Drug utilization research in a primary mental health service in Northeast of Brazil

Abstract

The Psychosocial Care Center (CAPS) is a community-based mental health service in Brazil, which aims to promote the psychosocial rehabilitation of patients. Accordingly, this study describes the drug use evaluation in a primary mental health service in Northeast of Brazil.

Setting

CAPS ‘Valter Correia’, São Cristovão, Sergipe, Brazil.

Methods

A cross-sectional study was conducted between August 2009 and May 2010. Initially, Medical records were reviewed and evaluated. Then, we applied interviews with the patients (and/or their informal/family caregivers) attended at the CAPS. Informations were obtained regarding to demographic and clinical features, diagnoses and drugs prescribed. All patients registered in the CAPS were included in the study. The results were statistically analyzed using the EpiInfo and were compared with results from literature.

Results

The CAPS ‘Valter Correia’ consists of 101 registered patients, the majority were male (58.4%), illiterate (51.5%), without monthly income (49.5%) and the average age of them 42.2 years (SD = 12.0). Schizophrenia was the most frequent mental disorder (31.5%). The average number of medications by patients was 3.11 (SD = 1.41), and the older group of patients (75-80 years) presented the largest consumption of medications (5.50 drugs/patient). The psychiatric drug class most frequently prescribed was antipsychotics (44.8%). Angiotensin-converting enzyme inhibitors were the most prevalent non-psychiatric therapeutic class (15.8%). It was detected 133 drug-drug interactions (3.0% mild, 54.1% moderate, 29.3% severe and 13.5% contraindicated).

Conclusion

The results revealed the need for monitoring the pharmacotherapy of patients with mental disorders to encourage the rational use of medications.

Resumo

O Centro de Atenção Psicossocial (CAPS) é um serviço de saúde mental de base comunitária no Brasil, que visa promover a reabilitação psicossocial dos pacientes. O presente estudo descreve a avaliação do uso de medicamentos em um service de saúde mental primário no Nordeste do Brasil.

Ambiente

CAPS «Valter Correia», São Cristovão, Sergipe, Brasil.

Métodos

Estudo transversal foi realizado entre agosto de 2009 e maio de 2010. Inicialmente, os registros médicos foram revisados e avaliados. Em seguida, foram realizadas entrevistas com os pacientes (e/ou seus cuidadores) atendidos no CAPS. Informações foram obtidas sobre as características demográficas e clínicas, diagnósticos e medicamentos prescritos. Todos os pacientes cadastrados no CAPS foram incluídos no estudo. Os resultados foram analisados estatisticamente utilizando o programa EpiInfo e foram comparados com os resultados da literatura.

Resultados

O CAPS “Valter Correia” é composto por 101 pacientes cadastrados, a maioria do sexo masculino (58,4%), analfabetos (51,5%), sem renda mensal (49,5%) e a média de idade deles era de 42,2 anos (DP = 12,0). A esquizofrenia foi o transtorno mental mais freqüente (31,5%). O número médio de medicamentos por pacientes foi de 3,11 (DP = 1,41), e o grupo de pacientes mais velhos (75-80 anos) apresentou o maior consumo de medicamentos (5,50 medicamentos/paciente). A classe de medicamentos psiquiátricos mais prescrita foi a dos antipsicóticos (44,8%). A classe dos inibidores da enzima conversora da angiotensina foi a mais prevalente classe não-psiquiátrica (15,8%). Foram detectadas 133 interações medicamentosas fármaco-fármaco (3,0% de severidade leve, 54,1% moderada, 29,3% grave e 13,5% contra-indicada).

Conclusão

Os resultados demonstram a necessidade de acompanhamento da farmacoterapia de pacientes com transtornos mentais para incentivar o uso racional de medicamentos.

Introduction

Mental disorders represent a health problem of social relevance for their high incidence in populations from different countries and culturally distinct societies. We estimated 17–35% prevalence of mental disorders in Brazilian population. However, these disorders are still far from receiving an adequate importance.^1–4

In this context, the introduction of psychosocial care centers (CAPS) were one of some health services created, based on Brazilian psychiatric reform. The CAPS are characterized by a day care service, which is proposed as an alternative to a psychiatric hospital. Its main objective is to offer a psychosocial rehabilitation to their patients.⁵

The sociodemographic characteristics of CAPS patients have an important influence to improve their assistance.^2,6 Moreover, psychotropic drugs cause adverse events, which compromises the adherence to treatment and then the quality of life.⁷

