SUMMARY Background: Psychopathology in children can be conceptualized as a normal development that has gone awry. That is, some conducts which are expectable at a certain age could turn to be inappropriate and pathological if they persist. When some traits, conducts or signs are very conspicuous and they are frequently present together, they are conventionally called syndromes. Studies registering children’s observed conducts by the parents have been very useful to identify groups of symptoms, and several scales have been designed to elicit psychopathology such as the Children’s Behavior Questionnaire (CBQ), Conner’s scales, and the Child Behavior Checklist, CBCL-P. With the exception of the CBQ, the other two instruments, although frequently used as screening instruments in several studies, are too long or too specific to be systematically employed at the general practice services and in the community. More recently, Goodman designed the Strengths and Difficulties Questionnaire (SDQ), which is a 25-item instrument showing an acceptable predictive validity for three groups of disorders: conduct, emotional, hyperactivity and inattentive. In Mexico, our epidemiological work on children’s mental health started at the end of the eighties using the Report Questionnaire for Children (RQC) which is a 10-item screening instrument developed at the end of the seventies for a WHO collaborative research with the aim of extending psychiatric services to primary care settings. In our population, the instrument showed good efficiency with a positive predictive value (PPV) of 76% and a negative predictive value (NPV) of 99%, and it has been useful in detecting mental health problems both in the general population, as well as in primary care services. However, the need to identify what kind of disorders are they and estimating their prevalence remains. The Brief Screening and Diagnostic Questionnaire (CBTD) was built based on previous experience using the RQC. Seventeen items which explored symptoms frequently reported as motives for seeking attention at the out-patient mental health services were added to the original 10 questions of the RQC. Most of them are items included in the CBCL-P, which explore hyperactivity, impulsivity, attention deficit, sadness, inhibition, oppositional and antisocial behaviors, and eating behaviors associated with low or high weight. The aim was to include cardinal symptoms that could lead to identify probable specific syndromes and disorders, based on the parent’s report. The reliability of the instrument was measured using the Kuder- Richarson coefficient (KR-20), obtaining a 0.81 value. Based on responses obtained in a general population sample of 1686 children aged 4 to 16 years in Mexico City, the score at the 90th percentile, five symptoms, was established to define probable caseness. Also, using logistic regression analysis, the association between the cardinal symptoms for different disorders -as defined in the DSMIV and ICD-10 diagnostic criteria- and the rest of the items from the questionnaire was studied in order to obtain symptom profiles or syndromes signaling probable psychiatric disorders. The main objective of the present study was to evaluate the concurrent validity and the efficiency of the diagnostic algorithms of the CBTD, as compared with the psychiatric diagnoses of children attended at two out-patient mental health services in Mexico City. Method: A random sample of consecutive new out-patients aged 4 to 16 years was obtained. The CBTD was administered to the accompanying parent before the consultation. Clinical evaluation was done independently and blind to these results; the psychiatrists emitted diagnoses following the ICD-10 criteria. Diagnostic reliability between this initial evaluation and further diagnosis of hyperactivity and attention deficit disorder, depressive disorder, oppositional and conduct disorder and anxiety disorders, established at the different clinics of the children’s psychiatric hospital showed good agreement with Kappa values ranging from 0.60 to 0.83. Concurrent validity between the diagnostic algorithms of the CBTD and the psychiatric diagnoses was measured using Kappa and Yule statistics. Efficiency measures: sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were also obtained. Results: A total of 530 children were included in the study; 73% were male and 27% female; mean-age was 9.35 (s.d. 3.12) year old. Only eight patients reported less than five symptoms in the CBTD. The 4/5 cut-off point showed a sensitivity of 98.7% and PPV of 99.8%. However, as very few children were below the cut-off point, specificity resulted in 50% and NPV was 12.5%. Also, as the children attended the psychiatric services, they showed a highly symptomatic profile (median= 11 symptoms), concurrent validity analyses were first carried out in a sub-sample including only those patients with three CBTD syndromes at the most (n= 102). Diagnostic algorithms for attention deficit and hyperactivity, depression, and conduct disorders showed fair agreement with the corresponding psychiatric diagnoses: Yule statistic range from 0.43 to 0.55. As it could be expected, sensitivity (range: 71% to 84%) and NPV (range: 85% to 97%) were higher for the most general algorithms, while specificity and PPV were higher for the most stringent definitions. Analyses including the whole sample showed a sensitivity ranging from 54% to 95%, and NPV from 70% to 98% for the different diagnostic algorithms, and thus indicating a high efficiency of this brief instrument. Conclusion: The CBTD seems to be a good and efficient screening instrument, useful for the detection of the most frequent psychiatric disorders in childhood and early adolescence. Results suggest that it should be tested and incorporated as a tool at primary health services for the systematic surveillance of mental health during childhood and adolescence.

