Factors associated with the use of anxiolytic drugs among military firefighters

Danielle Sandra da Silva de Azevedo Eduardo de Paula Lima Ada Ávila Assunção About the authors

ABSTRACT:

Introduction:

Use of anxiolytic drugs is an option for treating psychological symptoms. However, even if their use is controlled, there are risks of dependence, intoxication and cognitive alterations. Uncontrolled use among workers worsens these problems.

Objectives:

Identify the prevalence of anxiolytic use and to know the factors associated with consumption in military firefighters.

Method:

Cross-sectional survey of 711 firefighters from Belo Horizonte, Minas Gerais, Brazil, was conducted through self-reporting. Multinomial logistic regression was used to investigate associations between sociodemographic characteristics, living, working and health conditions and anxiolytic consumption in a controlled or uncontrolled manner.

Results:

Prevalence of anxiolytic use was 9.9%. For 7.5% of firefighters the consumption occurred without indication and/or specialized therapeutic control. Controlled use was only associated with symptoms compatible with Common Mental Disorder (OR = 23.6; 95%CI 6.54 - 85.11). Uncontrolled use was associated with length of service (OR = 2.57; 95%CI 1.03 - 6.40), smoking (OR = 3.22; 95%CI 1.50 - 6.91) and symptomatology compatible with Common Mental Disorder (OR = 4.02; 95%CI 2.17 - 7.45).

Conclusion:

The high prevalence of consumption indicates alert to occupational health programs.

Keywords:
Mental health; Occupational health; Anti-anxiety agents; Firefighters; Risk factors

INTRODUCTION

Anxiolytics are psychotropic adjunctive medications for the treatment of anxiety and other mental disorders11. Belleville G. Mortality hazard associated with anxiolytic and hypnotic drug use in the National Population Health Survey. Can J Psychiatry 2010; 55(9): 558-67. https://doi.org/10.1177/070674371005500904
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. They are a public health problem22. Sánchez MPV, Saint-Gerons DM, Honrubia CF, Bermejo DG, Corominas DM, Catalá-López F. Evolución del uso de medicamentos ansiolíticos e hipnóticos en España durante el período 2000-2011. Rev Esp Salud Pública 2013; 87(3): 247-55. http://dx.doi.org/10.4321/S1135-57272013000300004
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due to their increasing consumption and to the severity of adverse effects33. Carbon M, Correll CU. Rational use of generic psychotropic drugs. Adis Drugs 2013; 27(5): 353-65. https://doi.org/10.1007/s40263-013-0045-2
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.

When opting for the use of anxiolytics, it is essential to educate the user on the temporary nature of the prescription44. Schlosser VA, Ninnermann K. Introduction to the special section: the anthropology of psychopharmaceuticals: cultural and pharmacological efficacies in context. Cult Med Psychiatry 2012; 36(1): 2-9. https://doi.org/10.1007/s11013-012-9249-z
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and the necessary monitoring of the consumption55. Manthey L, Veen T, Giltay EJ, Stoop JE, Neven AK, Penninx BW, et al. Correlates of (inappropriate) benzodiazepine use: the Netherlands Study of Depression and Anxiety. Brit J Clin Pharmacol 2011; 71(2): 263-72. https://doi.org/10.1111/j.1365-2125.2010.03818.x
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. Anxiolytics can lead to addiction, intoxication, and cognitive and behavioral changes66. Dell’osso B, Lader M. Do benzodiazepines still deserve a major role in the treatment of psychiatric disorders? Eur Psychiatry 2013; 28(1): 7-20. https://doi.org/10.1016/j.eurpsy.2011.11.003
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.

