Análise da readmissão hospitalar do paciente com diagnóstico de esquizofrenia em um hospital psiquiátrico de referência no sul catarinense / Analysis of hospital readmission of the patient diagnosed with schizophrenia admitted to a psychiatric hospital in southern Santa Catarina

A esquizofrenia é um transtorno mental com sério comprometimento não apenas nas funções psiquiátricas do paciente, mas também no que abrange seu ciclo de apoio social e suas relações interpessoais. Este trabalho tem como objetivo principal tecer uma análise sobre as principais características do paciente com diagnóstico de esquizofrenia, assim como a abordagem de fatores sociodemográficos em um ponto de vista voltado à frequente institucionalização de tais pacientes, em um hospital psiquiátrico no sul catarinense, no período de janeiro 2007 a dezembro de 2016. Trata-se de um estudo observacional, retrospectivo, de abordagem quantitativa, com coleta de dados secundários obtidos através da análise de prontuários médicos de indivíduos com no mínimo duas internações, os quais 344 pacientes compuseram a amostra final. A população é 71,8% do sexo masculino, a média de idade é de 48,8 anos e é majoritariamente composta por indivíduos solteiros ou divorciados (88,1%). Maior parte das internações é de caráter voluntário (66,8%), além de que 72,1% das altas são do tipo melhorado. O número mediano de internações é 11, o tempo de reinternação de 2 meses e o tempo em comunidade de 3 meses. Observou-se que, como outros centros de hospitalização psiquiátrica, os pacientes com esquizofrenia tendem a perpetuar um perfil reinternante ao longo da vida, tornando imprescindível o acompanhamento dos mesmos fora da área hospitalar, a fim de garantir um curso mais brando da doença e reintegração social dessas pessoas.

Schizophrenia is a mental disorder with serious commitment, not only patient's psychiatric functions, but also when it comes to social support and interpersonal relationships. This paper aims to analyze the main features of the patient with the diagnosis of schizophrenia, as well as the socio-demographics factors involved on the frequent institutionalization of such patients in a mental hospital in southern Santa Catarina, from January 2007 to December 2016. This is an observational, retrospective and quantitative approach, with secondary data collection obtained through the analysis of medical records of individuals with at least two hospitalizations, which 334 patients composed the final sample. The population is 71.8% male, the average age is 48.8 years old and is mostly composed of single or divorced individuals (88.1%). Most of the hospitalizations are volunteer (66.8%) and 72.1% of the discharges are medically improved. The median number of hospitalizations is 11, the period of hospitalization is 2 months and the time in community is 3 months. It was noticed that, as seen at others psychiatric hospitalization centers, schizophrenic patients tend to perpetuate a readmission status throughout life, making it essential a treatment and rehabilitation follow-up outside the hospital environment, in order to ensure a smoother course of illness, besides social reintegration of such patients.

Orientación de Enfermería para detectar síntomas prodrómicos y evitar reingreso psiquiátrico temprano / Nursing guidance to detect prodromal symptoms and avoid early psychiatric readmission

A partir de una reflexión sobre los espacios académicos que tiene actualmente el problema de la puerta giratoria y el abordaje de la persona con trastorno mental desde la Enfermería, se logra desarrollar en el presente documento, un lineamiento teórico, histórico y práctico, en forma de orientación, dirigido al profesional de enfermería en salud mental, facilitando la detección temprana de síntomas prodrómicos psiquiátricos, teniendo en cuenta, los diferentes momentos en que se pueda exacerbar dicha sintomatología (prehospitalización, hospitalización y egreso) así como, sugerir un adecuado abordaje a cada uno de los actores participes en el tratamiento ( Familia, Sociedad, Instituciones, Profesionales) previniendo el reingreso psiquiátrico institucional de la persona con trastorno mental.

