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Background: Duration of untreated psychosis (DUP) depends on several factors, including socio-demographic, socioeconomic, clinical and contextual circumstances, such as availability of mental health services. Living arrangements may also play a role, especially in low- and middle-income countries, where most people who develop psychosis live with their relatives., Methods: Population-based study of first-episode psychosis in São Paulo, Brazil. Participants were aged 18-64 years, lived in a defined geographic area of the city and had a first contact in life with mental health services due to a psychotic episode. Duration of untreated psychosis was defined as the period between onset of first psychotic symptom and first contact with health service due to psychosis. The median DUP was used to classify participants into short and long DUP. Psychopathology, social adjustment and psychiatric diagnoses were made with standardized assessments. Type of service sought and living arrangements were examined., Results: Two hundred participants were included (52% women, 61% non-affective psychoses). The median DUP was 4.1 weeks (inter-quartile range: 1.9-11.4), and was shorter for affective psychoses. Most participants had their first contact with psychiatric emergency services. Those who did not live with a relative (children older than 18 years, parents, partner) were more likely to present long DUP (OR: 2.63; 95%CI: 0.98-7.04); p=0.05)., Conclusion: The DUP in São Paulo was shorter than expected. Living arrangements may play an important role in shortening the DUP in urban centres of low- and middle income countries that have a network of mental health services., (Copyright (c) 2009 Elsevier B.V. All rights reserved.)

Background: A consistent association between paternal age and their offspring's risk of schizophrenia has been observed, with no independent association with maternal age. The relationship of paternal and maternal ages with risk of bipolar affective disorders (BPAD) in the offspring is less clear. The present study aimed at testing the hypothesis that paternal age is associated with their offspring's risk of BPAD, whereas maternal age is not., Method: This population-based cohort study was conducted with individuals born in Sweden during 1973-1980 and still resident there at age 16 years. Outcome was first hospital admission with a diagnosis of BPAD. Hazard ratios (HRs) were calculated using Cox's proportional hazard regression., Results: After adjustment for all potential confounding variables except maternal age, the HR for risk of BPAD for each 10-year increase in paternal age was 1.28 [95% confidence interval (CI) 1.11-1.48], but this fell to 1.20 (95% CI 0.97-1.48) after adjusting for maternal age. A similar result was found for maternal age and risk of BPAD [HR 1.30 (95% CI 1.08-1.56) before adjustment for paternal age, HR 1.12 (95% CI 0.86-1.45) after adjustment]. The HR associated with having either parent aged 30 years or over was 1.26 (95% CI 1.01-1.57) and it was 1.45 (95% CI 1.16-1.81) if both parents were >30 years., Conclusions: Unlike schizophrenia, the risk of BPAD seems to be associated with both paternal and maternal ages.

Background: The determination of the prevalence of electrocardiographic alterations in the older age strata of the Brazilian population represents important information with clinical and epidemiological purpose., Objective: To verify the prevalence rates of atrial fibrillation, enlarged Q/QS waves (Minnesota code 1.1-1.2) and left bundle branch block., Methods: In a population-based study, 1,524 participants (921 women and 603 men) aged > 65 years and living in Sao Paulo, Brazil, were submitted to electrocardiographic assessment at rest as well as anthropometric and blood pressure measurements, in addition to fasting blood collection for the measurement of glycemia, total cholesterol and fractions., Results: The age-adjusted prevalence for enlarged Q/QS waves was 12.1% (men, 17.2%; women, 9.6%), 2.4% for atrial fibrillation (men 3.9%; women, 2.0%); and 3.1% for left bundle branch block (men, 3.1%; women, 3.8%). For atrial fibrillation (both sexes), enlarged Q/QS waves (men) and left bundle branch block (women) there was an increase in frequency according to the age stratum. After adjusted for age, sex, diabetes mellitus and dyslipidemia, the odds ratio among the frequencies of enlarged Q/QS waves; arterial hypertension was 2.4 (95% CI: 1.4 -3.9) being 5.1 (95%CI: 1.8 -14.4) for women and 1.7 (95%CI: 0.95-3.1] for men., Conclusion: The comparison of these data with those from other studies showed a high prevalence of enlarged Q/QS waves in this population, with a direct association with the prevalence of arterial hypertension.

Background and Purpose: Several morphometric MR imaging studies have investigated age- and sex-related cerebral volume changes in healthy human brains, most often by using samples spanning several decades of life and linear correlation methods. This study aimed to map the normal pattern of regional age-related volumetric reductions specifically in the elderly population., Materials and Methods: One hundred thirty-two eligible individuals (67-75 years of age) were selected from a community-based sample recruited for the São Paulo Ageing and Health (SPAH) study, and a cross-sectional MR imaging investigation was performed concurrently with the second SPAH wave. We used voxel-based morphometry (VBM) to conduct a voxelwise search for significant linear correlations between gray matter (GM) volumes and age. In addition, region-of-interest masks were used to investigate whether the relationship between regional GM (rGM) volumes and age would be best predicted by a nonlinear model., Results: VBM and region-of-interest analyses revealed selective foci of accelerated rGM loss exclusively in men, involving the temporal neocortex, prefrontal cortex, and medial temporal region. The only structure in which GM volumetric changes were best predicted by a nonlinear model was the left parahippocampal gyrus., Conclusions: The variable patterns of age-related GM loss across separate neocortical and temporolimbic regions highlight the complexity of degenerative processes that affect the healthy human brain across the life span. The detection of age-related limbic GM decrease in men supports the view that atrophy in such regions should be seen as compatible with normal aging.

Objective: To estimate the socioeconomic and sociodemographic factors associated with the daily intake of five servings of fruit and vegetables by elderly individuals living in low income areas, identifying the main fruits and vegetables which compose the diet of this population., Methods: This is a cross-sectional population-based study with 2,066 low income elderly individuals (> or =60 years) living in the city of São Paulo, Southeastern Brazil, in 2003-2005. To assess the fruit and vegetable intake a Food Frequency Questionnaire was administered. The answers were transformed into daily intake and compared with the recommendations of the World Health Organization (five or more servings per day). The relationship between recommended fruit and vegetable intake and socioeconomic variables was analyzed using logistic regression models., Results: Of the participants, 60.5% were women and 39.5% were men. Approximately one third of the elders (n=723; 35.0%) did not consume any kind of fruit or vegetable on a daily basis and 19.8% reported a daily intake of five or more servings of fruits and vegetables. This intake was positively associated with income and years of schooling., Conclusions: The fruit and vegetable intake of low income elderly individuals in the city of São Paulo was insufficient according to the recommendations of the World Health Organization and is associated with unfavorable socioeconomic conditions.

