SciELO - Scientific Electronic Library Online

 
vol.45 número1Qualidade do Sistema de Informações de Nascidos Vivos no estado do Paraná, 2000 a 2005Visão como instrumento da percepção na assistência em enfermagem traumato-ortopédica índice de autoresíndice de assuntospesquisa de artigos
Home Pagelista alfabética de periódicos  

Serviços Personalizados

Artigo

Indicadores

Links relacionados

  • Não possue artigos similaresSimilares em SciELO

Compartilhar


Revista da Escola de Enfermagem da USP

versão impressa ISSN 0080-6234

Rev. esc. enferm. USP vol.45 no.1 São Paulo mar. 2011

http://dx.doi.org/10.1590/S0080-62342011000100012 

ORIGINAL ARTICLE

 

Psychiatric hospitalization and maintaining the treatment outside the hospital

 

Internación psiquiátrica y continuidad del tratamiento extrahospitalario

 

 

Lucilene CardosoI; Sueli Aparecida Frari GaleraII

IPh.D. in Psychiatric Nursing, University of São Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, SP, Brazil. lucilenecardoso@usp.br
IIPh.D., Professor, Psychiatric Nursing and Human Sciences Department, University of São Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, SP, Brazil. sugalera@eerp.usp.br

Correspondence addressed to

 

 


ABSTRACT

The objective of this study was to identify common features between people that have been recently discharged from psychiatric hospitalization. A quantitative exploratory study was performed at an outpatient mental health service center. The sample was comprised by patients who had recently been discharged. A questionnaire was used and the study was approved by the Review Board. Interviews were performed with 48 patients who were in average 39 years old. Diagnosis for Schizophrenia and Schyzotypal Disorders were prevalent for 33.3% of the sample. An average 13 patients were discharged from psychiatric hospitalization every month, 62.5% of which had been previously hospitalized. In the studied period, 12.5% of the sample required rehospitalization. Psychiatric hospitalization proved to be a necessary resource in crisis episodes and as part of the psychiatric treatment, especially of severe mental disorders. It is evinced that there is a need for adequate treatment maintenance in community health care services to avoid the need of rehospitalizations.

Key words: Psychiatric nursing. Rehabilitation nursing.  Mental Health Services. Patient discharge.


RESUMEN

El objetivo de este trabajo fue identificar características comunes entre personas que tuviesen alta hospitalaria de internación psiquiátrica reciente. Se realizó un estudio cuantitativo exploratorio en un servicio ambulatorio de salud mental. La muestra se compuso de pacientes egresados de internación. Se utilizó un cuestionario, y la investigación fue aprobada por el CEP. Fueron entrevistados 48 pacientes con edad media de 39 años. Los diagnósticos de esquizofrenia y transtornos esquizotípicos prevalecieron en el 33% de la muestra. En promedio, trece pacientes reciben alta de internación psiquiátrica hospitalaria al mes y 62,5% de ellos tenían internaciones anteriores. Durante el período, 12,5% de la muestra necesitó de reinternación. La internación psiquiátrica demostró ser un recurso necesario en los momentos de crisis, y parte de la continuidad del tratamiento psiquiátrico, principalmente de los transtornos mentales graves, lo que pone en evidencia la necesidad de una adecuada continuidad del tratamiento en los servicios de atención comunitaria para que las reinternaciones sean evitadas.

Descriptores: Enfermería psiquiátrica. Enfermería en rehabilitación. Servicios de Salud Mental. Alta del paciente.


 

 

INTRODUCTION

Since early times, humanity faces difficulties to deal with differences and disagreements from common sense and life(1). In psychiatry, the treatment of madness has sometimes been based on intolerance towards mental patients' behaviors, with their reclusion as an option to chase away what is different and protect society.

Despite the evolution in psychiatric treatment and the understanding of madness as the representations of certain mental illness symptoms, the cause(s) of these illnesses and their cure remain a challenge. Hence, for many mental illnesses, psychiatric treatment becomes extensive and marked by repeated hospitalization, mainly when treating severe mental disorders(2-3).

Psychiatric hospitalizations involve different inquiries, based on the biased goal of their application. On the one hand, the goal is to treat, deliver care and protect mental patients from behaviors that are dangerous for themselves and/or other people; on the other, their autonomy is also limited and can even reach the point of limiting their civil rights. This is not a simple and practical option.

