Estigma e percepções dos médicos de Clínica Geral sobre a doença mental e o suicídio

RESUMO: INTRODUÇÃO: A OMS (2001) revela que cerca de 450 milhões de pessoas sofrem de perturbações mentais ou comportamentais em todo o mundo, mas apenas uma pequena minoria tem tratamento, ainda que elementar. Transformam-se em vítimas por causa da sua doença e convertem-se em alvos de estigma e discriminação. O suicídio é considerado como um grande problema de saúde pública em todo o mundo, é uma das principais causas de morte de jovens adultos e situa-se entre as três maiores causas de morte na população entre 15-34 anos (OMS, 2001). As perturbações mentais aumentam o risco de suicídio. A depressão, esquizofrenia, e a utilização de substâncias incrementam o risco de suicídio. Estudos (Sartorius, 2002; Magliano et al., 2012) mostram que os profissionais de saúde, tal como o público em geral, podem ter atitudes negativas e estigma em relação às pessoas com perturbações mentais, podendo agir em conformidade, uma vez feito e conhecido o diagnóstico psiquiátrico. Os clínicos gerais são os receptores das perturbações mentais e tentativas de suicídio nas principais portas de entrada no acesso a cuidados de saúde. As crenças, conhecimentos e contacto com a doença mental e o suicídio, podem influenciar a atenção clínica. OBJECTIVOS: Avaliar o estigma e as percepções dos médicos de clínica geral em relação às tentativas de suicídio, o suicídio e perturbações mentais bem como os possíveis factores associados a estes fenómenos. MATERIAIS E MÉTODOS: Estudo do tipo transversal, combinando métodos quantitativos e qualitativos. A amostra é constituída por 125 sujeitos, médicos de clínica geral. Utilizaram-se as versões adaptadas dos seguintes instrumentos: Questionário sobre Percepções e Estigma em Relação à Saúde Mental e ao Suicídio (Liz Macmin e SOQ, Domino, 2005) e a Escala de Atitudes sobre a Doença Mental (Amanha Hahn, 2002). Para o tratamento estatístico dos dados usou-se a estatística 1) descritiva e 2) Análise estatística das hipóteses formuladas (Qui Quadrado - 2) a correlação entre variáveis (Spearman: ρ, rho). Os dados conectados foram limpos de inconsistências com base no pacote informático e estatístico SPSS versão 20. Para a aferição da consistência interna foi usado o teste de Alfa de Cronbach. RESULTADOS: Uma boa parte da amostra (46.4%) refere que não teve formação formal ou informal em saúde mental e (69.35%) rejeitam a ideia de que “grupos profissionais como médicos, dentistas e psicólogos são mais susceptíveis a cometer o suicídio”. Já (28.0%) têm uma perspectiva pessimista quanto a possibilidade de recuperação total dos sujeitos com perturbação mental. Sessenta e oito(54.4%) associa sujeitos com perturbação mental, a comportamentos estranhos e imprevisíveis, 115 (92.0%) a um baixo QI e 35 (26.7%) a poderem ser violentas e e perigosas. Os dados mostram uma associação estatisticamente significativa (p0.001) entre as variáveis: tempo de serviço no SNS, recear estar perto de sujeitos com doença mental e achar que os sujeitos com doença mental são mais perigosos que outros. Em termos estatísticos, existe uma associação estatitisticamente significativa entre as duas variáveis(X2=9,522; p0.05): percepção de que “é vergonhoso ter uma doença mental” e os conhecimentos em relação à doença mental. Existe uma correlação positiva, fraca e estatisticamente significativa entre os conhecimentos dos clínicos gerais(beneficiar-se de formação em saúde mental) e a percepção sobre os factores de risco (0,187; P0,039). DISCUSSÃO E CONCLUSÕES: A falta de conhecimento sobre as causas e factores de risco para os comportamentos suicidários, opções de intervenção e tratamento, particularmente no âmbito da doença mental, podem limitar a procura de ajuda individual ou dos próximos. Percepções negativas como o facto de não merecerem prioridade nos serviços, mitos (frágeis e cobarde, sempre impulsivo, chamadas de atenção, problemas espirituais) podem constituir-se como um indicador de que os clínicos gerais podem sofrer do mesmo sistema de estigma e crenças, de que sofre o público em geral, podendo agir em conformidade (atitudes de afastamento ereceio). As atitudes são influenciadas por factores como a formação, cultura e sistema de crenças. Sujeitos com boa formação na área da saúde mental têm uma percepção positiva e optimista sobre os factores de risco e uma atitude positiva em relação aos sujeitos com doença mental e comportamentos suicidários.