Background: Neuropsychological deficits have been reported in association with first-episode psychosis (FEP). Reductions in grey matter (GM) volumes have been documented in FEP subjects compared to healthy controls. However, the possible inter-relationship between the findings of those two lines of research has been scarcely investigated., Objective: To investigate the relationship between neuropsychological deficits and GM volume abnormalities in a population-based sample of FEP patients compared to healthy controls from the same geographical area., Methods: FEP patients (n=88) and control subjects (n=86) were evaluated by neuropsychological assessment (Controlled Oral Word Association Test, forward and backward digit span tests) and magnetic resonance imaging using voxel-based morphometry., Results: Single-group analyses showed that prefrontal and temporo-parietal GM volumes correlated significantly (p<0.05, corrected) with cognitive performance in FEP patients. A similar pattern of direct correlations between neocortical GM volumes and cognitive impairment was seen in the schizophrenia subgroup (n=48). In the control group, cognitive performance was directly correlated with GM volume in the right dorsal anterior cingulate cortex and inversely correlated with parahippocampal gyral volumes bilaterally. Interaction analyses with "group status" as a predictor variable showed significantly greater positive correlation within the left inferior prefrontal cortex (BA46) in the FEP group relative to controls, and significantly greater negative correlation within the left parahippocampal gyrus in the control group relative to FEP patients., Conclusion: Our results indicate that cognitive deficits are directly related to brain volume abnormalities in frontal and temporo-parietal cortices in FEP subjects, most specifically in inferior portions of the dorsolateral prefrontal cortex.

Objective: We set out to assess the feasibility, reliability and convergent validity of the Camberwell Assessment of Needs for the Elderly Scale in older residents of a Brazilian urban elderly population of low socioeconomic status., Method: We identified 32 older users of community health services from a population-based catchment area survey. We administered the Brazilian version of the Camberwell Assessment of Needs for the Elderly Scale to the older person and to an informal caregiver, and tape-recorded the assessments. Interviewers made a rating. Tape-recordings were independently co-rated., Results: Items contributing to older person and caregiver reports of needs and unmet needs had a high internal consistency. Inter-rater reliability was excellent for all needs, and fair to good for unmet needs. Older person and caregiver's reports, and interviewer ratings were highly mutually consistent. Convergent validity was supported by associations, as hypothesized, between needs and disability, and needs and dementia., Conclusions: The Brazilian version of the Camberwell Assessment of Needs for the Elderly Scale is a feasible, reliable and, to the extent assessed, valid assessment of unmet needs in a disadvantaged low and middle income countries setting. Its practical utility as a clinical tool remains to be assessed.

Background: The Mini-Mental State Examination (MMSE) is the most widely used instrument for the screening of cognitive impairment worldwide, but its ability to produce valid estimates of dementia in populations of low socioeconomic status and minimal literacy skills has not been adequately established. The authors investigated the psychometric properties of the MMSE in a community-based sample of older Brazilians., Method: Cross-sectional one-phase population-based study of all residents of pre-defined areas of the city of Sao Paulo, aged 65 years or over. The Brazilian version of the MMSE was compared with DSM-IV diagnosis of dementia assessed with a harmonized one-phase procedure developed by the 10/66 Dementia Research Group., Results: Analyses were performed with 1,933 participants of the SPAH study. Receiver operating characteristic analysis showed that the MMSE cut-point of 14/15 was associated with 78.7% sensitivity and 77.8% specificity for the diagnosis of dementia amongst participants with no formal education, and the cut-point 17/18 with 91.9% sensitivity and 89.5% specificity for those with at least 1 year of formal education (areas under the curves 0.87 and 0.94, respectively; P = 0.03). Even with these best fitting cut-points, the MMSE estimate of the prevalence of dementia was four times higher than determined by the DSM-IV criteria. Education, age, sex and income influenced MMSE scores, independently of dementia caseness., Conclusion: The MMSE is an adequate tool for screening dementia in older adults with minimum literacy skills, but misclassification is unacceptably high for older adults who are illiterate, which has serious consequences for research and clinical practice in low and middle income countries, where the proportion of illiteracy among older adults is high.

Background: Although fatigue is a ubiquitous symptom across countries, clinical descriptions of chronic fatigue syndrome have arisen from a limited number of high-income countries. This might reflect differences in true prevalence or clinical recognition influenced by sociocultural factors., Aims: To compare the prevalence, physician recognition and diagnosis of chronic fatigue syndrome in London and São Paulo., Method: Primary care patients in London (n=2459) and São Paulo (n=3914) were surveyed for the prevalence of chronic fatigue syndrome. Medical records were reviewed for the physician recognition and diagnosis., Results: The prevalence of chronic fatigue syndrome according to Centers for Disease Control 1994 criteria was comparable in Britain and Brazil: 2.1% v. 1.6% (P=0.20). Medical records review identified 11 diagnosed cases of chronic fatigue syndrome in Britain, but none in Brazil (P<0.001)., Conclusions: The primary care prevalence of chronic fatigue syndrome was similar in two culturally and economically distinct nations. However, doctors are unlikely to recognise and label chronic fatigue syndrome as a discrete disorder in Brazil. The recognition of this illness rather than the illness itself may be culturally induced.

Objective: To investigate the recognition of depressive symptoms of major depressive disorder (MDD) by general practitioners., Introduction: MDD is underdiagnosed in medical settings, possibly because of difficulties in the recognition of specific depressive symptoms., Methods: A cross-sectional study of 316 outpatients at their first visit to a teaching general hospital. We evaluated the performance of 19 general practitioners using Primary Care Evaluation of Mental Disorders (PRIME-MD) to detect depressive symptoms and compared them to 11 psychiatrists using Structured Clinical Interview Axis I Disorders, Patient Version (SCID I/P). We measured likelihood ratios, sensitivity, specificity, and false positive and false negative frequencies., Results: The lowest positive likelihood ratios were for psychomotor agitation/retardation (1.6) and fatigue (1.7), mostly because of a high rate of false positive results. The highest positive likelihood ratio was found for thoughts of suicide (8.5). The lowest sensitivity, 61.8%, was found for impaired concentration. The sensitivity for worthlessness or guilt in patients with medical illness was 67.2% (95% CI, 57.4-76.9%), which is significantly lower than that found in patients without medical illness, 91.3% (95% CI, 83.2-99.4%)., Discussion: Less adequately identified depressive symptoms were both psychological and somatic in nature. The presence of a medical illness may decrease the sensitivity of recognizing specific depressive symptoms., Conclusions: Programs for training physicians in the use of diagnostic tools should consider their performance in recognizing specific depressive symptoms. Such procedures could allow for the development of specific training to aid in the detection of the most misrecognized depressive symptoms.

