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Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.45 no.6 São Paulo Dec. 2011
The supply and use of psychotropic drugs in Psychosocial Care Centers in Southern Brazil*
Descripción de oferta y consumo de psicofármacos en Centros de Atención Psicosocial en la región Sur brasileña
Luciane Prado KantorskiI; Vanda Maria da Rosa JardimII; Adrize Rutz PortoIII; Gabriele SchekIV; Jandro Moraes CortesV; Michele Mandagará de OliveiraVI
Ph.D. in Nursing, University of São Paulo at Ribeirão Preto College
of Nursing. Adjunct Professor and Dean of the College of Nursing, Federal University
of Pelotas. Pelotas, RS, Brazil. email@example.com
IINurse. Ph.D. in Nursing, Federal University of Santa Catarina. Adjunct Professor, College of Nursing, Nursing Graduate Program, Federal University of Pelotas. Pelotas, RS, Brazil. firstname.lastname@example.org
IIINurse. Student of the Nursing Master's Degree Program, Federal University of Pelotas. Pelotas, RS, Brazil. email@example.com
IVNurse. Student of the Nursing Master's Degree Program, Federal University of Pelotas. Pelotas, RS, Brazil. firstname.lastname@example.org
VNurse. Student of the Nursing Master's Degree Program, Federal University of Pelotas. Pelotas, RS, Brazil. email@example.com
VINurse. Ph.D. in Nursing, University of São Paulo at Ribeirão Preto College of Nursing. Adjunct Professor, College of Nursing, Federal University of Pelotas. Pelotas, RS, Brazil. firstname.lastname@example.org
The description of the supply and use of psychotropic drugs at the Centers for Psychosocial Care (CAPS) is relevant for the effectiveness of assistance from mental health services. The objective was to describe the use and supply of these drugs in CAPS types I and II, in Southern Brazil. This is a cross-sectional study, in which surveys were conducted, in May and June 2006, on the structural aspects of the referred service using charts of 1162 users, and self-applied questionnaires answered by 30 engineers working at CAPS where these users were being monitored. Users were identified as mostly female, adult, middle-aged, low economic status, mainly with a diagnosis of major depression and using antidepressants. It was also found that there might be a lack of distribution and supply of psychotropic drugs in the public health system (SUS) network, which affects the drug therapy of this specialized mental health service, given the socioeconomic conditions of the users.
DESCRIPTORS: Mental Health Services; Medication therapy management; Mental Health Assistance; Psychiatric nursing.
La descripción del consumo y de la oferta de psicofármacos en Centros de Atención Psicosocial (CAPS) es relevante para la efectividad asistencial de los servicios de salud mental. Se objetivó describir su consumo y oferta en CAPS de tipos I y II en región Sur de Brasil. Estudio transversal, en el cual fueron investigados en mayo y junio de 2006 aspectos estructurales del servicio, según historias clínicas de 1162 pacientes y cuestionarios autoaplicados a 30 coordinadores de CAPS en los que tales pacientes estaban en seguimiento. Se identificaron pacientes mayoritariamente femeninos, adultos, de mediana edad, de baja condición económica, prevalentemente con diagnóstico de depresión mayor y consumo de antidepresivos. Se constató también que puede existir carencia de distribución y provisión de psicofármacos en la red del SUS, lo que perjudica la terapia medicamentosa de ese servicio especializado en salud mental, tomando en cuenta las condiciones socioeconómicas de los pacientes.
DESCRIPTORES: Servicios de Salud Mental; Administración de terapia de medicación; Atención en Salud Mental; Enfermería psiquiátrica.
The Psychosocial Care Center (CAPS) aims at assisting the population living in the covered area, prioritizing the rehabilitation and psychosocial reintegration of individuals with mental disorders. The CAPS range in types according to the situation and population of the municipality. This study included CAPS of types I and II, which are, respectively, implemented in municipalities of population between 20,000 and 70,000, and with over 70,000 to 200,000(1).
Furthermore, there are three possible treatment modalities: intensive - for users who, due to their current clinical condition, require follow up on a daily basis; semi-intensive - users need frequent follow up, determined in their individual treatment project, but do not need to be at the CAPS every day; not intensive - refers to the care that, due to the clinical condition, can be less frequent(2).
