Lifetime Prevalence, age and gender distribution and age-of-onset of psychiatric disorders in the São Paulo Metropolitan Area, Brazil: results from the São Paulo Megacity Mental Health Survey

OBJECTIVES: To estimate prevalence, age-of-onset, gender distribution and identify correlates of lifetime psychiatric disorders in the São Paulo Metropolitan Area (SPMA). METHODS: The São Paulo Megacity Mental Health Survey assessed psychiatric disorders on a probabilistic sample of 5,037 adult residents in the SPMA, using the World Mental Health Survey Version of the Composite International Diagnostic Interview. Response rate was 81.3%. RESULTS: Lifetime prevalence for any disorder was 44.8%; estimated risk at age 75 was 57.7%; comorbidity was frequent. Major depression, specific phobias and alcohol abuse were the most prevalent across disorders; anxiety disorders were the most frequent class. Early age-of-onset for phobic and impulse-control disorders and later age-of-onset for mood disorders were observed. Women were more likely to have anxiety and mood disorders, whereas men, substance use disorders. Apart from conduct disorders, more frequent in men, there were no gender differences in impulse-control disorders. There was a consistent trend of higher prevalence in the youngest cohorts. Low education level was associated to substance use disorders. CONCLUSIONS: Psychiatric disorders are highly prevalent among the general adult population in the SPMA, with frequent comorbidity, early age-of-onset for most disorders, and younger cohorts presenting higher rates of morbidity. Such scenario calls for vigorous public health action.

Occurrence of bipolar spectrum disorder and comorbidities in women with eating disorders

Abstract Background Eating disorder (ED) patients often have comorbidities with other psychiatric disorders, especially with mood disorders. Although recent studies suggest an intimate relationship between ED and bipolar disorder (BD), the study on a broader bipolar spectrum definition has not been done in this population. We aimed to study the occurrence of bipolar spectrum (BS) and comorbidities in eating disorder patients of a tertiary service provider. Methods Sixty-nine female patients diagnosed with anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified were evaluated. The assessment comprised the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), clinical criteria for diagnosis of the Zurich bipolar spectrum. Mann–Whitney tests compared means of continuous variables. The association between categorical variables and the groups was described using contingency tables and analyzed using the chi-square or Fisher's exact test. The level of significance alpha was set at 5%. Results The results showed that 68.1% of patients had comorbidity with bipolar spectrum, and this was associated with higher family income, proportion of married people, and comorbidity with substance use. The ED with BS group showed higher rates of substance use comorbidity (40.4%) than the ED without BS group (13.6%). Discussion These results showed that the bipolar spectrum is a common comorbidity in patients with eating disorders and is associated with correlates of clinical importance, notably the comorbidity with substance use. Due to the pattern of similarity between the groups with and without comorbid bipolar spectrum in relation to various outcomes evaluated, the identification of comorbidity can be difficult. However, the precise diagnosis and careful identification of clinical correlates may contribute to future advances in treating these conditions. Further studies are necessary to evaluate the association of other clinical correlates and its possible causal association.

Well-being, distress and health status in a population of adolescent students

The present work explores the psychosocial issues emerging from a large cross-sectional study aimed to assess the prevalence, clinical manifestations, and psychosocial correlates of hyperandrogenism in a population of Italian high school students. Participants were 1804 adolescents, aged between 15 and 19 years, who volunteered to fill in a package of self-report questionnaires (including the Psychosocial Index, the Symptom Questionnaire and Ryff’s Psychological Well-Being scales for the assessment of psychological aspects) and undergo a comprehensive physical examination. Significant gender differences were found with regard to psychological distress, with females reporting higher scores compared with males, but not on well-being dimensions. The relationships of well-being to distress were found to be complex. Although inversely associated, well-being and ill-being appeared to be distinct domains of mental functioning. The evaluation of the moderating effects of well-being in the association between stress and psychological distress indicated that well-being may act as a protective factor, contributing to less pronounced psychological distress as stress levels increased. Higher rates of somatic complaints were found among current smokers. However, substance use (i.e., smoking and drug use) was also found to be positively associated with some well-being dimensions. A considerable number of participants were found to present with disordered eating symptoms, particularly females, and associated higher stress levels and lower quality of life. Sport activities were found to favourably affect psychological health. As to clinical signs of hyperandrogenism, a significant impairment in psychosocial functioning was found among females, whereas no effects on psychological measures could be detected among males. Subgroups of adolescents with distinct clinical and psychological characteristics could be identified by means of cluster analysis. The present study provides new insights into better understanding of the complex relationships between well-being, distress and health status in the adolescent population, with important clinical implications.

