ABSTRACT Introduction: Drug use and its social and health consequences are subject of interest. Students' surveys are epidemiological strategies to monitor this problem, and they are complemented with household and specific population surveys. All this can show in advance some phenomenon that later is visible in general population. Besides drug use trends and patterns, these studies show the influence of other factors that may increase the drugs use and their consequences. Objective: To know the drugs, alcohol and tobacco use prevalences in elementary (5th and 6th grade), middle and high school students (7th-12th grades) of Mexico and its States. Material and methods: This survey is a probabilistic elementary-high school students' survey with national and statal representativity. The study sample had 52 171 elementary students and 114 364 middle and high school students. The information was obtained with a previously standardized and validated questionnaire. Results: The lifetime tobacco use was 30.4% and the average onset age was 13.4 years old. 53.2% has drunk alcohol and 14.5% has binge drinking. Any drug use lifetime prevalence is 17.2%. The preferred drugs are marihuana (10.6%), followed by inhalants (5.8%) and cocaine (3.3%). Discussion and conclusion: The increase in drugs use, specially of marihuana and alcohol, highlights the importance of creating new prevention strategies focused to decrease their use rate among students.

RESUMEN Introducción: El consumo de drogas y sus consecuencias sociales y de salud son del interés de múltiples sectores. Las encuestas en estudiantes son estrategias epidemiológicas para monitorear el problema, las cuales se complementan con encuestas de hogares y en grupos especiales de la población, lo que permite ver anticipadamente fenómenos que posteriormente son evidentes en la población general. Además de las tendencias y del patrón de consumo de drogas, estos estudios muestran la influencia de otros factores que incrementan el uso y sus consecuencias. Objetivo: Conocer las prevalencias de uso de drogas, alcohol y tabaco en estudiantes de primaria (5° y 6°) y secundaría-bachillerato de México y sus Estados. Método: Es una encuesta probabilística en población escolar 5° y 6° de primaria, secundaria y bachillerato con representatividad nacional y de cada Estado del país. La muestra fue de 52 171 alumnos en primaria y 114 364 en secundaria-bachillerato. La información se obtuvo mediante un cuestionario estandarizado y validado en encuestas anteriores. Resultados: El consumo de tabaco alguna vez fue de 30.4% y la edad promedio de inicio de esta sustancia fue 13.4 años. El 53.2% ha bebido alcohol y 14.5% ha bebido en exceso. La prevalencia de consumo de drogas alguna vez fue de 17.2%. Las drogas de preferencia son la mariguana (10.6%), seguida de inhalables (5.8%) y cocaína (3.3%). Discusión y conclusión: El crecimiento del consumo de sustancias, principalmente mariguana y alcohol, resalta la importancia de la creación de nuevas estrategias de prevención para disminuir los índices de consumo entre los estudiantes.

Introduction In the international context, Mexico is a country with low drug use level, in turn, it shows an increase when considering the most recent epidemiologic trends. In order to maintain an updated analysis of drug use in general population and to identify the most at risk groups, the National Survey of Addictions (ENA) was held in 2011. Objetive The aim of the study was to determine the lifetime prevalence for any drug and any illegal drug use at a national and regional level, in population aged 12 to 65 years. Also, to acknowledge drug consumption trends since 2002 in Mexico. Material and methods ENA 2011 survey is a randomized, multistage probabilistic study. It is representative at a national level and also for eight regions of the country, including rural and urban population. The sample was 3 849 adolescents and 12 400 adults who answered a computerized version of a standardized questionnaire containing sections of tobacco, alcohol, medical drugs (opiates, tranquilizers, sedatives, amphetamines) and illegal drugs (marijuana, cocaine, crack, hallucinogens, inhalants, heroin and methamphetamines). All participants read and signed an informed consent. Emphasis was made on the voluntary and confidential use of the information. Results The national lifetime prevalence of any drug grew between 2002 and 2011, increasing significantly from 5.0% to 7.8%, while consumption of any illegal drugs increased from 4.1% to 7.2%. By sex, in men, any drug use increased from 8.6% to 13%. Illegal drugs increased from 8.0% to 12.5%. In women, use of any drug increased from 2.1% to 3.0% and use of any illegal drug increased from 1.0% to 2.3%. Marijuana is the first drug of choice (6.5%) followed by cocaine (3.6%). Considering regions, any drug consumption grew significantly in the Western (5.5% to 10.3%), Northeast (5.5% to 10.3%), North Central (7.5% to 9.2%) and South Central (4.2% to 7.5%). As for illegal drugs, there is also a statistically significant increase in these regions, however, growth was proportionally bigger in South Central region, going from 3.5% to 6.8%. Conclusions Results from this study indicate a growth in the consumption of illegal drugs from 2002 to 2011, especially in marijuana. It also shows that men from 18 to 34 years are the most affected by this consumption, while increases in adolescent men have been low. Moreover, the study shows that those who have received some type of prevention, showed a smaller consumption prevalence, indicating that further work is needed in this area with young people to consolidate activities of health promotion and drug use prevention, working with infant population is needed, including a systematic evaluation of the actions mentioned above. In the international context, data from this study confirms that Mexico continues reporting low levels of drug consumption.

Introducción En el contexto internacional, México es uno de los países con bajo nivel de consumo de drogas, pero que, a su vez, reporta un incremento si se consideran las tendencias epidemiológicas más recientes. Con la finalidad de mantener un diagnóstico actualizado del consumo de drogas en la población general y de identificar los grupos en mayor riesgo, se llevó a cabo la Encuesta Nacional de Adicciones 2011 (ENA). Objetivo Conocer la prevalencia alguna vez en la vida de uso de cualquier droga y de cualquier droga ilegal a nivel nacional y regional en población de 12 a 65 años. Así como conocer las tendencias que ha seguido el consumo a partir de 2002. Material y métodos La ENA 2011 es un estudio aleatorio, probabilístico y polietápico con representatividad nacional y para ocho regiones del país. Incluye poblaciones rurales y urbanas. La muestra fue de 3 849 adolescentes y 12 400 adultos quienes contestaron un cuestionario estandarizado en versión computarizada que contiene las secciones de tabaco, alcohol, drogas médicas (opiáceos, tranquilizantes, sedantes, anfetaminas) e ilegales (mariguana, cocaína, crack, alucinógenos, inhalables, heroína y metanfetaminas). Todos los participantes leyeron y firmaron una carta de consentimiento informado. Se hizo énfasis en el carácter voluntario y confidencial de la información. Resultados La prevalencia de consumo de cualquier droga alguna vez en la vida a nivel nacional creció significativamente entre 2002 y 2011 al pasar de 5.0% a 7.8%, mientras que el consumo de cualquier droga ilegal incrementó de 4.1% a 7.2%. Por sexo, en los hombres el consumo de cualquier droga pasó de 8.6% a 13% y de drogas ilegales de 8.0% a 12.5%. En las mujeres, la primera aumentó de 2.1% a 3.0% y la segunda de 1.0% a 2.3%. Las drogas de preferencia continúan siendo la mariguana (6.5%) y la cocaína (3.6%). A nivel regional el consumo de cualquier droga creció significativamente en la Occidental (5.5% a 10.3%), Nororiental (5.5% a 10.3%), Norcentral (7.5% a 9.2%) y Centro Sur (4.2% a 7.5%). En cuanto a las drogas ilegales, también se encuentra un incremento estadísticamente significativo en estas regiones, sin embargo el crecimiento fue proporcionalmente mayor en la región Centro Sur, al pasar de 3.5% a 6.8%. Conclusiones Los resultados de la ENA señalan un crecimiento en el consumo de drogas ilegales de 2002 a 2011, especialmente de la mariguana. Asimismo, se observa que los hombres de 18 a 34 años son la población más afectada por dicho consumo, mientras que en los adolescentes el aumento ha sido mínimo. Por otra parte, el estudio muestra que quienes han recibido algún tipo de prevención presentan las prevalencias de consumo más pequeñas, lo cual indica que es necesario seguir trabajando en esta área con los jóvenes para consolidar las acciones de promoción de la salud y prevención; así como trabajar más con la población infantil, con una evaluación sistemática de todas estas acciones. En el contexto internacional los datos confirman que México continúa con niveles bajos de consumo.