Professional mental health care today reflects countless discussions and changes that culminated in the deinstitutionalization process of patient care. In Brazil, psychiatric hospitals, the main sites for these treatments, are no longer the base of the care system, making room for an increasingly complex extra-hospital service network(4-5).

As psychiatric hospitalization is an extremely important procedure in the configuration of care and the evolution of the main psychiatric diseases, however, it is still very much used. In many clinical situations, hospitalization is prudent and can even be imperative, mainly for the most severe cases(3).

Today, psychiatric hospitalization is indicated for severe cases, when extra-hospital resources for treating or managing the problem have been exhausted, while hospitalizing people in asylum institutions is prohibited. Situations of mental disorders with at least one of the following conditions are considered severe cases: risk of self-harm, risk of harming others, risk of harm to public order, risk of social exposure, severe disability for self-care(3). Its goal focuses on stabilizing the patient: minimizing risks, surveying psychosocial needs, adjusting psychopharmacological treatment and reinserting patients in their social context. Medical professionals are responsible for carefully and ethically analyzing each case in order to verify when psychiatric hospitalization is necessary.

Law 10.216, issued in 2001, is essentially a letter of principles(6). Bill 3.657/89, which preceded the law, represented the just perception of the urgent need to reform psychiatric care and fight for the guarantee of mental patients' civil rights. It triggered debates and collisions between representatives from corporate entities of health professionals, civil associations, users and relatives and political groups, resulting in Law 10.216.

In summary, the current law addressed the guarantee of mental patients' basic rights, including the right to have access to the best diagnostic and therapeutic resources available, in a diversified service network; it highlights the need for specific deinstitutionalization policies and acknowledges psychiatric hospitalization as another valid therapeutic resource, provided that it is high-quality.

This paper intends neither to simplify nor polemize the applicability of hospitalization in mental illness treatment. The researchers consider that the discussion on its applicability is complex and also comes up against its social, cultural and economic representation. Nevertheless, when based on judicious medical assessments supported by qualified services, with specialized and committed professionals, hospitalizations can be an important therapeutic measure in the treatment of mental illnesses.

 

OBJECTIVE

This research aimed to get to know who mental disorder patients recently discharged from psychiatric hospitalization are and their common characteristics.

 

METHOD

Approval for this research was obtained from the Research Ethics Committee of the Teaching Health Center Joel Domingos Machado at the University of São Paulo at Ribeirão Preto Medical School (protocol 254/CEP-CSE-FMRP-USP). An exploratory, descriptive and prospective research was carried out between December 17th 2007 and April 17th 2008.

The Place of study was the Mental Health Center (NSM), an outpatient care unit linked with the Teaching Health Center Joel Domingos Machado at the University of São Paulo at Ribeirão Preto Medical School - USP - Brazil (CSE-FMRP-USP).

The study population comprises the universe of all patients living in the West of Ribeirão Preto and enrolled at the abovementioned outpatient service. The sample included all service clients discharged from psychiatric hospitalization during the study period. For data collection, a questionnaire was used with the following variables: Gender; Age (date of birth); Patient's education level; Patient's marital status; Number of children; Patient's occupational situation; Patient's personal income; Whom the patient lives with, Housing conditions; Number of people living in the same house; Family income; Psychiatric diagnosi(e)s; Patient's knowledge on his/her disease; Manifestation time of psychiatric disorder; Belief in psychopharmacological treatment; Knowledge of name of prescribed drugs; Prescription: Previous hospitalizations (number); Date of last psychiatric hospitalization; Place of last hospitalization; motive for hospitalization, Duration of last psychiatric hospitalization. Data analysis involved central trend measures in SPSS software, version 10.0.

 

RESULTS

Patients discharged from hospital

During four months, 54 patients were discharged from a psychiatric hospital and received care at the service. This represented an average 13 hospitalization per month, without cases in which the same patient needed rehospitalization. The sample included 48 patients who agreed to participate in the research.

Six patients were excluded from the study: two refused to participate; one was transferred to another service; one patient's discharge from hospital was suspended and his appointment postponed; two did not attend the consultation and the outdated enrollment in the information system of the public service system made any active search impossible. The sample patients' demographic, social and economic characteristics are presented in Table 1.

Thirty patients were women and 18 men, with a mean age of 39 years, ranging from 18 to 75 years. Among the sample patients, 39.6% were single and 37.5% married. Patients who had already been married or had lived with a fixed partner and were separated or divorced represented 16.7% of the sample, while 6.3% were widowed.

