ABSTRACT
Objectives:
to identify the prevalence of psychotropic drug use according to their Anatomical Therapeutic Chemical classification among Psychosocial Care Center users and assess their prescription compliance based on the recommended therapeutic dose.
Methods:
this is an analytical study, based on documents, from the study of 389 records between September 2017 and May 2018. Associations between the presence of underdose or overdose and participants’ characteristics were assessed using the chi-square test, adopting a significant value of p <0.05.
Results:
the most used drugs were antipsychotics (74.7%), 16.0% of users with at least one medication with a dose below the therapeutic level and another 3.6% above the recommended therapeutic dose.
Conclusions:
greater nonconformities in the prescribed dose were related to antihistamines, antipsychotics and antidepressants, with underdosage associated with females and overdose with the report of hearing voices.
Descriptors:
Psychotropic Drugs; Mental Health; Services Community Mental Health; Prevalence; Administration and Dosage
RESUMEN
Objetivos:
identificar la prevalencia del uso de psicofármacos según su clasificación Anatómica Terapéutica Química entre los usuarios de un Centro de Atención Psicosocial y evaluar el cumplimiento de su prescripción en base a la dosis terapéutica recomendada.
Métodos:
estudio analítico, basado en documentos, basado en el estudio de 389 historias clínicas entre septiembre de 2017 y mayo de 2018. Las asociaciones entre la presencia de subdosis o sobredosis y las características de los participantes se evaluaron mediante la prueba de chi-cuadrado valor significativo p<0,05.
Resultados:
los fármacos más utilizados fueron los antipsicóticos (74,7%), el 16,0% de los usuarios con al menos un medicamento con dosis por debajo del nivel terapéutico y otro 3,6% por encima de la dosis terapéutica recomendada.
Conclusiones:
las principales no conformidades en la dosis prescrita se relacionaron con antihistamínicos, antipsicóticos y antidepresivos, con infradosificación asociada a mujeres y sobredosis con el reporte de escuchar vocês.
Descriptores:
Psicotrópicos; Salud Mental; Servicios Comunitarios de Salud Mental; Prevalencia; Administración & Dosificación
RESUMO
Objetivos:
identificar a prevalência do uso de psicotrópicos conforme sua classificação Anatômico Terapêutico Químico entre usuários de um Centro de Atenção Psicossocial e avaliar a conformidade da prescrição dos mesmos com base na dose terapêutica recomendada.
Métodos:
estudo analítico, de base documental, a partir do estudo de 389 prontuários entre setembro de 2017 e maio de 2018. Associações entre a presença de subdose ou sobredose e as características dos participantes foram avaliadas por meio do teste qui-quadrado, adotando como valor significativo p <0.05.
Resultados:
os medicamentos mais utilizados foram os antipsicóticos (74,7%), 16,0% de usuários com pelo menos uma medicação com dose abaixo da terapêutica e outros 3,6% acima da dose terapêutica recomendada.
Conclusões:
maiores inconformidades na dose prescrita se relacionaram aos anti-histamínicos, os antipsicóticos e antidepressivos, com subdosagem associada ao sexo feminino e sobredose com o relato de audição de vozes.
Descritores:
Psicotrópicos; Saúde Mental; Serviços Comunitários de Saúde Mental; Prevalência; Administração & Dosagem
INTRODUCTION
Psychotropic drugs are defined as chemical substances that act on psychological function and alter mental state, which includes drugs with antidepressant, hallucinogenic and/or tranquilizer action. These substances act on the central nervous system has the potential to produce changes in behavior, mood and cognition of those who use them(11 Whitaker R. Anatomia de uma epidemia: pílulas mágicas, drogas psiquiátricas e o aumento assombroso da doença mental. 1.ed. Rio de Janeiro: Editora Fiocruz, 2017. 421p.).
