Psychoactive drugs in the Brazilian public health system: Use profile and associated factors

Manuela Roque Siani-Morello Lucas Borges Pereira Iahel Manon de Lima Ferreira Marcela Jirón Aliste Leonardo Régis Leira Pereira About the authors

Abstract

The purpose of this study is to estimate the prevalence of and characterize the use of psychoactive drugs among drug users in a Brazilian municipality, relating the findings to factors associated with the consumption of these substances. Through a cross-sectional design, 1,355 drug users from the public health systems community pharmacies were interviewed. Sociodemographic and health-related data were collected, as well as any other prescribed drugs. The prevalence of psychoactive drug use within the last month was 31.0%, with antidepressants and benzodiazepines being the most prescribed (53.5% and 24.6% respectively). Most psychoactive drug users were female (81.9%), lived with a partner (52.6%), had private health insurance (69.2%) and a monthly per-capita income up to one minimum wage (54.0%). The adjusted Odds Ratio (OR) confirmed the following factors to be positively associated with the use of psychoactive drugs: female gender (OR=2.06; 95% CI 1.44; 2.95), age ≥60 years old (OR=1.77; 95% CI 1.26; 2.48), follow-up with a psychologist (OR=4.12; 95% CI 1.84; 5.25), absence of regular physical activity (OR=1.59; 95% CI 1.13; 2.23), and smokers (OR=1.94; 95% CI 1.26; 2.97). Approximately one out of three individuals used at least one psychoactive drug. Health managers should focus the planning and actions aimed at their rational use for these groups, leading to increased overall treatment success.

Keywords:
Pharmacoepidemiology; Drug utilisation studies; Psychotropic drugs; Prescribing

INTRODUCTION

In 2008, neuropsychiatric conditions were considered the highest overall burden among chronic non-communicable morbidities, with DALYs/1000 (Disability Adjusted Life Year) equal to 30.6; ahead of cardiovascular diseases (22.8) (Schramm et al., 2004Schramm JMA, Oliveira AF, Leite IC, Valent JG, Gadelha AMJ, Portela MC, et al. Epidemiological transition and the study of burden of disease in Brazil. Cien Saude Colet . 2004;9(4):897-908.). The projections for 2030 are even more alarming and estimate that unipolar depressive disorders will become the leading cause of disability worldwide (WHO, 2004WHO. World Health Organization. The global burden of disease: 2004 update. Geneva: World Health Organization. Available from: http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf
http://www.who.int/healthinfo/global_bur...
). Despite data scarcity, in Brazil, mental disorders (MD) are estimated to account for 20.3% of the global burden of disease (WHO, 2004WHO. World Health Organization. The global burden of disease: 2004 update. Geneva: World Health Organization. Available from: http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf
http://www.who.int/healthinfo/global_bur...
). Likewise, it is estimated that the total costs for MD will increase 2.5 times globally between 2010 and 2030, almost tripling in low and middle-income countries, where indirect costs (two-thirds of total) include loss of productivity due to MD-induced disability (Bloom et al., 2011Bloom DE, Cafiero ET, Jané-llopis E, Abrahams-gessel S, Bloom LR, Fathima S, et al. The Global Economic Burden of Noncommunicable Diseases. Geneva: World Economic Forum. 2011. Available from: http://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommGlobalEconomicBu_2011.pdf
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). Following this scenario, the use of psychoactive drugs (PAD) by the general population has continued to increase in the last decades - mostly antidepressants (Gualano et al., 2014Gualano MR, Bert F, Mannocci A, Torre G, Zeppegno P, Siliquini R. Consumption of Antidepressants in Italy: Recent Trends and Their Significance for Public Health. Psychiatr Serv . 2014;65(10):1226-31.), as well as in Brazil (Rodrigues, Facchini, Lima, 2006Rodrigues MAP, Facchini LA, Lima MS. Modifications in psychotropic drug use patterns in a Southern Brazilian city. Rev Saude Publica. 2006;40(1):107-14.).

The main risk of some PAD is the development of physical and psychic dependence due to inappropriate use (e.g. increasing dosages, abrupt cessation of treatment, or exposure for longer than recommended). Regarding benzodiazepines, 50% of the users who consume it for more than a year are estimated to present withdrawal syndrome (Bateson, 2002Bateson AN. Basic pharmacologic mechanisms involved in benzodiazepine tolerance and withdrawal. Curr Pharm Des. 2002;8(1):5-21.), or to continue using them for five to ten years (Podhorna, 2002Podhorna J. The experimental pharmacotherapy of benzodiazepine withdrawal. Curr Pharm Des . 2002;8(1):23-43.). Furthermore, female gender and age represent factors associated with the use of PAD; however, these surveys are still limited in Brazil (Almeida, Coutinho, Pepe, 1994Almeida LM, Coutinho ESF, Pepe VLE. Consumption of Psychotropic Drugs in an Administrative Region of the City of Rio de Janeiro: Ilha do Governador. Cad Saúde Pública. 1994;10(1):5-16.; Rodrigues, Facchini, Lima, 2006Rodrigues MAP, Facchini LA, Lima MS. Modifications in psychotropic drug use patterns in a Southern Brazilian city. Rev Saude Publica. 2006;40(1):107-14.; Quintana et al., 2013Quintana MI, Andreoli SB, Moreira FG, Ribeiro WS, Feijo MM, Bressan RA, Coutinho ESF, Mari JJ. Epidemiology of psychotropic drug use in Rio de Janeiro, Brazil: gaps in mental illness treatments. PloS One. 2013;8(5):e62270.).

