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Introduction The World Health Organization (WHO) made a major shift on the outcomes of illness, diseases, and interventions from clinical indicators to those related with levels of functioning and disability, as well as the possibility to determine areas of improvement on a case-by-case basis. Along with this theoretical approach, a new instrument was proposed to WHO members: the International Classification of Functioning, Disability and Health (ICF). The instrument is flexible, easy to apply in different clinical scenarios (it is not attached to a cluster of diseases), culturally adapted in several languages, and complementary to clinical and para-clinical information. In psychiatry, the use of the ICF may be highly valuable to establish the preserved areas of functioning as well as the most salient disabilities to formulate a proper case management, and then, to plan adequate public policies. This report includes the results of an evaluation of functioning, disability and heath dimensions, along with the psychometric properties of the ICF checklist, among people with severe and persistent mental disorders that have been institutionalized in a psychiatric hospital in the State of Jalisco, Mexico. Method Subjects: Inmates of a 50 year old psychiatric facility, dependent from the Mental Health Institute of Jalisco (SALME), within the frame of the Ministry of Health of the State of Jalisco in Mexico. This facility is divided in acute wards, were patients are hospitalized in acute phases of severe and persistent mental disorders, and <
Introducción En este reporte se presentan los resultados de la evaluación de funcionalidad, discapacidad y estado de salud de las personas con trastornos mentales graves y persistentes que se encuentran asiladas en el Centro de Atención Integral en Salud Mental de Estancia Prolongada (CAISAME-EP) del Instituto Jalisciense de Salud Mental (SALME), la instancia de la Secretaría de Salud del Estado de Jalisco que se encarga de la atención psiquiátrica de la entidad. El estudio se llevó a cabo para impulsar el desarrollo de políticas y programas de atención en salud mental locales que puedan elevar el estatus funcional y el bienestar vital de estos individuos. Adicionalmente se proporcionan los primeros datos de validez y confiabilidad, en población mexicana con trastornos mentales graves y persistentes, de la versión en español del apartado de <
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Summary: Introduction. Only 20 to 30% of psychiatric disorders patients have a full-time competitive job. These figures might dramatically drop to 15% for those with more severe and persistent mental disorders, like schizophrenia, and could be obviously much lower in patients from developing countries. Lack of social competence and social skills necessary in the workplace have been suggested as an individual variable that explain the frequent difficulty in acquiring and maintaining a job among people with schizophrenia. Therefore, social skills' training has been widely used as an effective treatment modality to counteract those deficits. In order to develop cultural sensitive treatments, it is generally accepted that it is necessary to have valid and reliable methods to evaluate this construct in every particular population. Tsang and Pearson (2000) proposed a work-related social skills evaluation specifically designed for people with schizophrenia. This measure is composed of two parts: 1. A self-administered scale that evaluates subjective perception about social competence related to obtaining and maintaining a job. In this instance, patients rate a ten-item scale according to the degree of difficulty they experience in handling the situation. 2. A simple role playing exercise in which an expert evaluates the patient's work-related social skills by the simulation of two situations: participating in a job interview, and requesting one day of leave at short notice from a supervisor. Here, the kinds of behaviour rated include basic social survival skills, basic social skills related to voice quality and nonverbal communication, and overall performance. The expert evaluator uses a five point scale in which 4 indicates a normal performance and 0 a poor one. This kind of evaluation offers advantages compared to general social skills measures that were not designed to evaluate people with persistent and severe mental disorders, and specifically over the ones that consist merely in check lists. The aim of the present study was to translate into Spanish and to evaluate the reliability and validity of Tsang and Pearson's both self-administered scale (SA) and expert evaluation (EE) of work-related social skills among Mexican patients with schizophrenia. Method. A non-random sample of male and female Mexican adults with a confirmed diagnosis of schizophrenia by the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), completed SA and EE evaluations. Additionally, a psychiatrist recorded their global functioning based on the evaluation proposed by American Psychiatric Association (GAF), and all relevant socio-demographic and clinical variables (gender, age, educational level, previous work experience, and type of service required, between ambulatory and hospitalized patients). Fifteen days later, a sub-sample participated in a second evaluation with both work-related social skills measures. Cronbach's alphas were calculated for SA and EE measures to obtain internal consistencies. Pearson's correlations were performed to determine the relationship between these measures and first and fifteen day after applications, to have the data of split-half reliability and short temporally stability, respectively. Then, convergent validity was evaluated with Pearson