Toxoplasma gondii Seropositivity Interacts with Catechol-O-methyltransferase Val105/158Met Variation Increasing the Risk of Schizophrenia

Schizophrenia is a heterogeneous and severe psychotic disorder. Epidemiological findings have suggested that the exposure to infectious agents such as Toxoplasma gondii (T. gondii) is associated with an increased risk for schizophrenia. On the other hand, there is evidence involving the catechol-O-methyltransferase (COMT) Val105/158Met polymorphism in the aetiology of schizophrenia since it alters the dopamine metabolism. A case−control study of 141 patients and 142 controls was conducted to analyse the polymorphism, the prevalence of anti-T. gondii IgG, and their interaction on the risk for schizophrenia. IgG were detected by ELISA, and genotyping was performed with TaqMan Real-Time PCR. Although no association was found between any COMT genotype and schizophrenia, we found a significant association between T. gondii seropositivity and the disorder (χ2 = 11.71; p-value < 0.001). Furthermore, the risk for schizophrenia conferred by T. gondii was modified by the COMT genotype, with those who had been exposed to the infection showing a different risk compared to that of nonexposed ones depending on the COMT genotype (χ2 for the interaction = 7.28, p-value = 0.007). This study provides evidence that the COMT genotype modifies the risk for schizophrenia conferred by T. gondii infection, with it being higher in those individuals with the Met/Met phenotype, intermediate in heterozygous, and lower in those with the Val/Val phenotype.

Suicidality in primary care patients who present with sadness and anhedonia: a prospective European study

BACKGROUND

Sadness and anhedonia (loss of interest in activities) are central symptoms of major depression. However, not all people with these symptoms meet diagnostic criteria for major depression. We aimed to assess the importance of suicidality in the outcomes for primary care patients who present with sadness and anhedonia.

METHOD

Cohort study of 2,599 unselected primary care attenders in six European countries followed up at 6 and 12 months.

RESULTS

1) In patients with sadness and/or anhedonia who were not depressed at entry to the study, suicide plans (OR = 3.05; 95 % CI = 1.50-6.24; p = 0.0022) and suicide attempts (OR = 9.08; 95 % CI = 2.57-32.03; p = 0.0006) were significant predictors of developing new onset depression at 6 or 12 months. 2) In patients with sadness and/or anhedonia who met CIDI criteria for major depression at entry, suicidal ideation (OR = 2.93; 95 % CI = 1.70-5.07; p = 0.0001), suicide plans (OR = 3.70; 95 % CI = 2.08-6.57; p < 0.0001), and suicide attempts (OR = 3.33; 95 % CI = 1.47-7.54; p = 0.0040) were significant predictors of persistent depression at 6 or 12 months.

CONCLUSIONS

Three questions on suicidality could help primary care professionals to assess such patients more closely without necessarily establishing whether they meet criteria for major depression.

The risk for major depression conferred by childhood maltreatment is multiplied by BDNF and SERT genetic vulnerability: a replication study

BACKGROUND

There is limited evidence for a moderating role of both serotonin transporter (SERT) and brain-derived neurotrophic factor (BDNF) genes on the risk for major depression (MD) developing after childhood maltreatment. However, research on this topic remains inconclusive, and there is a lack of data from longitudinal studies with large and representative population samples. Our study aimed to clarify whether, in the presence of previous childhood maltreatment, individuals carrying low functional alleles for both SERT 5-HTTLPR and BDNF Val66Met polymorphisms had a higher risk for MD.

METHODS

We explored 2- and 3-way gene (SERT and BDNF) × environment (childhood maltreatment) interactions in a large sample of Spanish adults who were followed up over a 3-year period and assessed in person for both DSM-IV MD and exposure to childhood maltreatment.

RESULTS

Our study included 2679 participants. Those with both the 5-HTTLPR s allele and the BDNF Met allele showed the highest risk of MD if they had previously experienced emotional (z = 2.08, p = 0.037), sexual (z = 2.19, p = 0.029) or any kind of childhood abuse (z = 2.37, p = 0.018). These 3-way interactions remained significant regardless of whether the 5-HTTLPR triallelic or the 5-HTTLPR biallelic polymorphisms were included in the analyses.

LIMITATIONS

Retrospective assessment of childhood maltreatment may have resulted in a moderate degree of recall bias.

CONCLUSION

Our results confirm that the risk of depression conferred by childhood maltreatment is modified by variation at both SERT and BDNF genes.

Predicting the onset of anxiety syndromes at 12 months in primary care attendees. The predictA-Spain study

Background

There are no risk algorithms for the onset of anxiety syndromes at 12 months in primary care. We aimed to develop and validate internally a risk algorithm to predict the onset of anxiety syndromes at 12 months.

Methods

A prospective cohort study with evaluations at baseline, 6 and 12 months. We measured 39 known risk factors and used multilevel logistic regression and inverse probability weighting to build the risk algorithm. Our main outcome was generalized anxiety, panic and other non-specific anxiety syndromes as measured by the Primary Care Evaluation of Mental Disorders, Patient Health Questionnaire (PRIME-MD-PHQ). We recruited 3,564 adult primary care attendees without anxiety syndromes from 174 family physicians and 32 health centers in 6 Spanish provinces.

