Comparação de recomendações de diretrizes clínicas de alta qualidade metodológica para o cuidado em saúde mental na gestação
Data
2022-10-25
Autores
Oliveira, Rosyanne Michele Marques de 
Orientadores
Melo, Daniela Oliveira de
Tipo
Dissertação de mestrado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Introdução: Durante a gestação, os transtornos de saúde mental e o uso de psicotrópicos podem ser pauta de discussão entre profissionais da saúde e gestantes. A comparação e discussão de recomendações de diretrizes clínicas (DC) de alta qualidade pode contribuir para qualificar o processo de decisão considerando a escassez de estudos clínicos com grávidas e a chance de discordância entre o que é recomendado nas DC. Objetivo: Sintetizar as recomendações de DC de alta qualidade metodológica sobre o tratamento farmacológico de gestantes com transtornos mentais e epilepsia. Métodos: A partir de uma revisão sistemática, foram identificadas e avaliadas 38 DC sobre o cuidado de transtornos de saúde mental na gestação, publicadas ou atualizadas a partir de 2015. Somente DC de alta qualidade metodológica (escore ≥ 50% nos domínios 3 [rigor de desenvolvimento] e 6 [independência editorial] da segunda versão do AGREE-II) foram incluídas no estudo. As recomendações das DC selecionadas foram extraídas por dois avaliadores independentes, e tabuladas, organizadas em tópicos e comparadas quanto à concordância, divergências e complementação, e por fim, sintetizadas por um avaliador. Resultados: Das 38 DC avaliadas na revisão sistemática, 24 (63,2%) foram consideradas de alta qualidade metodológica, o que mostra que é possível encontrar documentos sobre o cuidado de transtornos de saúde mental na gestação. Dessas, 17 DC apresentaram 144 recomendações sobre o tratamento farmacológico de gestantes com transtorno mental, depressão, ansiedade, esquizofrenia, transtorno bipolar e epilepsia, o que é compatível com a relevância desses transtornos e do tópico. Observou-se concordância quanto as orientações gerais sobre o uso dos psicotrópicos e das principais classes farmacológicas, independentemente do transtorno para os quais foram recomendados. Para depressão moderada a grave, recomenda-se o uso de antidepressivos, principalmente da classe dos inibidores seletivos de recaptação de serotonina (ISRS), mas apenas uma DC orienta que a sertralina possa ser mais indicada. As DC recomendam a manutenção do uso de antipsicóticos - exceto por uma delas que recomenda interrupção em caso de tratamento de manutenção do transtorno bipolar, principalmente no primeiro trimestre - e contra o uso de antipsicóticos de depósito. Para grávidas que desenvolvem mania ou psicose, recomenda-se o uso de haloperidol ou clorpromazina. Para transtornos de ansiedade graves, ISRS são considerados primeira linha no tratamento em uma das diretrizes, bem como o uso de curto prazo de benzodiazepínicos para tratar sintomas moderados a graves de ansiedade. Para epilepsia recomenda-se o uso de antiepiléptico na menor dose efetiva e não há recomendação para monitoramento de rotina concentrações séricas, exceto para os fármacos fenitoína e lamotrigina. Especificamente sobre o lítio, duas DC recomendam contra seu uso enquanto outras DC não recomendam nem contra ou a favor do uso em grávidas; já sobre o uso de valproato, 5 DC são categóricas contra seu uso na gestação. Conclusão: A síntese das recomendações permitiu compilar recomendações de diferentes DC para tratamento de gestantes com transtornos mentais e epilepsia, assim como a comparação se houve, ou não, orientações divergentes sobre o tópico. Na maioria das vezes, as recomendações eram genéricas, preconizando-se principalmente a necessidade de avaliação de risco e benefício e discussão com a gestante.
