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An editorial is presented which addresses the principles behind the development of mental health policies in low and middle income countries (LMICs). The authors discuss the burden of mental health problems in LMICs. They cite the categories of resources for the development of mental health care services. They emphasize the need for the principles to guide mental health policies in LMICs to be founded on public health needs.

A letter to the editor is presented which discusses the mental health systems in Latin American and Caribbean countries (LAC).

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Objective: To review the literature concerning the role and the inclusion of emergency psychiatric services in mental health networks. Method: We performed a search in online databases (PubMed and SciELO) of empirical articles and reviews about emergency psychiatric services and networks of mental health services. Results: Emergency psychiatric services are a core unit for a proper functioning of mental health networks, by both the management of emergencies itself, and the regulation of the network where it belongs. The emergency psychiatric services relate to all inpatient and outpatient services, allowing the organization of the flow of admissions and avoiding the overload of the network of mental health. The functions of emergency psychiatric services are broad and go beyond the simple referral for hospitalization, since clinical stabilization and psychosocial support can be reached in well structured emergency psychiatric services. In Brazil, these functions were expanded after the mental health reform and the burden of mental health network caused by difficulties and limitations of inpatient and outpatient services. Conclusion: Emergency psychiatric services should be recovered and expanded; especially those located in general hospitals. It is suggested that investment in psychiatric emergencies should be a priority of the Brazilian public health policies for improving the mental health care. [ABSTRACT FROM AUTHOR]

The article presents an evaluation of the response to the journal's series on mental health published in 2007. An advisory group was consulted to track major events cited or based on the series. The findings were grouped into four categories including the effect on global advocacy, the effect on global-health programmes, the effect on policies and resources and the launch of the Movement for Global Mental Health. The creation of World Mental Health Day is mentioned. It is noted that the World Health Organization developed the Mental Health Gap Action Programme. Presentations and symposia have been held in various countries for the purpose of educating professionals and policy makers about the messages of the series.

Introduction: Guidelines for the treatment of psychoses recommend antipsychotic monotherapy. However, the rate of antipsychotic polytherapy has increased over the last decade, reaching up to 60% in some settings. Studies evaluating the costs and impact of antipsychotic polytherapy in the health system are scarce. Objective: To estimate the costs of antipsychotic polytherapy and its impact on public health costs in a sample of subjects with psychotic disorders living in residential facilities in the city of Sao Paulo, Brazil. Method: A cross-sectional study that used a bottom-up approach for collecting costs data in a public health provider´s perspective. Subjects with psychosis living in 20 fully-staffed residential facilities in the city of Sao Paulo were assessed for clinical and psychosocial profile, severity of symptoms, quality of life, use of health services and pharmacological treatment. The impact of polytherapy on total direct costs was evaluated. Results: 147 subjects were included, 134 used antipsychotics regularly and 38% were in use of antipsychotic polytherapy. There were no significant differences in clinical and psychosocial characteristics between polytherapy and monotherapy groups. Four variables explained 30% of direct costs: the number of antipsychotics, location of the residential facility, time living in the facility and use of olanzapine. The costs of antipsychotics corresponded to 94.4% of the total psychotropic costs and to 49.5% of all health services use when excluding accommodation costs. Olanzapine costs corresponded to 51% of all psychotropic costs. Conclusion: Antipsychotic polytherapy is a huge economic burden to public health service, despite the lack of evidence supporting this practice. Great variations on antipsychotic costs explicit the need of establishing protocols for rational antipsychotic prescriptions and consequently optimising resource allocation. Cost-effectiveness studies are necessary to estimate the best value for money among antipsychotics, especially in low and middle income countries. [ABSTRACT FROM AUTHOR]

The study objective was to observe the cortisol awakening response (CAR) pattern before and after a psychosocial intervention with children from dysfunctional families who had at least one child working on the streets, and to verify factors related to it. Two hundred and eleven children between 7 and 14 years old were selected and 191 were included, 178 were re-evaluated 2 years after, of whom 113 had cortisol measures completed. Besides cortisol, they were evaluated at baseline and at end point regarding: abuse/neglect, mental health symptoms, exposure to urban violence and family environment. There was no significant difference between the CAR area under the curve (AUC) before and after the intervention. Two regression analysis models were built to evaluate factors related to the CAR before and after intervention. Before the intervention, working on the streets (vs. not) was related to a greater cortisol increase after awakening, at follow-up, having suffered physical punishment (vs. not) was related to a flattened cortisol response. The intervention was not associated with changes in the magnitude of the CAR AUC, though the CAR was associated with psychosocial stressors pre- and post-intervention. Effective interventions for children at risk that might shape a physiological cortisol response are still needed. [ABSTRACT FROM AUTHOR]

