Income and mental health

RESUMO: A enorme carga e o sofrimento provocado pelas doenças mentais no mundo tornam imperioso conhecer melhor os seus determinantes. Combater as desigualdades em saude tornou-‐se uma prioridadade de saúde publica, mas e necessário estabelecer as suas vias causais para ser possível implementar intervenções e politicas efetivas. A literatura cientifica tem sugerido a importância dos determinantes sociais na etiologia e evolucao das principais doenças mentais e do suicidio, com especial enfase no papel da desvantagem social. Ainda assim, o papel dos factores psicossociais na saúde mental, e especificamente o papel do rendimento e da sua distribuição não tem sido investigado no meu pais, Portugal. No meu projecto de investigação proponho‐me a estudar se em Portugal existe uma associação entre as doenças mentais e o rendimento absoluto e relativo. Pretendo usar os dados do primeiro inquérito epidemiológico sobre saude mental realizado em Portugal,um inquérito nacional transversal no domicilio que foi conduzido em 2009, integrado no WHO World Mental Health Survey Consortium. Nesta tese de mestrado apresento os resultados da minha revisão da literatura Sobre a relação entre oestatuto socio-economico e a saúde mental e esboço uma proposta de pesquisa para continuar a investigar estetema. A evidencia que apresento mostra que a exposição aum vasto leque de riscos psicossociais, como o baixo rendimento, a educação limitada e o estatuto ocupacionalbaixo,aumenta a probabilidade de desenvolver problemas de saúde mental.. As diferencas em saúde seguem um gradiente social, com piores resultados de saúde a medida que a posição na hierarquia social diminui. Tambem sumarizo a literatura sobre o papel do contexto na produção de desigualdades em saúde para alem das características individuais. Tem especial interesse o potencial efeito na saúde do rendimento relativo e a importância da distribuição dos rendimentos como determinante de saude. Finalmente, delineio os possíveis mecanismos através dos quais o estatuto socio-economico contribui para as disparidades em saúde.-------------------ABSTRACT: The enormous burden and suffering from mental disorders worldwide makes it imperative to better understand its determinants. Tackling nhealth inequalities has become a public health priority, but it is necessary to establish their causalpathways in order to implement effective interventions and policies. Scientific literature has suggested the importance of social determinants in the aetiology and course of major mental disorders and suicide, with special emphasis on the role of social disadvantage. Nevertheless, the role of psychosocial factors on mental health, and specifically the role of income and its distribution, has not been researched in my home country, Portugal. In my research project I propose to study whether in Portugal there is an association between mental disorders and absolute and relative income. I intend to use data from the first Portuguese Mental Health Survey, a national cross-sectional household survey that was conducted in 2009, integrated in the WHO World Mental Health Survey Consortium. In this masters thesis I present the results of my literature review on the relation between Socioeconomic status and mental health and outline a research proposal to further nvestigate this topic. The body of evidence that I present shows that exposure to a wide range of psychosocial risks, such as low income, limited education, and low occupational status, increases the likelihood of mental health problems. Differences in health follow a social gradient, with worsening health as the position in the social ladder decreases. I also summarize the literature on the role of context in producing health inequalities beyond individual characteristics. Of special interest is the potential health effect of relative income and the importance of income distribution as a health determinant. Finally, I outline the various possible mechanisms for health disparities associated with socioeconomic status

Patterns of use of mental health care in Portugal, before and during an economic crisis