-------------ABSTRACT: INTRODUCTION: The WHO (2001) reveals that about 450 million people suffer from mental or behavioral disorders worldwide, but only a small minority have access to treatment, though elementary. They become victims because of their disease and they become the targets of stigma and discrimination. Suicide is seen as a major public health problem worldwide, is a leading cause of death for young adults and is included among the three major causes of death in the population aged 15-34 years (WHO, 2001). Mental disorders increase the risk of suicide. Depression, schizophrenia, and the substances misuse increase the risk of suicide. Studies (Sartorius, 2002; Magliano et al, 2012) show that health professionals, such as the general public, may have negative attitudes and stigma towards people with mental disorders, and can act accordingly after psychiatric diagnosis is known. General practitioners are the main entry points of mental disorders and suicide attempts in the health sistem. Beliefs, knowledge and contact with mental illness and suicide, may influence clinical care. OBJECTIVES: To assess stigma and perceptions of general practitioners in relation to suicide attempts, suicide and mental disorders as well as possible factors associated with these phenomena. MATERIAL AND METHODS: This was a descriptive cross-sectional study, combining quantitative and qualitative methods. The sample consisted of 125 subjects, general practitioners. We used adapted versions of the following instruments: Questionnaire of Perceptions and Stigma in Relation to Mental Health and Suicide (Liz Macmin and SOQ, Domino, 2005) and the Scale of Attitudes on Mental Illness (Tomorrow Hahn, 2002). For the statistical treatment of the data we used: 1) descriptive (Data distribution by absolute and relative frequencies for each of the variables under study (including mean and standard deviation measures of central tendency and deviation), 2) statistical analysis of hypotheses using (Chi Square - 2, a hypothesis test that is intended to find a value of dispersion for two nominal variables, evaluating the association between qualitative variables) and the correlation between variables (Spearman ρ, rho), a measure of non-parametric correlation, which evaluates an arbitrary monotonic function can be the description of the relationship between two variables, without making any assumptions about the frequency distribution of the variables). For statistical analysis of the correlations were eliminated subjects who did not respond to questions. The collected data were cleaned for inconsistencies based on computer and statistical package SPSS version 20. To measure the internal consistency was used the Cronbach's alpha test. RESULTS: A significant part of the sample 64 (46.4%) reported no formal or informal training in mental health and 86 (69.35%) reject the idea that "professional groups such as doctors, dentists and psychologists are more likely to commit suicide." On the other hand, 42 (28.0%) have a pessimistic view of the possibility of full recovery of individuals with mental disorder. Sixty-eight ( 54.4 % ) of them associates subjects with mental disorder to strange and unpredictable behavior, 115 ( 92.0 % ), to low IQ, 35 ( 26.7 % ) and even to violent and dangerous behavior, 78 ( 62.4 % ) The data show a statistically significant (p = 0.001) relationship between the following variables: length of service in the NHS, fear of being close to individuals with mental illness and considering individuals with mental illness more dangerous than others. In statistical terms, there is a dependency between the two variables (X2 = 9.522, p> 0.05): the perception that "it is shameful to have a mental illness" and knowledge regarding mental illness. There is a positive and statistically significant weak correlation between knowledge of general practitioners (benefit from mental health training) and the perception of the risk factors (0,187; P0,039). DISCUSSION AND CONCLUSIONS: The lack of knowledge about the causes and risk factors for suicidal behavior, intervention and treatment, particularly in the context of mental illness options, may decreaseseeking for help by individual and their relatives. Negative perceptions such as considering that they dont deserve priority in services, myths (weak and cowards, always impulsive, seeking for attentions, spirituals problems) may indicate that general practitioners, may suffer the same stigma and beliefs systems as the general public, and can act accordingly (withdrawal and fear attitudes). Attitudes are influenced by factors such as education, culture and belief system. Subjects with good training in mental health have a positive and optimistic perception of the risk factors and a positiveattitude towards individuals with mental illness and suicidal behaviour.

