Sandra Fortes

Nosological profile and prevalence of common mental disorders of patients seen at the Family Health Program (FHP) units in Petrópolis, Rio de Janeiro

OBJECTIVES This study aims to detect the prevalence of common mental disorders among patients seen by doctors at family health program units in Petrópolis-RJ, and to establish their nosological profile. METHOD The population of the study included all 18 to 65-year-old patient who attended any family health program units included in the study during a 30-day period, between August and December 2002 (n = 714). The prevalence of common mental disorders was assessed using the General Health Questionnaire, 12 item version. In order to establish the nosological profile, the Composite International Diagnostic Interview was administered to all common mental disorders positive patients who accepted to return (n = 215). RESULTS At the cut-off point of 2/3 the common mental disorders prevalence was 56% and for 4/5, it was 33%. The most frequent nosological categories found among common mental disorders positive patients were depression and anxiety categories along with posttraumatic stress disorder, somatoform pain disorder and dissociative disorders. There was a high frequency of comorbidity, especially between anxiety, depression, somatoform and dissociative disorders. CONCLUSIONS The common mental disorders prevalence and the nosological profile found in FHP were similar to those of other primary care studies in Brazil, but some disorders (posttraumatic stress disorder, somatoform pain disorder and dissociative disorders) that had not been previously studied in this context were also very frequent. The high common mental disorders prevalence found reinforces the urgent need for systematic inclusion of this level of care in mental health assistance planning.

Proposed new diagnoses of anxious depression and bodily stress syndrome in ICD-11-PHC: an international focus group study

BACKGROUND The World Health Organization is revising the primary care classification of mental and behavioural disorders for the International Classification of Diseases (ICD-11-Primary Health Care (PHC)) aiming to reduce the disease burden associated with mental disorders among member countries. OBJECTIVE To explore the opinions of primary care professionals on proposed new diagnostic entities in draft ICD-11-PHC, namely anxious depression and bodily stress syndrome (BSS). METHODS Qualitative study with focus groups of primary health-care workers, using standard interview schedule after draft ICD-11-PHC criteria for each proposed entity was introduced to the participants. RESULTS Nine focus groups with 4-15 participants each were held at seven locations: Austria, Brazil, Hong Kong, New Zealand, Pakistan, Tanzania and United Kingdom. There was overwhelming support for the inclusion of anxious depression, which was considered to be very common in primary care settings. However, there were concerns about the 2-week duration of symptoms being too short to make a reliable diagnosis. BSS was considered to be a better term than medically unexplained symptoms but there were disagreements about the diagnostic criteria in the number of symptoms required. CONCLUSION Anxious depression is well received by primary care professionals, but BSS requires further modification. International field trials will be held to further test these new diagnoses in draft ICD-11-PHC.

Brazilian multicentre study of common mental disorders in primary care: rates and related social and demographic factors

Problemas de saude mental sao comuns na atencao primaria e sao geralmente relacionados a ansiedade e a depressao. Este estudo tem o objetivo de avaliar a taxa de transtornos mentais comuns e suas associacoes com caracteristicas sociodemograficas em unidades de saude da familia. E um estudo multicentrico, transversal, com os usuarios da atencao primaria do Rio de Janeiro, Sao Paulo, Fortaleza (Ceara) e Porto Alegre (Rio Grande do Sul), Brasil. Utilizou-se o General Health Questionnaire (GHQ-12) e o Hospital Anxiety and Depression Scale (HAD). A taxa de transtornos mentais nos usuarios do Rio de Janeiro, Sao Paulo, Fortaleza e Porto Alegre foram, respectivamente, 51,9%, 53,3%, 64,3% e 57,7%, com diferencas significativas entre Porto Alegre e Fortaleza comparando-se ao Rio de Janeiro. Problemas de saude mental foram especialmente altos em mulheres, desempregados, em pessoas com baixa escolaridade e com baixa renda. Dadas as iniciativas do governo brasileiro para o desenvolvimento os cuidados primarios e para reorganizacao da politica publica de saude mental, e importante considerar os transtornos mentais comuns como uma prioridade tal como outras morbidades cronicas.Mental health problems are common in primary health care, particularly anxiety and depression. This study aims to estimate the prevalence of common mental disorders and their associations with socio-demographic characteristics in primary care in Brazil (Family Health Strategy). It involved a multicenter cross-sectional study with patients from Rio de Janeiro, São Paulo, Fortaleza (Ceará State) and Porto Alegre (Rio Grande do Sul State), assessed using the General Health Questionnaire (GHQ-12) and the Hospital Anxiety and Depression Scale (HAD). The rate of mental disorders in patients from Rio de Janeiro, São Paulo, Fortaleza and Porto Alegre were found to be, respectively, 51.9%, 53.3%, 64.3% and 57.7% with significant differences between Porto Alegre and Fortaleza compared to Rio de Janeiro after adjusting for confounders. Prevalence proportions of mental problems were especially common for females, the unemployed, those with less education and those with lower incomes. In the context of the Brazilian governments moves towards developing primary health care and reorganizing mental health policies it is relevant to consider common mental disorders as a priority alongside other chronic health conditions.

