Non-binary gender, vulnerable populations and mental health during the COVID-19 pandemic: Data from the COVID-19 MEntal health inTernational for the general population (COMET-G) study

BACKGROUND

The COVID-19 pandemic has brought significant mental health challenges, particularly for vulnerable populations, including non-binary gender individuals. The COMET international study aimed to investigate specific risk factors for clinical depression or distress during the pandemic, also in these special populations.

METHODS

Chi-square tests were used for initial screening to select only those variables which would show an initial significance. Risk Ratios (RR) were calculated, and a Multiple Backward Stepwise Linear Regression Analysis (MBSLRA) was followed with those variables given significant results at screening and with the presence of distress or depression or the lack of both of them.

RESULTS

The most important risk factors for depression were female (RR = 1.59-5.49) and non-binary gender (RR = 1.56-7.41), unemployment (RR = 1.41-6.57), not working during lockdowns (RR = 1.43-5.79), bad general health (RR = 2.74-9.98), chronic somatic disorder (RR = 1.22-5.57), history of mental disorders (depression RR = 2.31-9.47; suicide attempt RR = 2.33-9.75; psychosis RR = 2.14-10.08; Bipolar disorder RR = 2.75-12.86), smoking status (RR = 1.15-5.31) and substance use (RR = 1.77-8.01). The risk factors for distress or depression that survived MBSLRA were younger age, being widowed, living alone, bad general health, being a carer, chronic somatic disorder, not working during lockdowns, being single, self-reported history of depression, bipolar disorder, self-harm, suicide attempts and of other mental disorders, smoking, alcohol, and substance use.

CONCLUSIONS

Targeted preventive interventions are crucial to safeguard the mental health of vulnerable groups, emphasizing the importance of diverse samples in future research.

LIMITATIONS

Online data collection may have resulted in the underrepresentation of certain population groups.

Somatic multicomorbidity and disability in patients with psychiatric disorders in comparison to the general population: a quasi-epidemiological investigation in 54,826 subjects from 40 countries (COMET-G study)

BACKGROUND

The prevalence of medical illnesses is high among patients with psychiatric disorders. The current study aimed to investigate multi-comorbidity in patients with psychiatric disorders in comparison to the general population. Secondary aims were to investigate factors associated with metabolic syndrome and treatment appropriateness of mental disorders.

METHODS

The sample included 54,826 subjects (64.73% females; 34.15% males; 1.11% nonbinary gender) from 40 countries (COMET-G study). The analysis was based on the registration of previous history that could serve as a fair approximation for the lifetime prevalence of various medical conditions.

RESULTS

About 24.5% reported a history of somatic and 26.14% of mental disorders. Mental disorders were by far the most prevalent group of medical conditions. Comorbidity of any somatic with any mental disorder was reported by 8.21%. One-third to almost two-thirds of somatic patients were also suffering from a mental disorder depending on the severity and multicomorbidity. Bipolar and psychotic patients and to a lesser extent depressives, manifested an earlier (15-20 years) manifestation of somatic multicomorbidity, severe disability, and probably earlier death. The overwhelming majority of patients with mental disorders were not receiving treatment or were being treated in a way that was not recommended. Antipsychotics and antidepressants were not related to the development of metabolic syndrome.

CONCLUSIONS

The finding that one-third to almost two-thirds of somatic patients also suffered from a mental disorder strongly suggests that psychiatry is the field with the most trans-specialty and interdisciplinary value and application points to the importance of teaching psychiatry and mental health in medical schools and also to the need for more technocratically oriented training of psychiatric residents.

Results of the COVID-19 mental health international for the health professionals (COMET-HP) study: depression, suicidal tendencies and conspiracism

INTRODUCTION

The current study aimed to investigate the rates of anxiety, clinical depression, and suicidality and their changes in health professionals during the COVID-19 outbreak.

MATERIALS AND METHODS

The data came from the larger COMET-G study. The study sample includes 12,792 health professionals from 40 countries (62.40% women aged 39.76 ± 11.70; 36.81% men aged 35.91 ± 11.00 and 0.78% non-binary gender aged 35.15 ± 13.03). Distress and clinical depression were identified with the use of a previously developed cut-off and algorithm, respectively.

STATISTICAL ANALYSIS

Descriptive statistics were calculated. Chi-square tests, multiple forward stepwise linear regression analyses, and Factorial Analysis of Variance (ANOVA) tested relations among variables.

