Distúrbios psiquiátricos e assistência primária à saúde no Brasil

The aims of this study were a) to assess the ability of primary care doctors to make accurate ratings of psychiatric disturbance and b) to evaluate the use of a case-finding questionnaire in the detection of psychiatric morbidity. The estudy took place in three primary care clinics in the city of São Paulo, Brazil, during a six-month survey. A time sample of consecutive adult attenders were asked to complete a case-finding questionnaire for psychiatric disorders (the Self Report Questionnaire - SRQ) and a subsample were selected for a semi-structured psychiatric interview (the Clinical Interview Schedule - CIS). At the end of the consultation the primary care doctors were asked to assess, in a standardized way, the presence or absence of psychiatric disorder; these assessments were then compared with that ratings obtained in the psychiatric interview. A considerable proportion of minor psychiatric morbidity remained undetected by the three primary care doctors: the hidden morbidity ranged from 22% to 79%. When these were compared to those of the case-finding questionnaire, they were consistently lower, indicating that the use of these instruments can enhance the recognition of psychiatric disorders in primary care settings. Four strategies for adopting the questionnaire are described, and some of the clinical consequences of its use are discussed.Objetivou-se avaliar a habilidade de clínicos gerais em diagnosticar distúrbios emocionais na assistência primária, e investigar a possibilidade de se introduzir um questionário de "screening" para auxiliar o diagnóstico de doenças psiquiátricas. O estudo foi realizado em dois centros de saúde e um ambulatório de clínica geral na cidade de São Paulo (Brasil), por um período de 6 meses. Uma amostra representativa de pacientes adultos (16 anos) atendidos por clínico geral preencheu um questionário de "screening" para distúrbios psiquiátricos menores. Uma sub-amostra foi selecionada para entrevista psiquiátrica semi-estruturada, segundo a versão brasileira da "Clinical Interview Schedule" (CIS). No final da consulta os clínicos gerais avaliaram, através de uma escala padronizada, se o paciente apresentava ou não um distúrbio psiquiátrico e a severidade do mesmo. Considerável número de pacientes que apresentavam distúrbios psiquiátricos menores não foram identificados pelos clínicos gerais (de 22% a 79%), sendo que o questionário de "screening" contribuiria sobremaneira na identificação desses distúrbios. São apresentadas quatro estratégias que podem ser consideradas na adoção do "screening", e discutidas as conseqüências clínicas que circunscrevem a aplicação desse instrumental

Sociodemographic and clinical predictors of delay to and length of stay with early intervention for psychosis service: findings from the CRIS-FEP study

Purpose We investigated the influence of sociodemographic and clinical characteristics on delay to early intervention service (EIS) and the length of stay (LOS) with EIS. Methods We used incidence data linked to the Clinical Record Interactive Search—First Episode Psychosis (CRIS-FEP) study. We followed the patients from May 2010 to March 2016. We performed multivariable Cox regression to estimate hazard ratios of delay to EIS. Negative binomial regression was used to determine LOS with EIS by sociodemographic and clinical characteristics, controlling for confounders. Results 343 patients were eligible for an EIS, 34.1% of whom did not receive the service. Overall, the median delay to EIS was 120 days (IQR; 15–1668); and the median LOS was 130.5 days (IQR 0–663). We found that women (adj.HR 0.58; 95%C I 0.42–0.78), living alone (adj.HR: 0.63; 95% CI 0.43–0.92) and ethnicity (‘Other’: adj.HR 0.47; 95% CI 0.23–0.98) were associated with prolonged delay to EIS. However, family involvement in help-seeking for psychosis (adj.HR 1.37; 95% CI 1.01–1.85) was strongly associated with a shorter delay to EIS. Patients who have used mental health services previously also experienced long delays to EIS. Conclusions Our analyses highlight the link between sociodemographic status, help-seeking behaviours, and delay to EIS. Our findings also show the vulnerability faced by those with a previous mental health problem who later develop psychosis in receiving specialist treatment for psychosis. Initiatives that ameliorate indicators of social disadvantage are urgently needed to reduce health inequalities and improve clinical outcomes

Treating schizophrenia with cariprazine : from clinical research to clinical practice. Real world experiences and recommendations from an International Panel

Altres ajuts: Supported by an unrestricted grant from Recordati.Management of schizophrenia is sub-optimal in many patients. Targeting negative symptoms, among the most debilitating aspects of schizophrenia, together with positive symptoms, can result in significant functional benefits and dramatically improve quality of life for patients and their carers. Cariprazine, a partial agonist of the dopamine receptors D2/D3 has demonstrated effectiveness across symptom domains in clinical trials, particularly on negative symptoms. To obtain a broader insight from clinicians with specific experience with cariprazine, on how it affects patient populations outside the clinical trial setting. The panel addressed a series of psychopharmacologic topics not comprehensively addressed by the evidence-based literature, including characteristics of patients treated, dosing and switching strategies, duration of therapy, role of concomitant medications and tolerability as well as recommendations on how to individualize cariprazine treatment for patients with schizophrenia. Patients recommended for cariprazine treatment are those with first episodes of psychosis, predominant negative symptoms (maintenance/acute phase) and significant side effects (metabolic side effects, hyperprolactinemia, sedation) with other antipsychotics. When the long-term treatment of a lifetime illness is adequately weighted, cariprazine becomes one of the first-line medications, not only for patients with predominant negative symptoms but also for those with relatively severe positive symptoms, especially if they are at the first episodes and if a specific medication is added for symptoms such as agitation or insomnia. For instance, patients with agitation may also benefit from the combination of cariprazine and a benzodiazepine or another sedating agent. Cariprazine may be prescribed as add-on to medications such as clozapine, when that medication alone is ineffective for negative symptoms, and sometimes the first may be discontinued or its dose lowered, after a period of stability, leaving the patient on a better tolerated antipsychotic regimen. Based on real-world clinical experience, the panel considered that cariprazine, with its distinct advantages including pharmacokinetics/pharmacodynamics, good efficacy and tolerability, represents a drug of choice in the long-term management of schizophrenia not only for patients with predominant negative symptoms but also for those with positive symptoms

