Scielo RSS <![CDATA[Salud mental]]> vol. 30 num. 6 lang. en <![CDATA[SciELO Logo]]> <![CDATA[Conferencia Magistral. Pharmacogenetics of antidepressants]]> <![CDATA[Vías de neuroinmunomodulación. Primera parte]]> resumen está disponible en el texto completo<hr/>Summary: Inflammation is a normal response caused by physical stress like infection, injury and trauma; and processive or psychological stress like in psychiatric diseases such as major depression, schizophrenia and posttraumatic stress. The host responds with a complex series of immune, endocrine and nervous reactions to face the stressful stimuli named neuroendocrine immune interaction. These interactions help us to maintain the homeostasis under stressful stimuli. Stress is a physicochemical or emotional process that induces tension. This process promotes the release of proinflammatory cytokines, hormones such as the corticotrophin-release hormone (CRH) and cortisol, and a wide number of neurotransmitters that are together responsible for some behavioral alterations. Both systemic and psychological stress elicits an equivalent response in an organism. Particularly, the onset of inflammation is characterized by release of pro-inflammatory mediators including tumor necrosis factor (TNF)-α, interleukin (IL)-1, adhesion molecules, vasoactive mediators, and reactive oxygen species. The early release of pro-inflammatory cytokines by a widely variety of immune and no-immune cells has a pivotal role in triggering the local inflammatory response. Apart from their involvement in local inflammation, TNF-α and IL-1β are signal molecules for activation of brain derived neuroendocrine and immunomodulatory responses. Excessive production of cytokines, such as TNF-α and IL-1β however can be more injurious than the inciting event, initiating diffuse coagulation, tissue injury, hypotension, and death. The inflammatory response is balanced by anti-inflammatory molecules like the cytokines IL-10 and IL-4, soluble TNF receptors, IL-1 receptor antagonists, and transforming growth factor (TGF)-β. Neuroendocrine pathways, such as the hypothalamus-pituitary-adrenal (HPA) axis and the sympathetic division of the Autonomic Nervous System (SNS) control the inflammation process by triggering anti-inflammatory balancing mechanisms. The brain can monitor immune status and sense peripheral inflammation through two main pathways: neural and humoral. The neural mechanism relies upon activation of vagus nerve afferent sensory fibers that signal the brain that inflammation is occurring. Stressful stimuli activate vagal afferents either directly by cytokines released from dendritic cells, macrophages, and other vagal-associated immune cells, or indirectly through the chemoreceptive cells located in vagal paraganglia. The transmission of cytokine signals to the brain through the vagal sensory neurons depends upon the magnitude of the stressful challenge. Subdiaphragmatic vagotomy inhibits the stimulation of the HPA axis and noradrenaline (NA) release in hypothalamic nuclei in response to intraperitoneal administration of endotoxin or IL-1β. Intravenous endotoxin administration induces expression of the neural activation marker c-Fos in the brainstem medulla, regardless of the integrity of the vagus nerve. Vagotomy fails to suppress high dose endotoxininduced. IL-1β immunoreactivity in the brain and increases blood corticosterone levels. It is likely that the vagal afferent neural pathway plays a dominant role in mild to moderate peripheral inflammatory responses, whereas acute, robust inflammatory responses signal the brain primarily via humoral mechanisms. By other hand, humoral pathway are supported by a large body of evidence, especially in cases of systemic immune challenge; circulatory cytokines like IL-1 β and TNF-α can cross the blood-brain barrier and enter cerebrospinal fluid and the interstitial fluid spaces of the brain and spinal cord by a saturable carrier mediated mechanism that may function only at very high plasma cytokine concentrations. Cytokines also can bind to receptors at the surface of the endothelium of the brain capillaries and can enhance the synthesis and release of soluble mediators such as prostaglandins and nitric oxide, which diffuse into the brain parenchyma and modulate the activity of specific groups of neurons. It has been suggested that prostaglandins mediate fever and HPA axis activation. Cytokine-to-brain communication also may occur via circumventricular organs that lack normal blood-brain barrier function. Among the circumventricular organs, the AP (area postrema) appears to represent the best candidate for such a transduction site. The AP is located in the floor of the caudal fourth ventricle and dendrites of neurons in the NTS (nucleus tractus solitarius) and DMN (dorsal motor nucleus) penetrate both the AP and floor of the fourth ventricle. The close proximity of AP to NTS and RVM (rostral ventrolateral medulla) and the existing neural connections provide a way of signaling the SNS and HPA axis. Cytokine-induced production of prostaglandins within the AP, NTS, and RVM may activate the catecholamine projections to the PVN, resulting in subsequent HPA axis activation. This is one possible interaction between the neural and humoral mechanisms of immune to brain communication through which the brain mediates anti-inflammatory responses. Apart from their function in signaling the brain for immunomodulatory responses, cytokines play a multifunctional role in brain injury and neurodegenerative diseases. Restoration of homeostasis as a logical resolution of inflammation does not always occur. For instance, a lack of adequate inflammatory responses may result in increased susceptibility to infections or cancer. On the other hand, excessive responses are associated with autoimmune diseases, diabetes, sepsis, psychiatric diseases with an important inflammatory response like major depression or schizophrenia and other debilitating conditions. When control of local inflammatory responses is lost, pro-inflammatory mediators can spill into the circulation, resulting in systemic inflammation that may progress to shock, multiple organ failure, and death. A recent discovery, showed that a novel neuroimmunomodulatory pathway that interface the brain and the immune system, referred as to the autonomic cholinergic anti-inflammatory pathway, mediate inhibitory responses during inflammation possibly by recruiting central mechanisms that modulate systemic or peripheral inflammatory responses. Still unclear, this neural circuit has been implicated in promoting sort of psychotherapeutical activities such as hypnosis, meditation, prayer, biofeedback, including acupuncture, but this mechanims still remain elusive. The sympathetic and parasympathetic parts of the Autonomic Nervous System rarely operate alone; autonomic responses represent the interplay of both parts. A link between the parasympathetic part of the Autonomic Nervous System and immunoregulatory processes was suggested, when alleviation of T-lymphocyte cytotoxicity by muscarinic cholinergic stimulation was described. Communication between the immune, nervous, and endocrine systems is essential for host defense and involves a variety of mediators including cytokines, neurotransmitters, hormones, and humoral factors. The influence of the brain on immune function and the mechanisms involved in these interactions have been elucidated over the past 3 decades, however, two important questions arise when describing the brain-derived immunomodulation: How is the specific brain initially signaled by cytokines to trigger corresponding neural and neuroendocrine responses?; and: How is immunomodulation achieved through these mechanisms? This review outlines brain-related control mechanisms of immune function in the regulation of inflammation. <![CDATA[Bioethical guidelines for the study of chronic pain in animals: A paradox?]]