RESULTS

Clinical depression was detected in 13.16% with male doctors and 'non-binary genders' having the lowest rates (7.89 and 5.88% respectively) and 'non-binary gender' nurses and administrative staff had the highest (37.50%); distress was present in 15.19%. A significant percentage reported a deterioration in mental state, family dynamics, and everyday lifestyle. Persons with a history of mental disorders had higher rates of current depression (24.64% vs. 9.62%; p < 0.0001). Suicidal tendencies were at least doubled in terms of RASS scores. Approximately one-third of participants were accepting (at least to a moderate degree) a non-bizarre conspiracy. The highest Relative Risk (RR) to develop clinical depression was associated with a history of Bipolar disorder (RR = 4.23).

CONCLUSIONS

The current study reported findings in health care professionals similar in magnitude and quality to those reported earlier in the general population although rates of clinical depression, suicidal tendencies, and adherence to conspiracy theories were much lower. However, the general model of factors interplay seems to be the same and this could be of practical utility since many of these factors are modifiable.

The effect of different degrees of lockdown and self-identified gender on anxiety, depression and suicidality during the COVID-19 pandemic: Data from the international COMET-G study

INTRODUCTION

During the COVID-19 pandemic various degrees of lockdown were applied by countries around the world. It is considered that such measures have an adverse effect on mental health but the relationship of measure intensity with the mental health effect has not been thoroughly studied. Here we report data from the larger COMET-G study pertaining to this question.

MATERIAL AND METHODS

During the COVID-19 pandemic, data were gathered with an online questionnaire from 55,589 participants from 40 countries (64.85% females aged 35.80 ± 13.61; 34.05% males aged 34.90±13.29 and 1.10% other aged 31.64±13.15). Anxiety was measured with the STAI, depression with the CES-D and suicidality with the RASS. Distress and probable depression were identified with the use of a previously developed cut-off and algorithm respectively.

STATISTICAL ANALYSIS

It included the calculation of Relative Risk (RR), Factorial ANOVA and Multiple backwards stepwise linear regression analysis RESULTS: Approximately two-thirds were currently living under significant restrictions due to lockdown. For both males and females the risk to develop clinical depression correlated significantly with each and every level of increasing lockdown degree (RR 1.72 and 1.90 respectively). The combined lockdown and psychiatric history increased RR to 6.88 The overall relationship of lockdown with severity of depression, though significant was small.

CONCLUSIONS

The current study is the first which reports an almost linear relationship between lockdown degree and effect in mental health. Our findings, support previous suggestions concerning the need for a proactive targeted intervention to protect mental health more specifically in vulnerable groups.

Results of the COVID-19 mental health international for the general population (COMET-G) study

INTRODUCTION

There are few published empirical data on the effects of COVID-19 on mental health, and until now, there is no large international study.

MATERIAL AND METHODS

During the COVID-19 pandemic, an online questionnaire gathered data from 55,589 participants from 40 countries (64.85% females aged 35.80 ± 13.61; 34.05% males aged 34.90±13.29 and 1.10% other aged 31.64±13.15). Distress and probable depression were identified with the use of a previously developed cut-off and algorithm respectively.

STATISTICAL ANALYSIS

Descriptive statistics were calculated. Chi-square tests, multiple forward stepwise linear regression analyses and Factorial Analysis of Variance (ANOVA) tested relations among variables.

RESULTS

Probable depression was detected in 17.80% and distress in 16.71%. A significant percentage reported a deterioration in mental state, family dynamics and everyday lifestyle. Persons with a history of mental disorders had higher rates of current depression (31.82% vs. 13.07%). At least half of participants were accepting (at least to a moderate degree) a non-bizarre conspiracy. The highest Relative Risk (RR) to develop depression was associated with history of Bipolar disorder and self-harm/attempts (RR = 5.88). Suicidality was not increased in persons without a history of any mental disorder. Based on these results a model was developed.

CONCLUSIONS

The final model revealed multiple vulnerabilities and an interplay leading from simple anxiety to probable depression and suicidality through distress. This could be of practical utility since many of these factors are modifiable. Future research and interventions should specifically focus on them.

Community Psychiatry in a Latin American Context: Perú as a Case Example

Background:

Historical and conceptual issues related to community psychiatry as an innovative approach to clinical assistance across the world, precede a more or less detailed examination of its presence, role and current accomplishments in Latin America, particularly related to child and adolescent subpopulations. Information about transition processes from the traditional hospital-centered model to the community-based approach, applicable mental health policies, levels of implementation and quality of the available reports in different countries, are duly evaluated.

Objective:

Within an understanding of the broader Latin American context, the paper describes the situation in Perú, a country considered representative of the Low and Middle Income (LMIC) group in the subcontinent.

Methods:

The situation in Perú is presented with particular emphasis on a recently established community-based mental health centers program across its territory.

Results:

This description includes consideration of variables such as personal, family and identity empowerment, a focus on integrated care, and clinical outcomes and community relations. The development of community mental health centers across Perú is described.

