The Use of Benzodiazepines Among Brazilian Women: An Integrative Literature Review Uso de Benzodiazepínicos por Mulheres Brasileiras: Revisão Integrativa de Literatura Uso de Benzodiazepinicos por Mujeres Brasileñas: Revisión Integral de Literatura

The prolonged use of benzodiazepines among women has been a recurring issue in health services. Hence, this study aimed to conduct an integrative literature review to identify the profile of Brazilian women regularly using benzodiazepines. The SciELO, PePSIC, and BVS-LILACS databases were searched, and 86 articles were identified by combining the keywords “mulher(es) AND benzodiazepínico(s)”, but only 11 papers met the inclusion criteria. Data revealed a higher concentration of women aged between 40 and 60 years old who used benzodiazepines for between one month and 37 years to treat insomnia, anxiety, headaches, and sadness. Benzodiazepines appear as a resource to escape problems and are usually prescribed by general practitioners without taking into account these women’s social issues that involve role overload, among other factors.

The use of medications is one of the resources available to treat psychological distress, which, when coupled with other resources available at the public health service network and complementary health services, can bring relief and wellbeing, improving the mental health of individuals. These combined resources can support individuals facing conflictive and stres-and Psychosocial Care Centers) and in hospital facilities, when other resources have been exhausted (Amarante, 2017;Paranhos-Passos & Aires, 2013). The family, mainly women (mothers, grandmothers, wives, and sisters), gained a prominent role after the Psychiatric Reform in the home care provided to those assisted by mental health services (Kebbe, Rôse, Fiorati, & Carretta, 2014;Mota & Pegoraro, 2018;Pegoraro & Caldana, 2008). Nonetheless, the role of women within the mental health sphere should not only focus on them as caregivers, but the recipients of care, as well. Because of the importance of discussing women's mental health, there are legal frameworks regarding actions implemented in the context of Brazilian public health care that should be recalled. The "Programa de Assistência Integrada à Saúde da Mulher" (PAISM) [Integrated Women's Health Care Program] should be mentioned. It was created in the 1990s and expanded upon the health care once provided to Brazilian women in the 1930s, 1950s and 1970s, which mainly addressed issues related to pregnancy, motherhood, and the puerperal state. In accordance with SUS guidelines, PAISM reinforced the need for a holistic approach to women's health. With the support of the feminist movement, this program introduced other issues and actions to the public health agenda that took into account the various social, economic and cultural contexts in which women participate, including gynecological care, family planning, sexually transmissible infections, cancer, menopause, and mental health (Brasil, 2004). Following the I Conferência Nacional de Políticas para as Mulheres [1 st National Conference of Policies for Women], the Plano Nacional de Políticas para as Mulheres [National Policy Plan for Women] was created in 2004. Such a plan defends equality and respect for the diversity and autonomy of women, as well as equitable care and universality of public policies, among other aspects. Additionally, one of this plan's pillars is the implementation of Family Health teams and a mental health care model directed to women from the perspective of gender, in the same way it has been implemented in some Psychosocial Care Centers (Brasil, 2005). Hence, there is a group of professionals available in the various public health services provided by the SUS, such as psychologists, nutritionists, gynecologists, and occupational therapists, who deal with the most diverse demands, including: violence against women; reproductive problems; and family conflicts (Rennó Jr et al., 2005). Zanello, Fiuza and Costa (2015) note that situations that lead women to experience psychological distress include stereotypes linked to the female gender, such as valorization of marriage over being a single mother and how society deals with it; sex as a matrimonial duty and rarely as an activity for one's physical and emotional pleasure; a perspective of the role of mothers as being positive, but also a situation that causes emotional overload, leaving little time for one to take care of oneself; overload accruing from domestic chores, coupled with a perception that the failure of their children was a personal failure, allied with feelings of guilt.