RESUMO: Enquadramento: Eliminar a lacuna de cuidados de saúde mental deve ser uma prioridade de saúde pública em todo o mundo, porque o baixo acesso a cuidados de qualidade é uma negação de direitos humanos fundamentais e traduz-se em sofrimento, incapacidade e custos económicos substanciais. Os períodos de crise económica podem aumentar ainda mais a lacuna de tratamento, particularmente em grupos da população já vulneráveis. Organizada em três fases de investigação, esta tese de doutoramento pretende contribuir para um conhecimento mais sistematizado sobre a utilização dos cuidados de saúde mental em Portugal e para uma melhor compreensão do impacto das crises económicas na utilização dos cuidados de saúde mental. Na 1ª fase, foi feita uma revisão sistemática da evidência sobre a associação entre períodos de crise económica e o uso de cuidados de saúde mental. Na 2ª fase, foram avaliados o uso, os padrões e as barreiras à utilização de cuidados de saúde mental em adultos com doença mental em Portugal e o impacto da Grande Recessão no consumo de psicofármacos. Na 3ª fase foram explorados os fatores individuais e contextuais que influenciam os padrões de internamento de doentes agudos, especificamente a demora média, a readmissão e o internamento compulsivo, antes e durante uma crise económica. Métodos: Na 1ª fase da investigação, foi realizada uma revisão sistemática da literatura seguindo o PRISMA Statement. Na segunda fase, foram usados dados do Estudo Epidemiológico Nacional de Saúde Mental (2008/09), um estudo transversal representativo da população portuguesa (n=3849) parte da World Mental Health Survey Initiative, e dados do Follow-up do Estudo Epidemiológico Nacional de Saúde Mental (2015/16) (n=911). Foram efetuados quatro modelos de regressão logística múltipla para avaliar a associação entre variáveis sociodemográficas e clínicas e ter recebido tratamento (sim/não) ou barreiras ao tratamento (baixa necessidade percebida, barreiras atitudinais, barreiras estruturais) nos participantes com doença mental em 2008/09, ajustando por idade, género e presença de doença física. Foram efetuados modelos de equações de estimativas generalizadas múltiplas para estimar a probabilidade na população de consumo de psicofármacos em 2008/2009 (T0) e em 2015/2016 (T1), ajustando por educação. Foram estimados e interpretados odds ratios em níveis específicos dos efeitos principais e dos termos de interação considerando as diferenças de consumo de psicofármacos em T0 e T1, de acordo com o género e a idade. A 3ª fase de investigação usou dados do projeto SMAILE, que estudou utentes das áreas de influência de cinco serviços de Psiquiatria públicos com pelo menos um internamento em 2002, 2007 e 2012. Foram efetuados modelos de regressão logística múltipla para estimar a associação entre demora média mais longa (≥ 17 dias) e readmissão (> 1 admissão) e os fatores sociodemográficos, clínicos e contextuais em estudo. Além disso, foi utilizado um modelo linear generalizado de Poisson para modelar o número esperado de internamentos compulsivos em função das seguintes covariáveis: género, grupo etário, estado civil, educação, situação profissional, presença de tentativa de suicídio, diagnóstico psiquiátrico, ano de avaliação e serviço de Psiquiatria. Resultados: Na 1ª fase foi encontrado que 1) os períodos de crise económica estão associados a aumento da procura de cuidados gerais para problemas de saúde mental, com evidência contraditória quanto à utilização de cuidados especializados psiquiátricos; 2) esses períodos estão associados a maior consumo de psicofármacos e a aumento de internamentos por doença mental, com resultados contraditórios na utilizaçãos de cuidados de saúde mental por comportamento suicidário. Na 2ª fase foi encontrado que 1) a maioria dos participantes (65,4%) com doença mental não recebeu tratamento; 2) o determinante mais importante da utilização de serviços de saúde foi a presença de perturbação do humor, seguido da incapacidade, sendo os participantes solteiros e os que têm ensino básico e secundário os que menos acederam aos serviços de saúde; 3) as barreiras atitudinais foram as mais frequentemente reportadas, seguidas da baixa necessidade percebida e das barreiras estruturais; 4) a probabilidade de reportar barreiras atitudinais foi maior nos participantes com níveis mais baixos de educação e menor nos participantes com perturbação por utilização de substâncias; 5) a baixa necessidade percebida foi mais reportada por solteiros e menos reportada por participantes com perturbação da ansiedade e do humor; 6) a probabilidade de reportar barreiras estruturais foi maior nos participantes