Paulo Silva Belmonte de Abreu

Prevenção e tratamento de efeitos adversos de antipsicóticos

As drogas antipsicoticas, por ocasionarem prejuizo na sexuali-dade e no controle de peso dos seus usuarios, tem seus efeitosadversos como os principais responsaveis pela descontinuacao,pela baixa adesao, pela reducao da qualidade de vida, da intera-cao e da adaptacao social. Com frequencia, observa-se que atroca por outro antipsicotico provoca uma mudanca do perfil deefeitos indesejados, e nao a supressao dos mesmos. Assim, deve-se escolher o menos desastroso para o sujeito. O clinico deveestar sensivel para as dificuldades particulares de seu paciente, eselecionar o medicamento com maior efeito antipsicotico e menordesconforto e risco. Assim como os antipsicoticos de nova gera-cao (ANG) ou atipicos (como clozapina, risperidona, olanzapinae quetiapina) significaram uma grande contribuicao ao tratamen-to farmacologico das psicoses, ainda nao e tempo de aposentaros de primeira geracao, nao so por seus efeitos clinicos, mastambem por sua eventual vantagem em pacientes nos quais exis-te preocupacao com o ganho de peso e com o controle de glicemia.

Relato do uso de clozapina em 56 pacientes atendidos pelo Programa de Atenção à Esquizofrenia Refratária da Secretaria da Saúde e do Meio Ambiente do Estado do Rio Grande do Sul

ABSTRACT Introduction: Schizophrenia is a chronic severepsychiatric disease causing major psychological, so-cial and working deficiencies. Typical neurolepticsare widely used, but often produce incomplete res-ponses, toxicity and adverse effects on motricity.Clozapine was a significant development. It is effecti-ve in treating 30-61% of the psychotic symptoms withminimal adverse effects. Methods: Clinical experien-ce of 56 patients with refractory schizophrenia undertreatment at the Psychiatry Service of the Hospital deClinicas de Porto Alegre, included in the program tosupply clozapine free of charge, promoted by theDepartment of Health and the Environment of theState of Rio Grande do Sul. Results: The mean scorefor the Brief Psychiatric Rating Scale (BPRS) wasinitially 77.9 (SD=16.1) and, at the end, 41.1(SD=16.2). Two patients left the program and onewas excluded because he developed agranulocyto-sis. There were 4 hospitalizations. Discussion: Despi-te its well-established efficacy and applicability, clo-zapine is not free from adverse effects: posturalhypotension, tachycardia, cloudy vision, dry eyes,hypersalivation, constipation and sedation frequentlyoccur. Hematological alterations occur in 0.05-2.8%.Conclusions: There was a significant and lasting im-provement of the symptoms in the patients enrolled.Diseases with a longer evolution had worse respon-ses, probably related to neurochemical and neuro-physiological damage. The importance of early treat-ment and the need for State intervention, offeringpsychosocial and financial support to optimize thetreatment of this population should be highlighted.

Clozapine use report in 56 patients seen by Clerkship of Health and Environment of the State of Rio Grande do Sul's Program of Attention to the Refractory Schizophrenia

ABSTRACT Introduction: Schizophrenia is a chronic severepsychiatric disease causing major psychological, so-cial and working deficiencies. Typical neurolepticsare widely used, but often produce incomplete res-ponses, toxicity and adverse effects on motricity.Clozapine was a significant development. It is effecti-ve in treating 30-61% of the psychotic symptoms withminimal adverse effects. Methods: Clinical experien-ce of 56 patients with refractory schizophrenia undertreatment at the Psychiatry Service of the Hospital deClinicas de Porto Alegre, included in the program tosupply clozapine free of charge, promoted by theDepartment of Health and the Environment of theState of Rio Grande do Sul. Results: The mean scorefor the Brief Psychiatric Rating Scale (BPRS) wasinitially 77.9 (SD=16.1) and, at the end, 41.1(SD=16.2). Two patients left the program and onewas excluded because he developed agranulocyto-sis. There were 4 hospitalizations. Discussion: Despi-te its well-established efficacy and applicability, clo-zapine is not free from adverse effects: posturalhypotension, tachycardia, cloudy vision, dry eyes,hypersalivation, constipation and sedation frequentlyoccur. Hematological alterations occur in 0.05-2.8%.Conclusions: There was a significant and lasting im-provement of the symptoms in the patients enrolled.Diseases with a longer evolution had worse respon-ses, probably related to neurochemical and neuro-physiological damage. The importance of early treat-ment and the need for State intervention, offeringpsychosocial and financial support to optimize thetreatment of this population should be highlighted.