Conclusion:

Adolescents represent the unique future of socio-culturally diverse Latin American countries, and must be the target population of well-conceived, cohesive community mental health policies and programs. The importance of political will to promote community health centers that provide adolescents access to services is critical.

Peruvian psychiatry in America and the world: its journey in search of an identity

Throughout history, Latin American psychiatry has followed a variety of routes as its mythic-religious origins experienced the various influences of European and North American ideas of the last three centuries. In its modern trajectory, a post-colonial subordination was followed by a more selective import of ideas and a critical approach to their application in the New Continent. At one point, the identity of Latin American psychiatry was essentially considered mestiza, social and critical, reflecting a search for autonomy and originality. In this journey, Peruvian psychiatry has been considered one of the most representative versions of the history and position of the discipline. This article attempts to detail the identity-seeking process of Peruvian and Latin American Psychiatry through the life and work of three notable Peruvian figures: Honorio Delgado, Carlos Alberto Seguín and Humberto Rotondo. Delgado fostered the need for scientific evidence in support of any piece of knowledge, as well as humanism as essential component of best service and optimal patient care. Seguín led studies on folkloric and ethnic psychiatry, stimulated integrated approaches to care, and advocated in favour of a regional identity for psychiatry.

Latin American and Spanish-speaking perspectives on the challenges of global psychiatry

The multi-faceted phenomenon known as globalization has a particular impact on the conceptual and practical development of mental health disciplines in general, and psychiatry in particular, across different world regions. To be theoretically and functionally effective, global psychiatry requires an integration of its different components. To such objective, and after a brief review of continental European and Anglo-Saxon contributions, this article examines the history, characteristics, and contributions of Latin/Iberian American and Spanish-speaking psychiatry, in order to substantiate its role in world psychiatry. The Latin American proper (including Portuguese-speaking Brazil), Spain, and U.S.-based Hispanic components are described, revealing an identity that is based on a humanistic tradition, a value-based, culturally-determined clinical approach to patient care, and a pragmatic adaptation of different treatment resources and techniques. These may constitute supportive elements of an instrumental inter-regional bond in the present and future of our discipline.

World Opioid and Substance Use Epidemic: A Latin American Perspective

The opioid crisis is a growing social and public health phenomenon, particularly in developed countries such as the United States. Since the 1990s, this crisis has shown a variety of causal processes and consequences and has affected quality of life for millions of individuals, families, and communities across the globe. Although abuse of opioid‐based painkillers appears to have triggered the epidemic in the United States, in this article, the problem is examined with a focus on Latin America, where drug‐associated problems constitute threats to the health and quality of life for large segments of the population. After a review of the history of opium consumption and its consequences in the world and in Latin America, the authors present epidemiological data and information about regional market differences, professional involvement, clinical practices, public health realities, and prevention efforts. Recommendations are made for collaborative efforts to promote prevention policies and measures to improve the situation.

Pharmacogenomic perspectives on the management of mood disorders

Psychiatric pharmacogenomics is a relatively young field of clinical practice, focused on the identification of genetic profiles determining varieties of metabolic patterns that, in turn, assist in the choice of appropriate medications and their corresponding doses. In psychiatry, the mood disorders area has been the most active in trying to advance knowledge and expertise in pharmacogenomics. the cytochrome P450 system (particularly 2D6 and 2C19 enzymes and their respective codifying genes) and, more recently, serotonin transporter and receptor gene tests are among the most utilised and promising. In spite of encouraging findings, however, there are still many questions related to preciseness, scope, ethnic variations, diagnostic implications, ‘non-biological’ factors, and ethic considerations. the need of algorithms, follow-up studies, and assessment of financial impact, all listed here, require continuous and systematic research. It will not only add to the excitement of pharmacogenomics, but also to the creation of cogent evidence of its benefits.

Feasibility, acceptability and clinical utility of the Cultural Formulation Interview: mixed-methods results from the DSM-5 international field trial

BackgroundThere is a need for clinical tools to identify cultural issues in diagnostic assessment.AimsTo assess the feasibility, acceptability and clinical utility of the DSM-5 Cultural Formulation Interview (CFI) in routine clinical practice.MethodMixed-methods evaluation of field trial data from six countries. The CFI was administered to diagnostically diverse psychiatric out-patients during a diagnostic interview. In post-evaluation sessions, patients and clinicians completed debriefing qualitative interviews and Likert-scale questionnaires. The duration of CFI administration and the full diagnostic session were monitored.ResultsMixed-methods data from 318 patients and 75 clinicians found the CFI feasible, acceptable and useful. Clinician feasibility ratings were significantly lower than patient ratings and other clinician-assessed outcomes. After administering one CFI, however, clinician feasibility ratings improved significantly and subsequent interviews required less time.ConclusionsThe CFI was included in DSM-5 as a feasible, acceptable and useful cultural assessment tool.