desempregados; 7) ajustando para idade, género e educação, foi estimado que a probabilidade na população de consumir qualquer psicofármaco em 2015/16 foi 1,5 vezes maior do que em 2008/09 (OR = 1,50; IC 95%: 1,13–2,01), particularmente para hipnóticos / sedativos (OR = 1,60; IC 95%: 1,14–2,25); 8) as mulheres e os idosos apresentaram maior probabilidade de consumir qualquer psicofármaco, mas a crise económica teve um impacto desproporcional nos homens e nos jovens. Na 3ª fase da investigação, os principais resultados foram: 1) a demora média mais longa foi associada a idade superior, diagnóstico de psicose e internamento compulsivo; 2) a demora média mais curta foi associada a ser casado, ter ensino secundário, ter feito uma tentativa de suicídio, ter o diagnóstico de perturbação de utilização de substâncias e “outras doenças mentais”, ter sido internado em 2012 e pertencer à área de influência de dois dos serviços de Psiquiatria avaliados (Hospital de Magalhães Lemos EPE e Centro Hospitalar Psiquiátrico de Lisboa); 3) a maior probabilidade de readmissão foi associada a ser reformado, ter o diagnóstico de psicose, ter internamento compulsivo e pertencer à área de influência de quatro dos serviços de Psiquiatria avaliados (Hospital de Magalhães Lemos EPE, Centro Hospitalar Psiquiátrico de Lisboa, Hospital Professor Doutor Fernando Fonseca EPE e Unidade Local de Saúde do Baixo Alentejo EPE); 4) a menor probabilidade de readmissão foi associada a ter idade superior e ter ensino secundário ou superior; 5) o aumento de internamento compulsivo foi associado a sexo masculino, ensino secundário ou superior, diagnóstico psiquiátrico de psicose e internamento em 2007 e em 2012; 6) a diminuição de internamento compulsivo foi associada a ser casado ou coabitar, ter feito uma tentativa de suicídio e pertencer à área de influência de três dos serviços de Psiquiatria avaliados (Hospital de Magalhães Lemos EPE, Centro Hospitalar Psiquiátrico de Lisboa e Unidade Local de Saúde do Baixo Alentejo EPE). Conclusões: Os resultados desta tese de doutoramento confirmam as elevadas necessidades não satisfeitas de saúde mental em Portugal, sugerem quais são as principais barreiras aos cuidados e identificam os subgrupos mais vulneráveis a essas barreiras e a padrões de hospitalização mais graves. Esta evidência pode ajudar a estabelecer prioridades de ação quando estamos a viver uma grave crise económica e há uma necessidade urgente de reduzir a lacuna nos cuidados de saúde mental. O atual momento de interesse pela saúde mental deve ser uma oportunidade para investir e melhorar a utilização dos recursos e a organização dos serviços. As estratégias para melhorar a capacidade do setor da saúde mental para responder às necessidades de saúde mental incluem modelos de cuidados mais próximos da população, que facilitam a identificação precoce de problemas de saúde mental e a implementação de intervenções integradas e psicossociais. Este objetivo poderá ser alcançado com o desenvolvimento de uma rede mais robusta e ampla de equipas e de serviços de saúde mental baseados na comunidade, a solução mais efetiva para melhorar a continuidade de cuidados, reforçar a adesão ao tratamento, melhorar o apoio e a colaboração com as famílias e aprofundar a coordenação com os cuidados de saúde primários e os serviços sociais. É também essencial melhorar a procura de ajuda, implementando intervenções de literacia em saúde mental, usando tecnologias digitais e incentivando o contacto interpessoal com pessoas com doença mental. Por último, mas não menos importante, as pessoas com doença mental devem ser envolvidas em todos os aspetos dos cuidados de saúde mental, com pleno reconhecimento de seus desejos e das suas preferências e respeito pelos seus direitos humanos.ABSTRACT: I would like to thank my supervisor, Professor Benedetto Saraceno, for his warm support and critical feedback during the work for this thesis. I am truly grateful for his constant positive reinforcements and for the friendship throughout the years. I also would like to thank Professor Joaquim Gago for co-supervising this thesis. I am especially thankful for his kind support, availability and generosity, fundamental for the completion of this work. I am grateful to my team of the Lisbon Institute of Global Mental Health: it is a privilege to be part of this wonderful group, and this thesis was possible only with your