Introduction. Evidence is accumulating to support the presence of erectile dysfunction in patients with schizophrenia. This dysregulation may be amenable to therapeutic intervention to improve adherence and quality of life of patients who suffer from schizophrenia and schizoaffective disorders. Aim. We aimed to evaluate the use of adjunctive medication lodenafil for the treatment of erectile dysfunction in outpatients with schizophrenia and spectrum. Methods. The design was a randomized, double-blind, crossover, placebo-controlled trial with lodenafil and it was carried at the Schizophrenia Outpatients Program. Main Outcome Measures. The measures used to assess sexual dysfunction were Arizona Sexual Experiences Scale ( ASEX) and International Index of Erectile Function ( IIEF). The Positive and Negative Syndrome Scale ( PANSS) and the Quality of Life Scale ( QLS) were also used. The measures included the levels of prolactin, estradiol, luteinizing hormone, sex hormone-binding globulin, free testosterone, and total testosterone at baseline and end point. Lodenafil and placebo pills were used by the patients for 16 weeks. Results. Fifty male outpatients fulfilled the criteria and 94% of the participants completed the study. Lodenafil and placebo produced improvement in ASEX, IIEF scale, PANSS, and QLS, and there was no statistical difference between lodenafil and placebo groups in all sexual domains in the results of PANSS and QLS and in the results of hormone levels. Conclusion. These results indicate that both lodenafil and placebo were effective in the treatment of erectile dysfunction for schizophrenia. Placebo effect is very important in patients with schizophrenia and this study showed the importance of discussing sexuality and trying to treat these patients. Further studies designed to test treatments of erectile dysfunction in patients who suffer from schizophrenia are necessary. [ABSTRACT FROM AUTHOR]

Abstract: We evaluated whether traumatic events are associated with a distinctive pattern of socio-demographic and clinical features of obsessive–compulsive disorder (OCD). We compared socio-demographic and clinical features of 106 patients developing OCD after post-traumatic stress disorder (PTSD; termed post-traumatic OCD), 41 patients developing OCD before PTSD (pre-traumatic OCD), and 810 OCD patients without any history of PTSD (non-traumatic OCD) using multinomial logistic regression analysis. A later age at onset of OCD, self-mutilation disorder, history of suicide plans, panic disorder with agoraphobia, and compulsive buying disorder were independently related to post-traumatic OCD. In contrast, earlier age at OCD onset, alcohol-related disorders, contamination-washing symptoms, and self-mutilation disorder were all independently associated with pre-traumatic OCD. In addition, patients with post-traumatic OCD without a previous history of obsessive–compulsive symptoms (OCS) showed lower educational levels, greater rates of contamination-washing symptoms, and more severe miscellaneous symptoms as compared to post-traumatic OCD patients with a history of OCS. [Copyright &y& Elsevier]

The article focuses on the use of the SciELO publication system by the periodical "Revista Brasiliera de Psiquiatra" (RBP) in receiving manuscript submissions since August 1, 2007. The SciELO system uses the Open Journal Systems to support the management and publication of online journals. The online technology aims to reduce the time spent with tasks related to management, editing and maintenance of the editorial processes. It cites that RBP is the first journal of the SciELO collection to use the publication system.

This section introduces a series of articles published within the issue including one by Sonia Mansoldo Dainesi and Ricardo Pietrobon which explains the need of using bibliometric indices to assess the scientific relevance of articles, authors or research groups and another by Denise Razzouk and colleagues on two countries that show outstanding results in the geographical and cultural region.

Abstract: Emergence of depressive symptoms in schizophrenia results in a deteriorating course and poor prognosis. Schizophrenia and depressive disorder are both associated with low levels of brain-derived neurotrophic factor (BDNF) and with a longstanding low grade inflammatory state. The objective of this study is to analyze the relationship between these serum biomarkers and depressive and psychotic symptoms in schizophrenic patients. Thirty-nine individuals diagnosed with schizophrenia or schizoaffective disorder by Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), assessed by Structured Clinical Interview for DSM-IV (SCID), were included. Interviews were conducted with The Positive and Negative Syndrome Scale (PANSS) and The Calgary Depression Scale for Schizophrenia (CDSS). Blood samples were collected for determination of BDNF, IL-1beta, IL-6, IL-8, IL-10, IL-12 and TNF-alpha measurements. Positive correlations between BDNF and CDSS and between IL-1beta and severity in PANSS scores were found. BDNF levels were not correlated with any cytokine or with PANSS scores. The results of this study suggest that depressive and psychotic symptoms may be associated with different profiles of biomarkers in the association between schizophrenia and depression. [Copyright &y& Elsevier]

Abstract: As a consequence of the increasing urban violence in Brazil, many cases of posttraumatic stress disorder (PTSD) are now seen in the community and clinical settings. The main aim of this article is to assess the psychometric properties of the Clinician-Administered PTSD Scale (CAPS) to study factors related to the etiology, prognosis, and efficacy of interventions of PTSD in civilian populations. PTSD outpatients from a program of victims of violence and subjects identified in an epidemiological survey conducted in the city of Sao Paulo completed a battery of validated instruments and the CAPS. Instrument reliability and validity were measured. The comparison between the CAPS scores and the Structured Clinical Interview for DSM IV (SCID) interview resulted in the following validity coefficients: sensitivity=90%, specificity=95%, and misclassification rate=7.1%. The area under the receiver operating characteristic (ROC) curve was 0.97. There was a positive correlation between CAPS scores with Beck Depression Inventory (BDI; 0.70) and Beck Anxiety Inventory (BAI; 0.76) scores. The Kappa coefficients were all higher than 0.63 for all CAPS items. The internal consistency for all CAPS items resulted in a Cronbach''s alpha coefficient of 0.97. The CAPS showed to be both an accurate and a reliable research instrument to identify PTSD cases in a civilian population. [Copyright &y& Elsevier]