Objective: To empirically compare the Cox, log-binomial, Poisson and logistic regressions to obtain estimates of prevalence ratios (PR) in cross-sectional studies., Methods: Data from a population-based cross-sectional epidemiological study (n = 2072) on elderly people in Sao Paulo (Southeastern Brazil), conducted between May 2003 and April 2005, were used. Diagnoses of dementia, possible cases of common mental disorders and self-rated poor health were chosen as outcomes with low, intermediate and high prevalence, respectively. Confounding variables with two or more categories or continuous values were used. Reference values for point and interval estimates of prevalence ratio (PR) were obtained by means of the Mantel-Haenszel stratification method. Adjusted PR estimates were calculated using Cox and Poisson regressions with robust variance, and using log-binomial regression. Crude and adjusted odds ratios (ORs) were obtained using logistic regression., Results: The point and interval estimates obtained using Cox and Poisson regressions were very similar to those obtained using Mantel-Haenszel stratification, independent of the outcome prevalence and the covariates in the model. The log-binomial model presented convergence difficulties when the outcome had high prevalence and there was a continuous covariate in the model. Logistic regression produced point and interval estimates that were higher than those obtained using the other methods, particularly when for outcomes with high initial prevalence. If interpreted as PR estimates, the ORs would overestimate the associations for outcomes with low, intermediate and high prevalence by 13%, almost by 100% and fourfold, respectively., Conclusions: In analyses of data from cross-sectional studies, the Cox and Poisson models with robust variance are better alternatives than logistic regression is. The log-binomial regression model produces unbiased PR estimates, but may present convergence difficulties when the outcome is very prevalent and the confounding variable is continuous.

Objectives: estimate the prevalence and track the risk factors associated with, Maternity blues (MB)., Methods: a transversal study was performed with 113 women, on the tenth day of puerperium. The following instruments were used: Pitt Scale (1968), Stein (1980), Inventory for stressful life events by Holmes & Rahe (1967), and a questionnaire with sociodemographic and obstetric data., Results: the prevalence of MB was 32.7% according to the Stein scale. In the univariated analysis, civil status and tobacco use were associated with MB. Legally married women and nonsmokers showed a risk approximately 4 times lower of experiencing the problem., Conclusions: MB was very prevalent in this sample. Obstetricians must be aware of this condition which may be associated with postpartum depression.

Objective: To estimate the prevalence of the burnout syndrome and of common mental disorders among community-based health agents, also identifying associated factors., Methods: A cross-sectional survey was carried out in 2006 with 141 community-based health agents who had been working for at least six months in primary care units in the city of São Paulo (Southeastern Brazil). The participants answered three questionnaires: one about sociodemographic, health- and work-related characteristics, the Self Reporting Questionnaire, and the Maslach Burnout Inventory, which allows the assessment of three dimensions of the burnout syndrome: emotional exhaustion, depersonalization and reduced personal accomplishment. Multivariate logistic regression was used to examine associations between variables., Results: Overall, 24.1% of the interviewees presented burnout syndrome. Moderate or high levels of emotional exhaustion, depersonalization and reduced personal accomplishment were observed in 70.9%, 34.0% and 47.5% of the participants, respectively. The prevalence of common mental disorders was 43.3%. Positive correlations between the three dimensions of burnout, were observed. Presence of common mental disorder was independently associated with higher levels of emotional exhaustion and reduced personal accomplishment., Conclusions: The high frequency of intense levels of burnout and the high prevalence of common mental disorders among community-based health agents point to the need of intervention strategies in these individuals' daily lives and of further studies to better understand the actual picture and the determinants of burnout.

Background: Several mechanisms have been suggested to explain the association between adversities across life and dementia. This study aimed to investigate the association between indicators of socioeconomic disadvantages throughout the life-course and dementia among older adults in Sao Paulo, Brazil and to explore possible causal pathways., Methods: We used baseline data from the SPAH study which involved participants aged 65 years and older (n = 2005). The outcome of interest was prevalent dementia. Exposures included in the analyses were socioeconomic position (SEP) indicators in childhood (place of birth and literacy) and adulthood (occupation and income), anthropometric measurements as markers of intrauterine and childhood environment (head circumference and leg length), smoking, diabetes and hypertension. Logistic regression models were used to test the hypothesized pathways and to assess whether there was an association between cumulative adversities across the life course and prevalent dementia., Results: Indicators of socioeconomic disadvantage in early life were associated with increased prevalence of dementia. This association was partially mediated through adulthood SEP. Head circumference and leg length were also clearly associated with dementia but there was no evidence that this association was mediated by early life socioeconomic disadvantage. There was an association between cumulative unfavourable conditions across the life course and dementia., Conclusions: Early life disadvantages seem to operate through biological mechanisms associated with passive brain reserve and opportunities in life representing active cognitive reserve. Prevention of dementia should start early in life and continue through life span as seen with many other chronic diseases.

Objective: To evaluate the influence of socioeconomic conditions on the association between common mental disorders and the use of health services and psychoactive drugs., Methods: This was a population-based cross-sectional study conducted in the city of Botucatu, Southeastern Brazil. The sample was probabilistic, stratified and cluster-based. Interviews with 1,023 subjects aged 15 years or over were held in their homes between 2001 and 2002. Common mental disorders were evaluated using the Self-Reporting Questionnaire (SRQ-20). The use of services was investigated in relation to the fortnight preceding the interview and the use of psychotropic drugs, over the preceding three days. Logistic regression was used for multivariable analysis, and the design effect was taken into consideration., Results: Out of the whole sample, 13.4% (95% CI: 10.7;16.0) had sought health services over the fortnight preceding the interview. Seeking health services was associated with female gender (OR=2.0) and the presence of common mental disorders (OR=2.2). 13.3% of the sample (95% CI: 9.2;17.5) said they had used at least one psychotropic drug, especially antidepressives (5.0%) and benzodiazepines (3.1%). In the multivariable analysis, female gender and the presence of common mental disorders remained associated with the use of benzodiazepines. Per capita income presented a direct and independent association with the use of psychoactive drugs: the greater the income, the greater the use of these drugs was., Conclusions: Lower income was associated with the presence of common mental disorders, but not with the use of psychotropic drugs. The association of common mental disorders and the use of psychotropic drugs in relation to higher income strengthens the hypothesis that inequality of access to medical services exists among this population.

Background: White-matter hyperintensities have been associated with both schizophrenia and mood disorders, particularly bipolar disorder, but results are inconsistent across studies., Aims: To examine whether white-matter hyperintensities are a vulnerability marker for psychosis or are specifically associated with bipolar disorder., Method: T(2)-weighted magnetic resonance imaging data were acquired in 129 individuals with first-episode psychosis (either affective or non-affective psychoses) and 102 controls who were randomly selected from the same geographical areas. Visual white-matter hyperintensity ratings were used for group and subgroup comparisons., Results: There were no statistically significant between-group differences in white-matter hyperintensity frequency or severity scores. No significant correlations were found between white-matter hyperintensity scores and duration of illness, duration of untreated psychosis, or severity of psychotic, manic or depressive symptoms., Conclusions: White-matter hyperintensities are not associated with vulnerability to psychosis in general, or specifically with affective psychoses. Further, first-episode psychosis investigations using more quantitative methods are warranted to confirm these findings.