The psychopharmacological treatment is understood as an attempt to change behaviors, mood, and pathological thoughts following the biological therapy(3). It is extremely relevant to consider the structure providing the continuous drug treatment at the CAPS services, because socio-demographic indicators, which have shown a clear tendency towards increasing the individuals' life expectancy, can also affect drug use.
This factor is relevant, as it represents the process of population aging, which, above all, affects the demand for drugs used to treat chronic-degenerative diseases, in addition to new treatment procedures using costly products(4).
A literature review identified the main contents related to the adherence of mental patients to the psychopharmacological treatment, and found that the main factors reported were related to the user, type of drug, and social factors(5).
Understanding the association between those factors, the World Health Organization (WHO) and the Pan American Health Organization (PAHO) reported that 50 to 90% of drugs in the developing countries are still paid by health system users(6).
In this perspective, the purpose of the present study was to evaluate the structure of the CAPS in Southern Brazil in terms of the accessibility policies, describing the consumption and supply of psychotropic drugs to users being followed at the referred service.
This study is part of a larger research referred to as CAPSUL, which was performed with the objectives to evaluate the structure, process and outcome of the delivered health service. In this excerpt, we chose to present the structure of the services and also the cross-sectional outline phase, with the data being collected from May 7th to June 3rd, 2006.
A draft from the 102 CAPS in Southern Brazil was made, comprising a sample of 30 CAPS, taking into consideration the percentage of services per state and the CAPS types I or II: three CAPS in Paraná; nine Santa Catarina, and 18 in Rio Grande do Sul. The sample was calculated using Epi-info 6.04, an alpha of 5% and power of 80%, and considering the percentages of the care modality used at the CAPS.
The samples comprised 1,162 users (61.4%) and 30 service coordinators, and the items referred to questions addressing drug distribution and supply from the questionnaires that were self-administered by the coordinators, and information collected from the users medical file, regarding the variables: gender, age, income, occupation, first diagnosis, most used drug, and expenses with psychotropic drugs. The research instruments used with users were closed questionnaires addressing their socio-economical aspects, and their medical files to know how they used the drugs.
File losses occurred in the following cities: Timbó/SC, Passo Fundo/RS, Porto Alegre/RS, Carazinho/RS, Santa Maria/RS, and Içara/SC. In these cases, 123 had not been filled out, which resulted in 10.25% of the total loss. One of the possible reasons for this loss is the shortage of files at the services in time for their being filled out with the data needed for this study. It should be emphasized that the CAPS in Timbó/RS lists only 13 users, so there were only 13 files. The databank was constructed by double entry using the aforementioned software, and analyzes using the program Stata 7.0.
The CAPSUL study was approved by the Research Ethics Committee at Faculty of Medicine, Federal University of Pelotas, according to Document 074/05, of November 11, 2005.
We identified the socio-economical profile of the users attending the CAPS in Southern Brazil. Regarding their gender, 742 were female, representing 63.9%, against male subject, who represented 36.1% of the total sample.
The users' mean age was 42 years (SD 12.3). The age group between 15 and 18 years had eight people, whereas 207 were older than 18 years, and 46 were older than 60 years. The population is mostly adults (79.3%), with 17.6% seniors, and 3.1% adolescents.
Regarding the socio-economical factors of the participants, their income was from: Retirement 23.6% (274 users), Family income 19.6% (228 users), Sickness allowance 19.0% (221 users), Job 9.9% (115) and Pensions 77% (90 users). The previous income referred to the month of April 2006, and the mean value was R$ 338.02 (SD 369.48), while the family income per capita was 264.16 (SD 333.62). Furthermore, 296 users (26.84%) referred having no source of income.
As to their diagnosis, about 70% of users referred knowing it, as shown in the following table:
In 91.8% (1.067) of the cases, the users reported using some kind of psychotropic drug. Of all users with major depressive disorder, 6% used Haloperidol, 11% Fluoxetine, 11% Imipramine, 13% Lithium, 18% Diazepam, and the others used other drugs.
