El consumo de drogas en México: Resultados de la Encuesta Nacional de Adicciones, 2011 / Drug use in Mexico: Results from the 2011 National Addictions Survey

Introduction In the international context, Mexico is a country with low drug use level, in turn, it shows an increase when considering the most recent epidemiologic trends. In order to maintain an updated analysis of drug use in general population and to identify the most at risk groups, the National Survey of Addictions (ENA) was held in 2011. Objetive The aim of the study was to determine the lifetime prevalence for any drug and any illegal drug use at a national and regional level, in population aged 12 to 65 years. Also, to acknowledge drug consumption trends since 2002 in Mexico. Material and methods ENA 2011 survey is a randomized, multistage probabilistic study. It is representative at a national level and also for eight regions of the country, including rural and urban population. The sample was 3 849 adolescents and 12 400 adults who answered a computerized version of a standardized questionnaire containing sections of tobacco, alcohol, medical drugs (opiates, tranquilizers, sedatives, amphetamines) and illegal drugs (marijuana, cocaine, crack, hallucinogens, inhalants, heroin and methamphetamines). All participants read and signed an informed consent. Emphasis was made on the voluntary and confidential use of the information. Results The national lifetime prevalence of any drug grew between 2002 and 2011, increasing significantly from 5.0% to 7.8%, while consumption of any illegal drugs increased from 4.1% to 7.2%. By sex, in men, any drug use increased from 8.6% to 13%. Illegal drugs increased from 8.0% to 12.5%. In women, use of any drug increased from 2.1% to 3.0% and use of any illegal drug increased from 1.0% to 2.3%. Marijuana is the first drug of choice (6.5%) followed by cocaine (3.6%). Considering regions, any drug consumption grew significantly in the Western (5.5% to 10.3%), Northeast (5.5% to 10.3%), North Central (7.5% to 9.2%) and South Central (4.2% to 7.5%). As for illegal drugs, there is also a statistically significant increase in these regions, however, growth was proportionally bigger in South Central region, going from 3.5% to 6.8%. Conclusions Results from this study indicate a growth in the consumption of illegal drugs from 2002 to 2011, especially in marijuana. It also shows that men from 18 to 34 years are the most affected by this consumption, while increases in adolescent men have been low. Moreover, the study shows that those who have received some type of prevention, showed a smaller consumption prevalence, indicating that further work is needed in this area with young people to consolidate activities of health promotion and drug use prevention, working with infant population is needed, including a systematic evaluation of the actions mentioned above. In the international context, data from this study confirms that Mexico continues reporting low levels of drug consumption.

Introducción En el contexto internacional, México es uno de los países con bajo nivel de consumo de drogas, pero que, a su vez, reporta un incremento si se consideran las tendencias epidemiológicas más recientes. Con la finalidad de mantener un diagnóstico actualizado del consumo de drogas en la población general y de identificar los grupos en mayor riesgo, se llevó a cabo la Encuesta Nacional de Adicciones 2011 (ENA). Objetivo Conocer la prevalencia alguna vez en la vida de uso de cualquier droga y de cualquier droga ilegal a nivel nacional y regional en población de 12 a 65 años. Así como conocer las tendencias que ha seguido el consumo a partir de 2002. Material y métodos La ENA 2011 es un estudio aleatorio, probabilístico y polietápico con representatividad nacional y para ocho regiones del país. Incluye poblaciones rurales y urbanas. La muestra fue de 3 849 adolescentes y 12 400 adultos quienes contestaron un cuestionario estandarizado en versión computarizada que contiene las secciones de tabaco, alcohol, drogas médicas (opiáceos, tranquilizantes, sedantes, anfetaminas) e ilegales (mariguana, cocaína, crack, alucinógenos, inhalables, heroína y metanfetaminas). Todos los participantes leyeron y firmaron una carta de consentimiento informado. Se hizo énfasis en el carácter voluntario y confidencial de la información. Resultados La prevalencia de consumo de cualquier droga alguna vez en la vida a nivel nacional creció significativamente entre 2002 y 2011 al pasar de 5.0% a 7.8%, mientras que el consumo de cualquier droga ilegal incrementó de 4.1% a 7.2%. Por sexo, en los hombres el consumo de cualquier droga pasó de 8.6% a 13% y de drogas ilegales de 8.0% a 12.5%. En las mujeres, la primera aumentó de 2.1% a 3.0% y la segunda de 1.0% a 2.3%. Las drogas de preferencia continúan siendo la mariguana (6.5%) y la cocaína (3.6%). A nivel regional el consumo de cualquier droga creció significativamente en la Occidental (5.5% a 10.3%), Nororiental (5.5% a 10.3%), Norcentral (7.5% a 9.2%) y Centro Sur (4.2% a 7.5%). En cuanto a las drogas ilegales, también se encuentra un incremento estadísticamente significativo en estas regiones, sin embargo el crecimiento fue proporcionalmente mayor en la región Centro Sur, al pasar de 3.5% a 6.8%. Conclusiones Los resultados de la ENA señalan un crecimiento en el consumo de drogas ilegales de 2002 a 2011, especialmente de la mariguana. Asimismo, se observa que los hombres de 18 a 34 años son la población más afectada por dicho consumo, mientras que en los adolescentes el aumento ha sido mínimo. Por otra parte, el estudio muestra que quienes han recibido algún tipo de prevención presentan las prevalencias de consumo más pequeñas, lo cual indica que es necesario seguir trabajando en esta área con los jóvenes para consolidar las acciones de promoción de la salud y prevención; así como trabajar más con la población infantil, con una evaluación sistemática de todas estas acciones. En el contexto internacional los datos confirman que México continúa con niveles bajos de consumo.

