Prevalência de transtornos mentais na Estratégia Saúde da Família e avaliação de um modelo de capacitação em saúde mental
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Data
2012
Autores
Gonçalves, Daniel Almeida [UNIFESP]
Orientadores
Mari, Jair de Jesus [UNIFESP]
Tipo
Tese de doutorado
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Introdução: Problemas de Saúde mental sao comuns na atencao primaria a Saúde e sao geralmente relacionados a ansiedade e a depressao e associados com queixas genericas como irritabilidade, preocupacoes e multiplos sintomas fisicos. Dificultam a abordagem de medicos e enfermeiros de familia da Estrategia Saúde da Familia que nao estao completamente aptos a abordagem integral. Nao ha estudos nacionais que avaliaram a prevalencia destas morbidades em grandes centros urbanos. Para melhor resolutividade na atencao primaria, o Ministerio da Saúde criou os Nucleos de Apoio a Saúde da Familia que objetivam atraves da pratica matricial instrumentalizar os profissionais da atencao primaria para deteccao e manejo dos transtornos mentais neste nivel de atencao. Objetivo: Este estudo tem o objetivo de avaliar a taxa de transtornos mentais comuns e suas associacoes caracteristicas sociodemograficas no Brasil em quatro centros urbanos no Brasil. Objetiva ainda avaliar o impacto de um curso de aperfeicoamento em Saúde Mental na Atencao Primaria (sob a logica matricial) na deteccao de transtornos mentais, implementacao do metodo clinico centrado na pessoa e indicacao de terapeuticas especificas pelos profissionais da atencao primaria. Metodologia: E um estudo multicentrico, nao randomizado e sem controle, com cortes transversais antes e apos a intervencao (curso de aperfeicoamento), com um total de 1852 usuarios da atencao primaria do Rio de Janeiro, São Paulo, Fortaleza e Porto Alegre. Utilizou-se o Questionario Geral de Saúde -12 (GHQ-12) com ponto de corte 3 e Escalas de depressao e ansiedade (HAD) com ponto de corte 8 em 40. A analise dos fatores associados aos transtornos mentais comuns foi feita atraves de regressao logistica dentro do programa SPSS. A atuacao dos profissionais da atencao primaria foi aferida por meio de questionarios preenchidos apos atendimentos clinicos dos medicos e enfermeiros de familia. Resultados: A taxa de transtornos mentais comuns no Rio de Janeiro, São Paulo, Fortaleza e Porto Alegre foram, respectivamente, 51,9%, 53,3%, 64,3% e 57,7%, com diferencas significativas entre Porto Alegre e Fortaleza comparando-se ao Rio de Janeiro. Problemas de Saúde mental foram especialmente altos em mulheres, desempregados, em pessoas com baixa escolaridade e naqueles com baixa renda. O curso de aperfeicoamento nao alterou a deteccao dos transtornos mentais de uma forma geral entre os profissionais, apesar de aumentar a utilizacao do metodo clinico centrado na pessoa (de 69% para 75%, p= 0.01). No entanto, entre enfermeiros de familia houve significante aumento da deteccao de transtornos mentais (de 16% para 34%, p=0.00) ao passo que entre medicos houve diminuicao na deteccao apos a intervencao (de 37% para 25%, p=0.00). Tambem nao se observou alteracao na referencia para niveis secundarios de atencao e utilizacao do matriciamento e intervencoes psicossociais apos a intervencao. Conclusao: Observou-se elevados indices de transtornos mentais comuns entre os usuarios da atencao primaria das cidades estudadas. Dadas as iniciativas do governo brasileiro para a reorganizacao da politica publica de Saúde mental e da atencao primaria, e importante considerar os transtornos mentais comuns como uma prioridade, inclusive atencao aos fatores associados ao adoecimento, como oferta de melhor educacao e geracao de renda. Para enfrentamento deste problema, a capacitacao dos profissionais de atencao primaria e um recurso estabelecido. No entanto, o modelo de treinamento avaliado nesta tese nao mostrou melhoras consistentes na deteccao e manejo dos transtornos mentais na atencao primaria no contexto que foi estudado. Alem do investimento em atividades de capacitacao, sao necessarios investimentos para melhores recursos fisicos e estruturais e condicoes mais estaveis de trabalho, fazendo com o que os esforcos para pratica da integralidade e melhora na qualidade de vida dos usuarios SUS sejam um desafio multissetorial
Mental health illness is common in primary care and they are usually related to anxiety, depression and associated with general complaints such as irritability and unexplained symptoms. They are also a challenge to primary care professional who are not used to deal with these problems. To face this reality, the Brazilian Government has been promoting a progressive change in primary care and mental health policy through implementing Family Health Strategy and launching specific teams to support primary care professionals. This has led to introduction of a shared care model (matrix support) between primary care and mental health teams to promote continuing education in mental health for primary care staff and better integration between these public health services. Objective: This study aims to evaluate the rates of common mental disorders and their associations with socio-demographic characteristics in four urban centres in Brazil. Additionally, it aims to assess the impact of a training model in Mental Health in Primary Care (about matrix support) in detection of common mental disorders, patient centred method implementation and specific therapeutic indication for primary care professionals. Methodology: This is a multicentre, nonrandomized study, without controls with pre and post design. It analysed 1852 primary care patients in Rio de Janeiro, São Paulo, Fortaleza and Porto Alegre. The General Health Questionnaire-12 (GHQ-12) with a cut-off of 3 and depression and anxiety scales (HAD) with cut-off 8 in 40 were used. Logistic regression run the SPSS was used to analyse associated factors with common mental disorders. The role of primary