The Policy Gap. Global Mental Health in a Semi-Peripheral Country (Portugal, 1998-2016) / O fosso de políticas. A saúde mental global em um país semi-periférico (Portugal, 1998-2016) / El foso de políticas. La salud mental en un país semi-periférico (Portugal, 1998-2016)

This paper analyzes the impact of the hegemonic paradigm of global mental health (GMH) on Portugal. We specifically argue that GMH in Portugal has effected a change of priorities in health policies, favoring the prevention and treatment of common mental disorders to the detriment of the deinstitutionalizing process. Diffused through the media, this model has negative effects, such as the medicalization of social suffering, the reorganization of mental health policy areas according to utilitarian criteria, and the risk of greater invisibility of users with serious psychiatric diagnoses. However, the GMH approach, bringing to the frontline the impact of all social policies on mental health, represents a new opportunity to politically address social suffering. Characterized as a semi-peripheral country, Portugal may be representative of observable trends in similar countries.

Este artigo analisa o impacto do paradigma hegemônico da saúde mental global (SMG) em Portugal. Argumenta-se que a SMG em Portugal promoveu uma mudança de prioridades nas políticas de saúde, favorecendo a prevenção e o tratamento das desordens mentais comuns em detrimento do processo de desinstitucionalização. Difundindo-se nos media, este modelo tem efeitos negativos, ao contribuir para a medicalização do sofrimento social, o escalonamento de áreas de intervenção de acordo com critérios utilitaristas e o risco de uma maior invisibilidade dos usuários com diagnósticos psiquiátricos graves. Contudo, o enfoque da SMG no impacto do conjunto das políticas sociais sobre a saúde mental representa uma nova oportunidade para encarar politicamente o sofrimento social. Caracterizado como país semiperiférico, Portugal pode ser representativo de tendências observáveis em países similares.

Este artículo analiza el impacto del paradigma hegemónico de la salud mental (SMG) en Portugal. Se argumenta que la SMG en Portugal promovió un cambio de prioridades en las políticas de salud, favoreciendo la prevención y el tratamiento de los desórdenes mentales comunes en perjuicio del proceso de desinstitucionalización. Al difundirse en los medios, este modelo tiene efectos negativos, puesto que contribuye para la medicalización del sufrimiento social, el escalonamiento de áreas de intervención de acuerdo con criterios utilitaristas y el riesgo de una mayor invisibilidad de los usuarios con diagnósticos psiquiátricos graves. Sin embargo, el enfoque de la SMG en el impacto de las políticas sociales sobre la salud mental representa una nueva oportunidad para enfrentar políticamente el sufrimiento social. Caracterizado como país semi-periférico, Portugal puede ser representativo de tendencias observables en países similares.

Epidemiología del TDAH en niños y adolescentes chilenos / Epidemiology of ADHD in children and adolescents of Chile

ADHD prevalence, associated factors, comorbidity and service use are reported for a sample of 1,558 children and adolescents, belonging to four provinces in Chile. The sample is weighted in each step for selection bias. Psychiatric disorders and impairment are assessed with computerized in-home DISC-IV interviews, and a questionnaire regarding socioeconomic and family variables and service use. Estimates of prevalence rates are obtained by means of STATA 11.0 software, with complex sample design. Multivariate logistic regression is used to determine which factors were the best predictors for mental disorders. Participation rate is 82.4 %. The prevalence of ADHD is 10 %, and the most prevalent subtype is the hyperactive/impulsive, with no gender differences. Both hyperactive/impulsive and combined subtypes are more prevalent in children 4-11 than in adolescents. The most prevalent comorbidities are anxiety disorders and oppositional disorder. Anxiety is the more prevalent comorbid disorder in girls and correlated with a combined subtype. Perception of good family functioning, adolescent age and school dropout have a negative association with ADHD diagnosis, while maltreatment shows a positive correlation. Over 50 % of children and adolescents diagnosed with ADHD have used services in the last year. This is the first comprehensive community study of psychiatric disorders in children and adolescents in a South American country. It yields information for child and adolescent mental health programmes in Chile and contributes to cross-cultural epidemiological research. Key words: Psychiatric epidemiology, ADHD prevalence, Cross-cultural epidemiology, Infant and child Psychiatry.