Some studies have demonstrated the relationship between the process of use of drugs, morbidity and mortality related to drugs and as these may trigger adverse reactions. In these studies, problems such as adverse reactions, non-compliance, overdose or inadequate therapy are factors that lead to failure of therapy. If this is not detected and resolved, it can lead to death.^8–15

Thus, it is necessary to evaluate the drug utilization in mental health care in order to assess drug therapy, detect the risk factors associated with the use of medications and promote the rational use of drugs. Drug utilization research are defined, according to WHO, as studies on marketing, distribution, prescription, and use of drugs in a society, with special emphasis on the resulting medical, social and economic consequences. These studies have as their main objective the promotion of the rational use of drugs.^16,17

In recent years, literature has highlighted the involvement of the pharmacist in programs to optimize the effects of medications, through monitoring the use of drugs. The application of rational criteria can ensure greater compliance with therapy, effectiveness and safety of medications used by patients.^18–20

Aim of study

The present study aimed to evaluate the use of medications by patients in a primary mental health service located in a city at the Northeast of Brazil.

Methods

We conducted, in an unprecedented way in Sergipe state, a cross-sectional study between August 2009 and May 2010 at a type I psychosocial care center (CAPS) ‘Valter Correia’ in São Cristovão, Sergipe, Brazil. All patients registered in the CAPS (and/or their informal/family caregivers) were included in the study.

CAPS type I is a unit for own psychosocial care with therapeutic workshops and other forms of care and operational capacity to provide healthcare coverage to a population between 20,000 and 70,000 inhabitants, working under two shifts, developing daily activities in mental health.²¹

Data was collected from patient medical records, such as sociodemographics, clinical characteristics and pharmacological treatments. Sociodemographic data included patient gender, age, educational status, occupational activity, benefits or pensions, income and marital status. Diagnoses (according to the ICD-10 international classification of mental and behavioral disorders)²² and the patient's psychiatric admission history were the clinical characteristics obtained. Details of all psychiatric prescribed medications were also collected, including dose, frequency, administration routes and therapeutic indications. Drugs were classified according to the anatomical therapeutic chemical (ATC) classification system and the defined daily dose (DDD). The ATC/DDD system is a widely used tool for exchanging and comparing data on drug consumption at international, national or local levels.²³

In addition, personal interviews were performed (applied to the patients and/or their informal/family caregivers) and collective interviews (applied to groups of patients and/or their informal/family caregivers), in order to compare informations registered on records, collect the missing data on records, identify features on the use of medications and characterize the perception of patients about their health problems and their treatments. The interviews were conducted by a graduate student in pharmacy, previously trained.

The protocols were approved by the Ethics Committee on Human Research at the Federal University of Sergipe. Patients participating in the study were informed about every step and agreed to participate in the survey through a term of informed consent.

The programs EPI-INFO (version 3.5.1-obtained from www.cdc.gov/EpiInfo) and Excel (Microsoft^®) were used to statistical analysis. The study protocol was approved by the Ethics Committee of Federal University of Sergipe.

During the development of this study, it was ministered lectures, home visits, workshops and meetings for patients, informal/family caregivers, and for the multidisciplinary team of the CAPS. The themes approached the rational use of medications, mental disorder, psychopharmacology, medicinal plants, hygiene, handicraft, culture, integration, social inclusion, first aid and use of alcohol, tobacco and others drugs.

Results

101 registered patients were distributed in intensive (13.86%), semi-intensive (52.48%) and non-intensive (33.66%) regime at CAPS Valter Correia. Those regimes are defined by their clinical conditions, based on clinical care and therapy of patients. According to their needs, patients belonging to intensive regime require daily care by a specialized multidisciplinary team (up to 25 days/month), patients belonging to semi-intensive regime require frequent care (up to 12 days/month) and patients belonging to non-intensive regime require less frequent attendance (up to 3 days of the month).

The mean age of patients was 42.18 ± 12.01-years-old, median of 42 years. Table 1 describes the distribution of other important socio-demographic parameters.

Table 1.

Sociodemographics data of patients attended at CAPS Valter Correia (n = 101).

Variables	AF (RF%)^*
Gender
Male	59 (58.40)
Female	42 (41.60)
Educational status
Analphabet	52 (51.50)
Uncompleted primary school	36 (35.60)
Primary school	1 (0.99)
Uncompleted secondary school	8 (7.90)
Secondary school	4 (3.96)
Occupational activity
None	91 (90.10)
Housemaid	1 (0.99)
Homemaker	4 (3.96)
Bricklayer	2 (1.98)
Fishman	3 (2.97)
Benefit/pensions
Receive	51 (50.50)
No receive	50 (49.50)
Income (monthly)
No income	50 (49.50)
1 minimum wage ($ 28,736)	49 (48.50)
2 minimum wage ($ 57,471)	1 (0.99)
3 minimum wage ($ 86,207)	1 (0.99)
Marital status
Single	77 (76.20)
Married or living as married	17 (16.80)
Divorced	2 (1.98)
Widowed	5 (4.95)

*

AF – Absolute frequency, RF% – Relative frequency in percentage.

