Uso de antipsicóticos atípicos no tratamento da esquizofrenia no Sistema Único de Saúde do Brasil: estudo de coorte, 2008-2017 / Uso de antipsicóticos atípicos en el tratamiento de la esquizofrenia en el Sistema Único de Salud de Brasil: estudio de 2008 a 2017 / Use of atypical antipsychotics in the treatment of schizophrenia in the Brazilian National Health System: a cohort study, 2008-2017

Objective: to investigate sociodemographic and clinical characteristics of users of atypical antipsychotics receiving care via the Specialized Component of Pharmaceutical Assistance (Componente Especializado da Assistência Farmacêutica - CEAF), for the treatment of schizophrenia in Brazil, between 2008 and 2017. Methods: this was a retrospective cohort study using records of the authorizations for high complexity procedures retrieved from the Outpatient Information System of the Brazilian National Health System, from all Brazilian states. Results: of the 759,654 users, 50.5% were female, from the Southeast region (60.2%), diagnosed with paranoid schizophrenia (77.6%); it could be seen a higher prevalence of the use of risperidone (63.3%) among children/adolescents; olanzapine (34.0%) in adults; and quetiapine (47.4%) in older adults; about 40% of children/adolescents were in off-label use of antipsychotics according to age; adherence to CEAF was high (82%), and abandonment within six months was 24%. Conclusion: the findings expand knowledge about the sociodemographic and clinical profile of users and highlight the practice of off-label use.

Objetivo: investigar las características sociodemográficas y clínicas de los usuarios de antipsicóticos atípicos, atendidos por el Componente Especializado de Asistencia Farmacéutica (CEAF) para el tratamiento de la esquizofrenia en Brasil, de 2008 a 2017. Métodos: estudio de cohorte retrospectivo utilizando registros de autorizaciones de trámites de alta complejidad del Sistema de Información Ambulatorio del SUS, de todos los estados brasileños. Resultados: de los 759.654 usuários identificados, el 50,5% era del sexo feminino de la región Sudeste (60,2%), diagnosticadas con esquizofrenia paranoide (77,6%). Hubo una mayor prevalencia de risperidona (63,3%) entre niños y adolescentes; de olanzapina (34,0%) en adultos; y quetiapina (47,4%) en ancianos. Alrededor del 40% de los niños/adolescentes estaba bajo uso no autorizado de antipsicóticos según la edad. La adherencia al CEAF fue alta (82%), y la deserción a los seis meses fue del 24%. Conclusión: los hallazgos amplían el conocimiento sobre el perfil sociodemográfico y clínico de los usuarios y destacan la práctica del uso off-label.

Objetivo: investigar características sociodemográficas e clínicas de usuários de antipsicóticos atípicos assistidos pelo Componente Especializado da Assistência Farmacêutica (CEAF), para tratamento da esquizofrenia no Brasil, de 2008 a 2017. Métodos: estudo de coorte retrospectivo utilizando registros das autorizações de procedimentos de alta complexidade do Sistema de Informações Ambulatoriais do Sistema Único de Saúde, de todos os estados brasileiros. Resultados: dos 759.654 usuários, 50,5% eram do sexo feminino, da região Sudeste (60,2%), diagnosticados com esquizofrenia paranoide (77,6%); observou-se maior prevalência de uso da risperidona (63,3%) entre crianças/adolescentes; de olanzapina (34,0%), em adultos; e quetiapina (47,4%), nos idosos; cerca de 40% das crianças/ adolescentes estavam sob uso off-label de antipsicóticos segundo a idade; a adesão ao CEAF foi alta (82%), e o abandono em seis meses foi de 24%. Conclusão: os achados ampliam o conhecimento sobre perfil sociodemográfico e clínico dos usuários e destacam a prática do uso off-label.

