Community Therapy as complementary care for drug users and their contributions to anxiety and depression^a

Abstract

Objective

to evaluate the contributions of Community Therapy on anxiety and depression among psychoactive drug users.

Methods

a quasi-experimental study was conducted with 21 men living in three mental health institutions focused on recovery from chemical dependence, who underwent six rounds of community therapy as an intervention process in 2018. Data collection took place in three stages from the use of a semi-structured questionnaire and two Beck anxiety and depression inventories. The nonparametric statistical method was used to compare the results.

Results

depression was present in 76% of users and anxiety in 48%. Among the participants in the yarning circles, there was a reduction in depression levels during and after the intervention process (p=0.016; p=0.004) when compared to baseline and to maintain the average T1 and T2 anxiety score (9.90; 9.95) compared to T0 (13.10).

Conclusion and implications for practice

the use of community therapy has shown positive results on anxiety and depression, and therefore is considered in this study as an important mental health care tool to be used by nurses, aiming to expand their care to people in a situation of chemical dependence, also contributing to treatment adherence.

Keywords:
Therapeutic Community; Mental health; Complementary Therapies; Drug Users

Resumo

Objetivo

avaliar as contribuições da Terapia Comunitária sobre a ansiedade e a depressão entre usuários de drogas psicoativas.

Métodos

estudo quase-experimental, realizado com 21 homens residentes em três instituições de saúde mental voltadas à recuperação da dependência química, submetidos a seis rodas de terapia comunitária como processo de intervenção em 2018. A coleta de dados ocorreu em três etapas a partir do uso de um questionário semiestruturado e dois inventários de ansiedade e depressão de Beck. Utilizou-se método estatístico não-paramétricos na comparação dos resultados.

Resultados

a depressão esteve presente entre 76% dos usuários e a ansiedade entre 48%. Dentre os participantes das rodas, houve uma redução nos níveis de depressão durante e após o processo de intervenção (p=0,016; p=0,004) quando comparado ao estado inicial e para manter a média dos escores de ansiedade no T1 e T2 (9,90; 9,95) se comparado ao T0 (13,10).

Conclusão e implicações para a prática

o uso da terapia comunitária demonstrou resultados positivos sobre a ansiedade e a depressão, sendo então considerada uma importante ferramenta de cuidado em saúde mental a ser utilizada por enfermeiros, com vistas a ampliar o seu cuidado as pessoas em situação de dependência química, contribuindo ainda para adesão ao tratamento.

Palavras-chave:
Comunidade Terapêutica; Saúde Mental; Terapias Complementares; Usuários de Drogas

Resumen

Objetivo

evaluar las contribuciones de la terapia comunitaria sobre la ansiedad y la depresión entre los consumidores de drogas psicoactivas.

Método

se realizó un estudio cuasiexperimental con 21 hombres residentes en tres instituciones de salud mental focalizadas en la recuperación de la dependencia química, sometidos a seis rondas de terapia comunitaria como proceso de intervención en 2018. La recolección de datos se realizó en tres etapas, a saber: uso de un cuestionario semiestructurado y dos inventarios de ansiedad y depresión de Beck. Se utilizó un método estadístico no paramétrico para comparar los resultados.

Resultados

la depresión estuvo presente en un 76% de los consumidores y la ansiedad en el 48%. Entre los participantes en las ruedas, hubo una reducción en los niveles de depresión durante y después del proceso de intervención (p = 0.016; p = 0.004) en comparación con el valor inicial y para mantener el puntaje promedio de ansiedad T1 y T2 (9.90; 9.95) en comparación con T0 (13.10).

Conclusión e implicaciones para la práctica

el uso de la terapia comunitaria ha mostrado resultados positivos sobre la ansiedad y la depresión y, por lo tanto, se considera como una importante herramienta de atención a la salud mental a ser utilizada por las enfermeras, con a fin de extender su atención a las personas que se encuentran en una situación de dependencia química, además de fomentar la adhesión al tratamiento.