correlations between GAF scores and both SA and EE work-related social skills measures. Finally, the expected relationship between global functioning and type of mental health service employed (ambulatory service vs. hospitalization) was evaluated comparing both patient groups with independent samples t-Student test. EE and SA scores between these groups were then compared using another t-test. In all cases, predetermined alpha value was 95%. Results. A total of 54 schizophrenia patients was recruited; 64.8% were males (n=35) and 35.2% (n=19) females. Overall mean age was 36.6 ± 9 years old (range = 19-57). Years of formal education mean was 7.6 ± 3.8 (range = 1-17); and 77.8% reported some kind of previous work experience (non-competitive job; n = 42). Practically half of them were attending external consultation services (53.7% ambulatory patients, n = 29) and the rest of them were hospitalized (theoretically with more severe disorders). Reliability data. Cronbach´s alphas coefficients were SA=0.69, EE=0.85. A sub-sample of 36 patients completed initial and fifteen day work-related social skills evaluations. Correlations between them were SA=0.66 and EE=0.73, p≤.01. Validity data. For all the sample, high, positive and significant correlations between GAF and EE was obtained (r= 0.71, p≤ .01). No statistical relationship among GAF and AA was observed. EE total scores, but not SA ones, were clinically and statistically higher among outpatients in contrast to those who were hospitalized (12.9 ± 2.5 vs. 10.72 ± 3.4; t=-2.77, gl=52, p=.008). In congruence, outpatients had a better global functioning (59.79 ± 8.5 vs. 52.12 ± 8.5; t=2.97, gl=52, p=.004). Similarly, higher EE scores were obtained by patients with previous job experience (12.76 ± 2.55 vs. 8.91 ± 3.53; t=4.11, gl=51, p≤.0001). No gender differences were observed. Conclusions. Evidence of internal consistency, temporal stability and construct validity of EE format to measure work-related social skills among Mexican patients with schizophrenia were documented. Still, the self-administered scale did not show enough reliability coefficients nor validity indicators. This is congruent with data offered for the original version in English: Expert evaluation Cronbach's alphas were higher than the self-reported ones (.96 vs .80, respectively). However, for both SA and EE evaluations, the original English versions internal consistencies were higher than the Spanish ones evaluated in the present study. This could be explained by years of education and work status disparities among the samples. The expert evaluation by role playing showed a better short-temporal stability than the self-administered scale. Additionally, the EE scores, but not the SA ones, correlated in a high, positive and statistical fashion with the general functioning of the patients, and were higher in ambulatory than in hospitalized patients. Similarly, the original English EE, but not the SA evaluation, demonstrated better validity indicators by comparing people with and without schizophrenia. These data suggest that the evaluation of this construct among Mexican patients with a low educational level has to be performed by an expert using role playing exercises, instead of self-administered scales. Further studies are necessary in order to generalize the use of these measures among other populations.
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Abstract: Introduction: Dissociative disorders are characterized by impaired conscious integration functions, personal identity, memory and environment perception. Their frequent psychopathological manifestations are amnesia, depersonalization, fugue states, extra sensorial experiences, trance states and total personality changes. They usually appear under different life stressors, and their clinical course is highly variable. Prevalence estimates give figures ranging from 5 to 10% among general population, and reach 10.2 to 41.4% among psychiatric populations. This wide variation is one of the indicators of the complexity of this diagnostic entities and of its difficulty to be studied. Culture is a key factor in functionality of subjects with a dissociative disorder, because the acceptance of many of its clinical features varies. It is accepted that these diagnostic categories are barely-recognized, not only by general physicians, but by experienced mental health specialists. The original Structured Diagnostic Interviews (SCID, CIDI, SADS, SCAN), did not include them in their widely distributed packages, and many of them decided to create a separate appendix to address them. Unfortunately, structured interviews face an important limitation as there is a lack of trained, and some times, experienced psychopathologist, a fact that difficults to use them in large samples. Self-report instruments, when they show good reliability and validity, are of great value in terms of time, costs and feasibility. Their major limitation is the low reliability that they show in psychiatric conditions in which lack of insight is present (psychotic disorders). To evaluate the psychometric properties of translated versions of instruments is highly desirable. This is specially important when elusive disorders are being evaluated. Given that the cultural environment of Mexico is surrounded by several factors that influence this kind of disorders, the availability of reproducible research instruments is of outmost relevance. Therefore, the Dissociative Experiences Scale (DES) -the most widely used measure in this field- in contrast with the Dissociative Disorders Interview Schedule (DDIS), was evaluated, with the purpose to give a first approach to a 12 month prevalence of some Dissociative disorders in Mexican psychiatric patients. Methods: Subjects: A non-random, consecutive sample of