In the course of the last three years, a wide range of epidemiological studies related to drug use has been conducted, both at a national and international level. Talking about national studies in the field of school population, surveys have been conducted in the states of Colima, Nuevo León and Jalisco, as well as surveys in university population, among others. Regarding tobacco use, several studies were made and they covered many cities of the country. About household surveys, the fifth National Addictions Survey (ENA) was carried out in 2008 and it provided data at a national and state level. The Global Survey of Smoking in Adults (GATS) was also made having nationwide coverage. In relation to tobacco use, the trend shows a decrease in the prevalence of consumption. This is shown in ENA 2008 and GATS, as well as school population studies in different states. For alcohol consumption, the situation is different; both for the prevalence and for the proportion of people who start its early consumption, significant increases have been reported throughout the country. Alcohol abuse remains constant and is similar between men and women. When considering the use of illegal drugs, there is an overall increase. As for marijuana, data indicates that its consumption has increased and that it remains as the primary drug of use. However, the main increase is for inhalants, particularly among school population and especially in women. For cocaine, data from United Nations shows a significant decrease in the supply of this substance due to the increase of seizures. Data from ENA 2008 shows that the use of this drug has doubled between 2002 and 2008. The United Nations report indicates that the increase in our country is apparent until 2005 and since then it has been decreasing. Methamphetamine use remains low and it does not increase. Only in the case of the population that goes to service centers for drug users, a high rate of consumption is found. Finally, the consumption of heroin and hallucinogens is low. Chihuahua remains as the state with the most problems in the use of heroine. Most recent surveys have allowed us to see, in general, some of the trajectories in adolescent mental health, where sexual abuse is presented first in women, followed by ADDH, then the consumption of legal drugs, antisocial behavior, use of inhalants and suicide attempt. Then drug consumption, marijuana and cocaine. In men, the sequence is similar, although they face ADDH first and then sexual abuse. In this context, the objective of this study is to assess the prevalence of drug, alcohol and tobacco use, as well as consumption trends in school population from 7th to 12th grade from Mexico City and its political delegations. Method To ensure the comparability with similar studies carried out in Mexico in school population, the methodology used in this study maintains the basic aspects of the previous measurements that have been made in students from 7th to 1 2th grade from Mexico City and other states. The project had the approval of the ethics committee from the National Institute of Psychiatry Ramón de la Fuente Muñiz, and was approved by the educational authorities of Mexico City to be applied in school population. The unit of analysis from which the information was obtained were the students enrolled in 7th to 12th grade in 2008-2009 from public and private schools in Mexico City. The sampling frame was developed based on the official records of the 2008-2009 school year. A non-response rate of 20%, a confidence level of 95% and an average absolute error of 0.004 were considered. The sample design was stratified by level of education (7th to 9th grades and 10th to 12th grades) and political delegations, which gave 32 different strata. It was also clustered by scholar group which was the primary unit of selection. The sample of groups and students were weighted considering the group, educational level and the delegation. A final sample of 22 980 subjects was obtained: 49.8% were female and 50.2% were men. 56.3% of the sample attended to 7th to 9th grades and 43.7% attended to 10th to 12th grades. In addition, most of the male and female adolescents were full-time students during the year prior to the study and only 7% of men and 5.1% of women were not students. 23.3% of men and 11.9% of women worked part or full time, and additionally, most of them had both parents. The information was obtained through a standardized questionnaire, which has been applied in previous surveys and has been previously validated. Due to the extension of the instrument, four forms were used to include various sections, the main part of questionnaire was administered to all subjects and the last two pages corresponded to forms, so each form was applied to one quarter of the sample. Alcohol consumption indicators used are comparable with WHO indicators, international observatories from Europe and the ones used in <<Monitoring the Future.>> Additionally, a significant amount of risk and protective factors related to drug use was evaluated. Results Regarding tobacco use, it decreased from 48.3% to 44.3% compared to the study made in 2006, and men were the ones who had the highest percentage (45.9%) compared with women (42.6%). Additionally, the average onset age is of 12.8 years. As for the current use of tobacco the situation is similar, the percentage is higher in men than in women and is much higher among students from 7th to 9th grades than among students from 10th to 12th grades. In the case of alcohol, its consumption has increased from 68.8% to 71.4%; it was similar in women compared to the last measurement and in men it increased. The prevalence of alcohol abuse decreased from 25.2% to 23.4% compared to the previous survey. However, the students who have taken alcohol had an average onset age of 12.6 years. The problematic alcohol consumption measured with the long version of AUDIT found that in 7th to 9th grades, 1 7.1 % of men and 1 6.3% of women reported having this type of consumption. In 10th to 12th grades, 36.5% of men and 28.5% of women also reported problematic use of alcohol. Regarding dangerous alcohol consumption, 7.2% of men and 6.7% of women presented it in 7th to 9th grades. Students from 10th to 12th grades had higher percentages being of 22.5% in men and 15.3% in women. The study shows a significant increase in drug consumption: during the last three years it has raised from 17.8% to 21.5%. Within each substance use, the consumption of inhalants, marijuana, hallucinogens, and methamphetamines has increased in comparison with the study of 2006. The preference by drug type has changed slightly over the past three years; in men marijuana has the first place of preference (14%), followed by inhalants (10.8%) and in third place of preference is cocaine (4.3%). Women prefer inhalants (10.0%), followed by marijuana (8.8%) and then tranquilizers (5.6%). In terms of additional behaviors evaluated on this study, it is noteworthy that the age of first sexual intercourse decreased by almost half a year in women. All other behaviors (suicide attempt, depressive symptoms, risky eating behaviors, antisocial acts) remained equal. Discussion In this context, the study results show a widespread use of drugs in the population, with major increases specially between women. Adding the presence of other problematic behaviors related to drug use, leads us to make a reflection on the general mental health problems experienced by the population and together they give a guideline for working immediately on various preventive actions. The work made with nursery and elementary boys and girls developing strategies and social skills that enable them to increase their personal and social resources; likewise, working with parents, teachers and health personnel, through positive parenting programs, in groups and teaching them directly effective strategies for interaction and discipline with their children or students under their charge through modeling, are factors that lead to better prevention in most sectors of population. A social policy that allocates more financial and human resources aimed to support these activities must be added to these efforts, especially to support research in general and particularly to support research that leads to develop optimal prevention practices for new generations. Therefore, the importance of translating these elements into action lies in the possibility of having healthier generations and a society with better expectations, approaches and opportunities for growing.

Introducción En los últimos tres años, se ha realizado una amplia gama de estudios epidemiológicos, a nivel nacional e internacional, sobre el consumo de drogas. En cuanto a tabaco, la Encuesta Nacional de Adicciones 2008, la encuesta de GATS y los estudios estatales en población escolar muestran una tendencia importante a la disminución del consumo de la sustancia. Para el consumo de alcohol, tanto en la prevalencia como en la proporción de personas que inicia su consumo temprano, se han reportado incrementos. El abuso de alcohol se mantiene constante y similar entre hombres y mujeres. Al considerar el uso de drogas ilegales hay incrementos importantes. El incremento más pronunciado es el de los inhalables, especialmente en mujeres. En cuanto a la cocaína, la ENA 2008 señala que se ha duplicado el consumo y el informe de la ONU indica que al parecer el incremento se da hasta 2005 y a partir de ahí ha disminuido. Las metanfetaminas mantienen una prevalencia baja. Sólo entre quienes acuden a los centros de servicio para usuarios de drogas se encuentra un alto consumo. En este contexto, el objetivo de este trabajo es evaluar las prevalencias del uso de drogas, alcohol y tabaco, así como las tendencias de consumo en la población de estudiantes de enseñanza media y media superior de la Ciudad de México. Método El marco muestral se elaboró con base en los registros oficiales del ciclo escolar 2008-2009 de la Secretaría de Educación Pública (SEP). Se consideró una tasa de no respuesta de 20%, un nivel de confianza de 95%, con un error absoluto promedio de 0.004. El diseño de la muestra fue estratificado y por conglomerados; la unidad de selección fue el grupo escolar. Se obtuvo una muestra final de 22 980 sujetos y quedó conformada por 49.8% de mujeres y 50.2% de hombres. La información se obtuvo mediante un cuestionario estandarizado, que ha sido aplicado y validado en las anteriores encuestas. Los indicadores de consumo de alcohol, drogas y tabaco empleados son comparables con los indicadores de la OMS, de los observatorios internacionales de Europa y de los usados en <<Monitoring the Future>>. Resultados Con lo que respecta al tabaco, el consumo disminuyó de 48.3 a 44.3% y son los hombres quienes tienen el porcentaje más alto (45.9%) en comparación con las mujeres (42.6%). La edad de inicio promedio es de 12.8 años. En el caso del alcohol, el consumo se ha incrementado de 68.8 a 71.4%; se mantuvo similar en las mujeres y en los hombres se incrementó. En cuanto al consumo problemático del alcohol, medido con el AUDIT versión larga, se encontró que en secundaria, 1 7.1 % de los hombres y 16.3% de las mujeres reportaron tener este tipo de consumo. Para el bachillerato, 36.5% de los hombres y 28.5% de las mujeres reportaron un consumo problemático de alcohol. El estudio señala un incremento importante en el consumo de drogas en los últimos tres años, que de 1 7.8% ha pasado a 21.5%. Al interior de cada sustancia se observa que se ha incrementado el consumo de inhalables, mariguana, alucinógenos y metanfetaminas con respecto a 2006. En este contexto, la preferencia por tipo de droga ha cambiado ligeramente en los últimos tres años, de manera que en los hombres el primer lugar lo ocupa la mariguana (14%), seguido por los inhalables (10.8%) y en tercer lugar la cocaína (4.3%). Las mujeres prefieren los inhalables (10.0%), la mariguana (8.8%) y finalmente los tranquilizantes (5.6%). Discusión Los resultados indican un consumo de drogas importante en la población, con incrementos mayores en las mujeres, lo que debe dar pauta para trabajar inmediatamente en diversas acciones preventivas. El trabajo con los niños/as de preescolar y primaria, desarrollando estrategias y habilidades sociales para incrementar sus recursos personales y sociales, así como el trabajo con padres, maestros y personal de salud, en programas de parentalidad positiva, enseñando por medio del modelamiento estrategias efectivas de interacción y disciplina a sus hijos/as o estudiantes, son elementos que conducirán a una mejor prevención en diversos ámbitos y en la mayoría de los sectores de la población.

