Scielo RSS <![CDATA[Salud mental]]> vol. 30 num. 5 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<strong>Conferencia Magistral. In Memoriam Ramón de la Fuente Muñiz, 1921-2006</strong>]]> <![CDATA[El costo social de los trastornos mentales. Discapacidad y días productivos perdidos. Resultados de la Encuesta Nacional de Epidemiología Psiquiátrica]]> Summary: Introduction. When the impact of illness is evaluated by indicators like mortality, mental illness has a less significant impact than other illnesses. As a result, the impact of mental disorders was underestimated until the last two decades of the previous century This perception began to change as a result of two factors: On the one hand, the study of the Global Burden of Disease reported by Murray and Lopez, and, on the other hand, the definition of mental disorders by the American Psychiatric Association. The common element shared by these two factors is the inclusion of the concept of disability. Disability is the deterioration of the expected functioning of a subject of a particular age and sex in a social context. It is a part of the social cost of illness. Objective. To assess the disability burden associated with depression, mania, agoraphobia, social phobia, general anxiety, panic disorder, and post-traumatic stress disorder (PTSD) according to the Mexican Psychiatric Survey and to compare results with the disability produced by some chronic non-psychiatric conditions. Method. This survey is based on a stratified, multistage area, probabilistic sample of adults living in urban areas of Mexico. The instrument used was the third version of the Composite International Diagnostic Interview. We report the 12-month prevalence of psychiatric disorders as defined by DSM-IV criteria. We also evaluated non-psychiatric chronic conditions like diabetes, arthritis, hypertension, backache, and other painful illnesses, identified in general as "chronic conditions". Indicators of disability were Sheehan's scale and number of work days lost. This is an easy and fast self reporting scale, which can be used both in the clinic or research. The sub-scales can be added or averaged to obtain a total score. The scale of responses is a horizontal line with numerals from 0 to 10 and five verbal descriptions, with the description "Not at all" corresponding to a value of 0; "Mild" rangimg from 1 to 3; "Moderate" from 4 to 6; "Severe" from 7 to 9; and "Very severe" corresponding to 10. Results. Close relationships and social life were the areas most deeply affected. The disorders found to produce the highest levels of disability were depression, social phobia, and PTSD. The lowest disability levels were observed in chronic conditions. On the total score of Sheehan's scale, disorders with the highest level of disability were PTSD (mean 5.35 ± 0.307) and depression (mean 4.72 ± 0.167). Depression and panic attacks were the disorders by which most days were lost on average in the previous year (25.51, CI95: 16.53-34.5; 20, CI95: 3.02-36.97). Days lost were lower in chronic conditions than in the seven mental disorders studied (6.89, CI95: 3.04-10.74). Discussion. This is the first paper to demonstrate the impact of mental disorders in Latin America evaluating the association of disability with common mental disorders. We have shown that mental disorders, especially depression, are associated with deficits in functioning and result in the loss of work days. We have also shown that persons with common mental disorders have, on average, higher levels of disability than those observed among persons with a wide range of chronic physical conditions. These results are consistent with prior studies in North America and Europe that have found that persons with common mental disorders experience substantial disability in social role functioning.<hr/>resumen está disponible en el texto completo <![CDATA[Anomalías físicas menores y esquizofrenia]]> resumen está disponible en el texto completo<hr/>Summary: The neurodevelopment hypothesis in schizophrenia is a theoretic construction that tries to explain, at least partially, the etiopatho-geny of this disease. Since Kraepelin's early descriptions it has been suggested that schizophrenia is a disease linked to the Central Nervous System structure, and vast efforts have been made to prove the existence of the biological markers of schizophrenia that include clinically distinguishable features (like dermatoglyphs and neuropsychological tests), electrophysiological, endocrine, immunologic and genetic tests, and neuroimaging studies. The Minor Physical Anomalies (MPAs) are slight anatomical deviations of an individual's external physical features, which imply neither a serious medical consequence nor an aesthetic problem. MPAs could be considered a valid biological marker in the evaluation of schizophrenia if we interpret this disease as a disorder originating in the early months of intrauterine life during the first stages of neurodevelopment. Like dermatoglyphs, the MPAs may be seen as "fossil" signs that reflect the intrauterine environment. They could be useful as an indirect measurement of an alteration of structures related to the Central Nervous System in its embryologic origin, or in nervous structures and non-neuronal epidermic and other superficial tissues derived from ectoderm, especially in skin, eyes and ears, or else with those that belong to embrionary developmental fields adjacent to brain structures, that may induce cranial-facial alterations. This developmental fields theory explains the existence of a relationship between tissues or structures that do not have a common embryologic origin. After embryogenesis, they determine topographic zones of development, and the presence of a defect could affect a single structure (monotopic defect), but those that appear earlier would promote several areas in the body (polytopic field defects). Due to these complex interactions, it is not easy to correlate the intensity of the damage with the moment in which this occurred. A minor malformation could even have been generated in blastogenesis and could therefore be related to associated defects. It is not always a 'benign' abnormality. This observation is important if we consider that several genetic syndromes exist that present specific malformations. These are strongly associated with a high risk to develop schizophrenia (around 25 fold), such as the 22qll.2 deletion (velocardiofacial syndrome, DiGeorge syndrome and other variations). There has been speculation around a so-called "congenital" schizophrenia subtype on the basis of an association with several clinical features such as gender, age of onset, positive or negative symptoms, brain abnormalities that show up in MRI scans, additional cognitive impairment and a worse evolution and prognosis in which the neurodevelopmental disturbances factor would have a widespread significance in the etiopathogeny of the disease. The Waldrop's Scale for Minor Physical Anomalies has been the most used tool to measure these abnormalities and has been subject to numerous modifications. Even though it is considered a reliable instrument, with a good internal consistence, numerous limitations in results interpretation have been noted, most of them derived of limited inter-evaluator reliability, lack of consensus about the relative importance of each item and the extensive interracial variability in the presentation of MPAs. In the 1980's, the neurodevelopmental theory emerged as an explanation of the origin of schizophrenia and a number of investigations have been carried out, to measure MPAs and other biologic markers of neurodevelopment (like dermatoglyphs). Most studies have shown a greater prevalence of MPAs in schizophrenic patients compared to control groups, as it has been