Papel del índice de choque en embarazadas del tercer trimestre con hemorragia obstétrica para requerimiento transfusional atendidas en el Hospital General «Las Américas¼ / Role of the shock index in pregnancy of the third quarter with obstetric hemorrhage for transfusion requirement attended at the «Las Americas¼ General Hospital / Papel do índice de choque em gestantes no terceiro trimestre com hemorragia obstétrica com indicação para transfusão atendidas no Hospital ISEM «Las Americas¼

Resumen: La hemorragia obstétrica sigue siendo la causa más importante de muertes maternas en todo el mundo. Una mujer en el tercer trimestre puede perder hasta 30% del volumen sanguíneo antes de que disminuya la presión arterial sistólica, lo que lleva a suponer una estabilidad hemodinámica y retraso en la atención. El índice de choque (IC), calculado como la frecuencia cardiaca dividida por la presión arterial sistólica, se ha propuesto para predecir la hipovolemia temprana. En las poblaciones no embarazadas, el IC normal se ha sugerido como 0.5-0.7 y el IC ≥ 0.9 corresponde con mayor mortalidad y morbilidad. Hasta el momento, sólo un pequeño estudio obstétrico ha definido IC normal como 0.7-0.9. Diseño del estudio: Se calculó el índice de choque en pacientes gestantes en el tercer trimestre que llegaron con hemorragia obstétrica, las cuales llegaron a choque hipovolémico grado III. Se evaluó el efecto del ajuste de los factores de confusión en la relación entre los umbrales del IC y el resultado, utilizando métodos de regresión logística. Resultados: Nuestro estudio es el primero en evaluar la capacidad predictiva de índice de choque en mujeres gestantes con antecedente de hemorragia en el tercer trimestre, demostrando que no ayuda a la toma de decisiones sobre tratamiento final y eventos adversos, ya que los cambios hemodinámicos del embarazo y el postparto pueden retrasar el reconocimiento de la hipovolemia, subestimando la reanimación y derivación tempranas. Conclusiones: El índice de choque no es un valioso predictor del deterioro materno, pero sí impacta sobre la necesidad de transfusión o la intervención quirúrgica en el contexto de hemorragia del tercer trimestre. Proponemos un umbral de IC ≥ 0.9 para identificar mujeres que requieren atención urgente de alto nivel. Esto es más alto que el límite superior de la normalidad en las poblaciones no embarazadas, lo que refleja los cambios hemodinámicos del embarazo y el periodo postparto.

Abstract: Obstetric hemorrhage remains the most important cause of maternal deaths worldwide. A woman in the third trimester may lose up to 30% of the blood volume before the SBP falls, leading to hemodynamic stability and delayed attention. The shock index (SI), calculated as a heart rate divided by systolic blood pressure, has been proposed to predict early hypovolemia. In non-pregnant population, normal SI has been suggested as 0.5-0.7 and SI ≥ 0.9 corresponds with higher mortality and morbidity. So far, only a small obstetric study has defined normal SI, such as 0.7-0.9. Study design: The shock index was calculated in pregnant patients in the third trimester who arrived with obstetric hemorrhage in the third trimester, of which they reached grade III hypovolemic shock. The effect of the adjustment of the confounding factors on the relationship between the SI thresholds and the result was evaluated, using logistic regression methods. Results: Our study is the first to evaluate the predictive capacity of shock rate in pregnant women with a history of hemorrhage in the third trimester demonstrating that it does not help to make decisions about final treatment and adverse events, since the hemodynamic changes of pregnancy and postpartum may delay the recognition of hypovolemia by underestimating early resuscitation and referral. Conclusion: The shock index is not a valuable predictor of maternal deterioration, but it does impact on the need for transfusion or surgical intervention in the context of third trimester hemorrhage. We propose an SI threshold ≥ 0.9 to identify women who require urgent high-level care. This is higher than the upper limit of normality in non-pregnant populations, reflecting the hemodynamic changes of pregnancy and the postpartum period.

Resumo: A hemorragia obstétrica continua sendo a causa mais importante de mortes maternas no mundo. Uma mulher no terceiro trimestre pode perder até 30% do volume de sangue antes que a PAS descenda, levando à supor uma estabilidade hemodinâmica e ao atraso da atenção. O índice de choque (IC), calculado como uma freqüência cardíaca dividida pela pressão arterial sistólica, foi proposto para prever a hipovolemia precoce. Nas populações não gestantes, o IC normal foi sugerido como 0.5-0.7 e o IC ≥ 0.9 corresponde a maior mortalidade e morbidade. Até agora, apenas um pequeno estudo obstétrico definiu o IC normal, como 0.7-0.9. Desenho do estudo: A taxa de choque foi calculada em pacientes gestantes no terceiro trimestre que chegaram com hemorragia obstétrica, das quais atingiram o choque hipovolêmico grau III. Avaliou-se o efeito do ajuste dos fatores de confusão na relação entre os limiares do IC e o resultado, utilizando métodos de regressão logística. Resultados: Nosso estudo é o primeiro a avaliar a capacidade preditiva da taxa de choque em mulheres gestantes com história de hemorragia no terceiro trimestre, demonstrando que não ajuda a tomar decisões sobre o tratamento final e eventos adversos, já que as alterações hemodinâmicas da gestacão e o pós-parto podem retardar o reconhecimento da hipovolemia subestimando a ressuscitação e o encaminhamento precoces. Conclusão: O índice de choque não é um preditor valioso da deterioração materna, mas tem impacto sobre a necessidade de transfusão ou intervenção cirúrgica no contexto da hemorragia no terceiro trimestre. Propomos um limiar de IS ≥ 0.9 para identificar mulheres que necessitam de cuidados urgentes de alto nível. Isso é mais alto que o limite superior da normalidade nas populações não gestantes, refletindo as alterações hemodinâmicas da gestação e do período pós-parto.

National trends in alcohol consumption in Mexico: results of the National Survey on Drug, Alcohol and Tobacco Consumption 2016-2017 / Tendencias nacionales del consumo de alcohol en México: resultados de la Encuesta Nacional de Consumo de Drogas, Alcohol y Tabaco 2016-2017

Abstract: Introduction: Worldwide, binge drinking of alcohol has increased, especially among young people. In Mexico, various epidemiological sources allow us to account for the growth this pattern of consumption has had. Given this context, the Encuesta Nacional de Consumo de Drogas 2016-2017 (ENCODAT) shows the evolution in alcohol consumption. Objective: To determine the prevalence and national and regional trends, as well as state variations of alcohol consumption in the population aged 12 to 65. Method: The ENCODAT 2016-2017 is a random, probabilistic, and multi-stage study with national and state representation. The sample consisted of 56 877 people who answered a standardized questionnaire through ACASI (self-administered computer interviews) that collects information about the use of tobacco, alcohol, and medical and illegal drugs. Results: Binge drinking past month increased from 12.3% to 19.8% from 2011 to 2016. A similar situation occurs in daily use (from .8% to 2.9%) and weekly binge drinking (from 5.4% to 8.5%). The age of onset has remained stable since 2011 (16.6 years for men, 19.2 years for women in 2016). Meanwhile, 2.2% reported alcohol dependence. The states with the highest prevalence of binge drinking are Nuevo León (30.3%), Jalisco (27.7%) and, Coahuila (27.5%). Discussion and conclusion: The results show that alcohol use increased with respect to 2011, especially in women; data on treatment seeking indicate that women who use alcohol are also the least likely to seek help. Given this context, it is necessary to have specialized spaces that provide treatment in keeping with use-based needs and gender condition.