Inadequate consumption of these or any other medications significantly increases health care costs. Thus, drug utilization research is an important tool in describing patterns of PAD use for governments and health professionals to guarantee their rational use.

The purpose of this study is to estimate the prevalence of and characterize the use of PAD, relating these findings to associated factors with the consumption of such substances.

METHOD

Setting

This cross-sectional survey was carried out in the public health system of Ribeirão Preto (state of São Paulo), with approximately 605,000 inhabitants. The Brazilian Public Health System provides the population free access to all care levels, including drugs supply. All the 30 pharmacies linked to public health units constituted the scenario of this study. There, drugs listed in the Municipal List of Essential Drugs are dispensed free of charge to every citizen residing in Ribeirão Preto-SP who presents a valid prescription. Regarding psychoactive drugs (PAD), 25 different active ingredients were available for dispensing, such as antidepressants, antiepileptics, anxiolytics, and antipsychotics, among others.

The study population consisted of users of any medication (psychoactive or not) attended by these establishments. We included adults who were getting medication for their own use. All the participants signed a consent term of participation for this study.

For better understanding of the study’s operation (Figure 1), it consisted of the following steps:

FIGURE 1
Study operation flowchart, December 2012.

Sample size and data collection

Previous Brazilian surveys showed a prevalence of PAD use between 5.2% (Almeida, Coutinho, Pepe, 1994Almeida LM, Coutinho ESF, Pepe VLE. Consumption of Psychotropic Drugs in an Administrative Region of the City of Rio de Janeiro: Ilha do Governador. Cad Saúde Pública. 1994;10(1):5-16.) and 9.9% (Rodrigues, Facchini, Lima, 2006Rodrigues MAP, Facchini LA, Lima MS. Modifications in psychotropic drug use patterns in a Southern Brazilian city. Rev Saude Publica. 2006;40(1):107-14.), but their methodological approach was different from the present study. Therefore, we set the prevalence of the main outcome at 50%, thus maximizing the sample size (Luiz, Magnanini, 2006Luiz RR, Magnanini MMFO. Tamanho da Amostra em Investigações Epidemiológicas. In: Medronho RA (ed) Epidemiologia. São Paulo: Atheneu; 2006. p. 295-306.). The confidence interval (100-α) was 95% and the tolerable error (ε), 3%. The Sample size was calculated using the Epi InfoTM STATCALC software (version 6.04, Centers for Disease Control and Prevention).

The calculated value was increased by 20%, considering eventual losses common to epidemiological surveys, which resulted in a sample of 1,360 individuals. This number was distributed among the 30 aforementioned pharmacies through proportional partition (according to each one’s average customer attendance).

Data were collected through a personal form developed by the researchers. It included sociodemographic variables (gender, age, schooling, monthly per capita income, marital status, professional status, housing condition and access to health services) and other health related variables (follow-up with a psychologist, practice of regular physical activity - three days a week for at least 30minutes/day, coffee intake, alcohol consumption and smoking).

In addition, we recorded prescription information for the following analyses: prevalence of PAD use in the last month, PAD classification by the ATC/DDD system, number of PAD per person, and percentage of individuals using five or more drugs (polypharmacy) (Slabaugh et al., 2010Slabaugh SL, Maio V, Templin M, Abouzaid S. Prevalence and risk of polypharma Slabaugh cy among the elderly in an outpatient setting a retrospective cohort study in the Emilia-Romagna region, Italy. Drugs Aging. 2010;27(1):1019-28.).

Further medications reported by the interviewee were also listed. The individuals without a PAD prescription who referred to use it were screened through a local database that registers all dispensed medications by the public health system in Ribeirão Preto-SP, PAD users being considered those who had received any of these medications within 30 days before the interview.

Data was collected from September to December 2012 by two trained interviewers, in a single interview with each volunteer. The interviewers randomly approached individuals while waiting in pharmacy lines to get medications, and the interviews occurred at the same place. Refusals and those who did not the meet inclusion criteria were replaced by the next in line.

Statistical analysis

All the analyses were performed using the Statistical Package for the Social Sciences® program (SPSS Inc., version 17.1.0). The sample was described based on the use of PAD (yes/no). In order to compare independent variables between PAD users and non-users, independent-sample Student-t tests and chi-square tests were performed.

The univariate analysis identified factors associated with the use of PAD (dependent variable), by calculation of Odds Ratio (OR) and 95% confidence intervals (95% CI). Multivariate analyses were then performed to obtain OR adjusted values, through non-conditional multiple logistic regression (Enter method), by which it is possible to simultaneously adjust for the effect of confounding variables, herein considered as gender and age.

Ethics approval

The study was approved by the Research Ethics Committee of the School of Pharmaceutical Sciences of Ribeirão Preto - University of São Paulo, Brazil (CEP 066/2012).

All the procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Written consent was obtained from the participants enrolled in this study. All the information that could lead to the identification of the participants will not be published.

RESULTS

PAD use and associated factors

The final sample represented 1,355 interviews (five excluded due to fill-in errors). Two-thirds of the respondents were female (67.7%), the majority in the 45-59 age group (18-89 years old, A: 52.5, SD: 16.4). The monthly per-capita income ranged from zero to 8.2 minimum wages (A: 1.2, SD: 1.0), which corresponded to approximately US$365.00 in the year 2012.

