DPOC DEPRESSÃO ANSIEDADE DIAGNÓSTICO E MANUSEIO

Apresentação em tema: "DPOC DEPRESSÃO ANSIEDADE DIAGNÓSTICO E MANUSEIO"— Transcrição da apresentação:

1 DPOC DEPRESSÃO ANSIEDADE DIAGNÓSTICO E MANUSEIO
CURSO ATUALIZAÇÃO SBPT 2014 ALEXANDRE PINTO CARDOSO MD.PHD PROFESSOR PNEUMOLOGIA UFRJ

2 Comorbidity and multimorbidity
Adults with multiple chronic conditions are the main users of health care services and account for more than two thirds of health care spending. These patients had lower physical function – greater fragility and risk of disability – and a decrease in HRQoL even after adjustment for confounding variables such as age, sex, education, and perceived social support.22–24 The importance of comorbidities in COPD patients and their prognostic implications have been increasingly recognized in the last decade.10,25,26 Heart disease, hypertension, musculoskeletal disorders, and diabetes, among many other diseases, are common in COPD patients, and several epidemiological studies have shown that lung function impairment is associated with an increased risk of comorbid diseases.27,28 In fact, many patients with COPD have multiple concurrent comorbidities, and hence the term “multimorbidity” would be more accurate. Although multimorbidity is sometimes used interchangeably with comorbidity and pluripathology, multimorbidity implies a different concept. Comorbidity technically indicates a condition or conditions that coexist in the context of a principal disease, in our case COPD, whereas multimorbidity refers to co-occurrence of two or more chronic medical conditions that may or may not directly interact with each other within the same individual (Figure 3).29 The complexity of managing several chronic diseases simultaneously in the same patient requires changes in health care delivery.30 In a recent study performed in Scotland, multimorbidity was present in 23% of the 1.75 million people included in a database from .300 medical practices. In this study, only 18% of patients had COPD as an isolated disease, whereas almost half had three or more concomitant disorders.31 Similarly, in a cohort study conducted in patients with moderate or severe COPD (mean forced expiratory volume in 1 second of 51%), 62% of patients had three or more comorbidities and only 2% had COPD exclusively. This is the reason why some authors consider COPD to be just one component – and not necessarily the most important one – of the multimorbidity complex in many patients.10,32 Several reports have highlighted the relationship between comorbidities and an impairment of HRQoL in COPD. Two studies performed with a generic questionnaire (short-form Disease limitations Quality of life Personal values expectations Figure 2 Health-related quality of life.

3 AGENDA INTRODUÇÃO IMPACTO CONSIDERAÇÕES PARA O DIAGNÓSTICO
ABORDAGEM HOLÍSTICA NO TRATAMENTO FARMACOLÓGICA PSICOLOGICA CONCLUSÕES

4 I IMPACTO

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7 DPOC Depressão e Ansiedade
A depressão em DPOC , prevalência de 25 % - quase duas vezes maior do que pessoas sem DPOC. Esta prevalência aumenta para 57% em pacientes com DPOC grave, Dos quais 18 % têm grande depressão e apenas 6 % recebem tratamento Transtornos de ansiedade generalizada pode ocorrer em 10% -33% de pacientes com DPOC , prevalência de transtornos e ataques de pânico varia de 8% -67 %

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12 DEPRESSÃO Todo mundo passa, durante a vida, por períodos de tristeza, angústia e desânimo que parecem que não terão fim. Nesses momentos a vida perde a cor, o sentido, a graça e tudo parece meio sem propósito. Como saber se isso é uma resposta natural aos problemas do dia-a-dia? Qual é o limite entre a oscilação natural do humor e a depressão? Antônio Egídio Nardi Laboratório de Pânico e Respiração do Instituto de Psiquiatria da Universidade Federal Rio de Janeiro. National Institute for Translational Medicine (INCT-TM).

13 Depressão Unipolar A depressão é um problema freqüente
A prevalência anual na população em geral varia de 3 a 11% A prevalência de depressão é duas a três vezes mais freqüente em mulheres 80% terão recorrência 4° Causa 1990 e em 2020 sera a 2° Em serviços de cuidados primários e outros serviços médicos gerais, 30 a 50% dos casos de depressão não são diagnosticados A depressão é um problema freqüente A depressão é mais freqüente em mulheres A depressão é um transtorno crônico e recorrente A depressão é um transtorno incapacitante A depressão é pouco diagnosticada pelo médico não-psiquiatra

14 A distimia é um transtorno depressivo crônico com menor intensidade de sintomas, presente por pelo menos dois anos com períodos ocasionais e curtos de bem-estar. Além do humor depressivo, devem estar presentes até três dos seguintes sintomas: redução de energia insônia, diminuição da auto-confiança, dificuldade de concentração, choro, diminuição do interesse sexual e em outras atividades prazerosas,sentimento de desesperança e desamparo, inabilidade de lidar com responsabilidades do dia-a-dia, pessimismo em relação ao futuro, retraimento social e diminuição do discurso

15 ANSIEDADE A ansiedade é definida como uma sensação vaga e difusa, desagradável, de apreensão expectante que se acompanha de diversas manifestações físicas e, até certo ponto, é um estado afetivo normal e útil. Os transtornos de ansiedade surgem quando esta excede o limite da normalidade, de modo que tal sensação se torna tão intensa e desagradável que impede o funcionamento adequado do indivíduo. Antônio Egídio Nardi Laboratório de Pânico e Respiração do Instituto de Psiquiatria da Universidade Federal Rio de Janeiro. National Institute for Translational Medicine (INCT-TM).

