Intervenções farmacêuticas na atenção à saúde mental: Uma revisão

Uma revisão dirigida foi realizada nas bases de dados IBECS, LILACS e MEDLINE, até fevereiro/2011, para identificar intervenções farmacêuticas (IF) na atenção farmacêutica em saúde mental e os seus resultados. Para a busca utilizaram-se os descritores em saúde: Pharmaceutical Care, Pharmaceutical Services, Medication Adherence, Pharmacists, Mental Health, Mental Health Services, Mental Health Assistance, Community Mental Health Services, Mentally Ill Persons andMental Disorders. Identificaram-se 1686 publicações, das quais 21 contemplaram os critérios de inclusão. Após exploração do material, apenas cinco estudos tratavam-se de IF. Todos foram conduzidos no nível secundário de atenção, com abordagem individual, por meio do acompanhamento da terapia (3), intervenção educativa por cartas a médicos e pacientes (1), aconselhamento farmacêutico presencial e remoto e inserção de terapia com sistema transdérmico de nicotina (1). Os resultados, tais como promoção da adesão e resolução de problemas relacionados a medicamentos foram positivos para a terapêutica. No entanto, é necessário que as IF monitorem os parâmetros clínicos, as mudanças de hábitos, a melhora na qualidade de vida e os aspectos farmacoeconômicos a fim de avaliar os seus impactos. Palavras-chave:Atenção Farmacêutica. Assistência Farmacêutica. Adesão à Medicação. Farmacêuticos. Saúde Mental. ABSTRACT Pharmaceutical interventions in mental health services: a review A directed review was performed in IBECS, LILACS and MEDLINE databases, until February/2011, in order to identify the studies which developed pharmaceutical interventions (PI) in pharmaceutical care in mental health services and estimated their results. The search was carried out using the follow health science descriptors: Pharmaceutical Care, Pharmaceutical Services, Medication Adherence, Pharmacists, Mental Health, Mental Health Services, Mental Health Assistance, Community Mental Health Services, Mentally Ill Persons andMental Disorders. It was identified 1686 manuscripts, of whose 21 contemplated the inclusion criteria. After the content analysis of the eligible manuscripts, only five developed PI. All of them were conducted in the second level of health care, with individual approach, through: therapy follow-up (3), educational interventions by letters to physicians and patients (1), presence or remote pharmaceutical counseling and inclusion of therapy with nicotine transdermal patch (1). The data, such as adherence promotion and solving drug related problems, were positive for the therapeutic. However, it is necessary that the PI monitor the clinical parameters, the habit changes, the improvement in the quality of life and the pharmacoeconomic aspects, in order to assess their impacts. Keywords: Pharmaceutical Care. Pharmaceutical Services. Medication Adherence. Pharmacists. Mental Health. Mental Disorders.

Validade e coerência de instrumentos utilizados em avaliações clínicas de idosos

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Monitoring Drug Use Among HIV/AIDS Patients in Brazil: Should we Combine Self-Report and Urinalysis?

Illicit drug use in HIV-infected patients can be linked to impairment of physical and mental health, low health-related quality of life, and suboptimal adherence to HIV treatment. This study aimed to evaluate the correlation of self-report illicit drug use, urinalysis for cocaine and cannabis metabolites, and severity of dependence among HIV-infected patients on antiretroviral therapy (ART) in a treatment center in Brazil. Four hundred and thirty-eight outpatients of an HIV referral center were interviewed and assessed for drug use (lifetime, last year and last month). Urinalysis was performed to detect the presence of cocaine and cannabis metabolites in urine samples. Overall agreement between self-report and urinalysis was almost 68% for cannabis and higher than 85% for cocaine. Positive urinalysis was significantly associated with more than once a week cannabis (p < .0001) and cocaine (p <.0001) use during the last-month. Severity of Dependence Scale (SDS) properly predicted positive cocaine urinalysis results (area under the curve [AUC] = .81, p = .0001). Frequency of cannabis and cocaine use, SDS score degree and positive urinalysis for both drugs were correlated. Our findings suggest that positive self-report is a reliable predictor of positive urine sample both for cannabis and cocaine, but since the agreement was not perfect, there is a role for urine drug screening in the care of patients with HIV-related conditions.

