Resumo

ROBLES GARCIA, Rebeca; MEDINA DAVALOS, Rafael; PAEZ AGRAZ, Francisco  e  BECERRA RODRIGUEZ, Benjamín. Evaluation of functioning, disability, and health status for psychosocial rehabilitation among institutionalized patients with severe mental disorders. Salud Ment [online]. 2010, vol.33, n.1, pp.67-75. ISSN 0185-3325.

Introduction The World Health Organization (WHO) made a major shift on the outcomes of illness, diseases, and interventions from clinical indicators to those related with levels of functioning and disability, as well as the possibility to determine areas of improvement on a case-by-case basis. Along with this theoretical approach, a new instrument was proposed to WHO members: the International Classification of Functioning, Disability and Health (ICF). The instrument is flexible, easy to apply in different clinical scenarios (it is not attached to a cluster of diseases), culturally adapted in several languages, and complementary to clinical and para-clinical information. In psychiatry, the use of the ICF may be highly valuable to establish the preserved areas of functioning as well as the most salient disabilities to formulate a proper case management, and then, to plan adequate public policies. This report includes the results of an evaluation of functioning, disability and heath dimensions, along with the psychometric properties of the ICF checklist, among people with severe and persistent mental disorders that have been institutionalized in a psychiatric hospital in the State of Jalisco, Mexico. Method Subjects: Inmates of a 50 year old psychiatric facility, dependent from the Mental Health Institute of Jalisco (SALME), within the frame of the Ministry of Health of the State of Jalisco in Mexico. This facility is divided in acute wards, were patients are hospitalized in acute phases of severe and persistent mental disorders, and <<permanent>> wards which have existed since the origins of the hospital and became a place where people were abandoned and finally stayed institutionalized under the State's support and supervision. The later population was included in this evaluation. Measures: A psychiatrist (AM), previously trained on the administration of the ICF, supervised the evaluation of: 1) the <<Activities and Participation>> domains of the Short list of ICF proposed by WHO (AP-ICF); 2) The American Psychiatric Association's Global Assessment of Functionality Scale (GAF); and 3) The Life Skills Profile(LKP). Results A total sample of 205 subjects was included; they were 64.9% males, with a mean age of 40.28±14.39 years old. The mean hospitalization time was 18.04±10.29 years. Psychiatric diagnosis distribution was: severe mental retardation (MR) (29.8%); moderate MR (15.6%), residual or undifferentiated schizophrenia (8.3%), and paranoid schizophrenia (7.8%). A concurrent physical illness was identified in 48.8% (n=112) of the subjects. Salient health problems were: epilepsy (n=47, 22.9%), chronic obstructive pulmonary disease (n=6, 2.9%), diabetes (n=5, 2.4%), and systemic arterial hypertension (n= 4, 2%). AP-ICF validity and reliability: Correlations between AP-ICF domains and GAF were all moderate (between -.51 to -.71), negative and statistically significant. Cronbach's alphas were as follows: a) Learning and applying knowledge: .85 for the first qualifier, and .89 for the second; b) General tasks and demands: .90 and .92; c) Communication: .93 for both qualifiers; d) Movement: .78 for the first qualifier, and .89 for second qualifier; e) Self Care: .94 and .96; f) Domestic Life Areas: .91 and .95; g) Interpersonal Interactions: .79 and .91; h) Major Life Areas: .59 and .70; i) Community, Social and Civic Life: .75 and .72. Functionality and disability among institutionalized patients: In the Global Assessment of Functioning measure, subjects distribution belonging to punctuations ranges were: 31-40 points(n=54, 26.3%); 11-20 points (22.9%,n=47); 21-30 points (21%,n=43); 41-50 points (14.6%,n=30); 51-60 points (11.2%, n=23); 61-70 points (2.9%, n=6), and 1% felled in the <<more than 71 points>> range. On the Life Skills Profile (LSP), means and standard deviations were as follows: a) Self Care: row score= 19.85 ± 3.42, percentage transformation= 49.64% ± 8.56; b) Social Communication: row score= 16.70±3.42, percentage transformation= 41.76% ± 9.39; c) Communication with contact: row score= 14.00 ± 2.60, percentage transformation= 58.35% ± 10.85; d) Communication without contact: row score= 9.39 ± 2.47, percentage transformation= 39.12% ± 10.30; e) Autonomy Life: row score= 11.87 ±1.89, percentage transformation= 42.40% ± 6.76. Major <<activities and participation>> (ICF) dysfunction domains were as follows: Community, social and civic life, Domestic life areas, Interpersonal interactions, and Major life areas. For the first qualifier, mean row scores and percentage transformations for all activities and participation domains were: a) Learning & applying knowledge: 14.66 ± 5.40, 61.09% ± 22.5; b) General Tasks and demands: 4.78 ± 2.6, 59.75% ± 33.22; c) Communication: 8.88 ± 6.4, 44.43% ± 32.35; d) Movement: 2.63 ± 3.8, 10.99% ± 15.89; e) Self Care: 9.21 ± 8.5, 28.79% ± 26.73; f) Interpersonal Life Interactions: 20.06 ± 5.7, 71.67% ± 20.41; g) Major Life Areas: 15.15 ± 6.5, 63.15% ± 27.08; h) Community, Social & Civic Life: 17.42 ± 2.7, 87.10% ± 13.86. For the second qualifier, mean row scores and percentage transformations for all activities and participation domains were: a) Learning & applying knowledge:12.34 ± 5.8, 51.44% ± 24.33; b) General Tasks and demands: 3.91 ± 2.63, 48.90% ± 32.96; c) Communication: 7.36 ± 6.21, 36.82% ± 31.07; d) Movement: 2.24 ± 3.58, 9.34% ± 14.93; e) Self Care: 5.80 ± 7.15, 18.12% ± 22.37; f) Interpersonal Life Interactions: 16.88 ± 7.49, 52.77% ± 23.40; g) Major Life Areas: 13.5 ± 7.18, 56.25% ± 29.92; h) Community, Social & Civic Life: 14.29 ± 5.11, 71.48% ± 25.58. Conclusions In this study we identified three mayor groups of institutionalized patients, with different needs of attention. First, a group of people with severe disability, that do not require a permanent psychiatric hospitalization supervision and could benefit from treatment and increase quality of life in other kind community care facilities. A major second group (around 70% of patients) that are theoretically candidates for community rehabilitation and social reinsertion, in whom there is no scientific argument to justify their institutionalization in a psychiatric hospital. Reasons for this reality are to be explored in further social and service history implementation. A third subgroup of patients had been hospitalized many years, and for them, given the need of constant supervision is necessary and an alternative permanent assistance may be granted, but the psychiatric hospital is not the facility designated for them. Functioning and disability evaluation of persons with severe and persistent mental disorders that are institutionalized in the Mental Health Institute of Jalisco, Mexico, was useful to motivate and develop local communitarian psychiatric rehabilitation facilities and programs. Finally, we suggest that <<Activity and participation>> domains of ICF checklist are a valid and reliable tool to evaluate Mexican psychiatric patients.

Palavras-chave : Functioning; disability; health; severe mental disorders; health services.

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