Resumen: Introducción: A nivel internacional, el consumo excesivo de alcohol ha aumentado, principalmente entre la población joven. En México, diversas fuentes epidemiológicas dan cuenta del crecimiento de este patrón de consumo. Dado este contexto, la Encuesta Nacional de Consumo de Drogas, Alcohol y Tabaco 2016-2017 (ENCODAT) muestra la evolución en el consumo de alcohol. Objetivo: Conocer las prevalencias y tendencias nacionales y regionales, así como las variaciones estatales del consumo de alcohol en la población de 12 a 65 años. Método: La ENCODAT 2016-2017 es un estudio aleatorio, probabilístico y polietápico con representatividad nacional y estatal. En la muestra participaron 56 877 personas que contestaron un cuestionario estandarizado mediante ACASI (entrevistas auto-administradas por computadoras), que recaba información sobre consumo de tabaco, alcohol y drogas médicas e ilegales. Resultados: El consumo excesivo en el último mes se incrementó de 12.3% a 19.8% de 2011 a 2016. Una situación similar ocurre en el consumo diario (de .8% a 2.9%) y consuetudinario (de 5.4% a 8.5%). La edad de inicio se ha mantenido estable desde 2011 (16.6 años hombres; 19.2 años mujeres en 2016). En tanto, el 2.2% reportó dependencia al consumo de alcohol. Las entidades con las prevalencias más altas en consumo excesivo son Nuevo León (30.3%), Jalisco (27.7%) y Coahuila (27.5%). Discusión y conclusión: Los resultados muestran que el consumo de alcohol creció con respecto a 2011, especialmente en mujeres. Datos sobre la asistencia a tratamiento, indican que éstas son también quienes menos acuden. Dado este contexto, es necesario contar con espacios especializados que brinden atención conforme a las necesidades de consumo y de condición de género.

Contextual factors associated with marijuana use in school population / Factores contextuales asociados con el consumo de marihuana en población estudiantil

Abstract Introduction Marijuana use among the student population has increased in Mexico and Latin America. There are social, interpersonal and individual factors associated with the onset and continuation of marijuana use. These include the availability of drugs in the community, opportunity for use, low perceived risk of harm from marijuana use and social tolerance by family and close friends. Moreover, these factors increase the probability of experimenting with other drugs, polysubstance use and dependence. Objective To identify the relationship between the level of urbanization, drug availability, exposure to opportunity for use, risk perception and social tolerance of the level of marijuana use among Mexican middle and high school students. Method The results are drawn from various surveys conducted in Mexico City and the National Survey of Drug Use among Students 2014. A total of 114 364 middle and high school students participated (49.8% boys and 50.2% girls). Results Of the respondent 10.6% had used marijuana at least once (12.9% boys and 8.4% girls). The variables that predicted higher marijuana use were drug use approval by family and best friend,, the level of urbanization and low risk perception. Discussion and conclusion Action must be taken on the factors mentioned to decrease the availability and use of drugs in the environment, and raise awareness of their consequences. These elements must be introduced systematically and creatively into preventive programs in this area.

Resumen Introducción El consumo de mariguana en población estudiantil se ha incrementado en México y América Latina. Existen factores sociales, interpersonales e individuales asociados con el inicio y la continuación de su consumo. Entre ellos encontramos la disponibilidad de drogas en la comunidad, la oportunidad de consumo, la baja percepción de riesgo por consumir mariguana, la tolerancia social de la familia y la de los amigos cercanos. Además, estos factores aumentan la probabilidad de experimentar con otras drogas, ser policonsumidor y producir dependencia. Objetivo Conocer la relación entre el nivel de urbanización, la disponibilidad de drogas, la exposición a la oportunidad de consumo, la percepción de riesgo y la tolerancia social con el nivel de consumo de mariguana en los estudiantes mexicanos de secundaria y bachillerato. Método Los resultados parten de diversas encuestas realizadas en la Ciudad de México y de la Encuesta Nacional de Consumo de Drogas en Estudiantes 2014. Participaron 114 364 alumnos de secundaria y bachillerato (49.8% hombres y 50.2% mujeres). Resultados El 10.6% consumieron mariguana alguna vez (12.9% hombres y 8.4% mujeres). Las variables predictoras de un mayor consumo de mariguana fueron la tolerancia ante el consumo de drogas de la familia y del mejor amigo, el nivel de urbanización y una baja percepción de riesgo. Discusión y conclusión Es necesario incidir en los factores señalados con objeto de disminuir la disponibilidad y el consumo de drogas en el entorno, así como en el conocimiento real de sus consecuencias. Estos elementos deben introducirse sistemática y creativamente en los programas preventivos del área.

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.

Sociodemographic and personal factors related to depressive symptomatology in the Mexican population aged 12 to 65 / Fatores sociodemográficos e pessoais relacionados à sintomatologia depressiva na população mexicana entre 12 e 65 anos

OBJECTIVE: To describe the prevalence of depressive symptoms in the Mexican population, aged 12 to 65 years, by identifying the main related socio-demographic and personal factors. METHODS: Data are drawn from the National Survey on Addictions 2008 (ENA 2008), a random, probabilistic, multistage study. A randomly selected sub-sample of 22,962 persons answered the section on depressive symptomatology, measured with the Center for Epidemiologic Studies Depression Scale (CES-D). RESULTS: The total prevalence for depressive symptomatology was 5.1%; the prevalence was 7.5% for women and 2.5% for men. For women, more evidence of depressive symptoms was seen in the central region, whereas for men, symptoms were homogeneous across the country. Factors related to the presence of depressive symptoms include being divorced (in women) or widowed (in men), having lower educational attainment, perceiving one's place of residence as unsafe, displaying alcohol abuse or dependence, being a regular drug consumer (in men) and having been sexually abused (males and females). CONCLUSIONS: The regional distribution of depressive symptomatology in women indicates the need for region-specific prevention programs that take into account the different social problems that affect women's emotional well-being. More research is also needed to support the early identification and intervention of men suffering from depression.

OBJETIVO: Conhecer a prevalência de sintomas depressivos a nível nacional na população de 12 a 65 anos e identificar os principais fatores sociodemográficos e pessoais associados. MÉTODO: Os dados foram obtidos da Pesquisa Nacional de Adições (ENA 2008), um estudo aleatório e probabilístico. Uma sub-amostra de 22.962 indivíduos responderam a seção de sintomas depressivos medida com a Escala de Depressão do Centro de Estudos Epidemiológicos (CES-D). RESULTADOS: A prevalência de sintomas depressivos foi de 5,2%; 7,5% em mulheres e 2,5% em homens. Entre as mulheres, os sintomas se apresentaram mais na região central do país e, entre os homens, a distribuição geográfica foi homogênea. Os fatores que se associaram aos sintomas depressivos foram estar divorciado (mulheres) ou viúvo (homens), ter nível educacional inferior, sentir sua residência como um local não seguro, apresentar dependência de álcool, ser usuário regular de drogas (homens) e abuso sexual. CONCLUSÕES: A distribuição regional de sintomatologia depresiva em mulheres indica a necessidade regional de orientação para prevenção, levando em conta que as distintas problemáticas sociais podem afetar seu bem-estar emocional. Entre os homens, mais estudos são necessários para identificação precoce da depressão.