As for the number of children, 41.7% did not have any child and 27.0% three or more children. Patients with one or two children corresponded to 31.3% of the sample, divided as follows: subjects with only one child 16.7% and with two children 14.6%.

It was verified that 31.2% of the patients denied gaining any income, 37.5% reported one minimum wage (R$ 380 at the time of research) and 18.8% two minimum wages. Among the patients discharged after recent psychiatric hospitalization, 87.5% gained two or less minimum wages as a personal income. Only one patient declared revenues of three minimum wages and five declared four minimum wages or more as a personal income.

The large majority of patients (93.8%) lived with their relatives. Two patients reported that they lived alone and one lived with friends. In 78.8% of cases, patients discharged after hospitalization lived in their own home, while 27.1% paid rent and one patient mentioned living in his car, who was classified as a street dweller.

 

 

Mood (affective) Disorders grouped diagnoses for 29.2% of sample patients. Of all patients in this sample, 29.2% presented a psychiatric comorbidity. Twelve had received two diagnoses (25.0%) and two had three diagnoses (4.2%). None of the patients had received more than three psychiatric diagnoses. Among patients with two diagnoses, three cases were observed in which one mental illness diagnosis was associated with drugs use (psychoactive substances, alcohol and multiple drugs). In five other cases, the diagnosis of personality disorder was associated with other disorders. One diagnosis of emotionally unstable personality disorder was associated with dementia in human immunodeficiency virus disease.

Diagnosis time was verified in full years, and ranged from less than one year to 20 full years. On the average, the discharged patients' disease time was 4.4 years, and 50% had been diagnosed with a psychiatric illness about 3.5 years earlier. Diagnosis time was less than one year for 41.6% of patients, 20.8% between one and five years, 29.2% between six and ten years and 8.4% between eleven and twenty years.

Fifty-six percent of patients did not know the name of the mental illness they were victims of and why they were being monitored at the mental health service. Hence, only 21 patients could name the mental illness they had been diagnosed with.

Family income exceeded three minimum wages for 72.9% of patients. The patient who affirmed living on the street denied gaining a family income and twelve patients reported a monthly family income of two minimum wages.

Among subjects for whom only one diagnosis was registered, diagnoses classified in the group of Schizophrenia and Schizotypal Disorders prevailed in 33.3% of the sample. In this group, the Schizophrenia diagnosis stood out in ten subjects, corresponding to 20.8 % of the sample, as described in Table 2.

 

 

Mood (affective) Disorders grouped diagnoses for 29.2% of sample patients. Of all patients in this sample, 29.2% presented a psychiatric comorbidity. Twelve had received two diagnoses (25.0%) and two had three diagnoses (4.2%). None of the patients had received more than three psychiatric diagnoses. Among patients with two diagnoses, three cases were observed in which one mental illness diagnosis was associated with drugs use (psychoactive substances, alcohol and multiple drugs). In five other cases, the diagnosis of personality disorder was associated with other disorders. One diagnosis of emotionally unstable personality disorder was associated with dementia in human immunodeficiency virus disease.

Diagnosis time was verified in full years, and ranged from less than one year to 20 full years. On the average, the discharged patients' disease time was 4.4 years, and 50% had been diagnosed with a psychiatric illness about 3.5 years earlier. Diagnosis time was less than one year for 41.6% of patients, 20.8% between one and five years, 29.2% between six and ten years and 8.4% between eleven and twenty years.

Fifty-six percent of patients did not know the name of the mental illness they were victims of and why they were being monitored at the mental health service. Hence, only 21 patients could name the mental illness they had been diagnosed with.

Regarding the discharged patients' knowledge on the psychopharmacological treatment they had been prescribed, most of them either did not or partially knew the name and prescription of all drugs they had been prescribed, as shown in Table 3.

 

 

Although they could not or partially knew the name of the prescribed drugs, when asked about the importance of maintaining psychopharmacological treatment, 81.2% of the patients considered that drugs treatment was important.

The psychiatric hospitalization

Among discharged patients, 62.5% had already been hospitalized at least once before the most recent hospitalization. The number of previous hospitalizations ranged from one to three, as described in Table 4 below.

 

 

For 37.5% of sample patients, the recent hospitalization was the first psychiatric hospitalization in their lives. Among discharged patients, five had already been hospitalized ten times before the recent hospitalization and nine had already been hospitalized once. The mean hospitalization rate was 3.14. Information on the behaviors that motivated the recent hospitalization were collected from the referral form filled out for patients on the occasion of their discharge, which the mental health service receives when they come for the medical appointment. These behaviors are described in Table 5.

