International Journal of Psychosocial Rehabilitation
Experience in Brazil
the Committee of Experts in Psychopharmacology
Sessão de Saúde Mental e
Neurológica – SSMA/RS
Rua Annes Dias, 112/700
Porto Alegre /RS,
URI, Erechim –
UNIJUÍ, Ijuí –
Camargo, G.N., Hirdes, A.,
Goudochnikov, V. I. (2004). Expert committee on
An ongoing experience in
Brazil. International Journal of Psychosocial Rehabilitation.
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.
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.
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
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
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
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
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
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
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
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
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
considered the following tasks for the Expert Committee:
elaborate protocols for the use
of psychiatric medications in public health system;
to suggest some governmental
measures in this ambit;
to disapprove some practices
considered to be inefficient;
to prepare official
to send alerting messages to
official drug managers;
to help in preparation of
specific legislation acts;
to publish alerting
communications for physicians about the risks of inappropriate substance use or
to propose teaching programs and
continuing medical education for official institutions.
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.
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.
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
Functioning of Expert Committee in 2001The
following demands of the technical counseling were presented by the State
Government for theExpert Committee in 2001:
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
improvement of the protocol for use of
high cost medications in refractory psychoses;
counseling on the use of
methylphenidate in public health system;
demand to review and publish
alerting communicating on drug interactions;
counseling on medications used in
dementia and anxiety disorders.
Opinions on the
Work of the Expert Committee
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
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.
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.
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authors wish to acknowledge the assistance of Lucila Campesatto for the
translation into English from its original Brazilian.