Lacunas assistenciais no tratamento de transtornos mentais na região metropolitana de São Paulo, Brasil
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Data
2022-05-25
Autores
Franca, Mariane Henriques
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Universidade Federal do Espírito Santo
Resumo
Backgroud: The prevalence of mental disorders (MD) in the general population is high. Mood and anxiety disorders are the most prevalent MD in the general population. The high prevalence of MD, with the fact that they are chronic, results as the main cause of disability and social cost in the world, causing a high social burden and overburdening the health services systems. Early therapeutic interventions can play a crucial role in the prognosis of MD, preventing chronicity and disability. Therefore, it can contribute with a decrease in the time between early contact with treatment after the initiation of MD - a crucial step to increase the chances of recovery through the availability of cost-effective treatment. The aims of this thesis are: 1) to analyze the gaps in treatment coverage among individuals with TM common in the metropolitan region of São Paulo, Brazil, 2) to estimate the treatment delay after the first onset of MD and to analyze the sociodemographic predictors, and in addition; 3) to analyze the gaps related to effective treatment coverage among individuals diagnosed with major depressive disorder (MDD), and its predictors, developing the theoretical model of “Cascade of effective coverage” for Brazil, identifying critical quality gaps adjusted to user adherence, and pharmacological and psychotherapeutic care. Methodology: The São Paulo Megacity is a cross-sectional, population-based epidemiological study designed to assess psychiatric morbidity in a representative sample of individuals residents in the São Paulo metropolitan area (SPMA), with 81.3% overall response rate. Data were collected between May/2005 and April/2007 using the World Mental Health Survey, Composite International Diagnostic Interview (CIDI 3.0). The first study considered a total sample survey (n=5,037). The second and the thrird study considered a sample of respondents that fulfilled DSM-IV criteria for MDD over the past 12-months (n=491). Retrospective information about the age of onset of MD was obtained through questions that considered the respondent's memory bias for the first treatment. Effective treatment coverage was considered as the adequate combination of pharmacotherapy and psychotherapy. The “Contact Coverage” framework included adjustments for quality of care and user adherence. The correlation between contact coverage and effective treatment was analyzed through the survival analysis. The association of socioeconomic and demographic characteristics, health insurance, and clinical severity with contact coverage and its components, including type of treatment, quality of treatment, and adherence were analyzed as well. Results: Mostly of individuals with lifetime MD had health contact coverage. The contact coverage was more frequent among those being treated for mood disorders (94.4%) than with anxiety disorders (63.6%), and substance use disorders (46.6%). The average delay among those who eventually made contact with health treatment ranged from 3 to 13 years for mood disorders, 1 to 36 years for anxiety, and 8 to 14 for substance use disorders. The early age onset of MD was associated with lower contact coverage odds. The low contact coverage after the first disorder onset of the MD was associated to the type of coverage, accessibility, adherence, socio demographics predictors. Among those with MDD (n=491), 164 individuals (33.3%) had contact with health services. Among them, only 25.2% received effective treatment coverage, which represents 8.5% of those in need. The critical bottlenecks identified were related to the use of psychotropic medication (12.2 percentage points), use of antidepressants (6.5), adequate medication control (6.8), and receiving psychotherapy (19.8). Older age, having private health insurance, and having a moderately severe MDD episode were predictors for health services contact. Conclusions: This study demonstrated the low proportion and huge delay of treatment contact after the first onset of MD in Brazil. Furthemore, this study shown the enormous treatment gaps for MDD, considering not only contact coverage, but also identifying specific quality- and user-adjusted bottlenecks in providing pharmacological and psychotherapeutic care. This thesis highlights the importance of looking beyond the traditional focus of assessing the treatment gap of mental disorders, which has been typically based on low rates of seeking and accessing treatment. Effective coverage should be the added in the public health policies agenda not only to reduce the treatment gap, but mainly to reduce the delays between the onset of mental disorders, and the first contact with treatment.
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Transtornos mentais , Tratamento , Serviços de saúde , Transtorno depressivo , Cobertura de contato , Lacunas assistenciais