Prevalence of and pathways to benzodiazepine use in Brazil: the role of depression, sleep, and sedentary lifestyle

The effect of an intervention for organizing primary mental health care in Brazil: a study based on routine process indicators

BACKGROUND

The "Mental Health Care in Primary Health Care (PHC)" project (SMAPS, from Portuguese) was developed in six health regions from three Brazilian states. Considering the gap and relevance of monitoring and assessing mental health (MH) care in real-world settings using data from service records, this study aimed to evaluate the effect of SMAPS on indicators of MH care process in PHC, calculated from official records available in health services.

METHODS

This is a pilot study conducted between January 2022 and September 2023. The sample comprised 18 PHC units in 14 municipalities, which were in one of the three Brazilian states that adhered to SMAPS and assigned to one of two groups: control and intervention (2:1). Secondary data were collected at two times using the same instrument to systematize the retrieval of aggregated data, which were extracted from management reports from PHC units or municipalities departments. Data analysis was performed using descriptive statistics at the PHC units or municipality level.

RESULTS

The rate of referrals to MH specialties per consultation with a MH classifications record seemed to decline in intervention and control group. The percentage of benzodiazepine medications delivered for PHC decreased from 16.1 to 11.3% in the intervention group municipalities but increased from 20.3 to 24.1% in the control group. An inverse pattern was observed for antipsychotic, anticonvulsant, and antidepressant medications (increased from 82.2 to 86.2% in the intervention group municipalities and declined from 77.6 to 74.4% in the control group). Despite this, analyzing the mean variation in MH care indicators, statistically significant differences between groups in distribution at the 5% level were not identified.

CONCLUSION

The present pilot study points to possible effects of SMAPS for organizing MH care in PHC, especially regarding the referrals to specialty mental health care and the delivery of psychotropic medications. It contributes to the formulation of proposals for evaluating MH care based on data already available from records and reports from health services and emphasizes the need to improve the quality of MH care recording in PHC work routines.

Dispensing of zolpidem and benzodiazepines in Brazilian private pharmacies: a retrospective cohort study from 2014 to 2021

Objective

The study aimed to evaluate Zolpidem and Benzodiazepines prescription and dispensing data in private pharmacies in Brazil from 2014 to 2021. Methods: This retrospective cohort study was carried out with retrospective open data from the Brazilian Federal Government from January 2014 to August 2021 containing medicines registered in the National Controlled Products Management System (SNGPC).

Results

Between January 2014 and August 2021, a total of 32,441,392 sales of thirteen drugs from the z-drug and benzodiazepine classes used to treat sleep disorders were recorded in Brazil. Throughout the entire period, clonazepam emerged as the most popular drug, accounting for 29.8% of total sales. Alprazolam followed in second place with 20.6% of sales, while zolpidem came in third with 14.4%. The normal-release form of zolpidem was consistently the highest-selling variant during the evaluation period. However, the fast-acting-release form exhibited the most significant growth, indicated by a noticeable upward trend in sales since 2020. In contrast, the extended-release form of zolpidem remained stable over the years.

Conclusion

The increased sales of zolpidem in Brazilian private pharmacies raise concerns about potential misuse and dependence on this drug mainly for the treatment of insomnia. The epidemic of sleeping pills arises in a scenario of expectancy of short-term amelioration of symptoms, with no correspondence in best clinical practice. Education and counseling for both healthcare professionals and the general population are essential to address this growing health concern and ensure the safe and appropriate use of medications for sleep disorders.

Prevalence and clinical correlates of benzodiazepine use in the patients with major depressive disorder

BACKGROUND

Major depressive disorder (MDD) is a serious and disabling condition characterized by abnormal mood changes. Clinical guidelines for depression treatment recommend antidepressant medications, with benzodiazepines acting as short-term synergists. However, little is currently known about the prevalence and associated clinical risk factors of benzodiazepine use among Chinese patients with MDD. This study aimed to explore the prevalence and clinical risk factors associated with benzodiazepine use in this population.