observed in other disorders like mental retardation, autism, attention-deficit disorder and violent behavior in adolescence. Nevertheless, there are only a few consistent data sets that correlate with an increased number of MPAs, and amongst them we can point out a positive correlation with male gender, neuroimaging brain alterations, genetic charge for schizophrenia, more frequent obstetric complications and a more perceptible cognitive impairment. Additionally, other investigations draw attention to a positive correlation with a lower premorbid adjustment, an earlier beginning of the disease, a predominance of negative symptoms and a larger tendency to develop late dyskinesia, although these data show contradictory results. Even though the diverse ethnic groups' phenotypic variants tend to limit the interpretation of each minor physical anomaly, most investigations have found a prevalence of these abnormalities in the cranial-facial area, most of them in ears and mouth, although the peripheral zones are not unaffected. When we consider those studies, we notice that the diversity of data is predominant. We can explain this if we bear in mind that some of the MPAs can be normal phenotypic features in some ethnic groups, or frequent enough to be a normal variant without discriminative meaning. We must also take into account that different scales have been used for the measurements. For this specific problem it has been suggested to use anthropometric scales, similar to those used by cranial-facial surgeons. The variability of the presentation of MPAs and the phenotypic variations compel us to conduct local investigations focused on determining which variants are outstanding or not in any ethnic group in relation to neurodevelopment deviations. We can conclude than MPAs might be a biological marker that can help us to characterize at least a subgroup of clinically recognizable schizophrenic patients, or those that have predisposition to present some clinical features, but it is necessary to develop an objective evaluation tool that ideally would incorporate anthropometric measurements in order to compare these MPAs with the phenotypic variants in each ethnic group. It is necessary to design and carry out genetic studies (first among first and second-degree relatives and afterwards in bigger populations and also comparative studies with the general population) with the aim to distinguish between genetically-determined variants and those resulting from environmental factors, as well as establishing the interaction of both types of variants. The existence of a clinically recognizable subtype of schizophrenia on which we can rely on as an etiopathogeny hypothesis is an appreciable area that is still under discussion and which deserves further investigation efforts. This could have implications on our approach to nosologic, diagnostic and even prognostic features of this heterogeneous disorder. Such investigation could help us to reformulate the schizophrenia notion itself. <![CDATA[Autoestima, sintomatología depresiva e ideación suicida en adolescentes: resultados de tres estudios]]> Summary: Suicidal behavior has different levels: ideation, contemplation, planning and preparation, attempt, and consummation. Likewise, suicidal behavior comprises all the actions aimed at achieving suicide. During adolescence there is a tendency to a reduction of emotional well-being. Thus, adolescents may engage in dangerous behavior, extreme narcissism and individualization, exclusion and social isolation. Another element playing an important role during adolescence is self-esteem. Low self-esteem could lead to apathy, isolation, and passivity. Conversely, high self-esteem is associated with more active lives, a greater control over circumstances, less anxiety and greater capacity to cope with internal and external stress. Although there are other factors that could predispose adolescents towards suicidal behavior, certain studies have identified depressive symptomatology as the most powerful and independent risk factor in suicidal ideation and it has been argued that it should be regarded as an expression of severe depression. The purpose of this study is to explore the existence of a relationship between low self-esteem and depressive symptomatology with suicidal ideation and to explore if gender has an effect in this interaction. Data were obtained from three different samples of Mexican adolescent students. The instruments used were the Rosenberg Self-Esteem Scale, the CES-D, and the Roberts Suicidal Ideation Scale. Women showed a higher frequency of low self-esteem than men in two studies. In another, men had a significantly higher frequency of low self-esteem. Regarding depressive symptomatology, women obtained higher scores than men. No significant differences were found in one study. The percentages of high suicidal ideation displayed greater variability by gender and by study. Among the subjects who reported high suicide ideation, a greater proportion of women tended to have low self-esteem, though these differences were not significant in any study. Over half of the women in each study reported higher suicidal ideation and depressive symptomatology than men, with significant differences only among junior high students in two studies. The exploration of the link between depressive symptomatology and high suicidal ideation showed significant differences by gender, a finding which might be linked to the fact that women are more allowed to express their depressive or fatalistic feelings and thoughts or death wishes, whereas among men this type of ideas are perceived as a sign of weakness. Gender-related differences in low self-esteem were only found in one study; men had a higher percentage than women. The comparison of low self-esteem in subjects with high suicidal ideation did not reveal any statistical difference by gender, despite it has been identified as a risk factor for suicidal behavior. In the other hand, results of depressive symptomatology concurred with international literature about this being a determinant factor in the presence of suicidal ideation in women. Considering the objective of this study, three main conclusions can be suggested. First, low self-esteem is not significantly linked to suicidal ideation, perhaps because it is a risk factor more associated with suicidal behavior. Second, depressive symptomatology was related to suicidal ideation, and although this relationship and the one between depressive symptomatology and self-esteem have been reported before, it is important to note that there seems to be a domino effect among these problems. This effect could begin with depressive symptoms linked to suicidal ideation, which in turn could affect self-esteem, and subsequently trigger suicidal behavior. And third, differences between men and women raise the question of whether these are caused by intrinsic characteristics in a biological-genetic substrate inherent to each gender or whether they are determined by the cultural context and the formative patterns existing in the groups to which the subjects belong.