Estudio de traducción al español y evaluación psicométrica de una escala para medir el estigma internalizado en pacientes con trastornos mentales graves / Study of translation into Spanish and psychometric properties of a measure to evaluate internalized stigma among patients with severe mental disorders

Introduction Mental illness is one of the most stigmatized health problems. The stigma related to mental health disorders can be experienced from two different perspectives: i) social stigma (perpetrated by the general population) and ii) personal stigma (internalized by the affected). Research on stigma and discrimination among patients with mental health problems has been centered on the social viewpoint, that is, what the general population sets over people who suffer the condition. Nonetheless, the investigation that focuses on the way people with psychiatric illness experience adverse reactions (i.e. rejection) has received little attention and hence been poorly assessed. Until now there was no internalized stigma measuring instrument, validated in Mexican population, nothing that could allow us to score the level of stigma perceived by these patients. Thus, the objectives of the present study were to translate into Spanish the internalized stigma scale (ISS) created by King et al., and to evaluate its basic psychometric properties among Mexican patients with severe mental disorders. The ISS has 28 items to answer in a five-point Likert scale, ranging from «strongly agree¼ to «strongly disagree¼, to assesses stigma through three different sub-scales: i) discrimination, ii) disclosure, and iii) positive aspects of mental illness. The discrimination subscale contains items that refer to the negative reactions of other people, including acts of discrimination by health professionals, employers and police; the disclosure subscale includes questions regarding embarrassment or feeling bad about the illness and managing disclosure to avoid discrimination. Finally, the positive aspects subscale asks about how patients accept their illness and perceive themselves as less affected by stigma. A higher score means greater stigma, due the answer to items that explore positive aspects of mental illness are reversed. Method Subjects: One hundred severe mentally ill Mexican subjects were included in the study. All of the patients had been receiving psychiatric attention at the Mental Health Integral Attention Center, Long stay division of the Mental Health Institute in Jalisco (Instituto Jalisciense de Salud Mental), which is part of the health office of such State. They all had at least two years of diagnosis and treatment. None was suffering an acute process of the illness at the moment of administration of the instruments. Measures and procedure: The ISS was translated into Spanish by translation-back- translation method and then administered by a psychiatrist together with the global assessment functional scale (GAF) and the clinical global impression scale (CGI). Data analysis: Cronbach's alpha and varimax rotation factor analysis were employed in order to examine internal consistency and construct valididty of the main components of the scale. Results From the total one hundred patients that integrated the studied sample, 67 (67%) were males; most of them single (62%) and unemployed (70%). The most commonly diagnosis was schizophrenia (47%); the time of illness was between 2 and 44 years, while the duration of the treatment was 1 to 44 years. Along the evolution of the illness, 81 (81%) had been hospitalized due to the psychiatric condition at least once. The mean functional global assessment score was 58.4, and the mean score in the CGI scale was 3.78 points. Regarding the management, 89% (n= 89) were under treatment with some kind of antipsychotic; the most used kind were first generation ones (n= 68, 68%), particularly haloperidol, either in immediate release or intramuscular depot presentations. ISS score was drawn and compared to the one obtained for the original English version; both measurements were alike (60.15 vs. 62.6, respectively). Each of the subscales in the ISS also showed similar results respect the ones obtained in the original version (discrimination 27.6 vs. 62.6; disclosure 22.1 vs. 29.1 and positive aspects 10.3 vs. 8.8, respectively). Additionally, the Spanish version of the ISS has shown a proper internal consistency with Cronbach's alpha scores higher than 0.60 in all of the sub-scales; the whole being similar to the ones identified for the original version of the measurement (Spanish version: discrimination subscale=0.83, disclosure=0.76 and positive aspects= 0.60; Original version: discrimination subscale= 0.87, disclosure= 0.85 and positive aspects=0.64). The unidimensional construct of the instrument showed a 0.87 Cronbach's alpha, being highly reliable. Regarding the factor validity, three main components were obtained confirming the original structure. The first factor (discrimination) explains 25.46% of the variance, the second (disclosure), 10.08%, and the last one (positive aspects) explains 7.24%. Conclusions The present study reports the psychometric data of ISS-Spanish version among severe mentally ill patients. We demonstrated that is a measure with appropriate internal consistency for the whole version as well as for all the sub-scales; it has, in addition, factor validity. Thus, it is possible to state that now we count with a valid and reliable instrument to assess internalized stigma of mental illness to be used for the evaluation of Mexican population with clinical and research purposes.

