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SMAD. Revista eletrônica saúde mental álcool e drogas

On-line version ISSN 1806-6976

SMAD, Rev. Eletrônica Saúde Mental Álcool Drog. (Ed. port.) vol.14 no.3 Ribeirão Preto Jul./Sept. 2018

http://dx.doi.org/10.11606/issn.1806-6976.smad.2018.000412 

ORIGINAL ARTICLE
DOI: 10.11606/issn.1806-6976.smad.2018.000412

 

Differences in age and gender among CAPS ad users and the implications in the health care network

 

Las diferencias etarias y de género entre usuarios de CAPSs ad y las implicaciones en la red de atención

 

 

Marcos Antonio LopesI; Jonas Salomão SprícigoI; Myriam Raquel MitjavilaI; Daniela Ribeiro SchneiderI; Deidvid AbreuI

IUniversidade Federal de Santa Catarina, Florianópolis, SC, Brazil

 

 


ABSTRACT

OBJECTIVE: this study is part of the activities of the project Programa de Educação pelo Trabalho para a Saúde (PET-Saúde) [Education through Labor for Health Program ] and aimed to carry out a clinical and sociodemographic survey of users treated in Centros de Atenção Psicossocial, Álcool e Outras Drogas (CAPSs ad) [Psychosocial Care Centers for Alcohol and Other Drugs], in the City of Florianópolis.
METHOD: this is an observational and cross-sectional study. Data were collected through access to electronic records.
RESULTS: the population consisted of 1,191 Mainland and Island CAPS ad users. At the Island CAPS ad, alcohol dependent women were younger than men (p=0.075) and, in both CAPSs ad, cocaine/crack users were younger than alcohol users (p<0.05).
CONCLUSION: the age and gender differences have implications in the health care network.

Descriptors: Alcohol; Drugs; Users; Mental Health Services.


RESUMEN

OBJETIVO: este estudio forma parte de las actividades del Programa de Educação pelo Trabalho para a Saúde (PET-Saúde) [Programa de Educación por el Trabajo para la Salud] y tuvo como objetivo realizar un relevamiento clínico y sociodemográfico de los usuarios de los Centros de Atenção Psicossocial, Álcool e Outras Drogas (CAPSs ad) [Centros de Atención Psicosocial, Alcohol y Otras Drogas], en la Ciudad de Florianópolis.
MÉTODO: es un estudio observacional y transversal. Los datos fueron relevados de los registros electrónicos.
RESULTADOS: la población estuvo compuesta por 1.191 usuarios de los CAPSs ad Continente e Isla. En el CAPS ad Isla, las mujeres dependientes de alcohol eran más jóvenes que los hombres (p=0,075) y, en ambos CAPSs ad, los usuarios de cocaína/crack eran más jóvenes que los usuarios de alcohol (p<0,05).
CONCLUSIÓN: las diferencias etarias y de género tienen implicaciones en la red de atención.

Descriptores: Alcohol; Drogas; Usuarios; Servicios de Salud Mental.


 

 

Introduction

Psychosocial Care Centers (CAPSs) have been consolidated as important instruments for the Brazilian population’s mental health care. Since their creation, by Ordinance no. 336/GM dated February 19, 2002(1), which established the various CAPS modalities primarily aiming at treating users with severe mental disorders, 1,620 units were implemented in all regions of the country until 2010(2). Such expansion occurred from large to small urban centers and showed a great increase in the Northeastern region, which stood, at the end of this period, as the second largest region with proportional CAPS coverage (0.81/100 thousand inhabitants), remaining only behind the Southern region (0.87/100 thousand inhabitants). In particular, the 87% increase in the provision of Psychosocial Care Centers for Alcohol and Other Drugs (CAPSs ad) in the period from 2006 to 2010 is also noteworthy, as a total of 258 units were implemented to treat users with problems related to the use of alcohol and other drugs.

From a functional point of view, according to a survey conducted on 184 CAPS ad coordinators, 75% of the centers had a complete multiprofessional team, and almost all of them provided a great variety of services - family, group, workshops and home visits(2). These data thus showed that the CAPSs ad indicated in the Psychosocial Care Network(3) as the main sites of psychosocial care for users of alcohol and other drugs had appropriate conditions to fulfill the public policies that had already been established and have become consolidated in this area. Both the Policy for Integral Care for Alcohol and Drug Users(4) and the Integrated Plan to Combat Crack and Other Drugs(5) prioritize the integrality and transversality of care for users, thus being in consonance with the existing reality at the CAPSs ad. In addition, among the objectives of such policies are the development of human resources and the conduction of studies and diagnoses that can contribute to the improvement of measures for use prevention and users’ treatment and social reintegration.