Prescripción de antipsicóticos de depósito en la policlínica del Hospital Vilardebó / Prescripción de antipsychotics deposito in the polyclinic of the Hospital Vilardebó

Los medicamentos en su formulación de depósito son utilizados como una intervención para la adherencia cuando se dificulta el cumplimiento vía oral. Es frecuente la baja adherencia a los tratamientos por vía oral en las personas con enfermedades crónicas. Se llevó a cabo un estudio observacional, descriptivo de corte transversal, de una muestra aleatorizada de los pacientes que reciben antipsicóticos de depósito, asistidos en la Policlínica del Hospital Vilardebó en el año 2014. El objetivo fue describir las características de la población que tiene prescripto antipsicótico de depósito en la consulta ambulatoria y conocer los hábitos prescriptivos de estos para favorecer su uso racional. La patología psiquiátrica más prevalente fue la esquizofrenia con 56,4 %, donde se usó con más frecuencia la pipotiazina, siendo este más oneroso que el tratamiento con haloperidol y con un perfil de seguridad y efectividad similar. No se encontraron diferencias entre el uso de anticolinérgicos para los efectos extrapiramidales. Más de dos tercios de los pacientes (69,7 %) estuvieron con polifarmacia antipsicótica y un cuarto de los pacientes (24,7 %) con más de 2 antipsicóticos, a pesar de que en las pautas internacionales no recomiendan tratamientos que justifiquen el uso de más de dos antipsicóticos, dado que no existe evidencia que avale esta práctica, además del riesgo aumentado de reacciones adversas. Un bajo porcentaje (20 %) recibió la medicación de depósito todos los meses del año, resultando de vital importancia evaluar en estudios posteriores las causas intervinientes.

Depot formulation drugs are used as an adherence intervention when oral adherence is difficult to achieve. Low adherence to oral drugs is commonly observed in people with chronic diseases. An observational, descriptive, cross-sectional study was carried out on a randomized sample of patients receiving depot antipsychotics, treated at Hospital Vilardebó Outpatient Clinic in 2014. The aim was to describe this population's characteristics and prescription habits at the clinic in order to promote rational use. The most prevalent disorder was Schizophrenia (56.4%); pipothiazine was the most frequently used drug. It is more expensive than haloperidol with similar safety and efficacy profiles. There was no difference in the use of anticholinergic drugs to prevent extrapyramidal side effects. More than two thirds of the patients (69.7%) received antipsychotic polypharmacy and a fourth of the patients (24.7%) received more than two antipsychotics in spite of the fact that international treatment guides do not recommend the use of more than two because of lack of benefit evidence and increased risk of adverse reactions. Only 20 % of the patients received the depot every month of the year, being of vital importance to evaluate in subsequent studies the intervening causes.

Efficacy and safety of paliperidone palmitate 3-month formulation in Latin American patients with schizophrenia: A subgroup analysis of data from two large phase 3 randomized, double-blind studies

Objective: To analyze the efficacy and safety of paliperidone palmitate 3-monthly (PP3M) in Latin American patients with schizophrenia vs. rest-of-world (ROW). Methods: We analyzed data from two multinational, double-blind (DB), randomized, controlled phase 3 studies including patients with schizophrenia (DSM-IV-TR) previously stabilized on PP1M/PP3M (open-label [OL] phase). Patients were randomized to PP3M or PP1M (noninferiority study A) and PP3M or placebo (study B) in DB phase. The subgroup analysis included Latin American (Argentina, Brazil, Colombia, Mexico) patients. Primary efficacy endpoints were relapse-free rates (study A) and time-to-relapse (study B). Results: In study A, 63/71 (88.7%) and in study B 38/43 (88.4%) Latin American patients completed the DB phase. In study A, relapse-free percentage was similar in Latin America (PP3M: 97%, PP1M: 100%) and ROW (PP3M: 91%, PP1M: 89%). In study B, median time-to-relapse was not estimable in the Latin American subgroup for either placebo or PP3M groups, nor for the ROW PP3M group; the median time-to-relapse in the ROW placebo group was 395 days. Caregiver burden improved in patients switching from oral antipsychotics (OL baseline) to PP3M/PP1M in DB phase (Involvement Evaluation Questionnaire score mean ± SD change, -9.4±15.16; p < 0.001). Treatment emergent adverse events with PP3M during DB phase were similar in Latin America (study A: 24/34 [70.6%]; study B: 15/21 [71.4%]) and ROW (study A: 318/470 [67.7%]; study B: 84/139 [60.4%]) subgroups. Conclusion: PP3M was efficacious and showed no new safety concerns in patients with schizophrenia from Latin America, corroborating ROW findings. Clinical trial registration: NCT01515423, NCT01529515