Thus, considering the importance of providing care for women's mental health and the fact that anxiolytics are mainly consumed by women, especially benzodiazepines, as previously discussed, this study's objective was to perform an integrative literature review to identify a profile of the women in the Brazilian context consuming psychoactive drugs, specifically benzodiazepines, focusing on age, access to public health services, duration of medication use, and reasons for having initiated consumption.

Methodological Aspects
This integrative review was guided by six stages: (a) establishing the guiding question; (b) search or sampling in the literature; (c) data collection; (d) critical analysis of studies included in the sample; (e) discussion of results; and (f) presentation of results (Souza, Silva, & Carvalho, 2010). The question "Who is the woman, reported in the Brazilian literature, using benzodiazepines?" guided the literature search according to the following inclusion criteria: empirical papers and experience reports written in Portuguese and available at SciELO, PePSIC and BVS-LILACS databases, addressing topics specifically related to women's mental health and the use of benzodiazepines in Brazil, using the words woman/women AND benzodiazepines combined. Exclusion criteria were: papers written in languages other than Portuguese; theses, dissertations, or literature reviews. No time limit for date of publication was established.
The search took place in the first two weeks of September 2018. A total of 24 papers (full texts) were identified in the SciELO database; only one paper was found in the PePSIC; and 61 papers were found in BVS-LILACS, totaling 86 papers ( Table 1). Papers that appeared more than once (N=13) were considered only once and those that met the exclusion criteria (N=62) were disregarded. During this process (detailed in Table 1), papers that did not address the topic or did not address it within the fields of Psychology or Mental Health, such as dentistry and other biological sciences focusing on the biological use of benzodiazepines, were excluded. Ultimately, 11 papers remained at the end of the process and constitute this study's corpus of analysis. The 11 papers answered this study's guiding question and, after reading the full texts, the following information was recorded: (a) author(s) and year of publication; (b) Journal; (c) study design; (d) institutions to which authors were affiliated; and (e) main results.

Results and Discussion
Among the 11 papers, the oldest was published in 2000 and the most recent in 2017. Five were published in journals in the health field, one in a mental health journal, one in a primary health care journal, two in journals in the nursing field, two in psychiatrics, and one in medicine (Table 2). In regard to methodological designs, five out of the 11 papers adopted qualitative techniques, while the remaining six were quantitative studies. Most of the authors were affiliated with universities located in the southeast (five in the state of São Paulo and two in the state of Rio de Janeiro); two in the northeast (Pernambuco and Ceará); and two were in the south (Paraná). Most studies were conducted in the southeast (six studies), followed by the south (two studies) and northeast (two studies) ( Table 2). Another relevant piece of information is the fact that the number of participants addressed in the studies ranged from one (a case study) up to 634 participants. Most of the studies addressed only women, which converges with this study's objectives, while the samples addressed in the four studies that included both men and women (Auchewski et al., 2004;Lira et al., 2014;Mezzari & Iser, 2015;Naloto et al., 2015;) were mainly composed of women, that is, at least 71%. In contrast, only information regarding women was considered in this study. Additionally, the participants were of varied ages (from 16 to 60 years old), though women aged around 45-60 years old predominated, a finding that agrees with the results of other studies reporting an increased consumption of this medication among women at an older age. The increased use reported in these studies is explained by more frequent symptoms of insomnia and a feeling of worthlessness because women are unable to perform tasks they were used to perform (Fiorelli & Assini, 2017;Passos Neto et al., 2016).
Another piece of information is that the women addressed by studies conducted in PHC services (Mezzari & Iser, 2015;Lira et al., 2014;Nordon et al., 2009;Huf, et al., 2000) shared many common characteristics, such as: (a) most had used the medication between six months and two years (though, in two outlying cases, the shortest period was one month and the longest was 15 years); (b) women were most frequently aged between 50 and 70 years of age; (c) many were retired and homemakers; and (d) most were married or were in a stable union.
