Seguimiento clínico del paciente adulto con diagnóstico de esquizofrenia
Pregunta 9.1.1. ¿Cada cuánto se debe hacer control clínico del paciente adulto con diagnóstico de esquizofrenia que se encuentra en tratamiento?
Pregunta 9.1.2. ¿Cuándo se debe remitir al paciente adulto con diagnóstico de esquizofrenia en tratamiento a un nivel superior de complejidad o nivel de atención a un especialista?
Pregunta 9.1.3. ¿Cuándo se debe hospitalizar a un paciente adulto con diagnóstico de esquizofrenia? (Ver también: Tratamientos psicoterapéuticos y psicosociales en fase aguda y de mantenimiento para los adultos con diagnóstico de esquizofrenia)
9.2. Resumen de la evidencia
Para la formulación de recomendaciones con respecto a esta pregunta, se tomó como base el esquema de seguimiento planteado por la Guía de práctica clínica para la detección temprana y diagnóstico del episodio y trastorno depresivo recurrente en adultos (121,122).
A partir de este modelo, el grupo de expertos realizó los ajustes necesarios para el paciente adulto con esquizofrenia teniendo en consideración la práctica profesional de cada uno de ellos y adicionalmente se analizó la secuencia de exámenes paraclínicos propuestos en las recomendaciones de la pregunta 1 de esta guía, para así lograr un seguimiento acorde con los tiempos propuestos.
Posteriormente se presenta esta propuesta en la reunión de discusión de recomendaciones al grupo desarrollador ampliado.
Se discutieron los puntos críticos de las recomendaciones con énfasis en el control por el médico psiquiatra, los tiempos de los paraclínicos y la necesidad de diversos controles dependiendo del tipo de tratamiento psicoterapéutico que se encuentre recibiendo el paciente.
En esta etapa se hizo énfasis en las posibilidades que tiene el profesional de la salud de disponer de un número mayor o menor de controles con el paciente según el tipo de psicoterapia que esté recibiendo, su adherencia y la adecuada respuesta, ya que no todos los tratamiento pueden tener controles programados con mucho tiempo de antelación.
Para los controles con el médico psiquiatra se enfatizó que debe haber una periodicidad de los controles, que no deben ser muy seguidos, ya que algunos de los pacientes viven fuera de las ciudades en donde se encuentran los médicos psiquiatras, lo cual representa gastos adicionales para aquellos.
Durante la reunión de formulación de recomendaciones se escucharon diferentes propuestas sobre los criterios de hospitalización que utiliza cada uno de los especialistas presentes; de esta discusión se consolidaron los lineamientos para conocer cuándo se debe hospitalizar al paciente adulto con esquizofrenia.
Adicional al protocolo inicial de la Guía de práctica clínica para la detección temprana y diagnóstico del episodio y trastorno depresivo recurrente en adultos (121,122), se presentan en las recomendaciones.
9.3. Recomendaciones
Punto de buena práctica 9.1. Tanto en la evaluación inicial como en las de seguimiento clínico del adulto con esquizofrenia, el médico debe evaluar los siguientes aspectos clínicos adicionales:
• Hábitos tóxicos
• Factores y comportamientos sexuales de riesgo
• Índice de masa corporal (peso y talla)
• Presión arterial y frecuencia cardíaca
• Revisión del tratamiento (efectos adversos, problemas adicionales)
Punto de buena práctica clínica
Punto de buena práctica 9.2. Si el paciente adulto con diagnóstico de esquizofrenia se encuentra hospitalizado, se debe realizar un control diario por psiquiatría.
Punto de buena práctica clínica
Recomendación 9.1. Para el control por psiquiatría del adulto con diagnóstico de esquizofrenia: si se encuentra en fase aguda y es atendido de forma ambulatoria, se recomienda hacer un control semanal por seis semanas y luego cada quince días hasta completar dos meses. Posterior a esto el seguimiento puede ser cada mes hasta completar seis meses (24 semanas).
Recomendación fuerte
Recomendación 9.2. Se recomienda que luego de seis meses de la fase aguda los pacientes adultos con diagnóstico de esquizofrenia que están estables sean vistos por un psiquiatra por lo menos cada tres meses.
Recomendación fuerte
Recomendación 9.3. Para las diversas intervenciones psicoterapéuticas y psicosociales se determinará la frecuencia de seguimiento del adulto con diagnóstico de esquizofrenia de acuerdo con el criterio clínico.
Punto de buena práctica clínica
Recomendación 9.4. Las indicaciones de remisión a especialista en psiquiatría cuando el adulto con diagnóstico de esquizofrenia está en fase mantenimiento y es manejado por un médico general son las siguientes: identificación de riesgo suicida, un intento de suicidio reciente, consumo activo de sustancias o reactivación de los síntomas psicóticos.
Punto de buena práctica clínica
Recomendación 9.5. Las indicaciones de hospitalización del adulto con diagnóstico de esquizofrenia son:
• Intento de suicidio de cualquier tipo
• Ideación suicida estructurada que constituya un plan
• Conductas que generen riesgo para otros
• Compromiso del estado general (inanición, deshidratación, desnutrición)
• Conductas de riesgo o de daño autoinfligido en presencia de ideación suicida
• Consumo concomitante de sustancias que estén poniendo en riesgo la vida del paciente
• Reactivación de síntomas psicóticos si además cumple con alguno de los anteriores
• Presencia de condiciones (estresores psicosociales) que a juicio del médico psiquiatra dificulten el manejo ambulatorio (por ejemplo: paciente sin red de apoyo, o víctima de violencia intrafamiliar, abuso, negligencia u otros)
Punto de buena práctica clínica
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