As Sete Consequ\u00eancias Catastr\u00f3ficas das Recorr\u00eancias Psic\u00f3ticas<\/p>\n
It is very unfortunate when individuals with schizophrenia relapse repeatedly.\u00a0 The #1 cause for the recurrence of psychosis is either inconsistent adherence to antipsychotic (AP) medications or total non-adherence (1).\u00a0 The reasons for poor adherence in schizophrenia are related to the illness itself, and patients should not be blamed.<\/p>\n
Os sintomas da esquizofrenia que levam \u00e0 ades\u00e3o (2) incluem: 1) anosognosia<\/strong>, or the lack of insight that one is very sick with delusions and hallucinations, leading to patient rejection of medication 2) Dificuldades cognitivas<\/strong> inclusive comprometimento grave da mem\u00f3ria, que levam ao esquecimento de tomar o PA, 3) sintomas negativos<\/strong>, including apathy, lack of motivation (avolition) and loss of the ability to do many things, including taking medications every day, 4) desconfian\u00e7a<\/strong> que os efeitos colaterais comuns da medica\u00e7\u00e3o AP s\u00e3o evid\u00eancias de envenenamento, 5) Uso de \u00e1lcool e drogas<\/strong> which are very common in persons with schizophrenia living in the community, and being intoxicated or stoned precludes taking prescription medication.\u00a0 The combination of all those factors inevitably leads to a high rate of medication nonadherence after discharge from the first hospitalization.<\/p>\nAssim como diabetes tipo 1 ou hipertens\u00e3o, onde os medicamentos devem ser tomados todos os dias ou h\u00e1 risco de reca\u00edda, as pessoas com esquizofrenia devem tomar seus comprimidos orais todos os dias sem interrup\u00e7\u00e3o. Um estudo publicado mostrou que uma queda de apenas 25% no n\u00edvel sangu\u00edneo AP (o que significa perder uma dose uma vez a cada 4 dias) \u00e9 suficiente para causar uma reca\u00edda na esquizofrenia (3).<\/p>\n
Long-acting injectable (LAI) APs were developed in the 1970\u2019s, precisely to solve the problem of non-adherence with oral medication.\u00a0 However, due to the delay in scientific advances about the brain-damaging effects of psychosis (which appeared 3 decades later), clinicians back then were completely unaware that psychosis is associated with the dangers of recurring psychosis and resultant brain damage. They also believed that patients should \u201cmake their own decisions,\u201d despite the well-known fact that the decision-making region of the brain (frontal lobe) is impaired in schizophrenia. Patients were even led to regard LAI treatment as \u201cstigmatizing\u201d and as a \u201cpunishment\u201d for multiple relapses, so they resisted the LAIs. Now LAIs are regarded as a most compassionate and effective therapeutic approach to save patients with schizophrenia from psychosis-induced brain damage.<\/p>\n
Por volta do ano 2000, pesquisas em neuroci\u00eancia psiqui\u00e1trica revelaram que a psicose destr\u00f3i o tecido cerebral e causa atrofia cerebral (4) devido \u00e0 neuroinflama\u00e7\u00e3o e aos radicais livres (5), ambos os quais danificam a subst\u00e2ncia cinzenta e branca. A estrutura e a fun\u00e7\u00e3o do c\u00e9rebro se deterioram a cada reca\u00edda psic\u00f3tica. Isso evita que as pessoas que desenvolvem esquizofrenia retornem \u00e0 linha de base anterior ao primeiro epis\u00f3dio psic\u00f3tico (FEP), que \u00e9 muito tr\u00e1gico para jovens no final da adolesc\u00eancia ou no in\u00edcio dos 20 anos.<\/p>\n
A seguir est\u00e3o 7 consequ\u00eancias catastr\u00f3ficas de epis\u00f3dios psic\u00f3ticos recorrentes (6) devido \u00e0 baixa ades\u00e3o:<\/p>\n
\n- Perda de tecido cerebral e atrofia cerebral e desintegra\u00e7\u00e3o da extensa rede de fibras mielinizadas (cerca de 137.000 milhas) que conecta todas as regi\u00f5es do c\u00e9rebro e cria uma unidade do eu.<\/li>\n
- Treatment-resistance patients respond to low doses of AP in the first-episode of psychosis (FEP) but need higher and higher dose with each psychotic relapse until eventually they become completely treatment-resistant (and will need Clozapine, which most patients never have access to). The brain structure deteriorates successively with each episode and that\u2019s why APs that previously worked no longer do so.<\/li>\n
- Incapacidade funcional e incapacidade de retornar \u00e0 escola, faculdade ou ao trabalho, independentemente do que os pacientes estivessem fazendo antes do FEP. Assim, com repetidas reca\u00eddas, esses jovens tornam-se totalmente incapacitados em vez de serem membros produtivos da sociedade.<\/li>\n
