ABSTRACT
OriginalA
rticle
ofusersofamentalhealthsystem
formedicalresidentsandother
healthprofessionalsundergoing
trainingattheUniversidade
FederaldeSãoPaulo
NúcleodeAssistênciaePesquisaemResidênciaMédica(Napreme),Universidade
FederaldeSãoPaulo–EscolaPaulistadeMedicina,SãoPaulo,Brazil
•VanessaAlbuquerqueCítero •LuizAntonioNogueira-Martins
INTRODUCTION
Ahighprevalenceofsuicides,depression, psychoactivesubstanceabuse,stress,impair-ment,burnoutandprofessionaldysfunction among physicians, as well as the especially highratesofstressanddepressionamongresi-dents,havebeendescribedintheliterature.1-17
With regard to professional dysfunction, it is worthwhile emphasizing the importance of recent studies referring to “problem residents”.18,19Physicians’fatigueinrelation
topatientsafety,20aswellasresidents’weekly
workload,21haveonceagainbeenbroughtup
fordiscussion,andhavenowbecomeamatter ofinterest.
Overthelasttwentyyears,severalauthors have presented different suggestions for the prevention and management of personal andprofessionalproblemsoccurringduring medicalresidencetrainingprograms.22-24
Con-sequently, the Universidade Federal de São Paulo(Unifesp)advocatesthatstressreduction duringthetrainingprogram—therebycon-tributing towards personal and professional growth,andpreventingprofessionaldysfunc-tionandemotionaldisorders—shouldbethe maintargetofthetrainingprocessformedical professionals.The Assistance and Research Center for Medical Residency (Núcleo de AssistênciaePesquisaemResidênciaMédica —Napreme)wascreatedwithinUnifespand effectivelyimplementedinSeptember1996. Inapreviouscommunication25wepresented
adetailedexplanationofthecharacteristicsof theserviceatthetimeofitscreationaswellas thetargetsandstrategiesadoptedforpubliciz-ingitsserviceswithintheinstitution.
Inadditiontopsychologicalandpsychiat-richealthcare,Napremehasdevelopedseveral actionsaimedatpreventingemotionaldistur-bancesandprofessionaldysfunctionsamong trainees. For example, Napreme has been participatinginawelcomeprogramformedi-calandnursingresidentsbygivinglectureson thestressexperiencedduringresidency.Group meetingswiththeresidentshaveprovidedin-depthdiscussionofthestressfulnatureofthe residencyprogramandareaimedatworking ontheresident’sexpectations,desiresandfears regardingthetrainingprogram.Atthesemeet-ings,adetailedaccountisgivenofNapreme’s services,whichtheresidentsareencouragedto seekwheneveranyproblemsarise.Emphasis isgiventoensuringfullconfidentiality,andto thefactthatNapremeisindependentofthe trainingassessmentsystem.
AnotheractivitycarriedoutbyNapreme isresearch.AstudyperformedbyObara,26
us-ingtheBeckDepressionInventory(BDI)and including75first-yearresidentsindifferent clinicalandsurgicalspecialtiesdeservesmen-tion.Inthisstudy,theprevalenceofdepressive symptomswas24%(BDI>14),thusshowing amuchhigherpercentagethaninotherstudies usingthesamemethodology.10,14Inanother
studyinassociationwithNapreme,Franco27
alsousedtheBDItoevaluatetheprevalence of depressive symptoms among 68 nursing residents,findingarateof18.6%.Atpresent, theauthorsofthepresentstudyarenowinthe processofconcludingastudyonthequalityof lifeandwellbeingof140medicalresidents.
Napremeislocatedtwoblocksfromthe University’s main buildings, alongside the studenthealthservice(ServiçodeSaúdedo CONTEXT:Apostgraduateandresidenttraineemental
healthassistancecenterwascreatedinSeptember 1996withinouruniversity.
OBJECTIVE:Todescribetheclinicalanddemographic profileofitsusers.
TYPEOFSTUDY:Retrospective.
SETTING:UniversidadeFederaldeSãoPaulo—Escola PaulistadeMedicina(Unifesp-EPM).
METHODS:ThestudywascarriedbetweenSeptember 1996 and November 2002, when 233 semi-structuredregistrationformswerefilledouteither bythepsychologistorthepsychiatristduringtheir firstcontactwiththetrainees,whoweremedical andnursingresidents,andpostgraduatestudents atspecialization,masterordoctorallevels.The registration forms included demographic, occu-pationalandclinicaldata.