Tendencias del uso de drogas en la Ciudad de México: Encuesta de Estudiantes del 2009 / Drug use trends in Mexico City: 2009 students survey

In the course of the last three years, a wide range of epidemiological studies related to drug use has been conducted, both at a national and international level. Talking about national studies in the field of school population, surveys have been conducted in the states of Colima, Nuevo León and Jalisco, as well as surveys in university population, among others. Regarding tobacco use, several studies were made and they covered many cities of the country. About household surveys, the fifth National Addictions Survey (ENA) was carried out in 2008 and it provided data at a national and state level. The Global Survey of Smoking in Adults (GATS) was also made having nationwide coverage. In relation to tobacco use, the trend shows a decrease in the prevalence of consumption. This is shown in ENA 2008 and GATS, as well as school population studies in different states. For alcohol consumption, the situation is different; both for the prevalence and for the proportion of people who start its early consumption, significant increases have been reported throughout the country. Alcohol abuse remains constant and is similar between men and women. When considering the use of illegal drugs, there is an overall increase. As for marijuana, data indicates that its consumption has increased and that it remains as the primary drug of use. However, the main increase is for inhalants, particularly among school population and especially in women. For cocaine, data from United Nations shows a significant decrease in the supply of this substance due to the increase of seizures. Data from ENA 2008 shows that the use of this drug has doubled between 2002 and 2008. The United Nations report indicates that the increase in our country is apparent until 2005 and since then it has been decreasing. Methamphetamine use remains low and it does not increase. Only in the case of the population that goes to service centers for drug users, a high rate of consumption is found. Finally, the consumption of heroin and hallucinogens is low. Chihuahua remains as the state with the most problems in the use of heroine. Most recent surveys have allowed us to see, in general, some of the trajectories in adolescent mental health, where sexual abuse is presented first in women, followed by ADDH, then the consumption of legal drugs, antisocial behavior, use of inhalants and suicide attempt. Then drug consumption, marijuana and cocaine. In men, the sequence is similar, although they face ADDH first and then sexual abuse. In this context, the objective of this study is to assess the prevalence of drug, alcohol and tobacco use, as well as consumption trends in school population from 7th to 12th grade from Mexico City and its political delegations. Method To ensure the comparability with similar studies carried out in Mexico in school population, the methodology used in this study maintains the basic aspects of the previous measurements that have been made in students from 7th to 1 2th grade from Mexico City and other states. The project had the approval of the ethics committee from the National Institute of Psychiatry Ramón de la Fuente Muñiz, and was approved by the educational authorities of Mexico City to be applied in school population. The unit of analysis from which the information was obtained were the students enrolled in 7th to 12th grade in 2008-2009 from public and private schools in Mexico City. The sampling frame was developed based on the official records of the 2008-2009 school year. A non-response rate of 20%, a confidence level of 95% and an average absolute error of 0.004 were considered. The sample design was stratified by level of education (7th to 9th grades and 10th to 12th grades) and political delegations, which gave 32 different strata. It was also clustered by scholar group which was the primary unit of selection. The sample of groups and students were weighted considering the group, educational level and the delegation. A final sample of 22 980 subjects was obtained: 49.8% were female and 50.2% were men. 56.3% of the sample attended to 7th to 9th grades and 43.7% attended to 10th to 12th grades. In addition, most of the male and female adolescents were full-time students during the year prior to the study and only 7% of men and 5.1% of women were not students. 23.3% of men and 11.9% of women worked part or full time, and additionally, most of them had both parents. The information was obtained through a standardized questionnaire, which has been applied in previous surveys and has been previously validated. Due to the extension of the instrument, four forms were used to include various sections, the main part of questionnaire was administered to all subjects and the last two pages corresponded to forms, so each form was applied to one quarter of the sample. Alcohol consumption indicators used are comparable with WHO indicators, international observatories from Europe and the ones used in <

Introducción En los últimos tres años, se ha realizado una amplia gama de estudios epidemiológicos, a nivel nacional e internacional, sobre el consumo de drogas. En cuanto a tabaco, la Encuesta Nacional de Adicciones 2008, la encuesta de GATS y los estudios estatales en población escolar muestran una tendencia importante a la disminución del consumo de la sustancia. Para el consumo de alcohol, tanto en la prevalencia como en la proporción de personas que inicia su consumo temprano, se han reportado incrementos. El abuso de alcohol se mantiene constante y similar entre hombres y mujeres. Al considerar el uso de drogas ilegales hay incrementos importantes. El incremento más pronunciado es el de los inhalables, especialmente en mujeres. En cuanto a la cocaína, la ENA 2008 señala que se ha duplicado el consumo y el informe de la ONU indica que al parecer el incremento se da hasta 2005 y a partir de ahí ha disminuido. Las metanfetaminas mantienen una prevalencia baja. Sólo entre quienes acuden a los centros de servicio para usuarios de drogas se encuentra un alto consumo. En este contexto, el objetivo de este trabajo es evaluar las prevalencias del uso de drogas, alcohol y tabaco, así como las tendencias de consumo en la población de estudiantes de enseñanza media y media superior de la Ciudad de México. Método El marco muestral se elaboró con base en los registros oficiales del ciclo escolar 2008-2009 de la Secretaría de Educación Pública (SEP). Se consideró una tasa de no respuesta de 20%, un nivel de confianza de 95%, con un error absoluto promedio de 0.004. El diseño de la muestra fue estratificado y por conglomerados; la unidad de selección fue el grupo escolar. Se obtuvo una muestra final de 22 980 sujetos y quedó conformada por 49.8% de mujeres y 50.2% de hombres. La información se obtuvo mediante un cuestionario estandarizado, que ha sido aplicado y validado en las anteriores encuestas. Los indicadores de consumo de alcohol, drogas y tabaco empleados son comparables con los indicadores de la OMS, de los observatorios internacionales de Europa y de los usados en <

Encuesta de estudiantes de la Ciudad de México 2006: Prevalencias y evolución del consumo de drogas / Student survey of Mexico City 2006: Prevalence and trends of drug use