Perioperative antiplatelet therapy.

Aspirin is recommended as a lifelong therapy that should never be interrupted for patients with cardiovascular dis- ease. Clopidogrel therapy is mandatory for six weeks after placement of bare-metal stents, three to six months after myocardial infarction, and at least 12 months after placement of drug-eluting stents. Because of the hypercoagulable state induced by surgery, early withdrawal of antiplatelet therapy for secondary prevention of cardiovascular disease increases the risk of postoperative myocardial infarction and death five- to 10-fold in stented patients who are on continuous dual antiplatelet therapy. The shorter the time between revascularization and surgery, the higher the risk of adverse cardiac events. Elective surgery should be postponed beyond these periods, whereas vital, semiurgent, or urgent operations should be performed under continued dual antiplatelet therapy. The risk of surgical hemorrhage is increased approximately 20 percent by aspirin or clopidogrel alone, and 50 percent by dual antiplatelet therapy. The present clinical data suggest that the risk of a cardiovascular event when stopping antiplatelet agents preoperatively is higher than the risk of surgical bleeding when continuing these drugs, except during surgery in a closed space (e.g., intracranial, posterior eye chamber) or surgeries associated with massive bleeding and difficult hemostasis.

How Effective are Unemployment Benefit Sanctions? Looking Beyond Unemployment Exit

This paper provides a comprehensive evaluation of the effects of benefit sanctions on post-unemployment outcomes such as post-unemployment employment stability and earnings. We use rich register data which allow us to distinguish between a warning that a benefit reduction may take place in the near future and the actual withdrawal of unemployment benefits. Adopting a multivariate mixed proportional hazard approach to address selectivity, we find that warnings do not affect subsequent employment stability but do reduce post-unemployment earnings. Actual benefit reductions lower the quality of post-unemployment jobs both in terms of job duration as well as in terms of earnings. Copyright © 2012 John Wiley & Sons, Ltd.

Bradykinin in blood and cerebrospinal fluid after acute cerebral lesions: correlations with cerebral edema and intracranial pressure.

Abstract Bradykinin (BK) was shown to stimulate the production of physiologically active metabolites, blood-brain barrier disruption, and brain edema. The aim of this prospective study was to measure BK concentrations in blood and cerebrospinal fluid (CSF) of patients with traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), and ischemic stroke and to correlate BK levels with the extent of cerebral edema and intracranial pressure (ICP). Blood and CSF samples of 29 patients suffering from acute cerebral lesions (TBI, 7; SAH,: 10; ICH, 8; ischemic stroke, 4) were collected for up to 8 days after insult. Seven patients with lumbar drainage were used as controls. Edema (5-point scale), ICP, and the GCS (Glasgow Coma Score) at the time of sample withdrawal were correlated with BK concentrations. Though all plasma-BK samples were not significantly elevated, CSF-BK levels of all patients were significantly elevated in overall (n=73) and early (≤72 h) measurements (n=55; 4.3±6.9 and 5.6±8.9 fmol/mL), compared to 1.2±0.7 fmol/mL of controls (p=0.05 and 0.006). Within 72 h after ictus, patients suffering from TBI (p=0.01), ICH (p=0.001), and ischemic stroke (p=0.02) showed significant increases. CSF-BK concentrations correlated with extent of edema formation (r=0.53; p<0.001) and with ICP (r=0.49; p<0.001). Our results demonstrate that acute cerebral lesions are associated with increased CSF-BK levels. Especially after TBI, subarachnoid and intracerebral hemorrhage CSF-BK levels correlate with extent of edema evolution and ICP. BK-blocking agents may turn out to be effective remedies in brain injuries.

Outpatient treatment of acute psychotic episode with neuroleptic infusions: a retrospective study.

