Promoting healthy lives and well-being for all: The contribution of the International College of Person-Centered Medicine (ICPCM).

This article defines the scope of Person-Centered Medicine, traces its roots in ancient conceptions, explains the reasons for the revival of this perspective in our times, and highlights the contribution of the International College of Person-Centered Medicine (ICPCM) in the promotion of the personcentered perspective in health and disease. The value of communication is underlined with reference to both diagnosis and treatment. The concept of Health is considered historically and the inclusiveness, holistic vista and positive health orientation of the WHO definition of Health (1948) is underlined. It is emphasized that Mental Health Promotion is differentiated conceptually from Disease Prevention in that promotion deals with health and prevention deals with illness, the relationship of Health Promotion with Salutogenesis (Antonovsky 1996) is noted and it is pointed out that among the targets of health promotion, preservation of peace is also included (WHO, 2004). In line with this, the ICPCM has supported and co-signed the Athens Anti-War Declaration (2016). Evaluating the impact of Health Promotion efforts is a necessary but difficult task as it requires targeted research and there are many inherent confounding factors. The social or environmental contexts of health behaviors should be taken into account as well as the subjective indicators of health. In an attempt to resolve the difficulties arising from this issue, the ICPCM has developed a prototype "Person-centered Care Index" (Kirisci et al 2016). With reference to Education it is pointed out that it is necessary for the educators to speak with the students rather than speak to them. Concerning research, the ICPCM in its 2013 Geneva Declaration has identified the main research areas in the person-centered field. The importance of assuring healthy lives and well-being for ALL is underlined and the difficulties associated with the achievement of this goal are noted. Lastly, the need to apply the principles of Person-centered Medicine to victims of natural, human-made and economic disasters (Christodoulou et al 2016) is underlined, especially in view of the frequent occurrence of these disasters in our times. In conclusion, the contribution of the ICPCM during the ten years of its existence, with reference to the sensitization of health professionals in the Person-centered approach is noted. This contribution has been carried out in line with the principles of the ICPCM and with its Geneva Declarations.

Person-centred medicine and mental health.

This paper discusses an integrated approach to person-centred medicine and its role in the future of mental health care. The origins and current status of this emerging field are revised with special attention to the contributions made from psychiatry and to the implications for psychiatric diagnosis and evaluation of the three pillars of the Person-centred Integrative Diagnosis (PID) model: its conceptual domains (health status, experiences and contributors to ill and good health), the related evaluative procedures, the partnerships needed and the existing links and differences with people-centred care and personalised medicine. In spite of their striking complementarities person-centred medicine and personalised medicine do not yet have substantial bridges built between them. Knowledge transfer and coordination should be established between these two models which will cast medical evaluation and care in the upcoming future.

Mental health promotion: guidance and strategies.

Public mental health incorporates a number of strategies from mental well-being promotion to primary prevention and other forms of prevention. There is considerable evidence in the literature to suggest that early interventions and public education can work well for reducing psychiatric morbidity and resulting burden of disease. Educational strategies need to focus on individual, societal and environmental aspects. Targeted interventions at individuals will also need to focus on the whole population. A nested approach with the individual at the heart of it surrounded by family surrounded by society at large is the most suitable way to approach this. This Guidance should be read along with the European Psychiatric Association (EPA) Guidance on Prevention. Those at risk of developing psychiatric disorders also require adequate interventions as well as those who may have already developed illness. However, on the model of triage, mental health and well-being promotion need to be prioritized to ensure that, with the limited resources available, these activities do not get forgotten. One possibility is to have separate programmes for addressing concerns of a particular population group, another that is relevant for the broader general population. Mental health promotion as a concept is important and this will allow prevention of some psychiatric disorders and, by improving coping strategies, is likely to reduce the burden and stress induced by mental illness.

[A validation study of the Personal Health Scale in Argentina and Venezuela]. / Estudio de Validación de la Escalade Salud Personal en Argentina y Venezuela.

