Use of psychotropic medications in São Paulo Metropolitan Area, Brazil: pattern of healthcare provision to general population

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1 pharmacoepidemiology and drug safety (2015) Published online in Wiley Online Library (wileyonlinelibrary.com).3826 ORIGINAL REPORT Use of psychotropic medications in São Paulo Metropolitan Area, Brazil: pattern of healthcare provision to general population Angela Maria Campanha 1,2, Erica Rosanna Siu 1, Igor André Milhorança 3, Maria Carmen Viana 4, Yuan-Pang Wang 1 *, and Laura Helena Andrade 1 *, 1 Section of Psychiatric Epidemiology (LIM-23), Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, SP, Brazil 2 Department of Pharmacy, State University of Maringá, Maringá, PR, Brazil 3 Institute of Mathematics and Statistics, University of São Paulo, São Paulo, SP, Brazil 4 Department of Social Medicine, Health Sciences Center, Federal University of Espírito Santo, Vitória, ES, Brazil ABSTRACT Purpose We estimate the proportion of psychotropic medication use (PMU) among adults in São Paulo Metropolitan Area, Brazil. We investigated whether socio-demographic factors, comorbidity, and disease severity influence PMU among individuals with psychiatric disorders. Methods Data are from the São Paulo Megacity Mental Health Survey, a cross-sectional, population-based study, the Brazilian branch of the World Mental Health Survey Initiative. Trained lay interviewers face-to-face assessed psychiatric disorders and PMU through the Composite International Diagnostic Interview. Respondents were asked about use of healthcare service and prescribed medications for mental disorders in the previous year. Information on PMU was collected for 2935 adult residents in the area and among those with disorders who received treatment. Results Around 6% of respondents reported PMU in the past year: hypnotics or sedatives were used by 3.7% and antidepressants by 3.5%. Among individuals with 12-month disorders, only 14% reported past year PMU. Gender, age, education, income, occupational status, comorbidity, and severity were significant predictors for PMU. Among those with 12-month DSM-IV disorders who obtained treatment in healthcare settings, almost 40% received medication only. Among those treated in specialty mental health service, around 23% received combination of medication and psychotherapy. Conclusion Our study has pointed out that the recent trend of access to mental healthcare in Brazil depicts unmet needs, characterized by a low prevalence of PMU among individuals with psychiatric disorders. Policies that improve appropriate access to prescribed drugs for those most in need are urgent public health priority. Copyright 2015 John Wiley & Sons, Ltd. key words pharmacoepidemiology; mental disorders/therapy; psychotropic drugs; mental disorders/epidemiology Received 23 January 2015; Revised 22 May 2015; Accepted 4 June 2015 INTRODUCTION Increased burden of mental disorders and the impact of chronic conditions on the use of healthcare services are *Correspondence to: L. Helena Andrade, Instituto de Psiquiatria, Faculdade de Medicina da Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 785, CEP São Paulo, SP, Brazil. lhsgandr@usp.br Dr. Y-P Wang and L. H. Andrade share senior authorship. Parts of the results of this article were presented during the following meetings: the World Health Summit Regional Meeting Latin America, held in São Paulo, Brazil, April 2014; the American Psychiatric Association Annual Meeting, held in New York, NY, USA, May 2014; and the World Psychiatric Association 2014 Meeting, Section on Epidemiology and Public Health, held in Nara, Japan, October a recent phenomenon. 1,2 However, population-based studies have identified a profound gap between the need for treatment and the availability of appropriate care. 3,4 The prescription of psychotropic medications is one relevant aspect for which that gap is considerable. 5,6 Since 2000, a series of population surveys were conducted by the World Mental Health (WMH) Survey Initiative. 7 Pharmacoepidemiology was one aspect investigated in this worldwide consortium. Overall prevalence of psychotropic medication use (PMU) among individuals diagnosed with a mental disorder was low. Even in developed countries, the rates ranged from less than 6% in Germany to 19.2% in France. 5 8 In the majority of the surveyed populations, PMU was Copyright 2015 John Wiley & Sons, Ltd.