Schizophrenia was the most prevalent mental disorder (31.53%). The mental disorder profile presented by the patients attended on the CAPS, according with the international classification of mental and behavioral disorders (ICD-10)²² is described in Table 2.

Table 2.

Mental disorders diagnosed at CAPS patients according to ICD-10 (n = 101).

ICD	Mental disorders	AF (RF%)^a
F06	Other mental disorders due to brain damage and dysfunction and to physical disease	5 (4.50)
F10	Mental and behavioural disorders due to use of alcohol	20 (18.02)
F20	Schizophrenia	35 (31.53)
F21	Schizotypal disorder	3 (2.70)
F25	Schizoaffective disorders	3 (2.70)
F29	Unspecified nonorganic psychosis	8 (7.21)
F31	Bipolar affective disorder	7 (6.31)
F32	Depressive episode	1 (0.90)
F71	Moderate mental retardation	9 (8.11)
F72	Severe mental retardation	4 (3.60)
G40	Epilepsy	4 (3.60)
	Others	12 (10.81)
Total		111 (100)^b

a

AF – Absolute frequency, RF% – Relative frequency in percentage.

b

It is observed that some patients have more than one mental disorder.

Some patients presented other diseases associated to mental disorders, such as arterial hypertension (18.81%), diabetes mellitus (10.9%), gastritis (10.9%), asthma (4.0%), others heart problems (7.9%) and hypothyroidism (2.2%).

Regarding to the pharmacotherapeutic profile, Table 3 exhibits the therapeutic classes of psychiatric drugs used by patients attended at CAPS. Table 4 describes the therapeutic classes of non-psychiatric drugs used by patients attended at CAPS, according to the WHO-ATC/DDD methodology. The psychiatric drug class most frequently prescribed was antipsychotics (44.8%) and the non-psychiatric drug class most prevalent was angiotensin-converting enzyme inhibitors (15.8%).

Table 3.

Therapeutic classes of psychotropic drugs used by patients attended at CAPS Valter Correia, according to ATC classification.

ATC	Therapeutic class	AF (RF%)^*
N03A	ANTIEPILEPTICS	26 (9.63)
N03AA	Barbiturates and derivatives	12 (4.44)
N03AB	Hydantoin derivatives	2 (0.74)
N03AE	Benzodiazepine derivatives	8 (2.96)
N03AF	Carboxamide derivatives	16 (5.93)
N04A	ANTICHOLINERGIC AGENTS	18 (6.67)
N04AA	Tertiary amines	18 (6.67)
N05A	ANTIPSYCHOTICS	121 (44.81)
N05AA	Phenothiazines with aliphatic side-chain	46 (17.04)
N05AC	Phenothiazines with piperidine structure	6 (2.22)
N05AD	Butyrophenone derivatives	65 (24.07)
N05AN	Lithium	2 (0.74)
N05AX	Other antipsychotics	2 (0.74)
N05B	ANXIOLYTICS	22 (8.15)
N05BA	Benzodiazepine derivatives	22 (8.15)
N06A	ANTIDEPRESSANTS	23 (8.52)
N06AA	Non-selective monoamine reuptake inhibitors	16 (5.93)
N06AB	Selective serotonin reuptake inhibitors	7 (2.59)
R06A	ANTIHISTAMINES FOR SYSTEMIC USE	43 (15.93)
R06AD	Phenothiazine derivatives	43 (15.93)
V03A	ALL OTHER THERAPEUTIC PRODUCTS	5 (1.85)
V03AA	Drugs for treatment of chronic alcoholism	5 (1.85)
Total		219 (100)

*

AF – Absolute frequency, RF% – Relative frequency in percentage.

Table 4.

Therapeutic classes of non-psychotropic drugs used by patients attended at CAPS Valter Correia, according to ATC classification.