XPC participates in the initial recognition of DNA damage during the DNA nucleotide excision repair process in global genomic repair. Polymorphisms in XPC gene have been analyzed in case-control studies to assess the cancer risk attributed to these variants, but results are conflicting. To clarify the impact of XPC polymorphisms in cancer risk, we performed a meta-analysis that included 33 published case-control studies. Polymorphisms analyzed were Lys939Gln and Ala499Val. The overall summary odds ratio (OR) for the associations of the 939Gln/Gln genotype with risk of cancer was 1.01 (95% confidence interval (95% CI): 0.94-1.09), but there were statistically significant associations for lung cancer, observed for the recessive genetic model (Lys/Lys+Lys/Gln vs Gln/Gln), (OR 1.30; 95% CI: 1.113-1.53), whereas for breast cancer a reduced but nonsignificant risk was observed for the same model (OR 0.87; 95% CI: 0.74-1.01). The results for Ala499Val showed a significant overall increase in cancer risk (OR 1.15; 95% CI: 1.02-1.31), and for bladder cancer in both the simple genetic model (Ala/Ala vs Val/Val) (OR 1.30; 95% CI: 1.04-1.61) and the recessive genetic model (Ala/Ala+Ala/Val vs Val/Val) (OR 1.32; 95% CI: 1.06-1.63). Our meta-analysis supports that polymorphisms in XPC may represent low-penetrance susceptibility gene variants for breast, bladder, head and neck, and lung cancer. XPC is a good candidate for large-scale epidemiological case-control studies that may lead to improvement in the management of highly prevalent cancers.

Objective: While in many Western affluent countries there is widespread awareness of chronic fatigue syndrome (CFS), also known as myalgic encephalomyelitis (ME), little is known about the awareness of CFS/ME in low- and middle-income countries. We compared the awareness of CFS in Brazil and the United Kingdom., Methods: Recognition and knowledge of CFS were assessed among 120 Brazilian specialist doctors in two major university hospitals using a typical case vignette of CFS. We also surveyed 3914 and 2435 consecutive attenders in Brazilian and British primary care clinics, respectively, concerning their awareness of CFS., Results: When given a typical case vignette of CFS, only 30.8% [95% confidence interval (CI), 22.7-39.9%] of Brazilian specialist doctors mentioned chronic fatigue or CFS as a possible diagnosis, a proportion substantially lower than that observed in Western affluent countries. Similarly, only 16.2% (95% CI, 15.1-17.4%) of Brazilian primary care attenders were aware of CFS, in contrast to 55.1% (95% CI, 53.1-57.1%) of their British counterparts (P<.001). This difference remained highly significant after controlling for patients' sociodemographic and socioeconomic characteristics (P<.001)., Conclusions: The awareness of CFS was substantially lower in Brazil than the United Kingdom. The observed difference may influence patients' help-seeking behavior and both doctors' and patients' beliefs and attitudes in relation to fatigue-related syndromes. Attempts to promote the awareness of CFS should be considered in Brazil, but careful plans are required to ensure the delivery of sound evidence-based information.

Background: In low- and middle-income countries people with schizophrenia are reported to experience better outcomes than those in high-income countries., Aims: To examine structural brain differences in people with first-episode psychosis and controls in Brazil., Method: Magnetic resonance imaging using voxel-based morphometry was performed on 122 people with first-episode psychosis and 94 controls., Results: There were significant decreases in grey matter in the left superior temporal and inferior prefrontal cortices, insula bilaterally and the right hippocampal region in first-episode psychosis (P<0.05, corrected for multiple comparisons). The subgroup of people with schizophrenia (n=62) exhibited a similar pattern of decrease in grey matter relative to controls., Conclusions: Structural abnormalities reported in psychosis in high-income countries are also present in first-episode psychosis in Brazil.

Background: Little is known about the incidence of first-episode psychosis in urban centres of low- or middle-income countries., Aims: To estimate the incidence of psychosis in São Paulo, a large metropolis of Brazil., Method: Prospective survey of first-episode psychosis among residents aged 18-64 years resident in a defined area of São Paulo, over a 30-month period (July 20 2002-December 2004). Assessments were carried out with the SCID-I, and diagnoses given according to DSM-IV criteria. Population at risk was drawn from the 2000 Census data., Results: There were 367 first-episode cases identified (51% women), and almost 40% fulfilled criteria for schizophrenia or schizophreniform disorder. The incidence rate for any psychosis was 15.8/100 000 person-years at risk (95% CI 14.3-17.6). Incidence of non-affective psychoses was higher among younger males., Conclusions: Incidence of psychosis in São Paulo was lower than expected for a large metropolis.

Objective: To analyze the prevalence of cigarette smoking in individuals with severe mental illnesses in a large urban centre of a middle income country., Methods: Cross-sectional study carried out in São Paulo. The sample (N=192) comprised individuals diagnosed with severe mental illnesses who had contact with public psychiatric care services from September to November 1997 and were aged between 18 and 65 years. Prevalence of daily tobacco smoking in the 12 months previous to the interview and characteristics associated were studied., Results: Out of 192 subjects with severe mental illnesses interviewed, 115 (59.9%; 95% CI: 52.6%; 66.9%) reported smoking cigarettes on a daily basis. Male gender, marital status separated or widowed, irregular use of neuroleptic drugs and history of ten or more psychiatric admissions were independently associated with cigarette smoking., Conclusions: The prevalence of cigarette smoking in the present sample was higher than that found in the general Brazilian population. Mental care services should implement non-smoking policies and mental health providers need to help patients with severe mental illness who want to quit smoking.

Objective: To translate and adapt the Brazilian version of the Camberwell Assessment of Needs schedule for research, and to assess its inter-rater reliability in a sample of first-episode psychosis cases in São Paulo, Brazil., Method: A sub-sample of participants included in a study of first-episode psychosis in São Paulo was assessed utilizing the 22 domains of the Brazilian version of the Camberwell Assessment of Needs. The Camberwell Assessment of Needs was applied, tape-recorded and rated by research assistants. An independent rater gave scores to the same participants, based on the recorded interviews. The kappa coefficient and the intraclass correlation coefficient were used to assess inter-rater reliability., Results: Fifty-two subjects were included. For seven domains the inter-rater reliability was almost perfect to total (range: 0.81 to 1.0). The domains with the lowest agreement were transport and benefits. The inter-rater reliability for the total number of needs was excellent (ICC = 0.95)., Conclusions: The inter-rater reliability of the Camberwell Assessment of Needs was similar to what has been found in previous studies. The Camberwell Assessment of Needs showed to be easy to use and reliable with first-episode psychosis individuals. The use of standardized instruments to assess needs of care in Brazil will contribute to the assessment of the effectiveness of treatment and to the planning of individualized care for individuals with mental illnesses.