2 higher among women and individuals aged 65 years or older. 8,9 The most common prescriptions were hypnotics or anxiolytics, but appropriate medications were not always prescribed for the disorders. In well-established healthcare systems, such as Canada, less than 20% of individuals with mental disorders received psychotropic medication. This proportion was slightly higher for those with mood disorders (30%), although still relatively low (around 50%) when only moderate and severe cases were considered. 10 A similar pattern was described in the USA, 11,12 in either community or healthcare settings. In a bipolar patients sample, Baldessarini et al. 13 found that approximately 40% of patients have not received a psychotropic prescription in the first years after the diagnosis. Despite of availability of efficacious and tolerable psychopharmacological treatments, many people in need do not obtain care for their mental disorders. Population-based investigations devoted to mental health care are scarce in Brazil. 14 In a previous report, 2 we observed that around 30% of severe cases received treatment. In the last decades, a prescription is required to obtain psychotropic medication in Brazil. Consequently, health service delivery might impact on the access to medication and other forms of treatment for mental disorders. Investigating PMU in general population is critical to evaluate barriers of access to appropriate care. Therefore, the current report has two aims: (i) to estimate the proportion of PMU in a representative sample of adults living in the São Paulo metropolitan area to evaluate enabling factors of this use; and (ii) to evaluate need factors, examining, among respondents with 12-month disorders who obtained treatment, the proportion of individuals receiving only medication or in combination with psychological treatment in the healthcare system. METHODS Sample The São Paulo Megacity Mental Health Survey (SPMHS) was designed to be a survey of a representative sample of non-institutionalized individuals in São Paulo Metropolitan Area. 15 At the time of data collection, from 2005 to 2007, individuals aged 18 years or more accounted for 11 out of 20 million of inhabitants. 15 Respondents were selected using a stratified, multistage area probability sample of households. 16 Each municipality was represented in the total sample according to its population size. We initially selected 7700 households, allowing for a 35% non-response a. m. campanha et al. rate. The final sample comprised 5037 residents, and the overall response rate was 81.3%. All interviews were face-to-face conducted by trained lay interviewers using field quality control procedures. 17,18 The WMH Composite International Diagnostic Interview (CIDI) 19 consisted of two parts: Part I, which was applied for all respondents, was designed to identify core mental disorders (mood, anxiety, impulse-control, and substance use disorders, as well as suicidal behavior), and the Part II, which assessed additional correlates, disorders, and PMU. Regarding the assessment of PMU, we evaluated a total of 2935 respondents after the exclusion of seven subjects with missing values in the pharmacoepidemiology section. Data were weighted to adjust for the under-sampling of non-cases in Part II and for residual discrepancies between the sample and the population, in terms of the distributions of a range of socio-demographic variables. This sampling strategy allowed comparing cases versus non-cases and correlates of psychiatric morbidity, and to identify additional diagnoses among respondents who were negative for core disorders in Part I. The Research Ethics Committee of the University of São Paulo Medical School approved the survey. All respondents gave written informed consent prior to the study. Diagnostic assessment We used the Portuguese version of the WMH-CIDI, 19 a fully structured lay-administered interview designed to identify DSM-IV diagnoses. The respondents were classified as having an active disorder if the symptoms had been present for at least 12 months prior to the interview. The disorders were categorized into four broad classes: anxiety disorders (panic disorder, generalized anxiety disorder, agoraphobia without panic disorder, specific phobia, social phobia, post-traumatic stress disorder, obsessive compulsive disorder, and adult separation anxiety); mood disorders (major depressive disorder, dysthymia, and bipolar disorder); impulse-control disorders (ICD: oppositional-defiant disorder, conduct disorder, attention-deficit/hyperactivity disorder, and intermittent explosive disorder); and substance use disorders (SUD: alcohol and drug abuse or dependence). We consistently adopted DSM-IV organic exclusion criteria and non-hierarchical diagnostic rules in analyses of comorbidity. Severity and impairment in functioning Respondents were categorized as having severe mental illness if they were diagnosed with bipolar I disorder,

