Scielo RSS <![CDATA[Salud mental]]> http://www.scielo.org.mx/rss.php?pid=0185-332520090005&lang=pt vol. 32 num. 5 lang. pt <![CDATA[SciELO Logo]]> http://www.scielo.org.mx/img/en/fbpelogp.gif http://www.scielo.org.mx <![CDATA[<b>The psychiatry of a person</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252009000500001&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Psychiatric complications of a late diagnosis of acute porphyria in an affected male</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252009000500002&lng=pt&nrm=iso&tlng=pt Introduction Acute porphyrias are rare genetic disorders of incomplete penetrance (10%). This means that only 10% of the individuals with the genotype known to cause the disease will show any signs or symptoms of such disease. They consist of a deficiency of any enzyme of the heme biosynthesis and are considered as exceptional inborn errors of metabolism with an autosomal dominant inheritance. The incidence is 1 in 100 000. The symptoms are variable and unspecific, consisting mainly of severe abdominal pain, tachycardia, and hypertension. Other frequent manifestations are psychiatric symptoms like depression, psychosis, and hallucinations. In addition to these unspecific symptoms, patients may also present peripheral neuropathy and loss of sensation, which can become permanent. In severe cases, liver damage and chronic renal disease can occur. The objective of this study is to highlight the importance of the difficult diagnosis of acute porphyria, the implications of a misdiagnosis, and the importance of adequate treatment. Case We present a 47 year-old male with a history of abdominal pain for seven years. The pain was diffuse, progressive, and incapacitating. He was diagnosed and treated for chronic gastritis and cholecystitis without improvement. An elective cholecystectomy was performed but he continued with intense abdominal pain. Three years later he developed hallucinations, paresthesias, muscular weakness, depression, and irritability. He was managed as a psychiatric patient with psychotic tendencies. After a complete and thorough history of all his symptoms throughout the years and a re-examination of the patient, acute porphyria was considered as a possible diagnosis. Specific laboratory studies were indicated revealing elevated levels of porphyrines, elevated levels of PBGD, PBG in urine within normal levels, elevated presence of coproporphyrines by chromatography, and a normal PBGD enzymatic activity. The diagnosis of acute porphyria was established. Appropriate treatment was initiated starting with adequate pain management. A high carbohydrate diet was also recommended with appropriate nutritional requirements and caloric intake. Another important aspect of the management was the elimination of risk factors, like alcohol, cigarette smoking, and certain specific medications. Follow-up showed significant improvement of his symptoms and less frequent acute attacks with identification and elimination of risk factors. He was able to return to a stable work schedule. The patient presents residual permanent renal damage. Adequate doctor-patient education was maintained. Discussion This case is an important example of a not-so-rare genetic disease that any physician should have in mind when confronted with a patient with unspecific paroxysmal clinical manifestations. The possibility of acute porphyria should always be excluded before establishing a diagnosis of a psychiatric illness. Prompt diagnosis and management are crucial to reduce the risk of recurrences and permanent damage. Patient education is a very important aspect of the management of the disease since there is no cure. There is a specific treatment for the management of acute attacks (Hemin) but, unfortunately, it is still unavailable in our country. This is a problem that turns the management and prevention of risk factors into the most important tools we have to improve our patients' quality of life.<hr/>Introducción Las porfirias agudas son un conjunto de enfermedades genéticas de penetrancia incompleta (10%). Es decir, sólo 10% de los individuos con el genotipo determinado que causa la enfermedad presentan algún signo o síntoma de ella. Las porfirias agudas son causadas por una deficiencia de alguna de las enzimas de la biosíntesis del heme. Son unos de los pocos errores innatos del metabolismo que presentan herencia autosómica dominante. La incidencia es de 1 en 100 000, y es más común en mujeres de entre 30-40 años. Los síntomas son variables e inespecíficos; los más comunes son: dolor abdominal difuso e incapacitante, taquicardia e hipertensión. También se acompaña de síntomas psiquiátricos como depresión, intento de suicidio, paranoia y alucinaciones. Otros síntomas relacionados son neuropatía periférica y pérdidas sensitivas, daño hepático e insuficiencia renal crónica. El objetivo de este estudio es establecer la importancia de realizar un diagnóstico oportuno de porfiria aguda, ya que un diagnóstico erróneo puede generar tratamientos y gastos innecesarios al paciente. El diagnóstico de porfiria permite llevar a cabo un manejo y tratamiento adecuados que favorecen un buen pronóstico. Caso Se trata de un paciente masculino de 47 años de edad, sin antecedentes familiares relacionados, que presenta dolor abdominal intenso, difuso e incapacitante con siete años de evolución. Fue tratado como gastritis aguda y colecistitis. Se realizó colecistectomía sin lograr mejoría de los síntomas. Tres años después, se agregaron a los síntomas originales los siguientes: alucinaciones auditivas, parestesias, debilidad muscular, depresión e irritabilidad, por lo que se catalogó como paciente con trastorno psiquiátrico con tendencia psicótica. Se realizó historia clínica de todos los síntomas y una exploración física completa, por lo que se sospechó porfiria aguda. Se realizaron estudios de laboratorio específicos con los que se confirmó el diagnóstico de porfiria aguda por la presencia de niveles elevados de porfirinas en orina, niveles elevados de PBGD, niveles normales de PBG en orina, niveles significativamente elevados de coproporfirinas por cromatografía y actividad enzimática de PBGD en rangos normales. Se inició un tratamiento para el manejo adecuado del dolor. También, una dieta alta en carbohidratos, con aporte calórico adecuado. Se recomendó la eliminación de factores de riesgo como alcohol, cigarro y medicamentos específicos. Dos meses después se observó una mejoría significativa de los síntomas, control de crisis e identificación y eliminación de factores precipitantes. Los síntomas psiquiátricos desaparecieron y el paciente pudo reestablecer sus actividades laborales y sociales. El paciente presenta hasta el momento datos de insuficiencia renal crónica. Se continúa el seguimiento del paciente. Discusión El caso presentado representa un ejemplo de una enfermedad genética que todo médico debe tener en mente cuando se presenta un paciente con síntomas inespecíficos. El diagnóstico de porfiria aguda es un diagnóstico de exclusión, pero sigue siendo importante en el análisis del diagnóstico diferencial. Es de gran importancia descartar o confirmar un caso de porfiria aguda antes de establecer el diagnóstico de un trastorno psiquiátrico. Establecer un diagnóstico temprano y un tratamiento específico mejora el pronóstico y limita el daño, particularmente neurológico y hepático. La educación del paciente es de extrema importancia, ya que no existe cura para la porfiria aguda. Una prevención que evite los factores precipitantes conocidos es uno de los tratamientos principales de esta enfermedad, ya que el medicamento específico para el control de la crisis aguda (Hematina) no se distribuye en nuestro país. Aunado a un subdiagnóstico de la enfermedad, lo anterior vuelve aún más difícil el manejo de los pacientes. <![CDATA[<b>Content analysis of personal constructs in depression</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252009000500003&lng=pt&nrm=iso&tlng=pt Kelly's Personal Construct Psychology (PCP) proposes that attributing meaning to experience is the most fundamental process of human psychological functioning. He describes psychological activity as a continuous process of creating, testing and revising personal theories (usually implicit) that allow people to understand and anticipate events. Personal constructs are the basic units of these personal theories. Constructs are bipolar contrasts of meaning that form an evolving network through which psychological processes are canalized. This system provides with a limited number of alternative views for explaining, anticipating and participating in life. One of the most significant contributions to psychological research made by PCP concerns the possibility to develop tools for the study of subjective construing. The Role Construct Repertory Grid (RepGrid) has been extensively used to explore the view subjects have of themselves, others and their problems. This technique elicits a sample of verbal descriptions of contrasting alternatives, his or her personal constructs; and provides several measures of self construing (e.g., self-esteem) and systems organization (e.g., complexity). Several authors point out the utility and pertinence of exploring the construct system in the evaluation of depressive disorders. They show the interest of studying the construct systems of depressive patients in order to measure some aspects that symptom and standard cognitive measures of cognitive distortions do not take into account. Depressive mood is highly influenced by the subject's view of him or herself and others, and by the organization of his or her constructs. However, the content of these personal constructs has received far less attention from researchers. The main goal of this article is to complement the PCP model of depression through the content analysis of personal constructs. In contrast with traditional content analysis, we do not evaluate the valency of the content but the principal meaning dimensions through which depressive people describe their interpersonal experience. According to PCP and other cognitive approaches, we hypothesize that the contents of the construct systems in the depressive sample are different from those of the control group. Specifically, we believe that the depressive group will show a higher number of constructs related to emotions and morality. The present study was carried out with 53 patients seeking psychological treatment in various private clinics in Barcelona who met DSM-IV criteria for depressive unipolar disorders. The non-clinical comparison group (n= 53), paired by sex and age with the clinical one, included volunteers recruited by graduate and undergraduate students from the University of Barcelona as part of their practical experience with the RepGrid, after receiving specific training in its administration. To compare the pattern of the construct system of both groups, we categorized the content of the personal constructs elicited with the RepGrid using the Classification System for Personal Constructs (SCCP) developed by Feixas et al. The SCCP is composed of six thematic areas (moral, emotional, relational, personal, intellectual, and values/interests) broken down into 45 different categories. Inter-rater agreement was used to determine the reliability of the SCCP. The results were very satisfactory regarding the percentage of agreement between judges. Cohen's Kappa coefficient confirmed the high level of reliability of the SCCP, which was higher than that obtained in previous studies. Data provides evidence of the differences in content frequency distributions between the clinical and non-clinical groups. People from the depressive sample tend to use more constructs related to emotions and less to intellectual issues. The depressive group showed more constructs within certain specific categories such as <<tolerant-authoritarian>>, <<thoughtful-shallow>> and <<strong-weak>>, and less constructs referring to sexuality. The results indicate that content patterns of depressed people show various specific thematic emphases. Indeed, from the wide range of stimuli coming from interpersonal experience, the emotional aspects acquire a special saliency. Although the exploratory nature of the present study does not allow us to establish causal inference, it seems evident that the tendency of depressive people to focus on the emotional dimension could play an important role in the maintenance of the depressive symptoms. Likewise, the lack of constructs concerning intellectual and personal issues reinforces the idea that depressed people tend to focus on the emotional aspects of the interpersonal experience. The results from the content analysis of specific categories show some contrasting features in the construing systems of both groups. The low self-esteem frequently reported for depressive subjects, a self-demanding attitude, and a negative image of the self are aspects potentially related to the <<strong-weak>> dimension of meaning, which emerged as the most diverging dimension among the 45 categories within the six areas. On the other hand, constructs within the category <<tolerant-authoritarian>> allude to the focus on certain specific interpersonal aspects of experience. The concern about respect and power in relationships turns out to be an important meaning dimension, which is in line with the special interpersonal sensitivity displayed by depressive people when facing judgement and disapproval on the part of significant others. When we hypothesized that depressive people would present a greater number of moral constructs, we were considering that this higher frequency would be reflecting symptomatic aspects about perfectionism and self-demands. The explorative content analysis of this study has not shown enough sensitivity to this important feature of depressive people. Doubtlessly, a more refined research strategy is necessary in order to achieve a better understanding of the role played by morality in the construing systems. Finally, from the limitations of the present study, some issues are proposed for future lines of research. The combination of content and structural aspects, such as implicative dilemmas, seems to be the best alternative for the evaluation of the construct systems of depressive people. Thus, the advantages of studying the organization and the thematic emphases of individual systems of meaning can be combined. In any case, these results provide evidence for the clinical and theoretical advantages of the SCCP in studying the content of personal meaning systems. Therefore, it seems to be a fruitful and useful assessment instrument which allows the clinician to understand the patient's problem in his or her own way of construing.