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17 IMPACTO Wedzicha et al. BMC Medicine 2013, 11:181

18 IMPACTO de Voogd JN, eta al. CHEST 2009; 135:619–625

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20 Chronic Respiratory Disease
7(3) 147–157 2010

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23 Clinical and Economic Burden of Depression/Anxiety in Chronic Obstructive Pulmonary Disease Patients within a Managed Care Population Background: Anxiety and depression are common co-morbidities that can complicate the course of chronic obstructive pulmonary disease (COPD). The purpose of this study was to evaluate their impact on healthcare utilization and costs in amanaged care COPD population. Methods: Administrative claims data were used to conduct a retrospective cohort study of COPD patients ≥40 years of age, including those with co-morbid COPD-Depression (including anxiety). COPD-Depression patients were matched to COPD patients without depression (COPD-Only cohort) using propensity scores. Conditional logistic regression models assessed the 1-year risk of COPD exacerbations (i.e., emergency room [ER] visit/inpatient hospitalization) between cohorts. Differences in annual all-cause and COPD-related utilization/costs, along with 2-year costs, were also compared between the cohorts. Results: There were 3,761 patients per cohort. Patients in the COPD-Depression cohort were 77% more likely to have a COPD-related hospitalization (odds ratio [OR]= 1.77, P<0.001), 48% more likely to have an ER visit (OR=1.48, P<0.001), and 60% more likely to have hospitalization/ER visit (OR=1.60, P<0.001) compared to the COPD-Only cohort. Average annual all-cause medical cost per patient was $23,759 for COPD-Depression vs $17,765 for COPD-Only (P<0.001) and total (medical plus pharmacy) cost was $28,961 vs $22,512 (P< 0.001), respectively; corresponding average annual COPD-related medical cost was $2,040 vs $1,392 (P<0.001) and total cost was $3,185 vs $2,680 (P<0.001). Similar trends were observed over the 2-year period. Conclusions: In the COPD population, patients with depression/anxiety have significantly higher risk of COPD exacerbations and annual all-cause and COPD-related costs than patients without these co-morbidities. These findings may have therapeutic implications and seem worthy of further exploration. COPD: Journal of Chronic Obstructive Pulmonary Disease, 8:293–299, 2011

24 Evaluation of anxiety and depression
Depression and anxiety were assessed at baseline using the Hospital Anxiety and Depression Scale (HADS) [20]. This is a validated screening tool for cases of depression and anxiety in both hospitalized and primary care patients with chronic diseases, including COPD [21]. The HADS consists of seven items for anxiety (HAD-A) and seven items for depression (HAD-D). The scores range from 0 to 21 for each subscale, with a score of 0–7 denoting a non-case, 8–10 a possible case, and 11 or higher a probable case, which may guide referral for psychological support [20

25 Methods: An observational study at Keio University and affiliated hospitals enrolled 336 COPD patients and 67 non-COPD subjects. Health status was assessed by the CAT, the St. Georges Respiratory Questionnaire (SGRQ), and all components of the Medical Outcomes Study Short-Form 36-Item (SF-36) version 2, which is a generic measure of health. Comorbidities were identified based on patients’ reports, physicians’ records, and questionnaires, including the Frequency Scale for the Symptoms of Gastro-esophageal reflux disease (GERD) and the Hospital Anxiety and Depression Scale. Dual X-ray absorptiometry measurements of bone mineral density were performed. Results: The CAT showed moderate-good correlations with the SGRQ and all components of the SF-36. The presence of GERD, depression, arrhythmia, and anxiety was significantly associated with a high CAT score in the COPD patients. Conclusions: Symptomatic COPD patients have a high prevalence of comorbidities. A high CAT score should alert the clinician to a higher likelihood of certain comorbidities such as GERD and depression, because these diseases may co-exist unrecognized. Trial registration: Clinical trial registered with UMIN (UMIN

26 DIAGNÓSTICO

27 Níveis de ansiedade – Inventário Beck de Ansiedade
(BAI). Esse inventário foi proposto por Beck para medir os sintomas comuns de ansiedade. O inventário consta de uma lista de 21 sintomas com quatro alternativas cada um , em ordem crescente do nível de ansiedade 0 a 9 – mínimo; 10 a 16 –leve; 17 a 29 – moderado; e 30 a 63 – grave

28 – Inventário de Beck para Depressão (BDI).
O inventário compreende 21 categorias de sintomas e atividades, com quatro alternativas cada um, em ordem crescente do nível de depressão. 0 a 11 – mínimo; 12 a 19 – leve; 20 a 35 –moderado; e 36 a 63 – grave.

