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Trayectoria diagnóstica posterior al primer episodio psicótico en pacientes de un centro de tercer nivel del Oriente antioqueño
Diagnostic Trajectory After the First Psychotic Episode in Patients From a Tertiary Healthcare Center in Eastern Antioquia
Daniela Parra Dunoyera, Luis Miguel Vélez Véleza, Oscar Julián Vargas Muñoza, Clara Catalina Cossio Uribeb, Sergio Molina Osorioc, Diego Fernando Rojas-Gualdrónd,
Autor para correspondencia
dfrojas@ces.edu.co

Autor para correspondencia.
a Médico, residente de Psiquiatría, Facultad de Medicina, Universidad CES, Medellín, Colombia
b Médica psiquiatra, Magíster en Bioética, Facultad de Medicina, Universidad CES, Medellín, Colombia
c Médico psiquiatra. Facultad de Medicina, Universidad CES, Medellín, Colombia
d Neuropsicólogo clínico, Doctor en Epidemiología, Facultad de Medicina, Universidad CES, Medellín, Colombia
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Funci&#243;n de incidencia acumulada de primer diagn&#243;stico psiqui&#225;trico seg&#250;n d&#237;as desde la consulta por primer episodio psic&#243;tico &#40;PEP&#41;&#46;</p>"
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pron&#243;stico y tratamiento<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#44;5</span></a>&#44; por lo cual&#44; el PEP puede ser atribuido a m&#250;ltiples condiciones m&#233;dicas&#46; Los 5 primeros a&#241;os son determinantes para establecer el diagn&#243;stico&#44; el cual en aproximadamente el 40&#37; de los casos se relaciona con enfermedad mental&#44; siendo la esquizofrenia el principal diagn&#243;stico descrito en la literatura&#44; seguido de los trastornos afectivos<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;5&#44;6</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">En la literatura se plantean caracter&#237;sticas exploradas en la pr&#225;ctica cl&#237;nica&#44; como antecedentes familiares&#44; presencia de s&#237;ntomas negativos&#44; el estado prem&#243;rbido y los s&#237;ntomas afectivos como los principales factores orientadores de un diagn&#243;stico y tratamiento psiqui&#225;trico<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a>&#46; No obstante&#44; las variables cl&#237;nicas que mejor contribuyen a predecir el diagn&#243;stico psiqui&#225;trico m&#225;s probable entre pacientes que se presentan al servicio m&#233;dico con PEP no son claras&#44; particularmente en poblaciones latinoamericanas<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8&#44;9</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En Colombia no se cuenta con estudios sobre la trayectoria diagn&#243;stica de los pacientes que presentan PEP&#44; que reconozcan las particularidades sociodemogr&#225;ficas y epidemiol&#243;gicas&#46; Una de las poblaciones de alto inter&#233;s es la del oriente antioque&#241;o&#44; que se ha caracterizado por el aislamiento demogr&#225;fico&#44; los bajos niveles migratorios y una limitada mezcla gen&#233;tica&#46; Resultados preliminares del Paisa Project&#44; estudio que pretende analizar la prevalencia de enfermedad mental grave en la poblaci&#243;n paisa&#44; han identificado una mayor prevalencia de trastorno afectivo bipolar &#40;TAB&#41;&#44; con un 38&#37;&#44; con respecto a la prevalencia de esquizofrenia en la misma poblaci&#243;n &#40;13&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a>&#44; e incluso con la prevalencia de TAB&#44; estimada para Medell&#237;n en un 0&#44;9&#37;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Estas particularidades influyen en la epidemiolog&#237;a de los trastornos psiqui&#225;tricos de la regi&#243;n y por ende en la trayectoria diagn&#243;stica de los pacientes que se presentan con PEP&#44; pudiendo llegar a diferir a lo descrito en la literatura para otros grupos poblacionales&#46; As&#237; las cosas&#44; el objetivo de este estudio es describir la trayectoria diagn&#243;stica desde la presentaci&#243;n del PEP hasta el diagn&#243;stico de un trastorno psiqui&#225;trico y explorar antecedentes y caracter&#237;sticas cl&#237;nicas asociadas&#44; en una cohorte de adultos que consultaron en un centro de referencia de tercer nivel en el Oriente antioque&#241;o&#44; entre los a&#241;os 2007 y 2020&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Metodolog&#237;a</span><p id="par0030" class="elsevierStylePara elsevierViewall">Este estudio fue aprobado por el comit&#233; de &#233;tica de la investigaci&#243;n en seres humanos de la universidad CES &#40;c&#243;digo 937-2020&#41;&#46; En el reporte se siguen las recomendaciones de la gu&#237;a STROBE para estudios de