Results

The cumulative 12-month incidence of anxiety syndromes was 12.2%. The predictA-Spain risk algorithm included the following predictors of anxiety syndromes: province; sex (female); younger age; taking medicines for anxiety, depression or stress; worse physical and mental quality of life (SF-12); dissatisfaction with paid and unpaid work; perception of financial strain; and the interactions sex*age, sex*perception of financial strain, and age*dissatisfaction with paid work. The C-index was 0.80 (95% confidence interval = 0.78–0.83) and the Hedges' g = 1.17 (95% confidence interval = 1.04–1.29). The Copas shrinkage factor was 0.98 and calibration plots showed an accurate goodness of fit.

Conclusions

The predictA-Spain risk algorithm is valid to predict anxiety syndromes at 12 months. Although external validation is required, the predictA-Spain is available for use as a predictive tool in the prevention of anxiety syndromes in primary care.

The Maristán stigma scale: a standardized international measure of the stigma of schizophrenia and other psychoses

BACKGROUND

People with schizophrenia face prejudice and discrimination from a number of sources including professionals and families. The degree of stigma perceived and experienced varies across cultures and communities. We aimed to develop a cross-cultural measure of the stigma perceived by people with schizophrenia.

METHOD

Items for the scale were developed from qualitative group interviews with people with schizophrenia in six countries. The scale was then applied in face-to-face interviews with 164 participants, 103 of which were repeated after 30 days. Principal Axis Factoring and Promax rotation evaluated the structure of the scale; Horn's parallel combined with bootstrapping determined the number of factors; and intra-class correlation assessed test-retest reliability.

RESULTS

The final scale has 31 items and four factors: informal social networks, socio-institutional, health professionals and self-stigma. Cronbach's alpha was 0.84 for the Factor 1; 0.81 for Factor 2; 0.74 for Factor 3, and 0.75 for Factor 4. Correlation matrix among factors revealed that most were in the moderate range [0.31-0.49], with the strongest occurring between perception of stigma in the informal network and self-stigma and there was also a weaker correlation between stigma from health professionals and self-stigma. Test-retest reliability was highest for informal networks [ICC 0.76 [0.67 -0.83]] and self-stigma [ICC 0.74 [0.64-0.81]]. There were no significant differences in the scoring due to sex or age. Service users in Argentina had the highest scores in almost all dimensions.

CONCLUSIONS

The MARISTAN stigma scale is a reliable measure of the stigma of schizophrenia and related psychoses across several cultures. A confirmatory factor analysis is needed to assess the stability of its factor structure.

Standardization of the MARISTÁN scale to measure needs in people with schizophrenia and related psychoses

OBJECTIVE

Existing measures of needs in severe mental illness have been developed mainly from professionals' viewpoints and are Eurocentric. Our aim was to standardize a measure of the needs of people with schizophrenia across several cultures and based on users' own viewpoints.

METHOD

An instrument to measure needs, based on qualitative data on users', carers' and professionals' views, was tested in 164 people with schizophrenia or related psychoses in six countries. Participants underwent face-to-face interviews, one third of which were repeated 30 days later. Principal axis factoring and Promax rotation evaluated scale structure; Horn's parallel combined with bootstrapping determined the number of factors; and intra-class correlation assessed test-retest reliability.

RESULTS

The instrument contained four factors: (1) health needs; (2) work and leisure needs; (3) existential needs; and (4) needs for support in daily living. Cronbach's α for internal consistency was 0.81, 0.81, 0.77 and 0.76 for factors 1-4 and 0.81 for the scale as a whole. Correlation between factors was of moderate range for the first three factors (0.41-0.50) and low for the fourth factor (0.14-0.29). Intra-class correlation coefficient for test-retest reliability was 0.74 (0.64-0.82) for the whole scale. Mean item score on needs for support in daily living was lower than for the other factors.

CONCLUSIONS

The MARISTÁN Scale of Needs evaluates needs from the patient perspective and it is a valid instrument to measure the needs of people with severe mental illness across cultures.

Elder abuse and socioeconomic inequalities: a multilevel study in 7 European countries

OBJECTIVES

To compare the prevalence of elder abuse using a multilevel approach that takes into account the characteristics of participants as well as socioeconomic indicators at city and country level.

METHODS

In 2009, the project on abuse of elderly in Europe (ABUEL) was conducted in seven cities (Stuttgart, Germany; Ancona, Italy; Kaunas, Lithuania, Stockholm, Sweden; Porto, Portugal; Granada, Spain; Athens, Greece) comprising 4467 individuals aged 60-84 years. We used a 3-level hierarchical structure of data: 1) characteristics of participants; 2) mean of tertiary education of each city; and 3) country inequality indicator (Gini coefficient). Multilevel logistic regression was used and proportional changes in Intraclass Correlation Coefficient (ICC) were inspected to assert explained variance between models.

RESULTS

The prevalence of elder abuse showed large variations across sites. Adding tertiary education to the regression model reduced the country level variance for psychological abuse (ICC=3.4%), with no significant decrease in the explained variance for the other types of abuse. When the Gini coefficient was considered, the highest drop in ICC was observed for financial abuse (from 9.5% to 4.3%).

CONCLUSION

There is a societal and community level dimension that adds information to individual variability in explaining country differences in elder abuse, highlighting underlying socioeconomic inequalities leading to such behavior.

Study of coercive measures in prisons and secure psychiatric hospitals: the views of inmates and caregivers

AIM

The aim of the study was to ascertain the opinions of both inmates and staff of prison establishments about the use of coercive measures justified for clinical reasons for people with mental health problems and about the need to create protocols to regulate the application of these measures.

