Search

The recently modified General Law on Health (Ley General de Salud) establishes in article 74b, section VII, that any individual with mental or behavioral disorders will have «The right to be treated and cared for within his community or as closely as possible to his family's or friends' place of residence»; this leads us to the questions titling this article. In Mexico, according to the National Psychiatric Epidemiology Survey, 28.6% of the population has presented one of the 23 IDC disorders at some point in their lives. Only one out of 10 patients with a mental disorder had access to specialized care. One of the most important limiting factors explaining the difference between subjects requiring services and those being provided for is the insufficient number of available psychiatrists. The worldwide mean number of psychiatrists per 100000 individuals is 3.96 (SD 5.94) and their distribution varies from one region to another; they average 0.06 in low-income countries and 9.0 in those with high incomes. As a medical specialty, psychiatry is relatively new. Not until the XIXth Century did the treatment of mental disorder become part of the medical realm. In Mexico, the teaching of psychiatry as a specialty begins in 1950. In 2010, 137 positions for Psychiatry residency were made available throughout the country: Campeche, Coahuila, Jalisco, Mexico City, Nuevo León, Puebla, Sonora, San Luis Potosí, Tabasco, Tamaulipas and Yucatán. Most openings (and educational venues) providing specialization in Psychiatry are in Mexico City. Regardless, the number of psychiatrists remains scarce and the scope of their activity does not fulfill the World Health Organization's recommendations. The purpose of this paper was to determine the number and distribution of psychiatrists in Mexico and propose new fields for their activities. Methods A descriptive, cross-sectional, heterodemic study was conducted. The following data sources were reviewed: the 2008 Directory of the Mexican Psychiatric Association (MPA), the 2008 Directory of the Mexican Council of Psychiatry (MCP) and the II Assessment of Population and Housing (2005). Results In the Directory of the Mexican Psychiatric Association, 1397 active members were reported. In the Directory of the Mexican Council of Psychiatry, 1430 certified psychiatrists are tallied. We noticed that in total, there are more certified psychiatrists than members of the MPA. In terms of the second objective, we established that except for Mexico City, the number of psychiatrists vis-à-vis the number of inhabitants is notably inferior to the worldwide mean of 3.96/ 100 000, throughout the rest of the country. In 22 states, there is less than one psychiatrist per 100 000 inhabitants. Discussion In Mexico, the number of psychiatrists is insufficient to attend the population's needs; hence, as proposed in 2001 by the WHO, the option is to restructure the management of mental disorders via specific actions. In the model proposed for mental health, a continuum is established whereby care is provided directly in the community and progresses into that offered in the so-called «highly specialized» centers, psychiatric hospitals. This continuum follows a pyramidal pattern whereby the base, where most actions are concentrated, includes self-care and the apex represents specialized care. Where should psychiatrists be in this pyramidal context? At first glance, it would appear that the psychiatrist's expected activity realm would be within psychiatric services per se, such as in general or specialized hospitals. However, following the described pyramidal structure, most interventions take place at the base: self-care, informal care within the community and mental health care at the primary care level. It is interesting to mention that in another state, among all certified psychiatrists not one was assigned to primary care and only 18% were active in a general hospital. In the context of pyramidal care, who will provide the necessary information required for the encouragement of self-care? Informal care in the community refers to that provided by individuals without formal training and that should be trained in order to become the first contact point for patients with mental health issues. Mental health care at the primary care level has been broadly reviewed but the identification of a successful model depends not only on a particular country's circumstances but also on specific regions within that country. Until now, training primary care physicians has not proven to be an effective strategy in increasing mental health care coverage unless they are directly integrated within formal mental health services. An effective strategy is supervision and support of primary care physicians by psychiatrists. A possible schema could include the programming of case reviews and constant feedback to the primary care personnel such as physicians and psychologists. The community should be at the forefront in terms of the practice of psychiatry. From said position, the psychiatrist can: 1. support selfcare and informal care programs, 2. supervise and offer support to primary care providers, 3. provide direct attention to mental health issues requiring specialized attention and 4. act as a link between the different care levels. A psychiatrist's activities within a general hospital allow: 1. integration with medicine, 2. the appropriate management of nonpsychiatric co-morbidities due to more available resources and 3. blunting of stigmatization. Other forms of care for patients with mental health disorders deserve a paragraph; although their usefulness has been proven they have not been evaluated in our country and their application has not become commonplace. We are referring to daytime hospitalization and homecare provided by a team specialized in the management of crises. These models also require a psychiatrist as part of the team. The purpose of this study was to provide an overview of the activity of psychiatrists in Mexico without intending to exhaustively review the current situation. Its limitations are obvious since only certified and/or MPA members were included. Although we included all psychiatrists that at some point were certified and not only those with active current certification, it is evident that there are colleagues that belong to neither professional organization although these two include the greatest number of the country's psychiatrists. [ABSTRACT FROM AUTHOR]

