domingo, fevereiro 15
-
27 09
-
-
Allen Frances, atualmente professor de psiquiatria da Duke University, dirigiu a quarta edição do manual de psiquiatria DSM
Allen Frances (Nova York, 1942) dirigiu durante anos o Manual Diagnóstico e Estatístico (DSM), documento que define e descreve as diferentes doenças mentais. Esse manual, considerado a bíblia dos psiquiatras, é revisado periodicamente para ser adaptado aos avanços do conhecimento científico. Frances dirigiu a equipe que redigiu o DSM IV, ao qual se seguiu uma quinta revisão que ampliou enormemente o número de transtornos patológicos. Em seu livro Saving Normal (inédito no Brasil), ele faz uma autocrítica e questiona o fato de a principal referência acadêmica da psiquiatria contribuir para a crescente medicalização da vida.
Pergunta. No livro, o senhor faz um mea culpa, mas é ainda mais duro com o trabalho de seus colegas do DSM V. Por quê?
Resposta. Fomos muito conservadores e só introduzimos [no DSM IV] dois dos 94 novos transtornos mentais sugeridos. Ao acabar, nos felicitamos, convencidos de que tínhamos feito um bom trabalho. Mas o DSM IV acabou sendo um dique frágil demais para frear o impulso agressivo e diabolicamente ardiloso das empresas farmacêuticas no sentido de introduzir novas entidades patológicas. Não soubemos nos antecipar ao poder dos laboratórios de fazer médicos, pais e pacientes acreditarem que o transtorno psiquiátrico é algo muito comum e de fácil solução. O resultado foi uma inflação diagnóstica que causa muito dano, especialmente na psiquiatria infantil. Agora, a ampliação de síndromes e patologias no DSM V vai transformar a atual inflação diagnóstica em hiperinflação.
P. Seremos todos considerados doentes mentais?
R. Algo assim. Há seis anos, encontrei amigos e colegas que tinham participado da última revisão e os vi tão entusiasmados que não pude senão recorrer à ironia: vocês ampliaram tanto a lista de patologias, eu disse a eles, que eu mesmo me reconheço em muitos desses transtornos. Com frequência me esqueço das coisas, de modo que certamente tenho uma demência em estágio preliminar; de vez em quando como muito, então provavelmente tenho a síndrome do comedor compulsivo; e, como quando minha mulher morreu a tristeza durou mais de uma semana e ainda me dói, devo ter caído em uma depressão. É absurdo. Criamos um sistema de diagnóstico que transforma problemas cotidianos e normais da vida em transtornos mentais.
P. Com a colaboração da indústria farmacêutica...
Os laboratórios estão enganando o público, fazendo acreditar que os problemas se resolvem com comprimidos.
R. É óbvio. Graças àqueles que lhes permitiram fazer
publicidade de seus produtos, os laboratórios estão enganando o
público, fazendo acreditar que os problemas se resolvem com comprimidos.
Mas não é assim. Os fármacos são necessários e muito úteis em
transtornos mentais severos e persistentes, que provocam uma grande
incapacidade. Mas não ajudam nos problemas cotidianos, pelo contrário: o
excesso de medicação causa mais danos que benefícios. Não existe
tratamento mágico contra o mal-estar.P. O que propõe para frear essa tendência?
R. Controlar melhor a indústria e educar de novo os médicos e a sociedade, que aceita de forma muito acrítica as facilidades oferecidas para se medicar, o que está provocando além do mais a aparição de um perigosíssimo mercado clandestino de fármacos psiquiátricos. Em meu país, 30% dos estudantes universitários e 10% dos do ensino médio compram fármacos no mercado ilegal. Há um tipo de narcótico que cria muita dependência e pode dar lugar a casos de overdose e morte. Atualmente, já há mais mortes por abuso de medicamentos do que por consumo de drogas.
P. Em 2009, um estudo realizado na Holanda concluiu que 34% das crianças entre 5 e 15 anos eram tratadas por hiperatividade e déficit de atenção. É crível que uma em cada três crianças seja hiperativa?
R. Claro que não. A incidência real está em torno de 2% a 3% da população infantil e, entretanto, 11% das crianças nos EUA estão diagnosticadas como tal e, no caso dos adolescentes homens, 20%, sendo que metade é tratada com fármacos. Outro dado surpreendente: entre as crianças em tratamento, mais de 10.000 têm menos de três anos! Isso é algo selvagem, desumano. Os melhores especialistas, aqueles que honestamente ajudaram a definir a patologia, estão horrorizados. Perdeu-se o controle.