Se describe la prevalencia del TDAH, los factores asociados, la comorbilidad y el uso de servicios, en una muestra de 1.558 niños y adolescentes, pertenecientes a cuatro provincias de Chile. En cada etapa del diseño muestral, se efectúa un pesaje para manejar el sesgo de selección. La presencia de trastornos psiquiátricos y la discapacidad son evaluados en el hogar, a través de la entrevista computarizada DISC-IV y de un cuestionario sobre variables socioeconómicas y familiares, junto al uso de los servicios. Las estimaciones de las tasas de prevalencia son obtenidas, por medio de un software, STATA 11.0, con diseño de muestra complejo. Se utilizó la regresión logística multivariada, para determinar qué factores eran los mejores predictores para trastornos mentales. La tasa de participación es del 82.4%. La prevalencia del TDAH es del 10%, y el subtipo de mayor prevalencia, es el hiperactivo / impulsivo, sin diferencias de género. Ambos subtipos hiperactivo/ impulsivo y combinado, demuestran mayor prevalencia en niños de 4-11 años, que en adolescentes. Las comorbilidades más frecuentes, son los trastornos de ansiedad y el trastorno oposicionista. La ansiedad, es la comorbilidad más frecuente del trastorno en las niñas y se correlacionó con el subtipo combinado. La percepción de un buen funcionamiento familiar, la edad de los adolescentes y la deserción escolar disminuyen el riesgo de presentar TDAH, mientras que el antecedente de maltrato lo aumenta. Más del 50% de los niños y adolescentes que han sido diagnosticados con TDAH, han utilizado servicios en el último año. Este es el primer estudio amplio en la comunidad, en trastornos psiquiátricos en niños y adolescentes, en un país de América del Sur. Ofrece información para programas de Salud Mental en Niños y Adolescentes en Chile y contribuye a la investigación epidemiológica transcultural. Palabras clave: Epidemiología psiquiátrica, Prevalencia del TDAH, Epidemiología transcultural, Psiquiatría del Niño y el Adolescente.

De la epidemiología psiquiátrica a la psicología positiva. Historia de la trayectoria científica de María Martina Casullo / From a Psychiatric Epidemiology to a Positive Psychology. History of the Scientific Trajectory of María Martina Casullo

La presente investigación de carácter historiográfico examina un momento particular de la trayectoria científica de María Martina Casullo (19402008). En primer lugar, se revisan sus estudios sobre los factores de riesgo en adolescentes, realizados a partir del año 1985 desde una perspectiva epidemiológica-preventiva. En segundo lugar, se analiza cómo dichos estudios epidemiológicos sobre depresión, riesgo suicida y malestar psicológico en adolescentes fueron el puntapié inicial para el análisis de los procesos salugénicos o protectores que impedían que las personas enfermaran aún frente a situaciones ambientales adversas. Finalmente, se concluye que estas investigaciones constituyen el principal antecedente del campo, que posteriormente Casullo definiera como psicología salugénica o positiva, en la Argentina a finales del siglo XX. De esa manera, se cuestiona críticamente la tendencia naturalizada y whig que no se ha interesado en hallar las condiciones ideológicas y políticas de la emergencia de la psicología positiva.

The purpose of this historiographic paper is to carry out a critical analysis about one particular moment of the scientific trajectory of María Martina Casullo (1940-2008). In the first place, the article reviews her studies about the risk factors in adolescents from an epidemiologic-preventive approach since 1985. Secondly, the work points out how these epidemiologic studies concerning depression, suicidal risk and psychological unease were the kickoff for the analysis of the salutogenic or protective processes that prevent people to fall ill even when facing adverse environmental situations. Finally, this study concludes that these researches are the main record of the field that subsequently Casullo defined as salutogenic or positive psychology in Argentine at the end of 20th century. Thus, this paper critically analyzes the naturalized and whig tradition in psychology that has neglected the ideological and political conditions of the emergence of positive psychology.