When providing information about the drugs, 57% of Southern Region CAPS coordinators informed that the CAPS provided drugs at the service and had also had drugs for emergency use; and 100% said the Municipal Health Department provided the drugs prescribed by the CAPS. However, according to the users, the drugs were obtained as follows: 43.7% at the CAPS; 33.1% at the Municipal Health Department/Municipal Pharmacy; 6.1% at Primary Health Care Units; and 9.6% of the users bought their medications. In 53.6% of cases, the drugs had to be bought. In the month preceding the data collection, the mean expense had been R$ 46.07.
Of the users who needed to but the medication, 31% spent up to R$ 40.00 per month, and 24% spent over R$ 40.00. In both cases, the income was less than one minimum salary (R$ 350.00); and the others corresponded to users with income of more than one minimum salary or who did not inform their income.
The drugs available at the CAPS are listed below:
The medical files characterized drug use in 63.2% of cases, as well as the records of the number of drug evaluations over the last three months, which ranged from zero (25.2%) to 13 (0.1%), and a mean 1.6 (SD 1.5) evaluations.
Analyzing the medical files, it is observed that the drugs most used by the users were: Haloperidol 10, 6% (123), followed by Fluoxetine 9.8% (114), Lithium Carbonate 9.1% (106), Diazepam 7.5% (87), and Carbamazepine 5.3% (62). Regarding the second choice on the instrument, the most prescribed drugs were: Diazepam 7.2% (84), followed by Melleril/Biperiden 7.2% (83). In third place on the file, Melleril/Biperiden appears most frequently, with 4.6% (54), followed closely by Diazepam with 3.6% (42).
Most users using antidepressants were women (79%) and of age older than 45 years in 41%, 15 to 25 years in 6%, 25 to 35 years in 24%, and 35 to 45 years in 30%.
The Brazilian Southern CAPS users were most middle-aged women, housewives or housekeepers, as well as some who have never worked or were retired, reflecting the current situation of the country(7). The monthly income was equal or inferior to two minimum salaries. Regarding users who were employed, some had an informal job without a fixed salary, others depended on their retirement pension, social security, or their families (8).
Besides the socio-economic and demographic aspects observed, we also identified that users faced some difficulties related to knowing their diagnosis. Studies have shown that part of them do not know or do not mention their diagnosis because of prejudice and stigmas(9). It is important that users know their diagnosis and treatment, and the present study found that a considerable number of the participants reported not knowing. This occurs specially when there is comorbidity of psychiatric pathologies, which occurs quite often(10). Therefore, as observed in this study, there may be cases of psychosis together with another diagnosis that users already have.
Furthermore, through the referred diagnoses, it was possible to confirm that the Southern Region CAPS, modalities I and II, have generally assisted users in a more severe condition of psychiatric distress, such as major depressive disorder(11). In this aspect, it is central to consider the fact that the CAPS are places that deliver comprehensive health care services to people with severe psychiatric diseases in intermediary structures, which are characterized as innovative in terms of public mental health policies, are part of the psychiatric reform, and aim at having a rupture character(12).
Over the last decades, studies have observed a tendency of antidepressant use, which is related to the increased diagnoses of depressive diseases, new drugs, and the number of new therapeutic indications of those medications(13). Consequently, antipsychotic drugs are among the medications of greatest use following antidepressants(14). Contradicting the highest prevalence found in this study, Haloperidol was the most prescribed psychotropic drug, which is justified by the tendency to associate the diagnosis for schizophrenia(10), which comes close to the second most common diagnosis, psychosis.
In this study, the predominance of this drug group associated to antidepressants was the same, as well as the consumer profile being female patients with more than 40 years of age(15). This fact is justified because of the easy access to medication and the lack of medical guidance about the necessary care during the treatment, besides the fact that there may be cases of inappropriate use involving not only the distribution system, but a series of factors, which include the attitudes of health professionals(16).
Nevertheless, among other factors, there are complicating issues regarding the choice of an appropriate treatment, such as costs, because besides the fact of the CAPS being a service created to improve the accessibility to medications, many users need to buy their prescribed drugs. These factors, associate with the WHO recommendation to adopt national policies regarding medications based on the concept of essential medications, led, in 1998, the Ministry of Health to approve and pass the National Medication Policy (Directive 3.916/1998), after a long debate involving the many social segments and representations. This policy is based on the principles and guidelines of the National Unified Health System (SUS) and its ultimate purpose is to: "guarantee the necessary safety, efficacy and quality of the medications, promoting the rational use and the accessibility of the population to those considered to be essential(17)".