Use must take into account some criteria such as diagnosis, the profile of symptoms, users’ age, the presence of clinical problems, the concomitant use with other drugs and especially the doses that will be implemented, as such considerations will have direct interference on the effectiveness or not the drug used, and, consequently, in users’ quality of life(22 Cordioli AV. Psicofármacos: consulta rápida. 5.ed. Porto Alegre: Artmed, 2015. 1024p.). It should also be noted that using inadequate doses exposes to the risk of side effects, without providing therapeutic benefit, and it is recommended that “subtherapeutic doses and incomplete therapeutic experiments” be avoided(33 Sadock BJ, Sadock VA, Ruiz P. Compêndio de psiquiatria: ciência do comportamento e psiquiatria clínica [Internet] 11. ed. Porto Alegre: Artmed.; 2017 [cited 2020 Apr 25]. 1490p. Available from: https://oitavaturmadepsicofm.files.wordpress.com/2019/03/compecc82ndio-de-psiquiatria-kaplan-e-sadock-2017.pdf
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).
The Psychosocial Care Center (CAPS - Centro de Atenção Psicossocial) is an open and community health service of the Unified Health System (SUS - Sistema Único de Saúde) that has a multidisciplinary team to provide care to people in psychological distress(44 Argiles CTL, Andrade APM, Kantorski LP, Willrich JQ. Processes of subjectivation of workers and users in the micropolitical relations of the psychosocial attention mode. Av Psicol Latinoam. 2018;36(2):285-97. https://doi.org/10.12804/revistas.urosario.edu.co/apl/a.5181
https://doi.org/10.12804/revistas.urosar...
). Several intervention resources are used for the production of life, autonomy and health, existing in the territory and in service, which may include medication use(55 Mielke FB, Kantorski LP, Jardim VMR, Olschowsky A, Machado MS. Mental care delivered in psychosocial care centers (CAPS) from the viewpoint of the professionals. Ciênc Saúde Colet. 2009;14(1):159-64. https://doi.org/10.1590/S1413-81232009000100021
https://doi.org/10.1590/S1413-8123200900...
).
When necessary, the drug resource must be rationally selected, prescribed and used to bring better efficacy and safety, with less cost to users, cooperating for comprehensive care(66 Ministério da Saúde (BR). Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Uso racional de medicamentos: temas selecionados [Internet]. Brasília, DF: Ministério da Saúde; 2012 [cited 2020 Apr 25]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/uso_racional_medicamentos_temas_selecionados.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
). However, studies demonstrate weaknesses in the use and prescription process(77 Falci DM, Mambrini JVM, Castro-Costa E, Firmo JOA, Lima-Costa MF, Loyola Filho AI. Use of psychoactive drugs predicts functional disability among older adults. Rev Saúde Pública. 2019;53(21):1-12. https://doi.org/10.11606/s1518-8787.2019053000675
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-88 Borges TL, Hegadoren KM, Miasso AI. Common mental disorders and use of psychotropic medication in women consulting at primary care units in a Brazilian urban area. Rev Panam Salud Pública [Internet]. 2015 [cited 2020 May 20];38(3):195-201. Available from: https://www.scielosp.org/article/rpsp/2015.v38n3/195-201
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), and that psychotropic drug use should not be exclusive but added to other care resources(99 Prado MAMB, Francisco PMSB, Barros MBA. Use of psychotropic medications in adults and elderly living in Campinas, São Paulo, Brazil: cross-sectional population-based study. Epidemiol Serv Saúde. 2017;26(4):747-58. https://doi.org/10.5123/S1679-49742017000400007
https://doi.org/10.5123/S1679-4974201700...
). This reinforces the importance of monitoring psychiatric drug use in Psychosocial Care services, avoiding harm to users.
OBJECTIVES
To identify the prevalence of psychotropic drug use according to their Anatomical Therapeutic Chemical classification among Psychosocial Care Center users and assess the compliance of their prescription based on the recommended therapeutic dose.
METHODS
Ethical aspects
The research protocol was approved by the Research Ethics Committee of the Faculty of Medication of Universidade Federal de Pelotas. It was carried out in compliance with the Brazilian rules and guidelines for the regulation of research involving human beings, CNS (Conselho Nacional de Saúde - Brazilian National Health Council) Resolution 466/2012, guaranteeing participnats’ anonymity.
Study design, period, and location
This is an analytical study, based on documents, conducted from the study of medical records of CAPS users in the city of Pelotas, RS. This is an excerpt from the survey “Ouvidores de vozes - novas abordagens em saúde mental”, which took place between September 2017 and May 2018.
The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines were followed in this study.