Estudio de costo-efectividad del tratamiento de la depresión en México / Cost-effectiveness study of depression management in Mexico

Introduction Depression is a public health problem that carries substantial costs for the individual and the society. In order to establish evidence-based priorities for resource allocation in mental health care, it is necessary to integrate the costs and effectiveness of interventions and specify the essential packages for their treatment. The following are pioneering studies of cost-effectiveness for the treatment of depression: 1. compared psychopharmacology options (fluoxetine, imipramine and desipramine) to found no difference between drugs in terms of clinical efficacy, effect on quality of life and costs, and 2. evaluated cost-effectiveness of collaborative program of stepped care in primary care of persistent depression, to demonstrate a substantial increase in the effectiveness and additional moderate cost increase in comparison with usual treatment. Recently, the World Health Organization convened the National Institute of Psychiatry Ramón de la Fuente, as a collaborating center, to participate in the <

Introducción La depresión es un problema de salud pública que conlleva costos importantes para el individuo y la sociedad. Con la finalidad de establecer prioridades basadas en evidencias para la asignación de recursos en el cuidado de la salud mental, es necesario integrar los costos y la efectividad de las intervenciones y especificar los paquetes esenciales para su tratamiento. En esta dirección, la Organización Mundial de la Salud convocó al Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, como centro colaborador, a participar en el proyecto <

Disyuntivas en las concepciones sobre autonomía y beneficiencia que afectan la terapéutica del intento suicida / Conflicts between autonomy and beneficence conceptions which affect the therapeutics of suicidal attempt / Disjunções nas concepções sobre autonomia e beneficência que afetam a terapêutica do intento suicida

El objetivo del trabajo es conocer las disyuntivas entre los principios de beneficencia y autonomía que se presentan en la relación médico-paciente durante la terapéutica del intento de suicidio. La investigación se realizó en dos hospitales psiquiátricos de la Ciudad de México. La muestra incluyó a tres sujetos con intento de suicidio, mayores de 18 años -quienes eran atendidos en consulta externa a causa de una lesión autoinfligida en el último año- y a tres psiquiatras que trataban a estos pacientes. La información se obtuvo previo consentimiento informado en entrevistas individuales. Se llevó a cabo un análisis de discurso argumentado para encontrar los significados que los participantes otorgaron a los principios bioéticos y las posibles disyuntivas entre éstos. Las discordancias entre la beneficencia y la autonomía estuvieron relacionadas con el beneficio del tratamiento, el respeto por los valores y las creencias de los pacientes, entre otros. Este trabajo presenta consideraciones éticas relevantes en el escenario clínico, al ofrecer al psiquiatra un análisis bioético que le permita actuar de acuerdo con la beneficencia y respetando la autonomía del paciente frente a casos de intento de suicidio y, de esta forma, procurar una mejor atención para ellos.

The aim of this study is to know the conflicts between beneficence and autonomy principles present in physician-patient relationship during therapy of suicidal attempt. Research was carried out in two psychiatry hospitals of the city of Mexico. The sample included three subjects with suicidal attempt, older than 18 years, attended as outpatients for an injure self inflicted last year, and three psychiatrists treating these patients. Information was obtained by individual interviews with previous informed consent. An argumentative discourse analysis was carried out to find meaning given by participants to bioethics principles and possible conflicts between them. Conflicts between beneficence and autonomy were related to the benefit of treatment, respect to patients values and beliefs, among others. This study present relevant ethical considerations in the clinical scenery, by offering to the psychiatrist a bioethical analysis which allows him/her to act according with beneficence while respecting the autonomy of the patient in cases of suicidal attempt and, in this way, to give them better attention.

O objetivo do trabalho é conhecer as disjunções entre os principios de beneficência e autonomia que se apresentam na relação médico-paciente, durante a terapêutica do intento de suicidio. A pesquisa foi realizada em dois hospitais psiquiátricos da Cidade do México. A amostra incluiu três sujeitos com intento suicida, maiores de 18 anos, que eram atendidos em consulta externa por causa de uma lesão autoinfligida no último ano, e a três psiquiatras que tratavam destes pacientes. A informação foi obtida com prévio consentimento informado em entrevistas individuais. Se levou a cabo uma análise de discurso argumentado para encontrar os significados que os participantes outorgaram aos principios bioéticos e as possíveis disjunções entre estes. As discordâncias entre a beneficência e a autonomia estiveram relacionadas com o benefício do tratamento e o respeito pelos valores e as crenças dos pacientes, entre outros. Este trabalho apresenta considerações éticas relevantes para o cenário clínico ao oferecer ao psiquiatra uma análise bioética que lhe permita atuar de acordo com a beneficência e respeitar a autonomia do paciente frente aos casos de intenção de suicidio e, desta forma, procurar uma melhor atenção para eles.

