Salud mental en estudiantes de educación superior en Chile: una revisión de alcance con meta-análisis / Mental Health of Higher Education Students in Chile: Scoping Review and Meta-Analysis

Resumen Realizamos una revisión de alcance sobre la prevalencia de síntomas psicológicos, factores asociados a la salud mental, barreras y facilitadores para la búsqueda de ayuda, y la efectividad de intervenciones de salud mental en estudiantes de educación superior en Chile. Buscamos reportes indexados hasta el 15 de octubre de 2019 en las bases de datos CINAHL, Google Scholar, PubMed, Virtual Health Library/BIREME y Web of Science. Evaluamos la calidad de los estudios de prevalencia y exploramos la prevalencia combinada de síntomas psicológicos mediante meta-análisis. Incluimos 32 estudios publicados, 20 sobre prevalencia de síntomas - 10 con la calidad suficiente para ser incluidos en el meta-análisis. Observamos una heterogeneidad sustantiva en la exploración de prevalencia combinada de síntomas, con rangos entre 22,9% a 40,7% para malestar psicológico, 16,5% a 38,8% para síntomas depresivos, 16,5% a 23,7% para síntomas ansiosos, 19,7% a 29,7% para consumo de cannabis en los últimos 12 meses, y 84,0% a 92,6% para consumo de alcohol en los últimos 12 meses. El sexo femenino se asoció consistentemente con problemas de salud mental. Es necesario realizar más estudios que evalúen el acceso a tratamiento, facilitadores y barreras para la búsqueda de ayuda, e intervenciones para mejorar la salud mental de la población objetivo.

Abstract We conducted a scoping review on the prevalence of psychological symptoms, factors associated with mental health, barriers and facilitators to help-seeking, and effectiveness of mental health interventions in higher education students in Chile. We searched for indexed reports up to October 15, 2019, in CINAHL, Google Scholar, PubMed, Virtual Health Library/BIREME, and Web of Science databases. We assessed the quality of prevalence studies and explored the pooled prevalence of psychological symptoms using meta-analyses. We included 32 published studies, 20 on the prevalence of psychological symptoms - 10 of sufficient quality to be included in meta-analyses. We observed substantial heterogeneity in the exploration of combined prevalence of psychological symptoms, with ranges from 22.9% to 40.7% for psychological distress, 16.5% to 38.8% for depressive symptoms, 16.5% to 23.7% for anxious symptoms, 19.7% to 29.7% for cannabis use in the past 12 months, and 84.0% to 92.6% for alcohol use in the past 12 months. Female sex was consistently associated with mental health problems. More studies evaluating access to treatment, help-seeking barriers and facilitators, and interventions to improve the mental health of the target population are needed.

Salud mental primaria para niños, niñas y adolescentes institucionalizados: perspectiva de equipos de salud / Primary mental health care for institutionalized children and adolescents: a health team perspective / Saúde mental primária para crianças e adolescentes institucionalizados: uma visão das equipes de saúde

Resumen (Analítico) La salud mental de los niños, niñas y adolescentes institucionalizados en hogares es un desafío clínico y ético para Chile y América Latina. Con el objetivo de explorar experiencias y desafíos percibidos por profesionales de la atención primaria de salud que atienden esta población, se realizó una investigación cualitativa, utilizando un cuestionario con preguntas abiertas. Los datos se analizaron mediante teoría fundamentada. Los resultados mostraron que la atención era parcializada y discontinua. La información sobre el desarrollo vital, la familia, los contextos de vulneración e institucionalización era insuficiente y fragmentada. Además, existía escasa coordinación entre las instituciones que intervienen simultáneamente con los niños, niñas y adolescentes. Se discuten las implicancias para la formación de equipos de salud mental de la atención primaria de salud y la implementación efectiva del trabajo intersectorial y multinivel.

Abstract (analytical) Mental health care for vulnerable and institutionalized children and adolescents is a clinical and ethical challenge in Chile and Latin America. This study explores experiences and challenges encountered when providing mental health care among primary health care professionals. Qualitative research was conducted using an open-ended questionnaire for interviewing professionals in a rural area of Chile. The data was analyzed using Grounded Theory. The results show a fragmented and discontinuous delivery of care as a large portion of the children's clinical and social history is unknown. There is lack of coordination with other institutions that intervene in this area. The authors discuss implications for primary health care training for children's mental health teams and the need for the implementation of effective integrated and multilevel care systems.