Prevalence of mental disorders and recidivism in young offenders / Prevalência de transtornos mentais e reincidência em menores infratores

Several studies report that incarcerated young offenders show a high rate of psychiatric disorders whereas associations between specific psychiatric disorders and recidivism remain unknown. The Brazilian legal system has created a unique opportunity for the study of this issue when consider young offenders not that guilty in spite of the severity of the crime, settling in three years the maximum period of incarceration. This study aims to determine the rate of psychiatric disorders in a cohort of incarcerated young offenders and evaluate the possible psychiatric connections of primary offenders and recidivism. A group of 898 incarcerated young offenders at Fundação Casa answered psychiatric interviews and was diagnosed according to the criteria of ICD-10. Statistic connections were analyzed using the tests of Pearson and Cramer. The cohort was comprised of 619 primaries and 267 recidivists. 'Psychoactive Substance Use' and 'Disorders of Adult Personality and Behavior' categories were related to recidivism, whereas 'Organic Mental Disorders', 'Mood Disorders', and 'Stress-related Disorders' were related to primary offenders. Discriminating disorders were the most likely to represent reactions to primary incarceration. In relation to associations that might represent predictors of crime, it became highly suggestive that substance abuse is the main cause of incarceration for the entire cohort.

Diversos estudos revelam que jovens infratores encarcerados apresentam taxas aumentadas de transtornos psiquiátricos, ao passo que associações entre transtornos específicos e reincidência permaneçam desconhecidas. O sistema legal brasileiro criou uma oportunidade exclusiva para o estudo desta questão, conforme considera os menores não imputáveis, a despeito da severidade do crime, fixando em três anos o período máximo de encarceramento. Este estudo pretende determinar a taxa de transtornos psiquiátricos em uma coorte de jovens infratores encarcerados e avaliar possíveis conexões entre transtornos específicos encarceramento primário e reincidência criminosa. Um grupo de 898 internos da Fundação Casa foi submetido a entrevistas psiquiátricas e diagnosticado de acordo com os critérios do CID-10. Conexões estatísticas foram analisadas usando os testes de Pearson e Cramer. A coorte tinha 619 primários e 267 reincidentes. Uso de Substância Psicoativa e Desordens da Personalidade e Comportamento Adulto relacionaram-se com reincidência, ao passo que Doenças Mentais Orgânicas, Transtorno do Humor e Desordens Relacionadas ao Estresse apresentaram relação com encarceramento primário. No que tange aos preditores da criminalidade, reforça-se a noção de que o abuso de drogas é a principal causa de encarceramento na amostra investigada.

Evaluación de síntomas ansiosos y etnicidad en población escolar de la comuna de San Pedro de Atacama / Assessment of anxiety symptoms and ethnicity in students from the San Pedro de Atacama district

La comuna San Pedro de Atacama (SPA) tiene alta población rural y étnica, grupos vulnerables, según la literatura, a problemas de salud mental. El objetivo de este trabajo es conocer la prevalencia de síntomas ansiosos en escolares e investigar sus diferencias respecto de variables étnicas, de edad y género. Para ello se utilizó la escala de auto reporte de ansiedad para niños y adolescentes (AANA). La muestra quedó constituida por 416 alumnos, de ellos se analizaron 335 escalas, cuya media de edad fue de 10 años. Un 60,3 por ciento obtuvo sobre el punto de corte para sospecha de trastorno de ansiedad. El género femenino tenía mayor sintomatología ansiosa, junto con el grupo etario de 7 a 11 años. No existió diferencias significativas para la variable étnica. Respecto a las subescalas, la distribución etaria de la fobia social fue diferente a lo reportado en la literatura, lo que podría derivar del contexto sociocultural, necesario de investigaren futuros trabajos.

The San Pedro de Atacama (SPA) district has an important number of rural and ethnic population, which according to the literature, is more vulnerable to mental health problems. The aim of this research is to determine the prevalence of anxiety symptoms in school age children and to study its differences in relation to ethnicity, age and gender. The AANA (self report anxiety scale for children and adolescents) was applied in a sample of 416 students, from which 335 questionnaires were analyzed (mean age: 10 years). A 60.3 percent of the students were above the cut point for suspicion of an anxiety disorder. Females had a higher number of symptoms of anxiety, as did the group with ages 7 to 11 years. There were no statistically significant differences for ethnicity. In the subscales, the age distribution for social phobia was found to be different from the one previously reported; this could be explained by the sociocultural context, which remains to be studied in future research.

