Barriers preventing the successful integration of mental health services into Primary Health Care in Nigeria : a mixed methods approach

RESUMO: A Nigéria tem uma população estimada em cerca de 170 milhões de pessoas. O número de profissionais de saúde mental é muito diminuto, contando apenas com 150 psiquiatras o que perfaz aproximadamente um rácio de psiquiatra: população de mais de 1:1 milhão de pessoas. O Plano Nacional de Saúde Mental de 1991 reconheceu esta insuficiência e recomendou a integração dos serviços de saúde mental nos cuidados de saúde primários (CSP). Depois de mais de duas décadas, essa política não foi ainda implementada. Este estudo teve como objetivos mapear a estrutura organizacional dos serviços de saúde mental da Nigéria, e explorar os desafios e barreiras que impedem a integração bem-sucedida dos serviços de saúde mental nos cuidados de saúde primários, isto segundo a perspectiva dos profissionais dos cuidados de saúde primários. Com este objetivo, desenvolveu-se um estudo exploratório sequencial e utilizou-se um modelo misto para a recolha de dados. A aplicação em simultâneo de abordagens qualitativas e quantitativas permitiram compreender os problemas relacionados com a integração dos serviços de saúde mental nos CSP na Nigéria. No estudo qualitativo inicial, foram realizadas entrevistas com listagens abertas a 30 profissionais dos CSP, seguidas de dois grupos focais com profissionais dos CSP de duas zonas governamentais do estado de Oyo de forma a obter uma visão global das perspectivas destes profissionais locais sobre os desafios e barreiras que impedem uma integração bem-sucedida dos serviços de saúde mental nos CSP. Subsequentemente, foram realizadas entrevistas com quatro pessoas-chave, especificamente coordenadores e especialistas em saúde mental. Os resultados do estudo qualitativo foram utilizados para desenvolver um questionário para análise quantitativa das opiniões de uma amostra maior e mais representativa dos profissionais dos CSP do Estado de Oyo, bem como de duas zonas governamentais locais do Estado de Osun. As barreiras mais comummente identificadas a partir deste estudo incluem o estigma e os preconceitos sobre a doença mental, a formação inadequada dos profissionais dos CPS sobre saúde mental, a perceção pela equipa dos CSP de baixa prioridade de ação do Governo, o medo da agressão e violência pela equipa dos CSP, bem como a falta de disponibilidade de fármacos. As recomendações para superar estes desafios incluem a melhoria sustentada dos esforços da advocacia à saúde mental que vise uma maior valorização e apoio governamental, a formação e treino organizados dos profissionais dos cuidados primários, a criação de redes de referência e de apoio com instituições terciárias adjacentes, e o engajamento da comunidade para melhorar o acesso aos serviços e à reabilitação, pelas pessoas com doença mental. Estes resultados fornecem indicações úteis sobre a perceção das barreiras para a integração bem sucedida dos serviços de saúde mental nos CSP, enquanto se recomenda uma abordagem holística e abrangente. Esta informação pode orientar as futuras tentativas de implementação da integração dos serviços de saúde mental nos cuidados primários na Nigéria.------------ABSTRACT: Nigeria has an estimated population of about 170 million people but the number of mental health professionals is very small, with about 150 psychiatrists. This roughly translates to a psychiatrist:population ratio of more than 1:1 million people. The National Mental Health Policy of 1991 recognized this deficiency and recommended the integration of mental health into primary health care (PHC) delivery system. After more than two decades, this policy has yet to be implemented. This study aimed to map out the organizational structure of the mental health systems in Nigeria, and to explore the challenges and barriers preventing the successful integration of mental health into primary health care, from the perspective of the primary health care workers. A mixed methods exploratory sequential study design was employed, which entails the use of sequential timing in the combined methods of data collection. A combination of qualitative and uantitative approaches in sequence, were utilized to understand the problems of mental health services integration into PHC in Nigeria. The initial qualitative phase utilized free listing interviews with 30 PHC workers, followed by two focus group discussions with primary care workers from two Local Government Areas (LGA) of Oyo State to gain useful insight into the local perspectives of PHC workers about the challenges and barriers preventing successful integration of mental health care services into PHC. Subsequently, 4 key informant interviews with PHC co-ordinators and mental health experts were carried out. The findings from the qualitative study were utilized to develop a quantitative study questionnaire to understand the opinions of a larger and more representative sample of PHC staff in two more LGAs of Oyo State, as well as 2 LGAs from Osun State. The common barriers identified from this study include stigma and misconceptions about mental illness, inadequate training of PHC staff about mental health, low government priority, fear of aggression and violence by the PHC staff, as well as non-availability of medications. Recommendations for overcoming these challenges include improved and sustained efforts at mental health advocacy to gain governmental attention and support, organized training and retraining for primary care staff, establishment of referral and supportive networks with neighbouring tertiary facilities and community engagement to improve service utilization and rehabilitation of mentally ill persons. These findings provide useful insight into the barriers to the successful integration of mental health into PHC, while recommending a holistic and comprehensive approach. This information can guide future attempts to implement the integration of mental health into primary care in Nigeria.