INTRODUCTION: International reports have shown that the majority of patients with a psychiatric disorder are most often seen in non-psychiatric services and are not effectively diagnosed. The objectives of this study, conducted in Argentina and Venezuela, was to validate the Personal Health Scale (PHS), a 10-item instrument developed for the detection of possible cases of mental disorders. METHOD: A total of 227 subjects were recruited in both countries. The PHS's ease of use and the time required for completion was rated. Its internal structure (calculating the Cronbach's alpha) and factorial structures was analyzed. Mean total scores of psychiatric patients (n=127) and control subjects without psychiatric illness (n=100) were compared to determine its discriminant validity. RESULTS: Mean time for completion was less than 3 minutes and the majority of subjects judged it as easy to use. The Cronbach's alpha was 0.77 in both countries and the factorial analysis (extraction limited to one factor)showed that 8 (Venezuela) or 9 (Argentina) of the 10 items were represented in that factor; the variance explained by that factor was of 34%. A significant statistical difference (p<0.05) was found for the mean total scores between the psychiatric patients and controls. The best cut-off score to discriminate between groups was 6/7. CONCLUSIONS: The results suggest that the PHS is efficient, easy to use, has a high internal consistency, adequate factorial structure and ability to discriminate between samples of psychiatric patients and controls.We propose its use in primary care settings, clinical and epidemiological in Latin American countries.

A bibliometric study of the use of the classification and diagnostic systems in psychiatry over the last 25 years.

BACKGROUND: Our purpose was to examine the use of classification and diagnostic systems in the field of psychiatry (CDSP) from a bibliometric perspective, over the period 1980-2005. METHODS: We selected (in EMBASE and MEDLINE databases) documents that contained, in any of their sections, the descriptors 'psychiatr*', 'DSM*', 'ICD*', or 'diagnostic criteria',as well as other more specific descriptors. As a bibliometric indicator of production we applied Price's law. We also calculated the national participation index (PI) and correlated it with overall PI in biomedical and health sciences, and with PI in the discipline of psychiatry. RESULTS: We obtained 20,564 original documents; 15,743 referred to the Diagnostic and Statistical Manual of Mental Disorders (DSM) and 3,106 to the International Classification of Diseases (ICD). Our results indicate non-fulfilment of Price's law, since scientific production on CDSP does not undergo exponential growth (correlation coefficient r = 0.9651, vs. r = 0.9927 after linear adjustment). Of the 10 journals with the highest impact factor in the field of psychiatry, the Journal of Clinical Psychiatry has the highest PI in the DSM subgroup (PI = 14.77), and the British Journal of Psychiatry in the ICD subgroup (PI = 1.54). The principal producer country is the United States (PI = 37.9), though in proportion to its production in the psychiatric field the ranking is headed by Finland. Only 10 countries, of the 20 major producers in health sciences, surpass their own PI in the field of psychiatry (Brazil, Italy, Japan, Austria, Spain, Germany, France, India, Switzerland, and China). CONCLUSIONS: Over recent years, the use of CDSP (basically the DSM or ICD) in the scientific literature has increased. Nevertheless, the abstracts to these studies, included in the principal databases, should always specify the diagnostic criteria employed, with a view to increasing information levels and reliability for the reader.

The multicultural quality of life index in Argentina: a validation study.

INTRODUCTION: Evaluation of innovative instruments is important prior to its use in different settings; particularly, when they involve the assessment of concepts like quality of life (QOL). OBJECTIVE: To evaluate the internal structure (IS), factorial structure (FE), discriminant validity (DV), and time required for completion and ease of use of the Multicultural Quality of Life (MQLI) in Argentina. METHOD: The sample included 100 subjects divided into two groups with presumed different levels of QOL. The Cronbach's alpha was calculated for the IC and the FE was analyzed in the total sample. The DV was studied comparing statistically the average score in a group of psychiatric patients (presumed <> QOL, n=50) with a group of heath professionals and students (presumed <> QOL, n=50). Data on the time and ease of use was compiled. RESULTS: A high Cronbach's alpha (0.88) was documented. The factorial analysis showed two feasible solutions, one extracting one component with an explained variance of 46.7 %, and another one with two components, increasing the explained variance to 57.2 %. A significant difference between mean total scores was found for the groups with different levels of QOL. The time to complete the MQLI was less than 5 minutes and was reported by the majority of subjects (84 %) and the interviewers (90 %) as of easy application. CONCLUSIONS: The results showed that the MQLI has a high internal consistency, adequate factorial structure, and is capable of discriminating groups with different QOL levels; it is concise, and easy to use.