continuous support. To Professor José Miguel Caldas de Almeida, I thank the encouraging advices, friendship and generosity for the implementation of this research project. To Professor Graça Cardoso, I thank the valuable comments, the brainstorm and companionship throughout the execution of the project, and the friendship. I am deeply grateful to Ana Antunes for having been so important for the completion of this work, with our long conversations about everything, her attention to detail, the help with the manuscripts, and her friendship. I also thank Sofia Azeredo-Lopes for her rigour and invaluable help with statistics, essential to accomplish this work, and for the friendship. I thank Ana Oliveira for her always good teamwork. I want to express my gratitude to my colleagues over the years: Diana Frasquilho, Joana Zózimo, Ana Meireles, Marta Agostinho, Daniel Neto, Cheila Almeida, Gina Tomé, and Isa Figueira. I would like to thank Professor Miguel Xavier for all his support. My thanks also go to the SMAILE project team for the excellent learning experience. I am thankful for the fruitful collaboration with Professor Paula Santana, PI of the project. To Adriana Loureiro, thank you for the support, the availability and the beautiful maps. I extend my acknowledgments to all the members of the team: Professor Carla Nunes, Professor João Ferrão, Professor Pedro Pita Barros, Professor Maria do Rosário Partidário, Joana Lima, and all the other members of Centro de Estudos de Geografia e Ordenamento do Território da Universidade de Coimbra I thank the support of the coordinators of the SMAILE project in each participating hospital: Dr. Ana Matos Pires, Dr. António Leuschner, Dr. José Salgado, Dr. Luís Sardinha, and Professor Teresa Maia. I also thank the Psychiatry residents that contributed to the data collection: Drs. Sofia Gomes, Catarina Cochat, José Luís Fernandes, Maria Lima Peixoto, Marlene Alves, Marta Queirós, and Vítor Pimenta (Hospital de Magalhães Lemos EPE); Drs. Rafael Costa, Beatriz Lourenço, Catarina Agostinho, Ciro Oliveira, Filipe Gonçalves, Filipe Vicente, Gonçalo Sobreira, Guilherme Pereira, Gustavo Jesus, Inês Coelho, João Oliveira, Marco Duarte, Margarida Bairrão, Miguel Nascimento, Sérgio Saraiva, Sofia Charro, Tiago Sousa, and Vânia Viveiros (Centro Hospitalar Psiquiátrico de Lisboa); Drs. Ana Sofia Sequeira, Daniel Neto, Hugo da Silva, Ricardo Duque, and Sérgio Pereira (Centro Hospitalar de Lisboa Ocidental EPE); Drs. Ana Filipa Correia, Guilherme Martins, Salomé Magalhães, Márcia Sequeira, Marta Nascimento, Sara Castro, Sofia Barbosa, and Sílvia Batista (Hospital Professor Doutor Fernando Fonseca EPE); and Dr. Catarina Gaspar (Unidade Local de Saúde do Baixo Alentejo EPE). Your collaboration was essential to complete this work. To my global friends Davínia, Patricia, Maria Luisa, Pilar and Anna: it was great to share experiences and to learn from you. I thank Professor Marco Paulino for his role and example in my training as a psychiatrist and for the availability to monitor this thesis. I thank my team at Serviço de Psiquiatria e Saúde Mental of Centro Hospitalar Universitário Lisboa Norte EPE (Joana Pinheiro, Patrícia Plácido, Paula Alves and Tânia Carneiro) for the friendship. To Professor Daniel Sampaio, who inspired me to become a psychiatrist. To Dr. António Neves, Dr. Nazaré Santos, Professor Carlos Góis and Dr. Dulce Bouça, I thank all the good years and experiences that we’ve shared. To Professor António Barbosa, for his trust and encouragement. To Professor Luís Câmara Pestana, for his support. I thank Tiago, for his support over the years and help proofreading this thesis. All my gratitude to my parents and to Ana, for the constant trust, inspiration and availability. And to João, for all his support, understanding, and endless encouragement Background: Closing the mental health care gap should be at the top of the public health agenda worldwide, because low access to quality care is a denial of fundamental human rights and leads to substantial suffering, disability, and economic costs. Periods of economic crisis might further increase the treatment gap, particularly in already vulnerable population groups. Organised in three research phases, this doctoral thesis aims to contribute to a more systematised knowledge about the use of mental health care in Portugal, and to a better understanding of the impact of