METHOD

These opinions were gathered in a Qualitative Study with Focus Groups (prison inmates and prison staff) from the Granada Penitentiary Centre and the Alicante Penitentiary Psychiatric Hospital, both in Spain.

RESULTS

The results showed that forced medication is the most commonly used coercive measure in these institutions. The inmates did not understand and rejected the use of this measure, above all because they were poorly informed about their illness and the medication required to treat it. The staff however defended the benefits of psychiatric medicine, even when administered without the patient's consent.

CONCLUSIONS

Both inmates and staff agreed that it would be useful to have a protocol regulating the use of coercive measures. The study has also identified a number of important factors that could help to reduce the need for coercive measures or make their use unnecessary.

Unmet needs in the management of schizophrenia

Studies on unmet needs during the last decades have played a significant role in the development and dissemination of evidence-based community practices for persistent schizophrenia and other severe mental disorders. This review has thoroughly considered several blocks of unmet needs, which are frequently related to schizophrenic disorders. Those related to health have been the first block to be considered, in which authors have examined the frequent complications and comorbidities found in schizophrenia, such as substance abuse and dual diagnosis. A second block has been devoted to psychosocial and economic needs, especially within the field of recovery of the persistently mentally ill. Within this block, the effects of the current economic difficulties shown in recent literature have been considered as well. Because no patient is static, a third block has reviewed evolving needs according to the clinical staging model. The fourth block has been dedicated to integrated evidence-based interventions to improve the quality of life of persons with schizophrenia. Consideration of community care for those reluctant to maintain contact with mental health services has constituted the fifth block. Finally, authors have aggregated their own reflections regarding future trends. The number of psychosocial unmet needs is extensive. Vast research efforts will be needed to find appropriate ways to meet them, particularly regarding so-called existential needs, but many needs could be met only by applying existing evidence-based interventions. Reinforcing research on the implementation strategies and capacity building of professionals working in community settings might address this problem. The final aim should be based on the collaborative model of care, which rests on the performance of a case manager responsible for monitoring patient progress, providing assertive follow-up, teaching self-help strategies, and facilitating communication among the patient, family doctor, mental health specialist, and other specialists.

Spiritual and religious beliefs as risk factors for the onset of major depression: an international cohort study

BACKGROUND

Several studies have reported weak associations between religious or spiritual belief and psychological health. However, most have been cross-sectional surveys in the U.S.A., limiting inference about generalizability. An international longitudinal study of incidence of major depression gave us the opportunity to investigate this relationship further.

METHOD

Data were collected in a prospective cohort study of adult general practice attendees across seven countries. Participants were followed at 6 and 12 months. Spiritual and religious beliefs were assessed using a standardized questionnaire, and DSM-IV diagnosis of major depression was made using the Composite International Diagnostic Interview (CIDI). Logistic regression was used to estimate incidence rates and odds ratios (ORs), after multiple imputation of missing data.

RESULTS

The analyses included 8318 attendees. Of participants reporting a spiritual understanding of life at baseline, 10.5% had an episode of depression in the following year compared to 10.3% of religious participants and 7.0% of the secular group (p<0.001). However, the findings varied significantly across countries, with the difference being significant only in the U.K., where spiritual participants were nearly three times more likely to experience an episode of depression than the secular group [OR 2.73, 95% confidence interval (CI) 1.59–4.68]. The strength of belief also had an effect, with participants with strong belief having twice the risk of participants with weak belief. There was no evidence of religion acting as a buffer to prevent depression after a serious life event.

CONCLUSIONS

These results do not support the notion that religious and spiritual life views enhance psychological well-being.

Psychometric properties of the List of Threatening Experiences--LTE and its association with psychosocial factors and mental disorders according to different scoring methods

BACKGROUND

The List of Threatening Experiences (LTE) questionnaire is frequently used to assess stressful events; however, studies of its psychometric properties are scarce. We examined the LTE's reliability, factorial structure, construct validity and explored the association between LTE scores and psychosocial variables and mental disorders.

METHOD

This study involved interviewing 5442 primary care attendees from Spain. Associations between four different methods of quantifying LTE scores, psychosocial factors, major depression (CIDI), anxiety disorders (PRIME-MD), alcohol misuse and dependence (AUDIT) were measured.

RESULTS

The LTE showed high test-retest reliability (Kappa range=0.61-0.87) and low internal consistency (α=0.44). Tetrachoric factorial analysis yielded four factors (spousal and relational problems; employment and financial problems; personal problems; illness and bereavement in close persons). Logistic multilevel regression found a strong association between greater social support and a lower occurrence of stressful events (OR range=0.36-0.79). The association between religious-spiritual beliefs and the LTE, was weaker. The association between mental disorders and LTE scores was greater for depression (OR range=1.64-2.57) than anxiety (OR range=1.35-1.97), though the highest ORs were obtained with alcohol dependence (OR range=2.86-4.80). The ordinal score (ordinal regression) was more sensitive to detect the strength of association with mental disorders.

LIMITATIONS

We are unable to distinguish the direction of the association between stressful events, psychosocial factors and mental disorders, due to our cross-sectional design of the study.

CONCLUSIONS

The LTE is a valid and reliable measure of stress in mental health, and the strength of association with mental disorders depends on the method of quantifying LTE scores.