cohorte<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a>&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Dise&#241;o</span><p id="par0035" class="elsevierStylePara elsevierViewall">Estudio retrospectivo de seguimiento a una cohorte basada en registros m&#233;dicos de los pacientes que consultaron entre enero de 2007 y marzo de 2022&#46; El ingreso a la cohorte se defini&#243; como el d&#237;a de consulta al centro m&#233;dico y el tiempo de seguimiento se estim&#243; hasta el d&#237;a en que el paciente recibi&#243; el diagn&#243;stico de trastorno psiqui&#225;trico o&#44; en caso de no registrar nuevo diagn&#243;stico&#44; hasta la fecha de censura administrativa 3 a&#241;os despu&#233;s del ingreso&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Contexto</span><p id="par0040" class="elsevierStylePara elsevierViewall">Los registros de los pacientes se tomaron de un centro de referencia de tercer nivel en el oriente de Antioquia &#40;Colombia&#41;&#44; donde aproximadamente el 70&#37; de los pacientes consultan por enfermedad psiqui&#225;trica&#46; El Oriente antioque&#241;o es una de las 9 subregiones de Antioquia&#44; en la cual habitan aproximadamente 590&#46;000 personas&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Participantes</span><p id="par0045" class="elsevierStylePara elsevierViewall">Se incluyeron de forma consecutiva todos los pacientes mayores de 18 a&#241;os&#44; naturales del Oriente antioque&#241;o&#44; con diagn&#243;stico de PEP seg&#250;n el criterio del psiquiatra tratante registrado en la historia cl&#237;nica&#46; Se excluyeron los registros de pacientes con informaci&#243;n faltante relacionada con las fechas de diagn&#243;stico&#46; Para identificar a los pacientes se realiz&#243; un primer filtro considerando como potencialmente elegibles aquellos con cualquier diagn&#243;stico de la categor&#237;a F del CIE-10 &#40;Trastornos mentales y del comportamiento&#41;&#46; Posteriormente&#44; 3 m&#233;dicos residentes de Psiquiatr&#237;a de tercer a&#241;o&#44; previamente estandarizados&#44; aplicaron los criterios de inclusi&#243;n y exclusi&#243;n mediante el an&#225;lisis de los registros completos de la historia cl&#237;nica&#44; con acompa&#241;amiento y supervisi&#243;n del investigador senior doctor en Epidemiolog&#237;a&#46; Se realiz&#243; la validaci&#243;n de los registros antes de realizar la extracci&#243;n y el an&#225;lisis de los datos&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Variables y fuente de informaci&#243;n</span><p id="par0050" class="elsevierStylePara elsevierViewall">Como variable de resultado se consider&#243; el tiempo al primer diagn&#243;stico de trastorno psiqui&#225;trico posterior al ingreso por PEP&#46; Los diagn&#243;sticos fueron clasificados seg&#250;n c&#243;digos CIE-10 en&#58; 1&#41; TAB &#40;F30&#44; F31&#41;&#59; 2&#41; esquizofrenia &#40;F20&#41;&#59; 3&#41; otros trastornos del estado del &#225;nimo &#40;F32-39&#41;&#59; 4&#41; trastorno esquizot&#237;pico y trastorno delirante &#40;F21-F29&#41;&#59; 5&#41; trastornos de ansiedad&#44; disociativos&#44; relacionados con estr&#233;s&#44; somatomorfos y otros trastornos mentales no psic&#243;ticos&#44; y 6&#41; trastornos mentales y del comportamiento debidos al consumo de sustancias psicoactivas &#40;F10-F19&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Adicionalmente&#44; se extrajeron variables demogr&#225;ficas como sexo&#44; estado civil&#44; escolaridad&#44; situaci&#243;n laboral&#44; &#225;rea de residencia y red de apoyo social&#44; y las variables cl&#237;nicas&#58; antecedentes personales psiqui&#225;tricos y no psiqui&#225;tricos&#44; antecedentes familiares&#44; consumo actual de sustancias psicoactivas y tiempo de psicosis no tratada&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Sesgos y tama&#241;o de la muestra</span><p id="par0060" class="elsevierStylePara elsevierViewall">Las variables fueron extra&#237;das por 3 m&#233;dicos residentes de Psiquiatr&#237;a a partir de los registros de la historia cl&#237;nica electr&#243;nica&#46; Se realiz&#243; verificaci&#243;n de los registros de la historia cl&#237;nica para establecer que no hubiese antecedentes de episodios psic&#243;ticos&#46; No se realiz&#243; estimaci&#243;n del tama&#241;o de la muestra <span class="elsevierStyleItalic">a priori</span> para los an&#225;lisis exploratorios de factores asociados&#46; No obstante&#44; se estim&#243; el poder estad&#237;stico <span class="elsevierStyleItalic">a posteriori</span> para los an&#225;lisis de eventos competitivos estableciendo que con una confianza del 95&#37;&#44; una proporci&#243;n del 50&#37; y una hazard ratio de 1&#44;55 se tiene un poder