Introduction Depression and its symptoms are becoming one of the most important health problems worldwide. The impact of depression on the productive life of people, and the burden it represents because of its co-morbidity, is growing. Some authors estimate that depression is the second cause for the global loss of years of healthy life and the first one in developed countries. An increasing proportion of teenage population has mental health issues. Depression and its symptoms are among the most common, but they are not an epidemic problem yet, although spread enough as to maintain interest in its current impact and in its negative consequences over individual health. Depression has a prominent place among mood disorders in Mexico (4.5%), and women are who mostly suffer it (5.8%), which has remained consistent over time. Different difficult situations occur during adolescence along with depression, depressive mood, and depressive symptoms. This situation may be related to changes and processes that occur during this period when individuals cope with situations they cannot handle, which in turn become stressful. Therefore, it is necessary to study and to work with adolescents in order to be able to differentiate affective, cognitive, somatic, and behavioral expressions, which are proper to this stage, from those possibly caused by an illness that could have negative consequences. Adolescent depression influences mood and the way individuals live unpleasant or annoying experiences, thus it affects almost every aspect of life and becomes a risk factor for psychiatric and behavioral problems. However, there are some areas that need more research, for example: the specific characteristics and expressions of the problem including gender comparisons and using designs with special groups. Data show that depression is growing in adolescents; therefore it is a priority to work on detection and prevention to reduce its impact on mental health and to develop cost-effective intervention strategies. One way to do this is using valid-reliable screening tools because they are cheap, and methodologically-logistically useful. The Center for Epidemiological Studies Depression Scale (CESD) has been used in different studies with Mexican adolescents, and has proven to have good psychometric characteristics. The CES-D has never been used with an entire population in a great scale study. The objective of this paper is to measure the validity and reliability of the scale (construct, concurrent, and external validity, as well as internal consistency) in a population of high school and college freshman students from Mexico City. Method Design. The study was a census made with high school and college freshman students during 2009. Data were collected in 22 schools. Population. A sample of 58568 students participated in the census. The mean age was 17 years old (±2.7). Most of the students lived in homes with one to four other persons at the moment of the study (55.4%); 86% said that only their father worked at that moment, and 59.4 said that only the mother; 79.7% of the students lived with both parents, and 17.9% only with their mother; 57403 students (98.0% of the population) completed the CES-D in the age range of 14-24 years: 27264 (47.5%) men, and 30139 (52.5%) women. Instrument. The Automated Medical Examination (Examen Médico Automatizado-EMA) is a diagnostic questionnaire designed by the General Directorate of Medical Services (Dirección General de Servicios Médicos) of the Universidad Nacional Autónoma de México (UNAM). It is a questionnaire with four self-report forms that collect information about the physical and mental health, the family, and the general context of every student. This information is used to create a diagnosis of vulnerability and a predictive profile for developing prevention programs, as well as research protocols that help in promoting a culture for health care. The CES-D was included for the measurement in 2009. Results Overall internal consistency was adequate (α=.83). Internal consistency was tested by sex; the coefficient was higher for women (α=.84). Factor analysis generated a four-factor solution (explained variance 54.1%); each factor had good internal consistency and theoretical agreement. The scale showed a significant discriminative power for opposite scores (z=-144.121, p<.001), and a positive significant correlation with the Okasha Suicidality Scale (rΦ=.325, p=.000). A cut-off point of 16 or higher was established to identify students with high depressive symptomatology. 14.7% of the participants in this study had high depressive symptomatology (11.1% men, 17.9% women). Conclusions The CES-D is a valid and reliable epidemiological instrument for different populations. Since depression is a complex and dynamic phenomenon, it is important to evaluate the psychometric properties of any instrument used to measure it. The results of this study showed that the CES-D maintains its internal consistency as well as good concurrent-external validity. Coefficients are higher for women and they increase with age; thus, it would be necessary to refine some aspects to measure younger subjects in a more consistent manner. The data proved that CES-D is a useful instrument for distinguishing different levels of depressive symptomatology; this is relevant because the scale is often used in collective contexts, allowing systematic monitoring of depression with good cost-effective results. Monitoring is also important to keep acceptable levels of emotional wellbeing in student population. Development and refinement of instruments such as the CES-D would potentially lead to opportune and reliable detection of adolescents who may be at risk for suffering mental health problems. This would facilitate implementing more stable and continuous prevention and attention programs to reduce the negative impact of depression in the short term. [ABSTRACT FROM AUTHOR]