Differential impact of risk factors for women and men on the risk of major depressive disorder

PURPOSE

Our aim is to examine which risk factors have a greater impact in women than in men on the risk of major depressive disorder (MDD) and whether factors differ between a possible recurrent MDD and a first onset of MDD.

METHODS

Prospective cohort study of general practice attendees in seven countries, who were followed up at 6 and 12 months (predictD). Absolute risk differences (interaction contrast) across sex for onset of DSM-IV MDD after 6 or 12 months of follow-up were estimated for 35 risk factors from 7101 participants without MDD at baseline.

RESULTS

A total of 599 participants (80% female) had an onset of MDD at 6 or 12 months. Most risk factors had a greater impact in women than in men on the risk of MDD and were not restricted to a specific class of risk factors. After we stratified for a history of depressive symptoms, we found that the impact of risk factors across sex was generally stronger on possible recurrent MDD than on a first onset of MDD.

CONCLUSIONS

Our findings may partly account for the observed difference in incidence of MDD between men and women.

Recent life events pose greatest risk for onset of major depressive disorder during mid-life

BACKGROUND

The authors examined an additive model for the association of life events and age with onset of major depressive disorder (MDD) and whether the combination of life events and age posed greater risk than the sum of their independent effects.

METHODS

Data were used from a prospective cohort study of 10,045 general practice attendees (PredictD). We included those without MDD at baseline (N=8293). We examined age divided into tertiles and into 10 year groups. Life events were assessed at baseline using the List of Threatening Life Experiences Questionnaire and categorized according to type. Main outcome measure was onset of DSM-IV MDD at 6 or 12 months of follow-up. The authors calculated Relative Excess Risks due to Interaction (RERI).

RESULTS

6910 persons (83.3%) had a complete follow-up, of whom 589 (8.5%) had an onset of MDD (166 younger, 254 middle aged and 169 older). The combined effect of personal problems (RERI=1.30; 95% CI 0.29 to 2.32), events in family or friends (RERI=1.23; 95% CI 0.28 to 2.19), or problems with law (RERI=1.57; 95% CI 0.33 to 2.82) and middle age was larger than the sum of individual effects.

LIMITATIONS

Lower response to recruitment in the UK and the Netherlands.

CONCLUSIONS

Recent life events carry the largest risk of onset of MDD in mid-life. Understanding the different vulnerability to life events according to age may help to indicate groups at a particular risk and assist in preventive strategies.

Coerced hospital admission and symptom change--a prospective observational multi-centre study

INTRODUCTION

Coerced admission to psychiatric hospitals, defined by legal status or patient's subjective experience, is common. Evidence on clinical outcomes however is limited. This study aimed to assess symptom change over a three month period following coerced admission and identify patient characteristics associated with outcomes.

METHOD

At study sites in 11 European countries consecutive legally involuntary patients and patients with a legally voluntary admission who however felt coerced, were recruited and assessed by independent researchers within the first week after admission. Symptoms were assessed on the Brief Psychiatric Rating Scale. Patients were re-assessed after one and three months.

RESULTS

The total sample consisted of 2326 legally coerced patients and 764 patients with a legally voluntary admission who felt coerced. Symptom levels significantly improved over time. In a multivariable analysis, higher baseline symptoms, being unemployed, living alone, repeated hospitalisation, being legally a voluntary patient but feeling coerced, and being initially less satisfied with treatment were all associated with less symptom improvement after one month and, other than initial treatment satisfaction, also after three months. The diagnostic group was not linked with outcomes.

DISCUSSION

On average patients show significant but limited symptom improvements after coerced hospital admission, possibly reflecting the severity of the underlying illnesses. Social factors, but not the psychiatric diagnosis, appear important predictors of outcomes. Legally voluntary patients who feel coerced may have a poorer prognosis than legally involuntary patients and deserve attention in research and clinical practice.

Predicting the onset of major depression in primary care: international validation of a risk prediction algorithm from Spain

BACKGROUND

The different incidence rates of, and risk factors for, depression in different countries argue for the need to have a specific risk algorithm for each country or a supranational risk algorithm. We aimed to develop and validate a predictD-Spain risk algorithm (PSRA) for the onset of major depression and to compare the performance of the PSRA with the predictD-Europe risk algorithm (PERA) in Spanish primary care.

METHOD

A prospective cohort study with evaluations at baseline, 6 and 12 months. We measured 39 known risk factors and used multi-level logistic regression and inverse probability weighting to build the PSRA. In Spain (4574), Chile (2133) and another five European countries (5184), 11 891 non-depressed adult primary care attendees formed our at-risk population. The main outcome was DSM-IV major depression (CIDI).

RESULTS

Six variables were patient characteristics or past events (sex, age, sex×age interaction, education, physical child abuse, and lifetime depression) and six were current status [Short Form 12 (SF-12) physical score, SF-12 mental score, dissatisfaction with unpaid work, number of serious problems in very close persons, dissatisfaction with living together at home, and taking medication for stress, anxiety or depression]. The C-index of the PSRA was 0.82 [95% confidence interval (CI) 0.79-0.84]. The Integrated Discrimination Improvement (IDI) was 0.0558 [standard error (s.e.)=0.0071, Zexp=7.88, p<0.0001] mainly due to the increase in sensitivity. Both the IDI and calibration plots showed that the PSRA functioned better than the PERA in Spain.

CONCLUSIONS

The PSRA included new variables and afforded an improved performance over the PERA for predicting the onset of major depression in Spain. However, the PERA is still the best option in other European countries.