Resumo (Analítico) A saúde mental de crianças e adolescentes vulneráveis e institucionalizados é um desafio clínico e ético no Chile e na América Latina. O presente estudo explorou experiências e desafios do cuidado por profissionais da atenção primária à saúde que atendem esta população. A pesquisa qualitativa foi realizada utilizando um questionário de perguntas abertas para entrevistar profissionais da área rural do Chile. Os dados foram analisados usando a Grounded Theory. Os resultados mostraram um atendimento fragmentado e descontínuo. As informações sobre parte da história clínica e social das crianças, e os contextos de vulnerabilidade e institucionalização são insuficientes. Além disso, existia pouca coordenação entre as instituições que intervêm simultaneamente com os crianças e adolescentes. São discutidas implicações para o treinamento de equipes de saúde mental na atenção primária à saúde e para a implementação de sistemas efetivos de atendimento integrado e multinível.

Determinantes socioeconómicos y brechas de género de la sintomatología depresiva en Chile / Socioeconomic determinants and gender gaps in depressive symptoms in Chile

Background: There are marked differences associated with socio-economic factors in the prevalence of depressive symptoms (DS) in men and women. Aim: To estimate the association between socioeconomic status and DS in Chile and to estimate the gender gaps in this association. Material and Methods: The Patient Health Questionnaire-9 (PHQ-9) was applied as part of a socioeconomic survey carried out in a representative community sample (n = 2913). Using this information, we analyzed the influence of social status (education level, occupation, household income) and other psychosocial factors (gender, perceived social support, stressful life events) on DS. Results: The prevalence of DS was 23.2% in women and 13.4% in men. A socioeconomic gradient was found in the distribution of DS. This gradient was more pronounced for women than for men. Gender, social support and stressful life events were the most important predictors of severe DS, with an estimated risk twice as high among women and almost three times as high among those with low social support. Conclusions: There is a combined effect between socio-economic and gender inequalities on DS. This partially explains the greater vulnerability of poor women and the DS gap between men and women.

Validación inicial de Patient Health Questionnaire 2-Item para detectar síntomas depresivos en diabéticos y/o hipertensos en la atención primaria de salud

Background: Patient Health Questionnaire (PHQ-9) has nine questions and is used in diabetic or hypertensive patients to detect depressive symptoms. The PHQ-2 uses the first two questions of the PHQ-9 to rapidly detect those patients that should answer the whole questionnaire. Aim: To validate the PHQ-2 to detect depressive symptoms in diabetic or hypertensive patients consulting at Primary Health Care (PHC). Material and Methods: Secondary analysis of data obtained during the baseline assessment of a clinical trial. Diabetic and hypertensive patients aged 18 years or more, attending a public health care clinic of Metropolitan Santiago, were invited to participate. Those accepting, answered the Patient Health Questionnaire (PHQ-9), consisting in nine questions about depressive symptoms. Demographics and health data were also collected. The PHQ-2 capacity to discriminate PHQ-9 scores equal or higher than 10 and 15 and the correlation between both versions, were assessed. Results: Ninety-four participants aged 64 ± years (73% women) answered the questionnaire. A cut-off score of 3 or more points in the PHQ-2 achieved the best tradeoff between sensitivity and specificity for discriminating PHQ-9 scores equal or higher than 10 (area under the receiver operating characteristic curve (ROC) = 0.92, 95% confidence interval [95% CI] = 0.87 to 0.97) and 15 points (area under the ROC curve = 0.95, 95% CI = 0.92 to 0.99). Both versions had a high positive correlation (r = 0.87). Conclusions: The PHQ-2 allows a stepped, simple and accurate screening for depressive symptoms. Diabetic or hypertensive patients with 3 or more points should be immediately assessed with the remaining questions of the PHQ-9.

Implementing the protocol of a pilot randomized controlled trial for the recovery-oriented intervention to people with psychoses in two Latin American cities / Implementação de um protocolo para um estudo piloto randomizado e controlado sobre uma intervenção voltada para a recuperação em pessoas com psicoses em duas cidades latino-americanas / Implementando un protocolo para una prueba piloto controlada aleatorizada en una intervención orientada a la recuperación de personas con psicosis en dos ciudades latinoamericanas

Several Latin American countries have made remarkable strides towards offering community mental health care for people with psychoses. Nonetheless, mental health clinics generally have a very limited outreach in the community, tending to have weaker links to primary health care; rarely engaging patients in providing care; and usually not providing recovery-oriented services. This paper describes a pilot randomized controlled trial (RCT) of Critical Time Intervention-Task Shifting (CTI-TS) aimed at addressing such limitations. The pilot RCT was conducted in Santiago (Chile) and Rio de Janeiro (Brazil). We included 110 people with psychosis in the study, who were recruited at the time of entry into community mental health clinics. Trial participants were randomly divided into CTI-TS intervention and usual care. Those allocated to the intervention group received usual care and, in addition, CTI-TS services over a 9-month period. Primary outcomes include quality of life (WHO Quality of Life Scale - Brief Version) and unmet needs (Camberwell Assessment of Needs) at the 18-month follow-up. Primary outcomes at 18 months will be analyzed by Generalized Estimating Equations (GEE), with observations clustered within sites. We will use three-level multilevel models to examine time trends on the primary outcomes. Similar procedures will be used for analyzing secondary outcomes. Our hope is that this trial provides a foundation for planning a large-scale multi-site RCT to establish the efficacy of recovery-oriented interventions such as CTI-TS in Latin America.