Population and sample; inclusion and exclusion criteria
We sought to include in the study all medical records of users active in the service during the data collection period, i.e., users who maintained a link with the service, attending consultations, visits, groups, workshops and for withdrawing medication prescriptions. Thus, after surveying the lists of users at the service, data obtained from 400 medical records were accessed, of which 11 were excluded due to incomplete information, resulting in 389 medical records of participants in this study.
Study protocol
The outcome of this study was psychotropic drug use classified based on the Anatomical Therapeutic Chemical (ATC) classification of the World Health Organization(1010 World Health Organization (WHO). Collaborating Centre for Drug Statistics Methodology. Anatomical Therapeutic Chemical (ATC) index with defined daily doses (DDDs) [Internet]. 2003 [cited 2020 May 10]. Available from: http://www.whocc.no/atc_ddd_ index/
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) as well as the compliance of the prescribed dose with the recommended therapeutic dose.
In the ATC system, drugs are arranged in different groups according to their sites of action and their therapeutic and chemical characteristics. There are five different levels; medications are divided into 14 main anatomical groups (level 1), which house two therapeutic/pharmacological subgroups (levels 2 and 3), level 4, therapeutic/pharmacological/chemical subgroup and level 5, the chemical itself(1010 World Health Organization (WHO). Collaborating Centre for Drug Statistics Methodology. Anatomical Therapeutic Chemical (ATC) index with defined daily doses (DDDs) [Internet]. 2003 [cited 2020 May 10]. Available from: http://www.whocc.no/atc_ddd_ index/
http://www.whocc.no/atc_ddd_ index/...
-1111 Ministério da Saúde (BR). Secretária de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde. Departamento de Assistência Farmacêutica e Insumos Estratégicos. Relação Nacional de Medicamentos Essenciais: Rename 2020 [Internet]. Brasília, DF: Ministério da Saúde; 2020 [cited 2020 May 20]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/relacao_medicamentos_rename_2020.pdf
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). For each individual, the presence of psychotropic drugs was identified according to the substance (last ATC level) and therapeutic/pharmacological class (level 3 of ATC).
It was analyzed whether medications were in conformity or not, from the comparison between the doses prescribed in the sample of this study with the therapeutic doses described in literature(22 Cordioli AV. Psicofármacos: consulta rápida. 5.ed. Porto Alegre: Artmed, 2015. 1024p.,1212 Quevedo J. Emergências Psiquiátricas. 4.ed. Porto Alegre: Artmed; 2019. 344p.-1313 Moreno RA, Cordás T. Condutas em Psiquiatria: consulta rápida. 2. ed. Porto Alegre: Artmed ; 2018. 444 p.), classifying them in sub-dose, therapeutic dose, and overdose.
The study variables used the information related to users’ gender (female; male), age (continuous/18 to 30 years; 31 to 40 years; 41 to 50 years; 51 to 60 years; 61 years or more), marital status (single; with partner; separated or widowed), education (0 to 4 years of study; 5 to 8 years of study; 9 years of study or more), source of income (paid work; family income; aid or benefits), primary diagnosis (schizophrenia; bipolar affective disorder; depression; mental retardation; other neurotic disorders; other unspecified disorders), hearing voices (absent; present), history of violence (absent; present).
To collect the data, a form designed for the purposes of the research was used, composed of objective and discursive questions. They were answered by collectors, previously trained, based on the information available in the medical records.
Analysis of results, and statistics
The data were entered into Microsoft Excel software and later converted to the Stata 11 statistical package (StataCorp., CollegeStation, United States), where the analyzes were conducted. Inconsistencies in data were assessed and corrected when necessary.
Initially, descriptive statistics were used, by means of which the averages for continuous variables were calculated, as well as their respective standard deviations, in addition to the calculation of prevalence over each of the studied variables’ strata. For conducting hypothesis tests, in the case of categorical variables, a chi-square test was used to identify whether there was an association between independent variables, arranged in line, and the outcome variable, arranged in the column in a contingency table constructed from sample data. The null hypothesis was that the variables were not associated and the alternative hypothesis that the variables were associated. Statistical significance was defined as a p value <0.05.
