Antecedentes: En un escenario de postpandemia, estudios muestran que se han cronificado estados de ansiedad, depresión y estrés en los trabajadores de salud mental. El objetivo del presente estudio es evaluar síntomas de ansiedad y depresión en los trabajadores de la salud chilenos, atendiendo a las diferencias por sexo, edad y tipo de establecimiento. Método: Estudio de diseño transversal, llevado a cabo el 2022 se aplicó un cuestionario online a una muestra de 623 funcionarios(as) de la salud, constituida por 81,1 % mujeres (n=505) y 18,9 % hombres (n=118). Un 60,5% (n=385), funcionarios(as) de establecimientos hospitalarios y un 39,5%(n=238) pertenecían a Centros de Atención de Salud Familiar. Se aplicaron cuestionarios de síntomas depresivos (PHQ-9), ansiosos (GAD-7), Resultados: Un 41,0 % de los trabajadores en centros de Atención Primaria De Salud mostró un nivel de moderado y severo de ansiedad; en comparación, con la muestra total de funcionarios(as), un 29,8 % presenta un nivel moderado y severo. Con respecto al PHQ-9, un 29,3 % y 41,5 %, de los funcionarios(as) de centros hospitalarios y del mencionado nivel respectivamente, presentan un nivel moderado y grave de síntomas de depresión en comparación, con la muestra total, un 33,4 % presenta un nivel moderado y severo.

Parkinson disease (PD) patients are particularly vulnerable to the effects of loneliness. The objective of this longitudinal study was to assess how the COVID-19 pandemic affected loneliness in PD patients by identifying the correlates of loneliness during the pandemic in the US and to establish a rationale for providing emotional support and restoring morale. Consecutive PD outpatients were recruited during June 2016-May 2017. Data on sociodemographic, clinical, and psychological variables were obtained. During October-December 2020, participants were mailed a questionnaire about some of the variables studied at baseline and new variables specifically related to the pandemic. Univariate, bivariate, and forward linear regression analyses were used to identify the correlates of loneliness. Sex, demoralization, and baseline PD health-related quality of life were significantly associated with loneliness during COVID-19 pandemic, with women reporting more loneliness than men. To examine loneliness specifically associated with the COVID-19 pandemic, loneliness prior to the pandemic was controlled, with only sex and demoralization remaining statistically significant. Interventions aimed at restoring morale and providing emotional support should be included as an essential component of any treatment plan designed to alleviate loneliness during public health emergencies that require social isolation, such as a pandemic.

ObjectiveThis study aimed at identifying correlates of demoralization in breast cancer.Materials and methodsInformation was obtained from outpatients with breast cancer at the Oncology Clinic of a university-affiliated hospital in the United States, using reliable and valid scales, and from the participants’ medical records on demographic and social characteristics, location, type, and stage of cancer, whether it was a re-occurrence or first time diagnosed, type of cancer treatment, medications being used, history of mental disorder, functional impairment, perceived stress, perceived social support, resilience, subjective incompetence, demoralization, and depression. Demoralization was measured with the Demoralization Scale. Bivariable and multivariable analyses were conducted with demoralization as the dependent variable.ResultsDemoralization correlated positively with functional impairment, perceived stress, depression, and subjective incompetence, and negatively with months since diagnosed with breast cancer, perceived social support, resilience, and quality of life. Forward stepwise regression conducted without depression in the regression equation identified emotional wellbeing subscale of quality of life, resilience, subjective incompetence, perceived social support, and functional impairment as significant. After forced entry of depression, perceived social support and mild depression ceased to be significant, leaving only moderate and severe depression as significant. Perceived stress did not enter any of the regression models.ConclusionEarly detection of demoralization and of the co-occurrence of depression and demoralization are essential for promoting the well-being of patients with breast cancer. Psychotherapy should focus on strengthening the modifiable negative correlates of demoralization, countering the modifiable positive correlates, and preventing the co-occurrence of demoralization and depression.