Diversos países latino-americanos já alcançaram avanços notáveis na oferta de assistência em saúde mental para pessoas com psicoses. No entanto, as clínicas de saúde mental geralmente realizam atividades de extensão muito limitadas dentro das comunidades, tendem a ter vínculos fracos com a assistência primária, raramente envolvem os próprios pacientes nos cuidados e poucas vezes prestam serviços orientados para a recuperação. O artigo descreve um estudo piloto randomizado e controlado sobre a Critical Time Intervention-Task Shifting (CTI-TS), que teve como objetivo analisar essas limitações. O estudo piloto foi realizado em Santiago (Chile) e no Rio de Janeiro (Brasil). Teve como meta a inclusão de 110 pessoas com psicose, recrutadas no momento da entrada em clínicas comunitárias de saúde mental. Os participantes foram randomizados para o CTI-TS ou para os cuidados usuais. Aqueles alocados ao grupo da intervenção receberam os cuidados usuais e os serviços de CTI-TS ao longo de 9 meses. Os desfechos primários incluíram a qualidade de vida (WHO Quality of Life Scale - Brief Version) e as necessidades não atendidas (Camberwell Assessment of Needs) no acompanhamento aos 18 meses. Os desfechos primários aos 18 meses serão analisados com a técnica de Equações de Estimação Generalizadas (GEE), com as observações agrupadas dentro dos locais do estudo. Serão utilizados modelos em três níveis para examinar as tendências temporais nos desfechos primários. Procedimentos semelhantes serão utilizados para analisar os resultados secundários. Espera-se que o estudo forneça uma base para planejar um estudo randomizado e controlado em grande escala e em múltiplos locais para estabelecer a eficácia da intervenção orientada para a recuperação, a exemplo da CTI-TS, na América Latina.

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Depresión posparto: tamizaje, uso de servicios y barreras para su tratamiento en centros de atención primaria / Screening and barriers for treatment of postpartum depression in Chilean public primary health care centers

Background: Postpartum depression (PPD) is a public health issue, and appropriate screening may lead to clinical gains. Aim: To describe the screening for PPD, its relationship with the use of health care services, and treatment access barriers in Chilean public primary health care (PHC) centers. Material and Methods: Puerperal women attending PHC centers for a well-child check-up were assessed for the presence of PPD using the Edinburgh Postnatal Depression Scale and a structured psychiatric interview. PPD cases were assessed by telephone three months later. Also, women with PPD and PHC workers were interviewed to explore treatment barriers. Results: Of the 305 women assessed, 21% met diagnostic criteria for PPD. Sixty five percent of assessed women were previously screened for PPD while attending well-child check-ups. The results of the screening were communicated to 60% of them and 28% received some management indication. After three months of follow up, 70% of PPD cases continued to be depressed, and two thirds of them did not consult a health care provider and most of them rejected psychotherapy or medical treatment. Conclusions: Management of postpartum depression should be substantially improved in public PHC from screening to treatment.

Tamizaje de episodio depresivo en adolescentes: validación del instrumento PHQ-9 / Screening depressive episodes in adolescents: validation of the Patient Health Questionnaire-9 (PHQ-9)

Background: There is a paucity of validated instruments for screening depression in adolescent populations in Chile. Aim: To determine the diagnostic accuracy of the adolescent version of Patient Health Questionnaire-9 (PHQ-9). Material and Methods: The PHQ-9 was transculturally adapted and administered to adolescents aged 15 to 19 years residing in Santiago de Chile, who were then evaluated with a semi structured interview (Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version or K-SADS-PL) and the Beck Depression Inventory. Internal validity, concurrent validity, and discriminatory power of the PHQ-9 were analyzed. Results: We evaluated 245 adolescents aged 16.2 ± 1 years (71% females). Two hundred and ten presented with a depressive episode and 35 were healthy. The sensitivity and specificity of the scale were 86.2 and 82.9% for 11 points, with a positive likelihood ratio of 5.02. Conclusions: The PHQ-9 is sensitive and specific enough to be used as a screening tool in adolescents with suspected depression. At a 11-point cut-off score as proposed, the likelihood to find a positive result in a subject with depression is five times higher.