Acute psychopathology as a predictor of global functioning in patients with ICD-10 non-affective psychosis: a prospective study in 11 European countries

This prospective analysis aimed to study the influence of psychopathological dimensions on the global functioning of persons suffering from psychotic disorders, taking into account the role of a broad range of potential confounders. A large international cohort (n=1888) with ICD-10 non-affective psychosis was evaluated both at baseline during a hospital admission and three months after discharge. Trained interviewers administered a global functioning scale (GAF) and a psychopathological scale (BPRS) at baseline and follow-up). Baseline BPRS psychopathological dimensions were extracted using Principal Component Analysis. Results of multiple linear regression analyses demonstrated that affective symptoms (depressive or manic) prospectively predict a better global functioning, whilst agitation/cognitive symptoms determined poorer global functioning. Other predictors showing an independent effect on better global functioning were medication compliance, country of residence, female gender, married or coupled status, younger age and having a diagnosis of schizoaffective disorder rather than schizophrenia or other ICD-10 psychosis. A predicting model for global functioning in patients with psychosis is provided, showing that assessment of affective and agitation/cognitive symptoms should be emphasised during admission as they can be more informative than positive/negative symptoms in prospectively planning follow-up care that is geared towards a better functional recovery.

Factorial validity and measurement equivalence of the Client Assessment of Treatment Scale for psychiatric inpatient care - a study in three European countries

Patients' views of inpatient care need to be assessed for research and routine evaluation. For this a valid instrument is required. The Client Assessment of Treatment Scale (CAT) has been used in large scale international studies, but its psychometric properties have not been well established. The structural validity of the CAT was tested among involuntary inpatients with psychosis. Data from locations in three separate European countries (England, Spain and Bulgaria) were collected. The factorial validity was initially tested using single sample confirmatory factor analyses in each country. Subsequent multi-sample analyses were used to test for invariance of the factor loadings, and factor variances across the countries. Results provide good initial support for the factorial validity and invariance of the CAT scores. Future research is needed to cross-validate these findings and to generalise them to other countries, treatment settings, and patient populations.

Depression, anxiety and physical function: exploring the strength of causality

BACKGROUND

Depression, anxiety and physical function may be bi-directionally related. We aim to estimate the strength of the longitudinal associations between depression, anxiety and physical function.

METHODS

Prospective cohort study of general practice attendees across Europe (N=4757) assessed at baseline, 6, 12 and 24 months. Main outcome measures were Diagnostic and Statistical Manual of Mental Disorders-IV major depression, Patient Health Questionnaire anxiety and Short Form 12 physical function. Complete-case analyses using random coefficient models and logistic regression models were performed.

RESULTS

Those with depression (β=-1.90, 95% CI -3.42 to -0.39), anxiety (β=-4.12, 95% CI -5.39 to -2.86) or depression and anxiety (β=-5.74, 95% CI -7.38 to -4.10) had lower levels of physical function at baseline and over time compared with no diagnosis after adjustment for potential confounders. Physical function increased over time, but the rate of increase was not different between the groups. When compared with depression, those with anxiety (β=-2.22, 95% CI -4.08 to -0.36) or depression and anxiety (β=-3.83, 95% CI -5.95 to -1.71) had significantly lower levels of physical function at baseline. Lower levels of physical function at baseline were associated with onset of depression (OR 1.83, 95% CI 1.08 to 3.10) but even stronger with anxiety (OR 2.79, 95% CI 1.52 to 5.12) or depression and anxiety (OR 5.05, 95% CI 2.55 to 9.99) during 24 months compared with no dysfunction, after adjustment for potential confounders.

CONCLUSION

It is essential to prevent lower levels of physical function as this is likely to lead to onset of depression and anxiety over time.

[Mental health care: perceptions of people with schizophrenia and their carers]

The current study aims to discover the opinions of patients and their (informal and formal) carers concerning the mental health care of individuals with long term schizophrenic disorders within different contexts and cultures. It's a qualitative study with focus groups,in which 6 research centers (from Argentina, Brazil, Chile, Spain, England and Venezuela) participated. Eight focus groups were conducted in each center, totaling 303 individuals in 46 groups. The data were analyzed with the aid of the Qualitative Solutions and Research/Non-numerical Unstructured Data Indexing program (QSR NUD*IST 4.0). The perception regarding the quality of care is influenced by the professional-patient relationship and the availability of resources. Poor quality of care is also perceived as discrimination. People with schizophrenia in general consider themselves to be ostracized by professionals and services and lacking in more humanized care. In the contexts in which community care is less advanced, the complaints center on resources and services that do not meet demands. On the other hand, in more developed contexts criticism centers more on the attitude of the professionals and the professional patient relationship. Over and above the need for resources and services, people with schizophrenia require more humanized health care.