 

 

Most of the hospitalizations observed in this research were based on high risk for the patient or other people's life and health. Suicide ideas, with or without suicide attempts caused the hospitalization of 35.4% of the sample subjects. The manifestation of psychotic symptoms motivated the hospitalization of 29.1% and aggressive behaviors another 25%.

One patient was hospitalized due to akathisia, an adverse effect caused by the use of an antipsychotic drug (Haloperidol). Due to the use of alcoholic beverages, one patient suffered a considerable mood change that resulted in his hospitalization because of aggressive behavior. One hospitalization was due to hypersexualized behavior. On the average, these patients remained hospitalized for 27 days. The shortest hospitalization period was two days and the longest 160 days. Only eight patients affirmed having turned to an emergency health service during the month before the most recent hospitalization.

Psychiatric rehospitalization

Out of 48 subjects interviewed during four months, six (12.5%) were rehospitalized during the data collection period, four men and two women. These patients' mean age was 32 years, 50.0% were single, without children and retired. The low education level was characteristic in 66.7% of rehospitalized patients. Only one had a fixed job and was on a leave of absence. Individual income corresponded to one minimum wage in 50% of cases. Five lived with relatives in their own house. One was a street dweller and affirmed living in his car. Family income did not exceed two minimum wages.

None of them knew the name of their disease. On the average, rehospitalized patients had been diagnosed for 8.3 years. Three patients had been diagnosed with Schizophrenia, one with Bipolar affective disorder, one with two diagnoses (Emotionally unstable personality disorder and Mild depressive episode) and one with three diagnoses (Mental and behavioral disorders due to use of alcohol - dependence syndrome, together with Schizophrenia and Bipolar affective disorder). None of the rehospitalized patients knew the names of all drugs they were taking.

 

DISCUSSION

This research identified that the patients discharged from psychiatric hospitalization in this sample are mostly women (62.5%), live with relatives (93.8%), in their own home (70.8%), where they live with three or four people (58.4%). Individual income did not exceed one minimum wage (R$ 380) for 66.7% of patients, observing that 54.2% have finished primary education and that only 14.6% have some kind of regular job. These findings are similar to other studies involving patients attended by community care services(7-9). In this and other studies, it is verified that low education and socioeconomic levels affect many psychiatric patients' lives.

It is known that, among the ten main disability-provoking physical and mental health conditions, five are related to mental disorders, especially: depression, alcoholism, bipolar affective disorder, schizophrenia and obsessive compulsive disorder(8). In this study, these disorders were present, with the highest prevalence found for diagnoses classified under Schizophrenia, schizotypal and delusional disorders and Mood Disorders (ICD 10 F20-F29; F31-33), in accordance with different studies in the area(8-9).

These are severe illnesses, often accompanied by manifestations of symptoms that limit patients' labor, social and leisure activities. Besides, they trigger discrimination and stigmatization(10-11). Considering this aspect, low education and socioeconomic levels can be related with the severity of the symptoms manifested in these diseases. The constant manifestation of the symptoms and adverse effects of medication treatment impair mental patients' relations with their families and social context(12). In this research, the occurrence of adverse effects was so severe in one patients that it ended up being the reason for another hospitalization.

In view of the extent of this harm, adequate treatment maintenance is needed for non-hospitalized patients attended by community care services. Thus, the prevention of relapse can minimize damage and favor patients' social relations, turning health service, nurses and other professionals' activities fundamental in this daily reality.

Psychiatric comorbidity was present in 29.2% of the sample. Among patients with two diagnoses, in three cases, one of the mental illness diagnoses was associated with drugs use (psychoactive substances, alcohol and multiple drugs). One of the cases of patients with three diagnoses was related with drugs use. It is known that drugs addiction is often connected with the manifestation of mental illnesses and represents a public health problem nowadays(13).

Patients discharged from hospitalization showed low knowledge levels on the name of their mental illness and their psychopharmacological treatment. Although a large majority of the sample showed recent diagnosis and treatment (less than one year), 56% could not tell the name of the mental illness they were victims of and why they were being monitored at the mental health service and 56.2% did not know or partially knew about the drugs they had been prescribed.

Although they either did not know or partially knew the names of the prescribed drugs, when asked about the importance of psychopharmacological treatment maintenance, 81.2% of patients considered drugs treatment important. These little coherent opinions seem to reflect what is observed in practice.