> Summary: The study of nociception in animals is a biomedical research field directly implicated with an ethical framework. In this work I will refer to the ethical considerations we must bear in mind when dealing with experimental approaches in animals used for the study of normal -physiological- and abnormal -pathological-mechanisms related to what humans denote as pain. In fact, this implies a paradox for, if we are to comply with international bioethical guidelines, we have to show that our research animals are not subject to suffering or pain during the experimental procedures or as a consequence of them. Therefore, the use of procedures or agents to withdraw suffering or pain would intrinsically cancel the mechanisms which are the object of our study. How can we study pain without causing it? In some way, this implies the transgression of the ethical code of a society claiming to be more modern and civilized and which demands and promotes human well-being; this entails essentially a life without pain. The analysis of these problems needs several platforms or levels. The first level is the social one, where society plays various roles not only as a defender of animal rights, but also as a victim within itself or related fellow creatures of long-term pain suffering or that associated with terminal diseases. Secondly, an academic platform comprising thinkers of all the related disciplines in this area and, finally, a platform constituted by peer judges and experts dealing exactly with a specific bioethical problem. In this sense, the concrete proposal here is to incorporate society and make it share responsibility with the afore mentioned platforms, into a collegiate body provided with bioethical decision capacity in relation to the development of projects where nociception research is undertaken. We are faced with a problem of social shared responsibility between the scientific and general communities, having solutions subject of being improved by means of rational approaches and avoiding any radical positions, regardless of its scientific appearance or antivivisection resemblance.<hr/>Resumen: Hoy en día no queda claro, ni es un hecho consciente para amplios sectores sociales, el papel benéfico de las investigaciones biomédicas realizadas con animales, que han redundado en una mejor calidad de vida en el campo de la salud. Esta falta de claridad se debe, en parte, a la ignorancia y en parte a que algunos sectores que realizan este tipo de investigaciones prefieren mantener anestesiada la conciencia de la opinión pública por razones diversas, una de las cuales es la bioética. Es por esto que cada vez es más imperioso sacar a la luz pública y a los foros académicos estos temas que nos atañen a todos. Un campo de investigación biomédica directamente implicado con la bioética es el relacionado con el estudio del dolor. En este trabajo me referiré a las consideraciones bioéticas en torno a abordajes experimentales con animales, en los cuales se investigan los mecanismos normales -fisiológicos- y anormales -patológicos- relacionados con lo que el hombre expresa como dolor. Si nos atenemos a los lineamientos bioéticos internacionales nosotros debemos demostrar que nuestros animales de investigación no sufren dolor durante los procedimientos experimentales o a consecuencia de éstos. Por lo tanto, la utilización de técnicas o fármacos para eliminar el sufrimiento y el dolor cancelaría intrínsecamente los mecanismos objeto de nuestro estudio. Es decir, se establece una paradoja: ¿cómo estudiar el dolor sin producir dolor? Esto de alguna manera implica transgredir el código ético de una sociedad que se pretende hoy más moderna y civilizada, y que en otro sentido, exige y promulga el bienestar humano, lo cual incluye de manera prioritaria una vida sin dolor. El análisis de estos problemas tiene que realizarse desde distintas plataformas o niveles. El primero de ellos sería el nivel social, esa sociedad que se constituye tanto en defensora de los derechos de los animales, como también en la sociedad que padece en sí misma o en sus prójimos (animales domésticos) la desgracia del dolor de plazos largos o asociado a enfermedades terminales. La plataforma académica estaría constituida por pensadores de todas las disciplinas interesadas, y una constituida por jueces pares y expertos relacionados puntualmente con el problema bioético específico. En este sentido, la propuesta concreta es incorporar y corresponsabilizar a la sociedad civil integrada por las plataformas antes mencionadas en un cuerpo colegiado que tome las decisiones bioéticas relacionadas con el desarrollo de proyectos en que se investiga la nocicepción. <![CDATA[Ética de la investigación psicosocial]]> resumen está disponible en el texto completo<hr/>Summary: The aim of this manuscript is to open up a space for thinking about and debating the issue of ethics in psychosocial research. The ethics of research is put forward in order to identify, deliberate and to a certain extent mitigate the dilemmas arising during the process of generating knowledge. In research, the main questioning focuses on how to behave ethically at the various stages of research, in one's relationships with other scientists and in considering the social responsibility of science. The ethics of research in human beings becomes important when one admits that all kinds of studies contain dilemmas that constitute risks for those that participate in it. However, not all research in human beings is the same; the risks and benefits of biomedical experimentation differ from those that arise in studies in the psychosocial area. Social science research, including psychosocial research, generally entails emotional risks that may trigger mental health disorders and social risks, such as the discrimination or stigmatization of the subjects involved. The ethical dilemmas of social studies are different because they are conceived of in a morally heterogeneous context; in the relativist essence of social sciences; in the canons of scientific objectivity and methodological rigor; in the primacy of subjectivity and the recognition of otherness; in the processes of individuation and the social order; in historicity and culture; in the exercise of power and in the will to know. In other words, in the elements those represent and are inherent to social research. In general, these conflicts are