The International Journal of Psychosocial Rehabilitation

Expert Committee on Psychopharmacology:
An Ongoing Experience in Brazil

Gabriel Neves Camargo
President of the Committee of Experts in Psychopharmacology
Sessão de Saúde Mental e Neurológica – SSMA/RS
Rua Annes Dias, 112/700
Porto Alegre /RS,  Brasil
 
gabrielcamargo@uol.com.br

    Alice Hirdes
URI, Erechim – RS

Viktor Ivanovitch Goudochnikov
UNIJUÍ, Ijuí – RS


  Citation:
Camargo, G.N., Hirdes, A., Goudochnikov, V. I. (2004).  Expert committee on psychopharmacology:
An ongoing experience in Brazil.   International Journal of Psychosocial Rehabilitation. 9, 5-9.

Members of the Expert Committee on Psychopharmacology:Paulo S.B. Abreu, psychiatrist; Marta O. Alves, pediatrician; Jorge Cury, psychiatrist; Vânia K. Bifignandi, pharmacist; Gabriel N. Camargo, psychiatrist, president of the Committee of Experts in Psychopharmacology; Maria G. Cantarelli, psychiatrist; Bruno M. Costa, psychiatrist; Miriam Dias, MSc in social service; Adriana D. Dal’Pisol, psychiatrist; Silvia Edith, psychologist; Alessandra S. Eisenrich, administrative assistant of the Program for Integral Attention to Mental Health, State Secretariate of Health; Flávia Fraga, pharmacist; Marcelo P.A. Fleck, psychiatrist; Clarissa S. Gama, psychiatrist; Viktor I. Goudochnikov, Doctor in biochemistry; Alice Hirdes, MSc in nursing; Rogério Horta, psychiatrist; Mário F. Juruena, psychiatrist; Flávio Kapzinski, psychiatrist; Maria I. Lobato, psychiatrist; Liliane D. Lima, psychiatrist; Carlos A. Nascimento, psychiatrist; Jarbas F. Ozório, physician, coordinator of the Policy of Pharmaceutical Assistance, State Secretariate of Health, Rio Grande do Sul; Sérgio Rodrigues, psychiatrist; Tatiane B. Severo, trainee in psychology; Flávio Shansis, psychiatrist; Vera Vieira, psychiatrist, MSc in social psychology; Lino M. Zanatta, psychiatrist; Luciane Kopittke, pharmacologist; Fernando Amarante, psychiatrist; Rodrigo Machado Vieira, psychiatrist, MSc in biochemistry; Sônia Elizabethe Kunzler, psychiatrist; Ricardo Tavares Pinheiro, Doctor in medical psychology; Gisele Manfro, Doctor in biochemistry.


Abstract
The public administration has considered rather difficult to establish technical criteria in order to supply the increasing demand on the latest drugs, as well as new technologies associated with them. Besides, the high cost of these drugs is hard to fit on the limited budgets of developing countries. Quite frequently, economical and political issues do not correspond to scientific recommendations. In order to solve these problems, the Government of Rio Grande do Sul created an Expert Committee composed by members from the main scientific organizations of the State. The task of this Committee is to establish the dialogue between the local Health authorities and members of the community, to create protocols for the rational use of these high cost drugs and to give advice on issues of high technical complexity. In 2001, the Expert Committee elaborated one protocol to treat refractory schizophrenia and another one to treat affective disorders. Four other technical questions were answered since the beginning of work, showing that the experience of the Committee has been successful.

Introduction
To define public policies, which require specific technical knowledge in a field characterized by rapid evolution and changes, has always been a problem for governments. At present, there is a worldwide sociologic and political trend that imposes a mutual relationship between state administration and pressure groups that appeared in general population. On the other hand, the democratization of highly technical decisions can take those responsible for public policies to choose the options that are against to the scientific knowledge and frequently impossible to maintain on short-term or long-term basis.
This paper intends to show how the current Government of Rio Grande do Sul is trying to resolve this problem in the field of mental health, in order to promote rational use of highly cost psychotropic drugs in public health system of the State.
The solution proposed by the Mental Health Coordinating Group of the State Health Secretary was to call for the assistance of an Expert Committee on Psychopharmacology, to establish a permanent dialogue among governmental organs, scientific community and society.

Aims of the Committee
During the last years, several efficient drugs for the treatment of some mental disorders have been created. These drugs allow severe chronic patients, who required permanent nursing care, to have a quality of life pretty close to normal patterns.