Palabras clave:
Comunidad Terapéutica; Salud mental; Terapias complementarias; Consumidores de drogas

INTRODUCTION

Studies show that most of psychoactive drug users have some psychiatric disorder, cognitive and behavioral problems such as antisocial and personality disorders, mood disturbance and anxiety.^1-3 Due to the disabling characteristics and repercussions generated, these comorbidities must be considered during care in order to achieve success in therapeutic care.⁴

Depression is one of these comorbidities, being considered a global pandemic due to its presence in the various territories and social contexts of the world.^3,4 It can trigger personal/family damage as well as repercussions on other dimensions of coexistence/relationships.^2,5

On the other hand, anxiety is more reported in studies with psychoactive drug users.^3,6 This disorder is reflected in an inadequate response to coping with daily stimuli, uncontrolled, disrupting people's life dynamics and their interpersonal relationships.⁷

The sum of these comorbidities with or due to chemical dependence becomes a motivating factor for the non-cessation of psychoactive substance consumption and/or becomes an obstacle for adherence to treatment,^4,8,9 imposing challenges in providing assistance to this clientele.

Faced with this, researchers and professionals are constantly searching for more inclusive and interactive therapeutic strategies and practices in order to meet all the demands presented. This reality culminated in the National Policy for Integrative and Complementary Practices (Política Nacional de Práticas Integrativas e Complementares, PNPIC), created in 2006, ensuring the Brazilian population access to non-allopathic practices, but with scientifically proven effectiveness.¹⁰

It is believed that the integrative practices contribute to broadening the co-responsibility of individuals for health, to co-participation in their therapeutic care, and to increase the exercise of citizenship.¹⁰ These practices have also been pointed out as a contributing factor for reducing mental distress.^11,12

It is noteworthy that complementary therapies or complementary integrative practices are more offered in primary care health services than in mental health reference services.¹⁰ In this scenario, the dissemination and multiplication of these practices aim to broaden community access to therapies closer to life contexts and to value available individual/collective resources; when they materialize, they contribute to the integrality of health care.

In addition to the use of these practices to reduce psychiatric illness, they can contribute to the management and coping with drug addiction,^11,13,14 assisting in the process of social reintegration and achieving benefits such as cooperation.¹⁵

In chemical dependence, studies have already shown success of these complementary therapies, such as the use of auriculotherapy,¹⁶ art therapy,¹⁷ music therapy¹⁸ and Integrative Community Therapy (TCI).^19,20

Among these modalities, TCI presents itself as an auspicious approach. It was created in 1987, inserted in the Brazilian Public Health System (Sistema Único de Saúde, SUS) in 2008, being pointed out in 2017¹⁰ as an expressive, effective practice to manage suffering, including the disorder related with the use/abuse of alcohol, crack and other psychoactive substances.^19,20

The TCI is held in open, public and community yarning circles, to provide moments of comprehensive listening among its participants, and at the same time to foster ties, in order to strengthen support networks, redefine personal demands, restoring self-esteem, self-confidence, and autonomy, and generate space for collective health care and self-care.^11,12,19

However, to this date, there are no studies that measure the effectiveness of TCI intervention with drug users using validated psychometric instruments. Thus, this study aimed to assess the contributions of Community Therapy on anxiety and depression among psychoactive drug users. Assuming that TCI use has a positive impact on the anxiety and depression levels of recovering psychoactive drug users in the Therapeutic Community service.

METHODS

Quantitative quasi-experimental study conducted with 21 men residing in three mental health institutions (therapeutic community) focused on recovery from chemical dependence located in the Araguaia Valley region, Brazil.

This region has four Therapeutic Communities (CT), three male and one female. The selected CTs are similar institutions in relation to the accompanying proposal of a religious nature, evangelical Protestant, with capacity for up to 30 men, aged ≥18 years, who are in a situation of chemical dependence and clinically stable. Only male institutions were chosen, as this sample would increase the number of participants with similar characteristics.

The institutions were chosen by their similarity in the male recovery modality and because they are considered reference units for the welcoming of psychoactive drug users for the region and linked to the Psychosocial Care Network (Rede de Atenção Psicossocial, RAPS) as one of the options to support the recovery of psychoactive drugs users.

Users enter these CTs through spontaneous demand or referral from local health services. Inmates undergoing recovery may stay for up to twelve months. Medical assistance to users when necessary is carried out by the local health network, prioritizing if available in the municipality care in the Psychosocial Care Center Alcohol and Drugs (Centro de Atenção Psicossocial Álcool e Drogas, CAPS AD).²¹

As for the study population, it was selected for accessibility and convenience,²² totaling 29 men residing in these CT (for the purpose of analysis, the CT participants were grouped into a single group), having as inclusion criteria: men being ≥18 years old who participated in the six TCI yarning circles. Users with less than one week of follow-up in one of the three CTs and those who abandoned treatment were excluded from the study. After applying these criteria, a sample of 21 participants was reached.