Introduction Attention to the mental health of the elderly and protection of their human rights is receiving increased attention internationally. In addition, how to manage the increasing burden posed by Alzheimer’s disease and related disorders has become an international priority. The COVID-19 pandemic has brought into the forefront the need to also consider protection in humanitarian emergencies. Methods The current tools and mechanisms that protect the human rights of the elderly internationally are reviewed with a focus on mental health. The work of international commissions and reports with recommendations are examined. The state of human rights legislation in the Americas, Europe and Africa will be discussed. Examples of laws on human rights protection in specific countries such as India and China will be highlighted. Results On December 10, 1948 the General Assembly of the United Nations (UN) adopted resolution 217 A (III) The Universal Declaration of Human Rights. In the 1990’s the UN made a paradigm shift ethically and legally considering the elderly as bearers of rights rather than a vulnerable group requiring protection. The UN does not, however, have a specific treaty or convention regarding human rights of the elderly as part of its human rights system as is the case in relation to other specific groups. Office of the High Commissioner for Human Rights (OHCHR) has recognized this shortcoming, and its impact during the COVID-19 pandemic. In 1996 the Revised European Social Charter, Article 23, the Right of Elderly Persons to Social Protection to ensure the effective exercise of the right of elderly persons to social protection. The European Union has adopted the Charter of Fundamental Human Rights which includes respecting the rights of the elderly to lead a life of dignity and independence and to participate in social and cultural life. The African Charter on Human and Peoples' Rights has the distinction of being the only human rights treaty of its nature that embodies both civil and political as well as economic, social, and cultural rights in the same instrument. The aged and the disabled shall also have the right to special measures of protection in keeping with their physical or moral needs. Arguably, the Americas have gone further than any region in promoting the human rights of the elderly. On June 15, 2015 the OAS adopted the Inter-American Convention on Protecting the Human Rights of Older Persons. The most recent report on the progress of member states in its implementation was in 2022. How to manage the increasing burden of dementia has become a priority for many countries. Numerous countries have launched policies, plans, strategies or frameworks to improve the quality of life of those with dementia and their caregivers. The Alzheimer’s Disease International Kyoto Declaration, 2004 defined ten levels of action for countries to take. Conclusions Although many countries have legal and even some constitutional protection of the elderly, this is not universal. The right for the elderly to health and mental health is not yet universally encoded in international legal instruments as is the rights for other vulnerable groups.

The UN has produced various declarations addressing the human rights of older persons. The UN does not have a specific treaty or convention regarding human rights of older persons as part of its human rights system. Recently the Open-ended Working Group on Ageing has recommended to the General Assembly to adopt a binding convention on human rights for older persons. There has been progress already at the regional level. The European Convention of Human Rights Article 23 has been ratified by less than half the countries. The African Charter on Human and Peoples' Rights is the first human rights instrument to include older persons as a distinct group. In November 2024 a protocol on older persons human rights was adopted. The Organization of American States adopted the Inter-American Convention on Protecting the Human Rights of Older Persons, the first human rights document specific to older persons and the only legally binding instrument. Although progress has been made on focusing on human rights on older persons, a binding UN international convention on human rights of older persons would be a tool to improve dignified mental healthcare.

Forensic psychiatrists and neuropsychiatrists are likely to encounter individuals with intellectual disability as they are over-represented in the judicial system. These individuals may have the full range of mental illnesses and comorbid conditions, including physical infirmity, sensory deficits, language impairment, and maladaptive behaviors. They are frequently disadvantaged in the judicial system due to lack of comprehension, lack of accommodations, and stigmatization. Decision making capacity may need to be assessed for health care, sexual autonomy, marriage, financial management, making a will, and need for guardianship. The usual approach to conducting an evaluation needs adaptation to fit the unique characteristics and circumstances of the individual with intellectual disability. The forensic consultant can assist attorneys, defendants, and victims in recommending accommodations and the expert witness can provide education to juries.

Objectives:The objective of this study was to study the interrelations of demoralization, depression, and resilience in patients with Parkinson disease, and, more specifically, to determine if higher resilience in patients with Parkinson disease is associated with lower demoralization, lower depression, or both. Methods:Outpatients with Parkinson disease (N = 95) were assessed for demoralization, depression, and resilience, as well as sociodemographic, clinical, and treatment-related variables. Bivariable associations, standard regressions, linear regression with copula correction, and correspondence analysis were used to analyze the data. Results:Although the bivariable association between resilience and depression was statistically significant, the association ceased to be significant when demoralization was taken into consideration in both standard regressions and linear regression with copula correction. By contrast, the association between resilience and demoralization was significant when depression was not taken into consideration and continued to be significant when depression was taken into consideration. Correspondence analysis revealed that low resilience was strongly related to demoralization combined with depression, whereas normal resilience was closely correlated with depression without demoralization. Conclusion:These results expand our understanding of resilience by suggesting that it is a mechanism evolved to reduce or prevent demoralization and not just depression. Reducing demoralization and strengthening resilience as part of a comprehensive treatment plan are likely to improve the prognosis of Parkinson disease.

