The quality of life of HIV-infected women is associated with psychiatric morbidity

This study evaluated the effect of clinical, demographic and psychiatric factors on the health-related quality of life of 76 women with HIV infection seen in two HIV reference centres in Brazil. The generic questionnaire for evaluation of Health-Related Quality of Life (SF-36), the Hospital Anxiety and Depression Scale (HAD) and the Clinical Interview Schedule (CIS-R) were used. The statistical tests included the covariance analysis. The patients' mean age was 37.4 years; 44.7% had less than 8 years of schooling. A total of 44.8% were asymptomatic, 28.9% symptomatic non-AIDS and 26.3% had AIDS. Most (77.6%) used two or three kinds of antiretrovirals; 36.8 and 30.3% achieved scores for anxiety and depression, respectively (HAD); and 48.7% for conspicuous psychiatric morbidity (CIS-R). The sub-group of the non-AIDS symptoms (clinical stage B) showed the worst quality of life. The variables which better explained the scoring variation on both the mental and physical components of the SF-36 were related to mental health. The more mental symptoms present, the worse the health-related quality of life. We must rethink care strategies in the area of mental health which are directed toward HIV+ patients, by virtue of the levels of mental symptoms found and the request for care which the research revealed.

Repetition of suicide attempts: data from emergency care settings in five culturally different low- and middle-income countries participating in the WHO SUPRE-MISS Study

BACKGROUND

Attempted suicide is a strong risk factor for subsequent suicidal behaviors. Innovative strategies to deal with people who have attempted suicide are needed, particularly in resource-poor settings.

AIMS

To evaluate a brief educational intervention and periodic follow-up contacts (BIC) for suicide attempters in five culturally different sites (Campinas, Brazil; Chennai, India; Colombo, Sri Lanka; Karaj, Islamic Republic of Iran; and Yuncheng, People's Republic of China) as part of the WHO Multisite Intervention Study on Suicidal Behaviors (SUPRE-MISS).

METHODS

Among the 1,867 suicide attempters enrolled in the emergency departments of the participating sites, 922 (49.4%) were randomly assigned to a brief intervention and contact (BIC) group and 945 (50.6%) to a treatment as usual (TAU) group. Repeated suicide attempts over the 18 months following the index attempt - the secondary outcome measure presented in this paper - were identified by follow-up calls or visits. Subsequent completed suicide - the primary outcome measure - has been reported in a previous paper.

RESULTS

Overall, the proportion of subjects with repeated suicide attempts was similar in the BIC and TAU groups (7.6% vs. 7.5%, chi(2) = 0.013; p = .909), but there were differences in rates across the five sites.

CONCLUSIONS

This study from five low- and middle-income countries does not confirm the effectiveness of brief educational intervention and follow-up contacts for suicide attempters in reducing subsequent repetition of suicide attempts up to 18 months after discharge from emergency departments.

Is religiosity a protective factor against attempted suicide: a cross-cultural case-control study

This cross-cultural study investigates whether religiosity assessed in three dimensions has a protective effect against attempted suicide. Community controls (n = 5484) were more likely than suicide attempters (n = 2819) to report religious denomination in Estonia (OR = 0.5) and subjective religiosity in four countries: Brazil (OR = 0.2), Estonia (OR = 0.5), Islamic Republic of Iran (OR = 0.6), and Sri Lanka (OR = 0.4). In South Africa, the effect was exceptional both for religious denomination (OR = 5.9) and subjective religiosity (OR = 2.7). No effects were found in India and Vietnam. Organizational religiosity gave controversial results. In particular, subjective religiosity (considering him/herself as religious person) may serve as a protective factor against non-fatal suicidal behavior in some cultures.

Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries

OBJECTIVE

To determine whether brief intervention and contact is effective in reducing subsequent suicide mortality among suicide attempters in low and middle-income countries.