Introduction Since three years from now, in Mexico there has been several surveys and specific research regarding drug use. Over these years the national surveillance systems databases (SISVEA, CIJ) have shown that cocaine use has stabilized and marijuana use is still increasing, although there are some regional differences. Also, the results of the 2003 Mexico City Students' Survey revealed a similar inclination: an increase on marijuana use, a slight diminish on cocaine use and as a new stage: a rebound on inhalant use. However, these changes and trends on drug use are not the same all over the country. The results found in these databases suggest that the northern border behaves differently from the rest of the country, even all along the northern border itself. While drug use in Matamoros is lower than in other border cities, Nuevo Laredo, Reynosa and Ciudad Juarez registered high cocaine and heroin use. On the other hand, even though the border cities of Sonora and Baja California have these same drug use problems, they also show high rates of methamphetamine use. Another important issue on border cities is that Ciudad Juarez has reached Tijuana's use levels, mainly among teens between 12 and 1 7 years old. These two cities have the highest substance use levels in the country, even above Mexico City. On the central region of the country, the drug use rates are halfway between. Even though Mexico City's drug use levels are among the central region and the two border cities mentioned before, in all the states that have been studied, there's been a general significant increase in drug use. In southern states, especially Yucatan (where there's a household and a students' survey), the drug rates are the lowest in the country. However, the women's drug use rates keeps increasing. Specifically the 2003 students' survey showed that in some Mexico City's counties women have higher alcohol and tobacco prevalence, and their illegal drug use trends begin to be alike to men's illegal drug use trends. Objective To present drug use prevalence results from the 2006 Mexico City Students Survey. Material and methods This survey used a 10523 Mexico City students random sample. The sample design was stratified (by county), with two stages (by school) and clustered (by groups). This data is representative by State County and by educational level. The design is comparable with previous student's surveys made by the National Psychiatric Institute (INP) and the Mexican Board of Education (SEP). The marijuana, cocaine and inhalants variation coefficients (VC) were determined according to the 2003 survey. The variable with the highest VC, a non-response rate and a design effect of two were considered as in previous surveys. With all these parameters, it was considered a 15% non-response rate, the same found in previous studies. The sample's accuracy level was 95%, with an absolute error average of 0.004. The questionnaire was made with drug use indicators that the World Health Organization used in their own surveys. Besides, some youth behaviors were explored: suicide attempt, depression, eating risk behaviors, sexual behavior, etc. Results From this sample 49.9% were women and 50.5% male. As for Tobacco <>, it affected the same both men and women, and remained similar in comparison to 2003. Also, 68.8% of the adolescents have consumed alcohol at least once in their life and 41.3% has drunk it in the previous month, being women and men equally behaved. The total drug use prevalence was 1 7.8%, statistically higher than in the 2003 survey, with a 2.6% difference. Men use more drugs compared to women. Of the total sample, 12.9% is an experimental user and 4.9% is a regular user (have used drugs five or more times). As for medical drugs (tranquillizers and amphetamines), their use is higher in women, while illegal drugs use (marijuana, cocaine, hallucinogens, inhalants, methamphetamine and heroin) is higher in men. In general terms, illegal drug use is higher than medical drugs use. Substance use percentage was nearly twice for tenth to twelfth grade students, compared to seventh to ninth grade students. Women have experimented less with illegal drugs in the 'previous year of use' than men, yet women have shown an important increase on inhalant and marijuana use over the past three years, and cocaine use has remained similar. Marijuana is the first choice drug among adolescents, followed by inhalants, tranquillizers in third place and cocaine in fourth place of choice. Also, the results show that drug use is highly related with other problematic behaviors like suicidal attempt, depressive sintomatology, antisocial behavior, and sexual risk behaviors. Conclusions The study points out an important increase in drug use over the past three years, going from 15.2% to 17.8%. Different trends can be seen on each substance. On the one hand, marijuana and inhalants use has increased widely, on the other hand tranquillizers use remains stable and cocaine use has decreased. These results showed that the illegal drugs use among both men and women has increased (marijuana and inhalants mostly), women's cocaine use has remained steady, but men's has been reduced. Legal drugs use behavior hasn't changed: the use of alcohol has enhanced, while tobacco use is similar to the 2003 survey. It has also been reported that the use rate of both substances is practically the same among men and women. Also, the situation of México City has changed slightly. The counties that are more damaged by drug use are: Azcapotzalco, Cuauhtémoc, Benito Juárez, Coyoacán and Tlalpan. In order to improve drug use prevention programs to consider the relationship between several problematic behaviors like suicidal attempt or antisocial behavior, because users showed prevalence at least twice more than non users. Likewise, there still exist a low risk perception and a high tolerance towards tobacco and alcohol use, which are important risk factors for using other drugs. Additionally, if we also take into account that the first use takes place a younger age, the probabilities of using medical and illegal drugs increase significantly.

Introducción Desde hace tres años se han hecho varias encuestas sobre consumo de drogas en nuestro país, además de investigaciones específicas sobre el tema. En estos últimos tres años diversos sistemas de información del país (SISVEA, CIJ) han mostrado que el consumo de cocaína se ha estabilizado y que el consumo de mariguana sigue en aumento, aunque estos aspectos presentan variaciones a nivel regional. Asimismo, en los datos de la encuesta de estudiantes de la Ciudad de México del 2003, se encontró una situación similar, hubo un incremento en el consumo de mariguana, un ligero decremento en el consumo de cocaína y, como nueva situación, un repunte en el consumo de inhalables. Por supuesto que los cambios y comportamientos no son iguales en todo el país. Por otra parte, se ha observado que las mujeres han incrementado su consumo de drogas de manera específica. Por ejemplo, el reporte de la encuesta del 2003 muestra que en los casos del alcohol y del tabaco, en algunas delegaciones de la Ciudad de México hay una mayor prevalencia de mujeres que consumen estas sustancias y hay indicios de que en el consumo de algunas drogas ilegales las prevalencias del consumo son similares a las de los hombres. Objetivo El objetivo de este estudio fue el de presentar los resultados de la Encuesta del 2006 sobre las prevalencias del uso de drogas entre la comunidad escolar en la Ciudad de México. Material y métodos El estudio se realizó con una muestra aleatoria de 10 523 estudiantes de todo el Distrito Federal. Los datos de este estudio son representativos por delegación y por nivel educativo, y el diseño es comparable al de estudios anteriores realizados en escuelas por el Instituto Nacional de Psiquiatría Ramón de la Fuentes Muñiz y la Secretaría de Educación Pública. El cuestionario se conformó con los indicadores de consumo de drogas que se han utilizado en este tipo de estudios que corresponden a los empleados por la OMS. Además, se exploraron diversas conductas de los adolescentes, como el intento suicida, su nivel de depresión y sus conductas alimentarias de riesgo, así como diversos aspectos de su conducta sexual. Resultados Del total de la muestra el 49.5% fueron mujeres y el 50.5% fueron hombres. En los resultados se encontró que el consumo de tabaco alguna vez en la vida ha afectado de modo similar tanto a hombres como a mujeres y fue similar a lo encontrado en el 2003. Por otro lado, se encontró que el 68.8% de los/as adolescentes ha usado alcohol alguna vez en su vida y un 41.3% lo ha consumido en el último mes; resultando igualmente afectados tanto los hombres como las mujeres. La prevalencia total de consumo de drogas fue del 1 7.8%, porcentaje estadísticamente mayor al del 2003 en un 2.6%. Los hombres estuvieron dentro del subgrupo más afectado por el consumo actual en comparación con las mujeres. De acuerdo al nivel educativo de los participantes, el consumo de sustancias fue casi del doble para los/as adolescentes de escuelas de bachillerato, como para los de bachillerato técnico, en comparación con los/as de secundaria. En cuanto a las drogas ilegales, en el consumo durante el último año, una proporción menor de mujeres ha experimentado con drogas -en ellas se ha observado, en los últimos tres años, un incremento importante en el consumo de inhalables y mariguana- en tanto que el consumo de cocaína se ha mantenido estable. Por lo que respecta a cada sustancia, la mariguana ocupa el primer lugar de preferencia entre los/as adolescentes, le sigue el consumo de inhalables, los tranquilizantes en tercer lugar y la cocaína en cuarto. Conclusiones El estudio mostró un incremento importante en el consumo de drogas en los últimos tres años: del 15.2% ha pasado a 17.8%. Además, dentro del uso de cada sustancia se observan situaciones distintas. Por un lado, el incremento del uso de la mariguana y de los inhalables es grande, mientras que en los tranquilizantes el consumo se mantiene estable y el de la cocaína ha disminuido. Al analizar estos resultados según el sexo, se encontró que los niveles de consumo de drogas ilegales (mariguana e inhalables principalmente), en las mujeres, han aumentado y la cocaína se ha mantenido estable: en tanto que en los hombres también se han incrementado las dos primeras sustancias, pero el consumo de cocaína ha disminuido. Por lo que respecta a las drogas legales, la dinámica se mantiene similar. Por un lado, el consumo de alcohol se ha incrementado en tanto que el consumo de tabaco se mantiene similar al del 2003. Las delegaciones más afectadas por el consumo de drogas son Azcapotzalco, Cuauhtémoc, Benito Juárez, Coyoacán y Tlalpan, las cuales han desplazado a Gustavo A. Madero, Venustiano Carranza, Iztacalco y Miguel Hidalgo. En el caso del abuso del alcohol, también han cambiado las delegaciones más afectadas, actualmente son Miguel Hidalgo, Cuauhtémoc, Benito Juárez, Cuajimalpa y Tlalpan. Al analizar la relación del consumo de drogas con otras conductas problemáticas se observa que los y las usuarias de drogas, han presentado de dos a tres veces más sintomatología depresiva, intento suicida, conductas antisociales, así como un posible trastorno por déficit de atención.