The use of this type of medication can be a strategy for users to cope with the barriers they find in facing their anguish77. Leignel S, Schuster JP, Hoertel N, Poulain X, Limosin F. Mental health and substance use among self-employed lawyers and pharmacists. Occup Med 2014; 64(3): 166-71. https://doi.org/10.1093/occmed/kqt173
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. On the one hand, some barriers are related to the difficulty in compensating distressing effects through positive coping, such as physical and social activities88. Rebello TJ, Marques A, Gurejec O, Pike KM. Innovative strategies for closing the mental health treatment gap globally. Curr Opin Psychiatry 2014; 27(4): 308-14. https://doi.org/10.1097/YCO.0000000000000068
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, strengthening of family ties99. Avraham N, Goldblatt H, Yafe E. Paramedics’ experiences and coping strategies when encountering critical incidents. Qual Health Res 2014; 24(2): 194-208. https://doi.org/10.1177/1049732313519867
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and religious or spiritual trust1010. Thuné-Boyle ICV, Stygall J, Keshtgar MRS, Davidson TI, Newman SP. Religious coping strategies in patients diagnosed with breast cancer in the UK. Psychooncology 2011; 20(7): 771-82. https://doi.org/10.1002/pon.1784
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. On the other hand, the obstacles may be related to the deficiencies of mental health services33. Carbon M, Correll CU. Rational use of generic psychotropic drugs. Adis Drugs 2013; 27(5): 353-65. https://doi.org/10.1007/s40263-013-0045-2
https://doi.org/10.1007/s40263-013-0045-...
. In several localities, there is a shortage of professionals qualified to recognize the serious risks inherent in psychotropic drugs and other treatment possibilities1111. Lasserre A, Younès N, Blanchon T, Cantegreil-Kallen I, Passerieux C, Thomas G, et al. Psychotropic drug use among older people in general practice: discrepancies between opinion and practice. Br J Gen Pract 2010; 60(573): e156-62. https://dx.doi.org/10.3399%2Fbjgp10X483922
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.

Imbalances between the individual’s internal resources and contexts unfavorable to positive responses increase the chance of anxiolytic use77. Leignel S, Schuster JP, Hoertel N, Poulain X, Limosin F. Mental health and substance use among self-employed lawyers and pharmacists. Occup Med 2014; 64(3): 166-71. https://doi.org/10.1093/occmed/kqt173
https://doi.org/10.1093/occmed/kqt173...
. Workers in emergency services work in an environment characterized by high labor demands, as they deal with traumatic events, perform tasks in the face of imminent risks, and act under temporary pressure1212. Lim DK, Baek KO, Chung IS, Lee MY. Factors related to sleep disorders among male firefighters. Ann Occup Environ Med 2014; 26: 11. https://doi.org/10.1186/2052-4374-26-11
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. Such demands may exceed the ability to cope daily with strong emotional reactions1313. Adriaenssens J, De Gucht V, Van Der Doef M, Maes S. Exploring the burden of emergency care: predictors of stress-health outcomes in emergency nurses. J Adv Nurs 2011; 67(6): 1317-28. https://doi.org/10.1111/j.1365-2648.2010.05599.x
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.

In the case of military firefighters, besides being under the high demands inherent to emergency professionals1212. Lim DK, Baek KO, Chung IS, Lee MY. Factors related to sleep disorders among male firefighters. Ann Occup Environ Med 2014; 26: 11. https://doi.org/10.1186/2052-4374-26-11
https://doi.org/10.1186/2052-4374-26-11...
, they are also inserted in a work environment characterized by disciplinary and hierarchical rigidity1414. Hom MA, Stanley IH, Schneider ME, Joiner Jr. TE. A systematic review of help-seeking and mental health service utilization among military service members. Clin Psychol Rev 2017; 53: 59-78. https://doi.org/10.1016/j.cpr.2017.01.008
https://doi.org/10.1016/j.cpr.2017.01.00...
. Therefore, the nature of the activities and the negative psychosocial factors can influence the mental health of these professionals1515. Lima EP, Assunção AA, Barreto SM. Prevalence of depression among firefighters. Cad Saúde Pública 2015; 31(4): 733-43..

Assistance actions and mechanisms to protect the health of all workers are recommended both by the guidelines of the international agencies1616. World Health Organization. Global plan of action on workers’ health (2008-2017): baseline for implementation. Genebra: World Health Organization; 2013. and by public policies in Brazil1717. Brasil. Ministério da Saúde. Portaria nº 1.823, de 23 de agosto de 2012. Saúde do Trabalhador e da Trabalhadora. Brasília: Ministério da Saúde; 2012.. Epidemiological studies focusing on the use of psychoactive drugs by workers while performing their duties can support the planning of occupational surveillance actions by identifying factors associated with consumption. However, investigations that seek to know the circumstances of anxiolytic use in groups of urban emergency workers are rare. Thus, this study aimed to identify the prevalence of anxiolytic use and to know the factors associated with their use in military firefighters.