Propiedades psicométricas del inventario de depresión de Beck IA para la población chilena / Psychometric properties of a spanish version of the Beck depression inventory IA

Background: According to the Chilean National Health Survey (2009-2010), 17% of people aged 15 years or more have depressive symptoms. Thus, freely-available, easily-administered, and highly sensitive screening tests for depression are needed in clinical and research settings. Aim: To evaluate the psychometric properties of a Spanish version of the Beck Depression Inventory (BDI-IA) in adult Chilean population. Material and Methods: The inventory was applied to a sample of 1.105 adults aged between 18 to 73 years (94% women). Ninety nine participants were outpatients receiving treatment for affective disorders, 932 were parents and/or guardians of students enrolled in schools and 73 were university students (sample with no known depressive disorder). To perform data analysis, two groups from the random combination of both samples were generated. Results: The inventory showed an appropriate degree of internal consistency (Cronbach alpha = .92). An exploratory factor analysis suggested a one-factor solution. This solution was reinforced with a confirmatory factor analysis, which displayed an adequate goodness of fit. The cutoff score, based on the Youden Index, was 13/14 points. It was able to discriminate between depressed and non-depressed participants. Conclusions: These results indicate that the BDI-IA is an appropriate instrument to assess depressive symptoms in Chilean adults.

Comorbilidad en personas con depresión que consultan en centros de la atención primaria de salud en Santiago, Chile / Comorbidity in people with depression seeking help at primary health care centers in Santiago, Chile

Background: International evidence has shown the complex interaction between depression and chronic physical diseases. Depression in scenarios involving multiple comorbidities has not received enough attention in Chile. Aim: To characterize the depressed people who consult at Primary Health Care Centers (PHCCs), taking into account the presence of chronic physical or psychiatric comorbidity. Materials and Methods: A secondary analysis of databases used in a clinical trial. Two hundred fifty six adults seeking professional help were recruited in four PHCCs located in the Metropolitan Region. These people had a major depressive episode, identified with a structured psychiatric interview (MINI), and gave their informed consent to participate. Socio-demographic information was collected, depressive symptomatology was measured with the patient health questionnaire 9 (PHQ-9), psychiatric morbidity was assessed using the Mini International Neuropsychiatric Interview (MINI), and chronic physical diseases were self-reported by the patients. Descriptive analyses of all the variables were conducted. Results: Seventy percent of patients had a history of depression, with a median of two prior depressive episodes. Depressive symptoms were mostly considered as moderate to severe and severe and 31% of the patients had high suicide risk. Seventy eight percent displayed a physical or psychiatric comorbidity. Of these patients, 29% only had a chronic physical comorbidity, while 46% suffered from an additional psychiatric disorder. Conclusions: Depressed individuals who seek help at PHCCs constitute an especially complex population that must be treated taking into account multiple comorbidities.

Barriers to access to treatment for mothers with postpartum depression in primary health care centers: a predictive model / Barreiras de acesso a tratamento para mães com depressão pós-parto em centros de atenção primária: um modelo preditivo / Barreras de acceso a tratamiento de madres con depresión posparto en centros de atención primaria: un modelo predictivo

Objective to develop a predictive model to evaluate the factors that modify the access to treatment for Postpartum Depression (PPD). Methods prospective study with mothers who participated in the monitoring of child health in primary care centers. For the initial assessment and during 3 months, it was considered: sociodemographic data, gyneco-obstetric data, data on the services provided, depressive symptoms according to the Edinburgh Postpartum Depression Scale (EPDS) and quality of life according to the Short Form-36 Health Status Questionnaire (SF-36). The diagnosis of depression was made based on MINI. Mothers diagnosed with PPD in the initial evaluation, were followed-up. Results a statistical model was constructed to determine the factors that prevented access to treatment, which consisted of: item 2 of EPDS (OR 0.43, 95%CI: 0.20-0.93) and item 5 (OR 0.48, 95%CI: 0.21-1.09), and previous history of depression treatment (OR 0.26, 95%CI: 0.61-1.06). Area under the ROC curve for the model=0.79; p-value for the Hosmer-Lemershow=0.73. Conclusion it was elaborated a simple, well standardized and accurate profile, which advises that nurses should pay attention to those mothers diagnosed with PPD, presenting low/no anhedonia (item 2 of EPDS), scarce/no panic/fear (item 5 of EPDS), and no history of depression, as it is likely that these women do not initiate treatment.