RESULTS
Through this study, data were collected on 389 users of a CAPS in the municipality of Pelotas. Among these, 66% were female. The average age found for the studied population was 47.7 years, with a standard deviation of 12.5, with a range from 19 to 86 years. Among the users studied, 59.6% had up to 4 years of study, while 19.9% had studied between 5 and 8 years and 22.5% 9 years or more. Most users (60.5%) received some aid or benefit paid by the state, another 17.4% were in a paid job and 22.1% depended on family income. Regarding marital status, 40.7% of users had a partner, 31.6% were single and 27.6% were widowed or divorced. The most frequent diagnosis was depression (36.6% n=133), followed by schizophrenia (25.1% n=91), mental retardation (14.33% n=52), bipolarity (10.5% n=38), other neurotic disorders (8.3% n=30) and other unspecified disorders (5.2% n=19).
There was a prevalence of antipsychotic use in 74.7% of the users assessed; this psychotropic class was the most used by them. Then, antidepressants, used by 60.6% of users, and antiepileptics, used by 51.5%, stand out. Anxiolytic use was also observed by 48.2% of users studied, followed by anticholinergic agents, sedative hypnotics and antihistamines by 28.6%, 16.5%, and 5.7%, respectively. The prevalence of use of each medication belonging to the examined classes can be seen in Table 1.
Description of the psychotropic drugs used in the Psychosocial Care Center studied according to the therapeutic/pharmacological subgrouplevels 2/3 of the Anatomical Therapeutic Chemical classification
As noted in Table 1, the five most used drugs by the population studied were Diazepam (44.3%), Haloperidol (29.1%), Biperiden (28.6%), Fluoxetine (26.3%), and Clonazepam (24.7%).
With regard to the compliance of the prescribed dose with the recommended therapeutic dose, it was observed that 80.9% (n=314) of users had received a prescription for all drugs within the recommended therapeutic dose. However, 16% (n=62) of users had received indication of at least one medication with a dose below the therapeutic dose, and another 3.6% (n=14) received prescriptions with at least one medication with a dose above that recommended therapeutic dose. It is noted that in 2 cases (0.5%), users had received indication of at least one medication with a dose below the therapeutic dose and at least one medication with a dose above the recommended therapeutic dose concomitantly. Table 2 shows the prevalence of compliance or not with the recommended therapeutic dose for each psychotherapeutic class studied.
Conformity of the prescribed dose for psychotropic drugs used by users of the Psychosocial Care Center studied according to the therapeutic/ pharmacological subgrouplevels 2/3 of the Anatomical Therapeutic Chemical classification
As seen in Table 2, the psychotherapeutic class with the highest prevalence of prescribing a dose below the recommended therapeutic dose was that of antihistamines (27.3% n=6), followed by antipsychotics (17.6% n=51) and antidepressants (17.4% n=41). The psychotherapeutic classes for which there was a higher prevalence of prescription above the therapeutic dose, were those of antihistamines (13.6% n=3), antiepileptics (6% n=12) and sedative hypnotics (4.7% n=3).
With regard to the sociodemographic and clinical characteristics that were related to the prescription of a dose above or below the recommended therapeutic dose, there were sex, marital status and hearing of voices. The meaning of these relationships as well as the other variables studied can be seen in Table 3.
Prevalence of dosage below and above the therapeutic dose among users of a Psychosocial Care Center in the city of Pelotas, Rio Grande do Sul, according to strata of the variables selected for the study
As noted in Table 3, the women who composed the sample received a prescription for a psychotropic agent below the recommended therapeutic dose more frequently. Among women, this prevalence was 20.0%, while in men, 9.1%. The same is observed among individuals who reported marital status as separated or widowed, whose prevalence of this outcome was 19.6%. Among singles, in turn, this prevalence was 8.2%.
As for the prescription of a psychotropic drug in a dose higher than the recommended therapeutic dose, it was possible to observe that users who had a report of hearing voices were more prone to this outcome. Among users who did not report hearing voices, the prevalence of prescription above the therapeutic dose was 0.5%. Among voice listeners, this prevalence was 7.2%.
DISCUSSION
Initially, it is possible to verify in the sample studied subjects’ biological variability (age, sex, among others) as well as socioeconomic conditions and family structure, and these factors may interfere with the choice of medication and its dosage. In this sense, many variables must be considered in psychopharmacology regarding the choice of medication, prescription, administration, psychic representation of the medication for users and family and environmental issues(33 Sadock BJ, Sadock VA, Ruiz P. Compêndio de psiquiatria: ciência do comportamento e psiquiatria clínica [Internet] 11. ed. Porto Alegre: Artmed.; 2017 [cited 2020 Apr 25]. 1490p. Available from: https://oitavaturmadepsicofm.files.wordpress.com/2019/03/compecc82ndio-de-psiquiatria-kaplan-e-sadock-2017.pdf
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).
