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Background Despite the increasing use of comprehensive rehabilitation models for people with severe mental illness (SMI), there are still limitations to their implementation and replicability in a consensual way, particularly in Latin American countries. The REINTEGRA program aims to be a standardized model of comprehensive rehabilitation focused on psychosocial and cognitive improvement through a set of interventions on different areas of people’s functionality, with the goal of reintegrating people with SMI into the labour market. In this paper we summarize the protocol for its subsequent implementation in a mental health institution in Mexico. Method The protocol is based on a quasi-experimental, prospective longitudinal study, with a pragmatic or naturalistic control group. It will be carried out in three phases. Phase 1 consists of a series of interventions focused on psychosocial improvement; Phase 2 focuses on cognitive and behavioral improvement treatments; and Phase 3 targets psychosocial recovery through rehabilitation and reintegration into the labour market. The overall procedure will be monitored with standarized evaluations at different stages of the program. Discussion This study presents a model of integral rehabilitation of people with SMI. At the moment, one of the obstacles to overcome is the organization and procedural control of the different actors needed for its implementation (nurses, psychologists, doctors, companies, institutions, etc.). REINTEGRA will be the first comprehensive rehabilitation model that includes systematized procedures for job reinsertion for people with SMI in Mexico, which aims to be a standardized tool of easy adaptation and the replicability for other mental health centers and institutions. Research Ethics Committee Approval: 205-2021.

Introduction. Medical specialty residents have become a high-risk population for mental health disorders, mainly due to long working days, limited time for rest and recreation, problems inherent in the work environment, and substance use. Since all these factors not only alter the training of future specialists, but also the care they provide for people, the study of an intervention in this population is of interest to the health system and human resource training in the health sector. Objective. To evaluate the mental health status, prevalence of work exhaustion and associated psychosocial and work factors in medical residents in the Guadalajara Metropolitan Area. Method. This was a cross-sectional, observational, descriptive, and comparative study, in which, through a digitized survey on the Google Forms platform, the GHQ-28, ASSIST, and Maslach Burnout Inventory scales were administered to medical specialty residents from various health institutions in the Guadalajara Metropolitan Area. Results. The total sample comprised 306 residents, representing 11.23% of the total residents in the Guadalajara Metropolitan Area (2,724). Female physicians had a higher percentage of participation with 61.4% ( n = 188), with male physicians accounting for 38.6% ( n = 118). The average age was 28.9 years and 84.9% ( n = 260) were pursuing a clinical specialty, and 15.1% ( n = 46) a surgical one p ˂ 05. On average, they worked 74.1 hours per week, whereas in surgical specialties they worked another 10 hours (82.63 ± 23.40 vs . 72.67 ± 19.76, p = .002). 72.5% ( n = 222) showed a high risk of developing burnout. 9.2% ( n = 28) obtained scores compatible with severe depression, which was related to a higher number of hours worked per week and heavier alcohol consumption than residents without depression, 21.24% ( n = 65) of respondents frequently thought about dropping out, 22.5% ( n = 69) felt dissatisfied with their work, while 14.05% ( n = 43) of the residents had recently noticed that they had had frequent thoughts of taking their own lives. Discussion and conclusion. The higher number of hours worked per week, surgical specialties, and the presence of workplace harassment were recognized as psychosocial and occupational factors associated with mental health problems in resident physicians, such as depression, thoughts of death, burnout, and psychoactive substance use. In a country like Mexico, where medical residents are a crucial pillar of the public health system, it is necessary to ensure their well-being, and seek to improve the working and academic conditions of medical residencies to ensure that this is reflected in the quality and safety of patient care.

IntroductionThe world has been marked by the global COVID-19 pandemic, which has had an impact in everyone’s lives, but particularly in healthcare workers (HCW), whom have been exposed to higher workload, COVID exposure and stigma, all of which are known risk factors for mental health problems.ObjectiveThe aim of this study is to report the prevalence of depression, risk factors and resilience related to the initial phase of the COVID-19 pandemic among Mexican HCW.Method This is an observational cross-sectional study part of a larger international, prospective multicentric study “The COVID-19 HEalth caRe wOrkErs Study” (HEROES). A convenience sample with a total of 2,127 HCW from two states of Mexico (Chiapas and Jalisco) were recruited. Depression was the main outcome, assessed using the Patient Health Questionnaire (PHQ-9). A COVID-19 risk scale was developed with a total of 19 items. Resilience was studied with the Brief Resilience Scale (BRS). Model-adjusted prevalence ratios (PRs) were estimated.ResultsWe found moderate to severe depression in 16.6% of the study sample. HCW from Jalisco, medical staff, working in hospitals, and those with chronic illness and with a mental health history were more depressed. Regarding the COVID-19 related risk factors, we found more than double the prevalence of depression (2.14, 95%CI=1.64-2.8) for those exposed to ≥8 of the risk variables here studied. Depression was prevalent in 30% of HCW with low resilience, 13.3% with medium resilience and only 4.4% of those with high resilience. Discussion and conclusionCOVID-19 related risk factors increase the prevalence of depression in HCW, whereas resilience proved to be a protective factor (higher resilience, less prevalence of depression). This evidence proves the need to develop strategies to reduce the risk (developing measures to enhance trust in the workplace and anti-sigma campaigns) and enhance resilience (fostering wellness and building relationships) in HCW. Clinical Trial Registration: The COVID-19 HEalth caRe wOrkErs (HEROES). Study. Identifier: NCT04352634