Unavailability of appropriate doses and need for tablet splitting of psychotropic drugs by geriatric patients / Indisponibilidade de doses apropriadas e necessidade de fracionamento de medicamentos psicotrópicos por pacientes geriátricos

BACKGROUND: Tablet splitting appears common in older adults, but its safety, and the factors associated with this practice, remain unclear. OBJECTIVE: To identify which psychotropic drugs are most often split, which doses are intended with this practice, and whether these doses are provided by the Brazilian Unified Health System (SUS) or commercially available. METHODS: Cross-sectional descriptive study of 632 geriatric outpatients. The number of individuals who split tablets was identified, as well as the psychotropic drugs they used and split. The availability of these drugs on the SUS network and on the market was assessed by checking the 2017 National Formulary of Essential Medicines (RENAME 2017) and the Dictionary of Proprietary Medicinal Products (Dicionário de Especialidades Farmacêuticas) respectively. RESULTS: Tablet splitting was reported by 178 patients (28.2%). This practice was significantly more common among those aged 80 years or older. Tablet splitting was significantly associated with a greater number of medical visits and a higher pill burden. The most commonly affected therapeutic classes were antipsychotics (23.9%), other psychotropic drugs (18.7%) and antidepressants (12.3%). Of the 20 psychotropic drugs split, 45% were available on the SUS. CONCLUSIONS: Tablet splitting poses a challenge, as there is no guarantee of uniformity of concentration of the active ingredient in the split halves. Although the psychotropic drugs that were split in this sample are commercially available, most were not available from SUS in the desired dose forms for older adults.

INTRODUÇÃO: O fracionamento de comprimidos é comum em pacientes geriátricos, mas a segurança e os fatores associados a essa prática permanecem incertos. OBJETIVO: Identificar quais medicamentos psicotrópicos são mais frequentemente fracionados, quais doses se destinam a essa prática e se essas dosagens são fornecidas pelo Sistema Único de Saúde (SUS) ou comercialmente disponíveis. MÉTODOS: Estudo descritivo transversal de 632 pacientes ambulatoriais geriátricos. O número de indivíduos que fracionou os comprimidos foi identificado, bem como os medicamentos psicotrópicos que foram usados e fracionados. A disponibilidade desses medicamentos na rede SUS e no mercado foi avaliada através da verificação do Formulário Nacional de Medicamentos Essenciais (RENAME) de 2017 e do Dicionário de Especialidades Farmacêuticas, respectivamente. RESULTADOS: A partição de comprimidos foi relatada por 178 pacientes (28,2%). Essa prática foi significativamente mais comum entre aqueles com 80 anos ou mais. O fracionamento dos comprimidos foi significativamente associado a um maior número de consultas médicas e a uma maior carga de comprimidos. As classes terapêuticas mais comumente afetadas foram antipsicóticos (23,9%), outros medicamentos psicotrópicos (18,7%) e antidepressivos (12,3%). Dos 20 medicamentos psicotrópicos fracionados, 45% estavam disponíveis no SUS. CONCLUSÕES: O fracionamento de comprimidos representa um desafio, pois não há garantia de uniformidade de concentração do ingrediente ativo nas metades fracionadas. Embora os medicamentos psicotrópicos fracionados nesta amostra estejam disponíveis comercialmente, a maioria não estava disponível no SUS nas formas de dosagem desejadas para a população geriátrica.

Brazilian guidelines for the management of psychomotor agitation. Part 2. Pharmacological approach

Objective: To present the essential guidelines for pharmacological management of patients with psychomotor agitation in Brazil. Methods: This is a systematic review of articles retrieved from the MEDLINE (PubMed), Cochrane Database of Systematic Reviews, and SciELO databases published from 1997 to 2017. Other relevant articles in the literature were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools. Results: Of 5,362 articles retrieved, 1,731 abstracts were selected for further reading. The final sample included 74 articles that met all inclusion criteria. The evidence shows that pharmacologic treatment is indicated only after non-pharmacologic approaches have failed. The cause of the agitation, side effects of the medications, and contraindications must guide the medication choice. The oral route should be preferred for drug administration; IV administration must be avoided. All subjects must be monitored before and after medication administration. Conclusion: If non-pharmacological strategies fail, medications are needed to control agitation and violent behavior. Once medicated, the patient should be monitored until a tranquil state is possible without excessive sedation. Systematic review registry number: CRD42017054440.