Data collection occurred by interview, which was guided by a structured script prepared by the researchers themselves, consisting of objective questions about sociodemographic aspects (gender, age, marital status, education, skin color, family income, profession and religion), applied at collection T0 (Time 0), and by two validated inventories in Brazil, Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI), both applied at T0, at T1 (Time 1) and at T2 (Time 2) of the study.

The BDI is a self-assessment scale to identify depressive symptoms, pointed as a screening tool to detect the symptoms of the disease, as well as the severity of symptoms (mild, moderate and severe), consisting of 21 items, presented on a four-points Likert scale, ranging from 0 to 3. The summed items result in a total score ranging from 0 to 63. The cutoff points for depression are: 0 to 13 (absence or minimal depressive symptoms); 14 to 19 (mild depression); 20 to 28 (moderate depression); and 29 to 63 (severe depression).²³

The BAI is a self-administered questionnaire that assesses characteristic anxiety symptoms in order to determine the tendency to anxiety. It has 21 items, presented on a four-point Likert scale, ranging from 0 to 3. The summed items result in a total score ranging from 0 to 63. The cutoff points for anxiety are: 0 to 10 (absence of anxious symptoms); 11 to 19 (mild anxiety); 20 to 30 (moderate anxiety); and 31 to 63 (severe anxiety), considering the score ≥ 21 points as indicating the existence of clinically significant anxiety.²³

The participants answered the instruments in the three research phases (T0, T1, T2) in the CT itself, in a calm and safe place offered by the institution. The filling had an average duration of 30 minutes and was supported by research assistants.

The users underwent Integrative Community Therapy as an intervention process. This therapy is based on five theoretical pillars: systemic thinking; Paulo Freire's pedagogy; cultural anthropology; communication theory and resilience. It follows a protocol of execution/performance that comprises five steps: welcoming, choice of theme, contextualization, problematization and closure.²⁴ It is suggested the minimum participation of two persons who act as properly trained community therapists.^24,25

The intervention process was performed from the execution of six TCI yarning circles, with an average duration of 60 minutes each, which occurred separately in each CT in days and times combined with managers, users and researchers, carried out in January through May 2018. The entire research process lasted 10 consecutive weeks for each CT and was divided into three stages, called pre-intervention, intervention and post-intervention. The protocol for executing the intervention process is shown in Figure 1.

Figure 1
Flowchart of participant selection and intervention protocol with Integrative Community Therapy.

The first phase of the “pre-intervention” study (weeks 1 and 2) was intended to visit the CT to inform and clarify the users about the research objectives, and to collect signatures in the Informed Consent Form (ICF), as well as for the presentation of research assistants, volunteers of the mental health project of the Federal University of Mato Grosso (Universidade Federal de Mato Grosso, UFMT), Araguaia University Campus (Campus Universitário do Araguaia, CUA), who were properly trained to collect data (T0, T1, T2), and community therapists (nurse teachers from UFMT/CUA and from the State University of Mato Grosso - Universidade do Estado de Mato Grosso UNEMAT/Tangará da Serra). It is noteworthy that all users resident in the CT were invited to participate in the yarning circles. At this stage, the first phase of data collection (T0 considered before the beginning of the intervention process) was applied to 29 participants.

The second “intervention” stage (week 3 to 8) was intended for the execution of the six TCI yarning circles in each CT, and the circles were conducted by community therapists, who followed a systematized five-step script proposed by the author of the therapy.²⁴ At this stage, there was the application of the second phase of data collection (T1), in the interval from the 3rd to the 4th yarning circles to 23 interns, because there was loss of treatment abandonment in the CT of six participants.

The third “post-intervention” stage (week 9 and 10) was aimed at reapplying the data collection instruments (T2 considered the third collection phase, which took place after the intervention process was completed) to 21 participants, as there was loss due to treatment abandonment of two participants between the 5th and 6th yarning circles and the end of the research.

Data were double entered in a Microsoft Excel 2013 spreadsheet and were transported for statistical analysis in the program Statistical Package for Social Sciences-SPSS version 22. Quantitative data from the semi-structured questionnaire were analyzed using descriptive statistics. The values of the inventories scores used (BDI and BAI) were presented in a table as a numerical variable, with the analysis of the obtained intervals, median, mean and standard deviation, with subsequent application of the K paired groups comparison test, Friedman Test, at 5% significance level (p<0.05), and later comparison in pairs, post hoc Wilcoxon test with Bonferroni correction at 5% significance level (p<0.05).