estad&#237;stico mayor de 0&#44;8 para sub-hazard ratio &#40;sHR&#41;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#44;30 o sHR<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#44;77<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a>&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">An&#225;lisis estad&#237;stico</span><p id="par0065" class="elsevierStylePara elsevierViewall">El an&#225;lisis descriptivo se realiz&#243; mediante frecuencias y porcentajes para las variables categ&#243;ricas&#44; y mediante medianas y rangos intercuartiles &#40;RIQ&#41; para las variables cuantitativas&#46; Estos an&#225;lisis se presentan para la muestra total y seg&#250;n si el primer diagn&#243;stico psiqui&#225;trico posterior a PEP fue TAB o esquizofrenia&#46; La trayectoria diagn&#243;stica se analiz&#243; mediante el modelo de supervivencia para eventos competitivos&#44; bajo el supuesto de que los trastornos psiqui&#225;tricos &#171;compiten&#187; por ser el primer diagn&#243;stico posterior al PEP&#46; Se presenta la funci&#243;n de incidencia acumulada de diagn&#243;stico psiqui&#225;trico y se estimaron funciones acumuladas por grupo diagn&#243;stico para una semana&#44; uno&#44; 3&#44; 6 y 12 meses postingreso a la instituci&#243;n por PEP&#46; El an&#225;lisis de antecedentes y caracter&#237;sticas cl&#237;nicas asociadas al primer diagn&#243;stico de trastorno psiqui&#225;trico posterior al PEP se realiz&#243; mediante la estimaci&#243;n de sHR para TAB y esquizofrenia&#44; dado que juntos representan la mayor proporci&#243;n de diagn&#243;sticos recibidos por los pacientes&#46; Se presentan las estimaciones junto con intervalos de 95&#37; de confianza &#40;IC95&#37;&#41; y valores p&#46; El nivel de significaci&#243;n se estableci&#243; en 0&#44;05&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Los an&#225;lisis estad&#237;sticos fueron realizados en el programa Stata versi&#243;n 16&#46;1 &#40;College Station&#44; TX&#44; EE&#46; UU&#46;&#41;&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Resultados</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Participantes</span><p id="par0075" class="elsevierStylePara elsevierViewall">Durante el periodo de estudio 3&#46;189 pacientes recibieron un diagn&#243;stico psiqui&#225;trico y fueron considerados potencialmente elegibles&#46; Tras la verificaci&#243;n de las historias cl&#237;nicas se estableci&#243; que 143 pacientes se presentaron con PEP&#46; Los registros de 8 &#40;5&#44;6&#37;&#41; pacientes fueron excluidos por errores relacionados con las fechas de seguimiento&#46; Finalmente&#44; 137 pacientes fueron incluidos y analizados&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Datos descriptivos</span><p id="par0080" class="elsevierStylePara elsevierViewall">El 40&#44;9&#37; de los pacientes incluidos fueron mujeres y la edad mediana fue de 36 a&#241;os &#40;RIQ<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&#41;&#46; Aproximadamente la mitad de los pacientes estaban afiliados al r&#233;gimen subsidiado&#44; y el 57&#44;7&#37; eran residentes en &#225;rea rural&#46; El 86&#44;9&#37; de los pacientes ingresaron por urgencias con una mediana de d&#237;as de psicosis no tratada de 20 &#40;RIQ<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>82&#41;&#46; El 29&#44;9&#37; report&#243; consumo actual de sustancias psicoactivas&#46; La descripci&#243;n de las caracter&#237;sticas de los pacientes que fueron diagnosticados con TAB y esquizofrenia se presenta en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; Con relaci&#243;n a los antecedentes psiqui&#225;tricos&#44; el 48&#44;2&#37; registr&#243; antecedentes personales y el 32&#44;8&#37; familiares &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Entre los pacientes con antecedente psiqui&#225;trico personal &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#44; el 40&#44;9&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>27&#41; de los diagn&#243;sticos estaba relacionado con consumo de sustancias psicoactivas&#59; en 7 pacientes relacionado con cannabis y en 16 pacientes con otras sustancias psicoactivas&#44; de los cuales 4 registraban antecedente de abuso de otra sustancia psicoactiva&#44; con trastorno del estado de &#225;nimo inducido por sustancias psicoactivas&#46; Los trastornos del estado del &#225;nimo y de ansiedad fueron los segundos m&#225;s frecuentes entre los antecedentes personales&#44; en ambos casos con el 22&#44;7&#37; de los diagn&#243;sticos&#46; Entre estos grupos&#44; los m&#225;s frecuentes fueron trastorno depresivo mayor recurrente &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#41; y otros trastornos