The prevalence of PAD use in the last month was 31.0% (n=420) (Table I), of which 147 (35.0%) were using at least two PAD. The adjusted OR values confirmed the association with PAD use among the following variables: female gender, elderly, follow-up with a psychologist, no regular physical activity, and smokers (Table I). The probability of PAD use among women was twice the one among men. As to age, it was 77% higher for the elderly.

TABLE I
Prevalence and PAD use characterization (n=1,355), December 2012

Analysis of prescribed PAD

From 805 prescribed drugs, 619 were PAD. Of these, 592 (95.6%) were in the Municipal List of Essential Drugs. The mean number of PAD per user was 1.5 (SD 0.8), ranging from one to six. Themost prevalent class corresponded to antidepressants (Figure. 2). Clonazepam accounted for 14.5% of all the PAD. Although classified by the ATC (Anatomical Therapeutic Chemical) system as an antiepileptic drug, its indication is more frequent in several psychiatric conditions: anxiety, bipolar disorder, panic syndrome, insomnia, etc. (Fagan, Nichols, 2008Fagan SC, Nichols FT. Neurologic Disorders. In: Dipiro J, Talbert B, Yee GC, Matzke GR, Wells BG, Posey LM (ed) Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York: McGraw-Hill; 2008. p 909-1203.).

FIGURE 2
Frequency of prescribed PAD according to ATC classification (n=619), December 2012.

Regarding antidepressants, the most common active ingredients were sertraline (34.3%), fluoxetine (28.9%), and amitriptyline (20.8%). It is noteworthy that tricyclic antidepressants are the first-choice treatment for chronic neuropathic pain (Finnerup et al., 2005Finnerup NB, Otto M, McQuay HJ, Jensen TS, Sindrup SH. Algorithm for neuropathic pain treatment: an evidence based proposal. Pain. 2005;118(1):289-305.). In our sample, 35.6% of the amitriptyline users reported being in use of this PAD for pain management.

As for the most frequent antiepileptic drugs (carbamazepine accounted for 46.7%, phenobarbital for 22.7%, and valproic acid for 13.3%), carbamazepine and valproic acid are frequently used in the clinical practice as mood stabilizers. However, in our study, 76.9% of these PAD users stated that they were prescribed to control epileptic seizures.

DISCUSSION

PAD use and associated factors

The prevalence of the estimated PAD use for the general population ranged from 5.2% to 13.3% in Brazilian studies (Almeida, Coutinho, Pepe, 1994Almeida LM, Coutinho ESF, Pepe VLE. Consumption of Psychotropic Drugs in an Administrative Region of the City of Rio de Janeiro: Ilha do Governador. Cad Saúde Pública. 1994;10(1):5-16.; Rodrigues, Facchini, Lima, 2006Rodrigues MAP, Facchini LA, Lima MS. Modifications in psychotropic drug use patterns in a Southern Brazilian city. Rev Saude Publica. 2006;40(1):107-14.; Quintana et al., 2013Quintana MI, Andreoli SB, Moreira FG, Ribeiro WS, Feijo MM, Bressan RA, Coutinho ESF, Mari JJ. Epidemiology of psychotropic drug use in Rio de Janeiro, Brazil: gaps in mental illness treatments. PloS One. 2013;8(5):e62270.; Campanha et al., 2015Campanha AM, Siu ER, Milhorança IA, Viana MC, Wang YP, Andrade LH. Use of psychotropic medications in São Paulo Metropolitan Area, Brazil: pattern of healthcare provision to general population. Pharmacoepidemiol Drug Saf. 2015;24(1):1207-14.; Quintana et al., 2015Quintana MI, Andreoli SB, Peluffo MP, Ribeiro WS, Feijo MM, Bressan RA, Coutinho ESF, Mari JJ. Psychotropic drug use in São Paulo, Brazil: An epidemiological survey. PloS One . 2015;10(8):e 0135059.) and from 7.2% to 12.9% in other countries (Meng, D’Arcy, Tempier, 2013Meng X, D’Arcy C, Tempier R. Trends in psychotropic use in Saskatchewan from 1983 to 2007. Can J Psychiatry. 2013;58(7):426-31.), values which are lower than those from this study (31.0%). However, while such studies estimated the prevalence of PAD use for the general population, in our case the cohort "drug users" constituted study subjects, as previously detailed.

Despite the established regulation that controls the prescription and dispensing of PAD and other drugs under special control in Brazil, their consumption remains high. This reflects a culture in which the population resorts to drugs as a primary instant relief tool to any suffering (from pathological conditions to loneliness or financial crises). Furthermore, the paternalistic and assistentialist format of the Brazilian government does not stimulate collective interventions to cope with such emotional states (Ignácio, Nardi, 2007Ignácio VTG, Nardi HC. Medicalization as a biopolitical strategy: A study about the consuming of psychoactive prescribed drugs in a small town in state of Rio Grande do Sul. Psicologia e Sociedade. 2007;19(3):88-95.). At the same time, the number of non psychiatric physicians who prescribe PAD is increasing (Lasserre et al., 2010Lasserre A, Younès N, Balnchon T, Cantegreil-Kallen I, Passerieux C, Thomas G, Chan-Chee C, Hanslik T. Psychotropic drug use among older people in general practice:discrepacies betwee opinion and practice. Br J Gen Pract. 2010;60(573):e156-e162.; Meng, D’Arcy, Tempier, 2013Meng X, D’Arcy C, Tempier R. Trends in psychotropic use in Saskatchewan from 1983 to 2007. Can J Psychiatry. 2013;58(7):426-31.). The improvement in the diagnosis of psychiatric disorders, in addition to the greater number of available drugs and new therapeutic indications constitute factors that increase the consumption of PAD (Prado, Francisco, Barros, 2017Prado MAMB, Francisco PMSB, Barros MBA. Uso de medicamentos psicotrópicos em adultos e idosos residentes em Campinas, São Paulo: um estudo transversal de base populacional. Epidemiol Serv Saúde. 2017;26(4):1-11.).