Objetivo desenvolver um modelo preditivo para avaliar os fatores que modificam o acesso a tratamento para a DPP. Métodos estudo prospectivo com mães que participaram do acompanhamento da saúde da criança em centros de atenção primária. Na avaliação inicial e durante 3 meses, foram registrados: dados sociodemográficos, gineco-obstétricos, dados sobre o uso dos serviços, sintomas depressivos de acordo com a Escala de Depressão Pós-parto de Edimburgo (EPDS) e qualidade de vida de acordo com o Questionário de Saúde SF-36. O diagnóstico de depressão foi feito com o MINI. Foram acompanhadas as mães que tinham DPP na avaliação inicial. Resultados foi construído um modelo estatístico para determinar os fatores que impediram o acesso a tratamento, constituído por: item 2 da EPDS (OR 0,43, IC95%: 0,20-0,93) e 5 (OR 0,48, IC95%: 0,21-1,09), e história prévia de tratamento para depressão (OR 0,26, IC95%: 0,61-1,06). Área sob a curva ROC para o modelo=0,79; valor de p para o teste de Hosmer-Lemershow=0,73. Conclusão foi elaborado um perfil simples, bem padronizado e preciso, que recomenda que os/as enfermeiros/as estejam atentos/as àquelas mães com DPP que apresentem anedonia baixa/nula (item 2 da EPDS), pânico/medo escasso/nulo (item 5 da EPDS) e sem antecedentes de depressão, já que é provável que estas mulheres não entrem em tratamento.

Objetivo desarrollar un modelo predictivo para evaluar los factores que modifiquen el acceso a tratamiento para la DPP. Métodos estudio prospectivo de madres que asistieron a control de niño sano en centros de atención primaria. En evaluación basal y 3 meses, se registraron: datos sociodemográficos, gineco-obstétricos, variables de uso de servicios, síntomas depresivos con la Escala de Depresión Posparto de Edimburgo (EPDS) y calidad de vida con el Cuestionario de Salud SF-36. El diagnóstico de depresión se hizo con el MINI. Se siguió a madres que en evaluación basal tenían DPP. Resultados se construyó un modelo estadístico para determinar los factores que impidieron el acceso a tratamiento, compuesto por: ítems del EPDS 2 (OR 0,43, IC95%: 0,20-0,93) y 5 (OR 0,48, IC95%: 0,21-1,09), e historia previa de tratamiento de depresión (OR 0,26, IC95%: 0,61-1,06). Área bajo la curva ROC para el modelo=0,79; valor de p para la prueba de Hosmer-Lemershow=0,73. Conclusión se elaboró un perfil simple, bien calibrado y discriminante, que sugiere que los/las enfermeros/as estén atentos/as a aquellas madres con DPP que presenten baja/nula anhedonia (ítem 2 EPDS), escaso/nulo pánico/miedo (ítem 5 EPDS), y sin antecedentes de depresión, ya que es probable que estas mujeres no ingresen a tratamiento.

Análisis etnográfico en salas de espera de centros de salud primaria: implicancias para la detección y tratamiento de la depresión posparto / Ethnographic analysis at general practice waiting rooms: implications for postpartum depression detection and treatment

Chile cuenta con tamizaje y acceso universal para el tratamiento de la depresión posparto, no obstante, ésta es una patología sub-detectada y sub-tratada. Con el objetivo de describir y analizar las barreras de acceso para la detección y tratamiento de la depresión posparto implicadas en la producción de cuidados materno-infantiles en las salas de espera de consultorios, se llevó a cabo un estudio etnográfico en seis centros de salud primaria Santiago de Chile. La maternidad, como objeto de discursos y prácticas reproducidos en los espacios comunes del consultorio, se constituye en una condición conflictiva para las puérperas, implicando una sobrecarga diferencial de trabajo doméstico y de cuidados, exigiendo su movilización entre instancias formales e informales del cuidado de la salud. Se problematiza en torno al grado de integración entre trabajo remunerado y el cuidado de la salud en las mujeres.

In Chile, universal screening and treatment for postpartum depression has been implemented at a national level, however it remains under-detected and under-treated. To describe and analyze barriers to postpartum depression detection and treatment implied in maternal-infant health care production at general practice waiting rooms, an ethnographic study was carried out at six primary care clinics belonging to the Metropolitan Area of Santiago, Chile. Discourses and practices on maternity enacted at waiting room, reveals a conflicting condition for postpartum women, implying a differential overburden with domestic work and care tasks, demanding constant mobilization between formal and informal health care sources. The grade of integration between remunerated work and women's self-care is debated.

