[Psychiatric emergency services and their relationships with mental health network in Brazil]

Psychiatric hospitalizations in Brazil: exploratory and trend analysis from 2009 to 2019

ABSTRACT Objective: To examine the rates of psychiatric hospitalization and the average length of stay, in Brazil, from 2009 to 2019, according to sociodemographic variables and character of the hospitalization (elective or urgency). Methods: This is an ecological study, with data collected from the Hospital Information System of the Unified Health System (SIH/SUS). Hospital admission rates were described according to diagnosis, sex, and age group. Percentage variation and rate ratios were calculated. To evaluate the time series, the data were submitted to linear regression analysis. Results: The rate of hospitalization for mental disorders decreased from 14.2/10,000 in 2009 to 11.2 in 2019, with the most significant variation occurring between mental and behavioral disorders due to alcohol use. The men had about twice as many episodes as the women in all the years evaluated. Higher rates were found in the age group of 30 and 59 years. The length of stay also decreased in the period. Besides, the urgency character presented almost 82% of the total hospitalizations. Conclusions: There was a reduction in hospital admissions for mental disorders in the analyzed period, demonstrating the relevance of mental health care changes resulting from the Psychiatric Reform.

Atenção à crise na contemporaneidade: desafios à Reforma Psiquiátrica Brasileira

RESUMO Neste ensaio, são abordados os modos de viver e de acolher a experiência de crise no âmbito da saúde mental brasileira, considerando que esse acontecimento se impõe como um dos desafios estratégicos da fase atual da atenção psicossocial. Essa demanda heterogênea evidencia os efeitos coletivos e individuais decorrentes das transformações da vida contemporânea no mundo ocidental, cenário que, no contexto brasileiro, envolve, com frequência, crescentes situações associadas a rupturas e violências. Além disso, o acolhimento à crise e a clínica da urgência ainda se apresentam fortemente marcados pelo discurso psiquiátrico, que mantém legitimidade exclusiva nesse âmbito ao fornecer uma interpretação para a crise como evidência de uma psicopatologia. Em contrapartida, propõe-se uma noção de crise referida a um momento específico da existência, o qual condensa e atualiza uma série de afetos e impasses próprios à heterogeneidade que faz parte da vida. Nesse sentido, recupera-se a dimensão simbólica que intervém nesse acontecimento, privilegiando-a como recurso de subjetivação e tratamento para as modalidades de cuidado que se contrapõem à lógica discursiva psiquiátrica.

Leitos de saúde mental em hospitais gerais: o caso do Rio de Janeiro

RESUMO O objetivo deste artigo foi analisar o modelo de provisão de leitos de saúde mental em três hospitais gerais da cidade do Rio de Janeiro e sua relação com a Rede de Atenção Psicossocial. Foram realizadas entrevistas com gestores locais, um gestor municipal e dois ex-coordenadores nacionais de saúde mental. Os resultados apontaram que os hospitais estudados oferecem espaços restritivos, com predomínio de terapia farmacológica e forte influência do modelo biomédico. A presença dos leitos de saúde mental nos hospitais tem-se mostrado uma experiência bem-sucedida na melhoria do cuidado integral aos usuários. A interação com a Rede de Atenção Psicossocial foi apresentada como modelo de assistência preconizado, mas ainda enfrentando fragilidades em sua implementação. Os achados da pesquisa evidenciaram que a baixa implantação de leitos de saúde mental em hospital geral na cidade se deve a lacunas na formação de profissionais e ao estigma que faz com que gestores resistam em receber usuários com transtornos mentais em suas instituições. Modificações recentes na política nacional de saúde mental, no sentido de interromper o fechamento de leitos em hospitais psiquiátricos, devem acarretar alterações na direção da reforma psiquiátrica no País.

Systematic review of pathways to mental health care in Brazil: narrative synthesis of quantitative and qualitative studies

BACKGROUND

Pathways to care are actions and strategies employed by individuals in order to get help for health-related distress and the related processes of care providers. On several systematic reviews regarding pathways to mental health care (PMHC), studies regarding South American countries were not present. This review synthesizes qualitative and quantitative research about PMHC in Brazil.

METHODS

LILACS, MEDLINE and SCIELO databases were searched for papers regarding PMHC in Brazil. The results were organized in pathway stages, based on Goldberg and Huxley's 'model of Levels and Filters' and on Kleinman's framework of 'Popular, Folk and Professional health sectors'. Analysis also considered the changes in national mental health policy over time.

