Drug overdose deaths in Brazil between 2000 and 2020: an analysis of sociodemographics and intentionality

Objectives: To examine drug overdose records in Brazil from 2000 to 2020, analyzing trends over time in overdoses and overall sociodemographic characteristics of the deceased. Methods: Using data from the Brazilian Mortality Information System (Sistema de Informações sobre Mortalidade), we identified records from 2000-2020 in which the underlying cause-of-death was one of the following codes: X40-X45 (accidental poisoning), X60-X65 (intentional poisoning), or Y10-Y15 (undetermined intentionality poisoning). The Brazilian dataset included 21,410 deaths. We used joinpoint regression analysis to assess changes in trends over time. Results: People who died of drug overdoses in Brazil between 2000 and 2020 had a mean age of 38.91 years; 38.45% were women, and 44.01% were identified as White. Of the overdose deaths, 44.70% were classified as intentional and 32.12% were classified as unintentional. Among the identified drugs, stimulants were the most common class. However, most records did not report which drug was responsible for death. Conclusion: Sociodemographic trends in overdose deaths in Brazil must guide country-specific policies. Nevertheless, data collection protocols must be improved, particularly regarding the drug used in overdoses.

Violent behavior, perceived safety, and assault experiences among adolescents: results from the Brazilian National Adolescent School-based Health Survey

Objective To investigate factors associated with violent behavior in a large nationally representative sample of Brazilian adolescents. Methods The data were derived from the 2015 National Adolescent School-based Health Survey (Pesquisa Nacional de Saúde do Escolar [PeNSE]). The independent variables of interest included feelings of safety while on the way to and at school. The outcome was violent behavior, including bullying. Logistic regression models were developed to examine the relationship between violent behavior and each independent and control variable. Results In the adjusted regression model, male sex (aOR: 1.75; 95%CI 1.65-1.86), being assaulted by a family member (aOR: 1.74; 95%CI 1.59-1.90), and being assaulted in the past year (aOR: 1.70; 95%CI 1.57-1.85) all increased the chance of violent behavior. Feeling safe on the way to school (aOR: 0.82; 95%CI 0.74-0.92) and at school (aOR: 0.82; 95%CI 0.73-0.92) reduced the chance of violent behavior. Conclusion This study extends the body of literature on violent behavior among adolescents, demonstrating a correlation between school, domestic, family, or community violence and violent behavior. Our research supports the idea that adolescents who experience violence act violently with greater frequency. This finding has significant implications for pediatricians, child psychiatrists and psychologists, other health care professionals, school professionals, and other professionals involved in adolescent health. School professionals must be prepared to identify adolescents with violent behavior due to its potential consequences for their mental and physical health.

Treatment compliance and risk and protective factors for suicide ideation to completed suicide in adolescents: a systematic review

Objective: To review the literature regarding adolescent suicide risk and explore the associations between treatment compliance (expressed as a concept including measured adherence to treatment and/or mental health service utilization) and risk and protective factors for suicidal behavior (SB), as well as the association between treatment compliance and reattempts. Methods: PubMed, LILACS, and Google Scholar were searched using the following terms: (adolescent*) AND (suicide*) AND (risk factor OR protective factors) AND (treatment compliance OR treatment attrition OR treatment adherence OR treatment drop out OR treatment retention OR mental health utilization). We retrieved studies that focused on the relation of treatment compliance to risk and protective factors for SB and that had only adolescent samples. Results: Of 4,841 articles, 30 original articles were selected for review. Most studies indicated high mental health service (MHS) utilization and poor treatment adherence by SB patients. Social minority status and conduct disorder were associated with less treatment adherence, while female sex, parental perceived need for treatment, and major depression were associated with greater treatment adherence. Inpatient and intensive emergency care after SA and family interventions improved MHS utilization and treatment compliance. However, we found no substantial protective effect of treatment compliance against reattempts. Conclusion: Effective treatment planning for compliance requires considering psychopathology, treatment planning, and social, familial, and individual factors.

Brazilian Psychiatric Association guidelines for the management of suicidal behavior. Part 2. Screening, intervention, and prevention

This article continues our presentation of the Brazilian Psychiatric Association guidelines for the management of patients with suicidal behavior, with a focus on screening, intervention, postvention, prevention, and promotion. For the development of these guidelines, we conducted a systematic review of the MEDLINE (via PubMed), Cochrane Database of Systematic Reviews, Web of Science, and SciELO databases for research published from 1997 to 2020. Systematic reviews, clinical trials, and cohort/observational studies on screening, intervention, and prevention in suicidal behavior were included. This project involved 14 Brazilian psychiatry professionals and 1 psychologist selected by the Psychiatric Emergencies Committee of the Brazilian Psychiatric Association for their experience and knowledge in psychiatry and psychiatric emergencies. Publications were evaluated according to the 2011 Oxford Center for Evidence-Based Medicine (OCEBM) Levels of Evidence Classification. Eighty-five articles were reviewed (of 5,362 initially collected and 755 abstracts on the drug approach). Forms of screening, intervention, and prevention are presented. The intervention section presents evidence for psychotherapeutic and drug interventions. For the latter, it is important to remember that each medication is effective only for specific groups and should not replace treatment protocols. We maintain our recommendation for the use of universal screening plus intervention. Although the various studies differ in terms of the populations evaluated and several proposals are presented, there is already significant evidence for certain interventions. Suicidal behavior can be analyzed by evidence-based medicine protocols. Currently, the best strategy is to combine several techniques through the Safety Plan. Nevertheless, further research on the topic is needed to elucidate some approaches with particular potential for intervention and prevention. Systematic review registry number: CRD42020206517