Lifetime Prevalence, age and gender distribution and age-of-onset of psychiatric disorders in the São Paulo Metropolitan Area, Brazil: results from the São Paulo Megacity Mental Health Survey / Prevalência em toda a vida, distribuição por idade e sexo e idade de início de transtornos psiquiátricos na área metropolitana de São Paulo, Brasil: resultados do Estudo Epidemiológico de Transtornos Mentais São Paulo Megacity

OBJECTIVES: To estimate prevalence, age-of-onset, gender distribution and identify correlates of lifetime psychiatric disorders in the São Paulo Metropolitan Area (SPMA). METHODS: The São Paulo Megacity Mental Health Survey assessed psychiatric disorders on a probabilistic sample of 5,037 adult residents in the SPMA, using the World Mental Health Survey Version of the Composite International Diagnostic Interview. Response rate was 81.3%. RESULTS: Lifetime prevalence for any disorder was 44.8%; estimated risk at age 75 was 57.7%; comorbidity was frequent. Major depression, specific phobias and alcohol abuse were the most prevalent across disorders; anxiety disorders were the most frequent class. Early age-of-onset for phobic and impulse-control disorders and later age-of-onset for mood disorders were observed. Women were more likely to have anxiety and mood disorders, whereas men, substance use disorders. Apart from conduct disorders, more frequent in men, there were no gender differences in impulse-control disorders. There was a consistent trend of higher prevalence in the youngest cohorts. Low education level was associated to substance use disorders. CONCLUSIONS: Psychiatric disorders are highly prevalent among the general adult population in the SPMA, with frequent comorbidity, early age-of-onset for most disorders, and younger cohorts presenting higher rates of morbidity. Such scenario calls for vigorous public health action.

OBJETIVOS: Estimar a prevalência, idade de início, distribuição por sexo e idade e identifica fatores correlacionados à morbidade psiquiátrica na Região Metropolitana de São Paulo (RMSP). MÉTODOS: O Estudo Epidemiológico de Transtornos Mentais São Paulo Megacity avaliou transtornos psiquiátricos em uma amostra probabilística composta por 5.037 adultos (18+) residentes na RMSP, utilizando o Composite International Diagnostic Interview, versão World Mental Health Survey. A taxa global de resposta foi de 81,3%. RESULTADOS: A prevalência de pelo menos um transtorno mental ao longo da vida foi de 44,8% e o risco estimado aos 75 anos de idade foi de 57,7%; comorbidade ocorreu com frequência. Depressão maior, fobias específicas e abuso de álcool foram os transtornos mais prevalentes; transtornos de ansiedade foi a classe de transtornos mais frequente. Fobias específicas e transtornos do controle de impulsos tiveram idade de início precoce, enquanto transtornos do humor tiveram início mais tardiamente. Mulheres apresentaram maior risco para transtornos do humor e de ansiedade, e homens para transtornos decorrentes do uso de álcool e drogas. Com exceção de transtornos da conduta, que foram mais frequentes em homens, não se observou diferenças de gênero na distribuição de transtornos do controle de impulso. Observou-se uma tendência consistente entre os diferentes transtornos de maiores taxas de morbidade nas coortes mais jovens. Baixa escolaridade mostrou-se associada a transtornos decorrentes do uso de álcool e drogas. CONCLUSÃO: Transtornos psiquiátricos na população geral adulta da RMSP são altamente prevalentes, com comorbidade frequente, idade de início precoce na maior parte dos transtornos avaliados, e taxas mais elevadas nas coortes mais jovens. Tal cenário suscita ações vigorosas de saúde pública.