Tendencias del consumo de drogas de 1998 a 2005 en tres ciudades de la zona norte de México: Ciudad Juárez, Monterrey y Tijuana / Trends of drug use 1998 to 2005 in three cities in the northern zone of Mexico: Ciudad Juarez, Monterrey and Tijuana

Drug use in Mexico has been on the rise since the 1970s. Nonetheless, this problem has exhibited important variations in the different regions of Mexico. To document these trends, the National Institute of Psychiatry Ramón de la Fuente (INP) has performed household surveys on addictions in different Mexican cities. In the 1970s and early 1980s surveys were conducted in the following cities: Mexico City, La Paz, Baja California Sur; Mexicali, Baja California Norte; Monterrey, Nuevo León; San Luis Potosí, San Luis Potosí; and Puebla, Puebla, among others. The first national survey in urban population was carried out in 1 988, and was repeated in 1993 and 1998, while the first national survey to included rural population was conducted in 2002, which is being followed by another study currently in the field. The student population has also been extensively studied, and has been included in three national drug surveys and studies performed in different entities. Antecedents Results from these surveys show that drug use has not increased in a uniform fashion throughout the Mexican Republic and both student and household surveys have demonstrated higher rates in the northwestern region of the country comprising the states of Baja California, Sonora and Chihuahua, which have exhibited above-average drug use on comparison with the remaining regions of the country. The most frequently consumed drug by the population is marihuana. The 1988 national household survey registered a rising prevalence in use of 2.9% in Mexican population aged 12-65 years of individuals who had used drugs at some time during their lifetime; in 1993 this prevalence increased to 3.32% and in 1998 to 4.70%; while in 2002 the percentage demonstrated a slight decrease to 3.48%. In 1988, the second place in drug preferences of the population was inhalants with a prevalence of drug use at some time during their lifetime of 0.76%; by 1993, the second place was occupied by cocaine. Prevalence of use of the latter was 0.33% in 1988; by 1993, cocaine increased to 0.56% and to 1.45% in 1998, presenting a slight decrease in use in 2002 (1.23%). From 1988-2002 non-prescribed medical drugs consumed were found in the third place in population preference. Objective This article compared drug use rates observed in three cities on or near Mexico's northern border with the U. S.: Ciudad Juarez, Chihuahua; Tijuana, Baja California Norte, and Monterrey, Nuevo León, were studied as part of the 1 998 national survey on addictions by selecting independent representative samples of these localities and with a new survey of these entities in 2005. Method The 1998 national survey of addictions was carried out in a representative sample of Mexican urban population (in localities of 2500 inhabitants). Independent samples were drawn from inhabitants living in several cities throughout Mexico. In this article we report the drug-use trends for three of these cities (Ciudad Juarez, Monterrey and Tijuana) by comparing the rates observed in 1998 with the results of a new wave of household surveys conducted in 2005 in the same cities using comparable methodology. Samples in both periods included population 12-65 years of age residing in households. Sample design was stratified by means of the following: several stages with localities (Áreas Geoestadísticas Básicas, AGEBS, its acronym in Spanish, census tracts); blocks of houses within the selected localities; segments of houses within sample blocks, and one individual per household as the selection unit in each stage. Sample size in Tijuana was 466 and 553 in 1998 and 2005, respectively, while sample sizes for Ciudad Juarez were 472 in 1998 and 606 in 2005, and for Monterrey this was 637 in 1998 and 675 in 2005, and the non-response rate was 23% in 1 998 and 20.3% in 2005. Instruments for obtaining information employed in both time frames considered were similar. Two types of questionnaires were administered: a household questionnaire that included sociodemographic information on all household inhabitants in the sample and their housing conditions and an standardized individual questionnaire administered in a face-to-face interview that collected information on the following: prevalence and use patterns of tobacco, alcohol, five types of illegal drugs (marihuana, cocaine, heroin, hallucinogens, amphetamine-type stimulants and other drugs); four types of medical pharmaceuticals utilized without a prescription (narcotics, stimulants, tranquilizers and sedatives), determining consequences and services utilization. In this article tobacco and alcohol use is not reported. This questionnaire has been extensively tested and used in previous surveys. Interviewers were persons academically prepared in the Social Sciences and trained in the logistics of the several survey stages and extensively supervised during field work. Results Highest rates of use were observed in Tijuana and Ciudad Juarez in contrast with Monterrey, which had lower rates. When use of any drug was considered, an increase in lifetime use from 1998-2005 was observed in all three cities; when use during the past year was contemplated, an increase was observed from 1998-2005 from 2.8-4.8% in the case of Ciudad Juarez and in Monterrey from 1.3%-2.0%, while these rates for Tijuana decreased from 5.4%-4.01%. Reports of use during the previous month fell in Tijuana from 4.4%-2.81 % and in Monterrey this decreased from 1.1 %-0.71 %, while in Ciudad Juarez drug use rates during the previous month increased from 2.4%-3.24%. It is important to mention that there was no statistical significance in any of the different prevalences types. Lifetime use of medical drugs without prescription increased in Tijuana and in Monterrey, while in Ciudad Juarez this remained stable from 1998-2005. In 2005, use of medical drugs decreased in Ciudad Juarez from 1.2%-0.88% and in Tijuana from 1.3%-1 .28%, while in Monterrey no use was detected in 1998, but 0.48% of interviewees did reported drug use in 2005. Previous-month use increased in Tijuana from 0.7%-1 .28% and in Monterrey this ranged from no use in 1998 to 0.48% by contrast in Ciudad Juarez previous-month drug use fell from 1.2-0.88%. In referring only to use of any illegal drug (excluding medical pharmaceutical), lifetime use increased in all three cities from 1998-2005; lifetime use doubled in Monterrey and Ciudad Juarez, while use during the previous year decreased in Tijuana from 4.4%-3.25% and increased in Ciudad Juarez from 1.6%-3.98% and in Monterrey from 1.3%-1 .52%. Prior-month increased in Ciudad Juarez from 1.2%-2.42%, while this exhibited a decrease in Tijuana from 3.9%-2.05% and in Monterrey from 1.1%-0.23%. Data also indicate that a high proportion of individuals in Monterrey have used only one drug; these percentages rose in the 1998-2005 period from 3.7%-8.96% numbers of the poly-drug users doubled in Tijuana from 4%-8.44% and in Ciudad Juarez from 3.2%-7.43%; in Tijuana this was due to an increase among males, and in Ciudad Juarez the number of poly-drug users increased in both genders.

