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Depressive and anxiety disorders are highly comorbid, which has been theorized to be due to an underlying internalizing vulnerability. We aimed to identify groups of participants with differing vulnerabilities by examining the course of internalizing psychopathology up to age 45.
We used data from 24158 participants (aged 45+) in 23 population-based cross-sectional World Mental Health Surveys. Internalizing disorders were assessed with the Composite International Diagnostic Interview (CIDI). We applied latent class growth analysis (LCGA) and investigated the characteristics of identified classes using logistic or linear regression.
The best-fitting LCGA solution identified eight classes: a healthy class (81.9%), three childhood-onset classes with mild (3.7%), moderate (2.0%), or severe (1.1%) internalizing comorbidity, two puberty-onset classes with mild (4.0%) or moderate (1.4%) comorbidity, and two adult-onset classes with mild comorbidity (2.7% and 3.2%). The childhood-onset severe class had particularly unfavorable sociodemographic outcomes compared to the healthy class, with increased risks of being never or previously married (OR = 2.2 and 2.0, p < 0.001), not being employed (OR = 3.5, p < 0.001), and having a low/low-average income (OR = 2.2, p < 0.001). Moderate or severe (v. mild) comorbidity was associated with 12-month internalizing disorders (OR = 1.9 and 4.8, p < 0.001), disability (B = 1.1–2.3, p < 0.001), and suicidal ideation (OR = 4.2, p < 0.001 for severe comorbidity only). Adult (v. childhood) onset was associated with lower rates of 12-month internalizing disorders (OR = 0.2, p < 0.001).
We identified eight transdiagnostic trajectories of internalizing psychopathology. Unfavorable outcomes were concentrated in the 1% of participants with childhood onset and severe comorbidity. Early identification of this group may offer opportunities for preventive interventions.
Major depressive disorder (MDD) is a leading cause of morbidity and mortality. Shortfalls in treatment quantity and quality are well-established, but the specific gaps in pharmacotherapy and psychotherapy are poorly understood. This paper analyzes the gap in treatment coverage for MDD and identifies critical bottlenecks.
Seventeen surveys were conducted across 15 countries by the World Health Organization-World Mental Health Surveys Initiative. Of 35 012 respondents, 3341 met DSM-IV criteria for 12-month MDD. The following components of effective treatment coverage were analyzed: (a) any mental health service utilization; (b) adequate pharmacotherapy; (c) adequate psychotherapy; and (d) adequate severity-specific combination of both.
MDD prevalence was 4.8% (s.e., 0.2). A total of 41.8% (s.e., 1.1) received any mental health services, 23.2% (s.e., 1.5) of which was deemed effective. This 90% gap in effective treatment is due to lack of utilization (58%) and inadequate quality or adherence (32%). Critical bottlenecks are underutilization of psychotherapy (26 percentage-points reduction in coverage), underutilization of psychopharmacology (13-point reduction), inadequate physician monitoring (13-point reduction), and inadequate drug-type (10-point reduction). High-income countries double low-income countries in any mental health service utilization, adequate pharmacotherapy, adequate psychotherapy, and adequate combination of both. Severe cases are more likely than mild-moderate cases to receive either adequate pharmacotherapy or psychotherapy, but less likely to receive an adequate combination.
Decision-makers need to increase the utilization and quality of pharmacotherapy and psychotherapy. Innovations such as telehealth for training and supervision plus non-specialist or community resources to deliver pharmacotherapy and psychotherapy could address these bottlenecks.