Socio-demographic patterns of posttraumatic stress disorder in Medellin, Colombia and the context of lifetime trauma exposure

Colombia, South America is currently transitioning to post-conflict status following 6 decades of armed conflict. The population has experienced extensive exposures to potentially traumatic events throughout the lifespan. Sources of trauma exposure include the prolonged armed insurgency, narco-trafficking violence, urban gang violence, violent actions of criminal bands, intra-familial violence, gender-based violence, and sex trafficking. Exposure to potentially traumatic events is related to a variety of psychiatric outcomes, in particular, posttraumatic stress disorder. Given this context of lifetime trauma exposure, socio-demographic patterns of posttraumatic stress disorder were explored in a sample of residents of Medellin, Colombia, the nation's second largest city and a nexus for multiple types of trauma exposure.

Hispanic immigrants in the USA: social and mental health perspectives

Hispanic immigration in the USA and its effect on many areas of US society are of great relevance to health care, public health, mental health, and medical and social sciences. In this report, we review and discuss pertinent literature on causes, procedures, and eventual outcomes of Hispanic migration waves throughout the last four decades. Hispanic immigrants do not constitute a monolithic group, despite the clear predominance of Mexican and Mexican-American segments. Common features of Hispanic immigrants include a younger average age, higher presence of married households, and lower educational levels than the overall US population. Differences within the Hispanic immigrant population are present in naturalisation figures, English language fluency, occupational and income status, health insurance coverage, and sense of accomplishment in the host society. We examine most of these aspects in the context of the so-called Hispanic paradox, presented as both a cause and a result of a heavily discussed acculturative process. We investigate prevalence and other data on depression, anxiety, substance abuse, and psychotic syndromes, with emphasis on the need to do further neurobiological, epigenetic, and sociocultural research in the Hispanic population.

How Do Clinicians Prefer Cultural Competence Training? Findings from the DSM-5 Cultural Formulation Interview Field Trial

OBJECTIVE

This study's objective is to analyze training methods clinicians reported as most and least helpful during the DSM-5 Cultural Formulation Interview field trial, reasons why, and associations between demographic characteristics and method preferences.

METHOD

The authors used mixed methods to analyze interviews from 75 clinicians in five continents on their training preferences after a standardized training session and clinicians' first administration of the Cultural Formulation Interview. Content analysis identified most and least helpful educational methods by reason. Bivariate and logistic regression analysis compared clinician characteristics to method preferences.

RESULTS

Most frequently, clinicians named case-based behavioral simulations as "most helpful" and video as "least helpful" training methods. Bivariate and logistic regression models, first unadjusted and then clustered by country, found that each additional year of a clinician's age was associated with a preference for behavioral simulations: OR = 1.05 (95 % CI: 1.01-1.10; p = 0.025).

CONCLUSIONS

Most clinicians preferred active behavioral simulations in cultural competence training, and this effect was most pronounced among older clinicians. Effective training may be best accomplished through a combination of reviewing written guidelines, video demonstration, and behavioral simulations. Future work can examine the impact of clinician training satisfaction on patient symptoms and quality of life.

[Mental health in older adults: major neurocognitive, affective, and sleep disorders]

Numerous biological, psychological, and social factors influence the mental health of elderly individuals to varying degrees. Apart from components related to the normal aging process and the co-occurrence of various medical conditions, events such as the death of a loved one, retirement, or disability significantly contribute to a variety of mental and emotional problems in this stage of the life cycle. The most frequent problems affect the neurocognitive, emotional, and oneiric spheres. Major neurocognitive disorders reduce one's overall performance and, thus, increase their need for close care. Affective disorders may be exacerbated by the lack of family support and decreased social interactions, which may lead to significant isolation result in suicidal behavior. The increased frequency of sleep disorders such as insomnia and daytime sleepiness and specific disorders such as obstructive apnea significantly alter the quality of life of this population.

El precio de la ausencia: La Psiquiatría Latinoamericana en el mundo

Resumen El fenómeno de la globalización, impulsado por migraciones masivas y avances tecnológicos cada vez más complejos, plantea desafíos a la identidad individual y colectiva, a la fisonomía cultural de regiones y continentes y a sus expresiones científicas, entre ellas la medicina y la psiquiatría. Tras describir brevemente las rutas históricas de la psiquiatría latinoamericana, el artículo examina el trabajo de algunas de sus más destacadas figuras y sus contribuciones en campos como psiquiatría social, psicoanálisis, neurobiología, psicopatología y otros. El enfoque central en torno a la visibilidad y aceptación de contribuciones latinoamericanas en el escenario mundial se basa en cifras de Factor de Impacto de publicaciones especializadas, reconocimiento y participación de psiquiatras latinoamericanos en eventos e instituciones internacionales, colaboración en proyectos de investigación, etc. Se concluye que tal visibilidad es modesta y se examinan las razones de la misma y las reacciones de la comunidad psiquiátrica latinoamericana ante tal realidad. Finalmente, se formulan sugerencias y planteamientos de manejo de esta situación para una reafirmación del valor y calidad de aquellas contribuciones en los campos académico, clínico y heurístico.