Social network e capitale sociale degli ex-ospiti di Comunita' Liberta': Drug free e ricaduti a confronto

L'indagine condotta, avvalendosi del paradigma della social network analysis, offre una descrizione delle reti di supporto personale e del capitale sociale di un campione di 80 italiani ex post un trattamento terapeutico residenziale di lungo termine per problemi di tossicodipendenza. Dopo aver identificato i profili delle reti di supporto sociale degli intervistati, si è proceduto, in primis, alla misurazione e comparazione delle ego-centered support networks tra soggetti drug free e ricaduti e, successivamente, all'investigazione delle caratteristiche delle reti e delle forme di capitale sociale – closure e brokerage – che contribuiscono al mantenimento dell'astinenza o al rischio di ricaduta nel post-trattamento. Fattori soggettivi, come la discriminazione pubblica percepita e l'attitudine al lavoro, sono stati inoltre esplorati al fine di investigare la loro correlazione con la condotta di reiterazione nell'uso di sostanze. Dai risultati dello studio emerge che un più basso rischio di ricaduta è positivamente associato ad una maggiore attitudine al lavoro, ad una minore percezione di discriminazione da parte della società, all'avere membri di supporto con un più alto status socio-economico e che mobilitano risorse reputazionali e, infine, all'avere reti più eterogenee nell'occupazione e caratterizzate da più elevati livelli di reciprocità. Inoltre, il capitale sociale di tipo brokerage contribuisce al mantenimento dell'astinenza in quanto garantisce l'accesso del soggetto ad informazioni meno omogenee e la sua esposizione a opportunità più numerose e differenziate. I risultati dello studio, pertanto, dimostrano l'importante ruolo delle personal support networks nel prevenire o ridurre il rischio di ricaduta nel post-trattamento, in linea con precedenti ricerche che suggeriscono la loro incorporazione nei programmi terapeutici per tossicodipendenti.

From nature versus nurture, via nature and nurture, to gene x environment interaction in mental disorders

It is now generally accepted that complex mental disorders are the results of interplay between genetic and environmental factors. This holds out the prospect that by studying G x E interplay we can explain individual variation in vulnerability and resilience to environmental hazards in the development of mental disorders. Furthermore studying G x E findings may give insights in neurobiological mechanisms of psychiatric disorder and so improve individualized treatment and potentially prevention. In this paper, we provide an overview of the state of field with regard to G x E in mental disorders. Strategies for G x E research are introduced. G x E findings from selected mental disorders with onset in childhood or adolescence are reviewed [such as depressive disorders, attention-deficit/hyperactivity disorder (ADHD), obesity, schizophrenia and substance use disorders]. Early seminal studies provided evidence for G x E in the pathogenesis of depression implicating 5-HTTLPR, and conduct problems implicating MAOA. Since then G x E effects have been seen across a wide range of mental disorders (e.g., ADHD, anxiety, schizophrenia, substance abuse disorder) implicating a wide range of measured genes and measured environments (e.g., pre-, peri- and postnatal influences of both a physical and a social nature). To date few of these G x E effects have been sufficiently replicated. Indeed meta-analyses have raised doubts about the robustness of even the most well studied findings. In future we need larger, sufficiently powered studies that include a detailed and sophisticated characterization of both phenotype and the environmental risk.