- When individuals with schizophrenia become psychotic and behave erratically, sometimes they are killed by police, and many more are arrested and jailed, and often sentenced to prison. They no longer get admitted to state hospitals (because they have all been shuttered), and so are surrounded by armed guards instead of doctors, nurses and social workers who compassionately provide them with medical care instead of being thrown into a prison with murderers and rapists.<\/li>\n
- Muitas pessoas n\u00e3o est\u00e3o cientes da taxa incrivelmente alta de suic\u00eddio entre jovens com esquizofrenia quando recaem. Alguns estudos relatam taxas de mortalidade por suic\u00eddio mais de 10.000% (7) em compara\u00e7\u00e3o com jovens da mesma idade na popula\u00e7\u00e3o em geral.<\/li>\n
- Non-adherence can lead to drug abuse, a chaotic lifestyle and living on the sidewalks of large cities, with risk of becoming victims of crime.<\/li>\n
- Psychosis can cause unusual behavior, and poor dress and grooming, which intensify the public\u2019s negative bias against serious mental illness.<\/li>\n<\/ul>\n
No entanto, contra esse resultado sombrio, h\u00e1 esperan\u00e7a e boas not\u00edcias para as pessoas com esquizofrenia. A utiliza\u00e7\u00e3o do LAI muito precocemente, ou seja, logo ap\u00f3s a primeira interna\u00e7\u00e3o, pode fazer uma grande diferen\u00e7a na preven\u00e7\u00e3o da deteriora\u00e7\u00e3o. Existem estudos publicados que relatam que as recidivas no primeiro ano ap\u00f3s o FEP se LAIs s\u00e3o iniciadas \u00e9 650% menor do que a taxa de reca\u00eddas em pacientes recebendo AP oral (8). Eu pessoalmente tive pacientes que n\u00e3o reca\u00edram por 5 anos cont\u00ednuos ap\u00f3s troc\u00e1-los por AP injet\u00e1vel. Prevenir reca\u00eddas \u00e9 vital porque pesquisas recentes demonstram que a incapacidade realmente come\u00e7a ap\u00f3s o segundo<\/u>, n\u00e3o o primeiro epis\u00f3dio de psicose (9). Assim, prevenir o segundo epis\u00f3dio \u00e9 a chave para a remiss\u00e3o e recupera\u00e7\u00e3o da esquizofrenia. Assim, a deteriora\u00e7\u00e3o e o curso descendente da esquizofrenia podem ser evitados na maioria dos pacientes pelo uso de LAI AP logo ap\u00f3s a primeira hospitaliza\u00e7\u00e3o por esquizofrenia (10).<\/p>\n
Existem outras vantagens importantes no uso de formula\u00e7\u00f5es de LAI de segunda gera\u00e7\u00e3o. 24 estudos publicados relatam que s\u00e3o neuroprotetor<\/u> (isto \u00e9, ajudam a preservar a integridade do tecido cerebral) (11). Al\u00e9m disso, um estudo de acompanhamento de 7 anos na Su\u00e9cia relatou que um antipsic\u00f3tico LAI de segunda gera\u00e7\u00e3o foi associado ao menor taxa de mortalidade<\/u> de todas as causas (12). Isso \u00e9 muito importante, dada a alta mortalidade prematura na esquizofrenia.<\/p>\n
In summary, until a cure for schizophrenia is discovered, the best way to give patients a chance to return to their baseline and avoid the tragic, life-altering consequences, is to use second-generation LAIs immediately after discharge from the first hospitalization. Yet, inexplicably, this is rarely done, and 99% of clinicians in the country prescribe pills and do not use LAI APs for several years until patients have already relapsed several times.\u00a0 By that time, the patients have already lost substantial amounts of brain tissue and have become disabled and criminalized and incarcerated.\u00a0 Imagine how much different the landscape of schizophrenia would be if clinicians prevented any further episode of psychosis after the first one.\u00a0 Many young people with a diagnosis of schizophrenia may be able to return to their baseline, further their education, get a job, get married, raise a family and exercise their constitutional right to pursue happiness (13).<\/p>\n
Henrique A Nasrallah,<\/p>\n
Diretor cient\u00edfico<\/p>\n
Refer\u00eancias:<\/u><\/strong><\/p>\n\n- Valligan DI et al: Os pacientes preferem a ades\u00e3o<\/u> 11:449-468, 2018<\/li>\n
- Nasrallah HA: Atual Psiquiatria<\/u> 16:4-7, 2017<\/li>\n
- Subotnik KL et al: Am J Psiquiatria<\/u> 168:286-292, 2011<\/li>\n
- Cahn Wet al: Arquiger Psiquiatria<\/u> 59:1002-1010, 2002<\/li>\n
- Kohler-Torsberg O et al: Fronteiras da Psiquiatria<\/u> 11:1-3, 2020<\/li>\n
- Nasrallah HA: Atual Psiquiatria<\/u> 20:9-12, 2021<\/li>\n
- Zaheer J et al: Pesquisa sobre esquizofrenia<\/u> 222:282-38, 2020<\/li>\n
- Subotnik KL et al: Psiquiatria JAMA<\/u> 72:822-829, 2015<\/li>\n
- Taipale H et al: Lancet Psiquiatria<\/u> 9:271-279, 2022<\/li>\n
- Nasrallah HA: Atual Psiquiatria<\/u> 21:6-9, 2022<\/li>\n
- Chen AT et al: Pesquisa sobre esquizofrenia<\/u> 208:1-7, 2019<\/li>\n
- Taipale H et al: Pesquisa sobre esquizofrenia<\/u> 197:274-280, 2018<\/li>\n
- Nasrallah HA e outros: Atual Psiquiatria<\/u> 20:14-16, 202<\/li>\n<\/ol>\n<\/div><\/div><\/div><\/div><\/div>
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