Direct numerical simulations (DNS) of spatially evolving turbulent planar jets of viscoelastic fluids described by the FENE-P model, such as those consisting of a Newtonian fluid solvent carrying long chain polymer molecules, are carried out in order to develop a theory for the far field of turbulent jets of viscoelastic fluids. New evolution relations for the jet shear-layer thickness
, centreline velocity
and maximum polymer stresses
are derived and validated by the new DNS data, yielding
, respectively, where
is the coordinate in the streamwise direction. It is shown that, compared with a classical (Newtonian) turbulent jet, the effect of the polymers is to reduce the spreading rate, centreline velocity decay, Reynolds stresses and viscous dissipation rate. The self-preserving character of the flow is analysed and it is shown that profiles of mean velocity, Reynolds stresses and polymer stresses are self-similar provided the proper scales are used in the normalisation of these quantities. A fundamental difference from the Newtonian jet in this regard is the necessity for two, instead of only one, different velocity and length scales to properly characterise the evolution of the turbulent flow. These extra velocity and length scales are directly related to a time scale associated with the characteristic fading memory property of viscoelastic fluids.
This research communication describes the influence of diet, mammary quarter position and milking process on the temperature of teats and udder of cows fed diets containing different lipid sources. Five primiparous cows were fed diets containing cottonseed, sunflower seed, soybeans or soybean oil as a source of lipids and a reference diet without the inclusion of lipid sources in a 5 × 5 Latin Square design. Milk yield was determined in the last five days of each period. Milk samples were collected for SCC analysis on the last two days of each experimental period. The images of the mammary gland were obtained using an infrared camera and were analyzed with appropriate computer software. Milk yield was 14.8% higher for cows fed soybeans as a source of lipids. Diets and somatic cell counts did not influence the temperature of teats and udder. The milking process reduced the temperature of teats and udder by 0.79°C. Rear teats and rear quarters had higher surface temperatures than front teats and fore quarters. Changes in temperature of teats and mammary quarters occurred as a function of the milking process and quarter position. However, the diet and the SCC did not influence the temperature of teats and mammary quarters in this experiment.
Background: Telemedicine has been defined as the use of technology to provide healthcare when the provider and patient are geographically separated. Use of telemedicine to meet the needs of specific populations has become increasingly common across Canada. The current study employs the Ontario Telemedicine Network (OTN) to connect the emergency departments of a community hospital system and a pediatric tertiary care hospital. OTN functions through a two-way video conferencing system, allowing physicians at the tertiary site to see and hear the patient being treated in the community hospitals. Aim Statement: The aim of this project is to ensure essential care is provided to CTAS 1 and 2 pediatric patients who present to Niagara Health emergency departments, to increase the number of appropriate patient transfers. Measures & Design: Data for this project include a) description of common diagnoses, b) time of call, c) occurrence of transfers, and d) professional perceptions of the technology. A descriptive design was used together with the implementation of quality improvement cycles as the intervention occurred. Quality improvement methodologies including plan-do-study-act (PDSA) cycles ensured continuous improvement to the process of OTN use and therefore patient safety throughout the study. Evaluation/Results: Since the intervention was employed on December 17, 2018 there have been a total of 19 cases for which 4 transfers were requested. Changes to the process were made including the addition of weekly technology tests and feedback to health professionals involved to garner further support for the use. Results have indicated that seizure was the most common diagnosis, accounting for 37% of cases. The majority of calls were placed after 19:00 hours with no calls being placed between 24:00 and 10:00. Discussion/Impact: Healthcare providers had positive perceptions of the technology agreeing that decision making between on-site and remote teams was timely and collaborative, as well as that patient care and outcomes were improved with its use. The results of this study will be used to determine the benefits of employing telemedicine in the emergency departments of other hospital systems.
There is a substantial proportion of patients who drop out of treatment before they receive minimally adequate care. They tend to have worse health outcomes than those who complete treatment. Our main goal is to describe the frequency and determinants of dropout from treatment for mental disorders in low-, middle-, and high-income countries.
Respondents from 13 low- or middle-income countries (N = 60 224) and 15 in high-income countries (N = 77 303) were screened for mental and substance use disorders. Cross-tabulations were used to examine the distribution of treatment and dropout rates for those who screened positive. The timing of dropout was examined using Kaplan–Meier curves. Predictors of dropout were examined with survival analysis using a logistic link function.
