USERS OF THREE PSYCHI ATRI C SERVI CES: PROFI LE AND OPI NI ON
1Ver a Lucia Mendiondo Osinaga2
Ant onia Regina Fer r eir a Fur egat o3
Jair Licio Fer r eir a Sant os4
Osinaga VLM, Fur egat o ARF, Sant os JLF. User s of t hr ee psychiat r ic ser vices: pr ofile and opinion. Rev Lat ino- am En f er m agem 2 0 0 7 j an eir o- f ev er eir o; 1 5 ( 1 ) : 7 0 - 7 .
This st udy aim ed t o char act er ize m ent al pat ient s and t heir com panions at t hr ee psychiat r ic ser vices; t o
id en t if y d iseases, d iag n oses an d t r eat m en t s; t o lear n ab ou t t h eir ex p ect at ion s an d op in ion s ab ou t m en t al
illness and psy chiat r ic car e. Met hodology : Pat ient s w it h m ent al disor der s and t heir com panions ( 750) at t hr ee
car e ser vices ( Em er gency Unit , Psychosocial Car e Cent er and Ment al Healt h Clinic) answ er ed t he Clinical- Social
Char act er izat ion Quest ionnair e and t he Opinion Measur em ent Scale on concept s and psy chiat r ic car e. Result s:
Single pat ient s w it h unst able r elat ions w it h t heir par t ner s, low educat ional level, unem ployed, w it h lit t le infor m at ion
about t heir diagnoses and t r eat m ent s. Medicat ion t r eat m ent s and low com m it m ent lev els w er e pr edom inant .
Many pat ient s had acquir ed t he illness over t he last five year s. Subj ect s at t he t hr ee ser vices r evealed diver ging
opinions r egar ding concept s and car e.
DESCRI TORS: psy chiat r y ; m ent al healt h; nur sing
USUARI OS DE SERVI CI OS PSI QUI ÁTRI COS: PERFI L Y OPI NI ÓN
El obj et ivo de est e est udio fue car act er izar el por t ador de enfer m edad m ent al y su acom pañant e en el
at en dim ien t o en t r es ser v icios psiqu iát r icos; iden t if icar la en f er m edad, diagn óst icos y t r at am ien t os; con ocer
ex pect at iv as y opiniones a cer ca de la enfer m edad m ent al y asist encia psiquiát r ica. Met odología - Por t ador es
de t r ast or no m ent al y sus acom pañant es ( 750) en t r es ser v icios ( Unidad de Em er gencia, CAPS y Am bulat or io
de Salu d Men t al) r espon dier on al Cu est ion ar io de Car act er ización Clín ico- Social y a la Escala de Medida de
Opinión sobr e concept os y at ención psiquiát r ica. Result ados: pacient es solt er os, con uniones inest ables, baj o
n i v el d e escol ar i d ad , si n t r ab aj o, p oco i n f or m ad os sob r e su s d i ag n óst i cos y t r at am i en t os. Pr ed om i n ar on
t r at am ient os m edicam ent osos y baj os índices de int er nación. Muchos se enfer m ar on en los últ im os cinco anos.
Se obser vó conver gencia de opiniones sobr e concept os y sobr e la at ención ent r e los suj et os en los 3 ser vicios.
DESCRI PTORES: psiqu iat r ía; salu d m en t al; en fer m er ía
USUÁRI OS DE TRÊS SERVI ÇOS PSI QUI ÁTRI COS: PERFI L E OPI NI ÃO
Obj et iv ou- se car act er izar o por t ador de doença m ent al e seu acom panhant e em at endim ent o nos t r ês
ser v iços psiquiát r icos; ident ificar doença, diagnóst icos e t r at am ent os; conhecer ex pect at iv as e opiniões sobr e
doença m ent al e assist ência psiquiát r ica. Met odologia- Por t ador es de t r anst or no m ent al e seus acom panhant es
( 750) em 3 ser viços ( Unidade de Em er gência, CAPS e Am bulat ór io de Saúde Ment al) r esponder am ao Quest ionár io
de Car act er ização Clín ico- Social e a Escala de Medida de Opin ião sobr e con ceit os e assist ên cia psiqu iát r ica.
Resu l t ad o s: p aci en t es so l t ei r o s, co m u n i õ es i n st áv ei s, b ai x o n ív el d e esco l ar i d ad e, sem t r ab al h o , p o u co
infor m ados sobr e seus diagnóst icos e t r at am ent os. Pr edom inam t r at am ent os m edicam ent osos e baix os índices
de int er nação. Muit os adoecer am nos últ im os 5 anos. Obser v ou- se div er gência de opiniões sobr e conceit os e
sobr e a assist ência ent r e os suj eit os, nos 3 ser v iços.
DESCRI TORES: psiqu iat r ia; saú de m en t al; en fer m agem
1
St udy ext r act ed fr om Doct oral Disser t at ion, FAPESP funded; 2 PhD in Psychiat r ic Nur sing, e- m ail: w osinaga@t er r a.com .br ; 3 Full Pr ofessor, Univer sit y of São Paulo at Ribeir ão Pr et o College of Nur sing, WHO Collaborat ing Cent r e for Nur sing Resear ch Developm ent , e- m ail: fur egat o@eer p.usp.br ; 4 Full Pr ofessor,
Univer sit y of São Paulo at Ribeir ão Pr et o Medical School, e- m ail: j [email protected]
I NTRODUCTI ON
W
h y r e v i s i t c o n c e p t s a b o u t h e a l t h a n d m ent al illness and about car e based on t he opinionsof m ent al pat ient s and t heir r elat iv es?
Ther e ar e 500 m illion people all over t he w or ld
suffer ing fr om som e k ind of m ent al disor der, leading
t o a w o r k i n c a p a c i t y r a t e o f 4 0 % a n d o t h e r
consequences for pat ient s, fam ilies and societ y( 1).
Th e se r a t e s a r e r e l a t e d t o i n cr e a se d l i f e
ex pect ancy and aging, incr eased st r ess, fam ily cr ises
and lack of social suppor t . The pr esence of a disease
a n d i t s c o m p l i c a t i o n s a f f e c t t h e f a m i l y g r o u p ,
c o n d i t i o n i n g d i f f e r e n t l e v e l s o f a n x i e t y a n d
p sy ch od y n am ic d iseq u ilib r iu m .