Introduction Depression is a public health problem that carries substantial costs for the individual and the society. In order to establish evidence-based priorities for resource allocation in mental health care, it is necessary to integrate the costs and effectiveness of interventions and specify the essential packages for their treatment. The following are pioneering studies of cost-effectiveness for the treatment of depression: 1. compared psychopharmacology options (fluoxetine, imipramine and desipramine) to found no difference between drugs in terms of clinical efficacy, effect on quality of life and costs, and 2. evaluated cost-effectiveness of collaborative program of stepped care in primary care of persistent depression, to demonstrate a substantial increase in the effectiveness and additional moderate cost increase in comparison with usual treatment. Recently, the World Health Organization convened the National Institute of Psychiatry Ramón de la Fuente, as a collaborating center, to participate in the <<Selecting interventions that are cost-effective>> labeled WHO-CHOICE (CHOosing interventions that are Cost-Effective). This paper presents the findings of the evaluation of cost-effectiveness of different clinical interventions for the treatment of depression in Mexico, considering its implementation in primary care services. Method The cost-effectiveness unit of measure gathered by WHO (and used in this work) are the years of healthy life lost because of disease, named DALYs (Disability Adjusted Life Years). DALYs result from the sum of years lost by premature mortality over the years that are lost through living in disability status. The advantages of using a measure of health at the population level as lost DALYs is that it allows comparing interventions for different diseases and addresses a relevant question from the avoidable burden health policy standpoint. Interventions evaluated included: 1. tricyclic antidepressants, 2. new antidepressants (SSRIs), 3. brief psychotherapy, 4. trycliclic antidepressants + brief psychotherapy, 5. new antidepressants + brief psychotherapy, 6. tricyclic antidepressants + brief psychotherapy + proactive case management, and 7. new antidepressants + brief psychotherapy + proactive case management. DALYs avoided as a result of each intervention or combination were calculated to determine its effectiveness. Both patients and program costs, a 3% discount by the process of converting future values to present ones, as well as an age adjustment giving less weight to year lived by the young were included. Finally, the cost of averted DALYs for each intervention was estimated to determine their cost effectiveness. Results The combined strategies of proactive case management with psychotherapy plus antidepressants can be considered as the most effective one. With the combination with tricyclic antidepressants, the number of DALYs averted was 207,1 71, and with SSRI of 21 7,568, corresponding to more than double of DALYs when tricyclic anti-depressants are used alone and almost double when using only SSRIs. The most expensive intervention was the combination of SSRIs with brief psychotherapy, with a total of $12,256 million pesos (972 million dollars), the least expensive treatment were tricyclic antidepressants, which involved $4,523 million pesos (359 million dollars). Over 99% of the costs were from patient medications, and less than 1% from program and training costs. It is clear that the greatest cost is for added proactive case management. The use of SSRI was the most cost-effective treatment (no combination) for the management of depression in Mexican primary care. The most cost-effective combination was tryciclic antidepressants plus brief psychotherapy plus proactive case management. Conclusions Although the are some studies on health economics in Mexico, most are directed to consider costs, and few ones have evaluated the cost-effectiveness relationship of diagnostic and therapeutic interventions, lees son in the mental health field. Antecedents of the present study in Mexico included a study that observed that psychiatric patients require more medical consultations, laboratory analysis, hospitalization days, surgeries and medication, in contrast with patients that never needed mental attention. Nevertheless, investigations about cost-effectiveness relationship are rare. Just one study evaluates the costs of positive changes in psychopathology with antipsychotic medication for the treatment of schizophrenic patients. In this direction, the present work is the first effort to evaluate cost-effectiveness of different communitarian interventions to treat depression in Mexico. According with our findings, also in México, the interventions available to treat depression in primary care level prevent a substantial number of DALYs: almost six times when SSRIs plus brief psychotherapy plus proactive case management are administered. The specific effect of proactive case management is preventing relapses and increasing the time free of disease, which results in greater benefit to the patient, his family and the society. Thus, interventions are cost-effective despite the proactive case management significantly increases the cost of care to these patients. In conclusion, the inclusion of psychosocial treatments is advantageous from a cost-effectiveness standpoint. Averted DALYs with these interventions are more <<economic>>. As observed in previous studies, a modest investment in improving depression produces greater gains in resource-limited environments. In Mexico, there is evidence that such interventions in primary care are effective when they are given by medical staff with a brief training, making them a promising tool for a cost-effective and evidence-based public policy.

Introducción La depresión es un problema de salud pública que conlleva costos importantes para el individuo y la sociedad. Con la finalidad de establecer prioridades basadas en evidencias para la asignación de recursos en el cuidado de la salud mental, es necesario integrar los costos y la efectividad de las intervenciones y especificar los paquetes esenciales para su tratamiento. En esta dirección, la Organización Mundial de la Salud convocó al Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, como centro colaborador, a participar en el proyecto <<Seleccionando intervenciones que son costo-efectivas>> (WHO-CHOICE, por sus siglas en inglés: CHOosing Interventions that are Cost-Effective). El presente texto presenta los hallazgos del estudio de relación costo-efectividad de diferentes intervenciones clínicas para el tratamiento de la depresión en México, considerando su implantación en los servicios de atención primaria a la salud. Método La unidad de medición de costo-efectividad seleccionada por la OMS (y utilizada en este trabajo) son los Años de vida ajustados por discapacidad a causa de alguna enfermedad (AVISA perdidos, en inglés DALYs, Disability Adjusted Life Years), que resultan de la suma de los años que se pierden por mortalidad prematura más los años que se pierden por vivir en una situación de discapacidad. Las intervenciones evaluadas fueron: 1. antidepresivos tricíclicos; 2. antidepresivos nuevos (ISRS); 3. psicoterapia breve; 4. antidepresivos tricíclicos + psicoterapia breve; 5. antidepresivos nuevos + psicoterapia breve; 6. antidepresivos tricíclicos + psicoterapia breve + manejo proactivo de caso; y 7. antidepresivos nuevos + psicoterapia breve + manejo proactivo de caso. Para determinar su efectividad, se calcularon los AVISAs perdidos que se evitan como resultado de cada intervención. Se incluyeron los costos del paciente y los del programa, un descuento de 3% por el proceso de convertir valores futuros a presentes, así como un ajuste por edad, otorgando menos peso a los años vividos por los jóvenes. Finalmente, para determinar la relación costo-efectividad, se calculó el costo por cada AVISA evitado con cada intervención. Resultados Las estrategias combinadas de manejo proactivo de caso con psicoterapia breve más antidepresivos pueden considerarse como las más eficaces. Con la combinación con antidepresivos tricíclicos, el número de AVISAs evitados fue de 207171, y con la de ISRS fue de 217568, lo que corresponde a más del doble de AVISAs cuando se emplean únicamente antidepresivos tricíclicos, y casi al doble cuando se emplean únicamente ISRS. La intervención más costosa fue la combinación de ISRS con psicoterapia breve, con un monto total de $12,256 millones de pesos (972 millones de dólares), y la menos costosa fue el tratamiento con antidepresivos tricíclicos, que implicó $4,523 millones de pesos (359 millones de dólares). De los costos, más de 99% correspondieron a medicamentos, y menos de 1% a los costos del programa y del entrenamiento. Es evidente que el mayor costo corresponde a las intervenciones en que se agrega el manejo proactivo de caso. La intervención que tuvo la mejor relación costo-efectividad, considerando un solo tratamiento, fue el uso de ISRS. La combinación más costo-efectiva fue la de antidepresivos tricíclicos con psicoterapia breve y manejo proactivo de caso. Conclusiones Es claro que las intervenciones disponibles para el tratamiento de la depresión evitan un número considerable de AVISAs. Éste es casi seis veces mayor cuando se administran ISRS + psicoterapia + manejo proactivo de caso, lo que permite que las intervenciones resulten costo-efectivas a pesar de que el manejo proactivo de caso aumenta considerablemente los costos de atención a estos pacientes. El efecto específico del manejo proactivo de caso es que evita las recaídas y aumenta el tiempo libre de enfermedad, lo que se traduce en mayor beneficio para el paciente, su familia y la sociedad en general.

Introduction Schizophrenia is a disorder that causes significant disability. In addition, its treatment is expensive because the increased prescription of atypical antipsychotics with associated high costs. In a recent 14-country study on disability associated with physical and mental conditions, active psychosis was ranked the third most disabling condition in general population, more than paraplegia and blindness. In the global burden of disease study, schizophrenia accounted for 1.1% of the total Disability-adjusted life years (DALYs) and 2.8% of Years of lived with disability (YLDs). The economic cost of schizophrenia for society is also high. The study of the burden of schizophrenia for society, whether expressed in epidemiological or costs terms, is an insufficient basis for setting priorities for resources allocation. Thus, increasingly sophisticated economic models have been developed. Such is the case of cost-effectiveness studies, which show the relationship between resources used (costs) and benefit achieved (effectiveness) of an intervention compared with others. In Mexico, there is only one study that evaluated the cost-effectiveness of different antipsychotics to treat schizophrenia, but it was a specific approach (not generalized), and did not include psychological interventions. The present study is part of a World Health Organization's initiative labeled WHO-CHOICE: CHOosing Interventions that are Cost-Effective. WHO-CHOICE methodology involves the evaluation of interventions based on a generalized measure: DALYs, which allows carrying out several and important comparisons. The main objective was to determine the cost-effectiveness of different interventions for the treatment of schizophrenia in Mexican communitarian settings. Method Schizophrenia was modeled as a serious chronic disorder with a high level of disability, excess mortality from natural and unnatural causes, and a low rate of remission. The incidence, prevalence, and the fatality rate were estimated based on the study of the Global Burden of Disease and a review of the epidemiological literature. As the first episode of schizophrenia is currently not preventable, the occurrence represents how the epidemiological situation would be without intervention. In relation to the referral and the fatality, we did not found evidence that these rates change by a specific effect of the treatment; thus, they were kept as constants for the scenarios with or without treatment. Community-level interventions assessed were: 1. typical traditional antipsychotics (haloperidol), 2. new atypical antipsychotics (risperidone), 3. traditional antipsychotics + psychosocial treatment (family therapy, social skills training and cognitive behavioral therapy), 4. new antipsychotics + psychosocial treatment, 5. traditional antipsychotics + psychosocial treatment + case management, and 6. new antipsychotics + psychosocial treatment + case management. The effectiveness of the treatments referred to the control of positive and negative symptoms and associated levels of disability. To calculate the improvement in disability compared with natural history (when the disease is not treated), the effect sizes reported in controlled clinical trials were converted to a weight change of disability. Efficacy and extrapyramidal effects of typical and atypical antipsychotics compared to placebo were estimated from the meta-analysis of controlled clinical trials, with the score of the BPRS severity scale and the need anti-Parkinson drugs as efficacy measures. From another meta-analysis we obtained an estimate of the magnitude of the effect by adding psychosocial interventions. As an ad hoc Cochrane systematic review that found case management did not had a significant impact on clinical or psychosocial outcomes, only a minimal addition effect size when added to the combination of pharmacologic-psychosocial treatment was observed. Costs included those of the patient, the program and the training required to implement the intervention. The provision of community-based services, daily administration of antipsychotics and anticholinergics, and laboratory tests were taken into account. For psychological interventions were envisaged from 6 to 12 sessions: in primary care from 6 to 12 visits, in outpatients services a visit per month for 20-50% of cases, and in day care communitarian attention from 1-2 times a week for 20-50% of cases. A 3% discount by the process of converting future values to present ones and an age adjustment giving less weight to year lived by young were included. Finally, the cost of DALYs averted for each intervention was estimated to determine their cost-effectiveness. Results The main findings of the study are, in relation to the costs of interventions: 1. the largest share corresponds to those generated by medication, 2. the current intervention is the cheapest, and 3. the combination of new atypical antipsychotics, psychological treatment and proactive case management is the most expensive intervention. Concerning the effectiveness of interventions, the one available today, with a coverage of 50%, prevents 68 222 DALYs. Increasing coverage to 80%, the number of DALYs averted is almost doubled with the use of typical antipsychotics. The effect of psychological interventions makes the number of DALYs averted three to four times higher. Finally, in regard to cost effectiveness, the combination of typical antipsychotics, psychosocial intervention and proactive case management was the treatment with the best relation. The cost per DALY averted was $390,892 Mexican pesos, which corresponds to one third of the cost of DALY averted in the current scenario ($1,313,120 Mexican pesos). Conclusions The resources for the attention of a public health issue involve a social investment rather than an expense budget, but they are also finite and must be chosen properly to be allocated. Cost-effectiveness studies of available interventions are an essential tool for making such important decisions. Our Mexican study of cost-effectiveness of interventions to treat schizophrenia in communitarian settings suggests, in general terms: 1. That while the current situation is the one with the lowest cost, it is the least efficient, 2. all alternatives involve an additional cost to the current situation because they assume an expansion of coverage; however, the extra cost in not excessive, and 3) that within a model of community-based care, the least expensive option is treatment with typical antipsychotics combined with psychological intervention. Thus, for a modest extra cost it is possible to yield a major impact on disability. Recently, the Mexican Federal Government has included schizophrenia in the catalog of diseases covered by the program called <<Seguro Popular>>, that provides a health insurance to general population, especially to the poorest and unemployed ones. The planned actions include four specialty consultations in an interval of two months and annual psychopharmacological treatment. Clearly the addition of haloperidol, trifluoperazine and risperidone to the list of available medications should be considered a success. However, schizophrenia also requires a proactive case monitoring of long-term for best control of symptoms and a successful rehabilitation. Moreover, consistent with our findings, case management has proven to be cost-effective when compared with routine care in the community. Among the limitations of the study it is important to note that it was based on modeled parameters obtained from the international literature. In this sense, the challenge is the data generation directly from studies in Mexico.

