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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.
Life functioning difficulties are a relevant but undervalued consequence of major depression. Mood symptoms and cognitive deficits have a significant, and somehow independent, impact on them. Therefore, cognitive difficulties should be considered a potential target to improve patients’ functioning.
To examine the degree in which objective and subjective cognition explain functional outcome.
To assess objective cognitive function (CF) with a neuropsychological battery and to measure subjective CF using measures of cognitive perception.
Ninety-nine patients with depression were assessed by age, sex and level of schooling. Depressive symptoms severity was measured by Hamilton Depression Rating Scale (HDRS-17). Objective CF consisted in the following cognitive domains: memory, attention, executive functioning and processing speed. Subjective CF was assessed with Perceived Deficit Questionnaire-Depression (PDQ-D). Functioning Assessment Short Test (FAST) was used to evaluate life functioning, excluding the cognitive domain. All the listed measures were included in a multiple regression analysis with FAST scores as dependent variable.
The regression model was significant (F1,98 = 67.484, P < 0.001) with an R of 0.825. The variables showing statistical power included (from higher to lower β-coefficient) HDRS-17 (β = 0.545, t = 8.453, P < 0.001), PDQ-D (β = 0.383, t = 6.047, P < 0.001) and DSST (β = −0.123, t = −1.998, P = 0.049).
The severity of depressive symptoms is the variable that best explains life functioning. Surprisingly, the second factor hindering it is the patients’ perception of their cognition. Current findings highlight the importance of correcting cognitive bias in order to improve functionality. However, results have to be taken cautiously as mood symptoms could partly explain the bias.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Major depression cognitive impairments lasts in remission periods, have an impact on treatment outcome and hamper psychosocial functioning. Thus, its accurate detection and specific treatment has become a crucial step.
In order to assess objective cognitive functioning (OCF), a neuropsychological battery was administered. For subjective cognitive functioning (SCF), cognitive perception was evaluated by clinicians and patients.
To determine the concordance between OCF and SCF.
One hundred and two patients were grouped according to Hamilton Depressive Rating Scale (HDRS−17): 18 remitters (RE < 7), 40 partly remitters (PR, 7–18) and 44 acutely depressed (AD > 18). OCF was computed combining T-scores of digit symbol substitution test (WAIS-IV) with two RAVLT subtests (learning and memory). SCF was assessed with a CGI adaptation for cognitive disturbances severity.
The OFC was 41.21(8.49) for all patients and 45.54(6.8), 41.93(6.8) and 38.7 (9.7) for RE, PR, and AD, respectively. Psychiatrist and patients’ SCF had a poor agreement (α=0.518), with Cronbach's alpha for RE, PR and AD of −0.607, 0.518 and 0.404. Concordance between OCF and SCF was calculated for all patients (psychiatrist, r = −0.317, P = 0.002; patient, r = −0.310, P = 0.002), for RE (r = −0.535, P = 0.022; r = 0.395, P = 0.105) for PR (r = −0.013, P = 0.94; r = −0.328, P = 0.045) and for AD (r = −0.252, P = 0.122; r = −0.333, P = 0.033). Patients rated their SFC as more impaired than did clinicians.
