Lilian Ratto

Diretrizes da Associação Brasileira de Estudos do Álcool e outras Drogas (ABEAD) para o diagnóstico e tratamento de comorbidades psiquiátricas e dependência de álcool e outras substâncias

Recently, several studies have focused on comorbity psychiatric disorders with alcohol and other substance dependence. The Brazilian Association of Studies on Alcohol and Other Drugs proposed the Brazilian Guidelines project. This study review diagnostic and therapeutic criteria to the most prevalent psychiatric comorbidities. Randomized clinical trials, epidemiological, animal studies and other forms of research are reviewed. The main psychiatric comorbidities are studied based on guidelines adopted by other countries and the literature data resumed. Epidemiological aspects, diagnoses, integrated treatment and service organization, as well as specific psychotherapic and pharmacological treatment are discussed. The Brazilian Association of Studies on Alcohol and Other Drugs Guidelines reassures the importance of adequate diagnoses and treatment regarding alcoholic and drug dependent patients suffering of comorbid psychiatric disorders.

Fatores preditores e conseqüências clínicas do uso de múltiplas medicações entre idosos atendidos em um serviço ambulatorial de saúde mental

This study aimed to investigate the presence of polypharmacy and inappropriate use of medications among subjects aged 60 or over assessed consecutively at an outpatient mental health service in the city of Sao Paulo, Brazil. The names of the medications, dosage, and length of time since their introduction were investigated for all subjects - this information was gathered from an interview with the patient and carer, and by reviewing the medical notes. Psychological and physical symptoms were assessed with a simplified version of the scale Saftee-Up. The inappropriate use of medication was recorded using the modified version of the Stuck criteria. A total of 184 consecutive patients were included in the study. The mean number of medications consumed was 2.46 - 41.3% of the subjects were receiving 3 or more daily drugs, 10.9% were consuming 5 or more different medications. Antidepressants (42.4%), antihypertensives (32.6%) and benzodiazepines (21.2%) were the drugs most frequently used in this sample of patients. Subjects using 3 or more medications had significantly higher Saftee-Up scores than those using 2 or less drugs (p=0.007). Logistic regression indicated that Saftee-Up scores were influenced by the number of clinical diagnoses (OR=1.85, p=0.030), but not by age (OR=0.99, p=0.732), sex (OR=0.67, p=0.317), number of psychiatric diagnoses (OR=0.77, p=0.533) and medications (OR=1.18, p=0.258). Thirty-four subjects (18.5%) were receiving at least one medication considered inappropriate. Psychiatrists should familiarize themselves with the international guidelines for drug use in later life and be actively involved in reducing the risks associated with polypharmacy and inappropriate use of medications in the elderly.

Prevalence of substance misuse among individuals with severe mental illness in São Paulo.

The aims of this study were to estimate the prevalence of substance misuse among people with severe mental illness in a large urban centre of a developing country, and to investigate which are the individual characteristics associated with such comorbidity. A cross-sectional study was carried out in São Paulo, Brazil, with all mental health services that covered a defined geographical area. Eligible individuals had had any contact with such mental health services, had clinical diagnoses of functional psychoses, and were resident in the areas defined for the study. Use of alcohol, illegal and non-prescribed drugs, and criteria for substance misuse were assessed with a standardised clinical interview, the SCAN. Psychopathology and social adjustment were also assessed with standardised instruments. One hundred and ninety-two subjects were included. The prevalence of substance misuse was 10.4 % (95 % CI: 6.5–15.6), with 7.3 % fulfilling criteria for alcohol abuse or dependence, and 4.7 % fulfilling criteria for abuse or dependence of illegal or non-prescribed substances. Subjects with any abuse or dependence had lower scores for negative symptoms. Male subjects and those with a diagnosis of non-affective psychosis other than schizophrenia had higher probability of being cases of misuse of illegal or non-prescribed substances. Prevalence of substance misuse was lower than that found in developed countries. The lack of social policies for those suffering from severe mental illnesses, with consequent dependence on family support must play a major role. Cultural factors also seem to contribute to the prevalence of substance misuse.

