific population. The reform process, however, has occurred in different, unequal degrees throughout the country. The purpose of this investigation is to compare the characteristics, resources, and results of the mental health service networks that have successfully transitioned to and developed in the community with respect to those that are still centered in a hospital. The structural aspects were evaluated with the EvaRedCom-TMS (Evaluación de Redes de Servicios Comunitarios para Trastornos Mentales Severos), and the level of functioning was measured with World Health Organizations International Classification of Mental Health Care. Area networks with higher levels of community-based services show better indicators of geographic and financial accessibility, use less human resources (particularly psychiatrists and nursing assistants), have an equal level of specialization, and yet show better treatment adherence among the patients (84.2 percent versus 41.8 percent), despite the fact that the patients have worse socioeconomic and clinical indicators than area networks with lower levels of community-based services. In conclusion, the community-based psychiatric care model is more effective than the hospital-centered model.

Association between unmet needs and clinical status in patients with first episode of schizophrenia in Chile

Background Schizophrenia is a severe mental disorder involving needs in several matters that are often not covered. A need is defined as a gap between the ideal state and the current state of a patient about a specific topic. Aim To describe needs in patients with first episode of schizophrenia at the start of treatment and to describe associated clinical factors. Methods Observational descriptive cross-sectional design. Patients were over 15 years old, with first episode schizophrenia, and admitted to treatment in the public health system from six districts in two cities of Chile, between 2005 and 2006. Sociodemographic data, clinical evaluations of current psychosis based on the Positive and Negative Syndrome Scale (PANSS), and the time of untreated psychosis were obtained. A clinical interview was carried out followed by the Camberwell Assessment of Need. Results Twenty-nine patients were evaluated, 79.3% male, mean age 21.9 years old. The areas with more needs reported were; psychotic symptoms with 65.5% of sample, 21.1% of which reported it unmet; and daytime activities, where 44.8% of patients reported a need, 61.54% of them as unmet. The percentage of unmet needs correlated with PANSS score (r = 0.55; p = 0.003), and with time of positive symptoms prior to diagnosis (r = 0.416; p = 0.03). Discussion Needs assessment in schizophrenia is necessary. It may affect its clinical course, be relevant in its management, and help monitor recovery. Defining the main needs in people with first episode schizophrenia and associated factors allows for a better design of treatment strategies in order to obtain better therapeutic results and recovery.

Factors associated with unmet needs in individuals with schizophrenia in Chile

OBJECTIVE: To evaluate the possible associations between different sociodemographic, clinical, and healthcare factors and the number of unmet needs among people being treated for schizophrenia. METHODS: The sample was made up of 141 subjects who were being treated at eight mental health service networks throughout Chile. Unmet need was assessed with the Camberwell Assessment of Need, which was specifically created for people with severe mental disorders. A multiple linear regression analysis was also applied. RESULTS: It was found a direct association with clinical variables: score in the Positive and Negative Syndrome Scale, global functioning at diagnosis, and change in global functioning at diagnosis from diagnosis to interview. However, sociodemographic (ethnicity, education level, and number of people who live with subject) and other clinical variables (age at diagnosis, and annual rate of relapse) were indirectly associated with unmet needs. CONCLUSIONS: Our results can be applied in order to coordinate and improve the effectiveness of mental health services in Chile.