The contribution of mindfulness to outpatient substance use disorder treatment in Brazil: a preliminary study

Objective: To explore the contribution of a mindfulness-based intervention as an adjuvant to outpatient substance use disorder treatment. Outcomes included substance use behavior, depression and anxiety symptoms, and anger expression. Methods: This preliminary study for a pragmatic randomized controlled trial with stratified random allocation included three months of follow-up. In two outpatient clinics linked to public universities, a mindfulness-based intervention plus treatment as usual (experimental group n=22) was compared to treatment as usual (control group n=20). The study included data from self-report measurements and the patients' records, which were evaluated according to intention-to-treat analysis through generalized estimating equations and generalized method of moments estimation. Results: The experimental group had lower symptoms of depression (b=-6.82; 95%CI -12.45 to -1.18) and anxiety (b=-0.25; 95%CI -0.42 to -0.09), and anger expression (b=-9.76; 95%CI -18.98 to -0.54) three months after the intervention. We detected no effect on substance use behavior. Conclusion: The mindfulness-based intervention yielded promising results as an adjuvant to outpatient substance use disorder treatment, since it reduced levels of highly prevalent symptoms in this population. However, further studies with longer follow-up periods and larger samples are required.

Belief patterns and drug use in a sample of Brazilian youth: an exploratory latent class analysis

Objective: Adolescent substance abuse is a public health concern worldwide, and its prevention is the subject of numerous programmatic efforts. Yet, little research exists on the structure of drug-related belief patterns in youth and their utility in preventive program planning. The aim of this study is to determine the structure of drug-related beliefs among 12-15-year-old students in Brazil using latent class analysis. Methods: De-identified survey data were obtained from the baseline sample (n=6,176) of a randomized controlled trial on the #Tamojunto drug use prevention program in Brazilian middle schools. Using 11 survey items assessing drug-related beliefs as indicators, four models were run and assessed for goodness-of-fit. For the best fitting model, demographic variables and substance use across latent classes were assessed. Results: Model fit statistics indicated that the best fit was a three-class solution, comprising a large Drug-Averse Beliefs class (80.9%), a smaller Permissive Beliefs class (12.7%), and an Inconsistent Beliefs class (6.4%). Respondents in the Permissive Beliefs and Inconsistent Beliefs classes reported greater past-year drug use, were slightly older and less likely to be female than those in the Drug-Averse Beliefs class. Conclusions: These results indicate that conceptualizing drug beliefs as a categorical latent variable may be useful for informing prevention. Longitudinal studies are needed to establish temporality and assess further applicability of this construct.

Sociodemographic factors associated with smoking risk perception in adolescents in São Paulo, Brazil

Objective: We examined the sociodemographic factors associated with smoking risk perceptions (SRP) in youth living in two very different neighborhoods in the city of São Paulo, Brazil: a middle-class central area (Vila Mariana) and a poor outer-city area (Capão Redondo). Methods: A cross-sectional survey was conducted with 180 public school-attending youth (all aged 12 years) and their parents. SRP was evaluated through self-reports. Weighted multinomial logistic regression was used to examine factors associated with SRP. Results: Smoking was considered a high-risk behavior by 70.9% of adolescents. There were significant differences in SRP associated with socioeconomic status (SES) and maternal smoking status. Having a non-smoking mother was positively associated with perceiving smoking as having low to moderate risk versus no risk (OR=3.91 [95%CI 1.27-12.02]). Attending school in Capão Redondo was associated with perceiving smoking as having high risk compared to no risk (OR=3.00 [95%CI 1.11-8.12]), and low SES was negatively associated with perceiving at least some risk in smoking versus perceiving no risk in this behavior. Conclusions: Youth whose mothers smoke appear to have lower SRP than those whose mothers do not smoke. Living in a poor outer-city area was associated with higher SRP.

Exposure to violence: associations with psychiatric disorders in Brazilian youth

Objective: The effects of exposure to violent events in adolescence have not been sufficiently studied in middle-income countries such as Brazil. The aims of this study are to investigate the prevalence of psychiatric disorders among 12-year-olds in two neighborhoods with different socioeconomic status (SES) levels in São Paulo and to examine the influence of previous violent events and SES on the prevalence of psychiatric disorders. Methods: Students from nine public schools in two neighborhoods of São Paulo were recruited. Students and parents answered questions about demographic characteristics, SES, urbanicity and violent experiences. All participants completed the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) to obtain DSM-IV diagnoses. The data were analyzed using weighted logistic regression with neighborhood stratification after adjusting for neighborhood characteristics, gender, SES and previous traumatic events. Results: The sample included 180 individuals, of whom 61.3% were from low SES and 39.3% had experienced a traumatic event. The weighted prevalence of psychiatric disorders was 21.7%. Having experienced a traumatic event and having low SES were associated with having an internalizing (adjusted OR = 5.46; 2.17-13.74) or externalizing disorder (adjusted OR = 4.33; 1.85-10.15). Conclusions: Investment in reducing SES inequalities and preventing violent events during childhood may improve the mental health of youths from low SES backgrounds.