Prevalence of the Major Mental Disorders among the Korean Elderly

With a rapidly aging society, geriatric mental health is emerging as important public health concern. Despite the short history of psychiatric epidemiology in Korea, recently, epidemiologic data regarding geriatric psychiatric problems has started to accumulate. In the current study, we reviewed epidemiological findings regarding geriatric mental health in Korea. It was found that up to 10% of the elderly suffer from dementia, and 10% to 20% from depressive disorder. Further, prevalence estimates of Alzheimer's disease ranged from 4.2% to 9.0%, and vascular dementia from 1.0% to 4.8%. Annual incidence rates for Alzheimer's were 2.7% to 3.4% whereas that for vascular dementia was found to be as low as 0.3%. The prevalence of major depressive disorder was 4.2% to 9.1%, while that of clinically significant depressive symptom was between 9.1% and 33.0%. Finally, those with alcohol use disorders were found to comprise up to 13.6% of elderly population and additionally, 22% to 58% of the elderly were found to have sleep difficulties. Thus major mental disorders are already prevalent among the Korean elderly and are likely to increase rapidly.

Prevalence of the Major Mental Disorders among the Korean Elderly

With a rapidly aging society, geriatric mental health is emerging as important public health concern. Despite the short history of psychiatric epidemiology in Korea, recently, epidemiologic data regarding geriatric psychiatric problems has started to accumulate. In the current study, we reviewed epidemiological findings regarding geriatric mental health in Korea. It was found that up to 10% of the elderly suffer from dementia, and 10% to 20% from depressive disorder. Further, prevalence estimates of Alzheimer's disease ranged from 4.2% to 9.0%, and vascular dementia from 1.0% to 4.8%. Annual incidence rates for Alzheimer's were 2.7% to 3.4% whereas that for vascular dementia was found to be as low as 0.3%. The prevalence of major depressive disorder was 4.2% to 9.1%, while that of clinically significant depressive symptom was between 9.1% and 33.0%. Finally, those with alcohol use disorders were found to comprise up to 13.6% of elderly population and additionally, 22% to 58% of the elderly were found to have sleep difficulties. Thus major mental disorders are already prevalent among the Korean elderly and are likely to increase rapidly.

São Paulo Megacity Mental Health Survey - a population-based epidemiological study of psychiatric morbidity in the São Paulo metropolitan area: aims, design and field implementation / São Paulo megacity - um estudo epidemiológico de base populacional avaliando a morbidade psiquiátrica na região metropolitana de São Paulo: objetivos, desenho e implementação do trabalho de campo

The São Paulo Megacity Mental Health Survey is a population-based cross-sectional survey of psychiatric morbidity, assessing a probabilistic sample of household residents in the São Paulo Metropolitan Area, aged 18 years and over. Respondents were selected from a stratified multistage clustered area probability sample of households, covering all 39 municipalities, without replacement. Respondents were assessed using the World Mental Health Survey version of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI), which was translated and adapted into the Brazilian-Portuguese language. Data was collected between May 2005 and April 2007 by trained lay interviewers. The World Mental Health Survey version of the Composite International Diagnostic Interview comprises clinical and non-clinical sections, arranged as Part I and Part II, producing diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition, and the International Classification of Diseases - 10th Revision. Mood, anxiety, impulse-control and substance use disorders, and suicide-related behavior, considered core disorders, as well as socio-demographic information, were assessed in all respondents. Non-clinical modules and non-core clinical sections (obsessive-compulsive disorder, post-traumatic stress disorder, gambling, eating disorders, neurasthenia, pre-menstrual disorders, psychotic symptoms and personality traits) were assessed in a sub-sample (2,942 respondents), composed by all respondents with at least one core disorder and a 25 percent random sample of those who were non-cases. A total of 5,037 individuals were interviewed, with a global response rate of 81.3 percent. Saliva samples were collected from 1,801 respondents, with DNA extracted stored pending further investigations.