Another aspect pointed out in the research is that, as observed in other studies, health services are mostly accessed by women(1414 Ribeiro MCS, Barata RB, Almeida MF, Silva ZP. Sociodemographic profile and utilization patterns of the public health care system (SUS)-PNAD 2003. Ciênc Saúde Coletiva. 2006;11(4):1011-22. https://doi.org/101590/S1413-81232006000400022
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-1515 Levorato CD, Mello LM, Silva AS, Nunes AA. Factors associated with the demand for health services from a gender-relational perspective. Ciênc Saúde Colet. 2014;19(4):1263-74. https://doi.org/10.1590/1413-81232014194.01242013
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), which may justify the prevalence (36.6%) of depression diagnosis in the studied sample, considering that it is the psychopathological disorder that most affects women as a result of biological, social, and gender factors(88 Borges TL, Hegadoren KM, Miasso AI. Common mental disorders and use of psychotropic medication in women consulting at primary care units in a Brazilian urban area. Rev Panam Salud Pública [Internet]. 2015 [cited 2020 May 20];38(3):195-201. Available from: https://www.scielosp.org/article/rpsp/2015.v38n3/195-201
https://www.scielosp.org/article/rpsp/20...
,1616 Moura DCN, Pinto JR, Martins P, Pedrosa KA, Carneiro MGD. Abuse of psychotropic drugs by demand of the family health strategy integrative literature review. Senare [Internet]. 2016 [cited 2020 May 20];15(2):136-44. Available from: https://www.scielosp.org/article/rpsp/2015.v38n3/195-201/
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-1717 Pereira MO, Souza JM, Costa AM, Vargas D, Oliveira MAF, Moura WN. Profile of users of mental health services in the city of Lorena-São Paulo. Acta Paul Enferm. 2012;25(1):48-54. https://doi.org/10.1590/S0103-21002012000100009
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). Such prevalence is similar to a study carried out in substitute mental health services in the southern region, in which the diagnosis of depression was identified in 34.3% of the sample(1818 Kantorski LP, Jardim VMR, Porto AR, Schek G, Cortes JM, Oliveira MM. The supply and use of psychotropic drugs in Psychosocial Care Centers in Southern Brazil. Rev Esc Enferm USP. 2011;45(6):1481-7. https://doi.org/10.1590/S0080-62342011000600029
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). It is worth mentioning that in depressive conditions, users may present a multiplicity of symptoms, including psychotic symptoms(1919 Dalgalarrondo P. Psicopatologia e semiologia dos transtornos mentais. 3.ed. Porto Alegre: Artmed ; 2018. 505p.); this would justify the high rate of psychotropic drugs belonging to the class of antipsychotics (74.7%) and to the class of antidepressants (60.6%).
When associating the most prevalent diagnoses with the medications most used by the sample, hypotheses for use arise: diazepam (44.3%), used as an adjunct in treatment of schizophrenia, or associated with antidepressants in cases of depression with anxiety; haloperidol (29.1%), used to treat exacerbation of schizophrenic conditions and psychotic depression; biperiden (28.6%), for treatment of extrapyramidal symptoms caused by psychotropic use; fluoxetine (26.3%), as the first choice for the treatment of depression; clonazepam (24.7%), as an adjunct to sedation with antipsychotics(22 Cordioli AV. Psicofármacos: consulta rápida. 5.ed. Porto Alegre: Artmed, 2015. 1024p.).
The more frequent use of diazepam, in a sample of female predominance, is also justified by the social constructions of gender, as they are directly associated as determinants of consumption. Anxiolytics are widely used in the clinic as a “tranquilizer”, although it is a medication to treat specific anxiety attacks(2020 Carvalho LF, Dimenstein M. The woman, her physician and the psychotropic drug: a web of interfaces and subjectivity production in public health services. Interações Estud Pesqui Psicol. [Internet]. 2003 [cited 2020 May 20];8(15):37-64. Available from: http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1413-29072003000100003&lng=pt&nrm=iso
http://pepsic.bvsalud.org/scielo.php?scr...