Evaluation of inadequate anti-retroviral treatment in patients with HIV/AIDS

Introduction: Since the emergence of antiretroviral therapy, the survival of patients infected with human immunodeficiency virus has increased. Non-adherence to this therapy is directly related to treatment failure, which allows the emergence of resistant viral strains. Methods: A retrospective descriptive study of the antiretroviral dispensing records of 229 patients from the Center for Health Care, University Hospital, Federal University of Juiz de Fora, Brazil, was conducted between January and December 2009. Results: The study aimed to evaluate patient compliance and determine if there was an association between non-adherence and the therapy. Among these patients, 63.8% were men with an average age of 44.0 +/- 9.9 years. The most used treatment was a combination of 2 nucleoside reverse transcriptase inhibitors with 1 non-nucleoside reverse transcriptase inhibitor (55.5%) or with 2 protease inhibitors (28.8%). It was found that patients taking lopinavir/ritonavir with zidovudine and lamivudine had a greater frequency of inadequate treatment than those taking atazanavir with zidovudine and lamivudine (85% and 83.3%, respectively). Moreover, when the combination of zidovudine/lamivudine was used, the patients were less compliant (chi(2) = 4.468, 1 degree of freedom, p = 0.035). Conclusions: The majority of patients failed to correctly adhere to their treatment; therefore, it is necessary to implement strategies that lead to improved compliance, thus ensuring therapeutic efficacy and increased patient survival.

Transtorno afetivo bipolar: perfil farmacoterapêutico e adesão ao medicamento

This cross-sectional and descriptive study aimed to verify the adherence of patients with Bipolar Affective Disorder (BAD) to medication and to identify possible causes of adherence and non-adherence to medication according to the pharmacotherapeutic profile. The study was carried out in a mental health service in a city in the interior of the state of Sao Paulo. Participants included 101 patients with BAD. Structured interviews and the Morisky-Green test were used for data collection, and the Statistical Package for Social Science was employed for data analysis. Most subjects (63%) did not adhere to medication. Although there were no significant differences between the adherent and non-adherent groups for the researched variables, the use of polypharmacotherapy and complex treatment regimens was observed in treatment for BAD. In practice, implementing strategies to improve the adherence of patients to medication treatment remains a challenge.

Adesão ao tratamento e controle da pressão arterial em idosos com hipertensão

FUNDAMENTO: A não adesão ao tratamento tem sido identificada como a causa principal da Pressão Arterial (PA) não controlada, e pode representar um risco maior em idosos. OBJETIVO: O objetivo deste estudo foi avaliar e comparar a taxa de adesão ao tratamento da hipertensão arterial por diferentes métodos, para estimar a taxa de controle da PA, e observar se há uma associação entre controle da pressão arterial e adesão. MÉTODOS: A adesão ao tratamento foi avaliada em pacientes idosos com hipertensão, acompanhados pelo serviço público de saúde, por meio de quatro métodos, incluindo o teste de Morisky-Green (referência), o questionário sobre atitudes referentes à ingestão de medicação (AMI), uma avaliação da adesão por parte do enfermeiro em consultório (AEC), e avaliação domiciliar da adesão (ADA). A ingestão de sal foi estimada pela excreção urinária de sódio de 24 horas. O controle da pressão arterial foi avaliado pelo monitorização ambulatorial da pressão arterial na vigília. RESULTADOS: A concordância entre o teste de Morisky-Green e o AMI (Kappa = 0,27) ou a AEC (Kappa = 0,05) foi pobre. Houve uma concordância moderada entre o teste de Morisky-Green e a ADA. Oitenta por cento tinham a PA controlada, incluindo 42% com efeito do jaleco branco. O grupo com menor excreção de sal relatou evitar o consumo de sal mais vezes (p < 0,001) e também teve maior adesão ao medicamento (p < 0,001) do que o grupo com maior de excreção de sal. CONCLUSÃO: Os testes avaliados não apresentaram boa concordância com o teste de Morisky-Green. A adesão ao tratamento da hipertensão foi baixa; no entanto, houve uma elevada taxa de controle da pressão arterial, quando os sujeitos com o efeito do jaleco branco foram incluídos na análise.