METHOD

Cross-sectional study based on data from the survey entitled “Posttraumatic Stress Disorder in Belo Horizonte Firefighters, Brazil”1818. Lima EP, Assunção AA, Barreto SM. Transtorno de Estresse Pós-Traumático (TEPT) em bombeiros de Belo Horizonte, Brasil: prevalência e fatores ocupacionais associados. Psic Teor Pesq 2015; 31(2): 279-88. http://dx.doi.org/10.1590/0102-37722015022234279288
http://dx.doi.org/10.1590/0102-377220150...
. The subjects were the male firefighters from the Military Fire Brigade of Minas Gerais (CBMMG) in exercise for more than 12 months in the three battalions, based in Belo Horizonte. Firefighters working for less than one year were excluded considering the minimum time of exposure to the occupational stressors necessary to observe health effects1919. Bryant RA, Guthrie RM. Maladaptive appraisals as a risk factor for posttraumatic stress: a study of trainee firefighters. Psychol Sci 2005; 16(10): 749-52. https://doi.org/10.1111/j.1467-9280.2005.01608.x
https://doi.org/10.1111/j.1467-9280.2005...
. The exclusion of women occurred due to the reduced number of women in the force (7.3%), which would make it impossible to construct multivariate models separated by sex. In addition, women firefighters are more susceptible to the use of anxiolytics and less active in operational service (the most exposed to risk factors)1818. Lima EP, Assunção AA, Barreto SM. Transtorno de Estresse Pós-Traumático (TEPT) em bombeiros de Belo Horizonte, Brasil: prevalência e fatores ocupacionais associados. Psic Teor Pesq 2015; 31(2): 279-88. http://dx.doi.org/10.1590/0102-37722015022234279288
http://dx.doi.org/10.1590/0102-377220150...
.

Of the 954 firefighters working for more than one year in the corporation, 160 were considered ineligible: 70 women, 30 on vacation or leave, 30 assigned to other units, and 30 participants in the pilot phase. Thus, 794 firefighters were invited to participate and 711 (89.5%) responded to the survey, surpassing the goal set for health studies (60%)2020. Livingston EH, Wislar JS. Minimum response rates for survey research. Arch Surg 2012; 147(2): 110. https://doi.org/10.1001/archsurg.2011.2169
https://doi.org/10.1001/archsurg.2011.21...
.

The data were collected between February and August 2011, through a structured questionnaire that was self-administered anonymously. Adequacy and applicability were tested in a pilot study.

The outcome (use of anxiolytics) was investigated in three groups:

  1. non-users (no use);

  2. users with clinical indication and under medical monitoring (controlled use);

  3. users with no clinical indication and/or medical follow-up (uncontrolled use).

The variable was elaborated from the answers to three questions of said instrument, considering the last 12 months:

  1. “Have you ever used tranquilizers (anxiety medicine)?”;

  2. “Has a doctor ever told you that you have had or currently has an anxiety disorder?”;

  3. “Have you ever undergone psychiatric care?”.

The first group (“no use”) was composed by firefighters who answered “no” to the first question. The second (“controlled use”) consisted of those whose answers were positive for the three questions. The third (“uncontrolled use”) included subjects with negative responses to the second and/or third questions.

The differentiation between groups sought to empirically examine the care given to subjects vulnerable to the use of anxiolytics, once exposure to occupational stressors was recognized. Thus, the presence of the mental pathology indicative of anxiolytic consumption was identified (question 2) and considered relevant to identify whether pharmacological therapy occurred during follow-up by specialized professionals (question 3). To compare the prevalence of anxiolytic use, the frequencies found in the literature were grouped according to the classification adopted in the present investigation.

The explanatory variables were grouped into four blocks, considering the level of approximation with the outcome:

  • sociodemographic (more distal level);

  • stressful life events;

  • work conditions;

  • health conditions (more proximal level).

The sociodemographic variables studied were: skin color, marital status, children, schooling, and monthly family income.

Stressful life events were evaluated through validated questions about situations experienced in the last 12 months, classified as adverse events and social discrimination2121. Lopes CS, Faerstein E, Dóra C. Eventos de vida produtores de estresse e transtornos mentais comuns: resultados do Estudo Pró-Saúde. Cad. Saúde Pública 2003; 19(6): 1713-20. http://dx.doi.org/10.1590/S0102-311X2003000600015
http://dx.doi.org/10.1590/S0102-311X2003...
. Both variables were categorized according to the amount of events lived.