METHODS

Suicide attempters (n = 1867) identified by medical staff in the emergency units of eight collaborating hospitals in five culturally different sites (Campinas, Brazil; Chennai, India; Colombo, Sri Lanka; Karaj, Islamic Republic of Iran; and Yuncheng, China) participated, from January 2002 to October 2005, in a randomized controlled trial to receive either treatment as usual, or treatment as usual plus brief intervention and contact (BIC), which included patient education and follow-up. Overall, 91% completed the study. The primary study outcome measurement was death from suicide at 18-month follow-up.

FINDINGS

Significantly fewer deaths from suicide occurred in the BIC than in the treatment-as-usual group (0.2% versus 2.2%, respectively; chi2 = 13.83, P < 0.001).

CONCLUSION

This low-cost brief intervention may be an important part of suicide prevention programmes for underresourced low- and middle-income countries.

Psychosocial conditions and suicidal behavior in pregnant teenagers : a case-control study in Brazil

OBJECTIVE

To compare the psychosocial profile and suicidal behavior of 110 pregnant teenagers (PT) with 110 non-pregnant teenagers (NPT).

METHOD

Subjects were matched by age and residential district. The research instruments used were a structured clinical interview and a self-reporting questionnaire based on psychometric scales whose answers were subjected to univariate and multivariate logistic regression.

RESULTS

Prevalence in the PT and the NPT groups were found to be as follows: attempted suicide (20.0 vs. 6.3%); depression (26.3 vs. 13.6%); anxiety (43.6 vs. 28.0%). Univariate analysis revealed the following significant associations with pregnancy: relocation in the previous 3 years (odds ratio (OR) = 6); years of schooling < or =7 (OR = 3.4); repeating a year in school (OR = 2.4); dropping out of school (OR = 5.2); death of a parent during childhood (OR = 2.9); use of alcohol/drugs in the family (OR = 2.5); previous attempted suicide (OR = 3.6); suicide by a relative (OR = 2.1); threats of physical/sexual abuse (OR = 3.5); depression (OR = 2.2); low level of social support (OR = 4.2); traumatic events (OR = 5.1) and psychosocial difficulties (OR = 4.4); prior use of tobacco and marijuana (OR = 4.0 and 4.8 respectively); weekly intake of alcohol over the previous 12 months (OR = 4.2). Multivariate analysis identified the following associations: relocation (OR = 6.4); prior use of tobacco (OR = 2.9); dropping out of school for a period in excess of 6 months (OR = 2.3); suicide by a social acquaintance (OR = 2.5).

CONCLUSION

The PT case group exhibited a psychosocial profile whose characteristics clearly differentiate this group from the NPT control group. Preventive mental health care is needed to help PT because their behavioral pattern exposes them to high risk for suicide.

Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries

OBJECTIVE

To determine whether brief intervention and contact is effective in reducing subsequent suicide mortality among suicide attempters in low and middle-income countries.

METHODS

Suicide attempters (n = 1867) identified by medical staff in the emergency units of eight collaborating hospitals in five culturally different sites (Campinas, Brazil; Chennai, India; Colombo, Sri Lanka; Karaj, Islamic Republic of Iran; and Yuncheng, China) participated, from January 2002 to October 2005, in a randomized controlled trial to receive either treatment as usual, or treatment as usual plus brief intervention and contact (BIC), which included patient education and follow-up. Overall, 91% completed the study. The primary study outcome measurement was death from suicide at 18-month follow-up.

FINDINGS

Significantly fewer deaths from suicide occurred in the BIC than in the treatment-as-usual group (0.2% versus 2.2%, respectively; chi2 = 13.83, P < 0.001).

CONCLUSION

This low-cost brief intervention may be an important part of suicide prevention programmes for underresourced low- and middle-income countries.