Abstract: We investigated the association of dopamine receptor D1 gene (DRD1) rs4532 polymorphism with antipsychotic treatment response in schizophrenia. We have analyzed 124 patients with schizophrenia, consisting of 59 treatment resistant (TR) and 65 non-TR. We found an association between G-allele and TR schizophrenia (p =0.001; adjusted OR=2.71). Setting the common AA-genotype as reference, the GG-homozygous presented a five-fold risk compared to AA-homozygous (p =0.010; OR=5.56) with an intermediate result for AG-genotype (p =0.030; adjusted OR=2.64). The DRD1 rs4532 polymorphism showed a dose–response gradient with increased risk for treatment resistance and may be a potential pharmacogenetic marker for antipsychotic drug treatment response. [Copyright &y& Elsevier]

Background: Currently, there is a need for approaches to understand and manage the multidimensional autism spectrum and quantify its heterogeneity. The diagnosis is based on behaviors observed in two key dimensions, social communication and repetitive, restricted behaviors, alongside the identification of required support levels. However, it is now recognized that additional modifiers, such as language abilities, IQ, and comorbidities, are essential for a more comprehensive assessment of the complex clinical presentations and clinical trajectories in autistic individuals. Different approaches have been used to identify autism subgroups based on the genetic and clinical heterogeneity, recognizing the importance of autistic behaviors and the assessment of modifiers. While valuable, these methods are limited in their ability to evaluate a specific individual in relation to a normative reference sample of autistic individuals. A quantitative score based on axes of phenotypic variability could be useful to compare individuals, evaluate the homogeneity of subgroups, and follow trajectories of an individual or a specific group. Here we propose an approach by (i) combining measures of phenotype variability that contribute to clinical presentation and could impact different trajectories in autistic persons and (ii) using it with normative modeling to assess the clinical heterogeneity of a specific individual., Methods: Using phenotypic data available in a comprehensive reference sample, the Simons Simplex Collection ( n = 2744 individuals), we performed principal component analysis (PCA) to find components of phenotypic variability. Features that contribute to clinical heterogeneity and could impact trajectories in autistic people were assessed by the Autism Diagnostic Interview-Revised (ADI-R), Vineland Adaptive Behavior Scales (VABS) and the Child Behavior Checklist (CBCL). Cognitive assessment was estimated by the Total Intelligence Quotient (IQ)., Results: Three PCs embedded 72% of the normative sample variance. PCA-projected dimensions supported normative modeling where a multivariate normal distribution was used to calculate percentiles. A Multidimensional General Functionality Score (MGFS) to evaluate new prospective single subjects was developed based on percentiles., Conclusions: Our approach proposes a basis for comparing individuals, or one individual at two or more times and evaluating homogeneity in phenotypic clinical presentation and possibly guides research sample selection for clinical trials.

Cumulative trauma is usually devastating and can lead to severe psychological consequences, including posttraumatic stress disorder (PTSD). Exposure to various types of traumas, particularly during childhood, can be even more deleterious than the sheer number of events experienced. This epidemiological study is the first to investigate the impact of discrete childhood traumatic exposure on the risk of developing lifetime PTSD in a representative sample of the general population of the two biggest Brazilian cities. Participants were aged between 15 and 75 years old, living in São Paulo and Rio de Janeiro, Brazil, who had experienced traumatic events (N = 3,231). The PTSD diagnosis was assessed using the DSM-IV criteria through the version 2.1 of Composite International Diagnostic Interview. To operationalize childhood cumulative trauma, we considered the sum of 15 different childhood trauma categories that occurred before PTSD onset. The final multivariate logistic regression model indicated a strong relationship between the number of discrete types of childhood traumas and the likelihood of the lifetime PTSD development. The lifetime PTSD risk increased 28 % with each different type of childhood trauma when adjusted by confounds. Our study strengthens the evidence associating childhood cumulative trauma to increased lifetime PTSD risk., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2024. Published by Elsevier B.V.)

São Caetano do Sul, a city in southeastern Brazil, boasts exemplary social indicators and healthcare services, with a population of 162,763 and a density of 9,736.03 inhabitants/km². Allocating 25% of its budget to healthcare, the city's mental healthcare services adhere to the National Mental Health Policy. Structured services include a CAPS-II, CAPS-AD, outpatient teams, and teams in various locations. Initiatives since 2000 include inaugurating a CAPS-AD in 2006, a psychiatric emergency service in 2010, and a CAPS-II in 2016, relocating CAPS-AD in 2019, and establishing the Cuca Legal Project in 2022. São Caetano do Sul has a Mental Health Risk Classification Protocol to aid clinical decision-making. Developing care lines for various groups, it offers programs like smoking prevention, school psychology, and obesity support. Collaborating with community centers, these facilities serve as teaching environments. The mental health care network focuses on five axes: Communication, Care, Prevention, Management, and Education, with specific proposed actions and competencies. Despite progress, challenges remain. Expanding access, reducing stigma, and implementing robust monitoring are crucial. São Caetano do Sul's experience offers valuable insights for similar urban settings in LMICs developing mental health programs., Competing Interests: No conflicts of interest declared concerning the publication of this article.

