This paper tries to summarize the results of studies from different areas of knowledge supporting the idea that temperamental traits, such as “reckless/hyper-exploratory” attitudes, commonly believed to be associated with psychopathology, surprisingly turn out as adaptive under specific stress conditions. In particular, this paper analyzes an ethologic line of research on primates suggesting models for a sociobiological interpretation of mood disorders in humans; a study that found high frequencies of a genetic variance associated with bipolar disorder in people without bipolar disorder but with hyperactivity/novelty-seeking traits; the outcomes of socio-anthropological-historical surveys on the evolution of mood disorders in Western countries in the last centuries; surveys on changing societies in Africa and African migrants in Sardinia; and studies that found higher frequencies of mania and subthreshold mania among Sardinian immigrants in Latin American megacities. Although it is not unequivocally accepted that the prevalence of mood disorders has increased, it would be logical to suppose that a nonadaptive condition should have disappeared over time; mood disorders, on the contrary, persist and their prevalence might have even increased. This new interpretation could lead to counter discrimination and stigma towards people suffering from the disorder and would be a central point in psychosocial treatments in addition to pharmacological therapy. Our aim is to hypothesize that bipolar disorder, strongly characterized by these traits, may be the result of the interaction between genetic characteristics, not necessarily pathological, and specific environmental conditions rather than a mere product of an aberrant genetic profile. If mood disorders were mere nonadaptive conditions, they would have disappeared over time; however, their prevalence paradoxically persists if not even increases over time. The hypothesis that bipolar disorder may result from the interaction between genetic characteristics, not necessarily pathological, and specific environmental factors seems more credible than considering bipolar disorder as a mere product of an aberrant genetic profile. traits reckless/hyperexploratory recklesshyperexploratory reckless/hyper exploratory reckless hyper “reckless/hyper-exploratory attitudes psychopathology particular humans hyperactivity/noveltyseeking hyperactivitynoveltyseeking hyperactivity/novelty seeking hyperactivity novelty socioanthropologicalhistorical socio anthropological historical centuries Sardinia megacities increased time contrary therapy characteristics pathological profile however hyperexploratory recklesshyper noveltyseeking hyperactivitynovelty

Objective: To assess prevalence and correlates of family caregiver burdens associated with mental and physical conditions worldwide. Methods: Cross-sectional community surveys asked 43,732 adults residing in 19 countries of the WHO World Mental Health (WMH) Surveys about chronic physical and mental health conditions of first-degree relatives and associated objective (time, financial) and subjective (distress, embarrassment) burdens. Magnitudes and associations of burden are examined by kinship status and family health problem; population-level estimates are provided. Results: Among the 18.9-40.3% of respondents in high, upper-middle, and low/lower-middle income countries with first-degree relatives having serious health problems, 39.0-39.6% reported burden. Among those, 22.9-31.1% devoted time, 10.6-18.8% had financial burden, 23.3-27.1% reported psychological distress, and 6.0-17.2% embarrassment. Mean caregiving hours/week was 12.9-16.5 (83.7-147.9 hours/week/100 people aged 18+). Mean financial burden was 15.1% of median family income in high, 32.2% in upper-middle, and 44.1% in low/lower-middle income countries. A higher burden was reported by women than men, and for care of parents, spouses, and children than siblings. Conclusions: The uncompensated labor of family caregivers is associated with substantial objective and subjective burden worldwide. Given the growing public health importance of the family caregiving system, it is vital to develop effective interventions that support family caregivers.

OBJECTIVE: Schizophrenia is a highly disabling disease and is costly to treat. We set out to establish what are the most cost-effective interventions applicable to developing regions and countries. METHODS: Analysis was undertaken at the level of three WHO subregions spanning the Americas, Africa and South-East Asia, and subsequently in three member states (Chile, Nigeria and Sri Lanka). A state transition model was used to estimate the population-level health impact of older and newer antipsychotic drugs, alone or in combination with psychosocial intervention. Total population-level costs (in international dollars or local currencies) and effectiveness (measured in disability-adjusted life years averted) were combined to form cost-effectiveness ratios. FINDINGS: The most cost-effective interventions were those using older antipsychotic drugs combined with psychosocial treatment, delivered via a community-based service model (I$ 2350-7158 per disability-adjusted life year averted across the three subregions, I$ 1670-3400 following country-level contextualisation within each of these subregions). The relative cost-effectiveness of interventions making use of newer, "atypical" antipsychotic drugs is estimated to be much less favourable. CONCLUSION: By moving to a community-based service model and selecting efficient treatment options, the cost of substantially increasing treatment coverage is not high (less than I$ 1 investment per capita). Taken together with other priority-setting criteria such as disease severity, vulnerability and human rights protection, this study suggests that a great deal more could be done for persons and families living under the spectre of this disorder.