Prevalence of and factors associated with antipsychotic polypharmacy in patients with serious mental illness: Findings from a cross-sectional study in an upper-middle-income country

Objective: The aim of our study was to examine the prevalence of and factors associated with antipsychotic polypharmacy (APP) among patients with serious mental illness in the current South African health care context. Methods: We collected data on patient, illness, and treatment characteristics of patients discharged on one or more antipsychotic agents from January to June 2014. We analyzed the associations of APP with demographic and clinical variables using hierarchical multivariable logistic regression, and examined prescription patterns. Results: The prevalence of APP in our study population of 577 patients was 28.4%. Demographic and clinical characteristics significantly associated with APP included age > 29, male sex, diagnosis of schizophrenia, comorbid intellectual disability, comorbid substance use, greater number of hospital admissions, and high-dose prescribing. First-generation antipsychotics and long-acting injectable preparations were prominent in APP combinations. Co-prescription of anticholinergic agents and sodium valproate demonstrated a significant association with APP. Conclusion: APP appears common in our population, despite lack of evidence for the practice and possible risk of harm. Our findings suggest a complex interplay among patient, illness, and treatment factors relevant to APP in our setting that could be targeted for intervention.

Luxación témporo-mandibular recurrente y secundaria a distonía por antipsicóticos / Recurrent temporomandibular luxation secondary to dystonia induced by antipsychotics

La distonía aguda inducida por antipsicóticos sigue siendo una patología frecuente en los servicios de emergencia psiquiátrica. Sin embargo, la luxación de la articulación tómporo-mandibular, como secuela de distonía oromandibular, es una presentación inusual dentro de esta casuística. Presentamos el caso de una paciente mujer de 20 años de edad, quien recibió haloperidol intramuscular tras sendas crisis de agitación psicomotriz y persistencia de riesgo suicida, y que luego desarrolló distonía oro-mandibular, a consecuencia de la cual sufrió luxación témporomandibular unilateral. Como conclusión, se recomienda no repetir la administración de antipsicóticos parenterales de alta potencia a personas que han padecido luxación de la articulación témporo-mandibular como consecuencia de distonía secundaria a estos fármacos. Se plantea además la posibilidad de que, debido al uso masivo y creciente de antipsicóticos atípicos en el momento actual, la capacitación de los psiquiatras en cuanto a predicción y manejo de efectos adversos de los neurolépticos puede estar siendo negligida.

Antipsychotic-induced acute dystonia remains as a common presentation in psychiatric emergency services. However, luxation of the temporo-mandibular joint, as a sequel to oro-mandibular dystonia is an unusual clinical occurrence. We report the case of a 20-years-old-woman who received intramuscular haloperidol after two crisis of psychomotor agitation with persistent suicidal risk, developed then oro-mandibular dystonia and, as a result of which, suffered unilateral temporo-mandibular dislocation. A recommendation is made not to repeat a parenteral administration of high-potency antipsychotics to patients who have suffered dislocation of the temporo-mandibular joint as a result of secondary dystonia to these drugs. Additionally, we examine the possibility that, due to the massive and growing use of atypical antipsychotics at the present time, the training of psychiatrists about prediction and management of adverse effects of neuroleptics may be neglected.

Prescripción de antipsicóticos al egreso hospitalario durante el período abril-setiembre de 2012 en el Hospital Vilardebó de Montevideo, Uruguay / Prescribing antipsychotics to hospital discharge during the period April-September 2012 Vilardebó Hospital in Montevideo, Uruguay

Las guías clínicas recomiendan la monoterapia antipsicótica (mta). La polifarmacia antipsicótica (pfa, uso concomitante de dos o más antipsicóticos) es una práctica clínica frecuente. El objetivo del trabajo fue determinar el perfil de prescripción antipsicótica y su uso en mta o pfa, al egreso hospitalario durante el período abril setiembre de 2012 en el Hospital Vilardebó. Se realizó un estudio descriptivo, observacional y retrospectivo. Las variables estudiadas fueron sexo, edad, medicación y diagnóstico. Se definió mta para los que egresaron con un antipsicótico y pfa para aquellos que egresaron con dos o más antipsicóticos. El 52 % egresó con mta, de los cuales el 42% recibió un antipsicótico atípico y el 10%, uno típico. El 48 % restante egresó con dos o más antipsicóticos (pfa). El 19 % de los pacientes con pfa egresó con tres o más antipsicóticos. Es elevado el uso de pfa al egreso hospitalario.