expressed when researchers begin to wonder what to prioritize at the moment of choosing a research issue and the way the latter is undertaken. They also arise over the issue of what to publish and when considering the importance of the problem for the community, mainly at the time of giving back the information to those that participated in the study. As a result of the above, first must be questioned both the design of the work, the method and techniques to be used in achieving objectives and the impact of the study for the scientific and social community. The latter is crucial, since it determines whether or not social intervention policies that are important in people's lives can be implemented. The dissemination of information has often been an issue of great interest and ethical debate, since it involves confidentiality as well as the need for publication and the dissemination of results. In this respect, intellectual honesty and the guarantee that the results of the study will be properly used by researcher are crucial. It is therefore essential to take ethical reflection to other fields of action, where the different ethical implications are difficult to deal with, such as community studies, at-risk or minority populations, as well as the various research methods, such as the qualitative approach. At the same time, ethical problems encountered by social researchers tend to be avoided, perhaps because they are not interpreted as such or because, in the majority of cases, they can be regarded as mistakes or deficiencies by the researcher himself, who is not prepared to reveal them to the scientific community or perhaps because the recognition of a dilemma may influence the acceptance of a research project. Thus social scientists usually only recognize those displayed in biomedical experimentation as ethical dilemmas and therefore do not subject themselves to the ethical codes of these disciplines. It may also be because psychosocial research should not really have to apply ethical standards applied in other disciplines, whose object of study is different from that of social sciences. If it did so, it would be a non-reflexive way of understanding the construction of knowledge derived from social research. On the contrary, the ethics of psychosocial research attempts to problematize and generate reflection and interpretation, from the epistemological and ontological consistency characteristic of the social disciplines, where the ethical conflicts represented in everyday practices are obviated and become unquestionable in research, which is why one has to rethink the responsibility and commitment involved in social science. Thus, psychosocial research should propose its own ethical requirements, without having to make declarations or establishing principles that end up as ethical codes. The point is not to establish norms for the critical behavior of researchers or to recommend universal ethical guidelines. The point is for ethical requirements to arise from the inherent needs of social research, through constant dialog and consensus, the recognition of the ethical dilemmas that emerge and the critical work conducted in this area. The point is to provide rather than establish knowledge, skills and abilities in the interaction with people, to understand the duties of professionals and the rights of participants and to develop the sensitivity to be able to recognize the different cultural nuances, the expressions of group diversity and the vulnerability of the human condition. Unless the issue is examined in depth, ethics in the social field will be threatened by an ethical imperialism that imposes unilateral evaluation criteria on psychosocial research. It would be an ethics whose requirements would become excessively bureaucratic and complied with solely for the purpose of obtaining grants for research. At present, ethical concerns are only entrusted to institutions (Ethical committees) or financing organizations, whether national or foreign, since researchers regard them merely as an imposition that happens to be in vogue, rather than assuming that they are the ones that have the capacity and sensitivity, based on their experience, to identify and mitigate ethical dilemmas. This shows the importance of ensuring that researchers accept the rigorous, ethical review of their work during the entire research process, even at the time of the publication and presentation of results. Hence the need for an ethics committee, whose dialogic function operates with a variety of visions and opinions, that do not prevent debate and instead promote reflection, and which is far removed from belief, intuition, dogma, doctrine and fundamentalism, which would hamper dialog and tolerance and the creation of a space where moral and above all, ethical responsibility should prevail. Ethical dilemmas are inherent to psycho-social research, which is why the main challenge would be to ensure respect for autonomy, bearing in mind the fact that informed consent must be voluntary, individual and/or collective, verbal or written, but above all, a process that only ends after research has been completed. At the same time, researchers must protect the confidentiality, privacy and common good of those being researched, and avoid damage, discrimination and stigmatization. In short, efforts must be made to maximize benefits, in other words, to protect the rights and well-being of research subjects. In psychosocial research, one is ethically obliged to problematize and critically reflect on one's work and the way one behaves, in other words, one's ethos as researchers, with responsibility and moral commitment towards those being researched. <![CDATA[<strong>Tailoring an intervention model to help indigenous families cope with excessive drinking in central Mexico</strong>]]> Summary: Alcohol has been acknowledged as one of the psychotropic drugs consumed in nearly all cultures. The study of alcohol use among indigenous and rural communities from an anthropological perspective highlights the function of alcohol in the social cohesion, and tends to minimize the consequences of consumption. This research adopts a complementary paradigm more closely linked to the acknowledgement of the significant increase in alcohol availability, coupled with its excessive promotion and the lack of support services for other related social, economic and even religious problems. Two groups are affected by excessive drinking: consumers and their closest social nucleus, i.e. the family, both of which require assistance. The aim of this article is to describe the process followed to adapt to the indigenous context a brief intervention model to support the drinkers' families, which is based upon the stress-strain-coping-support model and has proved useful in helping to deal with the dilemmas faced by relatives concerned with a family member's excessive drinking. The adaptation process included four research phases involving different qualitative methods: 1. feasibility, which includes the initial ethnographic research, 2. the adaptation of instruments and psycho-educational materials, 3. the development of an intervention