<hr/>Resumen: El problema del suicidio ha cobrado mayor relevancia en años recientes. Esto se debe a la magnitud que ha alcanzado. El suicidio tiene un carácter multifactorial, es complejo, dinámico y creciente en nuestro país. A su vez, la autoestima baja y el malestar depresivo se han vinculado con la conducta suicida en la adolescencia; los individuos vulnerables enfrentados a factores estresantes o que implican riesgo pueden llegar a presentar ideación o alguna conducta suicida. El malestar depresivo se ha identificado como el factor de riesgo más importante para la ideación suicida. Esta se presenta de manera diferente en hombres y en mujeres, por lo que se cree que su impacto está matizado por las características de los roles de género. El propósito de este estudio es explorar si la autoestima baja y la sintomatología depresiva se relacionan con la ideación suicida, y si el sexo surte un efecto sobre esta interacción. Los datos se obtuvieron de tres estudios con adolescentes estudiantes mexicanos. En el primero (secundaria, 1992-1993, Delegación Tlalpan), se utilizó un muestreo no probabilístico. La muestra incluyó a 423 adolescentes (56% hombres y 44% mujeres, con una media de edad de 13.86±1.2 años). En el segundo (secundaria y bachillerato, 1996-1997, Delegación Coyoacán) participaron 816 adolescentes: 406 de secundaria (49% hombres y 51% mujeres, con una media de edad de 13.27±1.1 años), y 410 de bachillerato (51% hombres y 49% mujeres, con una media de edad de 17±4.3 años). El muestreo fue no probabilístico. El tercero (secundaria, 1998-1999, Centro Histórico) incluyó a 936 estudiantes (54% hombres y 46% mujeres, con una media de edad de 13.7±1.8 años). El muestreo fue no probabilístico. Los tres estudios fueron transversales. El instrumento incluyó la Escala de Autoestima de Rosenberg, la CES-D y la Escala de Ideación Suicida de Roberts. Se calcularon los puntos de corte para cada escala por sexo para identificar a los sujetos con baja autoestima, sintomatología depresiva e ideación suicida alta. En dos estudios, las mujeres alcanzaron frecuencias más altas de autoestima baja, aunque las diferencias no fueron significativas. En el de 1999, los hombres tuvieron una frecuencia de autoestima baja significativamente más elevada que las mujeres. A su vez éstas alcanzaron puntajes significativamente más altos de sintomatología depresiva en los estudios de 1996 y 1999. En el caso de la ideación suicida, sólo hubo diferencias significativas en el estudio de 1999. Las mujeres con ideación suicida mostraron porcentajes más elevados de autoestima baja (diferencia no significativa) y de sintomatología depresiva (con diferencias significativas en los estudios de 1996 y 1999) que los hombres. La comparación de autoestima baja en los sujetos con ideación suicida no reveló diferencias significativas por sexo, a pesar de que éste se ha identificado como un factor de riesgo importante para la conducta suicida. Por otro lado, los resultados de sintomatología depresiva coinciden con lo reportado a nivel internacional en el sentido de considerar el sexo como un elemento determinante para la presencia de ideación suicida en las mujeres. Teniendo en consideración el objetivo de este trabajo, se pueden señalar tres conclusiones: la autoestima baja no se asoció significativamente con la ideación suicida; esto se puede deber a que ésta es un factor de riesgo más relacionado con la conducta. Asimismo, la sintomatología depresiva se asoció con la ideación suicida, y aunque ésta y la que se da entre la sintomatología y la autoestima ya se han reportado, es importante señalar que parece haber un efecto en cadena entre estas problemáticas. Este efecto se originaría en los síntomas depresivos ligados con la ideación suicida, la cual puede afectar a la autoestima y ésta, a su vez, dispararía la conducta suicida. Finalmente, las diferencias entre hombres y mujeres dejan abierto el debate sobre si éstas se originan en factores biológicos inherentes al sexo o si están determinadas por los patrones de formación influidos por su parte por elementos contextuales caracterizados culturalmente. <![CDATA[Evaluación de habilidades sociales para el trabajo en pacientes con esquizofrenia: Validez y confiabilidad del autoreporte y la técnica de juego de roles]]> resumen está disponible en el texto completo<hr/>Summary: Introduction. Only 20 to 30% of psychiatric disorders patients have a full-time competitive job. These figures might dramatically drop to 15% for those with more severe and persistent mental disorders, like schizophrenia, and could be obviously much lower in patients from developing countries. Lack of social competence and social skills necessary in the workplace have been suggested as an individual variable that explain the frequent difficulty in acquiring and maintaining a job among people with schizophrenia. Therefore, social skills' training has been widely used as an effective treatment modality to counteract those deficits. In order to develop cultural sensitive treatments, it is generally accepted that it is necessary to have valid and reliable methods to evaluate this construct in every particular population. Tsang and Pearson (2000) proposed a work-related social skills evaluation specifically designed for people with schizophrenia. This measure is composed of two parts: 1. A self-administered scale that evaluates subjective perception about social competence related to obtaining and maintaining a job. In this instance, patients rate a ten-item scale according to the degree of difficulty they experience in handling the situation. 2. A simple role playing exercise in which an expert evaluates the patient's work-related social skills by the simulation of two situations: participating in a job interview, and requesting one day of leave at short notice from a supervisor. Here, the kinds of behaviour rated include basic social survival skills, basic social skills related to voice quality and nonverbal communication, and overall performance. The expert evaluator uses a five point scale in which 4 indicates a normal performance and 0 a poor one. This kind of evaluation offers advantages compared to general social skills measures that were not designed to evaluate people with persistent and severe mental disorders, and specifically over the ones that consist merely in check lists. The aim of the present study was to translate into Spanish and to evaluate the reliability and validity of Tsang and Pearson's both self-administered scale (SA) and expert evaluation (EE) of work-related social skills among Mexican patients with schizophrenia. Method. A non-random sample of male and female Mexican adults with a confirmed diagnosis of schizophrenia by the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), completed SA and EE evaluations. Additionally, a psychiatrist recorded their global functioning based on the evaluation proposed by American Psychiatric Association (GAF), and all relevant socio-demographic and clinical variables (gender, age, educational level, previous work experience, and type of service required, between ambulatory and hospitalized patients). Fifteen days later, a sub-sample participated in a second evaluation with both work-related social skills measures. Cronbach’s alphas were calculated for SA and EE measures to obtain internal consistencies. Pearson's correlations were performed to determine the relationship between these measures and first and fifteen day after applications, to have the data of split-half reliability and short temporally stability, respectively. Then, convergent validity was evaluated with Pearson correlations between GAF scores and both SA and EE work-related social skills measures. Finally, the expected relationship between global functioning and type of mental health service employed (ambulatory service vs. hospitalization) was evaluated comparing both patient groups with independent samples t-Student test. EE and SA scores between these groups were then compared using another t-test. In all cases, predetermined alpha value was 95%. Results. A total of 54 schizophrenia patients was recruited; 64.8% were males (n=35) and 35.2% (n=19) females. Overall mean age was 36.6 ± 9 years old (range = 19-57). Years of formal education mean was 7.6 ± 3.8 (range = 1-17); and 77.8% reported some kind of previous work experience (non-competitive job; n = 42). Practically half of them were attending external consultation services (53.7% ambulatory patients, n = 29) and