Evaluation of outpatient child-adolescent mental health services (CAMHS) in Attica-Greece

ABSTRACT: Background: Childhood is a critical time for social and emotional development, educational progress and mental health prevention. Mental health for children and adolescents is defined by the achievement of expected developmental, cognitive, social and emotional skills. The development of child-adolescent mental health services (CAMHS) is a necessity for each country, not only as a prevention measure for the wellbeing of people, but also as an investment to the future of countries. Qualitative evaluation of services is the only way to ensure whether services function under quality standards and increase the possibility of better outcomes for their patients. This study examines the greek outpatient CAMHS against the British Standards of National Institute of Excellence for community CAMHS. The Standards assessed refer to the areas of Assessment, Care and Intervention. Objectives: The main objectives of the study are 1) to evaluate Greek outpatient CAMHS in the Attica region 2) to promote the evaluation process for mental health services in Greece. Methods: Due to the fact that Greek services are based on the British model, the tool used was the British self-review questionnaire of Quality Network for Community CAMHS(QNCC).The tool was translated, adapted and posted to services. Twelve out of twenty outpatient CAMHS of Attica (including Athens) responded. Data was collected and performed by the Statistical Package for Social Sciences SPSS. Results: The study resulted that the CAMHS examined, meet moderately the British Standards of 1) Referral and Access, 2) Assessment & Care planning, 3) Care & Intervention. Two out of twelve services examined, meet the standards of "Assessment and Care" in a higher percentage between 75% and 100%. Conclusions: The paper describes a satisfactory function of CAMHS in Attica prefecture taking into consideration the extremely difficult political situation of Greece at the time of the research. Strong and weak domains are identified. Also the translation and adaptation of British tools promote the evaluation process and quality assurance of Greek CAMHS.

Implementation progress of mental health services in Rwanda: Bugesera district case