manual and finally, 4. the development of cost-benefit evaluation indicators. The data are drawn from two small indigenous communities located in the arid zone of Valle del Mezquital, in the state of Hidalgo, 300 km from Mexico City. Various strategies drawn from qualitative methods were used in the different phases, i.e. individual interviews with key informants and community members, focus groups, field notes, cognitive laboratories, and the application of semi-structured and structured questionnaires. Different factors were identified as potential challenges for intervention: The existence of a patriarchal organization, fear of gossip, the different perceptions of alcohol consumption, linguistic connotations, poverty, time constraints, and the right not to inform the participants exert. It is crucial to increase awareness in order to improve well-being through various means. Women must be offered alternative responses to a dominant patriarchal structure, by helping them overcome the fear of discussing their problems, taking care not to offend their traditions and encouraging mechanisms that will weaken the power of gossip. Likewise, men must be convinced of the harmfulness of alcohol consumption and its effects on the family.<hr/>Resumen: El alcohol se reconoce como una de las drogas psicotrópicas que se consumen en casi todas las culturas. El estudio del consumo de alcohol en las comunidades indígenas y rurales desde la perspectiva antropológica resalta el papel del alcohol en la cohesión social y tiende a minimizar las consecuencias del consumo. Esta investigación adopta un paradigma complementario que considera el incremento significativo en la disponibilidad del alcohol y la excesiva promoción que recibe, así como la falta de servicios de apoyo para atender otros problemas sociales, económicos e incluso religiosos que se relacionan con el consumo. Al menos dos grupos son afectados por el consumo excesivo de alcohol: los bebedores y su núcleo social más cercano, es decir, la familia, y ambos requieren atención. El objetivo de este artículo es describir el proceso que se siguió para adaptar al contexto indígena un modelo de intervención breve para apoyar a las familias de los consumidores. La intervención se basa en el modelo estrés-tensión-enfrentamiento-apoyo, y ha mostrado ser útil para ayudar a las familias a lidiar con los dilemas que enfrentan en relación con el consumo de alcohol de alguno de sus integrantes. El proceso de adaptación consta de cuatro fases de investigación: 1. factibilidad, que incluye una investigación etnográfica inicial, 2. adaptación de instrumentos y material psicodidáctico, 3. desarrollo de un manual de intervención, 4. desarrollo de indicadores para la evaluación del costo-beneficio. La información proviene de dos pequeñas comunidades localizadas en la región árida del Valle del Mezquital, en el estado de Hidalgo, a 300 km de la Ciudad de México. En la investigación se emplearon diferentes métodos cualitativos: entrevistas individuales con informantes clave y miembros de la comunidad, grupos focales, laboratorios cognitivos y la aplicación de cuestionarios semiestructurados y estructurados. Se identificaron diferentes retos para la intervención; entre ellos, la existencia de una estructura de organización patriarcal, el temor al chisme, las percepciones del consumo de alcohol, las connotaciones lingüísticas, la pobreza, las limitaciones de tiempo y el derecho a no informar que ejercen los participantes. Es crucial incrementar la conciencia en relación con la necesidad de lograr mayor bienestar. También es necesario ofrecer a las mujeres respuestas alternativas frente a la estructura patriarcal dominante sin transgredir sus tradiciones ni debilitar el poder del chisme. Por último se requiere sensibilizar a los hombres respecto a los daños que se asocian al consumo excesivo de alcohol y la forma en que éste afecta a la familia. <![CDATA[Trastorno por estrés postraumático en pacientes con lesiones no intencionales producidas en accidentes de tránsito]]> Resumen: En México los accidentes son un grave problema de salud pública. Estos eventos de tipo traumático tienen una probabilidad potencial de ocurrir de forma fortuita en cualquier momento de la vida de los individuos. Actualmente ocupan la tercera causa de mortalidad general y la primera en adultos jóvenes. Los accidentes producidos por vehículos de motor ocupan el primer puesto dentro del rango de los accidentes en general, esto de acuerdo a las tasas de mortalidad en adultos jóvenes que publican la OMS, la OPS y la SSA en México. Una de las consecuencias de los accidentes de tránsito por vehículo de motor es la secuela psicológica que dejan en los individuos en edad productiva. Estas secuelas se conocen como Trastorno por Estrés Postraumático (TEPT) y a pesar de que en nuestro país existen cifras alarmantes de ausentismo laboral y baja en la productividad como consecuencia de ello, no ha sido estudiado a profundidad. El Estrés Postraumático es un trastorno de ansiedad causante de disfunción psicosocial y aparece en condiciones de exposición a un estresor traumático. La etiología del TEPT es multifactorial y en ella intervienen factores genéticos, psicológicos, educativos y ambientales. El propósito del presente estudio fue determinar la frecuencia del TEPT en pacientes que hubiesen tenido lesiones físicas por accidentes de tránsito (accidentes automovilísticos producidos por vehículos de motor) y que fueron atendidos en el Servicio de Ortopedia y Trauma, del Hospital Regional "Lic. Adolfo López Mateos" del ISSSTE. Para ello se diseño un estudio transversal descriptivo con muestreo no probabilístico seleccionando una muestra mediante los criterios de inclusión siguientes: ser mayor de 18 años, haber sufrido accidente por vehículo de motor, haber sido atendido al menos por un mes en el Servicio de Trauma y Ortopedia de ese centro hospitalario, y encontrarse en condiciones físicas y mentales para contestar un cuestionario. El instrumento fue un formato autoaplicable conformado por la Escala de Mississippi para el TEPT para tamizaje, selección de casos y medición de la severidad de los síntomas. También se incluyó la Cédula de Evaluación Clínica en Neuropsiquiatría de la OMS (Schedules for Clinical Assessment in Neuropsychiatry-SCAN), un instrumento que establece el perfil de afecto (PANAS), y por último una cédula de identificación para datos sociodemográficos. En el estudio participaron 37 sujetos que cumplieron con los criterios de inclusión. De éstos, 57% fueron hombres y 43% mujeres, con un promedio de edad de 35 años (DE=12.44); 40.5% eran solteros, 51.4% casados; 43.2% de los sujetos tenía nivel de educación básica y 56.8% media superior y superior. Para la calificación de TEPT, se determinó como casos a los sujetos que puntuaron por arriba de 5 en la Escala de Mississippi y posteriormente eran confirmados con la cédula SCAN. La mayoría de los sujetos que sufrieron accidentes fueron hombres (57%), los eventos ocurrieron en día sábado, cuando éstos se dirigían a su casa, en su automóvil y sin compañía. La mayoría de los sujetos estuvieron involucrados en choques vehiculares. De todos los casos, 62.2% cumplieron con los criterios para ser corroborados con TEPT, lo cual representa un porcentaje mayor al reportado en población mexicana. Se encontraron diferencias estadísticamente significativas en la proporción de sujetos que reportaron TEPT y el tipo de vehículo en que se encontraban al ocurrir el accidente (X2=9.868, p=.007), así como en el tiempo que había trascurrido desde el momento del mismo (X2=8.651, p=.013). De las pruebas de asociación con el perfil de afecto, el afecto negativo durante la última semana anterior al estudio tuvo una correlación positiva y significativa con el TEPT, es decir que a mayor afecto negativo hay más síntomas de estrés.