OBJETIVOS: Validar la Prueba de Identificación de Trastornos Derivados del Consumo de Alcohol (AUDIT, por su sigla en inglés) en pacientes con esquizofrenia. MÉTODOS: Se aplicó la Cédula Diagnóstica Internacional Compuesta (CIDI, por su sigla en inglés) versión 1.0 y el AUDIT a 80 sujetos con esquizofrenia, de ambos sexos y mayores de 16 años, de la consulta externa del Instituto Nacional de Psiquiatría de la ciudad de México. RESULTADOS: De los 80 pacientes esquizofrénicos, 57 eran hombres y 23 mujeres con un promedio de edad de 30,5 y 34,3 años, respectivamente; la edad de inicio de la esquizofrenia fue de 22 años para los hombres y 26 años para las mujeres; 35 sujetos (43,7%) consumían alcohol al momento del estudio. La escala AUDIT mostró alta consistencia interna, con un alfa de Cronbach de 0,812; el punto de corte de la escala completa del AUDIT para esta población fue de 4 puntos o más; se construyeron los puntos de corte de la "prueba rápida" y de los "Problemas psicosociales y probable dependencia al alcohol" del AUDIT utilizando como estándar de comparación el CIDI (DSM-III-R y CIE-10). CONCLUSIONES: La validación del AUDIT mostró que es un instrumento de tamizaje muy útil y sensible para identificar a pacientes con esquizofrenia en riesgo de abuso o dependencia de alcohol, por lo que se recomienda su uso en estudios clínicos y epidemiológicos en Latinoamérica.
OBJECTIVES: To validate the Alcohol Use Disorders Identification Test (AUDIT) in schizophrenic patients. METHODS: The Composite International Diagnostic Interview (CIDI v. 1) and the AUDIT were administered to 80 subjects with schizophrenia, of both sexes, more than 16 years of age, from the outpatient services at the National Institute of Psychiatry in Mexico City. RESULTS: Of the 80 schizophrenic patients, 57 were men and 23 women, with a mean age of 30.5 years and 34.3 years, respectively; the age at schizophrenia onset was 22 years for men, and 26 years for women; 35 subjects (43.7%) were consumers of alcohol at the time of the study. The AUDIT scale showed high internal consistency with a Cronbach's alpha of 0.812; for this population, the cutoff point for the full AUDIT scale was 4 points or more; cutoff points for the AUDIT "rapid test" and the "psychosocial issues and probable alcohol dependence" were based on benchmarking against the CIDI (DSM-IIIR and ICD-10). CONCLUSIONS: The AUDIT validation showed it to be a useful and sensitive screening tool for identifying schizophrenic patients at risk for alcohol abuse and dependence; therefore, it is recommended for use in clinical and epidemiological studies in Latin America.
Summary In this manuscript we describe results obtained for Group III of the Integral Rehabilitation Program for Outpatient Schizophrenic Patients (IRPS III) at the National Institute of Psychiatry Ramón de la Fuente. This program was created for Mexican schizo-phrenic patients as a refined alternative for the treatment, rehabilitation and integration to a productive life within society. It is interdisciplinary and integral in nature; both patients and their relatives are involved in the treatment and rehabilitation. It includes admission, stabilization of clinical symptoms, and application of strategies for rehabilitation for one year (pharmacological treatment, group psychotherapy, labor -vocation induction therapy, music therapy, psychosocial psychotherapy, occupational therapy, artistic painting, drawing, and Hata-Yoga workshops, psycho-educational workshops for relatives, group dynamics therapy with responsible relatives, and unifamilial psychotherapy); there were assessments at the beginning and at end of the study. Objective To evaluate the efficacy of an interdisciplinary and integral program in these patients, with respect to a control group that received the usual medical-psychiatric treatment. Evaluation was carried out according to: a) Severity of psychiatric symptoms, b) Treatment compliance, c) Everyday performance, d) Psychosocial functioning, e) Global activity, f) Home occupational activities, g) Expressed emotion and attribution of the illness, and h) Patterns of communication and relationship within the family. The goals of this program were to reduce the disabilities and to profit from the conserved functions, as well as to develop other skills in order to increase the quality of life of patients. Methods This was a quasi-experimental pretest-postest prospective study where an experimental group and a control group were compared. The control group (n=39) received the usual psychiatric management, while the experimental group (n=39), participated in addition to this management, in a one-year integral rehabilitation program at the outpatient service of the institute. The sample was obtained in a non-probabilistic and sequential way, according to the established inclusion and exclusion criteria. Variables:Efficacy was evaluated through: a) Severity of psychiatric symptoms; b) Treatment compliance; c) Everyday functioning; d) Psychosocial functioning; e) Occupational activities at home; f) Expressed emotion; g) Patterns of communication and relationship within the family. Instruments: Composite International Diagnostic Interview (CIDI), Positive and Negative Syndrome Scale (PANNS), Clinical Interview and File, Everyday Unemployment Scale, Psychosocial Functioning Scale, Global Assessment Scale, Assessment and Follow-up Questionnaire, Patient Labor Performance Scale, Social Behavior Assessment Schedule (SBAS), Five Minute Speech Sample (FMSS), Verification of the Performance in Occupational Activities for Schizophrenic Patients, Extrapyramidal Symptom Scale. Procedures: a) Incorporation of