RESUMO: O Ministério da Saúde do Governo do Ruanda identifica a saúde mental como uma área de prioridade estratégica para a intervenção em resposta à alta carga dos transtornos mentais no Ruanda. Ao longo dos últimos 20 anos após o genocídio, o sector público reconstruiu sua Resposta Nacional de Saúde Mental com base no acesso equitativo aos cuidados, através do desenvolvimento de uma Política Nacional de Saúde Mental e novas estruturas de saúde mental. A política de Saúde Mental do Ruanda, revista em 2010, prima pela descentralização e integração dos serviços de saúde mental em todas as estruturas nacionais do sistema de saúde e ao nível da comunidade. O presente estudo de caso tem como objetivo avaliar a situação do sistema de saúde mental de um distrito típico de uma área rural no Ruanda, e sugerir melhorias, incluindo algumas estratégias para monitoras as mudanças. Os resultados do estudo permitirão ao Ruanda reforçar a sua capacidade para implementar o Plano Nacional de Saúde Mental ao nível dos distritos. O relatório também será útil para monitorar o progresso da implementação de serviços de saúde mental nos distritos, incluindo a prestação de serviços de base comunitária e a participação dos usuários, suas famílias e outros interessados na promoção, prevenção, assistência e reabilitação em saúde mental. Este estudo também procurou avaliar o progresso da implementação dos cuidados de saúde mental a nível descentralizado, com vista a compreender as implicações em termos de recursos desses processos. Foi realizada uma análise situacional num local do distrito, baseado em entrevistas com as principais partes interessadas responsáveis, usando o Instrumento de Avaliação de Sistemas de Saúde Mental da Organização Mundial da Saúde (WHO-AIMS). Os resultados sugerem que os recursos humanos para a saúde mental e serviços de base comunitária de saúde mental no distrito continuam a ser extremamente limitados. Os profissionais de saúde mental são adicionalmente limitados na sua capacidade para oferecer intervenções de emergência a pacientes psiquiátricos e garantir a continuidade do tratamento farmacológico a pacientes com condições crônicas. Para planejar efetivamente, de acordo com as necessidades da comunidade, sugerimos que o sistema de saúde mental deve envolver também os representantes das famílias e dos usuários no processo de planificação de modo a melhorar a sua contribuição no processo de implementação das atividades de saúde mental. Este estudo de caso do Distrito de Bugesera oferece a primeira análise de nível distrital dos serviços de saúde mental no Ruanda, e pode servir como uma mais-valia para a melhoria do sistema de saúde mental, incluindo a advocacia para a melhoria da qualidade dos cuidados de saúde mental a este nível, aumentando o financiamento para a implementação de serviços clínicos de saúde mental e os recursos humanos disponíveis para a prestação de cuidados de saúde mental, principalmente a nível dos cuidados primários.--------------------- ABSTRACT: To deal with the high burden of mental health disorders resulting from consequences of the 1994 genocide against Tutsis, the Rwanda Ministry of Health (MoH) considers mental health as a priority intervention. For the last 20 years, Ministry of Health focused on rebuilding a national and equity-oriented mental health program responding to the population needs in mental health. Mental health services are now decentralized and integrated in the national health system, from the community level up to the referral level. This study assessed the situation of mental health services in one rural district in Rwanda. It was aimed at assessing the progress of implementation of mental health care at the decentralized level, focusing on resource implications and processes. This study is based on interviews conducted with key stakeholders, using the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS). Findings show that human resources for mental health care and community-based mental health services of the assessed district remain extremely limited. Mental health professionals face limitation regarding the ability to provide emergency management of psychiatric patients and to ensure continuity of psychopharmacological treatment of patients with chronic conditions. To improve the implementation process of mental health interventions and activities, a planning process based on community needs and the involvement of representatives of families and users in planning process should be considered. The Bugesera case study on the situation of mental health services can serve as a baseline for improvement of the mental health program in Rwanda, in terms of quality care services, infrastructure and equipment, human and financial resources.

Rehabilitation and reintegration needs of female inmates and promotion mental health in Georgian prison