All ethical aspects in research with human beings were respected, according to Resolution 466/2012, of the National Health Council (Conselho Nacional de Saúde, CNS), starting the investigation only after approval by the Research Ethics Committee of EERP/USP, under CAAE: 68444017.8.0000.5393 and Opinion No. 2,487,000.

RESULTS

The sample consisted of 21 participants, men aged between 19 and 61 years, with a mean age of 37.57 years, who declared themselves brown (62%), single (62%), with religion (86%), having attended, complete or incomplete elementary school (67%), without paid work (82%) and absence of family income (57%).

Regarding the use of psychoactive substances, crack use (48%) was predominant and contributed to the search for hospitalization, followed by alcohol (28%). The other most consumed substances before treatment were cocaine (14%) and marijuana (10%).

Regarding treatment for chemical dependence, 67% of users reported a history of multiple hospitalizations, with the Therapeutic Community being the most sought-after service (63%). The current hospitalization was voluntarily sought by 67% of the inmates.

Using the inventory used to track depression (BDI) revealed that moderate (33%) and severe (29%) disease types were more frequent among respondents. It can be observed that during and after the use of TCI, there was a significant increase among users considered “without depression” (T0=24%, T1=33%, T2=52%) and an important reduction in cases of severe depression (T0=29%, T1=10%, T2=5%) and moderate (T0=33%, T1=24%, T2=10%), as shown in Table 1.

Table 1
Distribution of depression levels among participants, according to the classification of BDI (T0, T1, T2). Araguaia Valley Region, Brazil, 2018. (n=21)

Scores	BDI - T0	BDI - T1	BDI - T2
	N (%)	N (%)	N (%)
Without Depression	5 (24%)	7 (33%)	11 (52%)
Mild Depression	3 (14%)	7 (33%)	7 (33%)
Moderate Depression	7 (33%)	5 (24%)	2 (10%)
Severe Depression	6 (29%)	2 (10%)	1 (5%)
Total	21 (100%)	21 (100%)	21 (100%)

• Source: Research data, 2018

Table 2 shows changes in the mean and median BDI scores before, during and after the TCI intervention, showing that among the participants in the TCI yarning circles, there was a reduction in depression when compared to T1 and T2 at the initial state - T0 (p=0.016; p=0.004).

Table 2
Inferential analysis of BDI scores in the 3 moments answered (T0, T1, T2) by participants. Araguaia Valley Region, Brazil, 2018. (n=21)

Description	Average (±DP)	Median (Max-Min)	P Value
BDI –T0	20.33 ± 9.55	21.00 (36-03)	0.00*
BDI -T1	16.76 ± 8.88	16.00 (33-00)
BDI -T2	12.95 ± 7.71	13.00 (31-00)
BDI – T0 x T1			0.016**
BDI – T0 x T2			0.004**
BDI – T1 x T2			1.000

• ^*
  K paired groups comparison test, Friedman Test, at 5% significance level (p<0.05)
• ^**
  Comparison in pairs, post hoc Wilcoxon Test with Bonferroni correction, at 5% significance level (p<0.05).
• Source: Research data, 2018.

The data obtained from the BAI inventory used to track anxiety revealed that respondents had some level of anxiety (48%) in the T0 collection, especially mild type anxiety (29%).

It can be observed that during and after TCI use, there was a slight increase among users considered “without anxiety” (T0=52%, T1=62%, T2=67%), an important reduction in mild anxiety cases (T0=29% at T2=14%) and a 50% decrease in severe cases (T0=10% at T2=5%), as shown in Table 3.

Table 3
Distribution of anxiety levels among participants, according to the classification of BAI (T0, T1, T2). Araguaia Valley Region, Brazil, 2018 (n=21).