P. E há tanta síndrome de Asperger como indicam as estatísticas sobre tratamentos psiquiátricos?
R. Esse foi um dos dois novos transtornos que incorporamos no DSM IV, e em pouco tempo o diagnóstico de autismo se triplicou. O mesmo ocorreu com a hiperatividade. Calculamos que, com os novos critérios, os diagnósticos aumentariam em 15%, mas houve uma mudança brusca a partir de 1997, quando os laboratórios lançaram no mercado fármacos novos e muito caros, e além disso puderam fazer publicidade. O diagnóstico se multiplicou por 40.
P. A influência dos laboratórios é evidente, mas um psiquiatra dificilmente prescreverá psicoestimulantes a uma criança sem pais angustiados que corram para o seu consultório, porque a professora disse que a criança não progride adequadamente, e eles temem que ela perca oportunidades de competir na vida. Até que ponto esses fatores culturais influenciam?
Os melhores especialistas, aqueles que honestamente ajudaram a definir a patologia, estão horrorizados. Perdeu-se o controle.
R. Sobre isto tenho três coisas a dizer. Primeiro,
não há evidência em longo prazo de que a medicação contribua para
melhorar os resultados escolares. Em curto prazo, pode acalmar a
criança, inclusive ajudá-la a se concentrar melhor em suas tarefas. Mas
em longo prazo esses benefícios não foram demonstrados. Segundo: estamos
fazendo um experimento em grande escala com essas crianças, porque não
sabemos que efeitos adversos esses fármacos podem ter com o passar do
tempo. Assim como não nos ocorre receitar testosterona a uma criança
para que renda mais no futebol, tampouco faz sentido tentar melhorar o
rendimento escolar com fármacos. Terceiro: temos de aceitar que há
diferenças entre as crianças e que nem todas cabem em um molde de
normalidade que tornamos cada vez mais estreito. É muito importante que
os pais protejam seus filhos, mas do excesso de medicação.P. Na medicalização da vida, não influi também a cultura hedonista que busca o bem-estar a qualquer preço?
R. Os seres humanos são criaturas muito maleáveis. Sobrevivemos há milhões de anos graças a essa capacidade de confrontar a adversidade e nos sobrepor a ela. Agora mesmo, no Iraque ou na Síria, a vida pode ser um inferno. E entretanto as pessoas lutam para sobreviver. Se vivermos imersos em uma cultura que lança mão dos comprimidos diante de qualquer problema, vai se reduzir a nossa capacidade de confrontar o estresse e também a segurança em nós mesmos. Se esse comportamento se generalizar, a sociedade inteira se debilitará frente à adversidade. Além disso, quando tratamos um processo banal como se fosse uma enfermidade, diminuímos a dignidade de quem verdadeiramente a sofre.
P. E ser rotulado como alguém que sofre um transtorno mental não tem consequências também?
R. Muitas, e de fato a cada semana recebo emails de pais cujos filhos foram diagnosticados com um transtorno mental e estão desesperados por causa do preconceito que esse rótulo acarreta. É muito fácil fazer um diagnóstico errôneo, mas muito difícil reverter os danos que isso causa. Tanto no social como pelos efeitos adversos que o tratamento pode ter. Felizmente, está crescendo uma corrente crítica em relação a essas práticas. O próximo passo é conscientizar as pessoas de que remédio demais faz mal para a saúde.
P. Não vai ser fácil…
R. Certo, mas a mudança cultural é possível. Temos um exemplo magnífico: há 25 anos, nos EUA, 65% da população fumava. Agora, são menos de 20%. É um dos maiores avanços em saúde da história recente, e foi conseguido por uma mudança cultural. As fábricas de cigarro gastavam enormes somas de dinheiro para desinformar. O mesmo que ocorre agora com certos medicamentos psiquiátricos. Custou muito deslanchar as evidências científicas sobre o tabaco, mas, quando se conseguiu, a mudança foi muito rápida.
P. Nos últimos anos as autoridades sanitárias tomaram medidas para reduzir a pressão dos laboratórios sobre os médicos. Mas agora se deram conta de que podem influenciar o médico gerando demandas nos pacientes.
R. Há estudos que demonstram que, quando um paciente pede um medicamento, há 20 vezes mais possibilidades de ele ser prescrito do que se a decisão coubesse apenas ao médico. Na Austrália, alguns laboratórios exigiam pessoas de muito boa aparência para o cargo de visitador médico, porque haviam comprovado que gente bonita entrava com mais facilidade nos consultórios. A esse ponto chegamos. Agora temos de trabalhar para obter uma mudança de atitude nas pessoas.
