Problemas de saúde mental e cuidados de saúde mental em Portugal J.M. Caldas de Almeida
Prevalence of any mental disorder in the last 12 months in European countries 25 23,1 22,9 20 18,4 15 14,9 12 11,2 10 9,2 8,2 8,2 5 0 Adapted from Wang et al, 2011
PERTURBAÇÕES PSIQUIÁTRICAS EM PORTUGAL PREVALÊNCIA ANUAL % P. Ansiedade 16,5 P. Depressivas 7,9 P. Impulsividade 3,5 P. Abuso e Dependência Álcool 1,6
PERTURBAÇÕES DA ANSIEDADE PREVALÊNCIA ANUAL P. PÂNICO 0,9% ANSIEDADE GENERALIZADA 2,1% Não é possível apresentar a imagem neste momento. FOBIA SOCIAL 3,1% FOBIA ESPECIFICA 8,6% AGORAFOBIA SEM PÂNICO 0,7% STRESS PÓS TRAUMÁTICO 2,3% P. OBSESSIVO-COMPLUSIVA 4,4% P. ANSIEDADE DE SEPARAÇÃO NO ADULTO 1,2%
PERTURBAÇÕES DEPRESSIVAS PREVALÊNCIA ANUAL DISTIMIA Não é possível apresentar a imagem neste momento. 1% DEPRESSÃO MAJOR 6,8% P. BIPOLAR 1,1%
Severity by treatment in Portugal Severity by treatment Severe Moderate Mild None Total General medical Mental health Health care Non-health care Any treatment No treatment 47.1% 23.8% 10.2% 5.7% 9.8% 38.9% 14.9% 8.3% 3.6% 6.6% 66.1% 33.8% 16.2% 8.6% 14.4% 6.0% 3.2% 8.5% 1.0% 1.6% 66.4% 35.1% 18.2% 9.0% 15.0% 33.6% 64.9% 81.8% 91.0% 85%
Proportional treatment contact in the year of disorder onset and median duration of delay among cases that subsquently made treatment I. Anxiety disorders % making treatment contact in the year of onset Median duration of delay (years) Panic disorder 45.8 2 Generalized anxiety disorder 34.3 3 Specific phobia 3.8 34 Social phobia 7.5 18 Any anxiety disorder 12.7 23 II. Mood disorder Major depression 37.8 4 Dysthymia 37.5 3 Bipolar disorder 27.1 6 Any mood disorder 35.3 5 III. Alcohol Alchool abuse 3.0 29 Alcohol abuse with dependênce 4.3 21 Any substance disorder 2.1 29
Under- treatment of people with major depressive disorder in 22 countries
Follow- up 2015
What changed from 2008 to 2015 Professional Status 70 Professional status in 2008 and 2015 60 62,3 60,6 50 40 30 33,5 2008 2015 20 19,1 10 4,7 5,9 0 Working Looking for job Others
What changed from 2008 to 2015 Economic situation Self- reported change in income (last 5 years) Reported reasons for change in income 50 45 41,9 43,7 60 50 54,1 40 40 35 30 25 % 30 20 14,1 19,8 20 15 14,4 10 0 6,3 5,7 10 5 0 Increased Equal Decreased
What changed from 2008 to 2015 Financial Deprivation 40 Perceived financial deprivation 39 35 33,2 30 25 % 20 15 10 5 0 2008 2015
What changed from 2008 to 2015 Prevalence of mental health problems (K- 10) 35 30 Mental health problems in 2008 and 2015 (Kessler- 10) 31,2 25 20 16,8 19,8 15 13,6 10 5 4,4 7,6 1,8 6,8 0 Mild Moderate Severe Any psychological distress 2008 (n=562) 2015 (n=911)
What changed from 2008 to 2015 Increase of mental health problems (K- 10) according to gender Increase of mental health problems (k- 10) from 2008 to 2015 20 18,5 18 16 14 12 10 9,9 1. 8 10,2 8 6 3. 8 4 2,6 2 0 Men Women 2008 2015
What changed from 2008 to 2015 Increase of mental health problems (K- 10) according to age group Increase of mental health problems (k- 10) according to age group from 2008 and 2015 20 18 16 16,5 1. 2 15,3 18,7 14 12 10 8 6 4 7. 7 7,7 1. 8 6,6 12 3. 0 5,6 2 1 0 18-34 35-49 50-64 >65 2008 2015
Sociodemographic characteristics and mental health problems Education Education and mental health problems (K- 10) 25 23 20 15 12,8 10 9,9 10 5 0 No education and primary Basic Secundary University K-10: p<0.05*
Sociodemographic characteristics and mental disorders Education Education and mental health problems (MDE and GAD) 15 13,4 10 7,3 5,4 MDE GAD 5 2,3 2,2 2,6 2,7 3,1 0 No education and primary Basic Secundary University MDE: p<0.05* GAD: p<0.05*
Sociodemographic characteristics and mental health problems Professional Status 25 Professional status and mental health problems (K- 10) 20 19,1 20,3 15 10,6 10 5 0 Working Looking for job Others K-10: p<0.05*