RESULTS: The trainees were predominantly young (meanof27yearsold),single(82.0%ofcases), women (79.4%), seeking help especially during thefirstyearoftraining(63.1%).In70.8%ofthe
cases,theycametotheservicespontaneously.Such individualsshowedgreateradherencetothetreat-mentthanthosewhowerereferredbysupervisors (p<0.05).In30%ofthecases,thetraineesought psychologicalguidanceorsupportattheservice duetospecificsituationalconflicts.Depressionand anxietydisorderswerethemostfrequentdiagnoses; 22.3% of the trainees followed up mentioned a tendencytowardssuicidalthoughts.Incomparison withothertrainees,therewasahigherprevalence ofmalesamongthemedicalresidents(p<0.01), withmorecasesofsleepdisorders(p<0.05),a smallernumberofindividualsrefrainingfromthe useofalcohol(p<0.05)andahighernumberof traineesrequiringleaveofabsence(p<0.001).
DISCUSSION:Thefirst
yearoftraininginhealthsci-encesisthemoststressful,especiallyforwomen. Depressionandanxietysymptomsarecommon, reflecting transitory self-limited deadaptation. However, the severity of the cases can also be evaluatedinviewofthelargenumberoftrainees whomentionedsuicidaltendencies.
CONCLUSIONS:Thisstudyemphasizestheneedand importance of providing formal, structured and confidential mental health services for medical residents and postgraduate students from other health professions, in the training programs of academicinstitutions.
CorpoDiscente,SSCD),whichoffersmedi-calanddentalassistancetotheentirestudent body at Unifesp. Napreme’s medical team consistsoftwopsychologistsandonepsychia-trist,whoseservicesareofferedtooutpatients inthefollowingfields:psychiatrictreatment, individualbriefpsychotherapy,counselingand psychologicalorientation.
Itshouldbementionedthat,duetospon-taneousdemandwithintheuniversity,itwas decidedfromtheoutsetthathealthcareservices wouldbeprovidednotonlytoresidents,but to all students onstricto sensu andlato sensu postgraduate courses. In the literature avail-able,stresslevelsaresignificantlyhigheramong postgraduatestudentsthanamongmedicalstu-dentsorresidents.28Ithasalsobeenshownthat
physicianstakingpostgraduatecoursesseemto belongtoasubgroupthatisundergreaterstress thanforanyotherpostgraduatestudents.29The
stressexperiencedbypostgraduatestudentsis basically the result of: 1) difficulties in per-sonalrelationshipswithadvisors,professorsor colleagues;2)academicactivities(classesand scientific production); 3) being pressed for timeorfacingdeadlines;and4)financialand professionalworries.30Regardlessofthetype
ofdifficulties,thepostgraduatestudentsseen at Napreme considered that all the support receivedwasinvaluable,inrelationtoadvisors, institutionsorprofessionalproblems.31
Only a few structured services give as-sistance to this type of population.22 Since
Napreme was a pioneer in Brazil, its main concernwastocreatearesearchdatabaseto provide initial guidance for the team, with regard to identifying the trainees who were seekinghelp,andwhattheirproblemswere. Thepresentstudythushadtheaimofdescrib-ing the clinical and demographic profile of
theusersofthementalhealthcareservicesat apublicuniversityinBrazil.
METHODS
This was a retrospective study cover-ing the period from December 1, 1996, to November30,2002.Duringthisperiod,the demographic and clinical variables of each newcaseattendedatNapremeweresystem-aticallyrecorded.Thesampleconsistedofthe 233trainees(medicalandnursingresidents, and postgraduate students at specialization, master’sordoctorallevels)registeredduring theabovementionedperiod.Thetraineescame totheserviceinthreedifferentways:sponta-neousvisit,referralsfromtheirsupervisors,or referralsfromSSCDphysicians.