A st udy inv olv ing r elat iv es of schizophr enics
exam ined t he bur den t he pr esence of a m ent al pat ient
r ep r esen t s f o r f a m i l y m em b er s. I n l i t er a t u r e, t h e
i m p o r t an ce o f t h e car eg i v er ’s r o l e i s o b ser v ed , i n
m ent al illnesses as w ell as in ot her chr onic diseases.
These st udies dem onst r at e concer n w it h t he differ ent
t ypes of over load t he fam ily gr oup is exposed t o and
t he consequences for t hese people’s healt h( 2- 3).
On t h e ot h er h an d , t h e last t h r ee d ecad es
h a v e w i t n e sse d a m o v e m e n t t h a t h a s m o t i v a t e d
p r o f o u n d ch a n g e s i n p sy ch i a t r i c ca r e . Te a m w o r k
( m u lt ip r of ession al an d in t er d iscip lin ar y ) , k n ow led g e
p l u r a l i t y a n d t h e co m p l e x i t y o f a ct i o n s a n d ca r e
s e r v i c e s s t a r t t o d o m i n a t e t h e a c a d e m i c a n d
pr of ession al ar ea as f u n dam en t al r equ isit es f or t h e
psy chiat r ic car e r efor m pr ocess( 4 - 7 ).
Th u s, co n ce p t s l i k e d e h o sp i t a l i za t i o n a n d
deinst it ut ionalizat ion guide t he change pr ocess in t he
d o m i n a n t f o c u s o f p s y c h i a t r i c a c t i o n s f r o m t h e
specialized int r ahospit al ar ea t o out side t he hospit al,
w h e r e o u t p a t i e n t se r v i ce s a n d d a y ca r e ce n t e r s
gr adually st ar t t o assum e m ent al healt h car e.
I t is in cr easin g ly n ecessar y t o assess car e
q u alit y f r om t h e u ser s’ p er sp ect iv e. Th is m ak es it
p o ssi b l e t o d i sco v er at t i t u d es asso ci at ed w i t h t h e
received care. This inform at ion benefit s m ent al healt h
ser v ice or gan izat ion , w or k er s an d u ser s.
Th is giv es r ise t o t h e in t er est in get t in g t o
k n ow n ot on ly p at ien t s’ b u t also t h eir com p an ion s’
op in ion s, at t em p t in g t o m ak e n u r ses aw ar e of t h e
im por t ance of car e deliv er y t o pat ient s accor ding t o
t heir needs, in or der t o im pr ov e ser v ice qualit y and
t ak e t h is popu lat ion ’s f am ily an d social r elat ion sh ip
net w or k int o account .
OBJECTI VES
- To c h a r a c t e r i z e m e n t a l p a t i e n t s a n d t h e i r
com p an ion s, id en t if y in g t h e d isease m ot iv at in g t h e sear ch f or car e at t h r ee p sy ch iat r ic ser v ices, t h eir
diagn oses an d t r eat m en t .
- Get t ing t o know t heir expect at ions about t r eat m ent , cur e and car e.
- Get t ing t o k now t heir opinion about m ent al illness an d psy ch iat r ic car e.
METHODOLOGY
We car r ied ou t a q u an t it at iv e st u d y w it h a d escr ip t iv e ap p r oach .
Pl a ces
Dat a w er e collect ed at t h r ee m en t al h ealt h car e ser v ices in Ribeir ão Pr et o/ SP, Br azil:
- Em ergency Unit (EU), of the University of São Paulo at Ribeirão Preto Hospital das Clínicas (HCRP/ USP) - Covers
23 cities in the region and offers six beds for observation of acute or decom pensation cases. Care is delivered 24
hours per day, with an average m onthly flow of 180 cases.
Care is agile, with patients being discharged or referred to other services in up to 72 hours(6).
- Psy ch osoci al Car e Cen t er ( PCC) , of t h e Rib ei r ão Pr e t o M u n i c i p a l H e a l t h S e c r e t a r y. M u n i c i p a l l y
m an aged, t h is cen t er cov er s 4 5 n eigh bor h oods an d is lin k ed u p w it h t h e h ealt h n et w or k , at t en din g fiv e
Basic Healt h Unit s, w it h an av er age m ont hly flow of 4 3 0 cases. Th e PCC d eliv er s car e f r om Mon d ay t o
Fr i d a y, b e t w e e n 7 : 3 0 a n d 1 7 : 3 0 , i n c l u d i n g p s y c h o l o g i c a l , s o c i a l , p h a r m a c o l o g i c a l , g r o u p
act ivit ies, w it h nurses offering w elcom ing, occupat ional
an d r ecr eat ion al t h er apies.
- Regional Ment al Healt h Out pat ient Clinic ( RMHOC) ,
of t he Ribeirão Pret o Municipal Healt h Secret ary. Covers
51% of t he cit y populat ion and som e regional pat ient s, and aim s t o diagnose, t reat , deliver care and reinsert
m ent al pat ient s int o societ y. The Clinic m ost ly at t ends
chr onic pat ient s under t her apeut ic follow - up, w it h an average m ont hly flow of 2,065 cases, from Monday t o
Friday, bet ween 7: 00 and 18: 00.
Pop u lat ion / sam p le
A l l p a t i e n t s w i t h m e n t a l d i s o r d e r s a n d
si x - m o n t h d a t a co l l e ct i o n p e r i o d w e r e i n v i t e d t o
p ar t icip at e.
Th i s sam p l e r ep r esen t s t h e g r o u p o f n o n
-hospit alized pat ient s w ho needed psy chiat r ic car e at
t h at m om en t . Su bj ect s w er e in clu ded u n t il r each in g
250 pat ient s and t heir r espect iv e 250 com panions at
each inst it ut ion. This figur e w as r eached aft er m or e
or less t w o m ont hs of dat a collect ion at each ser vice
( N= 7 5 0 ) .
