887 resultados para schizophrenia
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OBJECTIVE: The aim of the study was to identify the variables that predict the revolving door phenomenon in psychiatric hospital at the moment of a second admission. METHODS: The sample consisted of 3,093 patients who have been followed during 5 to 24 years after their first hospital admission due to schizophrenia, and affective or psychotic disorders. Those who had had four or more admissions during the study period were considered as revolving door patients. Logistic regression analyses were used to assess the impact of gender, age, marital status, urban conditions, diagnosis, mean period of stay on the first admission, interval between the first and second admissions on the patterns of hospitalization. RESULTS: The variables with the highest predictive power for readmission were the interval between first and second admissions, and the length of stay in the first admission. CONCLUSIONS: These data may help public health planners in providing optimal care to a small group of patients with more effective utilization of the available services.
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O Factor Neurotrfico Derivado do Crebro (BDNF) est associado a processos de crescimento, diferenciao e sobrevivncia das clulas neuronais. A expresso diferencial do BDNF, particularmente no hipocampo, est relacionada com a manifestao clnica de algumas doenas do foro psiquitrico e cognitivo como a doena de Huntington, Alzheimer, depresso e esquizofrenia. Este trabalho pretende dar conhecimento das tcnicas utilizadas para avaliar a expresso do gene BDNF. As tcnicas de ELISA, IHC e Western blot, por permitirem a avaliao precisa da expresso de BDNF, so teis para uma melhor compreenso, diagnstico e tratamento de algumas doenas neurodegenerativas.
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A esquizofrenia uma perturbao mental grave caracterizada pela coexistncia de sintomas positivos, negativos e de desorganizao do pensamento e do comportamento. As alteraes motoras so consistentemente observadas mas, ainda pouco estudadas na esquizofrenia, sendo relevantes para o seu diagnstico. Neste quadro, o presente estudo tem como objetivo verificar se os indivduos com esquizofrenia apresentam alteraes na coordenao motora, comparativamente com o grupo sem esquizofrenia, bem como analisar se as disfunes dos sinais neurolgicos subtis (SNS) motores se encontram correlacionadas com o funcionamento executivo e com os domnios psicopatolgicos da perturbao. No total participaram 29 indivduos (13 com diagnstico de esquizofrenia e 16 sem diagnstico) equivalentes em termos de idade, gnero, escolaridade e ndice de massa corporal. Para avaliar o desempenho motor recorreu-se ao sistema Biostage de parametrizao do movimento em tempo real, com a tarefa de lanameto ao alvo; a presena de SNS foi examinada atravs da Brief Motor Scale; o funcionamento executivo pela aplicao do subteste do Vocabulrio e da fluncia verbal e a sintomatologia clnica atravs da Positive and Negative Sindrome Scale. Pela anlise cinemtica do movimento constatou-se que os indivduos com esquizofrenia recrutam um padro motor menos desenvolvido e imaturo de movimento, com menor individualizao das componentes (principalmente do tronco e plvis), necessitando de mais tempo para executar a tarefa, comparativamente com os sujeitos sem a perturbao que evidenciaram um movimento mais avanado de movimento. Os indivduos com esquizofrenia mostraram ndices elevados de disfuno dos SNS (mdia =6,01) estabelecendo este domnio uma relao boa e negativa com o desempenho verbal (rho Spearman=-0,62) e uma relao forte e positiva com todos os domnios psicopatolgicos (rho Spearman=0,74). O estudo da existncia de alteraes motoras como parte intrnseca da esquizofrenia revela-se pertinente uma vez que possibilita uma compreenso mais aprofundada da sua fisiopatologia e permite que se desenvolvam prticas mais efetivas na rea da sade e reabilitao.
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Trabalho apresentado em XIII Congreso Internacional Galego-Portugus de Psicopedagoxa, rea 5 Familia, Escuela y Comunidad. Universidad da Corua, 2 de Setembro de 2015.
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Dissertao de Mestrado, Psicologia da Educao, especialidade de Contextos Educativos, 12 de Outubro de 2015, Universidade dos Aores.
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Para alm das variveis clnicas e sociodemogrficas existem concerteza importantes componentes individuais que desempenham um contributo importante no nvel de insight apresentado por cada pessoa doente, por exemplo, o nvel de inteligncia, personalidade, cultura, experincias passadas, memria, etc. A natureza clnica, emocional e/ou intelectual do termo ajuda-nos a compreender a complexidade da dificuldade que existe na sua traduo e, inclusive, na sua compreenso. Da que as definies atribudas ao conceito sejam muito distintas e variem consoante a formao terica do autor/investigador. Pretende-se, a partir dessa identificao/compreenso, promover a qualidade de vida destas pessoas atravs do desenvolvimento de novas aprendizagens que possibilitem uma cooperao activa. igualmente fundamental ir ao encontro das capacidade intactas de maneira a possibilitar a aquisio de novos(s) comportamento(s) que tenham um impacte positivo nas queixas, sinais, sintomas, incapacidade e disfuncionalidade apresentados pelo/a utente. Uma vez que a prpria conceptualizao do termo traduzir aquilo que se pretende avaliar,ser efectuada uma reflexo detalhada acerca dos instrumentos e definies que tm sido mais utilizadas para explorar o insight nas psicoses.Procurei, no meu trabalho de investigao, realar e promover a importncia que cada sujeito, alvo de interveno, desempenha ao longo do seu processo de recuperao e na preveno de recadas. No seguimento dos objectivos acima descritos, para alm da reviso terica efectuada ao fenmeno em termos de conceptualizao e estudos desenvolvidos na rea de investigao, foi,neste estudo, realizada a contribuio para a validao do instrumento Assessment of Insight in Psychosis: a re-standartization of a New Scale de Markov & Berrios (2003).O fenmeno de insight escolhido pela Insight Scale, relata menos as mudanas vividas em relao doena mental, e mais a actual conscincia e articulao de tais mudanas. Tendo como base uma abordagem psicopedaggica, o fenmeno do insight aqui explorado assentou numa perspectiva reabilitativa, actual e multidimensional, que fosse para alm das dimenses clnicas tradicionais. Neste sentido apresentada uma escala original, intitulada Escala de Avaliao do Insight e Identificao das Necessidades em Pessoas com Psicose, bem como um modelo de interveno psicopedaggico breve, assente nos pressupostos descritos ao longo do trabalho.