<hr/>Desde el marco de la Psicología de los Constructos Personales (PCP) de Kelly, es posible estudiar de forma sistemática la construcción subjetiva que las personas hacen de sí mismas y de sus problemas. Feixas et al., destacan la pertinencia del estudio de los sistemas de construcción en la evaluación del trastorno depresivo puesto que miden aspectos que no son suficientemente valorados por las medidas cognitivas estándar sobre los síntomas y las distorsiones cognitivas. La mayoría de los trabajos sobre la depresión basados en la PCP se han centrado en las características estructurales, en cambio los aspectos del contenido han recibido menor interés. El propósito de este estudio es realizar un análisis de contenido de los constructos personales en la depresión. Actualmente no existe ningún estudio que haya explorado de forma sistemática las dimensiones de contenido más significativas para esta población. En concordancia con la PCP y otros enfoques cognitivos, hipotetizamos que el contenido de los sistemas de construcción de la muestra depresiva es distinto al de la población normal. En concreto, creemos que la población clínica presenta mayor frecuencia de constructos de tipo moral y emocional en comparación con la muestra no clínica. Para poder poner a prueba estas hipótesis se analizaron los constructos de 106 sujetos, con edades comprendidas entre los 19 y los 57 años, divididos en dos grupos, un grupo clínico (n = 53) de personas diagnosticadas con alguna modalidad depresiva unipolar y otro grupo no clínico (n = 53). Categorizamos el contenido de los constructos elicitados con la técnica de rejilla por medio del Sistema de Categorías de Constructos Personales (SCCP) desarrollado por Feixas et al. El SCCP es un sistema de clasificación compuesto por un total de seis áreas temáticas (moral, emocional, relacional, personal, intelectual y valores e intereses) que se desglosan en 45 categorías para codificar el contenido de los constructos personales. Los principales resultados muestran que existen diferencias significativas entre las distribuciones de frecuencias del contenido de ambas poblaciones. Las personas con depresión (PD) utilizan significativamente más constructos de tipo emocional, y menos de tipo intelectual. Además, en comparación a la muestra normal, los depresivos muestran mayor número de constructos en las categorías <<reflexiva-superficial>>, <<tolerante-autoritaria>> y, de forma más destacada, en la dimensión <<fuerte-débil>>. Los resultados indican que el patrón prototípico del contenido de los sistemas de constructos de las PD difiere en el énfasis temático predominante. En efecto, de la variedad de acontecimientos de la experiencia, los aspectos conativos resultan especialmente notorios para las personas con depresión. Por otro lado, la carencia de constructos intelectuales y personales refuerza la idea de que las personas con depresión emplean gran parte de su actividad mental en el procesamiento de los aspectos emocionales de la experiencia. Aunque la naturaleza exploratoria de este estudio no permite establecer líneas causales, parece evidente que la focalización de la actividad psicológica de las PD en la dimensión afectiva de la experiencia puede estar desempeñando un papel importante en el mantenimiento de la problemática depresiva. Por último, a partir de las limitaciones de este estudio se proponen algunos diseños para la investigación futura acerca de la relación entre el contenido y la estructura de los sistemas de construcción de las personas con depresión. <![CDATA[<b>Suicidal ideation and suicidal behavior in pregnancy</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252009000500004&lng=pt&nrm=iso&tlng=pt The aim is to explore the occurrence of suicide ideation and behavior in pregnant women receiving prenatal care and to analyze the motives behind these behaviors. Although there are very few studies evaluating the prevalence of the suicide phenomenon (suicide, intentional injuries with or without the aim of taking one's own life, ideas of harming oneself or death) during the prenatal period, it has been reported that pregnancy complications due to suicide attempts occur in 0.4 out of every 1 000 patients discharged from hospitals in the state of California in the United States and in one out of every 283 pregnant women in specialized mental health services. Suicide ideation occurs in 1.4% of English expectant mothers, 0.5% of Finnish ones and 27.8% of US pregnant women with psychiatric disorders. In Latin America, it is estimated to occur in 1 6.7% of pregnant teenagers. Although suicide ideation and suicide attempts during pregnancy are less frequent than at other times in life, they have major consequences, increasing the risk of death and affecting fetal development and pregnancy itself. Method Participants: The interviewees comprised 120 pregnant women who came in for prenatal care at 1.a state Health Center providing primary health care and 2. three Health Homes that provide basic medical services, run by the Health Secretariat in Mexico City. Three of the 120 questionnaires were rejected due to incomplete information, which left a total of 117. Sample characteristics include: mean age, 23.2 years (DS = 5); mean monthly income, $3,876 (SD = $239); schooling, 69% had completed junior high school while 31% had completed senior high school; 71% were housewives while 29% were also engaged in paid employment. Marital status: 18% married, 19% single and 63% cohabiting. Instrument: A structured questionnaire with the following areas: 1. Socio-demographic information (age, schooling, etc.). 2. Indicators of suicidal ideation and behavior: a) Have you thought a lot about death, whether your own, someone else's or death in general? b) Have you wished to die ? c) Have you ever been about to take your own life? and d) Have you ever intentionally hurt, cut, poisoned or harmed yourself in order to take your own life? 3. Timing and motives. If the event occurred sometime in their life, the interviewer explored whether the event took place during the current pregnancy as well as the reasons why it happened. Procedure: In the waiting room at the Health Center, expectant mothers were told about the purpose of the study and the informed consent form. In the Health Homes, final year medical students did the same and arranged appointments for the interviews. The same researcher conducted the interviews in the two settings. Results Suicidal ideation: Thinking a lot about death at some time in their lives was reported by 29 subjects (24.8%) and during pregnancy by 44 (37.6%). The reasons for these thoughts during this last period are: separation from one's partner, death of a child, fear of childbirth, fear of accidents or sickness and interest in the subject of death. Realizing one is pregnant, feeling lonely, the death or illness of someone close and family problems are among the reasons for thoughts about death as well as the desire to die. Desire to die: This was expressed by 29 subjects (24.8%) in the past and by nine (7.7%) during pregnancy. Among the latter group, the reasons were: realizing one is pregnant, the death or illness of someone close and family problems. They also mentioned problems with their partners and parents. Suicidal intention: Thirteen said that they had been about to take their own lives at some stage (11.1%), while three (2.6% said that they had done so during pregnancy. During this period, this had been caused by problems with their partners. Suicide attempts: Ten women mentioned suicide attempts (8.5%) at some time in their lives, while one (0.9%) did so during pregnancy. This particular case mentioned problems with her partner as being the cause. Discussion Thinking a lot about death is the most common indicator. It may be explained by disadvantageous social conditions, but also by the particular conditions of pregnancy. In this respect, there are various fears common to expectant mothers who are apprehensive about the well-being of the future baby and anticipate a difficult childbirth. As one would expect, suicide attempts are less common than suicide intentions and the desire for and ideas about death. The desire to die, suicide intentions and attempts are less frequent during pregnancy than at other times in a person's life. This may be due to the future mother's feeling of responsibility, or a possible hormonal effect, which act as protective factors. Problems with one's partner are a risk factor for suicide intention and attempts. This is hardly surprising, since marital problems adversely affect women's mental health at different times in their lives, but during pregnancy, they intensify their insecurity at a time of great transition, making them fearful of the future and leading them to wonder about whether getting pregnant was the right thing to do. These observations should be treated with caution due to methodological limitations, such as the small sample size and restricted scope of the research.<hr/>Los objetivos son investigar la ocurrencia de la ideación y comportamiento suicida en embarazadas que acuden a atención prenatal y analizar los motivos de las conductas. Hay pocos estudios que evalúen la prevalencia del fenómeno suicida en el periodo perinatal. Algunos señalan que las complicaciones en el embarazo por intento de suicidio se reportan en 0.4 de cada mil pacientes dadas de alta de hospitales y en una de cada 283 embarazadas en servicios especializados de salud mental. La ideación suicida se presenta entre 0.5 y 1.4% de las embarazadas y en 27.8% de este grupo con trastornos psiquiátricos. Método Participantes: Se entrevistó a 120 embarazadas que acudieron a control prenatal: 1. a un Centro de Salud que brinda atención primaria y 2. a tres Casas de Salud que proveen servicios médicos básicos en la Ciudad de México. Se excluyeron tres de los 120 cuestionarios debido a información incompleta, lo que dejó un total de 11 7. Instrumento: Un cuestionario estructurado con las siguientes áreas: 1. Información sociodemográfica. 2. Indicadores de ideación y comportamiento suicida: a) ¿Ha pensado mucho en la muerte, ya sea en la suya, en la de alguien más o en la muerte en general?, b) ¿Ha deseado morir?, c) ¿Ha estado a punto de quitarse la vida? y d) ¿Alguna vez, a propósito, se ha herido, cortado, intoxicado o hecho daño con el fin de quitarse la vida? 3. Momento en que ocurrió y motivos. Si la conducta ocurrió alguna vez en la vida, se indagó si fue durante el embarazo y las razones para hacerlo. Procedimiento: Una psicóloga aplicó el instrumento por medio de una entrevista en la sala de espera del Centro de Salud y en un consultorio en las Casas de Salud. Asistió en días fijos varias veces por semana hasta completar el tamaño de la muestra. Resultados Ideación suicida: Pensar mucho en la muerte lo manifestaron 29 (24.8%) alguna vez en la vida y 44 (37.6%) durante la gestación. Los motivos para este último periodo son: separación de la pareja, muerte de un hijo, miedo al parto, temor a accidente o enfermedad e interés en el tema de la muerte. Saberse embarazada, sentirse sola, la muerte o la enfermedad de una persona cercana y tener problemas familiares son razones para los pensamientos de muerte, pero también para el deseo de morir. Deseo de morir: Lo expresaron 29 (24.8%) en el pasado y en nueve (7.7%) ocurrió en la preñez. En ésta, los motivos fueron: saberse embarazada, la muerte o la enfermedad de una persona cercana y tener problemas familiares. También aludieron a problemas con la pareja y con los padres. Intención suicida: Trece dijeron haber estado a punto de quitarse la vida alguna vez (11.1%) y tres (2.6%), durante el embarazo; los problemas con la pareja son la causa de la intención en este periodo. Intento suicida: Diez mujeres hablaron de intento (8.5%) alguna vez en la vida y una (0.9%), durante el embarazo. Este único caso mencionó, como causa, los problemas con la pareja. Discusión Pensar mucho en la muerte es el indicador más frecuente. Lo anterior se explica quizá por condiciones sociales desventajosas, pero también por las particularidades del embarazo. En este sentido, existen diversos temores comunes en madres gestantes, quienes se muestran aprensivas por el bienestar del futuro bebé y por anticipar un parto difícil. Como era de esperarse, el intento suicida es menos frecuente que la intención y el deseo e ideas de muerte. El deseo de morir, la intención y el intento son a la vez menos frecuentes durante el embarazo que en otro momento de la vida. Esto se debe quizá al sentimiento de responsabilidad de la futura madre o a un posible efecto hormonal, que funcionan como factores protectores. Los problemas con la pareja son un factor de riesgo para la intención y el intento suicida, lo que amerita mayor estudio. Estas observaciones merecen tomarse con cautela debido a limitaciones metodológicas, como el reducido tamaño de la muestra y lo acotado de la indagación. <![CDATA[<b>A psychological model for therapeutic adherence behaviors in persons with HIV</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252009000500005&lng=pt&nrm=iso&tlng=pt Introduction HIV infection is a disease that demands a consistent and efficient practice of adherence behaviors