The medications considered essential according to the National List of Essential Medications (Relação Nacional de Medicamentos Essenciais - RENAME): carbamazepine, clonazepam, diazepam, phenytoin, phenobarbital, valproic acid, amitriptyline hydrochloride, clomipramine, fluoxetine, biperiden, chlorpromazine and nortriptyline, lithium carbonate, haloperidol, risperidone; the most commonly used are available at the CAPS and the public network, but users reported they had to buy their medications, despite their low monthly income(18).
Regarding the profile of Brazilian medication users, three groups exits: the first consists of individuals with income above 10 minimum salaries, corresponding to 15% of the population, who consume 48% of the total market and have a mean annual expense of 193.40 dollars per capita; the second group has an income of four to 10 minimum salaries, corresponding to 34% of the population, consumes 36% of the marked and spends a mean 64.15 dollars per capita annually; the third group has an income of zero to four minimum salaries, representing 51% of the population, consumes 16% of the market and has a mean annual expense of 18.95 dollars per capita(4). In the present study, the latter mean corresponds, approximately, to the users' monthly expense with medication.
These are rather high values for people receiving less than one minimum salary, or, in some cases, no income at all. The cost of antipsychotics and antidepressants for users are the following: 5% of the minimum salary for one day of antipsychotics, considering the user will find the lowest price available, and 6% of the minimum salary for one day of antidepressant medication, considering the most inexpensive drug available(7).
The budget for psychotropic drugs increased from 0.1% to 15.5%, while the budget for other types of mental disorders, health facilities and care increased from 3.6% to 20.2%(8). However, the investment in mental health does not correspond to the burden caused by psychiatric diseases, i.e. about 19%(19). Therefore, the WHO recommends a 5% increase in the mental health budget in the SUS, as it is essential for improving mental health services(7).
The SUS guarantees accessibility to psychotropic drugs, and essential medications are available for all mental health conditions; however, although a certain lack exists, as well as problems in the system, the percentage of patients being treated who would truly benefit from this policy remains unknown(7).
Since December 2007 a Directive (3.237, 24/12/2007) has been instituted to unify all resources to purchase medications, and delegated the work of purchase and distribution to the municipalities. To do this, a specific amount of money is provided by the Federal Government, another by the State Government, and a final part is a responsibility of the municipalities.
It was found that the medication supply by the CAPS meets the users' needs, but the distribution is a responsibility of the administration department of each unit, which still does not correspond to a considerable part of the demand for psychotropic drugs, as they need to but their medication from private pharmacies. This reinforces the importance of municipal programs, such as Popular Pharmacy. Some drugs can be purchased at the Popular Pharmacy for one-sixth the regular market price.
The people who are most benefited by the program are those facing financial difficulties to maintain the treatment because of the high market prices of the drug, specially patients with chronic diseases.
The Brazilian Popular Pharmacy Program was regulated in 2004 and its implementation began in June of the same year to increase the actions of pharmaceutical care and provide the population with one additional option to obtain medications. The program has its own budged and is independent of the resources applied in the free distribution of drugs, the program is non-profit because the medications are provided for users at cost price, does not harm the other supply actions guaranteed at the SUS units(20).
Besides the popular pharmacy units, the program also involves private drugstores enrolled in the program, which promote the brand Aqui Tem Farmácia Popular - Popular Pharmacy Here However, in Southern Brazil, only 5.5% of municipalities are supplied by the program, and, in this region, Paraná is the state with the lowest coverage, i.e. 4.1%(20).
The medication need of each CAPS user should be continuously evaluated by the health care professionals at the service. The CAPS can organize the drug distribution and/or assist users and their families in purchasing and administering the medications, considering the differentiated use according to each user's diagnosis and treatment. It is also recommended to improve the coverage of the treatment and evaluate the efficacy of the distribution of psychotropic drugs, so as to reduce the relapse rates and readmission at the services(7).