Introducción La esquizofrenia es un trastorno que produce una importante discapacidad, y su costo para la sociedad es muy elevado. El estudio de la carga que impone la esquizofrenia sobre la sociedad, ya sea expresada en términos epidemiológicos o de costos, es una base insuficiente para establecer las prioridades para la asignación de recursos, por lo que se han desarrollado modelos económicos cada vez más elaborados. Tal es el caso de los estudios de costo-efectividad, que muestran la relación entre los recursos empleados (costos) y los beneficios logrados (efectividad) de una intervención comparada con otra(s). El presente trabajo forma parte de la iniciativa de la Organización Mundial de la Salud (OMS) para la elección basada en evidencia de intervenciones costo-efectivas denominada WHO-CHOICE, Choosing Interventions that are Cost-Effective, que implica la determinación de una medida general que posibilita comparaciones internacionales: los años de vida vividos con discapacidad (AVISAs o DALYs, de las siglas de Disability-adjusted life years). Objetivo Fue determinar la relación costo-efectividad en México de diferentes intervenciones que han demostrado ser efectivas para el tratamiento comunitario de la esquizofrenia. Método Se evaluaron las siguientes intervenciones: 1. Antipsicóticos tradicionales típicos (haloperidol), 2. Antipsicóticos nuevos atípicos (risperidona), 3. Antipsicóticos tradicionales + tratamiento psicosocial (terapia familiar, entrenamiento en habilidades sociales y terapia cognitivo conductual), 4. Antipsicóticos nuevos + tratamiento psicosocial, 5. Antipsicóticos tradicionales + tratamiento psicosocial + manejo de caso, y 6. Antipsicóticos nuevos + tratamiento psicosocial + manejo de caso. La efectividad relativa de los tratamientos se refirió al control tanto de los síntomas positivos y negativos así como de los niveles asociados de discapacidad. Se consideraron los costos del paciente, del programa y del entrenamiento, así como un descuento de 3% por el proceso de convertir valores futuros a presentes, y un ajuste de edad, otorgando menos peso a los años vividos por los jóvenes. Finalmente, se calculó el costo por AVISA evitado por cada intervención para determinar su costo-efectividad. Resultados Los principales hallazgos del estudio son, en relación con los costos de las intervenciones: 1. que la mayor proporción corresponde a los generados por los medicamentos; 2. que la intervención actual resulta la más barata; y 3. que la combinación de antipsicótico nuevo o atípico con intervención psicosocial y manejo proactivo de caso es la más cara. En cuanto a la efectividad de las intervenciones, la disponible en la actualidad, con cobertura de 50%, evita 68 222 AVISAs. Aumentando la cobertura a 80%, el número de AVISAs evitados casi se duplica con el empleo de antipsicóticos típicos. El efecto de las intervenciones psicosociales hace que el número de AVISAs evitados sea tres a cuatro veces mayor. Finalmente, en lo que respecta a costo-efectividad, la combinación de antipsicóticos típicos, intervención psicosocial y manejo proactivo de caso fue el tratamiento con la mejor relación. El costo por AVISA evitado fue de $390,892, que corresponde a un tercio del costo de AVISA evitado en el escenario actual ($1,313,120). Conclusiones Los hallazgos del estudio sugieren, en términos generales: 1. Que aunque la situación actual es la de menor costo, es la menos eficiente; 2. Que todas las alternativas implican un costo adicional a la situación actual porque asumen una ampliación de la cobertura, sin embargo, ese costo extra no es excesivo; y 3. Que dentro de un modelo de atención basado en la comunidad, la opción menos costosa es el tratamiento con antipsicóticos típicos combinados con intervención psicosocial. Por un costo extra modesto se obtendría un impacto importante en la discapacidad. Entre las limitaciones del estudio destaca que fue producto de un modelado con parámetros obtenidos de la bibliografía internacional. En este sentido, el reto es la generación de datos derivados directamente de estudios realizados en México.

The aim of this study is to know the conflicts between beneficence and autonomy principles present in physician-patient relationship during therapy of suicidal attempt. Research was carried out in two psychiatry hospitals of the city of Mexico. The sample included three subjects with suicidal attempt, older than 18 years, attended as outpatients for an injure self inflicted last year, and three psychiatrists treating these patients. Information was obtained by individual interviews with previous informed consent. An argumentative discourse analysis was carried out to find meaning given by participants to bioethics principles and possible conflicts between them. Conflicts between beneficence and autonomy were related to the benefit of treatment, respect to patients values and beliefs, among others. This study present relevant ethical considerations in the clinical scenery, by offering to the psychiatrist a bioethical analysis which allows him/her to act according with beneficence while respecting the autonomy of the patient in cases of suicidal attempt and, in this way, to give them better attention.

El objetivo del trabajo es conocer las disyuntivas entre los principios de beneficencia y autonomía que se presentan en la relación médico-paciente durante la terapéutica del intento de suicidio. La investigación se realizó en dos hospitales psiquiátricos de la Ciudad de México. La muestra incluyó a tres sujetos con intento de suicidio, mayores de 18 años -quienes eran atendidos en consulta externa a causa de una lesión autoinfligida en el último año- y a tres psiquiatras que trataban a estos pacientes. La información se obtuvo previo consentimiento informado en entrevistas individuales. Se llevó a cabo un análisis de discurso argumentado para encontrar los significados que los participantes otorgaron a los principios bioéticos y las posibles disyuntivas entre éstos. Las discordancias entre la beneficencia y la autonomía estuvieron relacionadas con el beneficio del tratamiento, el respeto por los valores y las creencias de los pacientes, entre otros. Este trabajo presenta consideraciones éticas relevantes en el escenario clínico, al ofrecer al psiquiatra un análisis bioético que le permita actuar de acuerdo con la beneficencia y respetando la autonomía del paciente frente a casos de intento de suicidio y, de esta forma, procurar una mejor atención para ellos.

O objetivo do trabalho é conhecer as disjunções entre os principios de beneficência e autonomia que se apresentam na relação médico-paciente, durante a terapêutica do intento de suicidio. A pesquisa foi realizada em dois hospitais psiquiátricos da Cidade do México. A amostra incluiu três sujeitos com intento suicida, maiores de 18 anos, que eram atendidos em consulta externa por causa de uma lesão autoinfligida no último ano, e a três psiquiatras que tratavam destes pacientes. A informação foi obtida com prévio consentimento informado em entrevistas individuais. Se levou a cabo uma análise de discurso argumentado para encontrar os significados que os participantes outorgaram aos principios bioéticos e as possíveis disjunções entre estes. As discordâncias entre a beneficência e a autonomia estiveram relacionadas com o benefício do tratamento e o respeito pelos valores e as crenças dos pacientes, entre outros. Este trabalho apresenta considerações éticas relevantes para o cenário clínico ao oferecer ao psiquiatra uma análise bioética que lhe permita atuar de acordo com a beneficência e respeitar a autonomia do paciente frente aos casos de intenção de suicidio e, desta forma, procurar uma melhor atenção para eles.