Comorbidade: uso de álcool e outros transtornos psiquiátricos

Alcohol related disorders often coexist with other psychiatric disorders and its incidence is increasing in last decades. Studies show that patients with comorbidity, specially those with severe psychiatric disorders, have higher rates of suicide, relapse, money spent in treatment, homeless and they use more medical service. Their evaluation must be meticulous because the differencial diagnosis become complicated without a long period of alcohol withdrawal. These patients have a worse prognostic and their treatment is more difficult. Most of studies in this area have indicated that the integration of psychosocial and pharmacological techniques is more effective. The long term treatment must focus in the reduction of symptoms, improvement of social and familiar funcioning, coping skills and relapse prevention.

The social adjustment of people with severe mental illness in São Paulo, Brazil

OBJECTIVE To investigate the social adjustment of individuals with severe mental illness living in the community in a large urban center of a developing country, and the characteristics associated with poor social functioning. METHOD A cross-sectional study was performed in the city of Sao Paulo. Eligible subjects were residents of a defined geographic area, aged between 18 and 65, with a diagnosis of functional psychosis who had had contact with any public psychiatric service during a defined period. Structured assessments were used to obtain information on social-demographic characteristics, diagnosis (ICD-10), psychiatric symptoms (PANSS), and social adjustment (DAS). RESULTS One hundred and eighty-eight subjects were included, of whom, 120 (63.8%) had some degree of impairment in social functioning. The most frequently affected areas of social functioning were work performance and sexual role. Twenty-four patients (12.8%) showed poor or very poor social adjustment in the month prior to the interview. Negative symptoms, number of previous admissions and general symptoms showed statistically significant associations with global social adjustment scores. CONCLUSIONS The proportion of patients showing any degree of impairment in social adjustment was as high as in more developed societies. In order to successfully implement the new mental health policy in Brazil, better provision of community-based mental health services for those with severe mental illnesses is needed.

Prevalence of tobacco use in individuals with severe mental illnesses, São Paulo, Brazil

OBJECTIVE To analyze the prevalence of cigarette smoking in individuals with severe mental illnesses in a large urban centre of a middle income country. METHODS Cross-sectional study carried out in São Paulo. The sample (N=192) comprised individuals diagnosed with severe mental illnesses who had contact with public psychiatric care services from September to November 1997 and were aged between 18 and 65 years. Prevalence of daily tobacco smoking in the 12 months previous to the interview and characteristics associated were studied. RESULTS Out of 192 subjects with severe mental illnesses interviewed, 115 (59.9%; 95% CI: 52.6%; 66.9%) reported smoking cigarettes on a daily basis. Male gender, marital status separated or widowed, irregular use of neuroleptic drugs and history of ten or more psychiatric admissions were independently associated with cigarette smoking. CONCLUSIONS The prevalence of cigarette smoking in the present sample was higher than that found in the general Brazilian population. Mental care services should implement non-smoking policies and mental health providers need to help patients with severe mental illness who want to quit smoking.

Guidelines of the Brazilian Association of Studies on Alcohol and Other Drugs (ABEAD) for diagnosis and treatment of psychiatric comorbidity with alcohol and other substance and dependence

Abstract In recent years, several studies have been focused on the comorbidity of psychiatric disorders with alcohol and other substance dependence. In this context, the Brazilian Association of Studies on Alcohol and Other Drugs initiated a project to establish Brazilian Guidelines. The aim of this study was to review diagnostic and therapeutic criteria for the most prevalent psychiatric comorbidities. Randomized clinical trials, epidemiological studies, animal testing and other forms of research are reviewed herein. The main psychiatric comorbidities are investigated and data published in the literature are reviewed, based on guidelines adopted by other countries. Epidemiological aspects, diagnostic criteria, integrated treatment and the organization of specialized service, as well as details regarding psychotherapy and pharmacological treatment are discussed. The guidelines of the Brazilian Association of Studies on Alcohol and Other Drugs reinforce the importance of adequate diagnosis and treatment regarding alcoholic and drug dependent patients suffering of comorbid psychiatric disorders.