Estado neoliberal y gasto público en psicofármacos en el Chile contemporáneo / Neoliberal State and public expenditure of psychiatric drugs in contemporary Chile / Estado neoliberal e gastos públicos com drogas psicotrópicas no Chile contemporâneo

Resumen: El presente trabajo aborda el lugar del Estado en la concepción neoliberal de la salud mental en base al predominio del mercado farmacéutico. Para ello, se cuestiona la extensión de la atención ambulatoria y el aumento de la prescripción de psicofármacos como ejes articuladores de la política pública de salud mental en Chile. Junto con ello, se examina el rol del Estado neoliberal en base a la transferencia de recursos públicos al sector privado, considerando los montos de licitaciones y laboratorios involucrados en el gasto público en psicofármacos en el período 2011-2017. Se concluye que el uso masivo de fármacos psiquiátricos es la respuesta preferencial del Estado para la atención de salud mental y que la obtención de beneficios económicos con recursos públicos por parte de la industria farmacéutica, debe ser rebatida desde una clave de lectura crítica y alternativa al neoliberalismo.

Abstract: The following article addresses the States place in the neoliberal conception of mental health on the basis of the pharmaceutical market's predominance. For that purpose, the extension of outpatient care and the increase of psychiatric drug prescriptions as key elements of mental health public policies in Chile. In addition, the role of the neoliberal state on the basis of transferring public resources to the private sector is examined, considering the amounts of bids and laboratories involved in public expenditure of psychiatric drugs during the period of 2011-2017. It is concluded that the massive use of psychiatric drugs is the State's preferred response for mental health care and the obtaining of economic benefits with public resources on the part of the pharmaceutical industry, must be contested using a critical and alternative analysis to neoliberalism.

Resumo: O presente trabalho aborda o lugar do Estado na concepção neoliberal de saúde mental a partir do predomínio do mercado farmacêutico. Para tanto, questiona-se a extensão do atendimento ambulatorial e o aumento da prescrição de drogas psicotrópicas como eixos articuladores da política pública de saúde mental no Chile. Junto com isso, o papel do Estado neoliberal é examinado com base na transferência de recursos públicos para o setor privado, considerando os montantes das propostas e laboratórios envolvidos nos gastos públicos com drogas psicotrópicas no período 2011-2017. Concluise que o uso generalizado de medicamentos psiquiátricos é a resposta preferida do Estado para os cuidados de saúde mental e obter benefícios econômicos de fundos públicos pela indústria farmacêutica deve ser desafiados a partir de uma leitura crítica chave e alternativa neoliberalismo

Polifarmacia psiquiátrica en personas con esquizofrenia en un establecimiento público de salud mental en Lima / Psychiatric polypharmacy in people with schizophrenia in a public mental health facility in Lima

Objetivos: El presente estudio busca identificar retrospectivamente la prevalencia de polifarmacia psiquiátrica en pacientes con el diagnóstico de esquizofrenia que reciben atención ambulatoria en el Instituto Nacional de Salud Mental "Honorio Delgado - Hideyo Noguchi" (Lima, Perú). Material y Métodos: Se revisaron 430 historias clínicas de pacientes con diagnóstico único de esquizofrenia, supuestamente estables clínicamente, atendidos en Consulta Externa de la Dirección de Adultos o en el Módulo de Intervención Breve del Instituto, durante el año 2016. Resultados: El 84,4% de la muestra recibió más de un psicofármaco, con un promedio de 3,0 psicofármacos por paciente; el 40,5% recibió más de un antipsicótico, con un promedio de 1,5 antipsicóticos por paciente; al 96,2% de los que recibían antipsicóticos de depósito, se agregó uno o más psicofármacos, y al 86,2%, uno o más antipsicóticos por vía oral. Como psicofármacos adicionales, el 50,9% tomaba una benzodiacepina, el 47,0% un anticolinérgico, el 24,4% un antidepresivo inhibidor de la recaptación de serotonina, y el 21,2%, por lo menos un estabilizador del ánimo. El número de psicofármacos en general y antipsicóticos en particular se asoció significativamente con hospitalizaciones previas, antecedente de terapia electroconvulsiva, uso de antipsicóticos de primera generación y uso de antipsicóticos de depósito. Conclusiones: Se encontró una elevada prevalencia de polifarmacia psiquiátrica en la población estudiada, lo que debe motivar la revisión de las guías de práctica clínica y la elaboración de normas que regulen el uso de psicofármacos.