economic crises on the use of mental health care. A systematic review of the current evidence on the association between periods of economic crisis and the use of mental health care was conducted in the 1st phase. In the 2nd phase the use, patterns and barriers to mental health care among adults with mental disorders in Portugal, and the impact of the Great Recession on the use of psychotropic drugs were evaluated. The individual and contextual factors that influence patterns of use of acute psychiatric inpatient services, specifically length of hospital stay (LOS), readmission and involuntary hospitalisation, before and during an economic crisis, were explored in the 3rd phase. Methods: In the 1st research phase, a systematic literature review was carried out following the PRISMA guidelines. In the 2nd phase research was conducted using data from the National Mental Health Survey (2008/09), a nationally representative cross-sectional survey (n=3849) part of the World Mental Health Survey Initiative, and from the National Mental Health Survey Follow-up (2015/16) (n=911). Four multiple logistic regression models were performed to evaluate the association between sociodemographic and clinical variables and having received treatment (yes/no) or barriers to treatment (low perceived need, attitudinal barriers, structural barriers) among the participants with any 12-month mental disorder in 2008/09, adjusting for age, gender and presence of any physical disorder. Multiple generalised estimating equations models were performed to estimate the population odds of consuming psychotropic drugs in 2008/2009 (T0) and in 2015/2016 (T1), adjusting for education. Odds ratios were estimated and interpreted at specific levels of the main effects and of interaction terms considering differences in psychotropic drugs use in T0 and T1, according to gender and age. The 3rd research phase used data from the SMAILE project which studied patients from the catchment areas of five public psychiatric services who had at least one admission during 2002, 2007 and 2012. Multiple logistic regression models were used to estimate the association between longer LOS (≥17 days) and readmission (>1 admission) with the sociodemographic, clinical, and contextual factors under study. Additionally, a Poisson generalised linear model was employed for modelling the expected number of involuntary hospitalisations as a function of the following covariates: gender, age group, marital status, education, employment status, suicide attempt, psychiatric diagnosis, year of evaluation and psychiatric service. Results: In the 1st phase the main findings were that 1) periods of economic crisis are linked to an increase in seeking general help for mental health problems, with conflicting results regarding the changes in the use of specialised psychiatric care; 2) these periods are associated with a higher use of psychotropic drugs and an increase in hospital admissions for mental disorders, with mixed evidence on the use of mental health care specifically due to suicide behaviour. In the 2nd phase the main findings were that 1) the majority of participants (65.4%) with a mental disorder did not receive treatment; 2) the most important determinant of the use of health services was the presence of a mood disorder, followed by disability, while single participants and those with basic or secondary education were the ones who least accessed mental health care; 3) attitudinal barriers were the most commonly reported barrier to treatment, followed by low perceived need and structural barriers; 4) attitudinal barriers were more likely among participants with lower levels of education, and less likely among participants with substance use disorders; 5) low perceived need was higher among single people, and lower among those with anxiety and mood disorders; 6) structural barriers were more likely among unemployed participants; 7) after adjusting for age, gender and education, population odds of consuming any psychotropic drugs in 2015/16 were estimated to be 1.5 times higher than in 2008/09 (OR = 1.50; 95% CI: 1.13–2.01), particularly for hypnotics/sedatives (OR = 1.60; 95% CI: 1.14–2.25); 8) women and older individuals presented higher odds of consuming any psychotropic drugs, but the economic crisis had a disproportionate impact on men and younger individuals. In the 3rd research phase the main findings