Sociodemographic characteristics and mental disorders Professional Status Professional status and mental health problems (MDE and GAD) 14 12,6 12 10,4 10 8 7,4 MDE 6 5 GAD 4 3,5 3 2 0 Working Looking for job Others MDE: p<0.05* GAD: p>0.05
Factors associated with mental health problems during the economic crisis o Financial Deprivation o Perceived Social Status o Social Support o Community Involvement o Disability
Factors associated with mental health problems in 2015 Financial deprivation 25 Financial deprivation and mental health problems (K- 10) 22 20 15 10 9,4 5 0 More or enough Not enough K-10: p<0.05*
Factors associated with mental disorders in 2015 Financial deprivation 15 Financial deprivation and mental health problems (MDE and GAD) 10,9 10 % 6,4 MDE GAD 5 3,3 2,2 0 More or enough Not enough MDE: p<0.05* GAD: p<0.05*
Factors associated with mental health problems in 2015 Types of financial deprivation 30 Types of financial deprivation and mental health problems (K- 10) 28,9 28,7 25 20 19,1 15 10 5 0 Essential goods Debts Other goods food, water or electricity bills, rent house, car clothes or K-10: p<0.05* or credit K-10: p>0.05 leisure K-10: p>0.05 card debt
Factors associated with mental disorders in 2015 Types of financial deprivation Types of financial deprivation and mental health problems (MDE and GAD) 10 9,2 9,3 9,2 7,4 7 % 5 5,2 MDE GAD 0 Essential goods Debts Other goods food, water or electricity bills, rent MDE: p<0.05* GAD: p<0.05* house, car or credit card debt MDE: p>0.05 GAD: p>0.05 clothes or leisure MDE: p>0.05 GAD: p>0.05
Factors associated with mental health problems in 201 Perceived Social Position 30 28 27,2 25 22 20 16,8 15 14,3 13,6 13,8 12 11 10 7,9 8,2 8,3 5 0 4,4 4 3 2 1,4 0,40,3 0 1 2 3 4 5 6 7 8 9 10 2008 2015 Median 2008: 5th position 2015: 4th position
Factors associated with mental health problems in 2015 Perceived Social Position 25 Perceived Social Position and mental health problems (K- 10) 20 21 15 11,9 10 5 0 Below median Equal or above median K-10: p<0.05*
Factors associated with mental disorders in 2015 Perceived Social Position Perceived social position and mental health problems (MDE and GAD) 10 9,1 8 6 5,1 5,3 MDE 4 3,6 GAD 2 0 Below median Equal or above median MDE: p<0.05* GAD: p>0.05
Factors associated with mental health problems in 2015 Social Support 20 Social support and mental health problems (K- 10) 18 17,5 16 14 12 11,5 10 8 6 4 2 0 Bellow Low social median support Equal or Good above social median support K-10: p<0.05*
Factors associated with mental disorders in 2015 Social Support 10 Social support and mental health problems (MDE and GAD) 8,6 8 6 4,7 4,3 MDE GAD 4 3,2 2 0 Bellow Low social median support Equal Good or above social median support MDE: p<0.05* GAD: p>0.05
Factors associated with mental health problems in 2015 Community Involvement 18 Community Involvment and mental health problems (K- 10) 16 16,1 14 12,6 12 10 8 6 4 2 0 Bellow Low median community involveme nt Equal or Good above median community involvement K-10: p>0.05
Factors associated with mental disorders in 2015 Community Involvement 10 Community involvment and mental health problems (MDE and GAD) 8 6,2 6,4 6 4 5,4 MDE GAD 2,5 2 0 Bellow Low median community involveme nt Equal or above Good median community involvement MDE: p>0.05 GAD: p<0.05*
O Sistema de saúde mental português
Policy and Legislation National Debate on Mental Health (1995) Mental Health Law (1998) Mental Health Policy (1999) First Legislation on financingof psychosocial rehabilitation programs (1999) National Mental Health Plan (2006) Legislation on Mental Health Continued Care (2010)
Hospital Psiquiátrico Internamento Consultas Depósito asilar Hospital Geral Equipas de Saúde Mental Comunitárias Cuidados Continuados Saúde Mental CSP
Não é possível apresentar a imagem neste momento.