Having in count the reflection about the different academic meetings that has the early revolving door problem and the psychiatric nursing approach, it is possible to develop this paper, a theorical, historical and practical lineament, in orientation form, addressed to mental health nursing professionals, facilitating the psychiatric prodromal symptom's early detection, having in count, the different moments when it could exacerbate this symptomatology (pre-hospitalization, hospitalization and discharge) ) preventing patient's psychiatric reentry.

Inclusão da diferença e reinternação psiquiátrica: estudo através de um “caso traçador” / Inclusion of the different and psychiatric readmission: a study using a “case tracer” / Le rapport entre l’inclusion de la différence et l’internement psychiatrique répétée: réalisation d’une recherche à l’aide d’un ®cas traceur¼ / La inclusión de la diferencia y la readmisión psiquiátrica: un estudio mediante un “caso trazador

Tendo como referencial a Reforma Psiquiátrica Brasileira procurou-se investigar de que forma os vínculos de um usuário com seu território podem influenciar suas reinternações psiquiátricas. Com este objetivo, utilizamos a ferramenta metodológica do usuário guia e a noção de “caso traçador do cuidado”, para posterior análise de conteúdo do material. Concluímos que um fator protetor, o qual merece mais investigação, está relacionado à diversidade de tipos de vínculo construídos com o usuário. Formulamos a hipótese de que os dispositivos de saúde podem favorecer essa diversidade caso sejam capazes de se organizarem em equipes heterogêneas.

Based on the Brazilian Psychiatric Reform, the present study aims to investigate how the bonds of a subject with his territory may influence his psychiatric readmissions. This research was developed using the user-guide methodology, as well as the “case tracer care” concept to engage in content analysis. We concluded that the ‘protective factor’, which requires further investigation, is related to the diversity of the types of bonds constructed with the subject. We suggest the hypothesis that health services may encourage that diversity if they are able to set up heterogeneous teams.

Ayant comme repère la réforme psychiatrique brésilienne, notre recherche porte sur la façon dont les liens avec le territoire peuvent influencer les internements psychiatriques répétés. Dans ce but, nous nous sommes basés sur la méthodologie de ®l’usager-guide¼ et sur la notion de ®cas traceur des soins¼, ainsi que sur l’examen des contenus du matériel. Nous concluons que le facteur protecteur, qui demande une recherche plus détaillée, est lié à la diversité des types de liens construite avec l’usager. Nous formulons l’hypothèse selon laquelle les dispositifs de santé peuvent favoriser cette diversité dans la mesure où ils sont capables de s’organiser en équipes hétérogènes.

Teniendo como referencia la Reforma Psiquiátrica Brasileña, se buscó investigar cómo los vínculos del usuario con su territorio pueden influir en sus reingresos psiquiátricos. Con este objetivo, utilizamos la herramienta metodológica del usuario-guía y la noción de “caso trazador del cuidado” para posterior análisis del contenido del material. Llegamos a la conclusión de que un factor protector, que merece más investigación, está relacionado con la diversidad de tipos de vínculos construidos con el usuario. Hemos formulado la hipótesis que los dispositivos de salud favorecen esa diversidad, sólo si fuesen capaces de organizarse en equipos heterogéneos.

"Postauricular ""revolving door"" flap in one stage reconstruction of concha defect" / 中华医学美学美容杂志

Objective To study the technique of using the postauricular revolving door island flap in one-stage reconstruction of concha defect and its efficacy.Methods Fifteen cases of concha de fect were repaired by the postauricular revolving door island flap in one stage reconstruction from 2000-2010.The maximum size of defect was 2.7 cm× 3.0 cm,and the minimum was 1.0 cm×1.3 cm.Results All the island flaps were survived postoperatively,and satisfactory in auricular appearances of all patients by 6 months to 5 years follow-up.Conclusions The revolving door island flaps with abundant blood supply are transferred to reach the auricular defect,which match normal auricular tissue in contour,color,and texture. This flap on the retroauricular area is relatively concealed,and it therefore can be one of the best procedures for repair of the auricular defects,especially concha.