3 or substance dependence with physiologic signs; had attempted suicide in the past year, in conjunction with any other WMH-CIDI/DSM-IV core disorder (major depressive disorder, agoraphobia, post-traumatic stress disorder, generalized anxiety disorder, social phobia, specific phobia, intermittent explosive disorder, adult separation anxiety, dysthymia, bipolar I disorder, bipolar II disorder, or subthreshold bipolarity), or were diagnosed with more than one core DSM-IV diagnosis and showed a high level of impairment on the Sheehan Disability Scale in at least one of the disorders presented. 20 Respondents are asked to rate the impairment caused by each disorder assessed during the worse month in the past year. The 0 10 visual analog scale assessed disability domains in work role performance, household maintenance, social life, and intimate relationship on with associated scale scores of none, 0; mild, 1 3; moderate, 4 6; severe 7 9, and very severe, 10. These reports were combined by assigning respondents who had more than 1 disorder to the highest visual analog scale for any single disorder. Among those who are not categorized as severe cases, respondents are labeled moderate if they had at least one disorder with a moderate level of impairment on any domain or substance dependence without physiological signs. The remaining respondents with any active disorder were categorized as mild. Accordingly, respondents were classified as having no 12-month disorders, mild, moderate, or severe. Use of health services Respondents were asked whether they ever received treatment for mental health problems. Reports of 12- month service use were classified into the following categories: (i) specialized mental health service (MHS) to include psychiatrist, non-psychiatrist mental health specialist (psychologist, social worker, or counselor in MHS setting); (ii) general medical service (GMS) (primary care physician, nurse, or other healthcare professionals). A few proportion reported treatment by human services professionals. For the purpose of this paper, only GMS and MHS are considered. In each of the two healthcare settings, types of treatment were classified as: medication only, psychotherapy only, and medication and psychotherapy combined. Herein, we considered seeing a licensed psychologist as a restrictive definition for receiving psychotherapy. In Brazil, only physicians can prescribe medication. No active treatment was defined as individuals who received neither drugs nor psychological treatments. psychotropic medication use in são paulo, brazil Assessment of PMU All respondents were asked about PMU during the last 12 months for problems related to emotions, nerves, mental health, substance use, energy, concentration, sleep, or ability to cope with stress. The psychotropic medications in use were recorded using the brand names and were subsequently converted to the 2012 Anatomical Therapeutic Chemical Classification System. 21 The medications were grouped in the following classes: antidepressants, antipsychotics, mood stabilizers, and hypnotics/sedatives (including benzodiazepines). Socio-demographic correlates Socio-demographic correlates included age group (18 24, 25 34, 35 49, 50 64, and 65 years), gender (male and female), years of schooling (0 4, 5 8, 9 11, and 12 years; respectively low, low-average, high-average, and high level of education), employment status (employed/student, homemaker, retired, or unemployed), marital status (married/cohabiting, previously married, or never married), and family income. Family income was categorized on the basis of the household income per family member divided by the median household income per family member in the sample as a whole (ratio): low (<0.5); low-average ( ); high-average ( ): or high (>2.0). Statistical analysis Data analysis began by computing the proportions of respondents