In this retrospective pragmatic study, we define the necessary conditions that allow outpatient low dose intravenous neuroleptization, when hospitalization should otherwise be required. Intravenous neuroleptization is infrequently used in the outpatient treatment of acute psychotic decompensation. Rapid tranquilization with high dosage neuroleptics is controversial, and has a high risk of side effects. The indications for and potential advantages of this method in the perspective of a long-term ambulatory treatment are discussed by comparing a group of outpatients treated with infusions to a group of hospitalized patients. The method offers a satisfactory alternative to hospitalization for subjects who are not in imminent danger (current GAF rating between 20 and 40) and whose normal functioning is good (past year GAF rating = 70). Previous repeated hospitalizations favor the choice of hospitalization over infusion. Its potential advantages are the rapid evolution of the condition, with controlled regression but without psychosocial withdrawal, and an improvement in the patient's attitude towards treatment.

Perry Syndrome

Disease characteristics. Perry syndrome is characterized by parkinsonism, hypoventilation, depression, and weight loss. The mean age at onset is 48 years; the mean disease duration is five years. Parkinsonism and psychiatric changes (depression, apathy, character changes, and withdrawal) tend to occur early; severe weight loss and hypoventilation manifest later. Diagnosis/testing. The diagnosis is based on clinical findings and molecular genetic testing of DCTN1, the only gene known to be associated with Perry syndrome. Management. Treatment of manifestations: Dopaminergic therapy (particularly levodopa/carbidopa) should be considered in all individuals with significant parkinsonism. Although response to levodopa is often poor, some individuals may have long-term benefit. Noninvasive or invasive ventilation support may improve quality of life and prolong life expectancy. Those patients with psychiatric manifestations may benefit from antidepressants and psychiatric care. Weight loss is managed with appropriate dietary changes. Surveillance: routine evaluation of weight and calorie intake, respiratory function (particularly at night or during sleep), strength; and mood. Agents/circumstances to avoid: Central respiratory depressants (e.g., benzodiazepines, alcohol). Genetic counseling. Perry syndrome is inherited in an autosomal dominant manner. The proportion of cases attributed to de novo mutations is unknown. Each child of an individual with Perry syndrome has a 50% chance of inheriting the mutation. No laboratories offering molecular genetic testing for prenatal diagnosis are listed in the GeneTests Laboratory Directory; however, prenatal testing may be available through laboratories offering custom prenatal testing for families in which the disease-causing mutation has been identified.

Aspectos hidrológicos en el fondo marino peruano asociados a la Extensión Sur de la Corriente Cromwell (ESCC) entre 3° y 7°S

Para determinar la variabilidad estacional y espacial en el fondo marino del norte peruano, durante los últimos 30 años (1980-2009), se estudió la temperatura y el oxígeno disuelto entre las latitudes 3°-7°S. Se halló una mayor proyección latitudinal del oxígeno disuelto (OD), superior a 1,0 mL/L en la estación de otoño, delimitada por la isoterma de 15 °C al borde de la plataforma. Esta proyección estaría asociada a los flujos subsuperficiales hacia el sur, que constituyen la Extensión Sur de la Corriente de Cromwell (ESCC), a profundidades de 90-180 m. La oxigenación estaría influenciada por el incremento o repliegue de la ESCC presente en el área. La variación media de oxígeno registra valores de 0,7-1,3 mL/L en verano y 0,8-1,6 mL/L en otoño. Paita (5°S) presenta valores promedio de 1,0 mL/L en verano y de 1,4 mL/L en otoño. Los mayores valores de OD se asocian a latitudes menores en ambas estaciones; la estación de otoño presenta los mayores tenores de oxígeno, asociados a una mayor intensidad de la ESCC.

Stage of change of cigarette smoking in drug dependent patients.

