Psychological suffering in a city of Northeast Brazil: gender and medicalization
In the study, 202 people answered the questionnaire SRQ-20 in the city of Santa Cruz/RN/Brazil. Of the respondents, 130 (64%) were women and 72 (36%) men. It was found that 47.02% of these people had a score greater than seven (07), that points out to a significant index of psychological suffering during the research process, which corroborates with other studies conducted in different Brazilian territories using the SRQ-20 (Gonçalves, Stein, Kapczinski, 2008; Moreira et al., 2011; Lucchese et al, 2014; Coutinho, Almeida Filho, Mari, 1999).
Our results also pointed that among 130 respondent women, (71) 54.61% had a score greater than seven. Among 72 respondent man, this rate was 33.33% (24). This results corroborate with other studies that point out the high rate of Brazilian women in suffering (Zanello, Fouad & Costa, 2015; Costa, Dimenstein & Leite, 2014; Costa, Ludermir, 2005). In Recife, a population study found a total prevalence of common mental disorders in primary health care of approximately 35%. (Ludermir & Melo Filho, 2002). In Pelotas, the prevalence of minor psychiatric disorders in primary health care was 22,7% with 17.9% among men and 26% among women. (Lima, Soares, Mari, 1999).
The SRQ-20 questionnaire has 20 questions about their everyday life. It was observed that 70,8% of answers have affirmed that they use to feel nervous, tense or worried; 48% sleep badly and feel unhappy and 46% are easily tired and easily frightened. This set of symptoms is also more prevalent in other studies (Araujo et al., 2006; Lucchese et al., 2014)
There was also a higher rate of no responses to symptoms like daily work suffering. Although participants have demonstrated mainly symptoms as headaches, feeling nervous, being tired or finding it difficult to make decisions, the occupational occupancy was not considered a factor for the decrease in vital energy.
To better understand the life conditions of these participants, we conducted participant observations which were registered by field diaries and also deep interviews. In general, it was observed that many people come to health services with complaints of insomnia and/or anxiety asking the health care professional for a sleeping medication. It was also highlighted the use of psychotropic drugs by many participants. As the application was held in Basic Health Units, many people took the opportunity to talk with the researchers about their health condition. In this way, many participants complained about psychological symptoms and reported their life experience, full of negative situations. However, they had access only to the general practitioner and not to other health care practices.
Besides the participant observations, we conducted deep interviews with 4 women which have scored more than 7 items in the SRQ20 questionnaire. We have noticed that the interviewees tend to comment about their suffering intertwining with situations experienced and present in daily life:
There was several changes in my brain, and I have strong emotions, anger, I suffer from attacks and I faint. So it's not good that I stay in the hall where there are people. I don't like... Because I can fall anywhere, I have fallen and got injured, and my clothes shifted, revealing my body. I said I wanted that corner because I feel more protected. (Barbara, 49 years old).
There’s no way of not having stress. The routine is full of it, the coexistence of two is very difficult too, the family. I deal with people who make me feel angry every day. I had thyroid problems too. After this surgery, I was very nervous. (Carla, 47 years old).
The speeches of Barbara and Carla (fictitious names) denote the experience of a daily existence that brings ill-being and suffering under various orders. Emotions, common situations in everyday life, and relationships are aspects that make these women get sick. Simões-Barbosa and Dantas-Berger (2017) have demonstrated that in the (contradictory) processes of socialization, women are educated to be emotional, dedicate themselves to the care of others and not be competitive. Contradictory to capitalist ideology, based on individualism and competition, requires objective, rational, aggressive and competitive behaviors. Thus, the daily sufferings of women can be the result of this contradiction, a constant struggle between the ideals of being a passive and emotional woman and the capitalist society.
It is evident in these three moments of research that everyday health practices seem to include the request of health care users who wish to get rid of the uncomfortable symptom(s) and the need for health professionals to address health problems.
What is implicit in this relationship is that ruling relations can happen in two moments: when the professional, supposedly the owner of the knowledge, has the power to prescribe a “blue recipe” (popular term for psychotropic recipe), and when the non-specialist user, but with the power to make a scandal in the service because he/she can not get the medicine, require this medication or seek another professional to satisfy it.
Parallel to this “demand” of users for medicines, most health workers know little about psychological distress, and do not feel competent enough in this area to provide other care practices (Silveira, Almeida & Carrilho, 2019; Azevedo, 2010). Thus, Bezerra et al. (2016) state that the exacerbated consumption of medicines is related to the hegemonic and marketing social production of health, involving different actors, including: doctors, patients, pharmaceutical industry and health regulatory agencies. Therefore, drugs become socially valued and other health care practices remain invisible.
Consequently, what predominates in this context is the prescription of psychotropics due to complaints and symptoms of psychological suffering because, in this perspective, the user's demand is in the same way as the health worker’s: both will get rid of the problem in the way they were induced (by the pharmaceutical industry, for example), or by how they have learned (the hegemony of the biomedical model in health education, for example).
Silveira, Almeida and Carrilho (2019) also commented that “this is revealed in the speeches that bring out the insistence of the patients to request the prescription, the threats and aggressions that victimize the professionals and the complaints about the trafficking scheme to access controlled medicines. This is where we close the cycle into which benzodiazepines initially entered: its prescription is justified by the malaise caused by social conditions (drug trafficking and crime) and ends up sustaining the same trafficking and crime” (p.118). Here, benzodiazepines are part of a context in which drug trafficking contributes to the suffering of people who, in their turn, get drugs from this same drug traffic to alleviate malaise.