Alcohol and dr ugs user s w er e ex cluded fr om
t his sam ple, as w ell as com panions under 15 year s of
a g e.
Et h ics
Th e pr oj ect w as appr ov ed by t h e Resear ch
Et h ics Com m it t ee at HCRP/ USP, an d au t h or ized b y
t h e r esp o n si b l es f o r t h e l o ca l t ea m s. Al l su b j ect s
r eceiv ed t h e n ecessar y in f or m at ion an d sig n ed t h e
Fr ee an d I n for m ed Con sen t Ter m .
Dat a collect ion
I nt er view s w it h pat ient s and t heir com panions
w er e held indiv idually at t he consult at ion r oom s and
t ook abou t 5 0 m in u t es, as m an y par t icipan t s m ade
com m ent s and dem onst r at ed t he need for at t ent ion.
Ten subj ect s r efused t o par t icipat e. At t he EU, som e
cont act s occur r ed aft er an episode had been cont r olled.
I n st r u m en t s
1 - I dent ificat ion
- Me n t a l Pa t i e n t Ch a r a c t e r i z a t i o n Qu e s t i o n n a i r e
( MPCQ)
- Fa m i l y M e m b e r / Co m p a n i o n Ch a r a c t e r i z a t i o n
Qu est ion n air e ( FCQ) .
Th e t w o qu est ion n air es w er e u sed t o gr ou p
d a t a a b o u t : s u b j e c t ( p a t i e n t a n d c o m p a n i o n )
i d e n t i f i ca t i o n ; r e a so n t h e y a t t e n d e d t h e se r v i ce ;
infor m at ion about t he disease, pat ient , diagnoses and
t r eat m ent s; ex pect at ions about cur e and car e.
2 - Opinion Measur em ent Scale - OMS
This scale w as const r uct ed on t he basis of a
l a r g e n u m b er o f st a t em en t s t a k en f r o m sci en t i f i c
l i t e r a t u r e a n d t h e r e s e a r c h e r s ’ p r o f e s s i o n a l
ex per ien ce. I t s in it ial for m con t ain ed 5 6 st at em en t s
about healt h, m ent al illness and car e and w as applied
t o a popu lat ion of 2 5 0 su bj ect s ( pat ien t s, r elat iv es a n d p r o f e ssi o n a l s) , a s w e l l a s t o o t h e r su b j e ct s
( n u r s i n g s t u d e n t s ) . Re s u l t s w e r e a n a l y z e d
st at ist ically( 8 - 9 ). A cr it ical st u d y of t h is in st r u m en t allow ed us t o r efor m it , w it h t he help of cor r elat ion
an d sign if ican ce t est s, w it h a v iew t o im pr ov in g it s
efficiency. New st udies, w hich cr it ically analy zed t he inst rum ent ’s form ulat ions, as w ell as a crit ical analysis
t hat involved t en exper t s and a new cor r elat ion st udy
of quest ions r elat ed t o concept s, fam ily, nur sing and car e allow ed us t o r econsider over laps and r each t he
final form of t he scale, w it h 34 quest ions( 10).
A pilot st udy w as car r ied out at a psychiat r ic hospit al in Pelot as/ RS, involving 206 subj ect s ( pat ient s
and r elat ives) . This st udy m ade it possible t o per for m
new st at ist ical t est s and com par e bot h gr oups ( pat ient s and r elat ives) and ar eas of int er est ( concept and car e) .
Result s evidenced a w ell- balanced inst rum ent , in view
of it s hom ogeneous scor e dist r ibut ion and st at em ent s about concept s and car e( 11).
This inst r um ent ( Opinion Measur em ent Scale
- OMS on Concept s and Psy chiat r ic Car e) .
Dat a an aly sis
Nex t , w e pr esent t he char act er izat ion of t he
t w o st udy gr oups at t he t hr ee ser v ices, ident ificat ion of t h eir disease, diagn oses an d t r eat m en t s, as w ell
as t heir expect at ions, so as t o allow for analysis. The
r esult s of subj ect s’ opinions about healt h and m ent al illn ess con cept s an d car e w er e su bj ect t o st at ist ical
a n d q u a l i t a t i v e a n a l y s i s , b a s e d o n l i t e r a t u r e
r ef er en ces.
RESULTS AND ANALYSI S
The sam ple of 750 par t icipant s included 250
subj ect s ( 125 pat ient s and t heir 125 com panions) at each of t he t hree psychiat ric care services in Ribeirão
Pr e t o : ( Em e r g e n cy Un i t - EU, Psy ch o so ci a l Ca r e
Cent er - PCC and Regional Ment al Healt h Out pat ient
Clinic - RMHOC) .
Su bj ect pr of ile
Accor d in g t o d at a p r esen t ed in d et ail in a
concept s at t hree psychiat r ic ser vices, t he per cent age
of fem ale m ent al pat ient s was higher. Likew ise, about
6 0 % of com panions w er e fem ale car egiv er s( 1 2 ).
Alm ost 2/3 of pat ient s w er e single or divor ced
and less t han 10% w idow ed, w hile a lit t le m or e t han 1
/3 liv ed in som e k ind of union. Am ong com panions,
alm ost 2/3 had som e k ind of union, less t han 1
/3 w as
single or div or ced and about 10% w idow ed.
These dat a are in line w it h t he concent rat ion
( ar ou n d 9 0 % ) of com p an ion s’ d eg r ee of k in sh ip in
w iv es and m ot her s. At t he PCC, 11% of com panions
w er e ov er 7 0 y ear s of ag e, m ain ly w om en . At t h e
Clinic, 21% w as older t han 60.
Pat ient s’ age r anged fr om 15 t o 90 y ear s. A
younger populat ion at t ended t he EU, w it h 13.6% under
19 and anot her 40% up t o 29 year s old. At t he PCC,
43.2% of pat ient s w er e bet w een 40 and 59 year s old
and, at t he Clinic, 55% bet w een 30 and 59 year s old.