-----------------------------------------ABSTRACT: The importance of insight in people with mental illnesses was first studied in psychiatry, in the first decades of the 20th century, by people as important as Lewis (1934) and Jaspers (1959). However, this field of investigation was left unexplored for many years. Only in the last decade has this phenomenon become the object of numerous scientific investigations, having been given special attention by its investigators. For this reason a significant number of instruments for evalauting insight in psychotic disorders were developed. Since then many papers have been published, which has allowed for a more in depth knowledge on the subject. Therefore, in recent years, the concept of insight has been developed in an attempt to clarify its compexity. A once dichotomic phenomenon, described in terms of presence or absence, became considered multidimensional, which made the identification of different levels of insight and different dimensions possible. Current concepts categorize insight into five dimensions: the awareness of the patient in relation to his/her mental illness, the awareness of the patient in relation to the social consequences of his/her illness, the awareness of the need for treatment, the awareness of the symptoms and the explanation of those symptoms in relation to the illness. The lack of insight in psychiatry, in general terms, and as this phenomenon has been described, the lack of awareness of having a mental illness, represents one of the most common symptoms of schizophrenia and affects a big part of the population that suffer from this illness. It is estimated that bewteen 50 and 80 per cent of patients with schizophrenia do not believe that they are ill, which, consequently has a big impact in the process of adherence to treatment. It is still not possible, however, to identify all the factors that determine the lack of insight in schizophrenics. There are psychological, social and cultural influences that almost certainly play their role in the lack of insight registered in this pathology.Since the impact of scizophrenia is felt in many aspects of the individuals life, its effective treatment should be directed at various levels, including the improvement of insight. One of the objectives of this study is to explore the relationship between the level of insight in psychosis and the clinical and sociodemographic variables, the psychopathology and its global functioning. As well as the clinical and sociodemographic variables, there are of course important individual components that contribute to the level of insight seen in each patient, for example, their level of inteligence, personality, culture, past experiences, memory, etc. The clinical, emotional and/or intelectual nature of the term helps us understand the difficulty that lies in its interpretation as well as in its comprehension. Therefore, the definitions attributed to the term are very different and vary according to the theoretical training of the investigator. It is intended, from this identification/understanding, to promote the quality of life of these people through the development of new findings that might enable an active cooperation. It is equally fundamental to observe their unimpaired capacities in order to enable the acquisition of new behaviour(s) that have a positive impact on the complaints, signs, symptoms, incapacity and disfunctioning seen in the patient.As the actual comprehension of the term explains what we intend to evaluate, a detailed reflection is made on the instruments and definitions that have been used the most to explore insight in psychosis.In this investigation I tried to underline and promote the importance that each subject, undergoing medical intervention, plays during his/her process of recovery and prevention of relapses. Considering the above mentioned objectives, as well as a theoretical review of the phenomenon in terms of conceptualization and investigative studies developed, this study contributed to the validation of the instrument.The insight phenomenon chosen by the Insight Scale, records less changes experienced in relation to the mental illness and more actual awareness and articulation of these changes. Based on a psychopedagogical approach, the insight phenomenon explored here settled on a rehabilitation, current and multidimensional perspective that would go beyond the traditional clinical dimensions. For this reason an original scale entitled Insight Evaluation Scale and Need Identification in Psychosis Patients is presented, as well as a psychopedagogical intervention model soon to be used with admitted patients based on the presuppositions described in this study.
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Neste estudo procuramos determinar a satisfao e a percepo de mudanas especficas resultantes da participao num programa de treino metacognitivo e da cognio social (TMSC) para pessoas com Esquizofrenia. Participaram 21 participantes com diagnstico de Esquizofrenia responderam a um inqurito por questionrio de administrao direta com questes abertas, realizado a meio e no final do TMCS. A partir das categorias (1) Satisfao com o programa, (2) Reestruturao scio-cognitiva e (3) Mudanas na relao eu-outro, verificamos que o programa relevante, tem potencial para introduzir mudanas na relao com os outros e parece otimizar a cognio social. Os aspectos negativos apontados esto relacionados com a durao do programa e das sesses, e com a linguagem utilizada.
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RESUMO: A partir da desinstitucionalizao psiquitrica, a nfase nas polticas pblicas de sade mental passou para os servios comunitrios e para perodos mais curtos de hospitalizao. As famlias, ento, tornaram-se as principais provedoras de cuidados cotidianos e de apoio aos pacientes. As dificuldades e o despreparo em assumir este novo papel tm gerado um sentimento de sobrecarga nos familiares, o que pode afetar sua sade fsica e mental. Vrios estudos investigaram as consequncias de se tornar um cuidador de um paciente psiquitrico, mas poucos pesquisaram o impacto na sade mental desses cuidadores. A presente pesquisa investigou a relao entre a sobrecarga e a sade mental dos familiares cuidadores de pacientes psiquitricos. Participaram deste estudo 74 familiares cuidadores de pacientes com diagnstico de esquizofrenia, atendidos no ambulatrio do Servio de Referncia em Sade Mental, da cidade de Divinpolis, MG. Os familiares participaram de uma entrevista estruturada. Nela foram aplicadas a Escala de Avaliao da Sobrecarga dos Familiares de Pacientes Psiquitricos (FBIS-BR) e, para avaliar a sade mental dos cuidadores, a Escala de Depresso de Beck (BDI). Foram realizadas