In recent studies, the use of at least two PAD ranged between 32.9% and 47.2% (Lasserre et al., 2010Lasserre A, Younès N, Balnchon T, Cantegreil-Kallen I, Passerieux C, Thomas G, Chan-Chee C, Hanslik T. Psychotropic drug use among older people in general practice:discrepacies betwee opinion and practice. Br J Gen Pract. 2010;60(573):e156-e162.; Quintana et al., 2013Quintana MI, Andreoli SB, Moreira FG, Ribeiro WS, Feijo MM, Bressan RA, Coutinho ESF, Mari JJ. Epidemiology of psychotropic drug use in Rio de Janeiro, Brazil: gaps in mental illness treatments. PloS One. 2013;8(5):e62270.; Quintana et al., 2015Quintana MI, Andreoli SB, Peluffo MP, Ribeiro WS, Feijo MM, Bressan RA, Coutinho ESF, Mari JJ. Psychotropic drug use in São Paulo, Brazil: An epidemiological survey. PloS One . 2015;10(8):e 0135059.), similarly to the findings of this study. But in a previous survey, this proportion was lower (11.4%) (Almeida, Coutinho, Pepe,1994Almeida LM, Coutinho ESF, Pepe VLE. Consumption of Psychotropic Drugs in an Administrative Region of the City of Rio de Janeiro: Ilha do Governador. Cad Saúde Pública. 1994;10(1):5-16.), and another study showed an increasing use of at least two PAD (Meng, D’Arcy, Tempier, 2013Meng X, D’Arcy C, Tempier R. Trends in psychotropic use in Saskatchewan from 1983 to 2007. Can J Psychiatry. 2013;58(7):426-31.). These findings reflect that the prescription of combinations (two or more PAD) has become more popular in the last 20 years, which, on the one hand, is sustained by advances in research involving the efficacy/safety binomial of combined pharmacotherapy, particularly with regard to more complex MD (e.g. schizophrenia, drug-resistant epilepsy) (Mojtabai, Olfson, 2010Mojtabai R, Olfson M. National Trends in Psychotropic Medication Polypharmacy in Office-Based Psychiatry. Arch Gen Psychiatry. 2010;67(1):26-36.); but, on the other hand, the still high cost of modern PAD (e.g. escitalopram), potential substitutes for the classic - and sometimes misleading - benzodiazepine-antidepressant association (Brunoni et al., 2013Brunoni AR, Nunes MA, Figueiredo R, Barreto SM, Fonseca MJM, Lotufo PA, et al. Patterns of benzodiazepine and antidepressant use among middle-aged adults: The Brazilian longitudinal study of adult health (ELSA-Brasil). J Affect Disord. 2013;151(1):71-7.), is an obstacle to their insertion into the list of essential drugs, favoring the indication of the available combined therapy.

Regarding gender, other studies showed a predominance of female PAD users, ranging from 61.6% to 73.8% (Brunoni et al., 2013Brunoni AR, Nunes MA, Figueiredo R, Barreto SM, Fonseca MJM, Lotufo PA, et al. Patterns of benzodiazepine and antidepressant use among middle-aged adults: The Brazilian longitudinal study of adult health (ELSA-Brasil). J Affect Disord. 2013;151(1):71-7.; Rocha, Werlang, 2013Rocha BS, Werlang MC. Psychotropic drugs in the Family Health Strategy: profile of use, access and strategies to promote rational use. Cien Saude Colet. 2013;18(11):3291-3300.), lower than in this research. This reveals that when it comes to Primary Health Care (PHC), there may be a smaller proportion of women using PAD. From this, three conjectures emerge about the use of PAD among women: the nosological profile of the MD is distinct within PHC; the nosological profile of the MD is similar, but psychosocial support measures in this context reduce the need for treatment with PAD; or part of the demand for treatment with PAD in PHC is repressed, due to the general practitioner´s unawareness regarding the need to refer such cases to a psychiatrist. McLean et al. (2011McLean CP, Asnaani A, Litz BT, Hofmann SG. Gender differences in anxiety disorders: Prevalence, course of illness, comorbidity and burden of illness. J Psychiatr Res. 2011;45(8):1027-1035.) reported that although women were more likely to seek health care treatment in PHC than men, they were less likely to receive specialized health care services, because primary care physicians may be more willing to care for women MD than men’s, so they refer men to a mental health specialist.