Although they absorb health professionals' orientations on the importance of psychopharmacological treatment, in general, non-adherence affects about 50% of patients(14-15). Among patients treated with conventional antipsychotics, 40% stop taking their medication during the first year of treatment and 75 % within two years(16).

Treatment is a fundamental element in patients' lives. For them, who go through this hospitalization and rehospitalization process, other daily-life activities are organized around the possibilities of treatment, as the fact of being hospitalized or not completely changes this population's daily reality. Hospitalization represents not only a treatment form for patients, as relatives report difficulties to live with the disorder of madness and consider hospitalization a moment when they can relax and live calmly(17).

Extra-hospital services need to work towards the goal of hospitalizations, which is to stabilize patients (minimizing risks, surveying psychosocial needs, adjusting psychopharmacological treatment and reinserting patients in their social context), in which care systemization is quite a correlated strategy.

Symptoms like psychic anxiety, hostility and emotional retraction were symptoms with a significant degree of severity among the discharged patients (c2=183.712; p<0.000 - Friedman's Test). These symptoms were also related with the recent hospitalization. The main reasons for hospitalization were precisely hostility (aggressiveness, irritability, psychomotor agitation), suicide ideas or suicide attempt and psychotic symptoms (delusions, hallucinations, mania).

The reasons described above are in accordance with Law No 10.216, issued on June 04th 2001. Nowadays, psychiatric hospitalization is indicated for severe cases, in which extra-hospital service approaches were not sufficient, i.e. when extra-hospital resources for treating or managing the problem were exhausted. Severe cases are considered situations in which a mental disorder is present, with at least one of the following conditions: risk of self-harm, risk of harming others, risk of harm to public order, risk of social exposure, severe disability for self-care(17).

Although a large part of the sample presented recent diagnosis and treatment (less than one year), 56% could not tell the name of the mental illness they were victims of and why they were being monitored at the mental health service and 56.2% did not know or partially knew about the drugs they had been prescribed. Patients discharged from hospitalization showed low knowledge levels on the name of their mental illness and their psychopharmacological treatment.

Another important result was that, although they did not know or partially knew the names of the prescribed drugs when asked about the importance of maintaining the psychopharmacological treatment, 81.2% of patients considered medication treatment important. This opinion does not seem to exert practical influence on adherence though, as 70.8% of patients were classified with low treatment adherence.

 

CONCLUSION

In this study, the researchers attempted to deepen their knowledge on patients who use the current public mental health service network and needed psychiatric hospitalization during their treatment. Among other goals, this knowledge aims to generate reflection and support to collaborate in the dynamics between mental health knowledge and practice. Professional commitment to knowledge in its relation with practice is an important source of evolution.

The innovations produced by the change in psychiatric care paradigms demand further research and adaptations, so that health professionals and services can attend to these clients' demands. As a result of judicious psychiatric hospitalizations marked by shorter institutionalization period, patients and relatives have increasingly become the main mental health care providers. In this context, the chronicity of mental disorders makes these people live with the hospitalization-rehospitalization process, and their daily activities are organized around the possibilities of mental disorder treatment.

Thus, today, knowing whom people discharged from psychiatric hospitalization are makes it possible to identify characteristics that can promote the determination of the best treatment and professional support to patients and their caregivers. The discharged patients analyzed in this study represent the population attended by a public health service, but long-term studies will be accomplished to consider these patients' psychiatric hospitalization and treatment maintenance in further depth.

Research and interventions in the needs of patients discharged after hospitalization and their caregivers are important for mental health service professionals' systematic action. The data demonstrated that, on the average, 13 patients per month are discharged from psychiatric hospitalization and attended by the service. In most cases, treatment maintenance of "non-institutionalized" patients is based on psychopharmacology, signs and symptoms, resorting to hospitalization in case of increased health risks. This type of care does not absorb daily and collective needs that also interference in the maintenance of these treatments and which lack interventions.

Considering the whole evolution of the mental illness care paradigm and its complexity in view of symptom manifestations: limitations on psychopharmacological treatment, family overload, social prejudice, lack of services and professionals, this research attempted to characterize one moment in the life history of mental patients in order to reflect on systemized mental health nursing care. This systemization will be elaborated based on a new research project, to be developed as from 2009 together with the University of São Paulo at Ribeirão Preto College of Nursing-USP.

New possibilities for care delivery to people who suffer due to a disease will always exist. Nowadays, mental health care demands that professionals attempt to understand the patients' world, their emotional needs and life, acting either punctually or not to stimulate psychosocial skill development.