Background: During pregnancy, mental health disorders and the use of psychotropic drugs can be a topic of discussion between healthcare professionals and pregnant women. The comparison and discussion of high-quality clinical guidelines (CPG) recommendations can contribute to qualify the decision-making process, considering the lack of clinical trials with pregnant women and the chance of disagreement between what is recommended in these CPG. Objective: To synthesize recommendations from high-quality methodological CPG regarding the pharmacological treatment of pregnant women with mental health disorders and epilepsy. Methods: Based on a systematic review, 38 CPG (published or updated from 2015 onwards) for mental health disorders care during pregnancy were identified and evaluated. High-quality methodological CPG (score ≥ 50% in domains 3 (rigor of development) and 6 (editorial independence) of the second version of AGREE-II) were included. Recommendations were extracted from selected CPG by two independent evaluators, and tabulated, organized into topics and compared regarding agreement, divergences and complementation, and finally, synthesized by one evaluator. Results: Of 38 CPG evaluated in the systematic review, 24 (63.2%) were considered of high-quality methodology, which shows that it is possible to find documents on the care of mental health disorders during pregnancy. Of these, 17 CPG presented 144 recommendations on the pharmacological treatment of pregnant women with mental disorder, depression, anxiety, schizophrenia, bipolar disorder and epilepsy, which is consistent with the relevance of these disorders and the topic. There was agreement regarding the general recommendations on the use of psychotropics and the main pharmacological classes, regardless of the disorder for which they were recommended. For moderate to severe depression, the use of antidepressants is recommended, mainly from the class of selective serotonin reuptake inhibitors (SSRI), but only one CPG advises that sertraline may be more indicated. CPG recommend maintaining the use of antipsychotics - except for one of the CPG that recommends interruption in case of maintenance treatment of bipolar disorder, especially in the first trimester - and against the use of depot antipsychotics. For pregnant women who develop mania or psychosis, haloperidol or chlorpromazine is recommended. For severe anxiety disorders, SSRI are considered first-line treatment in one of the CPG, as well as short-term use of benzodiazepines to treat moderate to severe anxiety symptoms. For epilepsy, the use of antiepileptic drugs at a lower effective dose is recommended and there is no recommendation for routine monitoring serum concentrations, except for phenytoin and lamotrigine. Specifically, about lithium, two CPG recommend against its use, while other CPG do not recommend in favor or against its use in pregnant women; regarding the use of valproate, 5 CPG are categorical against its use during pregnancy. Conclusion: The synthesis of recommendations made it possible to compile recommendations from different CPG for the treatment of pregnant women with mental disorders and epilepsy, as well as to compare whether or not there were divergent guidelines on the topic. Most of time, recommendations were generic, mainly recommending the need for risk and benefit assessment and discussion with pregnant woman.
Background: During pregnancy, mental health disorders and the use of psychotropic drugs can be a topic of discussion between healthcare professionals and pregnant women. The comparison and discussion of high-quality clinical guidelines (CPG) recommendations can contribute to qualify the decision-making process, considering the lack of clinical trials with pregnant women and the chance of disagreement between what is recommended in these CPG. Objective: To synthesize recommendations from high-quality methodological CPG regarding the pharmacological treatment of pregnant women with mental health disorders and epilepsy. Methods: Based on a systematic review, 38 CPG (published or updated from 2015 onwards) for mental health disorders care during pregnancy were identified and evaluated. High-quality methodological CPG (score ≥ 50% in domains 3 (rigor of development) and 6 (editorial independence) of the second version of AGREE-II) were included. Recommendations were extracted from selected CPG by two independent evaluators, and tabulated, organized into topics and compared regarding agreement, divergences and complementation, and finally, synthesized by one evaluator. Results: Of 38 CPG evaluated in the systematic review, 24 (63.2%) were considered of high-quality methodology, which shows that it is possible to find documents on the care of mental health disorders during pregnancy. Of these, 17 CPG presented 144 recommendations on the pharmacological treatment of pregnant women with mental disorder, depression, anxiety, schizophrenia, bipolar disorder and epilepsy, which is consistent with the relevance of these disorders and the topic. There was agreement regarding the general recommendations on the use of psychotropics and the main pharmacological classes, regardless of the disorder for which they were recommended. For moderate to severe depression, the use of antidepressants is recommended, mainly from the class of selective serotonin reuptake inhibitors (SSRI), but only one CPG advises that sertraline may be more indicated. CPG recommend maintaining the use of antipsychotics - except for one of the CPG that recommends interruption in case of maintenance treatment of bipolar disorder, especially in the first trimester - and against the use of depot antipsychotics. For pregnant women who develop mania or psychosis, haloperidol or chlorpromazine is recommended. For severe anxiety disorders, SSRI are considered first-line treatment in one of the CPG, as well as short-term use of benzodiazepines to treat moderate to severe anxiety symptoms. For epilepsy, the use of antiepileptic drugs at a lower effective dose is recommended and there is no recommendation for routine monitoring serum concentrations, except for phenytoin and lamotrigine. Specifically, about lithium, two CPG recommend against its use, while other CPG do not recommend in favor or against its use in pregnant women; regarding the use of valproate, 5 CPG are categorical against its use during pregnancy. Conclusion: The synthesis of recommendations made it possible to compile recommendations from different CPG for the treatment of pregnant women with mental disorders and epilepsy, as well as to compare whether or not there were divergent guidelines on the topic. Most of time, recommendations were generic, mainly recommending the need for risk and benefit assessment and discussion with pregnant woman.