Estudio de costo-efectividad del tratamiento de la esquizofrenia en México / Cost effectiveness study of schizophrenia a management in Mexico

Introduction Schizophrenia is a disorder that causes significant disability. In addition, its treatment is expensive because the increased prescription of atypical antipsychotics with associated high costs. In a recent 14-country study on disability associated with physical and mental conditions, active psychosis was ranked the third most disabling condition in general population, more than paraplegia and blindness. In the global burden of disease study, schizophrenia accounted for 1.1% of the total Disability-adjusted life years (DALYs) and 2.8% of Years of lived with disability (YLDs). The economic cost of schizophrenia for society is also high. The study of the burden of schizophrenia for society, whether expressed in epidemiological or costs terms, is an insufficient basis for setting priorities for resources allocation. Thus, increasingly sophisticated economic models have been developed. Such is the case of cost-effectiveness studies, which show the relationship between resources used (costs) and benefit achieved (effectiveness) of an intervention compared with others. In Mexico, there is only one study that evaluated the cost-effectiveness of different antipsychotics to treat schizophrenia, but it was a specific approach (not generalized), and did not include psychological interventions. The present study is part of a World Health Organization's initiative labeled WHO-CHOICE: CHOosing Interventions that are Cost-Effective. WHO-CHOICE methodology involves the evaluation of interventions based on a generalized measure: DALYs, which allows carrying out several and important comparisons. The main objective was to determine the cost-effectiveness of different interventions for the treatment of schizophrenia in Mexican communitarian settings. Method Schizophrenia was modeled as a serious chronic disorder with a high level of disability, excess mortality from natural and unnatural causes, and a low rate of remission. The incidence, prevalence, and the fatality rate were estimated based on the study of the Global Burden of Disease and a review of the epidemiological literature. As the first episode of schizophrenia is currently not preventable, the occurrence represents how the epidemiological situation would be without intervention. In relation to the referral and the fatality, we did not found evidence that these rates change by a specific effect of the treatment; thus, they were kept as constants for the scenarios with or without treatment. Community-level interventions assessed were: 1. typical traditional antipsychotics (haloperidol), 2. new atypical antipsychotics (risperidone), 3. traditional antipsychotics + psychosocial treatment (family therapy, social skills training and cognitive behavioral therapy), 4. new antipsychotics + psychosocial treatment, 5. traditional antipsychotics + psychosocial treatment + case management, and 6. new antipsychotics + psychosocial treatment + case management. The effectiveness of the treatments referred to the control of positive and negative symptoms and associated levels of disability. To calculate the improvement in disability compared with natural history (when the disease is not treated), the effect sizes reported in controlled clinical trials were converted to a weight change of disability. Efficacy and extrapyramidal effects of typical and atypical antipsychotics compared to placebo were estimated from the meta-analysis of controlled clinical trials, with the score of the BPRS severity scale and the need anti-Parkinson drugs as efficacy measures. From another meta-analysis we obtained an estimate of the magnitude of the effect by adding psychosocial interventions. As an ad hoc Cochrane systematic review that found case management did not had a significant impact on clinical or psychosocial outcomes, only a minimal addition effect size when added to the combination of pharmacologic-psychosocial treatment was observed. Costs included those of the patient, the program and the training required to implement the intervention. The provision of community-based services, daily administration of antipsychotics and anticholinergics, and laboratory tests were taken into account. For psychological interventions were envisaged from 6 to 12 sessions: in primary care from 6 to 12 visits, in outpatients services a visit per month for 20-50% of cases, and in day care communitarian attention from 1-2 times a week for 20-50% of cases. A 3% discount by the process of converting future values to present ones and an age adjustment giving less weight to year lived by young were included. Finally, the cost of DALYs averted for each intervention was estimated to determine their cost-effectiveness. Results The main findings of the study are, in relation to the costs of interventions: 1. the largest share corresponds to those generated by medication, 2. the current intervention is the cheapest, and 3. the combination of new atypical antipsychotics, psychological treatment and proactive case management is the most expensive intervention. Concerning the effectiveness of interventions, the one available today, with a coverage of 50%, prevents 68 222 DALYs. Increasing coverage to 80%, the number of DALYs averted is almost doubled with the use of typical antipsychotics. The effect of psychological interventions makes the number of DALYs averted three to four times higher. Finally, in regard to cost effectiveness, the combination of typical antipsychotics, psychosocial intervention and proactive case management was the treatment with the best relation. The cost per DALY averted was $390,892 Mexican pesos, which corresponds to one third of the cost of DALY averted in the current scenario ($1,313,120 Mexican pesos). Conclusions The resources for the attention of a public health issue involve a social investment rather than an expense budget, but they are also finite and must be chosen properly to be allocated. Cost-effectiveness studies of available interventions are an essential tool for making such important decisions. Our Mexican study of cost-effectiveness of interventions to treat schizophrenia in communitarian settings suggests, in general terms: 1. That while the current situation is the one with the lowest cost, it is the least efficient, 2. all alternatives involve an additional cost to the current situation because they assume an expansion of coverage; however, the extra cost in not excessive, and 3) that within a model of community-based care, the least expensive option is treatment with typical antipsychotics combined with psychological intervention. Thus, for a modest extra cost it is possible to yield a major impact on disability. Recently, the Mexican Federal Government has included schizophrenia in the catalog of diseases covered by the program called <>, that provides a health insurance to general population, especially to the poorest and unemployed ones. The planned actions include four specialty consultations in an interval of two months and annual psychopharmacological treatment. Clearly the addition of haloperidol, trifluoperazine and risperidone to the list of available medications should be considered a success. However, schizophrenia also requires a proactive case monitoring of long-term for best control of symptoms and a successful rehabilitation. Moreover, consistent with our findings, case management has proven to be cost-effective when compared with routine care in the community. Among the limitations of the study it is important to note that it was based on modeled parameters obtained from the international literature. In this sense, the challenge is the data generation directly from studies in Mexico.