When comparing the adjusted OR values for PAD use among women, our study found results close to another three population-based studies (OR=2.12 / 95% CI 1.17; 3.85) (Almeida, Coutinho, Pepe, 1994Almeida LM, Coutinho ESF, Pepe VLE. Consumption of Psychotropic Drugs in an Administrative Region of the City of Rio de Janeiro: Ilha do Governador. Cad Saúde Pública. 1994;10(1):5-16.), (OR=2.4 / 95% CI 1.7; 3.5) (Quintana et al., 2015Quintana MI, Andreoli SB, Peluffo MP, Ribeiro WS, Feijo MM, Bressan RA, Coutinho ESF, Mari JJ. Psychotropic drug use in São Paulo, Brazil: An epidemiological survey. PloS One . 2015;10(8):e 0135059.), and (OR=2.1 / 95% CI 1.9; 2.4) (Alonso et al., 2004Alonso J, Angermeyer MC, Bernert S, Bruffaerts R, Brugha TS, Bryson H, et al. Psychotropic drug utilization in Europe: Results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatr Scand. 2004;109(suppl. 420):55-64.), suggesting a significant association between PAD use and the female gender. Concerning other studies, our adjusted OR value was higher than that recently estimated for Rio de Janeiro-RJ (OR=1.82 / 95% CI 1.05, 3.17) (Quintana et al., 2013Quintana MI, Andreoli SB, Moreira FG, Ribeiro WS, Feijo MM, Bressan RA, Coutinho ESF, Mari JJ. Epidemiology of psychotropic drug use in Rio de Janeiro, Brazil: gaps in mental illness treatments. PloS One. 2013;8(5):e62270.) and for Taiwan (OR=1.62 / 95% CI 1.58, 1.67) (Chien et al., 2007Chien IC, Bih SH, Chou YJ, Lin CH, Lee WG, Chou P. Trends in the Use of Psychotropic Drugs in Taiwan: A Population-Based National Health Insurance Study, 1997-2004. Psychiatr Serv. 2007;58(4):554-7.).

The major proportion of women in use of PAD in our cohort, compared with non-users, may be justified by the prescribers’ perception that women are emotionally more vulnerable than men and therefore, require drug treatment more often (Moreno Luna et al., 2000Moreno Luna ME, Clemente Lirola E, Pinero Acín MJ, Martinez Matías MR, Alonso Gómez F, Rodríguez Alcalá FJ. Influence of patient's gender on the management of clinical profiles of anxiety/depression. Aten Primaria. 2000;26(8):554-8.). It is also related to the fact that the most common MD in the population (mood and anxiety) are more diagnosed in women than in men (Brunoni et al., 2013Brunoni AR, Nunes MA, Figueiredo R, Barreto SM, Fonseca MJM, Lotufo PA, et al. Patterns of benzodiazepine and antidepressant use among middle-aged adults: The Brazilian longitudinal study of adult health (ELSA-Brasil). J Affect Disord. 2013;151(1):71-7.). Such epidemiological profile relates in part to biological aspects (Andrade, Viana, Silveira, 2006Andrade LH, Viana MC, Silveira CM. Epidemiology of women's psychiatric disorders. Rev Psiq Clín. 2006;33(2):43-54.), but psychosocial determinants like increased exposure to violence, sexual abuse, and worse socioeconomic status exert an undoubted influence on women’s MD rates (Stewart, Ashraf, Munce, 2006Stewart DE, Ashraf IJ, Munce SE. Women's mental health: A silent cause of mortality and morbidity. Int J Gynaecol Obstet. 2006;94(1):343-9.).

Additionally, these findings elucidate the need to focus on key features of the female gender in the mental health field. According to Stewart (2007Stewart DE. Social determinants of women’s mental health. J Psychosom Res. 2007;63(3):223-4.), women's mental health can only be understood when taking their biological, social, cultural, economic, and personal context into account. Given the important role that women represent in all aspects of life (as progenitor, family caregiver, and in society), the mental health approach in this group deserves special consideration (Stewart, Ashraf, Munce, 2006Stewart DE, Ashraf IJ, Munce SE. Women's mental health: A silent cause of mortality and morbidity. Int J Gynaecol Obstet. 2006;94(1):343-9.).

The mean age among PAD users was similar to that found in another study (53.1 years old; SD 18.6) and the increase in the prevalence of PAD use with age was also observed in this work (Rocha, Werlang, 2013Rocha BS, Werlang MC. Psychotropic drugs in the Family Health Strategy: profile of use, access and strategies to promote rational use. Cien Saude Colet. 2013;18(11):3291-3300.). Through logistic regression, it was observed that the advanced age groups presented greater propabilityof PAD use, as well as in other studies (Almeida, Coutinho, Pepe, 1994Almeida LM, Coutinho ESF, Pepe VLE. Consumption of Psychotropic Drugs in an Administrative Region of the City of Rio de Janeiro: Ilha do Governador. Cad Saúde Pública. 1994;10(1):5-16.; Chien et al., 2007Chien IC, Bih SH, Chou YJ, Lin CH, Lee WG, Chou P. Trends in the Use of Psychotropic Drugs in Taiwan: A Population-Based National Health Insurance Study, 1997-2004. Psychiatr Serv. 2007;58(4):554-7.). Although the strength of these associations has varied, this finding suggests that age affects PAD use regardless of the individual circumstances. Such trend reveals some natural consequences of aging and its relation to PAD use, such as existing chronic diseases that increases the risk of developing MD (Bloom et al., 2011Bloom DE, Cafiero ET, Jané-llopis E, Abrahams-gessel S, Bloom LR, Fathima S, et al. The Global Economic Burden of Noncommunicable Diseases. Geneva: World Economic Forum. 2011. Available from: http://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommGlobalEconomicBu_2011.pdf
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).