Concordance between clinicians and patients regarding SCF is very poor, worsening in AD group and being null in remission. This study also points out that CF is best detected by patients in acute episodes and by psychiatrists when patients are in clinical remission.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Haemonchus contortus is a haematophagous gastrointestinal nematode (GIN) that causes severe anaemia and even death in small ruminants, negatively impacting the economic viability of farms. Traditionally, this parasite has been controlled with chemical compounds; however, inadequate use of these types of products has favoured the emergence of anthelmintic resistance. Therefore, it is necessary to search for alternatives for GIN control. Previous studies have reported the anthelmintic activity of edible mushroom extracts against H. contortus. A recent study reported that a fraction constituted of different fatty acids and β-sitosterol isolated from the basidiomata of the edible mushroom Pleurotus djamor ECS-123 has ovicidal and larvicidal activity against H. contortus. Thus, this study aimed to assess the anthelmintic activity of the pure molecules: pentadecanoic acid, palmitic acid, β-sitosterol, stearic acid and linoleic acid. For this purpose, an egg-hatching inhibition test was carried out in which the compounds were evaluated individually and in combination at a final concentration of 20 mg mL−1. Furthermore, larval mortality was assessed using a combination of the five commercial compounds previously mentioned at different concentrations (1.25–20 mg mL−1). Palmitic acid and stearic acid, in some combinations, inhibited H. contortus egg hatching by 100%. On the other hand, in the larval mortality test, the combination of the five compounds showed dose-dependent behaviour, and 100% mortality was obtained 24 h post-incubation. Pure molecules and their combinations have anthelmintic-like activity against the eggs and larvae of H. contortus.
Intermittent explosive disorder (IED) is characterised by impulsive anger attacks that vary greatly across individuals in severity and consequence. Understanding IED subtypes has been limited by lack of large, general population datasets including assessment of IED. Using the 17-country World Mental Health surveys dataset, this study examined whether behavioural subtypes of IED are associated with differing patterns of comorbidity, suicidality and functional impairment.
IED was assessed using the Composite International Diagnostic Interview in the World Mental Health surveys (n = 45 266). Five behavioural subtypes were created based on type of anger attack. Logistic regression assessed association of these subtypes with lifetime comorbidity, lifetime suicidality and 12-month functional impairment.
The lifetime prevalence of IED in all countries was 0.8% (s.e.: 0.0). The two subtypes involving anger attacks that harmed people (‘hurt people only’ and ‘destroy property and hurt people’), collectively comprising 73% of those with IED, were characterised by high rates of externalising comorbid disorders. The remaining three subtypes involving anger attacks that destroyed property only, destroyed property and threatened people, and threatened people only, were characterised by higher rates of internalising than externalising comorbid disorders. Suicidal behaviour did not vary across the five behavioural subtypes but was higher among those with (v. those without) comorbid disorders, and among those who perpetrated more violent assaults.
The most common IED behavioural subtypes in these general population samples are associated with high rates of externalising disorders. This contrasts with the findings from clinical studies of IED, which observe a preponderance of internalising disorder comorbidity. This disparity in findings across population and clinical studies, together with the marked heterogeneity that characterises the diagnostic entity of IED, suggests that it is a disorder that requires much greater research.
The relationship between epilepsy and the presence of visceral larva migrans caused by Toxocara canis in Mexican children remains uncertain; however, this relationship needs to be elucidated because these parasite larvae can invade the human central nervous system. Accordingly, this study aimed to determine the frequency and specificity of anti-T. canis antibodies in the sera of children with epilepsy to determine the relationship between this parasite and epilepsy. The sera samples of 214 children were examined: 111 children diagnosed with epilepsy and 103 clinically healthy children without neurological disorders. In the sera of each group, the presence and specificity of anti-T. canis and anti-Ascaris lumbricoides antibodies, as well as the cross-reactivity between them, were assessed using enzyme-linked immunosorbent assay and Western blotting analysis. Among the children with epilepsy, 25.2% exhibited seropositivity to T. canis. Cross-reactivity against the A. lumbricoides antigen was present in 46.8% of the children with epilepsy, whereas 11.7% of the children with epilepsy and anti-T. canis antibodies did not exhibit cross-reactivity against this antigen. The Western blotting analysis of the sera from the children with epilepsy demonstrated the presence of T. canis proteins, with molecular weights of 24, 35, 55, 70, 120 and 210 kDa, and A lumbricoides proteins with molecular weights of 70, 80 and 110 kDa. Our results revealed the presence of anti-T. canis antibodies in the children with epilepsy; furthermore, cross-reactivity tests with A. lumbricoides showed the importance of the presence of anti-T. canis antibodies in revealing the relationship between this parasite and epilepsy in children.