O Estudo Epidemiológico dos Transtornos Mentais São Paulo Megacity é um estudo de corte transversal de base populacional avaliando a morbidade psiquiátrica em uma amostra probabilística da população geral residente na Região Metropolitana de São Paulo, com 18 anos ou mais. Respondentes foram selecionados através de um processo probabilístico multiestratificado de domicílios, cobrindo os 39 municípios, sem substituição. Respondentes foram avaliados usando a versão desenvolvida para o Estudo Mundial de Saúde Mental (World Mental Health Survey) do Composite International Diagnostic Interview da Organização Mundial da Saúde, que foi traduzido e adaptado para o Português vigente no Brasil. A coleta de dados ocorreu entre maio/2005 e abril/2007, por entrevistadores treinados. O WMH-CIDI é composto por seções clínicas e não-clínicas, dispostas em duas partes, gerando diagnósticos de acordo com o Manual Diagnóstico e Estatísticos de Doenças Mentais - Quarta Edição e a Classificação Internacional de Doenças - 10ª Revisão. Todos os respondentes receberam os módulos de avaliação de transtornos do humor, de ansiedade, do controle de impulsos, decorrentes do uso de substâncias psicoativas e comportamento suicida, considerados transtornos nucleares, assim como foram coletados dados sociodemográficos. Módulos não-clínicos e clínicos complementares (transtornos obsessivo-compulsivos, estresse pós-traumático, jogo patológico, alimentares, pré-menstruais, neurastenia, sintomas psicóticos e rastreio de personalidade) foram aplicados àqueles que tiveram pelo menos um dos transtornos nucleares e a uma amostra aleatória de 25 por cento dos negativos (2.942 respondentes). Um total de 5.037 indivíduos foi entrevistado, com uma taxa global de resposta de 81,3 por cento. Amostras de saliva foram coletadas de 1.801 respondentes, com extração de DNA e armazenamento para investigação futura.

Estudio epidemiológico de sucesos traumáticos, trastorno de estrés post-traumático y otros trastornos psiquiátricos en una muestra representativa de Chile / Epidemiology of trauma, PTSD and other psychiatric disorders in a representative population of Chile