patients and relatives to the study; b) Stabilization of clinical symptoms; c) Initial assessment; d) Program application; e) Final assessment. Results Demographic data: There were 47 subjects in the final sample, 25 in the experimental group, and 22 controls. There were more males than females in both groups (76% in the experimental group and 63.6% in controls). Being single was the most frequent marital status among patients (88% in the experimental group and 91% in controls). Education was slightly higher in the experimental group, were 40% had a bachelor´s degree as opposed to 27.2% in controls. Treatment compliance: The program had a final efficiency of 64% for the experimental group and 56% for controls. Some of the experimental subject’s characteristics at the beginning of the program were related with treatment compliance: age, years of illness history, and number of different diagnoses. It was determined that 62% of the patients who completed the program were less than 30 years old, and in 80% of the cases the onset of the illness was less than 10 years ago. Regarding the number of diagnoses per patient, 60% of those who completed the study had one diagnosis, 40% had two or more. On the contrary, 30% of the patients who abandoned the study had one diagnosis and 70% had two or more. In other words, almost three fourths of the sub-sample that abandoned the Program had more than one diagnosis: 31% had two, 31% had three, and 10% had four or more. Clinical area: In the clinical area, there were no significant differences between groups. However, patients in the experimen-tal group had a higher level of clinical adaptation and treatment compliance. Everyday performance: The everyday performance was improved in patients from the experimental group, with statistically significant changes in 71.5% of the pretest-postest evaluated areas, with emphasis on self-care, family and interpersonal relationships, and remunerated work. In the control group, there was an improvement only in 28.5% of the areas. Psychosocial functioning: Global and by-area psychosocial functioning showed statistically significant differences in the experimental group in all functioning areas; there was an improvement from three to two, the latter number meaning feeling satisfied. This was not the case in the control group. Behavior at home: In the experimental group, the perception in families was that occupational behavior at home was improved, according to the final score. Family assessment: Relatives in the experimental group attributed the problems they had with the patient to personality characteristics. These problems were diminished at the end of the study, but not in the control group. When relatives attributed problems to the way of being and attitudes of patients, there was a decrease of problems from 31.6% to 26.3%. Emotional Expression in relatives from the experimental group was observed in 79.2% at the beginning of the treatment program, which decreased to 33.3% at the end of the study, with a significant difference of p <0.006, as opposed to relatives in the control group, who did not show statistically significant differences. Clinical assessment of families: At the beginning of the program, this group established reiterative communication patterns. The patient showed rejection to communication. Relatives blamed schizophrenia for the lack of communication. At the end of the program, patterns of communication had importantly improved. Conclusions Demographic data in our sample are similar to those described in previous reports for male:female ratio, marital status, and education. Some characteristics of the patients, in particular age, years from onset of illness, and psychiatric comorbidity assessed at recruitment were associated with completing or not the program. At the end of the study it was clear the program reached its goals of reducing the patients’ disabilities and profiting of conserved functions: 64% of the patients in the experimental group were more stable in clinical terms, and treatment compliance was better. Also, everyday performance was notably improved. In the experimental group there were pretest-postest statistically significant differences in 71.5% of the studied area, especially in self-care and interpersonal relationships. In the control group there were significant changes only in 28.5% of the areas. One level of improvement was observed in global and by-area psychosocial functioning in the experimental group, but not in controls. Patients at the end of the study had switched from a score of three (neutral, unconcerned) to level two (satisfied with their own functioning). In the control group there were no statistically significant differences. Emotional expression in relatives in the experimental group significantly decreased at the end of the study (p< .006), but not in the control group, given that the latter did not show statistically significant differences. Occupational activities at home were also improved in the experimental group, with better scores at the end of the study. Regarding the assessment of occupational therapy, there were significant differences in four areas. Other areas with positive changes were: disease attribution to the patient, and patterns of communication in the family. The areas with better results were self-care, socialization, and family dynamics, which are frequently altered in schizophrenic patients. These results showed the efficacy of the program in its integral version (pluridimensional). Once the proposed objectives are reached, we propose to continue this program with important modifications of the method, which will be described in future publications.