related to antiretroviral treatment. However, research findings in the last few years have shown that psychological and social variables (e.g., depression, stress, low motivation, as well as little or no social support) interfere with the practice of those behaviors. This facilitates the clinical progression of the disease, and reduces the quality of life and survival time in people living with HIV. The intersection area between psychology and health involves widely diverse theoretical models, including self-regulation, health beliefs, and the one linking information-motivation-behavior. Such models have sought to account for the way in which the addressed variables affect adherence behavior. While analyzing psychological factors, these models usually emphasize either cognitive concepts or adopt a more traditional stance such as relating adherence behavior to personality, motivation, behavioral skills and stress management. Although this diversity seems inclusive, it fails to integrate explanations on therapeutic adherence under a more comprehensive theoretical umbrella. Thus, the present study was conducted within the scope of an interactive-functional model which attempts to articulate the interaction of sets of biological and psychological variables along four phases. The first involves psychological processes and results variables; the second comprises the diagnostic of HIV infection and later development of other opportunistic diseases; the third contains two types of behavior: therapeutic adherence and disease-related behaviors; the fourth involves conventional biological indicators and health outcomes. This model contrasts with others not only in the sense of proposing an inter-behavioral approach derived from Kantor's work, including articulated behavioral and personality theories, but it also proposes an interactive and functional emphasis on analyzing those variables assumed to determine therapeutic adherence behaviors. Such variables subsume personality phenomena, behavioral competencies and motives to behave. Thus, the approach includes those consistent ways in which HIV-positive persons interact with stress-related situations which contain unpredictable, ambiguous or uncertain stimulus signals and behavior consequences. The behavioral competencies category synthesizes what the patient knows on HIV, including those self-care actions that need to be taken efficiently. For instance, what is HIV-AIDS, what are the clinical stages of the infection, what medications help, how should they be used and, above all, why is so important to take medications in a consistent and efficient manner on the basis of the indications of the healthcare personnel. On the other hand, motives or motivation refer, in the traditional conception, to variables related to willing to act. It is said that a person is motivated to engage in therapeutic adherence behaviors when he/she is willing to behave accordingly, after having understood the relation between such behavior and some specific consequences. Such consequences may vary widely, ranging from interpersonal in nature, such as verbal praise or support from others, and intrinsic, such as self-perceived physical and psychological well-being. Materials and method A cross-sectional study was carried out in order to identify predictors of adherence behaviors related to antiretroviral treatment in a group of 68 persons living with HIV. Participants answered two self-administered questionnaires: i) psychological factors and adherence behaviors, and ii) stress-related situations in three modalities: decision-making, tolerance to ambiguity, and tolerance to frustration. Data analysis included univariate statistics, the Pearson's x² test, the T-test for independent samples, as well as a linear multiple regression analysis. Results Of the total of participants, 58 (85.3%) reported that they self-administered their antiretroviral medication everyday of the last week, and 10 (14.7%) did it with some inconsistence. Differences were significant (x² [1] =33.882; p<0.001); the T-test showed a significant difference among adherents and non-adherents in the motivation variable (t [66] = -27.954; p<0.001). Finally, the linear multiple regression analysis contributed as predictor of the adherence behaviors at variables like motivation (β =O.8O2; p<0.001), as well as low stress-related situations in the modalities of decision-making ( β = -0.268; p<0.01) and tolerance to frustration ( β = -0.280; p<0.01), with the adjusted determination coefficient [adjusted R²] = 0.629, thus explaining 62.9% of the total variance. Discussion The results of this study show that persons with HIV who are 100% adherent to antiretroviral medication are those who are clearly more motivated and are experiencing less stress-related to decision-making, as well as higher levels of tolerance to frustration. These findings suggest that interventions aimed at improving the treatment of HIV-positive patients should expressly include components related to these factors. It seems especially relevant to consider two additional aspects: first, once psychological factors are identified and explained through research, they need to be translated into viable intervention strategies subject to systematic methodological evaluation. Second, interventions must be consistent with the theoretical assumptions underlying the model used so that those techniques designed or selected to establish adequate medication use and other adherence and well-being-inducing behaviors will actually result effective. Given the context of the institutional treatment of this condition, it seems especially relevant to insure that such programs actually have an interdisciplinary character in order to facilitate and maintain therapeutic adherence. Such inter-professional collaboration is especially important in a public healthcare context in which resources, ranging all the way from facilities, equipment and caregiver salaries to the schooling of the patients, pose special challenges in places like Latin American countries, where real optimization can occur mainly through the quality of integrated professional performance. After all, the key healthcare ingredient in public health problems affecting ever-growing portions of the population, such as the HIV infection, remains the human being, i.e., actual persons with biological, psychological, and social functional components.<hr/>Introducción La infección por VIH es un padecimiento que demanda la práctica consistente y eficiente de los comportamientos de adhesión al tratamiento antirretroviral en sí y a otras actividades de apoyo al mismo. Sin embargo, en años recientes se ha identificado una diversidad de variables psicológicas y sociales (i.e., depresión, estrés, bajos niveles de motivación y carencia de apoyo social, principalmente) que dificultan la práctica de esos comportamientos, favoreciendo así el progreso clínico de la enfermedad y una reducción en la calidad y tiempo de sobrevida en las personas con VIH. En el subcampo de conocimiento conocido como psicología y salud existen diversos modelos teóricos con los que se ha buscado dar cuenta de cómo es que esas variables influyen sobre los comportamientos de adhesión; destacan, principalmente, el autorregulatorio, el de creencias en salud y el de información-motivación-habilidades conductuales. En general, se trata de modelos que, o bien privilegian el análisis de lo psicológico a partir de conceptos de naturaleza cognoscitiva, o bien carecen de análisis de fenómenos como los de estrés y personalidad, así como de los comportamientos asociados a la enfermedad. El presente estudio se realizó con base en un modelo psicológico para la investigación de los comportamientos de adhesión terapéutica; se trata de un modelo interactivo y funcional en el sentido de consignar la interacción de un conjunto de variables psicológicas y biológicas a lo largo de cuatro fases comportamentales en el proceso del desarrollo de padecimientos crónicos. En la primera se incluyen variables psicológicas de procesos y resultados; en la segunda el diagnóstico de la infección por VIH y el posterior desarrollo de otras enfermedades oportunistas; la tercera, psicológica, contempla la práctica de dos tipos de comportamientos, los de adhesión terapéutica y los asociados a la enfermedad; finalmente, en la cuarta se contemplan los indicadores biológicos convencionales y los resultados de salud. Materiales y método Se condujo un estudio transversal que tuvo como objetivo identificar predictores de los comportamientos de adhesión al tratamiento antirretroviral en 68 personas con VIH. Los participantes respondieron a dos instrumentos: i) factores psicológicos y comportamientos de adhesión, y ii) situaciones vinculadas con estrés. Para el análisis de los datos se utilizaron estadísticas univariadas, la x² de Pearson, la prueba T para muestras independientes y un análisis de regresión lineal múltiple. Resultados Del total de participantes, 58 (85.3%) respondieron que se habían administrado sus medicamentos todos los días de la última semana y los restantes 10 (14.7%) lo habían hecho con inconsistencia, diferencia que resultó significativa (x² [1] =33.882; p<0.001). La prueba T para muestras independientes arrojó una sola diferencia significativa entre las personas con VIH adherentes y no-adherentes en la variable motivos ( t [66] = -27.954; p<0.001); finalmente, el análisis de regresión lineal múltiple aportó como predictores de los comportamientos de adhesión a las variables motivos (β = 0.802; p<0.001) y bajos niveles de estrés vinculados con toma de decisiones ( β = -0.268; p<0.01) y con tolerancia a la frustración (β = -0.280; p<0.01), con un coeficiente de determinación [R² ajustado] = 0.629, es decir, que las tres variables explican 62.9% de la varianza total. Discusión Los resultados muestran que las personas con VIH 100% adherentes son aquellas que se encuentran claramente motivadas y que en general experimentan bajos niveles de estrés relacionados con la toma de decisiones y tolerancia a la frustración. Estos hallazgos sugieren que en el diseño e instrumentación de programas de intervención orientados a mejorar la adhesión de estos pacientes es indispensable incorporar módulos o componentes basados directamente en dichos factores, poniendo especial énfasis en programas interdisciplinarios. <![CDATA[<b>Burnout syndrome in medical practitioners and paramedic personel</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252009000500006&lng=pt&nrm=iso&tlng=pt Introduction Burnout syndrome is one of the most studied manifestations of job stress. The burnout concept was used by the first time in the area of psychology by Freudenberger in 1974. This psychologist defined it as a condition of fatigue or frustration that is produced by the commitment to a reason, lifestyle or relationship that does not produce the expected effort. Afterwards, Maslach and Jackson proposed three interrelated dimensions: emotional weariness (EW) which estimates the experience of emotional fatigue for the demands of work; the depersonalization (DP) which measures the answers of impersonal type and negative attitudes towards the patients; and the personal accomplishment (PA) which reflects the personal satisfaction and the competition in the practice of the daily work. These dimensions are joined in the Maslach Burnout Inventory (MBI) that is used to measure the afore mentioned syndrome. Several studies have demonstrated the presence of burnout syndrome among medical and paramedic personnel. The close contact with the patients and the work overload are the main reasons of this syndrome. In a multicentre study carried out among 248 doctors of the United States, 40% presented the syndrome with emotional detriment, which coincides with another study carried out with nurses attending patients with palliative care and marrow transplants. Also, in a study carried out among residents of internal medicine of the University of Washington, there was a prevalence of 76% of professional wear, with an autoperception of a lower quality in the professional care of the patients, after comparing them with non-affected residents. In Mexico, a study that investigated burnout level in a group of 450 medical practitioners, nurses and paramedics of 12 institutions revealed the following information: 10.9% presented emotional weariness, 19.6%, depersonalization, and 74.9, low personal accomplishment. Palmer et al. determined a general prevalence of 44% of the syndrome in anesthesiologists. The work overload and the conflict of values were variables that influenced the presence of this syndrome. At the Instituto Mexicano del Seguro Social, Aranda et al., carried out a study among family physicians, where the prevalence of burnout syndrome was 42.3%. Likewise, Cabrera et al., found that, out of 236 studied nurses, 92 (39%) had information compatible with burnout syndrome, with statistically significant differences for the age and the antiquity in the place after comparing them with nurses without burnout syndrome. The burnout syndrome was considered by the World Health Organization as work risk. Its trascendence is rooted in the impact it has in the labor relation between medical and/or paramedic personnel and the health institutions. For this reason, we considered it important to investigate the presence of this syndrome among the medical and paramedic personnel working at hospital of the Mexican social security. Material and Methods Design: Transversal comparative survey. Population: Of a total population of 240 workers of the health area assigned to a general hospital a sample of 160 was obtained that included doctors, nurses and medical assistants based on an average prevalence of the syndrome in 30%, with an alpha level of 0.05 and a power of 90%. Instrument of evaluation: The survey was based on the following sociodemographic and labor variables: age, marital status, academic level, labor antiquity, antiquity of