Nevertheless, these drugs sometimes have a very high cost that can make impossible fitting them to the budget of any Brazilian state, if such drugs were used by all patients suffering from mental diseases. But not giving these drugs to the patients with severe disturbances and with the decrease of their quality of life would be, obviously, the violation of these people’s rights regarding their health and a better quality of life.

For the State, the problem turns out to be the definition of possible limits for drug supplying and the formulation of concise criteria regarding the rational use of these drugs by the population of patients that suffer from mental diseases, as well as to try to diminish waste with inadequate prescription of drugs or indications of drugs with inadequate cost / benefit ratio to people involved in the process. Among the high cost drugs, one may focus attention on atypical anti-psychotics drugs, prescribed for the treatment of schizophrenia and for mood stabilization, in some complicated cases of affective disorders.

Schizophrenia alone with worldwide prevalence between 0.8 and 1.0% could result in 80,000 patients only in the State of Rio Grande do Sul. Moreover, serious affective diseases and with chronic course could affect more than 100,000 persons in the same State. Constant use of high cost drugs, most of them with prices exceeding 2.5 minimal regional salary per month, by the total population of these patients could make impossible the supply of this medication, if considering the State capacity to gain financial resources.

The decision of Health Sector management is to limit the use of these drugs only for treating more serious cases, particularly the so-called “patients refractory to common medication”. Only rational use of these resources can allow that a fraction of this population previously considered “untreatable” may beneficiate from the resources of modern pharmacology. However, even this decision requires a complex technical detailing, especially as referred to the limits of such approach. The task of the Expert Committee could be, therefore, to help in guiding government policies for detailing such decisions, with scientific counseling.
Through the institutionalization of a rational use policy of psychopharmacologic drugs, there might be undoubted benefits for the society as a whole. The target patients of these proposals generally require special nursing care that removes, at least, one of their relatives from productive processes. Obviously, the same mental patients are not capable to participate, even marginally, in any form of the productive process. Hence, the improvement of their conditions has economical implications. Also, re-establishing the dignity of human beings has one of the most significant values, although it cannot be measured in financial terms.

Methods of Work and Purposes of the Expert Committee
The idea to call for members of scientific community to perform the functions of counseling for public power in the field of their specific knowledge should correspond to a representation pattern of invited persons, preserving their neutrality in relation to the government and offering the amplitude and freedom of action. The invitation is based on a presupposition that those who have the knowledge would like to exert some kind of power and influence on the governmental decisions in the field of their specific knowledge. Therefore, the work is voluntary and consequently not paid. It was necessary to arrange that Expert Committee would not have a lot of bureaucracy and would not occupy the invited persons for excessively long periods of time. This is the reason why meetings of Expert Committee proceed in monthly periodicity.

After defining these principles for actions, some approaches were established to warrant representation pattern and adequate qualification of the invited persons. Considering the last criterion, it was decided that legitimate members of Expert Committee would be university professors possessing the degree of Doctor (PhD) or Master of Science (MSc) in psychopharmacology or related areas, independently of university localization, political orientation or current activities, provided their wish to participate. Considering the principle of representation pattern, each university of the State was requested to delegate one representative to the Expert Committee, always giving preference to persons that were, in some way, involved in functions related to activities in the field of psychopharmacologic knowledge. The universities that do not have strong affinity to this area could delegate representatives with knowledge in psychiatric nursing or sanitary legislation. Besides, the State scientific institutions related to psychiatry and pharmacology, The School of Public Health, LAFERGS (Pharmaceutical Laboratory of Rio Grande do Sul State), the ambulatory units of São Pedro Hospital, Presidente Vargas Hospital and Clinics Hospital of Porto Alegre, as well as the Public Ministry of Rio Grande do Sul were requested to delegate their representatives.

The Expert Committee has a political coordination and an executive secretary. The presence of members is spontaneous, and the decisions made in the meetings should be communicated to all the participants via Internet. Although government decisions can be discordant with those the Experts’, the functions of the last are broad, and in practice, the opinions of Committee have profound reflections in the policies acquired.
The Government considered the following tasks for the Expert Committee:

a)       to emit reports
b)       elaborate protocols for the use of psychiatric medications in public health system;
c)       to suggest some governmental measures in this ambit;
d)       to recommend policies;
e)       to disapprove some practices considered to be inefficient;
f)        to prepare official documents;
g)       to send alerting messages to official drug managers;
h)       to help in preparation of specific legislation acts;
i)         to publish alerting communications for physicians about the risks of inappropriate substance use or drug interactions;
j)         to propose teaching programs and continuing medical education for official institutions.