<hr/>Summary: We have carried out this research because accidents are a serious public health problem in Mexico. They are the third overall mortality cause and the first among young adults. In addition, in our country, the study of posttraumatic stress disorder (PTSD) has not been focused sufficiently on accidents, not to speak of motor vehicles accidents. Among the different types of accidents, traffic accidents are placed at the top of the list. Aside from causing injuries and the loss of man hours at work, these accidents bring about emotional distress to affected individuals. Stress is a factor that triggers short-and medium-term consequences which are in turn reflected in the quality of life of the patient and his/her family. PTSD is an anxiety disorder that causes psychosocial disfunctioning and appears due to the exposure to a stressor or traumatic event. It may come about in two ways: when the subject is a victim of a serious threat to his/her life or integrity and when the subject witnesses an event seriously affecting a third party. The main stressors may be natural phenomena, such as hurricanes and earthquakes, intentional attacks, such as rape or any form of criminal violence, and, as is the case here, from traumatic events caused by motor vehicles. The etiology of PTSD is multi-factorial and involves genetic, psychological, educational, and environmental aspects. It has three forms: severe, where the disorder appears immediately after the occurrence of the event or until a month later; chronic, lasting between one and three months; and delayed, where symptoms appear six months after the event. Our objective was to establish PTSD frequency in patients with physical injuries caused by motor vehicles accidents who were attended at the Regional Orthopaedics and Trauma Hospital "Adolfo López Mateos". Together with the application of the scales, we were interested in making a description of the socio-demographical side of accidents, comparing the affect profile, and somehow defining the wide range of factors involved in the occurrence of this problem. For this, we devised a transversal and descriptive study with a non-probabilistic sampling. The sample was chosen using the following inclusion criteria: a) Being older than 18 years. b) Having suffered a motor vehicle accident. c) Having received attention for a month at least at the Orthopaedics and Trauma Hospital "Adolfo López Mateos". d) Having the physical and mental conditions to answer a self-report questionnaire or at least to be interviewed instead. The instrument used was a self-report questionnaire consisting of different scales: 1. The Mississippi PTSD Scale for screening, case selection and symptoms severity measurement. This scale has been translated and validated in Mexico. 2. The WHO Schedules for Clinical Assessment in Neuropsychiatry (SCAN). 3. An instrument to establish the affect profile (PANAS). 4. A socio-demographical data identification schedule. Results from this study show some interesting characteristics from subjects involved in traffic accidents such as the fact that victims are mostly men driving alone at weekends. As has been pointed out, this supports the importance of putting into practice actions to educate drivers involved in such circumstances more often. In addition, policies which allow for the modification of traffic environments as to their adequateness to social contexts should be established. Likewise, data from this work agree with those from other studies as to the existence of an association between the presence of PTSD and the involvement in car accidents. Although the prevalence of the sample of this study is much higher than previous Mexican reports, it shows some interesting figures regarding the fact that most subjects who reported PTSD were women who had an elementary education level and a partner by the time of the accident. Falls from vehicles, people run over by cars and individuals driving alone at the time of accidents were other relevant high-impact findings. While it is true, on the one hand, that the aforementioned results are non-significant, they do give an idea of some aspects which would be useful to bear in mind in providing clinical attention to affected individuals. On the other hand, aspects which did have a statistical significance on the data from this sample should be taken into account. One of these was the fact that the higher rate of PTSD was reported in individuals who suffered an accident while being inside a vehicle, in individuals involved in an accident which had occurred between one and three months before and who in addition tended to present a negative affect profile. These are important findings because they give us the opportunity to consider more specific aspects at the time of developing attention strategies which could alleviate the temporal impact and scale of the problem. <![CDATA[The nightmare of a painful phantom]]> Summary: Pain has a representation in the central nervous system within some of the most ancient structures developed over the phylogenetical history. Also, it is the most important symptom for which patients seek medical attention. However, there are pathologies in which pain stops being the alarm and becomes a medical issue, perhaps the most dramatic example of this would be the presence of pain in a part of the body that is no longer present, this is known as 'phantom limb pain'. Over history, much attention has been given to pain understanding by well-known personalities and phantom limb itself was described first by Ambroise Paré in the 16th Century and later described by Silas Weir Mitchell in the 19th Century and thoroughly addressed by Livingston in the first half of the 20th Century. The non-painful phantom limb phenomena are reported by almost all amputees and there is pain in 50 to 80%, no matter the nature of the amputation. We face a puzzling public health problem. The major cause of limb amputations comes from vascular and neuropathic complications provoked by diabetes, followed in frequency by trauma, all astonishingly prevalent in the general working population in productive ages. A worrying cause of trauma and the phantom limb in some developing countries is caused by anti-personnel mines leading people, a majority of civilians with a considerable amount of children, to a living hell accompanied by a painful phantom. Phantom limb pain represents a challenge that involves a huge scope of study related