Social communication skills, especially eye contact and joint attention, are frequently impaired in autism spectrum disorder (ASD) and predict functional outcomes. Applied behavior analysis is one of the most common evidence-based treatments for ASD, but it is not accessible to most families in low- and middle-income countries (LMICs) as it is an expensive and intensive treatment and needs to be delivered by highly specialized professionals. Parental training has emerged as an effective alternative. This is an exploratory study to assess a parental intervention group via video modeling to acquire eye contact and joint attention. Four graded measures of eye contact and joint attention (full physical prompt, partial physical prompt, gestural prompt, and independent) were assessed in 34 children with ASD and intellectual disability (ID). There was a progressive reduction in the level of prompting required over time to acquire eye contact and joint attention, as well as a positive correlation between the time of exposure to the intervention and the acquisition of abilities. This kind of parent training using video modeling to teach eye contact and joint attention skills to children with ASD and ID is a low-cost intervention that can be applied in low-resource settings.

Objectives: There has been growing concern about the long-term effects of coronavirus disease 2019 (COVID-19) on mental health. The biological factors common to psychiatric conditions and COVID-19 are not yet fully understood., Methodos: We narratively reviewed prospective longitudinal studies that measured metabolic or inflammatory markers and assessed psychiatric sequelae and cognitive impairment in individuals with COVID-19 at least 3 months after infection. A literature search identified three relevant cohort studies., Results: Overall, depressive symptomatology and cognitive deficits persisted for up to 1 year after COVID-19; depression and cognitive changes were predicted by acute inflammatory markers, and changes in these markers correlated with changes in depressive symptomatology; female sex, obesity, and the presence of inflammatory markers were associated with more severe clusters of physical and mental health status in patients' self-perceived recovery; and plasma metabolic profiles of patients continued to differ from those of healthy controls 3 months after hospital discharge, which were associated with widespread alterations in neuroimaging, reflecting issues with white matter integrity., Conclusion: In individuals affected by COVID-19, prolonged exposure to stress and alterations in metabolic and inflammatory markers play a central role in psychiatric sequelae and cognitive deficits in the long term., Competing Interests: Jair de Jesus Mari was a speaker for the following laboratories in topics not related to this article: EMS, Eurofarma, Janssen, Apsen, Abbot, and Biolab. No other conflicts of interest declared concerning the publication of this article.

This is the first part of two documents prepared by experts for the Brazilian S20 mental health report. These reports outline strategies aimed at addressing the exacerbated mental health challenges arising from a post-pandemic world. Ongoing psychiatric epidemiology research has yielded evidence linking mental health with intricate social determinants, including gender, race/ethnicity, racism, socioeconomic status, social deprivation, and employment, among others. More recently, the focus has expanded to also encompass violence and social oppression. By prioritizing prevention and early intervention, harnessing technology, and fostering community support, we can mitigate the long-term impact of mental disorders emerging in life. Utilizing evidence-based practices and forging partnerships between the health and education sectors, S20 countries can promote health and safety of their student population, thereby paving the way for a more promising future for the next generations. The first document focuses on addressing the mental health concerns of vulnerable populations, catering to the needs of children, youth, and aging populations, assessing the current state of alcohol and drug addictions, scaling up psychosocial interventions in primary care, exploring the potential integration of health and educational systems, and emphasizing the imperative adoption of human rights in mental health policies., Competing Interests: JJM has received speaker’s fees from Apsen, Janssen, and Abbott. CK is the co-founder of Wida, a digital mental health platform. The other authors report no conflicts of interest.

Objective: To describe translation to Spanish and Portuguese and adaptation of the Mental Illness Clinicians' Attitudes Scale version 4 (MICA v4)., Methods: The questionnaire was administered to primary care physicians (PCPs) from four Latin-American countries, Brazil, Bolivia, Chile, and Cuba. The validation process included four phases: 1) translation of the questionnaire to Spanish and Portuguese; 2) assessment of face validity; 3) assessment of reliability; and 4) evaluation of construct validity with confirmatory factor analysis (CFA)., Results: The study sample comprised 427 PCPs. The mean age of the Spanish-speaking sample (n = 252) was 40.1 (S.D = 9.7) years and the mean age of the Portuguese-speaking sample (n = 150) was 40.2 (S.D = 10.9) years. Both models demonstrated "appropriate" internal reliability. Total omega was 0.91 for the Spanish-speaking sample and 0.89 for the Portuguese-speaking sample. The CFA of both questionnaires showed an appropriate fit for a three-factor model (Portuguese: CFI = 0.927; TLI = 0.913; RMSEA = 0.066; Spanish: CFI = 0.945; TLI = 0.935; RMSEA = 0.068)., Conclusion: The Latin-American versions of the MICA v4 in Spanish and Brazilian Portuguese have appropriate psychometric properties, good internal consistency, and are applicable to and acceptable in the Latin-American context. The instrument proved its validity for collecting data on stigmatizing attitudes among health professionals in different contexts and cultures., Competing Interests: No conflicts of interest declared concerning the publication of this article.