All of the healthcare provided required thefillingoutofasemi-structuredregistration form, which was subsequently standardized to build the service’s database.The records containedthepatient’sdemographicdataand informationontheirprofessionaltrainingand psychiatricandpersonalbackground,suchas: gender; age; marital status; how the trainee foundoutabouttheservice;whoreferredthe trainee;thetypeofacademicrelationshipwith theuniversity;theareaofspecializationbeing studied; profession; site of the training pro-gram;placeofbirth;whichschoolthetrainee graduatedfrom;homeaddress;clinicalhistory; recent use of medication; habits related to smoking,alcoholanddrugs;suicidalideas;sleep andfeedingdisorders;previouspsychological or psychiatric treatment; family psychiatric background; main diagnosis (International StatisticalClassificationofDiseaseandRelated HealthProblems,10thRevision,ICD-10);32
medicationprescribed;resultsoftreatment;and
leaveofabsencerequiredfromactivities. The data was recorded in a structured database, using the Statistical Package for SocialSciences(SPSS)version8.0software. Sevendifferentpsychologistsorpsychiatrists workedinNapremeduringthestudyperiod. Atthetimeofeachtrainee’sfirstconsultation, thepsychologistorpsychiatristwasaskedtofill outasemi-structuredform,whichwasthen reviewedbytheNapremecoordinator.
Thedescriptiveanalysiswasperformed byadirectcomparisonoftherates,distrib-utedintodifferentcategoriesofvariablessuch associodemographiccharacteristics,demand for the service, or adherence to the treat-ment. Contingency tables were developed and Pearson’s chi-squared test was applied to compare the trainees according to their academic relationship with the university, namely, medical and nursing residents, or postgraduate students at specialization, master’sordoctorallevels.
RESULTS
Demographics
Theaverageageofthetraineeswas27 (SD=4)years,rangingfrom21to48years. Thenursingresidentsweretheyoungestpa-tientstreatedattheservice,withanaverageage of24years.Therewasahigherfrequencyof femalepatients(79.4%)thanofmalepatients, butupondistributingthegroupsaccordingto theiruniversityqualification,thepopulation offemalepatientsaccountedfor67.9%ofthe medicalresidents,97.5%ofnursingresidents, 83.7% of the postgraduate specialization students,81.7%ofthemaster’sstudentsand 71.4%ofdoctoralstudents(Table1).Thus,
while32.1%oftheresidentsweremalepa-Table1.Distributionofsociodemographiccharacteristicsaccordingtothetrainees’academic relationshipwiththeuniversity(UniversidadeFederaldeSãoPaulo,Unifesp)
Medical
resident Postgraduatespecialization Master’sstudent Doctoralstudent Nursingresident Total
n % n % n % n % n % n %
Gender* Male 18 32.1 9 16.3 11 18.3 8 28.6 2 2.5 48 20.6
Female 38 67.9 39 83.7 49 81.7 20 71.4 39 97.5 185 79.4
StatusNS Single 46 82.1 43 89.6 45 75.0 18 64.3 39 97.5 191 82.0
Notsingle 10 17.9 5 10.4 15 25.0 10 35.7 2 2.5 42 18.0
GraduatedatNS Unifesp 20 39.2 5 10.4 14 26.9 6 25.0 8 22.2 53 22.7 Another
university 36 60.8 43 89.6 46 73.1 22 75.0 33 77.8 180 77.3
LivingwithNS family 16 30.2 22 57.1 26 46.4 14 50.0 9 23.7 87 37.3 othersituations
(alone,friends) 40 69.8 26 42.9 34 53.6 14 50.0 32 76.3 146 62.7
Total 56 24.0% 48 20.6% 60 25.8% 28 12.0% 41 17.6% 233 100.0
tients,only15.8%oftheremainingtrainees weremale(χ2=7.15;df=1;p<0.01).
Eighty-twopercentofthepatientstreated weresingle,whereastherewerefewersingle patients among the master’s and doctoral students.There were smaller numbers of medical and nursing residents living with their families than for the trainees in other groups.Asignificantnumberoftraineeshad notgraduatedatUnifesp(77.3%).
Professionalqualifications
The population consisted of physicians (31.3%),nurses(20.6%),biomedics(12.9%) andotherhealthprofessionals(35.2%).
The medical and nursing residents and postgraduate students at specialization, master’s and doctoral levels who were seek-ingtreatmentparticipatedasstaffmembers in different departments and sectors of the university.Ofthese,themostimportantones were:PediatricsandNephrology,with6.4% of the cases treated; SpeechTherapy with 6%; Nutrition with 4.3%; Pharmacology andMolecularBiologywith5.2%each;and Ophthalmology and Neurology with 3.9% each.Atotalof51departmentsandsectors attheUniversityusedtheservicesprovided byNapreme.