Metodologias utilizadas para detectar distúrbios emocionais em clínicas de assistência primária à saúde: revisão de literatura

A series of studies in the field of Epidemiological Psychiatry have been performed over the last two decades, and these have focused on the ability of primary care physicians to detect emotional disorders in the patients that attend their practices. The scientific methodology utilized in these studies is the subject of this review, which contains a discussion concerning: a) interviewer awareness bias; b) accuracy of the instruments and c) medical and psychological concepts involved in defining minor emotional disorders. Suggestions for change in the methodology are made in each of the sections of the review.Na área de epidemiologia psiquiátrica vêm sendo realizados, nos últimos vinte anos, estudos que têm como finalidade medir a habilidade que clínicos gerais possuem em detectar distúrbios emocionais nos pacientes que procuram atendimento na rede básica de saúde. A metodologia utilizada nesses estudos é o tema central da atual revisão, que contém a) viés do entrevistador; b) acuidade dos instrumentos; e c) conceitos médicos e psicológicos envolvidos na definição de distúrbio psiquiátrico menor. São também apresentadas sugestões para mudanças de metodologia

Estudio de confiabilidad inter-evaluadores de una escala para la evaluación de la interacción madre-bebé

OBJECTIVE: To develop a study to assess the inter-rater reliability of a modified version of Brown's scale designed to investigate early mother-child interaction. METHOD: Fourteen postpartum women and their newborn babies took part in this study. The tape-recorded observations lasted 15 minutes, and they were performed on the second day after birth, during breast-feeding. In a successive and isolated moment, two evaluators scored each item of the interaction established between the mother and the newborn. In order to do so, a modified version of the scale of Brown and collaborators (1975), was used and submitted to a reliability study. RESULTS: Nine out of ten items of the modified scale revealed an excellent inter-rater agreement: The Kappa coefficient was 0.85 or higher. Only one item showed a moderate degree of agreement = 0.59, concerning mother holds the baby. The results show that the modified scale is stable if used in a hospital setting for low-income mothers. CONCLUSIONS: The conclusion of this study indicates that categories are a reliable parameter to evaluate mother-baby interaction.OBJETIVO: Realizar un estudio de concordancia entre examinadores de la versión adaptada de una escala para la evaluación de la interacción madre-bebé (Brown y colaboradores - 1975). MÉTODO: catorce parturientas y sus recién nacidos participaron de este estudio. Las observaciones, que duraban quince minutos, fueron filmadas en la maternidad en el segundo día después del nacimiento del bebé, durante la amamentación. En un momento sucesivo e isoladamente, dos evaluadores atribuyeron escores para cada iten de interacción establecida entre la madre y el recién nacido. Para tal fin, fue utilizada y submetida al estudio de confiabilidad una versión adaptada de la escala de Browun y colaboradores (1975). RESULTADOS: nueve entre diez itens pertenecientes a la escala adaptada del estudio de Brown y colaboradores (1975) revelaron una concordancia excelente, el coeficiente Kappa arriba de 0,85. El único iten que presentó una concordancia moderada (K=0,59) fue madre agarra el bebé . Los resultados obtenidos indican la estabilidad de la escala adaptada y aplicada en ambiente hospitalar destinado a las madres de baja renta. CONCLUSIONES: los datos resultantes de este estudio indican que la utilización de las categorías es un parámetro fidedigno en la evaluación de la interacción madre-bebé.OBJETIVO: Realizar um estudo de concordância entre examinadores da versão adaptada de uma escala para a avaliação de interação mãe-bebê (Brown e colaboradores - 1975) MÉTODO: Quatorze puérperas e seus recém-nascidos participaram deste estudo. As observações, que duravam quinze minutos, foram filmadas na maternidade no segundo dia após o nascimento do bebê, durante a amamentação. Num momento sucessivo e isoladamente, dois avaliadores atribuíram escores para cada item de interação estabelecida entre a mãe e o recém nascido. Para tal fim, foi utilizada e submetida ao estudo de fidedignidade uma versão adaptada da escala de Brown e colaboradores.³ (1975). RESULTADOS: Nove entre os dez itens pertencentes à escala adaptada do estudo de Brown e colaboradores³ (1975) revelaram uma concordância excelente, o coeficiente Kappa acima de 0,85. O único item que apresentou uma concordância moderada (K= 0,59) foi 'mãe segura o bebê'.Os resultados obtidos indicam a estabilidade da escala adaptada e aplicada em ambiente hospitalar destinado às mães de baixa renda. CONCLUSÕES: Os dados trazidos por este estudo indicam que a utilização das categorias é um parâmetro fidedigno na avaliação da interação mãe-bebê.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de PsiquiatriaInstitute of Psychiatry Health Services Research DepartmentUNIFESP, EPM, Depto. de PsiquiatriaSciEL

Cariprazine as a treatment for negative psychotic symptoms in first-episode psychosis:Case series

Negative psychotic symptoms are among the most disabling features of schizophrenia, and are strongly associated with relatively poor clinical and functional outcomes. However, there are no effective treatments for negative symptoms, and this represents a major unmet clinical need. Recent research has shown that negative symptoms are already present in many patients at illness onset. There is evidence that cariprazine may improve negative symptoms in patients with chronic schizophrenia. However, its utility in treating negative symptoms in the early stage of the disorder is unclear. Here, we report six cases of patients with first-episode psychosis who were treated with cariprazine