Background: Esketamine has been approved by the US Food and Drug Administration (FDA) as an adjunctive treatment for use in conjunction with an oral antidepressant for patients with treatment-resistant depression (TRD), but dissociative symptoms are common adverse effects., Methods: A retrospective analysis of 394 subcutaneous esketamine injections given to 70 patients with TRD that were administered once a week during a six-week trial in conjunction with oral antidepressant therapy. Doses between 0.5 to 1.0 mg/kg were administered according to the patient's response. Dissociative symptoms were assessed using the Clinician-Administered Dissociative States Scale (CADSS) 30 and 60 min after every weekly treatment (day 1, 8, 15, 22, 29 and 36)., Results: Seventy patients received a total of 394 subcutaneous esketamine injections over six weeks. Over time, the evolution of CADSS scores demonstrated a significant mean difference of CADSS at 60 min post-injection ( p = 0.010) throughout the six infusions. The mean CADSS scores at 60 min on day 22, 29 and 36 were similar. There were no differences between mean CADSS scores 30 min after the injections, no clinical correlation between response and dissociative symptoms, no correlation between time and demographic and clinical characteristics and no interactions between time and combined medication., Conclusions: Our results suggest that repeated subcutaneous esketamine doses are safe and well-tolerated regarding their acute dissociative and psychotomimetic symptoms. Symptoms usually peak at 30 min and decrease at 60 min post-injection, returning to their pretreatment levels at 120 min. Dissociative symptoms do not correlate with antidepressant response.

Background: National Health Service use the Community Mental Health Service User Questionnaire (NHS-CMH) to assess care quality. However, its reliability and internal validity is uncertain., Aims: To test the NHS-CMH structure, reliability and item-level characteristics., Methods: We used data from 11,373 participants who answered the 2017 NHS-CMH survey. First, we estimated the NHS-CMH structure using Exploratory Factor Analysis (EFA) in half of the dataset. Second, we tested the best EFA-derived model with Confirmatory Factor Analysis (CFA). We tested the internal validity, construct reliability (omega - ω ), explained common variance of each factor (ECV), and item thresholds., Results: EFA suggested a 4-factor solution. The structure derived from the EFA was confirmed, demonstrating good reliability for the four correlated dimensions: "Relationship with Staff" ( ω = 0.952, ECV = 40.1%), "Organizing Care" ( ω = 0.855, ECV = 21.4%), "Medication and Treatments" ( ω = 0.837, ECV = 13.3%), and "Support and Well-being" ( ω = 0.928, ECV = 25.3%). A second-order model with a high-order domain of "Quality of Care" is also supported., Conclusions: The NHS-CMH can be used to reliably assess four user-informed dimensions of mental health care quality. This model offers an alternative for its current use (item-level and untested sum scores analysis).

Background: Epilepsy is the most common neurological disease in the world, affecting 50 million people, with the majority living in low- and middle-income countries (LMICs). A major focus of epilepsy treatment in LMICs has been task-sharing the identification and care for epilepsy by community health workers (CHWs). The present study aimed to assess the knowledge, attitudes, and practices (KAPs) of CHWs towards epilepsy in Mozambique., Methods: One hundred and thirty-five CHWs completed a questionnaire that included socio-demographic characteristics and 44-items divided into six subscales pertaining to KAPs towards epilepsy (QKAP-EPI) across nine districts of Sofala, Mozambique. The internal consistency was examined to evaluate the reliability of the instrument (QKAP-EPI). The association between sociodemographic variables and QKAP-EPI subscales was examined using linear regression models., Results: The internal consistency was moderate for two subscales (causes of epilepsy, α = 0.65; medical treatment, α = 0.694), acceptable for cultural treatment (α = 0.797) and excellent for 2 subscales (safety and risks, α = 0.926; negative attitudes, α = 0.904). Overall, CHWs demonstrated accurate epilepsy knowledge (medical treatment: mean = 1.63, SD = 0.28; safety/risks: mean = 1.62, SD = 0.59). However, CHWs reported inaccurate epilepsy knowledge of the causes, negative attitudes, as well as culturally specific treatments for epilepsy, such as: "if a person with epilepsy burns when set on fire they cannot be treated". Knowledge about how to manage epileptic seizures varied across the different emergency care practices, from the accurate belief that it is not advisable to place objects in the individual's mouth during an epileptic seizure, to the wrong perception of the need to hold the person in seizures to control seizures. Heterogeneity in the level of epilepsy knowledge was observed among CHWs, when considering epilepsy according to the local names as treatable ("Dzumba") and other forms as untreatable ("Nzwiti")., Conclusion: CHWs knowledge of medical treatment and epilepsy safety/risks were adequate. However, information on the causes of epilepsy, stigmatizing attitudes, cultural treatment, and some knowledge of epileptic seizure management were low. These areas of poor knowledge should be the focus of educating CHWs in increasing their ability to provide quality care for patients with epilepsy in Mozambique.