El consumo de drogas en México ha ido en aumento. En la década de 1970, el Instituto Nacional de Psiquiatría realizó las primeras encuestas de hogares sobre el tema de las adicciones en población de distintas ciudades del país: la Ciudad de México, La Paz, B.C.S.; Mexicali, B.C.; Monterrey, N.L.; San Luis Potosí, S.L.P., y Puebla, Pue, entre otras y ha documentado las tendencias del problema y sus variaciones regionales. A nivel nacional se han realizado en hogares cuatro encuestas en 1988, en 1993, en 1998 y en 2002, denominadas <>. Asimismo se han levantado tres encuestas nacionales sobre drogas entre la población estudiantil, las cuales han dado cuenta de que el consumo de drogas no se ha incrementado de manera uniforme en el país, sino que tanto en las encuestas estudiantiles como entre las de adicciones ha resaltado la zona noroccidental, conformada por estados como Baja California, Sonora y Chihuahua, donde se tienen las mayores cifras de consumo de drogas en la República Mexicana. Las encuestas de adicciones indican que la droga que más ha consumido alguna vez en la vida la población urbana de 12 a 65 años es la mariguana, con los siguientes porcentajes: en 1988, 2.99%; en 1993, 3.32%; en 1998, 4.70%; y en la medición de 2002 disminuyó ligeramente a 3.48%. En 1988, el segundo lugar lo ocupaban los inhalables con 0.76%, pero en las demás mediciones ocupa este lugar la cocaína, con 0.56% en 1 993; 1.45% en 1998 y en 2002, 1.23%. En el tercer lugar se encuentran las drogas médicas consumidas sin prescripción desde 1988 hasta 2002. Este artículo presenta una comparación de las prevalencias de uso de drogas en tres ciudades de la Encuesta Nacional de Adicciones de 1998 con respecto a la Encuesta de ciudades de 2005 de las tres ciudades siguientes: Ciudad Juárez, Monterrey y Tijuana. La Encuesta Nacional de Adicciones de 1998 se realizó en una muestra representativa de la población urbana de todo el país (en localidades de más de 2500 habitantes). En esta encuesta, las 32 entidades del país se dividieron en tres regiones y también se obtuvieron muestras en ciudades fronterizas que fueron: Tijuana, Ciudad Juárez y Matamoros y en tres zonas metropolitanas que fueron: La ciudad de México, Guadalajara y Monterrey. La muestra fue de 12015 entrevistas completas. La encuesta de ciudades de 2005 se realizó en cuatro ciudades que fueron: Querétaro, Monterrey, Ciudad Juárez y Tijuana. Sin embargo, para efectos de este trabajo, solamente se comparan las tres últimas. Las dos encuestas tuvieron como objetivo a la población de 12 a 65 años de edad. En ambas se aplicaron dos cuestionarios: el de hogar con datos socioeconómicos y otro individual, cuyas secciones de consumo de drogas fueron iguales. El muestreo en ambas encuestas fue multietápico, probabilístico y estratificado, y en la última etapa se seleccionó a un individuo de cada hogar con un rango de edad de 12 a 65 años. Se obtuvo una no respuesta de 23% en 1998 y de 20.3% en 2005.

La familia y el maltrato como factores de riesgo de conducta antisocial

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Summary: Antisocial behavior emerges as the result of different factors such as scholar problems, drug consumption, alcoholism, antisocial peer relationships, emotional problems, etc., which may in turn predispose to the individual to develop a pattern of antisocial behavior. The present work aims to determine the association of antisocial behavior between the factors of a bad family environment and mistreatment, and to determine if they can predict the presence of antisocial behaviors in adolescents. Family plays a primary role in the development of a person, especially in adolescent. In recent times, several problems of family disintegration and inadequate parent-child relationships are observed, and it has been described that antisocial personalities may arise from environments with child abuse, economical problems, humiliation, physical punishment and family disintegration. The experience of such emotions during childhood may lead to a severe impairment in the conformation of an emotionally-adapted personality, and may promote a tendency for the commitment of delictive behaviors in the future. It is necessary to close the vicious cycle where mistreated parents mistreat their own children and avoid that the parents who lived unpleasant experiences of hostility, rejection, lack of communication, inestability, etc., repeat these patterns with their children. It is important to revalorize the role of family, its functions and characteristics and the most important, its determinant influence on young people that have behavior problems as antisocial behavior. It is vital to create conscience about the harm that some children, adolescents and even adults have from their negative familial experiences of hostility, aggression, and mistreatment, because these experiences increase the possibilities of delictive behavior in these individuals. Objective. In this context, the present research has its main interest in showing the relationship between past experiences of mistreatment or inadequate familial environments and the presence of antisocial behaviors in adolescents. Method. The present research is supported on results of the Mexico City Survey on drug consumption in 7 th to 12 th grade population carried on October 2003. The total sample of the survey comprised 10659 students. For this research we used 3603 students, that corresponds to the number of students that completed the Form A of the questionnaire, that contained the areas of interest of the study. The questionnaire was previously validated an its main indicators have shown adequate stability in different surveys. This instrument was applied in three different times due to its extension. Total time for its application was of 75 minutes. Raters were trained for the application of the questionnaire. The course lasted 12 hours and included all the theoretical aspects related to addictions, objectives of the study, management of the questionnaire and the instructions for its application in the groups. Results. First of all, a comparative analysis by gender was performed. It was observed that antisocial behaviors were more frequent in men than in women. It is important to mention that men committed this acts in a double frequency than women, specially in terms of severe acts, where 10% of men committed them in contrast to the 3.3% observed in women. Additionally, two factor ANOVA was performed (gender and antisocial behaviors) with the variables of this study, mistreatment and family environment, to determine if there were differences between groups (p<0.05) and significant differences were observed in all the areas of family environment. The interaction analysis of the two factors: gender, act-non acts with family environment showed that for the area of hostility and rejection there were significant differences where women that committed antisocial acts were the ones that reported higher levels of hostility and rejection. In terms of communication of the son/daughter, women that committed antisocial acts were also the ones that reported a lower level of communication. In the area of parent support, women that committed antisocial acts were also the ones that reported the lower levels. In the areas of parent communication and support to the son/daughter, men and women that committed antisocial acts reported less communication and support, respectively. For the area of mistreatment, women reported higher levels of prosocial discipline and negative discipline when compared to men. No significant differences emerged between men an women in the area of severe negative discipline. Also, no significant differences emerged between adolescents that committed antisocial acts and adolescents than do not committed these acts, in terms of prosocial discipline. Nevertheless, adolescents that committed antisocial acts reported higher levels of severe negative discipline. For the analysis of the interaction of the factors gender, acts-non acts in the area of mistreatment, no differences emerged in the area of negative discipline. Significant differences emerge for prosocial discipline, where men that do not committed antisocial acts reported the lowest levels of prosocial discipline. For severe negative discipline, both men and women that committed antisocial acts reported the highest levels. Finally, using logistic regression, we find that the main predictors of antisocial behavior were the presence of high hostility, low level of communication from the children, less child support and the presence of higher negative discipline and negative severe discipline. Communication, parent support and prosocial discipline were not predictive variables for antisocial behavior. Our results support what is described in other studies where family is the main agent of socialization as family teaches the ways of social interaction, values, habit, etc. Furthermore, several studies that evaluated the relationship of the family and antisocial behavior were performed by analyzing the role of the family as a mediator of behavior and society, on the basis that family teaches children rules, abilities and motivations that in some way constitute their cultural and social patterns. We conclude that family environment and mistreatment are factors associated to the presence of antisocial behavior. We must prevent this problem by improving familial relationships and providing a positive family environment to adolescents. In this way, our adolescents may have an adequate development throughout their lives. If an adequate and positive environment is provided during childhood and is maintained through adolescence, with positive affective family relationships, the adolescent may see his/her parents as a guide; a reasonable not arbitrary discipline allows the adolescent to develop a social behavior that leads to an adequate self-control and self-directedness. On the contrary, if the relationships between parents and children are not favorable, the social behavior of the adolescent may be easily impaired and it is very common that these adolescents exhibit severe difficulties for social adaptation.