Pharmacological treatment and staging in bipolar disorder: evidence from clinical practice

Objectives: Staging models for medical diseases are widely used to guide treatment and prognosis. Bipolar disorder (BD) is a chronic condition and it is among the most disabling disorders in medicine. The staging model proposed by Kapczinski in 2009 presents four progressive clinical stages of BD. Our aim was to evaluate pharmacological maintenance treatment across these stages in patients with BD. Methods: One hundred and twenty-nine subjects who met DSM-IV criteria for BD were recruited from the Bipolar Disorders Program at Hospital de Clínicas de Porto Alegre, Brazil. All patients were in remission. The subjects were classified according to the staging model: 31 subjects were classified as stage I, 44 as stage II, 31 as stage III, and 23 as stage IV. Results: Patterns of pharmacological treatment differed among the four stages (p = 0.001). Monotherapy was more frequent in stage I, and two-drug combinations in stage II. Patients at stages III and IV needed three or more medications or clozapine. Impairment in functional status (Functioning Assessment Short Test [FAST] scale scores) correlated positively with the number of medications prescribed. Conclusions: This study demonstrated differences in pharmacological treatment in patients with stable BD depending on disease stage. Treatment response can change with progression of BD. Clinical guidelines could consider the staging model to guide treatment effectiveness. .

Clozapina, lamotrigina, olanzapina, quetiapina e risperidona para o tratamento do transtorno afetivo bipolar / Clozapine, lamotrigine, olanzapine, quetiapine and risperidone for the treatment of bipolar affective disorder