the rest of them were hospitalized (theoretically with more severe disorders). Reliability data. Cronbach´s alphas coefficients were SA=0.69, EE=0.85. A sub-sample of 36 patients completed initial and fifteen day work-related social skills evaluations. Correlations between them were SA=0.66 and EE=0.73, p≤.01. Validity data. For all the sample, high, positive and significant correlations between GAF and EE was obtained (r= 0.71, p≤ .01). No statistical relationship among GAF and AA was observed. EE total scores, but not SA ones, were clinically and statistically higher among outpatients in contrast to those who were hospitalized (12.9 ± 2.5 vs. 10.72 ± 3.4; t=-2.77, gl=52, p=.008). In congruence, outpatients had a better global functioning (59.79 ± 8.5 vs. 52.12 ± 8.5; t=2.97, gl=52, p=.004). Similarly, higher EE scores were obtained by patients with previous job experience (12.76 ± 2.55 vs. 8.91 ± 3.53; t=4.11, gl=51, p≤.0001). No gender differences were observed. Conclusions. Evidence of internal consistency, temporal stability and construct validity of EE format to measure work-related social skills among Mexican patients with schizophrenia were documented. Still, the self-administered scale did not show enough reliability coefficients nor validity indicators. This is congruent with data offered for the original version in English: Expert evaluation Cronbach’s alphas were higher than the self-reported ones (.96 vs .80, respectively). However, for both SA and EE evaluations, the original English versions internal consistencies were higher than the Spanish ones evaluated in the present study. This could be explained by years of education and work status disparities among the samples. The expert evaluation by role playing showed a better short-temporal stability than the self-administered scale. Additionally, the EE scores, but not the SA ones, correlated in a high, positive and statistical fashion with the general functioning of the patients, and were higher in ambulatory than in hospitalized patients. Similarly, the original English EE, but not the SA evaluation, demonstrated better validity indicators by comparing people with and without schizophrenia. These data suggest that the evaluation of this construct among Mexican patients with a low educational level has to be performed by an expert using role playing exercises, instead of self-administered scales. Further studies are necessary in order to generalize the use of these measures among other populations. <![CDATA[Evaluación de la conducta adolescente con las Escalas de Achenbach: ¿existe concordancia entre diferentes informantes?]]> resumen está disponible en el texto completo<hr/>Summary: Introduction Behavioural problems in adolescents are thought to be relevant as strong predictors for the detection of other psychological disorders. For this reason and due to the importance they present by themselves, carrying out an adequate assessment of them is fundamental. Mental health professionals have diverse opinions about the value and importance of the different informants. The majority choose of their sources according to the disorder and necessities of each evaluator. On the other hand, the need to obtain data about adolescents' functioning from multiple resources has been emphasised and numerous reasons have been exposed. Concretely, the fact of carrying out the most objective and complete evaluations as possible has been considered essential in those studies aimed at evaluating behavioural alteration in adolescents. For this reason, Achenbach developed three versions of his scale: one for the parents, another for the teachers and a third one for the adolescents themselves. Numerous investigations have studied the concordance between groups of informants about different behavioural alterations in adolescents, but none have carried out a complete analysis of all informants in all subscales (not only the total ones). For this reason, the current study has been developed with the aim of contributing to obtain an enriching vision for the professional in the field. Objectives. a) To systematically explore agreement patterns between adolescents, teachers and parents who inform of behavioural problems in adolescents in the general population and b) in those cases in which no agreement is found, to analyse the level of disagreement between each pair of informants for each subscale. Methodology. Cross-sectional and descriptive study Participants. The study was formed by 160 triads of parents, teachers and 13-16 year old adolescents selected from several schools in Barcelona. Instruments. The three forms of the Achenbach scale to measure behavioural alterations were applied. The scale was translated into Spanish by the Unit of Epidemiology and Diagnostic in Psychopathology of the Development of the Universidad Autónoma de Barcelona: Youth Self-Report, self-evaluated, Child Behaviour Checklist/4-18 and Teacher's Report Form, both heteroevaluated and completed by parents and teachers, respectively. These three forms contain a 89-item set that evaluates the same behaviour, where eight items are organised in scales of syndromes derived empirically and which are invariant throughout informants. The eight subscales are: withdrawn, somatic complaints, anxious/depressed, social problems, thought problems, attention problems, delinquent behaviour and aggressive behaviour. Some of them are grouped in second order factors: the first three in internalising, the last two in externalising, and the rest of them provide a total problems punctuation. Statistical procedure. Agreement values were analysed for each pair of informants and each subscale through the Intraclass Correlation Coefficient (ICC). A value below 0.40 indicates low concordance. In these cases, the statistical analysis proceeds with the discordance analysis by pairs of informants and for each subscale through the Bland Altman Method. Results. A low concordance (below 0.40) between informants was found especially in internalizing scales (0.230). A slightly higher value was found in attention (0.334), aggressive behaviour (0.371), externalizing (0.357), and total subscales (0.327). Secondly, it was observed that, when informing about somatic complains, thought and attention problems, internalising items and the total scale, parents reported more alterations, followed by adolescents and teachers. Also, parents indicated more withdrawal problems in adolescents, although in this case they were followed by teachers and adolescents themselves. Finally, in the evaluation of the anxiety/depression scales, social problems, delinquent behaviour, aggressiveness and externalising conducts, adolescents informed of more alterations followed by their parents, and then by the teachers. Regarding the agreement/disagreement variability throughout the scales scores, the discordance between different informants was higher when the punctuation was further away from normality, generally when the scales were scored higher. Discussion. The normative criteria of comparison and the reference frames for each group of informants are different. For instance, the fact that teachers report less behavioural alterations could be explained because of their familiarity in dealing with adolescents and a higher tolerance towards some behaviors. In general terms, this result fits in with most conclusions from investigations carried out in this field. On the other hand, the fact that parents inform of more internalising problems could be attributed to adolescent behaviour which would in turn alter the family context. Another explanation might be that parents are on the whole more implicated and more sensitive in detecting certain conducts or behavioural alterations in their offspring. In any case, it is disputable whether the lack