La rehabilitación integral del paciente esquizofrénico en México: el modelo del Instituto Nacional de Psiquiatría Ramón de la Fuente, Grupo III

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Summary In this manuscript we describe results obtained for Group III of the Integral Rehabilitation Program for Outpatient Schizophrenic Patients (IRPS III) at the National Institute of Psychiatry Ramón de la Fuente. This program was created for Mexican schizo-phrenic patients as a refined alternative for the treatment, rehabilitation and integration to a productive life within society. It is interdisciplinary and integral in nature; both patients and their relatives are involved in the treatment and rehabilitation. It includes admission, stabilization of clinical symptoms, and application of strategies for rehabilitation for one year (pharmacological treatment, group psychotherapy, labor -vocation induction therapy, music therapy, psychosocial psychotherapy, occupational therapy, artistic painting, drawing, and Hata-Yoga workshops, psycho-educational workshops for relatives, group dynamics therapy with responsible relatives, and unifamilial psychotherapy); there were assessments at the beginning and at end of the study. Objective To evaluate the efficacy of an interdisciplinary and integral program in these patients, with respect to a control group that received the usual medical-psychiatric treatment. Evaluation was carried out according to: a) Severity of psychiatric symptoms, b) Treatment compliance, c) Everyday performance, d) Psychosocial functioning, e) Global activity, f) Home occupational activities, g) Expressed emotion and attribution of the illness, and h) Patterns of communication and relationship within the family. The goals of this program were to reduce the disabilities and to profit from the conserved functions, as well as to develop other skills in order to increase the quality of life of patients. Methods This was a quasi-experimental pretest-postest prospective study where an experimental group and a control group were compared. The control group (n=39) received the usual psychiatric management, while the experimental group (n=39), participated in addition to this management, in a one-year integral rehabilitation program at the outpatient service of the institute. The sample was obtained in a non-probabilistic and sequential way, according to the established inclusion and exclusion criteria. Variables:Efficacy was evaluated through: a) Severity of psychiatric symptoms; b) Treatment compliance; c) Everyday functioning; d) Psychosocial functioning; e) Occupational activities at home; f) Expressed emotion; g) Patterns of communication and relationship within the family. Instruments: Composite International Diagnostic Interview (CIDI), Positive and Negative Syndrome Scale (PANNS), Clinical Interview and File, Everyday Unemployment Scale, Psychosocial Functioning Scale, Global Assessment Scale, Assessment and Follow-up Questionnaire, Patient Labor Performance Scale, Social Behavior Assessment Schedule (SBAS), Five Minute Speech Sample (FMSS), Verification of the Performance in Occupational Activities for Schizophrenic Patients, Extrapyramidal Symptom Scale. Procedures: a) Incorporation of patients and relatives to the study; b) Stabilization of clinical symptoms; c) Initial assessment; d) Program application; e) Final assessment. Results Demographic data: There were 47 subjects in the final sample, 25 in the experimental group, and 22 controls. There were more males than females in both groups (76% in the experimental group and 63.6% in controls). Being single was the most frequent marital status among patients (88% in the experimental group and 91% in controls). Education was slightly higher in the experimental group, were 40% had a bachelor´s degree as opposed to 27.2% in controls. Treatment compliance: The program had a final efficiency of 64% for the experimental group and 56% for controls. Some of the experimental subject's characteristics at the beginning of the program were related with treatment compliance: age, years of illness history, and number of different diagnoses. It was determined that 62% of the patients who completed the program were less than 30 years old, and in 80% of the cases the onset of the illness was less than 10 years ago. Regarding the number of diagnoses per patient, 60% of those who completed the study had one diagnosis, 40% had two or more. On the contrary, 30% of the patients who abandoned the study had one diagnosis and 70% had two or more. In other words, almost three fourths of the sub-sample that abandoned the Program had more than one diagnosis: 31% had two, 31% had three, and 10% had four or more. Clinical area: In the clinical area, there were no significant differences between groups. However, patients in the experimen-tal group had a higher level of clinical adaptation and treatment compliance. Everyday performance: The everyday performance was improved in patients from the experimental group, with statistically significant changes in 71.5% of the pretest-postest evaluated areas, with emphasis on self-care, family and interpersonal relationships, and remunerated work. In the control group, there was an improvement only in 28.5% of the areas. Psychosocial functioning: Global and by-area psychosocial functioning showed statistically significant differences in the experimental group in all functioning areas; there was an improvement from three to two, the latter number meaning feeling satisfied. This was not the case in the control group. Behavior at home: In the experimental group, the perception in families was that occupational behavior at home was improved, according to the final score. Family assessment: Relatives in the experimental group attributed the problems they had with the patient to personality characteristics. These problems were diminished at the end of the study, but not in the control group. When relatives attributed problems to the way of being and attitudes of patients, there was a decrease of problems from 31.6% to 26.3%. Emotional Expression in relatives from the experimental group was observed in 79.2% at the beginning of the treatment program, which decreased to 33.3% at the end of the study, with a significant difference of p <0.006, as opposed to relatives in the control group, who did not show statistically significant differences. Clinical assessment of families: At the beginning of the program, this group established reiterative communication patterns. The patient showed rejection to communication. Relatives blamed schizophrenia for the lack of communication. At the end of the program, patterns of communication had importantly improved. Conclusions Demographic data in our sample are similar to those described in previous reports for male:female ratio, marital status, and education. Some characteristics of the patients, in particular age, years from onset of illness, and psychiatric comorbidity assessed at recruitment were associated with completing or not the program. At the end of the study it was clear the program reached its goals of reducing the patients' disabilities and profiting of conserved functions: 64% of the patients in the experimental group were more stable in clinical terms, and treatment compliance was better. Also, everyday performance was notably improved. In the experimental group there were pretest-postest statistically significant differences in 71.5% of the studied area, especially in self-care and interpersonal relationships. In the control group there were significant changes only in 28.5% of the areas. One level of improvement was observed in global and by-area psychosocial functioning in the experimental group, but not in controls. Patients at the end of the study had switched from a score of three (neutral, unconcerned) to level two (satisfied with their own functioning). In the control group there were no statistically significant differences. Emotional expression in relatives in the experimental group significantly decreased at the end of the study (p< .006), but not in the control group, given that the latter did not show statistically significant differences. Occupational activities at home were also improved in the experimental group, with better scores at the end of the study. Regarding the assessment of occupational therapy, there were significant differences in four areas. Other areas with positive changes were: disease attribution to the patient, and patterns of communication in the family. The areas with better results were self-care, socialization, and family dynamics, which are frequently altered in schizophrenic patients. These results showed the efficacy of the program in its integral version (pluridimensional). Once the proposed objectives are reached, we propose to continue this program with important modifications of the method, which will be described in future publications.