Objectives The objective of this study was to determine whether depression and anxiety are mediators between perceived stress and demoralization via a loss of the cognitive map to get out of the predicament manifesting as subjective incompetence. Methods Ninety-five consecutive outpatients with Parkinson's disease were evaluated for perceived stress, depression, anxiety, subjective incompetence, and demoralization using reliable and valid scales. Inclusion criteria were ages 40–90, intact cognition, and no current history of substance use. The setting was a Movement Disorders Clinic at a university-affiliated hospital. The outcome variable was demoralization, selected a priori. Mediators between perceived stress and demoralization were examined using path analysis. Results Depression, anxiety, and subjective incompetence were mediators between perceived stress and demoralization. Among all variables, subjective incompetence was the largest contributor to demoralization. Depression connected to demoralization indirectly via subjective incompetence (β = 0.25, p < 0.001), whereas anxiety bypassed subjective incompetence (β = −0.01, p = 0.882), connecting directly to demoralization (β = 0.37, p = 0.008). Conclusion Early treatment and reversal of subjective incompetence and anxiety could potentially prevent the escalation of demoralization and the associated disruption in health-related quality of life and eventual suicide.

This chapter reviews the literature on migration as a risk factor for psychosis dating from the work of Ødegaard. The earlier crude hospital counts have been replaced by more sophisticated population-based incidence studies. Research has identified several major trends: Various explanations are given for the above findings. The chapter then considers issues of screening and assessment of immigrants and concludes with treatment approaches. The need for an anthropological and ethnographic approach is emphasized. The encounters between providers and migrants and their families are to be seen essentially as transcultural encounters.

Introduction: Demoralization is quite prevalent in patients with Parkinson disease (PD). Unrecognized or untreated, demoralization may progress, at times, to demands for euthanasia and the desire for suicide. Typically, patients with PD do not complain of being "demoralized"; rather, they report disruptions in the quality of their lives. Hence, early identification of disruptions in health-related quality of life (HRQoL) specifically associated with demoralization may prompt earlier recognition and treatment. Published data on such associations, however, could not be found. Alleviation of demoralization in PD is likely to improve treatment outcomes. Objective: This research aimed at identifying the disruptions of HRQoL specifically associated with the demoralization of patients with PD. Methods: Consecutive general hospital outpatients with PD (n = 95) were assessed for: demoralization, with the Diagnostic Criteria for Psychosomatic Research Demoralization Scale (DCPR-D) and the Demoralization Scale (DS); depression, with the Patient Health Questionnaire-9 (PHQ-9); HRQoL, with the Parkinson Disease Questionnaire-Short Form (PDQ-8); sociodemographic variables; medical comorbidities; PD severity; and types of treatment. Results: The prevalence of demoralization was 19%. Regression analyses showed that demoralization was significantly more likely to be experienced by participants who had difficulty with mobility and felt embarrassed in public due to having PD. Demoralization explained HRQoL over and above depression. Conclusions: Stigma and perceived difficulty with mobility are associated with demoralization of PD patients, and they may signal the need for psychotherapeutic and behavioral interventions to prevent the progression to helplessness, hopelessness, demands for euthanasia, and desire for suicide.

and dual-diagnosis services.A personalized treatment planning approach was developed in each case and included the time period of the COVID-19 quarantine.Results: Mr A: 64 year old man with Generalized Anxiety Disorder, Panic Disorder, Opioid Use Disorder in sustained remission on Methadone 270mg daily and Sedative Hypnotic Use Disorder.The patient entered treatment for impending Benzodiazepine withdrawal after losing his provider.He was taking alprazolam 2mg, clonazepam 6m and zolpidem 10mg daily over the past 30 years.Following treatment for acute withdrawal and treatment with a slow taper of clonazepam the patient has been struggling with episodic anxiety and feelings of loss.Isolation and boredom related to COVID-19 quarantine conditions have contributed to this making the issue of worsening anxiety with protracted withdrawal symptoms difficult to delineate.Ms B:74 year old woman with Generalized Anxiety Disorder entered treatment after her provider closed his practice.The patient was prescribed diazepam 40mg, lorazepam 2mg and zolpidem 10mg daily for the past 5 years.In addition she was prescribed dextroamphetamine 20 mg daily for 3 years for fatigue.Over a 2 year period the medications were tapered using clonazepam; the dextroamphetamine was discontinued.While being maintained on clonazepam 0.5mg daily she started to complain of fearfulness, loneliness, insonia and chronic pain which increased with the onset of the COVID-19 quarantine.Mirtazpine 7.5mg was started at bedtime with improvement.Ms D: 59 year old woman with PTSD, Major Depressive Disorder, Alcohol Use Disorder, Cannabis Use Disorder and Cocaine Use Disorder treated with lorazepam 2 mg daily entered treatment after a previous provider was unable to administer Naltrexone LAI.The dose was reduces by 25% every 3 to 4 weeks while mirtazapine was utilized to manage emerging symptoms of depression and insomnia.Conclusions: We found that patients often entered treatment as a result of prior providers either refusing to continue prescribing benzodiazepines or limiting their practice.Patients responded well to engagement but under the increased stress of COVID-19 quarantine conditions symptoms increasingly emerged.Our population included patients who were also receiving MAT for sustained remission of Opioid Use Disorder and faced greater risks related to benzodiazepine use.Patients were receptive to educational interventions regarding the risks of continuing use and were able to engage in treatment.Despite the proven negative outcomes of chronic use providers continue to prescribe benzodiazepines inappropriately to older adults.The need to care for patients treated with these agents is high.Post-acute withdrawal syndrome is poorly understood and under recognized in older adults.Efforts such as de-prescribing, patient centered approaches to rational prescribing and use remote education programs should be increased.COVID-19 pandemic conditions lead to an increase in overall symptoms reported but did not prevent patients from engaging in successful treatment.