Gender differences in first episode psychotic mania

Background The aim of this paper was to delineate the impact of gender on premorbid history, onset, and 18 month outcomes of first episode psychotic mania (FEPM) patients. Methods Medical file audit assessment of 118 (male = 71; female = 47) patients with FEPM aged 15 to 29 years was undertaken on clinical and functional measures. Results Males with FEPM had increased likelihood of substance use (OR = 13.41, p < .001) and forensic issues (OR = 4.71, p = .008), whereas females were more likely to have history of sexual abuse trauma (OR = 7.12, p = .001). At service entry, males were more likely to be using substances, especially cannabis (OR = 2.15, p = .047), had more severe illness (OR = 1.72, p = .037), and poorer functioning (OR = 0.96, p = .045). During treatment males were more likely to decrease substance use (OR = 5.34, p = .008) and were more likely to be living with family (OR = 4.30, p = .009). There were no gender differences in age of onset, psychopathology or functioning at discharge. Conclusions Clinically meaningful gender differences in FEPM were driven by risk factors possibly associated with poor outcome. For males, substance use might be associated with poorer clinical presentation and functioning. In females with FEPM, the impact of sexual trauma on illness course warrants further consideration.

Atypical depression and alcohol misuse are related to the cardiovascular risk in the general population

OBJECTIVE: The aims of the present study were to assess the associations between mood, anxiety and substance use disorders, including their subtypes, and the prevalence of cardiovascular risk factors (CVRFs). METHOD: Thorough physical investigations, biological measures and standardized interview techniques were used to assess 3716 subjects of an urban area, aged 35-66 years. RESULTS: Atypical depression was associated with increased prevalence of overweight, diabetes and the metabolic syndrome (OR = 1.5, 95% C.I. 1.1-2.0; OR = 2.0, 95% C.I. 1.1-3.5, OR = 1.6, 95% C.I. 1.0-2.4 respectively), whereas decreased prevalence of overweight was found in melancholic (OR = 0.7, 95% C.I. 0.6-0.9) and unspecified depression (OR = 0.8, 95% C.I. 0.7-1.0). Alcohol abuse was associated with diabetes (OR = 1.8, 95% C.I. 1.1-2.9) and dyslipidemia (OR = 1.3, 95% C.I. 1.0-1.8), alcohol dependence with dyslipidemia only (OR = 1.4, 95% C.I. 1.0-2.0). Almost all mental disorders were associated with a lifetime history of regular cigarette smoking, and atypical depression, alcohol misuse and drug dependence were associated with inactivity. CONCLUSION: To conclude results emphasize the need to subtype depression and to pay particular attention to the atypical subtype. Comorbid alcohol misuse may further increase the cardiovascular risk. Efforts to diminish smoking in subjects with mental disorders could be crucial measures to reduce their high incidence of cardiovascular disease.

[Psychiatric assessment of alcoholic patients on a waiting list for liver transplantation : Which prognostic criteria are empirically proven?]

Liver disorders are the most frequent somatic complications of alcoholism. As 10‑20% of alcoholic patients will develop liver cirrhosis, this is the most frequent reason for premature death in alcoholic patients. Liver transplantation is now an accepted therapy for alcoholic liver cirrhosis but psychiatric assessment is usually required for patients entering a waiting list for transplantation. Prognostic criteria are controversially discussed, especially the so-called 6-month rule. Numerous studies and recent meta-analyses have indicated that duration of alcoholism, family history, age, sex, comorbid substance use and psychiatric disorders, noncompliance and social instability are outcome predictors. The 6-month criterion is not well proven but some studies are indicative. Possible therapeutic interventions for alcoholic patients on a waiting list are discussed.

Prevalence and predictors of suicide attempt in an incidence cohort of 661 young people with first-episode psychosis

Studies investigating suicidal behaviour in psychosis rarely focus on incidence cohorts of first-episode patients. This is important, because patients who refuse study participation have higher rates of comorbid substance use disorders and longer duration of untreated psychosis as well as worse course illness, variables potentially linked to higher prevalence of suicidal behaviour. The aims of the present study were therefore to examine the prevalence and predictors of suicide and suicide attempt before and during the first 18-24 months of treatment.