To provide cross-national data for selected countries of the Americas on service utilization for psychiatric and substance use disorders, the distribution of these services among treatment sectors, treatment adequacy and factors associated with mental health treatment and adequacy of treatment.
Data come from data collected from 6710 adults with 12 month mental disorder surveys across seven surveys in six countries in North (USA), Central (Mexico) and South (Argentina, Brazil, Colombia, Peru) America who were interviewed 2001–2015 as part of the World Health Organization (WHO) World Mental Health (WMH) Surveys. DSM-IV diagnoses were made with the WHO Composite International Diagnostic Interview (CIDI). Interviews also assessed service utilization by the treatment sector, adequacy of treatment received and socio-demographic correlates of treatment.
Little over one in four of respondents with any 12 month DSM-IV/CIDI disorder received any treatment. Although the vast majority (87.1%) of this treatment was minimally adequate, only 35.3% of cases received treatment that met acceptable quality guidelines. Indicators of social-advantage (high education and income) were associated with higher rates of service use and adequacy, but a number of other correlates varied across survey sites.
These results shed light on an enormous public health problem involving under-treatment of common mental disorders, although the problem is most extreme among people with social disadvantage. Promoting services that are more accessible, especially for those with few resources, is urgently needed.
The predominantly carbonate nature of the mountains near the coast of Málaga and Marbella (Costa del Sol, southern Spain) and the presence of springs have favored the formation of travertine buildups during the Quaternary. The geomorphic characteristics of the slopes and the location of the springs have determined the development of three types of travertine growths: (1) spring travertines, located preferentially on the south mountainside, where the slope is steepest; (2) pool-dam-cascade travertines, which form along the north and east edges, far from the carbonate relief and with a gentler slope; and (3) river-valley travertines, formed in the courses of the springs of any sector. Field observations combined with new amino acid racemization (AAR) dating of Helicidae gastropods show that most of the travertine formations are polyphasic and that their development was interrupted by stages of erosion and incision. Five stages of travertine development are evident, most of which are related to warm, moist episodes corresponding to marine oxygen isotope stages (MIS) 7, 5, 3, and 1, although local travertine growth also occurred during MIS 6 and during the transition from MIS 3 to 2.
The aim of this investigation was to study castor, canola, and sesame vegetable oils in order to evaluate their potential use as lubricants in steel mechanical components. For this purpose, densities of each oil were evaluated using the pycnometer method, as well as their dynamic viscosities through a Brookfield DV-II rotational viscometer. Both properties were evaluated at temperatures of 25, 40 and 100 °C. Additionally, viscosity indexes were determined according to ASTM D 2270. These rheological properties were used to estimate the lubrication regime considering parameters of real contact conditions in mechanical components. Friction and wear analyses were carried out to investigate the behaviour of the vegetable oil as lubricants. Such tests were carried out at room temperature on a CSM tribometer with pin-on-disk configuration by using castor, canola and sesame oils as lubricants. AISI 4140 hardened steel against AISI 100Cr6 steel pin was used as a mechanical component. From the rheological study, it was observed that canola and sesame oils behave as dilatant fluids at the evaluated temperatures, while castor oil behaves like a Newtonian fluid at 25 and 40 °C. Castor oil showed the highest density value among oils studied, but it also exhibited the lowest value of viscosity index (271). Contrarily, sesame oil was the least dense, but it exhibited the highest viscosity index (545). On the other hand, the lubrication regime study showed that by using castor oil as a lubricant in the mechanical component (4140/100Cr6), the system worked in a mixed lubrication regime while by using canola and sesame oils the system operated in boundary lubrication conditions. Finally, the kinetic friction coefficients were different for each lubricant obtaining the lowest value with castor oil while the highest value of friction coefficient was exhibited by the sesame oil lubricant.