Religião e transtornos mentais em pacientes internados em um hospital geral universitário

A fim de determinar a prevalência de transtornos mentais em uma amostra de pacientes de um hospital geral e sua relação com a denominação religiosa e religiosidade, foram investigados 253 pacientes internados no Hospital das Clínicas da Universidade Estadual de Campinas por intermédio de um questionário sócio-demográfico e um instrumento para diagnóstico psiquiátrico (MINI-Plus). A maioria dos pacientes era católica (63,2%; n = 177); seguidos dos evangélicos pentecostais (20,4%; n = 57); dos "sem-religião" (7,5%; n = 21); espíritas (4,3%; n = 12) e protestantes históricos (2,3%; n = 8). Consideraram-se muito religiosos 43,2% (n = 116), religiosos 46,9% (n = 129), pouco religiosos 9,8% (n = 27), não religiosos 1,1% (n = 3). A filiação religiosa evangélica e maior freqüência a cultos relacionaram-se à menor freqüência de problemas com álcool. É possível que a filiação religiosa evangélica exerça uma ação inibidora na ocorrência de transtornos relacionados ao álcool. Indivíduos muito religiosos ou pouco/nada religiosos apresentaram maior prevalência de transtorno bipolar. A dimensão intensidade da religiosidade revelou-se modestamente associada à prevalência geral dos transtornos, especialmente ao transtorno bipolar. É razoável que situações extremas (de muito ou reduzido envolvimento) relacionem-se a tal achado, relacionando tanto a busca exacerbada ou o afastamento da religiosidade com estados mentais alterados.

Maintained attitudinal changes in nursing personnel after a brief training on suicide prevention

Nursing personnel (N = 317) working at a general hospital attended a 6-hour training program on suicide prevention. They answered anonymously pre- and post-training the Suicide Behavior Attitude Questionnaire (SBAQ), which comprises 21 visual analogue scale items divided in three factorial subscales. The results indicated there were positive changes in the attitudes and these gains were significantly maintained at the 6-month follow-up evaluation. Improvement was in the Feelings and Professional Capacity subscales (ANOVA; p = 0.0001 and 0.01, respectively). There was no change on the Right to Suicide subscale. Because attitudes influence the effectiveness of health care personnel interventions, our findings may have important implications for the development of suicide prevention programs.

Concurrent validity, internal consistency and responsiveness of the portuguese version of the king's health questionnaire (KHQ) in women after stress urinary incontinence surgery

OBJECTIVE

To evaluate the concurrent validity, internal consistency and responsiveness of King's Health Questionnaire (KHQ) in patients who underwent sling procedures for the treatment of stress urinary incontinence.

MATERIALS AND METHODS

We performed a prospective open label multicenter study in 4 tertiary referral centers. Sixty-eight female patients were enrolled with urodynamically diagnosed urinary stress incontinence. Patients were treated using surgical procedures, mostly (73%) with the synthetic sling procedure, which has been considered one of the gold standard methods for the treatment of urinary incontinence. The patients were assessed before and after one month of postoperative follow up, using the KHQ in its validated Portuguese version. Patients also underwent preoperative urodynamic test, Stamey incontinence grading, pad usage and the assessment of number of pads used per day. After surgery, patients underwent stress test, Stamey incontinence grading pad usage and the assessment of number of pads used per day.

RESULTS

The concurrent validity showed good correlations in some domains of KHQ to clinical parameters. The internal consistency was higher after treatment compared to preoperative values. Objective parameters, such as pad usage and the assessment of number of pads used per day, had significant correlation with changes in post-treatment scores on KHQ. The responsiveness expressed in terms of standardized effect size (SES) and standardized response mean (SRM) was large.

CONCLUSION

The results showed moderate concurrent validity, strong internal consistency and high responsiveness for KHQ, indicating that it is suitable for measuring outcomes in clinical trials among female patients with stress urinary incontinence.

A semistructured interview for psychologycal autopsy: an inter-rater reliability study

This study developed and evaluated the inter-rater reliability of a semistructured interview for psychological autopsy (SIPA). The SIPA is composed of 69 items that are distributed into four modules (precipitators and stressors, motivation, lethality, intentionality). The interviews of 42 subjects, related to 21 cases of suicide, were audiotaped and then transcribed and evaluated by the interviewer, and also evaluated by a research assistant and two referees who all acted independently. The SIPA was able to provide information that demonstrated a high degree of concordance (kappa) among the raters. The results of this study demonstrate that the SIPA is a very reliable instrument for psychological autopsy in cases of suicide.