Additionally, the studies (Mezzari & Iser, 2015;Lira et al., 2014;Nordon et al., 2009;Huf et al., 2000) also report that the medications most frequently used were: diazepam, clonazepam and bromazepam; the first two appeared as the most popular (Mezzari & Iser, 2015;Lira et al., 2014;Nordon et al., 2009), while the study by Huf et al. (2000) notes that bromazepam was the benzodiazepine most frequently reported. Concerning the reasons the women identified as leading to the use of tranquilizers, insomnia appears as the main reason, followed by anxiety, headache and sciatica. Regarding disorders and pathologies: Generalized Anxiety Disorder, Major Depressive Disorder, Epilepsy, Schizophrenia and Panic Disorder were the most common. Increased use of medications is a very relevant issue. Clonazepam, for instance, was the seventh best-selling drug in 2012 in Brazil, according to the Federal Council of Pharmacy (2016). The consumption of benzodiazepines has been higher in the largest capitals, with a high number of inhabitants and physicians, while medical training and the frequent medicalization of modern society are topics discussed (Azevedo, Araújo, & Ferreira, 2016). The wide use of psychoactive drugs to treat mental disorders within the context of PHC stands out (Roman & Werlang, 2011).
When we consider PHC services and workers involved in mental health care, another important issue was investigated to understand how women accessed the drugs and/or how they were prescribed. In the four papers addressing PHC services (Mezzari & Iser 2015;Lira et al., 2014;Nordon et al., 2009;Huf et al., 2000), women reported that the medication was first prescribed by a general practitioner, then by a psychiatrist, cardiologist or neurologist. The results reported in the oldest paper (Huf et al., 2000) show that women obtained the medication through other routes, including getting it from relatives and family members, who had first acquired them through a medical prescription. The use of drugs without a prescription and medical assistance is a reality in Brazil and worldwide; such a practice is harmful, with the potential to cause death. According to Telles Filho, Chagas, Pinheiro, Lima and Durão (2011), self-medication may cause intoxication and lead to drug interactions, with severe consequences for the health and lives of patients, even worsening previous diseases. According to a report released by the Federal Council of Pharmacy (2016), benzodiazepines are usually prescribed by a general practitioner who gives in to patients' requests without considering the tolerance and dependency these drugs can cause. Another risk is the interaction of benzodiazepines with other psychoactive drugs and alcohol, which may even lead to death.
Studies specifically addressing older women (Mendonça & Carvalho, 2005a;Mendonça & Carvalho, 2005b;Mendonça et al., 2008) report that most began using tranquilizers between 40 and 45 years of age, while the average length for the use of benzodiazepines was 16 years. The studies previously discussed (Mezzari & Iser, 2015;Lira et al., 2014;Nordon et al., 2009;Huf et al., 2000) reported such prolonged use only in isolated cases. According to Carvalho and Dimenstein (2004), the safe use of benzodiazepines is between two to 12 weeks, after which patients should be gradually weaned from the medication. The reality, however, is that these medications are used for prolonged periods, bringing consequences for the health of these women, including chemical dependency. Mendonça and Carvalho (2005a) and Mendonça et al. (2008) note that the prolonged use of these drugs, such as an average of 16 years, is more common among elderly women than in younger ones. A study conducted by Silva, Botti, Oliveira and Guimarães (2016) states that almost 83% of the women interviewed, aged between 50 and 69 years old, were chemically dependent on benzodiazepines. Some report side effects such as dry mouth, dizziness, headache, and drowsiness. Additionally, almost 70% of these women had some medical condition (e.g., hypertension, diabetes, heart diseases, depression) that required medical monitoring to check for drug interactions. There are some severe drug interactions, such as the use of fluoxetine with amitriptyline, so that medical monitoring is extremely important to ensuring the health of patients (Balen et al., 2017). Another important fact is that, while the first papers discussed here (Mezzari & Iser 2015;Liera et al. 2014;Nordon et al., 2009;Huf et al., 2000) highlighted anxiety, insomnia and headache as the reasons leading women to use tranquilizers, regardless of age, the studies focusing on elderly women (Mendonça & Carvalho, 2005a;Medonça et al., 2008) list life events, such as mourning, the marriage of children and experiencing them leaving home, divorce, conflict with spouses due to the abusive