Evaluation of a mental health training intervention for multidisciplinary teams in primary care in Brazil: a pre- and posttest study

OBJECTIVES The aim of this research was to investigate whether a training intervention to enhance collaboration between mental health and primary care professionals improved the detection and management of mental health problems in primary health care in four large cities in Brazil. The training intervention was a multifaceted program over 96 h focused on development of a shared care model. METHOD A quasiexperimental study design was undertaken with assessment of performance by nurse and general practitioners (GPs) pre- and postintervention. Rates of recognition of mental health disorders (compared with the General Health Questionnaire) were the primary outcome, while self-reports of patient-centered care, psychosocial interventions and referral were the secondary outcomes. RESULTS Six to 8 months postintervention, no changes were observed in terms of rate of recognition across the entire sample. Nurses significantly increased their recognition rates (from 23% to 39%, P=.05), while GPs demonstrated a significant decrease (from 42% to 30%, P=.04). There were significant increases in reports of patient-centered care, but no changes in other secondary outcomes. CONCLUSIONS Training professionals in a shared care model was not associated with consistent improvements in the recognition or management of mental health problems. Although instabilities in the local context may have contributed to the lack of effects, wider changes in the system of care may be required to augment training and encourage reliable changes in behavior, and more specific educating models are necessary.

Common mental disorders in Petrópolis-RJ: a challenge to integrate mental health into primary care strategies

OBJECTIVE Common mental disorders are present in more than 50% of patients attending primary care clinics. The main objectives of this study were to detect whether there is any special group of patients within the Family Health Strategy that should be considered to be in greater risk for common mental disorders and to recommend alternative interventions to aid these patients. METHOD In 2002, a cross-sectional study on common mental disorders seen at Family Health Strategy centers was conducted in Petrópolis, State of Rio de Janeiro. RESULTS Common mental disorders were associated with women (OR = 2.90; 95% CI 1.82-4.32), younger than 45 years of age (OR = 1.43; 95% CI 1.02-2.01), with a monthly per capita family income of less than US

Mindfulness-based stress reduction (MBSR) in perceived stress and quality of life: an open, uncontrolled study in a Brazilian healthy sample.

40.00 (OR = 1.68; 95% CI 1.20-2.39), and without a partner (OR = 1.71; 95% CI 1.22-2.39). Illiteracy was associated with common mental disorders among patients who were not extremely poor. Social support networks such as going often to church (OR = 0.62; 95% CI 0.43-0.89); participating in artistic and sporting activities (OR = 0.42; 95% CI 0.26-0.70) and having at least four trusted relatives or friends (OR = 0.53; 95% CI 0.31-0.91) was inversely associated with common mental disorders. DISCUSSION Poor women with little social support represent a special group at risk for common mental disorders in the primary care setting. Some countries have developed special interventions to treat patients with common mental disorders in primary care. CONCLUSION Mental health care programs could include evidence-based psychosocial interventions to assist women in overcoming the vicious circle of poverty and dealing with their mental disorders.

Screening for anxiety, depression, and anxious depression in primary care: A field study for ICD-11 PHC

Mindfulness-based interventions (MBI) are effective therapies for a variety of psychological problems, especially for improving anxiety, mood disorders, and other stress-related conditions, and so may have potential application in and impact on national health systems on a cost-effective basis. In Brazil, meditative practices, along with many other complementary and integrative therapies, have been encouraged and supported by the Ministry of Health, which established the National Policy on Integrative and Complementary Practices (PNPIC) inside the Brazilian National Health System in 2006. According to PNPIC, these actions should ideally be carried out by Primary Care (PC) teams, whose practitioners, including community health trainers, could be trained to implement MBI with the potential to impact on more than 100 million people. Despite this fact and the existing literature on meditation and health, there is still a lack of studies on MBI in the Brazilian population. Culture-specific studies on MBI are in great need, and so our aim was to explore the impact of an MBI program on perceived stress (PS) and quality of life (QoL) in a healthy sample in Brazil. A one-group pre-/post-test design was used to measure the impact of the mindfulness-based stress reduction (MBSR) program (eight-week; 2.5 h/wk; retreat-day) using the Brazilian validated version of the Perceived Stress Scale (PSS) and the WHOQOL-BREF questionnaire. The eligibility criteria included the following: (1) 18 years of age or older; (2) lack of any clinical problems or conditions; and (3) able to understand, read, and write in Portuguese. Subjects (n 1⁄4 23)