METHODS

A total of 2742 patients with MDD (males/females = 816/1926, aged 14-60 years) participated in this cross-sectional observational study. General information and psychosis assessments were collected online. Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9), anxiety symptoms using the Generalized Anxiety Disorder-7 (GAD-7), and sleep problems and suicidal tendencies using the third and ninth items of the PHQ-9. Multivariable logistic regression analysis models were employed to identify factors associated with benzodiazepine use.

RESULTS

The prevalence of benzodiazepine use among patients with MDD was 42.9 %. Among these patients, 99.6 % used a single benzodiazepine, with oxazepam being the most frequently prescribed. Age, severity of sleep problems, depressive symptoms, and anxiety symptoms were significantly correlated with benzodiazepine use (all P < 0.001).

LIMITATIONS

The cross-sectional design of this study precludes establishing causal relationships.

CONCLUSION

Our findings indicate a high prevalence of benzodiazepine use among Chinese patients with MDD. Factors such as severe depressive symptoms, anxiety symptoms, age, and sleep problems appear to be associated with benzodiazepine use. These results underscore the importance of vigilance regarding benzodiazepine use in patients with MDD.

[Factors associated with benzodiazepines dependence in insomnia patients]

Background

The use of benzodiazepines as a treatment for insomnia can have side effects such as impaired coordination causing falls in adults and even dependence.

Objective

To assess the factors associated with dependence on benzodiazepines in patients with insomnia.

Methods

Observational, cross-sectional, prospective, and analytical study, at the first level of care. Patients older than 18 years with a diagnosis of insomnia and a benzodiazepine prescription were selected. The dependency was measured with the International Neuropsychiatric Interview.

Results

107 patients were included. Median age 67 years, predominantly female (72%), 74% attended secondary school or more, 71% had more than 3 years of diagnosis, 84% used clonazepam. The 54% presented dependency. In the bivariate analysis, schooling RM 0.392 (95%CI: 0.15-0.96) p = 0.038, moderate and severe clinical insomnia RM 3.618 (95%CI: 1.44-9.08) p = 0.005 and more than 3 years of diagnosis RM 2.428 (95%CI: 1.03-5.71) p = 0.040. In the multivariate model, schooling (p = 0.084), years of diagnosis (p = 0.062) and frequency of consumption (p = 0.065) obtained an R2 of 0.13.

Conclusions

Primary schooling showed a lower risk of presenting dependence on benzodiazepines. The risk was increased in those with more than 3 years of diagnosis, and in those with moderate and severe insomnia.

2023 Guidelines on the Diagnosis and Treatment of Insomnia in Adults - Brazilian Sleep Association

Chronic insomnia disorder (simplified in this document as insomnia) is an increasingly common clinical condition in society and a frequent complaint at the offices of different areas of health practice (particularly Medicine and Psychology). This scenario has been accompanied by a significant evolution in treatment, as well as challenges in approaching patients in an appropriately way. This clinical guideline, coordinated by the Brazilian Sleep Association and the Brazilian Association of Sleep Medicine and counting on the active participation of various specialists in the area, encompasses an update on the diagnosis and treatment of insomnia in adults. To this end, it followed a structured methodology. Topics of interest related to diagnosis were written based on theoretical framework, evidence in the literature, and professional experience. As for the topics related to the treatment of insomnia, a series of questions were developed based on the PICO acronym (P - Patient, problem, or population; I - Intervention; C - Comparison, control, or comparator; O - Outcome). The work groups defined the eligible options within each of these parameters. Regarding pharmacological interventions, only the ones currently available in Brazil or possibly becoming available in the upcoming years were considered eligible. Systematic reviews were conducted to help prepare the texts and define the level of evidence for each intervention. The final result is an objective and practical document providing recommendations with the best scientific support available to professionals involved in the management of insomnia.