Comparing growth trajectories of risk behaviors from late adolescence through young adulthood: An accelerated design

Risk behaviors such as substance use or deviance are often limited to the early stages of the life course. Whereas the onset of risk behavior is well studied, less is currently known about the decline and timing of cessation of risk behaviors of different domains during young adulthood. Prevalence and longitudinal developmental patterning of alcohol use, drinking to the point of drunkenness, smoking, cannabis use, deviance, and HIV-related sexual risk behavior were compared in a Swiss community sample (N = 2,843). Using a longitudinal cohort-sequential approach to link multiple assessments with 3 waves of data for each individual, the studied period spanned the ages of 16 to 29 years. Although smoking had a higher prevalence, both smoking and drinking up to the point of drunkenness followed an inverted U-shaped curve. Alcohol consumption was also best described by a quadratic model, though largely stable at a high level through the late 20s. Sexual risk behavior increased slowly from age 16 to age 22 and then remained largely stable. In contrast, cannabis use and deviance linearly declined from age 16 to age 29. Young men were at higher risk for all behaviors than were young women, but apart from deviance, patterning over time was similar for both sexes. Results about the timing of increase and decline as well as differences between risk behaviors may inform tailored prevention programs during the transition from late adolescence to adulthood.

A randomized, double-blind, placebo-controlled pilot study of naltrexone in outpatients with bipolar disorder and alcohol dependence.

BACKGROUND: Alcohol dependence is extremely common in patients with bipolar disorder and is associated with unfavorable outcomes including treatment nonadherence, violence, increased hospitalization, and decreased quality of life. While naltrexone is a standard treatment for alcohol dependence, no controlled trials have examined its use in patients with co-morbid bipolar disorder and alcohol dependence. In this pilot study, the efficacy of naltrexone in reducing alcohol use and on mood symptoms was assessed in bipolar disorder and alcohol dependence. METHODS: Fifty adult outpatients with bipolar I or II disorders and current alcohol dependence with active alcohol use were randomized to 12 weeks of naltrexone (50 mg/d) add-on therapy or placebo. Both groups received manual-driven cognitive behavioral therapy designed for patients with bipolar disorder and substance-use disorders. Drinking days and heavy drinking days, alcohol craving, liver enzymes, and manic and depressed mood symptoms were assessed. RESULTS: The 2 groups were similar in baseline and demographic characteristics. Naltrexone showed trends (p < 0.10) toward a greater decrease in drinking days (binary outcome), alcohol craving, and some liver enzyme levels than placebo. Side effects were similar in the 2 groups. Response to naltrexone was significantly related to medication adherence. CONCLUSIONS: Results suggest the potential value and acceptable tolerability of naltrexone for alcohol dependence in bipolar disorder patients. A larger trial is needed to establish efficacy.

Crossing borders: Ethnic minorities matter? A meta analytic examionation of the alliance-outcome relationship

Objectives: The purpose of this meta analysis was to examine the moderating impact of substance use disorder as inclusion/exclusion criterion as well as the percentage of racial/ethnic minorities on the strength of the alliance-outcome relationship in psychotherapy. It was hypothesized that the presence of a dsm axis i substance use disorders as a criterion and the presence of racial/ethnic minority as a psychosocial indicator are confounded client factors reducing the relationship between alliance and outcome. Methods: A random effects restricted maximum-likelihood estimator was used for omnibus and moderator models (k = 94). results: the presence of (a) substance use disorder and, (b) racial/ethnic minorities (overall and specific to african americans) partially moderated the alliance-outcome correlation. The percentage of substance use disorders and racial/ethnic minority status was highly correlated. Conclusions: Socio-cultural contextual variables should be considered along with dsm axis i diagnosis of substance use disorders in analyzing and interpreting mechanisms of change.