P. Em que sentido?
R. Que em vez de ir ao médico em busca da pílula mágica para algo tenhamos uma atitude mais precavida. Que o normal seja que o paciente interrogue o médico cada vez que este receita algo. Perguntar por que prescreve, que benefícios traz, que efeitos adversos causará, se há outras alternativas. Se o paciente mostrar uma atitude resistente, é mais provável que os fármacos receitados a ele sejam justificados.
P. E também será preciso mudar hábitos.
R. Sim, e deixe-me lhe dizer um problema que observei. É preciso mudar os hábitos de sono! Vocês sofrem com uma grave falta de sono, e isso provoca ansiedade e irritabilidade. Jantar às 22h e ir dormir à meia-noite ou à 1h fazia sentido quando vocês faziam a sesta. O cérebro elimina toxinas à noite. Quem dorme pouco tem problemas, tanto físicos como psíquicos.
El País
LEIA TAMBÉM
sábado, fevereiro 14
Doctor admits taking kickbacks for prescribing risky drug
A
suspended doctor pleaded guilty Friday to a felony charge of taking
kickbacks and other benefits from a pharmaceutical company to prescribe
its risky antipsychotic drug for thousands of his patients.
Michael Reinstein, who for decades treated patients in Chicago nursing homes and mental health wards, admitted in a 22-page plea agreement with prosecutors that he was given nearly $600,000 in benefits over the years for prescribing various forms of the drug clozapine, known as a risky drug of last resort, to patients in his care.
Prosecutors revealed in court that Reinstein is cooperating in an ongoing investigation. Under preliminary sentencing calculations, he faces up to four years in prison, but if he continues to assist investigators, the government will recommend a reduced sentence of a year and a half behind bars, according to his plea agreement.
At the same time Reinstein was entering his guilty plea, he also settled a civil lawsuit brought by the U.S. attorney's office alleging he submitted more than 140,000 false Medicare and Medicaid claims as part of the kickback scheme. The settlement calls for Reinstein to pay more than $3.7 million in penalties to the U.S. government and the state of Illinois.
In addition, Reinstein must forfeit an additional $592,000 as part of his guilty plea to the criminal charge.
Reinstein, 71, of Skokie, appeared in court in a rumpled gray suit. He told the court he’s suffering from a number of ailments, including bladder cancer, hypertension, diabetes and an enlarged prostate.
Two decades ago, Reinstein was known as one of the most prolific Medicaid billers in Chicago history, once charging the taxpayer-funded program for the care of 490 patients in just five days.
In 2009, a joint Tribune-ProPublica investigation found that Reinstein had been overprescribing powerful antipsychotic drugs in Chicago nursing homes and mental health facilities, amassing a worrisome record of assembly-line care that was linked to three patients' deaths and triggered lawsuits as well as accusations of kickbacks and fraud.
Now, six months after state regulators indefinitely suspended Reinstein's medical license, federal authorities filed a criminal charge alleging Reinstein took kickbacks from a pharmaceutical company to prescribe clozapine — known as a risky drug of last resort — to patients in his care.
In a telephone interview earlier this month, Reinstein's attorney, Terence Campbell, said that Reinstein was "working toward resolving the issues raised by the government and hopes to put this episode behind him soon."
While the charge alleges only one kickback from pharmaceutical giant Teva totaling $2,000, federal prosecutors want to seize nearly $600,000 of allegedly ill-gotten gains stemming from clozapine prescriptions.
Reached by phone Thursday, Reinstein said he could not comment on the criminal charge. But he denied any payments from Teva were for prescribing clozapine, saying he earned the money from lectures he gave at medical conferences talking about the benefits of that and other anti-psychotic medications.
Reinstein also defended his history of prescribing clozapine, which is manufactured under the trade name Clozaril. He described it as a "very useful" state-of-the-art drug whose benefits can far outweigh the risks as long as patients are closely monitored.
"I think it's an under-prescribed treatment for severe mental illness," Reinstein said. "I and many other people have been involved in many research studies that show it keeps people from engaging in violent behavior … and is helpful in suicide prevention."
First licensed in Illinois in 1968, Reinstein built a lucrative practice in Chicago providing psychiatric care to mentally ill patients in nursing homes concentrated near his strip-mall office in the city's Uptown neighborhood.