The work of Expert Committee is coordinated by a politician coordinator that mediates interactive dialogues with the State Secretary of Health and sometimes, with other official organs, offering suggestions of the Committee and bringing governmental counseling requirements. In case of specific demand (for example, request for protocols of the use of certain drugs), the Committee can delegate some part of activities to a working group composed of some of its members interested in the question more directly.

Constitution and Beginning of the Expert Committee Work
In order to perform the tasks described above, at first the group was invited in experimental mode, trying to continue a previous experience of another working group composed by collaborators from Clinics Hospital of Porto Alegre and State Secretary of Health that had already elaborated technical protocols of the use of high cost medication for the treatment of patients with schizophrenia, refractory to therapy by common anti-psychotics. It can be said that the success of this experience served as the basis for implantation of the Expert Committee. The first task developed by the Experts was to improve this protocol. Shortly after that, a working group of the Expert Committee, together with a representative of Brazil Health Ministry, elaborated a proposal for public counseling performed by Health Ministry, concerning protocols for the use of atypical anti-psychotics in the cases of refractory schizophrenia. This proposal served as the basis for the official document announced by Health Ministry later on.

Considering the success of previous experience, the Expert Committee was officially recognized by the Government of the State of Rio Grande do Sul by means of Governmental Decree 508 / 2001 of May, 14, 2001. Dr. Gabriel Neves Camargo was elected as the political coordinator of the Committee, and an executive secretary was also employed.

Activities and Functioning of Expert Committee in 2001The following demands of the technical counseling were presented by the State Government for theExpert Committee in 2001:

1)       elaboration of protocols for the use of high cost medication or the drugs not included in standardized list of RENAME (National List of Essential Medicines), for the treatment of affective disorders;

2)        improvement of the protocol for use of high cost medications in refractory psychoses;

3)       counseling on the use of methylphenidate in public health system;

4)       demand to review and publish alerting communicating on drug interactions;

5)       counseling on medications used in dementia and anxiety disorders.

Opinions on the Work of the Expert Committee
Although it is not possible to evaluate quantitatively the effects of optimization following the use of protocols on supplying high cost medication (considering also that such supplying is still in the phase of implantation), the pattern of demands for medication by physicians taking care of the patients began to change as the protocols became known by the interested practitioners. Particularly, the demands are closer to the patterns recommended by the algorithms of protocols. Thus, the State officials observed lower number of rejections in the processing of demands.

The precision in rational use of these drugs is really crucial, since only in 2001 the State of Rio Grande do Sul spent R$ 900,000.00 (in Brazilian currency units, the amount equivalent is approximately to 300,000.00 USD) for the supplying of drugs to 2,000 patients. Since there is a tendency of increasing in the following years, it is important not to spend these precious resources with inadequate prescriptions or providing benefits similar to medications supplied by RENAME, as their cost for the State is 45 times lower, on average.

The opinions in the area of administration sciences are also evident. In fact, a form of management for technical questions was created, according to the pattern established by Sanitary Reform in 1988 in Brazil, concerning the necessity of a dialogue between scientific community (including State officials and university researchers) and the society, both directly and by means of elected Government representatives.

Conclusion
The experience initiated with the creation of the Expert Committee on Psychopharmacology in the State of Rio Grande do Sul has revealed an extraordinary form of optimization of the use of financial resources in this field of knowledge and besides, it has established a fruitful dialogue between the scientific community and the Government. The elaboration of protocols for the use of psychoactive drugs in the basic units of care by general practitioners has resulted in the improvement of rational use of psychotropic medicines and consequently, in the diminish of demands for special medication. Nevertheless, more time is necessary for the development of new actions and methods aiming the evaluation of results obtained in a quantitative and a more precise way.


References

Gonçalves, E.L. et al. Administração de Saúde no Brasil. São Paulo: Pioneira, 1982.

Knox, E.G. La Epidemiologia en la Planificación de la Atencíon a la Salud.. Buenos Aires: Siglo Veintiuno, 1982.

Rivera, F.J.U. et al. Planejamento e Programação em Saúde, um Enfoque Estratégico. São Paulo: Cortez, 1989.

Souêtre, E. Economic Assessment of Neuroleptic Strategies in Schizophrenia. International Academy for Biomedical and Drug Research. Basel: Karger, 1995, vol.10.

Talbot, Hales, Yudofsky et al. Tratado de Psiquiatria. Artes Médicas: Porto Alegre, 2000.

The authors wish to acknowledge the assistance of Lucila Campesatto for the translation into English from its original Brazilian.



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