consumption of alcohol, or conflict and disagreement from husbands spending more time at home after retirement. Older women (Mendonça & Carvalho, 2005b;Medonça et al., 2008) reported self-medication and a feeling of autonomy as they used the medication as they see fit. The women addressed in these studies also frequently reported they recommended the use of tranquilizers to their children or friends when they deemed necessary. Some of them reported giving a tranquilizer to a son who abused alcohol or to a sister who was nervous or upset. This information converges with the results reported by Huf et al. (2000) concerning women using tranquilizers without medical assistance or prescription, leading us to wonder what was the role played by these drugs in the lives of these women, considering many used them to deal with stressful social situations and/or family relationships. Additionally, other issues, such as hierarchical power relationships established between men and women, sexuality, unemployment and lack of opportunities to change one's life, are aggravating situations that may lead to the use of medications. Coupled with these situations, there is a lack of additional care actions that should be provided within the scope of public health to women in these situations; that is, workers lack opportunity to assist these women and actively listen to them, so that the use of psychoactive drugs is the only resource that remains in these situations (Carvalho & Dimenstein, 2004).
Another issue to be discussed refers to three studies addressing the use of benzodiazepines in the same sample of elderly women cared for by the same health facility (Mendonça & Carvalho, 2005a;Mendonça & Carvalho, 2005b;Mendonça et al., 2008). The studies were conducted by the same two authors who reported few new results between one paper and another, suggesting a single study was fragmented into three with the objective to increase the number of publications and productivity (Reinach, 2016). These studies report repeated data, such as: (a) the women's profiles (age, length of time using the medication, most frequently used medication, institution where data were collected); (b) the reasons that lead to the use of tranquilizers; and (c) self-medication. New information is provided by Mendonça and Carvalho (2005b), such as: the fact women felt discriminated and excluded because they use tranquilizers; difficulty in understanding the physicians' language, which contributes to the inappropriate use of medication; and drugs as being the immediate "remedy" to deal with life's pains and problems, which women valued more than other care actions, such as therapy. Alvarenga et al. (2015) consider that excessive prescriptions and the use of benzodiazepines is something healthcare workers should reflect upon because these drugs are often the only form of care provided to patients. Hence, health workers would be using medications instead of giving women the opportunity to talk about their anguish, fears, and difficult situations.
Two studies specifically addressed the inappropriate or abusive use of benzodiazepines. One was a case study (Martins et al., 2017), while another study (Souza et al., 2013) interviewed 33 women. The case study addressed a woman using benzodiazepines for 15 years. She started using the medication when she married at the age of 18 years old. She reported she considered herself aggressive and irritated, while she also experienced breakdowns, immense sadness, and had constant headaches and insomnia. A cardiologist prescribed the medication, telling her she had hypertension and was uncontrolled (Martins et al., 2017). The other study, addressing 33 women (14 of whom were single), reports that almost all the women had previously used antidepressants (29 out of the 33) and the use of benzodiazepines ranged from 50 days to 37 years; the latter was the longest period found in this integrative literature review. The physicians who most frequently prescribed the medication were psychiatrists (21), followed by gynecologists (5), cardiologists (4), and general practitioners (4). This piece of information is contrary to what other papers report, in which general practitioners were the most common physicians prescribing the medication. In regard to the medical specialties, most of the times in which guidance regarding the side effects was provided, psychiatrists were the ones providing such guidance and only once did a gastroenterologist provided such information (Souza et al., 2013). This information also conflicts with the results found in the literature, such as those provided by Gomes, Fontes and Franco (2014), in which the physicians who most frequently prescribed benzodiazepines were: general practitioners (34%), cardiologists (26%), psychiatrists (14%), gynecologists (11%), geriatricians (8%), and others (1%).