DETERMINANTS OF COMMON MENTAL DISORDERS DETECTION BY GENERAL PRACTITIONERS IN THE PRIMARY HEALTH CARE IN BRAZIL

BACKGROUND In this field study of WHOs revised classification of mental disorders for primary care settings, the ICD-11 PHC, we tested the usefulness of two five-item screening scales for anxiety and depression to be administered in primary care settings. METHODS The study was conducted in primary care settings in four large middle-income countries. Primary care physicians (PCPs) referred individuals who they suspected might be psychologically distressed to the study. Screening scales as well as a structured diagnostic interview, the revised Clinical Interview Schedule (CIS-R), adapted for proposed decision rules in ICD-11 PHC, were administered to 1488 participants. RESULTS A score of 3 or more on one or both screening scale predicted 89.6% of above-threshold mood or anxiety disorder diagnoses on the CIS-R. Anxious depression was the most common CIS-R diagnosis among referred patients. However, there was an exact diagnostic match between the screening scales and the CIS-R in only 62.9% of those with high scores. LIMITATIONS This study was confined to those in whom the PCP suspected psychological distress, so does not provide information about the prevalence of mental disorders in primary care settings. CONCLUSIONS The two five-item screening scales for anxiety and depression provide a practical way for PCPs to evaluate the likelihood of mood and anxiety disorders without paper and pencil measures that are not feasible in many settings. These scales may provide substantially improved case detection as compared to current primary care practice and a realistic alternative to complex diagnostic algorithms used by specialist mental health professionals.

Multiple somatic symptoms in primary care: A field study for ICD-11 PHC, WHO's revised classification of mental disorders in primary care settings

Objective: Common Mental Disorders (CMD) are highly prevalent among patients attending primary care. Many of these disorders remain unrecognized by general practitioners (GPs), with the detection rates varying from 30 to 60%. This study aims to evaluate the CMD detection rates by Primary Heath Care (PHC) practitioners in Brazil—and factors that affect CMD detection. Methods: A cross sectional study was conducted with users of five PHC units in the city of Petrópolis. The CMD prevalence of psychiatric morbidity was estimated by the General Health Questionnaire-12, and the physicians CMD detection was evaluated by a questionnaire completed by GPs after each consultation. Results: Seven hundred and fourteen subjects participated of the study, and 400 (56%) were screened positive using GHQ-12 cut-off point of 2/3. GPs diagnosed 379 people with CMD (53.1%), and 256(36%) subjects were detected by both GHQ and the GPs with an OR of 3.04 (95%CI 2.23–4.13). CMD detection accuracy by GPs was 65%. There was a strong association between the detection of CMD and the report of medically unexplained physical symptoms by GPs. Being female, married, and a frequent service user was also related to higher detection rates. Conclusion: CMD detection rate was similar to those reported worldwide, but contrary to other studies, the presence of MUS increased detection rates. The high frequency of CMD in Primary Health Care highlights the need for improving GP and health workers training in order to enable them to accurately recognize and treat psychological distress with evidence-based interventions.

The management of adult psychiatric emergencies in low- income and middle-income countries: a systematic review

OBJECTIVE A World Health Organization (WHO) field study conducted in five countries assessed proposals for Bodily Stress Syndrome (BSS) and Health Anxiety (HA) for the Primary Health Care Version of ICD-11. BSS requires multiple somatic symptoms not caused by known physical pathology and associated with distress or dysfunction. HA involves persistent, intrusive fears of having an illness or intense preoccupation with and misinterpretation of bodily sensations. This study examined how the proposed descriptions for BSS and HA corresponded to what was observed by working primary care physicians (PCPs) in participating countries, and the relationship of BSS and HA to depressive and anxiety disorders and to disability. METHOD PCPs referred patients judged to have BSS or HA, who were then interviewed using a standardized psychiatric interview and a standardized measure of disability. RESULTS Of 587 patients with BSS or HA, 70.4% were identified as having both conditions. Participants had an average of 10.9 somatic symptoms. Patients who presented somatic symptoms across multiple body systems were more disabled than patients with symptoms in a single system. Most referred patients (78.9%) had co-occurring diagnoses of depression, anxiety, or both. Anxious depression was the most common co-occurring psychological disorder, associated with the greatest disability. CONCLUSION Study results indicate the importance of assessing for mood and anxiety disorders among patients who present multiple somatic symptoms without identifiable physical pathology. Although highly co-occurring with each other and with mood and anxiety disorders, BSS and HA represent distinct constructs that correspond to important presentations in primary care.