Introducción La esquizofrenia es un trastorno que produce una importante discapacidad, y su costo para la sociedad es muy elevado. El estudio de la carga que impone la esquizofrenia sobre la sociedad, ya sea expresada en términos epidemiológicos o de costos, es una base insuficiente para establecer las prioridades para la asignación de recursos, por lo que se han desarrollado modelos económicos cada vez más elaborados. Tal es el caso de los estudios de costo-efectividad, que muestran la relación entre los recursos empleados (costos) y los beneficios logrados (efectividad) de una intervención comparada con otra(s). El presente trabajo forma parte de la iniciativa de la Organización Mundial de la Salud (OMS) para la elección basada en evidencia de intervenciones costo-efectivas denominada WHO-CHOICE, Choosing Interventions that are Cost-Effective, que implica la determinación de una medida general que posibilita comparaciones internacionales: los años de vida vividos con discapacidad (AVISAs o DALYs, de las siglas de Disability-adjusted life years). Objetivo Fue determinar la relación costo-efectividad en México de diferentes intervenciones que han demostrado ser efectivas para el tratamiento comunitario de la esquizofrenia. Método Se evaluaron las siguientes intervenciones: 1. Antipsicóticos tradicionales típicos (haloperidol), 2. Antipsicóticos nuevos atípicos (risperidona), 3. Antipsicóticos tradicionales + tratamiento psicosocial (terapia familiar, entrenamiento en habilidades sociales y terapia cognitivo conductual), 4. Antipsicóticos nuevos + tratamiento psicosocial, 5. Antipsicóticos tradicionales + tratamiento psicosocial + manejo de caso, y 6. Antipsicóticos nuevos + tratamiento psicosocial + manejo de caso. La efectividad relativa de los tratamientos se refirió al control tanto de los síntomas positivos y negativos así como de los niveles asociados de discapacidad. Se consideraron los costos del paciente, del programa y del entrenamiento, así como un descuento de 3% por el proceso de convertir valores futuros a presentes, y un ajuste de edad, otorgando menos peso a los años vividos por los jóvenes. Finalmente, se calculó el costo por AVISA evitado por cada intervención para determinar su costo-efectividad. Resultados Los principales hallazgos del estudio son, en relación con los costos de las intervenciones: 1. que la mayor proporción corresponde a los generados por los medicamentos; 2. que la intervención actual resulta la más barata; y 3. que la combinación de antipsicótico nuevo o atípico con intervención psicosocial y manejo proactivo de caso es la más cara. En cuanto a la efectividad de las intervenciones, la disponible en la actualidad, con cobertura de 50%, evita 68 222 AVISAs. Aumentando la cobertura a 80%, el número de AVISAs evitados casi se duplica con el empleo de antipsicóticos típicos. El efecto de las intervenciones psicosociales hace que el número de AVISAs evitados sea tres a cuatro veces mayor. Finalmente, en lo que respecta a costo-efectividad, la combinación de antipsicóticos típicos, intervención psicosocial y manejo proactivo de caso fue el tratamiento con la mejor relación. El costo por AVISA evitado fue de $390,892, que corresponde a un tercio del costo de AVISA evitado en el escenario actual ($1,313,120). Conclusiones Los hallazgos del estudio sugieren, en términos generales: 1. Que aunque la situación actual es la de menor costo, es la menos eficiente; 2. Que todas las alternativas implican un costo adicional a la situación actual porque asumen una ampliación de la cobertura, sin embargo, ese costo extra no es excesivo; y 3. Que dentro de un modelo de atención basado en la comunidad, la opción menos costosa es el tratamiento con antipsicóticos típicos combinados con intervención psicosocial. Por un costo extra modesto se obtendría un impacto importante en la discapacidad. Entre las limitaciones del estudio destaca que fue producto de un modelado con parámetros obtenidos de la bibliografía internacional. En este sentido, el reto es la generación de datos derivados directamente de estudios realizados en México.