RESUMO: As mulheres presas encontram-se num sistema essencialmente dirigido por e concebido para homens. As mulheres que entram na prisão geralmente vêm de ambientes marginalizados e desfavorecidos e muitas vezes têm histórias de violência e abuso físico e sexual. As mulheres presas são um grupo particularmente vulnerável, uma vez que dentro do sistema prisional as suas necessidades de saúde e higiene são muitas vezes negligenciadas. O primeiro passo para o desenvolvimento de programas e práticas sensíveis ao género é compreender as características das mulheres delinquentes e definir fatores de vida específicos que contribuem para a formação do comportamento criminoso de mulheres. Em junho de 2012 foi realizada uma investigação na única prisão feminina da Geórgia, para estudar as necessidades mentais e psicossociais das mulheres presas. O objetivo da pesquisa foi o desenvolvimento de programas de apoio pertinentes para a reabilitação, ressocialização e reintegração, e a elaboração de recomendações práticas para a gestão das prisões. Foi desenvolvido um instrumento de pesquisa (inquérito) com uma fundamentação conceptual baseada em quatro principais teorias: Teoria dos Caminhos (Pathways Theory), teoria do desenvolvimento psicológico da mulher (Theory of Women’s Psychological Development), Trauma e Teorias da Dependência (Trauma and Addiction Theories). Foram inquiridas 120 mulheres presas. Os resultados deste estudo mostram que muitas das necessidades das mulheres presas são diferentes das dos homens e requerem estratégias adaptadas às suas características e situações psicossociais específicas. A maioria das mulheres encarceradas é jovem, enérgica, pode trabalhar, tem profissão e família. As presas sofrem de problemas psicológicos e muitas vezes são rejeitadas pelas suas famílias. Uma parte substancial das mulheres presas tem múltiplos problemas de saúde física e mental. A maioria delas tem filhos e sofre com o facto das crianças estarem a crescer longe da mãe. Com base nos resultados desta investigação é possível elaborar um contexto promotor do planeamento e desenvolvimento de serviços com um enfoque de género na prisão. Na perspetiva de longo prazo, o conhecimento das necessidades básicas e a introdução de programas e serviços com necessidades específicas pertinentes irá beneficiar as presas e as suas famílias, e melhorar a eficácia do sistema de justiça criminal.----------ABSTRACT: Female inmates find themselves in a system essentially run by men for men. Women who enter prison usually come from marginalized and disadvantaged backgrounds and are often characterized by histories of violence, physical and sexual abuse. Female prisoners constitute an especially vulnerable group given their specific health and hygienic needs within the system are often neglected. The first step in developing gender-sensitive program and practice is to understand female offenders’ characteristics and the specific life factors that shape women’s patterns of offending. In June 2012 a research was carried out in the Georgian only female prison facility to assess the mental and psychosocial needs of women prisoners, aiming to develop effective support programs for their rehabilitation, re-socialization and reintegration, as well as to elaborate new recommendations concerning prison management. A survey instrument (questionnaire) was developed within a theoretical framework based on four fundamental theories: Pathways Theory, Theory of Women’s Psychological Development and Trauma and Addiction Theories. Sample size was defined to be 120 surveyed persons. The study showed that needs of incarcerated women were different from those of men, thus requiring approaches tailored to their specific psychosocial characteristics and situations. The basic population of imprisoned women consisted of young, energetic, working-age females, most often with a professional qualification. Female prisoners suffered from psychological problems and are were more likely to be rejected by their families. Most of them had children and suffered that the children were growing without mothers. A substantial proportion of women offenders had multiple physical and mental health problems. Based on the study findings a conceptual framework can be elaborated towards planning and developing gender-sensitive services in prison. In the long-term perspective, acknowledgement of baseline needs and introduction of the relevant needs-specific programs and services may benefit women prisoners as well as their families, improving the effectiveness of the criminal justice system.

Needs assessment of people with severe mental illnesses and their families in Azerbaijan