anlises estatsticas descritivas, univariadas e multivariadas. Os resultados mostraram que a maioria dos cuidadores era do sexo feminino (78,40%), pais (62,20%) e com idade mdia de 59,14 anos. Os cuidadores apresentaram uma mdia de sobrecarga global objetiva de 2,05 (DP 0,54), em uma escala de 1 a 5 pontos, e uma mdia de sobrecarga global subjetiva de 2,44 (DP 0,71), em uma escala de 1 a 4 pontos. Os resultados da escala BDI mostraram que 42 cuidadores poderiam ser classificados com depresso mnima (56,80%), 17 com depresso leve (23,00%), 7 com depresso moderada (9,50%) e 8 com depresso grave (10,80%). Foram encontradas correlaes positivas significativas entre o grau de sobrecarga global e das subescalas e o nvel de depresso. As anlises multivariadas mostraram que o principal preditor de depresso dos cuidadores foi a sobrecarga global subjetiva. Outros preditores foram a obrecarga objetiva das rotinas dirias e da superviso dos comportamentos problemticos dos pacientes e a sobrecarga subjetiva das preocupaes com o paciente. As informaes levantadas mostraram o impacto do papel de cuidador na sade mental dos familiares e apontaram para a necessidade de uma maior ateno, por parte dos gestores e profissionais da rea, aos cuidadores de pacientes psiquitricos.----------ABSTRACT: The emphasis in public policy on mental health was transferred to community services and for shorter periods of hospitalization from the psychiatric deinstitutionalization. Then the families become the first provider of daily care and support to patients. The difficulties and unprepared to assume this new role has generated a sense of overload in the relatives, which can affect your physical and mental health. Several studies have investigated the consequences of becoming a caregiver of a psychiatric patient, but few scholars have researched the impact on the mental health of caregivers. The present study has investigated the relationship between overload and mental health of family caregivers of psychiatric patients. The study included 74 family caregivers of patients with schizophrenia and outpatient clinic of the Department of Mental Health Reference, in Divinpolis, Minas Gerais, Brazil. The Rating Scale Burden of Relatives of Psychiatric Patients and the scale of Beck Depression Inventory (BDI) to assess the mental health of caregivers were applied in the interview. Descriptive statistics and univariate and multivariate analysis have performed. The results showed that the majority of caregivers were female (78.40%), parents (62.20%) and mean age of 59.14 years. The caregivers had an average burden overall objective of 2.05 ( 0.54) on a scale of 1 to 5 points, and a subjective global average burden of 2.44 ( 0.71) in a scale of 1 to 4 points. The results of the BDI showed that 42 caregivers could be classified with minimal depression (56.80%), 17 with mild depression (23.00%), 7 with moderate depression (9.50%) and 8 with severe depression (10 80%). Significant positive correlations were found between the degree of overloading and global subscales and depression levels. Multivariate analysis showed that the main predictor of caregivers' depression was the global subjective burden. Other predictors were the objective burden of daily routines and supervision of problem behaviors of patients and subjective burden of the concerns about patient. The resulting information showed the impact of caregiver role in the mental health of relatives and pointed to the need for higher attention of managers and professionals to caregivers of psychiatric patients.
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RESUMO: Os programas psicoeducacionais para cuidadores de pessoas com esquizofrenia so muitas vezes construdos sem terem em conta as necessidades educacionais destes utilizadores dos servios de sade mental. Apresenta-se uma reviso da literatura sobre esquizofrenia, famlia, intervenes familiares e avaliao de necessidades educacionais. Conduziu-se um estudo transversal descritivo com caractersticas exploratrias numa amostra de convenincia de principais cuidadores (N=74) de pessoas com esquizofrenia em tratamento no Departamento de Psiquiatria e Sade Mental do Hospital de S. Francisco Xavier. A metodologia utilizada do tipo qualitativo e quantitativo. Objectivos: Descrever as caractersticas de uma amostra de principais cuidadores de pessoas com esquizofrenia e as suas necessidades educacionais, bem como contribuir para a validao do Educational Needs Questionnaire (ENQ). Instrumentos: Educational Needs Questionnaire (ENQ) e Inventrio Scio-Demogrfico para Familiares (RSDS). Resultados: O doente com esquizofrenia cuidado sobretudo pela famlia, sendo as mes os cuidadores por excelncia. Trata-se de mulheres idosas que cuidam do doente h muitos anos e que necessitam saber mais sobre como obter ajuda dos servios de sade mental. Concluses: Os cuidadores sentem que os servios de sade mental no lhes do o apoio de que necessitam e esto preocupados sobretudo com o estigma e com o que acontecer aos seus doentes aps a sua morte. A verso portuguesa do ENQ mostrou possuir boa fiabilidade, recomendando-se o desenvolvimento de estudos que dem continuidade ao esforo de validao aqui iniciado.-------------ABSTRACT: The psychoeducational programs for caregivers of people with schizophrenia are often built without regard for the educational needs of users of mental health services. We present a review of the literature on schizophrenia, family, family interventions and evaluation of educational needs. We conducted a cross-sectional study with exploratory characteristics in a convenience sample of primary caregivers (N = 74) of people with schizophrenia being treated in the Department of Psychiatry and Mental Health at the Hospital of St. Francisco Xavier. We used a qualitative and quantitative methodology. Objectives: To describe the characteristics of a sample of primary caregivers of people with schizophrenia and their educational needs, as well as contribute to the validation of the Educational Needs Questionnaire (ENQ). Instruments: Educational Needs Questionnaire (ENQ) and Inventrio Scio-Demogrfico para Familiares (RSDS). Results: Patients with schizophrenia are cared by the family, mothers are the caregivers for excellence. They are older women who take care of the patient for many years and they need to know more about how to get help from mental health services. Conclusions: Caregivers feel that mental health services dont give them the support they need and they are especially worried about the stigma and what will happens to their patients after their death. The Portuguese version of the ENQ proved to have good reliability and we recommend the development of studies that give continuity to the validation effort here started.