Homicidal/violent thoughts, suicidal ideation and violent behavior in adolescents with social phobia in Metropolitan Lima, Perú

INTRODUCTION

Social phobia and violent behavior are both important mental health problems among adolescent populations in different parts of the world. This study attempts to evaluate possible connections between social phobia, homicidal/violent thoughts, suicidal ideation, and subsequent violent behavior among adolescents living in the metropolitan area of Lima, Perú.

METHODS

A sample of 991 adolescents, part of the 2002 Epidemiological Study in Metropolitan Lima, conducted by the National Institute of Mental Health "Honorio Delgado-Hideyo Noguchi" (INSM "HD-HN") was studied. Social phobia was diagnosed on the basis of clinical assessment and the use of MINI, and suicidal ideation, homicidal/violent thoughts, and violent behavior were identified through the Mental Health Questionnaire. Odds ratio (OR) statistical analyses adjusted by logistic regression controlling for age and gender were performed.

RESULTS

Variables associated with social phobia were homicidal thoughts in the last month (OR: 5.19, confidence interval [CI] at 95% 4.95-5.40), an impulse to hit known (OR: 1.56; 95% CI, 1.53-1.59) and unknown (OR: 3.98, 95% CI,3.89-4.07) persons, the wish to take revenge for a past offense (OR: 2.60, 95% CI 2.54-2.64), getting involved in fights with different kinds of weapons (OR: 1,78, 95% CI 1.70-1.87), suicidal ideation throughout lifetime (OR: 4.74, 95% CI 4.65-4.83), and life prevalence of suicidal attempt (OR: 5.39, 95% CI 5.23-5.55).

DISCUSSION

Social phobia in adolescents of this Peruvian sample seems to be closely associated with both homicidal/violent thoughts, violent behavior, and suicidal ideation.

[Psychiatric education and cultural components during medical training: Latin American perspectives]

Medical education has incorporated psychiatric or mental health components more consistently during the last decades thanks to various factors such as: advances in neurobiological research; the increasing prevalence of mental disorders in global health; the increasingly close relationship between mental health and public health; comorbidities with medical conditions and the impact of sociocultural phenomena in clinical manifestations, diagnosis, treatment, prognosis and prevention. Based on acquisition of core competencies and ethical principles of universal acceptance, the teaching process examined in this article proposes an education based on the provision of clinical experiences integrated throughout the collection of adequate information, the development of diagnostic capabilities, and exposure to a wide variety of forms of academic assessment of students and residents in training. The cultural components of psychiatric education receive special mention; we provide examples of their systematic integration with the acquisition of general skills. The teaching tools include theoretical and applied activities and supervision. Particular attention is paid to how the principles of modern psychiatric medical education, including cultural aspects and practice of holistic health care objectives, can and should be in effect in Latin American countries.

Depression in a Latino man in New York

This case illustrates some of the issues that may affect a Latino patient's presentation. Although the patient's constellation of symptoms are classically representative of major depression, the patient also raises themes regarding the process of immigration, subsequent challenges in acculturation and identification with the host culture versus the culture of origin, and culture-specific notions about causes of symptoms. In addition to some of the special features of stigma in Latino cultures, the prominence of physical concerns in the presentation and the use of traditional healers contribute to the complexity of selecting appropriate interventions for this young man.

[Cultural components within DSM-5: achievements, hopes, and expectations]

Cultural Psychiatry deals with the description, definition, evaluation and management of psychiatric conditions as a clinical reflection of cultural factors within an integral context, and as an explanatory, interpretative, nosological, therapeutic and preventive attribute in professional practice. This article attempts to analyze that link in the context of the dominant classification in our era, the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association (APA), with emphasis on the development of its latest version, DSM-5. The cultural content of the International Classification of Diseases (ICD) of the World Health Organization (WHO) can be the subject of further analysis, even when it can be said that, in general, it seemingly has less reach than the American classification. The author's participation, work and reflections about the DSM-5 Committee, created by the APA at the beginning of this century, constitute the basis of the presentation and discussion of concrete achievements, more or less idealized hopes, and more or less realistic expectations with a view to the future. Conclusions will also try to cover implications of DSM-5 cultural components in the field of Latin American and spanish-speaking psychiatry.