Social cost of mental disorders: Disability and work days lost. Results from the Mexican survey of psychiatric epidemiology / El costo social de los trastornos mentales. Discapacidad y días productivos perdidos. Resultados de la Encuesta Nacional de Epidemiología Psiquiátrica

Summary: Introduction. When the impact of illness is evaluated by indicators like mortality, mental illness has a less significant impact than other illnesses. As a result, the impact of mental disorders was underestimated until the last two decades of the previous century This perception began to change as a result of two factors: On the one hand, the study of the Global Burden of Disease reported by Murray and Lopez, and, on the other hand, the definition of mental disorders by the American Psychiatric Association. The common element shared by these two factors is the inclusion of the concept of disability. Disability is the deterioration of the expected functioning of a subject of a particular age and sex in a social context. It is a part of the social cost of illness. Objective. To assess the disability burden associated with depression, mania, agoraphobia, social phobia, general anxiety, panic disorder, and post-traumatic stress disorder (PTSD) according to the Mexican Psychiatric Survey and to compare results with the disability produced by some chronic non-psychiatric conditions. Method. This survey is based on a stratified, multistage area, probabilistic sample of adults living in urban areas of Mexico. The instrument used was the third version of the Composite International Diagnostic Interview. We report the 12-month prevalence of psychiatric disorders as defined by DSM-IV criteria. We also evaluated non-psychiatric chronic conditions like diabetes, arthritis, hypertension, backache, and other painful illnesses, identified in general as "chronic conditions". Indicators of disability were Sheehan's scale and number of work days lost. This is an easy and fast self reporting scale, which can be used both in the clinic or research. The sub-scales can be added or averaged to obtain a total score. The scale of responses is a horizontal line with numerals from 0 to 10 and five verbal descriptions, with the description "Not at all" corresponding to a value of 0; "Mild" rangimg from 1 to 3; "Moderate" from 4 to 6; "Severe" from 7 to 9; and "Very severe" corresponding to 10. Results. Close relationships and social life were the areas most deeply affected. The disorders found to produce the highest levels of disability were depression, social phobia, and PTSD. The lowest disability levels were observed in chronic conditions. On the total score of Sheehan's scale, disorders with the highest level of disability were PTSD (mean 5.35 ± 0.307) and depression (mean 4.72 ± 0.167). Depression and panic attacks were the disorders by which most days were lost on average in the previous year (25.51, CI95: 16.53-34.5; 20, CI95: 3.02-36.97). Days lost were lower in chronic conditions than in the seven mental disorders studied (6.89, CI95: 3.04-10.74). Discussion. This is the first paper to demonstrate the impact of mental disorders in Latin America evaluating the association of disability with common mental disorders. We have shown that mental disorders, especially depression, are associated with deficits in functioning and result in the loss of work days. We have also shown that persons with common mental disorders have, on average, higher levels of disability than those observed among persons with a wide range of chronic physical conditions. These results are consistent with prior studies in North America and Europe that have found that persons with common mental disorders experience substantial disability in social role functioning.

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Modelo integral de satisfacción cotidiana en usuarios dependientes de alcohol y otras drogas

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Summary The objective of this study was to evaluate a conceptual model to explain alcohol and drugs abstinence in persons that meet the DSM-IV dependence criteria. This study incorporated and evaluated the conceptual proposal of the Integrated Model of Everyday Satisfaction. The structure of this model is based on the Niaura's Dynamic Regulatory Model and the Social Learning Theory that included the classical conditioning, the operant and the vicar to explain the dependent-consumption and incorporated some of the criticisms to the different cognitive-behavioral models, as the need to measure, by means of a direct observation, the specific type of skills used by the consumption-dependent users when facing everyday situations; as well as identifying changes of the functioning of the variables making up the model at the moment of turning towards abstinence; it also considered the indicators that the variable everyday satisfaction has been poorly studied and not been included in the study of conceptual models. Thus, the proposed conceptual model: Integrated Model of Everyday Satisfaction, included the following variables: consumption, precipitators, self-efficacy, everyday satisfaction, as well as variables measuring the facing of specific situations: communication, problem-solving, refusal of consumption, depression and anxiety. These variables were evaluated in an intentional, non-probabilistic sample with 20 dependent users of addictive substances, before and after the cognitive-behavioral intervention adapted to the Mexican population. This intervention model included the following components: Functional Analysis, Demonstration of Non-Consumption, Daily Life Goals, Communication, Problem Solving, Consumption Refusal, Marriage Guidance, Employment Searches, Recreational and Social Skills, Emotional Self-Control and Prevention of Relapses. The pre-post-test evaluation methods were: Retrospective Baseline, Situational Confidence Scale and/or Drug Consumption Self Confidence Scale, Daily Life Satisfaction Scale, Inventories of Drug Consumption Situations and/or Inventories of Alcohol Consumption Situations, Beck´s Inventories for Depression and Anxiety. Occurrence records were used to assess the video-filmed behavioral assays of consumption refusal, problem-solving and communication. The didactic techniques used in the training were: verbal instruction, modeling, behavioral trials and feedback. In the scaled analysis, the Model showed, at the moment of consumption, solidity accounting for 95% of the variance. At this moment, significantly related to the variables: risk situations, selfefficacy to avoid consumption, everyday satisfaction and anxiety. Dependent consumers, showed bigger diversity and intensity of risk situations previously associated to consumption, reduction of facing skills that caused their insecurity to refuse consumption, increased of their physical symptoms of anxiety and decreased of everyday satisfaction related with their poor functioning in different areas of daily living. The increase of anxiety was an indicator of manifested abstinence syndrome, and confirmed that the used filter criterion, showed sensitivity to attract target population; in turn, anxiety as precipitator confirmed, was sustained by the conditioned withdrawal model. Refusal of consumption, communication and problem-solving at the moment of consumption in the user prior to the training were not significantly associated, indicating the need to acquire and develop these skills in the behavioral repertoire. Eighteen from the twenty dependent users showed in the analysis of interrupted time series, that the amount and frequency of the consumption was significantly changed toward abstinence after their participation in the cognitive-behavioral intervention. The scaled analysis indicates that it was a solid model in terms of abstinence accounting for 96% of the variance. In the final configuration of the Model variables with regard to its proximity to abstinence, identified the proximity between the: decreased of consumption, the more skills for facing risk situations, and refusal of consumption were detected with major proximity; subsequently, more everyday satisfaction and more self-efficacy to avoid consumption; then less anxiety and depression; and eventually, more communication and problem-solving skills. The following variables were significantly associated, during abstinence: the More Everyday Satisfaction from the functioning in daily living, more skills and variety of behavioral alternatives to cope risk situations, more self-efficacy to avoid consumption at coping different risk situations, less anxiety and depression, also more skills to consumption refusal, and decrease of substance consumption. Self-efficacy worked as mediator between behavior and emotion; everyday satisfaction was associated to cognitive variables: self-efficacy and emotional self-control; anxiety and depression. This study detected that it may work as an early advice of relapse, and as antecedent of abstinence. The variables that acted as predictor of abstinence, accounted for 73.2% of the variance and were: coping risk situations with alternative behaviors, getting everyday satisfaction from their performance in activities of different areas of daily living, self-efficacy to resist consumption at risk situations and refusal of consumption in front of persons modeling consumption and invitations and pressure to consume; depression was not significant with the Enter method regression model. The measuring of problem-solving did not include the efficacy of application in everyday life, so that it was not directly associated to consumption. One limitation was not having evaluated the generalization behavior of variables: communication and problem-solving in natural settings; and the lack of physiological measures in order to evaluate the emotional self-control. In another study, it is suggested to assess the variables during follow-up to detect changes in its functioning in this other moment. It may be concluded that the relationship between the diversity of variables inserted in this Model during the organism-environment interaction, is favorable to the abstinence, everyday satisfaction, facing non-consumption, behavior entails, flexibility and integration of a number of cognitive-behavioral skills. The functioning of Everyday Satisfaction as early warning of relapse is an important finding to be considered by the therapist who, when applying the intervention on these users, will have to perform subsequent evaluations of this variable in the process of change in order to anticipate and avoid relapses.