Tendencias de la conducta antisocial en estudiantes del Distrito Federal: mediciones 1997-2003

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Abstract: Introduction. This paper analyses the evolution of antisocial behavior within the context of representative cross-sectional studies in student population from Mexico City. Surveys with students have collected data about substance use and related factors. The latter is associated with antisocial behavior and delinquency eating disorders, risk sexual behavior, and suicide attempt. Statistics on younger offenders show an increased number of subjects presented before law institutions, meaning that they have been prosecuted somehow (there were 2623 cases in 1999, and 3506 in 2003). At the same time, there is a decrease in the age for committing these faults which are becoming more serious; a larger number of homicides, raping, and carrying weapons have been reported. The objective of this paper is to present tendencies of antisocial behavior through data obtained from three different representative surveys in junior high school and high school students from Mexico City (1997, 2000, and 2003). Surveys were held by the Instituto Nacional de Psiquiatría Ramón de la Fuente and by the Secretaría de Educación Pública. Method. The analysis unit considered for this study was the student himself coming from state and private schools. Three levels were studied: junior high school, high school, and technical schools. Sample design was planned based on the evaluation of drug use tendencies in the students from this population, determining the level of contribution of each district in the city. Schools were randomly selected in each of the 16 districts. Sample design was stratified, two-staged, and in clusters. Stratification variable was the level of the school. First selection unit was the school, and second was the school group. Sample was self-weighted using the city district as the weigh variable. Three probabilistic samples were obtained, representing each one of the districts and education level: 1997 sample, N=10173; 2000 sample, N = 10578; 2003 sample, N=10659. Outcome rate in each measure was 97% in 1997, 95% in 2000, and 98% in 2003. Age mean in the three samples was 14.6 years old, and equivalence men-women was similar in the three studies. Questionnaire used has been validated before, and its basic indicators have maintained consistency through different researches. Socioeconomic and antisocial behavior data were used for this study. Two factors previously obtained were used. The first one was called Violence and Thieving Behaviors, this one includes picking things worth 50 pesos or less, taking things from a store without paying for them, damaging other people's property, punching or hurting someone, being involved in fights, and using firing objects. The second factor was called Serious Antisocial Behaviors, and it included: picking things worth 500 pesos ormore, breaking locks, attacking someone using an object or weapon, selling drugs, and using a knife or gun to rob someone. These factors have been already used and have shown good consistency. The survey operative design included a main coordinator, supervisors, and pollsters who were trained on conceptual issues about addiction, project background and objectives, instrument use, instructions for interviewing, and group selection. Emphasis was made on proper instructions for subjects, as well as remarks for anonymity and confidentiality in handling information. Inconsistent questionnaires were corrected or eliminated. Intelligent software was used for registering data, which verified that the answers were coherent. Results. There was a 2% increase in antisocial behaviors among students between 1997 and 2000; the most notorious raise was observed in behaviors from factor Violence and Thieving, which fluctuated between .57% and 1.8%. From 2000 to 2003 there was a raise of 6.7% for any antisocial behavior, and the increase was again more notorious in Violence and Thieving (6.5%). There were minor increases in the second factor, though these were important. For instance, picking things worth 500 pesos or more, and attacking someone had a bigger raise in 2000 and 2003, while breaking locks had its bigger raise between 1997 and 2000. No changes were observed for selling drugs and using a knife or gun to rob someone. There was a 2.47% increase for any antisocial behavior in men between 1997 and 2000, basically in the factor Violence and Thieving. From 2000 to 2003 this increase raised to 7.36%, observed again in the Violence and Thieving factor. In the case of women, there was only an increase in two behaviors between 1997 and 2000: picking things for 50 pesos or less and breaking locks. From 2000 to 2003 there was an important increase in behaviors pertaining to Violence and Thieving (5.71%), to be involved in fights had the highest increase. Between 2000 and 2003, women participated in more serious acts. The proportion of students behaving antisocially was calculated considering the districts. The district of Tlalpan had the only increase observed between 1997 and 2000. Significant raise was observed in almost every district (except for Cuajimalpa and Gustavo A. Madero) from 2000 to 2003. Venustiano Carranza, Benito Juarez, Iztacalco, and Alvaro Obregon had the biggest increase. Variations are the same for both factors. Discussion. This study allows to see the changes in antisocial behavior rates in Mexico City students from 1997 to 2003. Slight variations were found in some behaviors between 1997 and 2000, there were no modifications in others. However, there was an important raise from 2000 to 2003, which is bigger if compared to 1997. Increase in antisocial behavior is similar for men and women, although proportion is unequal yet; almost two men for every woman. When considering district as a control variable, Benito Juarez and Tlalpan show the higher prevalences on any antisocial behavior. This situation is similar for Violence and Thieving. In the case of Serious Antisocial Behaviors, Venustiano Carranza and Azcapotzalco had the higher prevalences. It is important to fully understand the reasons of adolescents for behaving antisocially. Apparently the conditions facilitating this type of behaviors are not only related to marginalization and social disadvantage, but to others, such as new interaction ways, which favor the search for exciting sensations and hiding from supervision. This includes involvement in risk behaviors, such as unsafe sexual intercourse, drug use, violence, and burgling. It is necessary to go deeper into these new forms of antisocial behavior and to work more in prevention as an attempt to counteract present tendencies of this issue.