Cuestiones existenciales en la esquizofrenia: percepción de portadores y cuidadores

OBJETIVO: Examinar los temas y cuestiones existenciales del cotidiano de personas con esquizofrenia y de sus cuidadores. MÉTODOS: Estudio cualitativo con grupos focales. Fueron incluidos 146 sujetos con esquizofrenia (55% hombres) y 80 cuidadores (75% mujeres) que provenían de servicios primarios y secundarios de salud de Argentina, Brasil, Chile, España, Inglaterra y Venezuela. Cada grupo tenía de 6 a 10 participantes. Los datos fueron explorados por el proceso de análisis de contenido. RESULTADOS: Fueron identificadas cuatro cuestiones existenciales omnipresentes en los discursos: la necesidad de realización como persona y de encontrar un sentido en la vida; la necesidad de ser respetado y no sufrir discriminación; el conflicto decurrente de la pérdida de autonomía; la importancia de comprender la enfermedad y de reconocerse como enfermo. Las cuestiones existenciales aparecieron fuertemente conectadas a necesidades objetivas, como la falta de ocupación y trabajo, que generalmente resultan en una vida sin propósito y sentido. CONCLUSIONES: Hace falta desarrollar un nuevo tipo de cuidado en salud, en que la consideración por la persona con esquizofrenia y la valoración de su subjetividad sean tan importantes cuanto el tratamiento biológico, así como crear estrategias de promoción de la salud que comprendan mecanismos de inclusión laboral y combato al estigma.

Mental health of older people: the role of primary care

There are currently over 600 million people aged over 60 and it is predicted that, by 2025, the number will double and, by 2050 there will be over 2 billion people aged 60 and above and the number of over 60's will be greater than the number of children under the age of 15. Co-morbid physical and mental health conditions are associated with an aging population and many of this population will suffer from stroke, hypertension, loneliness, depression, dementia, mobility and sight problems. The traditional approach of caring for people in hospitals is increasingly inappropriate for many of the elderly population and primary care is often the first point of contact for many people seeking access to health and social care. In 2008, the WHO and Wonca (World Organisation of Family Doctors) published a document about the integration of mental health into primary care across spectrum. We will be describing the principles and method of integration of mental health problems in old age into primary care using examples from the Australian and UK setting. Also we will examine the role non-governmental organisations can play in the process of integration. Caring for the elderly is rewarding and possible in the primary care setting. The current situation where many elderly people do not have access to an integrated health care system is unacceptable. Using data and a series of case vignettes we will illustrate that primary care has an important role to play within an integrated system.

Patients' views of involuntary hospital admission after 1 and 3 months: prospective study in 11 European countries

BACKGROUND

Legislation and practice of involuntary hospital admission vary substantially among European countries, but differences in outcomes have not been studied.

AIMS

To explore patients' views following involuntary hospitalisation in different European countries.

METHOD

In a prospective study in 11 countries, 2326 consecutive involuntary patients admitted to psychiatric hospital departments were interviewed within 1 week of admission; 1809 were followed up 1 month and 1613 3 months later. Patients' views as to whether the admission was right were the outcome criterion.

RESULTS

In the different countries, between 39 and 71% felt the admission was right after 1 month, and between 46 and 86% after 3 months. Females, those living alone and those with a diagnosis of schizophrenia had more negative views. Adjusting for confounding factors, differences between countries were significant.

CONCLUSIONS

International differences in legislation and practice may be relevant to outcomes and inform improvements in policies, particularly in countries with poorer outcomes.

Comparison of risk factors for the onset and maintenance of depression

BACKGROUND

Factors associated with depression are usually identified from cross-sectional studies.

AIMS

We explore the relative roles of onset and recovery in determining these associations.

METHOD

Hazard ratios for onset and recovery were estimated for 39 risk factors from a cohort study of 10,045 general practice attendees whose depression status was assessed at baseline, 6 and 12 months.

RESULTS

Risk factors have a stronger relative effect on the rate of onset than recovery. The strongest risk factors for both onset and maintenance of depression tend to be time-dependent. With the exception of female gender the strength of a risk factor's effect on onset is highly predictive of its impact on recovery.

CONCLUSIONS

Preventive measures will achieve a greater reduction in the prevalence of depression than measures designed to eliminate risk factors post onset. The strength of time-dependent risk factors suggests that it is more productive to focus on proximal rather than distal factors.

High-activity variants of the uMAOA polymorphism increase the risk for depression in a large primary care sample

Studies on the association between the functional uMAOA polymorphism and depression have yielded non-conclusive results up till now. One thousand two hundred twenty eight consecutive Spanish primary care attendees, participating in the PREDICT study, agreed to take part in this genetic PREDICT-Gene study. We explored the association between depression and either high-activity uMAOA alleles or genotypes. Depression was diagnosed using the Composite International Diagnostic Interview (CIDI) to establish three different depressive outcomes (ICD-10 Depressive Episode (DE), ICD-10 Severe Depressive Episode (SDE) and DSM-IV Major Depression (MD)). uMAOA genetic variation was determined by PCR amplification and subsequent electrophoresis. Crude and adjusted (gender and/or age) odds ratios, with 95% confidence intervals, were calculated for the associations between allele or genotype frequencies and all three depressive outcomes. We found associations between all three depressive phenotypes and either high-activity alleles or high-activity genotypes in both sexes. The associations were statistically significant for females but not for males. Testing the same associations on the entire sample (males and females) also yielded significant associations between depression and either high-activity alleles or high-activity genotype distribution that were independent of age and/or gender (ICD-10 DE: OR = 1.98; 95% CI: 1.42-1.77; P = 0.00002; ICD-10-SDE: OR = 2.05; 95% CI: 1.38-3.05; P = 0.0002; DSM-IV MD: OR = 1.91; 95% CI: (1.26-2.91); P = 0.0014). Our results provide fairly consistent evidence that high-activity variants of the MAOA promoter polymorphism confer a modestly higher risk for depression.