Intervención grupal para reducir la sintomatología depresiva y promover la sensibilidad materna en embarazadas chilenas / Group intervention for reducing depressive symptoms and promoting maternal sensitivity in pregnant Chilean women

La sintomatología depresiva es frecuente en el embarazo y repercute en el posparto y en el vínculo madre-bebé. Se reportan los resultados de una intervención grupal de 5 sesiones para reducir la sintomatología depresiva y promover una adecuada sensibilidad materna. Participaron 134 embarazadas con antecedentes de depresión (grupo experimental = 88 y grupo control = 46). Se evaluó sintomatología depresiva (Inventario para la Depresión de Beck), resolución de problemas sociales (Inventario de Resolución de Problemas Sociales Abreviado), sensibilidad materna, cooperatividad infantil y riesgo vincular (Índice Experimental de Relación Niño-Adulto) en ambos grupos. Se observó una reducción significativa de la sintomatología depresiva, así como un incremento de las habilidades para la resolución de problemas sociales en el grupo intervenido. Este grupo muestra también puntajes significativamente mayores en sensibilidad materna y cooperatividad infantil, así como menores frecuencias de riesgo vincular en la evaluación postintervención. Se discute la relevancia de desarrollar estrategias de intervención durante el embarazo, considerando su impacto en la sensibilidad materna, en la calidad de las interacciones madre-bebé y en las habilidades de las madres para resolver problemas.

Depressive symptoms are frequently observed during pregnancy, and these affect the mother and her relationship with her baby during the post-partum period. Results are reported on a 5-session group intervention for reducing depressive symptoms and promoting maternal sensitivity. The participants included 134 pregnant women with a history of depression (experimental group = 46 and control group = 88). Depressive symptoms (Beck Depression Inventory), social problem-solving strategies (Social Problem-Solving Inventory-Revised), maternal sensitivity, infant cooperativeness and bonding risk (Child-Adult Relatinoship Experimental Index) were assessed in both groups. The group intervened showed a significant reduction of depressive symptoms and an improvement of social problem-solving strategies. This group also shows significantly higher scores in maternal sensitivity, and infant cooperativeness, as well as lower frequencies of bonding risk in the post-intervention assessment. The importance of considering intervention strategies during pregnancy, including its impact on maternal sensitivity, the quality of mother-baby interactions and the problem-solving abilities of the mothers, is discussed.

Barreras de acceso a tratamiento de la depresión posparto en Centros de Atención Primaria de la Región Metropolitana: un estudio cualitativo / Barriers restricting postpartum depression treatment in Chile

Background: In Chile, postpartum depression is a prevalent and disabling condition. Universal screening is available but has not been translated into better treatment rates, suggesting the existence of access barriers. Aim: To describe access barriers to postpartum depression treatment in six primary health care clinics in Metropolitan Santiago, Chile. Material and Methods: Twenty women with postpartum depression and 18 primary health care professionals were subjected to a semi-structured interview. A qualitative methodology based on Grounded Theory was used. Results: There are user associated barriers such as lack of knowledge about the disease, a negative conceptualization and rejection of available treatment options. There are also barriers associated with poor network support and some features of the health care system such as long waiting times and lack of coordination between clinical and administrative decisions. Conclusions: Patient and provider related barriers restricting treatment of postpartum depression were identified.

Programa colaborativo a distancia para el tratamiento de la enfermedad depresiva / Assessment of a distant collaborative program for the treatment of depression in primary care

Background: In the treatment of depression, primary care teams play an important role, whose effectiveness improves when inserted into a collaborative model of disease management. Aim: To report the results of a clinical trial carried out to test the effectiveness of a collaborative program between primary health teams and specialists supported by an electronic platform. Material and Methods: Physicians from four community hospitals belonging to the Reloncavi Health Service network, recruited 81 patients with depression aged 37 to 43 years, 84% of whom were female. Participants were divided in an active group, which participated in the collaborative program and a control group, which received the usual care, according to the Ministry of Health’s Guidelines for Depression. The main outcome was the Beck Depression Inventory (BDI-I) score at three months of intervention. Results: Participants had an average of 29.6 points (95% CI: 27.6-31.6) in the BDI-I and 38% of them had a high suicide risk. There were no statistically significant baseline differences between active and control group. In the intervention group, the BDI-I score changed from 30.0 (95% CI 27.0 to 32.8) to 15.3 (95% CI 11.8 to 18.8). In the control group the score changed from 29.2 (95% CI: 26.4-31.9) points to 20.8 (95% CI 16.8 to 24.7). The decrease was significantly higher in the intervention groups. Conclusions: A program of this kind may be useful to assist primary care teams in remote areas of the country to improve treatment outcomes for depression.