Reinstein's history of improbably prolific Medicaid billing goes back to at least 1991, when he was suspended from the program for a year after officials accused him of failing to keep records to substantiate his work.
A 1993 Tribune series highlighting problems in the Medicaid system showed that in 1991 alone Reinstein had billed for 15,480 patient encounters, mostly in Chicago-area nursing homes. He claimed in bills submitted to the system that he had cared for more than 70 patients a day on 44 different days, the newspaper found. The number of patients visits topped more than 100 a day on 12 days, his bills claimed.
For years, Reinstein routinely prescribed antipsychotic and other psychiatric medications to indigent patients based on kickbacks from pharmaceutical companies, not his own independent evaluation of the patients' needs, according to the civil suit filed by prosecutors in 2012.
According to the suit, the company that originally made Clozaril paid Reinstein to promote it even as he became the largest prescriber of the drug to Medicaid recipients in the nation. In 2003, Reinstein agreed to begin prescribing a generic version made by IVAX Pharmaceuticals in exchange for a $50,000 annual "consulting agreement" that included paying his nurse to speak on behalf of the drug and funding for a Reinstein-affiliated entity known as Uptown Research Institute.
"He quickly became the largest prescriber of generic clozapine in the country," prosecutors alleged.
Between 2003 and 2006, IVAX continued to provide other perks, including flying Reinstein, his wife and seven other associates to IVAX's headquarters in Miami, where the entourage went on fishing trips, a boat cruise and golf outing.
After Israel-based Teva took over IVAX in January 2006, the company paid all expenses for Reinstein and his associates to again travel to Miami. That trip featured a $2,300 boat cruise and at least two dinners costing $1,700 each. Over the next two years, Teva paid Reinstein more than $100,000 in annual speaking fees.
Teva, also sued by federal and state officials over the alleged kickbacks to Reinstein, agreed to settle the litigation last March by paying $27.6 million. The company did not admit wrongdoing.
The Tribune-ProPublica investigation found that in 2007 Reinstein prescribed various medications to 4,141 Medicaid patients, including more prescriptions for clozapine that were written by all the doctors in Texas put together. Records from that year suggested that if each of his patient visits had lasted only 10 minutes, Reinstein would have had to work 21 hours a day, seven days a week.
Reporters
also uncovered autopsy and court records showing that three patients
under Reinstein's care died of clozapine intoxication between 1999 and
2007. One was Alvin Essary, who had more than five times the toxic level
of clozapine in his blood when he died in 1999, medical records showed.
His family sued Reinstein for negligence, claiming the doctor should
not have prescribed multiple medications to a patient with one kidney.
The lawsuit settled for $85,000.Michael Reinstein, who for decades treated patients in Chicago nursing homes and mental health wards, admitted in a 22-page plea agreement with prosecutors that he was given nearly $600,000 in benefits over the years for prescribing various forms of the drug clozapine, known as a risky drug of last resort, to patients in his care.
Prosecutors revealed in court that Reinstein is cooperating in an ongoing investigation. Under preliminary sentencing calculations, he faces up to four years in prison, but if he continues to assist investigators, the government will recommend a reduced sentence of a year and a half behind bars, according to his plea agreement.
At the same time Reinstein was entering his guilty plea, he also settled a civil lawsuit brought by the U.S. attorney's office alleging he submitted more than 140,000 false Medicare and Medicaid claims as part of the kickback scheme. The settlement calls for Reinstein to pay more than $3.7 million in penalties to the U.S. government and the state of Illinois.
In addition, Reinstein must forfeit an additional $592,000 as part of his guilty plea to the criminal charge.
Reinstein, 71, of Skokie, appeared in court in a rumpled gray suit. He told the court he’s suffering from a number of ailments, including bladder cancer, hypertension, diabetes and an enlarged prostate.
Two decades ago, Reinstein was known as one of the most prolific Medicaid billers in Chicago history, once charging the taxpayer-funded program for the care of 490 patients in just five days.
In 2009, a joint Tribune-ProPublica investigation found that Reinstein had been overprescribing powerful antipsychotic drugs in Chicago nursing homes and mental health facilities, amassing a worrisome record of assembly-line care that was linked to three patients' deaths and triggered lawsuits as well as accusations of kickbacks and fraud.
Now, six months after state regulators indefinitely suspended Reinstein's medical license, federal authorities filed a criminal charge alleging Reinstein took kickbacks from a pharmaceutical company to prescribe clozapine — known as a risky drug of last resort — to patients in his care.