When seeking health services, many users have nonspecific somatic complaints, which can lead to difficulties in the correct management of these manifestations of suffering. Thus, there is an underdiagnosis and abuse of benzodiazepines and unnecessary examinations and referrals, commonly performed by health professionals (Silveira, Almeida & Carrilho, 2019; Souza et al, 2017). This practice is considered as medicalization of suffering, that is, any emotional, social or cultural aspect of daily life is now understood as a health problem and must be solved with medical technology. In the words of Bezerra et al. (2016), medicalization “refers to the incorporation of social, economic and existential aspects of the human condition, such as sleep, sex, food and emotions, under the domain of the medicalizable, such as diagnosis, therapy, cure, etc.” (p.149).
Even though the “demand” for the medication did not appear in the speeches of the interviewees, it is evident in the interviews of two of the participants, how the medication is valued:
(...)I am stressed, I think because of college things, homesickness, this sore throat, I am taking a medicine that is really bad, and stomachache. I've been to the nutritionist and she said that maybe it has to do with my diet, (...) For headache, I only take little doses of a medicine that I have at home (Carla, 19 years old)
I take Rivotril and Sertralina (Barbara, 49 years old)
The participants' discourse highlighted the increasingly aggressive and naturalized medicalization of existential suffering. It is one of the most striking symptoms of this contemporary mode of health and experience of illness (Santos & Sá, 2013). Accoording to Simões-Barbosa and Dantas-Berger (2017) “the medicalization of malaise resulting from various types of gender-based discrimination and violence that many women experience or witness - structural, institutional, ethnic-racial, urban violence, domestic, sexual, at work - has become a legitimate resource, generating what can be considered a pharmacological violence ” (emphasis added, p.04).
And this pharmacological violence is made invisible by the postmodern ideals that emphasize speed, productivity, being always ready to respond to professional, social and affective demands. In the case of women, this is even more evident since social demands accentuate the feelings of unhappiness, inadequacy and frustration associated with psychic disorders (Simões-Barbosa & Dantas-Berger, 2017).
What is heard in services on a daily basis is that health workers are generally not satisfied with working conditions and resent the demands of users, who often want only the renewal of the prescription and nothing more. In a study on benzodiazepines in another northeastern city, the authors also found this difficulty among health professionals and users (Silveira, Almeida & Carrilho, 2019).
In the excerpt below, Josefa tells her story:
I had a long-term treatment with Dr. X and then I improved ... I took strong medicine for 5 years. I was “weaned” and I only took it at night. The symptoms disappeared with treatment. (...). Then came the loss of my mother, she died of heart attack ... At first, I acted normally, but when I realized it was real, the problems returned with the crises. I fell into depression (Josefa, 51 years old)
In this discourse of Josefa, it can be observed how situations of loss contributed to her psychological suffering. However, when she really feels the loss of her mother, instead of grief, a process that is part of life, she gets sick and demands medication. In this sense, there is a very direct relationship between the suffering of life with the illness and the consequent use of medicines.
Like Josefa, Silveira, Almeida & Carrilho (2019) have observed that many women enter health services with widespread complaints in order to be more likely to enter the benzodiazepine cycle of dependence, as they function in a rapid medical response, alleviating these inconvenient pains. It is the so-called chemical gag (Simões-Barbosa & Dantas-Berger, 2017). Socially and politically, women are required to assume various roles, but at the same time surreptitiously charged with maintaining a passive stance and adapting to the status quo:
Historically, disciplining the female body has been a surprisingly durable and flexible strategy for social control, with the health system being an important ally in the exercise of these (bio) power practices (Simões-Barbosa & Dantas-Berger, 2017, p. .06).
Josefa continues talking about her complaints:
Yes, morning and night. I use carbamazepine and carbolytic because of the discovery of bipolar disorder. Sometimes, I have a sudden behavior change. (...) but besides that, I fight a lot for myself, sometimes I avoid talking because I'm bipolar. I'm afraid that people willl misinterpret when I talk. Therefore, I avoid (...) I fight for myself! (...) Imagine, you are a good worker but you lose your job in an hour, I cried a lot.
When Bezerra et al. (2016) comments that “the holder of the decision must be, in fact, the user, who, for this, must be informed about the risks and benefits of using the drug”, (emphasis added, p.152), which is not what you see in Josefa's speech. There is some passivity in her speech when she says she is taking medication for a diagnosis of bipolar disorder. Have the risks and benefits of these medicines been discussed with her? Have other health care alternatives been considered? How long would she take these medications for?
Another worrying aspect is how Josefa deals with her diagnosis. She stops talking and expressing herself to others because she is “bipolar”. Josefa is not a person anymore. She becomes her disease, attributed to her by some criteria (because in other contexts, her symptoms would not have this connotation). This also characterizes the medicalization of life and suffering. Her ability to fight and to assume the political confrontation of the real causes of suffering are depotentialized, in addition to maintaining a licit drug market that sustains a business branch that has not shown any commitment to the human wellness (Simões-Barbosa & Dantas-Berger, 2017).
The texts on mental health care are unanimous in strengthening the idea that the psychosocial paradigm, which values one’s autonomy, is essential for mental health care. However, in the reality of services, what is seen is the presence of contradictions between the different texts (such as health policies X the biomedical paradigm) and the predominance of medicalizing practices. According to Sousa, Maciel and Medeiros (2018), there is still a view anchored in the biomedical paradigm in relation to psychic suffering and mental health issues. In the conception of care in which there is a predominance of the clinical model, centered on the physician, people do not have the power to decide on their treatment, which implies lack of autonomy (Bezerra et al. 2016). Josefa would be able to exercise her autonomy, since she says she is fighting for herself. But is this being valued in her daily life?
In this sense, medicalizing practices that strengthen the exclusion of the person are very evident in the context of this research. Even health policies advocating welcoming and bonding with users of primary health care, this discourse is still very fragile in practice. Suffering is still considered eminently of biological / organic etiology and the search for the elimination of symptoms is the main goal of users as well as health professionals.