Background According to the stress inoculation hypothesis, successfully navigating life stressors may improve one's ability to cope with subsequent stressors, thereby increasing psychiatric resilience. Aims Among individuals with no baseline history of post-traumatic stress disorder (PTSD) and/or major depressive disorder (MDD), to determine whether a history of a stressful life event protected participants against the development of PTSD and/or MDD after a natural disaster. Method Analyses utilised data from a multiwave, prospective cohort study of adult Chilean primary care attendees (years 2003–2011; n = 1160). At baseline, participants completed the Composite International Diagnostic Interview (CIDI), a comprehensive psychiatric diagnostic instrument, and the List of Threatening Experiences, a 12-item questionnaire that measures major stressful life events. During the study (2010), the sixth most powerful earthquake on record struck Chile. One year later (2011), the CIDI was re-administered to assess post-disaster PTSD and/or MDD. Results Marginal structural logistic regressions indicated that for every one-unit increase in the number of pre-disaster stressors, the odds of developing post-disaster PTSD or MDD increased (OR = 1.21, 95% CI 1.08–1.37, and OR = 1.16, 95% CI 1.06–1.27 respectively). When categorising pre-disaster stressors, individuals with four or more stressors (compared with no stressors) had higher odds of developing post-disaster PTSD (OR = 2.77, 95% CI 1.52–5.04), and a dose–response relationship between pre-disaster stressors and post-disaster MDD was found. Conclusions In contrast to the stress inoculation hypothesis, results indicated that experiencing multiple stressors increased the vulnerability to developing PTSD and/or MDD after a natural disaster. Increased knowledge regarding the individual variations of these disorders is essential to inform targeted mental health interventions after a natural disaster, especially in under-studied populations.

BACKGROUND:Natural disasters are associated with a variety of negative health consequences, including enhanced suicide risk. Factors that moderate the relationship between disaster exposure and enhanced suicide risk are unknown. The aim of the current study was to determine whether pre-disaster PTSD moderates the association between change over time in thoughts of death, suicidal ideation (SI), suicide plans, and suicide attempts (SA) from pre- to post-disaster.METHODS:Participants (n = 2832) were recruited from Chile as part of the larger PREDICT study and completed a measure of lifetime PTSD and panic disorder at baseline and a lifetime death/suicide measure at baseline in 2003 and again 6, 12, and 24 months later (i.e. "pre-disaster"). One year following a major earthquake and tsunami in 2010 (i.e., "post-disaster"), participants completed another death/suicide measure.RESULTS:Both those with and without pre-disaster PTSD experienced significant increases in SI from pre- to post-disaster. However, pre-disaster PTSD was associated with significantly accelerated increases in thoughts of death and SI from pre-to post-disaster. At nearly all time-points, pre-disaster PTSD was associated with higher thoughts of death and SI, suicide planning, and SA. In contrast, panic disorder did not moderate the association between time and changes in SI.LIMITATIONS:There was a long time-gap between pre-disaster and post-disaster, with limited data about what occurred during this time.CONCLUSION:Pre-disaster PTSD is an important predictor of increased SI following a natural disaster, and groups with pre-disaster PTSD should be prioritized for receipt of mental health resources following a natural disaster.