ATC	Therapeutic class	AF (RF%)^*
A02B	Drugs for treatment of peptic ulcer	3 (7.89)
A04A	Antiemetics and antinauseants	2 (5.26)
A06A	Laxatives	2 (5.26)
A07D	Antipropulsives	1 (2.63)
A10B	Oral blood glucose lowering drugs	1 (2.63)
B03A	Iron preparations	1 (2.63)
B03B	Vitamin B12 and folic acid	2 (5.26)
C01D	Vasodilators used in cardiac diseases	1 (2.63)
C02A	Antiadrenergic agents, centrally acting	1 (2.63)
C03A	Low-ceiling diuretics, thiazides	1 (2.63)
C03C	High-ceiling diuretics	1 (2.63)
C07A	Beta blocking agents	3 (7.89)
C09A	Ace inhibitors, plain	6 (15.79)
C09C	Angiotensin II antagonists, plain	1 (2.63)
G03A	Hormonal contraceptives for systemic use	1 (2.63)
G03G	Gonadotropins and other ovulation stimulants	1 (2.63)
G04B	Other urologicals, incl. antispasmodics	1 (2.63)
H02A	Corticosteroids for systemic use, plain	1 (2.63)
M03A	Muscle relaxants, peripherally acting agents	3 (7.89)
R03A	Adrenergics, inhalants	1 (2.63)
R03C	Adrenergics for systemic use	1 (2.63)
R03D	Other anti-asthmatics for systemic use	1 (2.63)
R05C	Expectorants, excl. combinations with cough suppressants	1 (2.63)
R06A	Antihistamines for systemic use	1 (2.63)
Total		38 (100)

*

AF – Absolute frequency, RF% – Relative frequency in percentage.

The average number of medications (psychotropic and non-psychotropic) used by patients was 3.11 ± 1.41 medications/patients, median 3 (Table 5).

Table 5.

Mean number of medications (psychotropic and non-psychotropic) used by patients attended at CAPS Valter Correia, according to the age group.

Age group (years)	Average amount of medications used/patient
20–24	2.33 ± 1.21
25–29	3.89 ± 1.17
30–34	2.82 ± 1.01
35–39	2.62 ± 0.96
40–44	2.91 ± 1.20
45–49	2.70 ± 1.42
50–54	3.88 ± 1.96
55–59	3.50 ± 0.71
60–64	3.00 ± 0.71
65–69	3.00 ± 0.00
70–74	3.00 ± 0.00
75–80	5.50 ± 0.00

Values are expressed as mean ± standard deviation.

Table 6 shows the percentage of drug interactions presented by pacients of the CAPS, according to the degree of severity.

Table 6.

Drug interactions (drug–drug) presented by patients attended at CAPS Valter Correia, classified by degreed severity.

Type of interaction	AF (RF%)^*
Light	4 (3.01%)
Moderate	72 (54.13%)
Several	39 (29.32%)
Contraindicated	18 (13.54%)
Totaly	133 (100%)

*

AF – Absolute frequency, RF% – Relative frequency in percentage.

With respect to consumption of others substances, it is observed in Table 7 the profile of use alcohol, tobacco, illicit drugs and teas.

Table 7.

Consume of alcohol, tobacco, coffee, illicit drugs and tea by patients attended at CAPS Valter Correia.

Substances	Consume	AF (RF%)^*
Alcohol	<2 cups/week	1 (0.99)
	>6 cups/week	18 (17.82)
	2–6 cups/week	4 (3.96)
	Sporadically	1 (0.99)
	Do not consume	76 (75.25)
	Trying to stop	1 (0.99)
Tobacco	<1 wallet/day	15 (14.85)
	>1 wallet/day	23 (22.77)
	Does not consume	63 (62.38)
Coffee	<2 cup/day	17 (16.83)
	>6 cups/day	8 (7.92)
	2–6 cups/day	20 (19.80)
	Sporadically	36 (35.64)
	History of dependence	5 (4.95)
	Do not consume	14 (13.86)
	Trying to stop	1 (0.99)
Illicit drugs	>6 times/week	1 (0.99)
	2–6 times/week	1 (0.99)
	Sporadically	2 (1.98)
	History of dependence	2 (1.98)
	Do not consume	95 (94.06)
Tea	<2 cups/day	10 (9.90)
	>2 cups/day	9 (8.91)
	Sporadically	46 (45.54)
	Do not consume	36 (35.64)

*

AF – Absolute frequence, RF% – Relative frequency in percentage.