Regarding the profile of users undergoing treatment, the data produced by the survey on CAPS ad coordinators showed a population predominantly consisting of adults and young individuals who mainly use alcohol, crack and tobacco. Three other Brazilian studies also provided sociodemographic information and data related to drug-use patterns among CAPS ad users. The study conducted in the City of Feira de Santana (State of Bahia) compared adolescents (12 to 19 years old) and young adults (20 to 24 years old) and observed a larger proportion of heavy marijuana use among adolescents and heavy alcohol use among young adults(6). When evaluating only alcohol users, the study conducted in the City of Teresina (State of Piauí) observed that almost half of the individuals in its sample were employed, married and had attended elementary school. Additionally, as regards the pattern of use, almost all of them used it daily (55%) or more than three times a week (35.2%)(7). In the study conducted in the City of Blumenau (State of Santa Catarina), problems resulting from alcohol use still prevailed, which was followed by the cross-use of substances, particularly the alcohol/marijuana/cocaine-crack tripod. Alcohol use was greater as age increased, while cross-use followed the opposite way, with higher occurrence among younger people(8). In all the studies, the population predominantly consisted of males (over 85%).

One aspect that needs to be investigated is the representation at the CAPSs ad in relation to the population of users of alcohol and other drugs present in the community. If we consider the use in the last month(9), which would be the closest to current and present use, what proportions of 36.1% of alcohol users, 0.3% of marijuana users and 0.3% of cocaine users are undergoing treatment at the CAPSs ad? Are the predominance of alcohol use among men, the peak of alcohol use by men between the ages of 25 and 34 and the peak in women between 18 and 24 years of age somehow reproduced at the CAPSs ad? In summary, it is necessary to obtain information about the clientele that demands treatment from CAPSs ad, thus seeking a better understanding of the role played by these institutions in relation to the population and the health care network. The present study aims at conducting a sociodemographic and clinical survey of users assisted by the CAPSs ad in the City of Florianópolis (State of Santa Catarina), investigating the prevalence of the main psychiatric diagnoses in the studied population with emphasis on those related to the use of psychoactive substances, and examining the sociodemographic and clinical distribution of such diagnoses.

 

Methods

This study is part of the activities in the project entitled Programa de Educação pelo Trabalho para a Saúde - PET-Saúde/Saúde Mental - Crack, Álcool e Outras Drogas (PET-Saúde/Saúde Mental/Crack) [Education through Labor for Health Program - Health/Mental Health - Crack, Alcohol and Other Drugs], promoted by the Department of Health (Work Management and Health Education Office, Health Care Office and National Office for Drug Policies) and the Department of Education (Higher Education Office)(10). "PET-Saúde/Saúde Mental/Crack presupposes education through work and aims at fostering tutorial learning groups in Care for Mental Health, Crack, Alcohol and Other Drugs, being characterized as an instrument for the in-service qualification of professionals for care provision in mental health, crack, alcohol and other drugs, as well as an instrument for the introduction to work and training of undergraduate students in health care programs, according to the needs of the Sistema Único de Saúde (SUS) [Brazilian Unified Health Care System], taking into account the qualification of care provision and the insertion of service needs as a source of knowledge production and research in higher-education institutions". This project was conducted through a partnership between the Federal University of Santa Catarina (UFSC) and the Prefeitura Municipal de Florianópolis (PMF) [Municipality of Florianópolis] and had the participation of four professors and 24 students from UFSC and four technicians from PMF in the period from March 2011 to February 2012.

Study Design

It is a descriptive, observational, cross-sectional study conducted at the CAPSs ad and based on the PMF’s electronic database.

Population

All users treated at the Mainland CAPS ad and Island CAPS ad in the City of Florianópolis from July 1 to December 31, 2011.

Instruments

Sociodemographic and clinical inventory. This inventory was completed according to the records of the services provided by the professionals working at the PMF CAPS ad, which were stored in its own electronic system. The digital database was consulted by students of Medicine, Psychology, Nursing and Social Work, after they were appropriately trained, and under supervision of PMF technicians and UFSC professors. A priori, sociodemographic variables included age, gender, education, professional occupation and socioeconomic status, and clinical variables were restricted to the main diagnoses related to the use of psychoactive substances.

Data Analysis

A descriptive analysis was performed including the main sociodemographic and clinical elements, and the proportions were initially calculated. Comparisons between groups were made by using chi-square and the corresponding p-value calculation.

Ethics in Research

The project followed recommendations from Resolution MS/CNS 466/2012 and was approved by the Comitê de Ética em Pesquisa com Seres Humanos of UFSC (CEPSH-UFSC) [Committee for Ethics in Research on Human Beings of UFSC].

 

Results

Initially, the data available in the electronic system for services provided by the PMF health care technicians and the recording format of such information were evaluated. Then, a form was designed in order to access age (by age ranges), gender, education (by categories) and the main diagnoses related to the use of alcohol and other drugs. Variables professional occupation, which showed a large variety of categories, and socioeconomic status were excluded from the survey. Due to the digital format of the records, it was not possible to calculate the mean age or the mean number of school years attended.