The psychotropic drug policy established that the CAPS can have a center for the regulation and distribution of mental health medications to cover the prescriptions made by Family Health physicians and teams and the outpatient care network in their area, in addition to very specific cases, such as patients hospitalized in the region who need to maintain an exceptional use of high-cost medications in their treatment(1).
It is also necessary for these services and their management team to make special effort to prepare and supervise Family Health teams so they can follow the patients' medication use and provide appropriate prescriptions aiming at a rational use of medications in the primary health network. The registration of the CAPS in the medication delivery network is not automatic and should be subject to the local norms of health surveillance, mental health and pharmaceutical care, hoping that the principle of making the medications reach those in need prevails over ideal norms dissociated from the concrete reality(21). It is observed that in this regard, the benefit for users is that by receiving the medication they are able to maintain their treatment.
Furthermore, the National Therapy Form is currently underused, and should be broadly disseminated as an important instrument to guide the prescription and distribution of medications by health professionals, and to rationalize the use of those products (4).
Making rational prescriptions and having patients visit their doctors periodically should be encouraged and performed in appropriate conditions, with careful monitoring, always with the objective to establish a strong attachment with the patient. As to the frequency of the appointments, it was noticed that most patients returned to their physicians between every one to three months for a new appointment, which shows that patients had a frequent contact with their doctor(21).
In this study, because the medical files were used as a secondary source of data, the lack of records regarding some information were a limitation to obtaining additional data, which may have influenced the mental patients' drug use behavior, as the document is relevant in the continuous course of treatment and to reevaluate the use of psychotropic drugs. Furthermore, they are also important in order to perform studies and reflect upon the clients' needs and the health care they receive, stressing that health care professionals should be aware about filling out the forms with information about their clients and maintaining these data with the purpose to collaborate for a better understanding about the needs of the users attending that service(10).
Finally, we believe the National System for Pharmaceutical Care Management - Hórus should be considered as a possible resource to improve the management of the distribution, consumption, and supply of psychotropic drugs in the SUS mental health care network. The Hórus was implemented in the late 2009, and permits, among other uses, control the stock, tracking distributed and stored medications, the schedule of the storage, knowing the consumption prolife, following the use of medications, and manage the data to develop pharmaceutical care indicators to help plan, evaluate and monitor the action in this area. In addition, the software is integrated with the National Health Card and the National Registration of Health Facilities, and can thus be used by State Health Departments to follow the distribution of drugs to the municipalities(22).
It was possible to describe the sociodemographic and economical profile of CAPS users and their diagnosis, the consumption and supply of psychotropic drugs in the SUS network, understanding the relationship with the other social conditions and the difficulties that users face to obtain these medications.
In this setting, it should be stressed that it is important to manage financial resources and maintain a focus on mental health investments, as well as on the transparency in regarding the definition of priorities and the use of resources, which were considered to be difficulties related to medication supply.
We also identified the need to prepare and sensitize professionals, focusing on the elaboration and execution of individual treatment plans, according to service modality. There is also a need to be aware about making good quality records on patient files, in order to reevaluate not only the drug treatment but every care that is delivered, and also regarding the use of instruments, such as: the National Therapy Form and the Hórus software, which has recently become available.
Furthermore, we identified there is a need for psychotropic drugs and a minimum package that would specify the distribution of these drugs in the SUS network, as this is extremely relevant in view of services that provide care for chronic patients.
However, it should be said that in the broader CAPSUL study, namely in Joinville/SC, it was possible to organize the medication supply, and this situation can serve as reference for other cities. Therefore, besides organizing the distribution of medications, there is a need to determine the percentage of users that truly benefit from the current policy.
Furthermore, it is emphasized that other psychosocial therapies are important, ones that value self-care, the user's and family's co-responsibility for their participation and for establishing a relationship network in the community.
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This study was funded by the CNPq AND THE Ministério da Saúde/SCTIE-DECIT/CT/Saúde. Edital 07/2005
* Extracted from the Study "Avaliação dos Centros de Atenção Psicossocial da Região Sul do Brasil (CAPSUL)", Federal University of Pelotas, RS, 2005.