adscript ion to the hospital, category, service and labor shift. To evaluate the burnout syndrome, the MBI questionnaire was used in its previously validated Spanish version. The afore mentioned instrument is an objective way of measuring and determining the burnout level that a person experiences, in its three subscales: EW, DP and PA. The survey consists of 22 items with a Likert type punctuation scale (0-6), of which 9 valued EW, 5, DP, and 8, PA. With regard to the EW, which values the sensation of being emotionally exhausted by the daily contact with people to whom it is necessary to attend as object of work, a punctuation of 27 or higher indicated a high level; between 19 and 26, moderated; and lower than 19, low. In the subscale DP, which measures the degree in which the response towards the patients is cold, distant and impersonal, punctuations above 10 indicated a high level; from 6 to 9, moderated; lower than 6, low. In the subscale PA, which values the feelings of competition and efficiency for the accomplishment of the work and the relation with the people who are being attended, values above 40 indicated personal high accomplishment; from 34 to 39, intermediate; and under 33, low. In the case of obtaining a low emotional depletion, a low depersonalization and a high personal accomplishment, it was considered that no burnout was present. In the rest of the cases, the presence of burnout syndrome was established. Compilation of the information: From August to December, 2005, the survey was applied to each of the workers, indicating them that they should answer and return it in a term not longer than five days. They were all informed previously about the general objectives of the study and its confidential and anonymous character. The head investigator integrated later on the database. Statistical tests: Descriptive and inferential statistics were carried out. The odds ratio and confidence intervals of 95% were calculated to measure the association between the sociodemographic and labor factors with the professional wear. Results Of 160 workers to whom the survey MBI was applied, only 146 returned it in a complete form. Regarding the frequency and the percentages of the three categories studied with the qualifications of low, average and high for every subscale that composes the burnout syndrome, it was observed that the highest evaluations fit the medical assistants. There was a 19.6% prevalence of burnout syndrome among the groups of doctors with at least one of three disturb subscales. Likewise, it was observed that all medical assistants had an alteration of a minimum of two subscales. The nursing personnel did not present information that constitutes a risk for the development of burnout syndrome. Only four sociodemographic and labor variables were found as risk factors for the presence of burnout syndrome, as well as their relation with each of the subscales composing it. When the variables compared age, labor antiquity and time of adscript ion in the service with each of the subscales of the burnout, we observed that depersonalization appeared in older workers and longer antiquity in the position and the lack of personal accomplishment in workers with longer time in the service. There were no statistically significant differences in the subscale of emotional weariness. Discussion In the last years, burnout syndrome has acquired special relevance, mainly because of the series of repercussions that it has in the labor and personal area. Numerous studies exist on the prevalence of this syndrome in different health professionals, but in present work incorporated medical assistants, since they are those who have the first contact with the patients in our institution.<hr/>Introducción El concepto de burnout fue utilizado por primera vez en el ámbito de la psicología por Freudenberger en el año de 1974. Este psicólogo lo definió como un estado de fatiga o frustración que se produce por la dedicación a una causa, forma de vida o relación que no produce el esperado esfuerzo. Más tarde, Maslach y Jackson propusieron tres dimensiones interrelacionadas: el cansancio emocional (CE), la despersonalización (DP) y la realización personal (RP). Estas dimensiones se integran en el cuestionario Maslach Burnout Inventory (MBI) que se utiliza para medir dicho síndrome. Material y métodos Diseño: Encuesta transversal comparativa. Población: Se entregó el cuestionario MBI a 160 trabajadores del área de la salud adscritos al Hospital General de Zona con Medicina Familiar 36 de la Ciudad de Cardel, Veracruz. Instrumento de evaluación: Se construyó una encuesta sobre las siguientes variables sociodemográficas y laborales: edad, estado civil, nivel académico, antigüedad laboral, antigüedad de adscripción al hospital, categoría, servicio y turno laboral. Para evaluar el síndrome de burnout se utilizó el cuestionario MBI en su versión en español. Dicho instrumento consta de 22 ítems con escala de puntuación tipo Likert (0-6), de los cuales 9 valoran CE, 5 la DP y 8 la RP. Recolección de la información: Durante el periodo comprendido de agosto a diciembre del 2006 se entregó el cuestionario a cada uno de los trabajadores de la salud. Pruebas estadísticas: Se realizó estadística descriptiva e inferencial. Se calculó la razón de momios e intervalos de confianza de 95% para medir la asociación entre los factores sociodemográficos y laborales con el desgaste profesional. Resultados De 160 trabajadores a quienes se les entregó el cuestionario MBI, sólo 146 lo regresaron en forma completa. En lo que respecta a la frecuencia y los porcentajes de las tres categorías estudiadas se observó que las evaluaciones más altas corresponden a las asistentes médicas. Hubo una prevalencia del síndrome de burnout entre el grupo de médicos del 19.6% con al menos una de las tres subescalas alteradas. Asimismo se observa que en todas las asistentes médicas hubo alteración de un mínimo de dos subescalas. Sólo se encontraron cuatro variables sociodemográficas y laborales como factores de riesgo para la presencia del síndrome de burnout, así como su relación con cada una de la subescalas que lo componen. Discusión Existen numerosos estudios sobre la prevalencia de este síndrome en diferentes profesionales de la salud, pero en el presente trabajo se incorpora a las asistentes médicas, ya que son quienes tienen un primer contacto con los pacientes en nuestra institución. Las cifras de prevalencia del síndrome de burnout reportadas por otros estudios realizados en México entre el personal médico van desde el 42.3% y 44% hasta 50%; en esta investigación la prevalencia fue menor y la dimensión de cansancio emocional es la más afectada. Entre las variables que se consideraron factores de riesgo en nuestro estudio se encuentra el estado civil. Asimismo, el trabajar en el turno vespertino y ofrecer sus servicio en la consulta externa también estuvieron relacionados con mayor predisposición al síndrome de burnout. Al igual que otros estudios, en esta investigación se encontró un mayor nivel de Burnout en profesionales con mayor edad. En lo que respecta a la DP y RP, éstas se presentaron en trabajadores cuya antigüedad laboral era mayor. En conclusión, la prevalencia del síndrome de burnout entre las asistentes médicas es muy alta y es necesario adoptar medidas para evitar el desarrollo de esta patología. <![CDATA[<b>Prescription drugs misuse: benzodiazepine dependence in the elderly</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252009000500007&lng=pt&nrm=iso&tlng=pt Misuse and potential abuse of prescription drugs are growing problems in elderly people over 65 years old. Although the prevalence of this condition is difficult to estimate, drug misuse is most common in elderly women. A great proportion of the psychoactive prescriptions in old people include tranquilizers and hypnotics. There are several risk factors related to increased risk misuse, abuse, and dependence of prescription drugs. The following are among these risk factors: the female gender, social isolation, history of substance abuse or dependence, history of mental illness and medical exposure to prescription drugs with abuse potential. Also, BDZ consumption for a period longer than four weeks has also been associated to BDZ dependence, even at therapeutic doses. Until now, BDZ dependence in the elderly has been poorly studied, so the present study may increase our knowledge of this complex phenomenon. Objective The aim of the present study was to describe and compare sociodemographic and clinical features related to the prescription and benzodiazepines use in old people with and without dependence to these drugs in an outpatients psychogeriatric service. Method A total of 39 patients from the outpatients service at the psychogeriatric clinic of the National Institute of Psychiatry Ramón de la Fuente in Mexico City were recruited. All of the participants signed an informed consent to be included in the study. Several assessments were performed to determine the psycho-pathological status. Diagnosis of BDZ dependence was obtained with the SCID-I Interview, the severity of depression and anxiety symptoms were evaluated through the Montgomery & Asberg Scale (MADRS) and the Hamilton Anxiety Scale, respectively. For the evaluation of the functionality level, the Katz Index and GAF were used. Results No significant differences were found between patients with and without BDZ dependence in terms of social and demographic characteristics and medical comorbidity. The main Axis I diagnoses of the patients were depressive disorder or anxiety disorders. The first medical prescription of BDZ in patients with BDZ dependence was the presence of anxiety symptoms, while for patients without BDZ dependence the aim of BDZ prescription was the treatment of insomnia. The mean age of BDZ use onset and the time of consumption were 57.5 years and 675.2 weeks, respectively. The average dose of BDZ used by the patients was 14.4mg of diazepam equivalents. Significant differences were found between groups in terms of BDZ consumption features. Patients with BDZ dependence exhibited more drug seeking behavior, more abandonment of daily activities, and more tolerance and abstinence symptoms. Patients with BDZ dependence exhibited more prominent symptoms of anxiety and depression than patients without BDZ dependence. Also, these patients had a poorer cognitive performance and lower psychosocial functioning. Discussion BDZ dependence is a complex phenomenon related to the severity of depressive and anxiety symptoms. These symptoms were the main reason for the medical prescription of BDZ. Although BDZ use was indicated for the treatment of anxiety disorders, the use of BDZ in the elderly has been contraindicated for the treatment of depression with anxiety features. The potential risk to develop BDZ dependence in elderly patients can be related to pharmacological variations due to changes in the metabolism process of aging and the interactions with other drugs. Both factors could increase half life of BDZ and their pharmacological effect in the organism. There were statistical differences in the drug-taking pattern of BDZ consumption in the patients. Patients with BDZ dependence had an earlier onset of BDZ consumption and longer use. The chronic use of BDZ is one of the most important risk factors for dependence development. For the present study, BDZ dependence was clinically defined in terms of tolerance and abstinence symptoms. This definition is in accordance to what has been described in international scientific literature as BDZ physiologic dependence. In this way, tolerance and abstinence symptoms might be the main reason why patients with BDZ dependence needed higher BDZ dosages for the treatment of anxiety symptoms. Sociodemographic characteristics in this sample were not related to the presence of BDZ dependence; nevertheless, it has been reported that the female gender and the presence of chronic pain are risk factors for BDZ abuse and dependence. Future longitudinal studies with an increased number of patients should assess the effect of these variables in BDZ dependence development in the elderly. Differences found in terms of cognitive performance may be related to the psychomotor retardation conferred by the use of BDZ, which may in turn have a direct impact on the velocity of mental performance in the patients. Also, the presence and severity of depressive and anxiety symptoms may also have a negative impact on cognitive performance. Generalization of the findings of the present research is limited by sample size. Nevertheless, the relevance of the present results highlight the importance of the careful prescription and inherent risks related to potentially addictive medications. Increasing our knowledge in the prescription of these medications will improve our medical attention and our patients' quality of life.