Unequal Advances in the Coverage of Psychosocial Care Centers in Rio Grande do Sul, Brazil, From 2009 to 2010

The Centers for Psychosocial Care (CAPS) are mental health services and community open the Unified Health System (SUS). With the advancement of public mental health in the reorientation of a care model that for decades was reduced to the supply of beds in psychiatric hospitals, generating segregation and exclusion of patients with mental disorders. Considering Ordinance of the Ministry of Health GM/MS No. 336 of February 19, 2002, laying down the rules and guidelines for the organization of services that provide mental health care. This objective of this study was to determine whether there was an increase in the coverage of CAPS in the state of Rio Grande do Sul, Brazil, from 2009 to 2010.

Humor e psicose em esquizofrenia: explorando fronteiras diagnósticas com o Inventário de Critérios Operacionais para Doenças Psicóticas (OPCRIT) e o caso John Nash

INTRODUCAO: Utilizamos uma simulacao diagnostica no caso John Nash, Premio Nobel de Matematica de 1994 e descrito como portador de esquizofrenia, para apresentar o Inventario de Criterios Operacionais para Doencas Psicoticas (OPCRIT) e discutir as frageis delimitacoes dos diagnosticos categoricos, bem como o uso de diagnosticos dimensionais em psiquiatria. METODO: Baseados na biografia escrita por Sylvia Nasar e no filme Uma mente brilhante, os autores discutiram a sintomatologia e preencheram o OPCRIT. Devido a ausencia inicial de consenso, repetiu-se a simulacao mais duas vezes, modificando-se os itens que avaliam a presenca de pensamentos acelerados (item 31), a ocorrencia de aumento de sociabilidade (item 53) e o balanco entre sintomas psicoticos e de humor (item 52), a fim de verificar as repercussoes dessas mudancas no diagnostico. RESULTADOS: Os diagnosticos obtidos em duas simulacoes foram esquizofrenia (DSM-IV) e esquizofrenia indiferenciada (CID-10), corroborando o diagnostico de John Nash em sua biografia. Outra simulacao apresentou os diagnosticos de transtorno esquizoafetivo tipo bipolar (DSM-IV) e transtorno esquizoafetivo tipo maniaco (CID-10). Apenas a mudanca do criterio de proporcionalidade entre sintomas psicoticos e de humor (item 52) alterou o diagnostico de esquizofrenia para transtorno esquizoafetivo. DISCUSSAO: As fronteiras que separam os diagnosticos de esquizofrenia e transtorno esquizoafetivo sao muito tenues, o que explica a frequente dificuldade diagnostica. CONCLUSOES: Ressaltamos a importância do estudo detalhado do curso da doenca, enfatizando o balanco entre sintomas psicoticos e de humor, para a definicao diagnostica dos transtornos psicoticos conforme as classificacoes atuais. Por fim, destacamos a importância dos diagnosticos dimensionais e a necessidade de mais estudos para a validacao das categorias diagnosticas atuais.BACKGROUNDS: A diagnostic simulation exercise was carried out using John Nashs case (the 1994 Mathematics Nobel Prize winner and described as suffering from schizophrenia) to introduce the Operational Criteria Checklist for Psychotic Illness (OPCRIT) and discuss the uncertain boundaries between some of the diagnostic categories presented by the instrument, as well as the use of dimensional diagnosis in psychiatry. METHODS: Data were obtained from John Nashs biography (written by Sylvia Nasar) and from the movie A Beautiful Mind. The authors discussed the symptoms shown in both the biography and the movie and then entered data into the OPCRIT program. Because consensus was not reached in some items, two additional simulations were carried out. In these, three items were modified, in order to investigate the effects of these changes on diagnosis: thoughts racing (31st item), increased sociability (53rd item), and relationship psychotic/affective symptoms (52nd item). RESULTS: The diagnoses provided by two of the simulations were schizophrenia (DSM-IV) and undifferentiated schizophrenia (ICD-10). Other results included schizoaffective disorder/bipolar type (DSM-IV) and schizoaffective disorder/manic type (ICD-10). It is important to emphasize that the 52nd item (relationship psychotic/affective symptoms) was the only one with an effect on diagnosis when altered (schizophrenia vs. schizoaffective disorder). DISCUSSION: The boundaries between schizophrenia and schizoaffective disorder are not clear and explain the frequent difficulty faced by psychiatrists in establishing diagnosis. CONCLUSIONS: This exercise revealed the importance of a detailed assessment of the course of illness for a correct diagnosis, emphasizing the relationship between psychotic and affective symptoms. We emphasize the importance of dimensional diagnosis and the need for further studies in order to validate the diagnostic categories currently used.