[Patients who benefit from psychiatric admission in the general hospital]

OBJECTIVES

Psychiatric hospitalization though burdensome remains a very important therapeutic option for severely-ill psychiatric patients. Hospitalization in general hospital psychiatry units (GHPU) are often regarded as the best option. A study was carried out with the purpose of assessing socioeconomic and medical variables associated with success and failure of hospitalization.

METHODS

A review was performed on sociodemographics and medical data of 1,463 patients admitted to a general hospital's GHPU in the period between 1986 and 1997. Statistical analysis was conducted using univariate and multivariate polythomic logistic regression.

RESULTS

In the multivariate analysis three factors were identified as associated to poor hospitalization outcomes (poor condition at discharge and longer hospital stay): age >60 years, poor social functioning, and diagnosis of organic mental disorder.

CONCLUSIONS

Although 80% of the patients experienced a considerable symptomatic improvement, a small group benefited less from hospitalization. It is suggestive that these patients would benefit more from psychosocial interventions.

Restructuring mental health: a South American survey

BACKGROUND

There is little information available on the changes in mental health services in South American countries following the social and political upheavals of recent decades.

METHODS

A postal survey was conducted of all South American countries (health ministries, national psychiatric associations and key informants) to assess the development of mental health programs and the organization of alternative psychiatric care centers such as the psychiatric units in general hospitals (PUGH).

RESULTS

Most of the mental health programs were implemented during the 1980s and 1990s, and aimed at incorporating psychiatric care into primary health care, as well as relocating provision from large hospitals to decentralized services. Most of the countries surveyed have less than 0.5 psychiatric beds per 1000 inhabitants. This change reflects a tendency to reduce the total number of psychiatric beds and increase the number of PUGH. Over the last 10 years this increase was significant in some countries (50-75%), but was not reflected in the availability of adequate human and material resources.

CONCLUSIONS

A transition from a system based on large mental hospitals to alternative service provision is on the way in South American countries. Intensive efforts have to be made to collect and disseminate information, as well as to monitor the development and outcome of the mental health programs in these countries.

Physician-patient communication in the prevention of female reproductive tract infections: some limitations

The objective of this study was to describe the information that women with tubal infertility recalled having received from physicians when they consulted for a reproductive tract infection (RTI) and the information physicians reported having provided to women consulting for RTIs. Interviews were conducted with 16 women presenting primary tubal infertility selected on the basis of purposeful sampling criteria. Also, 15 physicians working in the public health network in the city of Campinas, Brazil, were selected at random and interviewed. Analysis of the women's statements concerning previous RTI-related medical consultations showed that they did not recall having received any information on either prevention or the impact of RTI on their reproductive future. Analysis of interviews with physicians showed that the information they provided to women consulting for RTIs was incomplete and unclear. The information women recalled having received and that which physicians remembered having provided at the time of treating a patient with RTI was similar. In conclusion, these women lacked adequate or complete information and that it was probably not possible for them to adopt measures to avoid repetition of RTI and minimize risk of tubal infertility.

[Psychiatric care policies and deinstitutionalization in South America]

INTRODUCTION

The process of restructuring psychiatric care in South America began in the 80's and increased in the 90's. This process had its landmark in the Declaration of Caracas (1990), which reinforced the need for alternative services to the mental hospital.

OBJECTIVES

to analyse the current situation of the psychiatric care in South America, with special emphasis on Psychiatric Units in General Hospitals (PUGHs).

METHODS

Two mail surveys were carried out. Questionnaires were sent to all Ministries of Health, Psychiatric Societies and key informants.

RESULTS

All countries were represented in the returned questionnaires. In 7 countries there is a mental health plan. Material and human resources are inadequate in most countries. There has been a decrease in the total number of psychiatric beds over the last tem years. PUGHs were created in all the countries surveyed.

CONCLUSIONS

All South America countries have a mental health program. A higher percentage of the programs is devoid of an evaluation system and almost all the countries lack budget estimates for mental health care. It was observed that the total number of psychiatric beds has been decreasing in most countries, and that the PUGHs and other decentralized centers were adopted as an alternative to the mental hospital.