de ansiedad &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>13&#41;&#44; respectivamente&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Entre los pacientes con antecedente psiqui&#225;trico familiar&#44; el 44&#44;4&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>20&#41; registraba familiares con trastorno del estado del &#225;nimo&#58; 7 antecedente de TAB&#44; 7 de trastorno depresivo mayor de episodio &#250;nico y 6 de trastorno depresivo mayor recurrente&#46; Pese a la alta frecuencia de antecedentes personales de trastornos relacionados con el consumo de sustancias psicoactivas&#44; entre los pacientes con antecedente familiar estos solo dieron cuenta del 11&#44;1&#37; de los diagn&#243;sticos&#46; Es importante resaltar que en el 31&#44;1&#37; de los pacientes con antecedente psiqui&#225;trico familiar no fue posible establecer el grupo diagn&#243;stico &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Desenlaces</span><p id="par0095" class="elsevierStylePara elsevierViewall">Una semana despu&#233;s del ingreso a la instituci&#243;n por PEP el 56&#44;9&#37; de los pacientes hab&#237;a recibido diagn&#243;stico de un trastorno psiqui&#225;trico&#44; 28&#44;9&#37; TAB y 11&#44;8&#37; esquizofrenia&#44; siendo los m&#225;s frecuentes&#46; Al mes&#44; los pacientes diagnosticados aumentaron al 69&#44;9&#37;&#44; y al a&#241;o al 84&#44;9&#37;&#44; distribuy&#233;ndose en 39&#44;8&#37; TAB&#44; 9&#44;1&#37; otro trastorno del estado de &#225;nimo &#40;total de 49&#37;&#41;&#44; 24&#44;7&#37; esquizofrenia y 2&#44;1&#37; otro trastorno psic&#243;tico &#40;total de 26&#44;8&#37;&#41;&#46; En menor medida&#44; un 5&#44;0&#37; recibi&#243; diagn&#243;stico del grupo de trastornos de ansiedad&#44; disociativos&#44; relacionado con estr&#233;s&#44; somatomorfos u otros trastornos mentales no psic&#243;ticos&#44; y un 4&#44;3&#37; diagn&#243;stico de trastornos mentales y del comportamiento debidos al consumo de sustancias psicoactivas&#46; La <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> presenta la funci&#243;n de incidencia acumulada de diagn&#243;sticos posteriores al PEP&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Resultados principales</span><p id="par0100" class="elsevierStylePara elsevierViewall">La <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a> presenta los factores asociados al diagn&#243;stico comparando TAB y esquizofrenia&#44; los 2 trastornos de mayor frecuencia&#46; Las mujeres fueron m&#225;s propensas a TAB &#40;sHR 2&#44;14&#59; IC95&#37; 1&#44;09-4&#44;20&#41; y los hombres al diagn&#243;stico de esquizofrenia &#40;sHR 3&#44;28&#59; IC95&#37; 1&#44;38-7&#44;79&#41;&#46; Con relaci&#243;n a los antecedentes psiqui&#225;tricos&#44; los pacientes con antecedentes personales fueron m&#225;s propensos a un diagn&#243;stico de esquizofrenia &#40;sHR 2&#44;28&#59; IC95&#37; 0&#44;95-5&#44;44&#41;&#44; mientras que los pacientes con antecedentes familiares fueron m&#225;s propensos al diagn&#243;stico de TAB &#40;sHR 2&#44;92&#59; IC95&#37; 1&#44;34-6&#44;98&#41;&#46; El consumo actual de sustancias se asoci&#243; con mayor propensi&#243;n a TAB &#40;sHR 3&#44;05&#59; IC95&#37; 1&#44;34-6&#44;98&#41; y mayor cantidad de d&#237;as de psicosis no tratada se asoci&#243; con el diagn&#243;stico de esquizofrenia &#40;sHR 1&#44;01&#59; IC95&#37; 1&#44;01-1&#44;02&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Discusi&#243;n</span><p id="par0105" class="elsevierStylePara elsevierViewall">Este estudio tuvo como objetivo describir la trayectoria diagn&#243;stica desde la presentaci&#243;n del PEP en una muestra de pacientes del Oriente antioque&#241;o&#44; encontrando que al a&#241;o el 84&#44;9&#37; hab&#237;a recibido diagn&#243;stico de alg&#250;n trastorno psiqui&#225;trico&#44; siendo los m&#225;s probables TAB &#40;39&#44;8&#37;&#41; y esquizofrenia &#40;24&#44;7&#37;&#41;&#46; Adicionalmente&#44; se pudo establecer que el TAB es la trayectoria diagn&#243;stica m&#225;s probable en mujeres&#44; pacientes en los extremos educativos &#40;sin escolaridad o con estudios superiores&#41;&#44; con antecedentes familiares de enfermedad mental y personales de uso de sustancias psicoactivas&#59; por otra parte&#44; la esquizofrenia es la trayectoria diagn&#243;stica m&#225;s probable en hombres&#44; pacientes con antecedentes psiqui&#225;tricos personales y con mayor cantidad de d&#237;as de psicosis no tratada&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Al comparar nuestro estudio con lo descrito en la literatura m&#233;dica revisada&#44; encontramos investigaciones multic&#233;ntricas<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">14&#44;15</span></a>&#44; con