Culture and psychiatric evaluation: operationalizing cultural formulation for DSM-5

The Outline for Cultural Formulation (OCF) introduced with DSM-IV provided a framework for clinicians to organize cultural information relevant to diagnostic assessment and treatment planning. However, use of the OCF has been inconsistent, raising questions about the need for guidance on implementation, training, and application in diverse settings. To address this need, DSM-5 introduced a cultural formulation interview (CFI) that operationalizes the process of data collection for the OCF. The CFI includes patient and informant versions and 12 supplementary modules addressing specific domains of the OCF. This article summarizes the literature reviews and analyses of experience with the OCF conducted by the DSM-5 Cross-Cultural Issues Subgroup (DCCIS) that informed the development of the CFI. We review the history and contents of the DSM-IV OCF, its use in training programs, and previous attempts to render it operational through questionnaires, protocols, and semi-structured interview formats. Results of research based on the OCF are discussed. For each domain of the OCF, we summarize findings from the DCCIS that led to content revision and operationalization in the CFI. The conclusion discusses training and implementation issues essential to service delivery.

Crossroads: Identity struggles in Latin America and Latin American psychiatry

Identity can be defined from different perspectives such as those from philosophy, social sciences and phenomenology. The latter entails sameness, uniqueness, distinctiveness, continuity, diversity, universality and equality connotations to define characteristics of the existence and action of individuals, institutions, entities, organizations and collectivities. In order to elaborate on the identity of Latin American Psychiatry, this chapter deals first with the identity of the Latin American continent, the result of a 'collision of cultures' with mestizaje as its most prominent collective contribution. In turn, the Latin American population (and its 'Hispanic' equivalent in other countries and regions of the world) has been the subject of a pluralistic search, and played a combined role of hope and conflict, advances and setbacks in a fascinating historical process. In such context, Latin American psychiatry offers a mixed identity, resulting from a succession of mythic-religious, moral, phenomenologico-existential, biological and social/community-based routes. Each of them are assessed, and the contributions of two eponymous figures, Honorio Delgado and Gregorio Bermann, are duly delineated. Current realities in Latin American psychiatry and mental health in socio-political, conceptual, professional, ideological, academic and heuristic areas, are examined. The chapter ends with considerations of the future of psychiatry in the continent, the postulation of a 'new synthesis' embracing the essence of contemporary neurobiological knowledge and a new, revitalized humanism in the context of a healthy eclecticism, progressive educational training and didactic programmes, and concrete contributions embodying the promise of well justified expectations.

Personality profiles and minor affective psychopathology in a non-clinical sample: an empirical verification of Cloninger's theoretical model

BACKGROUND

Psychopathological vulnerability may be related to certain personality traits. The aim of this study was to explore the association of minor affective psychopathology and the regular use of psychotropic medication with temperament and character profiles from Cloninger's personality model, in a sample of active professional people.

METHODS

This cross-sectional study included 498 non-clinical subjects, teachers in a local school system. Instruments used included the self-administered General Health Questionnaire (GHQ-28) to measure psychiatric morbidity; the Center for Epidemiologic Studies Depression scale (CES-D) to measure depressive symptoms; documentation of regular use of psychotropic medication; and the Temperament and Character Inventory (TCI-125) for personality traits self-assessment.

RESULTS

The proportion of subjects presenting psychiatric morbidity (GHQ-28>6) or depressive symptoms (CES-D>20) was significantly higher among explosive, passive-aggressive, and obsessional temperament profiles, and among schizotypal, moody, melancholic and dependent character profiles. Similar results were observed with the scores on each of the four GHQ-28 subscales (depression, anxiety, social dysfunction, and somatic symptoms). The regular use of psychotropic medications was significantly higher among the passive-aggressive and explosive temperament types, and among the schizoptypal and moody character types.

LIMITATIONS

Being a cross-sectional study, no causal attributions can be inferred. Subjects on sick leave were excluded, so the sample was not representative of the general population. The data were collected using self-reporting questionnaires, and no specific psychiatric diagnoses were obtained.

CONCLUSIONS

It is possible to identify certain personality configurations associated with minor psychopathology and concomitant use of psychotropics, among active professional people.

Improving mental and neurological health research in Latin America: a qualitative study

BACKGROUND

Research evidence is essential to inform policies, interventions and programs, and yet research activities in mental and neurological (MN) health have been largely neglected, particularly in low- and middle-income countries. Many challenges have been identified in the production and utilization of research evidence in Latin American countries, and more work is needed to overcome this disadvantageous situation. This study aims to address the situation by identifying initiatives that could improve MN health research activities and implementation of their results in the Latin American region.