The associat ion bet w een t he onset of sev er e
d iseases lik e sch izop h r en ia, m ood an d p er son alit y
d isor d er s an d ad olescen ce an d y ou n g ad u lt ag e is
q u it e w ell- k n ow n , accom p an ied b y w or se ev olu t ion
an d low ex pect at ion s. Mor eov er, t h e ear ly ph ase of
t h e s e d i s e a s e s i s a s s o c i a t e d w i t h s t u d y, w o r k ,
con st it u t ion of n ew f am ily g r ou p s an d ot h er social
com m it m ent s( 1 , 3 - 4 ).
Psy ch o se s a n d sch i zo p h r e n i a s a r e p u b l i c
healt h pr oblem s, as t hey st ar t befor e t he age of 25,
br eak in g u p t h e life pr oj ect s of m an y y ou n g people
and t heir fam ilies( 13). Hence, ear ly ident ificat ion and
ad eq u at e t r eat m en t ar e v er y im p or t an t , as w ell as
incr eased infor m at ion deliv er y t o pat ient s, r elat iv es,
healt h professionals and t he gener al populat ion about
disor der s, t r eat m ent s and w ays of w elcom ing pat ient s.
D i f f i c u l t i e s t o d i s t i n g u i s h b e t w e e n s o m e
behavior s and t he pr odr om ic sym pt om s of a psychot ic
e p i s o d e a r e a s s o c i a t e d w i t h t h e p h a s e o f g r e a t
t r ansfor m at ions in y oung people’s liv es and t he new
r oles t h ey assu m e in societ y. Gen er ally t r each er ou s
m an if est at ion s of t h e d isease at an ear ly ag e ar e
r esp on sib le f or h ig h lev els of sin g le p er son s, w h o
int er r upt t heir educat ion and/ or w or k .
We f o u n d l o w e d u c a t i o n l e v e l s a m o n g
pat ien t s, 1 0 % of w h om w er e illit er at e an d bet w een
65 and 73% had only finished basic educat ion at t he
t h r ee ser v ices. Th ese su bj ect s’ occu pat ion w as also
concent r at ed in sim ple act iv it ies, such as housew or k
and gener al m aint enance ( about 50% at t he EU and
PPC and 76% at t he Clinic) , w hile 30% of pat ient s at
t h e EU an d PPC h ad n ev er w or k ed or w er e r et ir ed.
Ab ou t t w o t o f ou r p er cen t of p at ien t s p ossessed a
h igh er edu cat ion degr ee.
Th e sit u at ion w as n ot v er y dif f er en t am on g
com panions, w it h a concent r at ion in sim ple act iv it ies
( 57- 61% ) , bet w een t w o and six % of self- em ploy ed
p r o f e ssi o n a l s, b e t w e e n si x a n d 1 8 % r e t i r e d a n d
ar ound 15% of st udent s, unem ploy ed or m er chant s.
I n su m , t h is sam p le of t h e p op u lat ion t h at
a t t e n d s p u b l i c p s y c h i a t r i c c a r e s e r v i c e s i s
char act er ized by low educat ion lev el, unem ploy m ent
or act ive in professionals w it h low qualificat ion levels,
a n d d i f f i c u l t i e s t o a s s u m e s o c i a l c o m m i t m e n t s .
Mor eover, especially at t he EU, w e found m any young
p a t i e n t s w h o w e r e e x p e r i e n ci n g t h e i r f i r st a cu t e
d isease ep isod e, w h ich ex p lain s t h e d at a an aly zed
a b o v e .
Th e disease, diagn oses an d t r eat m en t s.
I n t h e cat egor y com plain t / r eason t o at t en d
t he ser vice, w e found a significant per cent age ( 64.8% )
of im pr ecise infor m at ion at t he EU, i.e. 24% could not
infor m w hy t hey w er e t her e, 19.2% alleged t hey w er e
h av in g a cr isis, 1 7 . 6 % t h at t h ey w er e n er v ou s an d
4% for an appoint m ent . Pat ient s at t he PCC ( 68.8% )
an d Clin ic ( 7 0 . 4 % ) alleg ed t h ey v isit ed t h e ser v ice
for a doct or ’s appoint m ent and r et ur n; bet w een four
and five per cent of t hem could not t ell w hy t hey w er e
t h er e. Th ey m ade lit t le m en t ion of t h eir disease or
sym pt om s. At t he EU, 12% indicat ed a suicide at t em pt ,
9 . 6 % d e p r e ssi o n , 5 . 6 % p a n i c/ a n x i e t y a n d 4 . 8 %
hallucinat ions and lack of cont r ol, w hich is ex pect ed
as t he EU is an em er gency car e ser v ice.
As t o t he com panions, t he r eason w hy t hey
visit t he service is not very different , but t he follow ing
should be highlight ed: at t he EU, only 6% acknow ledge
t h e su i ci d e a t t e m p t s, a g a i n st 1 2 % a cco r d i n g t o
pat ient s; 5% alleged som at ic pr oblem s; at t he PCC,
3 9 % cam e t o pick u p dr u gs fr om t h e ph ar m acy ; at
t he Clinic, 18% sim ply cam e t o accom pany a pat ient
and few com panions knew about t he pat ient ’s disease.
Th ese r esu lt s r ev eal d en ial of t h e d isease,
a m o n g p a t i e n t s a s w e l l a s, m a i n l y, a m o n g t h e i r
r elat iv es an d com p an ion s. Mor e t h an 2/3 of p eop le
at t ending t he PCC alleged t hat t hey did not know and
t hat t hey visit ed t he ser vice for a m er e appoint m ent ,
w h i l e 3 9 % o f c o m p a n i o n s h a d c o m e t o p i c k u p
I t is not iceable t hat t he PCC should r esist t o
ch r o n i f i ca t i o n , m o v i n g b e y o n d sy m p t o m co n t r o l ,
s t i m u l a t i n g u s e r s ’ p a r t i c i p a t i o n i n a u t o n o m o u s
com m unit y spaces and valuing r elat ives’ involvem ent .
I n t h eor y, t h is ser v ice’s goal is in lin e w it h
t h e id ealizer s of d ein st it u t ion alizat ion , p sy ch osocial
r ehabilit at ion and t he pat ient s’ r einser t ion int o t heir
com m u n it y, in clu din g act iv e fam ily par t icipat ion an d
im proving t heir qualit y of life( 4- 5,14- 15).