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Dissertao para obteno do Grau de Mestre em Gentica Molecular e Biomedicina
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RESUMO: O uso de ratinhos transgnicos em neurocincias aumentou consideravelmente nos ltimos anos devido ao crescente interesse em compreender o crebro e a necessidade de solucionar situaes clnicas do foro neurolgico e psiquitrico. Para esse efeito, diferentes mtodos de produo de animais transgnicos tm sido testados. O objectivo desta tese foi comparar mtodos de integrao aleatria de um transgene no genoma de ratinhos em termos de eficincia, estabilidade da integrao do transgene, nmero de animais e de horas de trabalho necessrias para cada mtodo. Assim, foi comparado o mtodo mais utilizado - microinjeco pronuclear (PNMI) - com duas outras tcnicas cujo desempenho foi considerado promissor a transferncia gnica atravs dos testculos por electroporao e transfeco por lentivrus in vivo. As trs tcnicas foram realizadas usando um gene reprter sob o controlo de um promotor constitutivo, e depois reproduzidas usando um gene de interesse de modo a permitir obteno de um animal capaz de ser usado em experimentao laboratorial. O transgene de interesse utilizado codifica uma protena de fuso correspondendo a uma variante da rodopsina (channelrhodopsin) fundida protena enhanced yellow fluorescente protein ((EYFP) resultando num produto designado ChR2-EYFP. Este animal transgnico apresentaria expresso deste canal inico apenas em clulas dopaminergicas, o que, com manipulao optogentica, tornaria possivel a activao especifica deste grupo de neurnios e, simultaneamente, a observao do impacto desta manipulao no comportamento num animal em livre movimento. Estas ferramentas so importantes na investigao bsica em neurocincias pois ajudam a esclarecer o papel de grupos especficos de neurnios e compreender doenas como a doena de Parkinson ou a esquizofrenia onde a funo de certos tipos de neurnios de encontra alterada. Quando comparados os trs mtodos realizados verifica-se que usando um gene reprter PMNI resulta em 31,3% de, a de animais transgnicos obtidos, a electroporao de testculos em 0% e a injeco de lentivrus em 0%. Quando usado o gene de interesse, os resultados obtidos so, respectivamente, 18,8%, 63,9% e 0%.--------------ABSTRACT: The use of transgenic mice is increasing in all fields of research, particularly in neuroscience, due to the widespread need of animal models to solve neurological and psychiatric medical conditions. Different methodologies have been tested in the last decades in order to produce such transgenic animals. The ultimate goal of this thesis is to compare different methods of random integration of a transgene in the genome of mice in terms of efficiency, stability of the transgene integration, number of animals required and the labour intensity of each technique. We compared the most used method pronuclear microinjection (PNMI) with two other promising techniques Testis Mediated Gene Transfer (TMGT) by electroporation and in vivo lentiviral transfection. The three techniques were performed using a reporter gene green fluorescent protein (GFP), whose transcription was driven by the constitutive cytomegalovirus (CMV) promoter. These three techniques were later reproduced using the tyrosine hydroxylase promoter (TH) and the neuronal manipulator, channelrhodopsin-2 fused to the enhanced yellow fluorescent reporter protein (ChR2-EYFP). The transgenic animal we sough to produce would express the light driven channel only in dopaminergic cells, making possible to specifically activate this group of neurons, while simultaneously observe the behaviour in a freely moving animal. This is a very important tool in basic neuroscience research since it helps to clarify the role of specific groups of neurons, map circuits in the brain, and consequently understand neurological diseases such as Parkinsons disease or schizophrenia, where the function of certain types of neurons is affected. When comparing the three methods, it was verified that using a reporter gene PNMI resulted in 31.3% of transgenic mice obtained, testis electroporation in 0% and lentiviral injection in 0%. When using the gene of interest, the results obtained were, respectively, 18.8%, 63.9% and 0%.
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RESUMO: Os psicofrmacos desempenham um papel central no tratamento das doenas mentais. Apesar das divergncias verificadas nos padres de prescrio de psicofrmacos intra e inter pases, diversos estudos tm alertado para os riscos da polifarmcia e da sobredosagem, particularmente de antipsicticos. Em Portugal, o Plano Nacional de Sade Mental 2007-2016 prev a monitorizao peridica do padro de prescrio de psicofrmacos. No entanto, apenas existem dados relativos utilizao de psicofrmacos em ambulatrio, faltando dados relativos ao padro de prescrio nos cuidados especializados. Este estudo teve como principal objetivo estabelecer o Padro de Prescrio de Psicofrmacos em Unidades de Internamento Agudo de Servios de Psiquiatria em Portugal e determinar a prevalncia da polifarmcia e sobredosagem antipsictica, de modo a recolher dados que possam servir de base para posteriores monitorizaes. Mtodos: Censo de 1 dia da prescrio de psicofrmacos em 12 Unidades de Internamento Agudo de Psiquiatria em Portugal, num total de 272 doentes. Resultados: A larga maioria (94,1%) dos doentes includos estava medicada com mais do que um psicofrmaco. Apenas 1,1% dos doentes no tinham qualquer psicofrmaco prescrito e 4,8% encontravam-se em monoterapia. A mdia de psicofrmacos prescritos por doente era de 3,21,3, significativamente superior nos indivduos do sexo feminino, naqueles com antecedentes de acompanhamento em consulta de psiquiatria, nos que tinham internamentos prvios e nos que estavam internados voluntariamente. As classes de psicofrmacos mais prescritas de modo regular eram os antipsicticos (prescritos a 87,5% dos doentes), as benzodiazepinas (81,2% dos doentes), os antidepressivos (39% dos doentes) e os estabilizadores de humor (31,6% dos doentes). Dos doentes medicados com antipsicticos, 41,6% tinham prescritos pelo menos 2 antipsicticos em associao e esta prescrio combinada era significativamente superior nos doentes com internamento prvio e naqueles que tinham prescrito um antipsictico injetvel de ao prolongada. Excluindo as prescries em SOS, encontraram-se prescritas doses de antipsicticos superiores s recomendadas em 13,9% dos doentes, os quais eram significativamente mais novos. A sobredosagem antipsictica era significativamente superior nos doentes do sexo masculino, nos desempregados e reformados, naqueles com internamento prvio, nos que estavam internados compulsivamente, naqueles com diagnstico de esquizofrenia ou outra psicose, naqueles medicados com antipsicticos em associao e nos que faziam antipsicticos injetveis de ao prolongada. Incluindo as prescries de antipsicticos em SOS, presentes em mais de metade dos doentes, a percentagem de doentes em sobredosagem antipsictica atingia os 49,2%. Concluso: Os resultados so indicadores de prticas de prescrio divergentes das recomendadas, o que pode ter implicaes clnicas e econmicas. Parece imperativo otimizar a prescrio de psicofrmacos nas unidades de internamento agudo de psiquiatria em Portugal, no sentido de melhorar a qualidade dos servios prestados ---------------- ABSTRACT: Psychotropic drugs play a central role in the treatment of mental disorders. Despite the variation in patterns of psychotropic prescription within and between countries, several studies have warned about the risks of prescribing more than one psychotropic drug at a time and high-doses, particularly antipsychotics. The Portuguese National Mental Health Plan (20072016) includes regular monitoring of patterns of psychiatric drug prescription. However, there is only available data on the pattern of use in outpatients, but no information regarding prescribing patterns at the level of specialized care. This study aimed to establish psychotropic drug prescribing patterns in acute psychiatric wards across Portugal and to determine the prevalence of antipsychotic polypharmacy and high-doses treatment, in order to collect data that can serve as a baseline for future monitoring. Methods: "One day census" of psychotropic drug prescribing in 12 Acute Inpatient Psychiatry Units in Portugal, in a total of 272 patients. Results: The majority (94.1%) of patients were treated with more than one psychotropic drug. Only 1.1% of patients had no psychotropic drugs prescribed and 4.8% were on monotherapy. The average prescribed psychotropics per patient was 3.2 1.3, significantly higher in females, in patients with a psychiatry history, in patients with previous admissions and in patients admitted voluntarily. The most commonly prescribed classes of psychotropic drugs on a regular basis were: antipsychotics (87.5% of patients), benzodiazepines (81.2% of patients), antidepressants (39% of patients) and mood stabilizers (31.6% of patients). Of patients taking antipsychotics, 41.6% had at least 2 antipsychotics prescribed in combination, and this prescription combination was significantly higher in patients with previous hospitalization and those who had been prescribed a long-acting injectable antipsychotic. Excluding p.r.n. prescriptions, we verified higher than recommended antipsychotic doses in 13.9% of patients, which were significantly younger. Antipsychotic high-doses was significantly higher in males, unemployed and pensioner patients, patients with previous hospitalization, involuntary admitted patients, those diagnosed with "schizophrenia or other psychosis", patients with a combination of 2 or more antipsychotics and in patients with long-acting injectable antipsychotics. Including antipsychotics p.r.n. prescriptions, present in more than a half of patients, the percentage of those on antipsychotic high-doses reached 49.2%. Conclusion: These results are indicative of prescribing practices divergent of those that are recommended, and this may have clinical and economic implications. It seems imperative to optimize the prescription of psychotropic drugs in Portuguese Acute Inpatient Psychiatry Units, in order to improve the quality of services provided.