<hr/>El abuso potencial y el uso inapropiado de fármacos de prescripción en adultos mayores de 65 años o más está en aumento. Aunque la prevalencia de esta condición es difícil de estimar, se sabe que es más frecuente en mujeres. Una gran proporción de los tranquilizantes e hipnóticos son prescritos a adultos mayores. El género femenino, el aislamiento social y una historia de abuso de sustancias y de trastornos mentales son los principales factores de riesgo asociados al uso inapropiado de fármacos. Por otro lado, el uso prolongado de benzodiazepinas (BDZ) -mayor a cuatro semanas- también se ha asociado al desarrollo de dependencia, aun cuando las BDZ se utilicen a dosis terapéuticas Objetivo El objetivo del presente estudio es describir y comparar las características sociodemográficas y clínicas relacionadas con la prescripción y el uso de benzodiazepinas en adultos mayores con y sin dependencia a las mismas en un servicio especializado de psicogeriatría. Método Se reclutó un total de 39 pacientes de la Clínica de Psicogeriatría del Instituto Nacional de Psiquiatría Ramón de la Fuente en la Ciudad de México. Todos los participantes consintieron por escrito su participación en el estudio. El diagnóstico de dependencia a BDZ se realizó a partir del SCID-I; la gravedad de los síntomas de depresión se evaluó mediante la Escala de Montgomery y Asberg (MADRS); los síntomas de ansiedad, con la Escala de Ansiedad de Hamilton (HAM-A), y el nivel de funcionalidad, mediante el Índice de Katz y el GAF. Resultados No se encontraron diferencias significativas entre los grupos en las variables sociodemográficas y la comorbilidad médica. Los pacientes incluidos cursaron en su mayoría con un cuadro depresivo o algún trastorno de ansiedad como diagnóstico principal. La indicación médica inicial para el consumo de BDZ fue el tratamiento de la ansiedad para los pacientes con dependencia y del insomnio para los no dependientes. La edad de inicio del consumo de las BDZ y el tiempo de consumo fue de 57.5 años y 675.2 semanas en promedio, respectivamente. La dosis promedio utilizada por los pacientes fue de 1 4.4mg en equivalentes de diazepam. Los pacientes con dependencia a las BDZ mostraron una mayor gravedad de los síntomas de depresión y ansiedad, menor desempeño cognoscitivo y menor funcionamiento psicosocial, así como conductas de búsqueda y abandono de actividades relacionadas con el consumo y mayores síntomas de tolerancia y abstinencia a las BDZ. Discusión La dependencia a las BDZ se presentó como un fenómeno complejo relacionado con la intensidad de los síntomas de depresión y ansiedad, un consumo crónico y una mayor dosificación. La depresión con síntomas de ansiedad en el adulto mayor no debería tratarse con BDZ, ya que, además del riesgo de desarrollar dependencia, éstas pueden efectuar negativamente el desempeño cognoscitivo y el funcionamiento global de los pacientes. Al momento de prescribir una BDZ a la población geriátrica se deben tomar en consideración variables sociodemográficas y clínicas de los pacientes. De la misma forma, será necesario evaluar en futuros estudios la influencia de la personalidad y otras variables clínicas sobre el desarrollo de esta dependencia. <![CDATA[<b>Distribution and socio-demographic determinants of the suicidal behavior in Mexico</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252009000500008&lng=pt&nrm=iso&tlng=pt Introduction Mexico has seen constant increases in the rate of completed suicide in the last decades, especially among youth. The Mexican population between 1 5-24 years of age is currently the most affected, with 28% of all suicides in 2007. In this context of increasing suicide mortality, the study of suicide-related behaviors, that is, suicidal ideation, plans, gestures and suicide attempts, has special relevance. All of these are immediate precursors to death by suicide and independent risk factors of subsequent suicide attempts and completed suicides. Episodes that do not result in death, can lead to serious, long-term consequences in one's physical health, as well as being an important cause of psychological suffering on the part of the individual and his/her family. Up until now, research in our country has emphasized the prevalence of lifetime suicidal behavior and its associated factors. However, the current (12-month) prevalences are indispensable in order to define the demographic profile and clinical needs, and to build risk profiles for immediate application by the clinics treating these individuals. Objectives To report the prevalence and sociodemographic characteristics of suicide-related behaviors in the past 12 months in a nationally representative sample of respondents from the Encuesta Nacional de Adicciones (ENA) of 2008. Methods Cross-sectional prevalence study which obtained data from a nationally-representative sample of 22 966 individuals, between the ages of 12 and 65, during 2008, who answered the section on suicidal behaviors. The response rate was 77%. Twelve-month prevalences of suicidality are reported according to different sociodemographic and economic factors. Multiple logistic regression models for odds ratios and 95% confidence intervals, corrected for the study design, are reported. Results We found the prevalence of any suicidal ideation to be 8.79% (ranging from 4.2 to 6.2%, depending on the question used), the prevalence of a suicide plan was 1.22%, and 0.79% of the sample reported to attemp suicide within the past 12 months, with the prevalence of suicide attempts that required medical attention being 0.13%. If we use the sample weights to make estimations regarding the 75 million inhabitants of Mexico that the ENA 2008 represents, we estimate that 6 601 210 Mexicans experienced suicidal ideation in the past 12 months, 918 363 Mexicans planned suicide, a total of 593 600 individuals attempted suicide and 99 731 utilized medical services as a consequence of their attempt. We found that women, people who are not married or in a relationship, those with less education, younger age groups and the unemployed have, in general, a higher risk of exhibiting suicidal behavior. Some regions of the country, especially the southeast, were more affected, whereas individuals who live in rural areas consistently reported lower prevalences of the three suicidal behaviors. Conclusion The epidemiology of completed suicide in Mexico has changed within the last decades by a process that has been gradual but constant. The epidemiology of current suicidal behaviors shows that the problem is already at similar levels to other highly affected countries. Mexico needs immediately to dedicate much more efforts to detection, treatment and prevention of these behaviors to avoid further increases in suicidality and its consequences.<hr/>Introducción En las últimas décadas, México ha visto incrementos constantes en la tasa de suicidio consumado, especialmente entre la población joven. La población mexicana de entre 15 y 24 años de edad es hoy día de las más afectadas, con 28% de todos los suicidios en 2007. En este contexto de incremento de la mortalidad por suicidio cobra especial relevancia el estudio de las conductas relacionadas con el suicidio, es decir, la ideación suicida, los planes, los gestos y los intentos de suicidio. Todos éstos son precursores inmediatos de la muerte por suicidio y factores de riesgo independientes de intentos subsecuentes de suicidio y de suicidios consumados. Aun cuando estas conductas no lleven a la muerte, pueden acarrear consecuencias graves y de largo alcance para la salud física, y pueden constituir una importante causa de sufrimiento psicológico para el individuo y sus familiares. Hasta ahora, las investigaciones en nuestro país han enfatizado el conocimiento de la prevalencia y los factores asociados con la conducta suicida alguna vez en la vida. Las prevalencias actuales (últimos 12 meses) son, sin embargo, indispensables para definir el perfil demográfico y las necesidades clínicas de atención, y para elaborar perfiles de riesgo de aplicación inmediata para el clínico tratante de estos sujetos. Objetivos En este trabajo reportamos las prevalencias y el perfil sociodemográfico de las conductas relacionadas con el suicidio en los últimos 12 meses en una muestra representativa de la población nacional. Para hacerlo se utilizó la Encuesta Nacional de Adicciones (ENA) del 2008. Métodos Encuesta transversal de prevalencia que obtuvo datos de una muestra representativa de 22 966 miembros de la población nacional, de edades entre los 12 y 65 años, durante el año de 2008, que contestaron la sección de conductas suicidas. La tasa de no respuesta de la ENA 2008 fue de 77%. Se reportan las prevalencias de los eventos relacionados con el suicidio en los últimos 12 meses por diferentes factores sociodemográficos y económicos. Se reportan modelos de regresión logística múltiple con razones de momios y los intervalos de confianza a 95%, que se han corregido por los efectos del diseño de estudio. Resultados Encontramos una prevalencia de cualquier ideación suicida de 8.79% (con variaciones de 4.2 a 6.2%, dependiendo de la pregunta utilizada). La prevalencia de plan suicida fue de 1.22% y 0.79% de la muestra reportó que intentó suicidarse en los últimos 12 meses. La prevalencia de intentos de suicidio que requirieron atención médica fue de 0.13%. Si utilizamos los ponderadores muestrales para hacer estimaciones hacia los 75 millones de habitantes de la República Mexicana que representa la ENA 2008, tenemos que 6 601 210 mexicanos tuvieron ideación suicida en los últimos 12 meses, 918 363 mexicanos planearon suicidarse, un total de 593 600 personas intentaron suicidarse y 99 731 utilizaron servicios médicos como consecuencia de un intento de suicidio. Encontramos que las mujeres, las personas que no están casadas o en unión libre, las de menor escolaridad, los grupos más jóvenes y los subempleados tienen, en general, riesgos más elevados de presentar conducta suicida. Algunas áreas del país, en particular el sureste, se vieron más afectadas, mientras que las personas que viven en áreas rurales reportaron consistentemente menores prevalencias de las tres conductas suicidas. Conclusión La epidemiología del suicidio consumado en México ha cambiado en las últimas décadas, en un proceso paulatino pero constante. La epidemiología de la conducta suicida actual muestra que el problema ha alcanzado ya dimensiones similares a otros países tradicionalmente afectados. México necesita dedicar ya mayores esfuerzos a la detección, tratamiento y prevención de estas conductas para evitar futuros incrementos en la conducta suicida y en sus consecuencias. <![CDATA[<b>Alcoholics Anomymous (AA): affiliation and related aspects, differences between relapsed and non-relapsed alcoholics in process of recovery</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252009000500009&lng=pt&nrm=iso&tlng=pt The work of Alcoholics Anonymous (AA) in fighting against alcohol abuse and alcoholism has placed it as an institution of great importance in Mexico and around the world. Although its labor has been subject for controversy, there is a lot of evidence that frequent attendance and affiliation to the groups and sessions can be very helpful for many individuals. Research has been dedicated to the identification of the elements contributing to affiliation, such as involvement, commitment, and participation, or the level of adherence to the program's beliefs and activities. Some studies have used the time of membership and the frequency of attendance to AA as indicators of affiliation, but there are some authors who think that it is difficult to explore it using only these variables. Other authors have mentioned that alcoholics can go to AA for many reasons, but that mere attendance is not enough for reaching or maintaining abstinence. It has been established that when the impact of AA is measured only by the time of membership or the frequency of attendance, it is not possible to comprehend the essence of the subjective and behavioral characteristics involved in the process. Thus, it is important to differentiate between these and the true affiliation. There are only a few researches about the elements forming the affiliation to AA, and the ones available do not bring light over the process of its beginning. Some authors say that it is something more than the time or the frequency of attendance to meetings, and that is possible that it is a complex and heterogeneous phenomenon formed by several behaviors and beliefs about the 12 steps. Some studies have pointed out the interaction of different factors to achieve affiliation, but they have also remarked the need for including more variables in measuring it. One conclusion is that affiliation is a whole dimension that encompasses attendance and the level of participation in the activities. There are different questionnaires to measure the affiliation process, but most of them are difficult to interpret, and little is known about their fitting to AA members' perspective of things. Research in Mexico is complicated because of a lack of instruments developed from the local situation and experience. There are data that about 14 000 alcoholics enter AA every year. Relapse is high during the first three months (near 50%), but almost half of the persons that stay show adherence to the program, and eventually reach abstinence. Yet, the topic of the specific elements of affiliation, as well as their influence to maintain abstinence, has not received enough attention. The objectives of this study were: 1. to analyze the elements that constitute an affiliation profile, 2. to know if such elements are different or if they are part of a single construct, and 3. to find out if the amount of affiliation (the way an alcoholic involves him/herself in the activities of the group) can distinguish between those who have relapsed and those who have not. Method The sample was non-probabilistic; it included 192 AA members (87% men and 13% women). Average age was 42 years old. Two groups were formed: relapsed and non-relapsed (143 who did not consume any amount of alcohol since they entered AA or 10 years or more ago, and 49 who consumed any amount of alcohol within the four years prior to the interview). The questionnaire included scales to measure the service, the practice of the 12 steps, the spiritual awakening, sponsoring, time spent in AA, frequency of attendance, and reading of the materials. The questionnaire was specifically designed for measuring affiliation. Results There were significative differences in the mean participation time (it was higher in the non-relapsed subjects: t = -3.225, df=181, p<.00), in the activities related to <<service>> (they were more frequent and more extended in time in the non-relapsed subjects: X² = 7.76, p< .01; t = -2.258, df= 145, p< .02), in <<being a sponsor>> (most of the non-relapsed subjects are one: X² = 15.06, p< .000), in the practice of the steps 3-12 (non-relapsed AA practiced them more: X² = 5.16, p<.02), and in having the spiritual awakening experience (more frequent in the non-relapsed subjects: X² = 4.282, p<. 