H o w e v e r, d a t a i n f o r m e d b y p a t i e n t s a n d
com pan ion s at t r act at t en t ion t o t h e n eed t o assess
w het her t his service is act ually achieving it s int ended
g oals.
I n t h e d i a g n o s i s c a t e g o r y ( i n f o r m e d b y
p at ien t s, in f or m ed b y com p an ion s an d r ecor d ed in
t he m edical file) , r esult s point t ow ar ds disinfor m at ion
an d in f or m at ion m isalign m en t ( Table 1 ) . At t h e EU,
38% of pat ient s neit her knew t heir diagnosis nor t he
n am e of t h eir d isease; t h e sam e h ap p en ed at t h e
PCC ( 2 2 % d id n ot k n ow an d 1 5 % u sed cr azin ess,
crazy, disorient ed as designat ions) ; at t he Clinic, 32%
did n ot k n ow an d 1 9 % h ad ot h er design at ion s. We
found sim ilar per cent ages of com panions w ho did not
k now t he diagnosis.
Am on g pat ien t s w h o k n ew t h e diagn osis at
t h e EU, h i g h er co i n ci d en ce a b o u t d ep r essi o n a n d
bipolar disor der st ood out , as w ell as a lar ger num ber
o f m e d i ca l r e f e r e n ce s t o p sy ch o t i c e p i so d e s a n d
schizophr enia. At t he PCC, w e found closer pr ox im it y
bet w een pat ien t s’ an d r elat iv es’ in f or m at ion . At t h e
t h r ee ser v ices, disagr eem en t lev els w er e h igh er f or
s c h i z o p h r e n i a , w i t h h i g h e r r e c o r d s t h a n c a s e s
infor m ed by subj ect s. We also found 7.2% and 19.2%
of dem ent ia cases in m edical file r ecor ds.
Table 1 - Per cent age dist r ibut ion of diagnoses infor m ed by m ent ally ill pat ient s and r ecor ded in t he pat ient file,
at t he t hr ee ser v ices under st udy ( Em er gency Unit , Psy chosocial Car e Cent er and Clinic)
* P - Diagnosis infor m ed by pat ient , C - Diagnosis infor m ed by com panion, M - Medical diagnosis as infor m ed in pat ient file
Medical diagn oses r egist er ed in pat ien t files
w ere m ore concent rat ed in schizophrenias, depression
an d per son alit y disor der s. We f ou n d m or e balan ced
and consensual diagnoses for depr ession cases at t he
t hree services and according t o t he t hr ee infor m at ion
so u r ces.
Disease t im e: accor ding t o pat ient s, a lar ge
num ber of people got ill over t he last four year s ( 66%
at EU, 47% at PCC and 54% at t he Clinic) . Relat ives
r e p o r t e d l o w e r l e v e l s a t t h e t h r e e se r v i ce s. Th i s
im p r ecise in f or m at ion can b e d u e t o d ist an ce f r om
t h e f a ct a s w e l l a s t o d e n i a l o f t h e d i se a se a n d
suffer ing. Mor eover, t he durat ion of t he per iod bet w een
t h e a p p e a r a n c e o f s y m p t o m s a n d t h e i r
“ acknow ledgem ent ” as par t of t he disease is var iable.
We also obser ved t hat 19. 2% of pat ient s at
t h e Clin ic h ad been liv in g w it h t h eir m en t al disease
for m or e t han 20 year s, and 24% bet w een 10 and 20
y e a r s.
Som e st udies focus on t he st igm at izat ion of
psychiat r ic pat ient s and t he im por t ance of know ledge
about t he disease and it s t r eat m ent s( 15). The aut hor s
affirm t hat know ledge is r elat ed w it h posit ive at t it udes
t ow ar ds t he pat ient .
As f or t r eat m en t s, a lar g e m aj or it y ( m or e
t h an 8 0 % at t h e t h r ee ser v ices) w as t r eat ed w it h
p sy ch o a ct i v e d r u g s, l e ss t h a n h a l f o f w h i ch w a s
associat ed w it h p sy ch ot h er ap eu t ic t r eat m en t s. Th e
h ig h est lev els w er e f ou n d at t h e Clin ic, w it h 7 2 %
r ecei v i n g o n l y m ed i cat i o n an d 2 2 % m ed i cat i o n i n
com binat ion w it h psychot her apeut ic t r eat m ent . At t he
PCC, w h er e t h e t w o t r eat m en t m odes w er e offer ed,
33% m ent ioned r eceiv ing only m edicat ion t r eat m ent
and 61% bot h m odalit ies.
Anot her t her apeut ic conduct exam ined in t his
st u d y w a s t h e n u m b e r o f h o sp i t a l i za t i o n s a m o n g
p at ien t s in t er v iew ed at t h e t h r ee ser v ices. Tab le 2
show s t hat pat ient s and com panions pr ov ide sim ilar
i n f o r m a t i o n ; m a n y p a t i e n t s h a d n e v e r b e e n
h ospit alized ( 3 9 % at EU; 5 4 % at PCC; 4 0 % at t h e
Clinic) ; hospit alizat ion t im es for t hose w ho had already
been hospit alized r anged fr om 1 t o 5 t im es.
n o i t u t i t s n I s i s o n g a i D t o n s e o D w o n
k Depression r a l o p i B r e d r o s i
D Schizophrenia y t e i x n A r e d r o s i D c i t a m o S r e d r o s i D y t i l a n o s r e P r e d r o s i D c i t o h c y s P e d o s i p
E Dementia Others Total P A M P A M P A M P A M P A M P A M P A M P A M P A M P A M P A M
t i n U y c n e g r e m
E 37.6 33 - 26.4 26 24 5.6 8 9.6 8 1119.23.2 1 - 6.4 10 3.2 1.6 1 16 2.4 8 20 0.8 2 4 7.2 - - 100100100
l a i c o s o h c y s P r e t n e C e r a
C 22.4 32 - 23.2 22 25.6 6.4 8 11.210.4 16 25.610.4 6 12 5.6 5 3.2 1.6 3 11.2 1.6 2 0.8 3.2 6 9.6 15.2 - 0.8 100100100
h tl a e H l a t n e M c i n il
Tab le 2 - Per cen t ag e d ist r ib u t ion of m en t al p at ien t
hospit alizat ion t im es as infor m ed by subj ect s at t he
t h r e e s e r v i c e s u n d e r a n a l y s i s ( Em e r g e n c y Un i t , Psy chosocial Car e Cent er and Regional Ment al Healt h
Ou t pat ien t Clin ic)
- At t he Clinic, 68% of pat ient s and 63% of com panions
r ev ealed g ood ex p ect at ion lev els f or im p r ov em en t
and cur e, w it h 22% and 16% r espect iv ely.