One of the proposed mechanisms for the development of diabetic nephropathy (DN) is the increase of end products of advanced glycosylation (AGEs), which bind to its receptor (RAGE), favoring nephron cellular damage. An isoform of this receptor is soluble RAGE (sRAGE), which can antagonize AGE-altered intracellular signaling. It has known that green tea extract (GTE) increases the expression of sRAGE, but it is unknown whether this could improve kidney function. The objective of this study was to evaluate the effect of the administration of GTE on the concentrations of sRAGE, renal function, and metabolic profile in patients with type 2 diabetes mellitus (T2DM) and DN. A randomized, double-blinded, placebo-controlled clinical trial was carried out in 39 patients who received GTE (400 mg every 12 h) or placebo for 3 months. sRAGE levels, renal function, and metabolic parameters were determined before and after the intervention. In the GTE group, there were statistically significant increase on sRAGE (320.55 ± 157.63 pg/mL vs. 357.59 ± 144.99 pg/mL

Background Charles Bonnet Syndrome (CBS) is a rare clinical entity that is classically composed of visual hallucinations in the context of an altered optic pathway with preservation of reality judgment. This case aims to present the association of visual hallucinations with complex alterations of the nervous structures adjacent to the visual pathway and an atypical clinical presentation, thus explaining the possible mechanisms involved in the generation of these symptoms. Case presentation A 43-year-old man presents seeking care due to visual hallucinations with partial preservation of reality judgment and symptoms compatible with a major depressive disorder, including irritability and diminished hygiene habits. He has a history of complete gradual loss of vision and hyposmia. Due to poor treatment response during hospitalization, an MRI was obtained, which showed a frontal tumor lesion with meningioma characteristics adjacent to the olfactory groove and compression of the optic chiasm. He underwent surgical resection of the lesion, which remitted the psychotic symptoms, but preserving the visual limitation and depressive symptoms. Conclusions The presence of visual hallucinations, without other psychotic features as delusions, is a focus of attention for basic structural pathologies in the central nervous system. Affection at any level of the visual pathway can cause CBS. When finding atypical symptoms, a more in-depth evaluation should be made to allow optimization of the diagnosis and treatment.

Introduction. In 2016, there were 4,393 psychiatrists in Mexico, with an estimated rate of 3.68 per 100,000 inhabitants. It is essential to keep this information updated in order to achieve the overall objectives of mental health care. Objective. Estimate the total number of psychiatrists and paidopsychiatrists in Mexico in 2018; identify their geographical distribution, and compare the results with those obtained in 2011 and 2016. Method. Comparative, longitudinal study. Various sources were consulted to update the number of psychiatrists and paidopsychiatrists in 2018 and to determine their sociodemographic characteristics. These characteristics were compared with those found in 2011 and 2016. Results. A total of 4,999 specialists in psychiatry practiced their specialty in Mexico in 2018, 365 of whom are child and adolescent psychiatrists. A rate of 3.71 psychiatrists per 100,000 inhabitants was obtained for a population of 124,737,789. Regarding pedopsychiatric specialists, if we consider a population of 37,714,991 inhabitants under 16, the corresponding rate is .96 child and adolescent psychiatrists per 100,000 minors. These specialists are unevenly distributed throughout the country. Approximately 60% of all psychiatrists and child and adolescent psychiatrists practice in the three largest cities in Mexico. Discussion and conclusion. Although the national rate of psychiatrists was increased in comparison with 2016, it is still lower than that recommended by the World Health Organization (WHO). The geographical distribution of psychiatrists is uneven due to centralization and economic factors as happens in many countries in the world.