 

REFRENCES

1. Rodrigues LR. "Só quem sabe da doença dele é Deus": o significado da doença mental no contexto cultural [dissertação]. Ribeirão Preto: Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo; 2001.         [ Links ]

2. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Saúde mental no SUS: os Centros de Atenção Psicossocial. Brasília; 2004.         [ Links ]

3. Brasil. Ministério da Saúde. Secretaria Executiva. Legislação em saúde mental: 1990-2002. 3ª ed. Brasília; 2002.         [ Links ]

4. Dalgalarrondo P, Botega NJ, Banzato CEM. Pacientes que se beneficiam de internação psiquiátrica em hospital geral. Rev Saúde Pública. 2003;37(5):629-34.         [ Links ]

5. Oliveira AGB, Alessi NP. Mental health nursing work: contradictions and current potentialities. Rev Lat Am Enferm. 2003;11(3):333-40.         [ Links ]

6. Brasil. Lei n.10.216, de 6 de abril de 2001. Dispõe sobre a proteção e os direitos das pessoas portadoras de transtornos mentais e redireciona o modelo assistencial em saúde mental [Internet]. Brasília; 2001. [citado 2008 nov. 22]. Disponível em: http://www.planalto.gov.br/ccivil_03/leis/leis_2001/l10216.htm        [ Links ]

7. Gomes MP, Couto MCV, Pepe VLE, Almeida LM, Delgado PGG, Coutinho ESF. Censo de pacientes internados em uma Instituição Asilar no Estado do Rio de Janeiro: dados preliminares. Cad Saúde Pública. 2002;18(6):1803-7.         [ Links ]

8. Coutinho ESF, Almeida Filho N, Mari JJ. Fatores de risco para morbidade psiquiátrica menor: resultados de um estudo transversal em três áreas urbanas no Brasil. Rev Psiquiatr Clin. 1999;26(5):246-56.         [ Links ]

9. Josef F, Silva JAR. Doença mental e comportamento violento: novas evidências da pesquisa. J Bras Psiquiatr. 2003;52(2):127-35.         [ Links ]

10. Newstead L, Kelly M. Early intervention in psychosis: who wins, who loses, who pay the price? J Psychiatr Ment Health Nurs. 2003;10(1):83-8.         [ Links ]

11. Van Meijel B, Van Der Gaag M, Kahn RS, Grypdonck. The practice of early recognition in early intervention to prevent psychotic relapse in patients with schizophrenia: an exploratory stud - Part 1. J Psychiatr Ment Health Nurs. 2002;9(3):347-55.         [ Links ]

12. Medeiros ARC. Adesão ao tratamento anti-hipertensivo em Unidade de Saúde da Família de João Pessoa - PB [dissertação]. João Pessoa: Centro de Ciências da Saúde, Universidade Federal da Paraíba; 2006.         [ Links ]

13. Strelec MAAM, Pierin AMG, Mion Junior D. A influência dos conhecimentos sobre a doença e a atitude frente à tomada dos remédios no controle da hipertensão. Arq Bras Cardiol. 2003;81(4):343-8.         [ Links ]

14. Davis NJ, Billett HH, Cohen HW, Arnsten JH. Impact of adherence, knowledge, and quality of live on anticoagulation control. Ann Pharmacother. 2005;39(4):632-36.         [ Links ]

15. Garcia RAC. Os fatores de aderência ao tratamento farmacológico de hiperlipidemias em pacientes atendidos pela Secretaria Municipal de Saúde de Ribeirão Preto [dissertação]. Ribeirão Preto: Faculdade de Medicina de Ribeiro Preto, Universidade de São Paulo; 2003.         [ Links ]

16. Piñeiro F, Gil V, Donis M, Orozco D, Pastor R, Merino J. Validez de seis métodos indirectos para valorar el cumplimiento del tratamiento farmacológico en la hipertensión arterial. Aten Primaria. 1997;19(7):372-5.         [ Links ]

17. Salles MM, Barros S. Reinternação em hospital psiquiátrico: a compreensão do processo saúde/doença na vivência do cotidiano. Rev Esc Enferm USP. 2007;41(1):73-81.         [ Links ]

 

 

Correspondence addressed to:
Lucilene Cardoso
Rua Itapira, 41 - Apto. 31 - Jardim Paulista
CEP 14090-120 - Ribeirão Preto, SP, Brazil

Received: 01/27/2009
Approved: 04/12/2010