OBJETIVO: La esquizofrenia es una enfermedad muy discapacitante y de tratamiento costoso. Decidimos determinar cuáles son las intervenciones más costoeficaces aplicables a los países y regiones en desarrollo. MÉTODOS: Se emprendieron análisis en tres subregiones de la OMS que abarcaban las Américas, África y Asia Sudoriental, y posteriormente en tres Estados Miembros (Chile, Nigeria y Sri Lanka). Se utilizó un modelo de transición de estados para estimar el impacto sanitario en la población de medicamentos antipsicóticos viejos y nuevos, solos o en combinación con medidas psicosociales. A partir de los costos totales a nivel poblacional (en dólares internacionales o en las monedas nacionales) y de la eficacia (medida como el número de años de vida ajustados en función de la discapacidad evitados) se calculó la relación costo-eficacia. RESULTADOS: Las intervenciones más costoeficaces fueron las basadas en el uso de los medicamentos antipsicóticos más viejos unidos a tratamiento psicosocial, en el marco de un modelo de servicios basados en la comunidad (I$ 2350-7158 por año de vida ajustado en función de la discapacidad evitado en las tres subregiones, I$ 1670-3400 tras la contextualización por países dentro de cada una de esas subregiones). Se calcula que la relación costo-eficacia relativa de las intervenciones basadas en medicamentos antipsicóticos «atípicos» más nuevos es mucho menos favorable. CONCLUSIÓN: Adoptando un modelo de servicio comunitario y seleccionando opciones terapéuticas eficaces, el costo de aumentar sustancialmente la cobertura de tratamiento no es elevado (menos de I$ 1 por habitante). Considerados junto con otros criterios de fijación de prioridades como la gravedad de la enfermedad, la vulnerabilidad y la protección de los derechos humanos, el presente estudio parece indicar que se puede ayudar mucho más a las personas y las familias que viven bajo la amenaza de ese trastorno.

OBJECTIF: La schizophrénie est une maladie hautement handicapante et coûteuse à traiter. Nous nous sommes efforcés de déterminer les interventions les plus efficaces parmi celles applicables aux régions et aux pays en développement. MÉTHODES: L'analyse a été effectuée au niveau de trois régions de l'OMS, comprenant les Amériques, la région africaine et l'Asie du Sud-est, puis dans trois de leurs Etats Membres (le Chili, le Nigeria et le Sri Lanka). Un modèle de transition d'état a été utilisé pour estimer l'impact sanitaire en population de médicaments antipsychotiques anciens et plus récents, seuls ou associés à une intervention psychosociale. A partir des coûts totaux pour les populations (en dollars internationaux ou en monnaie locale) et de l'efficacité (mesurée en perte d'années de vie corrigée de l'incapacité évitée), on a établi les rapports coût/efficacité. RÉSULTATS: Le meilleur rapport coût/efficacité a été établi pour les interventions associant des antipsychotiques anciens et un traitement psychosocial, délivrés par un service à base de communautaire (I$ 2350 - 7158 par perte d'année de vie corrigée de l'incapacité évitée pour l'ensemble des trois régions et I$ 1670 - 3400 après contextualisation au niveau des pays dans chacune des régions). Le rapport coût/efficacité des interventions faisant usage d'antipsychotiques nouveaux et « atypiques » est estimé comme nettement moins favorable. CONCLUSION: Si l'on passe à un service à base de communautaire et si l'on choisit des options de traitement efficaces, le coût d'une augmentation substantielle de la couverture thérapeutique n'est pas élevé (moins de I$ 1 d'investissement par habitant). Cette étude, ainsi que d'autres critères de définition des priorités tels que la gravité de la maladie, la vulnérabilité et la protection des droits de l'homme, laissent à penser que beaucoup de choses pourrait être faites pour les personnes et leurs familles confrontées dans la vie à ce trouble.

O fato de que a esquizofrenia possui um melhor prognóstico em sociedades não industrializadas tornou-se um axioma na psiquiatria internacional; as evidências mais comumente citadas provêm de três estudos trans-nacionais da Organização Mundial da Saúde (OMS). Ainda que um conjunto de fatores socioculturais tenha sido considerado como contribuinte para o curso da esquizofrenia em diferentes ambientes, possuímos poucas evidências de países de baixa renda que demonstrem claramente a influência benéfica dessas variáveis. Neste artigo, sugerimos que o achado de melhores desfechos em países em desenvolvimento necessita ser reexaminado por cinco razões: falhas fundamentais nos estudos da Organização Mundial da Saúde; a falta de evidências sobre os fatores socioculturais específicos que contribuem aparentemente para os melhores desfechos; as crescentes evidências incidentais que descrevem o abuso dos direitos humanos das pessoas portadoras de esquizofrenia nos países em desenvolvimento; novas evidências de coortes em países em desenvolvimento descrevendo um quadro muito mais sombrio do que se pensava originalmente; e as rápidas transformações sociais e econômicas estão enfraquecendo os sistemas de atenção familiares para pessoas com esquizofrenia nos países em desenvolvimento. Afirmamos que o estudo do curso de longo prazo desse transtorno mental é fundamental e acreditamos que é tempo de explorar completa e sistematicamente a variação transcultural no curso e no desfecho da esquizofrenia.

That schizophrenia has a better prognosis in non-industrialized societies has become an axiom in international psychiatry; the evidence most often cited comes from three World Health Organization (WHO) cross-national studies. Although a host of socio-cultural factors have been considered as contributing to variation in the course of schizophrenia in different settings, we have little evidence from low-income countries that clearly demonstrates the beneficial influence of these variables. In this article, we suggest that the finding of better outcomes in developing countries needs re-examination for five reasons: methodological limitations of the World Health Organization studies; the lack of evidence on the specific socio-cultural factors which apparently contribute to the better outcomes; increasing anecdotal evidence describing the abuse of basic human rights of people with schizophrenia in developing countries; new evidence from cohorts in developing countries depicting a much gloomier picture than originally believed; and, rapid social and economic changes are undermining family care systems for people with schizophrenia in developing countries. We argue that the study of the long-term course of this mental disorder in developing countries is a major research question and believe it is time to thoroughly and systematically explore cross-cultural variation in the course and outcome of schizophrenia.