A interação entre pessoas com esquizofrenia e familiares interfere na adesão medicamentosa?

OBJETIVO: Identificar, na perspectiva da pessoa com esquizofrenia e de seu familiar, como ocorre a interação paciente-familiar relacionada à adesão ao tratamento medicamentoso. MÉTODOS: Estudo de abordagem qualitativa, com referencial metodológico da Teoria Fundamentada nos Dados e pressupostos do Interacionismo Simbólico. Participaram do estudo 36 pessoas com esquizofrenia em tratamento ambulatorial e 36 familiares. Para obtenção dos dados, usadas a entrevista gravada e a observação. RESULTADOS: Os depoimentos obtidos revelaram que familiares podem fornecer apoio e motivação, propiciando a adesão do paciente ao tratamento, podendo também incentivá-lo a não aderir à farmacoterapia. Destacaram-se ainda a influência da sobrecarga e o despreparo do familiar cuidador sobre a qualidade dos cuidados prestados. CONCLUSÃO: Profissionais da saúde podem intervir junto aos familiares, encorajando as interações que colaboram com o sucesso do tratamento e incentivando-os a modificar as interações que o comprometem.

The impact of cardiac rehabilitation on lifestyles, psychological correlates and the clinical course of cardiac disease

Objectives: The aim of this research was to evaluate the impact of Cardiac Rehabilitation (CR) on risky lifestyles, quality of life, psychopathology, psychological distress and well-being, considering the potential moderating role of depression, anxiety and psychosomatic syndromes on lifestyles modification. The influence of CR on cardiac morbidity and mortality was also evaluated. Methods: The experimental group (N=108), undergoing CR, was compared to a control group (N=85) of patients affected by cardiovascular diseases, not undergoing CR, at baseline and at 1-month, 6- and 12-months follow-ups. The assessment included: the Structured Clinical Interview for DSM-IV, the structured interview based on Diagnostic Criteria for Psychosomatic Research (DCPR), GOSPEL questionnaire on lifestyles, Pittsburgh Sleep Quality Index, Morisky Medication Adherence Scale, MOS 36-Item Short Form Health Survey, Symptom Questionnaire, Psychological Well-Being Scale and 14-items Type D Scale. Results: Compared to the control group, CR was associated to: maintenance of the level of physical activity, improvement of correct dietary behaviors and stress management, enhancement of quality of life and sleep; reduction of the most frequently observed psychiatric diagnoses and psychosomatic syndromes at baseline. On the contrary, CR was not found to be associated with: healthy dietary habits, weight loss and improvement on medications adherence. In addition, there were no relevant effects on sub-clinical psychological distress and well-being, except for personal growth and purpose in life (PWB). Also, CR did not seem to play a protective role against cardiac recurrences. The presence of psychosomatic syndromes and depressive disorders was a mediating factor on the modification of specific lifestyles. Conclusions: The findings highlight the need of a psychosomatic assessment and an evaluation of psychological sub-clinical symptomatology in cardiac rehabilitation, in order to identify and address specific factors potentially associated with the clinical course of the heart disease.

Evidence-based polytherapies and long-term mortality after acute myocardial infarction in very old subjects compared with elderly and adults: a nested case-control study