Dispensing of psychotropic drugs in the Brazilian capital city before and during the COVID-19 pandemic (2018-2020)

Objective: Evaluate the data on the psychotropic drugs dispensed by private community pharmacies before and during the SARS-CoV-2 pandemic. Methods: This cross-sectional study compared the quarterly and annual consumption of psychotropic drugs per Defined Daily Dose per 1000 inhabitants-day (DHD). Interrupted time series were also constructed to expose changes in the consumption pattern in the periods before and after March 2020. Results: Among the 20 most consumed psychoactive drugs, 12 were antidepressants, for example, escitalopram (DHD 7.996 and 10.626; p < 0.001), and sertraline (DHD 6.321 and 8.484; p < 0.001), in addition to the hypnotic zolpidem (DHD 6.202 and 8.526; p < 0.001). The time series reveals (R ² value) a variation in drug dispensing, in DHD values, during the pandemic. Conclusion: Despite the higher variance, a significant increase is clearly seen in the consumption trends of psychoactive drugs, particularly antidepressants, consistent with the pandemic's influence on the general population's mental health.

Benzodiazepines utilization in Brazilian older adults: a population-based study

OBJECTIVE

To evaluate the utilization of benzodiazepines (BZD) in Brazilian older adults, based on the Pesquisa Nacional de Acesso, Utilização e Promoção do Uso Racional de Medicamentos (PNAUM - National Survey of Access, Use and Promotion of Rational Use of Medicines).

METHODS

The PNAUM is a cross-sectional study conducted between 2013 and 2014, representing the Brazilian urban population. In the present study, we included 60 years or older (n = 9,019) individuals. We calculated the prevalence of BZD utilization in the 15 days prior to survey data collection according to independent variables, using a hierarchical Poisson regression model. A semistructured interview performed empirical data collection (household interview).

RESULTS

The prevalence of BZD utilization in the older adults was 9.3% (95%CI: 8.3-10.4). After adjustments, BZD utilization was associated with female sex (PR = 1.88; 95%CI: 1.52-2.32), depression (PR = 5.31; 95%CI: 4.41-6, 38), multimorbidity (PR = 1.44; 95%CI: 1.20-1.73), emergency room visit or hospitalization in the last 12 months (PR = 1.42; 95%CI: 1.18-1.70 ), polypharmacy (PR = 1.26; 95%CI: 1.01-1.57) and poor or very poor self-rated health (PR = 4.16; 95%CI: 2.10-8.22). Utilization was lower in the North region (PR = 0.18; 95%CI: 0.13-0.27) and in individuals who reported abusive alcohol consumption in the last month (PR = 0.42; 95%CI: 0.19-0.94).

CONCLUSION

Despite contraindications, results showed a high prevalence of BZD utilization in older adults, particularly in those with depression, and wide regional and sex differences.

Dependence on hypnotics: a comparative study between chronic users of benzodiazepines and Z-drugs

Objective:

To evaluate dependence among chronic benzodiazepine and Z-drug users in Brazil.

Methods:

Chronic users of benzodiazepines (n=94), Z-drugs (n=74), or both (n=11) were recruited from the community, underwent a psychiatric evaluation and completed self-report instruments on hypnotic dependence, insomnia, anxiety, and depression. Users of benzodiazepines and Z-drugs were compared using t-tests, and logistic regression models were employed to explore significant predictors of a dependence diagnosis.

Results:

There was no difference in the prevalence of dependence among benzodiazepine (77.2%) and Z-drug (69.4%) users. Benzodiazepine users reported increased psychosocial aspects of dependence, anxiety, and depression. Preoccupation with the availability of medication (prevalence ratio [PR] = 2.39 [1.15-5.20]) and insomnia (PR = 1.10 [1.02-1.19]) were associated with a diagnosis of dependence (n=175).