Dropout rates are high, both in high-income (30%) and low/middle-income (45%) countries. Dropout mostly occurs during the first two visits. It is higher in general medical rather than in specialist settings (nearly 60% v. 20% in lower income settings). It is also higher for mild and moderate than for severe presentations. The lack of financial protection for mental health services is associated with overall increased dropout from care.
Extending financial protection and coverage for mental disorders may reduce dropout. Efficiency can be improved by managing the milder clinical presentations at the entry point to the mental health system, providing adequate training, support and specialist supervision for non-specialists, and streamlining referral to psychiatrists for more severe cases.
Sociologists and anthropologists have long been engaged to study the changes in society, over time. This is particularly true since the end of the nineteenth century and beginning of the twentieth century, heights of history, that caused profound changes in the forms of relationships between men, in family scale and in the society itself. The industrial revolution, the exodus to the city, the emancipation of women, the world wars, the creation of the European economic community, the mass media and consumerism, have profoundly altered the social networks and engagement in which man lived since ancient times. The authors aim to address this issue, by trying to understand the behavioral changes that were needed to adapt to this new structure of society and in what way they were responsible for the loss of mechanisms of cooping, with the anti - social behaviour, with stress and depression.
The Portuguese example is finally exploited, given the most significant changes in the last century, as the fall of the monarchy, the instability of the early republic, the dictatorship, the colonial war, the April 25, the entry into the EEC.
Recent studies involved the pathways of kinases regulated by extracellular signal (ERK - extracellular signal regulated kinases), a broad range of key cellular processes, in the mechanisms of depression and consequently in the action of antidepressants. It is also known that the use of specific inhibitors of phosphorylation of ERKs1 / 2 showed to have antidepressant effect in animal models. Fluoxetina (SSRI) was recently discovered to be a potente inhibitor of phosphorylation of ERKs. The ERKs1 / 2 and recently the 3, are present in neurons and glia, these also engaged in biological mechanisms of depression.
The authors propose to do, based on the current literature, the characterization of the type (s) of cell (s) where changes in activation of ERKs1 / 2, occur during depression, and during the administration of antidepressants, in order to understand, to what extent these kinases may be considered as biological markers of depression. Possibly also to examine the feasibility of using these markers in clinical use.
Several studies have been conducted to establish a profile of the suicidal/parasuicidal patient. Also several factors have been identified as possibly influencing the suicidal rates, including the religious practices.
Characterize the profile of suicidal behavior in a sample of patients followed in a general psychiatric consultation.
It was done an analytical observational study of a random sample of 100 patients followed in a general psychiatric consultation. A survey was conducted with the collection of socio-economic, religious aspects and clinical data, and it was consulted the patient"s clinical process. Data analysis was done in Excel 2003.
The sample was consisted mostly by women (74%), being the most representative age group between 40 and 50 years (27%), mostly married (61%), 24% had 2 children and 65% lived in the rural area. The clinical diagnosis (ICD-9) was in 46% of cases, neurotic depression. 52% consider themselves religious not practitioners, being 90% catholics. History of suicide attempts/parasuicide occurred in 32% of patients, in the form of drug intoxication (31%) or with another method (11%). Most of the individuals said to have already thought about suicide at least once in their lifetime (74%). Only 8% had current suicidal ideation. Family history of suicide occurred in 27%, particularly in first degree family members, mainly by drowning (7%) and hanging (7%).
Our results suggest that exists a high prevalence of suicidal behavior in this patients. For that reason, it should be done a systematic screening for suicidal ideation in this risk population.
In the 20th century, scientists attempted to limitate the workings of the mind onto the brain by detailing its anatomy and physiology. The task of localizing function, however, has proven to be very difficult than initially presumed, with almoust all regions of the brain subserving a variety of processes and having only loose coupling of structure and function. As we know, the majority of neuropsychological tests and the brain capacities they tap lack brain regional specificity. This is a complex and sophisticated problem, that gets much worse in the brain that is compounded significantly by damage or disease. However, in the past two decades, neuroimaging has rekindled and renewed enthusiasm for unraveling brain function. Recent studies of cerebral image show “in vivo” what had already been proven in the laboratory: there are multiples neuroquimical changes in cortical and subcortical areas of the brain in psychiatric patients.