Main advances Advocacy Information and research Passing of legislation Programme of continued care (Residential facilities, day centers, home intervention) Downsizing and closure of psychiatric hospitals Creation of new services in general hospitals Funding and development of community projects Developments of child and adolescent mental health services Training of professionals Programs for Homeless and Victims of Domestic Violence Project Monitoring of quality and human rights Intersectoral cooperation Financing
Novos serviços locais de saúde mental Lisboa/Oeiras (CHLO) Amadora/Sintra (H. Fernando Fonseca) Almada (H. Garcia Orta) Tomar (C. Hospitalar Médio Tejo) Barreiro (H. Setúbal (H. S. Bernardo) Portimão Guimarães (CH Alto Ave) Cascais Porto (Centro Hospitalar do Porto) ULS Matosinhos Centro Hospitalar de Entre- Douro- e- Vouga Centro Hospitalar da Póvoa de Varzim/Vila do Conde Centro Hospitalar do Médio Ave
Novos serviços/unidades de SM Infância e Adolescência Unidade de Psiquiatria da Infância e Adolescência do Hospital Sousa Martins, Guarda (Setembro 2009); Unidade de Psiquiatria da Infância e Adolescência do Hospital da Figueira da Foz (Setembro de 2009); Equipa de psiquiatria e saúde mental da infância e adolescência do H. Fernado da Fonseca (2010); Unidade de Psiquiatria da Infância e Adolescência do Centro Hospitalar do Médio Ave (2010); Serviço de Psiquiatria da Infância e Adolescência no Centro Hospitalar das Caldas da Rainha (2010)
New mental health departments in general hospitals (1995-2010)
New community care programmes initiated in 2009 (n=46)
New child/adolescent services (2008-2011)
New psychosocial rehabilitation services 27
Training programs (2008-2011) 26 workshops throughout the country: 683 professionals trained Themes: organization of services, Case management programs for people with severe mental disorders, training of leaders.
Departmento Saúde Mental do CHLO Communidade Hospital S. Francisco Xavier Serviço PSM Crianças e adolescentes Consultas Ligação à Pediatria Cuidados Primários (CP) 5 EQUIPAS COMUNITÁRIAS Tatamento D. Mentais comuns & Ligação com CP Programa Integrar para DMG Hospital Egas Moniz Unidade de Internamento Hospital de Dia Equipa Psiquiatria de Ligação Serviço Urgência Áreas de Dia Treino profissional Communidade Outras estruturas comunitárias
Results of INTEGRAR n To à n1 = 146 patients ; n T1 à n2=109 (evaluation after 1 year of follow- up) n 97 (66%) were male and 49 (34%) females with a mean age of 36 years n program drop out = 26 à 18% n Diagnoses (ICD10): Schizophrenia (F20) = 116 (79,4%) and Schizoaffective D. (F25) = 30 (20,6%)
Results Outcomes: First vs. second evaluation (the year before and after one year of intervention) Admissions (number of patients) Admission (number of days) T0 T1 39 14 p=0,001 1522 523 p=0,001 In absolute terms, there was a reduction of 999 days (65,6%). There was also a 45,6% reduction of relapses (p = 0,001).
Results Outcomes: First vs. second evaluation (the year before and after one year of intervention) Psychopathology: global mean scores for the BPRS, decreased (p=0,001), as did the four sub scales: positive symptoms (p=0,003);; negative symptoms (p=0,002);; manic symptoms (p=0,002) and symptoms of depression/anxiety (p=0,001);; Social and occupational functioning, quality of life and patient satisfaction: statistically significant improvement from the first to the second assessment.
Results Outcomes: First vs. second evaluation (the year before and after one year of intervention) n Attitudes towards medication DAI (p=0,690) and with insight evaluation SAI (p=0,079): no statistically significant differences from the first to the second assessment ( for p 0,05); n Employment status: in the first assessment 8 (7,4%) patients were in full time employment and in the second evaluation the number increased to 18 (16,7%).