When mourning becomes pandemic

Pandemics tend to be marked by mass losses, not only of human lives, but also of routines, customs, and rules, forcing people to cope with a scenario of atypical unpredictability ¹1. Weir K. Grief and COVID-19: mourning our bygone lives. https://www.apa.org/news/apa/2020/grief-covid-19 (acessado em 28/Mai/2021).
https://www.apa.org/news/apa/2020/grief-... . Expected consequences include an increase in psychological suffering, stress, anxiety, and irritability, besides prolonged fear and insecurity. Thus, an increase in the incidence of psychiatric disorders is predicted, including depression, anxiety, and post-traumatic stress disorder ²2. Bao Y, Sun Y, Meng S, Shi J, Lu L. 2019-nCoV epidemic: address mental health care to empower society. Lancet 2020; 395:e37-8.. According to the COVID-19 Data Repository of Johns Hopkins University (United States), as of August 28, 2021 there had been 578,326 deaths from the novel coronavirus in Brazil, representing almost 13% of the 4.49 million deaths in the world ³3. Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infec Dis 2020; 20:533-4.. In this context, the intrinsic burden of uncertainties during the current pandemic has been accompanied by a need for changes in habits, customs, and protocols that involve patients, deaths, and mourning, aimed at reducing spread of the virus. Clearly, the impacts on rituals surrounding death reflect negatively on the psychosocial domains of individuals and social groups in mourning. In addition, sequential mourning within the same family is not rare, making the process even more difficult ⁴4. Wallace CL, Wladkowski SP, Gibson A, White P. Grief during the COVID-19 pandemic: considerations for palliative care providers. J Pain Symptom Manage 2020; 60:e70-6..

In the normal mourning process, the experience of suffering emerges as an opportunity to learn, change, and develop, a process known as “traumatic growth”. Working through mourning is facilitated by rituals of farewell/passage, social and family communication, sharing memories of happy moments, expressions of gratitude, requests for forgiveness, and obtaining answers - even if subjective and private - to various questions. In Brazilian culture, such occasions involve physical closeness, handshakes, and hugs, so the health measures that recommend reduction or elimination of these experiences exacerbate the families’ anguish, instilling a feeling of guilt that their loved ones have not received the farewell they deserve ⁵5. Crepaldi MA, Schmidt B, Noal DDS, Bolze SDA, Gabarra LM. Terminalidade, morte e luto na pandemia de COVID-19: demandas psicológicas emergentes e implicações práticas. Estud Psicol (Campinas) 2020; 37:e200090.. The stress provoked by these situations can lead to complicated mourning, sometimes considered pathological, in which the premise of emotional growth is not completely valid, since brooding and persistent negative feelings may lead to the development of prolonged anxious and/or depressed states ⁶6. Mello R. Luto na pandemia Covid-19. Revista PsicoFAE: Pluralidades em Saúde Mental 2020; 9:7-17..

Further in the pandemic context, the uncertainty and possibility of death can lead to anticipatory mourning, which is experienced by family members and health professionals dealing with patients naturally at the end of life (e.g., elderly, individuals with serious diseases) or, in the current case, with severe COVID-19 )⁷. Such suffering can be experienced even before actual death, through empathy for the affected families and the sensitization caused by social instability ¹1. Weir K. Grief and COVID-19: mourning our bygone lives. https://www.apa.org/news/apa/2020/grief-covid-19 (acessado em 28/Mai/2021).
https://www.apa.org/news/apa/2020/grief-... . The acknowledgement of each individual’s unique pain thus requires the development of personalized strategies of care by health professionals, facilitating functional adaptation and the promotion of mental health in moments such as in the present pandemic ⁷7. Zhai Y, Du X. Loss and grief amidst COVID-19: a path to adaptation and resilience. Brain Behav Immun 2020; 87:80-1..

Pathologization of suffering and increased consumption of psychoactive drugs

In this time of increased psychosocial burden, the impact on mental health is an expected consequence ²2. Bao Y, Sun Y, Meng S, Shi J, Lu L. 2019-nCoV epidemic: address mental health care to empower society. Lancet 2020; 395:e37-8.. More than in other situations, there is an evident reconfiguration of the purpose of psychoactive medication, with an increase in prescriptions, which have come to viewed as “conflict mediators” as the basis for management of any sign of psychological suffering labeled as illness, even if the pain is consistent with the catastrophic moment. This type of management reinforces the predominance of biomedical rationality and the view of diseases as concrete and immutable entities, suppressing the uniqueness of subjects, spaces, and contexts, especially relevant in psychiatric conditions ⁸8. Molck BV, Barbosa GC, Domingos TS. Psicotrópicos e atenção primária à saúde: a subordinação da produção de cuidado à medicalização no contexto da saúde da família. Interface (Botucatu) 2021; 25:e200129.. There is an alarming reduction in the space reserved for experiencing the pain and working through losses, with a worrisome and growing medicalization of natural life phenomena. This includes arbitrarily considering normal mourning as a pathological category, redefining normal events through a biomedical prism ⁹9. Conrad P. The medicalization of society: on the transformation of human conditions into treatable disorders. Baltimore: Johns Hopkins University Press; 2007.. Importantly, there is no single culprit: although medical intervention is important in this pathologization, the phenomenon can also occur with other health professionals and even with other social actors such as patients themselves, family members, and associations, frequently biased by the culture of excessive medicalization ¹⁰10. Conrad P. Medicalization and social control. Annu Rev Sociol 1992; 18:209-32..