Background: Clinical trials have demonstrated that selected secondary prevention medications for patients after acute myocardial infarction (AMI) reduce mortality. Yet, these medications are generally underprescribed in daily practice, and older people are often absent from drug trials. Objectives: To examine the relationship between adherence to evidence-based (EB) drugs and post-AMI mortality, focusing on the effects of single therapy and polytherapy in very old patients (≥80 years) compared with elderly and adults (<80 years). Methods: Patients hospitalised for AMI between 01/01/2008 and 30/06/2011 and resident in the Local Health Authority of Bologna were followed up until 31/12/2011. Medication adherence was calculated as the proportion of days covered for filled prescriptions of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), β-blockers, antiplatelet drugs, and statins. We adopted a risk set sampling method, and the adjusted relationship between medication adherence (PDC≥75%) and mortality was investigated using conditional multiple logistic regression. Results: The study population comprised 4861 patients. During a median follow-up of 2.8 years, 1116 deaths (23.0%) were observed. Adherence to the 4 EB drugs was 7.1%, while nonadherence to any of the drugs was 19.7%. For both patients aged ≥80 years and those aged <80 years, rate ratios of death linearly decreased as the number of EB drugs taken increased. There was a significant inverse relationship between adherence to each of 4 medications and mortality, although its magnitude was higher for ACEIs/ARBs (adj. rate ratio=0.60, 95%CI=0.52–0.69) and statins (0.60, 0.50–0.72), and lower for β-blockers (0.75, 0.61–0.92) and antiplatelet drugs (0.73, 0.63–0.84). Conclusions: The beneficial effect of EB polytherapy on long-term mortality following AMI is evident also in nontrial older populations. Given that adherence to combination therapies is largely suboptimal, the implementation of strategies and initiatives to increase the use of post-AMI secondary preventive medications in old patients is crucial.

Compliance- und Lebensqualitätsmessung bei Patienten vor einer Nieren- oder Lebertransplantation

Die Arzneimittelcompliance hat eine hohe Vorhersagekraft für den Ausgang einer Organtransplantation. Allerdings wurden soweit keine Studien zur Arzneimittelcompliance mittels eletronischen Compliancemessung bei Dialyse- und Leberzirrhosepatienten durchgeführt. Das primäre Ziel dieser Studie war die Arzneimittelcompliance dieser beiden Patientenkollektive zu evaluieren und als sekundäres Ziel wurden die Einflussfaktoren von Non-Compliance untersucht. rnLeberzirrhosepatinten, die Propranolol und Dialysepatienten, die Phosphatbinder, jeweils 3 x tgl. einnahmen, konnten in der Studie teilnehmen. Die Arzneimittelcompliance wurde mittels MEMSTM über einen Zeitraum von jeweils 6 Monaten bestimmt. Des Weiteren wurde nach Einflussfaktoren wie die demopraphischen Daten, Depression, Lebensqualität und der Gesundheitszustand, bei den Dialysepatienten zusätzlich die Formulierung der Phosphatbinder und die Anzahl evaluiert. Zwischen den organinsuffizienten Patientenkollektiven war ein signifikanter Unterschied in der Dosing Compliancerate auszumachen (p<0,023). Die mittlere DC Rate war bei 61%±6% für Leberzirrhosepatienten im Vergleich zu 43%±5% in Dialysepatienten. Nur 10 Leberzirrhosepatienten (30%) and 6 Dialysepatienten (17%) konnten als compliant eingestuft werden. Je höher die Phosphatbinderdosen waren, umso niedrigere Dosing Complianceraten wurden erzielt. Bei 1,5-3 Tabletten pro Tag betrug die Compliancerate 55%±8% (n=16), bei 4-6 Tabletten pro Tag nur noch 37%±7% (n=15) und bei mehr als 7 Tabletten lediglich 21%±10% (n=5) (p<0,036). Bei den Dialysepatienten war jedoch auffällig, dass die Dosing Compliancerate in Abhängigkeit von der Anzahl der dokumentierten Erkrankungen inkl. Grunderkrankung stieg (Dosing Compliancerate 34%±9% für ≤1 Grunderkrankung, 42%±6% für 1-4 Komorbiditäten, 83%±3% für ≥5 Komorbiditäten; p<0,036).Das geringe Patientenwissen über die Arzneimittel und die Erkrankung und die niedrige Compliancerate bedürfen weitere Untersuchungen um die Aspekte zu verbessern. Diese Studie zeigte das eine pharmazeutische Betreuung schon vor einer Transplantation benötigt wird. Aber eine pharmazeutische Betreuung ist sehr kosten- und zeitintensiv. Vielleicht müssen neue Modelle der pharmazeutische Betreuung untersucht werden oder non-compliante Patienten müssen noch besser identifiziert werden für eine selektive pharmazeutische Betreuung.