to both public health and neuroscience. It is an entity that involves peripheral, central and psychological factors. Neuroscientific research has studied the system from the amputated peripheral nerve, where a neuroma develops, to the cerebral cortex in which there are changes in the somatosensory cortex after limb amputations, related to a decreased activation of the area that would represent the missing limb. Besides, this problem has caused the development of theories such as the 'neuromatrix' that is activated in the absence of peripheral sensory information. In this sense, the anterior cingulate cortex has been proposed as a key structure in the development of phantom nociception in animals. After a huge amount of research, only 30% of patients benefits for a good number of interventions. Phantom limb pain is a clear example that consciousness can indeed become ill and that the clinical frequency, importance and transcendence make research on the neuroscience of consciousness of vital importance. The painful phantom represents a tool and challenge in the neuroscientific field, opens the door for the study on consciousness, supports the need for improved healthcare and allows us to think about war and its consequences in the development of society.<hr/>Resumen: El dolor es representado en el Sistema Nervioso Central en algunas de las estructuras más antiguas desarrolladas a lo largo de la historia filogenética. Además, es el síntoma más importante por el que los pacientes buscan atención médica. Sin embargo, existen patologías en las que el dolor deja de ser la alarma y se convierte en un problema médico; probablemente el ejemplo más dramático sea la presencia de dolor en una parte del cuerpo que no está presente, esto se conoce como "miembro fantasma doloroso". A lo largo de la historia, se ha prestado mucha atención en el entendimiento del dolor por renombradas personalidades. El miembro fantasma fue descrito por primera vez por Ambroise Paré en el siglo XVI; en el siglo XIX hizo lo mismo Silas Weir Mitchell, y posteriormente fue revisado con mayor profundidad por Livingston a inicios del siglo XX. El fenómeno del miembro fantasma no doloroso es reportado prácticamente por todas las personas amputadas, y el doloroso en 50 a 80% de los casos, sin importar la naturaleza de la amputación. Nos encontramos frente un importante problema de salud pública. La principal causa de amputación de miembros viene de las complicaciones vasculares y neuropáticas de la diabetes, seguida en frecuencia por causas traumáticas, extremadamente frecuentes en la población económicamente activa. Una causa preocupante de trauma y del fantasma en algunos países en desarrollo son las minas anti-persona. Estas, llevan a los afectados, la mayoría civiles con un número considerable de niños, a un infierno viviente acompañado de un fantasma doloroso. El dolor por miembro fantasma representa un desafío que involucra un enorme campo de estudio relacionado con la salud pública y las neurociencias. Es una entidad que involucra factores periféricos, centrales y psicológicos. La investigación neurocientífica ha estudiado el Sistema desde el nervio periférico amputado donde se forma un neuroma, hasta la corteza cerebral en donde hay una activación disminuida del área que representa al miembro amputado en la corteza somatosensorial después de una amputación. Además, esto ha provocado el desarrollo de teorías como la "neuromatriz". En este sentido, la corteza anterior del cíngulo ha sido propuesta como una estructura clave en el desarrollo de la nocicepción fantasma en animales. Después de una gran cantidad de investigación, sólo 30% de los pacientes se ve beneficiado, gracias a un buen número de intervenciones. El dolor por miembro fantasma es un ejemplo claro de que la conciencia se puede enfermar y la frecuencia clínica, la importancia y la trascendencia de este problema hacen que la investigación en la neurofisiología de la conciencia sea de vital importancia. El fantasma doloroso representa una herramienta y un desafío en el campo neurocientífico; abre la puerta para el estudio de la conciencia, apoya la necesidad de mejorar los servicios de salud y nos permite meditar acerca de la guerra y las consecuencias que tiene para el desarrollo de las sociedades. <![CDATA[<strong>Female depression and substance dependence in the Mexico City penitentiary system</strong>]]> Summary: The prevalence of mental disorders in people deprived of freedom has been estimated at between 10 and 15%. Acute or chronic mental illnesses provoke a major breakdown and maladjustment to prison conditions. The more frequent diagnose of mental disorders have been substance consumption, major depression, bipolar disorder, post-traumatic stress disorder and psychotic disorders. Objective To identify the frequency of major depressive episode in women in prison in Mexico City, its frequency of association with alcohol and substance dependence, and to describe the symptomatic and socio-demographic characteristics. Material and method A transversal, non-experimental, descriptive, ex post facto field study, in two prisons of Mexico City (Centro Preventivo Femenil Oriente [Preventivo Oriente] and the Feminine Center for Social Readaptation Tepepan CERESO), in a non- probabilistic sample of 213 women, selected by convenience. The instrument was designed ex profeso. For the evaluation of the major depressive episode, the Mini International Neuropsychiatric Interview (MINI) and DSM-IV criteria were used for substance dependence. Field work lasted from August 2001 to March 2004. Interviews were carried out under previous informed consent; confidentiality and anonymity were guaranteed. In collaboration with the Center of Orientation and Classification (COC), each center elaborated a list of inmates with a history of substance abuse who met the inclusion criteria to take part in the research. Results The mean age of the interviewed population was 30.6 ± 7.9 years; 45.5% belonged to the age group between 28 to 40 years; the school attainment more frequent was elementary school (41.3%), followed by secondary school. Single women represented 48.6% of the population and 50.2% referred having, at the moment of the interview, a partner relationship. The type of offense reported with major frequency was robbery (51.6%, in different modalities: unspecific, simple, aggravated, not-aggravated, unspecific, burglary, tentative of robbery and car theft). The researched population referred that 43.7% had previously done time in some penal institution. The frequency of depressive episodes was 62% (n=132) in the interviewed population. The group between 18 to 27 years, with lower years of schooling, single mothers with children under 18 years presented the highest frequency of depression and substance abuse. Alcohol dependence and depression were more frequent in women with less than six months in prison. For depression and substance dependence, the more affected group was the one between one to four years of imprisonment. As to the length of the sentence, women with three to seven years were the most affected by the two diagnoses. Conclusions