Psychiatric severity and behavior change in alcoholism

Individuals who are diagnosed with a chronic mental illness and an alcohol use disorder comprise a high risk population that challenges the mental health care system. Effective treatment for the dually diagnosed, who are characterized by heterogeneity in their psychiatric diagnoses, their substance use patterns, and their current degree of dysfunction, presents a challenge. Several integrated treatment models have been developed that attempt to concurrently treat patients' psychiatric and substance abuse problems. At this point in the development of these "dual diagnosis" programs, treatment planning is hindered by a lack of knowledge about the relation of psychiatric severity to the process of recovery from alcohol abuse and dependence.^ The present study sought to advance the field's understanding of the relation between psychiatric severity and the process of behavior change through an examination of the relation between dimensions of psychiatric severity and Prochaska and DiClemente's Transtheoretical Model (TTM) constructs. The TTM, which focuses on identifying the processes of change that appear to underlie the modification of addictive behaviors, provides a way of conceptualizing and measuring specific elements relevant to the desired behavior change. Knowledge of the relation between these constructs and psychiatric severity will enable treatment planners to develop dual diagnosis programs which target clients' needs with a much higher level of specificity.^ One hundred-thirty two alcohol dependent patients in a dual diagnosis treatment program were assessed on psychiatric severity (defined as number of symptoms and level of distress resulting from symptoms) and the Transtheoretical Model constructs. The constructs include stages and processes of change for alcohol use, alcohol decisional balance, and alcohol abstinence self-efficacy. Results indicate that the TTM variable of "temptation to drink" is most strongly related to psychiatric severity: the more psychiatric distress a person is experiencing, the more he or she is tempted to drink. The "cons" of drinking were also related to psychiatric severity, indicating that participants who were experiencing more psychiatric distress also endorsed as important a higher number of the negative aspects of drinking.^ Additional aims of this investigation were to determine whether participants' scores on the Transtheoretical Model variables were associated with their: (a) severity of drinking, defined as frequency, quantity and consequences of use, (b) previous psychiatric and substance abuse treatment episodes, and (c) functional impairment. Associations were found among these variables and each of the key constructs of the Transtheoretical Model. Each association is explored in detail and implications for treatment programming are discussed. ^

Motivation as a predictor of drinking outcomes after residential treatment programs for alcohol dependence

OBJECTIVES: Patients' motivation to change their substance use is usually viewed as a crucial component of successful treatment. The objective of this study was to examine whether motivation contributes to drinking outcomes after residential treatment for alcohol dependence. METHODS: Our sample included 415 Swiss patients from 12 residential alcohol treatment programs. We statistically controlled for important predictors, such as sex, employment, alcohol consumption before admission, severity of alcohol dependence, severity of psychiatric symptoms at admission, and alcohol-related self-efficacy at discharge. Abstinence, alcohol consumption, and time to first drink were used as primary outcome measures and were assessed 1 year after discharge from treatment. RESULTS: Action-oriented motivation to change substance use had a modest impact on drinking outcomes. At the 1-year follow-up, only the Taking Steps subscale of the Stages of Change Readiness and Treatment Eagerness Scale and alcohol-related self-efficacy were found to be significant predictors of abstinence and the number of standard drinks. CONCLUSIONS: The impact of action-oriented motivation at admission to residential treatment is modest but still relevant, compared with other outcome predictors. It may be useful to focus treatment on improving action-oriented motivation to reduce substance use

Ist eine wirksame psychosoziale Behandlung von Patienten mit Suchterkrankungen und komorbiden psychischen Störungen eine unmögliche Aufgabe?

Auf der Grundlage von Metaanalysen und umfassenden Überblicksarbeiten werden Schlussfolgerungen über eine wirksame psychosoziale Behandlung von Patienten mit einer Komorbidität von psychischen Störungen und Sucht (Doppeldiagnosen) gezogen. Dabei wird näher auf die Studienergebnisse zu schweren und zu leichten Formen von Doppeldiagnosen eingegangen. Die Heterogenität der Patienten-, Behandlungs-, Settings- und Ergebnismerkmale erschweren allgemeingültige Schlussfolgerungen über die Wirksamkeit psychosozialer Behandlungen. Integrative, gestufte Behandlungsprogramme, die störungsspezifische Interventionen kombinieren und motivierende Gesprächsführung, kognitiv-verhaltenstherapeutische Interventionen, suchtmittelreduzierende Interventionen wie Rückfallprävention oder Kontingenzmanagement und/oder Familieninterventionen enthalten, sind Kontrollgruppen (z.B. Wartegruppen, Standardbehandlungen) meistens, anderen aktiven Behandlungen (z.B. Psychoedukation) manchmal in den drei Ergebnisbereichen (Sucht, psychische Störung und Funktionsniveau) überlegen.