Spatial analysis to identify hotspots of prevalence of schizophrenia

INTRODUCTION

The geographical distribution of mental health disorders is useful information for epidemiological research and health services planning.

OBJECTIVE

To determine the existence of geographical hotspots with a high prevalence of schizophrenia in a mental health area in Spain.

METHOD

The study included 774 patients with schizophrenia who were users of the community mental health care service in the area of South Granada. Spatial analysis (Kernel estimation) and Bayesian relative risks were used to locate potential hotspots. Availability and accessibility were both rated in each zone and spatial algebra was applied to identify hotspots in a particular zone.

RESULTS

The age-corrected prevalence rate of schizophrenia was 2.86 per 1,000 population in the South Granada area. Bayesian analysis showed a relative risk varying from 0.43 to 2.33. The area analysed had a non-uniform spatial distribution of schizophrenia, with one main hotspot (zone S2). This zone had poor accessibility to and availability of mental health services.

CONCLUSION

A municipality-based variation exists in the prevalence of schizophrenia and related disorders in the study area. Spatial analysis techniques are useful tools to analyse the heterogeneous distribution of a variable and to explain genetic/environmental factors in hotspots related with a lack of easy availability of and accessibility to adequate health care services.

Predicting the onset and persistence of episodes of depression in primary health care. The predictD-Spain study: methodology

Background

The effects of putative risk factors on the onset and/or persistence of depression remain unclear. We aim to develop comprehensive models to predict the onset and persistence of episodes of depression in primary care. Here we explain the general methodology of the predictD-Spain study and evaluate the reliability of the questionnaires used.

Methods

This is a prospective cohort study. A systematic random sample of general practice attendees aged 18 to 75 has been recruited in seven Spanish provinces. Depression is being measured with the CIDI at baseline, and at 6, 12, 24 and 36 months. A set of individual, environmental, genetic, professional and organizational risk factors are to be assessed at each follow-up point. In a separate reliability study, a proportional random sample of 401 participants completed the test-retest (251 researcher-administered and 150 self-administered) between October 2005 and February 2006. We have also checked 118,398 items for data entry from a random sample of 480 patients stratified by province.

Results

All items and questionnaires had good test-retest reliability for both methods of administration, except for the use of recreational drugs over the previous six months. Cronbach's alphas were good and their factorial analyses coherent for the three scales evaluated (social support from family and friends, dissatisfaction with paid work, and dissatisfaction with unpaid work). There were 191 (0.16%) data entry errors.

Conclusion

The items and questionnaires were reliable and data quality control was excellent. When we eventually obtain our risk index for the onset and persistence of depression, we will be able to determine the individual risk of each patient evaluated in primary health care.

The risk for depression conferred by stressful life events is modified by variation at the serotonin transporter 5HTTLPR genotype: evidence from the Spanish PREDICT-Gene cohort

We report results from the PREDICT-Gene case-control study nested in a prospective cohort designed to identify predictors of the onset of depression among adult primary-care attendees. We tested the potential gene-by-environment interaction between 5HTTLPR genotype at the serotonin transporter gene and previous exposure to threatening life events (TLEs) in depression. A total of 737 consecutively recruited participants were genotyped. Additional information was gathered on exposure to TLEs over a 6-month period, socio-demographic data and family history of psychological problems among first-degree relatives. Diagnoses of depression were ascertained using the Composite International Diagnostic Interview (CIDI) by trained interviewers. Two different depressive outcomes were used (ICD-10 depressive episode and ICD-10 severe depressive episode). Both the s/s genotype and exposure to increasing number of TLEs were significantly associated with depression. Moreover, the 5HTTLPR s/s genotype significantly modified the risk conferred by TLEs for both depressive outcomes. Thus, s/s homozygous participants required minimal exposure to TLE (1 TLE) to acquire a level of risk for depression that was only found among l/s or l/l individuals after significantly higher exposure to TLEs (two or more TLEs). The interaction was more apparent when applied to the diagnosis of ICD-10 severe depressive episode and after adjusting for gender, age and family history of psychological problems. Likelihood ratios tests for the interaction were statistically significant for both depressive outcomes (ICD-10 depressive episode: LR X(2)=4.7, P=0.09 (crude), LR-X(2)=6.4, P=0.04 (adjusted); ICD-10 severe depressive episode: LR X(2)=6.9, P=0.032 (crude), LR-X(2)=8.1, P=0.017 (adjusted)).

Social predictors of out-patient mental health contact in schizophrenia patients

INTRODUCTION

Since community-based health care was introduced, the use of mental health services by patients with serious mental disorders has been an issue of much interest. However, our knowledge of intervening factors is both scarce and partial.

OBJECTIVE

To study socio-demographic variables which may predict time-lapse (in days) between each out-patient contact among a cohort of schizophrenia patients.

METHOD

Data comes from the South Granada Schizophrenia Case Register. We used Cox's regression analysis to study the influence of the socio-demographic variables in the time lapsed between out-patient contacts.

RESULTS

After adjusting for all other socio-demographic variables included, we found that to live in a rural area and being younger independently predicted a longer time-lapse between out-patient contacts while being retired predicted a shorter interval between such contacts. Other variables such as sex, educational level and marital status did not determine such length between out-patients contacts.

CONCLUSION

Socio-demographic variables, and not only psychopathological ones, determine mental health out-patient service use.