CONTEXTO: Com vistas a elaborar o Protocolo Clínico e Diretrizes Terapêuticas do TAB, a SAS solicitou a incorporação, para tratamento do TAB, dos medicamentos clozapina, lamotrigina, olanzapina, quetiapina e risperidona. Esses medicamentos já se encontram no Componente Especializado da Assistência Farmacêutica, sendo indicados para uso na esquizofrenia, exceto a lamotrigina que é indicada para epilepsia. A DOENÇA: O transtorno afetivo bipolar (TAB) é caracterizado por alterações no humor que se manifestam como episódios de mania, hipomania e depressão. A doença se divide em tipos I e II. Pacientes com transtorno bipolar tipo I apresentam episódios de mania e episódios mistos de mania e depressão. O transtorno bipolar tipo II caracteriza-se por pelo menos um episódio de hipomania, pelo menos um episódio de depressão e ausência de episódios de mania e mistos1. A principal complicação do TAB é o suicídio. Se não tratados, os pacientes com TAB podem ter mais de 10 episódios de mania e de depressão durante toda a vida, com a duração dos episódios e dos períodos de intervalo entre os episódios se estabilizando após a quarta ou quinta crises. Frequentemente, o intervalo entre os primeiro e segundo episódios podem durar 5 anos ou mais, embora 50% dos pacientes possam apresentar outra crise maníaca 2 anos após sua crise inicial. Os intervalos entre as crises subsequentes geralmente são menores. O tratamento farmacológico depende da apresentação da doença (ex.: mania aguda, depressão, manutenção, ciclagem rápida) e consiste em monoterapia ou terapia combinada com lítio, anticonvulsivantes (valproato, carbamazepina, lamotrigina, oxcarbazepina, topiramato), antipsicóticos ou antidepressivos. Antipsicóticos atípicos incluem olanzapina, clozapina, quetiapina, risperidona, ziprasidona e aripiprazol. ANÁLISE DA EVIDÊNCIA CIENTÍFICA: Com vistas a elaborar o Protocolo Clínico e Diretrizes Terapêuticas (PCDT) do Transtorno Afetivo Bipolar (TAB), a Secretaria de Atenção à Saúde (SAS) do Ministério da Saúde solicitou a incorporação, para tratamento do TAB, dos seguintes medicamentos: clozapina, lamotrigina, olanzapina, quetiapina e risperidona. Esses medicamentos já se encontram no Componente Especializado da Assistência Farmacêutica (CEAF), sendo indicados para uso na esquizofrenia, exceto a lamotrigina que é indicada para epilepsia, de acordo com a Portaria nº 1554/GM/MS de 30 de julho de 2013. A SAS enviou duas propostas de algoritmos de tratamento: um para tratamento farmacológico da mania (incluindo os medicamentos clozapina, olanzapina, risperidona, lítio, ácido valpróico, carbamazepina e haloperidol) e outro para tratamento farmacológico da depressão bipolar (incluindo os medicamentos lamotrigina, olanzapina, quetiapina, lítio, ácido valpróico e fluoxetina). Os medicamentos ácido valpróico, carbamazepina, fluoxetina, haloperidol e lítio já se encontram no Componente Básico da Assistência Farmacêutica (CBAF) e, de acordo com o Formulário Terapêutico Nacionali, possuem indicação para tratamento do TAB. A seleção, a aquisição e a dispensação, assim como o financiamento dos medicamentos pertencentes ao CBAF são de responsabilidade dos Estados, Distrito Federal e Municípios, conforme a Portaria nº 1.555, de 30 de julho de 2013. CONSIDERAÇÕES FINAIS: Com vistas a elaborar o Protocolo Clínico e Diretrizes Terapêuticas do Transtorno Afetivo Bipolar, a Secretaria de Atenção à Saúde (SAS) do Ministério da Saúde solicitou a incorporação dos medicamentos clozapina, lamotrigina, olanzapina, quetiapina e risperidona, para tratamento desta condição de saúde. Foram avaliadas as recomendações de algumas diretrizes internacionais para tratamento do TAB: diretrizes do National Institute for Health and Care Excellence (NICE), da British Association for Psychopharmacology, do grupo Canadian Network for Mood and Anxiety Treatments (CANMAT), do Royal Australian and New Zealand College of Psychiatrists (RANZCP) e da American Psychiatric Association. Os algoritmos de tratamento dos episódios agudos de mania e de depressão propostos pela SAS foram comparados com as recomendações gerais das cinco diretrizes avaliadas. DELIBERAÇÃO FINAL: Os membros da CONITEC presentes na reunião do plenário do dia 04/12/2014 deliberaram, por unanimidade, recomendar a incorporação dos medicamentos clozapina, lamotrigina, olanzapina, quetiapina e risperidona para tratamento do Transtorno Afetivo Bipolar, conforme Protocolo Clínico e Diretrizes Terapêuticas estabelecido pelo Ministério da Saúde. Nos termos do art. 21 do Decreto 8.077/2013, a inclusão da clozapina está condicionada à autorização de uso pela ANVISA. DECISÃO: A PORTARIA Nº 3, de 9 de março de 2015 - Torna pública a decisão de incorporar os medicamentos clozapina, lamotrigina, olanzapina, quetiapina e risperidona, para tratamento do Transtorno Afetivo Bipolar no âmbito do Sistema Único de Saúde - SUS.

Administration of medication to use when needed and the care of psychiatric nursing / Administração de medicação de uso quando necessário e o cuidado de enfermagem psiquiátrica / La administración de medicamentos de uso cuando sea necesario y el cuidado de enfermería psiquiátrica

This qualitative study aimed to analyze the clinical criteria used for the administration of prescribed medications for use when needed (SOS); and discuss the implication of the findings in this research to clinical psychiatric nursing. The records of female patients admitted to a psychiatric institution in the city of Rio de Janeiro, in the time frame from May to June 2009, were analyzed. In the 38 patient records, 16 prescriptions for medications SOS were found. The mean age of patients was around 45-55 years with a clinical diagnosis of Bipolar Mood Disorder. The medication category most prescribed as SOS was of benzodiazepines, followed by antipsychotics. It was noticed a tendency to not valuing the administration of medication in SOS notes. The study points out the importance to establish clinical criteria to indicate the need, or not, to administer prescribed SOS medications.