05). Internal consistency tests were executed, as well as a factor analysis to explore if the items that differentiated between the groups could form a single dimension. The first analysis resulted in a satisfactory internal consistency (cc = .67). The items were grouped in a unique dimension with an explained variance of 43.6%. An indicator for affiliation was developed through the sum of the scores from variables grouped in the factor analysis. A comparison using this indicator showed significant differences in the degree of involvement in AA (Z = -3.367, p<.001). Non-relapsed subjects had an affiliation ranging from high to very high. Discussion Results suggest that affiliation is an event formed by several elements that, either separated or combined, can behave significantly different between relapsed and non-relapsed AA members. This could mean that such variables are adherence or affiliation indicators. These elements are not exclusive or unrelated entities, but they constitute a measure of affiliation to AA. Its structure leads to consider them as part of the same phenomenon which could help to determine more precisely the degree of affiliation; the categorization made evident that there is an important association with abstinence. Thus, affiliation scores varied importantly between groups; the highest ones were on those who have maintained abstinence. It is possible to deduct that alcoholic subjects who participate more actively and during more time in AA get more positive results. These results concur with others in the sense that reaching long periods of abstinence in AA is related to a greater involvement in the activities of the groups. Likewise, the frequency of attendance to the meetings did not differentiate between relapsed and non-relapsed; this could suggest that just being there is not enough to obtain a satisfactory result. AA literature points out to the fact that attendance is a necessary condition for recovering, but its benefits reduce considerably without a genuine desire of involvement. The performance of the affiliation indicators identified in this study suggests the possibility of considering them as a dimension that explain the amount in which it exists in AA members. The fact that such dimension emerged from the experience of members from national groups represents an opportunity to use it as a valid scale in broader researches with bigger samples, and a chance to find out in a more reliable way the real role of AA in the recovery process. Since AA represents one of the most popular choices for the treatment of alcoholism in Mexico, research should continue for broadening the knowledge that health professionals, researchers, and everyone involved in prevention have about this organization. As shown by the results of this study, a better understanding of the benefits produced by the active participation in AA could help to motivate not only attendance to the meetings, but a full involvement in the activities suggested by the groups. The final effects may result in a reduction of the health costs generated by alcoholism and related problems attention.<hr/>La labor realizada por los grupos de Alcohólicos Anónimos (AA) para combatir el problema del alcoholismo los ha convertido en una de las opciones importantes. La adherencia o afiliación a estos grupos puede ser benéfica para ciertos alcohólicos, por lo que la investigación ha buscado identificar los aspectos que contribuyen a su establecimiento. Aunque la investigación aún no aclara el proceso mediante el que se logra, la ha destacado como un constructo que entrelaza la asistencia a las reuniones y el nivel de participación en los grupos, y se menciona que, cuanto mayor es el involucramiento, tiende a mejorar el pronóstico del alcohólico. A pesar de este panorama, en nuestro contexto, el tema de los componentes específicos de la afiliación a AA, así como su relevancia para mantener la abstinencia en comparación con la recaída, no ha recibido atención suficiente por parte de los investigadores en alcoholismo. Este trabajo tiene como objetivos: explorar elementos que pueden constituir un perfil de afiliación a AA, conocer si esos elementos son diferentes o forman parte de un mismo constructo y si la graduación de afiliación (clasificación de la forma en que el alcohólico se involucra en las diferentes actividades de los grupos) puede diferenciar entre quienes han recaído o no en el consumo de alcohol. Método La muestra fue no probabilística intencional; incluyó a 192 miembros de AA (87% hombres y 1 3% mujeres). Se formaron dos grupos: no recaídos y recaídos (143 no consumieron ninguna cantidad de alcohol y 49 consumieron cualquier cantidad de alcohol después de por lo menos tres meses de abstinencia). Se diseñó un cuestionario para evaluar la afiliación a AA; en éste se indaga el servicio, el apadrinamiento, la práctica de los 12 pasos, el <<despertar espiritual>>, el tiempo en AA, la frecuencia de asistencia y la lectura de literatura de AA. Resultados Hubo diferencias significativas en el tiempo promedio de participación (t = -3.225, gl = 181, p<.00), en la actividad de <<servicio>> (tenerlo: χ² = 7.76, p<.01 y horas dedicadas: t = -2.258, gl = 145, p<.02), tener la función de <<padrino>> ( χ²=15.06, p< .000), en la práctica reciente de los pasos 3 al 12 ( χ² = 5.166, p<.02) y en la experiencia del <<despertar espiritual>> ( χ² = 4.282, p<. 05), todos mayores en los no recaídos. Tras eliminar <<tiempo dedicado al servicio>>, se encontró una consistencia interna adecuada (α =.67) y un análisis factorial mostró que los reactivos se agrupaban en una sola dimensión, con una varianza explicada de 43.6%. Se construyó un indicador del grado de afiliación usando la sumatoria de los puntajes de las variables agrupadas y se trabajó una comparación por quintiles, la cual mostró diferencias significativas según el grado de involucramiento en AA (Z = -3.367, p<.001). Los no recaídos mostraron una afiliación que va de alta a muy alta. Discusión En este estudio, la afiliación a AA parecería un suceso compuesto por distintos elementos que se comportaron de modo significativamente diferente entre los recaídos y no recaídos. No fueron entidades separadas, sino partes de un mismo constructo que, trabajado en forma de quintiles (muy baja, baja, moderada, alta y muy alta), evidenció una asociación importante con la abstinencia. Los índices variaron de manera significativa entre los grupos de recaídos y no recaídos; los mayores se vieron en quienes han mantenido la abstinencia por largos periodos. Este resultado confirma hallazgos de estudios anteriores, en el sentido de que los alcohólicos más participativos en AA obtienen resultados más favorables. Los indicadores de afiliación detallados sugieren la posibilidad de considerarlos como una dimensión que dé cuenta del grado en que se manifiesta en los miembros de AA. Además, el que emergiera de la experiencia de los miembros de grupos nacionales representa la oportunidad de estructurarla como una escala válida para futuras investigaciones con muestras más grandes e indagar con mayor confiabilidad sobre el papel que desempeña AA en el proceso de recuperación del alcoholismo. <![CDATA[<b>Psychiatric neuroethics: a pending assignment</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252009000500010&lng=pt&nrm=iso&tlng=pt The work of Alcoholics Anonymous (AA) in fighting against alcohol abuse and alcoholism has placed it as an institution of great importance in Mexico and around the world. Although its labor has been subject for controversy, there is a lot of evidence that frequent attendance and affiliation to the groups and sessions can be very helpful for many individuals. Research has been dedicated to the identification of the elements contributing to affiliation, such as involvement, commitment, and participation, or the level of adherence to the program's beliefs and activities. Some studies have used the time of membership and the frequency of attendance to AA as indicators of affiliation, but there are some authors who think that it is difficult to explore it using only these variables. Other authors have mentioned that alcoholics can go to AA for many reasons, but that mere attendance is not enough for reaching or maintaining abstinence. It has been established that when the impact of AA is measured only by the time of membership or the frequency of attendance, it is not possible to comprehend the essence of the subjective and behavioral characteristics involved in the process. Thus, it is important to differentiate between these and the true affiliation. There are only a few researches about the elements forming the affiliation to AA, and the ones available do not bring light over the process of its beginning. Some authors say that it is something more than the time or the frequency of attendance to meetings, and that is possible that it is a complex and heterogeneous phenomenon formed by several behaviors and beliefs about the 12 steps. Some studies have pointed out the interaction of different factors to achieve affiliation, but they have also remarked the need for including more variables in measuring it. One conclusion is that affiliation is a whole dimension that encompasses attendance and the level of participation in the activities. There are different questionnaires to measure the affiliation process, but most of them are difficult to interpret, and little is known about their fitting to AA members' perspective of things. Research in Mexico is complicated because of a lack of instruments developed from the local situation and experience. There are data that about 14 000 alcoholics enter AA every year. Relapse is high during the first three months (near 50%), but almost half of the persons that stay show adherence to the program, and eventually reach abstinence. Yet, the topic of the specific elements of affiliation, as well as their influence to maintain abstinence, has not received enough attention. The objectives of this study were: 1. to analyze the elements that constitute an affiliation profile, 2. to know if such elements are different or if they are part of a single construct, and 3. to find out if the amount of affiliation (the way an alcoholic involves him/herself in the activities of the group) can distinguish between those who have relapsed and those who have not. Method The sample was non-probabilistic; it included 192 AA members (87% men and 13% women). Average age was 42 years old. Two groups were formed: relapsed and non-relapsed (143 who did not consume any amount of alcohol since they entered AA or 10 years or more ago, and 49 who consumed any amount of alcohol within the four years prior to the interview). The questionnaire included scales to measure the service, the practice of the 12 steps, the spiritual awakening, sponsoring, time spent in AA, frequency of attendance, and reading of the materials. The questionnaire was specifically designed for measuring affiliation. Results There were significative differences in the mean participation time (it was higher in the non-relapsed subjects: t = -3.225, df=181, p<.00), in the activities related to <<service>> (they were more frequent and more extended in time in the non-relapsed subjects: X² = 7.76, p< .01; t = -2.258, df= 145, p< .02), in <<being a sponsor>> (most of the non-relapsed subjects are one: X² = 15.06, p< .000), in the practice of the steps 3-12 (non-relapsed AA practiced them more: X² = 5.16, p<.02), and in having the spiritual awakening experience (more frequent in the non-relapsed subjects: X² = 4.282, p<. 05). Internal consistency tests were executed, as well as a factor analysis to explore if the items that differentiated between the groups could form a single dimension. The first analysis resulted in a satisfactory internal consistency (cc = .67). The items were grouped in a unique dimension with an explained variance of 43.6%. An indicator for affiliation was developed through the sum of the scores from variables grouped in the factor analysis. A comparison using this indicator showed significant differences in the degree of involvement in AA (Z = -3.367, p<.001). Non-relapsed subjects had an affiliation ranging from high to very high. Discussion Results suggest that affiliation is an event formed by several elements that, either separated or combined, can behave significantly different between relapsed and non-relapsed AA members. This could mean that such variables are adherence or affiliation indicators. These elements are not exclusive or unrelated entities, but they constitute a measure of affiliation to AA. Its structure leads to consider them as part of the same phenomenon which could help to determine more precisely the degree of affiliation; the categorization made evident that there is an important association with abstinence. Thus, affiliation scores varied importantly between groups; the highest ones were on those who have maintained abstinence. It is possible to deduct that alcoholic subjects who participate more actively and during more time in AA get more positive results. These results concur with others in the sense that reaching long periods of abstinence in AA is related to a greater involvement in the activities of the groups. Likewise, the frequency of attendance to the meetings did not differentiate between relapsed and non-relapsed; this could suggest that just being there is not enough to obtain a satisfactory result. AA literature points out to the fact that attendance is a necessary condition for recovering, but its benefits reduce considerably without a genuine desire of involvement. The performance of the affiliation indicators identified in this study suggests the possibility of considering them as a dimension that explain the amount in which it exists in AA members. The fact that such dimension emerged from the experience of members from national groups represents an opportunity to use it as a valid scale in broader researches with bigger samples, and a chance to find out in a more reliable way the real role of AA in the recovery process. Since AA represents one of the most popular choices for the treatment of alcoholism in Mexico, research should continue for broadening the knowledge that health professionals, researchers, and everyone involved in prevention have about this organization. As shown by the results of this study, a better understanding of the benefits produced by the active participation in AA could help to motivate not only attendance to the meetings, but a full involvement in the activities suggested by the groups. The final effects may result in a reduction of the health costs generated by alcoholism and related problems attention.