were that: 1) longer LOS was associated with older age, a diagnosis of psychosis, and compulsory admission; 2) shorter LOS was associated with being married, having a secondary education, having experienced a suicide attempt, having been diagnosed with a substance use disorder and “other mental disorders”, being admitted in 2012, and belonging to the catchment area of two of the psychiatric services evaluated (Hospital de Magalhães Lemos EPE and Centro Hospitalar Psiquiátrico de Lisboa); 3) higher odds of readmission were associated with being retired, a diagnosis of psychosis, compulsory admission, and belonging to the catchment area of four of the psychiatric services evaluated (Hospital de Magalhães Lemos EPE, Centro Hospitalar Psiquiátrico de Lisboa, Hospital Professor Doutor Fernando Fonseca EPE, and Unidade Local de Saúde do Baixo Alentejo EPE); 4) lower odds of readmission were associated with older age and with having secondary or higher education; 5) an increase of involuntary hospitalisations was associated with male gender, secondary or higher education, a psychiatric diagnosis of psychosis, and admission in 2007 and in 2012; 6) a decrease in involuntary hospitalisations was associated with being married or cohabitating, having experienced a suicide attempt, and belonging to the catchment area of three of the psychiatric services evaluated (Hospital de Magalhães Lemos EPE, Centro Hospitalar Psiquiátrico de Lisboa and Unidade Local de Saúde do Baixo Alentejo EPE). Conclusions: The results of this doctoral thesis confirm the high unmet mental health needs in Portugal, suggest what are the main barriers to care, and identify the subgroups most vulnerable to these barriers and to more severe hospitalisation patterns. This evidence might help to establish priorities for action when we are experiencing a serious economic crisis and there is an urgent need to reduce the mental health care gap. The current momentum of interest in mental health should be an opportunity to invest and improve the use of resources and the organisation of services. Strategies to improve the capacity of the mental health sector to respond to the mental health demands include models of care that are closer to the population, facilitating the early identification of mental health problems and the implementation of integrated and psychosocial interventions. This could be achieved by developing a more robust and widespread network of community-based mental health teams and services, the best solution to enhance continuity of care, to reinforce treatment compliance, to improve support for and collaboration with families, and to improve coordination with primary care and social services. It is also essential to improve help-seeking attitudes by implementing mental health literacy interventions, using digital technologies, and encouraging interpersonal contact with people with mental disorders. Last but not least,people with mental disorders should be engaged in all aspects of mental health care, with the full recognition of their desires and preferences and respect for their human right

Uso da cimicifuga racemosa para tratamento dos sintomas no climatério: Use of racemosa cimicifuga to treat climate symptoms

Introdução: O climatério é uma fase de transição na vida das mulheres, com manifestações clínicas como irritabilidade, fogachos e a diminuição da libido. A partir dos 40 anos, há o início das alterações físicas e psicossociais nas mulheres, e, tal faixa etária aliada ao padrão menstrual alterado indicam muitas vezes o diagnóstico do climatério. Sendo assim, há demandas de estratégias que melhorem a qualidade de vida, como as terapias adjuvantes. A fitoterapia é uma terapia adjuvante histórica e promissora, nesse âmbito, a Cimicifuga Racemosa (CR) se destaca pelas possíveis propriedades sobre os sintomas climatéricos durante essa fase. Objetivo: O presente artigo tem por objetivo avaliar os benefícios do uso da CR em mulheres climatéricas avaliando os resultados obtidos desse fitoterápico de acordo com a literatura. Metodologia: Trata-se de uma revisão bibliográfica integrativa, qualitativa e retrospectiva de estudos nacionais e internacionais das bases de dados: Biblioteca Virtual em Saúde, Scientific Electronic Library Online e Medical Literature Analysis and Retrieval System Online. A fórmula de busca foi composta pelos descritores: “Cimicifuga”, “Fitoterapia”, “Climatério” e “Saúde da Mulher” dos Descritores em Ciências da Saúde (DeCS) aliado aos operadores booleanos “OR” e “AND”, resultando em 5989 artigos, após o uso de critérios de inclusão e exclusão, 10 artigos dos últimos 6 anos foram selecionados para compor essa revisão.  