Mostofthepatientsweretraineesfrom the clinical sectors (52.4%) and laboratory
researchers(30.5%).Thesurgicalsectorcon-tributedwith9.9%ofthecaseswhereasthe field of diagnostic techniques and methods accountedfor3.4%.
Demandfortheservice
Although patients usually sought help spontaneously(in70.8%ofthecases),29.9% ofthecasescameviareferrals.Fifty-eightcases weretreatedduringthefirsttwo-yearperiod coveringthemonthofDecember1996and 1997-1998. In the second two-year period (1999-2000) there were 100 new cases and in the third two-year period (2001-2002) another75newcaseswererecorded.Thedis-tributionofthedemandforprimarymental healthcarewascharacterizedbyamajoroccur- renceduringtheperiodfromMaytoSeptem-ber,coincidingwiththemiddleoftheannual trainingcycle,whichrunsfromFebruaryof oneyeartoJanuaryofthenextyear.
Regardlessofthetypeofacademicrela- tionshipwiththeUniversity,eitherasmedi-calandnursingresidents,oraspostgraduate studentsatspecialization,master’sordoctoral level,therewasahigherfrequencyofpatients seeking treatment in the first year of the training program (Table 2).There was also areductionintheneedtosearchforhelpas the training program progressed: 63.1% of thepatientsseekingtreatmentwereintheir
firstyear,22.7%intheirsecondyear,7.7% intheirthirdyear,1.3%intheirfourthyear and0.9%wereintheirfifthyear.
Adherencetotreatment
Themajorityofpatientsadheredtotheir treatment(67.4%ofthecases).Attheendof the study period (November 2002), 13.3% of the total population studied were being regularly treated at the service, 27.9% had been discharged from treatment, 32.6% had discontinued their treatment, 21.9% hadrequestedareferralforpsychotherapyor psychiatrictreatmentelsewhere,andthedata wasincompletefor4.3%ofthecases.Among thecasesthatcametotheserviceafterbeing referredbysupervisors,amuchhigherpropor-tion(61.1%)droppedoutfromthetreatment (χ2=4.48;df=1;p<0.05).
Clinicalcharacteristics
When the patients came to the service, 12.9%reportedsomekindofclinicaldisease; 13.3% mentioned having used some kind of non-psychotropic medication during the lastmonth;and13.3%statedthattheyhad takensomekindofpsychotropicdrugs,with benzodiazepinesbeingusedby7.7%ofthese patients.In73.4%ofthecases,noreference wasmadetotheuseofmedication.
A little more than half (52.4%) of this
Table2.Distributionoffirstconsultationattheservice,accordingtothetrainees’academic relationshipwiththeuniversity(UniversidadeFederaldeSãoPaulo,Unifesp)
Medicalresident Postgraduate
specialization
Master’s student
Doctoral student
Nursing
resident Total
n % n % n % n % n % n %
Yearoftraining ProgramNS
Firstyear 32 57.1 38 71.4 34 61.8 13 46.4 30 76.9 147 63.1 Otheryears 24 42.9 10 28.6 26 38.2 15 53.6 11 23.1 86 46.9
Total 56 24.0% 48 20.6% 60 25.8% 28 12.0% 41 17.6% 233 100.0
NS:differencesarenotsignificant.