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RESUMO: De acordo com o estado da arte, existem intervenes psicofarmacolgicas, psicolgicas e psicossocias, com evidncia cientfica dos seus resultados, no tratamento de pessoas com esquizofrenia e perturbao esquizoafectiva. No entanto, muitos destes doentes, no procuram ajuda dos servios de sade mental, no recebem os referidos cuidados ou no so detectados nem seguidos por estes. Esta realidade levou ao desenvolvimento de programas integrados, intervenes e estudos mais especficos, nomeadamente para tentar ultrapassar os obstculos na acessibilidade aos cuidados de sade e na continuidade de seguimento destes doentes. No conjunto das dificuldades apuradas, as questes da exequibilidade (feasibility) e da implementao, tm tido particular relevo na literatura cientfica recente, bem como a melhor forma de vencer as respectivas barreiras e adaptar essas intervenes s varias realidades, culturas e recursos. Objectivos: Objectivos gerais:1) Avaliar a exequibilidade e a implementao inicial de um programa de cuidados integrados, para pessoas com esquizofrenia ou perturbao esquizoafectiva, no contexto clnico das equipas de sade mental comunitrias de um departamento de psiquiatria do Servio Nacional de Sade, em Portugal, com os recursos materiais e humanos existentes; 2) Avaliar o impacto deste programa, nestes doentes e na respectiva prestao de cuidados de sade mental. Metodologia. Elabormos um programa de cuidados integrados (Programa Integrar) com base no modelo clnico de case management, com seguimento mantido e integrado. Cada doente passou a ter um terapeuta de referncia, um plano individual de cuidados e manteve o seguimento com o seu psiquiatra assistente. Foram seleccionadas intervenes, nomeadamente, psicoeducativas, familiares, estratgias para lidar com os sintomas e a doena, preveno de recadas e intervenes para melhorar o funcionamento social e ocupacional. A estas intervenes foi sempre associado o tratamento psicofarmacolgico. O estudo delineado incluiu dois componentes: avaliao da exequibilidade e implementao inicial do programa de cuidados integrados (componente A) e avaliao do impacto deste programa (componente B), atravs de um estudo de interveno, prospectivo, naturalista, no aleatorizado e no ontrolado. A amostra do estudo resultou das sucessivas referenciaes, para o Programa Integrar, de pessoas com os diagnsticos de esquizofrenia ou perturbao esquizoafectiva, seguidas nas cinco equipas de sade mental comunitrias do Departamento de Psiquiatria do Centro Hospitalar de Lisboa Ocidental, com uma rea assistencial correspondente a uma populao de, aproximadamente, 400 000 pessoas. Definimos etapas, estratgias, parmetros e indicadores para o estudo da exequibilidade do programa. Efectumos a monitorizao e a avaliao de tarefas, procedimentos e intervenes recomendadas aos terapeutas de referncia. Realizmos duas avaliaes, uma no incio do programa e outra aps um ano de interveno. Foram avaliadas as seguintes dimenses (com indicao do acrnimo do instrumento de avaliao utilizado entre parntesis): psicopatologia (BPRS), depresso (MADRS), necessidades (CAN), incapacidade (DAS), actividade social e ocupacional (SOFAS), atitude em relao medicao (DAI), insight (SAI), qualidade de vida (WHOQOL-S) e satisfao (POCS). Resultados: Dos 146 doentes que foram includos no estudo, 97 (66%) eram do sexo masculino e 49 (34%) do sexo feminino, com uma idade mdia de 36 anos. Destes oentes,116 (79,4%)tinham o diagnstico (ICD10) de esquizofrenia e 30 (20,6%) de perturbao esquizoafectiva. Os restantes dados sociodemogrficos eram tpicos de populaes afins em servios de sade mental nacionais. Do total de doentes (146) que iniciaram o estudo, 26 (18%) abandonaram o seguimento neste programa. Para o componente A da investigao (estudo de exequibilidade) salientamos: exerceram funes a totalidade (15) dos terapeutas de referncia que receberam formao, 76 % efectuaram o nmero mnimo recomendado de sesses / ano por doente (18), 44,9 fizeram o nmero mnimo de sesses familiares pretendido ( 3). Nas intervenes mais especficas foram atingidos os objectivos em mais de 75% dos doentes, excepo das intervenes domicilirias (19,4%), preveno do abuso de substncias (45,4%) e do risco de suicdio (34,3%). O plano individual de cuidados foi realizado em 98 % dos doentes e em 38,9 % dos casos ocorreu a participao da famlia. Neste plano, a mdia de objectivos definidos foi de 5 e a mdia de objectivos atingidos correspondeu a 3 (p= 0,001). Na primeira avaliao, estavam a frequentar estruturas de reabilitao psicossocial 42 doentes (28,8%) e,12 meses aps, esse nmero passou para 80 (74,1%).Tambm aumentou o nmero de doentes com actividade profissional a tempo completo, de 8 (7,4%) para 18 (16,7%). No componente B do estudo (avaliao do impacto do programa), em termos de psicopatologia, e para as pontuaes mdias globais do BPRS, ocorreu uma diminuio entre a primeira e a segunda avaliao (p=0,001), tal como nas subescalas: sintomas positivos (p=0,003), sintomas negativos (p=0,002), sintomas de mania (p=0,002) e sintomas de depresso/ansiedade (p=0,001). Na avaliao da depresso (p= 0,001) e da incapacidade (p=0,003), as diferenas foram significativas e favorveis. O mesmo no sucedeu na atitude em relao medicao (p=0,690) nem na escala de avaliao do insight (p=0,079). Em relao ao funcionamento social e ocupacional, qualidade de vida e satisfao dos doentes, ocorreu uma melhoria significativa da primeira para a segunda avaliao As necessidades sem resposta mais frequentes, na primeira avaliao, corresponderam aos itens: actividades dirias, contactos sociais, relaes ntimas, relacionamento sexual, benefcios sociais, sintomas psicticos, sofrimento psicolgico, informao sobre a doena / tratamento e gesto/problemas de dinheiro. Para todos estes ltimos nove itens, verificou-se uma diferena estatisticamente significativa, entre a primeira e a segunda avaliao, com diminuio destas necessidades, excepto nas relaes ntimas, relacionamento sexual e nos problemas de dinheiro. Na distribuio dos trs estados de necessidades, para todos os itens, diminuram as necessidades sem resposta e as necessidades com resposta parcial e aumentaram as situaes em que deixaram de se verificar necessidades relevantes. Dos resultados obtidos para outros indicadores clnicos e de utilizao dos cuidados, ser importante referir que na comparao do ano anterior com o ano em que decorreu o programa, o nmero de doentes da amostra internados diminuiu 64,1%, bem como a mdia do nmero de internamentos (p=0,001). Em relao durao dos internamentos, no ano anterior ao programa, os 39 doentes internados, tiveram um total de dias de internamento de 1522, sendo que, no ano do programa, para os 14 doentes internados, o total foi de 523 dias. Em termos absolutos, ocorreu uma reduo de 999 dias (menos 65,6% dias). Tambm se verificou uma diminuio de 45,6 % de recadas (p=0,001).Discusso e concluses A exequibilidade do programa de cuidados integrados permitiu a aplicao do modelo clnico de case management, com seguimento mantido e integrado, atravs do qual cada doente passou a ter