Quality of life after partial penectomy for penile carcinoma

OBJECTIVES

To investigate the impact of partial penectomy on the quality of life of patients with carcinoma of the penis.

METHODS

Fourteen patients who had undergone partial penectomy for penile cancer were studied. Their median age was 50.5 years and the median time of follow-up was 11.5 months. The quality of life was evaluated in three dimensions: social adjustment, sexuality, and emotional state. The patients underwent a semistructured interview and were asked to complete the Overall Sexual Functioning Questionnaire, the Social Problem Questionnaire, the General Health Questionnaire, and the Hospital Anxiety and Depression Scale.

RESULTS

In 9 (64%) patients, the overall sexual function was normal or slightly decreased. Only 2 (14%) men had precarious or absent sexual function. The masculine self-image and the relationship with their partners remained practically unchanged in all the patients. Sexual interest and satisfaction remained normal or slightly reduced in 9 and 12 patients, respectively. The frequency of sexual intercourse was unchanged or slightly decreased in 9 patients. Three patients had no sexual intercourse after surgery. No significant levels of anxiety and depression were found. Within the areas of living conditions, family life, and interactions with other people, all the patients remained as they were before the surgery.

CONCLUSIONS

Patients who undergo partial penectomy for penile cancer can maintain the quality of life (in social, psychological, and sexual terms) at levels similar to those that existed in the period before surgery.

[Referral to the psychiatrist in the general hospital: a psychodynamic approach]

INTRODUCTION

It is not clear as to the process by which the psychiatrist attracts referrals and the reasons and motivations that doctors have for referring or not. This study describes the modus operandi of referrals to the psychiatrist in the context of a university general hospital.

METHOD

A semi-structured interview was carried out on 50 doctors (35 male, 15 female) from the teaching hospital of the Universidade Estadual de Campinas, Brazil. Data was analyzed qualitatively, by means of content analysis, according to the psychodynamic approach.

RESULTS

Some referrals need to be worked through in order for the doctor to overcome his resistance. Others are automatic: because something moved him deeply, the doctor directs his anguish and responsibility outside himself, without realizing the motives that lead him to do so.

CONCLUSION

Referral is used in a variety of ways and different things are expected of the psychiatrist, all influenced by unconscious aspects of the patient-doctor-specialist triad.

Attitudes of medical students to necropsy

AIM

To compare the attitudes of students towards the necropsy at different stages of their undergraduate career.

METHOD

Students in the first, fourth and sixth academic years (n = 283) were asked to respond anonymously to a questionnaire comprised of 26 attitude statements. These statements dealt with the importance of the necropsy in medicine, rapport with the bereaved family and emotional reactions to the necropsy.

RESULTS

Of the students, 226 (80%) completed the questionnaire. Overall, the students agreed on/the importance of the necropsy. The three groups differed in 10 statements on the approach to the bereaved family and emotional reactions to the necropsy. First year students showed more personal involvement and would have more difficulties in approaching the family of the deceased as well as in attending a necropsy. These reactions were increasingly less noticeable with fourth and sixth year students. The latter group was also more inclined to accept cremation, organ donation and necropsy of their own corpses.

CONCLUSION

The changes in attitudes towards the necropsy throughout undergraduate study may reflect both the influence of psychological defense mechanisms and the viewing of necropsy as a relevant tool in medical practice. Necropsy should be carefully and sensitively incorporated into programmes designed to teach students about death and dying. This might reduce both their reluctance to seek permission for necropsy and their difficulty in looking after the dying patient.