muestras 2 a 4 veces m&#225;s grandes&#44; pero realizadas fuera de Latinoam&#233;rica&#59; nuestro proyecto fue llevado a cabo en un solo centro asistencial&#44; referente en la atenci&#243;n de una poblaci&#243;n de inter&#233;s particular y por un mismo grupo de evaluadores&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">A diferencia de trabajos previos&#44; decidimos incluir variables demogr&#225;ficas y cl&#237;nicas que permitiesen orientar hacia un diagn&#243;stico psiqui&#225;trico espec&#237;fico&#46; Nuestro estudio incluy&#243; &#250;nicamente adultos mayores de 18 a&#241;os&#44; sin l&#237;mite de edad&#44; distinto a otros estudios que incluyeron muestras con poblaci&#243;n pedi&#225;trica<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">15&#44;16</span></a>&#44; uno de ellos excluyendo a personas mayores de 35 a&#241;os<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a>&#44; lo que supone diferencias etiol&#243;gicas al abordar la psicopatolog&#237;a del PEP&#46; Nuestro estudio no excluy&#243; participantes con antecedente de discapacidad intelectual&#44; trastorno por uso de sustancias psicoactivas o diagn&#243;stico de psicosis exot&#243;xica&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Nuestro estudio reporta resultados similares a lo observado en el estudio de Salvatore et al&#46;&#44; realizado en Italia&#44; con una tendencia hacia la enfermedad bipolar como principal diagn&#243;stico inicial<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a>&#44; y contrarios a lo visto en muestras de Espa&#241;a e Inglaterra<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a>&#44; donde el principal diagn&#243;stico es la esquizofrenia y trastornos psic&#243;ticos asociados &#40;31-48&#37;&#41;&#44; siendo el TAB menos frecuente &#40;14-15&#37;&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Aunque son heterog&#233;neos los resultados de los estudios que pretenden determinar la estabilidad diagn&#243;stica<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">17&#44;18</span></a>&#44; hay una tendencia a que se considere la esquizofrenia como el primer trastorno psiqui&#225;trico que se presenta con mayor frecuencia despu&#233;s del diagn&#243;stico de PEP&#44; tal como lo describen Fusar-Poli et al&#46; en el metan&#225;lisis que incluy&#243; 42 estudios con m&#225;s de 14&#46;000 pacientes y donde la trayectoria diagn&#243;stica se orient&#243; m&#225;s a esquizofrenia que a los trastornos afectivos<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a>&#46; Sin embargo&#44; los resultados de este estudio son contrarios a esta afirmaci&#243;n&#44; pues el primer diagn&#243;stico de trastorno psiqui&#225;trico que se encontr&#243; con m&#225;s frecuencia posterior al PEP fue el TAB&#44; en un relativo corto tiempo para llegar a este diagn&#243;stico&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">En gran parte de la literatura se describe la asociaci&#243;n que hay entre variables demogr&#225;ficas y cl&#237;nicas y la funcionalidad y el pron&#243;stico posterior al PEP&#44; no con la trayectoria diagn&#243;stica inicial<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">20&#44;21</span></a>&#46; Nuestro estudio encontr&#243; que algunas variables demogr&#225;ficas orientan hacia un diagn&#243;stico en particular&#44; contrario a lo encontrado por Ta&#351; et al&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a>&#44; donde ninguna caracter&#237;stica demogr&#225;fica se asoci&#243; de forma significativa&#46; Por otra parte&#44; nuestros resultados son similares a lo visto por Salagre et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a>&#44; quienes encontraron asociaci&#243;n entre el antecedente familiar de enfermedad mental y el TAB&#44; as&#237; como entre el tiempo de psicosis no tratada y el diagn&#243;stico de esquizofrenia&#59; llama la atenci&#243;n que dicho estudio no encontr&#243; asociaciones significativas con la edad&#44; el g&#233;nero&#44; el estado civil&#44; la formaci&#243;n educativa&#44; la situaci&#243;n laboral&#44; el estrato socioecon&#243;mico o el consumo de sustancias&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Para el momento de la elaboraci&#243;n de este manuscrito&#44; no conocemos estudios latinoamericanos que exploren la trayectoria diagn&#243;stica en pacientes con PEP&#46; S&#237; se conocen estudios que describen servicios para intervenci&#243;n de psicosis temprana en pa&#237;ses como Chile&#44; Brasil&#44; Argentina y M&#233;xico<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a>&#44; as&#237; como la iniciativa de la red iberoamericana