um terapeuta de referncia assim como, em 98% casos, um plano individual de cuidados. As famlias continuaram a ser o principal suporte para os doentes, mas surgiram dificuldades quando se pretendeu uma participao mais activa destas no tratamento.A diminuio do nmero e da durao dos internamentos constituram importantes resultados com implicaes no s em termos clnicos mas tambm econmicos. Os valores obtidos, para as diferentes variveis, tambm sugerem o impacto favorvel do Programa Integrar a nvel da psicopatologia, das necessidades, da incapacidade, do funcionamento social e ocupacional, da qualidade de vida e da satisfao dos doentes. O mesmo no sucedeu para o insight e para a mudana de atitudes dos doentes em relao medicao, resultados que devem ser igualmente considerados em futuros reajustamentos deste programa ou no desenvolvimento de novos programas. Como principais concluses podemos referir que: 1) Foi possvel a exequibilidade de um programa de cuidados integrados inovador e a implementao inicial desse programa, para doentes com esquizofrenia ou perturbao esquizoafectiva, com os recursos humanos e materiais existentes, no contexto clnico das equipas de sade mental comunitrias, de um departamento de psiquiatria e sade mental, em Portugal; 2) Na avaliao do impacto do programa, os resultados obtidos indiciam potencialidades de aplicao, deste programa de cuidados integrados, com vista melhoria clnica e psicossocial destes doentes. Devem ser realizados estudos de replicao, ou complementares presente investigao, no entanto, os dados obtidos so encorajadores para o desenvolvimento de programas similares, a nvel nacional e internacional, que possam beneficiar um grupo mais alargado de doentes.------------ABSTRACT: Although there are psychological and psychosocial interventions well supported by scientific evidence, which show benefit when combined with psychopharmacological treatments, we know that a significant number of people with schizophrenia or schizoaffective disorders, do not seek help from mental health services, do not receive the care mentioned and are not detected or followed-up by them. This reality led to the development of integrated programs, interventions and more specific studies, to try to overcome the obstacles in the accessibility to the health services and on the follow-up of these patients. Amongst the barriers identified, feasibility and implementation of those programs have been of special relevance in recent scientific literature, as well as the best way to overcome such difficulties and adapt the interventions to the various realities, cultures and resources. Objectives: General objectives were defined: 1) Assessment of the feasibility and initial implementation of an integrated care program, for people with schizophrenia or schizoaffective disorder, in the clinical setting of community mental health teams, in a psychiatric department from the national health service in Portugal; 2) Impact evaluation of the integrated care program, for these patients and their mental health care delivery. Methods: We drew up an integrated care program (Program Integrar) based on the clinical case management model, with continuous and integrated follow-up. Each patient got one case manager, an individual care plan and kept the same psychiatrist. Were selected the appropriated interventions, namely: psycho-educative, family-based interventions, strategies for dealing with the symptoms and the disorder, relapse prevention and interventions to improve social and occupational functioning. These interventions were always associated with psychopharmacological treatment. The investigation was outline with two parts: assessment of the feasibility and initial implementation of the Program Integrar (part A of the study) and impact evaluation of the program (part B of the study). We designed a naturalistic, prospective, intervention study, non-randomized and without control group. Our chosen sample was made with successive referrals of patients with the diagnosis of schizophrenia or schizoaffective disorder, followedup in one of the five community mental health teams of the Psychiatric Department of Centro Hospitalar Lisboa Ocidental, with a catchment area for a population of about 400 000 people. Different stages, strategies, criteria and indicators for studying the feasibility of the program and its implementation were set and the tasks, procedures and recommended interventions of the case managers were monitored and evaluated. We did two assessments with an interval of one year and we evaluated the following dimensions (the acronym of the assessment instrument used in brackets): psychopathology (BPRS), depression (MADRS), needs (CAN), disability (DAS), social and occupational functioning (SOFAS), attitude toward medication (DAI), insight (SAI), quality of life (WHOQOL-S) and satisfaction (POCS). Results: Of the 146 patients who started the study, 97 (66%) were male and 49 (34%) females with a mean age of 36 years. Of these, 116 (79,4%) were diagnosed (ICD10) with schizophrenia and 30 (20,6%) with schizoaffective disorder. The other socio-demographic data were typical of populations within Portuguese mental health services. Of all patients (146), who started the program, 26 (18%) of patients left the program (program dropout rate). Of the regarding part A of the study, which focused on feasibility, the following is of note: all professionals who had been trained for this purpose (15) acted as case manager, 76% did the recommended minimum number of sessions / year per patient (18) and 44,9% did the minimum number of family sessions desired ( 3). For the more specific interventions the parameters set out were met for more than 75% of patients, with the exception of domiciliar interventions (19.4%), prevention of substance abuse (45.4%) and suicide risk prevention(34.3%). The individual care plan was done for 98% of patients and in 38,9% of cases this involved family participation. For this plan the mean objectives defined were 5 and in average was achieved 3 (p=0,001). On the first assessment, 42 patients (28.8%) were attending psychosocial rehabilitation structures and 12 months later that number rose up to 80 (74,1%). Regarding their employment status, in the first assessment 8 (7,4%) were in full time employment and in the second evaluation the number rise to 18 (16,7%). For part B of the study (impact program evaluation), in terms of psychopathology, global mean scores for the BPRS, decreased (p=0,001), as did the four sub scales: positive symptoms (p=0,003); negative symptoms (p=0,002); manic symptoms (p=0,002) and symptoms of depression/anxiety (p=0,001). Both in the evaluation of depression (p=0,001), as in the assessment of disability (p=0,003), the differences were significant. However, this was not the case with attitudes towards medication (p=0,690) and with insight evaluation (p=0,079). In relation to social and occupational functioning, quality of life and patient satisfaction there was a statistically significant improvement from the first to the second assessment. The most commonly