General practitioners attitudes towards depression: a study in primary care setting in Brazil

A self-report instrument comprising twenty visual analogue scale statements about attitudes towards depression was sent to all 110 general practitioners working in primary health care centres in the city of Campinas, Brazil. The statements of the Depression Attitude Questionnaire (DAQ) cover three main areas: nature of depression, treatment preferences and professional reactions regarding depressed patients. Seventy-eight (71%) doctors returned the questionnaire. Forty-two percent of the doctors believe "it is difficult to differentiate whether patients are presenting with unhappiness or a clinical depressive disorder that needs treatment". Sixty-three percent believe that "antidepressants usually produce a satisfactory result in the treatment of depressed patients in general practice". However, most doctors would refer patients in need of anti-depressants (66%) or psychotherapy (60%) to a specialist. They also view the treatment of depression as "heavy going" (46%) and "unrewarding" (57%). These findings suggest a need for further education of general practitioners on the nature, diagnosis and management of depressive disorders.

[Mood disorders among inpatients in ambulatory and validation of the anxiety and depression scale HAD]

The revised Clinical Interview Schedule (CIS-R) and the Hospital Anxiety and Depression (HAD) Scale were used to estimate the prevalence of mood disorders among 78 consecutive admissions to a general medical ward in a university general hospital in Brazil (43 males and 35 females; mean age = 43.2yr). Interviewers also completed a 5-point symptom severity scales for anxiety and depression. The definition of cases of anxiety [and depression] was based on two criteria: a. score > or = 2 on the CIS-R section of anxiety [> or = 4 on the CIS-R sections of depression and depressive ideas]; and b. score > or = 2 on the clinical severity scale for anxiety [score > or = 2 on the clinical severity scale for depression]. A 39% prevalence rate of affective disorders was found. Sixteen (20.5%) patients met criteria for anxiety, most of the disorders being of mild severity. Twenty-sic patients (33%) were depressed, 7 of them in a moderate degree. The HAD was easily understood by the patients. Anxiety and depression subscales had internal consistency of 0.68 and 0.77, respectively. At a cut-off point of 8/9 sensibility and specificity were 93.7% and 72.6% for anxiety, and 84.6% and 90.3% for depression. HAD items correlated positively with the respective subscales. To a lesser degree, they also correlated with the alternative subscale. Our findings confirm the high prevalence of mood disorders among medical in-patients. In clinical practice, the HAD may have a useful role in detecting those patients requiring further psychological care.

Psychiatric morbidity among medical in-patients: a standardized assessment (GHQ-12 and CIS-R) using 'lay' interviewers in a Brazilian hospital

The 12-item General Health Questionnaire (GHQ-12) and the revised Clinical Interview Schedule (CIS-R) were used to estimate the prevalence of psychiatric morbidity among 78 consecutive admissions to a general medical ward in a Brazilian university hospital (43 males and 35 females; mean age = 43.2 years). The CIS-R was administered by three 5th-year medical students after a brief training. A prevalence rate of 36% was found for psychiatric disorders. The most frequent symptoms were sleep disorders (48.7%), worry (35.9%), depression (28.2%) and anxiety (26.9%). The sensitivity and specificity of the GHQ-12 were 71% and 76%, respectively. The CIS-R was simple to administer and acceptable both to patients and interviewers. Misunderstanding was most likely to occur with the poorly educated (20% were illiterate) in questions involving time calculation. Alternative options might be used to specify the length of time in future studies. The findings support the feasibility of the CIS-R and the use of 'lay' interviewers to produce epidemiological information on psychiatric disorders in developing countries at lower costs.

Consultation-liaison psychiatry in Brazil. Psychiatric residency training

A mailing survey assessed consultation-liaison (C-L) service delivery and training among all 23 approved psychiatric residency training programs throughout the country. Twenty questionnaires were returned. Outpatient, inpatient, emergency, and consultation services were present together in 35% of the academic hospitals where residency training took place. Consultation service was provided by 18 (90%) responding programs. Eleven of those reported C-L training as part of their general psychiatry rotation. Nevertheless, educational objectives, weekly case conferences, and didactic seminars were provided by only five of them. The training time varied from 40 to 560 hours, 190 hours on average. The same five programs offered an elective third-year residency training, including liaison with specific units. The results illustrate the migration of academic psychiatric departments from the psychiatric hospital to the general hospital as well as the beginning of C-L training programs in Brazil.