OBJECTIVE:To understand the mental health treatment gap in the Region of the Americas by examining the prevalence of mental health disorders, use of mental health services, and the global burden of disease.METHODS:Data from community-based surveys of mental disorders in Argentina, Brazil, Canada, Chile, Colombia, Guatemala, Mexico, Peru, and the United States were utilized. The World Mental Health Survey published data were used to estimate the treatment gap. For Canada, Chile, and Guatemala, the treatment gap was calculated from data files. The mean, median, and weighted treatment gap, and the 12-month prevalence by severity and category of mental disorder were estimated for the general adult, child-adolescent, and indigenous populations. Disability-adjusted Life Years and Years Lived with Disability were calculated from the Global Burden of Disease study.RESULTS:Mental and substance use disorders accounted for 10.5% of the global burden of disease in the Americas. The 12-month prevalence rate of severe mental disorders ranged from 2% - 10% across studies. The weighted mean treatment gap in the Americas for moderate to severe disorders was 65.7%; North America, 53.2%; Latin America, 74.7%; Mesoamerica, 78.7%; and South America, 73.1%. The treatment gap for severe mental disorders in children and adolescents was over 50%. One-third of the indigenous population in the United States and 80% in Latin America had not received treatment.CONCLUSION:The treatment gap for mental health remains a public health concern. A high proportion of adults, children, and indigenous individuals with serious mental illness remains untreated. The result is an elevated prevalence of mental disorders and global burden of disease.

The number of individuals with intellectual disability and/or autism spectrum disorder who are 65 or older is growing because of increased longevity and a proportionally larger number of individuals being diagnosed across the lifespan. Many of these individuals live with caregivers who are aging and thus eventually need out-of-home placement. Individuals with Down syndrome may also need out-of-home placement as they have an exceedingly high risk of neurocognitive disorder with age. This chapter provides the epidemiology of older adults with intellectual disability and/or autism spectrum disorder and discusses the changes in criteria for these in DSM-5. The chapter also discusses the challenges these individuals and the forensic psychiatrist may face in the judicial system. Individuals may not understand their rights and may be prone to confess or be coerced. They may also lack of full comprehension, making it difficult for them to assist in their defense and describe details of offense. The overlap of geriatric psychiatry and intellectual disability and/or autism spectrum disorder and the law is an area ripe for further research.

There are five principal domains of elder abuse: physical abuse, psychological abuse, sexual abuse, neglect, and financial abuse. This chapter discusses the prevalence, prediction, and assessment of elder abuse as well as other factors related to abuse. The incidence of elder abuse is 24 times greater than the number of cases referred to social service, law enforcement, or other legal authorities. Caregiver factors, rather than risk factors associated with the abused elder, may be more important in predicting abuse. Lack of compliance with medical regimens, delay in seeking medical care, disparity in explanations given for injuries, unexplained injuries, and implausible or vague explanations may be warning signs. Elder financial victimization can be classified as door-to-door scams, professional swindles, and caregiver abuse. Elder abuse increases mortality, emergency room visits, hospitalizations, and skilled nursing home placement. The psychiatric assessment may raise red flags of suspected elder abuse and may necessitate reporting to adult protective services. Interventions should be tailored to the circumstances and the resources available.

As life expectancy increases and the baby-boom generation ages, clinicians will see a growing aging population, many of whom have experienced individual or mass psychic trauma. In these individuals, a personal history of trauma can compound the expected traumas of aging. This chapter provides the epidemiology of older adults who have experienced trauma and discusses issues such individuals face, as well as measures clinicians can use to avoid retraumatization. There is a relatively high prevalence of posttraumatic stress disorder (PTSD) among older persons generally. Fragile elders with a history of helplessness, trauma, and massive loss are vulnerable to reactivation of posttraumatic symptomatology through the experience of pain, fear, or helplessness that can accompany even ordinary aging, especially in nursing homes. Aging persons show varying levels of resilience in the face of trauma due to genetic factors and/or life experience. Clinicians and researchers need to take into account individual, family, and communal histories of trauma and respect patients’ autonomy in order to implement an informed-consent process within a trusting patient–family–clinician alliance.

Elderly persons are not often thought of as being associated with criminal activity. Among the elderly for both genders, however, the percentage of persons arrested in the United States for violent crimes increased significantly from 1995 to 2013, this increase being due to more aggravated assault arrests. Epidemiological studies on antisocial personality disorder and FBI crime statistics provide an understanding of sociopathy and directed aggression in the geriatric population. This chapter addresses the risk factors for violent behavior among elderly persons and provides U.S. crime data for persons age 65 and older, presented by type of crime and by gender and race of perpetrators. The act of homicide among elderly persons is given particular attention. The chapter also discusses the role of dementia in crimes committed by elderly persons, as a sizable proportion of persons with dementia take part in criminal activity, particularly theft, although rates differ according to type of neurocognitive disorder.