Introducción Se ha demostrado que la enfermedad mental es una de las condiciones que generan más estigma. El estigma producido por los trastornos psiquiátricos se puede experimentar desde la perspectiva social y la personal (estigma internalizado). La forma en que las personas con padecimientos psiquiátricos experimentan las reacciones adversas de los otros ha sido poco estudiada. Hasta ahora no existía una escala validada en la población mexicana que permitiera la medición del estigma percibido por este tipo de pacientes. El objetivo del presente trabajo fue traducir al español y determinar la consistencia interna y la validez factorial de la Escala de estigma de King et al. Método Sujetos: Se incluyeron 100 pacientes mexicanos con diagnósticos de trastornos mentales graves y persistentes (TMSP) que reciben atención en el Centro de Atención Integral en Salud Mental de Estancia Prolongada del Instituto Jalisciense de Salud Mental (SALME), con un mínimo de dos años de evolución y que no se encontraran cursando con un episodio agudo de su enfermedad. Instrumentos y procedimiento: Se aplicó la escala de estigma internalizado de King et al. (EEI) y las escalas de evaluación de la actividad global (EEAG) y de impresión clínica global (CGI). Análisis de datos: Se evaluó la consistencia interna de la EEI mediante el coeficiente alpha de Cronbach y la validez de constructo con base en un análisis factorial de componentes principales con rotación varimax. Resultados La muestra estuvo integrada por 100 pacientes, 67 (67%) eran hombres, mayoritariamente solteros (62%) y desempleados (70%). La mayoría contaba con un diagnóstico principal de esquizofrenia (47%); el tiempo de enfermedad y de tratamiento fue de dos a 44 años y de uno a 44 años, respectivamente. El 81% había sido hospitalizado en una institución psiquiátrica al menos en una ocasión. Respecto al funcionamiento global, la media fue de 58.4 puntos, y la puntuación promedio del CGI fue de 3.78. El 89% (n=89) se encontraba medicado con algún tipo de antipsicótico, más frecuentemente típico (n= 68, 68%). El promedio del nivel de estigma obtenido se comparó con el puntaje de la validación de la escala original; dichos valores fueron muy similares (60.15 y 62.6, respectivamente). La versión en español de la EES se caracterizó por una adecuada consistencia interna, con alphas superiores a .60 en todas las sub-escalas. La evaluación unidimensional del constructo resultó altamente confiable, con un coeficiente de 0.87. Se obtuvieron tres factores principales congruentes con la versión original, lo que da prueba de su validez. Conclusiones El presente estudio es el primero en reportar las propiedades psicométricas de la versión en español de la EES en pacientes mexicanos con trastornos mentales graves y persistentes. Con base en nuestros hallazgos es posible concluir que la EES-español cuenta con una adecuada consistencia interna total y en todas las sub-escalas; además da prueba de validez factorial, por lo que es posible recomendarla para su uso con fines clínicos y/o de investigación.

Interfase neurología-psiquiatría en pacientes hospitalizados por patologías del sistema nervioso central / Neurology-psychiatry interface in central nervous system diseases

Objetivo: Las enfermedades cerebrales condicionan con frecuencia alteraciones mentales y conductuales. Para analizar el área de interfase entre la neurología y la psiquiatría, analizamos todas las interconsultas neuropsiquiátricas realizadas en los servicios de Neurología, Neurocirugía, Terapia Intensiva Neurológica y Urgencias Neurológicas, en el Instituto Nacional de Neurología y Neurocirugía de México (2007-2009). Resultados: En 506 casos, la edad promedio fue 44.24 años (DE 17 años); 240 fueron mujeres (47.4 %). Las patologías neurológicas que generaron más interconsultas fueron neoplasias del sistema nervioso central (14.2 %), encefalitis viral (8.7 %), enfermedad vascular cerebral isquémica (7.1 %), epilepsia (6.5 %) y enfermedad vascular cerebral hemorrágica (4.7 %). Los trastornos mentales más frecuentes (de acuerdo con el DSM-IV) fueron delirium (38.5 %), trastorno depresivo (15 %), demencia (7.7 %), deterioro cognoscitivo, sin criterios de demencia (6.5 %), trastorno de ansiedad (6.9 %). El delirium fue la condición neuropsiquiátrica más frecuente independientemente de las categorías etiológicas. En las infecciones cerebrales hubo mayor frecuencia del síndrome catatónico (p < 0.001). En pacientes con enfermedad vascular cerebral se manifiesta más frecuentemente la risa y el llanto patológico (p = 0.012). Conclusiones: Este estudio muestra la relevancia clínica del delirium, la depresión, la ansiedad, la demencia, los síndromes frontales y la catatonia en pacientes hospitalizados con enfermedades neurológicas y psiquiátricas.

OBJECTIVE: Brain pathologies are frequent sources of mental and behavioral disorders. In order to analyze the boundary between neurology and psychiatry, we analyzed all neuropsychiatric consultations seen at the inpatient Neurology, Neurosurgery, Critical Medicine and Neurological Emergencies clinics of the National Institute of Neurology and Neurosurgery of Mexico between 2007 and 2009. RESULTS: A total of 506 neuropsychiatric visits were included, patient mean age was 44.2 years (SD 17 years) 240 patients were female (47.4%). The main neurological disorders for which patients sought medical care at the neuropsychiatry service, were: brain tumors (14.2%), viral encephalitis (8.7%), ischaemic cerebrovascular disorders (7.1%), epilepsy (6.5%) and haemorragic cerebrovascular disorders (4.7%). The most common DSM-IV psychiatric diagnoses included: delirium (38.5%), depressive disorders (15%), dementia (7.7%), cognitive decline, without fulfilling criteria for dementia (6.5%), and anxiety disorders (6.9%). Delirium was the most common neuropsychiatric condition among the etiological groups. Catatonic syndrome was more frequent among patients with brain infections (p < 0.001), and pathological laughter and crying were more frequent among atients with cerebrovascular disorders (p = 0.012). CONCLUSIONS: Our study highlights the clinical relevance of delirium, depression, anxiety, dementia, frontal syndromes and catatonia among neurologic and neurosurgical in-patients attending a tertiary care reference center in Mexico.

Evaluación de habilidades sociales para el trabajo en pacientes con esquizofrenia: Validez y confiabilidad del autoreporte y la técnica de juego de roles

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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.