RESUMO: Os indivíduos com doença mental grave, assim como os seus familiares, podem ser caracterizados como uma população em que ocorre uma combinação complexa de necessidades médicas e psicossociais, nomeadamente a nível do diagnóstico e do acesso aos serviços de saúde mental. A avaliação de necessidades pode fornecer informações importantes para o desenvolvimento de intervenções eficazes, tanto a nível da população como a nível individual. Este estudo teve como objetivo determinar as diferentes necessidades reportadas pelos pacientes com doença mental grave e seus familiares , assim como investigar as possíveis relações entre o estado de necessidades e as variáveis sócio-demográficas e clínicas. Simultaneamente, o estudo teve como objetivo avaliar a sobrecarga familiar e a satisfação dos utentes com os serviços de saúde mental. Foi elaborado um estudo transversal, realizado numa amostra de conveniência de cinquenta díades de paciente/membro da família, seguidos em regime de ambulatório no Centro Nacional de Saúde Mental. Foram utilizados como instrumentos de avaliação um questionário sociodemográfico, a Escala Breve de Avaliação Psiquiátrica (BPRS), o questionário de Avaliação de Necessidades de Camberwell (CAN), o Questionário de Avaliação do Envolvimento (IEQ) e a Escala de Verona de Satisfação com os Serviços (VSSS). As mais frequentes necessidades não-satisfeitas foram o ‘sofrimento psicológico’, as ‘atividades sociais’ e os ‘benefícios sociais’. O estudo mostrou uma sobrecarga significativa nas famílias que cuidam de pessoas com doença mental grave, que se correlacionou com as suas opiniões sobre as necessidades dos pacientes e teve um impacto negativo sobre o bem-estar psicológico. Os três mais importantes predictores de sofrimento psíquico em familiares foram o sexo, a situação laboral e a relação com o paciente. A avaliação da satisfação com os serviços revelou a existência de um hiato significativo entre os serviços prestados e os serviços desejados, reportados pelos pacientes e seus familiares. A maioria dos participantes do estudo desejavam ter um trabalho protegido, ou receber ajuda para encontrar emprego. Os resultados deste estudo poderão ser usados para fins de planeamento desenvolvimento e avaliação de serviços de saúde mental no Azerbeijão. Algumas recomendações sobre a melhoria dos serviços de saúde mental para pacientes com doença mental grave e suas famílias são feitas na secção final do trabalho.----------ABSTRACT: Patients suffering from severe mental illness, in addition to their family members, may be characterized as a population with a complex combination of medical and psychosocial needs, which are under-recognized and under-addressed by mental health services. At the same time, needs assessment provides important information necessary for developing effective interventions at both population and individual level. The study was aimed to determine various needs perceived by patients with SMI and their family members, as well as to find out possible relations between the needs and socio-demographic and clinical variables. Similarly the study was intended to evaluate family burden and users’ satisfaction with services. This was a cross-sectional study conducted on a convenience sample. Fifty dyads of a patient and family member applying for out-patient services to the National Mental Health Centre participated in the study. Sociodemographic questionnaire, Brief Psychiatric Rating Scale, Camberwell Assessment of Need, Involvement Evaluation Questionnaire, and Verona Service Satisfaction Scale were used as assessment tools. The most prominent unmet needs reported by people with SMI and their relatives were psychological distress, social activities and welfare benefits. The study showed significant burden in families caring for people with SMI, which correlated with their views about patients’ needs and had a negative impact on the psychological well-being. The three most important predictors of psychological distress in family members were gender, employment status and relationship to patient. Evaluation of satisfaction with services pointed out the gap between provided and desired services reported by patients and their relatives. Most of study participants wished to have sheltered work, or receive help in finding employment. The results of this study may be used for the purposes of mental health service planning, development and evaluation in our country. Some recommendations on improvement of mental health services for patients with SMI and their families have been made in the conclusion.