<hr/>La labor realizada por los grupos de Alcohólicos Anónimos (AA) para combatir el problema del alcoholismo los ha convertido en una de las opciones importantes. La adherencia o afiliación a estos grupos puede ser benéfica para ciertos alcohólicos, por lo que la investigación ha buscado identificar los aspectos que contribuyen a su establecimiento. Aunque la investigación aún no aclara el proceso mediante el que se logra, la ha destacado como un constructo que entrelaza la asistencia a las reuniones y el nivel de participación en los grupos, y se menciona que, cuanto mayor es el involucramiento, tiende a mejorar el pronóstico del alcohólico. A pesar de este panorama, en nuestro contexto, el tema de los componentes específicos de la afiliación a AA, así como su relevancia para mantener la abstinencia en comparación con la recaída, no ha recibido atención suficiente por parte de los investigadores en alcoholismo. Este trabajo tiene como objetivos: explorar elementos que pueden constituir un perfil de afiliación a AA, conocer si esos elementos son diferentes o forman parte de un mismo constructo y si la graduación de afiliación (clasificación de la forma en que el alcohólico se involucra en las diferentes actividades de los grupos) puede diferenciar entre quienes han recaído o no en el consumo de alcohol. Método La muestra fue no probabilística intencional; incluyó a 192 miembros de AA (87% hombres y 1 3% mujeres). Se formaron dos grupos: no recaídos y recaídos (143 no consumieron ninguna cantidad de alcohol y 49 consumieron cualquier cantidad de alcohol después de por lo menos tres meses de abstinencia). Se diseñó un cuestionario para evaluar la afiliación a AA; en éste se indaga el servicio, el apadrinamiento, la práctica de los 12 pasos, el <<despertar espiritual>>, el tiempo en AA, la frecuencia de asistencia y la lectura de literatura de AA. Resultados Hubo diferencias significativas en el tiempo promedio de participación (t = -3.225, gl = 181, p<.00), en la actividad de <<servicio>> (tenerlo: χ² = 7.76, p<.01 y horas dedicadas: t = -2.258, gl = 145, p<.02), tener la función de <<padrino>> ( χ²=15.06, p< .000), en la práctica reciente de los pasos 3 al 12 ( χ² = 5.166, p<.02) y en la experiencia del <<despertar espiritual>> ( χ² = 4.282, p<. 05), todos mayores en los no recaídos. Tras eliminar <<tiempo dedicado al servicio>>, se encontró una consistencia interna adecuada (α =.67) y un análisis factorial mostró que los reactivos se agrupaban en una sola dimensión, con una varianza explicada de 43.6%. Se construyó un indicador del grado de afiliación usando la sumatoria de los puntajes de las variables agrupadas y se trabajó una comparación por quintiles, la cual mostró diferencias significativas según el grado de involucramiento en AA (Z = -3.367, p<.001). Los no recaídos mostraron una afiliación que va de alta a muy alta. Discusión En este estudio, la afiliación a AA parecería un suceso compuesto por distintos elementos que se comportaron de modo significativamente diferente entre los recaídos y no recaídos. No fueron entidades separadas, sino partes de un mismo constructo que, trabajado en forma de quintiles (muy baja, baja, moderada, alta y muy alta), evidenció una asociación importante con la abstinencia. Los índices variaron de manera significativa entre los grupos de recaídos y no recaídos; los mayores se vieron en quienes han mantenido la abstinencia por largos periodos. Este resultado confirma hallazgos de estudios anteriores, en el sentido de que los alcohólicos más participativos en AA obtienen resultados más favorables. Los indicadores de afiliación detallados sugieren la posibilidad de considerarlos como una dimensión que dé cuenta del grado en que se manifiesta en los miembros de AA. Además, el que emergiera de la experiencia de los miembros de grupos nacionales representa la oportunidad de estructurarla como una escala válida para futuras investigaciones con muestras más grandes e indagar con mayor confiabilidad sobre el papel que desempeña AA en el proceso de recuperación del alcoholismo. <![CDATA[<b>Francisco Alonso-Fernández. <i>¿Por qué trabajamos? El trabajo entre el estrés y la felicidad</i></b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252009000500011&lng=pt&nrm=iso&tlng=pt The work of Alcoholics Anonymous (AA) in fighting against alcohol abuse and alcoholism has placed it as an institution of great importance in Mexico and around the world. Although its labor has been subject for controversy, there is a lot of evidence that frequent attendance and affiliation to the groups and sessions can be very helpful for many individuals. Research has been dedicated to the identification of the elements contributing to affiliation, such as involvement, commitment, and participation, or the level of adherence to the program's beliefs and activities. Some studies have used the time of membership and the frequency of attendance to AA as indicators of affiliation, but there are some authors who think that it is difficult to explore it using only these variables. Other authors have mentioned that alcoholics can go to AA for many reasons, but that mere attendance is not enough for reaching or maintaining abstinence. It has been established that when the impact of AA is measured only by the time of membership or the frequency of attendance, it is not possible to comprehend the essence of the subjective and behavioral characteristics involved in the process. Thus, it is important to differentiate between these and the true affiliation. There are only a few researches about the elements forming the affiliation to AA, and the ones available do not bring light over the process of its beginning. Some authors say that it is something more than the time or the frequency of attendance to meetings, and that is possible that it is a complex and heterogeneous phenomenon formed by several behaviors and beliefs about the 12 steps. Some studies have pointed out the interaction of different factors to achieve affiliation, but they have also remarked the need for including more variables in measuring it. One conclusion is that affiliation is a whole dimension that encompasses attendance and the level of participation in the activities. There are different questionnaires to measure the affiliation process, but most of them are difficult to interpret, and little is known about their fitting to AA members' perspective of things. Research in Mexico is complicated because of a lack of instruments developed from the local situation and experience. There are data that about 14 000 alcoholics enter AA every year. Relapse is high during the first three months (near 50%), but almost half of the persons that stay show adherence to the program, and eventually reach abstinence. Yet, the topic of the specific elements of affiliation, as well as their influence to maintain abstinence, has not received enough attention. The objectives of this study were: 1. to analyze the elements that constitute an affiliation profile, 2. to know if such elements are different or if they are part of a single construct, and 3. to find out if the amount of affiliation (the way an alcoholic involves him/herself in the activities of the group) can distinguish between those who have relapsed and those who have not. Method The sample was non-probabilistic; it included 192 AA members (87% men and 13% women). Average age was 42 years old. Two groups were formed: relapsed and non-relapsed (143 who did not consume any amount of alcohol since they entered AA or 10 years or more ago, and 49 who consumed any amount of alcohol within the four years prior to the interview). The questionnaire included scales to measure the service, the practice of the 12 steps, the spiritual awakening, sponsoring, time spent in AA, frequency of attendance, and reading of the materials. The questionnaire was specifically designed for measuring affiliation. Results There were significative differences in the mean participation time (it was higher in the non-relapsed subjects: t = -3.225, df=181, p<.00), in the activities related to <<service>> (they were more frequent and more extended in time in the non-relapsed subjects: X² = 7.76, p< .01; t = -2.258, df= 145, p< .02), in <<being a sponsor>> (most of the non-relapsed subjects are one: X² = 15.06, p< .000), in the practice of the steps 3-12 (non-relapsed AA practiced them more: X² = 5.16, p<.02), and in having the spiritual awakening experience (more frequent in the non-relapsed subjects: X² = 4.282, p<. 05). Internal consistency tests were executed, as well as a factor analysis to explore if the items that differentiated between the groups could form a single dimension. The first analysis resulted in a satisfactory internal consistency (cc = .67). The items were grouped in a unique dimension with an explained variance of 43.6%. An indicator for affiliation was developed through the sum of the scores from variables grouped in the factor analysis. A comparison using this indicator showed significant differences in the degree of involvement in AA (Z = -3.367, p<.001). Non-relapsed subjects had an affiliation ranging from high to very high. Discussion Results suggest that affiliation is an event formed by several elements that, either separated or combined, can behave significantly different between relapsed and non-relapsed AA members. This could mean that such variables are adherence or affiliation indicators. These elements are not exclusive or unrelated entities, but they constitute a measure of affiliation to AA. Its structure leads to consider them as part of the same phenomenon which could help to determine more precisely the degree of affiliation; the categorization made evident that there is an important association with abstinence. Thus, affiliation scores varied importantly between groups; the highest ones were on those who have maintained abstinence. It is possible to deduct that alcoholic subjects who participate more actively and during more time in AA get more positive results. These results concur with others in the sense that reaching long periods of abstinence in AA is related to a greater involvement in the activities of the groups. Likewise, the frequency of attendance to the meetings did not differentiate between relapsed and non-relapsed; this could suggest that just being there is not enough to obtain a satisfactory result. AA literature points out to the fact that attendance is a necessary condition for recovering, but its benefits reduce considerably without a genuine desire of involvement. The performance of the affiliation indicators identified in this study suggests the possibility of considering them as a dimension that explain the amount in which it exists in AA members. The fact that such dimension emerged from the experience of members from national groups represents an opportunity to use it as a valid scale in broader researches with bigger samples, and a chance to find out in a more reliable way the real role of AA in the recovery process. Since AA represents one of the most popular choices for the treatment of alcoholism in Mexico, research should continue for broadening the knowledge that health professionals, researchers, and everyone involved in prevention have about this organization. As shown by the results of this study, a better understanding of the benefits produced by the active participation in AA could help to motivate not only attendance to the meetings, but a full involvement in the activities suggested by the groups. The final effects may result in a reduction of the health costs generated by alcoholism and related problems attention.<hr/>La labor realizada por los grupos de Alcohólicos Anónimos (AA) para combatir el problema del alcoholismo los ha convertido en una de las opciones importantes. La adherencia o afiliación a estos grupos puede ser benéfica para ciertos alcohólicos, por lo que la investigación ha buscado identificar los aspectos que contribuyen a su establecimiento. Aunque la investigación aún no aclara el proceso mediante el que se logra, la ha destacado como un constructo que entrelaza la asistencia a las reuniones y el nivel de participación en los grupos, y se menciona que, cuanto mayor es el involucramiento, tiende a mejorar el pronóstico del alcohólico. A pesar de este panorama, en nuestro contexto, el tema de los componentes específicos de la afiliación a AA, así como su relevancia para mantener la abstinencia en comparación con la recaída, no ha recibido atención suficiente por parte de los investigadores en alcoholismo. Este trabajo tiene como objetivos: explorar elementos que pueden constituir un perfil de afiliación a AA, conocer si esos elementos son diferentes o forman parte de un mismo constructo y si la graduación de afiliación (clasificación de la forma en que el alcohólico se involucra en las diferentes actividades de los grupos) puede diferenciar entre quienes han recaído o no en el consumo de alcohol. Método La muestra fue no probabilística intencional; incluyó a 192 miembros de AA (87% hombres y 1 3% mujeres). Se formaron dos grupos: no recaídos y recaídos (143 no consumieron ninguna cantidad de alcohol y 49 consumieron cualquier cantidad de alcohol después de por lo menos tres meses de abstinencia). Se diseñó un cuestionario para evaluar la afiliación a AA; en éste se indaga el servicio, el apadrinamiento, la práctica de los 12 pasos, el <<despertar espiritual>>, el tiempo en AA, la frecuencia de asistencia y la lectura de literatura de AA. Resultados Hubo diferencias significativas en el tiempo promedio de participación (t = -3.225, gl = 181, p<.00), en la actividad de <<servicio>> (tenerlo: χ² = 7.76, p<.01 y horas dedicadas: t = -2.258, gl = 145, p<.02), tener la función de <<padrino>> ( χ²=15.06, p< .000), en la práctica reciente de los pasos 3 al 12 ( χ² = 5.166, p<.02) y en la experiencia del <<despertar espiritual>> ( χ² = 4.282, p<. 