Introduction Distresses related to depressive conditions in men have not been sufficiently acknowledged, and yet less studied. The difference between distress and its attention is originated in factors such as a rigid and dual classification of the problem, a false conception that it is a <<women's problem>>, and the social stigma that leads men to accept and face negative emotional states that affect their life quality. This article shows the results of a qualitative study which sought to uncover the social construction of distress from a gender approach and to deepen the understanding about the way men live it and exteriorize it. The concept of loss was taken as a methodological strategy throughout the study to access the male distress experiences, considering that, before an emotionally meaningful loss or an unfavorable event, individuals may react using those experiences. Method Four adult men participated in the study; they were selected using an intensive intentional sampling strategy. We carefully selected only a few cases, seeking to characterize the object of study and to obtain profound information based on reality; they were males who had suffered an important loss. They received a detailed explanation of the study and its objectives, voluntarily accepted to participate and allowed the recording of the interviews. Confidentiality and anonymity were guaranteed. The information was gathered by means of in depth interviews and a thematic guide. We developed categories of analysis from the guide and the study objectives to classify data. Categories were grouped according to their meanings and they generated subcategories that allowed a deeper and more precise analysis. Results The analysis focused on the experiences of four men: Manuel (30 years old), Oscar (36), José (40), and Rodrigo (40). They lived in Mexico City. Manuel and Rodrigo completed high school education, while Oscar and José obtained a college degree. They had different marital status: Oscar is single, Rodrigo is a widower, José is separated from his wife, and Manuel lived together with his girlfriend. Their most important and emotionally meaningful losses, which had caused distress, are described as well as the relationship these had with other aspects of their masculine subjectivity, such as sexuality, the body, violence, sports and work. Loss of couple. Losing the couple was one of the most important experiences the four men lived. This had common causes: psychological and physical violence, cheating, and sexual dissatisfaction. Manuel and Rodrigo spoke about extremely violent episodes where they were beaten-up by their fathers and schoolmates during childhood, followed by brawls during youth as a way of gaining respect. They also said they later reproduced this violence in their relationships with women. Both were jealous and controlling men, but they used different ways to intimidate their couples. Manuel did not use physical, but psychological violence. Instead of psychologically controlling his couple, Rodrigo used to act violently against her. Different elements can be identified from the experience of these men, which entwine in the distress-gender-violence relationship: <<uncontrollable>> jealousy that triggers violence and using physical or psychological violence as a means for controlling and subordinating the couple. Once they committed and act of violence, they experienced guilt and fear of neglecting that lead them to the rarely kept promise of never doing it again. These events are usually minimized, naturalized, and hardly acknowledged. In the case of cheating, it is important to consider the context where breaking-up takes place, since it is necessary to incorporate other relevant elements of masculine subjectivity: the relationship with the body, the practice of sexuality, the forced heterosexuality, and the continuous evaluation of manhood through social pressure from other men (father, brothers, uncles, and friends). Manuel's experience represents an example of this, because his link with sports and the fitness world allowed him to model his body in order to keep an appealing figure for women and a vehicle for socializing with other men that had similar interests. Being a part of this fellowship allowed Manuel to become a personal trainer and to have several affairs while he was living together with his couple. He said his interest in women and the constant cheating had four basic reasons: the context where fitness takes place, living together for a long time with the same person, feeling sexually unsatisfied, and the realization that her partner showed little interest at home and in doing housework. Thus, in the relationship distress-gender-cheating, when she finds out about him cheating and decides to break-up with him and she leaves him, become the causes on Manuel's distress. José told that problems in his sexual life caused the end of his relationship. He lost his interest in sex and ceased contact with his wife for five or six years because on a genital infection. He also had diabetes since his youth, which also contributed to his lack of interest in sex. José was reluctant to seek medical or psychological help, so his wife decided not to stay with him anymore. Then he reacted with sorrow, impotence, and anger, feelings he considered as a depressive phase. Loss of health. The loss of health could be the result of a chronic illness or a severe injury. It was a distress generating experience for two of them, which had an important impact on their masculine identity in two basic axes: the body and the sexual life. The experiences of José and Manuel allow recognizing the difficulty that men face when they try to accept and admit their own illness and vulnerability, as well as their reticence for taking care of their bodies and health. José said his first painful event was when he was diagnosed with the diabetes at age 25; it was a total self-image change. <<I was not normal anymore, I became a sick man>> who had to take medication for life. The most traumatic situation Manual had lived was when one of his girlfriends stabbed him in his heart during a fight. This changed the meaning of his life and body; he was downhearted for seven years, affecting his work and his social and sexual life. The origin of distress is beyond losing a couple or health in these cases, because, deep down this distress-health-gender relationship, the problem is in losing the ability to fight or in stopping being sexually active, and therefore in not being able to sustain the gender based commands. Loss of job. Oscar talked about one of this distress generating experiences. Even though he considered himself a competent architect, he had not reached a position where he could get enough social success and economic balance. His story offers the possibility of understanding the meaning of a well-paid job in the life of men: the notion of value as a self-reference, the illusion of self-nomination as someone different and unique, the possibility of recognition and appreciation from others, and the money and power. These elements interact to structure what seams to be one of the most important axes for masculine identity. Because when men cannot enter into the working world, they face crisis and distress periods, which in turn have negative repercussions on their gender identity. Male expressions before losses. There were some fundamental physical expressions of distress: muscular pain, difficult in sleeping, laziness, and untidy appearance. The most frequent emotional expressions included sadness, anger, rage, and vindictive impulses. Other manifestations were more related to the way they have learned to <<master their emotions>> by repressing their feelings: not to cry, not to be vulnerable before others, not to show any feelings, and to endure pain.

Introducción Los malestares asociados con estados depresivos en los hombres han sido poco reconocidos y aún menos abordados. Esta diferencia entre el malestar y su atención se origina en factores como una clasificación rígida y dual del padecimiento, la falsa concepción de que es un problema sólo de mujeres y el estigma social que dificulta que el hombre acepte y enfrente estados de ánimo negativos que afectan su calidad de vida. En este artículo presentamos un estudio de corte cualitativo que desde la perspectiva comprensiva-interpretativa y el enfoque de género pretendió desentrañar la construcción social del malestar, con el fin de profundizar en el entendimiento de la forma en que los hombres manifiestan y viven este malestar. Método El estudio se llevó a cabo con cuatro varones adultos y para seleccionarlos se utilizó la estrategia de muestreo intencional intensivo. Se buscó seleccionar cuidadosamente pocos casos que pudieran caracterizar al objeto de estudio. Se seleccionaron varones que hubieran vivido una pérdida importante, a los cuales se les dio una explicación detallada del estudio y de sus objetivos. Se llevaron a cabo entrevistas en profundidad y se recopiló la información por medio de una guía temática. Se elaboraron categorías de análisis para clasificar la información a partir de esta guía y los objetivos del estudio. Estas categorías se agruparon de acuerdo con sus significados y generaron otras subcategorías de análisis, las cuales permitieron, a su vez, realizar un análisis más preciso de la información. Resultados El análisis se centró en las vivencias de cuatro varones: Manuel, de 30 años; Oscar, de 36; José, de 40 y Rodrigo, de 48, todos residentes de la Ciudad de México. Dos de ellos terminaron la preparatoria (Manuel y Rodrigo) y los otros dos estudiaron una licenciatura (Óscar y José). Su estado civil era heterogéneo: Óscar era soltero, Rodrigo era viudo, José era casado, pero estaba separado y Manuel vivía en unión libre. De todos ellos se describen las pérdidas más importantes que han originado su malestar y la relación que guardan con otros aspectos de la subjetividad masculina, como la sexualidad, el cuerpo, la violencia, el deporte y el trabajo. La pérdida de la pareja. Es una de las principales experiencias vividas por los cuatro varones entrevistados, en función de la cual se encontraron causas comunes de ruptura: la violencia física y psicológica de ellos hacia sus parejas, su infidelidad y la insatisfacción de la mujer en su vida sexual con su pareja. La pérdida de la salud. Ocasionada por alguna enfermedad crónica o alguna lesión grave. Como ya se preveía, ésta fue una experiencia que produjo malestar en dos de ellos (José y Manuel) y que tuvo un fuerte impacto en su identidad masculina, sobre todo en dos ejes importantes de la subjetividad: el cuerpo y la sexualidad. La pérdida del trabajo. El testimonio de Óscar permite comprender lo que significa el mundo laboral en la vida de los hombres. Sin embargo, cuando no pueden acceder al mundo del trabajo, los hombres enfrentan estados de crisis y malestar, con fuertes repercusiones en su identidad de género. Manifestaciones del malestar masculino ante las pérdidas. Aparecieron expresiones físicas como dolores musculares, problemas para conciliar el sueño, flojera y descuido en el arreglo personal. Las expresiones emocionales más frecuentes fueron los sentimientos de tristeza, enojo, ira y deseos de venganza. Otras manifestaciones estuvieron muy vinculadas con la forma en que aprendieron a <<dominar su vida emocional>>, como no llorar, no mostrarse vulnerables ante los demás, no exteriorizar los sentimientos y aguantar el dolor en general.