Prevalence, predictors, and consequences of long-term refusal of antipsychotic treatment in first-episode psychosis

Studies investigating medication adherence in psychosis are limited by the need of a certain degree of medication adherence and the inclusion of mostly multiple-episode patients. By contrast, noninformed consent, epidemiological studies in first-episode psychosis (FEP) allow the assessment of an important subgroup of patients who persistently refuse antipsychotic medication and thereby never receive an adequate antipsychotic trial. The present study aims to assess the prevalence and predictors of such a "medication refusal" subgroup and its association with illness outcome.

Anticoagulation in primary care - a cross sectional study in 14 heterogeneous countries

Background: New oral anticoagulants (NOACs) are predicted to become the new standard treatment for stroke prevention in patients with atrial fibrillation, and may replace vitamin K antagonists (VKAs). NOACs are prescribed less than expected, even though they do not require international normalised ratio (INR) monitoring. In this study we assessed methods for INR monitoring after the introduction of NOACs a in heterogeneous sample of countries. Methods: We asked representatives of the Vasco da Gama Movement, a network of junior and future gen- eral practitioners (GPs) in Europe, and WONCA, the World Organization of Family Doctors, to describe the way INR is monitored in their respective countries. Results: Representatives of 14 countries responded. In most countries, the INR is monitored by GPs; in some countries, these patients are treated by other specialists or in specialised anticoagulation centres. In only a few countries, anticoagulated patients monitor the INR themselves. Conclusion: Our study showed several strategies for managing anticoagulation in different countries. In most countries, the INR is monitored by GPs. These consultations offer opportunities to address other is- sues, such as blood pressure control or medication adherence. These factors may be considered when de- ciding to switch patients from VKAs to NOACs.

A randomized, double-blind, placebo-controlled pilot study of naltrexone in outpatients with bipolar disorder and alcohol dependence.

BACKGROUND: Alcohol dependence is extremely common in patients with bipolar disorder and is associated with unfavorable outcomes including treatment nonadherence, violence, increased hospitalization, and decreased quality of life. While naltrexone is a standard treatment for alcohol dependence, no controlled trials have examined its use in patients with co-morbid bipolar disorder and alcohol dependence. In this pilot study, the efficacy of naltrexone in reducing alcohol use and on mood symptoms was assessed in bipolar disorder and alcohol dependence. METHODS: Fifty adult outpatients with bipolar I or II disorders and current alcohol dependence with active alcohol use were randomized to 12 weeks of naltrexone (50 mg/d) add-on therapy or placebo. Both groups received manual-driven cognitive behavioral therapy designed for patients with bipolar disorder and substance-use disorders. Drinking days and heavy drinking days, alcohol craving, liver enzymes, and manic and depressed mood symptoms were assessed. RESULTS: The 2 groups were similar in baseline and demographic characteristics. Naltrexone showed trends (p < 0.10) toward a greater decrease in drinking days (binary outcome), alcohol craving, and some liver enzyme levels than placebo. Side effects were similar in the 2 groups. Response to naltrexone was significantly related to medication adherence. CONCLUSIONS: Results suggest the potential value and acceptable tolerability of naltrexone for alcohol dependence in bipolar disorder patients. A larger trial is needed to establish efficacy.

The Hamburg-Model of Integrated Care for Patients with Psychosis: Part 2

Objective: Since the beginning of the integrated care model for severely ill patients with psychotic disorders ("Hamburg model") in 2007 different clinical parameters have been consecutively assessed within a naturalistic, observational, prospective study.Methods: Clinical outcome of the 2-year and 4-year follow-ups of n = 158 patients.Results: A significant and ongoing improvement of psychopathology, severity of illness, functional outcome, quality of life and satisfaction with care in this sample of severely ill and merely chronic patients with psychosis was shown. Moreover, medication adherence improved and quality and quantity of outpatient treatment increased.Conclusion: The ongoing psychosocial stabilisation of the patients most likely result from a combination of various factors: continuity of care, multimodal and individualized care, therapeutic specialisation and the multidisciplinary ACT team. Results provide clinical and scientific evidence for future implementations of the integrated care model "Hamburg Model" for the treatment of psychosis.