Culture in DSM-IV, ICD-10, and evolving diagnostic systems.

The past decade has shown interesting attempts to articulate the cultural framework of psychiatric diagnosis. Most distinctive in this regard has been the culture presence in DSM-IV. Less substantial concerning culture has been the core ICD-10. Of high cultural interest are the national and international adaptations of ICD-10 because of their aim at articulating universality with local realities and needs. The WPA International Guidelines for Diagnostic Assessment exhibits an innovative diagnostic system that combines standardized multiaxial and personalized idiographic formulations with pointed attention to culture considerations. Finally, this article outlines some culture-informed recommendations for the development of future diagnostic systems.

The Latin American guide for psychiatric diagnosis. A cultural overview.

The ICD-10 Classification of Mental and Behavioral Disorders is being accepted by most countries and by the World Psychiatric Association as the international standard in the field for statistical reporting and for clinical care and research. Emerging now, however, is the need to harmonize international communication with recognition of cultural diversity and specific local requirements. Latin American psychiatrists hold a long-standing commitment to the formulation of a reliable and valid diagnostic system in international psychiatry. Examples of important Latin American contributions include the pioneering use of explicit operational criteria in diagnostic methodology by Horwitz and Marconi in Chile, and the proposal of a multiaxial diagnostic formulation by Leme-Lopes in Brazil. In recent times, two main Latin American efforts at developing diagnostic adaptations to the international classification in psychiatry have emerged. One is the Cuban Glossary of Psychiatry, already in its third edition, and the second is a more ambitious project to develop the Latin American Guide for Psychiatric Diagnosis (GLADP). Departing from the experience gained by the Cuban psychiatry and keeping ICD-10 as the basis for nosological organization of mental disorders, the GLADP is being developed with the contributions of psychiatrists and other mental health professionals from most countries in Latin America. The GLADP comprises 4 parts: (I) historical and cultural framework of Latin American psychiatry; (II) a comprehensive diagnostic process and formulation, (III) psychiatric nosology (including ICD-10 major classes of disorders and Latin American cultural syndromes); and (IV) appendixes (including, a lexicologic glossary, concepts and proposals for future study, and bibliography). This is an overview of the basic principles and dimensions for psychiatric diagnosis in Latin America, with an emphasis on its cultural framework.

Culture and urban mental health.

The previous panoramic view provides sufficient evidence that cultural understanding of urban realities and expressions of their impact on mental health are necessary for a successful approach to mental health in cities. The issues go beyond understanding how urban realties and cultural issues differ in New York from Jakarta; every city has a variety of unwritten cultural norms that permeate every aspect of its mental health. Unless these norms are understood within the dynamic structure of city living, any attempt to intervene on mental health programs will be doomed to failure. Understanding the cultural blueprint of a city, however, is only the first step, as we need to shed our cultural assumptions while we consider contextual socioeconomic and political factors for each city. Finally we need to adapt our western view of cultural values and how citizens function or do not function within the urban environments. Because each city in is its own culturally specific entity, the three steps outlined previously can help create an accurate portrait of what is needed to implement culturally sensitive changes. A paradigm shift, laid on a bicurcated foundation, on the one hand a locally attuned awareness of urban cultural dimensions and on the other educational programs based on extensive knowledge of worldwide problems such as stigma, gender-specific issues, disability, and the plight of vulnerable populations can potentially have far reaching implications on mental health policy changes addressing the cultural needs of cities. Urban mental health is poised to be one of the central issues for the next few decades, because of the size of the world urban population and because of the protean nature of its problems. Cultural factors interplay with urban dynamics in a unique, at times creative, other times destructive, fashion. Under conditions of socioeconomic disadvantage vulnerable individuals who lack adaptive mechanisms may become mentally ill or experience an exacerbation of their mental illness. Understanding how cultural dynamics articulate with adaptation to urban life may greatly enhance our ability to properly assess and treat mental disorders in cities. In the assessment and treatment of patients living in urban areas contextual cultural factors rather than being merely complementary assume a preeminent if not crucial role.

Predictive validity of the physical disorders axis of the DSM multiaxial diagnostic system.