para el estudio de la psicosis precoz &#8211;ANDES&#8211;&#58; &#171;La red es un consorcio Iberoamericano para el estudio de la psicosis temprana&#44; entendido como los primeros dos a&#241;os de enfermedad&#46; Ella apoya la creaci&#243;n de conocimiento y su r&#225;pida transferencia a la cl&#237;nica&#44; sobre todo en pa&#237;ses en desarrollo iberoamericanos&#44; con el fin &#250;ltimo de mejorar la calidad de vida de los pacientes&#187;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a>&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Tal como se&#241;alan Fonseca et al&#46;&#44; la mayor&#237;a de los estudios gen&#233;ticos en psicosis se han llevado a cabo en pa&#237;ses de altos ingresos&#44; generando una importante subrepresentaci&#243;n de la poblaci&#243;n latinoamericana<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a>&#46; Si bien los factores gen&#233;ticos no ofrecen una explicaci&#243;n absoluta del riesgo de aparici&#243;n de trastornos psic&#243;ticos&#44; y la exposici&#243;n a factores ambientales incide de manera importante en la presentaci&#243;n de trastornos mentales&#44; los factores gen&#233;ticos podr&#237;an ser sustanciales a la hora de explicar&#44; por ejemplo&#44; la diferencia en t&#233;rminos de trayectoria diagn&#243;stica que puede encontrarse entre los estudios reportados previamente y nuestros resultados&#46; Este asunto est&#225; siendo explorado a trav&#233;s del Paisa Project&#44; que busca la fenotipificaci&#243;n de 8&#46;000 muestras de pacientes con enfermedad mental severa &#40;trastornos psic&#243;ticos y trastornos afectivos&#41; en los lugares donde se ha determinado una alta prevalencia de enfermedad mental en nuestro pa&#237;s&#44; como son Caldas&#44; Risaralda y Antioquia&#44; departamento donde se llev&#243; a cabo el presente estudio<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">La principal limitaci&#243;n de este estudio es la heterogeneidad de los psiquiatras que dieron los diagn&#243;sticos posteriores al PEP&#44; dado el amplio periodo de selecci&#243;n&#44; entre 2007 y marzo de 2022&#46; Si bien esto refleja la variabilidad observada en la pr&#225;ctica&#44; no es posible determinar la concordancia interevaluador&#46; En estudios posteriores de naturaleza prospectiva podr&#237;a establecerse la influencia del operador en la trayectoria diagn&#243;stica&#46; En la misma v&#237;a&#44; nuestro estudio reporta la trayectoria al primer diagn&#243;stico posterior al PEP&#46; No obstante&#44; en futuros estudios se deber&#225; esclarecer la estabilidad diagn&#243;stica de dicho diagn&#243;stico y el pron&#243;stico&#44; la funcionalidad y la calidad de vida de los pacientes seg&#250;n si el diferencial se establece hac&#237;a TAB o esquizofrenia&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Adicionalmente&#44; la naturaleza retrospectiva de nuestro estudio implica limitaciones en relaci&#243;n con los antecedentes valorados&#44; ya que estos son reportados por el paciente al psiquiatra en el marco de la entrevista cl&#237;nica con fines de pr&#225;ctica rutinaria&#44; no de investigaci&#243;n&#46; Con relaci&#243;n a los antecedentes psiqui&#225;tricos personales&#44; la principal limitaci&#243;n est&#225; en el desconocimiento del tiempo entre el diagn&#243;stico psiqui&#225;trico y el PEP&#46; Nuestro estudio muestra una asociaci&#243;n diferencial entre el antecedente personal y familiar respecto al curso diagn&#243;stico psiqui&#225;trico m&#225;s probable posterior al PEP&#44; pero no nos es posible discriminar esta asociaci&#243;n seg&#250;n el tipo de antecedente personal y la velocidad de presentaci&#243;n del PEP&#46; Si bien en este estudio se ajusta por la edad al PEP y los d&#237;as de psicosis no tratada&#44; esto se debe verificar en estudios confirmatorios&#46; Con relaci&#243;n a los antecedentes psiqui&#225;tricos familiares&#44; la principal limitaci&#243;n de este estudio est&#225; en la calidad de la informaci&#243;n&#59; en el 31&#44;1&#37; de los pacientes que reportaron antecedente familiar no fue posible establecer los diagn&#243;sticos espec&#237;ficos&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">No obstante las limitaciones del estudio&#44; entender el comportamiento y los determinantes del riesgo de instauraci&#243;n de trastornos psic&#243;ticos en la poblaci&#243;n local ofrece beneficios a nivel asistencial&#44; ya que se comporta como insumo sustancial para la generaci&#243;n de evidencia cient&#237;fica que oriente a diagn&#243;sticos y tratamientos m&#225;s precisos y oportunos&#44; impactando directamente en el pron&#243;stico de los pacientes y la carga por