Ethics, understood as the study of moral norms in terms of its assumptions, origins, and changes over time, systematizes similarities and differences between various moral codes. It therefore serves as a meeting point between different perspectives, through dialogue, a fundamental characteristic of this discipline. One of its derivations, as applied ethics, is bioethics, defined by Van Rensselaer Potter as "New knowledge that provides knowledge on how to use knowledge for the good of society". Although bioethics emerged in the 1970s under the imperative of medical discourse, its development as a discipline reflecting human behavior surrounding health has permitted the combination of various types of knowledge, including the contribution of social sciences in this field. Thus bioethics deals with the dilemmas that may arise in social studies on health (such as addictions, violence and migrations). The aims of this manuscript are to systematize and explain some of the implications of the pertinence and adaptation of informed consent (IC) in a bi-national Mexico-United States study on mental health and migration. It also provides elements of analysis for the detection of ethical dilemmas in these community interventions in mental health in Mexico. It therefore attempts to answer the following questions: Within the context of bi-national research, how does one deal with the principle of autonomy and the notion of "voluntariness" included in the requirement of informed consent, in public mental health interventions in Mexican rural communities? Is it possible to respect the way participants in the host country make decisions while at the same time, meeting the demands of the ethics committee of the sponsor country? In order to arrive at the elements of analysis, the authors briefly explain the conceptualization of the terms ethics and bioethics, and explore some of the postulates put forward in both North American (principalism and casuism) and European bioethics (communitarianism), in addition to approaching other bioethical positions (ethics of responsibility and protection), by highlighting certain cultural elements that particularize the world views that give rise to the aforementioned ethical approaches. At the same time, the authors review the principal contributions of the various international codes, declarations and reports, including recommendations by the National Commission of Bioethics of Mexico that regulate the process of Informed Consent (IC) in Social Research. IC is a social process which, through active, respectful exchange provides information on research in a comprehensible way for the subject, in such a way that he is aware of the risks, benefits, consequences or problems that may occur during research. The researcher must ensure that the participant has properly understood all the information related to the project, has the opportunity to ask and be given answers to his doubts and is aware of his right to dissent (not adjust to someone's feeling or opinion) or express his will to collaborate by consenting (to allow or agree to something being done) without having been subjected to coercion, intimidation or undue influences of incentives. The process of informed consent (IC) is essentially verbal, and without underestimating this fact, given the importance of the decision about to be taken, as happens when one agrees to take part in a research project, it is sometimes necessary to leave a written record of this. In this respect, the process of informed consent consists of three elements: information, understanding and voluntariness. In itself, it involves the protection of the individual's freedom of choice and respect for his autonomy. One should therefore consider the context of development of different cultural groups from that of the researcher and his traditions regarding communication and decision and these procedures must be respected. The study also includes aspects that have rarely been discussed in the process of informed consent (PIC) such as the need to clarify the type of relationship and exercise of power that may occur between the researcher and the person being researched, the lack of questioning about whether the commitment acquired by the researcher to respect the participants' autonomy during the PIC helps or prevents people from regarding themselves as rights-holders. Finally, the study highlights the fact that, although social research is considered of "minimum risk", the information provided in the PIC may cause emotional distress classified as "psychological risks" such as stress anxiety, fear or lack of tranquility. In social research, as in no other, the implementation of PIC normative approach is extremely varied, due to the fact that one works with sectors prepared to participate (prostitutes, drug users, first-time offenders, etc.) on the condition that they will not sign any informed consent, thereby giving priority to the quality of the relationship established, rather than the format. This manuscript explains the reflection on certain ethical dilemmas that arose during a social research project, the aim of which was to identify the emotional distress associated with Mexico-United States international migration and the use of mental health services. The ethical analysis specifically focuses on the information obtained during the field work through the participatory observation technique, in a rural community in the state of Michoacan. The main conflictive situations experienced due to the notion of voluntariness and the principle of autonomy underpinning PIC include: • The fact that for some residents, discussing certain issues related to public mental health such as alcohol and drug consumption may be interpreted as "disloyalty" to their community and constitutes sufficient grounds for not participating. • Understanding that some researchers suffer the consequences of their colleagues' mistakes, as borne out by another of the arguments given for not participating: " We are fed up of fly-by-night researchers, who just come in, obtain their data and are never seen in the community again". It is also worth reflecting on whether this argument reflects a questioning of the researcher's authority and/or a loss of faith in social progress through science, but how can one speak of social progress with the residents of communities that lack drainage and electricity?

A pesar de que la bioética surge en la década de 1970, bajo el imperativo del discurso biomédico, su desarrollo como disciplina que reflexiona sobre el comportamiento humano en torno a la salud ha permitido la reunión de varios saberes, entre ellos, la aportación de las ciencias sociales en dicho campo. De esta forma, la bioética se ocupa de los dilemas que pueden presentarse en los estudios sociales sobre salud (adicciones, violencia, migraciones), incluso en aquellos que, por cuestiones de interés común, son de tipo binacional o multicéntrico. Los objetivos de este artículo son sistematizar y exponer algunas implicaciones de la pertinencia y adecuación del consentimiento informado (CI) en un estudio binacional México-Estados Unidos sobre salud mental y migración. Además, se aportan elementos de análisis para la detección de dilemas éticos en estas intervenciones comunitarias en salud mental en México. De esta forma, se intenta responder a las siguientes preguntas: En el contexto de una investigación binacional, ¿cómo encarar el principio de autonomía y la noción de "voluntariedad", insertos en el requerimiento de un consentimiento informado, en intervenciones de salud mental pública en comunidades rurales mexicanas? ¿Es posible respetar la manera en que los participantes del país anfitrión toman decisiones y cubrir, al mismo tiempo, las exigencias del comité de ética del país patrocinador? Para allegarse los elementos de análisis, se expone someramente la conceptualización de los vocablos ética y bioética, y se abordan algunos postulados planteados tanto de la bioética norteamericana como de la europea, además de aproximarnos a otras posturas bioéticas. Por otro lado, se revisan los principales aportes de los diversos códigos, declaraciones e informes internacionales, incluidas las recomendaciones de la Comisión Nacional de Bioética de México, que norman el proceso del consentimiento informado (CI) en investigación social. El CI es un "proceso social que, a través de un intercambio activo y respetuoso, brinda información sobre la investigación en forma comprensible para el sujeto, permite cerciorarse de que la entienda y tenga opción de preguntar y recibir respuestas a sus dudas, brinde oportunidad para negarse a participar o manifestar voluntad de colaborar y pueda expresarla oralmente o firmar un formulario, sin haber sido sometido a coerción, intimidación ni a influencias o incentivos indebidos". En este sentido, el proceso de consentimiento informado (PCI) protege la libertad de elección del individuo y el respeto de su autonomía. Por ello, también se debe considerar el contexto de desarrollo de grupos culturales diversos al del investigador, sus tradiciones en cuanto a comunicación y decisión, y se deben respetar estos procedimientos. En la investigación social, como en ninguna otra, la puesta en práctica de la normatividad del PCI es muy variada, debido a que se trabaja con sectores dispuestos a participar (prostitutas, usuarios de drogas, primo-delincuentes, etc.) a condición de no firmar ningún consentimiento escrito, lo que otorga prioridad a la calidad de la relación establecida y no sólo al formato. Este documento expone la reflexión sobre algunos dilemas éticos que se presentaron durante una investigación social cuyo objetivo fue identificar los malestares emocionales asociados a la migración internacional México-EUA y la utilización de servicios de salud mental. Específicamente, el análisis ético se centra en la información recabada en el trabajo de campo por medio de la técnica observación participante, en una comunidad rural en el estado de Michoacán.

Summary: Introduction. When the impact of illness is evaluated by indicators like mortality, mental illness has a less significant impact than other illnesses. As a result, the impact of mental disorders was underestimated until the last two decades of the previous century This perception began to change as a result of two factors: On the one hand, the study of the Global Burden of Disease reported by Murray and Lopez, and, on the other hand, the definition of mental disorders by the American Psychiatric Association. The common element shared by these two factors is the inclusion of the concept of disability. Disability is the deterioration of the expected functioning of a subject of a particular age and sex in a social context. It is a part of the social cost of illness. Objective. To assess the disability burden associated with depression, mania, agoraphobia, social phobia, general anxiety, panic disorder, and post-traumatic stress disorder (PTSD) according to the Mexican Psychiatric Survey and to compare results with the disability produced by some chronic non-psychiatric conditions. Method. This survey is based on a stratified, multistage area, probabilistic sample of adults living in urban areas of Mexico. The instrument used was the third version of the Composite International Diagnostic Interview. We report the 12-month prevalence of psychiatric disorders as defined by DSM-IV criteria. We also evaluated non-psychiatric chronic conditions like diabetes, arthritis, hypertension, backache, and other painful illnesses, identified in general as "chronic conditions". Indicators of disability were Sheehan's scale and number of work days lost. This is an easy and fast self reporting scale, which can be used both in the clinic or research. The sub-scales can be added or averaged to obtain a total score. The scale of responses is a horizontal line with numerals from 0 to 10 and five verbal descriptions, with the description "Not at all" corresponding to a value of 0; "Mild" rangimg from 1 to 3; "Moderate" from 4 to 6; "Severe" from 7 to 9; and "Very severe" corresponding to 10. Results. Close relationships and social life were the areas most deeply affected. The disorders found to produce the highest levels of disability were depression, social phobia, and PTSD. The lowest disability levels were observed in chronic conditions. On the total score of Sheehan's scale, disorders with the highest level of disability were PTSD (mean 5.35 ± 0.307) and depression (mean 4.72 ± 0.167). Depression and panic attacks were the disorders by which most days were lost on average in the previous year (25.51, CI95: 16.53-34.5; 20, CI95: 3.02-36.97). Days lost were lower in chronic conditions than in the seven mental disorders studied (6.89, CI95: 3.04-10.74). Discussion. This is the first paper to demonstrate the impact of mental disorders in Latin America evaluating the association of disability with common mental disorders. We have shown that mental disorders, especially depression, are associated with deficits in functioning and result in the loss of work days. We have also shown that persons with common mental disorders have, on average, higher levels of disability than those observed among persons with a wide range of chronic physical conditions. These results are consistent with prior studies in North America and Europe that have found that persons with common mental disorders experience substantial disability in social role functioning.