).
In mental health, antihistamines are prescribed for sedative-hypnotic purposes, in isolation or in combination with other medications, for treatment of insomnia, extrapyramidal manifestations of antipsychotics or to control agitation. It should be considered that antihistamines reduce tolerance as age advances, i.e., their sedative effect is prolonged, with the need to decrease the therapeutic dose(2121 Camelo-Nunes IC. New antihistamines: a critical view. J Pediatr. 2006;82(Suppl5):S173-S180. https://doi.org/10.1590/S0021-75572006000700007
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-2222 Pastorino AC. Revision on efficacy and safety of antihistamines of first and second generation. Rev Bras Alergia Imunopatol[Internet]. 2010 [cited 2020 May 20];33(2):88-92. Available from: http://www.sbai.org.br/revistas/Vol333/anti-histaminicos_33_3.pdf
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), which could explain the prevalence of underdosing found in our study.
It is observed that antihistamines are the class with the highest non-conformity in this sample, also showing prevalence for overdose. A justification would be that antihistamines, whose main action is anti-allergic and commonly used for their sedative action, are well-known medications among health professionals, users, and family members, and may generate overdoses prescription, paying little attention to the effects, safety, and effectiveness. It is worth highlighting the alert with this class, because although it is of low dependence, doses above therapy are potentially lethal(2222 Pastorino AC. Revision on efficacy and safety of antihistamines of first and second generation. Rev Bras Alergia Imunopatol[Internet]. 2010 [cited 2020 May 20];33(2):88-92. Available from: http://www.sbai.org.br/revistas/Vol333/anti-histaminicos_33_3.pdf
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). The search for enhancing a medication also explains why the hypnotic-sedative class is the third most prevalent of overdoses.
It is noteworthy in this sample the fact that antipsychotics are the second drug class with the highest prevalence of underdose, in contrast to literature, in which it is presented as the main class used with doses above the therapeutic level(2323 Harrington M, Lelliott P, Paton C, Konsolaki M, Sensky T, Okoha C. Variation between services in polypharmacy and combined high dose of antipsychotic drugs prescribed for in-patients. Psychiatr Bull. 2002;26(11):418-42. https://doi.org/10.1192/pb.26.11.418
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-2424 Hodgson R, Sukumaran MK, Sudharsan S, Skimar M. Prescribing on psychiatric acute wards at four hospitals. Prog Neurol Psychiatry. 2008;12(3):10-14. https://doi.org/10.1002/pnp.66
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). It is observed that currently using antipsychotics in underdoses in the clinic is for hypnotic purposes, since the idea is to decrease the prescription of benzodiazepines, which are prescribed in great majority by general practitioners in Basic Health Units(2525 Mezzari R, Iser BPM. Challenges in benzodiazepines prescriptions in basic health units. Rev. AMRIGS [Internet]. 2015 [cited 2020 May 18]; 59(3):198-203. Available from:https://www.amrigs.org.br/revista/59-03/07_1507_Revista%20AMRIGS.pdf
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).
The presence of the antidepressant class in therapeutic underdoses may be related to individuals’ adaptation to medication doses. This can be verified in another study(2626 Miranda P, Botas P, Abreu M, Pereira C, Santiago LM. Patient’s profile and the context of consultations in which the diagnose of depression was made for the first time in Eiras Health Centre in 2011. Rev Bras Med Fam Comun. 2016;11(38):1-9. https://doi.org/10.5712/rbmfc11(38)923
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), which found cases of sub-therapeutic doses of antidepressants without mentioning them in the medical record, if the dose would be increased gradually, stating that the records need to be improved.
As for the association of overdose with hearing voices, it can be neurochemically justified based on the biomedical model, in which they consider the experience of hearing voices as a psychotic symptom. The prescription of higher doses occurs as a result of antipsychotics blocking most of the brain’s D2 receptors, and neurons, in order to compensate, increase the density of these dopaminergic receptors, making the pathways dysfunctional, which aggravates psychotic symptoms (psychosis belated). Moreover, morphological changes (in the ganglia, thalamus, and frontal lobe) caused by antipsychotics have been found, which are related to the worsening of positive and negative symptoms, causing increasing doses of these psychotropic drugs to be used, thus occurring prescription of overdoses(11 Whitaker R. Anatomia de uma epidemia: pílulas mágicas, drogas psiquiátricas e o aumento assombroso da doença mental. 1.ed. Rio de Janeiro: Editora Fiocruz, 2017. 421p.).