Características organizacionales, estrés y consumo de alcohol en trabajadores de una empresa textil mexicana

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Abstract: There are different factors within work environment that could créate both wellbeing and distress in workers. The climate perception employees have, as well as their evaluation of some, could have positive and negative consequences at personal and organizational levels. Work stress is another element that has meaningful repercussions on the health of people and on the quality of their performance; it has been related to alcohol and psychoactive substances abuse, besides of an increase in different social and work problems. The main objective of this paper is to determine the relationship between organizational factors (such as work stress, organization climate, and work satisfaction) and alcohol use, and the occurrence of industrial problems and accidents in Mexican workers in a textile organization. Method In order to interfere as less as possible with the production process, this study was carried out at the facilities of the organization, during work hours and during weekends. Thus, only employees who attended to work these days were interviewed. The sample included 277 workers who basically performed as operative staff. No more organization characteristics are described on behalf of an agreement, and of the anonymity of the answers given by the subjects. All the interviewees were men, their ages fluctuated between 16 and 65 years, 85% of them had attained junior high school, and 72% were married or living with a partner. A self rated questionnaire was used, along with the AUDIT (alcohol use disorder identification test) alcohol test, a work stress scale, another scale for organization climate, one more for work satisfaction, and some general questions. All the scales had good internal consistency. The procedure consisted in gathering 20 workers in a well-ventilated and illuminated room. The interviewer, who was previously trained, read the instructions aloud, emphasizing anonymity and confidentiality of any information the workers give, and stating that no one from the company would have access to the data. Analyses were performed with statistical software SPSS 11.5. EQS 6.0 was used to test the structural equation model with the relationship between organizational factors, alcohol use and negative consequences at work. Results Organizational climate. Most of the workers (92%) perceived a good level of communication with the work group, 87.2% mentioned to receive help from the boss when they have to do an activity they are not familiar with, 78% said they have enough support to solve the problems related to work. There were differences between the workers according to education level; the ones with the higher level perceived a more adverse climate. There were differences also between shifts (morning, evening, and mixed); the workers from the first one perceived a less favorable climate. Work satisfaction. Most of the workers think of their job as something useful (95%), 93% said they liked it, and 88.3% mentioned their families are satisfied. There are statistical differences be-tween satisfaction and education levels; subjects who had only basic education were more satisfied than those with a higher level. The stress sources are related to the effort implied in the struggle to move forward (87.6%), to have too much work to do (60.5%), and to the possibility of an accident when subjects are careless (51.6%). The total scale scores indicated that 14.2% of the workers had high levels of work stress. Alcohol use: 61.7% of the workers consumed alcohol during the previous year. According to the AUDIT (using eight or more as a cutoff score) 25.8% were classified as cases for alcohol related problems; 26.5% of the subjects had risk consumption, and 5.3% were consuming in a dangerous way because of the frequency and the amount they drink. Work problems: 24.1% of the subjects mentioned they have invested more time than usual in some activity related to work, 21% have been told off because of their performance, 18% felt they could not achieve quality outcomes. The incidents that workers mentioned were: hand injuries (17.5%), finger injuries (15.7%), being close to suffer an accident (13.5%), and suffering damage or injuries when working (10%). A structural equation model allowed to observe that organizational factors, climate, satisfaction, and work stress are meaningful predictors of work accidents and problems. Of all the variables included in this analysis, work stress also was the one that best predicted alcohol use at the work place. A direct effect of the individual level of alcohol use and of the use at the work place on problems and accidents, was observed. This effect was not initially considered in the model of individual consumption, neither were the frequency, the amount consumed, nor the excessive use; it was necessary to add this direct path to adjust the model so they were observed as important elements. Discussion Interviewees perceived communication as an important climate issue, mainly when established with the work group. Another element mentioned as important was perceived, that is support from the boss or supervisor to solve problems. Education level has a relevant role in the way workers live their work climate; those with a lower level experience it as more favorable. This could be the consequence of higher work expectations related to a higher education level. There are differences among shifts; workers from the first shift experienced a more favorable climate. The model included climate as a meaningful element for the presence of consequences at work place; this had a direct effect over the existence of problems and the occurrence of accidents, it was opposite to the results observed in other studios were there was not a direct relationship. Work satisfaction has to do with job usefulness, the joy for the task done, and family satisfaction with the position. The education at level affects perception of work climate. This evaluation of the worker climate has been identified as a significant factor for the reduction of negative effects at work. It is necessary to mention that employees with a higher stress level are the married ones, which may be caused by the responsibilities implied in being a family supplier. This concurs with the result of a study on burnout, which found that being married is a risk factor to develop high stress. Work stress was the most predictive component of accidents and problems at the work place, which had a direct relation (0.50). It also directly predicted alcohol use at the work place (0.22), and had a negative statistical difference with climate (-.29). Thus, it is important to consider that when workers perceive a better climate, stress level goes down, and it is necessary to consider this organizational factor to improve work conditions besides employees' physical and mental health. According to the model tested in this study, alcohol use has a direct and meaningful effect on performance and on the frequency of problems and accidents, inside and outside the organization. It is important to consider that prevention in work places must be done globally, taking into account organizational factors such as climate, stress, and worker satisfaction. It also should include educative and practical elements that allow reducing excessive alcohol use and its negative consequences (poor performance, bad interpersonal relationships, and bad outcome quality) at work, besides reducing also industrial accidents. The most frequent work problems were as follows: to invest more time than necessary in an activity, to be told-off because of mistakes, and to have problems with the boss or supervisor. These events have an impact on productivity and represent money loss for the company. The most frequent accidents were as follows: hand injuries, which are related to heavy machinery operation, basic in the production process of this industry. This reflects the need to consider the physical aspects of the place where activities are performed, as well as the psychosocial factors affecting individuals, all of which will result in benefit of any organization.