Prevención, detección, tratamiento o seguimiento en salud mental de adolescentes a través del uso de Internet: una revisión sistemática cualitativa / Use of Internet for mental health programs aimed at adolescents

Background: The widespread use of INTERNET by adolescents, renders it a simple and accessible means for health care campaigns Aim: To perform a systematic review of ISI publications about INTERNET use for adolescent mental health prevention, detection, treatment or follow up. Material and Methods: Systematic reviews, meta analyses and controlled clinical trials in all languages were searched. Manuscripts without an abstract or only publishing the study design were excluded. All selected articles were critically read. Results: One hundred and five papers were found and 61 were excluded because they did not address the research question. Of the resting 44, only six complied with the search criteria among then, 3 articles correspond to systematic reviews addressing early intervention programs and mental hearth treatment based on Internet; the other 3 articles correspond to controlled clinical trials addressing treatment interventions of anxiety and depression and 1 address on depression prevention program. Conclusions: INTERNET facilitates the application of mental health promotion, prevention and intervention among adolescents. However the resource is still underused.

Intervenciones psicológicas perinatales en depresión materna y vínculo madre-bebé: una revisión sistemática / Psychological perinatal interventions in maternal depression and mother-child bond: a systematic review

La depresión perinatal constituye un trastorno de alta prevalencia con repercusiones negativas en la madre y en el bebé. A partir de estos antecedentes se revisa la literatura existente sobre intervenciones psicológicas focalizadas en reducir la depresión y/o favorecer un vínculo madre-infante positivo desde el embarazo hasta los dos años del niño/a. Se consideran 27 estudios publicados entre los años 1996 y 2012, que incluyen grupos experimental y control. Los resultados muestran que un mayor número de intervenciones se focalizan en la depresión perinatal como variable, distinguiendo entre intervenciones en el embarazo y postparto. Un menor número de estudios se dirige a la calidad del vínculo madre-infante y a ambas variables. Las intervenciones reportadas como exitosas, incluyen intervenciones grupales e individuales dirigidas a favorecer la sensibilidad materna y técnicas corporales.

Perinatal depression constitutes a high prevalence disorder, with negative repercussions in the mother and the baby. From these precedents, this article reviews different psychological interventions developed to reduce depression and/or to promote a mother-infant bond-quality, from pregnancy to children's second year of life. There are considered 27 studies published between 1996 and 2012, with inclusion of experimental and control groups. Results show that most of the interventions are focused in perinatal depression as a variable, differentiating between interventions during pregnancy and at postpartum. A minor number of studies focused on the mother-baby bond quality and to modify both variables in a simultaneous way. Interventions that were reported to be successful considered group and individual interventions focused on promoting maternal sensitivity and corporal techniques.

Lessons from scaling up a depression treatment program in primary care in Chile / Enseñanzas derivadas de la ampliación de un programa para el tratamiento de la depresión en atención primaria en Chile

In Chile, the National Depression Detection and Treatment Program (Programa Nacional deDiagnóstico y Tratamiento de la Depresión, PNDTD) in primary care is a rare example ofan evidence-based mental health program that was scaled up to the national level in a low- ormiddle-income country. This retrospective qualitative study aimed to better understand howpolicymakers made the decision to scale up mental health services to the national level, andto explore the elements, contexts, and processes that facilitated the decision to implementand sustain PNDTD. In-depth semistructured interviews with six key informants selectedthrough intentional sampling were conducted in August–December 2008. Interviewees weresenior officers at the Ministry of Health who were directly involved in the decision to scale upthe program.Results yielded four elements pivotal to the decisionmaking process: scientific evidence,teamwork and leadership, strategic alliances, and program institutionalization. Each elementcontributed to building consensus, securing funding, attracting resources, and gaining lastingsupport from policymakers. Additionally, a review of available documentation led the authorsto consider sociopolitical context and use of the media to be important factors.While research evidence for the effectiveness of mental health services in the primary caresetting continues to accumulate, low- and middle-income countries should get started on thelengthy process of scaling up by incorporating the elements that led to decisionmaking andimplementation of the PNDTD in Chile.

En Chile, el Programa Nacional de Diagnóstico y Tratamiento de la Depresión(PNDTD) en atención primaria constituye un raro ejemplo de programa de saludmental basado en la evidencia ampliado al nivel nacional en un país de ingresos medioso bajos. Con este estudio retrospectivo cualitativo se buscó conocer más a fondola forma en que los responsables de las políticas tomaron la decisión de ampliar losservicios de salud mental al nivel nacional e investigar los elementos, contextos y procesosque facilitaron la decisión de implementar y mantener el PNDTD. Entre agostoy diciembre de 2008, seis informantes clave seleccionados mediante muestreo intencionalllevaron a cabo entrevistas en profundidad semiestructuradas. Los entrevistadoseran funcionarios de alto nivel del Ministerio de Salud directamente involucradosen la decisión de ampliar el programa.Los resultados arrojaron cuatro elementos fundamentales para el proceso de tomade decisiones: las pruebas científicas, el trabajo en equipo y el liderazgo, las alianzasestratégicas y la institucionalización del programa. Los cuatro elementos contribuyerona la creación de consensos, la obtención de financiamiento, la captación derecursos y la obtención de un apoyo duradero por parte de los responsables de laspolíticas. Además, la revisión de la documentación disponible llevó a los autores aconsiderar al contexto sociopolítico y el uso de los medios factores importantes.Mientras se siguen acumulando datos de investigación sobre la eficacia de losservicios de salud mental en la atención primaria, los países con ingresos medios ybajos deben comenzar el largo proceso de ampliación incorporando los elementos quecondujeron a la toma de decisiones y la implementación del PNDTD en Chile.