The variables related to working conditions were: rank, time of service, operational stressors, organizational stressors (demand, control, support) and physical environment. Exposure to operational stressors was evaluated by the Traumatic Events List2222. Lima EP, Vasconcelos AG, Barreto SM, Assunção AA. Lista de eventos traumáticos ocupacionais para profissionais de emergências: adaptação e validação. Aval Psicol 2016; 15(3): 391-401. https://doi.org/10.15689/ap.2016.1503.12
https://doi.org/10.15689/ap.2016.1503.12...
, adapted for emergency professionals, in which are listed 15 typical stressors experienced during work in the last 12 months. Considering the median of the total score, the variable was analyzed dichotomously.

Organizational stressors were constructed using indicators of psychosocial aspects of work, evaluated by the Job Content Questionnaire (JCQ) in its Portuguese adapted version2323. Araújo TM, Karasek R. Validity and reliability of the job content questionnaire in formal and informal jobs in Brazil. Scand J Work Environment Health 2008; 34(6): 52-9.. Such an instrument maps the perception of psychosocial stressors in the workplace that relate to the demand required by the tasks, to the control over work and to social support. Based on the median, the dimensions were analyzed as dichotomous variables.

The workplace’s physical environment was investigated through questions regarding the availability of personal protective equipment (PPE), noise in the workplace, noise originated outside work, and the adequacy of material resources to perform the tasks. Positive responses were added and included as ordinal variable.

Regarding health conditions, the following were addressed: physical activity, smoking, problematic use of alcohol, and reporting of Common Mental Disorder (CMD) symptoms. To evaluate the existence of CMD-compatible symptoms, the Portuguese version of the Self-Reporting Questionnaire (SRQ)2424. Mari JJ, Williams P. A validity study of a psychiatric screening questionnaire (SRQ-20) in primary care in the city of São Paulo. Br J Psychiatry 1986; 148: 23-6. was used, which includes 20 questions for screening for non-psychotic disorders through somatic complaints. The variable considered seven or more positive responses as a cut-off point.

The problematic use of alcohol was analyzed by the CAGE Questionnaire for detection of alcoholism2525. Masur J, Monteiro M. Validation of the CAGE alcoholism screening test in brazilian psychiatry inpatient hospital setting. J Biol Res 1983; 16(3): 215-8., a tracking tool named with the acronym for its four questions: cut down, annoyed by criticism, guilty, and eye-opener. Two or more positive responses were considered indicative of alcohol abuse and dependence.

All participants signed an Informed Consent. The project was approved by CBMMG and by the Research Ethics Committee.

DATA ANALYSIS

Multinomial logistic regression was used to investigate the associations with the outcome in the three groups, the first being the reference. The entry of the explanatory variables considered the approximation in relation to the outcome: from the most distal to the most proximal level. There was a multicollinearity between age and length of service. The length of service variable was chosen because of the relevance for the interpretation of the study hypothesis.

The analysis was performed using Statistical Package for Social Sciences (SPSS) software version 20.0 in four stages. The first (descriptive) presented the frequencies of the variables. The second (univariate) verified probable factors related to controlled and uncontrolled use, considering p value ≤ 0.20. The third (multivariate intermediate) included the variables indicated in the previous step in each of the four blocks, with manual withdrawal graded according to the highest p value, considering p ≤ 0.10. The last step (multivariate final) grouped all variables selected in the intermediate models by blocks. The variables with the highest p value were excluded one by one, with only the p ≤ 0.05 remaining in the final model.

RESULTS

About 90% of firefighters reported not having used anxiolytics in the past 12 months. The use was reported by 70 (9.9%) firefighters, of whom 17 (2.4%) indicated controlled use and 53 (7.5%), uncontrolled use.

Among the respondents, the following were the predominant: brown skin color (51.8%), married (55.4%), children (53.1%), secondary schooling level (66%), and monthly family income up to seven minimum wages (65.5%). Among firefighters, 30.7% experienced two or more adverse events and 25.9% were exposed to some type of discrimination. There was a predominance of privates (45.3%) and those working for less than three years in the institution (35.3%). In relation to stressors, 48.8% reported high exposure to operational stressors, 46.9% had low control, 40.6% had high demand, 30.9% reported low support and 50.4% were experiencing two or more poor conditions in their physical work environment. Less than half (45.1%) practiced physical activity three or more times per week, 7.6% were smokers, 9.6% reported problematic use of alcohol and 15.9% had CMD-compatible symptoms.