Background Polypharmacy increases the risk of pharmacological interactions, prevalence of secondary effects and with this the lack of adherence to treatment. It is estimated that between 10 and 40% of patients hospitalized in psychiatric institutions are prescribed more than one antipsychotic. The objective of the present study was to identify the prevalence of polypharmacy, evaluate adverse effects associated to the use of psych drugs and to estimate the risk in specific groups. Methods We carried out a longitudinal, retrospective study that included the analysis of all discharged patients (n = 140) in the first trimester of the year in a psychiatric hospital in Mexico. The information was classified into 7 sections: sociodemographic, diagnosis, clinical follow-up information, prescribed drugs, adverse reactions, substance abuse, laboratory and complementary results. Risk estimation was obtained with Odds Ratios, to correlate continuous variables Pearson’s correlation was used. Student’s T and Mann Whitney’s U were used to compare 2 independent samples; multiple and linear regressions were carried out. Results The mean number of drugs used during hospitalization was 7.8 drugs per patient. The mean prescribed psych drugs was 4.07. The mean antipsychotic dose was the risperidone equivalent of 5.08 mg. 29.2% of patients had at least one secondary effect associated to the use of drugs, 17.8% presented extrapyramidal symptoms. 81.4% of patients were prescribed 6 or more drugs (polypharmacy) and were 5 times more likely to suffer a secondary effects (OR 6.24). 14.2% had polypharmacy while receiving antipsychotics and had more than twice the risk of presenting extrapyramidal symptoms (OR 3.05). For each added psych drug, hospital stay increased by 6.56 days. Conclusions Despite international guideline recommendations where reasoned and conciliatory prescription of psych drugs is advised, there is still a high prevalence of polypharmacy in patients hospitalized in psychiatric institutions. In the present study 4 out of 5 patients received polypharmacy decreasing tolerability, treatment adherence and increasing the risk and costs secondary to an increased hospital stay.

Background Access to mental health care is a worldwide public health challenge. In Mexico, an unacceptably high percentage of the population with mental disorders does not receive the necessary treatment, which is mainly due to the lack of access to mental health care. The community mental health care model was created and has been implemented to improve this situation. In order to properly plan and implement this model a precise situational diagnosis of the mental health care network is required, thus this is a first approach to evaluate the community mental health networks in the state of Jalisco. Methods Two components from the EvaRedCom–TMS instrument were used including a general description and accessibility of the community mental health care network. A geographic and economic accessibility evaluation was carried out for the different regions of the state ranging from scattered rural to urban communities using information gathered from health institutions, telephone interviews and computer applications. Results Jalisco’s community mental health network includes a total of 31 centers and 0.64 mental health workers for every 10,000 inhabitants > 15 years of age. The mean transportation cost required to access mental health care was 16.25 USD per visit. The time needed to reach the closest mental health center in 7 of the 13 analyzed regions was more than 30 min and the mean time required to reach a prolonged stay center was 172.7 min with transportation cost (taxi, private and public transport) of 22.3 USD. Some marginalized regions in the state have a mean 114 min required to reach the closest mental health care center and 386 min to reach a prolonged stay center. Conclusions This first approach to evaluate the mental health networks in Mexico showed that there are multiple barriers to access its care including an unfavorable number of human resources, long distances, and high costs. The identification of Jalisco’s mental health network deficiencies is the first step towards establishing a properly planned community mental health care model within the country.

Background: Access to mental health care is a worldwide public health challenge. In Mexico an unacceptably high percentage of the population with mental disorders does not receive the necessary treatment, which is mainly due to the lack of access to mental health care. The community mental health care model was created and has been implemented to improve this situation. In order to properly plan and implement this model a precise situational diagnosis of the mental health care network is required, thus this is a first approach to evaluate the community mental health networks in the state of Jalisco. Methods: Two components from the EvaRedCom–TMS instrument were used including a general description and accessibility of the community mental health care network. A geographic and economic accessibility evaluation was carried out for the different regions of the state ranging from scattered rural to urban communities using information gathered from health institutions, telephone interviews and computer applications. Results: Jalisco’s community mental health network includes a total of 31 centers and 0.64 mental health workers for every 10,000 inhabitants >15 years of age. The mean transportation cost required to access mental health care was 16.25 USD. The time needed to reach the closest mental health center in 7 of the 13 analyzed regions was more than 30 minutes and the mean time required to reach a prolonged stay center was 172.7 minutes with transportation cost of 22.3 USD. Some marginalized regions in the state have a mean 114 minutes required to reach the closest mental health care center and 386 minutes to reach a prolonged stay center. Conclusions: This first approach to evaluate the mental health networks in Mexico showed that there are multiple barriers to access its care including an unfavorable number of human resources, long distances and high costs. The identification of Jalisco’s mental health network deficiencies is the first step towards establishing a properly planned community mental health care model within the country.