The issue generated controversies ¹¹11. Wakefield JC. The DSM-5 debate over the bereavement exclusion: psychiatric diagnosis and the future of empirically supported treatment. Clin Psychol Rev 2013; 33:825-45.^,1212. Iglewicz A, Seay K, Zetumer SD, Zisook S. The removal of the bereavement exclusion in the DSM-5: exploring the evidence. Curr Psychiatry Rep 2013; 15:413. during the drafting of the latest revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), considering proposals that would lower the diagnostic threshold for depressive disorders by removing recent mourning as an exclusion criterion ¹³13. Park SC, Kim YK. Challenges and strategies for current classifications of depressive disorders: proposal for future diagnostic standards. Adv Exp Med Biol 2021; 1305:103-16.. In addition to touching on philosophical and scientific questions, the medicalization of emotional responses to loss may represent not only important ethical dilemmas ¹⁴14. Zachar P. Grief, depression, and the DSM-5: a review and reflections upon the debate. Rev Latinoam Psicopatol Fundam 2015; 18:540-50.^,1515. Kaczmarek E. Promoting diseases to promote drugs: the role of the pharmaceutical industry in fostering good and bad medicalization. Br J Clin Pharmacol 2021; 1-6. but also an opportunity to leverage the prescription of psychoactive drugs and promote pharmacological interventions, or “pharmaceuticalization” applied to daily reality, whether mediated by health professionals or not (via self-medication) ¹⁶16. Camargo Jr. KR. Medicalização, farmacologização e imperialismo sanitário. Cad Saúde Pública 2013; 29:844-6.^,1717. Esher A, Coutinho T. Uso racional de medicamentos, farmaceuticalização e usos do metilfenidato. Ciênc Saúde Colet 2017; 22:2571-80.. The pharmaceutical management of recent mourning with antidepressants or anxiolytics, for example, is not only seriously simplistic (i.e., as a search for a “silver bullet” or universal panacea), but also flawed. For many people, the experience may be part of adequately working through mourning (which alone is already counter to the view that it should be suppressed pharmacologically). Besides, there is a lack of clear evidence to justify this kind of intervention ¹⁸18. The Lancet. Living with grief. Lancet 2012; 379:589.^,1919. Kleinman A. Culture, bereavement, and psychiatry. Lancet 2012; 379:608-9..

The population often overuse psychoactive drugs, either through self-medication or prescription error ²⁰20. Rassool GH. The rational use of psychoactive substances. Nurs Stand 2005; 19:45-51.. The inappropriate use of such drugs may involve tolerance, excessive dosage, dependence, and unpredictable interactions with other drugs ²¹21. Preuss CV, Kalava A, King KC. Prescription of controlled substances: benefits and risks. Treasure Island: StatPearls Publishing; 2021., resulting in harm to the individual’s social life on top of the mourning that they are already experiencing. Average annual consumption of psychoactive drugs in Brazil is 500 million presentations (boxes or bottles), up to 70% of which potentially represented by benzodiazepines ²²22. Laureano FRC, Falone VE, Amaral-Filho WN, Amaral WN. Medicamentos psicotrópicos: uso, prescrição e controle. Rev Goiana Med 2015; 47:22-6., which are used for a wide variety of reasons, from anxiety and sleep disorders to epilepsy and as adjuvants in anesthetic procedures, with a major risk of developing addiction due to indiscriminate use.

A study in Curitiba (Brazil) in 2017 ²³23. Fávero VR, Sato MDO, Santiago RM. Uso de ansiolíticos: abuso ou necessidade? Visão Acadêmica 2017; 18:98-106. interviewed users and found that 84.4% of indications for use of psychoactive drugs - especially anxiolytics - were made by physicians, mainly general practitioners (47%), psychiatrists (25%), and neurologists (15.6%). Twenty-five percent of interviewees reported ever having received the medicines from friends or acquaintances, and 15.6% said they had used them without a prescription, even though the sale of psychoactive medicines is controlled in Brazil. The principal complaints leading to their use included insomnia (62.5%), depression (53.1%), and anxiety (43.8%), although some interviewees had used them without professional follow-up and possibly lacked a formal diagnosis. More than two-thirds of the interviewees (68.7%) had used them for more than a year, and 30% reported at least one previous attempt to discontinue their use. Failure to discontinue psychoactive medication is frequently associated with the rebound of the principal complaints, such as nervousness, insomnia, agitation, and restlessness, predisposing to oscillating consumption of these psychoactive drugs.