Síndrome de dependencia al alcohol: comparación entre hombres y mujeres

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Summary The main objective of this paper is to describe the way in which the Alcohol Dependence Syndrome is manifested, according to the criteria and indicators proposed by the DSM-IV, in a female sample that sought help at a treatment center due to alcohol consumption-related problems. A comparison was made with the results obtained in a previous 211-male-sample at the same treatment center. Method: This project is a case study in which a sample of 100 females was interviewed at the Clínica para Atención de Problemas Relacionados con el Alcohol (CAPRA) (Clinic for the Attention of Alcohol Related Problems) at the Hospital General de México (the main general hospital for patients who do not have social security benefits and come from different regions of the country including rural areas). The criteria for inclusion were: being aged 18 or over, female, having sought help for the first time (at these centers) due to alcohol problems and being physically and mentally able to answer the questionnaire correctly. Females that had previously been treated were included. However, one of the requisites was that they had to have drunk alcohol during the year before the interview to warrant recent and current consumption, regardless of being exposed to prior treatments, since the questionnaire includes the previous 12 months as a parameter. The instrument used to conduct this study was the Composite International Diagnostic Interview, Substance Abuse Module (CIDI-SAM). This instrument has been widely used with excellent results on various population samples in the U.S., as well as on the male population receiving treatment in Mexico. The instrument included the following sections: sociodemographic characteristics, amount and frequency of consumption; physical, psychological and social problems; symptoms of alcohol dependence, and pathways to health services. A few new sections were incorporated with specific characteristics for women, such as the effects of alcohol on women, alcohol consumption during pregnancy and nursing, partner's alcohol consumption and violent behavior in the couple and their associated risks. Results: The average age of the women interviewed was 47 years old, ranging from 22 to 91. Thirty-two percent were either married or living with a partner, 20% were divorced, 26% were widows and 22% were single. Seventy-four percent of them had children and they had 4.5 children in average. The average educational level was 4.7 years. Fifty-two percent of the respondents reported drinking alcohol every day and 19% almost every day (five or six days a week), with an average of 4.2 drinks per occasion (52% of the women reported having three to four drinks per occasion). The preferred reported beverage was «pulque¼ (28%), followed by beer (25%) and distilled beverages (21%). Other traditional drinks and «96° proof" alcohol also showed a significant percentage (20%). As for the Alcohol Dependence Syndrome, 50% of the women met the dependency criteria proposed by the DSM-IV, compared with 82% of the 211 men interviewed in the same center with a statistically significant difference (X2= 34.22; p = 0.000). Women with alcohol dependence syndrome presented an average of five symptoms. A more detailed analysis was carried out based on the severity of the dependence syndrome, measured by the number of reported symptoms (1-2, 3-4, 5-7). The most frequently reported symptom across all levels of severity was the presence of physical and/or psychological problems. In the group of non-dependent women (those who reported less than 3 symptoms), an important difference between men and women was observed. The most frequent symptoms reported by men, after the presence of physical and psychological problems, were withdrawal symptoms (34.2%) and loss of control (15.8%). In the case of the women, unsuccessful efforts to reduce alcohol intake (16%) and withdrawal symptoms (16%) appeared in the second place. The group of women with low dependence (three to four criteria reported) presented similar characteristics to those observed in the group of non-dependent women. In men with low levels of dependence, the most frequent symptom presented were: giving up or reducing activities (social, occupational or recreational) in order to drink and withdrawal symptoms. In the groups with the highest severity level (5-7 symptoms), differences between men and women were less evident. Conclusions: The most important differences in dependence symptoms between men and women are probably related to gender-specific cultural expectations and social norms regarding alcohol use. This situation is reflected in the type of symptoms presented more frequently in women and men. Women reported more symptoms related to unsuccessful efforts to reduce alcohol intake; whereas men presented symptoms related to the time spent drinking or recovering from the effects of alcohol and giving up or reducing activities (social, occupational or recreational) in order to drink. The information presented evidences the need to conduct more specific studies that take in consideration biological and psychological, as well as social conditions underlying female alcohol use in order to provide appropriate and effective treatment to meet their gender needs and expectations.