Ánimo y psicosis en esquizofrenia: explorando fronteras diagnósticas con el Inventario de Criterios Operacionales para Enfermedades Psicóticas (OPCRIT) y el caso John Nash

INTRODUCAO: Utilizamos uma simulacao diagnostica no caso John Nash, Premio Nobel de Matematica de 1994 e descrito como portador de esquizofrenia, para apresentar o Inventario de Criterios Operacionais para Doencas Psicoticas (OPCRIT) e discutir as frageis delimitacoes dos diagnosticos categoricos, bem como o uso de diagnosticos dimensionais em psiquiatria. METODO: Baseados na biografia escrita por Sylvia Nasar e no filme Uma mente brilhante, os autores discutiram a sintomatologia e preencheram o OPCRIT. Devido a ausencia inicial de consenso, repetiu-se a simulacao mais duas vezes, modificando-se os itens que avaliam a presenca de pensamentos acelerados (item 31), a ocorrencia de aumento de sociabilidade (item 53) e o balanco entre sintomas psicoticos e de humor (item 52), a fim de verificar as repercussoes dessas mudancas no diagnostico. RESULTADOS: Os diagnosticos obtidos em duas simulacoes foram esquizofrenia (DSM-IV) e esquizofrenia indiferenciada (CID-10), corroborando o diagnostico de John Nash em sua biografia. Outra simulacao apresentou os diagnosticos de transtorno esquizoafetivo tipo bipolar (DSM-IV) e transtorno esquizoafetivo tipo maniaco (CID-10). Apenas a mudanca do criterio de proporcionalidade entre sintomas psicoticos e de humor (item 52) alterou o diagnostico de esquizofrenia para transtorno esquizoafetivo. DISCUSSAO: As fronteiras que separam os diagnosticos de esquizofrenia e transtorno esquizoafetivo sao muito tenues, o que explica a frequente dificuldade diagnostica. CONCLUSOES: Ressaltamos a importância do estudo detalhado do curso da doenca, enfatizando o balanco entre sintomas psicoticos e de humor, para a definicao diagnostica dos transtornos psicoticos conforme as classificacoes atuais. Por fim, destacamos a importância dos diagnosticos dimensionais e a necessidade de mais estudos para a validacao das categorias diagnosticas atuais.BACKGROUNDS: A diagnostic simulation exercise was carried out using John Nashs case (the 1994 Mathematics Nobel Prize winner and described as suffering from schizophrenia) to introduce the Operational Criteria Checklist for Psychotic Illness (OPCRIT) and discuss the uncertain boundaries between some of the diagnostic categories presented by the instrument, as well as the use of dimensional diagnosis in psychiatry. METHODS: Data were obtained from John Nashs biography (written by Sylvia Nasar) and from the movie A Beautiful Mind. The authors discussed the symptoms shown in both the biography and the movie and then entered data into the OPCRIT program. Because consensus was not reached in some items, two additional simulations were carried out. In these, three items were modified, in order to investigate the effects of these changes on diagnosis: thoughts racing (31st item), increased sociability (53rd item), and relationship psychotic/affective symptoms (52nd item). RESULTS: The diagnoses provided by two of the simulations were schizophrenia (DSM-IV) and undifferentiated schizophrenia (ICD-10). Other results included schizoaffective disorder/bipolar type (DSM-IV) and schizoaffective disorder/manic type (ICD-10). It is important to emphasize that the 52nd item (relationship psychotic/affective symptoms) was the only one with an effect on diagnosis when altered (schizophrenia vs. schizoaffective disorder). DISCUSSION: The boundaries between schizophrenia and schizoaffective disorder are not clear and explain the frequent difficulty faced by psychiatrists in establishing diagnosis. CONCLUSIONS: This exercise revealed the importance of a detailed assessment of the course of illness for a correct diagnosis, emphasizing the relationship between psychotic and affective symptoms. We emphasize the importance of dimensional diagnosis and the need for further studies in order to validate the diagnostic categories currently used.

Mood and psychosis in schizophrenia: exploring diagnostic frontiers with the Operational Criteria Checklist for Psychotic Illness (OPCRIT) and John Nash case