Op in ion s ab ou t m en t al illn ess an d p sy ch iat r ic car e
a m o n g u s e r s a t t h e t h r e e s e r v i c e s a n d t h e i r co m p an i o n s
Let u s st ar t f r om t h e p r em ise t h at m en t al pat ient s ar e people w hose subj ect iv it y is in conflict ,
going t hr ough int ense suffer ing, and w ho ar e par t of
a social group insert ed in a social relat ionship net w ork t hat bot h r ej ect s and w elcom es t hem .
Th e 3 4 st at em en t s ex am i n ed t h r o u g h t h e
Opinion Measur em ent Scale - OMS at t em pt ed t o cover t h e m ain m en t al h ealt h issu es, b ot h in con cep t u al
t er m s an d con sid er in g su b j ect s’ p er cep t ion of t h is
ca r e.
Th e r ecor d ed d at a w er e v er if ied in STATA,
calcu lat in g pat ien t s’ an d com pan ion s’ m ean opin ion
scor es at t h e t h r ee ser v ices. We f ou n d d if f er en ces bet w een t he t w o dom ains ( Concept and Car e) at t he
t hr ee ser v ices, w it h 2.36 as t he m ean scor e for PCC
pat ient s and 2.20 for t heir com panions.
I n o r d er t o assess t h e si g n i f i can ce o f t h e
d i f f e r e n c e s , t h e f o l l o w i n g s t a t i s t i c a l t e s t s w e r e per for m ed: Kr usk all Wallis v er ified w het her subj ect s’
o p i n i o n a b o u t t h e co n ce p t s si g n i f i ca n t l y d i f f e r e d
a m o n g t h e t h r e e s i t e s ; W i l c o x o n c h e c k e d f o r sig n if ican t d if f er en ces am on g su b j ect s at t h e t h r ee
services, w it h higher agreem ent levels in t he Concept
dom ain at t he EU ( P= 0.55) t han at t he ot her ser vices. Wh en l o o k i n g at su b j ect s’ o p i n i o n s at t h e
t h r ee ser v ices, w e f ou n d t h at , f or som e con cep t s,
pat ient s and com panions at t ending t he EU display ed d if f er en t op in ion s, w h ich w as n ot t h e case am on g
su b j ect s f r o m t h e t w o o t h er ser v i ces. To g i v e a n
exam ple, par t icipant s fr om t he EU agr eed t hat m ent al pat ient s ar e aggr essiv e. Subj ect s fr om t he ot her t w o
ser v ices did not shar e t his concept .
Par t icip an t s ag r eed t h at liv in g w it h m en t al p at ien t s p r ov ok es t en sion an d con f lict s, g en er at in g
diseases and disequilibr ia w it hin t he fam ily.
Pat ien t s an d com p an i on s al so ag r eed t h at h ospit alizat ion h as been in dicat ed an d f acilit at ed in
cases of aggr ession and lack of cont r ol, and t hat good
care at out pat ient clinics, healt h unit s and em ergency ser v ices decr eased t h e n eed for h ospit alizat ion .
Nu r ses’ r elat ion s w it h m en t al p at ien t s an d
t heir r elat iv es w er e valued in t his st udy. P = Pat ient s, C = Com panions
Ot h e r r e p o r t e d ca r e i n cl u d e d Em e r g e n cy
Car e, Basic Healt h Un it an d Ou t p at ien t Clin ic. Th e
frequency of t hese resources w as high in care w it hout
h ospit alizat ion .
Th e p sy ch osocial m od el is t h e p ar ad ig m of
p r a ct i ce s t h a t r e p l a ce t h e a sy l u m m o d e l . I n t h i s
par adigm , t he pat ient should be t he m ain par t icipant
in t he ent ir e t her apeut ic pr ocess, as w ell as m em ber
of a fam ily and a social gr oup( 7).
I n an in cr easin g ly sp ecialized w ay, m en t al
healt h professionals are insert ed in advances t hat not
on ly f or esee ( ad eq u at e an d n ecessar y ) m ed icat ion
t r eat m en t , b u t t h e in d iv id u al p r oj ect t h at in clu d es
o t h e r p sy ch o so ci a l t h e r a p i e s, a ct i v i t i e s t o v a l u e
i n d i v i d u a l ca p a ci t i e s, se l f - ca r e a ct i v i t i e s, h o l d i n g
pat ien t s accou n t able for t h eir act iv e par t icipat ion in
t h i s p r o c e s s , r e l a t i v e s ’ j o i n t e x p e r i e n c e a n d
p ar t icip at ion an d v alu at ion of p at ien t s’ r elat ion sh ip
net w or k w it h t heir env ir onm ent .
Ex pect at ions about t r eat m ent and cur e
Now aday s and t hank s t o scient ific adv ances,
som e t r eat m en t s can allev iat e m an y sy m p t om s of
m en t a l i l l n ess. Ho w ev er, n o n e o f t h ese p r ov i d e a
p er m an en t cu r e.
I n t h i s st u d y, w e f o u n d d i f f er en t o p i n i o n s
about im pr ov em ent and cur e am ong subj ect s at t he
t h r ee ser v ices:
- At t he EU, 38% of pat ient s’ ex pect ed t heir disease
t o im pr ov e, again st 6 1 % of com pan ion s. Mor eov er,
3 9 % of p at ien t s an d 1 8 % of com p an ion s ex p ect ed
cu r e.