Table3.Distributionofclinicalcharacteristicsaccordingtothetrainees’academic relationshipwiththeuniversity(UniversidadeFederaldeSãoPaulo,Unifesp)
Medical resident
Postgraduate specialization
Master’s student
Doctoral student
Nursing
resident Total
n % n % n % n % n % n %
Alcoholuse* Yes 23 45.1 26 54.2 28 52.8 17 65.4 28 75.7 122 52.4
No 33 54.9 22 45.8 32 47.2 11 34.6 13 24.3 111 47.7
Sleepdisorder* Yes 31 60.8 14 29.2 28 52.8 10 38.5 18 48.6 101 43.3
No 25 39.2 34 70.8 32 47.8 18 51.5 23 51.4 132 56.7
Leaveofabsence required**
Yes 11 20.8 3 6.3 1 1.7 3 10.7 1 2.6 19 8.2
No 45 79.2 45 93.7 59 98.3 25 89.3 40 97.4 214 91.8
SuicidalideasNS Yes 13 25.0 10 20.8 14 25.5 5 17.9 10 26.3 52 22.3
No 43 75.0 38 79.2 36 74.5 23 82.1 31 73.7 181 77.7
Total 56 24.0% 48 20.6% 60 25.8% 28 12.0% 41 17.6% 233 100.0
population reported having refrained from theuseofalcoholicbeverages,whereas31.3% were“socialdrinkers”only.Ofthesepatients, 4.7%werenotonly“socialdrinkers”,and2.1% believedtheyhadincreasedtheuseofalcohol overthelastmonth(Table3).Inthegroupof medicalresidents,therewereclearlyfewerindi-vidualswhorefrainedfromtheuseofalcoholic beverages(χ2=4.46;df=1;p<0.05).
Ofthepatientswhowereattended,11.6% hadalreadythoughtofcommittingsuicide, 3.4% had previously attempted suicide, 22.3%werehavingsuicidalideasatthetime ofthefirstinterview(Table3),and0.4%not onlyhadalreadyattemptedsuicidepreviously, butwerealsohavingsuicidalideasatthatvery moment.
Sleeping disorders proved to be quite frequentatthetimeofthefirstvisit(Table3). Thesewerefoundin43.3%ofthepatients,of whom25.3%weresufferingfrominsomnia, 8.6%complainedofhypersomniaand9.4% hadsleepingdisturbances.Themedicalresi-dentsshowedahigherincidenceofsleeping disordersthanamongtheothertrainees(χ2=
4.50;df=1;p<0.05;Table3).
Changesinappetitewerereportedin42.1% ofthepatients,ofwhom17.2%hadlessappetite and24.9%hadanincreaseinappetite.
Alittleoverhalfoftheindividualswho sought Napreme (54.1%) had never previ-ously looked for any type of psychological or psychiatric help. Among those who had previouslybeentreated,22.3%hadreceived psychotherapy; 9.4% had had psychiatric treatment;3%hadhadpsychiatricandpsy-chotherapytreatmentand4.7%mentioned otherkindsoftreatment.
With regard to diagnoses, it should be noted that 30% of the cases it was not possible to meet the ICD-10 criteira32 for
diagnosis. 13.3% had adjustment disorders (F43.2);11.2%hadepisodesoflightdepres-sion(F32.0);8.2%hadepisodesofmoderate depression (F32.1); 7.3% had personality disorders(F60);5.6%hadmixedanxietyand depressiondisorders(F41.2);5.2%hadgen-eralizedanxietydisorders(F41.1);and19.2% werediagnosedasotherminordisorders.
Duringthecourseoftreatment,psycho-tropicdrugswerenotprescribedin70.8%of thecases.In4.7%ofthecases,anxiolyticdrugs wereprescribed;11.2%weregivenantidepres-santdrugs;0.4%weregivenmoodstabilizers; and8.6%weregivenmorethanonetypeof psychotropicdrug.
Anotherdifferenceobservedwhencom-paring the medical residents with the other usersoftheNapremeserviceswasinrelation
to the need for temporary permits for sick leave.Themedicalresidentsneededtotake leaveofabsencefromworkduetoillnessin 20.8% of the cases, whereas for the other traineesthiswasonlyrequiredin4.7%ofthe cases.Thisdifferencewasfoundtobestatisti-callysignificant(χ2=13.4;df=1;p<0.001;
Table 3). Of the 11 medical residents who tooksickleave,threeendedupabandoning theirresidencyprogram.
