SUJEITOS E MÉTODOS
5.14 – CONFIABILIDADE INTERAVALIADOR NA APLICAÇÃO DA ESCALA ALDA
A aplicação da escala ALDA exige um conhecimento prévio dos critérios do transtorno bipolar, julgamento clínico e minuciosa análise do curso da doença. O preenchimento da escala requer que seja selecionado o maior período no qual o
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uso de lítio é bem documentado, e preferencialmente usado em monoterapia. A escolha desse período de estabilidade clínica é crucial para definir o escore dos diferentes itens que compõem o instrumento (40,48).
Na análise de confiabilidade observou-se desarmonia entre os avaliadores, principalmente com relação a pontuação atribuída aos Critérios B1-B5. O ICC para o Critério A foi de 0,748, enquanto para o Critério B TOTAL foi 0,672.
Uma vez que o curso do TAB é bastante heterogêneo (118), uma possível explicação para estes dados concerne a escolha do período para pontuação da escala. Diferentes períodos resultam em heterogeneidade no número de episódios (B1), frequência de episódios (B2), duração do tratamento (B3), interpretação da adesão ao tratamento (B4) e também diferente uso de medicações adjuvantes no período (B5). Estes dados sugerem que a Escala ALDA exige não apenas experiência clínica para que seja bem utilizada, mas também que os pesquisadores sejam submetidos a um treinamento cuidadoso e se reúnam periodicamente para calibrar os escores.
No que se refere a confiabilidade entre avaliadores, dados da literatura mostram que, em estudos nos quais a confiabilidade é testada periodicamente, o índice de concordância não se mantém estável. Altas taxas de confiabilidade no início da pesquisa podem não se sustentar ao longo do tempo (119). Ou seja, confiabilidade não é uma característica constante de um instrumento.
Quando os investigadores sabem que a confiabilidade será testada, a aplicação dos instrumentos é realizada com maior rigor e os índices de concordância são melhores (119). Estes dados apontam que além das aconselháveis calibragens periódicas, os entrevistadores devem ser treinados em conjunto e devem
preferencialmente estar cientes que serão testados no que se refere à confiabilidade dos resultados.
Com relação aos dados obtidos em nosso estudo, a boa confiabilidade interavaliador (ICC variando entre 0,610 - 0,833) demonstrou que o instrumento pode ser útil e confiável na avaliação retrospectiva de resposta terapêutica ao lítio.
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CONCLUSÃO
Nosso estudo realizou, com sucesso, a tradução e adaptação da escala ALDA para o português. Além disso, a aplicação da escala por dois avaliadores independentes, com boa confiabilidade interavaliador (o Coeficiente de Correlação Intraclasse variou entre 0,610 – 0,833), demonstrou que o instrumento pode ser útil e confiável na avaliação retrospectiva de resposta terapêutica ao lítio.
Utilizando a escala ALDA, nós avaliamos a resposta terapêutica dos pacientes ao lítio, no tratamento de manutenção do Transtorno Afetivo Bipolar (TAB). Apesar dos avaliados terem apresentados índices de melhora clínica com o tratamento satisfatórios (Critério A ≥ 7), estes também tiveram pontuações altas no Critério B, em especial no item B5 (uso de outros fármacos que não o lítio). Estes resultados apontam para uma melhora clínica dos pacientes tratados, porém não permitem que esta seja atribuída exclusivamente ao uso de lítio.
Para contornar este problema, tratamos o Critério A como variável contínua e excluímos pacientes com muitos confundidores (altos valores no Critério B), estratégia também adotada por outros estudos internacionais. Esta estratégia permitiu a análise da relação entre os resultados obtidos com a escala ALDA e as demais variáveis estudadas.
Finalmente, no modelo preditivo criado em nosso estudo, encontramos que pacientes com maior número de episódios de humor com sintomas psicóticos apresentaram pior resposta ao tratamento de manutenção com lítio, o que vai ao encontro de boa parte dos dados na literatura. Além disso, nosso estudo constatou que pacientes com história de uso atual ou prévio de tabaco tiveram melhor
resposta ao tratamento com lítio. Neste caso, os nossos resultados distanciam-se da ideia mais aceita de que pacientes tabagistas portadores de TAB apresentam pior prognóstico. Acreditamos que este é um resultado que precisa ser mais bem explorado em futuros estudos, com melhor caracterização do uso de tabaco por estes pacientes.
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