Background: The high level of care needs for adolescents with mental health conditions represents a challenge to the public sector, especially in low and middle-income countries. We estimated the costs to the public purse of health, education, criminal justice and social care service use associated with psychiatric conditions among adolescents in Brazil; and examined whether the trajectory of psychopathology and its impact on daily life, and parental stigma towards mental illness, was associated with service utilisation and costs., Methods: Data on reported service use among adolescents from a prospective community cohort (n = 1,400) were combined with Brazilian unit costs. Logistic regression and generalised linear models were used to examine factors associated with service use and associated costs, respectively., Results: Twenty-two percent of those who presented with a psychiatric disorder used some type of service for their mental health in the previous twelve months. Higher odds of service use were associated with having a diagnosed mental disorder (either incident, [OR = 2.49, 95%CI = 1.44-4.30, p = 0.001], remittent [OR = 2.16, 95%CI = 1.27-3.69, p = 0.005] or persistent [OR = 3.01, 95%CI = 1.69-5.36, p<0.001]), higher impact of symptoms on adolescent's life (OR = 1.32, 95%CI = 1.19-1.47, p<0.001) and lower parental stigma toward mental illness (OR = 1.12, 95%CI = 1.05-1.20, p = 0.001). Average annual cost of service use was 527.14 USD (s.d. = 908.10). Higher cost was associated with higher disorder impact (β = 0.25, 95%CI = 0.12-0.39, p<0.001), lower parental stigma (β = 0.12, 95%CI = 0.02-0.23, p = 0.020) and white ethnicity (β = 0.55, 95%CI = 0.04-1.07, p = 0.036)., Conclusion: The impact of mental health problems on adolescents' daily lives and parental stigmatising attitudes toward mental illness were the main predictors of both service use and costs., Competing Interests: All authors report no conflict of interest associated with this publication. Luis Augusto Rohde has received grant or research support from, served as a consultant to, and served on the speakers’ bureau of Aché, Bial, Medice, Novartis/Sandoz, Pfizer/Upjohn, and Shire/Takeda in the last three years. The ADHD and Juvenile Bipolar Disorder Outpatient Programs chaired by Dr Rohde have received unrestricted educational and research support from the following pharmaceutical companies in the last three years: Novartis/Sandoz and Shire/Takeda. Dr Rohde has received authorship royalties from Oxford Press and ArtMed. None of these commercial relationships alter our adherence to PLOS ONE policies on sharing data and materials.

Background: Psychotic disorders contribute significantly to the global disease burden by causing disability, impaired quality of life, and higher mortality in affected people compared with the general population. In rural settings, where there is limited or no access to healthcare, individuals living with psychotic disorders often seek support from Community Health Workers (CHWs). However, little is known about what CHWs know about psychosis and how they manage such cases. This study aimed to explore the CHWs perception of psychosis and their experiences and beliefs about the factors that might enable or hinder care-taking for patients with psychosis in rural settings in Mozambique., Methods: A qualitative study was conducted in rural districts of Maputo Province, a southern region of Mozambique, using six focus group discussions with participation of 79 CHWs. Thematic analysis was used informed by the Capabilities, Opportunities, Motivation and Behaviour framework (COM-B)., Results: Nine primary themes were identified. Overall, CHWs perceived psychosis as treatable medical conditions and held a positive attitude about being part of the care-taking process of patients with psychosis in rural settings. Partnerships with key-stakeholders such as traditional healers, health care workers, and families, were perceived by CHWs as enablers to improve access to care in rural areas. However, stigma, myths, and lack of competencies to treat people with psychosis were perceived by CHWs as barriers for appropriate care., Conclusion: CHWs, with adequate support, could play an important role in the care of patients with psychosis in rural settings, including identifying patients requiring care and referring them to appropriate healthcare professionals, and following up medicated patients with psychosis. Training of CHWs should consider inclusion of basic mental health care competencies., (© 2022. The Author(s).)

Objective: The objective of our study was to explore clinical decisions of psychiatrists regarding the management of common mental disorders in primary care (PC) in four Latin Americans countries, through the application of clinical vignettes., Methods: Using a cross-sectional design, we conducted a self-administered online questionnaire survey of psychiatrists from Bolivia, Brazil, Cuba, and Chile. The questionnaire covered sociodemographic and professional information. The psychiatrists' clinical decisions were assessed through three clinical vignettes representing typical PC cases of depression, anxiety, and somatization., Results: 230 psychiatrists completed the online survey. Psychiatrists from Brazil were less likely to recognize depression as a mental disorder than those from Cuba (odds ratio (OR) = 0.30, 95% confidence interval (CI), 0.10 to 0.91, p < 0.04). Female gender (OR = 0.19, 95% CI, 0.04 to 0.91, p < 0.02) and older age (OR = 0.92, 95% CI, 0.87 to 0.97, p < 0.01) reduced the likelihood of agreement that depression cases should be treated by a Primary Care Physician (PCP). In the somatoform symptoms vignette, longer training duration increased the likelihood of agreement that treatment should be done by a psychiatrist instead of a PCP (OR = 1.19, 95% CI, 1.04 to 1.37, p < 0.01). In the anxiety vignette, females (OR = 2.38, 95% CI, 1.10 to 5.13, p < 0.01) and participants from Bolivia (compared with Cubans, OR = 4.19, 95% CI, 1.22 to 14.42, p < 0.02) were more likely to consider that these patients should be treated by a psychiatrist instead of a PCP., Discussion: Most psychiatrist respondents agreed that patients with depression should be treated by PCPs and that somatoform and anxiety cases should be treated by psychiatrists. These results show that psychiatrists consider that they, and not PCPs, should treat patients with common mental disorders, regardless of the evidence showing that common mental disorders can be treated by primary care physicians in PC., Competing Interests: The authors have declared that no competing interests exist.