Role of Intersectoral Collaboration in Mental Health Policy Formulation And Service Delivery in Saint Lucia

RESUMO: Santa Lúcia pequena ilha de país em desenvolvimento com recursos limitados e é confrontada com uma série de desafios socioeconômicos que exigem soluções criativas e inovadoras. É comprovado que a combinação de recursos entre setores para estabelecer os determinantes social, econômico e ambiental da saúde são uma estratégia útil para melhorar a saúde da população, principalmente a sua saúde mental. Este estudo, o primeiro do seu tipo em Santa Lúcia, procurou examinar até que ponto a disponibilidade de uma política nacional de saúde mental levou a ação intersetorial para o fornecimento de serviços e promoção da saúde mental. Além disso, o estudo examinou o nível de colaboração intersetorial que existe entre as agências que prestam cuidados diretos e serviços de suporte para pessoas com doenças mentais e problemas sérios de saúde mental. O estudo também teve como objetivo identificar os fatores que promovem ou dificultam a colaboração intersectorial e gerar recomendações que possam ser aplicadas para países muito pequenos e com perfis socioeconômicos semelhantes. Os dados gerados a partir de três (3) fontes foram sintetizados para formar uma visão ampla das questões. Uma avaliação da política de saúde mental de 2007, uma avaliação que identifica até que ponto a ação intersetorial atualmente deixa a prestação de serviços de saúde mental e a administração de entrevistas semiestruturadas nas mãos de gestores do programa de diferentes agências em todos os setores. O estudo concluiu que, apesar da disponibilidade de uma política de saúde mental, que articula clara e explicitamente a colaboração intersetorial como área prioritária para ação, quase não existe no sistema de fornecimento atual do serviço. Os provedores de serviços em todos os setores reconhecem que há os benefícios da colaboração intersectorial e com entraves significativos em relação à colaboração intersetorial, que por sua vez, impede uma abordagem nacional para o planejamento e o fornecimento do serviço. A colaboração intersetorial não será possível se os próprios setores dependerem da abordagem direta do setor da saúde ou se a atmosfera geral for ofuscada pela estigmatização das doenças mentais.------------------------------------------------------------------------ABSTRACT: Saint Lucia a small island developing country with limited resources, is faced with a number of socio-economic challenges which require creative and innovative solutions to address. Combining resources across sectors to address the social, economic and environmental determinants of health has proven to be a useful strategy for improving population health in particular mental health. This study, the first of its kind for Saint Lucia sought to examine the extent to which the availability of a national mental health policy led to intersectoral action for mental health promotion and service delivery. In addition the study examined the level of intersectoral collaboration which actually exist between agencies which provide direct care and support services to people with mental illnesses and significant mental health problems. The study also aimed to identify the factors which promote or hinder intersectoral collaboration and generate recommendations which can be applied to extremely small countries with similar socio-economic profiles. Data generated from three (3) sources was synthesized to form a broad picture of the issues. An evaluation of the mental health policy of 2007, an assessment of the extent to which intersectoral action currently exist in mental health service delivery and the administration of semi-structured interviews with program managers from different agencies across sectors to identify implementation issues. The study concluded that despite the availability of a mental health policy which clearly and explicitly articulates intersectoral collaboration as a priority area for action, very little exists in the current service delivery system. Services providers across sectors acknowledge the benefits of intersectoral collaboration and that there are significant barriers to intersectoral collaboration, which in turn hinders a national approach to service planning and delivery. Intersectoral collaboration is not possible if sectors themselves are dependent on a top-down health sector driven and dominated approach, or if the general atmosphere is clouded by stigmatization of mental health illnesses.

