EDITORIAL
DOI: 10.11606/issn.1806-6976.v13i2p60-63

Impacting themes

Margarita Antonia Villar Luis

Chief Editor of the SMAD, Revista Eletrônica Saúde Mental Álcool e Drogas, Full Professor of the University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, Brazil, e-mail: margarit@eerp.usp.br

This volume contains six original articles and one review, which discuss themes present in the discussions in the academic and other communication media, such as psychoactive substances, violence at work in psychiatry and suicide.

In two articles, the treatment of psychoactive substance addiction is discussed, describing the available (open and closed) institutions for this end, as well as the workers’ adherence to the theoretical models defining this treatment, who at bottom should be aligned with the foundations these institutions defend.

This result responds to the peculiarity in the Brazilian healthcare context, in which the antagonistic co-existence of perspectives is found, witnessing the contradictions of the Brazilian model. Despite recommending the damage reduction policy, modeled on the Psychosocial Care Centers to respond to the problems related to psychoactive substance use, this coexists with the therapeutic communities (religious or not)⁽¹⁾, as care providers that do not follow the institutional guidelines of the Unified Health System (SUS)⁽²⁾, representing a relevant aspect for consideration in the debate on these institutions, the care they offer and the role they play in societies.

In addition, it should be acknowledged that professional work, in line with the Psychosocial Model (originating in the psychiatric reform movement), demands flexibility in the professional roles, demanding some degree of versatility from the workers. Nevertheless, it should be taken into account that the work prescribed in the mental health project may differ from the actual work the professionals perform, an aspect that is appropriately presented in the specific article.

Some professionals are directly responsible for the users in legal terms, for the management of procedures and/or of the service itself, which can lead to excessive control and centralization of decisions, behaviors that need to be addressed in the service context through frank relationships that are open to dialogue. The greater share of responsibility should not make knowledge sharing, trust in the other’s competency and agreed decision taking unfeasible. The balance among positions is not an easy task and requires skills that can be gained with time, practice, effort and knowledge.

The mental and behavioral disorders due to psychoactive substance use represent considerable weight in psychiatric internments. In a study presented in this volume, this fact is evidenced, as well as the importance of professional activities that privilege the broad mental health perspective that truly incorporates addictive disorders. For the sake of reflection, it should be reminded that the neuropsychiatric conditions that most contribute to the disability adjusted life years are the unipolar and bipolar affective disorders, disorders due to the use of alcohol and other psychoactive substances, schizophrenia and dementia⁽³⁾. Therefore, these study results support this fact.

It is also highlighted that, in a global ranking of risk factors in the total disease burden (in the age range between 15 and 49 years), alcohol use ranks first, an important fact as an investment in the prevention of mortality due to accidents and neuropsychiatric conditions deriving from the consumption of this substance as, among men, alcohol and tobacco caused a relatively large disease burden when compared to other risk factors⁽⁴⁾.

Hence, in case of addictions, users who do not present a single health problem are increasingly frequent. Comorbidity is a recurring fact, not only in mental and behavioral disorders, but in other organic and infectious conditions as well. It is the responsibility of the care professional to heed that reality, which is not that new, but has appeared more strongly in the past years.

Crack emerged at the end of the 1980’s in Brazil and represents a source of national concern today. Due to its enigmatic, complex and multidimensional nature, it mobilizes society, experts, the media and even religious people⁽⁵⁾.

In this volume, studies were included in which the consequence of psychoactive substance use for crack-cocaine users are discussed and, in this case, the possible behavioral changes, such as attention deficit hyperactivity disorder, present in the comparison between users and non-users. Also, in a systematic review, the challenge for the user to cope with craving, the symptoms reported when the craving is felt and the strategies the users adopt to manage the discomfort are presented. The authors highlight the need to further deepen the studies on the influence of individual, interpersonal and social factors in craving.

The process of helping the user is not easy and demands effort and engagement from many departments, ranging from health and social services, which promote bonding with the users, to the possible elements that can be included as a part of their support network. In that sense, it is important to strengthen the user’s ability to cope with the "craving"⁽⁶⁾, permit comprehensive care and strengthen the psychosocial network, with a view to helping to recover or tighten bonds with social groups⁽⁷⁾.

The fear of relapse is constant among the participants, in view of the many uncertainties, fears and inquiries about their ability to overcome or control the use, which are frequent among drug users⁽⁸⁾.