Despite intensive research during the last few decades, understanding of ecological and physiological factors related to haemosporidian infections in birds is still fragmentary. Since more model organisms are needed in order to understand these infections in the wild, we analysed avian haemosporidian infections in the rufous-collared sparrow (Zonotrichia capensis, Emberizidae) in a dry forest of the Ecuadorian Andes. Parasite diversity was screened using molecular and morphological approaches. By molecular diagnosis, we identified three linages that were phylogenetically placed in the context of molecular haemosporidian diversity and associated with a morphospecies. By microscopy, we identified five described morphospecies and one additional undescribed morphospecies. We found that avian haemosporidian prevalence on the study site was 76.3%. Additionally, we used a series of generalized linear models to explore the potential relationship of parasite prevalence and parasitaemia with a set of variables related to physiological and environmental conditions. Although our results revealed associations of haemosporidian infections with precipitation, age and sampling site, the models only explained a small fraction of the variation.
Gluten is only partially digested by intestinal enzymes and can generate peptides that can alter intestinal permeability, facilitating bacterial translocation, thus affecting the immune system. Few studies addressed the role of diet with gluten in the development of colitis. Therefore, we investigate the effects of wheat gluten-containing diet on the evolution of sodium dextran sulphate (DSS)-induced colitis. Mice were fed a standard diet without (colitis group) or with 4·5 % wheat gluten (colitis + gluten) for 15 d and received DSS solution (1·5 %, w/v) instead of water during the last 7 d. Compared with the colitis group, colitis + gluten mice presented a worse clinical score, a larger extension of colonic injury area, and increased mucosal inflammation. Both intestinal permeability and bacterial translocation were increased, propitiating bacteria migration for peripheral organs. The mechanism by which diet with gluten exacerbates colitis appears to be related to changes in protein production and organisation in adhesion junctions and desmosomes. The protein α-E-catenin was especially reduced in mice fed gluten, which compromised the localisation of E-cadherin and β-catenin proteins, weakening the structure of desmosomes. The epithelial damage caused by gluten included shortening of microvilli, a high number of digestive vacuoles, and changes in the endosome/lysosome system. In conclusion, our results show that wheat gluten-containing diet exacerbates the mucosal damage caused by colitis, reducing intestinal barrier function and increasing bacterial translocation. These effects are related to the induction of weakness and disorganisation of adhesion junctions and desmosomes as well as shortening of microvilli and modification of the endocytic vesicle route.
Surgical site infections (SSIs) following colorectal surgery (CRS) are among the most common healthcare-associated infections (HAIs). Reduction in colorectal SSI rates is an important goal for surgical quality improvement.
To examine rates of SSI in patients with and without cancer and to identify potential predictors of SSI risk following CRS
American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data files for 2011–2013 from a sample of 12 National Comprehensive Cancer Network (NCCN) member institutions were combined. Pooled SSI rates for colorectal procedures were calculated and risk was evaluated. The independent importance of potential risk factors was assessed using logistic regression.
Of 22 invited NCCN centers, 11 participated (50%). Colorectal procedures were selected by principal procedure current procedural technology (CPT) code. Cancer was defined by International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes.
The primary outcome of interest was 30-day SSI rate.
A total of 652 SSIs (11.06%) were reported among 5,893 CRSs. Risk of SSI was similar for patients with and without cancer. Among CRS patients with underlying cancer, disseminated cancer (SSI rate, 17.5%; odds ratio [OR], 1.66; 95% confidence interval [CI], 1.23–2.26; P=.001), ASA score ≥3 (OR, 1.41; 95% CI, 1.09–1.83; P=.001), chronic obstructive pulmonary disease (COPD; OR, 1.6; 95% CI, 1.06–2.53; P=.02), and longer duration of procedure were associated with development of SSI.
Patients with disseminated cancer are at a higher risk for developing SSI. ASA score >3, COPD, and longer duration of surgery predict SSI risk. Disseminated cancer should be further evaluated by the Centers for Disease Control and Prevention (CDC) in generating risk-adjusted outcomes.
A substantial proportion of persons with mental disorders seek treatment from complementary and alternative medicine (CAM) professionals. However, data on how CAM contacts vary across countries, mental disorders and their severity, and health care settings is largely lacking. The aim was therefore to investigate the prevalence of contacts with CAM providers in a large cross-national sample of persons with 12-month mental disorders.