Purpose: To carry out a systematic review and meta-analysis of the efficacy of chemonucleolysis in the treatment of lumbar disc herniation., Methods: Clinical trials were selected from 3 electronic databases (The Cochrane Controlled Trials Register, MEDLINE, and EMBASE). Data were analyzed with the software STATA, using the meta command., Results: Twenty-two clinical trials were eligible. For chemonucleolysis versus placebo, the summary risk ratio estimate for pain relief as outcome was 1.51 (95% CI: 1.27-1.80). The summary estimate was 1.07 (95% CI: 0.95-1.20) for the comparison between chymopapain and collagenase. Regarding chemonucleolysis with chymopapain versus surgery, the fixed-effect summary estimate of effect for pain relief was 0.93 (95% CI: 0.88-0.98) with surgery as the reference group. In this case, heterogeneity was statistically significant., Conclusions: Chemonucleolysis with chymopapain was superior to placebo and was as effective as collagenase in the treatment of lumbar disc prolapse. Results for studies comparing chemonucleolysis with surgery were heterogeneous, making it difficult to interpret the summary measure of effect.

Objective: The Chalder Fatigue Questionnaire (CFQ) is an instrument used to measure physical and mental fatigue. We translated and adapted the questionnaire and tested its reliability and validity in a Brazilian primary care setting., Method: A pilot study with 204 consecutive primary care attenders in Sao Paulo, Brazil, verified the internal consistency and factor structure of the questionnaire. After some modifications through a rigorous translation, back-translation, and cross-cultural adaptation procedure, a validation study was conducted with 304 attenders, who also completed the fatigue section of the Revised Clinical Interview Schedule (CIS-R)., Results: The internal consistency of the Brazilian CFQ slightly improved from the pilot to the validation study: Cronbach's alpha from .86 to .88. The two-factor structure (physical and mental fatigue) also improved. According to the receiver operating curve analysis with the fatigue section of the CIS-R as the standard criterion, 3/4 was chosen as the cutoff for Brazilian primary care (sensitivity 69.1% and specificity 79.4%)., Conclusion: The Brazilian CFQ had good reliability and validity. The cutoff was determined as 3/4 and the factor structure of the English CFQ was closely reproduced.

Background: Studies conducted in high-income countries have reported significant cognitive deficits in first on set schizophrenia subjects relative to asymptotic controls, and it has been suggested that the severity of such deficits could be directly related to the duration of untreated psychosis (DUP). It is relevant to conduct similar studies in developing countries, given the supposedly better outcome for schizophrenia patients living in the latter environments., Methods: We applied verbal fluency and digit span tests to an epidemiological-based series of patients with first-onset psychoses (n=179) recruited in the city of São Paulo, and compared the findings with those from non-psychotic control subjects randomly selected from the same geographical areas (n=383)., Results: Psychosis subjects showed lower scores on the three tests relative to controls, with greatest between-group differences for the backward digit span task (p<0.0001). There were no significant differences between subjects with affective and schizophreniform psychosis. Cognitive performance indices were negatively correlated with the severity of negative symptoms, but showed no relation to DUP., Conclusion: We found significant cognitive deficits in patients investigated early during the course of psychotic disorders in an environment that is distinct from those where the subjects investigated in previous studies have been drawn from. We found no support to the hypothesis of an association between greater cognitive deficits and a longer DUP.

This study aimed to determine whether candiduria is associated with the occurrence of nosocomial candidaemia. In the case-control part of the study, 115 cases (nosocomial candidaemia) and 115 controls (nosocomial bacteraemia) were similar in age, severity of condition and time of hospitalisation. There was a significant association of candidaemia with candiduria (OR 9.79; 95% CI 2.14-44.76). In the microbiology part of the study, 23 pairs of Candida-positive urine and blood cultures were obtained from 23 patients. In ten (43%) cases, the urine and blood culture isolates belonged to different species, and molecular typing showed a difference in two of the 13 cases yielding the same species from both specimens. Overall, there was a significant association between candiduria and candidaemia, but the Candida isolates from urine and blood were different for 52% of the patients. Thus, the data indicated that the urinary tract was probably not a source for the candidaemia.

Objective: To study factors related to preference for cesarean delivery, among pregnant women without medical complications., Methods: A cross-sectional study was carried out among 156 pregnant women, in a private clinic in the city of Osasco, State of São Paulo, from October 2000 to December 2001. The pregnant women were at 28 weeks of pregnancy or more, with no formal contraindication for vaginal delivery at the time of the interview. Sociodemographic data and past and present obstetric history were assessed by applying a questionnaire. The pregnant women were specifically asked what their current preference for delivery was. Pearson's Chi-square test and logistic regression for multivariate analysis were performed with a 5% significance level., Results: Sixty-seven pregnant women (42.9%) said they had little motivation to undergo vaginal delivery. In the multivariate analysis, the following variables were statistically significant: previous vaginal birth (p=0.001; ORadj=0.04; 95% CI=0.01-0.12); husband's monthly income greater than 750 reais (p=0.006, ORadj=3.44; 95% CI=1.38-8.33). The women with a previous vaginal delivery presented 25-fold lower chance of choosing cesarean delivery. The opinion that the previous delivery experience was unsatisfactory was marginally associated with the main outcome (p=0.06; ORadj=0.42; 95% CI=0.16-1.05)., Conclusions: Motivation for cesarean delivery is associated with influences such as the type and degree of satisfaction with previous delivery and income.

Background: Studies investigating the performance of instruments to detect major depressive disorder (MDD) have reported inconsistent results. Subsyndromal depression (SD) has also been associated to increased morbidity, and little is known about its detection in primary care setting. This study aimed to investigate the performance of the Primary Care Evaluation of Mental Disorders (PRIME-MD) to detect MDD and any depression (threshold at SD) in an outpatient unit of a teaching general hospital., Methods: Nineteen primary care physicians using the PRIME-MD evaluated 577 patients, 240 of them (75% female; mean age, 40.0 +/- 14.4), including all with MDD and a randomly subset of those without MDD, were evaluated by 11 psychiatrists using the Structured Clinical Interview Axis I Disorders, Patient Version (SCIDI/P) for DSM-IV as the standard instrument., Results: The kappa between the PRIME-MD and the SCID was 0.42 for the diagnosis of any depression and 0.32 for MDD. The distribution of the number of depressive symptoms per patient suggested the existence of a continuum between SD and MDD, and a high frequency of subjects with 4-6 symptoms (close to the cutoff for the diagnosis of MDD)., Limitations: The sample has a modest size and is a subset of an original one., Conclusion: A continuum between SD and MDD may in part explain the relatively low agreement for the diagnosis of MDD in our sample and possibly in other studies. Studies investigating the performance of screening instruments to detect MDD, should consider the relevance of identifying SD, and the influence of the distribution of the number of depressive symptoms in their results.