- At t h e PCC, r elat iv es d isp lay ed low ex p ect at ion s
ab ou t im p r ov em en t ( 4 % ) , b u t b et t er ex p ect at ion s
ab ou t r eceiv in g h elp ( 2 4 % ) ; as f or p at ien t s, 5 0 %
expect ed im pr ovem ent , 33% cur e and 21% som e help. s
n o i t a z i l a t i p s o
H 0 1to5 5to10 11to20+than20 Total
P C P C P C P C P C P C
t i n U y c n e g r e m
E 39 36 48 49 5 7 6 6 2 2 100100
l a i c o s o h c y s P
r e t n e C e r a
C 54 51 39 39 3 6 2 2 2 2 100100
c i n il C t n e it a p t u
The m adness/ m ent al illness binom ial has been
st r ongly quest ioned over t he last 30 year s. What ar e
t h e cr it er ia t o classif y som eon e as ill? Wh at is t h e psy chiat r ic inst it ut ion’s funct ion in t his pr ocess? This
kind of reflect ions becam e cent ral, t hat is, t he obvious
becam e a sour ce of doubt s and concer ns.
FI NAL REFLECTI ONS
Th i s d e scr i p t i v e st u d y w a s b a se d o n t w o
q u e s t i o n n a i r e s a n d a s c a l e , w h i c h g a t h e r e d in f or m at ion abou t pat ien t s at t h r ee psy ch iat r ic car e
ser v ices and t heir opinions on healt h, m ent al illness
an d car e in t h is ar ea. Som e p oin t s d eser v e t o b e h igh ligh t ed.
I n t er m s of g en er al ch ar act er ist ics, r esu lt s
fr om each of t he t hr ee ser vices ( Em er gency Unit , PCC and Ment al Healt h Clinic) com posed a sam ple of 750
subj ect s, ev idencing higher concent r at ions of fem ale
pat ient s and car egiver s. Many m ent al disor der pat ient s w ere single or involved in unst able relat ions, w it h low
e d u c a t i o n l e v e l s a n d h i g h u n e m p l o y m e n t r a t e s .
S p e c i f i c a l l y a t t h e EU, s u b j e c t s w e r e y o u n g e r, e x p e r i e n c i n g t h e i r f i r s t e p i s o d e s a n d w i t h l i t t l e
hospit alizat ion ex per ience. At t he Clinic and t he PCC, w e found a m or e chr onic populat ion, but w it h sim ilar
c h a r a c t e r i s t i c s f o r e d u c a t i o n , c i v i l s t a t u s a n d
occu p at ion .
At t h e t h r e e se r v i ce s, b o t h p a t i e n t s a n d
r elat iv es had lit t le infor m at ion about t heir diagnoses
a n d t r e a t m e n t s . M e d i c a t i o n t r e a t m e n t a n d l o w h o sp i t a l i za t i o n l e v e l s w e r e p r e d o m i n a n t . A l a r g e
num ber of pat ient s got ill dur ing t he last five year s.
Ex p e ct a t i o n s o f cu r e w e r e m o r e p r e se n t a m o n g p a t i e n t s a t t h e EU t h a n a t t h e o t h e r t w o
se r v i ce s, w h e r e su b j e ct s si m p l y co n f o r m e d t o a
possible im provem ent . Pat ient s experiencing t heir first episode do not alw ays have a ver y clear view on t heir
d iag n osis an d it s con seq u en ces. Bot h p at ien t s an d
r e l a t i v e s a t t h e Cl i n i c a n d t h e PCC h a v e b e t t e r k n o w l e d g e a b o u t t h e d i s e a s e , s y m p t o m s a n d
t r eat m en t s, as t h ey h av e liv ed w it h t h e disease for
m any y ear s. When t hey ar e aw ar e of t he pr ognosis, any possibilit y t o r eliev e t heir suffer ing m ak es t hem
h ap p y.
We found div er ging opinions am ong subj ect s at t he t hr ee ser v ices, especially on som e issues lik e
a g g r e s s i v e n e s s , w h i c h i s m o r e p r e s e n t a m o n g
par t icipant s fr om t he EU.
K n o w l e d g e a b o u t t h e so ci a l a n d cu l t u r a l
d i m e n s i o n o f t h e d i s e a s e , i n t e r m s o f c u r e ,
im pr ov em en t , t r eat m en t s an d com m u n it y r esou r ces can be of gr eat help for pat ient s w it h m ent al disor der s
and t heir r elat iv es t o liv e w it h t he disease, bur dens
der iv in g fr om t h is pr ocess, h ealt h sy st em r esou r ces an d en v ir on m en t s, t h u s gr an t in g a bet t er qu alit y of
life t o all people inv olv ed.
I t is int erest ing t hat cult ure, beliefs and values can int er fer e in t he per cept ion and int er pr et at ion of
disease sy m pt om s, as w ell as in beh av ior s t o seek
help and par t icipat e act iv ely in t his ex per ience. Wit hin t he syst em , people using m ent al healt h
ser v ices w er e t r adit ionally seen as passiv e r eceiv er s,
w h o w er e in cap ab le of ex p r essin g t h eir ow n id eas and desir es, and w er e subj ect t o car e and t r eat m ent
for m s w hich ot her people had t o for m ulat e and decide
on. How ever, in r ecent year s, due t o t he w hole r efor m m ov em en t an d t h e dev elopm en t of st at e- of - t h e- ar t
m edicat ion, condit ions hav e incr eased for pat ient s as
w ell as r elat iv es and healt h pr ofessionals t hem selv es t o st art living w it h t his sit uat ion in a m ore hum anized
w a y.
I n t his st udy, t he ill expressed t heir personal view about t heir needs as pat ient s and about t he car e
t h ey r eceiv ed , ev id en cin g t h eir act iv e p ar t icip at ion and account abilit y in t his pr ocess.
Them es t hat deser ve special at t ent ion on t he
basis of t his st udy include: r ight t o self- det er m inat ion; n eed f or in f or m at ion abou t t h e disease, m edicat ion
a n d o t h e r f o r m s o f t r e a t m e n t ; p a t i e n t s ’ a c t i v e
par t icipat ion in t heir t r eat m ent and ot her act ivit ies in t h eir com m u n it y ; n eed for alt er n at iv e ser v ices; en d
of com m it m en t s in lar ge in st it u t ion s; im por t an ce of
effect iv e an d adequ at e t r eat m en t s.