This paper reports on the predictive validity of the physical disorders axis (axis III) of the DSM multiaxial diagnostic system at 3-year follow-up. A total of 515 general psychiatric patients were assessed with a semistructured procedure that covers all DSM-III diagnoses and axes, and were subsequently followed up for 3 years. Outcome was assessed with several measures of adaptive functioning. Baseline axis III was analyzed according to a) presence of any physical disorder, b) the number of these, c) presence of major chronic physical disorders (MCPD), and d) the number of these. Prediction of impairment in functioning (Strauss-Carpenter Scale), derived from baseline axis III, ranged from a correlation coefficient of .18 when expressed as the presence of any physical disorder to .35 when represented by the number of MCPD. Furthermore, within patients with specific psychiatric disorders, it was found that number of MCPD reached a predictive validity of .55 for patients with dysthymic disorders, .44 for those with anxiety disorders, and .41 for those with major depression. Comparative multiple regression analyses, controlling for demographic and clinical variables, showed that the number of MCPD at baseline was the most important predictor of functioning outcome among patients with dysthymic disorders and major depression. The number of MCPD experienced by general psychiatric patients seems to be an important predictor of future functioning, particularly for patients with certain psychiatric disorders. This points out the importance of considering the relationship between psychiatric and MCPD when conducting systematic clinical assessments towards the prediction of course and outcome.

Characterizing female bipolar alcoholic patients presenting for initial evaluation.

This study examined gender differences of age and race-matched group of bipolar disorder (BPO) patients with comorbid alcohol dependence (AD; n = 65; males = 35, females = 30) to a group of BPO patients without comorbid AD (n = 61; males = 22, females = 39). The two groups were also similar on marital status and frequency of BPO subtypes. The results revealed that female bipolar alcoholic patients were more likely to report depressive symptoms as compared to either male bipolar alcoholics or both male and female non-alcoholic bipolar patients. When compared to male bipolar alcoholics, they had higher frequency of depressed mood, slow motor behavior, low self-esteem, decreased libido, decreased appetite, and higher general anxiety symptoms. On the other hand, female bipolar alcoholics differed from female non-alcoholic bipolar patients on reports of mood lability, depressed mood, low self-esteem, suicidal indicators, decreased libido, and general anxiety symptoms. These results raise the question of whether alcohol increases the frequency of depressive symptoms among female bipolar patients.

Quality of life: a dimension in multiaxial classification.

The study provides an overview of the historical aspects of multiaxial classification. Particular reference is paid to the multiaxial formats of ICD-10, DSM-IV and the WPA International Guidelines for Diagnostic Assessment (IGDA). The IGDA proposes a tetraaxial format with quality of life as one axis as well as an axis on symptomatology, an axis on adaptive functioning and an axis on environmental/psychosocial conditions. The axis on quality of life is added in recognition of the increasing importance placed upon the patient's perception of his/her capacity of self fulfillment and the attention paid to quality of life as a major descriptor of health status as well as an outcome measure of clinical care.

The Spanish version of the quality of life index: presentation and validation.

Latino or Spanish-speaking individuals constitute a substantial and growing population in the United States, in addition to their general presence, with cultural variations, throughout Latin America and the Iberian Peninsula. To respond to the needs of this population, a Spanish version of the Quality of Life Index (QLI-Sp) was developed. The QLI, in its various language versions, is a concise instrument for comprehensive, culture-informed, and self-rated assessment of health-rated quality of life. It is composed of 10 dimensions collated from the international literature, including aspects ranging from physical well-being to spiritual fulfillment, as well as a global perception of quality of life. Each item is to be rated on a 10-point line by Latino subjects according to their culture-informed understanding of that concept. The study samples included 60 Latino psychiatric patients (20 outpatient, 20 inpatient, and 20 partial hospitalization) and 20 Latino actively working hospital professionals. Mean time of completion was 2.4 minutes among health professionals and 3.6 minutes among patients. The vast majority of respondents (72% of patients and 1000% of professionals) judged the instrument as easy to use. The test-retest reliability correlation coefficient of the QLI-Sp mean score was .89. The discriminant validity of the QLI-Sp was documented by the highly significant difference obtained between the mean scores of the two samples selected to represent quite different levels of quality of life.

The place of culture in DSM-IV.