DISCUSSION
Aftersixyearsofactivity,itisnowpos-sible to present a profile of Napreme users. After the first two years of activities, while thisnewservicewasstillbeingstructured,it was already achieving some stability in the numbersofpatientsseekinghelp,atalevelof approximately50newcasesperyear.Aspecific monthlydemandpatternwasalsonoted.Dur-ingthefirstandlastmonthsoftheyearthere wasadropinthedemandfortreatmentatthe service,whichthenincreasedandreachedits highestconcentrationduringtheperiodfrom MaytoSeptember.Withregardtothemedical residents, this increase in demand has been explainedinstudiesthathaveshownacor-relationbetweenthefirstyearoftrainingand asharpincreaseinstress.24Itwasinthefirst
yearthatthegreatestdemandoccurred,and thislendsfurthersupporttootherfindingsin theliteraturethatindicatethatthefirstyearis themoststressful.3,5,8,9,16
Thisdemandpatternforpsychologicalhelp wasalsofoundamongthenursingresidentsand studentsonotherpostgraduatecourses.Thus, itwouldbereasonabletosuggestthatthestress patternamongmedicalresidentscouldbethe generalpatternfeltbytheentirepostgraduate studentbody,particularlyduringthefirstyear ofaspecializedhealthcaretrainingprogram.In anyevent,suchrelevantdatashouldbepassed ontothedirectorsofhealthcaretrainingpro-grams,withtherecommendationthatcareful attention should be given to trainees during their first year, especially through ensuring constantsupervision.
Theprevalenceoffemalepatientsamong thepopulationtreatedatNapremeisasign of the growing participation of women in residency programs and postgraduate work. Womenarealsoinclinedtobemoresuscep-tibletodepressivesymptomsandemotional disordersduringtrainingprograms7,11,16and,
whenfacedwithemotionalsuffering,tendto seekmorehelpthanmendo.33
Thefactthatsleepdisordersweremore prevalent among medical residents than in
othergroupsisprobablyduetosleepdepriva-tion,whichisasignificantcauseforconcern inthetrainingprogram.Thisalsoreinforces themovementinfavorofdiscontinuing“36 x12”shifts,orschemesof36hoursofwork followedby12hoursofrest.Itfurthermore contributes towards advocating a policy for settingalimittomedicalresidents’workload. InBrazil,alawregulatingtheweeklyworkload to60hourscameintoforcein1981.34
Anotherimportantfindingfromthepres-ent study relates to the greater need among medicalresidentstotaketimeoffonsickleave thanamongothergroups.Thisappearstobe consistentwiththeintenseactivityrequiredin attendingtopatientsandthemorestringent commitments,shiftsandschedulesthatcharac-terizethemedicalresidencytrainingprogram.
There were fewer medical residents thanothertraineestreatedatNapremewho refrained from the use of alcohol.This is probably because there was a significantly greaternumberofmalepatientsinthegroup ofmedicalresidentsthanintheothertrainee subgroups.Nonetheless,afteradjustingthis incidenceforgender,itssignificanceremained unaltered. In another study with similar findings regarding the statistical correlation betweenemotionalproblemsandtheuseof alcoholamongmedicalresidents,thesignifi-canceremainedunalteredwhentheincidence ofpersonalproblemswasadjustedforgender, usingvarianceanalysis.35
Inthecasesinwhichaformalpsychiatric diagnosiswasestablished,therewasahigher prevalence of anxiety-depressive disorders. This was also found in a survey within a similarserviceattheUniversityofCalifornia, LosAngeles.23
In30%ofthecaseswefailedtomeetthe ICD-10criteria32forformulatingapsychiatric
diagnosis.Thisfindingwasprobablybiased, becauseNapremeusuallyadoptsthepolicyof distinguishingbetweenthedegreesofpsycho-logicalsuffering,whichhasoftenprevented theformulationofamoreprecisediagnosis accordingtotheICD-10criteria,forexample inthediagnosisofadaptationdisorders.Ina certainnumberofcases,amoreappropriate diagnosiswouldprobablyhavebeen“transi-toryself-limiteddeadaptation”.Itshouldbe keptinmindthatmostoftheproblemsfaced duringthetrainingcoursecanoftenbeover-comewiththehelpofa“mentor”:someone whoismoreexperiencedorbetteradapted, andwhoknowshowtobesympatheticand offersupporttootherpeople.24,31
wereotherveryserioussituations,inwhich the classification in and by itself failed to conveythefulldramathatwastakingplace. Threeofthemostseriouscaseswereoffemale residentswho,afterbeingonsickleavefora certainperiod,finallyabandonedtheresidency trainingprogram,duetopsychopathological problems.Oneofthesepatients,besideshav-ingaseverepersonalitydisorder,wassuffering fromheavyabuseofillegaldrugs.Despitethe significantsupportprovidedbycolleaguesand supervisors,thepatientfailedtocomplywith thetreatmentandabandonedtheuniversity withouteverrespondingtoourattemptsto contacther.Thesecondcasewasofaresident with a well structured family and financial resources, who had been under psychiatric treatmentandpsychotherapyeversinceshe hadbeenanundergraduateatmedicalschool. The patient’s serious clinical condition was diagnosedasanobsessive-compulsivedisor-der,andthispreventedherfromcontinuing withthetrainingcourse,despitetheseveral attemptsthatshemadetoreturn.Thethird casewasofafemaleresidentwhoseparanoid personality disorder caused serious conflicts withhercolleagues,supervisors,patientsand familymembers.Thesituationworsenedto suchapointthatthepressureofthehostil-ity she had created became unbearable and shefinallyabandonedthetrainingprogram. Althoughthepatient’scompliancewithtreat-menthadbeenquiteirregular,shemanaged tocreatefriendlytieswithoneoftheservice’s psychologistsand,beforeleavingtheuniver-sity,sheaskedthispsychologisttorecommend
anotherpsychologistwhocouldhelpherto continuewiththetreatment.