In the univariate analysis, significant associations with the outcome indicated a higher proportion of uncontrolled consumption among firefighters with children. Controlled use was higher among those with less schooling (Table 1). There was greater consumption in both uses among firefighters with higher exposure to adverse life events (Table 2). There was an increase in the two modes of consumption in relation to the length of service (Table 3). There was a greater proportion in both modes among those with CMD-compatible symptoms. Uncontrolled use was also more frequent among smokers (Table 4).

Table 1.
Distribution of sociodemographic characteristics, according to the use of anxiolytics in firefighters. Brazil, 2011.
Table 2.
Distribution of life events according to the use of anxiolytics in firefighters. Brazil, 2011.
Table 3.
Distribution of working conditions according to the use of anxiolytics in firefighters. Brazil, 2011.
Table 4.
Distribution of health conditions according to the use of anxiolytics in firefighters. Brazil, 2011.

Considering controlled use, the following variables were included in the intermediate stage (p ≤ 0.20 in the univariate): children, schooling (socio-demographic block); adverse events (life events block); rank, time, control (work block); physical activity, alcohol, CMD (health block). As for uncontrolled use, these were included in the intermediate analysis: children, marital status (sociodemographic block); adverse events, discrimination (life events block); rank, time, operational stressor, support (work block); physical activity, smoking, alcohol, CMD (health block).

At the final stage of the multivariate analysis (p ≤ 0.10), the following variables were included for the controlled use: children, schooling, adverse events, time, control and CMD. In the final stage for uncontrolled use were: children, adverse events, time, operational stress, smoking and CMD. In the final model (p ≤ 0.05), only the CMD variable remained associated with controlled use of anxiolytics. As for uncontrolled consumption, these remained associated: time, smoking and CMD. The Goodness-on-fit test indicated a satisfactory fit of the final model (Table 5).

Table 5.
Final multivariate logistic regression for factors associated with the use of anxiolytics in firefighters. Brazil, 2011a.

DISCUSSION

The prevalence of anxiolytic use in firefighters was 9.9%. It should be pointed out that, for 7.5%, the use occurred without indication and/or specialized therapeutic control, being significantly associated with a longer time of service in the corporation, with smoking, and with reports of symptoms compatible with CMD.

Comparing the results with other samples of workers, the prevalence was superior to that of electricians (4%)2626. Souza SF, Carvalho FM, Araújo TM, Porto LA. Psychosocial factors of work and mental disorders in electricians. Rev Saúde Pública 2010; 44(4): 710-7. http://dx.doi.org/10.1590/S0034-89102010000400015
http://dx.doi.org/10.1590/S0034-89102010...
, lawyers (5%)77. Leignel S, Schuster JP, Hoertel N, Poulain X, Limosin F. Mental health and substance use among self-employed lawyers and pharmacists. Occup Med 2014; 64(3): 166-71. https://doi.org/10.1093/occmed/kqt173
https://doi.org/10.1093/occmed/kqt173...
and pharmacists (6%)77. Leignel S, Schuster JP, Hoertel N, Poulain X, Limosin F. Mental health and substance use among self-employed lawyers and pharmacists. Occup Med 2014; 64(3): 166-71. https://doi.org/10.1093/occmed/kqt173
https://doi.org/10.1093/occmed/kqt173...
; being similar to that found in military police (10%)2727. Souza ER, Schenker M, Constantino P, Correia BSC. Consumption of licit and illicit substances by police officers in the city of Rio de Janeiro. Ciên Saúde Coletiva 2013; 18(3): 66-76. http://dx.doi.org/10.1590/S1413-81232013000300012
http://dx.doi.org/10.1590/S1413-81232013...
. With regard to uncontrolled use, the result also surpassed the prevalence classified in this modality. Among workers in the tertiary sector, the prevalence of non-medical use was 2.5%2828. Molina S, Miasso AI. Benzodiazepine use among employees of a private company. Rev Latin-Am Enfermagem 2008; 16(n. esp.): 1-6. http://dx.doi.org/10.1590/S0104-11692008000700003
http://dx.doi.org/10.1590/S0104-11692008...
.