Trata-se de estudo qualitativo que objetivou analisar os critérios clínicos utilizados para a administração das medicações prescritas de uso quando necessário (SOS); e discutir a implicação dos achados nesta pesquisa para a clínica da enfermagem psiquiátrica. Foram analisados os prontuários de pacientes do sexo feminino, internadas em uma instituição psiquiátrica na cidade do Rio de Janeiro, no recorte temporal de maioo a junho de 2009. Nos 38 prontuários analisados, foram encontradas 16 prescrições de medicações SOS. A idade média das pacientes girou em torno de 45-55 anos, com diagnóstico clínico de Transtorno Bipolar do Humor. A categoria de medicação mais prescrita como SOS foi a dos benzodiazepínicos, seguidos de antipsicóticos. Notou-se uma tendência à não valorização da administração da medicação SOS nas anotações. O estudo aponta a necessidade de que sejam estabelecidos critérios clínicos que indiquem a necessidade, ou não, de administrar medicações prescritas como SOS.

Este estudio cualitativo tuvo como objetivo analizar los criterios clínicos utilizados para la administración de medicamentos prescritos para su uso cuando sea necesario (SOS); y discutir las implicaciones de los hallazgos en esta investigación a la clínica de enfermería psiquiátrica. Fueran utilizados los registros de pacientes de sexo femenino admitidos en una institución psiquiátrica en la ciudad de Río de Janeiro, en el marco de tiempo de mayo a junio de 2009. En los 38 prontuarios de pacientes analizados, se encontraron 16 recetas para medicamentos SOS. La edad media de los pacientes fue de alrededor de 45 a 55 años con un diagnóstico clínico de trastorno bipolar del estado de ánimo. La categoría de medicamento más prescrito como SOS fue la de benzodiacepinas, seguido de los antipsicóticos. Notó-se una tendencia a no valorar la administración de medicamentos SOS en los registros. El estudio apunta a la importancia de estabelecimiento de criterios clínicos que indiquen la necesidad o no de administrar los medicamentos prescritos como SOS.

Meta-analysis on the efficacy and tolerability of the augmentation of antidepressants with atypical antipsychotics in patients with major depressive disorder

We assessed the efficacy and tolerability of the augmentation of antidepressants (ATDs) with atypical antipsychotics (AAPs) to treat patients with major depressive disorder. A retrograde study to identify relevant patient data included databases of PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and Database of Abstracts of Reviews of Effects. Data from 17 trials, involving 3807 participants, were identified. The remission rate (RR) and overall response rate (ORR) of adjunctive treatment with AAPs were significantly higher than placebo treatment: RR=1.90 (95%CI=1.61-2.23, z=7.74, P<0.00001) and ORR=1.68 (95%CI=1.45-1.94, z=7.07, P<0.00001). We found that the short-term (4 weeks) treatment [ORR=1.70 (95%CI=0.98-2.95, Z=1.89, P=0.06)] was significantly different from the long-term (6-12 weeks) treatment [ORR=1.68 (95%CI=1.45-1.94, z=7.07, P<0.00001)]. No significant difference in ORR was observed between groups with or without sedative drugs. The discontinuation rate due to adverse effects was higher for adjunctive treatment with AAPs: ORR=3.32 (95%CI=2.35-4.70, z=6.78, P<0.00001). These results demonstrate that the augmentation of ATDs with AAPs (olanzapine, quetiapine, aripiprazole, and risperidone) was more effective than a placebo in improving response and remission rates, although associated with a higher discontinuation rate due to adverse effects.

Capgras syndrome presenting in an adolescent girl in the Caribbean / El síndrome de capgras en una adolescente del Caribe

The case of a 16-year old Jamaican girl who presented to the psychiatric service of a general hospital with features of Capgras syndrome is presented. Her history, treatment, progress and relevant psychodynamic and neurocognitive issues are explored. This is the first known published case of an adolescent with Capgras syndrome from the Caribbean. The case highlights that the syndrome may occur in different cultural contexts and that clinicians should be sensitive to its existence in order to avert under-diagnosis or misdiagnosis.