The population evaluated comprised 535 users of the Mainland CAPS ad and 656 users of the Island CAPS ad. The sociodemographic composition was very similar between the Mainland CAPS ad and the Island CAPS ad (Table 1) in relation to both age pattern (77.4% vs. 81.2%: between 20 and 49 years old) and education (65.1% vs. 69.1%: up to elementary school), and particularly in relation to gender (82.6% in both: males). However, when schooling was evaluated by gender, females showed significantly higher education than males at the Mainland CAPS ad (p=0.001).

As regards the diagnoses related to the use of psychoactive substances, the most prevalent at the Mainland CAPS ad and the Island CAPS ad were, respectively:

• Dependence on cocaine/crack: 40.7% and 50.7%.

• Dependence on alcohol: 28.0% and 32.97%.

• Harmful use of alcohol: 1.8% and 4.1%.

• Harmful use of cocaine/crack: 0.6% and 3.2%.

Marijuana dependence accounted for a very small proportion of users treated at both CAPSs ad (approximately 2.5%). It was not possible to specify the diagnosis of dependence on multiple substances or other substances, since there was, in different proportions in the two CAPSs ad, an overlap of such diagnosis with the other diagnoses restricted to a single type of substance, which is why it was excluded from the analysis.

Regarding gender, the male-female ratio at both CAPSs ad was as follows, considering that for each female at the Mainland CAPS ad and the Island CAPS ad, respectively, there were:

• Dependence on cocaine/crack: 8 and 6.2 males.

• Dependence on alcohol: 8.5 and 5.5 males.

Among the users with alcohol dependence at the Island CAPS ad, women were younger than men, with a female predominance in the age group below 40 years old (20.9% vs. 12%; p=0.075). At the Mainland CAPS ad, this result was not observed (Figures 1 and 2). Also, there was no gender difference in relation to presentation age at both services among cocaine/crack-dependent users. In other words, cocaine/crack-dependent men and women did not differ as regards age.

However, when comparing the presentation age among alcohol-dependent users and cocaine/crack-dependent users of each gender, a clear predominance of younger ages was observed among cocaine/crack-dependent users. In other words, cocaine/crack-dependent users tended to be younger than alcohol-dependent users at both services (Mainland CAPS ad: females: p=0.017, males: p<0.001; Island CAPS ad: females: p=0.002, males: p<0.001).

 

Discussion

The present study observed that, among the users assisted at the CAPSs ad in the City of Florianópolis, the most prevalent diagnoses were cocaine/crack dependence and alcohol dependence, with a reasonably larger number of users in the former group, and males were expressively predominant in both diagnoses. It was also observed that, among alcohol-dependent users at the Island CAPS ad, women were younger than men and, at both CAPSs ad, cocaine/crack-dependent users were younger than those alcohol-dependent.

When comparing the prevalence of cocaine/crack dependence and alcohol dependence in the Brazilian population present in the community, 0.9%(11) and 9-12.3%(12-13), respectively, with the proportions of these two diagnoses at the two CAPSs ad evaluated, an important inversion in favor of the former diagnosis was clearly observed. In other words, while for each cocaine/crack-dependent user in the community, there are approximately 10 alcohol-dependent users (1 to 10), at the two CAPSs ad such ratio is approximately 1 to 0.6 (the community data mentioned above are related only to cocaine dependence, since information concerning crack dependence is not available). Several hypotheses could explain that significant inversion although they have not been evaluated in this study and very little evidence has been found in other investigations. As regards the organization of health care services, would alcohol users have preferably been referred to other traditional health care services (primary care units, hospitals) or to therapeutic communities? Would the expressive presence of Family Health Teams in primary care in the City of Florianopolis, associated with the presence of Family Health Support Centers in the five sanitary districts(14), be contributing to the preferential access of alcohol users at this care provision level? On the other hand, would the application of "brief interventions" for problems related to alcohol use in primary care, according to orientation from the World Health Organization(15), in which the cases of alcohol dependence would be prepared and duly referred to specialized care, be failing to occur? Could the greatest stigma towards cocaine/crack users by health care professionals in primary care, whether actually present, be influencing such differentiated flow between alcohol users and cocaine/crack users in the health care network? Could another distinguished and essential variable in the orientation of the flow of cases in SUS Mental Health Care, which is severity, explain the greater presence of cocaine/crack users at the CAPSs ad if society’s perception that these cases are more serious than those of alcohol users is confirmed? However, a Spanish study on cocaine users undergoing treatment found greater severity among alcohol users when compared to cocaine users in several medical and psychosocial parameters(16). As regards hospitalization, a predominance of mental disorders resulting from alcohol use was observed over those stemming from the use of multiple substances or other psychoactive substances (most likely resulting mainly from cocaine/crack), in the data referring to hospitalization in the State of Rio de Janeiro (from 2008 to 2010)(17), 14.3% vs. 9.0%, and to psychiatric hospitalization in the City of Campo Grande, State of Mato Grosso do Sul (from 2004 to 2008)(18), 24.6% vs. 5.9%, respectively (the rates described in the State of Rio de Janeiro refer to males, since those found for females are very similar). Thus, a ratio of approximately 1 to 1.5 to 4 is observed between cocaine/crack-dependent users and hospitalized alcohol-dependent users. By transposing this reality to the City of Florianópolis, we could say that the hospitalization of alcohol-dependent users, in comparison with that of cocaine/crack-dependent users, would not explain the inversion of these two diagnoses in the present study. In spite of all these considerations about the structure of the health care network, there is also the self-perception of problematic alcohol users, involving the difficulties in acknowledging the problem itself and the need to seek treatment, which could be leading to a reduction in their presence in the health care services. National epidemiological data from the United States indicate that fewer than 25% of these users have already undergone treatment for those problems(19). In short, given such great complexity, it is necessary to gather more information so as to better understand the path that problematic alcohol and cocaine/crack users travel from the community to the health care services.