METHODS

Thirty-four MN health actors from 13 Latin American countries were interviewed as part of an initiative by the Global Forum for Health Research and the World Health Organization to explore the status of MN health research in low- and middle-income countries in Africa, Asia and Latin-America.

RESULTS

A variety of recommendations to increase MN health research activities and implementation of their results emerged in the interviews. These included increasing skilled human resources in MN health interventions and research, fostering greater participation of stakeholders in the generation of research topics and projects, and engendering the interest of national and international institutions in important MN health issues and research methodologies. In the view of most participants, government agencies should strive to have research results inform the decision-making process in which they are involved. Thus these agencies would play a key role in facilitating and funding research. Participants also pointed to the importance of academic recognition and financial rewards in attracting professionals to primary and translational research in MN health. In addition, they suggested that institutions should create intramural resources to provide researchers with technical support in designing, carrying out and disseminating research, including resources to improve scientific writing skills.

CONCLUSION

Fulfillment of these recommendations would increase research production in MN health in Latin American countries. This, in turn, will raise the profile of these health problems, and consequently will underscore the need of continued high-quality and relevant research, thus fostering a virtuous cycle in the decision-making process to improve MN health care.

What challenges does mental and neurological health research face in Latin American countries?

OBJECTIVE

The World Health Organization Atlas Project identified important deficiencies in world mental and neurological health resources. These deficiencies, especially evident in low and middle-income countries, can be overcome by improving research capacity. The objective of this study is to assess the status of mental and neurological research in Latin American countries and identify the main difficulties encountered in conducting research, publishing results, and shaping health policies, interventions, and programs.

METHOD

Semi-structured interviews were conducted with 34 key informants from 13 Latin American countries.

RESULTS

Participants reported that production of mental and neurological research in Latin American countries is low. Lack of financial and human resources, including lack of support from government agencies, were identified as the main factors contributing to the dearth of local research. The few research projects that do take place in Latin American countries are often funded at researchers' personal expense. Few policies, interventions, or programs are generated from research results. To address these deficiencies, participants called for training in research methodology, mechanisms for identifying funding opportunities, and greater recognition of their research products.

CONCLUSIONS

Researchers and stakeholders recognize the need to mobilize local and international efforts aimed at strengthening research capacity and results implementation. This will lead to an overall optimization of mental and neurological research in the region.

Subjectivity in the perception and measurement of quality of life: conceptualization and development of the Seville questionnaire

Quality of life (QoL) is a significant parameter in estimating the social and interpersonal impact of psychopathology, clinical course, and response to treatment in many mental illnesses, particularly schizophrenia. The clinician's assessment and patient's subjective report are essential ingredients of this process. We describe the development and structure of a QoL questionnaire based on the patient's subjective understanding of the problems. Ninety areas identified by four groups of experts resulted in a 126-item questionnaire administered to 279 patients with a DSM-IV diagnosis of schizophrenia. A factorial approach led to 59 total items and two final scales (favorable and unfavorable), with three factors each. The Seville QoL Questionnaire (SQLQ) results can be presented as individual scores for each scale, or a total for both. Its psychometric properties have proven quite acceptable in reliability and validity, comparing favorably with other scales. SQLQ may prove to be a useful addition to QoL-measuring instruments.

When the poetry no longer rhymes: mental health issues among Somali immigrants in the USA

To identify and explore cultural dynamics influencing the psychiatric care of immigrant Somalis in the USA, we reviewed demographic data from Minnesota Departments of Human Services, and interviewed health professionals, exploring community perceptions of medical/psychiatric needs, cultural characteristics, barriers to care, and potential solutions. An informal survey of 37 members of the Mayo Clinic Department of Psychiatry and Psychology, to determine caregiver perceptions of care of Somali patients, cited language barriers (74%), and cultural misperceptions (68%) as the most frequent obstacles. Difficulties working within the patriarchal family structure, limited community resources, poor compliance, and financial issues ranged between 18 and 8%. Additional barriers mentioned were problems working with interpreters from ;warring clan factions,' patients' fears of being labeled ;crazy,' difficulties viewing illness within an emotional framework, and the need to address mental health from a physical framework through a focus on somatic symptoms. Somalis rarely acknowledge psychiatric problems and common traditional treatments have become ineffective in the new context. Recommendations include alternative health care approaches utilizing family values, ;bargaining,' and educational approaches to acculturation.