Objectives: The present study attempts to identify retrospectively the prevalence of psychiatric polypharmacy among patients with the diagnosis of schizophrenia who receive outpatient care at the National Institute of Mental Health "Honorio Delgado - Hideyo Noguchi" (Lima, Perú). Material and Methods: Four-hundred thirty clinical records of supposedly clinically stable patients with a single diagnosis of schizophrenia, which were assisted in the External Consultation of the Adult Directorate or in the Brief Intervention Module of the Institute during the year 2016, were reviewed. Results: Of the sample, 84.4 % received more than one psychotropic drug, with an average of 3.0 psychotropic drugs per patient; 40.5 % received more than one antipsychotic, with an average of 1.5 antipsychotics per patient; 96.2 % of those that received depot antipsychotics received, in addition, one or more psychiatric drugs, and 86.2 % received one or more oral antipsychotics. As additional psychiatric drugs, 50.9 % took a benzodiazepine, 47.0 % an anticholinergic, 24.4 % a selective serotonin reuptake inhibitor antidepressant, and 21.2 %, at least one mood stabilizer. The number of psychotropic drugs in general and antipsychotics in particular was significantly associated with previous hospitalizations, history of electroconvulsive therapy, use of first generation antipsychotics and use of depot antipsychotics. Conclusions: A high prevalence of psychiatric polypharmacy was found in the studied population, which should motivate the revision of the clinical practice guidelines and the elaboration of norms that regulate the use of psychotropic drugs.

Prevalência de transtornos mentais e utilização de psicofármacos em pacientes atendidos em um ambulatório médico de especialidades / Prevalence of mental disorders and use of psychiatric drugs in patients of an ambulatory medical specialties

Introdução: Nos últimos anos, muitos autores têm se dedicado para uma maior compreensão das doenças psiquiátricas, destacando-se principalmente: esquizofrenia e transtorno bipolar como as doenças mais graves e depressão, ansiedade e dependência como as mais prevalentes. A terapia medicamentosa para o tratamento dessas doenças psiquiátricas é feita pelo uso de psicofármacos. O presente estudo tem como objetivo determinar a prevalência dos transtornos mentais em um Ambulatório Médico de Especialidades (AME) e o perfil de utilização de psicofármacos nestes pacientes. Métodos: Estudo retrospectivo, do tipo análise documental, em prontuários de pacientes atendidos no AME. A coleta dos dados foi feita com o auxílio do Formulário de Coleta de Dados desenvolvido pelas autoras. Os dados foram compilados em um banco de dados utilizando o programa Microsoft Excel® e apresentados principalmente na forma de estatística descritiva. Resultados: Foram coletados dados de 33 prontuários com indivíduos entre 21 e 79 anos sendo a maioria do sexo feminino, com companheiro, com ocupação e baixa escolaridade. Os transtornos mais prevalentes foram os transtornos de humor, primeiramente depressão (46%) e posteriormente bipolaridade (23%). Os psicofármacos mais utilizados foram os antidepressivos (42%) seguidos pelos antipsicóticos (29%). Conclusão: Os transtornos mais prevalentes foram os transtornos de humor, sendo eles depressão e transtorno bipolar. Quanto aos psicofármacos, a classe mais utilizada foram os antidepressivos, seguidos pelos antipsicóticos. Os dados mostraram a importância do ambulatório para a comunidade local, pois a maioria dos pacientes não faz nenhum outro tipo de acompanhamento.