Gender differences, with a predominance of men between the two main diagnoses at both CAPSs ad and younger age among alcohol-dependent women at the Island CAPS ad, corroborate previous findings and contribute to the understanding of the unequal presentation of these problems between men and women. Although the drug-use pattern has been changing among women in recent decades, the prevalence of alcohol- and cocaine-dependent men in our milieu is still remarkable, according to national community surveys pointing to a male:female ratio of 5:1 and 3:1, respectively(11-12). Furthermore, in a study conducted in the City of Florianópolis on an adult population, three times as many "problems with alcohol use" were observed in men as in women(20). Specifically in relation to crack users, according to a national survey conducted in "use scenes" (Florianópolis is one of the study sites), again a male predominance was observed, with a ratio close to 3.5:1(21). However, in the present study, which shows very similar gender results to those in studies conducted at the CAPSs ad in the State of Piauí, and the Cities of Curitiba and Blumenau(7-8,22), the smaller proportion of women present in the services, as compared to that in the community, is noteworthy. Only at the Island CAPS ad was the gender ratio very similar to that in the community, thus indicating possible and real characteristics of the women in that area of coverage and/or organization of the health care service (for example, the creation of a specific group for women), which could have led to the greater female presence at that CAPS ad. With this regard, if on one hand women are generally seeking more help, on the other, they are more socially stigmatized by drug dependence, less likely to be diagnosed with problems resulting from alcohol use and presenting obstacles to treatment, such as fear of being abandoned by their spouses/partners and fear of losing their children(23).

With regard to the younger age of alcohol-dependent female users at the Island CAPS ad, this result probably reproduces what occurs in the community (the world data are conflicting), and it could be partly associated with women’s greater sensitivity to the effects of alcohol, which leads to their early help-seeking and/or onset of problems(24).

Further on the age differences in the present study, the results showing the older age of alcohol-dependent users as compared to cocaine/crack-dependent users, at both CAPSs ad, corroborate the results found in a Spanish study that also observed greater severity among the former users(16). Although they are inaccurate as to the age aspect, national community data show a proportionally higher dependence ratio over use in the past year (dependence prevalence: use prevalence in the past year) among cocaine users as compared to alcohol users(11- 13). In other words, the greater progression to dependence among cocaine users, and probably in a shorter time, may explain this age difference, which would be amplified, due to the same reasons, by the presence of crack users in both services.

The main limitations in this study are the digital form of data collection, which limited or prevented the analysis of variables of interest, and the procedure for inclusion of the main diagnoses, which led to the difficulty in clearly distinguishing users who were only alcohol dependent and those who were only cocaine/crack dependent from the ones with a diagnosis of multiple dependence, as well as in differentiating cocaine from crack users.

 

Conclusion

The main contributions from this study were the presentation of CAPS ad users’ profile, which is characterized by the marked predominance of males and the discrete predominance of cocaine/crack users in relation to alcohol users; the presentation of younger alcohol users among women than among men and the presentation of younger cocaine/crack users than alcohol users. In this way, it sought to shed light on certain aspects that influence both the morbidity and the flow of users of alcohol and other drugs within the health care network, especially in the City of Florianópolis.

 

Acknowledgment

To the PMF technicians and UFSC students who composed the PET team and contributed to data collection, and to the users of the CAPSs ad in the City of Florianópolis.

 

References

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Received: Ago 25th, 2017
Accepted: July 31st, 2018

Corresponding author:
Marcos Antonio Lopes
E-mail: lopes.marcos.ant@gmail.com
 https://orcid.org/0000-0002-1007-1721

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