Profile of use of benzodiazepines and mental distress in patients cared in a public health unit

INTRODUCTION Globally, a total of 10% of the population suffers from some sort of mental health disorder. Taking into account that the world’s population has surpassed 7.5 billion, mental health care has become a great challenge. The exhausting fast pace of life associated with daily pressures have paved the way to the use of psychotropic medications because they rapidly and efficiently relieve mental distress.1 The WHO and the International Narcotics Control Board (INCB) have warned developing countries about the risks attached to the indiscriminate use of psychotropic drugs and its insufficient control in these countries. In Brazil, this alert was reinforced by studies that reveal the grave reality ABSTRACT Background: Benzodiazepines are a class of drugs especially used in the treatment of insomnia and anxiety. The shortterm use is considered safe, but the long-term treatment is associated with drug dependence and loss of efficacy due to the development of tolerance. Given the lack of mental health management services in primary healthcare, benzodiazepines have been prescribed to be used for undetermined periods of time, resulting in distress for patients and representing an important issue in the public health context. Methods: This is a transversal study with a descriptive quantitative approach, which aimed to characterize the profile of patients served by the Basic Health Unit Pharmacy Taboão in São Bernardo do Campo, São Paulo, Brazil, and correlate the different studied variables with the mental distress of these patients. A questionnaire including demographic, socioeconomic and physical and mental health variables was applied to the pharmacy customers. Results: It was revealed that among female patients (p=0.042, β=0.61, 95% CI: 0.38-0.98), suicidal ideation (p0.001, β=1.53, 95% CI: 1.22-1.92), perceptions regarding their own health condition (p0.001, β=0.48, 95% CI: 0.34-0.67), occurrences of polypharmacy (p=0.137, β=1.19, 95% CI: 0.94-1.50), knowledge on the risks associated with the use of benzodiazepines (p=0.176, β=0.85, 95%CI: 0.067-1.07) and engagement in physical activities (p=0.685, β=0.93, 95% CI: 0.68-1.27) are significantly associated with mental distress. Conclusions: Therefore, after these findings were obtained, errors that contribute to the occurrence of this scenario were identified and possible strategies to deal with the issue were suggested. Keywords: Benzodiazepines, Misuse, Public healthcare, Mental distress, Brazil 1Departamento de Ciências Farmacêuticas, Universidade Federal de São Paulo/UNIFESP, Diadema, Brasil 2Laboratório de Análises Clínicas, Faculdade de Medicina do ABC, Santo André, Brasil 3Departamento de Saúde Coletiva, Faculdade de Medicina do ABC, Santo André, Brasil Received: 28 December 2020 Revised: 10 February 2021 Accepted: 11 February 2021 *Correspondence: Fernando Luiz Affonso Fonseca, E-mail: Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. DOI: Kawano LDO et al. Int J Community Med Public Health. 2021 May;8(5): International Journal of Community Medicine and Public Health | May 2021 | Vol 8 | Issue 5 Page 2091 related to the use of benzodiazepines (BZDs).1-3 According to Razzouk et al, BZDs topped the list of the five most used psychotropics in Brazil.4 In the year 2010 over 10 million boxes of clonazepam were sold in the country, and a total of R$ 92.4 million (approximately US$ 23.1 million) were spent on it. In 2013, clonazepam was the ninth most sold medication in Brazil. BZDs have been available since 1960. They are highly effective psychoactive drugs with anxiolytic, hypnotic, muscle-relaxant, and anticonvulsant properties, which are commonly used to treat the symptoms of anxiety and insomnia.5,6 These medications enhance the effects of gamma-aminobutyric acid (GABA), the main inhibitory neurotransmitter in the central nervous system via a modulatory site on the GABAA receptor complex. GABAA receptors are a family of ligand-gated chloride channel inhibitory receptors and one of the main transmembrane neurotransmitter receptors in the brain.7 The main possible adverse effects (AE) caused by the use of BZDs include acute effects on psychomotor performance, both in acute and chronic administrations, thus impairing the capacity to carry out even the simplest tasks.8 According to some studies published in 2015, there is also positive association between the use of BZDs and the risk for dementia (OR=1.24-2.30). Such effects increase as the treatment is prolonged and with the use of long half-life BZDs.9 Regarding the cognitive function, memory deficit is a common manifestation. The long-term use of BZDs is associated with the risk of drug dependence and loss of efficacy due to the development of tolerance.10,11 Some BZDs, among them clonazepam and diazepam, are not recommended to older patients, regardless of the diagnosis or the patient's clinical condition, due to the high risk of adverse effects and the existence of other safer marketed drugs for treatment in Brazil.3 Diazepam and clonazepam, long-acting medications most often prescribed, are benzodiazepines listed in the Municipal essential medicines lists (REMUME) in the municipality where this study was performed, São Bernardo do Campo. They can be found at basic health units (UBS), which are a reference in mental health, and prescriptions can be dispensed at pharmacies in the presence of a pharmacist according to ANVISA.12 The information system used in the municipality for the management and control of the dispensation of these drugs is the hygia web. Since, the correct diagnosis of mental disorders is not efficiently established by non-specialists and the desired effects of BZDs, such as anxiety relief and sedation, are easily attainable, the proper medical indication for the use of these drugs is seriously compromised. The aim of this study was to analyze the profile of use of BZDs among patients served by the Basic Health Unit Pharmacy Taboão in São Bernardo do Campo, São Paulo, Brazil. This study also aimed to correlate the different variables with these patients' mental distress. METHODS This is a descriptive transversal study carried out in the municipality of São Bernardo do Campo, São Paulo, Brazil, more specifically in a basic health Unit (UBS) in Taboão. It is mandatory that this population be registered in the hygia web system, and during the period this study was conducted, there were a few more than 42 thousand active registrations. This study was conducted during the period from July of 2017 to September of 2018. The project was submitted and approved by the Research Ethics Committee (Approval number: 2.491.607). All participants individually received proper clarification of the study, and they were only interviewed after th