of concordance between the different informants does really exist or, on the contrary, adolescent behaviour changes depending on the context. Finally, a result contradicting those found in the studies reviewed is that adolescents are the ones who report more externalising problems. Other authors have found that adolescents inform more about internalising problems, something which should be expected taking into account that they are the ones who know themselves better. This could be possibly explained by the presence of more social desirability/undesirability among the adolescents of our sample in front of their pair group when answering to the evaluation scales; this may be due to the group context in which the case was applied. The main limitation of the present study that it was carried out with a general population sample, although from another point of view this may be considered as a gain of the study. We recommend carrying out explicative studies about discordance, which could clarify the predictive validity of each informant group and make variations in the type of sample under study. Conclusions. Data from different sources contribute with specific information of relative validity. This is why a multidimensional, multisituational and mulitiinformant approach is fundamental. This is necessary not only to evaluate behavioural alterations in adolescents within a research context, but also when taking diagnostic decisions in a clinical context, because, depending on the chosen informant, the diagnostic criteria for one disorder or another might change. Also, our results imply that there may be an underdetection of behavioural problems in adolescents by the adults, which would result in a lower psychological demand than the necessary. <![CDATA[Una medida breve de la sintomatología depresiva (CESD-7)]]> resumen está disponible en el texto completo<hr/>Summary: Depression is a mental health condition with a high prevalence in the population, low rates of detection in the health system, and a significant influence in the quality of life of individuals, affecting their family and social contexts. Because of this, research focusing on the development of instruments to measure depression has been an active area of research with a growing development in the Latin American context. In this paper, we present a brief version of the Center for Epidemiological Studies-Depression Scale (CESD-20), and analyze its psychometric properties, factorial structure, and construct validity in a sample of Spanish adult population. Our aim is to provide researchers and professionals of Spanish-speaking countries with an instrument that allows to obtain relevant information about the mental health of individuals in a reliable and efficient way. The CESD-20 was originally designed to evaluate the severity of depressive symptomatology in adult population and has shown excellent properties among both adult and adolescent populations. The CESD evaluates depressed mood, positive affect, somatic and retarded activity and negative perception of interpersonal relationships during the last week. There is extensive literature about the factorial structure of the original instrument. In this sense, there is a general agreement among researches about the usefulness of using a summed up score of the 20 items to reflect depressive symptomatology. This global score is used as an indicator of the individual risk of developing clinic depression rather than to classify depressed individuals. The Spanish version of the original CESD-20 has been consistently validated in different populations, but so far a brief version in this language has not been avaliable to researchers. In this study we explore the internal consistency and factorial structure of a 7-item version (CESD-7), as well as its construct validity. To analyze the construct validity of the CESD-7 we explore the relationships of the scale scores with two variables of the physiological and social context, respectively. On the one hand, we explore the relationship between health perceptions and both the original and brief versions of the CESD. On the other hand, we analyze the relationship between social integration and the two versions of the CESD. There is extensive empirical evidence about the relationship of depression with physical health and social integration. In this sense, there is a general agreement as to the association between poor health conditions and higher levels of depression over time. Likewise, the levels of social integration have been traditionally regarded as antecedents of depression. Therefore, we expect that both the original and brief versions of the CESD would be negatively associated with physical health and social integration. Moreover, the statistical relationships among these constructs would not be different when analyzed with the original or brief versions of the CESD. This would indicate that the brief version might be used as a substitute of the long one. Method: Participants For this study we used data from a two-wave panel design with repeated measures in a community sample of Spanish adult population. In the first panel, 1051 participants of both sexes with ages ranging from 18 to 80 years completed the questionnaires. Participants in this panel were selected from a cross-section of representative neighbourhoods from a one million metropolitan area (Valencia, Spain). Participants completed questionnaires refering to their mental health, physical health, and social integration. Age, sex, educational level, and household income of participants were also coded. After six months, almost 75% (N = 740) of the respondents completed the same questionnaires in the second panel. Attrition analyses between respondents and drop-outs showed nonsignificant differences in socio-demographic variables. A 54% of the respondents were women. The mean age was 39 years. Average educational level was high school (full-time education until 18 years) and average household income was 21500 euros (26000 US dollars, approximately). Instruments Original version of the CESD (CESD-20). The original Spanish version of the CESD-20 used in this paper was adapted by the authors in previous works. Previous research with the CESD-20 scores of the translated version showed a high degree of internal consistency and construct validity. Brief version of the CESD (CESD-7). Based on the available literature, we selected seven items that showed the highest validity to classify cases of depression. Items for the revised measure included dysphoric mood (items 3, 6, and 18), motivation (item 7), concentration (item 5), loss of pleasure (item 16), and poor sleep (item 11 ). As indicated above, we also measured health perceptions and social integration to further analyze the construct validity of this brief scale. Two instruments were selected: Health Perception. We used the General Health Perception Questionaire developed by Davies and Ware to obtain information about the health status as appraised by the individual. The GHPQ includes 29 items with five category responses ranging from totally disagree to totally agree (e. g., "My health condition is excellent") that provides a global score with higher scores indicating better health perceptions. Social Integration. To measure social integration we used the Social Integration in the Community Scale. This is a five-item scale that measures the sense of belonging and/or identification to a community or neighbourhood (e.g., "I feel identified with my community"). A higher score represents a higher level of social integration. Results: Results showed that the CESD-7 can be described as undidimensional and that this one-factor structure remains mostly invariant after six months. Internal consistency was adequate (α’ ≥ .82) in both panels. As