Ideas autolíticas, violencia autoinfligida, y síntomas depresivos en escolares chilenos / Suicidal ideation, self-directed violence and depression among Chilean school adolescents

Background: Suicidal behaviors and depression are prevalent phenomena among adolescents, and are considered a public health problem. Aim: To determine the prevalence of depressive symptoms and suicidal behaviors and the relationship between both phenomena, in a representative sample of students from ninth grade in Santiago, Chile. Material and Methods: We recruited a probability sample of 2,597 adolescents who answered a questionnaire with questions about suicidal behavior and the Beck Depression Inventory (BDI-II). Results: The lifetime prevalence of suicidal ideation and planning was 21 and 14%, respectively. The prevalence for the past two weeks was 6.7 and 4.4% for suicidal ideation and planning, respectively. Autolytic behaviors, once in lifetime and in the past week were referred by 26 and 4% of respondents, respectively. In one third of these, self-harm coincided with recent suicide ideation or planning. All levels of suicidal behavior were more frequently reported by women. Clinically significant depressive symptoms were present in 23.5% of adolescents. Females doubled male rates. Severe depressive symptoms were present in 9.4% of the sample. A higher level of suicidal behavior correlated with more severe forms of depression. Sixty percent of adolescents who reported recent self-harm, had clinically relevant depressive symptoms. Two thirds of them had severe symptoms. Conclusions: Suicidal behavior in Chilean adolescents is prevalent, and there is an association between this behavior and the level of depression. The school is a good place to identify and develop preventive measures for teenagers.

Telepsiquiatría: una revisión sistemática cualitativa / Feasibility of implementing tele-psychiatry in Chile

Background: The objective of this review was to search the literature on the use of telemedicine in mental health and evaluate if it can play a role in Chile. A systematic, qualitative review was carried out to compile systematic reviews, meta-analysis, and clinical controlled trials (CCT) that were in English or Spanish and that applied information technologies for the treatment of psychiatric diseases. Excluded from the review were articles without summaries or articles that included only the trial design, without results. The references of each selected article were critically evaluated. Of the 265 articles found, 224 were excluded for failing to comply with the inclusion criteria. Therefore, 41 articles were left for analysis, 30 reporting CCT and 11 systematic reviews. It is concluded that the use of information technologies to provide mental health care is widespread. It can be implemented in geographically remote places, without access to specialized mental health care and be a part of complex interventions that integrate several components.

Uso de programas de terapia cognitivo conductual computarizada para la prevención y tratamiento de depresión en adolescentes / Use of computerized cognitive behavioral therapy programs for the prevention and treatment of depression in adolescents

La terapia cognitivo conductual computarizada (TCC-c) ha demostrado ser efectiva en depresión en adultos. En adolescentes la investigación en esta área es aún limitada. El objetivo de este trabajo es revisar la literatura sobre el uso de programas de TCC-c para la prevención y tratamiento de depresión en adolescentes. Se realizó una búsqueda en las bases de datos PubMed, LILACS y SciELO. Diez estudios que corresponden a seis diferentes programas fueron analizados. Los programas varían en extensión y grado de contacto con los profesionales. En general, los estudios reportaron buena aceptabilidad y reducción de la sintomatología depresiva. Sin embargo, en su mayoría hubo una alta tasa de abandono. La evidencia preliminar sugiere que la TCC-c es una alternativa útil en la prevención y tratamiento de la depresión en adolescentes. Faltan estudios que apunten a mejorar la adherencia y eficacia de programas con TCC-c.

Computerized cognitive behavioral therapy (cCBT) is a demonstrated effective therapy for depression in the adult population. In the adolescent population, however, little research has been done. The objective of this study is to review the literature about the use of cCBT programs to prevent and treat depression in adolescents. A search was done in the databases PubMed, LILACS, and SciELO. In the end, ten studies, corresponding to six different programs, were analyzed. The programs varied in length and degree of contact with professionals. In general, the studies reported good acceptance and reduced depressive symptomatology; however, the majority of the studies had a high rate of dropouts. Preliminary evidence suggests that cCBT is a useful alternative in the prevention and treatment of depression in adolescents, but additional studies must be done to show improved cCBT program adherence and efficacy.