male and female patients, between 18 and 63 years old were included. They were receiving treatment, regardless of the diagnosis, at the Institute of Mental Health of Jalisco, from the State's Ministry of the Health in Mexico. The ethics committee authorized the study, and they all gave informed consent. Translation: The Spanish version of the DES, has a Spanish translation, and a Mexican Spanish idiomatic adaptation was performed by consensus. The DDIS was translated by one bilingual psychiatrist, and independently reviewed by another. Consensus was reached in controverted items. Once a final translated version was obtained, it was given to 10 subjects (mainly with primary school level), to assess item understanding. A second review was performed to reach a culturally compatible version, concentrating in respecting item content validity. Back translation was not considered, because this method does not capture common language of low school population, which is the case of most Mexicans. Measures: Dissociative Experiences Scale (DES): This is a 28 items, self-report scale, designed to evaluate different kinds and severity of Dissociative conditions, in a 0 to 100 range. Most populations without a psychiatric condition or with a non-Dissociative disorder, scored under 20. A cut-off point of 30, usually indicates the possibility of a Dissociative disorder diagnosis. Given that a Spanish version of the DES is available from Spain, only an idiomatic adaptation to Mexican Spanish was performed (changes in slang or word content differences between countries). Dissociative Disorder Interview Scale (DDIS): This is a structured diagnostic interview, of 132 yes/no items, designed to assess the presence of DSM-IV Dissociative disorders entities. It is to be applied by mental health professionals, properly trained on its use. It does not give a total score, it assesses each disorder independently. As previous studies performed in different languages, it has adequate psychometric properties, and is the usual golden standard for Dissociative categories. Previous reports on DDIS correlation with DES have shown variations between disorders, with Kappa values for Identity Dissociative Disorder ranging 0.68 to 0.95. Procedures: A 4th year general psychiatry residency doctor was trained in the DDIS, and, after obtaining the patient's consent, applied the DDIS interview, and then gave the patient the DES to be completed. Demographic and clinical variables were obtained, as well as the diagnosis assigned in the patient chart. To analyze results two procedures were planned: 1) compare DES total score punctuation between positive and negative presence of Dissociative disorders according with the DDIS and 2)compare between patients with a Dissociative disorder with or without concomitant major depression. Results: A total of 100 subjects were included, 63% female, with a mean age of 32.4±12.5 (range 18 - 63) years old. The DES internal consistency index was 0.96. Patients with a Dissociative Disorder (according to the DDIS), showed clinically and significantly higher DES values than non-Dissociative patients (34.7±24.8 n= 38 vs. 10.7±9.6 n=62; T -6.8, d.f. 98, p< 0.001). Frequency of Dissociative disorders and symptoms: Mean DES total score was 19.8±20.6. According to DDIS criteria, 38 subjects fulfilled DSM IV diagnostic criteria for a Dissociative disorder: Dissociative identity disorder 24, Depersonalization Disorder 6, psychogenic fugue 3. The most common concomitant diagnosis as assessed in the patient chart was unipolar major depression (17 44.7%. When a Dissociative disorder was comorbid with major depression, comparing it with Dissociative disorders only, the difference was greater (34.7±24.2 n= 38, 9.3±8.55, T 6.3, d.f. 80, p<000.1. Discussion: Dissociative disorder measurements evaluated, seem to work adequately in Mexican population. Prevalence of dissociative disorders found in this psychiatric population, is consistent with other studies. Further research in the field is needed, to evaluate the influence of cultural factors, including rural and indigenous samples.
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En este artículo se revisan algunos aspectos generales del concepto de esquizofrenia que son relevantes para la investigación cientítifa en al ámbito biológico. Posteriormente se aborda cada una de la áreas específicas de los campos estudiados de la enfermedad. En genética se revisan las metodologías utilizadas para determinar los factores heredados del padecimiento y los hallazgos más relevantes hasta el momento. Se especifica la agregación familiar del padecimiento, la concordancia en gemelos monocigóticos, que es superior que en los dicigóticos, y la persistencia de dicha concordancia en los estudios de adopción. Finalmente, abordamos los resultados obtenidos por medio de técnicas de biología molecular. Se revisan las alteraciones estructurales encontradas en estudios in vivo, por medio de diversas técnicas de gabinete, tanto pasivas(neumoencefalografía), tomografía computarizada, resonancia magnética) como dinámicas (SPECT, PET), para después describir la evidencia anatomopatológica de los cambios tisulares y celulares que se producen en los cerebros de pacientes esquizofrénicos. Se especifican los resultados obtenidos desde el punto de vista neurofisiológico, especialmente con potenciales evocados auditivos(P3). Se revisan someramente algunos aspectos relacionados con la neuroquímica del trastorno, especialmente la participación de los sistemas dopaminérgicos y serotoninérgicos. Se concluye que la esquizofrenia se acompaña de manifestaciones en casi todos los niveles en los que se ha investigado, pero hasta el momento, no se ha encontrado un eje integrador que permita conocer el mecanismo común de todos estos hallazgos