for the validity of the brief version, we estimated several regression models for both the CESD-20 and CESD-7 as dependent variables. Predictors in these equations were: previous levels of depression, socio-demographic variables, physical health and social integration. Results showed a moderate relationship between measures of depression across time (CESD-20, β = 0.12, p &lt; .001; CESD-7, β = 0.13, p &lt; .001), and also that the CESD-20 and CESD-7 scores in panel two were significantly associated with sex, social integration, and physical health almost with the same strength for both versions. Also, non-significant associations were found for age, educational level, and household income for both versions. These results suggested that using the CESD-7 instead of the CESD-20 did not substantially change the results of linear regression models. Discussion. The results of this study indicate that the brief version of the CESD (CESD-7) has an adequate reliability and validity and that this brief measure is virtually equivalent to the original version (CESD-20) when used as a dependent variable in several linear regression models. Thus, both the original and brief versions scores were negatively and significantly associated with previous levels of good health conditions (perceived health) and social integration even after controlling for previous levels of depression in panel 1. There is extensive research showing that women report more depressive symptomatology than men. Also, physical health has been related with depression. Regarding social integration, there is also a vast array of empirical evidence relating it to the mental health of the individual. In our study, we found these expected associations both for the original CESD-20 and the brief version (CESD-7). According to the results obtained in this study, we encourage researchers to use this brief measure of depression when survey space is limited or a fast and reliable measure of depression is needed. <![CDATA[Neurotransmisores del sistema límbico. Hipocampo. GABA y memoria. Segunda parte]]> resumen está disponible en el texto completo<hr/>Summary: Action of GABA agonists and antagonists on memory. The θ rhythm. Muscimol may directly alter memory. Recently, a modified matching to position (MTP) paradigm was employed aimed at influencing the type of associations a rat may use to solve the task. The main behavioral manipulation was the application of a differential outcomes procedure (DOP). DOP implies correlating each event to be remembered with a different reward condition. This procedure will result in the development of specific reward expectations which will in turn increase and guide choice behavior. Such different reward expectations will not be present when the reward assignation used is either common or random (non-differential outcomes procedure, NOP). Intraventricular infusion of muscimol or CSF in rats carrying out a delayed MTP using either a MOP or an NOP protocol will affect both groups of rats, but the nature of the deficit will differ depending on the reinforcement contingencies. Rats trained in DOP will show general non-mnemonic damage independent of delay, i.e., performance will be affected at all delay intervals employed. On the contrary, rats trained in NOP will show delay-dependent damage. This appears to demonstrate that muscimol may also have untoward memory effects, which further indicates that activation of GABA receptors will affect a set of memory associations and functions. Difficulties experienced in the past regarding LTP induction at the level of the CA3-CA1 synapse using time-based spike presentation protocols have been disconcerting given the preeminence of these synapses as a model system for the study of synaptic plasticity. Results previously discussed in experiments using picrotoxin as a GABA inhibitor have suggested that such difficulties arise from the requirement that, for LTP to be induced, CA1 dendrites must be persistently and totally activated. Doublets used in this case represent a minimal burst, or level of post-synaptic stimulation for LTP induction that subsumes greater depolarizations. In vitro, synaptically induced bursts would correspond to regenerative electrical events in apical dendrites of pyramidal neurons. The same requirements for dendritic activation would be satisfied in vivo during the θ rhythm, which is present during active exploration. Therefore, GABA might serve as an engram modulator through the activation of the hippocampal θ rhythm. Effect of μ-opioid receptors on hippocampal memory activity. Hippocampal μ-opioid receptors (MOR) have been involved in the formation of memory associated with the abuse of opioid drugs. When chronically activated, and during programmed drug abstinence, MORs acutely modulate hippocampal synaptic plasticity At the level of neuronal networks, MORs increase excitability of area CA1 by means of a disinhibition of pyramidal cells. The specific inhibitory interneuronal subtypes which become affected by activation of MORs are not known. Nevertheless, not all subtypes are inhibited and some subtypes preferentially express these receptors. In one study, the effect of activation of MORs on inhibitory patterns and propagation of excitatory activity in CA1 of rat hippocampus was investigated through cortical images created using voltage-sensitive dyes. MOR activation increased excitatory activity originated by the increased stimulating input to stratum oriens (i.e., Schäffer collateral and commissural [SCC] fibers, as well as the retrograde pathway), to stratum radiatum (i.e., SCC fibers) and to stratum lacunosum-moleculare (i.e., the perforant pathway and the thalamus). Increased excitatory activity was additionally facilitated by propagation through the neural network of area CA1. This was observed as a proportionally greater increment of amplitudes of excitatory activity in sites distant from the originally evoked activity. Such facilitation was noted in excitatory activity propagating from three sites of stimulation. The increment and facilitation were prevented with GABAA receptor antagonists (bicuculline, 30 μM), but not with GABAB receptor antagonists (CGP, 10 μM). Besides, MOR activation inhibited inhibitory post-synaptic potentials (IPSPs) in every layer of area CA1. These findings suggest that MOR-originated suppression of GABA release to GABAA receptors increases every type of input to pyramidal CA1 neurons and facilitates propagation of excitatory activity through the neural network of area CA1. Cannabis indica and memory. Cannabinoids (derived from Cannabis indica, or marihuana) disturb memory processes in mammalians. In spite of the fact that the neuronal cannabinoid CB1 receptor was identified several years ago, the neuronal network mechanisms mediating these effects are still controversial. Tritium-labeled GABA-releasing experiments have been used to test for the localization of this receptor at a cellular and subcellular level in the human hippocampus. CB1 expression detected with this technique is limited to hippocampal interneurons, most of which, it could be determined, are cholecystokinin-containing basket neurons. The CB1-positive neuronal somata show immune staining of their cytoplasm, but not of their somatodendritic plasma membrane. CB1-immunoreactive axonic terminals densely cover the entire hippocampus and form symmetrical synapses, characteristic of GABAergic neuronal boutons. It could thus be observed that WIN 55,212-2, a CB1-receptor agonist, considerably reduces the release of tritium-labeled GABA, and that this effect is preventable using the receptor antagonist, SR 141716A. This single pattern of expression and pre-synaptic modulation of GABA release suggests the existence of a preserved role of CB1 receptors in the control