Nicotine cessation programmes in Switzerland, which are commonly based on the stage of change model of Prochaska and DiClemente (1983), are rarely offered to patients with illicit drug dependence. This stands in contrast to the high smoking rates and the heavy burden of tobacco-related problems in these patients. The stage of change was therefore assessed by self-administered questionnaire in 100 inpatients attending an illegal drug withdrawal programme. Only 15% of the patients were in the contemplation or decision stage. 93% considered smoking cessation to be difficult or very difficult. These data show a discrepancy between the motivation to change illegal drug consumption habits and the motivation for smoking cessation. The high proportion of patients remaining in the precontemplation stage for smoking cessation, in spite of their motivation for illicit drug detoxification, may be due to the perception that cessation of smoking is more difficult than illicit drug abuse cessation.

Valuing equity-linked death benefits in jump diffusion models

The paper is motivated by the valuation problem of guaranteed minimum death benefits in various equity-linked products. At the time of death, a benefit payment is due. It may depend not only on the price of a stock or stock fund at that time, but also on prior prices. The problem is to calculate the expected discounted value of the benefit payment. Because the distribution of the time of death can be approximated by a combination of exponential distributions, it suffices to solve the problem for an exponentially distributed time of death. The stock price process is assumed to be the exponential of a Brownian motion plus an independent compound Poisson process whose upward and downward jumps are modeled by combinations (or mixtures) of exponential distributions. Results for exponential stopping of a Lévy process are used to derive a series of closed-form formulas for call, put, lookback, and barrier options, dynamic fund protection, and dynamic withdrawal benefit with guarantee. We also discuss how barrier options can be used to model lapses and surrenders.

Genomic and transcriptomic analysis of the streptomycin-dependent Mycobacterium tuberculosis strain 18b.

The ability of Mycobacterium tuberculosis to establish a latent infection (LTBI) in humans confounds the treatment of tuberculosis. Consequently, there is a need to discover new therapeutic agents that can kill M. tuberculosis both during active disease and LTBI. The streptomycin-dependent strain of M. tuberculosis, 18b, provides a useful tool for this purpose since upon removal of streptomycin (STR) it enters a non-replicating state that mimics latency both in vitro and in animal models. The 4.41 Mb genome sequence of M. tuberculosis 18b was determined and this revealed the strain to belong to clade 3 of the ancient ancestral lineage of the Beijing family. STR-dependence was attributable to insertion of a single cytosine in the 530 loop of the 16S rRNA and to a single amino acid insertion in the N-terminal domain of initiation factor 3. RNA-seq was used to understand the genetic programme activated upon STR-withdrawal and hence to gain insight into LTBI. This revealed reconfiguration of gene expression and metabolic pathways showing strong similarities between non-replicating 18b and M. tuberculosis residing within macrophages, and with the core stationary phase and microaerophilic responses. The findings of this investigation confirm the validity of 18b as a model for LTBI, and provide insight into both the evolution of tubercle bacilli and the functioning of the ribosome.

Moderating effects of gender on the relationships among substance use and school outcomes /

The following study was a secondary analysis of data drawn from adolescents in South Western Ontario. The purpose of the study was to: examine the relationships among substance use and school outcomes, explore the relationships between gender and school outcomes, examine the moderating potential of gender on the substance useschool outcomes relationship, and to provide researchers and educators further knowledge of adolescent substance use behaviours. Many previous studies have failed to include the three most common substances used by adolescents (i.e., alcohol, tobacco, and marijuana). Furthermore, many studies have included only one school outcome instead of comparing several outcome variables. Moderated hierarchical regression was used to determine if gender moderated the substance use-school outcomes relationships. The dependent variables consisted of alcohol use, binge drinking, tobacco use, and marijuana use. Five measure of school outcomes were used as independent variables, including Grade Point Average, Positive School-role Behaviour, Negative School Behaviour, School Withdrawal, and School Misbehaviour. The results for this study indicated that substance use and gender were both predictors of all school outcome variables. Furthermore, gender was found to moderate 5 of the 25 substance use-school outcome relationships.