In the last decade, our understanding of posttraumatic stress disorder (PTSD) has progressed from studies of war veterans and specific disaster victims to studies that examine the epidemiology of PTSD in the United States (USA) population. Epidemiologic data on PTSD in developing countries is an understudied area with the majority of studies were developed in the USA and other developed countries. Of the few epidemiological surveys undertaken in other countries, most of them have focused its interest on the prevalence rates of PTSD and its risk factors for following specific traumatic events. Besides increasing the international normative and descriptive data base on PTSD, an examination of prevalence rates and risk factors for PTSD in a socio-political and cultural context (that is markedly different to established market economies) can deepen our understanding of the phenomenology and determinants of PTSD. Although many psychiatric diagnoses can be related with previous traumatic experiences, PTSD has been identified as a disorder that requires a previous traumatic exposure for its diagnosis. A growing literature strongly suggests that early exposure to traumatic events disrupts crucial normal stages of childhood development and predisposes children to subsequent psychiatric sequelae. A series of epidemiological studies has demonstrated that childhood sexual abuse is associated with a range of psychiatric disorders in adulthood that includes mood, anxiety, and substance use disorders, even after adjusting for possible confounds, such as family factors and parental psychopathological disorders or other childhood adversities. There is little evidence of diagnostic specificity of childhood sexual abuse, although a consistent finding has been that alcohol and drug disorders are more strongly related to childhood sexual abuse than other psychiatric disorders. Other forms of childhood traumas have been less well studied. This article reviews the findings of an epidemiological study that took place in Chile and examined prevalence rates of PTSD, traumatic events most often associated with PTSD, comorbidity of PTSD with other lifetime psychiatric disorders, gender differences in PTSD as well as trauma exposure in a representative sample of Chileans. This article also reported a comparison of prevalence rates of various psychiatric disorders among persons who reported the first trauma during their childhood, those who reported the first trauma during their adulthood, and those with no trauma history. The study was based on a household-stratified sample of people defined by the health service system to be adults (aged 15 years and older). The study was designed to represent the population of Chile. This analysis is limited to three geographically distinct provinces, chosen as being representative of the distribution of much of the population. The interviews were administered to a representative sample of 2390 persons aged 15 to over 64 years. The measures used were the DSM-III-R PTSD and antisocial personality disorder modules from the Diagnostic Interview Schedule and modules for a range of DSM-III-R diagnoses from the Composite International Diagnostic. Traumatic events were categorized into one of 11 categories: military combat, rape, physical assault, seeing someone hurt or killed, disaster, threat, narrow escape, sudden injury/ accident, news of a sudden death or accident, other event (e.g. kidnapping, torture), or other experience. The translation into Spanish was conducted using the protocol outlined by the World Health Organization. The interviewers were all university students in their senior year studying social sciences. Taylor series linearization method was used to estimate the standard errors due to the sample design and the need for weighting. The analysis was conducted using procedures without replacement for non-respondents. The region, province, comuna, and district selected were used as the defined strata. Logistic regression with the corresponding 95% confidence interval was used to examine associations among PTSD, demographic risk factors, and trauma type. To examine whether the association between PTSD and gender could be explained by other risk factors, multivariate logistic regression analyses were also conducted. The first analysis found that the lifetime prevalence of PTSD was 4.4% (2.5% for men and 6.2% for women). Among the traumatic events, rape was most strongly associated with PTSD diagnosis. Among those exposed to traumas, women were significantly more likely to develop PTSD than men, after controlling for assaultive violence. The second analysis revealed that exposure to a lifetime trauma was associated with a higher probability of psychiatric morbidity in comparison with no trauma exposure. Traumas with childhood onset were significantly related to lifetime panic disorder, independent of number of lifetime traumas and demographic differences. This revealed that women had more probabilities than men of developing PTSD once they are exposed to trauma, independent of previous traumas, experiences of sexual assault, other violent experiences or level of education. Some authors have proposed that women have a higher vulnerability than men to develop PTSD and that there are sex differences in brain morphology, in the social interpretation of trauma, or/and in the peritraumatic dissociative experience. Although many theories have been proposed to explain this gender difference in PTSD, more research is needed to evaluate them empirically. This study highlights the importance of investigating the prevalence of PTSD, the patterns of comorbidity of PTSD, as well as gender differences of PTSD in non-English speaking countries. Although Chile has a different historical and socio-cultural context with respect to other countries in which the epidemiology of PTSD has been examined, in general, this study achieved similar results as those found in other studies. The results showed that PTSD is not an uncommon psychiatric illness, it is associated with a high degree of psychiatric comorbidity, it is more likely to predate other psychiatric disorders. Also, the results showed that men are more likely to be exposed to traumas than women, women are more likely than men to develop PTSD, and that PTSD is associated with relatively high treatment utilization. However, compared to another country in Latin America, such as Mexico, Chile has a lower prevalence of PTSD and trauma exposure, which may due to socio-economic factors, such as less inequity between the wealthy and the poor and less violence, crime, and poverty in Chile than Mexico. These studies also suggest that traumatic events that occur in childhood are related to specific disorders rather than those that occurred later in life. Individuals with childhood interpersonal trauma exposure are more likely to suffer from lifetime panic disorder, agoraphobia or PTSD compared to those who experience interpersonal trauma as an adult. However, research should examine the specificity of these disorders in relation to various types of childhood traumas. Limitations of the current study include the use of lay interviewers who, despite acceptable levels of reliability and validity, may be less accurate than clinicians as interviewers. Also the retrospective recall of lifetime disorders is likely to be less accurate than a more recent time frame. The sample used in this study does not show nation wide perspective, because the Southern portion of the country which includes much of the indigenous population was excluded. This study, like most epidemiological studies, did not use an-depth or validated index of trauma, which may have diluted findings. Since this study was cross-sectional, a direct cause-effect relationship cannot be assumed between trauma exposure and subsequent disorders.