Resultados e Discussão: Dos artigos selecionados para compor essa revisão, 37,5% abordaram o uso do extrato da CR no controle dos sintomas da menopausa. Outros 25% retrataram sobre o uso da CR em relação a parâmetros metabólicos, bem como, suas consequências em relação à perda ponderal. Além disso, 12,5% relataram sobre um ensaio clínico randomizado que analisou os efeitos dos ativos botânicos na pele e antioxidante nas mulheres pós menopausa. Outrossim, 12,5% analisaram sobre o uso da CR na síndrome menopausa causada por LHRH-a no câncer de mama, e 12,5% dos estudos realizaram uma revisão do desenvolvimento ao longo dos 60 anos de medicamentos a partir do extrato da CR. Desta forma, a CR é destacada como relevante no alívio das ondas de calor, sudorese, comprometimento do sono e irritabilidade, nos distúrbios ginecológicos, bem como pode contribuir com a modulação de receptores cerebrais de áreas relacionadas ao sono e ao humor, tais como, os receptores de dopamina e serotonina. Conclusão: A CR demonstra ser eficaz nos sintomas do climatério, todavia, configura-se necessário mais estudos para consolidar as propriedades e benefícios do fitoterápico

Income and mental health

RESUMO: A enorme carga e o sofrimento provocado pelas doenças mentais no mundo tornam imperioso conhecer melhor os seus determinantes. Combater as desigualdades em saude tornou-‐se uma prioridadade de saúde publica, mas e necessário estabelecer as suas vias causais para ser possível implementar intervenções e politicas efetivas. A literatura cientifica tem sugerido a importância dos determinantes sociais na etiologia e evolucao das principais doenças mentais e do suicidio, com especial enfase no papel da desvantagem social. Ainda assim, o papel dos factores psicossociais na saúde mental, e especificamente o papel do rendimento e da sua distribuição não tem sido investigado no meu pais, Portugal. No meu projecto de investigação proponho‐me a estudar se em Portugal existe uma associação entre as doenças mentais e o rendimento absoluto e relativo. Pretendo usar os dados do primeiro inquérito epidemiológico sobre saude mental realizado em Portugal,um inquérito nacional transversal no domicilio que foi conduzido em 2009, integrado no WHO World Mental Health Survey Consortium. Nesta tese de mestrado apresento os resultados da minha revisão da literatura Sobre a relação entre oestatuto socio-economico e a saúde mental e esboço uma proposta de pesquisa para continuar a investigar estetema. A evidencia que apresento mostra que a exposição aum vasto leque de riscos psicossociais, como o baixo rendimento, a educação limitada e o estatuto ocupacionalbaixo,aumenta a probabilidade de desenvolver problemas de saúde mental.. As diferencas em saúde seguem um gradiente social, com piores resultados de saúde a medida que a posição na hierarquia social diminui. Tambem sumarizo a literatura sobre o papel do contexto na produção de desigualdades em saúde para alem das características individuais. Tem especial interesse o potencial efeito na saúde do rendimento relativo e a importância da distribuição dos rendimentos como determinante de saude. Finalmente, delineio os possíveis mecanismos através dos quais o estatuto socio-economico contribui para as disparidades em saúde.-------------------ABSTRACT: The enormous burden and suffering from mental disorders worldwide makes it imperative to better understand its determinants. Tackling nhealth inequalities has become a public health priority, but it is necessary to establish their causalpathways in order to implement effective interventions and policies. Scientific literature has suggested the importance of social determinants in the aetiology and course of major mental disorders and suicide, with special emphasis on the role of social disadvantage. Nevertheless, the role of psychosocial factors on mental health, and specifically the role of income and its distribution, has not been researched in my home country, Portugal. In my research project I propose to study whether in Portugal there is an association between mental disorders and absolute and relative income. I