Also, approximately one third of people who are diagnosed with schizophrenia are resistant to drug treatment even in high doses of psychotropic drugs(2727 Curson DA, Barnes TRE, Bamber RW, Piatt SD, Hirsch SR, Duffy JC. Course of Illness, Stability of Diagnosis, and the Role of a Special Maintenance Clinic. Br J Psychiatr. 1985;146(5):464-69. https://doi.org/10.1192/bjp.146.5.464
https://doi.org/10.1192/bjp.146.5.464...
-2828 Conley RR, Kelly DL (2001). Management of treatment resistance in schizophrenia. Biol Psychiatr. 2001;50(11):898-911. https://doi.org/10.1016/s0006-3223(01)01271-9
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), i.e., hearing voices remains even with the constant use and increase of psychotropic drugs.
It should be noted that using psychotropics related to the discrepancy in therapeutic doses, whether in the case of underdoses or overdoses, may be related to a service performed in a prescriptive way, without taking into account a person’s uniqueness, neither the periodicity of reassessment nor the need to continue using these medications.
A survey carried out in an emergency department of a mental health clinic resulted in the majority of people who arrive at the service already having a prescription for psychiatric medications, and the complaints presented are often not taken into account, which causes maintenance of the prescribed medications(2929 Ferraza ACF, Luzio CA, Rocha LC, Sanches RR. Trivializing the prescription of psychopharmacologic drugs in a mental health servisse. Paidéia (Ribeirão Preto). 2010;20(47):381-90. https://doi.org/10.1590/S0103-863X2010000300010
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).
It is necessary to point out the need for the CAPS nursing team to guide users on the prescribed medication, monitor the establishment of users’ relationship with their medications, as well as clarify the expected therapeutic effects, frequency of use and probable side effects(3030 Alcântara CB, Capistrano FC, Czarnobay J, Ferreira ACZ, Brusamarello T, Maftum A. Drug therapy for people with mental disorders in the view of nursing profissionals. Esc Anna Nery. 2018;22(2):e20170294. https://doi.org/10.1590/2177-9465-ean-2017-0294
https://doi.org/10.1590/2177-9465-ean-20...
). Furthermore, it is important that monitoring users regarding the prescribed medications needs to occur in an interdisciplinary way so that their rational use happens considering the participation of users and family in planning this therapeutic resource, in a co-management of medication use.
Study limitations
Little research can be considered as limitations of this study that address the prescription of psychotropic drugs and the analysis of their doses (in underdoses or overdoses). It is identified the lack of bibliographies that allow assessing the justification for the use or not of these dosages, which brings to reflection the importance of criteria for the rational use of psychotropics.
Contributions to nursing, health, and public policies
Psychotropic drug use as one of the care strategies must win the contribution of all the actors involved in this process. The study reaffirms the responsibility and the importance of nursing to actively participate in team discussions regarding the rational use of medications, to contribute in an interdisciplinary way in monitoring, in addition to their duties in guidance and administration of these medications.
CONCLUSIONS
In this study, the prevalence of antipsychotics was evidenced as the psychotropic class most used by CAPS users, followed by antidepressants and antiepileptics. Considering the compliance of the dose, antihistamines, antipsychotics, antidepressants, antiepileptics and sedative hypnotics were the ones that presented the greatest nonconformities, underdosing or overdosing, highlighting a higher frequency of underdosing in women.
According to the study, people who reported hearing voices presented therapeutic doses above the recommended, bringing to reflection the imperative need to search for perspectives that explore other approaches related to the phenomenon of hearing voices.
Thus, the need for monitoring and continuous reviews of medication by the team of service professionals, especially nursing, is highlighted. Also, it is important to use psychotropics appropriately and responsibly, recognizing them and using them as one of the resources available at CAPS added to others and not as a focus of care developed by these services.
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Publication Dates
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Publication in this collection
13 Aug 2021 -
Date of issue
2021
History
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Received
24 July 2020 -
Accepted
19 Nov 2020