The seriousness of the cases attended is alsoclearlyevidentinrelationtosuicide.Inthe presentstudy,22.3%ofthetraineeshadwhat theydescribedassuicidalthoughts.Itisawell-knownfactthatself-destructivenessishighly prevalentamonghealthcareprofessionals,and particularlyamongphysicians.Thecreationof Napremewashighlyinfluencedbythesuicide offouryoungphysicians.Thiscausedasevere impactontheuniversity,especiallybecauseone ofthesephysiciansdiedbyjumpingfromthe 10thfloorofthehospitalduringa24-hourshift.
The other two were cared for and admitted totheuniversityhospital,wheretheyeventu-allydied.Theimpactoftheseeventsnotonly contributedtowardsthecreationoftheservice, butalsotowardsincreasedsensitivityregarding universityissuesandthementalhealthofpro-fessionalsontrainingprograms.Inthissense, moreextensive,in-depthdiscussionsonthese mattershavegraduallybeenmadepossible.It hasalsobecomeeasiertodevelopstudiesinthis area,forexampleastudyondepressionthat was carried out among medical and nursing residents.26,27Itshouldalsobenotedthatthis
typeofserviceisofficiallyrecommendedinthe UnitedStatesforallschoolsofferingpostgradu-atecoursesinthefieldofmedicine.12
The acceptance and institutional cred-ibilityofNapreme’sservicesappearstobevery positive.Thisisdemonstratedbythesponta-neousdemandforsuchservicesandalsoby thefactthat,inoverhalfofthecases,theusers themselves have recommended the service.
Thecredibilitythatinducespatientstosponta-neouslyseekhelpfromtheserviceseemstobe relatedtothelowerrateofdiscontinuationof treatment,whenpatientspontaneouslycome totheserviceforhelp.
Napremewascreatedtoprovideservicesfor young academically productive professionals. Mostoftheseindividualsaredirectlyresponsible forhospitalcare,forthemakingoflifeanddeath decisionsregardingpatientsandforteaching activitieswithintheuniversity.Theserviceis not only concerned with the needs of these patients,butalsowiththoseoftheuniversityit belongsto.Thesituationstobedealtwithrange frompsychosistopersonalitydisorders,from deadaptationtotheworkingenvironmentand familyconflicts.Forthis,Napremefunctions inanextremelyflexiblemannerencompassing differentactionsindifferentsituations,withcon-tingenciesforvariabilityindemand.Atcertain periodsoftheyear,demandcanincreasefivefold inrelationtootherperiods.
CONCLUSION
Among the different groups of trainees treatedthereweremoresimilaritiesthandif-ferences.Thisshowsthattheconcentrationof psychological/psychiatriccarewithinasingle serviceisappropriateforthispopulation.
ThecreationofservicessuchasNapreme mustbeencouragedatallinstitutionsoffer-ingprofessionaltraininginthemedicalfield, sincesuchservicescandealwithmanyofthe problemsthatcauseanimpactonboththe institutionanditstrainees.
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Perfil clinico e demográfico dos usuários de umserviçodesaúdementalparamédicos residentes e outros profissionais da saúde em treinamento na Universidade Federal deSãoPaulo
CONTEXTO: O serviço Napreme foi criado em setembro de 1996 dentro de nossa universidade.