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Summary The objective of this study was to evaluate a conceptual model to explain alcohol and drugs abstinence in persons that meet the DSM-IV dependence criteria. This study incorporated and evaluated the conceptual proposal of the Integrated Model of Everyday Satisfaction. The structure of this model is based on the Niaura’s Dynamic Regulatory Model and the Social Learning Theory that included the classical conditioning, the operant and the vicar to explain the dependent-consumption and incorporated some of the criticisms to the different cognitive-behavioral models, as the need to measure, by means of a direct observation, the specific type of skills used by the consumption-dependent users when facing everyday situations; as well as identifying changes of the functioning of the variables making up the model at the moment of turning towards abstinence; it also considered the indicators that the variable everyday satisfaction has been poorly studied and not been included in the study of conceptual models. Thus, the proposed conceptual model: Integrated Model of Everyday Satisfaction, included the following variables: consumption, precipitators, self-efficacy, everyday satisfaction, as well as variables measuring the facing of specific situations: communication, problem-solving, refusal of consumption, depression and anxiety. These variables were evaluated in an intentional, non-probabilistic sample with 20 dependent users of addictive substances, before and after the cognitive-behavioral intervention adapted to the Mexican population. This intervention model included the following components: Functional Analysis, Demonstration of Non-Consumption, Daily Life Goals, Communication, Problem Solving, Consumption Refusal, Marriage Guidance, Employment Searches, Recreational and Social Skills, Emotional Self-Control and Prevention of Relapses. The pre-post-test evaluation methods were: Retrospective Baseline, Situational Confidence Scale and/or Drug Consumption Self Confidence Scale, Daily Life Satisfaction Scale, Inventories of Drug Consumption Situations and/or Inventories of Alcohol Consumption Situations, Beck´s Inventories for Depression and Anxiety. Occurrence records were used to assess the video-filmed behavioral assays of consumption refusal, problem-solving and communication. The didactic techniques used in the training were: verbal instruction, modeling, behavioral trials and feedback. In the scaled analysis, the Model showed, at the moment of consumption, solidity accounting for 95% of the variance. At this moment, significantly related to the variables: risk situations, selfefficacy to avoid consumption, everyday satisfaction and anxiety. Dependent consumers, showed bigger diversity and intensity of risk situations previously associated to consumption, reduction of facing skills that caused their insecurity to refuse consumption, increased of their physical symptoms of anxiety and decreased of everyday satisfaction related with their poor functioning in different areas of daily living. The increase of anxiety was an indicator of manifested abstinence syndrome, and confirmed that the used filter criterion, showed sensitivity to attract target population; in turn, anxiety as precipitator confirmed, was sustained by the conditioned withdrawal model. Refusal of consumption, communication and problem-solving at the moment of consumption in the user prior to the training were not significantly associated, indicating the need to acquire and develop these skills in the behavioral repertoire. Eighteen from the twenty dependent users showed in the analysis of interrupted time series, that the amount and frequency of the consumption was significantly changed toward abstinence after their participation in the cognitive-behavioral intervention. The scaled analysis indicates that it was a solid model in terms of abstinence accounting for 96% of the variance. In the final configuration of the Model variables with regard to its proximity to abstinence, identified the proximity between the: decreased of consumption, the more skills for facing risk situations, and refusal of consumption were detected with major proximity; subsequently, more everyday satisfaction and more self-efficacy to avoid consumption; then less anxiety and depression; and eventually, more communication and problem-solving skills. The following variables were significantly associated, during abstinence: the More Everyday Satisfaction from the functioning in daily living, more skills and variety of behavioral alternatives to cope risk situations, more self-efficacy to avoid consumption at coping different risk situations, less anxiety and depression, also more skills to consumption refusal, and decrease of substance consumption. Self-efficacy worked as mediator between behavior and emotion; everyday satisfaction was associated to cognitive variables: self-efficacy and emotional self-control; anxiety and depression. This study detected that it may work as an early advice of relapse, and as antecedent of abstinence. The variables that acted as predictor of abstinence, accounted for 73.2% of the variance and were: coping risk situations with alternative behaviors, getting everyday satisfaction from their performance in activities of different areas of daily living, self-efficacy to resist consumption at risk situations and refusal of consumption in front of persons modeling consumption and invitations and pressure to consume; depression was not significant with the Enter method regression model. The measuring of problem-solving did not include the efficacy of application in everyday life, so that it was not directly associated to consumption. One limitation was not having evaluated the generalization behavior of variables: communication and problem-solving in natural settings; and the lack of physiological measures in order to evaluate the emotional self-control. In another study, it is suggested to assess the variables during follow-up to detect changes in its functioning in this other moment. It may be concluded that the relationship between the diversity of variables inserted in this Model during the organism-environment interaction, is favorable to the abstinence, everyday satisfaction, facing non-consumption, behavior entails, flexibility and integration of a number of cognitive-behavioral skills. The functioning of Everyday Satisfaction as early warning of relapse is an important finding to be considered by the therapist who, when applying the intervention on these users, will have to perform subsequent evaluations of this variable in the process of change in order to anticipate and avoid relapses.

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Summary: Alcoholism is among the main worldwide public health problems and it affects men and women differentially. Several studies show that, when compared to men, women develop more severe dependence, more family and social consequences and experience more difficulties to stop drinking. Differences on the impact that substance abuse has on women’s life and health are related to the roles, functions and social expectancies placed on them concerning the continuity and care for the rest of the family. For this reason, alcohol intake constitutes a special problem since it affects the health of both the mother and her offspring. Alcoholic women have a higher risk of suffering obstetric complications during pregnancy, such as placenta insufficiency, intrauterine development retardation, early placenta detachment, spontaneous abortion, stillbirth and pre-term delivery. Alcohol abuse during pregnancy is also associated with low weight offspring, congenital abnormalities and further behavioral and learning difficulties. In some countries, drinking during pregnancy is considered an offense which requires legal action. In some cases, women may be put in jail until delivery and lactation. In other regions, children welfare authorities view drinking during pregnancy as a form of aggression or neglect. Such measures prevent women from searching prenatal attention which in its case might lead to severe health consequences for the mother, the embryo and the society. Estimates of alcohol consumption during pregnancy around the world vary considerably and figures range from 4.1% to 83%. However, the variation might be related to the amount of alcohol units and the period of time considered in each measurement. A case-control study in Naucalpan, Mexico, found that 11% of the women interviewees admitted having drank during pregnancy, 5% of the mothers in the control group and 2% of the case group stopped drinking during lactation. Still, any of the considered variables was found to predict postnatal mortality through logistic regression analyses. Another study performed with data from the 1988 National Survey on Addictions documents that alcohol intake during pregnancy is a risk factor for congenital abnormalities (OR=3.4). The available data about the risks associated with drinking during pregnancy in Mexico comes from research in general population, while little is known about clinical population. For this reason, the objectives of this article are: 1. to analyze the characteristics of alcohol consumption in a group of women who sought help to stop drinking, 2. to identify family history of alcohol abuse in this group and 3. to explore the consequences of drinking on their offspring. In this case study, interviews were held with 200 women who attended two treatment agencies in Mexico City due to alcohol consumption problems. The questionnaire used includes the Spanish version of the CIDI-SAM and other sections to explore drinking during pregnancy and lactation, as well as family history of alcoholism. Selection criteria were: 1. aged 18 or older, 2. seeking help for the first time, 3. physical and mental conditions that would allow to answer the questionnaire, 4. having drank during the previous year. Women agreed to participate voluntarily once the objectives of the study were explained and confidentiality assured. Personnel of both treatment agencies administered the questionnaire and interviews lasted 60 minutes average. The diagnostics of alcohol dependence were obtained according to DSM-IV criteria. Data were analyzed with the statistical program SPSS v. 10, for Windows. A total of 134 women reported having been pregnant at least once, and 57.5% of them admitted having drank alcoholic beverages during pregnancy. Age ranged from 18 to 61 years (mean=40), 50% were married or living with a partner, 18% were divorced or separated and 13% had never married. The number of children ranged from 1 to 12 with a mean of 3. High percentages of family history of alcohol abuse were found among this group (93.5%): mostly the father (72.7%), siblings (63.6%) and the partner (48.1%). Significant differences in family history of alcohol use were found between women who drank during pregnancy and those who did not drink. Around 66% reduced alcohol intake after the confirmation of pregnancy; however, 26% continued drinking as usual and 6.5% started drinking at this period. The mean number of drinks consumed per drinking occasion during pregnancy was 3.5, being the traditional beverage pulque (48.8%) and beer (34.9%) the preferred beverages. In addition, 9.2% also took medical drugs. At least three out of the seven criteria proposed in DSM-IV for alcohol dependency were met by 70.3% of the women who drank during pregnancy. More severe dependence was found among the women who drank during pregnancy than among the group of women who abstained. As to the consequences of drinking, 12% of the women reported spontaneous abortion, 13.7% pre-term deliveries, 5.5% stillbirth, 6.8% congenital abnormalities and 13.7% low birth weight. When comparing women who drank and those who did not during pregnancy, significant differences were found in the percentage of pre-term deliveries (X2=5.63; p=0.01) and congenital abnormalities (X2=4.22; p=0.05). A number of logistic regression models was assessed using three independent variables: drinking during pregnancy, frequency of alcohol consumption and severity of dependence. Dependent variables, on the other hand, were spontaneous abortion, pre-term delivery, stillbirth, congenital abnormalities, low birth weight, alcohol use by the offspring and drinking problems in the offspring. The analysis shows that alcohol consumption during pregnancy is related to pre-term deliveries (OR=7.9), and alcohol use by the offspring (OR=2.1). Severity of dependence is related as well to low birth weight (OR=3.7) and further drinking problems in the offspring (OR=2.7). Likewise, drinking every day or almost every day is also related to later drinking problems in their children (OR=2.9). Finally, having siblings who drink (OR=2.11) and meeting alcohol dependency (OR=2.21) criteria are factors that predict alcohol consumption during pregnancy. These results are consistent with other studies that report positive family history of alcohol abuse among alcoholic women. The proportion of women who stopped drinking during pregnancy (42.5%) is higher than the one reported by other authors. Prevalence of spontaneous abortion, stillbirth and congenital abnormalities are higher than the prevalence reported among general population. These findings suggest that women with severe dependence face more difficulties to stop drinking during pregnancy in spite of the social stigma imposed to future mothers who drink. The results provide some elements that support an association of alcohol abuse during pregnancy with adverse pregnancy outcomes. Nevertheless, the impact of fetal alcohol exposure responds to a complex model where a number of interacting factors, longitudinal reaserch is needed to determine the weight of each participating variable and the underlying relationship between them.