Introduction: In recent years, many authors have tried to get a greater understanding of psychiatric diseases, highlighting in particular: schizophrenia and bipolar disorder as the most serious illnesses and depression, anxiety and addiction as the most prevalent. Drug treatment of these psychiatric disorders is made mainly with the use of psychoactive drugs. This study aims to determine the prevalence of mental disorders in a Medical Specialties Ambulatory (AME) and the profile of use of psychotropic drugs in these patients. Methods: Retrospective study of document analysis type in records of patients treated at AME. Data collection was made with the help of the Data Collection Form developed by the authors. They have been compiled into a database using Microsoft Excel® and being presented as descriptive statistics. Results: Data were collected from medical records of 33 individuals between 21 and 79 years with the majority of females, mate, with occupation and low education. The most prevalent disorders are mood disorders, first depression (46%) and subsequently bipolarity (23%). The most widely used psychoactive drugs were antidepressants (42%) followed by antipsychotics (29%). Conclusion: The most prevalent disorders were mood disorders, namely depression and bipolar disorder. As for psychiatric drugs, the most widely used class antidepressants were followed by antipsychotics. Data showed the importance of the clinic for the local community, because most patients do not do any other type of monitoring.

Comparison and Analysis about Off-indication Use of Psychiatric Drugs in Our Hospital by the Standards of CFDA and FDA / 中国药房

OBJECTIVE:To investigate off-indication use of oral chemical drugs medical orders by the standards of CFDA and FDA,and to compare the differences between the two standards,analyze reasons and rationality of drug use,so as to pro-vide reference for establishing off-indications use management system. METHODS:The oral chemical drugs medical orders of inpatients were analyzed statistically during Jan.-Jun. 2016. Off-label uses was judged according to the standards of CFDA and FDA. RESULTS:Totally 507 oral chemical drugs medical orders were collected,the percentage of off-indications use were in high level,being 58.58% and 55.82% respectively by the standards of CFDA and FDA. The incidence of off-indication use of quetiapine and aripiprazole by the CFDA standards were significantly higher than the results of FDA standards,with statistical significance(P<0.05). Magnesium valproate(54.03%),escitalopram oxalate(10.45%)and quetiapine(10.15%)occupied the top 3 places in the list of constituent ratio. Among off-indication medical orders,7 orders had no evidence-based medicine,ac-counting for 2.36% of total. CONCLUSIONS:Most off-indication medical orders of our hospital could provide the basis and lit-erature support,while there are still a few off-indication use with insufficient evidence. The corresponding management system of the hospital should be formulated to guarantee the medication safety of the patients and legitimate rights and interests of the doctors.

Analysis of 114 Cases of Serious ADR in Our Hospital / 中国药房

OBJECTIVE:To investigate the characteristics of serious ADR in psychiatric hospital,and to provide reference for effective and safe use of drugs in the clinic. METHODS:114 cases of serious ADR in our hospital from 2004 to 2015 were ana-lyzed retrospectively in terms of general information,primary disease,route of administration,dosage form,drug types,organs or systems involved in ADR and clinical manifestations,top 5 ADR-inducing drugs and main clinical manifestations,etc. RESULTS:Of 114 serious ADR cases,the number of female was more than that of male(71/43). Patients aged 21-30 years old took up the greatest proprotion(35 cases,30.70%). The main involved primary disease was schizophrenia(54 cases,47.37%). Oral adminis-tration-induced ADR was most common(103 cases,90.35%). The main involved drugs were antipsychotics,occupying the great-est proportion(75 cases,65.79%). Digestive system involved was the most common(53 cases,42.74%), Olanzapine tablets had the highest incidence of serious ADR (23 cases,18.55%),the main clinical manifestation were both abnormal liver function. There were 8 cases of new serious ADR (7.02%). Most of the ADR can be cured after drug withdrawal or countermeasures,no death case was found. CONCLUSIONS:Psychiatric drugs can induce serious ADR as treat psychiatric disease,among which the in-cidence of ADR induced by Olanzapine tablets is the highest and mainly manifestes digestive system symptoms. It is suggested to strengthen serious ADR monitoring to promote the safe use of drugs.