Among several factors, chronic morbidities may predispose the development of MD because of emotional load in response to the stress faced by these individuals (Bloom, et al. 2011Bloom DE, Cafiero ET, Jané-llopis E, Abrahams-gessel S, Bloom LR, Fathima S, et al. The Global Economic Burden of Noncommunicable Diseases. Geneva: World Economic Forum. 2011. Available from: http://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommGlobalEconomicBu_2011.pdf
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). Since these morbidities predominantly affect older people, they may be more susceptible to PAD use. Furthermore, the presence of a chronic organic disease strengthens the bond between patient and physician, which increases the likelihood of receiving a PAD prescription (Ohayon, Lader, 2002Ohayon MM, Lader MH. Use of psychotropic medication in the general population of France, Germany, Italy and the United Kingdom. J Clin Psychiatry. 2002;63(9):817-25.).

From another perspective, the São Paulo Megacity study showed that the mood and anxiety MD were associated with younger age groups (Andrade et al., 2012Andrade LH, Wang Y-P, Andreoni S, Silveira CM, Alexandrino-Silva C, Siu ER, et al. Mental disorders in megacities: Findings from the São Paulo Megacity Mental Health Survey, Brazil. PLoS One. 2012;7(2):e31879.). In this case, considering the chronic nature of some MD such as depression, PAD could last for many years (Hirschfeld, 2001Hirschfeld RMA. Clinical importance of long-term antidepressant treatment. Br J Psychiatry Suppl. 2001;179(S42):s4-8.).

Other aspects, such as presence of cognitive deficits and sleep habit changes, may also influence PAD use at more advanced ages, as found by an earlier study conducted in the Western district of Ribeirão Preto-SP, where 12.2% reported suffering from insomnia (Baldoni et al., 2013Baldoni AO, Ayres LR, Martinez EZ, Dewulf NLS, Santos V, Obreli-Neto PR, et al. Pharmacoepidemiological profile and polypharmacy indicators in elderly outpatients. Braz J Pharm Sci. 2013;49(3):443-52.).

Furthermore, a number of studies show that approximately 30 to 63% of the elderly require medical contact or hospitalization due to adverse drug reactions (Rudolph et al., 2008Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med. 2008;168(5):508-13.). The high use of PAD in the elderly in this research should be alarming, since most of these drugs cause anticholinergic effects that may cause significant harm to the health of these individuals (e.g. delirium, reduction in gastrointestinal motility, constipation, dry mouth, urinary retention). Therefore, monitoring the safety of these drugs in this age group should be of extreme concern to the health team (Rudolph et al., 2008Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med. 2008;168(5):508-13.). In this sense, some tools such as the Beers criteria have been developed to identify potentially inappropriate medications for the elderly and to prevent their use, reducing drug-related problems as well as health-related costs (American Geriatrics Society Beers Criteria, 2019American Geriatrics Society Beers Criteria. American Geriatrics Society 2019 Updated AGS Beers Criteria®for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019;67(1):674-694.).

In this sense, international guidelines have been implemented in order to deprescribe benzodiazepines for patients aged 65 years old or more, regardless the duration of use. For those between 18 and 64 years old, deprescription should occur when benzodiazepine has been used for more than four weeks (Pottie et al., 2018Pottie K, Thompson W, Davies S, Grenier J, Sadowski CA, Welch V, et al. Deprescribing benzodiazepine receptor agonists Evidence-based clinical practice guideline. Can Fam Pysician. 2018;64(5):339-51.). There is also another guideline which focus on the deprescription of PAD for adults with behavioral and psychological symptoms of dementia treated for at least three monts, once symptoms are stabilized (Bjerre et al., 2018Bjerre LM, Farrel B, Hogel M, Graham L, Lemay G, McCarthy L. Deprescribing antipsychotics for behavioural and psychological symptoms of dementia and insomnia Evidence-based clinical practice guideline. Can Fam Physician. 2018;64(1):17-27.).

The proportion of PAD users undergoing follow-up with a psychologist both in this and in another Brazilian study (Campanha et al., 2015Campanha AM, Siu ER, Milhorança IA, Viana MC, Wang YP, Andrade LH. Use of psychotropic medications in São Paulo Metropolitan Area, Brazil: pattern of healthcare provision to general population. Pharmacoepidemiol Drug Saf. 2015;24(1):1207-14.) show that few individuals have access to this professional, fostering discussions about the Brazilian Public Health System still being driven by a biomedical model that invests on medication as the primary health technology, to the detriment of preventive and psychosocial non-pharmacological interventions - proposed by this same institution in the integral health care model.

Also due to the subjectivity of most of the MD diagnoses, the indication of a PAD treatment relates intimately to the physician's interpretation of the situation. Thus, it is assumed that not all PAD users benefit from a pharmacological approach (Brunoni et al., 2013Brunoni AR, Nunes MA, Figueiredo R, Barreto SM, Fonseca MJM, Lotufo PA, et al. Patterns of benzodiazepine and antidepressant use among middle-aged adults: The Brazilian longitudinal study of adult health (ELSA-Brasil). J Affect Disord. 2013;151(1):71-7.), while potential beneficiaries remain neglected (Brunoni et al., 2013Brunoni AR, Nunes MA, Figueiredo R, Barreto SM, Fonseca MJM, Lotufo PA, et al. Patterns of benzodiazepine and antidepressant use among middle-aged adults: The Brazilian longitudinal study of adult health (ELSA-Brasil). J Affect Disord. 2013;151(1):71-7.; Quintana et al., 2013Quintana MI, Andreoli SB, Moreira FG, Ribeiro WS, Feijo MM, Bressan RA, Coutinho ESF, Mari JJ. Epidemiology of psychotropic drug use in Rio de Janeiro, Brazil: gaps in mental illness treatments. PloS One. 2013;8(5):e62270.). The dDrugs operate solely biochemically, while psychosocial support strategies, with emphasis on cognitive-behavioral therapy, show effectiveness in the management of several MD (Baldwin et al., 2014Baldwin DS, Anderson IM, Nutt DJ, Allgulander C, Bandelow B, Den Boer JA, et al. Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: A revision of the 2005 guidelines from the British Association for Psychopharmacology. J Psychopharmacol. 2014;28(5):403-39.). Empowering the individuals to deal with the adversities of their health problems, therefore, leads to a positive impact on their quality of life, which in turn reduces the disability associated with these disorders.