Th e s e r e s u l t s a r e i m p o r t a n t f o r s e r v i c e
o r g a n i za t i o n a s w el l a s f o r p r o f essi o n a l s w o r k i n g
t h er e, in v iew of ev er y b od y ’s com m it m en t t o of f er qualit y care, w hich influences conduct s and pract ices.
Th i s i s esp eci al l y i m p o r t an t f o r n u r si n g , as t h ese
p r of ession als ar e r esp on sib le 2 4 h ou r s p er d ay f or d ir ect car e in closed ser v ices ( Em er g en cy Un it an d
hospit alizat ion unit s) , as w ell as for care delivery during
open in g h ou r s in open ser v ices ( Clin ic, Psy ch osocial Car e Nu cleu s an d Psy ch osocial Car e Cen t er ) .
Th e se d a t a g i v e r i se t o o p p o r t u n i t i e s f o r
r eflect ion, discussion, pr oduct ion and r epr oduct ion of k n ow ledge an d pr act ices, as w ell as t o t h e n eed t o
hum anize int er per sonal r elat ions bet w een nur ses and
REFERENCES
1 . Mu eser KT, Co r r i g a n PW, D a v i d W, Hi l t o n D W. I l l n ess m an agem en t r ecov er y : a r ev iew of t h e r esear ch . Psy ch iat r Se r v i ce s 2 0 0 2 ; 5 3 ( 1 0 ) : 1 2 7 2 - 8 4 .
2 . Ko g a M, Fu r e g a t o ARF. Co n v i v e n d o co m u m a p e sso a e s q u i z o f r ê n i c a : s o b r e c a r g a f a m i l i a r. I n : La b a t e RC, o r g a n i z a d o r a . Ca m i n h a n d o p a r a a a ssi st ê n ci a i n t e g r a l . Rib eir ão Pr et o ( SP) : Scala 1 9 9 8 . p 3 6 3 - 7 7 .
3. Addingt on J, Coldham EL, Jones B, Ko T, Addingt on D. The fir st episode of psy chosis: t he ex per ience of r elat iv es. Act a Psy ch i at r Scan d 2 0 0 3 ; 1 0 8 : 2 8 5 - 9 .
4. Sar aceno C. Sociologia da fam ília. Lisboa ( PO) : Est am pa; 1 9 9 2 .
5 . Am ar an t e P. Lou cos p ela v id a: a t r aj et ór ia d a r ef or m a psiquiát r ica no Br asil. Rio de Janeir o ( RJ) : SDE/ ENSP, 1995. 6 . D e l - Be n CM, Ma r q u e s JMA, Sp o n h o l z AJr, Z u a r d i AW. Po l ít i ca s d e sa ú d e m e n t a l e m u d a n ça s n a d e m a n d a d e s e r v i ç o s d e e m e r g ê n c i a . Re v S a ú d e Pu b l i c a 1 9 9 9 ; 5 ( 3 3 ) : 4 7 0 - 6 .
7 . Jo r g e MR. A Asso ci a çã o Br a si l e i r a d e Psi q u i a t r i a e a r e f o r m a d a a ssi st ê n ci a p si q u i á t r i ca n o Br a si l . Re v Br a s Psi q u i at r i a 2 0 0 1 ; 2 3 ( 1 ) : 3 - 6 .
8 . Osi n a g a VLM. Co n ce i t o s d e sa ú d e e d o e n ça m e n t a l : segundo por t ador es, fam iliar es e pr ofissionais. [ Disser t ação] . Ribeir ão Pr et o ( SP) : Escola de Enfer m agem de Ribeir ão Pr et o/ USP; 1 9 9 9 .
9 . Osin ag a VLM, Fu r eg at o ARF. Op in ião d e est u d an t es d e en f er m ag em sob r e a d oen ça m en t al e a assist ên cia n est a ár ea. Rev Br as En f er m agem 2 0 0 3 ; 5 6 ( 2 ) : 1 4 3 - 6 .
1 0 . Osin ag a VLM, Fu r eg at o ARF, San t os JLF. Red u ção d as q u est ões d e u m a Escala d e Med id a d e Op in ião. Rev Br as En f er m ag em 2 0 0 5 ; 5 7 ( 6 ) : 7 0 3 - 5 .
1 1 . Osi n ag a VLM, Fu r eg at o ARF, San t o s JLF. Co n cep t s o f m ent al healt h and car e accor ding t o m ent ally- ill pat ient s and t h e i r r e l a t i v e s . Re v La t i n o - a m d e En f e r m a g e m 2 0 0 5 ; 1 3 ( 3 ) : 3 3 2 - 8 .
12. Osinaga VLM. Est udo com par at iv o ent r e os conceit os de sa ú d e e d e d o e n ça m e n t a l e m a ssi st ê n ci a p si q u i á t r i ca , segundo por t ador es e fam iliar es [ Tese] . Ribeir ão Pr et o ( SP) : Escola de En f er m agem de Ribeir ão Pr et o/ USP; 2 0 0 4 . 13. Jest e DV, Twam ley EWL, Zor r illa TE, Golshan S, Pat t er son TL, Palm er BW. Ag in g an d ou t com e in sch izop h r en ia. Act a Psy ch i a t r Sca n d 2 0 0 3 ; 1 0 7 : 3 3 6 - 4 3 .
14. Sar aceno B, Funk M. Pr oyect o de polít ica de Salud Ment al. Paqu et e de or ien t ación sobr e polít ica y ser v icios. Gin ebr a: OMS - Or ganización Mundial de la Salud; 2 0 0 1 .
1 5 . Vezzoli R, Ar ch iat i l, Bu izza C, Pasq u alet t i P, Rossi G, Pioli R. Act it ud hacia los pacient es psiquiát r icos: un est udio pilot o en una ciudad del nor t e de I t alia. Eur J Psychiat r 2002; 9 ( 2 Ed i ci ó n esp eci al ) : 5 7 - 6 1 .