The high prevalence of use of anxiolytics in firefighters is intriguing. In view of the periodic health assessments carried out by the corporation, smaller values related to health impacts would be expected in this group1818. Lima EP, Assunção AA, Barreto SM. Transtorno de Estresse Pós-Traumático (TEPT) em bombeiros de Belo Horizonte, Brasil: prevalência e fatores ocupacionais associados. Psic Teor Pesq 2015; 31(2): 279-88. http://dx.doi.org/10.1590/0102-37722015022234279288
http://dx.doi.org/10.1590/0102-377220150...
. This result allows us to shed light on the phenomenon of presenteeism. It is possible that anxiolytic consumption indicates a strategy for the presence of the firefighters in the line of duty, despite some physical or psychological problems. Presenteeism relates health problems to loss of productivity, and failure to comply may lead to aggravation of the disease2929. Umann J, Guido LA, Grazziano ES. Presenteísmo em enfermeiros hospitalares. Rev Latino-Am Enfermagem 2012; 20(1): 159-66. https://doi.org/10.1590/S0104-11692012000100021
https://doi.org/10.1590/S0104-1169201200...
.

The chance of uncontrolled anxiolytic consumption increased linearly according to length of service in the corporation. However, it is difficult to distinguish the effects of work seniority from those related to age, because, generally, those who are older are also the ones at work for the longest time. If this is so, instead of directing the discussion to the focus that admits the accumulation of the effects of exposure to the working environment in the groups with longer working hours, it will be necessary to consider the expected effects of the human aging process. In older individuals, a higher prevalence of symptoms, chronic diseases, and treatment seeking, including drug therapy, is expected3030. Queiroz Netto MU, Freitas O, Pereira LRL. Antidepressivos e benzodiazepínicos: estudo sobre o uso racional entre usuários do SUS em Ribeirão Preto, São Paulo. Rev Ciênc Farm Básica Apl 2012; 33(1): 77-81.. Thus, firefighters with longer working hours may be more vulnerable to the cumulative effects of the activities performed, in addition to the physiological effects of aging3131. Chau N, Bhattacherjee A, Kunar BM, Group L. Relationship between job, lifestyle, age and occupational injuries. Occup Med 2009; 59(2): 114-9. https://doi.org/10.1093/occmed/kqp002
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.

Smoking is related to the consumption of anxiolytics in higher doses, because nicotine, by speeding up the metabolism, reduces the drug’s effect. It is known that cessation of smoking may reduce the uncontrolled use of anxiolytics3232. Nordfjaern T, Bjerkeset O, Bratberg G, Moylan S, Berk M, Grawe R. Socio-demographic, lifestyle and psychological predictors of benzodiazepine and z-hypnotic use patterns. Nord J Psychiatry 2014; 68(2): 107-16. https://doi.org/10.3109/08039488.2013.775342
https://doi.org/10.3109/08039488.2013.77...
.

Firefighters reporting symptomatology compatible with mental disorder presented four times more chance of uncontrolled consumption of anxiolytics. If, on the one hand, this result is consistent, because anxiolytics are used in the treatment of such symptoms3333. Gomes VF, Miguel TLB, Miasso AI. Common Mental Disorders: sociodemographic and pharmacotherapeutic profile. Rev Latin-Am Enfermagem 2013; 21(6): 1-9. http://dx.doi.org/10.1590/0104-1169.2990.2355
http://dx.doi.org/10.1590/0104-1169.2990...
, it is worrying, on the other hand, to identify that workers with psychic symptoms are using anxiolytics without specialized therapeutic follow-up.

Uncontrolled consumption of anxiolytics by active firefighters calls for in-depth discussions regarding the increase in risks of adverse effects arising from use without adequate monitoring. The practice of inappropriate consumption of psychiatric medication can have serious consequences, such as precarious living, especially due to the high risk of dependence22. Sánchez MPV, Saint-Gerons DM, Honrubia CF, Bermejo DG, Corominas DM, Catalá-López F. Evolución del uso de medicamentos ansiolíticos e hipnóticos en España durante el período 2000-2011. Rev Esp Salud Pública 2013; 87(3): 247-55. http://dx.doi.org/10.4321/S1135-57272013000300004
http://dx.doi.org/10.4321/S1135-57272013...
. In the social sphere, the possible cognitive and behavioral changes generated by the uncontrolled consumption of anxiolytics can cause interpersonal conflicts and increase the occurrence of accidents33. Carbon M, Correll CU. Rational use of generic psychotropic drugs. Adis Drugs 2013; 27(5): 353-65. https://doi.org/10.1007/s40263-013-0045-2
https://doi.org/10.1007/s40263-013-0045-...
; in addition to raising costs for the health system, including the use of emergency care and hospitalization3434. McPhail SM. Multimorbidity in chronic disease: impact on health care resources and costs. Risk Manag Healthc Policy 2016; 9: 143-56. https://dx.doi.org/10.2147%2FRMHP.S97248
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.