OBJETIVO: Descreveroperfilclínicoedemo-gráficodosusuários.
TIPODEESTUDO:Retrospectivo.
LOCAL: UniversidadeFederaldeSãoPaulo–Es-colaPaulistadeMedicina(Unifesp-EPM).
MÉTODOS: Estudo de 233 registros semi-es- truturados,preenchidospelopsicólogo/psi-quiatra,duranteoprimeiroatendimentodo usuário (médico ou enfermeiro residente, pós-graduandoouespecializando)noperíodo de01/12/1996a30/11/2002.Oregistrocon-tinhadadossócio-demográficos,ocupacionais eclínicosdousuáriodoserviço.
RESULTADOS: Os usuários tinham idade média de 27 anos, predomínio do sexo feminino(79,4%),eramsolteiros(82,0%), e procuravam ajuda no primeiro ano de treinamento(63,1%).Em70,8%doscasos, aprocurafoiespontânea,sendoaadesãoao tratamentomaiornessegrupoemcompara-çãoaosusuáriosqueforamencaminhados porsupervisores(p<0,05).Em30%dos
casos,ousuárioprocurouoserviçoembusca de orientação psicológica ou suporte com relaçãoaconflitossituacionaisespecíficos. Transtornos depressivos e ansiosos foram osdiagnósticosmaisfreqüentes;22,3%dos usuáriosatendidosreferiramideaçãosuicida. Osmédicos-residentesdiferiramdorestante dosusuáriosporserempredominantemente do sexo masculino (p < 0,01), com mais distúrbiosdosono(p<0,05),commenor númerodeabstêmios(p<0,05)eporne-cessitaremdemaislicençaseafastamentos (p<0,001).
DISCUSSÃO: Emconformidadecomalitera-tura,oprimeiroanodetreinamentoémais estressante, sobretudo para as mulheres. A maiorpartedossintomasapresentadosédo espectrodepressivo-ansioso,refletindotrans-tornosdeadaptação.Noentanto,agravidade pode ser avaliada tendo-se como critério o grandenúmerodecasosemquetendências suicidasforamreferidas.
CONCLUSÕES: Este estudo enfatiza a neces-sidadeeaimportânciadeseproverserviços formais,estruturadoseconfidenciaisdeassis-tênciaàsaúdementalparamédicosresidentes epós-graduandosdaáreadasaúde.
PALAVRAS-CHAVE: Serviços de saúde. Resi-dênciamédica.Educaçãodepós-graduação. Estafaprofissional.Saúdeocupacional.Saúde mental.
PUBLISHINGINFORMATION
RafaelFagnaniNeto. PsychiatristattheNúcleodeAs- sistênciaePesquisaemResidênciaMédica(Napreme),Uni-versidadedeFederaldeSãoPaulo,SãoPaulo,Brazil.
CristinaSuekoObara. PsychologistattheNúcleodeAs- sistênciaePesquisaemResidênciaMédica(Napreme),Uni-versidadedeFederaldeSãoPaulo,SãoPaulo,Brazil.
Paula Costa Mosca Macedo. Psychologist at the Nú-cleo de Assistência e Pesquisa em Residência Médica (Napreme),UniversidadedeFederaldeSãoPaulo,São Paulo,Brazil.
VanessaAlbuquerqueCítero.Psychiatristformerlyatthe NúcleodeAssistênciaePesquisaemResidênciaMédica (Napreme),UniversidadedeFederaldeSãoPaulo,São Paulo,Brazil.
LuizAntonioNogueira-Martins.Assistantprofessorin theDisciplineofMedicalPsychologyandSocialPsychiatry, Department of Psychiatry, Universidade Federal de São Paulo, and Coordinator of the Núcleo de Assistência e PesquisaemResidênciaMédica(Napreme),SãoPaulo, Brazil.
Sourcesoffunding:Notdeclared
Conflictofinterest:Notdeclared
Dateoffirstsubmission:July28,2003
Lastreceived:February17,2004
Accepted:March2,2004
Addressforcorrespondence:
LuizAntonioNogueiraMartins R.BorgesLagoa,426
SãoPaulo(SP)—Brasil—CEP04038-000 Tel.(+5511)5573-0072
E-mail:nogmartins@psiquiatria.epm.br
COPYRIGHT©2004,AssociaçãoPaulistadeMedicina
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