Introduction: The use of psychoactive substances in patients diagnosed with mental illness is an increasing public health problem; the purpose of this work was to carry out a study to identify the most prevalent psychoactive drug abuse patterns in hospitalized patients in a psychiatric hospital, to estimate the severity of substance abuse, as well as to determine the factors associated with drug consumption using multivariate statistical modeling. Methods An analytical, retrospective study was carried out through the review of patient records discharged during 2018. Sociodemographic data, diagnoses, clinical follow-up information, clinimetric score of the alcohol consumption, Tobacco and Substances Detection Test (ASSIST 2.0) were obtained as well as the toxicological profile results. Results A representative sample of 268 participants was obtained, 61.6% men and 38.4% women, 86.6% unemployed, 67.9% single, with an average age of 36 years and 8 years of schooling. The most frequent diagnoses were Schizophrenia (42%), Substance-Induced Psychotic Disorder (22%), and Bipolar Disorder (17.9%). The most frequent substances detected in urine toxicology test were: Cannabis 21.8% (n = 45) and methamphetamines 10.7% (n = 22). The substances with the most frequent consumption in the last 3 months were tobacco, ethanol, cannabis, and methamphetamines. The highest score in the severity of consumption were methamphetamines and cannabis. The most important predictors for ethanol consumption were tobacco and cannabis abuse, for cannabis abuse were schooling years and ethanol consumption, and for methamphetamine consumption, the most important predictors were cocaine and cannabis abuse. Conclusions Young, male, unemployed subjects, with lower educational level, a psychiatric condition, and psychoactive consumption represent an identifiable "sociodemographic phenotype" that has an increased risk of requiring hospital services on a more recurrent basis and that could represent a burden to the health system. Methamphetamines abuse continues to increase and is becoming a significant mental health and public health issue. Cannabis and methamphetamine use are more severe and have more serious repercussions in terms of psychiatric morbidity. Correct public policies must be designed to intervene in this population.

OBJECTIVE The Outcome Reduction With Initial Glargine Intervention (ORIGIN) trial reported neutral effects of insulin glargine on cardiovascular outcomes and cancers and reduced incident diabetes in high–cardiovascular risk adults with dysglycemia after 6.2 years of active treatment. Omega-3 fatty acids had neutral effects on cardiovascular outcomes. The ORIGIN and Legacy Effects (ORIGINALE) study measured posttrial effects of these interventions during an additional 2.7 years. RESEARCH DESIGN AND METHODS Surviving ORIGIN participants attended up to two additional visits. The hazard of clinical outcomes during the entire follow-up period from randomization was calculated. RESULTS Of 12,537 participants randomized, posttrial data were analyzed for 4,718 originally allocated to insulin glargine (2,351) versus standard care (2,367), and 4,771 originally allocated to omega-3 fatty acid supplements (2,368) versus placebo (2,403). Posttrial, small differences in median HbA1c persisted (glargine 6.6% [49 mmol/mol], standard care 6.7% [50 mmol/mol], P = 0.025). From randomization to the end of posttrial follow-up, no differences were found between the glargine and standard care groups in myocardial infarction, stroke, or cardiovascular death (1,185 vs. 1,165 events; hazard ratio 1.01 [95% CI 0.94–1.10]; P = 0.72); myocardial infarction, stroke, cardiovascular death, revascularization, or hospitalization for heart failure (1,958 vs. 1,910 events; 1.03 [0.97–1.10]; P = 0.38); or any cancer (524 vs. 529 events; 0.99 [0.88–1.12]; P = 0.91) or between omega-3 and placebo groups in cardiovascular death (688 vs. 700; 0.98 [0.88–1.09]; P = 0.68) or other outcomes. CONCLUSIONS During >6 years of treatment followed by >2.5 years of observation, insulin glargine had neutral effects on health outcomes and salutary effects on metabolic control, whereas omega-3 fatty acid supplementation had no effect.