Conclusion:

The prevalence of dependence was similar among both drug classes. The increased self-reported dependence, anxiety, and depression among benzodiazepine users may be due to behavioral rather than pharmacological aspects of medication use. Behaviors related to hypnotic use were important predictors of dependence.

[Consumption of psychotropic medications in primary healthcare in Ribeirão Preto, São Paulo State, Brazil]

The consumption of psychotropic drugs is considered a public health problem, due to the potential for addiction and the occurrence of adverse events. In this context, the current study aimed to characterize the consumption of psychotropic medications dispensed in primary healthcare units in Ribeirão Preto, São Paulo State, Brazil. This ecological study consulted the Hygia database from 2008 to 2012. The following variables were extracted: psychotropic drugs dispensed, amount dispensed per year, and patients' sex and age bracket. For each psychotropic drug, we calculated the defined daily dose per 1,000 inhabitants/day (DDD/1,000PD), defined daily dose per 1,000 inhabitants/day considering 75% of the population (DDD75%/1,000PD) who withdrew medicines through the Brazilian Unified National Health System (SUS), and the prescribed daily dose (PDD). The study compared the population growth rate to the growth in the medicines' consumption. A total of 1,577,241 patients were identified who withdrew medications during the study period, of whom 287,373 (18.2%) used at least one drug subject to special control. There was an increase in the total consumption of psychotropic drugs (DDD/1,000PD), but comparison to the population growth rate showed that only sertraline (p = 0.021), risperidone (p = 0.034), and clonazepam (p = 0.043) presented higher growth rates. The PDD for seven drugs were higher than the World Health Organization (WHO) DDD. Identifying discrepancies between DDD and PDD can be useful as a strategy for screening patients eligible for pharmaceutical care, since they can contribute to the prevention of morbidity and mortality related to medications.

Deprescribing benzodiazepines: Do Brazilian package inserts address this issue?

OBJECTIVE: To analyze the presence and quality of content on drug deprescribing in Brazilian package inserts for benzodiazepine drugs. METHODS: Documentary study where we analyzed data on deprescribing extracted from electronic package inserts of drugs containing benzodiazepines; these documents were available at the Brazilian Health Surveillance Agency website. Our search was performed independently by 2 researchers who used the following keywords: “deprescription,” “withdrawal,” and “tapering.” The deprescribing plan, when presented by the package insert, was compared to deprescribing protocols for benzodiazepines found in the literature. Moreover, we assessed the presence of guidance on the maximum length of treatment and risks of long-term use. RESULTS: We found 12 package inserts for benzodiazepines and 100% of them suggested gradual withdrawal; only 1 (8.33%) suggested a systematized deprescribing plan. One document (8.33%) did not offer guidance on maximum treatment duration. Eleven (91.67%) had the information on long-term use possibly causing dependence or tolerance, and 1 (8.33%) did not describe the risks of continuous use. CONCLUSIONS: It is known that benzodiazepines should be withdrawn in a gradual and schematized manner, but package inserts do not currently bring this information in detail. It is of utmost importance that health professionals be educated on their conduct, hence the necessity for updating medication package inserts.

Psychometric properties of the Benzodiazepine Dependence Self-Report Questionnaire - Portuguese Version (BENDEP-SRQ-PV)

Objective

To assess psychometric properties of the Benzodiazepine Dependence Self-Report Questionnaire – Portuguese Version (BENDEP-SRQ-PV) in a sample of Brazilian chronic hypnotic users.

Methods

One hundred and seventy-nine chronic hypnotic users (benzodiazepines and Z-drugs) were recruited, attended a psychiatric evaluation, and answered the BENDEP-SRQ-PV. Factor structure, reliability, and influence of covariates (dependence diagnosis and type of drug consumed) were assessed in a structural equation modelling environment. Discrimination was assessed with receiver operating characteristic (ROC) plots and stability with the test-retest method.