Six-month outcomes of a multi-campus smoking cessation contest

Background: Up to 40% of North American post-secondary students smoke at least occasionally, and most want to quit. Given students' preferences for free, easy-to-access, self-directed, convenient cessation methods, a motivational, incentive-based cessation contest may be an effective way to assist students to quit. The current study describes 3- and 6-month outcomes experienced by post-secondary student smokers who entered the 'Let's Make A Deal!' contest. Methodology: Contestants from five university campuses who chose to quit completely ('Quit For Good') or reduce their tobacco consumption by 50% ('Keep The Count') were invited to participate in a study of the contest. Three and six months after registration, participants were contacted by phone to assess their smoking and quitting behaviours. Qualitative and quantitative measures were collected, including weekly tobacco consumption, efficacy to resist temptations to smoke, use of quitting aids, and strategies to cope with withdrawal. Quitting was assessed using 7-day point prevalence and continuous abstinence. Results: Seventy-four (64.9%) of the 114 participants recruited for the study completed the follow-ups. Over 31 % of participants who entered Quit For Good and 23.5% of participants who entered Keep The Count were identified as quitters at the 6-month follow-up. Among the quitters, 45.5% experienced sustained abstinence from smoking for the 6-month duration of the study. Keep The Count contestants reduced their tobacco consumption by 57.2% at 3-month follow-up and sustained some of this reduction through to the 6-month follow-up. Qualitative data provides insights into how quitters coped with withdrawal and what hampered continuing smokers' efforts to quit. Significance: A motivational, incentive-based contest for post-secondary students can facilitate both smoking cessation and harm reduction. The contest environment, incentives, resources, and "buddies" provide positive structural and social supports to help smokers overcome potential barriers to quitting, successfully stop smoking, and manage potential triggers to relapse. The contest cessation rates are higher than the typical 5-7% associated with unassisted quitting.

When job dissatisfaction leads to customer-oriented citizenship behaviors

This thesis places boundary conditions on the withdrawal model in the frontline setting of service organizations by considering continuance commitment and supervisory support as moderators of the relationship between job dissatisfaction and customer-oriented citizenship behaviors (COCBs). Departing from traditional research in the areas of the service-profit chain and employee withdrawal, the author advances our understanding of conditions that may lead frontline service employees who are dissatisfied to deposit COCBs into the organizational system. Specifically, based on principles derived from social exchange theory, high continuance commitment and high supervisory support are expected to lead to COCBs, because under this condition the benefits of performing such behaviors are increased (i.e., promotion-based, reciprocity-based), while the costs are decreased (i.e., opportunity costs). Utilizing a sample of 127 frontline employees from both the financial services and travel agency industries, the hypothesized relationships are empirically supported using moderated hierarchical regression analysis. To conclude discussion, implications of the results for both academics and p

A Basis for Understanding Volunteer Coach Retention in Youth Sports

Youth sport organizations depend on volunteers to coach the teams in the organization. The purpose of this quantitative study was to develop a further understanding of volunteer coach retention in youth sport. The data was collected through a quantitative questionnaire which used close-ended and Likert-scale questions. The questionnaire collected data on the modified Model of Volunteer Retention in Youth Sports, reasons to withdraw from coaching and human resource management. There were 126 surveys collected from members of the three largest youth sport associations in the town of Aylmer, Ontario. The study found that Person-Task fit was the best predictor of volunteer coach retention as it significantly correlated to one’s intention to continue coaching (p< 0.01). Furthermore, additional reasons were found to explain withdrawal from coaching - if one’s child stops playing the sport or if coaching is too time consuming. The retention of volunteer coaches in youth sport organizations requires a multi-dimensional approach in understanding how to best retain volunteer coaches.

Meeting Minutes July 7th, 1972

The first "business arising out of the minutes" is a protest made by Mr. W.R. Barnes concerning action taken at a previous meeting by the Directors. In the meeting in February, he had been replaced as Vice-President after 20 years in the role and 38 years as a Director. His record of attendance was called into question and would be discussed and shown at the next meeting. The second issue discussed is the "proposal with respect to purchasing the assets of the Corporation". A letter was received from F.L. Laundry Real Estate Limited with interest from a Central European client in "acquiring the assets of the Corporation, and indicating that if the circumstances warranted, a figure of 3.5 millions would not be beyond their capabilities". The offer would be explored by the solicitor. The next agenda item discusses was the Sault Ste. Marie store. Another issue discussed was the "Withdrawal from Valley Rouge Wines Limited".