Introduction. In 2011 we had 3823 psychiatrists in Mexico, with an estimated rate of 3.4 per 100 000 inhabitants. In order to achieve the global targets of mental health attention, it is important to update this information. Objetive. To estimate the total number of psychiatrists in Mexico in 2016; detemine their geographic distribution and compare the results with the ones obtained in 2011. Method. Longitudinal and comparative study. Diverse sources of information were consulted in order to update the number of psychiatrists in 2016 and to know their sociodemographic characteristics, that were compared with the ones obtained in 2011. Results. 4 393 psychiatrists practiced their specialty in Mexico in 2016. With a population of 119 530 753 inhabitants, we obtained a rate of 3.68 psychiatrists per 100 000 inhabitants. There´s a poor distribution of theese specialists in the country. Around 60% of all psychiatrists practice in the tree major cities of Mexico. Discussion and conclusion. The national rate of psychiatrists increase in comparisson with the one we found in 2011, it remains lower that the one recommended by the World Health Organization (WHO). Geographic distribution of the psychiatrists is inequitative because of centralization and economic factors. Key words: Mexico, psychiatrists, distribution, board certification.

International audience; BACKGROUND: The use of n-3 fatty acids may prevent cardiovascular events in patients with recent myocardial infarction or heart failure. Their effects in patients with (or at risk for) type 2 diabetes mellitus are unknown. METHODS: In this double-blind study with a 2-by-2 factorial design, we randomly assigned 12,536 patients who were at high risk for cardiovascular events and had impaired fasting glucose, impaired glucose tolerance, or diabetes to receive a 1-g capsule containing at least 900 mg (90% or more) of ethyl esters of n-3 fatty acids or placebo daily and to receive either insulin glargine or standard care. The primary outcome was death from cardiovascular causes. The results of the comparison between n-3 fatty acids and placebo are reported here. RESULTS: During a median follow up of 6.2 years, the incidence of the primary outcome was not significantly decreased among patients receiving n-3 fatty acids, as compared with those receiving placebo (574 patients [9.1%] vs. 581 patients [9.3%]; hazard ratio, 0.98; 95% confidence interval [CI], 0.87 to 1.10; P=0.72). The use of n-3 fatty acids also had no significant effect on the rates of major vascular events (1034 patients [16.5%] vs. 1017 patients [16.3%]; hazard ratio, 1.01; 95% CI, 0.93 to 1.10; P=0.81), death from any cause (951 [15.1%] vs. 964 [15.4%]; hazard ratio, 0.98; 95% CI, 0.89 to 1.07; P=0.63), or death from arrhythmia (288 [4.6%] vs. 259 [4.1%]; hazard ratio, 1.10; 95% CI, 0.93 to 1.30; P=0.26). Triglyceride levels were reduced by 14.5 mg per deciliter (0.16 mmol per liter) more among patients receiving n-3 fatty acids than among those receiving placebo (P

International audience; BACKGROUND: The provision of sufficient basal insulin to normalize fasting plasma glucose levels may reduce cardiovascular events, but such a possibility has not been formally tested. METHODS: We randomly assigned 12,537 people (mean age, 63.5 years) with cardiovascular risk factors plus impaired fasting glucose, impaired glucose tolerance, or type 2 diabetes to receive insulin glargine (with a target fasting blood glucose level of ≤95 mg per deciliter [5.3 mmol per liter]) or standard care and to receive n-3 fatty acids or placebo with the use of a 2-by-2 factorial design. The results of the comparison between insulin glargine and standard care are reported here. The coprimary outcomes were nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes and these events plus revascularization or hospitalization for heart failure. Microvascular outcomes, incident diabetes, hypoglycemia, weight, and cancers were also compared between groups. RESULTS: The median follow-up was 6.2 years (interquartile range, 5.8 to 6.7). Rates of incident cardiovascular outcomes were similar in the insulin-glargine and standard-care groups: 2.94 and 2.85 per 100 person-years, respectively, for the first coprimary outcome (hazard ratio, 1.02; 95% confidence interval [CI], 0.94 to 1.11; P=0.63) and 5.52 and 5.28 per 100 person-years, respectively, for the second coprimary outcome (hazard ratio, 1.04; 95% CI, 0.97 to 1.11; P=0.27). New diabetes was diagnosed approximately 3 months after therapy was stopped among 30% versus 35% of 1456 participants without baseline diabetes (odds ratio, 0.80; 95% CI, 0.64 to 1.00; P=0.05). Rates of severe hypoglycemia were 1.00 versus 0.31 per 100 person-years. Median weight increased by 1.6 kg in the insulin-glargine group and fell by 0.5 kg in the standard-care group. There was no significant difference in cancers (hazard ratio, 1.00; 95% CI, 0.88 to 1.13; P=0.97). CONCLUSIONS: When used to target normal fasting plasma glucose levels for more than 6 years, insulin glargine had a neutral effect on cardiovascular outcomes and cancers. Although it reduced new-onset diabetes, insulin glargine also increased hypoglycemia and modestly increased weight. (Funded by Sanofi; ORIGIN ClinicalTrials.gov number, NCT00069784.).