INTRODUCAO: Utilizamos uma simulacao diagnostica no caso John Nash, Premio Nobel de Matematica de 1994 e descrito como portador de esquizofrenia, para apresentar o Inventario de Criterios Operacionais para Doencas Psicoticas (OPCRIT) e discutir as frageis delimitacoes dos diagnosticos categoricos, bem como o uso de diagnosticos dimensionais em psiquiatria. METODO: Baseados na biografia escrita por Sylvia Nasar e no filme Uma mente brilhante, os autores discutiram a sintomatologia e preencheram o OPCRIT. Devido a ausencia inicial de consenso, repetiu-se a simulacao mais duas vezes, modificando-se os itens que avaliam a presenca de pensamentos acelerados (item 31), a ocorrencia de aumento de sociabilidade (item 53) e o balanco entre sintomas psicoticos e de humor (item 52), a fim de verificar as repercussoes dessas mudancas no diagnostico. RESULTADOS: Os diagnosticos obtidos em duas simulacoes foram esquizofrenia (DSM-IV) e esquizofrenia indiferenciada (CID-10), corroborando o diagnostico de John Nash em sua biografia. Outra simulacao apresentou os diagnosticos de transtorno esquizoafetivo tipo bipolar (DSM-IV) e transtorno esquizoafetivo tipo maniaco (CID-10). Apenas a mudanca do criterio de proporcionalidade entre sintomas psicoticos e de humor (item 52) alterou o diagnostico de esquizofrenia para transtorno esquizoafetivo. DISCUSSAO: As fronteiras que separam os diagnosticos de esquizofrenia e transtorno esquizoafetivo sao muito tenues, o que explica a frequente dificuldade diagnostica. CONCLUSOES: Ressaltamos a importância do estudo detalhado do curso da doenca, enfatizando o balanco entre sintomas psicoticos e de humor, para a definicao diagnostica dos transtornos psicoticos conforme as classificacoes atuais. Por fim, destacamos a importância dos diagnosticos dimensionais e a necessidade de mais estudos para a validacao das categorias diagnosticas atuais.BACKGROUNDS: A diagnostic simulation exercise was carried out using John Nashs case (the 1994 Mathematics Nobel Prize winner and described as suffering from schizophrenia) to introduce the Operational Criteria Checklist for Psychotic Illness (OPCRIT) and discuss the uncertain boundaries between some of the diagnostic categories presented by the instrument, as well as the use of dimensional diagnosis in psychiatry. METHODS: Data were obtained from John Nashs biography (written by Sylvia Nasar) and from the movie A Beautiful Mind. The authors discussed the symptoms shown in both the biography and the movie and then entered data into the OPCRIT program. Because consensus was not reached in some items, two additional simulations were carried out. In these, three items were modified, in order to investigate the effects of these changes on diagnosis: thoughts racing (31st item), increased sociability (53rd item), and relationship psychotic/affective symptoms (52nd item). RESULTS: The diagnoses provided by two of the simulations were schizophrenia (DSM-IV) and undifferentiated schizophrenia (ICD-10). Other results included schizoaffective disorder/bipolar type (DSM-IV) and schizoaffective disorder/manic type (ICD-10). It is important to emphasize that the 52nd item (relationship psychotic/affective symptoms) was the only one with an effect on diagnosis when altered (schizophrenia vs. schizoaffective disorder). DISCUSSION: The boundaries between schizophrenia and schizoaffective disorder are not clear and explain the frequent difficulty faced by psychiatrists in establishing diagnosis. CONCLUSIONS: This exercise revealed the importance of a detailed assessment of the course of illness for a correct diagnosis, emphasizing the relationship between psychotic and affective symptoms. We emphasize the importance of dimensional diagnosis and the need for further studies in order to validate the diagnostic categories currently used.

El relato del uso de clozapina en 56 pacientes atendidos por el Programa de Atención a la Esquizofrenia Refractaria de la Secretaria de Salud y Medio Ambiente del Estado de Rio Grande do Sul

ABSTRACT Introduction: Schizophrenia is a chronic severepsychiatric disease causing major psychological, so-cial and working deficiencies. Typical neurolepticsare widely used, but often produce incomplete res-ponses, toxicity and adverse effects on motricity.Clozapine was a significant development. It is effecti-ve in treating 30-61% of the psychotic symptoms withminimal adverse effects. Methods: Clinical experien-ce of 56 patients with refractory schizophrenia undertreatment at the Psychiatry Service of the Hospital deClinicas de Porto Alegre, included in the program tosupply clozapine free of charge, promoted by theDepartment of Health and the Environment of theState of Rio Grande do Sul. Results: The mean scorefor the Brief Psychiatric Rating Scale (BPRS) wasinitially 77.9 (SD=16.1) and, at the end, 41.1(SD=16.2). Two patients left the program and onewas excluded because he developed agranulocyto-sis. There were 4 hospitalizations. Discussion: Despi-te its well-established efficacy and applicability, clo-zapine is not free from adverse effects: posturalhypotension, tachycardia, cloudy vision, dry eyes,hypersalivation, constipation and sedation frequentlyoccur. Hematological alterations occur in 0.05-2.8%.Conclusions: There was a significant and lasting im-provement of the symptoms in the patients enrolled.Diseases with a longer evolution had worse respon-ses, probably related to neurochemical and neuro-physiological damage. The importance of early treat-ment and the need for State intervention, offeringpsychosocial and financial support to optimize thetreatment of this population should be highlighted.