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To investigate the social adjustment of individuals with severe mental illness living in the community in cid episode 1007 online dating large urban center of a developing country, and the characteristics associated with poor social functioning. A cross-sectional study was performed in the city of Sao Paulo. Eligible subjects were residents of a defined geographic area, aged between 18 and 65, with a diagnosis of functional psychosis who had had contact with any public psychiatric service during a defined period. Cid episode 1007 online dating hundred and eighty-eight subjects were included, of whom, The most Video sex free random webcam chat affected areas of social functioning were work performance and sexual role.
Inclusion of subjects at this phase was broad, due to the poor quality of medical records in most services. Research assistants, all mental health workers, were oriented to include everyone who could possibly have a psychotic illness.
This phase of the fieldwork took place from December to August The sample was then drawn from this list, and letters were sent to subjects, explaining the study, and informing about a domicile visit by research workers.
These were also mental health professionals, trained in the use of all the instruments described above. Research workers tried to contact subjects at least three times, at different hours, before considering the subject as a non-participant. If no such information could be obtained, medical notes of all the mental health services were revised, to check for a possible updated address. Subjects were interviewed at their homes, whenever possible.
Key informants, generally relatives, were also interviewed at home. This phase of the study took place from October to July Analysis A data file was created using EpiInfo 6. Data were entered twice, in order to avoid data entry mistakes. After that, the data file was converted to be analyzed with the Stata 7. Consistency of data was then checked, and corrections were made when necessary. When explanatory variables were continuous, analysis of variance was used in order to compare means between 2 or more groups.
Analysis of associations between categorical variables and 'poor social adjustment' was performed using chi-square test. P-values equal to or lower than 0. Logistic regression was used to examine independent associations. A forward stepwise process was accomplished, checking whether adding a new variable would improve the goodness-of-fit of data, at a statistical level of significance of 0. Results 1. Characteristics of the sample Data obtained by searching records in psychiatric health services allowed the identification of subjects who were potentially eligible, of whom individuals were randomly selected to be included in the study.
Two hundred and six interviews The main reasons for non-response were: Compared to subjects who were interviewed, non-respondents had higher proportions of women However, these differences were not statistically significant.
Fourteen subjects were excluded from the remaining analysis because they did not meet diagnostic criteria for severe mental illness. The final sample was composed by men and 90 women. The mean age was They were predominantly single, were not born in the city of Sao Paulo, had 8 years or less of formal education and were receiving anti-psychotic drugs at any frequency.
One hundred subjects It was not possible to obtain information from 4 subjects who were living alone, and there were no key informants for them. The areas with higher levels of disability were the occupational and sexual roles, with These areas were followed by underactivity In terms of severity of disability, when considering work performance and interest in getting a job together, Interest in getting information followed, with Considering the scores for global social adjustment, 68 subjects In order to analyze which of the subjects' characteristics were associated with poor social adjustment, the global social adjustment was then binarily categorized, with scores 0 to 3 considered as 'good social adjustment', while scores 4 and 5 were taken together into 'poor social adjustment'.
Variables that showed significant statistical associations with poor social adjustment in the univariate analysis were: Subjects who were single were also more likely to be younger and to have been admitted to psychiatric wards more frequently than subjects who were married or separated. They also showed a higher mean of negative symptoms than subjects with other marital status did and had lower monthly income.
Older subjects had the highest number of admissions. A strong positive association between number of previous admissions and score for positive symptoms was found. Subjects who had lower monthly family income showed a higher number of previous admissions and were younger.
It was also found that individuals who had higher scores of negative symptoms had regular use of anti-psychotic drugs. Using logistic regression, the model that best fit the data was obtained by including negative symptoms, number of previous admissions and general symptoms Table 4. Discussion 1. Methodological limitations Poor quality of information in the medical records consulted, regarding data on address, date of birth or age, and diagnosis, did not allow the identification of some individuals who might have been eligible for this study.
However, this may be a random loss, not influencing the measures of social adjustment or the associations found in the present study. The sample was composed by individuals who were seen at public mental health services, and therefore those who seek care in private mental health services were not represented in this sample.
However, when the study was accomplished, few private health care plans included psychiatric care, particularly psychiatric admissions, and those who had such plans and needed psychiatric care were likely to have sought mental health services of the public sector.
Individuals who did not have a permanent residence and homeless patients were not included in the present study. Individuals who are not in contact with any mental health service were also not included. This group may be constituted by individuals with better social functioning or by those with poorer functioning who do not leave home to seek care in mental health services.
However, the proportion of people with severe mental illness who remain out of contact with any type of care, including emergency services, for more than three consecutive months must be relatively low, considering the severity and disruption caused by such conditions. The most important limitation of the present study is the high proportion of non-responses.
Forty-nine percent of the individuals selected to be included in the study were not interviewed; There may be possibly a different proportion of individuals who present poor social adjustment among non-interviewed respondents.
In order to assess the presence and the intensity of psychotic symptoms and to analyze the social adjustment subjects, semi-structured scales were used PANSS and DAS , which require clinical evaluation by interviewers. Possible systematic errors among interviewers were minimized by constant training and supervision developed along the study.
Interpretation of results The proportion of subjects showing any degree of impairment in social adjustment was very high, with Comparison of results with international literature is not straightforward because most studies dealt only with samples of subjects with schizophrenia or with affective disorders, and a small number has examined mixed samples with people with any severe mental illness.
This difference may be explained by the fact that in the previous study the sample was constituted by more severe cases those who were admitted to hospital and by people with schizophrenia exclusively. Several studies performed in developed countries have also shown that individuals with severe mental illness have marked levels of impairment in social functioning. They observed a trend of subjects in the extreme categories to remain in such groups, and those in the intermediate category to drift towards better or poor levels of functioning.
The sample was predominantly single, was not born in the city of Sao Paulo, had less than 9 years of formal education, and aged from 18 to 64, being very similar to the sample analyzed by Menezes and Mann. The item where fewer subjects were reported to have any level of disability was social contacts, a finding similar to that of Menezes and Mann.
Some studies have suggested some relation between symptom severity and social outcome, at least in specific areas of functioning. Strong associations were found between social adjustment levels and current symptomatology, particularly with negative symptoms, differently from MacEwan et al. Consequently, these patients receive anti-psychotic drugs more often, as detected in this study. Due to a higher mean of negative symptoms, they also present lower former education levels and lower familial income.
All these characteristics lead these patients to have a lower monthly per capita income, as stated above. Implications Results of the present study point to the need of a much larger and better network of mental health services in the community for those with severe mental illness, within a multidisciplinary approach. Rehabilitation programs are needed, in order to reduce the high levels of social disability observed, trying to improve them in society, since disability arises first in peripheral social contacts, progressing towards closer patient's friends, reaching, lastly, the self-care area.
As most patients are single, their parents and relatives can't be left aside, no matter whether they are carers or not. Financial support, information about the illness and its treatment, respite care and other forms of help for informal carers are extremely important, since most of the burden of caring for people with severe mental illness in less developed countries relies on relatives or close friends.
Provision of mental health care should start to be based on needs of care assessments, and research in this field is necessary in order to better plan and organize mental health services.
The findings from the present study are not easily generalizable to the country as a whole, because there are huge regional differences in Brazil regarding culture, social economic development and organization and availability of health care services. Regional investigations are needed to guide service provision and to add knowledge on environmental and socio-cultural factors that may be related to the social adjustment of those with severe mental illness.
Nevertheless, the picture seen in the present study must be similar to that found in many large cities of less developed countries all over the world. References 1. The natural history of schizophrenia: Psychol Med Monograph Suppl.
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