Determinants of mother-baby relationship evaluated during pregnancy

ABSTRACT Background Mental health promotion is supported by a strong body of knowledge and is a matter of public health with the potential of a large impact on society. Mental health promotion programs should be implemented as soon as possible in life, preferably starting during pregnancy. Programs should focus on malleable determinants, introducing strategies to reduce risk factors or their impact on mother and child, and also on strengthening protective factors to increase resilience. The ambition of early detecting risk situations requires the development and use of tools to assess risk, and the creation of a responsive network of services based in primary health care, especially maternal consultation during pregnancy and the first months of the born child. The number of risk factors and the way they interact and are buffered by protective factors are relevant for the final impact. Maternal-fetal attachment (MFA) is not yet a totally understood and well operationalized concept. Methodological problems limit the comparison of data as many studies used small size samples, had an exploratory character or used different selection criteria and different measures. There is still a lack of studies in high risk populations evaluating the consequences of a weak MFA. Instead, the available studies are not very conclusive, but suggest that social support, anxiety and depression, self-esteem and self-control and sense of coherence are correlated with MFA. MFA is also correlated with health practices during pregnancy, that influence pregnancy and baby outcomes. MFA seems a relevant concept for the future mother baby interaction, but more studies are needed to clarify the concept and its operationalization. Attachment is a strong scientific concept with multiple implications for future child development, personality and relationship with others. Secure attachment is considered an essential basis of good mental health, and promoting mother-baby interaction offers an excellent opportunity to intervention programmes targeted at enhancing mental health and well-being. Understanding the process of attachment and intervening to improve attachment requires a comprehension of more proximal factors, but also a broader approach that assesses the impact of more distal social conditions on attachment and how this social impact is mediated by family functioning and mother-baby interaction. Finally, it is essential to understand how this knowledge could be translated in effective mental health promoting interventions and measures that could reach large populations of pregnant mothers and families. Strengthening emotional availability (EA) seems to be a relevant approach to improve the mother-baby relationship. In this review we have offered evidence suggesting a range of determinants of mother-infant relationship, including age, marital relationship, social disadvantages, migration, parental psychiatric disorders and the situations of abuse or neglect. Based on this theoretical background we constructed a theoretical model that included proximal and distal factors, risk and protective factors, including variables related to the mother, the father, their social support and mother baby interaction from early pregnancy until six months after birth. We selected the Antenatal Psychosocial Health Assessment (ALPHA) for use as an instrument to detect psychosocial risk during pregnancy. Method Ninety two pregnant women were recruited from the Maternal Health Consultation in Primary Health Care (PHC) at Amadora. They had three moments of assessment: at T1 (until 12 weeks of pregnancy) they filed out a questionnaire that included socio-demographic data, ALPHA, Edinburgh post-natal Depression Scale (EDPS), General Health Questionnaire (GHQ) and Sense of Coherence (SOC); at T2 (after the 20th weeks of pregnancy) they answered EDPS, SOC and MFA Scale (MFAS), and finally at T3 (6 months after birth), they repeated EDPS and SOC, and their interaction with their babies was videotaped and later evaluated using EA Scales. A statistical analysis has been done using descriptive statistics, correlation analysis, univariate logistic regression and multiple linear regression. Results The study has increased our knowledge on this particular population living in a multicultural, suburb community. It allow us to identify specific groups with a higher level of psychosocial risk, such as single or divorced women, young couples, mothers with a low level of education and those who are depressed or have a low SOC. The hypothesis that psychosocial risk is directly correlated with MFAS and that MFA is directly correlated with EA was not confirmed, neither the correlation between prenatal psychosocial risk and mother-baby EA. The study identified depression as a relevant risk factor in pregnancy and its higher prevalence in single or divorced women, immigrants and in those who have a higher global psychosocial risk. Depressed women have a poor MFA, and a lower structuring capacity and a higher hostility to their babies. In average, depression seems to reduce among pregnant women in the second part of their pregnancy. The children of immigrant mothers show a lower level of responsiveness to their mothers what could be transmitted through depression, as immigrant mothers have a higher risk of depression in the beginning of pregnancy and six months after birth. Young mothers have a low MFA and are more intrusive. Women who have a higher level of education are more sensitive and their babies showed to be more responsive. Women who are or have been submitted to abuse were found to have a higher level of MFA but their babies are less responsive to them. The study highlights the relevance of SOC as a potential protective factor while it is strongly and negatively related with a wide range of risk factors and mental health outcomes especially depression before, during and after pregnancy. Conclusions ALPHA proved to be a valid, feasible and reliable instrument to Primary Health Care (PHC) that can be used as a total sum score. We could not prove the association between psychosocial risk factors and MFA, neither between MFA and EA, or between psychosocial risk and EA. Depression and SOC seems to have a clear and opposite relevance on this process. Pregnancy can be considered as a maturational process and an opportunity to change, where adaptation processes occur, buffering risk, decreasing depression and increasing SOC. Further research is necessary to better understand interactions between variables and also to clarify a better operationalization of MFA. We recommend the use of ALPHA, SOC and EDPS in early pregnancy as a way of identifying more vulnerable women that will require additional interventions and support in order to decrease risk. At political level we recommend the reinforcement of Immigrant integration and the increment of education in women. We recommend more focus in health care and public health in mental health condition and psychosocial risk of specific groups at high risk. In PHC special attention should be paid to pregnant women who are single or divorced, very young, low educated and to immigrant mothers. This study provides the basis for an intervention programme for this population, that aims to reduce broad spectrum risk factors and to promote Mental Health in women who become pregnant. Health and mental health policies should facilitate the implementation of the suggested measures.

Mental health and the crisis: Evidence from share

Mental health constitutes a significant share of the global burden of disease. It is shaped to a great extent by socioeconomic factors and is vulnerable to external shocks. The recent financial crisis brought about stressors prone to trigger and aggravate mental illnesses. This project presents a micro analysis of the effect of the economic crisis on mental health in eleven European countries, through the estimation of individual health production functions accounting for socioeconomic controls and macroeconomic indicators. We find that mental health has deteriorated since 2007, even though the development of depression episodes is unchanged. Additionally, his variation can be partially attributed to economic recession and budgetary cuts in health spending.

Mental health and neuroscience. A perspective from the magazine market

Mental health awareness has been rising worldwide, motivated by its social and economic costs. Despite the investment in research in neuroscience in the recent years, little is known about the underlying mechanisms in the brain that are correlated with psychiatric conditions. This project, through two feature articles suitable to be published in magazines, provides perspectives onto mental health research. First it presents an example where psychiatry joins forces with neuroscience and computer science in an interdisciplinary effort to improve the life of those affected by mental disorders. The second article gathers opinions which claim that mental health research priorities should be set by patients themselves, or even that people with lived experience of mental health issues should have an active role in that research. This project was planned and researched while I was an Erasmus student at Nottingham Trent University, in the United Kingdom.