Análise contextual de reinternações frequentes de portador de transtorno mental / Contextual analysis of frequent hospital readmissions of the individual with mental disorder / Análisis contextual de reingresos frecuentes del portador de trastorno mental

Este estudo analisou o contexto de reinternações frequentes de indivíduos com sofrimento psíquico em suas dimensões: imediata, específica, geral e metacontextual. Seguindo a perspectiva contextual proposta pelo referencial teórico de Hinds, Chaves e Cypress (1992), categorizaram-se os resultados encontrados na revisão narrativa da literatura científica em quatro subtemas referentes às dimensões contextuais: 1) a porta giratória da psiquiatria (nível contextual imediato); 2) desarticulação da rede de atenção em saúde mental (nível contextual específico); 3) o louco e a loucura no imaginário social: o hospital como o lugar da "cura" (nível contextual geral); 4) paradigmas da saúde mental: a dimensão epistemológica do saber/fazer psiquiátrico (metacontexto). Analisar e compreender os contextos nos quais estão inseridas as reinternações psiquiátricas torna-se, na atualidade, aspecto significativo para a efetivação dos avanços conquistados pela Reforma Psiquiátrica brasileira e pelo Sistema Único de Saúde.

This study analyzed the context of frequent hospital readmissions of individuals with psychic suffering in the following dimensions: immediate, specific, general and metacontextual. Following the contextual perspective proposed by the theoretical framework of Hinds, Chaves and Cypress (1992), the results of the narrative review of the scientific literature were categorized in four subthemes corresponding to the contextual dimensions: 1) the revolving door of psychiatry (immediate contextual level); 2) disarticulation of the mental health care network (specific contextual level); 3) the mad person and madness in the social mental imagery: the hospital as the "healing" place (general contextual level); 4) mental health paradigms: the epistemological dimension of psychiatric knowledge and action (metacontext). The analysis and comprehension of the contexts in which psychiatric hospital readmissions are included are significant so that the advances achieved by the Brazilian Psychiatric Reform and by the National Health System become effective.

Este estudio examina el contexto de los frecuentes reingresos de pacientes con trastornos psicológicos en las dimensiones: inmediatas, específicas, generales y meta-contextuales. Siguiendo la perspectiva contextual propuesta por el marco teórico de Hindes, Chaves y Cypress (1992), los resultados encontrados en la revisión narrativa de la literatura científica se clasifican en cuatro sub-temas relativos a las dimensiones contextuales: 1) la puerta giratoria de la psiquiatría (contexto inmediato); 2) desarticulación de la red de salud mental (contexto específico); 3) el loco y la locura en lo imaginario social; el hospital como un lugar de "curación" (contexto general); 4) paradigmas de salud mental: la dimensión epistemológica del saber/hacer psiquiátricos (metacontexto). Analizar y comprender los contextos donde se insertan los reingresos psiquiátricos se convierte, actualmente, en un aspecto significativo para confirmar los avances conquistados por la Reforma Psiquiátrica brasileña y el Sistema Único de Salud.

O fenômeno da reinternação: um desafio à reforma psiquiátrica / The phenomenon of "revolving door": a challenge to the psychiatric reform

O fenômeno da reinternação em hospital psiquiátrico, conhecido na literatura como "revolving door", é de altíssima incidência na maioria das instituições, indicando a relevância de conhecer suas causas e pensar estratégias que o evitem. Objetivou-se avaliar as reinternações no Hospital Dr. João Machado (HJM), em Natal, RN, bem como identificar os efeitos da proposta de alta assistida desse hospital. Realizaram-se leituras dos prontuários de usuários que passaram pela alta assistida do HJM e entrevistas abertas com profissionais, além de uma revisão bibliográfica acerca da reinternação psiquiátrica, a fim de elucidar o que a literatura tem encontrado. Constatou-se que o projeto enfrenta alguns entraves e que a estratégia de dar assistência após a alta hospitalar, garantindo uma atenção continuada e inserida no meio social e familiar, é fundamental na tentativa de evitar a reinternação.