In a telephone interview earlier this month, Reinstein's attorney, Terence Campbell, said that Reinstein was "working toward resolving the issues raised by the government and hopes to put this episode behind him soon."
While the charge alleges only one kickback from pharmaceutical giant Teva totaling $2,000, federal prosecutors want to seize nearly $600,000 of allegedly ill-gotten gains stemming from clozapine prescriptions.
Reached by phone Thursday, Reinstein said he could not comment on the criminal charge. But he denied any payments from Teva were for prescribing clozapine, saying he earned the money from lectures he gave at medical conferences talking about the benefits of that and other anti-psychotic medications.
Reinstein also defended his history of prescribing clozapine, which is manufactured under the trade name Clozaril. He described it as a "very useful" state-of-the-art drug whose benefits can far outweigh the risks as long as patients are closely monitored.
"I think it's an under-prescribed treatment for severe mental illness," Reinstein said. "I and many other people have been involved in many research studies that show it keeps people from engaging in violent behavior … and is helpful in suicide prevention."
First licensed in Illinois in 1968, Reinstein built a lucrative practice in Chicago providing psychiatric care to mentally ill patients in nursing homes concentrated near his strip-mall office in the city's Uptown neighborhood.
Reinstein's history of improbably prolific Medicaid billing goes back to at least 1991, when he was suspended from the program for a year after officials accused him of failing to keep records to substantiate his work.
A 1993 Tribune series highlighting problems in the Medicaid system showed that in 1991 alone Reinstein had billed for 15,480 patient encounters, mostly in Chicago-area nursing homes. He claimed in bills submitted to the system that he had cared for more than 70 patients a day on 44 different days, the newspaper found. The number of patients visits topped more than 100 a day on 12 days, his bills claimed.
For years, Reinstein routinely prescribed antipsychotic and other psychiatric medications to indigent patients based on kickbacks from pharmaceutical companies, not his own independent evaluation of the patients' needs, according to the civil suit filed by prosecutors in 2012.
According to the suit, the company that originally made Clozaril paid Reinstein to promote it even as he became the largest prescriber of the drug to Medicaid recipients in the nation. In 2003, Reinstein agreed to begin prescribing a generic version made by IVAX Pharmaceuticals in exchange for a $50,000 annual "consulting agreement" that included paying his nurse to speak on behalf of the drug and funding for a Reinstein-affiliated entity known as Uptown Research Institute.
"He quickly became the largest prescriber of generic clozapine in the country," prosecutors alleged.
Between 2003 and 2006, IVAX continued to provide other perks, including flying Reinstein, his wife and seven other associates to IVAX's headquarters in Miami, where the entourage went on fishing trips, a boat cruise and golf outing.
After Israel-based Teva took over IVAX in January 2006, the company paid all expenses for Reinstein and his associates to again travel to Miami. That trip featured a $2,300 boat cruise and at least two dinners costing $1,700 each. Over the next two years, Teva paid Reinstein more than $100,000 in annual speaking fees.
Teva, also sued by federal and state officials over the alleged kickbacks to Reinstein, agreed to settle the litigation last March by paying $27.6 million. The company did not admit wrongdoing.
The Tribune-ProPublica investigation found that in 2007 Reinstein prescribed various medications to 4,141 Medicaid patients, including more prescriptions for clozapine that were written by all the doctors in Texas put together. Records from that year suggested that if each of his patient visits had lasted only 10 minutes, Reinstein would have had to work 21 hours a day, seven days a week.
Clozapine is not a commonly prescribed drug. But while Reinstein was allegedly soliciting kickbacks, he had more than half of his patients on it, according to the government. At one nursing home, he had prescribed the medication to 300 of its 400 residents, the lawsuit alleged.
Originally developed in the 1960s, clozapine has potentially severe side effects, including seizures, a decrease in white blood cells and inflammation of the heart wall. It is typically prescribed only for patients that have not responded to other treatments. Several studies, however, have lauded the drug's ability to reduce the symptoms of schizophrenia, particularly in patients who have harmed themselves in the past or attempted suicide.
In his comments Thursday to the Tribune, Reinstein said there are risks with any kind of psychiatric care — including not medicating a patient enough — and that clozapine has been unfairly portrayed as dangerous. He said he was not aware of any patient of his who had died from the drug since 2007.
"I'm not trying to be cavalier about it — anyone on Clozaril or any other psychotropic medication needs to be monitored carefully," Reinstein said. "But the drug is not by itself dangerous."
Assinar:
Postagens (Atom)