Reinvigorating and redesigning early intervention in psychosis services for young people in Auckland

RESUMO: Auckland tem sido pioneira na implementação de modelos de Intervenção Precoce em Psicose. No entanto, esta organização do serviço não mudou nos últimos 19 anos. Segundo os dados obtidos da utilização do serviço, no período de 1996 -2012 foram atendidos 997 doentes, que tinham um número médio de 89 contactos (IQR: 36-184), com uma duração média de 62 horas de contactos (IQR: 24-136). Estes doentes passaram um número médio de 338 dias (IQR: 93-757) em contacto com o programa. 517 doentes (52%) não necessitaram de internamento no hospital, e os que foram internados, ficaram uma mediana de 124 dias no hospital (IQR: 40-380). Os doentes asiáticos tiveram um aumento de 50% de probabilidade de serem internados no hospital. Este relatório inclui 15 recomendações para orientar as reformas para o serviço e, nomeadamente, delinear a importância de uma visão organizacional e dos seus componentes-chave. As recomendações incluem o reforço da gestão e da liderança numa estrutura de equipe mais integrada, com recursos dedicados a melhorar a consciencialização da comunidade, a educação e deteção precoce, bem como a capacidade de receber referenciações diretas. Os Indicadores Chave de Desempenho devem ser estabelecidos, mas os Exames de Estado Mental em risco, devem ser removidos. Auckland deve manter a faixa etária alvo atual. A duração do serviço deve ser aumentada para um mínimo de três anos, com a opção de aumentá-la para cinco anos. A proporção de gestor de cuidados para os doentes deve ser preconizada em 1:15, enquanto o pessoal de apoio não-clínico deve ser aumentado. Os psiquiatras devem ter uma carga de trabalho de cerca de 80 doentes por equivalente de tempo completo. Um serviço local de prestação de cuidados deve ser desenvolvido com, nomeadamente, intervenções culturais para responder às necessidades da população multicultural de Auckland. A capacidade de investigação deve ser incorporada no Serviço de Intervenção Precoce em Psicoses. Qualquer alteração deverá envolver contacto com todas as partes interessadas, e a Administração Regional de Saúde deve comprometer-se em tempo, recursos humanos e políticos para apoiar e facilitar a mudança do sistema, investindo de forma significativa para melhor servir a comunidade Auckland.----------------------------------- ABSTRACT: Auckland has been pioneering in the adoption of Early Intervention in Psychosis models but the design of the service has not changed in 19 years. In service utilisation data from 997 patients seen from 1996 -2012, patients had a median number of 89 contacts (IQR: 36-184), with a median duration of 62 hours of contact (IQR: 24-136). Patients spent a median number of 338 days (IQR: 93-757) in contact with the program. 517 patients (52%) did not require admission to hospital, and those who did spent a median of 124 days in hospital (IQR: 40-380). Asian patients had a 50% increased chance of being admitted to hospital. This report includes 15 recommendations to guide reforms to the service, including outlining the importance of vision and key components. It recommends strengthened managerial leadership and a more integrated team structure with dedicated resources for improved community awareness, education and early detection as well as the capacity to take direct referrals. Key Performance Indicators (KPIs) should be established but At Risk Mental States should be excluded. Auckland should maintain the current target age range. The duration of service should be increased to a minimum of three years, with the option to extend this to five years. The ratio of care co-ordinator to patients should be capped at 1:15 whilst non-clinical supporting staff should be increased. Psychiatrists should have a caseload of about 80 per FTE. A local Service Delivery framework should be developed, as should cultural interventions to meet the needs of the multicultural population of Auckland. Research capacity should be incorporated into the fabric of Early Intervention in Psychosis Services. Any changes should involve consultation with all stakeholders, and the DHB should commit to investing time, human and political resources to support and facilitate meaningful system change to best serve the Auckland community.