Durante la década de 1990 en los Estados Unidos (EU), el conocimiento sobre el trastorno de estrés post-traumático (TEPT) evolucionó de estudios específicos en un principio, sobre veteranos de guerra y sobre víctimas de desastres, a estudios epidemiológicos más tarde, sin embargo, la epidemiología del TEPT en países en desarrollo ha sido un área poco estudiada hasta ahora. Los expertos en el área de trauma han propuesto que los sucesos traumáticos que ocurren en la niñez son más perjudiciales para la salud mental que aquellos que ocurren más tarde en la vida. Este trabajo revisa los resultados de un estudio epidemiológico llevado a cabo en Chile. Específicamente, se revisan los resultados sobre las tasas de prevalencia del TEPT, traumas asociados más frecuentemente con él, así como la comorbilidad de este trastorno con otros trastornos psiquiátricos a lo largo de la vida. Igualmente se analizaron las diferencias del TEPT en cada sexo, así como la exposición a traumas en una muestra representativa de chilenos. Además se comparó la prevalencia de trastornos psiquiátricos en personas que sufrieron su primer trauma durante la niñez, durante la edad adulta, o que no reportaron traumas durante su vida. En estos estudios epidemiológicos se usaron módulos del TEPT y trastorno de personalidad antisocial (TPA) de la entrevista diagnóstica siguiendo los criterios del DSM-III-R (DIS-III-R). Para evaluar el resto de los trastornos psiquiátricos se usó la Entrevista Diagnóstica Internacional Compuesta (CIDI). Estos instrumentos fueron administrados en tres ciudades chilenas a 2390 personas mayores de 15 años. Para estimar los errores estándares (EE) debido al diseño de la muestra y a la necesidad de ajuste se usó el método Taylor de linearización seriada. También se usó un análisis de regresión logística para examinar la relación entre el TEPT, los factores demográficos de riesgo y el tipo de trauma. Además se utilizó la regresión logística multivariada para evaluar si la relación entre el TEPT y el sexo pudiera ser explicada por medio de otros factores de riesgo, así como para calcular las tasas y la oportunidad relativa (razón de productos cruzados) de trastornos psiquiátricos a lo largo de la vida. El primer análisis arrojó que la prevalencia de TEPT a lo largo de la vida fue de 4.4% (2.5% para hombres y 6.2% para mujeres). De los hechos traumáticos reportados, la violación sexual tuvo una correlación más alta con el TEPT que los demás hechos traumáticos. Las mujeres tuvieron más probabilidades de experimentar TEPT que los hombres, después de controlar la variable asalto violento. El segundo análisis evidenció que los que habían sufrido traumas a lo largo de la vida tuvieron mayor probabilidad de tener un trastorno psiquiátrico en comparación con aquellos que no reportaron traumas. También se encontró que los que sufrieron su primer trauma durante la infancia tuvieron más probabilidad de desarrollar trastornos de pánico a lo largo de la vida que aquellos que sufrieron su primer trauma en la edad adulta, independientemente del número de traumas que sufrieron y de las diferencias demográficas. Aunque Chile tiene un contexto histórico-cultural y una economía diferente a otros países en los que se ha estudiado anteriormente la epidemiología del TEPT, el presente estudio reflejó tendencias similares a las reportadas en estudios previos. Los hallazgos expuestos enfatizan la importancia de investigar la prevalencia del TEPT, los patrones de comorbilidad del TEPT y las diferencias de sexo en la prevalencia del TEPT en diferentes países. También estos resultados sugieren que los sucesos traumáticos en la infancia (y no en la adultez) pueden estar relacionados con la ocurrencia de trastornos psiquiátricos específicos.

Model Development of School Mental Health Service: 1. A School-Based Study on the Emotional and Behavioral Problems of Elementary Students / 신경정신의학

As an initial step for promoting a mental health service for elementary school children, a school-based epidemiologic study on children's mental problems and their social background was conducted. The subjects were 3,021 students from 20 elementary schools in a rural community in Korea. The epidemiologic study consisted of two stages, initial screening using the Child Behavior Check List(CBCL) and a structured psychiatric evaluation. After the study, we received feedback from teachers and parents. The results were as follows: 1) Initially, 251(8.3%) students with total CBCL score higher than 54 were selected as problem children. Among the 251 students, only 31 had completed a structured psychiatric evaluation, and 71%(22 students) of them met the DSM-III-R citeria of psychiatric disorders. 2) Attention deficit hyperactivity disorder was the most common problem in both sexes, followed by oppositional defiant disorder in males and depression and anxiety disorder in females. Other students also had borderline intellectual functioning, learning disorders, somatoform disorder, sleep disorder and obsessive-compulsive disorder 3) The socio-environmental factors that were significantly related with mental health problems were poor economic status and little education in parents, no family religion, and children living with their maternal grandmother or with a single parent. Students who had mental problems also showed low levels of social competence. 4) The feedback from parents and teachers showed that the stigma of mental disorders, limitations of available time, and a poor understanding and lack of knowledge on the par of parents and teachers were the major obstacles in mental health service. Based on these results, the future direction of research and practice of school mental health was discussed.