Amongst the many techniques and technologies that have been developed, functional magnetic resonance imaging (fMRI) has proven to be one of the most exciting and perhaps the most used. It has permitted unprecedented access to the living brain. The authors propose to do a brief review on the late descoverys and studys that have been done with neuroimage.
Suicide is represented in the arts since the beginning of time. Since the time of the Roman Impire to Impressionism, Rafaelism or even Modern art, the suicide has a significant expression in the arts striking over the centuries and in various civilizations.
The authors propose to characterize the various forms of art that represented the suicide and its concept. Since classicism, the liturgical representation of suicide, almost disappeared. IT rebirth “by the new art,” were the various representations of the suicide were seen as “representative” of several current and various forms of contest the new society.
The suicide in the arts is the sociological expression how societies deal with this issue.
The authors describe case of a male of 48 years old admitted in an acute psychiatric unit with psychomotor restlessness, temporal disorientation and severe distractibility, although prior to the admission he had shown symptoms of apathy and social retraction suggesting a depressive syndrome. This was a patient without prior psychiatric history, with a good psychosocial functioning and well adjusted prior personality. Within one year, there was a change in his personality and the appearance of an inadequate social conduct, with an insidious onset and gradual progression. CT scan and MRI showed lobar fronto-temporal atrophy. The SPECT showed also changes consistent with a fronto-temporal dementia. During the admission he manifested hyperactivity, some desinhibition, mental rigidity, inflexibility, stereotyped behaviors and persevering with continuous walking and changes in eating habits, alternating severe anorexia with hyperphagia. He also presented distractibility, poor speech with loss of spontaneity, an indifferent attitude, emotional flattening and lack of insight for his condition. In the neuropsychological evaluation initially existed only prejudice of the frontal lobes functions, with preservation of other cognitive functions, but gradually evolved. Addressing to the therapy, it were used various drugs, including SSRI"s, that until now have not proved to be effective in controlling the symptoms, highlighting the difficulty in the psychopharmacological approach of FTD.
The present 6 month follow-up study was conducted to investigate the possible influence of comorbid personality disorders on drug treatment, as well as associated psychopathology and HIV-related risk behaviors outcomes.
Subjects and methods
Data were collected initially from a consecutive sample of 74 patients with a diagnosis of opiate abuse or dependence, admitted for inpatient detoxification.
During intake, 80.9% of patients reported at least one HIV-related risk behavior in the previous 6 months. Not using condoms during sexual intercourse was the most common and the only risk behavior that showed a statistically significant reduction over the follow-up period. A total of 58.1% of subjects had at least one personality disorder (PD). Borderline PD was the most prevalent. However, antisocial PD was the only PD that influenced substance use outcomes. The presence of this diagnosis increased the chance of worse opiate use outcomes, but decreased likelihood of not using condoms. Patients with low obsessive–compulsive PD dimensional scores showed a significant increase in the number of risk behaviors. However, these influences were only seen at the 3-month follow-up assessment.
These results suggest that personality disorders need to be considered when planning effective interventions for opiate dependent individuals and when preparing and evaluating HIV risk-reduction interventions, particularly for the more severe substance dependent patients.
It is often assumed that sexuality in the classical world was experienced in a free manner, without the censorship imposed during the midle ages. We also know that this culture is characterized by the symbolism and implicit messages, present in the speech, art, literature, always targeting a knowledge that would allow the spirit to achieve a higher level and be more perfect. But how was sexuality actually experienced by these people? What were their interests, what were their fears, and how were they transmitted? How did they related affection and sexuality? Using the metaphor of representations in erotic art, the authors seek to address the issue of sexuality in ancient world and how it may be compared to current affairs. Using for examples the art of ceramics (eg: the author Triptolemus), sculpture (eg: the statue from Herculaneum) and painting (eg: fresh Pompeii), the authors try to make a pictorial journey by the theme of sexuality and their role in society, as an interface between man with himself and with nature.