intend to use data from the first Portuguese Mental Health Survey, a national cross-sectional household survey that was conducted in 2009, integrated in the WHO World Mental Health Survey Consortium. In this masters thesis I present the results of my literature review on the relation between Socioeconomic status and mental health and outline a research proposal to further nvestigate this topic. The body of evidence that I present shows that exposure to a wide range of psychosocial risks, such as low income, limited education, and low occupational status, increases the likelihood of mental health problems. Differences in health follow a social gradient, with worsening health as the position in the social ladder decreases. I also summarize the literature on the role of context in producing health inequalities beyond individual characteristics. Of special interest is the potential health effect of relative income and the importance of income distribution as a health determinant. Finally, I outline the various possible mechanisms for health disparities associated with socioeconomic status

NEOTROPICAL XENARTHRANS: a data set of occurrence of xenarthran species in the Neotropics

Xenarthrans—anteaters, sloths, and armadillos—have essential functions for ecosystem maintenance, such as insect control and nutrient cycling, playing key roles as ecosystem engineers. Because of habitat loss and fragmentation, hunting pressure, and conflicts with domestic dogs, these species have been threatened locally, regionally, or even across their full distribution ranges. The Neotropics harbor 21 species of armadillos, 10 anteaters, and 6 sloths. Our data set includes the families Chlamyphoridae (13), Dasypodidae (7), Myrmecophagidae (3), Bradypodidae (4), and Megalonychidae (2). We have no occurrence data on Dasypus pilosus (Dasypodidae). Regarding Cyclopedidae, until recently, only one species was recognized, but new genetic studies have revealed that the group is represented by seven species. In this data paper, we compiled a total of 42,528 records of 31 species, represented by occurrence and quantitative data, totaling 24,847 unique georeferenced records. The geographic range is from the southern United States, Mexico, and Caribbean countries at the northern portion of the Neotropics, to the austral distribution in Argentina, Paraguay, Chile, and Uruguay. Regarding anteaters, Myrmecophaga tridactyla has the most records (n = 5,941), and Cyclopes sp. have the fewest (n = 240). The armadillo species with the most data is Dasypus novemcinctus (n = 11,588), and the fewest data are recorded for Calyptophractus retusus (n = 33). With regard to sloth species, Bradypus variegatus has the most records (n = 962), and Bradypus pygmaeus has the fewest (n = 12). Our main objective with Neotropical Xenarthrans is to make occurrence and quantitative data available to facilitate more ecological research, particularly if we integrate the xenarthran data with other data sets of Neotropical Series that will become available very soon (i.e., Neotropical Carnivores, Neotropical Invasive Mammals, and Neotropical Hunters and Dogs). Therefore, studies on trophic cascades, hunting pressure, habitat loss, fragmentation effects, species invasion, and climate change effects will be possible with the Neotropical Xenarthrans data set. Please cite this data paper when using its data in publications. We also request that researchers and teachers inform us of how they are using these data

Characterisation of microbial attack on archaeological bone

As part of an EU funded project to investigate the factors influencing bone preservation in the archaeological record, more than 250 bones from 41 archaeological sites in five countries spanning four climatic regions were studied for diagenetic alteration. Sites were selected to cover a range of environmental conditions and archaeological contexts. Microscopic and physical (mercury intrusion porosimetry) analyses of these bones revealed that the majority (68%) had suffered microbial attack. Furthermore, significant differences were found between animal and human bone in both the state of preservation and the type of microbial attack present. These differences in preservation might result from differences in early taphonomy of the bones. © 2003 Elsevier Science Ltd. All rights reserved

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research