Proposing an algorithm for the pharmacological management of posttraumatic stress disorder

The clinical management of posttraumatic stress disorder (PTSD) is as complex as the condition itself. Pharmacotherapy is an important component of this treatment process, which also includes psychosocial interventions and, in most cases, entails long-term efforts. The authors propose a systematic approach to the pharmacological treatment of PTSD using algorithmic techniques. After a careful history-taking phase and a review of available psychotropic agents, the practitioner usually ends up dealing with either PTSD alone or, more frequently, accompanied by other identifiable syndromes. Various antidepressants have demonstrated efficacy in the former, while the latter requires a management aimed at depressive, anxiety/dissociative, hypomanic/manic, or psychotic symptoms. The proposed algorithm provide guidelines for treatment issues such as medication choice, medication dose, maintenance pharmacotherapy, alternative options, and eventual outcomes. Algorithms summarize current information and suggest pharmacotherapy guidelines as a significant component of a comprehensive PTSD management program.

Personality disorders and culture: contemporary clinical views (Part A)

This article reviews the basic concepts surrounding the clinical relationships between culture and personality disorders (PDs). Culture plays a significant role in the construction of self-concept and self-image, the egocentric/sociocentric dichotomy, and the determination of biases in the clinical study of PDs. Cultural contextualization is, therefore, crucial in the demarcation between normal and abnormal personalities. From a clinical perspective, culture has three roles vis-à-vis the psychopathology of personality: (a) as an interpretive/explanatory tool; (b) as a pathogenic/pathoplastic agent; and (c) as a diagnostic/nosological factor. The first of two parts, this article examines the interpretive/explanatory and pathogenic/pathoplastic roles, substantiated by clinical examples gleaned from the existing literature.

Personality disorders and culture: contemporary clinical views (Part B)

This article reviews the basic concepts surrounding the clinical relationships between culture and personality disorders (PDs). Part A of this article, which appeared in Cultural Diversity and Mental Health, Vol. 1, No. 1, pp 3-17 (1995), examined the interpretive/explanatory and pathogenic/ pathoplastic roles of culture. Herein, culture's role as a diagnostic/nosological factor is discussed through the use of measurement instruments and the cultural formulation included in DSM-IV (American Psychiatric Association, 1994). In addition to these three roles, some authors would also consider a therapeutic/protective function for cultured in PDs. Following a critique of the biological perspective, a research model based on the definition of the cultural profile and the estimation of the cultural distance between clinical examiners and populations is proposed. It is important to reject both biological reductionism and the extremes of cultural determinism, in order to better assess the intraethnic distribution of psychopathology, and interethnic variations represented by the notion of cultural relativism.

Mental health policy developments in Latin America

New assessment guidelines for measuring the overall impact of mental health problems in Latin America have served as a catalyst for countries to review their mental health policies. Latin American countries have taken various steps to address long-standing problems such as structural difficulties, scarce financial and human resources, and social, political, and cultural obstacles in the implementation of mental health policies and legislation. These policy developments, however, have had uneven results. Policies must reflect the desire, determination, and commitment of policy-makers to take mental health seriously and look after people's mental health needs. This paper describes the development of mental health policies in Latin American countries, focusing on published data in peer-reviewed journals, and legislative change and its implementation. It presents a brief history of mental health policy developments, and analyzes the basis and practicalities of current practice.

Clinical relevance of contemporary cultural psychiatry

In recent years, the field of cultural psychiatry has gained recognition and accumulated evidence of its clinical relevance. This article examines the intersections of culture and psychopathology and describes five independent but interrelated clinical dimensions that identify and define culture as: a) an interpretive/explanatory tool, b) a pathogenic/pathoplastic agent, c) a diagnostic/nosological factor, d) a therapeutic/protective element, and e) a service/management instrument. Along these lines, conceptual boundaries, clinical findings, specific applications, and research implications for each of the five dimensions are systematically reviewed. Cultural psychiatry adds significantly to the comprehensiveness of psychiatric evaluation and management and addresses prominent issues regarding understanding, classification, diagnosis, and competent treatment of most psychiatric disorders in every society and region of the world. Based on the strength of these clinical dimensions, and on the related educational and research efforts, cultural psychiatry can also contribute decisively to the design of comprehensive mental health policies.

[Clinical dimensions of contemporary cultural psychiatry]

In spite of the difficulties to define the term "culture" there is agreement with regards to its profound influence in the contemporary social environment of which medicine and psychiatry are important components. Cultural psychiatry studies psychopathology inasmuch as it reflects and it is subjected to the influence of cultural factors within the biopsychosocial context. Its contemporary clinical dimensions cover five fundamental areas: culture as an interpretive/explanatory instrument of human behavior; as a pathogenic/pathoplastic agent; as a diagnostic/nosological factor; as a therapeutic/protective element, and as a tool for management and service delivery. This paper examines the conceptual nature of each of these roles and presents pertinent examples from the clinical literature, away from theoretical lucubrations. The cultural legacy of each and every patient seen by the psychiatrist or any other mental health professional demands serious studies and effective actions at all levels.