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OBJECTIVE: The growing burden of mental disorders in Latin America and the Caribbean has become too large to ignore. There is a need to know more about the prevalence of mental disorders and the gap between the number of individuals with psychiatric disorders and the number of those persons who remain untreated even though effective treatments exist. Having that knowledge would make it possible to improve advocacy, adopt better policies, formulate innovative intervention programs, and apportion resources commensurate with needs. METHODS: Data were extracted from community-based psychiatric epidemiological studies published in Latin America and the Caribbean from 1980 through 2004 that used structured diagnostic instruments and provided prevalence rates. Estimates of the crude rates in Latin America and the Caribbean for the various disorders were determined by calculating the mean and median rates across the studies, by gender. In addition, data on service utilization were reviewed in order to calculate the treatment gap for specific disorders. RESULTS: Nonaffective psychosis (including schizophrenia) had an estimated mean one-year prevalence rate of 1.0%; major depression, 4.9%; and alcohol use abuse or dependence, 5.7%. Over one-third of individuals with nonaffective psychosis, over half of those with an anxiety disorder, and some three-fourths of those with alcohol use abuse or dependence did not receive mental health care from either specialized or general health services. CONCLUSIONS: The current treatment gap in mental health care in Latin America and the Caribbean remains wide. Further, current data likely greatly underestimate the number of untreated individuals. The epidemiological transition and changes in the population structure will further widen the treatment gap in Latin America and the Caribbean unless mental health policies are formulated or updated and programs and services are expanded.

OBJETIVO: La creciente carga de trastornos mentales que afecta a las poblaciones de América Latina y el Caribe es demasiado grande para hacer caso omiso de ella. Por lo tanto, es una necesidad impostergable conocer la prevalencia de los trastornos mentales y la brecha de tratamiento, que está dada por la diferencia entre las tasas de prevalencia verdadera y las de las personas que han sido tratadas, que en algunos casos es grande pese a la existencia de tratamientos eficaces. Si se dispone de mayor informacion, se hace más factible 1) abogar mejor por los intereses de las personas que necesitan atención, 2) adoptar políticas más eficaces, 3) formular programas de intervención innovadores y 4) adjudicar recursos en conformidad con las necesidades observadas. MÉTODOS: Los datos se obtuvieron de estudios comunitarios publicados en América Latina y el Caribe entre 1980 y 2004. En esas investigaciones epidemiológicas se usaron instrumentos diagnósticos estructurados y se estimaron tasas de prevalencia. Las tasas brutas de diversos trastornos psiquiátricos en América Latina y el Caribe se estimaron a partir de las tasas media y mediana extraídas de los estudios, desglosadas por sexo. También se extrajeron los datos correspondientes al uso de servicios de salud mental para poder calcular la brecha en el tratamiento según trastornos específicos. RESULTADOS: Las psicosis no afectivas (entre ellas la esquizofrenia) tuvieron una prevalencia media estimada durante el año precedente de 1,0%; la depresión mayor, de 4,9%; y el abuso o la dependencia del alcohol, de 5,7%. Más de la tercera parte de las personas afectadas por psicosis no afectivas, más de la mitad de las afectadas por trastornos de ansiedad, y cerca de tres cuartas partes de las que abusaban o dependían del alcohol no habían recibido tratamiento psiquiátrico alguno, sea en un servicio especializado o en uno de tipo general. CONCLUSIONES: La actual brecha en el tratamiento de los trastornos mentales en América Latina y el Caribe sigue siendo abrumadora. Además, las tasas actuales probablemente subestiman el número de personas sin atención. La transición epidemiológica y los cambios en la composición poblacional acentuarán aun más la brecha en la atención en América Latina y el Caribe, a no ser que se formulen nuevas políticas de salud mental o que se actualicen las existentes, procurando incluir en ellas la extensión de los programas y servicios.

OBJECTIVE: To estimate the risk of psychiatric disorders across three family generations. MATERIAL AND METHODS: The research design corresponds to a "family history study" and is based upon a household survey conducted in 1995, on a representative sample of Mexico City's adult population aged 18 - 65 years (n=1 932). Briefly, a standardized assessment of adults' lifetime prevalence of psychiatric disorders was obtained using an amended version of the Composite International Diagnostic Interview, CIDI. In addition, all respondents provided information on their parents' psychiatric history of anxiety, affective disorders, and substance-use disorders. Also, respondents who had 4-16 year old children living in the same household were interviewed using a standardized questionnaire that included specific questions on their children's psychiatric symptoms (n=925 parents, corresponding to 1 686 children and adolescents). Familial psychopathology across generations was defined as follows: a) history of psychiatric disorders only in grandparents; b) history of psychiatric disorders in one parent only (mother or father); and, c) history of psychiatric disorders history in grandparents and in parent. The risk of psychiatric morbidity was estimated via odds ratios obtained from logistic regression models with and without random-effects and using Generalized Estimation Equations with robust variance estimation. RESULTS: The risk for psychopathology in the offspring across generations was estimated to be two to three times higher when psychiatric disorders occurred among the parents. The risk of psychiatric disorders was estimated to be higher when comorbidity among different types of disorders was present. CONCLUSIONS: The results suggest that the risk for developing psychopathology across generations is at least moderate and relatively stable. Familial transmission of psychopathology across three generations seems to resemble a genetic mixed model.