Aims: Mental health problems early in life can negatively impact educational attainment, which in turn have negative long-term effects on health, social and economic opportunities. Our aims were to: (i) estimate the impacts of different types of psychiatric conditions on educational outcomes and (ii) to estimate the proportion of adverse educational outcomes which can be attributed to psychiatric conditions., Methods: Participants ( N = 2511) were from a school-based community cohort of Brazilian children and adolescents aged 6-14 years enriched for high family risk of psychiatric conditions. We examined the impact of fear- (panic, separation and social anxiety disorder, specific phobia, agoraphobia and anxiety conditions not otherwise specified), distress- (generalised anxiety disorder, major depressive disorder and depressive disorder not otherwise specified, bipolar, obsessive-compulsive, tic, eating and post-traumatic stress disorder) and externalising-related conditions (attention deficit and hyperactivity disorder, conduct and oppositional-defiant conditions) on grade repetition, dropout, age-grade distortion, literacy performance and bullying perpetration, 3 years later. Psychiatric conditions were ascertained by psychiatrists, using the Development and Well-Being Behaviour Assessment. Propensity score and inverse probability weighting were used to adjust for potential confounders, including comorbidity, and sample attrition. We calculated the population attributable risk percentages to estimate the proportion of adverse educational outcomes in the population which could be attributed to psychiatric conditions. Analyses were conducted separately for males and females., Results: Fear and distress conditions in males were associated with school dropout (odds ratio (OR) = 2.76; 95% confidence interval (CI) = 1.06, 7.22; p < 0.05) and grade repetition (OR = 2.76; 95% CI = 1.32, 5.78; p < 0.01), respectively. Externalising conditions were associated with grade repetition in males (OR = 1.66; 95% CI = 1.05, 2.64; p < 0.05) and females (OR = 2.03; 95% CI = 1.15, 3.58; p < 0.05), as well as age-grade distortion in males (OR = 1.66; 95% CI = 1.05, 2.62; p < 0.05) and females (OR = 2.88; 95% CI = 1.61, 5.14; p < 0.001). Externalising conditions were also associated with lower literacy levels ( β = -0.23; 95% CI = -0.34, -0.12; p < 0.001) and bullying perpetration (OR = 3.12; 95% CI = 1.50, 6.51; p < 0.001) in females. If all externalising conditions were prevented or treated, we estimate that 5.0 and 4.8% of grade repetition would not have occurred in females and males, respectively, as well as 10.2 (females) and 5.3% (males) of age-grade distortion cases and 11.4% of female bullying perpetration., Conclusions: The study provides evidence of the negative impact of psychiatric conditions on educational outcomes in a large Brazilian cohort. Externalising conditions had the broadest and most robust negative impacts on education and these were particularly harmful to females which are likely to limit future socio-economic opportunities.

Objective: Antidepressant use is increasing worldwide, but national data on psychotropic drug use by depressed patients in Brazil is lacking., Methodology: Between 2013 and 2014, a representative sample of urban adult individuals were asked if they had a diagnosis of chronic disease, had a medical indication for drug treatment, and were taking chronic medications at the time for each reported diagnosis. We analyzed the frequencies of reported depression and the medications related to this disease., Results: Overall, 6.1% of respondents reported depression. The prevalence increased with age - 9.5% among the elders - was higher among women (8.9%) and in the south of the country (8.9%). As a single disease, the prevalence of depression was higher among young people (17.6%). Among those with multimorbidity, the prevalence of depression rose to 25.7%. Of those who reported depression, 81.3% had medical indication for treatment and 90.3% were under treatment - this proportion was lower among young people (84.5%) and those living in the poorest region (78.6%). Antidepressants accounted for 47.2% of psychotropic drugs taken by respondents with depression, with regional differences - only 30% used antidepressants in the North. Polypharmacy was reported by 22% of those with depression and other chronic diseases., Conclusion: Depression in Brazil, is common among young adults as a single chronic disease and highly prevalent among people with chronic multimorbidity, especially the young. The treatment gap was larger among young people and in the less developed regions of the country.

Background: This study investigated the patterns of comorbidity between PTSD and depression, other anxiety disorders, alcohol-related disorders using the DSM-IV and ICD-10 criteria. The temporal sequence of the comorbid diagnoses was also investigated., Methods: We used data from a large population-based survey carried out between 2007 and 2008 in the two largest cities in Brazil: São Paulo and Rio de Janeiro., Results: Diagnoses of depression, other anxiety disorders, and alcohol-related disorder were more prevalent in the people with PTSD than in those without PTSD. Using the DSM-IV criteria, approximately 67% of cases presenting PTSD were also diagnosed with another mental disorder. The diagnosis category of other anxiety disorders presented the highest proportion of comorbidity (53%). Depression was found in 34% person with PTSD whilst alcohol-related disorders were observed in 7%. Considering the temporal relationship, the onset of comorbid depression was uniformly distributed through the periods before, within the same year and after PTSD's onset. When other anxiety disorders were comorbid with PTSD, in almost 90% of the cases the other anxiety disorders preceded PTSD. For comorbidity between of alcohol-related disorders and PTSD, in 50% of the cases alcohol-related disorders preceded the diagnosis of PTSD., Limitations: The cross-sectional design imposes limitations on establishing a temporal relationship between the onset of psychiatric disorders due to memory bias., Conclusions: Our findings indicate that among individuals presenting comorbid PTSD and other anxiety disorders, this diagnosis tend to precede PTSD. Comorbid cases are more frequent and more severe, and this should be taken into account in therapeutic research and clinical practice., Competing Interests: Declaration of Competing Interest Bressan reports, during the conduct of the study: grants, personal fees and non-financial support from Janssen, personal fees from Aché Laboratórios Farmacêuticos, grants and personal fees from Roche, outside the submitted work. The other authors declare that they have no competing interests., (Copyright © 2019. Published by Elsevier B.V.)