Some life habits directly influence physical and mental health, being widely explored by the scientific literature (Atlantis et al., 2004Atlantis E, Chow CM, Kirby A, Singh MF. An effective exercise-based intervention for improving mental health and quality of life measures: A randomized controlled trial. Prev Med. 2004;39(1):424-34.). In the present study, the higher proportion of regular physical activity practitioners among PAD non-users suggests that this variable relates to ppreventing the consumption of these substances, as evidenced by a Finnish longitudinal study (Lahti et al., 2013Lahti J, Lallukka T, Lahelma E, Rahkonen O. Leisure-time physical activity and psychotropic medication: a prospective cohort study. Prev Med . 2013;57(3):173-7.). On the other hand, the symptomatological profile of some MD includes loss of vitality, leading to a reduction of physical activity, as it occurs in depression (Studer, Weicker, 2001Studer HK, Weicker H. Physiology and pathophysiology of the serotonergic system and its implications on mental and physical performance: Part I. Int J Sports Med. 2001;22(7):467-81.).

The same thought applies to smoking, which confirmed a positive association with PAD use both in this and in several other studies. In these cases, the pleasure felt when smoking , exceeded that related to other activities that produce the same effect in individuals without any MD diagnosis, such as eating candies or watching an exciting movie (Spring, Pingitore, McChargue, 2003Spring B, Pingitore R, McChargue DE. Reward value of cigarette smoking for comparably heavy smoking schizophrenic, depressed, and nonpatient smokers. Am J Psychiatry. 2003;160(2):316-22.).

Analysis of prescribed PAD

Antidepressants were the most prescribed PAD both in this and in other surveys around the world (Meng, D’Arcy, Tempier, 2013Meng X, D’Arcy C, Tempier R. Trends in psychotropic use in Saskatchewan from 1983 to 2007. Can J Psychiatry. 2013;58(7):426-31.; Quintana et al., 2013Quintana MI, Andreoli SB, Moreira FG, Ribeiro WS, Feijo MM, Bressan RA, Coutinho ESF, Mari JJ. Epidemiology of psychotropic drug use in Rio de Janeiro, Brazil: gaps in mental illness treatments. PloS One. 2013;8(5):e62270.; Rocha, Werlang, 2013Rocha BS, Werlang MC. Psychotropic drugs in the Family Health Strategy: profile of use, access and strategies to promote rational use. Cien Saude Colet. 2013;18(11):3291-3300.; Quintana et al., 2015Quintana MI, Andreoli SB, Peluffo MP, Ribeiro WS, Feijo MM, Bressan RA, Coutinho ESF, Mari JJ. Psychotropic drug use in São Paulo, Brazil: An epidemiological survey. PloS One . 2015;10(8):e 0135059.), differing from past studies in which benzodiazepines predominated (Almeida, Coutinho, Pepe, 1994Almeida LM, Coutinho ESF, Pepe VLE. Consumption of Psychotropic Drugs in an Administrative Region of the City of Rio de Janeiro: Ilha do Governador. Cad Saúde Pública. 1994;10(1):5-16.; Rodrigues, Facchini, Lima, 2006Rodrigues MAP, Facchini LA, Lima MS. Modifications in psychotropic drug use patterns in a Southern Brazilian city. Rev Saude Publica. 2006;40(1):107-14.; Meng, D’Arcy, Tempier, 2013Meng X, D’Arcy C, Tempier R. Trends in psychotropic use in Saskatchewan from 1983 to 2007. Can J Psychiatry. 2013;58(7):426-31.). This transition in PAD prescribing patterns denotes the popularization of antidepressants in the world over the last ten years (especially second generation) as first-choice medications in several MD instead of benzodiazepines (Baldwin et al., 2014Baldwin DS, Anderson IM, Nutt DJ, Allgulander C, Bandelow B, Den Boer JA, et al. Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: A revision of the 2005 guidelines from the British Association for Psychopharmacology. J Psychopharmacol. 2014;28(5):403-39.). Aspects such as the increase in the number of depressive disorder diagnoses (Marcus et al., 2012Marcus M, Yasamy MT, Ommeren MV, Chisholm AD, Saxena S. Depression: a global public health concern. 2012. Available from: http://www.who.int/mental_health/management/depression/who_paper_depression_wfmh_2012.pdf
http://www.who.int/mental_health/managem...
), the greater number of conditions which can be treated with these drugs (Baldwin et al., 2014Baldwin DS, Anderson IM, Nutt DJ, Allgulander C, Bandelow B, Den Boer JA, et al. Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: A revision of the 2005 guidelines from the British Association for Psychopharmacology. J Psychopharmacol. 2014;28(5):403-39.), and in the case of Brazil, the higher access to medications due to the growing development of generics and to the funding of the Brazilian government have notably contributed to these findings.