RESULTS

25 papers were found, with data ranging from 1989 to 2013. Complex social networks were involved in the initial recognition of MH issues. The preferred points of first contact also varied with the nature and severity of problems. A high proportion of patients is treated in specialized services, including mild cases. There is limited capacity of primary care professionals to identify and treat MH problems, with some improvement from collaborative care in the more recent years. The model for crisis management and acute care remains unclear: scarce evidence was found over the different arrangements used, mostly stressing lack of integration between emergency, hospital and community services and fragile continuity of care.

CONCLUSIONS

The performance of primary care and the regulation of acute demands, especially crisis management, are the most critical aspects on PMHC. Although primary care performance seems to be improving, the balanced provision and integration between services for adequate acute and long-term care is yet to be achieved.

Rapid Tranquilization for Psychiatric Patients with Psychomotor Agitation: What is Known About it?

Rapid tranquilization is an intervention used in control of agitation or aggression in patients with mental disorders. This study synthesized the available evidence regarding efficacy and safety of drugs used for rapid tranquilization in psychiatric patients with psychomotor agitation. It is an overview study of systematic reviews and meta-analysis of randomized controlled trials (RCT) identified in the database MEDLINE, EMBASE, CINAHL, Web of Science, Cochrane Library and LILACS until April 2015. A team of reviewers, in pairs and independently, identified eligible studies and assessed methodological quality using AMSTAR. Data were extracted from four studies (61 RCT, 8021 participants). The association of haloperidol with promethazine (H + P) promoted tranquilization and presented better safety profile, with moderate quality evidence. Olanzapine demonstrated benefit towards tranquilization and good safety profile, but needed additional administration to keep tranquilization. There was no benefit in the use of haloperidol alone or associated to another psychotropic to most outcomes evaluated. The evidence was of low quality to most of the interventions. H + P was considered a good option for rapid tranquilization, however, more RCT are necessary to confirm the efficacy and safety of the available interventions.

A regionalização da saúde mental e os novos desafios da Reforma Psiquiátrica brasileira

Resumo Novos desafios estão postos à Política Nacional de Saúde Mental no Brasil com o processo de regionalização da Rede de Atenção Psicossocial (RAPS). Trata-se da ampliação do acesso e melhora da qualidade de atenção em saúde mental em todos os níveis e pontos de atenção no âmbito do SUS. Objetiva-se analisar a organização da RAPS a partir da constituição das regiões e Redes de Atenção à Saúde no Brasil, apresentando o mapeamento dos serviços e sua distribuição na rede de serviços. Realizou-se um estudo de corte transversal a partir dos dados recuperados das plataformas CNES, DataSUS e Coordenação Nacional de Saúde Mental. Os resultados indicam o aprofundamento do processo de expansão e regionalização da rede de serviços ao longo desses quinze anos de aprovação da Lei da Reforma Psiquiátrica Brasileira (Lei nº 10.216/2001), apesar dos “vazios assistenciais” em diversos pontos de atenção, o que gera fragilidade na cobertura da rede de serviços.

Profile of patients attended as psychiatric emergencies at a university general hospital

CONTEXT AND OBJECTIVE

The prevalence of psychiatric conditions in clinical settings is high, particularly in emergency services. This is a challenge for healthcare professionals and an essential element in the functioning of the mental health network. The objective here was to describe the sociodemographic and clinical profile and the practices among patients treated psychiatrically in the Emergency Unit.

DESIGN AND SETTING

Descriptive and quantitative study, conducted at Hospital das Clínicas (HC), Universidade Estadual de Campinas (Unicamp).

METHODS

Sociodemographic data, reasons for attendance, diagnostic hypotheses and practices were analyzed.

RESULTS

Psychiatric staff attended 1,835 cases over the study period, corresponding to 1465 patients. The patients were predominantly women (53.7%) and white (79.6%); their mean age was 37 years and 41.3% lived with their parents. The commonest reasons for attendance were depressive symptoms (28.1%), agitation (23.6%) and problems with psychoactive substances (19.5%). The commonest diagnoses were psychoactive substance-related disorders (23%) and depressive disorders (18.5%). 31.6% of the patients were referred to healthcare centers and 29.2% to specialized outpatient clinics, while 8.2% were hospitalized.

CONCLUSIONS

This study emphasizes that it is important for professionals working in emergency service to have information about the patients' profile and the main reasons that lead them to seek psychiatric care, and to establish a diagnosis that will allow proper management at the emergency service and case referral.