enfermedad<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a>&#46; Adem&#225;s&#44; esta caracterizaci&#243;n tambi&#233;n es esencial como eje para el dise&#241;o de pol&#237;ticas p&#250;blicas en salud orientadas a rutas integrales de atenci&#243;n m&#225;s eficientes y oportunas en el PEP&#44; por ejemplo&#44; a trav&#233;s del desarrollo de programas de intervenci&#243;n temprana en psicosis&#44; buscando disminuir el tiempo de psicosis no tratadas&#44; reducir el riesgo de reca&#237;das&#44; instruir a la comunidad en la identificaci&#243;n de signos tempranos de enfermedad y optimizar la utilizaci&#243;n de recursos econ&#243;micos y humanos&#44; los cuales en entornos como el nuestro con frecuencia terminan siendo insuficientes para solventar los gastos de la atenci&#243;n en fases posteriores de la enfermedad<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">23&#44;27</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Los resultados del presente estudio tienen implicaciones directas sobre la comprensi&#243;n de la trayectoria pron&#243;stica de los pacientes del escenario regional&#44; y contribuyen a aumentar la consciencia sobre la necesidad de implementar intervenciones preventivas oportunas<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a>&#44; y de desarrollar y validar modelos de predicci&#243;n cl&#237;nica que reconozcan las caracter&#237;sticas espec&#237;ficas de estos pacientes&#44; as&#237; como las particularidades de la epidemiolog&#237;a de los trastornos psiqui&#225;tricos en la regi&#243;n<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">29&#44;30</span></a>&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Financiaci&#243;n</span><p id="par0165" class="elsevierStylePara elsevierViewall">No se recibi&#243; financiaci&#243;n espec&#237;fica para este estudio&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflicto de intereses</span><p id="par0170" class="elsevierStylePara elsevierViewall">Los autores declaramos no tener conflictos de inter&#233;s&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Describir la trayectoria diagn&#243;stica desde el primer episodio psic&#243;tico &#40;PEP&#41; hasta el diagn&#243;stico de un trastorno psiqui&#225;trico en adultos del Oriente antioque&#241;o y explorar caracter&#237;sticas asociadas&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de seguimiento a una cohorte basada en registros m&#233;dicos&#46; Se incluyeron pacientes adultos&#44; del Oriente antioque&#241;o&#44; con diagn&#243;stico de PEP seg&#250;n el criterio del psiquiatra&#44; atendidos en un centro m&#233;dico de tercer nivel &#40;2007-marzo de 2022&#41;&#46; El tiempo al diagn&#243;stico psiqui&#225;trico posterior al PEP fue la variable de desenlace&#46; Los factores asociados a trastorno afectivo bipolar y esquizofrenia se analizaron mediante el modelo de supervivencia para eventos competitivos&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 137 pacientes&#44; 40&#44;9&#37; mujeres&#44; edad mediana de 36 a&#241;os &#40;RIQ<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&#41;&#46; El 48&#44;2&#37; registr&#243; antecedentes psiqui&#225;tricos personales y el 32&#44;8&#37; familiares&#46; Al a&#241;o el 84&#44;9&#37; hab&#237;a recibido diagn&#243;stico de trastorno psiqui&#225;trico&#44; trastorno afectivo bipolar en 39&#44;8&#37; y esquizofrenia en 24&#44;7&#37; de los casos&#46; Trastorno afectivo bipolar fue la trayectoria diagn&#243;stica m&#225;s probable en pacientes&#58; mujeres&#44; con antecedentes psiqui&#225;tricos familiares y uso actual de sustancias psicoactivas&#46; Esquizofrenia lo fue en pacientes&#58; hombres&#44; con antecedentes psiqui&#225;tricos personales y mayor cantidad de d&#237;as de psicosis no tratada&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se requieren rutas integrales de atenci&#243;n del PEP que reconozcan las particularidades de la epidemiolog&#237;a de los trastornos mentales en el Oriente antioque&#241;o&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To describe the diagnostic trajectory from the first psychotic episode &#40;FPE&#41; to the diagnosis of a psychiatric disorder in adults from Eastern Antioquia and explore associated characteristics&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Method</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A medical records-based retrospective follow-up study&#46; Adult patients from Eastern Antioquia diagnosed with FPE according to the psychiatrist&#39;s criteria and treated at a tertiary care medical center &#40;2007 to March 2022&#41; were included&#46; Time to psychiatric diagnosis after the FPE was the outcome