Discussion

The CAPS is an open and community service of mental health on the unified health system (SUS) in Brazil. Its main objective is to establish a reference place to treatment for people with mental disorders, who need an intensive care related to their severity and/or persistence demand.⁵

101 registered patients at CAPS ‘Valter Correia’ were distributed in intensive (13.86%), semi-intensive (52.48%) and non-intensive (33.66%) regime. The average age of patients was 42.18 ± 12.01 years. These results were in concordance by other studies, which claim that mental disorders affect people of all ages, with the prevalence on 30–49 years.^24,25 The presence of mental disorder at this age group influences the way of life, interrupting productivity as a result of disability caused by disease.²⁴

It is observed in Table 1 that the CAPS consisted mainly of male patients (58.50%), which differs from others studies that indicate the prevalence of females.^24,26

Most patients were single (76.20%), childless (54.50%), illiterate (51.50%), without occupation (90.10%), without benefits (49.50%) and without monthly income (49.50%). These results suggest that the presence of mental disorder can influence the cultural background of people and the chance to attend school is low, which can make it difficult to enter at university and gain a good job. According to OMS (2001)², five from ten causes of inability on the world are mental disorder.

Regarding to the nosological profiles, Table 2 reveals that there are patients with more than one type of mental disorder and that schizophrenia is the most prevalent mental disorder (31.53%).

Schizophrenia is one of the most serious neuropsychiatric diseases and affects about 1% of world population. Currently, there is no specific prevention for this disease. Neuroleptic or antipsychotic drugs are used as the primary treatment for all stages of the disease.²⁷

Depressive episodes are common mental disorders on Brazilian population,^28–31 but we found in only 0.90% of our CAPS patients. This difference should be caused due to the introduction of a new model of psychiatric care, which is still suffering transition in Brazil. Part of the population, who suffers from mood and anxiety disorders, is probably under-diagnozed. Another part, even receiving the correct medical diagnosis, chooses to receive ambulatory treatment without resort to the CAPS, which could be in consequence of stigmas fear.

Consumption of alcohol and others drugs is an important cause of disorder. Mental behavioral disorders due the consumption of alcohol were found in 18.02%, due the consumption of multiple drugs and others psychoactive substances in 0.90% and due to the use of cocaine in 0.90%. Those patients should be indicated for an AD type of CAPS.

The psychiatric drug class most frequently prescribed was antipsychotics (44.8%), described in Table 3. Angiotensin-converting enzyme inhibitors (ACEI) were the most prevalent non-psychiatric drug class (15.8%) (Table 4). Those results are in consistence with the most prevalent diseases, schizophrenia for antipsychotics and hypertension for ACEI medications.

There is currently a very large number of antipsychotic medications, with different profile of side effects, but with similar potency when use in equivalent doses. However, there are individual differences on efficacy, tolerance and cost. Particular context should be used to choose the adequate drug.

The average number of medications used by patients was 3.11 ± 1.41 medications/patients. The largest consumption of medications was found in the 75–80 years group, 5.5 medications for patient (Table 5). These data are in with the literature. Elderly population is marked by a higher frequency of chronic degenerative diseases. It has greater demand for health services and medication, which predisposes the geriatric population to great risks with the practice of polypharmacy and adverse effects of medications.³²

In regard to drug interactions,^33–35 3.0% mild, 54.1% moderate, 29.3% severe and 13.5% contraindicated (Table 6). Those results demonstrate the need to evaluate possible interventions, since drug interactions may, among other things, increase undesired medications effects, lead to ineffective therapy and endanger the life of patient.^36–39

It is observed in Table 7 that 24.75% of patients consumed alcohol, 37.62% tobacco, 86.14% caffeine, 5.94% illicit drugs and 64.36% tea. It is necessary a further detailed study, since these substances can interact with several medications.

The medications have an important role in the health system, they can save lives or remove the signs and symptoms of numerous diseases.⁴⁰ However, the drugs may increase the costs of health care if used improperly.⁴¹ According to WHO data, hospitals spend 15%–20% of their budgets to deal with the complications caused by misuse of medications.⁴²

In this context, pharmacists are professionals who can actively participate in the multidisciplinary team, make the management of pharmacotherapy, assess the use of medications, provide guidelines and perform pharmacotherapeutic monitoring of patients, which contribute to the rational use of medications and improve the quality of life of patients.⁴³

Conclusion

Our results revealed the need for monitoring the pharmacotherapy of patients with mental and behavioral disorders to encourage the rational use of medications. This monitoring is necessary, since these patients are polymedicated, have other comorbidities, and use drugs that cause adverse effects, which compromise the adherence of treatment and consequently their quality of life.

Conflicts of interest

The authors have no conflicts of interest to declare.

Acknowledgments

We would like to thank the Fundação de Apoio à Pesquisa e à Inovação Tecnológica do Estado de Sergipe/FAPITEC-SE and National Council of Technological and Scientific Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico/CNPq/Brazil) for the fellowship support.