Impacto do estigma no manejo clinico dos transtornos mentais na atenção primária
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Data
2018-02-08
Autores
Rojas Vistorte, Angel Olider [UNIFESP]
Orientadores
Mari, Jair de Jesus [UNIFESP]
Tipo
Tese de doutorado
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Introdução: O tratamento de transtornos mentais comuns em unidades da atenção primária tem sido sugerido como estratégia prioritária para garantir que todos os portadores de transtornos mentais tenham acesso à abordagem terapêutica que necessitam. Porém, médicos da atenção primária enfrentam importantes obstáculos para o diagnóstico e tratamento de transtornos mentais, por não estarem capacitados para fazê-lo, ou por apresentarem atitudes estigmatizantes em relação a eles. Objetivo: Avaliar como o estigma relacionado aos transtornos mentais pode afetar os cuidados oferecidos aos pacientes com transtornos mentais comuns na atenção primária. Método: No primeiro artigo foi realizada uma revisão sistemática da literatura das atitudes estigmatizantes que apresentam os médicos da atenção primária com respeito às pessoas com transtornos mentais. No segundo artigo foi realizado o processo de tradução, adaptação e validação de um instrumento que avalia os níveis do estigma nos médicos da atenção primária. E no terceiro artigo foi realizado análises da associação entre as condutas clínicas e os níveis de estigma, assim como a identificação de potenciais fatores associados às atitudes estigmatizantes. Os artigos 2 e 3 foram baseados em uma amostra de médicos que trabalham em unidades de atenção primária no Brasil, Bolívia, Chile. Participaram 550 profissionais dos quatro países. As condutas clínicas dos médicos em relação aos transtornos mentais comuns foram investigadas por meio de vinhetas clínicas. As atitudes estigmatizantes foram avaliadas por meio do questionário Mental Illenss: Clinicians’ Attitudes Scale (MICA v4). Resultados: Após aplicar critérios de elegibilidade, onze artigos foram incluídos na revisão. Os médicos de atenção primária apresentaram atitudes estigmatizantes com respeito às pessoas com transtornos mentais, e mostraram atitudes mais negativas em relação aos pacientes com esquizofrenia do que com pessoas com depressão. Os dois modelos na validação do MICA v4 demonstraram uma boa confiabilidade e ajuste para as amostras em Espanhol e Português (Português: CFI=0.927; TLI=0.913; RMSEA= 0.066; Spanish: CFI=0.945; TLI=0.935; RMSEA= 0.068). 70% dos médicos que atuam na atenção primária reconhecem a presença de um transtorno mental nas vinhetas apresentadas, e 80.9% se sentem capacitados para diagnosticar e tratar pessoas com transtornos mentais comuns. Mais de 90% dos médicos da Bolívia, Cuba e Chile concordaram em tratar os pacientes apresentados nas três vinhetas. Não encontramos diferenças significativas entre os quatro países nas pontuações dos níveis de estigma no MICA v4 (M=36.1, SD=8.3). O gênero (p = .672), a idade (p = .171), os anos de experiência (p = 0,28) e treinamento (p = .673) não estão relacionados ao estigma. Aqueles médicos que não se sentem preparados para o diagnóstico e tratamento de transtornos mentais apresentam maiores níveis do estigma (t(385)=2.5, p<0.01). Médicos com níveis mais baixos de estigma apresentaram maior probabilidade de não encaminhar para um psiquiatra os pacientes com sintomas de depressão e somatoformes. Conclusões: As versões do MICA v4 em espanhol e português possuem boas propriedades psicométricas, boa consistência interna e são aplicáveis e aceitáveis para o contexto latino-americano. Há uma correlação entre níveis de estigma e habilidade do médico para cuidar adequadamente dos transtornos mentais na atenção primária. Atitudes estigmatizantes podem atuar como uma barreira importante para que os pacientes recebam o tratamento que eles precisam.