unmet needs in the first assessment were daily activities, social contacts, intimate relationships, sexual relations, social benefits, psychotic symptoms,psychological distress, information about the disorder / treatment and money problems money management. Of these, in the second assessment, all of those nine unmet needs showed significant improvement, excepted intimate relationships, sexual relations and Money problems / money management. In the distribution of the three states of needs for all items, it happened a decreased in unmet needs and partially met needs and increased in the situations where relevant needs were no longer found. For other clinical indicators it is important to note, when we compared the year prior to this program and the year after, there were fewer hospitalizations (reduction of 64,1% of admissions) and in the mean number of admissions (p=0,001). Regarding the length of hospitalization in the year prior to the program, the 39 patients admitted had a total of 1522 hospital days, and in the year of the program for the 14 hospitalized patients, the total was 523 days. In absolute terms, there was a reduction of 999 days (65,6%). There was also a 45,6% reduction of relapses (p = 0,001). Discussion and Conclusions: The feasibility of the integrated care program allowed the application of the clinical case management model, with continuous follow-up. Each patient got a case manager and in 98% of the cases they also got an individual plan of care. Families continued to be the main support for patients but, difficulties occurred when it was claimed a more active participation. The decrease in the number and duration of admissions were important findings with implications not only in clinical terms but also in economic field. The achieved results for the different variables can also indicate the favorable impact of this program, at the level of psychopathology, needs, disability, social and occupationa functioning, quality of life and patient satisfaction. The same did not happen for the evaluation of insight and in the changes of attitudes towards medication. These data should also be considered for future readjustments of this program and for the developing of new programs.Finally, the two-overview conclusions are: 1) It was possible the feasibility of an integrated care program and initial implementation of this innovative program, for patients with schizophrenia or schizoaffective disorder, with the human and material resources available in the clinical context of the community mental health teams, in a psychiatry and mental health department of the national health service in Portugal; 2) In assessing the impact of the program, the results suggest potential application of this integrated care program, to improve clinical state and psychosocial variables for these patients. There should be done studies to replicate these results, however the results obtained are promising for the development of similar programs at nationally and internationally level, that could benefit a wider group of patients.
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RESUMO: OBJECTIVO: Avaliar as necessidades, incapacidade, qualidade de vida, satisfao com os servios e as caractersticas sociodemogrficas numa amostra de pacientes com esquizofrenia num Servio de Psiquiatria, em Cabo Verde. MTODOS: Realizou-se estudo transversal com 122 doentes com recurso a instrumentos estruturados para as necessidades (CAN), incapacidade (WHODAS II), qualidade de vida (WHOQOL-BREF) e satisfao com os servios (VSSS) e uma ficha para recolha de dados sociodemogrficos. RESULTADOS: Os doentes eram maioritariamente do sexo masculino (73,8%) com uma idade mdia de 35,23 anos, uma escolaridade baixa (59,8%), solteiros (81.1%), residindo em meio urbano (72,1%) e desempregados (63,2%). A maioria estava a tomar medicao antipsictica (97,5%), tinha histria de internamento (76.2%), uma mdia de incio da doena aos 23,43 anos e uma durao mdia de 11,80 anos. As necessidades referidas foram baixas e as facetas mais identificadas foram a informao, os subsdios e benefcios sociais, as actividades dirias, os contactos sociais e sofrimento psicolgico. Cerca 20% dos participantes manifestaram uma incapacidade, sobretudo no domnio da da participao na sociedade (47,2%). A mdia da qualidade de vida foi 65,08 (desvio-padro: 21,35), com o domnio psicolgico a apresentar o valor mais alto (74,21, desvio-padro: 14,87) e o ambiental o mais baixo (59,27, desvio-padro: 15,15). A satisfao com os servios foi avaliada de forma positiva nas dimenses satisfao global e competncia dos profissionais. As dimenses informao, envolvimento dos familiares, eficcia e acesso tiveram avaliao insatisfatria. Os tipos de intervenes, com vrios servios pouco disponibilizados, tiveram uma satisfao relativa. DISCUSSO: Num contexto de carncia, os resultados revelaram-se mais satisfatrios do que esperados, mas com grandes insuficincias no processo de cuidados. CONCLUSO: O estudo permitiu conhecer o processo de cuidados aos doentes com esquizofrenia e disponibilizou elementos para programas de cuidados.-----------ABSTRACT: OBJECTIVE: Assess needs, disability, quality of life, satisfaction with the services and the socio-demographic characteristics in a sample of patients with schizophrenia in a Psychiatric Service in Cape Verde. MATHODS: It was carried out a cross-sectional study with 122 patients using the structured instruments for the needs (CAN), disability (WHODAS II), quality of life (WHOQOLBREF),satisfaction with the services (VSSS) and socio-demographic data collection. RESULTS: The patients are mainly of the male sex (73.8%) with average age of 35.23 years old, low education level (59.8%), single (81.1%), living in urban area and unemployed (63.2%). Most of them were taking antipsychotic medication (97.5%), had a history of hospitalization (76.2%), an average of disease onset at 23.43 years old and an average duration of 11.80 years. The needs mentioned were low and the most identified facets were information, subsidies and social benefits, daily routines, social contacts and psychological distress. Around 20% of the participants expressed one disability, especially at the domain of the participation in the society (47.2%). The average quality of life was 65.08 (standard deviation: 21.35), with the domain of the psychological presenting the highest value (74.21, standard deviation: 14.87) and environmental the lowest (59.27, standard deviation: 15.15). The satisfaction with services was positively assessed in the dimensions of overall satisfaction and competency of the professionals. The dimensions information, family involvement, effectiveness and access had positive evaluation. The types of intervention with services poorly available had a relative satisfaction. DISCUSSION: In a context of shortage, the results were considered more satisfactory than expected, but with many inadequacies in the process of care. CONCLUSION: This study allowed to know the process of care to the patients with schizophrenia and provided elements for the programs of care.