The phenomenon of rehospitalization in a psychiatric hospital, known in the literature as "revolving door", has a high incidence in the majority of the institutions. Knowing the causes of that phenomenon and thinking about strategies to enable its rupture are pertinent worries. On this path, the present research was developed, seeking to evaluate the "revolving door" on a psychiatric hospital - the Dr. João Machado Hospital (HJM), in the city of Natal, Rio Grande do Norte, Brazil - and the effects of the proposal of a assisted discharge in this hospital. The handbook of the patients who were submitted to the assisted discharge was read and interviews with professionals were carried out. In addition, it was made a literature review about the psychiatric rehospitalization to elucidate what the literature has found. In the end, it was possible to detect problems that evolve this follow-up and it was verified that the strategy of assisting the patient on the after-discharge, giving him/her appropriate and continuing attention in the social and familiar environment is fundamental to avoid the "revolving door".

Association between violent behavior and psychotic relapse in schizophrenia: once more through the revolving door? / Asociación de la conducta violenta y la recída psicótica en la esquizofrenia: ¿una vez más a través de la puerta revolvente?

Summary: The potential for violence in a number of persons with mental illnesses stimulates public fear and prevents general acceptance of persons with psychiatric disabilities. Schizophrenia has been the diagnosis most often associated with violence as it has been taken as a paradigm of insanity, incompetence and dangerousness. Clinicians' efforts to prevent violence through conventional external patient treatment are impede by several situational variables and patients become trapped in a costly cycle of repeated institutional admissions (revolving door phenomenon) in the most restrictive settings, going through involuntary in-patient treatment. The major hypothesis proposed in this review is that violence in schizophrenia can become a part of a self-perpetuating cycle, in which the combination of non-adherence to treatment and an inadequate management of illness from families and caregivers leads to violent behavior and deteriorated social relationships, finally resulting in institutional recidivism. As some of the initial symptoms of the illness, such as irritability and agitation may not be detected by the patient and his/her family, these symptoms eventually can easily escalate into open hostility, and the accompanying behavior is frequently violent. Disturbed moods secondary to psychotic symptoms, such as fear and anger apparently can also activate violent psychotic action. Accordingly, the path from the characteristics of the illness to violence leads to them through psychotic symptoms and lack of insight, and results in symptom-consistent violence. When psychotic symptoms and violent behavior cannot be managed by caregivers, patients are brought to the attention of psychiatric services and frequently admitted to patient service. During admission for a psychotic episode, there are more violent incidents than later on in the disease. As patients respond to medication and hospital environment, violent incidents and psychotic symptoms decrease in frequency and severity. After hospital discharge, patients may assume greater autonomy and control over several aspects of their daily lives. Nevertheless, this process may be hampered by familial reactions to the burden of living with a family member with schizophrenia. This burden can also be exacerbated because many patients have a history of violent behavior and families may experience negative attitudes towards them. In line with this, there is evidence of significant differences between the professionals' perception about symptoms and illness, and that of the patient and his/her family. Sometimes, these different conceptions may reflect a lack of awareness regarding illness and treatment that may lead to discontinue medication. Medication suspension can lead to an eventual relapse which most obvious sign is the emergence of positive psychotic symptoms. Nevertheless if a patient has a past history of violent behavior, it is very likely that these behaviors will appear during relapse and it may be necessary to consider hospitalization. Although treatment with antipsychotics may be useful when violence is secondary to psychotic symptoms, violence might be indirectly reduced through clinical programs aimed at increasing insight into illness and treatment. A psychoeducational strategy may improve antipsychotic treatment compliance by helping the patients to work through their ambivalence regarding antipsychotic medication. For families, a psychoeducation strategy can lead to a change in attitudes toward the disorder, as well as to promote problem-solving skills for violence. The model presented here suggests that violence in schizophrenia is conditioned by several factors such as psychotic symptoms, medication non-compliance and lack of social support. The prevention of violent behavior in schizophrenia should include attention to other areas, such as the quality of the social environment surrounding the patient. For the "revolving door" patients, violence may be a key factor that complicates treatment. Health professionals have the responsibility to work in partnership with patients and their families for the prevention of violence.