Effect of comprehensive intervention on antipsychotic drug induced constipation / 中华健康管理学杂志

Objective To explore the effect of comprehensive intervention on constipation caused by antipsychotic drugs.Methods Ninty patients with antipsychotic drug induced constipation who were admitted to our hospital from June 2012 to October 2013 were enrolled in this investigation and randomly assigned to the comprehensive intervention group(CIG,n=46) and the routine care group(RCG,n=44).The subjects of the RCG received routine diet and medication therapy; and those of CIG received comprehensive intervention of life style,psychological ability,cognition,nursing and traditional chinese medicine(TCM) for 3 months.Constipation symptoms scale and Patient Assessment of Constipation Quality of Life Questionnaire (PAC-QOL) were assessed before and after the intervention.Results CIG showed significant improvement in defecation difficulty,defecation force,defecation duration,frequency,abdominal distension,total symptom score,PAC-QOL,physical discomfort,psycho-social discomfort,anxiety and treatment satisfaction were(2.8±2.1),(2.2±1.6),(2.4±1.3),(2.1±1.7),(1.5±0.9),(14.0±8.1)respectively (t values were 2.629,3.818,2.328,2.593,2.578,2.913,7.499,2.570,5.012,2.249 and 12.259,respectively; all P＜0.05).Conclusion Comprehensive intervention may be an effective therapy against psychiatric drug induced constipation.

A Study on Polypharmacy in the Elderly Psychiatric Outpatients with Persistent Treatments for 3 years

OBJECTIVES: The objective of this study was to investigate the prescription trends for the elderly psychiatric outpatients at a university hospital. METHODS: We performed a retrospective study based on medical records. Data on 146 elderly patients (65 years and older) diagnosed with psychiatric disorders according to ICD-10 from January 2005 to March 2008 were collected. Analyses were performed regarding demographic characteristics, prevalence of polypharmacy, and the doses and types of drugs prescribed. RESULTS: In 146 subjects, the mean age was 76.14+/-5.21. More than five types of drugs were prescribed to 49.5% of the patients in 2008. The percentage of stable users (those without changes in the category of polypharmacy for 3 years) was 69.8%. Each patient received an average of 4.20+/-1.50 kinds of drugs in 2005 and 4.02+/-1.77 in 2008. The average dose of drugs was 6.1+/-3.50 in 2005 and 6.49+/-4.09 in 2008, and the difference was not statistically significant. The average number of types of psychiatric drugs prescribed to the patients decreased from 2.37+/-0.86 in 2005 to 2.17+/-0.87 in 2008 (p<0.05). CONCLUSION: Although practice of polypharmacy showed a slow increase over the 3 years from 2005 to 2008, almost half of the elderly patients we studied received multiple drugs. Since polypharmacy can increase drug-drug interactions and adverse effects in the elderly, appropriate drug monitoring and careful prescription are necessary.

A Study on Polypharmacy in the Elderly Psychiatric Outpatients with Persistent Treatments for 3 years

OBJECTIVES: The objective of this study was to investigate the prescription trends for the elderly psychiatric outpatients at a university hospital. METHODS: We performed a retrospective study based on medical records. Data on 146 elderly patients (65 years and older) diagnosed with psychiatric disorders according to ICD-10 from January 2005 to March 2008 were collected. Analyses were performed regarding demographic characteristics, prevalence of polypharmacy, and the doses and types of drugs prescribed. RESULTS: In 146 subjects, the mean age was 76.14+/-5.21. More than five types of drugs were prescribed to 49.5% of the patients in 2008. The percentage of stable users (those without changes in the category of polypharmacy for 3 years) was 69.8%. Each patient received an average of 4.20+/-1.50 kinds of drugs in 2005 and 4.02+/-1.77 in 2008. The average dose of drugs was 6.1+/-3.50 in 2005 and 6.49+/-4.09 in 2008, and the difference was not statistically significant. The average number of types of psychiatric drugs prescribed to the patients decreased from 2.37+/-0.86 in 2005 to 2.17+/-0.87 in 2008 (p<0.05). CONCLUSION: Although practice of polypharmacy showed a slow increase over the 3 years from 2005 to 2008, almost half of the elderly patients we studied received multiple drugs. Since polypharmacy can increase drug-drug interactions and adverse effects in the elderly, appropriate drug monitoring and careful prescription are necessary.