care professionals was measured by a questionnaire completed after clinical care of family doctors and nurses. Results: The rate of common mental disorders in Rio de Janeiro, São Paulo, Fortaleza and Porto Alegre were respectively, 51.9%, 53.3%, 64.3% and 57.7%. It was found significant differences between rates in Porto Alegre and Fortaleza comparing to Rio de Janeiro. Mental health illness was especially high in women, unemployed persons, people with low education and those with low incomes. The training model did not improve mental disorders' detection among professional though it increased the patient centred method adoption for primary care professional (from 69% to 75%, p = 0.01). However, nurses increased significantly their ability in detecting common mental disorders (16% to 34%, p = 0.00) whereas doctors' detention decreased after the intervention (37% to 25%, p = 0.00). There were no changes in reference to secondary levels, matrix support and psychosocial interventions by primary care professionals. Conclusion: High rates of common mental disorders among users of primary care were found. Given the Brazilian government's efforts to reorganize public policy on mental health and primary care, it is important to consider common mental disorders as a priority. Special attention to factors associated with mental disorder must be implemented, such as provision of better education and income generation. Training models to improve primary care professional's ability in mental health are a well established resource. However, the training model evaluated in this study showed no consistent improvement in the detection and management of mental disorders in primary care. More than implementing training activities in primary care, it is necessary investments to reach better work conditions including professional stability. Efforts to promote an integrative care in the Brazilian health System (SUS) and to reach better quality of life among their users are an on-going challenge.
Mental health illness is common in primary care and they are usually related to anxiety, depression and associated with general complaints such as irritability and unexplained symptoms. They are also a challenge to primary care professional who are not used to deal with these problems. To face this reality, the Brazilian Government has been promoting a progressive change in primary care and mental health policy through implementing Family Health Strategy and launching specific teams to support primary care professionals. This has led to introduction of a shared care model (matrix support) between primary care and mental health teams to promote continuing education in mental health for primary care staff and better integration between these public health services. Objective: This study aims to evaluate the rates of common mental disorders and their associations with socio-demographic characteristics in four urban centres in Brazil. Additionally, it aims to assess the impact of a training model in Mental Health in Primary Care (about matrix support) in detection of common mental disorders, patient centred method implementation and specific therapeutic indication for primary care professionals. Methodology: This is a multicentre, nonrandomized study, without controls with pre and post design. It analysed 1852 primary care patients in Rio de Janeiro, São Paulo, Fortaleza and Porto Alegre. The General Health Questionnaire-12 (GHQ-12) with a cut-off of 3 and depression and anxiety scales (HAD) with cut-off 8 in 40 were used. Logistic regression run the SPSS was used to analyse associated factors with common mental disorders. The role of primary care professionals was measured by a questionnaire completed after clinical care of family doctors and nurses. Results: The rate of common mental disorders in Rio de Janeiro, São Paulo, Fortaleza and Porto Alegre were respectively, 51.9%, 53.3%, 64.3% and 57.7%. It was found significant differences between rates in Porto Alegre and Fortaleza comparing to Rio de Janeiro. Mental health illness was especially high in women, unemployed persons, people with low education and those with low incomes. The training model did not improve mental disorders' detection among professional though it increased the patient centred method adoption for primary care professional (from 69% to 75%, p = 0.01). However, nurses increased significantly their ability in detecting common mental disorders (16% to 34%, p = 0.00) whereas doctors' detention decreased after the intervention (37% to 25%, p = 0.00). There were no changes in reference to secondary levels, matrix support and psychosocial interventions by primary care professionals. Conclusion: High rates of common mental disorders among users of primary care were found. Given the Brazilian government's efforts to reorganize public policy on mental health and primary care, it is important to consider common mental disorders as a priority. Special attention to factors associated with mental disorder must be implemented, such as provision of better education and income generation. Training models to improve primary care professional's ability in mental health are a well established resource. However, the training model evaluated in this study showed no consistent improvement in the detection and management of mental disorders in primary care. More than implementing training activities in primary care, it is necessary investments to reach better work conditions including professional stability. Efforts to promote an integrative care in the Brazilian health System (SUS) and to reach better quality of life among their users are an on-going challenge.
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Citação
GONÇALVES, Daniel Almeida. Prevalência de transtornos mentais na Estratégia Saúde da Família e avaliação de um modelo de capacitação em saúde mental. Tese (Doutorado em Ciências) - Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, 2012.