Objective: To investigate the social adjustment of individuals with severe mental illness living in the community in a large urban center of a developing country, and the characteristics associated with poor social functioning., Method: A cross-sectional study was performed in the city of Sao Paulo. Eligible subjects were residents of a defined geographic area, aged between 18 and 65, with a diagnosis of functional psychosis who had had contact with any public psychiatric service during a defined period. Structured assessments were used to obtain information on social-demographic characteristics, diagnosis (ICD-10), psychiatric symptoms (PANSS), and social adjustment (DAS)., Results: One hundred and eighty-eight subjects were included, of whom, 120 (63.8%) had some degree of impairment in social functioning. The most frequently affected areas of social functioning were work performance and sexual role. Twenty-four patients (12.8%) showed poor or very poor social adjustment in the month prior to the interview. Negative symptoms, number of previous admissions and general symptoms showed statistically significant associations with global social adjustment scores., Conclusions: The proportion of patients showing any degree of impairment in social adjustment was as high as in more developed societies. In order to successfully implement the new mental health policy in Brazil, better provision of community-based mental health services for those with severe mental illnesses is needed.

Objectives: To describe the application in Brazil of a simple, low-cost procedure, developed in India by the 10/66 Dementia Research Group, for the identification of dementia cases in the community., Design: Community-based dementia case-finding method., Setting: Piraju, São Paulo, Brazil., Participants: Twenty-five community health workers were trained to identify dementia cases in 2,222 people aged 65 and older in Piraju, a Brazilian town with 27,871 inhabitants., Measurements: After the training, the health workers prepared a list of possible cases that afterward an experienced psychiatrist clinically evaluated, according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria and the Clinical Dementia Rating., Results: Of the 72 cases that were clinically assessed, 45 met the DSM-IV diagnostic criteria for dementia. Therefore, the positive predictive value of this case finding method was 62.5%; the estimated frequency of dementia was 2%. Most of the confirmed cases met clinical criteria for Alzheimer's disease and vascular dementia., Conclusion: This simple method was appropriate to identify cases of dementia in the general population and can possibly be extended to other developing countries with limited resources to be applied in health programs.

Objective: Functional neuroimaging studies using phonological verbal fluency tasks allow the assessment of neural circuits relevant to the neuropsychology of psychosis. There is evidence that the prefrontal cortex and anterior cingulate gyrus present different activation patterns in subjects with chronic schizophrenia relative to healthy controls. We assessed the functioning in these brain regions during phonological verbal fluency in subjects with recent-onset functional psychoses, using functional magnetic resonance imaging (FMRI)., Methods: Seven patients with functional psychoses (3 schizophreniform, 4 affective) and 9 healthy controls were studied. We compared functional magnetic resonance images acquired during articulation of words beginning with letters classified as easy for word production in Portuguese. Statistical comparisons were performed using non-parametric tests., Results: There were no differences between patients and controls in task performance. Controls showed greater activation than patients in the left rostral anterior cingulate gyrus and right inferior prefrontal cortex, whereas patients showed stronger activation than controls in a more dorsal part of the anterior cingulate gyrus bilaterally and in a more superior portion of the right prefrontal cortex., Conclusion: Our preliminary findings of attenuated engagement of inferior prefrontal cortex and anterior cingulate gyrus in patients with recent onset psychosis during phonological verbal fluency are consistent with those of previous studies. The greater activation found in other parts of the anterior cingulate gyrus and prefrontal cortex in patients may be related to a compensatory response that is required to maintain normal task performance, and suggests a pattern of disorganized activity of different functional anterior cingulate gyrus units in association with psychotic conditions.

Objective: There is an increasingly number of demented elderly in Brazil but empirical data on the resulting impact on their informal caregivers is still poorly documented. The purpose of this study was to evaluate the impact on informal caregivers of elderly with dementia., Methods: A cross-sectional study was conducted at a psychogeriatric unit in the city of Sao Paulo, Brazil. Structured and semi-structured interviews were administered to 49 elderly patients with dementia and their caregivers. The impact on the caregiver was measured using the Zarit Burden Interview., Results: Most patients were females, had an average score of 12.2 in the Mini Mental State Examination and high incidence of disruptive behavior. Caregivers were predominantly females, generally wives or daughters who lived with their patients. The mean impact score was 32.4 (SD 16.7). Variables statistically associated with the level of impact were: degree of kinship between patient and caregiver (p=0.011); caregiver's psychiatric symptoms (p<0.001), and duration of caregiving role (p=0.001)., Conclusions: A high impact on caregivers of demented elderly who required psychogeriatric intervention was detected. Healthcare providers should be able to provide the needed support to caregivers in order to minimize problems to both patients and their caregivers.

Hydroalcoholic extracts of 10 medicinally used species collected from the area covered by a reservoir due to a dam built for the Salto Caxias Hydro-electric power plant in the State of Paraná, Southern Brazil, and Casearia sylvestris, were investigated for their potential antioxidant activity against DPPH (1,1-diphenyl-2-picrylhydrazyl) free radicals and by the phosphomolybdenum method. The extract of Bauhinia microstachya was found to be the most potent in both models., (Copyright 2004 Elsevier B.V.)

The purpose of this study was to estimate the prevalence of postpartum depression (PPD) and its relationship with life events (LE) and patterns for coping. We performed a cross-sectional study of 113 women, on the 10(th) day of puerperium, at the Obstetric Clinic of the São Paulo University Medical School. The study was based on the following: Pitt (1967) and Stein (1980) Scales, Beck Depression Inventory (1961), Holmes and Rahe Schedule of Recent Events (1967), Folkman and Lazarus Ways of Coping (1985) and questionnaire of social-demographic and obstetric data. Logistic regression was performed to calculate prevalence of PPD and its association with several risk factors. The significance level was defined at 5%. The prevalence of PPD was 15.9% (IC 9.7% to 24.0%). According to the multivariate analyses, the variables of coping with distancing, number of children and ethnic origin were significant. There were no association between PPD and LE. The depressed puerperal women have a low educational level, greater number of children and resort to inadequate coping strategies, such as distancing. This pattern of coping might be an etiological factor of the PPD as well as a reaction to their difficult life environment.