La depresión con inicio temprano: prevalencia, curso natural y latencia para buscar tratamiento / Early onset depression: prevalence, course, and treatment latency

OBJETIVO: Conocer, en la población mexicana, la prevalencia de la depresión con inicio temprano, y comparar el curso natural, la comorbilidad y la latencia para buscar tratamiento entre los deprimidos con inicio temprano y aquellos con inicio en la edad adulta. MATERIAL Y MÉTODOS: La Encuesta Nacional de Epidemiología Psiquiátrica es representativa de la población nacional urbana, de entre 18 a 65 años de edad. Se realizó en México, entre 2001 y 2002, con el instrumento diagnóstico de la versión computarizada de la Entrevista Internacional Compuesta de Diagnóstico. Los análisis toman en cuenta el diseño complejo de la muestra multietápica, estratificada y ponderada utilizando análisis descriptivo y regresiones logísticas. RESULTADOS: El 2.0 por ciento de la población ha padecido depresión en la infancia o adolescencia con un promedio de siete episodios a lo largo de la vida (comparado con tres para los de inicio en la adultez), el primero persiste por unos 31 meses (comparado con 16 meses), durante los cuales generalmente no reciben tratamiento. CONCLUSIONES: La mayor duración del primer episodio y el mayor número de episodios en la vida de aquellos con depresión de inicio temprano se debe a la falta de detección y tratamiento oportuno en jóvenes.

Consumo de drogas entre adolescentes: resultados de la Encuesta Nacional de Adicciones, 1998 / Drug used among adolescents: results from the National Survey on Addictions, 1998

OBJETIVO: Describir el consumo de drogas y los factores de riesgo en adolescentes de 12 a 17 años. MATERIAL Y MÉTODOS: Los datos provienen de la Encuesta Nacional de Adicciones 1998, realizada en hogares ubicados en zonas urbanas de la República Mexicana. El diseño de la muestra fue probabilístico, estratificado y por conglomerados en varias etapas de muestreo, donde la última unidad de selección fue un individuo en la vivienda. Los resultados se analizaron obteniendo los intervalos de confianza de las prevalencias del consumo de drogas, y se realizó un análisis de regresión logística para evaluar los factores asociados con el consumo de drogas. RESULTADOS: El 3.57 por ciento de los varones y 0.6 por ciento de las mujeres habían usado una o más drogas excluyendo al tabaco y al alcohol; 2.14 de hombres y 0.45 por ciento de mujeres lo habían hecho en los doce meses previos al estudio, y 1.4 de los hombres y 0.3 por ciento de las mujeres en los 30 días anteriores a la encuesta. La mariguana es la droga más usada (2.4 y 0.45 por ciento), seguida por los inhalables (1.08 y 0.20 por ciento) y la cocaína (0.99 y 0.22 por ciento) por hombres y mujeres, respectivamente. El riesgo de usar drogas se asoció con ser hombre, no estudiar, considerar fácil conseguir drogas, no ver mal el uso de drogas por parte de los amigos, que éstos las usaran, usarlas por parte de la familia y estar deprimido. CONCLUSIONES: El entorno que rodea a nuestros jóvenes de 12 a 17 años indica que el consumo de drogas está cada vez más presente. Los índices de consumo se han incrementado, especialmente en la región norte del país y en las grandes metrópolis (Tijuana, Ciudad de México y Guadalajara, principalmente). Estos datos refuerzan la necesidad de desarrollar campañas que permitan detectar a los menores que tienen problemas emocionales y darles la atención apropiada para evitar que consuman drogas como un mecanismo para enfrentar problemas de esta naturaleza. Asimismo, es necesario identificar a los menores con mayor probabilidad de desarrollar dependencia, quienes requieren de intervenciones preventivas más intensas