Awareness-raising campaigns and specific governmental programs have been recurring in recent times as "combat" strategies. Hence, it is more than timely to present studies that contribute to the knowledge of aspects related to the use of this substance.

Another theme that is hardly explored in mental health research, addressed in an article in this volume, refers to the nurses’ perception of violence in the workplace in psychiatry, whose results appoint the following foci of origin: health team members, the patients themselves, the patients’ relatives and the institution, which does not offer the material and human resources needed to develop the work. The authors alert about the possible repercussions for the work performance and health of nursing workers.

Suffering at work is defined based on the wear factor, through fatigue, dissatisfaction with the professional relationships and with the task division. The hierarchical strictness, bureaucratic procedures, lack of participation in activities and limited professional growth perspective are important factors that cause suffering. In addition, due to differences between the prescribed task and the actually performed work, the subject faces a situation of ongoing effort to cope with his job reality⁽⁹⁾.

Unfortunately, this scenario seems to be very common among the nursing workers, which is severe, as this situation culminates in repercussions for care performance, interferes in professional satisfaction and, ultimately, in these workers’ health.

In coping with the situations that cause suffering, however, institutional support and cooperation from colleagues can contribute to normality, as these sources of support change the perception and, instead of burdens, these situations start to be faced as challenges, specifically in nursing, as opportunities to exercise creativity, solidarity and partnerships, which in this case turns suffering into pleasure⁽⁹⁾.

Therefore, the way the workspace is managed and the relations established among the members inside the team and among the different professional teams that compose the health service in this case, makes the difference between experiencing suffering or pleasure at work.

Suicide is a relegated theme to the detriment of others. Despite its importance, health researchers hardly seem inclined to investigate it, and the workers are very afraid of managing situations that may involve this condition, as suggested in the study published here, in which the authors try to describe the actions primary care nurses perform to prevent suicide.

Suicide has been discussed from two apparently opposite perspectives: on the one hand resulting from factors that originate in the social and cultural context, and on the other as a unique consequence of individual characteristics and experiences that make the subject attempt against his own life. The public health perspective approaches the position focused on suicide prevention. Therefore, however, both viewpoints need to be integrated to develop strategies that benefits most lives effective and measurably⁽¹⁰⁾.

Suicide prevention programs that use public health strategies are a recent initiative⁽¹¹⁾. The most common is to focus on high-risk groups (patients with severe depression and other mental illnesses) and promote strategies that target this population. This strategy by itself has not been the most effective though, due to its restriction of mental illnesses as risk factors in the planning of preventive actions, as these conditions are subject to high rates of false positives⁽¹²⁾, reducing the expected benefits of the program.

A frequently used strategy to bring down suicide rates has been environmental modification, whose denomination derives from its orientation on the restriction of the existing means in the environment used in suicide attempts, considering that the probability of suicide attempts drops when the individual has no available means for self-aggression. Nevertheless, that does not mean that (s)he will not different, accessible and perhaps less lethal methods. This represents a benefit as, from the public health and damage prevention perspective, the choice of less lethal methods can represent an advantage if the attempt does not end in death⁽¹⁰⁾.

In the results of the article presented, nursing professionals demonstrate that they are sensitized to understand the relevance of the suicide problem, but feel incapable of coping with it, either because they do not feel affinity with the problem or because they consider that they do not have specific skills which, for other illnesses or health problems, they could gain by training.

This issue becomes more complicated because suicidal behavior in general results from complex interactions among socio-environmental, behavioral and psychiatric factors⁽¹¹⁾. Training health teams to prevent this condition, which dramatically affects a wide range of community groups, requires a broad health focus, especially in mental health, attentively focused on different pressures from society, possible triggering factors of suffering, as well as on the individual vulnerabilities that affect the members of these groups.

There is also an urgent need to discuss the theme in the education of the professionals who deliver care to the population, and certainly in the health service context, during (increasingly necessary) support and continuing education meetings and not only on punctual occasions, when episodes of suicide or attempts appear that cause commotion in the spaces they occur in, whether in teaching or work. Attempting against one’s own life, or being successful in an event with this purpose frequently causes feelings of perplexity, anger, guilt, nonconformity and many others in the people who live or lived with the perpetrator of the self-aggression. None of these feelings is pleasant, and precisely this set of emotions should emerge and be addressed among the people going through this kind of experiences, also at places where prevention programs are planned, in which the emotions suicide attempts and suicide arouse should play a relevant role.

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