who received any psychotropic medication within 12 months of the survey. Second, we examined, among respondents with 12-month disorders, the proportion receiving PMU. Finally, we examined the proportions of those in treatment, and, among them, the proportion in each healthcare settings (GMS or MHS) who received medication, and/or psychotherapy, across strata defined by classes and severity of disorders. Logistic regression analysis was then used to study socio-demographic predictors and presence of an active disorder according to its level of severity on each type of treatment received. Logistic regression coefficients and standard errors (SE) were exponentiated. The SE was adjusted by design-based Taylor series linearization method, according to data weight and sample clustering. The estimates are reported as odds ratios (OR) with 95% confidence intervals (CI). All analyses were performed using the SAS and SUDAAN Wald s chi-square tests based on Taylor series coefficient variance covariance

4 matrices were used to evaluate the statistical significance of sets of coefficients, with a two-sided alpha of RESULTS The characteristics of the sample are shown in Table 1. Briefly, the mean age was 41.0 years (95%CI: ), with 77% of the respondents being <50 years of age. Females accounted for 53% of the sample. Approximately 20% reported having had 12 years of schooling. At the time of data collection, nearly 60% of the respondents were married and 66% were employed. PMU in total sample. Around 6% (n = 289) of the 2935 respondents reported any 12-month PMU. Hypnotics/benzodiazepines were the most prescribed class of psychotropic medication (3.7% of the respondents), followed by antidepressants (3.5%). A small proportion of the respondents reported receiving antipsychotics or mood stabilizers (0.7% for both). The exclusive use of only one class of psychotropic medication was reported by 3.7% of the respondents, being hypnotics/benzodiazepines and antidepressants the Table 1. Demographic characteristics of the São Paulo Megacity Mental Health Survey sample (n = 2935) Characteristic n % (SE)* Age, years (1.3) (1.2) (1.3) (1.0) (0.8) Gender Male (1.5) Female (1.5) Education (years of schooling) Low (0 4) (1.0) Low-average (5 8) (1.1) High-average (9 11) (1.4) High ( 12) (1.2) Family income Low (0.9) Low-average (0.9) High-average (1.1) High (1.3) Marital status Married/cohabiting (1.6) Previously married (1.1) Never married (1.2) Employment status Employed/student (1.3) Homemaker (0.8) Retired/unemployed (0.5) *Weighted proportions. a. m. campanha et al. most common prescriptions, either as monotherapy or in combination (1.5%). Women were more likely than men to receive a prescription (OR = 3.0), particularly antidepressants or hypnotics/benzodiazepines (OR = 4.0 and 3.7, respectively). Correlates of PMUS are described in Table 2. Women were more likely than men with similar severity to receive a prescription. PMU increased with advancing age, with odds around four times higher among individuals 50 years than the reference group (18 24 years). We identified an inverse relationship between PMU and years of schooling, being the respondents with <11 years of schooling more likely (range OR = 2.1 to 2.6) to report PMU than were those with some college education. Additional correlates of higher PMU were being in the group of highest family income, homemaker (OR = 1.8), or retired (OR = 2.0). The presence of a 12-month disorder increased the likelihood of PMU, in a dose response relationship with Table 2. Correlates of psychotropic medication use in the previous 12 months: socio-demographic variables and level of disorder severity. São Paulo Megacity Mental Health Survey (n = 2935) Variable OR (95% CI) Age, years ( ) ( ) ( ) ( ) Gender Male 1 Female 2.2 ( ) Education (years of schooling) Low (0 4) 2.1 ( ) Low-average (5 8) 2.5 ( ) High-average (9 11) 2.6 ( ) High ( 12) 1 Family income Low 0.4 ( ) Low-average 0.3 ( ) High-average 0. 5 ( ) High 1 Marital status Married/cohabiting 1 Previous married 0.9 ( ) Never married 1.0 ( ) Employment status Employed/student 1 Homemaker 1.8 ( ) Retired 2.0 ( ) Unemployed 1.5 ( ) Severity No 12-month disorder 1 Mild disorder 2.2 ( ) Moderate disorder 4.3 ( ) Severe disorder 11.7 ( ) OR, odds ratio; CI, confidence interval. p < p <