Summary Background: Between 1% and 1.5% of the world population is affected by schizophrenia. In Mexico, it has been estimated that between 619,550 and 1,239,101 (1-2%) individuals suffered from schizophrenia in 2000. The condition is more common among male teenagers and young adults. The main features of schizophrenia are the positive and negative symptoms closely associated with a psychosocial functioning impairment. In addition, between 25% and 80% of the psychiatric population uses addictive substances, with alcohol, at 50%, being one of the most highly used. These substances use is closely associated with a poor psychosocial functioning; when alcohol use is accompanied by schizophrenia, psychosocial functioning is even more disrupted. In the last few years, it has been shown that an early reinsertion of schizophrenic individuals into their social and familial environment causes a lesser degree of impairment in their psychosocial functioning. This functioning is evaluated through the acquisition of new skills to move about in familial, social and work environments. The latter is called psychosocial treatment. In this sense, psychosocial functioning is described as each individual’s ability to adapt, function, move about and interact in a social and personal environment. This functioning evaluates the social, occupational, economic, sexual and familial areas. Objective: The objective of this study was to establish the association between schizophrenic patients’ psychosocial functioning according to their alcohol use and the severity of schizophrenia. Methodology: Eighty schizophrenic, psychiatrically stable, subjects were selected during a 14-month period of time. All of them were submitted only once to the Psychosocial Functioning Scale (PFS), the Composite International Diagnostic Interview (CIDI), the Positive and Negative Symptoms Scale (PANSS) and the Alcohol Use Disorders Identification Test (AUDIT). These scales were used in order to confirm the schizophrenia diagnostic and its severity, to measure the psychosocial functioning of this population, to identify early on problems related to alcohol use and to perform an alcohol use/dependency diagnostic on those individuals who met such diagnostic criteria. A Chi squared, Mann-Whitney’s U, the t test, Kruskal-Wallis and the one-way ANOVA were used for statistical analysis purposes. Results: Seventy-one percent of the subjects were males and 29% females; 87% were single and 70% were unemployed or had an informal job. Thirty-one years was the average age among males and 34 among females. Subjects started suffering schizophrenia when they were between 12 and 30 years (average: 23 years; SD: 6.36), and 94% of them started using alcohol while they were at this very same age range (average: 20 years; SD: 4. 98). Seventy-six percent of the subjects presented a schizophrenia evolution of less than ten years. Comparing alcohol use with psychosocial functioning according to the AUDIT, the social and familial were the more affected areas, both of which showed statistically significant differences. As to the period of evolution of schizophrenia and psychosocial functioning, the 16-20 year group was the one which showed less satisfaction. Schizophrenia severity did not show any statistical significance when compared to the type of alcohol use. Conclusion: Results from this research are similar to those from other Mexican and international studies which have found out that schizophrenia onset is more common during teenage, that more men than women are affected by the condition and that most subjects suffer it first when they are between 16 and 25 years. On the other hand, it has been found out that alcohol use is starting at increasingly early ages, with men being the main users. Such an association has lead many researchers to think that schizophrenia onset is highly associated with alcohol use, be it because the negative symptoms of schizophrenia promote the initial use of alcohol or because alcohol use triggers the early onset of schizophrenia. In this study it was not possible to prove such an hypothesis given the reduced number of subjects in the sample. This was not either the main objective of the study and given the fact that some other type of methodology is required to identify such an association. However, it is clear that there is a high non-diagnosed comorbidity between schizophrenia and alcohol use which, as a result, is not treated and translates, ultimately, into a bigger impairment of the psychosocial functioning. Among the scales employed, AUDIT is an excellent screening instrument to detect subjects at risk of becoming alcoholics and to identify incipient alcohol use patterns and the problems associated with it. Thus, it is suggested that it could be used both in first and third level hospitals. Finally, although no statistically significant results were found out in any of the variables, there is enough evidence where the association between schizophrenia and alcohol leads to an accumulated effect influencing the psychosocial functioning impairment. In the light of this, it is suggested that clinicians inquire about alcohol use in patients showing some mental pathology to research more in depth the schizophrenia-alcohol comorbidity phenomenon and its association with psychosocial functioning so as to design adequate prevention, treatment and rehabilitation programs for the schizophrenic population.