of inhibitory hippocampal networks responsible for the generation and maintenance of fast and slow oscillation patterns. Therefore, a probable mechanism whereby cannabinoids could affect associational processes in memory might be a disturbance of synchrony of rhythmical events in distinct neuronal populations. GABA effects against aging. Certain components which stimulate GABAergic neurotransmission might prevent the hippocampal and striatal degeneration which typically appears with old age and causes memory deterioration. On using a 4-vessel occlusion model in animals to study the effect of ischemia on expression of GABAA receptor subunits, which are vulnerable in region CA1 and resistant in region CA3 of Amnion's horn, an increment in expression of GABAA2, GABA B2, GABA G2 units and a decrement in expression of GABA A1 and GABA A3 subunits in region CA3 were obtained. On the contrary, there was no change in region CA1 or the dentate gyrus under the same conditions. These data speak in favor of the stimulation of type 2 receptor GABAergic subunits which might protect certain hippocampal areas against a harmful neurodegenerative effect, for example, of memory activities during old age. <![CDATA[Expectativas, percepción del paciente hacia su terapeuta y razones para asistir a dos o más sesiones]]> resumen está disponible en el texto completo<hr/>Summary: In Mexico, patients who seek psychological therapy attend on average only three sessions, which are not enough to truly benefit from therapy One variable that might be related with dropping out is the patient’s expectations. When the patient attends the first session and does not find what he expected he might not return for additional sessions. Unfortunately, contradictory evidence prevents us from fully understanding the role of patients' expectations in determining whether patients will attend additional sessions after their first interview. In addition, if the patient perceives unfavorable qualities in his therapist he may choose not to return for more sessions. This was the case in some studies but in some others the patients' perceptions of their therapists' qualities were not useful predictors of which patients would return after the first interview. In any case, every time that a patient does not return without warning his therapist the question may remain: why didn't the patient return? Thus, the aims of this study were: 1. To document the expectations subjects had before their first interview, 2. To identify whether these expectations were met, 3. To determine if there is a relationship between having one's expectations met and attending a second session, 4. To document subjects' reasons for attending two or more sessions, and 5. To compare the perceptions of the therapists' personal qualities among patients who did return or not for a second session. Method. Thirty-nine subjects who attended a psychotherapy session at any time were contacted. The average age was 32.05 years (range from 20 to 63 years), 26 were single and 13 were married. Since this was an exploratory study, an open questions interview was used. Questions included: what expectations did you have before your therapeutic interview? Were your expectations met? Did you return after your first interview? Why did you attend two or more sessions? What qualities did you perceive in your therapist? All of the answers subjects gave were encoded and frequencies were computed. The responses of subjects who attended two or more sessions were compared with answers of subjects who did not. Results. Before the first interview, subjects expected therapists would be attentive, supportive, friendly, and honest. Second, subjects expected concrete results from the first interview: they expected solutions to their problems and doubts, and to feel better in general. They also expected they would be able to confide in their therapists. Last, subjects expected that their pain would be eased, that they would be able to talk about their problems, and that they would not be afraid. When patients' expectations were met they explained that their therapists were attentive listeners. They described their therapists as kind, objective and reliable. They also felt that their therapists were able to help them, often by offering another perspective on their problems. These subjects felt better after the session. On the contrary, when patients' expectations were not met they explained that their therapists did not listen, were critical, acted as if conducting a test, and arrived late to the session. Also, subjects did not feel that they could confide in their therapists and were disappointed that they did not help them to solve their problems. After the first interview, 19 subjects returned for a second session and eight did not. Twelve of these subjects reported having their expectations met on the first interview, while 27 subjects reported that their expectations were not met. Having one's expectations met was significantly correlated with attending a second session (r = +.34, p &lt; .05). The main reasons subjects reported when asked why they attended two or more sessions were the following: I had to continue the treatment, I wanted to feel better, I wanted to overcome my problems, I needed help, I thought the therapist would improve in the next session, and the therapist helped me. Reasons subjects gave for not attending were: the therapist did not listen to me, the therapist was not friendly, I did not like the therapist, the therapist criticized me, I learned that the best way to solve my problems is by my self, the therapy was expensive, I had to study, and I had to work. Subjects who attended a second session perceived more positive qualities in their therapists (e.g. the therapist was kind, reliable, punctual, intelligent, respectful, understanding) than negative (e.g. arrived late, unkind, authoritarian, aggressive, impulsive, incompetent). Subjects who did not attend a second session perceived more negative qualities in their therapists. Finally, those who attended a second session perceived that their therapists were more experienced than subjects who did not attend a second session. Conclusions. Having one's expectations met was significantly correlated with attending a second session, a finding that contradicts other studies. In addition, when patients perceived therapists did not listen to them, they were less likely to attend additional sessions, a finding that is consistent with other research. Finally, also in agreement with other studies, subjects who attended a second session perceived more positive qualities in their therapists than those who did not attend a second session for these perceived more negative qualities in their therapists. One problem that sometimes arises when drop out subjects are interviewed, is that they may lie because they do not want to have any problems with the institution providing them the service or because they do not want to meet their therapists again. However, it is likely that this was not the case for this research. Since interviews were not conducted in a consulting room or a psychological services setting, it is also likely that the "social desirability" was reduced. That is, subjects had the opportunity to speak the truth because the researcher did not know the therapists or institutions they were talking about. One important limitation to this study was that subjects were asked retrospectively about events that took place prior to the interview. So, it is possible that subjects' answers were distorted due to the effect of time on memory. Clearly, more research is needed in prospective studies to explore the relationship between the attendance of more than one session and patient's expectations of therapy sessions and their perceptions about