In 2007 the Government launched a new Mental Health Plan (MHP), written in the spirit of international principles, including the WHO 2001 Global Mental Health Report and the Helsinki European Declaration. The new MHP includes a special section with guidelines for Child and Adolescent Mental Health Services (CAMHS) development. This is relevant, given that, according to WHO, 2 million young people in Europe suffer from mental disorders, sometimes receiving no care.
Regarding mental health needs of the children and youth, the MHP focus on i. how to develop new CAMHS in public general hospitals, across the country, and ii. how to integrate CAMHS in the general health system (including primary care), in order to promote access and decrease stigma.
A national task force has been empowered by the Government to assure the implementation of the MHP, with external monitoring from WHO. This task force includes a team of child and adolescent mental health experts, belonging to different administrative catchment areas throughout the country.
Relevant advances have been: appraisal of current resources, development of new CAMHS, planning of residential and day unit facilities for adolescents, mental health promotion and domestic violence prevention programmes, advocacy and stigma.
Despite several positive outcomes, CAMHS evaluation detected significant problems (access, equity and quality of care). Special attention should be given to CAMHS, namely through the increase of new services and new teams. Nevertheless, given the present crisis context, broad policies can negatively influence and restraint the mental health plan implementation.
Although some improvements during the last decade, Portuguese mental health services still bear substantial shortages, in terms of accessibility, equity and quality of care. A new National Mental Health Plan with a community model has been launched in 2007.
To assess unmet needs at public mental health services in Portugal.
Cross-sectional study, steering all the public mental health services throughout the country, both for adults (39 units) and children/adolescents (11 units). Evaluation was done by means of the WHO “Quality Assurance in Mental Health Care” tool, which includes dimensions such as physical environment, administrative arrangements, care process, interaction with families, outreach, discharge and follow-up.
The quality of services, according to the assessment made with the participation of professionals, did not reach the “Good level” (> 80% met needs). Level of unmet needs was worse in adult outpatient services (35%) than in inpatient units (27%, despite the relevance of the former. Most critical areas of unmet needs included human resources (only 44% met needs, concerning provision, distribution, interdisciplinary composition of the staff) and administrative arrangements (66% met needs). Regarding the child/adolescent units, the weighted level of quality of outpatient services (67% met needs) was similar to that of inpatient units (68%).
The implementation of the mental health plan has to tackle some of the unmet needs present in mental health services in Portugal. Special attention should be given to the outpatient facilities, in order to undertake with the community philosophy of the National Mental Health Plan.
Following the principles and recommendations of international institutions and documents (e.g., WHO, European Union, WHO 2001 Global Mental Health Report and the Helsinki European Declaration), the Portuguese Government launched a new Mental Health Plan (MHP), to be implemented from 2007 to 2016.
a) To evaluate the current situation of mental health facilities in Portugal,
b) assess the feasibility of national training programmes and
c) to ascertain the key obstacles of the execution of the Mental Health Plan.
Level of achievements was appraised by i. A full assessment piloted by the Portuguese National Coordination for Mental Health and ii. a cross-sectional evaluation conducted by a task force from WHO-European Regional Office.
So far the MHP has been moderately executed. Relevant accomplishments include: closing of psychiatric hospitals (40% of chronic patients deinstitutionalized), creation of 20 mental health services for adults, children and adolescents, training of 650 professionals, sponsoring of 46 community mental health projects, launching the residential and supported care network with the Health and Social Affairs Ministries.
Significant challenges persisting are:
a) To increase provision of crisis services and residential places,
b) To strength the role of primary care services regarding common mental disorders,
c) To reinforce the role of non-medical professionals in MHS and
d) To change the financing system that has disincentives to establish community based services.