In the World Mental Health Surveys, the Composite International Diagnostic Interview was administered to determine the presence of past 12 month mental disorders in 138 801 participants aged 18–100 derived from representative general population samples. Participants were recruited between 2001 and 2012. Rates of self-reported CAM contacts for each of the 28 surveys across 25 countries and 12 mental disorder groups were calculated for all persons with past 12-month mental disorders. Mental disorders were grouped into mood disorders, anxiety disorders or behavioural disorders, and further divided by severity levels. Satisfaction with conventional care was also compared with CAM contact satisfaction.
An estimated 3.6% (standard error 0.2%) of persons with a past 12-month mental disorder reported a CAM contact, which was two times higher in high-income countries (4.6%; standard error 0.3%) than in low- and middle-income countries (2.3%; standard error 0.2%). CAM contacts were largely comparable for different disorder types, but particularly high in persons receiving conventional care (8.6–17.8%). CAM contacts increased with increasing mental disorder severity. Among persons receiving specialist mental health care, CAM contacts were reported by 14.0% for severe mood disorders, 16.2% for severe anxiety disorders and 22.5% for severe behavioural disorders. Satisfaction with care was comparable with respect to CAM contacts (78.3%) and conventional care (75.6%) in persons that received both.
CAM contacts are common in persons with severe mental disorders, in high-income countries, and in persons receiving conventional care. Our findings support the notion of CAM as largely complementary but are in contrast to suggestions that this concerns person with only mild, transient complaints. There was no indication that persons were less satisfied by CAM visits than by receiving conventional care. We encourage health care professionals in conventional settings to openly discuss the care patients are receiving, whether conventional or not, and their reasons for doing so.
Traumatic events are associated with increased risk of psychotic experiences, but it is unclear whether this association is explained by mental disorders prior to psychotic experience onset.
To investigate the associations between traumatic events and subsequent psychotic experience onset after adjusting for post-traumatic stress disorder and other mental disorders.
We assessed 29 traumatic event types and psychotic experiences from the World Mental Health surveys and examined the associations of traumatic events with subsequent psychotic experience onset with and without adjustments for mental disorders.
Respondents with any traumatic events had three times the odds of other respondents of subsequently developing psychotic experiences (OR=3.1, 95% CI 2.7–3.7), with variability in strength of association across traumatic event types. These associations persisted after adjustment for mental disorders.
Exposure to traumatic events predicts subsequent onset of psychotic experiences even after adjusting for comorbid mental disorders.
The treatment gap between the number of people with mental disorders and the number treated represents a major public health challenge. We examine this gap by socio-economic status (SES; indicated by family income and respondent education) and service sector in a cross-national analysis of community epidemiological survey data.
Data come from 16 753 respondents with 12-month DSM-IV disorders from community surveys in 25 countries in the WHO World Mental Health Survey Initiative. DSM-IV anxiety, mood, or substance disorders and treatment of these disorders were assessed with the WHO Composite International Diagnostic Interview (CIDI).
Only 13.7% of 12-month DSM-IV/CIDI cases in lower-middle-income countries, 22.0% in upper-middle-income countries, and 36.8% in high-income countries received treatment. Highest-SES respondents were somewhat more likely to receive treatment, but this was true mostly for specialty mental health treatment, where the association was positive with education (highest treatment among respondents with the highest education and a weak association of education with treatment among other respondents) but non-monotonic with income (somewhat lower treatment rates among middle-income respondents and equivalent among those with high and low incomes).
The modest, but nonetheless stronger, an association of education than income with treatment raises questions about a financial barriers interpretation of the inverse association of SES with treatment, although future within-country analyses that consider contextual factors might document other important specifications. While beyond the scope of this report, such an expanded analysis could have important implications for designing interventions aimed at increasing mental disorder treatment among socio-economically disadvantaged people.