therapists. <![CDATA[Uso de alcohol, tabaco y drogas en población Mexicana, un estudio de cohortes]]> resumen está disponible en el texto completo<hr/>Summary: Introduction. The availability of drugs and its impact upon our society is undeniably a public concern; the question that remains is to what extent is the population affected. Different sources of information suggest that drug use in Mexico is increasing, especially among the adolescent population. As it has been thirty years since the first epidemiological study of drug use was conducted in Mexico in the 1970’s, this is an opportune moment to evaluate the problem by age cohort. This research addresses the question of whether changes in substance use have differentially affected the younger population in terms of the evolution of ages of onset and the socio-demographic determinants of lifetime consumption. Method. This study is a part of the World Mental Health Surveys Initiative from the WHO which was undertaken simultaneously in 30 countries. The target population was taken from uninstitutionalized persons with a fixed residence, between 18 and 65 years of age, and living in urban areas (as defined by more than 2500 inhabitants). The survey is based on a probabilistic, multistage design, stratified by six geographic areas at the national level. Eligible respondents were defined as persons, aged 18 to 65 at the time of the survey, who normally eat, sleep and prepare meals in the household and limited to those that speak Spanish. A total of 5826 individuals were interviewed with a weighted individual response rate of 76.6%. The computer assisted version of the World Mental Health Composite International Diagnostic Interview (WMH-CIDI)was administered. The interview length varied from a minimum of 20 minutes to a maximum of nine hours in four sessions. Fieldwork was carried out by 34 lay interviewers with prior experience in survey data collection and trained by professionals certified by the WHO in the use and training of the CIDI. Standard errors of the estimated prevalences were calculated by the Taylor linearization method using the SUDAAN 2002 statistical package. Kaplan Meir survival curves were generated for the ages of onset using the SAS 2001 software. Logistic regressions were performed to study the demographic correlates of substance use. Estimates of standard errors of odds ratio (ORs) from logistic regression coefficients were also obtained by SUDAAN, and 95% Confidence Intervals (CI) have been adjusted to design effects. Results. Alcohol is the most used substance with less variation by age; 86% of those interviewed report alcohol consumption at some time in their life. The prevalence of alcohol use is followed by tobacco use. Sixty percent of the population report having used tobacco, reaching the greatest proportion of the population in the 45 to 54 year old age group (63%). The non-medical use of drugs, including illicit drugs and legal drugs without a medical prescription, reaches 10% of the population. The illegal use of drugs, including the non-medical use of legal drugs and illicit drugs, in particular marijuana and cocaine, is more frequent among the young and prevalence diminishes with age. Beginning in adolescence, there is a growing prevalence of those reporting the use of these substances, stabilizing shortly before the age of 30. A discrete time survival analysis to estimate the variation in the lifetime prevalence by cohort showed variations in drug use by cohort for all the substances studied, even for alcohol consumption. In all cases, compared to the oldest cohort, the younger cohort are at greater risk of substance use and the greatest risks are concentrated always in the youngest cohort. The cohort differences in probability of substance use is greatest for cocaine, with increases of up to 100 times the risk for those between 18 and 29 years of age. Results of a logistic regression model demonstrate that age continues to be an important risk factor for non-prescription medical substance use, marijuana and cocaine, but not for alcohol and tobacco. For all substances, use is substantially lower for females as well as for the homemaker category of employment. There are no consistent differences for the other demographic variables across the five types of substances. Discussion. This report documents an increase in the risk for substance abuse problems among today’s youth, greater than the risk faced by their parents or grandparents at the same age. Use begins increasing during adolescence and stabilizes shortly before the age of 30. There are variations by type of drug such that marijuana has maintained an early age of onset in the different age cohorts while for the use of other substances new cases of onset are found after this age; the substance that shows the greatest proportion of new onset at later ages is cocaine. Even so, the risk of cocaine use is considerably greater in younger cohorts. Survival analysis confirms that compared to older cohorts, the younger have greater risk of substance use and these risks are particularly striking for cocaine use, with as much as 100 times the risk for those between 18 and 29 years of age. These findings coincide with those reported in previous studies in that alcohol and tobacco use surpass by far the use of other substances, with greater use of alcohol than tobacco and both above any other substance. The rate of tobacco and alcohol use is similar throughout the lifespan signifying that this is an endemic problem in our country. On the other hand, findings regarding the use of illegal drugs, in particular marijuana and cocaine, and non-prescription medical drugs show a preponderance of use in the young. These findings reflect the tendencies already reported in other studies. Marijuana use is not new, and has a long tradition throughout the country for which it is not surprising that these results show cases of consumption in all age groups and that the age of onset is similar in all age cohorts, around 17 years of age. However, the growth of marijuana use is reflected by greater lifetime prevalence in the young, three times greater among those now currently 18 to 29 years of age than those of the same age in the 1970’s. The use of cocaine before that decade was limited to isolated groups as a socially sophisticated diversion; there is a resurgence in the 1990’s when an important increase in use is reflected in all the available surveillance systems. This is reflected in our results by the lower exposure to this drug in the older cohorts. While the risk of marijuana use is 16 times lower in the older cohort than the younger, the risk of cocaine use is 100 times lower in the older cohort than the younger. Our findings suggest that age continues to be an important risk factor for the use of illegal drugs and medical drugs without a prescription, but not for alcohol or tobacco. For all substances, use is lower for females as well as for homemakers indicating that double standards between the genders are still applied. For alcohol there are slightly lower risks for those with lesser educational attainment. This is consistent with other studies which have documented that alcohol consumption increases with buying power which is in turn associated with increased education. These results suggest the need to undertake further research which would allow us a more in depth understanding of the role that social position, including marital status, plays in substance use and abuse. Conclusions. These findings support the hypothesis that the younger generation of today has a greater risk of substance use when compared to their parents when they were young. This point out to the need of increasing actions aimed at reducing the negative impact of this phenomena upon health and society.