OBJETIVO: Estimar el riesgo para desarrollar psicopatología entre padres e hijos a lo largo de tres generaciones. MATERIAL Y MÉTODOS: Se utilizó el método del "estudio de la historia familiar". Para el estudio se utilizaron datos de una encuesta probabilística de hogares efectuada en 1995 en la Ciudad de México. Los probandos fueron adultos entre los 18 a 65 años de edad (n=1 932) a quienes se entrevistó utilizando la Entrevista Internacional Diagnóstica Compuesta. Además, se obtuvo información acerca de antecedentes psiquiátricos en sus padres empleando el método y los criterios diagnósticos de la historia familiar. Finalmente, en aquellos adultos con hijos de entre 4 a 16 años viviendo en el mismo hogar (n=925) se les aplicó un cuestionario para detectar la presencia de psicopatología en cada uno de sus hijos, obteniéndose información acerca de 1 686 niños y adolescentes. Para estimar el riesgo de morbilidad entre generaciones y la interacción entre éstas, se distinguió cuando sólo hubiera antecedentes en los abuelos, solamente en los padres y cuando estaban presentes en los abuelos y en los padres. La probabilidad de ser "caso" se obtuvo a partir de la razón de momios resultante de los análisis de regresión logística siguiendo tres diferentes modelos: el clásico, el con efectos aleatorios y el con ecuaciones de estimación generalizada con varianza robusta. RESULTADOS: La probabilidad de presentar psicopatología es entre dos a tres veces mayor cuando hay trastornos psiquiátricos en los padres. La probabilidad es mayor cuando existe comorbilidad entre diferentes tipos de trastornos. CONCLUSIONES: El riesgo para desarrollar psicopatología entre las generaciones es al menos moderado y relativamente estable. Los resultados sugieren que, en general, la transmisión de psicopatología entre las generaciones es acorde con la de un modelo genético mixto.

OBJECTIVE: To estimate the risk of psychiatric disorders across three family generations. MATERIAL AND METHODS: The research design corresponds to a "family history study" and is based upon a household survey conducted in 1995, on a representative sample of Mexico City's adult population aged 18 - 65 years (n=1 932). Briefly, a standardized assessment of adults' lifetime prevalence of psychiatric disorders was obtained using an amended version of the Composite International Diagnostic Interview, CIDI. In addition, all respondents provided information on their parents' psychiatric history of anxiety, affective disorders, and substance-use disorders. Also, respondents who had 4-16 year old children living in the same household were interviewed using a standardized questionnaire that included specific questions on their children's psychiatric symptoms (n=925 parents, corresponding to 1 686 children and adolescents). Familial psychopathology across generations was defined as follows: a) history of psychiatric disorders only in grandparents; b) history of psychiatric disorders in one parent only (mother or father); and, c) history of psychiatric disorders history in grandparents and in parent. The risk of psychiatric morbidity was estimated via odds ratios obtained from logistic regression models with and without random-effects and using Generalized Estimation Equations with robust variance estimation. RESULTS: The risk for psychopathology in the offspring across generations was estimated to be two to three times higher when psychiatric disorders occurred among the parents. The risk of psychiatric disorders was estimated to be higher when comorbidity among different types of disorders was present. CONCLUSIONS: The results suggest that the risk for developing psychopathology across generations is at least moderate and relatively stable. Familial transmission of psychopathology across three generations seems to resemble a genetic mixed model.

OBJETIVO: Estimar el riesgo para desarrollar psicopatología entre padres e hijos a lo largo de tres generaciones. MATERIAL Y MÉTODOS: Se utilizó el método del "estudio de la historia familiar". Para el estudio se utilizaron datos de una encuesta probabilística de hogares efectuada en 1995 en la Ciudad de México. Los probandos fueron adultos entre los 18 a 65 años de edad (n=1 932) a quienes se entrevistó utilizando la Entrevista Internacional Diagnóstica Compuesta. Además, se obtuvo información acerca de antecedentes psiquiátricos en sus padres empleando el método y los criterios diagnósticos de la historia familiar. Finalmente, en aquellos adultos con hijos de entre 4 a 16 años viviendo en el mismo hogar (n=925) se les aplicó un cuestionario para detectar la presencia de psicopatología en cada uno de sus hijos, obteniéndose información acerca de 1 686 niños y adolescentes. Para estimar el riesgo de morbilidad entre generaciones y la interacción entre éstas, se distinguió cuando sólo hubiera antecedentes en los abuelos, solamente en los padres y cuando estaban presentes en los abuelos y en los padres. La probabilidad de ser "caso" se obtuvo a partir de la razón de momios resultante de los análisis de regresión logística siguiendo tres diferentes modelos: el clásico, el con efectos aleatorios y el con ecuaciones de estimación generalizada con varianza robusta. RESULTADOS: La probabilidad de presentar psicopatología es entre dos a tres veces mayor cuando hay trastornos psiquiátricos en los padres. La probabilidad es mayor cuando existe comorbilidad entre diferentes tipos de trastornos. CONCLUSIONES: El riesgo para desarrollar psicopatología entre las generaciones es al menos moderado y relativamente estable. Los resultados sugieren que, en general, la transmisión de psicopatología entre las generaciones es acorde con la de un modelo genético mixto.