5 level of disorder severity (range OR = 2.2 to 11.7, from mild to severe disorders). PMU by respondents with 12-month disorder. The proportion of respondents with at least one 12-month DSM-IV disorder was 29.6%, evenly distributed across the severity gradient from mild to severe cases. Approximately one in ten residents presented a severe 12-month mental disorder. The most prevalent classes of disorders were anxiety (19.9%) and mood (11%), followed by ICD (4.2%), and SUD (3.6%). Although most active cases of mental disorder present with one single disorder (17.8%), 5.9% of the respondents had two disorders, and 5.8% had three or more. 2 Almost 14% of individuals presenting 12-month disorder received a prescription (Table 3). Antidepressant use was comparable to use of hypnotic/sedative (9.1% vs. 7.8%), being the most frequent classes of medication reported by respondents with mood and anxiety disorders. Only a small proportion of respondents with disorders reported use of antipsychotics or mood stabilizer. Around 25% respondents with mood disorder reported PMU, 14.4% of those with anxiety and about 10% of those with ICD or SUD. Supplementary Table 1 depicted the proportional distribution of PMU, by specific disorders, comorbidity, and severity. Panic disorder (50%), bipolar disorder (34%), and agoraphobic cases (30%) had the highest proportion of PMU. Only around 24% of active cases of depression reported PMU. The presence of comorbidity and level of severity was associated with PMU in a dose response pattern, with increased usage in those with three or more disorders (26.9%; χ 2 = 22.5; p < ), and in respondents presenting serious disorders (23.8%; χ 2 = 21.6; p < ). Pattern of treatment in healthcare sector. Around 10% of the total sample used services in the prior year, including 23.0% of those with 12-month DSM-IV disorders (Supplementary Table 2). Less than one-third of psychotropic medication use in são paulo, brazil active cases with some level of impairment (severe and moderate cases) were seen by a service provider in the previous year. The highest proportion of cases in treatment was among those with mood disorders (36.4%), and the lowest was cases of SUD (19%). Most treatments occurred in the healthcare sector (8.8% of respondents, representing 87.1% of those in treatment) and, within the healthcare sector, the majority was seen in MHS (6.3% of respondents, representing 62.4% of those in treatment), and 3.3% received care from GMS (32.5% of those in treatment). As expected, the greatest proportion (around 40%) of cases seen in GMS received only medication. Proportional medication treatment was similar across classes of disorders and levels of severity. Only a minority treated in this sector received combined medication and psychotherapy with higher proportion among respondents with severe/moderate disorders (10%), and comorbid cases (12%). In MHS, a similar proportion of cases were treated only with medication, but much more cases reported psychotherapy alone or in combination (17% and 23% of those with any disorder). Proportional combined medication-psychotherapy treatment was highest among severe/moderate and comorbid cases (about 25% each). Predictors of any 12-month service use. Disorder severity was a strong predictor, associated not only with probability of receiving any treatment, but also related significantly to treatment in the healthcare sector. Other determinants are being female (for any treatment and GMS), homemaker (for any treatment and MHS), or unemployed (for any treatment) (Supplementary Table 3). Table 4 depicted socio-demographic and disorder severity predictors of receiving medication and psychotherapy, alone or in combination by respondents with 12-month treatment. Predictors for receiving only medication were: having <12 years of education Table 3. Weighted prevalence of psychotropic medication use in the past year, by class of disorders. São Paulo Megacity Mental Health Survey (n = 2935) Any psychotropic medication Any antidepressant Any antipsychotic Any mood stabilizer Any hypnotic/sedative Class of disorders n % (SE) n % (SE) n % (SE) n % (SE) n % (SE) No disorder (0.6) (0.3) (0.1) (0.1) (0.3) Any disorder* (1.0) (0.8) (0.4) (0.3) (0.8) Any anxiety disorder (1.4) (1.0) (0.5) (0.5) (1.0) Any mood disorder (2.3) (1.8) (0.9) (0.7) (2.4) Any ICD (1.9) (1.7) (0.8) (0.6) (1.7) Any SUD (3.1) (1.8) (1.1) (1.2) (2.5) *As defined in the DSM-IV and determined with the WMH-CIDI. Impulse control disorders. Substance use disorders.