Se presenta el caso de una joven jamaicana de 16 años que acudió al servicio de psiquiatría de un hospital general con los rasgos del síndrome de Capgras. Se explora su historia, tratamiento, progreso, problemas neurocognitivos y psicodinámicos relevantes. Éste es el primer caso publicado de que se tenga noticias, de una adolescente con el síndrome de Capgras en la región del Caribe. El caso pone de relieve que el síndrome puede ocurrir en diferentes contextos culturales, y que los médicos deben de estar sensibilizados con su existencia a fin de evitar un subdiagnóstico o un diagnóstico erróneo.

Síntomas de discontinuación luego de suspensión abrupta de olanzapina / Discontinuation symptoms following olanzapine abrupt withdrawal

Extended use of atypical neuroleptics in clinical practice, may be explained by their effectiveness as antipsychotics and also with recent approvals for therapeutic benefits of this drugs beyond psychotic disorders. Receptor adaptation mechanisms rises critical issues about treatment discontinuation strategies. Clinical data of two patients who have required the use of atypical antipsychotics are discussed. In both cases, abrupt discontinuation of the drug occurred followed by the emergence of extrapyramidal symptoms. Adaptation mechanisms in synaptic structures would be responsible for this phenomena and the subsequent amelioration of this extrapyramidal symptoms when initial treatment is replaced. The authors concluded that atypical antipsychotics, as other psychotropic agents shouldn't be abruptly discontinued even when they are replaced by other drugs from the same family.

El uso de los antipsicóticos atípicos ha ido aumentando con el tiempo entre otras cosas, por el hecho de que se están usando no sólo para los cuadros psicóticos sino que también para otras patologías. Como con otros fármacos que actúan a nivel de receptores deben considerarse los mecanismos de adaptación receptorial que se producen con su uso. Lo anterior es de suma importancia cuando pensamos en la discontinuación del tratamiento y en sus formas de hacerlo. En este trabajo presentamos dos casos clínicos de pacientes que han requerido el uso de antipsicóticos atípicos. En ambos casos se ha realizado una suspensión brusca del fármaco lo que ha generado la aparición de síntomas extrapiramidales, que en nuestra opinión, son explicados por mecanismos de adaptación a nivel sináptico y que han disminuido con el reinicio del tratamiento inicial. Debemos tener presente que estos fármacos no deben ser discontinuados en forma súbita aun cuando sean remplazados por otros de la misma familia.

Medication errors in psychiatric practice — A Cross-sectional Study.

Objectives: To analyse current prescription writing practices among psychiatrists and to identify and quantify various types of medication errors in psychiatric prescriptions in general and specifically in the prescriptions of antipsychotics. Method: A cross-sectional study of medication errors was carried out in the extra-mural psychiatry prescriptions brought by the patients attending the psychiatry outpatient department of a tertiary care hospital in Delhi. The study period ranged from 1st March, 2009 to 1st November, 2011. Microsoft Excel was used for data analysis. The WHO guidelines for prescription writing were used as a standard while making an assessment of the results. Results: Most of the prescriptions analysed exhibited polypharmacy, illegible handwriting, lack of necessary details pertaining to the patients (address, weight) as well as those pertaining to the prescriber (signature, contact details, registration number) and necessary instructions for the patient regarding taking drugs and advice for follow up.In the 648 extramural prescriptions analysed, the most common error was prescription of drug without dose (30 %). The least common error was the prescription of a wrong drug (2 %). In comparison to the rates found in all the 648 prescriptions, the error of prescribing drugs with same indication was identified at a relatively higher frequency (15%) among antipsychotics (only) prescriptions. Among the various antipsychotic drugs, the errors related to wrong frequency and wrong route of administration were observed at relatively higher frequencies in the prescriptions of the newly introduced drug asenapine while the first generation antipsychotic drugs like haloperidol and trifluoperazine exhibited comparatively higher rates of wrong dose errors. Conclusions: Routine psychiatric prescriptions exhibit large number of easily identifiable errors which are preventable. The need of the hour is to promote rational drug prescribing practices among psychiatrists, encouraging them to detect and report medication errors encountered by them. This approach will enrich our existing research base about this hitherto neglected domain of psychiatric practice thereby helping us in developing and implementing effective strategies to combat this menace of medication errors.