According to WHO, 2 million young people in Europe suffer from mental disorders, sometimes receiving no care. in 2007, the Portuguese Government set a new Mental Health Plan (MHP), which included guidelines for Child and Adolescent Mental Health Services (CAMHS) development. Although positive aspects have been achieved, CAMHS evaluation identified significant deficiencies (accessibility, equity and quality of care).
In what concerns children and adolescents, the MHP aims:
To program new CAMHS in every central and district hospital, in order to cover the entire country.
To ensure equity and promote human rights.
To decentralise and integrate mental health in the general health system (including primary care) in order to increase access and reduce stigma;
A National Coordination Body for Mental Health has been empowered to assure the implementation of the MHP, with external monitoring from WHO. This Coordinating Body includes a team of child and adolescent mental health experts.
There have been significant improvements in several key areas: diagnosis of current situation (structures, human resources), creation of new CAMHS, reshaping financing model proposals, planning of residential and day unit facilities for adolescents with double diagnosis, mental health promotion and domestic violence prevention programmes, advocacy and stigma.
The MHP can help to overcome some of the problems present in MHS in Portugal. Special attention should be given to CAMHS, namely through the increase of new services and new teams. Nevertheless, given the present crisis context, broad policies can negatively influence and restraint the mental health plan implementation.
Regarding mental health problems in Portugal the most vulnerable groups seem to exhibit a higher risk than in the rest of Europe. the organisational model remains excessively centred on doctors and on intra-hospital interventions. Investment in human resources has a central role in the new Portuguese Mental Heath Plan.
To evaluate the profile of the MH teams and its adequacy to the MH needs of the population.
National survey covering every public MH service.
Portugal (10 million inhabitants) has 2500 MH professionals in the public MH services, concentrated in Lisbon, Oporto and Coimbra. for less that half the population, these 3 cities have 72% of total psychiatrists, 74% of the child psychiatrists, 70% of psychologists, 71% of MH Nurses, 68% of all OT's and 75% of SW's.
The rural regions (10% of total population) have about 4% of total psychiatrists and child psychiatrists, undermining access to care.
Hospitals assisting the same number of population can have ratio asymmetries of number of psychiatrists/population between 1.3/100 000 and 12.6/100 000.▮
The scarcity of resources is a factor that hampered the improvement of MH services in Portugal. MH teams continue to rely on a small number of psychologists, nurses, social workers, occupational therapists and other non-medical professionals, with most teams maintaining the traditional model of delivery of care.
The management and financing model of the services represents a restraint to the development of MH services.
Mephedrone is a synthetic cathinone derivative included in the class of “New-Novel Psychoactive Substances”. Synthetic cathinones are marketed as “bath salts” or “plant food” and gained notable popularity for similar effects to 4-methylenedioxymethamphetamine (MDMA, ecstasy), or amphetamines. Mephedrone is commonly consumed simultaneously with alcohol.
Objectives and aims
The aim of the present study was to evaluate the interactions between mephedrone and ethanol in humans.
Twelve healthy male, recreational users of psychostimulants participated as outpatients in four experimental sessions. They received a single oral dose of mephedrone (200 mg) and alcohol (0.8 g/kg), mephedrone placebo and alcohol (0.8 g/kg), mephedrone (200 mg) and placebo alcohol, and both placebos. Design was double-blind, double-dummy, randomized, cross-over and controlled with placebo. Study variables included: vital signs (blood pressure, heart rate, temperature, and pupil diameter), subjective effects (visual analogue scales-VAS, ARCI-49 item short form, and VESSPA questionnaire).
The combination produced an increase in the cardiovascular effects of mephedrone and induced more intense feeling of euphoria and well-being in comparison to mephedrone and alcohol. Mephedrone reduced the drunkenness and sedation produced by alcohol.
These results are similar to those obtained with the combination of other psychostimulants as amphetamines and MDMA. Abuse liability of the combination is greater that induced by mephedrone.
Disclosure of interest
The authors have not supplied their declaration of competing interest.