This study evaluated the frequency of obsessive-compulsive disorder (OCD), obsessive-compulsive symptoms (OCS), and related disorders (e.g., tic disorders, trichotillomania, and body dysmorphic disorder) in 100 patients with Parkinson's disease (PD) and 100 individually matched controls. When compared with controls, OCD, OCS, and related disorders were not higher in PD. Findings revealed an association of some OCS with left side motor symptom predominance in PD patients, particularly for symmetry and ordering/arranging. These findings suggest that the right hemisphere likely functions in the expression of OCS.

As the world population is ageing, dementia becomes an important public health problem, particularly in developing countries. Epidemiological research in these settings is scarce and present additional methodological difficulties, mainly regarding the socio-cultural adequacy of instruments used to identify cases of dementia. As a result of these concerns the 10/66 Dementia Research Group was founded to fill this gap. This is an international network of investigators, mostly from developing countries, and the group's name was based on the paradox that less than 10% of the population-based studies on dementia are directed to 2/3 or more cases of people with dementia living in developing countries. The aim of the paper is to update data in the literature regarding the differences in dementia prevalence and incidence seen in developed and developing countries.

Background: Mental disorders are among the most prevalent chronic conditions in old age, depression being the most widespread. The aim of this study was to examine the burden and distress reported by carers of elderly patients with depression., Method: Patients aged 60 or over starting outpatient treatment for depression and their relatives were included. Patients were assessed for the severity of depressive symptoms, behaviour and mood disturbance, and abilities of daily living. Relatives were assessed for burden and emotional distress., Results: Eighty-two patients and their relatives were included. Levels of carers' burden were high. Multiple linear regression showed that patients' behaviour and mood disturbance and relatives's emotional distress scores were independently associated with relatives' burden., Conclusions: Levels of burden were similar to those found in studies with carers of elderly people with dementia, indicating that depressive symptoms can be considered an important source of distress for caregivers.

The present study examines the prevalence of chronic fatigue (CF) among bank workers in Brazil and possible associations with gender and working conditions. The study sample included all 735 workers from the department of data processing of a state bank. CF was assessed using the Chalder Fatigue Scale. Working conditions and socio-demographic, socio-economic and psychosocial factors at work were analysed. Psychiatric symptoms were measured with the SRQ-20. The overall estimate of the prevalence of CF was 8.7% [95% confidence intervals (95% CI) = 6.4-10.9%]: 7.8% (95% CI = 5.5-10.7%) among men and 11.0% (95% CI = 6.7-16.9%) among women. The male-female difference was not statistically significant, even after adjusting for minor psychiatric disorders. The overall prevalence of CF without minor psychiatric disorders was 4.5% (95% CI = 2.7-6.3%): 3.9% (95% CI = 1.9-5.9%) among men and 6.4% (95% CI = 2.0-10.1%) among women. In the final model, risk factors for CF were fast work speed [odds ratio (OR) = 3.5], dissatisfaction at work (OR = 3.1), minor psychiatric disorders (OR = 6.8), and medium (OR = 1.8) and heavy domestic workload (OR = 12.0). CF is common among these bank workers and is associated with psychosocial factors at work. Particularly among women, domestic workload, marital status and the presence of young children were associated with CF in the stratified analysis. Domestic workload may add physical and mental stress, putting employees at risk for CF from overload, or CF may cause workers to perceive domestic work as heavy.

This study provides the cancer mortality pattern for a cohort of 10,017 electric power plant workers from 1978 to 1994. Standard mortality ratio (SMR) analysis showed lower mortality from all causes (0.47: 0.43-0.51) and from all groups of causes including neoplasms (0.73: 0.60-0.90) among these workers, in comparison with the same sex and age bracket in Rio de Janeiro. In relation to specific cancer sites, standard cancer mortality ratios (SCMRs) greater than one were observed for neoplasms of the small bowel (10.35: 3.34-32.09), gallbladder (2.64: 0.99-7.03), pancreas (1.83: 0.91-3.66), kidney (2.91: 1.39-6.10), and bladder (2.60: 0.58-4.12), as well as for melanoma (1.82: 0.46-7.28). Important limitations were the workers' relatively young age and the short period of time since job admission (less than 15 years). The small number of deaths for each anatomic site led to instability in the study results, with many non-significant SCMRs and wide confidence intervals. Due to these limitations, study results are difficult to interpret in light of currently available evidence.

Objectives: The perception of negative emotions in close relatives may play an important role in explaining how external stressors can affect vulnerable individuals with schizophrenia. However, there is considerable debate about the ability of people with schizophrenia to perceive emotions in others. The present study aimed to examine the reliability of patients' perception of relatives' criticism. Secondly, it aimed to investigate whether patients' judgement about relatives' criticism agreed with an independent assessment of relatives' criticism towards patients., Method: Forty-three patients with a DSM-III-R diagnosis of schizophrenia and their relatives were assessed soon after patients' admission to a psychiatric hospital and again 9 months after their discharge from hospital. Test-retest reliability of patients' answers to a question about patients' perception of relatives' criticism towards them was carried out. The association between patients' perception of relatives' criticism and the expressed emotion (EE) measure of relatives' criticism was examined at inclusion and follow-up. Patients' symptomatology was examined at both assessments., Results: Reliability of the measurement of patients' perception of relatives' criticism was moderate to good. Patients' judgement of relatives' criticism towards them was associated with the number of critical comments and presence of hostility at inclusion. At follow-up, this association became weaker., Conclusion: The ability to judge and describe reliably negative emotions in close relationships may help to explain how perception of the external environment may act as a stressor in people who are vulnerable to schizophrenia.

The authors compared the outcomes of 35 outpatients with dysthymic disorder randomized to receive either treatment with moclobemide and interpersonal therapy (IPT) or moclobemide and routine clinical management. Diagnosis was based on the ICD-10 symptom checklist. Patients were evaluated by trained raters using the 17-item Hamilton Rating Scale for Depression (Ham-D), Montgomery-Asberg Depression Rating Scale (MADRS), Global Assessment of Functioning, and Quality of Life and Satisfaction Questionnaire at baseline, 12, 24, and 48 weeks. Patients in both treatment groups showed statistically significant improvement in all measures across time. There was a nonsignificant trend toward lower scores on Ham-D and MADRS for patients in the moclobemide plus IPT group. Longer, better-powered trials should be carried out to study the efficacy of IPT plus antidepressant medication in the treatment of dysthymic disorder.

Objective: To compare the service use and costs of individuals who have a dual diagnosis of psychosis and substance abuse with those who have a diagnosis of psychosis but no substance abuse., Method: Patients with psychosis were identified and a representative sample were interviewed. Six-month service use was measured and costs calculated. Regression models were developed to predict costs from background characteristics and dual diagnosis status., Results: A greater proportion of the patients with dual diagnosis used community psychiatric nurses, in-patient care and the emergency clinic. The regression analysis revealed that dual diagnosis patients had significantly higher 'core' psychiatric service costs (a difference of pound sterling 1362) and non-accommodation service costs (pound sterling 1360) than non-dual-diagnosis patients. The difference when all services were analysed was pound sterling 1046, but this was not statistically significant., Conclusion: Specific interventions for dual diagnosis patients should be introduced and assessed in terms of individual outcomes, service use and costs.