In this survey, the use of anxiolytics was not related to coping with symptoms arising from labor-related factors. There are two characteristics in this professional field that possibly explain such an outcome. The first is the employment relationship of firefighters. The guarantee of permanence in the job can help implementing instrumental coping strategies3535. Colell E, Sanchez-Niubo A, Ferrer M, Domingo-Salvany A. Gender differences in the use of alcohol and prescription drugs in relation to job insecurity. Int J Drug Policy 2016; 37: 21-30. https://doi.org/10.1016/j.drugpo.2016.07.002
https://doi.org/10.1016/j.drugpo.2016.07...
. Therefore, it is possible to assume that the employment stability of firefighters attenuated the magnitude of the effects of labor stressors3636. Lassalle M, Chastang JF, Niedhammer I. Working conditions and psychotropic drug use: cross-sectional and prospective results. J Psychiatr Res 2015; 63: 50-7. https://doi.org/10.1016/j.jpsychires.2015.02.019
https://doi.org/10.1016/j.jpsychires.201...
. The second characteristic is the social recognition given to firefighters. Strengthened self-esteem in recognition situations favors resilience mechanisms3737. Lee JS, Ahn YS, Jeong KS, Chae JH, Choi KS. Resilience buffers the impact of traumatic events on the development of PTSD symptoms in firefighters. J Affect Disord 2014; 162: 128-33. https://doi.org/10.1016/j.jad.2014.02.031
https://doi.org/10.1016/j.jad.2014.02.03...
. Thus, resilience and self-esteem are psychological characteristics that can exert modulations on symptoms and adversities3838. Hiyoshi A, Udumyan R, Osika W, Bihagen E, Fall K, Montgomery S. Stress resilience in adolescence and subsequent antidepressant and anxiolytic medication in middle aged men: Swedish cohort study. Social Sci Med 2015; 134: 43-9. https://doi.org/10.1016/j.socscimed.2015.03.057
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, favoring adaptive confrontation methods3939. Horn SR, Charney DS, Feder A. Understanding resilience: new approaches for preventing and treating PTSD. Exp Neurol 2016; 284(Pt B): 119-32. https://doi.org/10.1016/j.expneurol.2016.07.002
https://doi.org/10.1016/j.expneurol.2016...
. These characteristics seem to mark the entrance and the permanence of these professionals, favoring the confrontation process to take place in the occupational routine, with less adherence to the practice of seeking solutions in drug therapy.

It is worth highlighting the importance of improving occupational surveillance actions in order to identify early risk factors and increase access to mental health services, so as to ensure vulnerable workers the tranquility to report symptoms and adhere to the treatment, when applicable1414. Hom MA, Stanley IH, Schneider ME, Joiner Jr. TE. A systematic review of help-seeking and mental health service utilization among military service members. Clin Psychol Rev 2017; 53: 59-78. https://doi.org/10.1016/j.cpr.2017.01.008
https://doi.org/10.1016/j.cpr.2017.01.00...
. It is noteworthy that CBMMG initiatives have innovated the work of occupational health services. Special mention is made of the recent regulation of the Occupational Health Program of Military Firefighters4040. Minas Gerais. Resolução nº 640, de 15 de outubro de 2015. Programa de Saúde Ocupacional Bombeiro Militar. Belo Horizonte: Corpo de Bombeiros Militares de Minas Gerais; 2015., whose focus is the early screening of psychic symptoms identified in a previous study1818. Lima EP, Assunção AA, Barreto SM. Transtorno de Estresse Pós-Traumático (TEPT) em bombeiros de Belo Horizonte, Brasil: prevalência e fatores ocupacionais associados. Psic Teor Pesq 2015; 31(2): 279-88. http://dx.doi.org/10.1590/0102-37722015022234279288
http://dx.doi.org/10.1590/0102-377220150...
. This program intends to recover the interface with the National Mental Health Policy4141. Brasil. Ministério da Saúde. Lei nº 10.216, de 6 de abril de 2001. Política Nacional da Saúde Mental. Brasília: Ministério da Saúde ; 2001. insofar as it proposes not only periodical individual clinical evaluation, but also an integral and collective approach, through a multiprofessional team with permanent qualification.

The findings of this study suggest three reflections: the use of anxiolytics among older firefighters causes greater vulnerability to adverse effects; the association with smoking is an overlapping of coping strategies that is harmful to health; and the consumption of anxiolytics is related to the worse state of mental health.