Stressors are triggers or aggravators of mental disorders and thus intensify the abuse of legal drugs such as alcohol, tobacco, and medicines, besides illicit drugs ²⁴24. Pfefferbaum B, North CS. Mental health and the Covid-19 pandemic. N Engl J Med 2020; 383:510-2.^,2525. Clay JM, Parker MO. Alcohol use and misuse during the COVID-19 pandemic: a potential public health crisis? Lancet Public Health 2020; 5:e259.. Especially in the last two years, one can assume the pandemic´s importance and impacts as critical factors for the increase in medicalization associated with the use (rational or otherwise) of psychoactive drugs. In fact, comparing the first quarter of 2020 (covering the period immediately prior to and concurrent with the first COVID-19 cases in Brazil) and 2021 (during the pandemic), there was a considerable increase in the sale of various psychoactive drugs in Brazil, for example, the antidepressants bupropion (137%), amitriptyline (41.5%), escitalopram (37.9%), and trazodone (17.4%), the benzodiazepine bromazepam (120%), and the hypnotic zopiclone (29.3%) ²⁶26. Brasil. Consultar dados de vendas de medicamentos controlados, antimicrobianos e outros. https://www.gov.br/pt-br/servicos/consultar-dados-de-vendas-de-medicamentos-controlados-antimicrobianos-e-outros (acessado em 25/Mai/2021).
https://www.gov.br/pt-br/servicos/consul... . Notably, these increases are not constant when one compares the same periods with previous years, which reinforces the association between the COVID-19 pandemic and the current sudden increase. Although not surprising, the increase in the sale of these drugs during the pandemic should be assessed critically and cautiously: one cannot rule out the expected increase in the incidence of psychiatric disorders during the pandemic ²2. Bao Y, Sun Y, Meng S, Shi J, Lu L. 2019-nCoV epidemic: address mental health care to empower society. Lancet 2020; 395:e37-8. or underestimate the importance of therapeutic management in adequate cases, which would explain at least an important share of these statistics.

Medicalization and pharmaceuticalization are part of Brazilian culture, especially in some niches of the lay population, who feel that a medical consultation is incomplete if it does not include a drug prescription ²⁷27. Zorzanelli RT, Giordani F, Guaraldo L, Matos GCD, Brito Junior AGD, Oliveira MGD, et al. Consumo do benzodiazepínico clonazepam (Rivotril(r)) no Estado do Rio de Janeiro, Brasil, 2009-2013: estudo ecológico. Ciênc Saúde Colet 2019; 24:3129-40.. Still, although the indication of psychoactive drugs is common practice in extreme situations, their rational use should always be recommended ²⁸28. Fundação Oswaldo Cruz. Saúde mental e atenção psicossocial na pandemia COVID-19: psicofármacos na COVID-19. https://www.arca.fiocruz.br/bitstream/icict/41826/2/Cartilha_Psicofarmacos.pdf (acessado em 25/Mai/2021).
https://www.arca.fiocruz.br/bitstream/ic... ^,2929. Banerjee D. The COVID-19 outbreak: crucial role the psychiatrists can play. Asian J Psychiatr 2020; 50:102014., keeping their use limited to evidence-based situations. The pandemic period is sensitive to the impact of irrational and even abusive prescription and use of medicines, and the implications extend beyond the drugs used directly in the context of COVID-19. The creation of World Smart Medication Day on May 6, 2021 ³⁰30. International Union of Basic & Clinical Pharmacology. World Smart Medication Day. https://iuphar.org/clinical-division/world-smart-medication-day (acessado em 25/Mai/2021).
https://iuphar.org/clinical-division/wor... , is consistent with this demand by encouraging educational measures to orient the rational use of medicines worldwide and increasing the issue’s visibility, given the burden of inappropriate use in generating harms to health and the onus for the global health system. The pharmaceuticalization of mourning raises serious issues with the lack of clarity as to the benefits, associated with the possible risks from the use of psychoactive drugs (e.g., iatrogenic effects, drug-drug interactions) and interference in the natural process of recovery ³¹31. Guina J, Rossetter SR, Derhodes BJ, Nahhas RW, Welton RS. Benzodiazepines for PTSD: a systematic review and meta-analysis. J Psychiatr Pract 2015; 21:281-303.. Working through mourning should not be seen as exemption from its experience or an “effacement of the associated memory”, but as adaptation and transposition of an emotional response that should not be arbitrarily suppressed or eliminated before an adequate assessment of the patient within his or her biopsychosocial context ¹⁸18. The Lancet. Living with grief. Lancet 2012; 379:589.^,1919. Kleinman A. Culture, bereavement, and psychiatry. Lancet 2012; 379:608-9..

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