Considering clonazepam, its proportion in our study corresponded to more than twice that found in Porto Alegre-RS (Rocha, Werlang, 2013Rocha BS, Werlang MC. Psychotropic drugs in the Family Health Strategy: profile of use, access and strategies to promote rational use. Cien Saude Colet. 2013;18(11):3291-3300.). However, this included only PAD prescribed in one PHC unit, which reinforces the existence of peculiarities in this environment as previously discussed. Other studies evaluating all types of PAD did not discriminate the contribution of each one to the total, further limiting discussions regarding clonazepam (Almeida, Coutinho, Pepe, 1994Almeida LM, Coutinho ESF, Pepe VLE. Consumption of Psychotropic Drugs in an Administrative Region of the City of Rio de Janeiro: Ilha do Governador. Cad Saúde Pública. 1994;10(1):5-16.; Rodrigues, Facchini, Lima, 2006Rodrigues MAP, Facchini LA, Lima MS. Modifications in psychotropic drug use patterns in a Southern Brazilian city. Rev Saude Publica. 2006;40(1):107-14.; Quintana et al., 2013Quintana MI, Andreoli SB, Moreira FG, Ribeiro WS, Feijo MM, Bressan RA, Coutinho ESF, Mari JJ. Epidemiology of psychotropic drug use in Rio de Janeiro, Brazil: gaps in mental illness treatments. PloS One. 2013;8(5):e62270.).

Similarly to this research, antiepileptics and anxiolytics represented the second and third most prescribed groups respectively in Rocha, Werlang (2013Rocha BS, Werlang MC. Psychotropic drugs in the Family Health Strategy: profile of use, access and strategies to promote rational use. Cien Saude Colet. 2013;18(11):3291-3300.) study. Other researchers have not detected such results possibly because of differences in the classification criteria adopted (Quintana et al., 2013Quintana MI, Andreoli SB, Moreira FG, Ribeiro WS, Feijo MM, Bressan RA, Coutinho ESF, Mari JJ. Epidemiology of psychotropic drug use in Rio de Janeiro, Brazil: gaps in mental illness treatments. PloS One. 2013;8(5):e62270.), since some antiepileptics are commonly used as mood stabilizers (e.g. carbamazepine and valproic acid). The most prevalent active ingredients among the antiepileptics (except for clonazepam) and the anxiolytics in the present study coincided with other studies (Quintana et al., 2013Quintana MI, Andreoli SB, Moreira FG, Ribeiro WS, Feijo MM, Bressan RA, Coutinho ESF, Mari JJ. Epidemiology of psychotropic drug use in Rio de Janeiro, Brazil: gaps in mental illness treatments. PloS One. 2013;8(5):e62270.; Rocha, Werlang MC, 2013Rocha BS, Werlang MC. Psychotropic drugs in the Family Health Strategy: profile of use, access and strategies to promote rational use. Cien Saude Colet. 2013;18(11):3291-3300.) as with the most prevalent antipsychotics (Rocha, Werlang MC, 2013Rocha BS, Werlang MC. Psychotropic drugs in the Family Health Strategy: profile of use, access and strategies to promote rational use. Cien Saude Colet. 2013;18(11):3291-3300.).

The aforementioned data reflect the consolidation of the list of essential drugs, given the similarity of the PAD prescription profile in different periods and regions of the Brazilian territory and, even more, in different contexts of the public health care system, which also points out that our sample may represent PAD use all over the city.

Nevertheless, considering the wide range of therapeutic indications for PAD, nothing can be consistently stated regarding the clinical purpose in using these substances, since such diagnoses have not been evaluated in this or in other cited studies.

Although our study sample was not random, we enrolled participants from all 30 public pharmacies of Ribeirão Preto-SP. Moreover, the participants’ sociodemographic profile reached the municipality’s profile, which suggests it represented the entire city. Still, results generalization should be made with caution, since institutionalized/bedridden individuals were not included, nor those younger than 18 years old.

Despite the worldwide popularity of the theme, available and updated data remain concentrated in developed countries. Thus, this study contributed to broadly and consistently characterize PAD use among drug users in a developing country. We also consider that these results should represent Brazilian localities with similar socioeconomic and urbanization profiles, as well as other Western developing countries.

One out of three individuals attended by pharmacies at health facilities in Ribeirão Preto-SP was a PAD user, with antidepressants and benzodiazepines being the most prescribed. Elderly, women, and smokers were more likely to use these medications, as well as individuals undergoing follow-up with a psychologist, and who did not perform regular physical activity. These findings provide a general overview of the current consumption of PAD, indicating the most susceptible groups in which the health managers should focus the planning and actions aimed at their rational use, leading to increased overall treatment success with safety.

ACKNOWLEDGMENTS

The authors would like to thank all the individuals who kindly agreed to participate in the study, availing their time during the interviews, thus allowing for this work to be accomplished. The authors also thank Marília Silveira de Almeida Campos, who was responsible for the exquisitely design performance of the statistical analysis.

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Publication Dates

  • Publication in this collection
    25 July 2022
  • Date of issue
    2022

History

  • Received
    05 Aug 2019
  • Accepted
    05 Jan 2020
Universidade de São Paulo, Faculdade de Ciências Farmacêuticas Av. Prof. Lineu Prestes, n. 580, 05508-000 S. Paulo/SP Brasil, Tel.: (55 11) 3091-3824 - São Paulo - SP - Brazil
E-mail: bjps@usp.br