Resumen: La esquizofrenia ha sido el principal diagnóstico psiquiátrico asociado con la violencia. La prevención de la violencia a través del tratamiento ambulatorio se ha visto obstaculizada por diversas variables situacionales y muchos pacientes llegan a verse inmersos en un ciclo de continuas admisiones hospitalarias (fenómeno de la puerta revolvente). La hipótesis central de la presente revisión es que la violencia en la esquizofrenia puede formar parte de un ciclo recurrente de hospitalizaciones psiquiátricas, en el que, combinados la falta de adhesión al tratamiento y el manejo inadecuado de la enfermedad por parte de los familiares, dan por resultado la manifestación del comportamiento violento. Diversas investigaciones han mostrado que tanto los síntomas psicóticos, como las alteraciones del ánimo secundarias a su presencia y la falta de una conciencia de enfermedad, son las principales características de la esquizofrenia, asociadas con la manifestación de la violencia en dicho padecimiento. Cuando los familiares no pueden manejar los síntomas psicóticos y el comportamiento violento del paciente, se busca la atención en un servicio especializado de psiquiatría, y con frecuencia, el paciente tiene que ser hospitalizado. La manifestación de conductas violentas ha sido considerada como una de las principales causas de hospitalización psiquiátrica. Diversas investigaciones han documentado que los actos violentos se presentan con mayor frecuencia durante la admisión hospitalaria por un episodio psicótico que en otros momentos durante el curso del padecimiento. Asimismo, la hospitalización psiquiátrica pos sí misma reduce la frecuencia e intensidad de la violencia, debido probablemente al tratamiento con antipsicóticos y al entorno restrictivo de las instalaciones. Tras la alta hospitalaria, los pacientes viven un proceso de transición mediante el cual van asumiendo mayor autonomía y control sobre diversos aspectos de su vida cotidiana. Sin embargo, este proceso se puede ver obstaculizado por las reacciones familiares secundarias al desgaste físico y emocional de vivir con un familiar con esquizofrenia. Asimismo, este desgaste puede verse exacerbado debido al antecedente de violencia en muchos de estos pacientes. Se ha descrito que la percepción que tienen los pacientes y sus familiares con respecto a los síntomas de la enfermedad difiere significativamente de la de los especialistas de la salud mental. A veces, estas diferencias se asocian con falta de discernimiento y conciencia sobre la enfermedad y con la necesidad de tratamiento médico, lo que a su vez puede llevar a la suspensión del mismo. La suspensión del tratamiento farmacológico induce a una eventual recaída cuyos signos más evidentes son los síntomas psicóticos. No obstante, si un paciente tiene antecedentes de comportamiento violento, es muy probable que este comportamiento surja durante la recaída y que sea necesario considerar nuevamente la hospitalización. En estos pacientes, en quienes la violencia tiene un importante papel en las hospitalizaciones recurrentes, es necesario considerar el establecimiento de programas clínicos, que incluyan la psicoeducación, dirigidos a incrementar la conciencia del paciente y de los familiares, sobre la enfermedad y la necesidad del tratamiento farmacológico. El modelo presentado en esta revisión sugiere que la violencia en la esquizofrenia es una condición generada por diversos factores tales como los síntomas psicóticos, la falta de adherencia al tratamiento y el inadecuado apoyo social. La prevención de la conducta violenta en la esquizofrenia no sólo debe fundamentarse en el uso de antipsicóticos, ya que existen otras áreas en las que intervienen las características propias del individuo y su entorno social. Los profesionales de la salud mental tienen la responsabilidad de trabajar en conjunto con los pacientes y sus familiares para prevenir la manifestación de conductas violentas. Es necesario realizar futuros estudios dirigidos a evaluar la forma en la que los servicios de salud mental pueden ser más efectivos en la reducción y prevención de la violencia en la esquizofrenia.