6 Table 4. Socio-demographic and disorder severity predictors of receiving medication and psychotherapy, alone or in combination by respondents with 12-month treatment (n = 471). São Paulo Megacity Mental Health Survey Variable (range OR = 7.3 to 3.5); being in the top quartile of family income, and presenting a severe disorder (OR = 4.1). Conversely, the likelihood of receiving only psychotherapy was lower among those with <12 years of education (OR = 0.3) and mild disorder (OR = 0.4). Predictors of receiving combined medication and psychotherapy were: being unemployed (OR = 2.1) and having a severe disorder (OR = 4.2). DISCUSSION Medication only Psychotherapy only Medication and psychotherapy OR (95% CI) OR (95% CI) OR (95% CI) Age 1.0 ( ) 0.9 ( ) 1.0 ( ) Gender Female 1.3 ( ) 1.0 ( ) 1. 3 ( ) Male Education (years) Low (0 4) 7.3 ( ) 0.7 ( ) 3.9 ( ) Low-average 5.5 ( ) 0.3 ( )* 1.0 ( ) (5 8) High-average 3.5 ( ) 0. 7 ( ) 1.6 ( ) (9 11) High ( 12) Family income Low 0.4 ( ) 0. 9 ( ) 0.3 ( ) Low-average 0.2 ( ) 1.4 ( ) 0.3 ( ) High-average 0.3 ( ) 0.8 ( ) 0.2 ( ) High Marital status Married/ cohabiting Previous married 1. 4 ( ) 0.9 ( ) 1.2 ( ) Never married 1.0 ( ) 1.1 ( ) 0.6 ( ) Employment status Employed/student Homemaker 1. 8 ( ) 1.2 ( ) 1.5 ( ) Retired 2.3 ( ) 0.6 ( ) 0.1 ( ) Unemployed 1.1 ( ) 1.1 ( ) 2.1 ( ) Severity No 12-month disorder Mild disorder 1.0 ( ) 0.4 ( )* 2. 4 Moderate disorder 2.2 ( ) 1.2 ( ) 2.1 ( ) Severe disorder 4.1 ( ) 1. 5 ( ) 4.2 ( ) OR, odds ratio; CI, confidence interval. *p < p < p < This study provided empirical data on use of psychotropic medication in the largest metropolitan area in Brazil. Considering general population, only 6.2% of our respondents reported past-year PMU. This proportion was comparable to some methodologically analogous a. m. campanha et al. studies in Germany, 8 Israel, 24 and the Netherlands, 8 but below Italy, 8 Spain, 6 Belgium, 9 and France. 5 In comparison with previous studies in Brazil, with different methodologies, the prevalence of PMU in our study was approximately half of that reported in São Paulo in 1970s 25 and 1990s, 26 and only a quarter of recent data for Rio de Janeiro. 27 Those differences could be attributable to the prevalence of mental disorders, utilization of healthcare services, or laws regulating the sale of prescription medications. 8 Consistent with the literature, women, elder people, less educated, and lower income people were more likely to receive a prescription. 8 Because the majority of psychotropic medications are not available via the public healthcare system in Brazil, individuals in the higher income strata are more likely to be able to bear the out-of pocket expenditure for such medications. 27 Although the prevalence of a 12-month mental disorder was high in São Paulo, 2 less than 14% of active cases reported PMU, a rate lower than that reported in the majority of the WMH surveys, 5,6 but similar to that that reported for Rio de Janeiro. 27 Considering that not all those who meet the criteria for a disorder need be treated, even among respondents with severe disorder and high comorbid cases, only 25% reported PMU. Our results reveal high prevalence rates of mental disorders and substantial levels of unmet need for mental health treatment even among serious cases. Only 30% of moderate/serious cases received any treatment. Among the minority of cases receiving some services, less than half were treated with medication. As expected, in GMS, few cases received medication and psychotherapy combined, what contrasted with MHS, where one in five patients reported this form of treatment. Moreover, a substantial proportion of respondents using GMS and MHS sector did not report either medication or psychotherapy. This might be attributable to initial phase of treatment and/or the respondents did not receive minimally adequate treatment for their disorder. Similar to the total sample, the likelihood of, once in treatment, receiving medication only was inversely proportional with years of education, and positively associated with severity. Unemployment and severity were associated with the combined modalities of medication and psychotherapy. This study has several limitations. First, the sample is from a large metropolitan area; therefore, our findings cannot be generalized to other Brazilian regions. In addition, our sample did not include populations at high risk for PMU, such as homeless, night shift workers, individuals hospitalized with severe psychiatric disorders, and individuals under 18 years of age. Furthermore, we did not evaluate PMU in individuals