The interviewed population showed that the longer the imprisonment or the sentence, the higher the frequency of the depressive disorder. A possible explanation is that being imprisoned for a long time may have severe consequences in women's well-being due in part to the fact that in most of the cases women are abandoned by their relatives and loved ones, which intern increases their loss of social support networks. The problem of mental disorders becomes more evident when it is estimated that only 40% of the people who have a disorder had received treatment. Nearly half of the depressed women had not received support and care for their mental health problem. In the group of women with alcohol dependence, less than a quarter had asked for help, in contrast with the group with substance dependence where half of the women had asked for help. On the other hand, prison by itself generates depression and it is a normal reaction in the face of the new situation. There is also the erroneous belief that symptoms will fade away by themselves. In other studies it has been observed that being deprived of freedom causes the lose of emotional relationships, solitude and boredom, lack of services, heterosexual relationships, autonomy, security, a problematic cohabitation with other unpredictable prisoners, all of which cause fear and anxiety. All these deprivations may constitute serious threats to the personality and self-esteem.<hr/>resumen está disponible en el texto completo <![CDATA[Caracterización del nivel de dependencia al alcohol entre habitantes de la Ciudad de México]]> resumen está disponible en el texto completo<hr/>Summary: The dynamic and scope of the consumption of alcoholic beverages, in Mexico, have been known by household surveys, since the last third of the last century. Nowadays those surveys describe alcohol use as one of the main public health tasks nationwide, due not only to its consequences but also to the damage on the different areas of individual's everyday life. A number of indicators have been highlighted by the first survey on 1988, such as teetotalism rates, the alcohol consumers proportion, age of first use, and problems associated with alcohol consumption. As a public health problem, alcohol consumption represents high costs to health institutions because of the problems related to the consumption. So, it requires undertaking certain actions that would be deal with this problem on primary and structural attention, as well as in the individual susceptibility as prevention, or attention levels, diagnosis and treatment. All actions to face this problem are practically impossible in the absence of instruments to establish differential diagnosis between heavy drinking and alcohol dependence. Along the study of alcoholism, have been distinguished two issues to establish differential diagnosis. First is a traditional version of dependence diagnosis by DSM criterions, defined as disadaptative pattern of alcohol consumption that produces significant malaise, expressed trough one year long. The second diagnosis issue quantifies the individual differences of physical, psychological and social damage degrees, caused by the alcohol consumption. From this, appears the motion of Multiple Alcoholism Syndrome. From this last point of view, The Alcohol Use Inventary by Skinner, Horn and Wanberg (1983), is compose by 147 items self administrated, clusted in 24 scales. Time latter, as of many researches done by this research group, aroused The Multiple-syndrome Alcohol Model as The Alcohol Use Inventary simplified version, used as a useful differential diagnosis questionnaire in alcoholics. There for, last version has been done many researches that agree on characterize the alcohol use inventory as screening questionnaire useful to detect problematic drinking to implement primary intervention. Those authors suggest the use of this questionnaire at different stages and populations, with different cut points. Antecedent's use of the questionnaire in Mexico, by Ayala et al., made the adapted version, however, researches seems to be not enough to know the validity of diagnostic instruments on ethanol dependence. The Alcohol Dependence Scale (ADS) consider the dependence as a continuum of four levels, depending on the damage degree associated with alcohol consumption, on the different areas of physical, intellectual, social and psychiatric functioning. In the questionnaire 1 is the minimum cut point for dependence diagnostic and 48 as the highest point, this rank lets differentiate with respect to low dependence, moderate dependence, substantial dependence and severe dependence. This article pretends to diffuse the EDS’s validity on inhabitants in Mexico City. As methodology, a case design and 1:1 paired controls were used by age and marital status. Through a not intentioned sampling by quotas were selected 240 men of 18 to 50 years old. The cases group was integrated by 120 individuals that voluntarily sought treatment at the Center of Assistance for the Alcoholic and Relatives (CAAF) from June, 1998 to June, 2000. All cases comply with DSM-IV alcohol dependence criterion; they reported the last consumption at one month before the beginning of the research and with basic school as scholar level. In the control group were 120 volunteers that request treatment to CAAF from June, 1998 to June, 2000. They did not comply with alcohol dependence criterion. As gold standard, was considered the DSM-IV criteria to sensibility, specificity and predictive values; the factorial structure and internal consistency of the scale are indicated. Socio-demographic data indicated 34 years old as sample average, just over the half had a partner at the time of the study; the predominant education level was secondary school (35%). In the cases the 86% covered 6 to 7 criteria for ethanol dependence in the DSM-IV; the predominant dependence level was moderate at 37%, while 53% of the control group had no evidence of dependence. The heterogeneity test showed significant statistics differences on dependence levels in cases and controls (t=23, df=238 and p=0.00). The ADS displays overall internal consistency of 0.96, based on the Cronbach Reliability Coefficient, a higher level of consistency than that reported in previous studies. With a factorial analysis by varimax rotation and maximum likelihood extraction, revealed the presence of three factors with 56.5% of variance explained: intoxication (48.3%), abstinence (5.6%) and delirium tremens. In the application manual, the authors specify 13/14 as values to use the DAS as a diagnosis questionnaire, and 9 for a screening instrument. While other authors suggest less cut points 13/14 to 2/3 to reduce the false-negative; however, on Mexico City inhabitants, such cut points were inappropriate. The most suitable cut point to detect a significant dependence on clinical was at 8 points, with 96% sensitivity, 98% specificity and a 94% likelihood of making correct diagnoses. These findings show that DAS is a suitable screening instrument for using on Mexico City inhabitants. We suggest including items to evaluate social area or any other scale to