Resumo:
RESUMO: INTRODUO E OBJETIVOS: Trata-se de estudo transversal descritivo, em etapa nica, cujo objetivo foi traar o perfil dos beneficirios do Programa De volta para casa (PVC), muncipes de Belo Horizonte / Minas Gerais / Brasil, quanto s habilidades de vida independente (autonomia) e comportamento social. MTODO: O universo inicial de beneficirios era de 210, em julho de 2013, data de aprovao do protocolo. Por questes operacionais, o pblico-alvo considerado e estudado foi de 121 beneficirios. Foram utilizados como instrumentos as escalas Independent Living Skills Survey (ILSS) e Social Behavior Scale (SBS). Foi feita a anlise estatstica dos dados e os resultados foram analisados luz do paradigma emergente de produo social da sade. RESULTADOS: Considerando o total vlido estudado de 121 beneficirios, os resultados revelaram que 82,4% apresentam diagnstico de esquizofrenia e 62% eram do sexo masculino. Apresentaram mdia de idade de 57,9 anos e tempo mdio de internao psiquitrica antes de insero no programa de 30,9 anos. Quanto autonomia, os resultados da ILSS revelaram uma mdia global de 1,6 sendo que os melhores ndices foram alcanados nos subitens Cuidados pessoais (2,69), Alimentao (2,53), Sade (2,07) e os piores ndices foram encontrados nos subitens Emprego (0,47), Lazer (0,86) e Preparo e armazenamento de alimentos (0,98). Quanto aos problemas no comportamento social, os resultados da SBS revelaram uma mdia global de 0,69 sendo que as reas de maiores dificuldade foram: Rir ou falar sozinho (40,5%), Incoerncia da fala (29%), Auto-cuidado precrio e Pouca atividade (ambas com 25,6% cada). As reas de menores dificuldades, ainda quanto SBS, foram: Idias suicidas 92,4%), Comportamento sexual inapropriado (7,4%) e Depresso (9,9%). CONCLUSO: Concluiu-se que o perfil dos beneficirios do PVC, quanto autonomia e aos problemas de comportamento social, aponta para mdias relativamente baixas. O desafio para o enfrentamento desta questo dever considerar estratgias mltiplas de ao luz do paradigma emergente de sade e da reabilitao psicossocial que priorize o empoderamento e protagonismo do beneficirio. necessrio o desenvolvimento de outros estudos que ampliem o evidenciamento desta clientela no que tange s suas reais necessidades e potencialidades para que se possa efetivar o ajuste necessrio para a legitimao do programa enquanto ao efetivo-eficaz de promoo de sade.-------------ABSTRACT: descriptive cross-sectional study in a single stage was conducted to investigate independent living skills and social behavior profile of beneficiaries of Programa De Volta para casa (PVC) who live in Belo Horizonte/Minas Gerais/Brazil. METHODS: The target population included a total of 210 individuals in july 2013, when the study was approved by the ethics committees. Because of operational reasons only 121 individuals were evaluated. Data were collected using the Independent Living Skills Survey (ILSS) and the Social Behavior Scale (SBS). Statistical results were analyzed considering as a reference framework both the emerging paradigm of social health production. RESULTS: Considering a sample of 121 individuals, results revealed that 82.4% were diagnosed with schizophrenia, and 62% were male. The mean age was 57.9 years and the mean stay in the psychiatric hospital prior to PVC was 30.9 years. Independent living skills measured by ILSS revealed a global mean of 1.6, and the best scores were in the following subscales: personal care (2.69), feeding (2.53) and health (2.07). On the other hand, the worst scores were in the following subscales: employment (0.47), leisure (0.86) and food preparation (0.98). Impairment of social functioning measured by SBS revealed a global mean of 0.69, and the best scores were in the following subscales: laughing and talking by itself (40.5%), conversation: incoherence (29%), appearance and personal hygiene (25.6%), and idleness (25.6%). The worst scores were in the following subscales: suicidal ideations (92.4%), improper sexual behavior (7.4%), and depression (9.9%). CONCLUSION: It was concluded that the profile of PVC beneficiaries, regarding their autonomy and their problems of social behavior, points to a relatively low average. The challenge of facing this issue should consider multiple strategies of intervention that prioritizes the empowerment and leadership of the beneficiaries, based on the emerging paradigm of health and psychosocial rehabilitation as a reference framework. The development of other studies that expand the evidencing of this target population with respect to their real needs and capabilities in order to carry out the necessary adjustments for the legitimacy of the program as effective health promotion action is required.