According to Souza et al. (2013), the reasons leading women to use the medications were the same as the ones previously mentioned. These recurrent symptoms included insomnia and panic, but also stressful situations at family and work, which contributed to the use of tranquilizers to escape daily problems. In regard to the perception of potential risks imposed by tranquilizers, some women reported dependency (especially an inability to sleep without medication), altered reflexes and motor capacity. However, the most concerning fact is that most women appeared unconcerned over the possibility of experiencing these symptoms. Finally, another curious fact is that almost all the women (28 out of 33) did not want the possibility of stop using of the medication at some point in their lives, nor did they consider it, even though they had previously used and stopped using in the past. Women justified their reports telling they suffered from insomnia and for this reason did not see a reason to stop using tranquilizers.
Only two papers (Auchewski et al. 2004;Naloto et al., 2016) specifically addressed the medical orientation provided to adult and elderly individuals who were prescribed benzodiazepines, indicating the need for further research addressing this topic, considering that a lack of guidance may lead to mistakes during the ingestion of medications, posing risks to the health of patients. According to Portela, Simões, Fook, Montenegro-Neto and Silva (2010), 58.3% of the individuals receiving care from the PHC services of a city in the interior of Bahia did not know the name of the medication they used; 20.3% did not know the right dosage they were supposed to take; 25.4% did not know the time to take it; 57.4% were unaware of the maximum period recommended; and 94.4% did not receive information regarding potential side effects. No differences were found between information provided within the public health system or within the complementary health system (Auchewski et al., 2004). Most of the 120 participants were women (67%) aged from 18 to 76 years old: 63% of them had private health insurance/plans and 24% were cared for by SUS, while only 38% of the patients reported having received at least one of three recommendations regarding the use of medication (in regard to not drinking alcohol, 78% of the patients were informed by the physician about the possibility of experienced decreased attention; 38% were advised to be careful when performing daily tasks; while 26% were informed of the possibility of dependency). Finally, Naloto et al. (2016) addressed one of the largest samples using benzodiazepines, mostly composed of adults (63.8%), rather than of elderly individuals (36.2%). Most were women, married, who were using and had already used antidepressants, and were retired or on sick leave. These individuals had used medications for approximately seven to eight years. Only 5.8% of the benzodiazepines were used rationally and for a proper amount of time by elderly individuals, while the percentage was even smaller (1.9%) among adult individuals. The authors note that these findings reflect the risk of severe drug interactions, the need to qualify physicians to decrease the number of prescriptions that cover prolonged and inappropriate periods, in addition to the need to implement different programs intended to promote the appropriate use of medications, aiming to benefit patient health.

Final Considerations
This study's main results indicate that Brazilian women using benzodiazepines are generally aged between 50 and 70 years old, are homemakers, and seek the medication to alleviate symptoms, such as insomnia, anxiety, irritability, and less frequently, sadness. Additionally, they use drugs to deal with conflicting social situations, such as marital conflicts, their children leaving home, role overload, in addition to a feeling of being unable to perform tasks at the same pace they previously maintained due to aging.
This study's limitations include the fact that the search was performed in only three databases (SciELO, PePSIC and LILACS) and only included papers written in Portuguese, which resulted in a small number of papers (only 11). There is a need for further studies addressing the orientation patients receive regarding the use of benzodiazepines, information that is seldom explored, as well as the perceptions of patients regarding how the medication alleviates their symptoms and the use of medication associated with other therapeutic possibilities, such as psychotherapies and integrative and complementary practices. Finally, data obtained here need to be further compared and discussed, especially in regard to quantitative studies in order to problematize results considering social issues. This is important considering that all the studies report women are the main users of these medications and, in our patriarchal society, they are often exposed to violent affective relationships, are responsible to perform all domestic chores, and suffer from an overload of roles.

Financing
The author Raissa de Brito Braga received a CNPq master's scholarship. The Institutional Research Support Program from the Federal University of Uberlândia (Public Notice UFU 02/2018) supported the research.