Uso de psicofármacos en adultos mayores institucionalizados en Sector Oriente de la Región Metropolitana / Prescription of psychiatric drugs in elderly patients in nursing homes in east side of Santiago, Chile

Introducción: La población de adultos mayores (AM) ha aumentado en los últimos años en nuestro país. Ellos presentan una alta prevalencia de patologías neuropsiquiátricas. Se sabe que el hecho de institucionalizar a un AM es un factor desencadenante o mantenedor de patología psiquiátrica. En relación al tratamiento de los ancianos, es conocido que éstos son más lábiles frente a fármacos, por lo que la prescripción debe ser indicada individual y apropiadamente, sopesando los beneficios y los riesgos. El objetivo de este estudio es evaluar los factores que influyen en el uso de psicofármacos en casas de reposo del sector oriente de Santiago de Chile. Metodología: Se recolectaron datos de fichas médicas de cuatro centros de la Región Metropolitana aprobados por MINSAL. Resultados: Influyen en el número de psicofármacos prescritos a los ancianos: costo mensual de la institución, número de ancianos a cargo de un funcionario de la casa de reposo, grado de autovalencia, meses institucionalizados y la edad del adulto mayor. Discusión: Los AM institucionalizados tienen una alta prevalencia de diagnósticos psiquiátricos (74,7 por ciento), así como indicación de psicofármacos (75,3 por ciento). Hay factores distintos al diagnóstico que influyen en el número de psicofármacos que se indican al AM.

Introduction: Elderly population has increased in Chile in the past years. Elderly people show a high prevalence of neuropsychiatric disorders. It is known that institutionalization of an elderly person is a triggering factor or a maintenance factor for psychiatric disorders. It is also known that old people have greater liability to present side effects of medications, thus the importance of individual appropriate prescription, considering benefits and risks. The objective of this study is to evaluate factors affecting the use of psychiatric drugs in nursing homes in the east side of the city of Santiago, Chile. Method: Data was obtained from the medical record of patients from four centers located in the city, all of them certified by the Ministry of Health. Results: Factors affecting the number of psychiatric drugs prescribed are: cost of the nursing home, number of elderly patients per caregiver at the nursing home, time elapsed since date of institutionalization, age and degree of self care capacity of elderly patients. Discussion: Elderly patients in nursing homes have a high prevalence of psychiatric disorders (74,7 percent), and also of psychiatric drug prescription(75,3 percent). There are factors other than the diagnosis, that affect the number of different psychiatric drugs prescribed to the elderly patient.

The relationships of leptin, adiponectin levels and paraoxonase activity with metabolic and cardiovascular risk factors in females treated with psychiatric drugs

OBJECTIVES: The aim of this study was to investigate serum leptin, adiponectin and paraoxonase1 levels in adult females receiving pharmacotherapy for various psychiatric disorders. METHODS: The study group consisted of 32 obese females (mean age 40.53 ± 11.00 years, mean body mass index 35.44 ± 5.33 kg/m2) who were receiving treatment for psychiatric disorders, and the control group included 22 obese females (mean age 35.95 ± 9.16 years, mean body mass index 30.78 ± 3.33 kg/m2) who were free of psychiatric disorders. Analyses were performed using a bioelectrical impedance device. Fasting blood samples were obtained for complete blood count and various biochemical tests, including determination of leptin, adiponectin and paraoxonase1 activity. RESULTS: Body mass index, waist and hip circumference, body fat percentage, fasting blood glucose, insulin, glycosylated hemoglobin, homeostasis model assesment of insulin resistance, alanine transaminase, aspartate tarnsaminase, and leptin levels were significantly higher in the study group than in controls. Although body weight was positively correlated with leptin levels in both groups, body weight was negatively correlated with adiponectin levels in the control group and positively correlated with adiponectin levels in the study group. In the study group, body mass index and hip circumference correlated positively with leptin levels, hip circumference correlated positively with adiponectin levels, and waist to hip ratio correlated positively with paraoxonase levels. In the control group, body mass index as well as waist and hip circumferences were positively correlated with leptin levels. Weight, body mass index, and hip circumference were also negatively correlated with the adiponectin/leptin ratio in the control group. CONCLUSION: This study indicates a higher risk for obesity-related disorders, particularly metabolic syndrome, diabetes and cardiovascular disease, in patients treated with psychiatric drugs.