Introduction: The treatment of common mental disorders in primary care units has been suggested as a strategic priority to ensure that all people with mental disorders have access to the treatment they need. However, there are barriers that hinder primary care services´ ability to treat mental disorders properly, because they are not able to do so, or because they have stigmatizing attitudes towards mental disorders. Objective: to evaluate stigma related to mental disorders may affect the care offered to patients with common mental disorders in primary care. Methods: A survey comprising three articles, the first of which is a systematic literature review of stigmatizing attitudes that primary care physicians present towards people with mental disorders. The second article offers a translation, adaptation and validation of an instrument used to assess the stigma levels in primary care physicians. In the third article, we analyze the association between clinical behavior and stigma levels, as well as the identification of potential factors associated with stigmatizing attitudes. Articles 2 and 3 were based on a sample of physicians working in primary care units in Brazil, Bolivia, Chile and Cuba (Más Médicos program in Brazil). 550 professionals from all four countries participated. Clinicians’ stigmatizing attitudes towards mental health was measured using the Mental Illness Clinicians' Attitudes Scale (MICA v4). The clinical management of PCPs was assessed through three clinical vignettes representing typical cases of depression, anxiety and somatization. Results: After applying the eligibility criteria eleven articles were included in the review. Primary care physicians have stigmatizing attitudes towards people with mental disorders, and show more negative attitudes toward patients with schizophrenia than people with depression. The two validation models of MICA v4 presented good reliability and fitness for the samples in Spanish and Portuguese (Portuguese: CFI=0.927; TLI=0.913; RMSEA= 0.066; Spanish: CFI=0.945; TLI=0.935; RMSEA= 0.068). 70% of primary care physicians recognize the presence of a mental disorder in the vignettes presented, and 80.9% feel capable to diagnose and treat people with common mental disorders. More than 90% of physicians from Bolivia, Cuba and Chile agreed to treat patients presented in three vignettes. There were no significant differences between the four countries in scores of stigma levels MICA v4. Gender (p = .672), age (p = .171), experience (p = 0.28) and training years (p = .673) were not related to stigma. Those physicians who do not feel prepared for the diagnosis and treatment of mental disorders have higher levels of stigma (t (385) = 2.5, p <0.01). Primary care physicians with low levels of stigma were more likely to not refer to a psychiatrist patient with symptoms of depression and somatoform. Primary care physicians with higher levels of stigma were more likely to refer to a psychiatrist patient with symptoms of depression and somatoform. Conclusions: The MICA v4 versions in Spanish and Portuguese have good psychometric properties, good internal consistency and are applicable and acceptable to the Latin American context. There is a correlation between levels of stigma and the physician's ability to adequately care for mental disorders in primary care. Stigmatizing attitudes can act as an important barrier for patients to receive the treatment they need.
Introduction: The treatment of common mental disorders in primary care units has been suggested as a strategic priority to ensure that all people with mental disorders have access to the treatment they need. However, there are barriers that hinder primary care services´ ability to treat mental disorders properly, because they are not able to do so, or because they have stigmatizing attitudes towards mental disorders. Objective: to evaluate stigma related to mental disorders may affect the care offered to patients with common mental disorders in primary care. Methods: A survey comprising three articles, the first of which is a systematic literature review of stigmatizing attitudes that primary care physicians present towards people with mental disorders. The second article offers a translation, adaptation and validation of an instrument used to assess the stigma levels in primary care physicians. In the third article, we analyze the association between clinical behavior and stigma levels, as well as the identification of potential factors associated with stigmatizing attitudes. Articles 2 and 3 were based on a sample of physicians working in primary care units in Brazil, Bolivia, Chile and Cuba (Más Médicos program in Brazil). 550 professionals from all four countries participated. Clinicians’ stigmatizing attitudes towards mental health was measured using the Mental Illness Clinicians' Attitudes Scale (MICA v4). The clinical management of PCPs was assessed through three clinical vignettes representing typical cases of depression, anxiety and somatization. Results: After applying the eligibility criteria eleven articles were included in the review. Primary care physicians have stigmatizing attitudes towards people with mental disorders, and show more negative attitudes toward patients with schizophrenia than people with depression. The two validation models of MICA v4 presented good reliability and fitness for the samples in Spanish and Portuguese (Portuguese: CFI=0.927; TLI=0.913; RMSEA= 0.066; Spanish: CFI=0.945; TLI=0.935; RMSEA= 0.068). 70% of primary care physicians recognize the presence of a mental disorder in the vignettes presented, and 80.9% feel capable to diagnose and treat people with common mental disorders. More than 90% of physicians from Bolivia, Cuba and Chile agreed to treat patients presented in three vignettes. There were no significant differences between the four countries in scores of stigma levels MICA v4. Gender (p = .672), age (p = .171), experience (p = 0.28) and training years (p = .673) were not related to stigma. Those physicians who do not feel prepared for the diagnosis and treatment of mental disorders have higher levels of stigma (t (385) = 2.5, p <0.01). Primary care physicians with low levels of stigma were more likely to not refer to a psychiatrist patient with symptoms of depression and somatoform. Primary care physicians with higher levels of stigma were more likely to refer to a psychiatrist patient with symptoms of depression and somatoform. Conclusions: The MICA v4 versions in Spanish and Portuguese have good psychometric properties, good internal consistency and are applicable and acceptable to the Latin American context. There is a correlation between levels of stigma and the physician's ability to adequately care for mental disorders in primary care. Stigmatizing attitudes can act as an important barrier for patients to receive the treatment they need.
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Citação
ROJAS VISTORTE, Angel Olider. Impacto do estigma no manejo clinico dos transtornos mentais na atenção primária. 2018. Tese (Doutorado em Psiquiatria e psicologia médica) - Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, 2018.