7 with a lifetime psychiatric disorder, duration of treatment, or dosage, all of which could have provided information about inadequate treatment. Moreover, we evaluated only the use of prescribed psychotropic medications, and it is possible that some respondents were self-medicating without a formal prescription, which would have increased the prevalence of PMU. Our study has pointed out that the recent trend of access to mental healthcare in Brazil depicts unmet needs of foremost concern. The observed under-treatment characterized by a low prevalence of PMU among individuals with psychiatric disorders is a phenomenon reported for various countries. 5 8 These findings underscore those of previous studies suggesting that many individuals with psychiatric disorders go untreated. 28 Policies that improve appropriate access to prescribed drugs for those most in need are urgent public health priority, because the majority of individuals diagnosed with severe mental disorder are undertreated with appropriate psychotropic medication. CONFLICT OF INTEREST The authors declare no conflict of interest. KEY POINTS Mental disorders are highly prevalent in São Paulo. Only a small proportion of people with mental disorders are treated. Small proportion of people has received psychotropic medications. Hypnotics or sedatives are the most prescribed psychotropic medications. There is inequality in access to medication. ACKNOWLEDGEMENTS We thank the WMH staff for their assistance with instrumentation, fieldwork, and data analysis. We are also grateful to the SPMMHS team members Beatriz Margarita Adler, Marlene Galativicis Teixeira, Indaiá de Santana Bassani, and Fidel Beraldi. SPONSORS The São Paulo Megacity Mental Health Survey was funded by the Fundação de Amparo à Pesquisa do Estado de São Paulo (São Paulo Research Foundation; FAPESP 03/ ), and the Brazilian Conselho Nacional de Desenvolvimento Científico e Tecnológico (National Council for Scientific and Technological Development; CNPq /2013-0) supports psychotropic medication use in são paulo, brazil Dr. L. H. Andrade. The São Paulo Megacity Mental Health Survey was carried out in conjunction with the World Health Organization World Mental Health Survey Initiative. The main coordination center activities, at Harvard University, were supported by the United States National Institutes of Mental Health (R01- MH070884), the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, and the US Public Health Service (R13-MH066849, R01-MH069864, and R01-DA016558), as well as by the Fogarty International Center (FIRCA R03-TW006481), the Pan American Health Organization, the Eli Lilly and Company Foundation, Ortho-McNeil Pharmaceutical, GlaxoSmithKline, Bristol-Myers Squibb, and Shire. A complete list of World Mental Health publications can be found at wmh/. The current study received financial support from the Araucária Foundation for the Support of Scientific and Technological Development in the State of Paraná (01/ / , Angela Maria Campanha was the recipient of the scholarship for doctoral thesis), the Programa de Excelência Acadêmica (PROEX, Academic Excellence Program) of the Brazilian Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES, Office for the Advancement of Higher Education; Angela Maria Campanha was the recipient of the scholarship for doctoral thesis), and the Fundo de Apoio à Ciência e Tecnologia de Vitória (FACITEC, Vitória [Municipal] Fund for the Support of Science and Technology; 002/2003 for instrument development). None of the sponsors had any role in the design, analysis, interpretation of results, or preparation of this paper. REFERENCES 1. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. 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