29 DEPRESSÃO MAIOR

30 Psychometric properties of The Hospital Anxiety and Depression Scale and The General Health Questionnaire-20 in COPD inpatients Hospital Anxiety and Depression Scale (HADS) General Health Questionnaire–version 20 (GHQ-20)

31 DPOC Como Cuidar Comorbidity and multimorbidity
Adults with multiple chronic conditions are the main users of health care services and account for more than two thirds of health care spending. These patients had lower physical function – greater fragility and risk of disability – and a decrease in HRQoL even after adjustment for confounding variables such as age, sex, education, and perceived social support.22–24 The importance of comorbidities in COPD patients and their prognostic implications have been increasingly recognized in the last decade.10,25,26 Heart disease, hypertension, musculoskeletal disorders, and diabetes, among many other diseases, are common in COPD patients, and several epidemiological studies have shown that lung function impairment is associated with an increased risk of comorbid diseases.27,28 In fact, many patients with COPD have multiple concurrent comorbidities, and hence the term “multimorbidity” would be more accurate. Although multimorbidity is sometimes used interchangeably with comorbidity and pluripathology, multimorbidity implies a different concept. Comorbidity technically indicates a condition or conditions that coexist in the context of a principal disease, in our case COPD, whereas multimorbidity refers to co-occurrence of two or more chronic medical conditions that may or may not directly interact with each other within the same individual (Figure 3).29 The complexity of managing several chronic diseases simultaneously in the same patient requires changes in health care delivery.30 In a recent study performed in Scotland, multimorbidity was present in 23% of the 1.75 million people included in a database from .300 medical practices. In this study, only 18% of patients had COPD as an isolated disease, whereas almost half had three or more concomitant disorders.31 Similarly, in a cohort study conducted in patients with moderate or severe COPD (mean forced expiratory volume in 1 second of 51%), 62% of patients had three or more comorbidities and only 2% had COPD exclusively. This is the reason why some authors consider COPD to be just one component – and not necessarily the most important one – of the multimorbidity complex in many patients.10,32 Several reports have highlighted the relationship between comorbidities and an impairment of HRQoL in COPD. Two studies performed with a generic questionnaire (short-form Disease limitations Quality of life Personal values expectations Figure 2 Health-related quality of life.

32 Antidepressivos Os antidepressivos são efetivos no tratamento agudo das depressões moderadas e graves, porém não diferentes de placebo em depressões leves. Uma revisão sistemática de tratamento antidepressivo em transtorno depressivo associado com doença física mostrou taxas de resposta semelhantes

33 Antidepressivos Os diferentes antidepressivos têm eficácia semelhante para a maioria dos pacientes deprimidos Variando em relação ao perfil de efeitos colaterais Potencial interação com outros medicamentos

34 Antidepressivos Os antidepressivos ISRS têm mais chance do que os tricíclicos de serem prescritos em doses recomendadas por tempo recomendado Novos antidepressivos são mais caros que as drogas mais antigas, mas é controverso se o custo geral tratamento seria maior. Não há dados brasileiros sobre custos

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36 Tratamentos psicológicos específicos para episódio depressivo são efetivos com maiores evidências para depressões leves a moderadas Psicoterapia cognitivo-comportamental Psicoterapia comportamental psicoterapia interpessoal psicoterapia de resolução de problemas. Psicoterapia breve Psicodinâmica Terapia de casal e aconselhamento.

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38 Fases Tratamento Depressão

39 - ENCAMINHAMENTO/CONSULTORIA AO PSIQUIATRA PELO MÉDICO NÃO ESPECIALISTA
1) risco de suicídio; 2) sintomas psicóticos; 3) história de transtorno afetivo bipolar. O encaminhamento ou consultoria com psiquiatra é apropriado nas seguintes situações: 1) médico sente-se incapaz de lidar com o caso; 2) duas ou mais tentativas de tratamento antidepressivo mal sucedidas ou com resposta parcial.

40 Tratamento da DPOC GOLD 2011
Objetivos do tratamento Reduzir sintomas Reduzir risco futuro Redução dispnéia Melhora capacidade exercício Melhora da qualidade de vida Redução da queda da função pulmonar Redução das exacerbações Redução da mortalidade

41 ✗ Recomendações GOLD - 2011 Scoring range 0–40 Total score 1 2 4 3 5
22 Total score Scoring range 0–40 Recomendações GOLD

42 CONCLUSÕES VENCER BARREIRAS MÉDICAS PACIENTES ATITUDES INOVAÇÃO

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44 OBRIGADO

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