Introduction Depression is a public health problem that carries substantial costs for the individual and the society. In order to establish evidence-based priorities for resource allocation in mental health care, it is necessary to integrate the costs and effectiveness of interventions and specify the essential packages for their treatment. The following are pioneering studies of cost-effectiveness for the treatment of depression: 1. compared psychopharmacology options (fluoxetine, imipramine and desipramine) to found no difference between drugs in terms of clinical efficacy, effect on quality of life and costs, and 2. evaluated cost-effectiveness of collaborative program of stepped care in primary care of persistent depression, to demonstrate a substantial increase in the effectiveness and additional moderate cost increase in comparison with usual treatment. Recently, the World Health Organization convened the National Institute of Psychiatry Ramón de la Fuente, as a collaborating center, to participate in the «Selecting interventions that are cost-effective» labeled WHO-CHOICE (CHOosing Interventions that are Cost-Effective). This paper presents the findings of the evaluation of costeffectiveness of different clinical interventions for the treatment of depression in Mexico, considering its implementation in primary care services. Method The cost-effectiveness unit of measure gathered by WHO (and used in this work) are the years of healthy life lost because of disease, named DALYs (Disability Adjusted Life Years). DALYs result from the sum of years lost by premature mortality over the years that are lost through living in disability status. The advantages of using a measure of health at the population level as lost DALYs is that it allows comparing interventions for different diseases and addresses a relevant question from the avoidable burden health policy standpoint. Interventions evaluated included: 1. tricyclic antidepressants, 2. new antidepressants (SSRIs), 3. brief psychotherapy, 4. trycliclic antidepressants + brief psychotherapy, 5. new antidepressants + brief psychotherapy, 6. tricyclic antidepressants + brief psychotherapy + proactive case management, and 7. new antidepressants + brief psychotherapy + proactive case management. DALYs avoided as a result of each intervention or combination were calculated to determine its effectiveness. Both patients and program costs, a 3% discount by the process of converting future values to present ones, as well as an age adjustment giving less weight to year lived by the young were included. Finally, the cost of averted DALYs for each intervention was estimated to determine their cost effectiveness. Results The combined strategies of proactive case management with psychotherapy plus antidepressants can be considered as the most effective one. With the combination with tricyclic antidepressants, the number of DALYs averted was 207,171, and with SSRI of 217,568, corresponding to more than double of DALYs when tricyclic antidepressants are used alone and almost double when using only SSRIs. The most expensive intervention was the combination of SSRIs with brief psychotherapy, with a total of $12,256 million pesos (972 million dollars), the least expensive treatment were tricyclic antidepressants, which involved $4,523 million pesos (359 million dollars). Over 99% of the costs were from patient medications, and less than 1% from program and training costs. It is clear that the greatest cost is for added proactive case management. The use of SSRI was the most cost-effective treatment (no combination) for the management of depression in Mexican primary care. The most cost-effective combination was tryciclic antidepressants plus brief psychotherapy plus proactive case management. Conclusions Although the are some studies on health economics in Mexico, most are directed to consider costs, and few ones have evaluated the cost-effectiveness relationship of diagnostic and therapeutic interventions, lees son in the mental health field. Antecedents of the present study in Mexico included a study that observed that psychiatric patients require more medical consultations, laboratory analysis, hospitalization days, surgeries and medication, in contrast with patients that never needed mental attention. Nevertheless, investigations about cost-effectiveness relationship are rare. Just one study evaluates the costs of positive changes in psychopathology with antipsychotic medication for the treatment of schizophrenic patients. In this direction, the present work is the first effort to evaluate cost-effectiveness of different communitarian interventions to treat depression in Mexico. According with our findings, also in México, the interventions available to treat depression in primary care level prevent a substantial number of DALYs: almost six times when SSRIs plus brief psychotherapy plus proactive case management are administered. The specific effect of proactive case management is preventing relapses and increasing the time free of disease, which results in greater benefit to the patient, his family and the society. Thus, interventions are cost-effective despite the proactive case management significantly increases the cost of care to these patients. In conclusion, the inclusion of psychosocial treatments is advantageous from a cost-effectiveness standpoint. Averted DALYs with these interventions are more «economic». As observed in previous studies, a modest investment in improving depression produces greater gains in resource-limited environments. In Mexico, there is evidence that such interventions in primary care are effective when they are given by medical staff with a brief training, making them a promising tool for a cost-effective and evidence-based public policy. [ABSTRACT FROM AUTHOR]