This paper critically reviews the process and outcome of an effort to enhance the cultural validity of DSM-IV and outlines recommendations to improve future diagnostic systems. An ordered presentation of the antecedents and the main phases of this developmental effort is followed by a content analysis of what was proposed and what was actually incorporated, and a conceptual analysis of underlying biases and their implications. The cultural effort for DSM-IV, spearheaded by a scholarly independent NIMH workgroup, resulted in significant innovations including an introductory cultural statement, cultural considerations for the use of diagnostic categories and criteria, a glossary of culture-bound syndromes and idioms of distress, and an outline for a cultural formulation. However, proposals that challenged universalistic nosological assumptions and argued for the contextualization of illness, diagnosis, and care were minimally incorporated and marginally placed. Although a step forward has been taken to introduce cultural elements in DSM-IV much remains to be done. Further culturally informed research is needed to ensure that future diagnostic systems incorporate a genuinely comprehensive framework, responsive to the complexity of health problems in increasingly multicultural societies.

Ethics and comprehensive diagnosis.

This paper briefly reviews basic concepts of ethics, including its meanings and dimensions and its relationship to culture. It then examines the ethical bases of medicine and psychiatry. Of particular relevance here is the connection between ethics as concern for totality and the fundamentals of health and healing. Next, the ethical bases and implications of clinical diagnosis are considered. Finally, the paper outlines the features of a comprehensive diagnostic model and explicates how ethics is linked to the integrative nature of comprehensive diagnosis and its therapeutic purpose.

Mental health care for Hispanic Americans: a current perspective.

In this article, the authors review patterns and challenges in the conceptualization, implementation, and academic support of the mental health services of Hispanic Americans. A critical analysis was conducted on information obtained through manual and computerized searches of published literature and conference reports. New clinical care approaches include the DSM-IV's cultural formulation with its complement of standardized multiaxial diagnosis, integration of services across clinical disorders or conditions and across sources of care, as well as pluralistic criteria and judges for service outcome appraisal. Emerging clinical approaches offer an opportunity to enhance the mental health care of Hispanic Americans within an increasingly multicultural U.S. society.

Age effects on the clinical presentation of alcoholics at a psychiatric hospital.

Little is known about the effects of age on the clinical presentation of alcoholism in various treatment settings, despite the clinical importance of this factor. This study evaluates the effects of age on the clinical profile of 604 alcoholics who presented for initial evaluation and treatment at a psychiatric hospital. Young alcoholics displayed the most prominent substance use, antisocial behavior, depressive symptoms (including suicidality), and impulsivity. Early middle-aged alcoholics displayed the highest levels of drinking. Elderly alcoholics displayed the highest levels of cognitive dysfunction, although some level of cognitive dysfunction was present among even the youngest alcoholics. These findings confirm and clarify the effects of age on the clinical profile of alcoholics presenting for initial evaluation at a psychiatric hospital.

The World Health Organization Short Disability Assessment Schedule (WHO DAS-S): a tool for the assessment of difficulties in selected areas of functioning of patients with mental disorders.

The World Health Organization Short Disability Assessment Schedule (WHO DAS-S) is an instrument for clinicians' assessment and rating of difficulties in maintaining personal care, in performing occupational tasks and in functioning in relation to the family and the broader social context due to mental disorders. The WHO DAS-S was developed and underwent preliminarily testing in the context of two international field trials of the multiaxial presentation of ICD-10 for use in adult psychiatry. The instrument was found to be useful, user-friendly and reasonably reliable for use by clinicians belonging to different schools of psychiatry and psychiatric traditions. Further work on the WHO DAS-S should include development of national adaptations of the instrument, studies of concurrent validity of the instrument and modification of the instrument to accommodate changes in the next edition of the International Classification of Impairments, Disabilities and Handicaps (ICIDH).

Contextual aspects of mental disorders: a proposal for axis III of the ICD-10 multiaxial system.

After several years of development and testing, the World Health Organization (WHO) has recently completed work on the multiaxial presentation of ICD-10 for use in adult psychiatry. Axis III of the ICD-10 multiaxial system is intended for clinicians' reporting of contextual factors which may influence the diagnosis, treatment or prognosis of mental disorders that are recorded on Axis I. It was tested in two WHO-co-ordinated international field trials and found to be user-friendly, reasonably reliable and useful in routine clinical work, in the training of mental health professionals and in research on mental disorders.