Purpose: Psychotic experiences in childhood (such as hearing voices or being suspicious) represent an important phenotype for early intervention. However, these experiences can be defined in several ways: self-reported psychotic experiences (SRPE) rely exclusively on the child's report, clinically validated psychotic experiences (CRPE) are based on clinical assessment, and attenuated psychotic symptoms (APS) represents a categorization to do with clinical relevance in relation to severity. Very few studies have investigated how these distinctions impact clinical and other domains. The present study aims to compare SRPE, CRPE, and APS among children and adolescents. Methods: This study is part of the Brazilian High-Risk Cohort Study for Psychiatric Disorders, in which 2,241 individuals aged 6-14 years provided self-ratings of 20 psychotic experiences using the Community Assessment of Psychic Experiences (CAPE). A trained psychologist conducted an interview to validate or reject reported experiences and to rate the presence of APS and affective flattening. In parallel, parents provided information about child mental health to an independent interviewer. We tested the association of mutually exclusive categories of non-validated SRPE (nSRPE), clinically validated PE below the threshold for APS (nCRPE), and APS (nSRPE = 33%, nCRPE = 11%, APS = 6%), with parents' information about the child's positive attributes and levels of psychopathology and psychologist assessment of blunted affect. Results: Most associations were qualitatively similar, and there was a dose-response in the strength of associations across categories, such that APS > nCRPE > nSRPE. Experiences in all three categories were associated with female sex. nSRPE were associated with overall levels of psychopathology, but to a lesser degree than nCRPE and APS. APS and nCRPE were associated with less positive attributes, with APS more so than nCRPE. Only APS was associated with affective flattening. Conclusions: In children and adolescents, SRPE, CRPE, and APS all index liability for psychopathology, but as clinician rated relevance increases, associations get stronger and become evident across more domains., (Copyright © 2019 Moriyama, van Os, Gadelha, Pan, Salum, Manfro, Mari, Miguel, Rohde, Polanczyk, McGuire, Bressan and Drukker.)

Background: Children exposed to substance use in their families are vulnerable to multiple risk factors in their development and at increased risk for emotional and behavioral problems. The aims of the study were as follows 1) estimate the prevalence of emotional and behavioral problems among children aged 6-11 years old, living with addicted family members in a low-income urban community of São Paulo, Southeastern Brazil; 2) evaluate the children's exposure to family psychosocial stressors and substance use; and 3) investigate the factors related to the increased risk of emotional and behavioral problems and substance use., Methods: A cross-sectional study was conducted among 101 children aged 6-11 years old (M = 9.16 years, SD = 1.61). The instruments used were a sociodemographic questionnaire, the Child Behavior Checklist (CBCL) and the Psychosocial Stress Factors (PSF)., Results: High prevalence of problems was found for this sample: the CBCL showed 26.7% of clinical scores for Internalizing Problems, 40.6% for Externalizing Problems, and 40.6% for Total Problems. Exposure to family psychosocial stressors was also high, including severe disease (33%), physical aggression (28.9%), death (27.8%), psychiatric hospitalization (16.7%), suicide attempts (15.5%), and suicide (9.3%). Exposure to these family stressors was associated with an increase of two to four times in the prevalence of internalizing and externalizing problems., Conclusions: Children exposed to substance abusers have more mental health problems than general population, even when compared to peers living in similar low-income areas. This is a group that should be target of a selective preventive intervention., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: The aim of this study is to investigate measurement invariance (MI) for an ADHD latent trait across different sociodemographic groups (sex, age, and maternal education), IQs, and co-occurring psychiatric diagnoses., Method: Participants were 2,299 children aged 6 to 14 years. ADHD symptoms were assessed by parent report using the Development and Well-Being Assessment (DAWBA). MI was tested through multigroup confirmatory factor analysis and multiple indicators multiple causes models., Results: In a bifactor model including a general ADHD factor and three specific factors (hyperactivity, inattention, and impulsivity), invariance properties were demonstrated and no individual items showed differential functioning. The ADHD general factor was higher in boys and in those with psychiatric disorders. Younger age predicted hyperactivity. Lower IQ and higher level of education of the mother predicted inattention., Conclusion: The ADHD trait, as measured by the DAWBA, functions in the same way, and with equivalent scale, revealing true differences in ADHD symptoms based on those.