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Abstract: There are different factors within work environment that could créate both wellbeing and distress in workers. The climate perception employees have, as well as their evaluation of some, could have positive and negative consequences at personal and organizational levels. Work stress is another element that has meaningful repercussions on the health of people and on the quality of their performance; it has been related to alcohol and psychoactive substances abuse, besides of an increase in different social and work problems. The main objective of this paper is to determine the relationship between organizational factors (such as work stress, organization climate, and work satisfaction) and alcohol use, and the occurrence of industrial problems and accidents in Mexican workers in a textile organization. Method In order to interfere as less as possible with the production process, this study was carried out at the facilities of the organization, during work hours and during weekends. Thus, only employees who attended to work these days were interviewed. The sample included 277 workers who basically performed as operative staff. No more organization characteristics are described on behalf of an agreement, and of the anonymity of the answers given by the subjects. All the interviewees were men, their ages fluctuated between 16 and 65 years, 85% of them had attained junior high school, and 72% were married or living with a partner. A self rated questionnaire was used, along with the AUDIT (alcohol use disorder identification test) alcohol test, a work stress scale, another scale for organization climate, one more for work satisfaction, and some general questions. All the scales had good internal consistency. The procedure consisted in gathering 20 workers in a well-ventilated and illuminated room. The interviewer, who was previously trained, read the instructions aloud, emphasizing anonymity and confidentiality of any information the workers give, and stating that no one from the company would have access to the data. Analyses were performed with statistical software SPSS 11.5. EQS 6.0 was used to test the structural equation model with the relationship between organizational factors, alcohol use and negative consequences at work. Results Organizational climate. Most of the workers (92%) perceived a good level of communication with the work group, 87.2% mentioned to receive help from the boss when they have to do an activity they are not familiar with, 78% said they have enough support to solve the problems related to work. There were differences between the workers according to education level; the ones with the higher level perceived a more adverse climate. There were differences also between shifts (morning, evening, and mixed); the workers from the first one perceived a less favorable climate. Work satisfaction. Most of the workers think of their job as something useful (95%), 93% said they liked it, and 88.3% mentioned their families are satisfied. There are statistical differences be-tween satisfaction and education levels; subjects who had only basic education were more satisfied than those with a higher level. The stress sources are related to the effort implied in the struggle to move forward (87.6%), to have too much work to do (60.5%), and to the possibility of an accident when subjects are careless (51.6%). The total scale scores indicated that 14.2% of the workers had high levels of work stress. Alcohol use: 61.7% of the workers consumed alcohol during the previous year. According to the AUDIT (using eight or more as a cutoff score) 25.8% were classified as cases for alcohol related problems; 26.5% of the subjects had risk consumption, and 5.3% were consuming in a dangerous way because of the frequency and the amount they drink. Work problems: 24.1% of the subjects mentioned they have invested more time than usual in some activity related to work, 21% have been told off because of their performance, 18% felt they could not achieve quality outcomes. The incidents that workers mentioned were: hand injuries (17.5%), finger injuries (15.7%), being close to suffer an accident (13.5%), and suffering damage or injuries when working (10%). A structural equation model allowed to observe that organizational factors, climate, satisfaction, and work stress are meaningful predictors of work accidents and problems. Of all the variables included in this analysis, work stress also was the one that best predicted alcohol use at the work place. A direct effect of the individual level of alcohol use and of the use at the work place on problems and accidents, was observed. This effect was not initially considered in the model of individual consumption, neither were the frequency, the amount consumed, nor the excessive use; it was necessary to add this direct path to adjust the model so they were observed as important elements. Discussion Interviewees perceived communication as an important climate issue, mainly when established with the work group. Another element mentioned as important was perceived, that is support from the boss or supervisor to solve problems. Education level has a relevant role in the way workers live their work climate; those with a lower level experience it as more favorable. This could be the consequence of higher work expectations related to a higher education level. There are differences among shifts; workers from the first shift experienced a more favorable climate. The model included climate as a meaningful element for the presence of consequences at work place; this had a direct effect over the existence of problems and the occurrence of accidents, it was opposite to the results observed in other studios were there was not a direct relationship. Work satisfaction has to do with job usefulness, the joy for the task done, and family satisfaction with the position. The education at level affects perception of work climate. This evaluation of the worker climate has been identified as a significant factor for the reduction of negative effects at work. It is necessary to mention that employees with a higher stress level are the married ones, which may be caused by the responsibilities implied in being a family supplier. This concurs with the result of a study on burnout, which found that being married is a risk factor to develop high stress. Work stress was the most predictive component of accidents and problems at the work place, which had a direct relation (0.50). It also directly predicted alcohol use at the work place (0.22), and had a negative statistical difference with climate (-.29). Thus, it is important to consider that when workers perceive a better climate, stress level goes down, and it is necessary to consider this organizational factor to improve work conditions besides employees' physical and mental health. According to the model tested in this study, alcohol use has a direct and meaningful effect on performance and on the frequency of problems and accidents, inside and outside the organization. It is important to consider that prevention in work places must be done globally, taking into account organizational factors such as climate, stress, and worker satisfaction. It also should include educative and practical elements that allow reducing excessive alcohol use and its negative consequences (poor performance, bad interpersonal relationships, and bad outcome quality) at work, besides reducing also industrial accidents. The most frequent work problems were as follows: to invest more time than necessary in an activity, to be told-off because of mistakes, and to have problems with the boss or supervisor. These events have an impact on productivity and represent money loss for the company. The most frequent accidents were as follows: hand injuries, which are related to heavy machinery operation, basic in the production process of this industry. This reflects the need to consider the physical aspects of the place where activities are performed, as well as the psychosocial factors affecting individuals, all of which will result in benefit of any organization.

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Summary This paper is aimed at exploring the relationship of some socio-demographic variables with the presence of depressive disorders among a low-income urban sample. Different variables have consistently been associated with such disorders, for instance, marital status, sex, and socio-economic status. As to marital status, some studies show that married people have better health conditions and feel more satisfied with their lives than their unmarried counterparts. Similarly, it has been found that widowed or divorced people present a number of psychological problems. Low-income population is also at high risk of suffering depressive symptoms, in this sense, some researchers have stated that the lack of resources is associated with sadness, high stress levels, isolation, uncertainty, and low access to health care and/or other sources of support. According to the Mexican National Survey on Mental Health conducted with urban population over 18, the prevalence of depressive disorders is higher among widowers and divorced individuals -both males and females- than among their married counterparts. In addition, an association was found between depression, low schooling and unemployment. A survey undertaken in Mexico City yielded similar results though gender differences were not explored; higher prevalences of depression were found for those who reported having lost their couple or marital break up than for those who were married or single. Other groups that had high depression prevalence were lower income individuals, and those with less schooling. Couple relationships and other socio-demographic variables play a key role in the presence of depressive disorders. Thus, the present study is aimed at: a) analysing how marital status affects the presence of depressive disorders in men and women; b) exploring the role of low socio-economic level in the presence of depressive symptoms; c) exploring which combination of socio-demographic variables better predict the presence of depressive disorder in males and females Method: This research was carried out in four low-income communities located in southern Mexico City. The selected communities include Topilejo, Isidro Fabela and San Pedro Mártir within the Tlalpan district, and the fourth community was constituted by the neighbourhoods of San Marcos and San Juan, in the Xochimilco district. The research design was multistage; blocks were selected at the first stage, dwelling segments, at second stage, and finally, in the third stage the interviewed individual was selected. After this procedure, the final sample consisted of 1156 interviewees, 49% were males and 51% females. The information was gathered through a household questionnaire that explores the general characteristics of the people living in the same dwelling listed on the questionnaire, such as relationship to the family head, age, sex, schooling and income. Some other aspects related to the dwelling characteristics were also explored. Diagnosis of depressive disorder was obtained through the diagnostic interview CIDI version 1.1, which assesses the presence of mental disorders according to the criteria of the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association. The selected interviewees participated voluntarily after the research objectives were explained; in addition, the terms of confidentiality were particularly emphasized. Each interview lasted 90 minutes on average. Data analysis were performed with the statistical program SPSS v. 10 for Windows. Results: The findings showed higher prevalence of depressive disorders among females, among people that experienced loss or family rupture and among those with lower economic resources. Similarly, prevalence of depression was higher for men (6.1%) and women (18.3%) who had lost their spouse than for their married counterpart. As to differences between married and single people, the prevalence of depressive disorders in the group of men that had ever married was lower (4.9%) than the prevalence found in the group of married men (5.8%). The opposite was observed among females, since single women present more depressive problems (13.2%) than married women (5.3%). Results also showed how economic difficulties have an effect on the presence of depressive disorders. However, differencesbetween married and single men with the lowest income were minimal. Two logistic regression models show that, particularly among women, the presence of depressive disorder is related to the lack of a couple, economic disadvantages; for instance, low family income, belonging to a large extended family, and playing the social role of family head, which implies responsibility to a large extent. Discussion: The findings of the present study are consistent with previous research that report higher prevalence of depression among females, people without a couple and those with less economic resources. Different authors have confirmed that problems of economic nature are consistently associated with depression problems. Lack of resources leads to high stress levels, sadness, isolation, among other troubles. This situation is more severe for females. Women play a number of social roles that put them at higher risk of suffering mental disorders. Nowadays, women still bear the responsibility of being wives, mothers, educators and care providers for many people, and have become an important part of the work force at the same time. The deficiencies that female family heads must face in different areas not only increase the risk of suffering disorders such as depression and poor quality of life, but also jeopardize their children’s opportunities in the future. Dejarlais and colleagues suggest that in order to improve these women’s mental health it is necessary to take actions in two ways. On the one hand, it is essential to deal with the factors related to the presence of female distress; on the other, it is crucial to provide attention to reduce the negative consequences. In this way, any prevention or intervention program must include, among other elements, tools to expand women’s capabilities to have an income, reinforce social support networks, and to stimulate social and community participation in order to improve their cognitive and relational resources as well as self-esteem. In addition, women must have information about the pathological process they undergo and attention options at their disposal, but to make these programs effective it is above all necessary to tailor them according to women’s concerns and needs. This can only be possible if women act as active collaborators. Finally, to work on intervention and prevention programs for female family heads encloses the possibility of breaking the cycle that reproduces distress among their children.

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