05), todos mayores en los no recaídos. Tras eliminar <<tiempo dedicado al servicio>>, se encontró una consistencia interna adecuada (α =.67) y un análisis factorial mostró que los reactivos se agrupaban en una sola dimensión, con una varianza explicada de 43.6%. Se construyó un indicador del grado de afiliación usando la sumatoria de los puntajes de las variables agrupadas y se trabajó una comparación por quintiles, la cual mostró diferencias significativas según el grado de involucramiento en AA (Z = -3.367, p<.001). Los no recaídos mostraron una afiliación que va de alta a muy alta. Discusión En este estudio, la afiliación a AA parecería un suceso compuesto por distintos elementos que se comportaron de modo significativamente diferente entre los recaídos y no recaídos. No fueron entidades separadas, sino partes de un mismo constructo que, trabajado en forma de quintiles (muy baja, baja, moderada, alta y muy alta), evidenció una asociación importante con la abstinencia. Los índices variaron de manera significativa entre los grupos de recaídos y no recaídos; los mayores se vieron en quienes han mantenido la abstinencia por largos periodos. Este resultado confirma hallazgos de estudios anteriores, en el sentido de que los alcohólicos más participativos en AA obtienen resultados más favorables. Los indicadores de afiliación detallados sugieren la posibilidad de considerarlos como una dimensión que dé cuenta del grado en que se manifiesta en los miembros de AA. Además, el que emergiera de la experiencia de los miembros de grupos nacionales representa la oportunidad de estructurarla como una escala válida para futuras investigaciones con muestras más grandes e indagar con mayor confiabilidad sobre el papel que desempeña AA en el proceso de recuperación del alcoholismo. <![CDATA[<b>Autoevaluación</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252009000500012&lng=pt&nrm=iso&tlng=pt The work of Alcoholics Anonymous (AA) in fighting against alcohol abuse and alcoholism has placed it as an institution of great importance in Mexico and around the world. Although its labor has been subject for controversy, there is a lot of evidence that frequent attendance and affiliation to the groups and sessions can be very helpful for many individuals. Research has been dedicated to the identification of the elements contributing to affiliation, such as involvement, commitment, and participation, or the level of adherence to the program's beliefs and activities. Some studies have used the time of membership and the frequency of attendance to AA as indicators of affiliation, but there are some authors who think that it is difficult to explore it using only these variables. Other authors have mentioned that alcoholics can go to AA for many reasons, but that mere attendance is not enough for reaching or maintaining abstinence. It has been established that when the impact of AA is measured only by the time of membership or the frequency of attendance, it is not possible to comprehend the essence of the subjective and behavioral characteristics involved in the process. Thus, it is important to differentiate between these and the true affiliation. There are only a few researches about the elements forming the affiliation to AA, and the ones available do not bring light over the process of its beginning. Some authors say that it is something more than the time or the frequency of attendance to meetings, and that is possible that it is a complex and heterogeneous phenomenon formed by several behaviors and beliefs about the 12 steps. Some studies have pointed out the interaction of different factors to achieve affiliation, but they have also remarked the need for including more variables in measuring it. One conclusion is that affiliation is a whole dimension that encompasses attendance and the level of participation in the activities. There are different questionnaires to measure the affiliation process, but most of them are difficult to interpret, and little is known about their fitting to AA members' perspective of things. Research in Mexico is complicated because of a lack of instruments developed from the local situation and experience. There are data that about 14 000 alcoholics enter AA every year. Relapse is high during the first three months (near 50%), but almost half of the persons that stay show adherence to the program, and eventually reach abstinence. Yet, the topic of the specific elements of affiliation, as well as their influence to maintain abstinence, has not received enough attention. The objectives of this study were: 1. to analyze the elements that constitute an affiliation profile, 2. to know if such elements are different or if they are part of a single construct, and 3. to find out if the amount of affiliation (the way an alcoholic involves him/herself in the activities of the group) can distinguish between those who have relapsed and those who have not. Method The sample was non-probabilistic; it included 192 AA members (87% men and 13% women). Average age was 42 years old. Two groups were formed: relapsed and non-relapsed (143 who did not consume any amount of alcohol since they entered AA or 10 years or more ago, and 49 who consumed any amount of alcohol within the four years prior to the interview). The questionnaire included scales to measure the service, the practice of the 12 steps, the spiritual awakening, sponsoring, time spent in AA, frequency of attendance, and reading of the materials. The questionnaire was specifically designed for measuring affiliation. Results There were significative differences in the mean participation time (it was higher in the non-relapsed subjects: t = -3.225, df=181, p<.00), in the activities related to <<service>> (they were more frequent and more extended in time in the non-relapsed subjects: X² = 7.76, p< .01; t = -2.258, df= 145, p< .02), in <<being a sponsor>> (most of the non-relapsed subjects are one: X² = 15.06, p< .000), in the practice of the steps 3-12 (non-relapsed AA practiced them more: X² = 5.16, p<.02), and in having the spiritual awakening experience (more frequent in the non-relapsed subjects: X² = 4.282, p<. 05). Internal consistency tests were executed, as well as a factor analysis to explore if the items that differentiated between the groups could form a single dimension. The first analysis resulted in a satisfactory internal consistency (cc = .67). The items were grouped in a unique dimension with an explained variance of 43.6%. An indicator for affiliation was developed through the sum of the scores from variables grouped in the factor analysis. A comparison using this indicator showed significant differences in the degree of involvement in AA (Z = -3.367, p<.001). Non-relapsed subjects had an affiliation ranging from high to very high. Discussion Results suggest that affiliation is an event formed by several elements that, either separated or combined, can behave significantly different between relapsed and non-relapsed AA members. This could mean that such variables are adherence or affiliation indicators. These elements are not exclusive or unrelated entities, but they constitute a measure of affiliation to AA. Its structure leads to consider them as part of the same phenomenon which could help to determine more precisely the degree of affiliation; the categorization made evident that there is an important association with abstinence. Thus, affiliation scores varied importantly between groups; the highest ones were on those who have maintained abstinence. It is possible to deduct that alcoholic subjects who participate more actively and during more time in AA get more positive results. These results concur with others in the sense that reaching long periods of abstinence in AA is related to a greater involvement in the activities of the groups. Likewise, the frequency of attendance to the meetings did not differentiate between relapsed and non-relapsed; this could suggest that just being there is not enough to obtain a satisfactory result. AA literature points out to the fact that attendance is a necessary condition for recovering, but its benefits reduce considerably without a genuine desire of involvement. The performance of the affiliation indicators identified in this study suggests the possibility of considering them as a dimension that explain the amount in which it exists in AA members. The fact that such dimension emerged from the experience of members from national groups represents an opportunity to use it as a valid scale in broader researches with bigger samples, and a chance to find out in a more reliable way the real role of AA in the recovery process. Since AA represents one of the most popular choices for the treatment of alcoholism in Mexico, research should continue for broadening the knowledge that health professionals, researchers, and everyone involved in prevention have about this organization. As shown by the results of this study, a better understanding of the benefits produced by the active participation in AA could help to motivate not only attendance to the meetings, but a full involvement in the activities suggested by the groups. The final effects may result in a reduction of the health costs generated by alcoholism and related problems attention.<hr/>La labor realizada por los grupos de Alcohólicos Anónimos (AA) para combatir el problema del alcoholismo los ha convertido en una de las opciones importantes. La adherencia o afiliación a estos grupos puede ser benéfica para ciertos alcohólicos, por lo que la investigación ha buscado identificar los aspectos que contribuyen a su establecimiento. Aunque la investigación aún no aclara el proceso mediante el que se logra, la ha destacado como un constructo que entrelaza la asistencia a las reuniones y el nivel de participación en los grupos, y se menciona que, cuanto mayor es el involucramiento, tiende a mejorar el pronóstico del alcohólico. A pesar de este panorama, en nuestro contexto, el tema de los componentes específicos de la afiliación a AA, así como su relevancia para mantener la abstinencia en comparación con la recaída, no ha recibido atención suficiente por parte de los investigadores en alcoholismo. Este trabajo tiene como objetivos: explorar elementos que pueden constituir un perfil de afiliación a AA, conocer si esos elementos son diferentes o forman parte de un mismo constructo y si la graduación de afiliación (clasificación de la forma en que el alcohólico se involucra en las diferentes actividades de los grupos) puede diferenciar entre quienes han recaído o no en el consumo de alcohol. Método La muestra fue no probabilística intencional; incluyó a 192 miembros de AA (87% hombres y 1 3% mujeres). Se formaron dos grupos: no recaídos y recaídos (143 no consumieron ninguna cantidad de alcohol y 49 consumieron cualquier cantidad de alcohol después de por lo menos tres meses de abstinencia). Se diseñó un cuestionario para evaluar la afiliación a AA; en éste se indaga el servicio, el apadrinamiento, la práctica de los 12 pasos, el <<despertar espiritual>>, el tiempo en AA, la frecuencia de asistencia y la lectura de literatura de AA. Resultados Hubo diferencias significativas en el tiempo promedio de participación (t = -3.225, gl = 181, p<.00), en la actividad de <<servicio>> (tenerlo: χ² = 7.76, p<.01 y horas dedicadas: t = -2.258, gl = 145, p<.02), tener la función de <<padrino>> ( χ²=15.06, p< .000), en la práctica reciente de los pasos 3 al 12 ( χ² = 5.166, p<.02) y en la experiencia del <<despertar espiritual>> ( χ² = 4.282, p<. 05), todos mayores en los no recaídos. Tras eliminar <<tiempo dedicado al servicio>>, se encontró una consistencia interna adecuada (α =.67) y un análisis factorial mostró que los reactivos se agrupaban en una sola dimensión, con una varianza explicada de 43.6%. Se construyó un indicador del grado de afiliación usando la sumatoria de los puntajes de las variables agrupadas y se trabajó una comparación por quintiles, la cual mostró diferencias significativas según el grado de involucramiento en AA (Z = -3.367, p<.001). Los no recaídos mostraron una afiliación que va de alta a muy alta. Discusión En este estudio, la afiliación a AA parecería un suceso compuesto por distintos elementos que se comportaron de modo significativamente diferente entre los recaídos y no recaídos. No fueron entidades separadas, sino partes de un mismo constructo que, trabajado en forma de quintiles (muy baja, baja, moderada, alta y muy alta), evidenció una asociación importante con la abstinencia. Los índices variaron de manera significativa entre los grupos de recaídos y no recaídos; los mayores se vieron en quienes han mantenido la abstinencia por largos periodos. Este resultado confirma hallazgos de estudios anteriores, en el sentido de que los alcohólicos más participativos en AA obtienen resultados más favorables. Los indicadores de afiliación detallados sugieren la posibilidad de considerarlos como una dimensión que dé cuenta del grado en que se manifiesta en los miembros de AA. Además, el que emergiera de la experiencia de los miembros de grupos nacionales representa la oportunidad de estructurarla como una escala válida para futuras investigaciones con muestras más grandes e indagar con mayor confiabilidad sobre el papel que desempeña AA en el proceso de recuperación del alcoholismo.