LIMITATIONS AND ADVANTAGES

Because of the study’s design, it is impossible to establish causal and/or temporal relationships. The information obtained through self-report is subject to bias because it causes the subjects to minimize their failures in the care for their own health or to value their personality4242. Reuver M, Bouwman H. Dealing with self-report bias in mobile internet acceptance and usage studies. Information Management 2015; 52(3): 287-94. https://doi.org/10.1016/j.im.2014.12.002
https://doi.org/10.1016/j.im.2014.12.002...
. However, when used after an adequate pilot test, self-reports have high validity and reliability4343. Pacheco DS, Sakae TM. Validade do autorrelato de diabete mellitus gestacional no pós-parto imediato em hospital privado no sul de Santa Catarina. Arq Catarin Med 2012; 41(1): 47-50..

The comparison of the consumption figures with other groups was limited, due to the heterogeneity of the parameters to study and classify the prevalences of anxiolytic use22. Sánchez MPV, Saint-Gerons DM, Honrubia CF, Bermejo DG, Corominas DM, Catalá-López F. Evolución del uso de medicamentos ansiolíticos e hipnóticos en España durante el período 2000-2011. Rev Esp Salud Pública 2013; 87(3): 247-55. http://dx.doi.org/10.4321/S1135-57272013000300004
http://dx.doi.org/10.4321/S1135-57272013...
. In addition, the results may have been underestimated, given the moral barriers to revealing symptoms and practices, especially in military institutions that are faithful to behavioral norms1414. Hom MA, Stanley IH, Schneider ME, Joiner Jr. TE. A systematic review of help-seeking and mental health service utilization among military service members. Clin Psychol Rev 2017; 53: 59-78. https://doi.org/10.1016/j.cpr.2017.01.008
https://doi.org/10.1016/j.cpr.2017.01.00...
, and also because of the Healthy Worker Effect, a common survival effect in cross-sectional studies, since patients are more likely not to be in their posts at the time of the research4444. Naimi AI, Richardson DB, Cole SR. Causal inference in occupational epidemiology: accounting for the healthy worker effect by using structural nested models. Am J Epidemiol 2013; 178(12): 1681-6. https://doi.org/10.1093/aje/kwt215
https://doi.org/10.1093/aje/kwt215...
.

It should also be mentioned that the model used, with hierarchical input of variables, as well as the amplitude of the confidence intervals for association estimates, although reflecting the initial expectation considering the characteristics of the outline and the population, indicate caution when interpreting the results. In addition, bias is possible because the analyzes were not adjusted for sex.

The novelty of the approach to emergency professionals, the high rate of participation and the use of instruments validated and adapted to the Brazilian context ensured the quality and relevance of the study. The training and supervision of the collection team minimized possible biases. The pilot phase allowed for the adequacy of the items constructed for the questionnaire and the participants’ adherence. The distribution of the respondents in the three groups of outcome analysis allowed the comparison between them and reinforced the innovative character of this investigation. Taken together, such characteristics increased the strength of the results to support the interpretations presented.

CONCLUSION

The prevalence of anxiolytic use in military firefighters was higher than in other professional categories. The high consumption in a group with such social responsibility requires alertness and deserves special attention from managers and government agencies. Uncontrolled consumption increases the risks of adverse effects, and may compromise workers’ quality of life.

The association of uncontrolled use of anxiolytics with increased time in the corporation can increase the vulnerability of firefighters. The findings also indicate that anxiolytic and smoking is a risky combination of harmful habits, and consumption associated with worse mental health indicates a response to deal with suffering.

The results stimulate the continuity of investigations related to firefighters’ health, especially regarding innovations in the planning of mental health services. Prospective studies may further analyze the factors associated with drug consumption and the mechanisms involved.

ACKNOWLEDGEMENTS

The authors would like to thank the Minas Gerais Military Fire Brigade for their collaboration.

Ethics Approval: The study was approved by the Research Ethics Committee of Universidade Federal de Minas Gerais (ETIC nº 0387.0.203.000-10).

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  • Financial support: none

History

  • Received
    04 July 2017
  • Reviewed
    18 Sept 2017
  • Accepted
    18 Oct 2017
  • Online publication
    21 Mar 2019
Associação Brasileira de Pós -Graduação em Saúde Coletiva São Paulo - SP - Brazil
E-mail: revbrepi@usp.br