complement the ADS. <![CDATA[Guía de práctica clínica para el diagnóstico y tratamiento de depresión en los adultos mayores]]> Resumen: Introducción La depresión cada día cobra mayor importancia, y se estima que en el año 2020 será la segunda causa de años de vida saludable perdidos a escala mundial y la primera en países desarrollados, por lo que el diagnóstico adecuado y oportuno permitirá brindar un manejo integral que incluya psicoterapia y tratamiento médico adecuado, lo que mejorará de manera significativa la calidad de vida y el pronóstico de estas personas. En atención primaria existe sub diagnóstico y retraso en la identificación de la depresión, por lo que, desde el inicio del tratamiento, impacta negativamente en el bienestar de los individuos, en la salud pública y en los costos directos e indirectos de los servicios sanitarios. Es frecuente que el médico de atención primaria considere como "causa" de la depresión las quejas de la vida cotidiana, la incapacidad para hacer frente al estrés familiar, el aislamiento social o el cambio de roles y los problemas financieros; por lo tanto la considera "justificada" y evita proporcionar tratamiento, cuando en realidad esta incapacidad suele ser ocasionada por la misma depresión. La depresión es uno de los padecimientos psicogeriátricos más frecuentes y en México su prevalencia global es de 9.5% en mujeres y 5% en hombres mayores de 60 años. En la mayoría de los casos no es diagnosticada por la presentación atípica de la misma o por la falsa creencia de que forma parte del envejecimiento normal, puesto que en el adulto mayor la depresión se puede esconder en síntomas somáticos, ya sea como manifestaciones del síndrome depresivo o porque a causa de éste se acentúan los síntomas de otras enfermedades concomitantes. Los síntomas cognitivos secundarios se presentan con más frecuencia en este grupo etario. Objetivo Proporcionar a los médicos de primer nivel de atención, una guía de práctica clínica con los elementos técnico-médicos suficientes que faciliten el diagnóstico y tratamiento integral de adultos mayores con depresión. Usuarios. La guía está dirigida a los médicos del primer nivel de atención. Población blanco. Hombres y mujeres de 60 años de edad en adelante. Método El estudio comprendió dos fases: el diseño y la validación de la guía clínica. Selección de evidencia 1. Las palabras clave para la búsqueda fueron: Depresión, adulto mayor, guías clínicas, prevalencia, atención primaria, valoración, tratamiento, riesgo de suicidio. 2. Bases de datos consultadas: Cochrane, Pub-Med y Medline, en el período de 1990-2006. 3. Se encontraron 26 referencias para depresión mayor en adulto mayor: ocho meta análisis de estudios clínicos aleatorizados, dos clínicos aleatorizados, uno de cohorte, 12 descriptivos no experimentales y tres artículos de libros (DSM-IV TR; CIE 10, Manual de psicogeriatría). 4. Categoría de evidencia y fuerza de recomendación, indica al usuario el origen de las recomendaciones emitidas. En el algoritmo de la guía clínica se identifican los conceptos o el sustento de cada una de las recomendaciones. En la presente guía el diagnóstico de depresión se fundamenta en la CIE 10 y su gradación podría ser comparable con la depresión mayor del DSM IV TR. Se incluye el diagnóstico diferencial, los criterios de referencia al psiquiatra, los lineamientos para el tratamiento farmacológico, psicoterapéutico y psicosocial; fase de inicio y fase de mantenimiento. Conclusión La guía de práctica clínica propuesta se basa en metodología rigurosa, da al médico elementos suficientes para realizar el diagnóstico oportuno, así como el tratamiento integral en adultos mayores con depresión, e incorpora criterios con base en evidencia científica que permitirán actualizarla y evaluar su solidez ante el surgimiento de nueva evidencia, manteniendo así su validez.<hr/>Summary: Introduction Depression is growing in importance every day. It is estimated that by the year 2020 it will be worldwide the second cause for the loss of healthy life years and the first in developed countries. Considering this, an adequate and opportune diagnosis will allow for a complete handling of the disorder. This should include adequate psychotherapy and medical treatment which will in turn improve significantly the prognosis and life quality of depressed individuals. In the primary care area, sub-diagnosis and delays to identify depression are common. These have a negative effect on the individuals' well-being, in public health and in the direct and indirect costs of health services. It is not uncommon for primary care practitioners to consider everyday complaints, the inability to cope with family stress, social isolation, role change and money problems as «causes » for depression. Thus, they deem depression «justified » and fail to offer treatment when actually this very inability is often caused by depression. Depression is among the most frequent psycho-geriatric ailments. In Mexico, its overall prevalence is 9.5% in women and 5% in men age 60 or more. In most instances, it goes undiagnosed given its atypical expression or the false belief which considers it part of the normal aging process. In the elderly, depression may conceal somatic symptoms, be it as expressions of the depressive syndrome or because these same symptoms aggravate symptoms from other concomitant diseases. Secondary cognitive symptoms are more frequent among this age group. Objective To provide physicians at primary care a guideline with enough technical-medical elements to facilitate the timely diagnosis and integral treatment of elderly with depression. Method This study comprised two phases: design and validation of the guideline. Evidence selection 1. Key words for search: depression, elderly, clinical guidelines, prevalence, primary care, assessment, treatment, suicide risk. 2. Data bases used: Cochrane, Pub-Med and Medline for the 1990-2006 period. 3. Twenty-six references for major depression in the elderly were found: eight random meta-analysis, two random clinical, one cohort, twelve descriptive non-experimental, and three book articles (DSM-IV[HRM1] TR; CIE 10, Psycho-geriatrics Manual). 4. Evidence category and strength of recommendation. This indicates the user about the origin of recommendations issued. In the algorithm from the clinical guide, the concepts or support for each recommendation are identified. In this guide, the diagnosis of depression is based on the CIE-10 and its ranking may be comparable to that for major depression in the DSM-IV TR. Differential diagnosis; criteria for referring a patient to the psychiatrist; guidelines for pharmacological, psychotherapeutic and psychosocial treatment; onset phase and maintenance phase are included. Thus, the clinical practice guide proposed is based on a strict methodology. It offers enough elements for the general practitioner to assess an opportune and complete treatment for elderly people with depression. In addition, it incorporates criteria based on scientific evidence, which will allow updating it, and evaluating its solidity in the face of new evidence, which will in turn maintain its validity.