Results

Participants, mostly women (91.6%), aged 51 to 64 years old, had been using hypnotics for an average of 34.8 months, with a mean defined daily dose of 0.72. Psychometric analysis demonstrated construct and criterion validity, reliability, and response stability. The factor structure was maintained as originally proposed: problematic use (ω = 0.73), preoccupation (ω = 0.74), lack of compliance (ω = 0.74), and withdrawal (ω = 0.93).

Conclusion

The BENDEP-SRQ-PV is an adequate measure of hypnotic dependence in the Brazilian population of chronic users. Our results support using the scale for follow-up in clinical and research applications and in correlational studies.

Exploring the relationship of sleep quality with drug use and substance abuse among university students: a cross-cultural study

Background

There is a growing interest in studying the area of drugs and college students due to the negative effects that drugs have on a student’s social life, academics, psychology, finances, and health. So, this study aims to identify the relationship between drug/substance abuse and quality of sleep among university students in Yemen and Saudi Arabia.

The sample size was 935 (43.21% N = 404 female, 56.79% N = 531 male, 55.40% N = 518 Yemeni, and 44.60% N = 417 Saudi). Students responded to the Drug Abuse Screening Test (DAST-10), the Pittsburgh Sleep Quality Index (PSQI), and the Substance Abuse Questionnaire.

Results

The results showed a high prevalence of drug use: 43.1% of respondents (27.27% N = 219 Yemenis and 15.83% N = 148 Saudis) abuse drugs, 29.41% were in the low level of drug use, 10.48% were in the moderate level of drug use, 2.46% were in the substantial level of drug, and 0.75% were in the severe level of drug use as per the DAST-10. The differences between both countries in terms of drug use were significant (X2 19.394, P < 0.001). The prevalence rate of inhalants was 16.36% and of sedatives was 12.09%, and the differences between countries were significant. The prevalence of poor sleep quality was 24.81%; a total of 7.91% of respondents had very poor sleep quality, while 16.90% had poor sleep quality. The differences between countries were not significant.

The relationship between sleep quality and drug use, smoking, and substance abuse was significant. The quality of sleep decreased consistently with a high level of drug use or substance abuse.

Conclusions

Poor sleep quality is significantly associated with drug use and substance abuse, and it is important to recognize the factors affecting drug and substance abuse among university students. A significant contribution can make for the protection of university students by guaranteeing that psychological interventions for high-risk groups are planned in advance.

Epidemiologic assessment of benzodiazepine exposure among suicide deaths in Colorado, 2015-2017

BACKGROUND

Suicide rates have been climbing in the U.S., particularly in Rocky Mountain states such as Colorado. Benzodiazepines have been linked with suicidal ideation, but there have been few population level assessments of this link. We conducted a public health assessment to determine the epidemiology and prevalence of recent benzodiazepine exposure, among suicide deaths in Colorado from 2015 to 17.

METHODS

This epidemiologic assessment linked Colorado's Prescription Drug Monitoring Program, death certificate data, and Violent Death Reporting System to determine patterns of benzodiazepine exposure among suicide deaths in Colorado between 2015 and 2017. Recent benzodiazepine exposure was defined as receiving a prescription within 30 days of death or having a positive toxicology screen post-mortem.

RESULTS

Among the 3465 suicide deaths in Colorado between 2015 and 2017, 20% had recent benzodiazepine exposure, and nearly 50% of those also had recent opioid exposure. Recent benzodiazepine exposure was more common among females than males (34% versus 16%). Among suicide deaths, those who died via drug overdose were more likely to have had recent benzodiazepine exposure (48%), compared to suicides by firearm (17%), hanging/asphyxiation (13%) and all other methods (approximately 20%).

CONCLUSIONS

Benzodiazepines have been linked to suicidal ideation, but population level assessments of benzodiazepine exposure among suicide deaths are rare. Our epidemiologic assessment indicates a relatively high prevalence of recent benzodiazepine exposure that warrants further investigation from both clinical and public health perspectives.