The 5-HTTLPR s/s genotype at the serotonin transporter gene (SLC6A4) increases the risk for depression in a large cohort of primary care attendees: the PREDICT-gene study

Previous reports and meta-analyses have yielded inconclusive results as to whether the s/s genotype at the 5-HTTLPR serotonin transporter polymorphism confers increased risk for depression. We tested the association between s/s genotype and depression in a large cohort (n = 737) of Spanish primary care consecutive attendees participating in a European study on predictors for depression in primary care (PREDICT study). Participants were administered the Composite International Diagnostic Interview (CIDI) depression subscale allowing diagnoses using ICD-10 criteria for depressive episodes. Participants were genotyped to establish 5HTTLPR genotype. Both univariable and multivariable associations between the s/s genotype and depression were tested twice using two different depressive outcomes (ICD-10 depressive episode and ICD-10 severe depressive episode). We found an association between the s/s genotype and both depressive outcomes that was independent of age, sex, family history of psychological problems among first degree relatives and presence of comorbid generalized anxiety disorder. When comparing s/s homozygous versus the rest, the adjusted odds ratio for any ICD-10 depressive episode and for severe ICD-10 depressive episode were 1.50 (95% CI: 1.0-2.2; P = 0.045) and 1.79 (95% CI: 1.1-2.8; P = 0.016), respectively. The association was significantly stronger with increasing severity of depression (chi2 for linear association=6.1; P = 0.013) suggesting a dose-dependent relationship. Our results are consistent with previous reports suggesting a small but independent effect by the s/s 5-HTTLPR genotype increasing the risk for depression.

Prediction of depression in European general practice attendees: the PREDICT study

Background

Prevention of depression must address multiple risk factors. Estimating overall risk across a range of putative risk factors is fundamental to prevention of depression. However, we lack reliable and valid methods of risk estimation. This protocol paper introduces PREDICT, an international research study to address this risk estimation.

Methods/design

This is a prospective study in which consecutive general practice attendees in six European countries are recruited and followed up after six and 12 months. Prevalence of depression is assessed at baseline and each follow-up point. Consecutive attendees between April 2003 and September 2004 who were aged 18 to 75 were asked to take part. The possibility of a depressive episode was assessed using the Depression Section of the Composite International Diagnostic Interview. A selection of presumed risk factors was based on our previous work and a systematic review of the literature. It was necessary to evaluate the test-retest reliability of a number of risk factor questions that were developed specifically, or adapted, for the PREDICT study. In a separate reliability study conducted between January and November 2003, consecutive general practice attendees in the six participating European countries completed the risk factor items on two occasions, two weeks apart. The overall response rate at entry to the study was 69%. We exceeded our expected recruitment rate, achieving a total of 10,048 people in all. Reliability coefficients were generally good to excellent.

Discussion

Response rate to follow-up in all countries was uniformly high, which suggests that prediction will be based on almost a full cohort. The results of our reliability analysis are encouraging and suggest that data collected during the course of PREDICT will have a satisfactory level of stability. The development of a multi-factor risk score for depression will lay the foundation for future research on risk reduction in primary care. Our data will also provide the necessary evidence base on which to develop and evaluate interventions to reduce the prevalence of depression.

The EUNOMIA project on coercion in psychiatry: study design and preliminary data

Previous national research has shown significant variation in several aspects of coercive treatment measures in psychiatry. The EUNOMIA project, an international study funded by the European Commission, aims to assess the clinical practice of these measures and their outcomes. Its naturalistic and epidemiological design is being implemented at 13 centres in 12 European countries. This article describes the design of the study and provides preliminary data on the catchment areas, staff, available facilities and modalities of care at the participating centres.

Spanish psychiatric reform: what can be learned from two decades of experience?

OBJECTIVE

The objective of the paper is to describe the impact of Spanish psychiatric reform on the organization and functioning of mental health services.

METHOD

This paper is based on official administrative reports and on relevant related publications.

RESULTS

The most significant achievements of Spanish psychiatric reform have been: (i) the development of a new organization of mental health care, decentralized in character and territorially based; (ii) the integration of psychiatric patients in general health care; (iii) the creation of an extensive community network of health centres; and (iv) the development of more positive attitudes towards mental illness. However, our analysis also reveals the existence of significant deficiencies.

CONCLUSION

Analysis of the Spanish experience shows that the process of psychiatric reform depends basically on long-term commitments, which in a system such as Spain's must come from central administration and also from the autonomous communities.

[AIDS in children. 8 years experience at La Raza Medical Center Infectology Hospital, Mexican Social Security Institute]

The objective for this work was to describe the transmission mechanisms and the clinical behavior of 60 HIV-infected pediatric patients. We studied children from newborn to 15 years old according to the CDC criteria. From January 1985 to February 1992, were evaluated 60 patients, 40 males and 20 females; 25 with perinatal transmission (23 transplacental and 2 breast-feeding), 22 hemophiliacs, 12 by blood transfusion and 1 by intramuscular injection with contaminated needle. The disease was symptomatic in 50 patients, asymptomatic in 5 and indeterminate in 5 cases. Up to date, 28 children are in phase P2, 10 in P0 and P1, and 22 patients have died. The clinical manifestations in 50 patients were: altered growth and development in 50, generalized lymphadenopathy in 30, severe infections in 23, fever in 15, hepatosplenomegaly in 15, chronic diarrhea in 10, and HIV-encephalopathy in one. It is concluded what at present time perinatal transmission is the main mechanism.