Background: Compliance with outpatient treatment can reduce the use of psychiatric inpatient services by people with severe mental disorders. In developing countries, socio-economic factors may be associated with compliance with outpatient treatment., Methods: A 2-year prospective cohort study was conducted of 99 patients with non-affective functional psychoses who were discharged from hospital. Standardized assessments were used for psychopathology, social functioning and use of psychiatric services., Results: Forty-two patients (42.4%) missed all outpatient appointments for at least 2 consecutive months. Household crowding was the only variable associated with poor compliance, patients living in very crowded homes being more than twice as likely to show poor compliance as those living in less crowded homes., Conclusions: In large urban centres in developing countries, strategies to improve compliance with outpatient treatment targeted towards those living in overcrowded households may reduce use of psychiatric beds.

Obsessive-compulsive disorder (OCD) has been reported in association with some neurological diseases that affect the basal ganglia such as Tourette's syndrome, Sydenham's chorea, Parkinson's disease, and Huntington's disease. Furthermore, studies such as neuroimaging, suggest a role of the basal ganglia in the pathophysiology of OCD. The aim of this paper is to describe the association of OCD and several neurologic disorders affecting the basal ganglia, report the existing evidences of the role of the basal ganglia in the pathophysiology of OCD, and analyze the mechanisms probably involved in this pathophysiology.

Studies on psychiatric disorders in Brazil have shown high prevalence rates, both in the community and in primary care centers. However, psychiatric assessments carried out by interviewers have some inherent problems which influence inter-observer reliability. There is great potential for the use of computerized interviews. This article discusses some advantages of this kind of assessment, and indicates a need for investigation into its applicability to Brazilian health care settings.

A prospective cohort study of schizophrenia was carried out in Sao Paulo, Brazil, in order to investigate clinical and social outcomes in schizophrenia and related psychoses after hospitalization. A sample of 124 individuals who were living in a defined catchment area and had been consecutively admitted to psychiatric hospitals in that area with clinical diagnoses of non-affective functional psychoses was followed up for 2 years. Assessments of clinical status and social adjustment at inclusion and at 2-year follow-up were carried out by means of standardized instruments, the PSE and the DAS. At the end of the follow-up period, 120 subjects (96.8%) were traced, and 103 (83.1%) were re-assessed. At the second assessment, the proportion of subjects with a nuclear syndrome of schizophrenia had halved (from 68.3% to 32.7%), 23.8% were symptom free and 60.2% showed at least one psychotic symptom. Presence of psychotic symptoms at follow-up was best predicted by educational level (less than 4 years of formal education) and an initial DSM-III-R diagnosis of schizophrenia. The distribution of global social adjustment levels at 2-year follow-up was similar to that observed at the outset, with approximately one third of subjects showing good, one third showing intermediate and one third showing poor global social adjustment. Social disability was best predicted by longer duration of illness, worse social adjustment levels at inclusion and lower educational level.

High mortality rates among those suffering from schizophrenia and related psychoses have been consistently described in developed societies. However, to date there is a lack of data on this matter in Brazil. In order to examine this issue, a prospective 2-year follow-up study was carried out in S. Paulo. The sample consisted of 120 consecutive admissions to psychiatric hospitals in a defined catchment area, aged 18 to 44 years old, with clinical diagnoses of non-affective functional psychoses according to the ICD-9. After 2 years, 116 (96.7%) subjects were traced. During the study period there were 7 deaths (6.0% of those traced), 5 (4.3%) due to suicide. All but one of the suicides occurred in the first year after discharge from hospital. Age and sex Standardised Mortality Ratios (relative to rates for the population of the city of Sao Paulo) were 8.4 for overall mortality (95% confidence interval: 4.0-15.9) and 317.9 for deaths due to suicide (95% confidence interval: 125.2-668.3). These results are in agreement with previous studies, and show that in Brazil non-affective functional psychoses are life-threatening illnesses, which need adequate care, particularly when patients go back to live in the community after hospital discharge.

Background: High rates of comorbid alcohol and drug disorders have previously been found among individuals with severe mental illnesses such as schizophrenia and bipolar affective disorders. Clinical and social outcomes have been reported to be worse in this group and service costs greater than in individuals with severe mental illness only. These 'dual diagnosis' patients have mainly been investigated in the USA, and there has been very little research in Europe, where patterns of substance abuse may be different., Method: All patients with psychotic illnesses who had any contact with the mental health services in a geographically defined sector in South London over a specified period were studied. Individuals with problems related to alcohol or drugs were identified using standardised interviews with subjects and their keyworkers. Data on psychiatric service use during the previous 2 years were also obtained., Results: One hundred and seventy-one subjects with psychotic illnesses were interviewed (response rate: 78.4%). The one-year prevalence rate for any substance problem was 36.3% (95% CI = 29.1-43.5), for alcohol problems it was 31.6% (95% CI = 24.6-38.5), and for drug problems 15.8% (95% CI = 10.3-21.3). Young male subjects were at higher risk of having substance problems. Patients with substance problems had spent almost twice as many days in hospital as those without such problems over the previous two years (difference = 26.3 days, 95% CI = 3.8-48.7)., Conclusions: The prevalence of substance problems among people suffering from severe mental disorders is high, and seems to be associated with greater use of in-patient services. This is a significant clinical problem, with cost implications. Further investigation is needed for adequate service provision.

This paper reports a study on the prevalence of hospital-treated schizophrenia in a large urban centre in Brazil. A sample of 124 individuals from a defined catchment area of São Paulo consecutively admitted to psychiatric hospitals due to acute episodes of non-affective psychoses were assessed by standardized instruments for mental state and social adjustment. The sample was predominantly white (72.6%), single (65.2%), Catholic (61.3%) and not born in that city (58.9%). Eighty-six subjects fulfilled DSM-III-R criteria for schizophrenia (69.3%), 15 were classified as schizophreniform psychosis (12.1%), and 7 as schizoaffective (5.6%). Almost two-thirds showed Schneider's 'first rank' symptoms. Social adjustment before admission was poor or very poor in nearly half the sample. Mean age at onset was 3.2 years earlier in men than in women (P = 0.007). No gender differences in mental state or social adjustment were observed. Individuals born outside São Paulo State had significantly more florid symptoms than those born in that state. These findings suggest that the features of schizophrenia in a large urban centre of Brazil are consistent with the patterns of schizophrenia described in Western developed countries.