variable&#46; In addition&#44; factors associated with bipolar affective disorder and schizophrenia were analyzed using the survival model for competitive events&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">One hundred and thirty-seven patients were included&#44; 40&#46;9&#37; women&#44; median age 36 years &#40;IQR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&#41;&#46; 48&#46;2&#37; had personal psychiatric history&#44; and 32&#46;8&#37; had a family history&#46; At one year&#44; 84&#46;9&#37; had received a diagnosis of psychiatric disorder&#44; bipolar affective disorder in 39&#46;8&#37;&#44; and schizophrenia in 24&#46;7&#37; of cases&#46; Bipolar affective disorder was the most likely diagnostic trajectory in patients&#58; women&#44; with family psychiatric history and current use of psychoactive substances&#46; Schizophrenia was in patients&#58; men&#44; with a personal psychiatric history&#44; and with higher days of untreated psychosis&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Integrated healthcare routes for the FPE that recognize the particularities of the epidemiology of mental disorders in Eastern Antioquia are required&#46;</p></span>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Estudios superiores&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Psiqui&#225;trico&#44; familiar&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Trastornos relacionados con otras sustancias psicoactivas&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No especificado&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Esquizofrenia&#44; trastorno esquizot&#237;pico&#44; delirante y otros trastornos psic&#243;ticos no relacionados con el estado de &#225;nimo</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Esquizofrenia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Trastornos del estado de &#225;nimo</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Trastorno afectivo bipolar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Trastorno depresivo mayor&#44; episodio &#250;nico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Trastorno depresivo mayor&#44; recurrente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No especificado&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Trastornos de ansiedad&#44; disociativos&#44; relacionado con estr&#233;s&#44; somatomorfos u otros trastornos mentales no psic&#243;ticos</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Trastornos de ansiedad f&#243;bica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Otros trastornos de ansiedad&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Discapacidad intelectual</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Discapacidad intelectual leve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Discapacidad intelectual moderada&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Secundaria incompleta&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;0&#44;35-17&#44;61&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bachiller&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Estudios superiores&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">R&#233;gimen</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Subsidiado&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;0&#44;44-3&#44;81&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;640&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Contributivo-particular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;1&#44;04-5&#44;09&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="7" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Consumo actual de sustancias psicoactivas</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#40;1&#44;34-6&#44;98&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;00&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Antecedentes</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Psiqui&#225;trico&#44; personal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#40;0&#44;10-0&#44;58&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#40;0&#44;95-5&#44;44&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;064&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No psiqui&#225;trico&#44; personal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#44;59-2&#44;07&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;751&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#40;0&#44;29-2&#44;95&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;900&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Psiqui&#225;trico&#44; familiar&nbsp;\t\t\t\t\t\t\n
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