Scores	BAI – T0	BAI – T1	BAI – T2
	N (%)	N (%)	N (%)
Without Anxiety	11 (52%)	13 (62%)	14 (67%)
Mild Anxiety	6 (29%)	6 (29%)	3 (14%)
Moderate Anxiety	2 (10%)	1 (5%)	3 (14%)
Severe Anxiety	2 (10%)	1 (5%)	1 (5%)
Total	21 (100%)	21 (100%)	21 (100%)

• Source: Research data, 2018

Table 4 shows the average anxiety scores, as well as the value of “p” evaluated before, during and after the intervention, showing no evidence of anxiety reduction when comparing T1 and T2 to the initial state - T0 (p=0.076; p=0.092), but there was significance of the mean and median values in the evaluated times (p=0,03). In addition, the use of TCI may contribute to maintaining the average BAI score at T1 and T2 (9.90; 9.95) if compared to T0 (13.10).

Table 4
Inferential analysis of the BAI scores in the 3 moments answered (T0, T1, T2) by the participants. Araguaia Valley Region, Brazil, 2018. (n=21)

Description	Mean (SD)	Median (Max-Min)	P Value
BAI –T0	13.10 ± 10.30	10.30 (43-00)	0.03*
BAI -T1	9.90 ± 9.04	7.00 (38-00)
BAI -T2	9.95 ± 10.11	6.00 (34-00)
BAI - T0 x T1			0.076**
BAI - T0 x T2			0.092**
BAI - T1 x T2			1.000

• ^*
  K paired groups comparison test, Friedman Test, at 5% significance level (p<0.05)
• ^**
  Comparison in pairs, post hoc Wilcoxon Test with Bonferroni correction, at 5% significance level (p<0.05).
• Source: Research data, 2018.

DISCUSSION

The sociodemographic characteristics, psychoactive drug use and treatment found in this research were similar to other national and international studies.^26-30

Regarding depression, this research highlighted users with moderate and severe types. These findings were also verified in national studies conducted in Rio Grande do Sul,^4,31 in Paraná,²⁵ in Bahia,²⁶ and in the interior of São Paulo,²⁸ as well as in international studies, both conducted in Australia.^32,33

This study revealed that psychoactive drug users had some level of anxiety, especially mild anxiety. The presence of anxiety has also been mentioned in other studies.^4,25,31,34

Research conducted in Mato Grosso (BR) pointed out that anxiety can be common among drug users when recovering, as they live moments of insecurity, loss and fear of relapse, in addition to the condition of deprivation of family contact and under new routine of life determined by the therapeutic community.¹⁹

As in the present research, other studies also reported the presence of mental disorders associated with chemical dependence.^28,33 There are highlights in national⁸ and international studies⁹ that mention drug use as an aggravating factor in the levels of these disorders.

Such aspects should draw the attention of caregivers and health professionals working in places aimed at drug recovery (CAPS AD, CT, therapeutic clinics, detox hospitals), since the presence of these comorbidities negatively affects rehabilitation for chemical dependence. Thus, there is a need to use supportive approaches to manage symptoms and provide social and health support to ensure the maintenance of users in therapeutic care.

Some studies have pointed to the importance of the use of complementary therapies^{11,15,16,19,35} as a way to assist users in the search and rescue of health, not only in relation to chemical dependence, but in the various dimensions that integrate the user's life. In addition, the possibility of incorporating other possibilities of attention to improve mental health care in this population.

The present research emphasized the positive impact of TCI in reducing depression and anxiety when compared to the initial state and, in addition, it can be inferred that the greater the number of yarning circles in which the user participates, the better the results may be. However, only with future research can such inference be tested.

It should be noted that users admitted to these therapeutic communities, as well as others of the same nature, do not receive care from specialized professionals within the CT; only in obvious cases of pathology there is the referral to CAPS AD or to other RAPS services (Primary Care, Emergency Care Unit, General Hospital and Psychiatric Hospital). Then, as positive aspects, it is highlighted the fact that the anxiety indicators maintained the same levels they were in T1 and T2 and the depression indicators showed a progressive reduction when compared to the initial state –T0.

As an expanded therapeutic approach, TCI is considered a practice aimed at welcoming, strengthening bonds, social support, improving self-esteem, respecting the participation and protagonism of each person, valuing their individuality and the horizontality of the dialogue. In addition, its form of execution, in group and in a yarning circle, allows participants moments of comprehensive listening, sharing life stories and fostering affective bonds with each other.³⁶

The TCI is a complementary technique that can help in the problems arising from the use of psychoactive substances, which presented positive results in the management of depression and anxiety, acting on various user needs and can be used in isolation. However, the results indicate that their benefits could be increased by offering them in conjunction with other therapeutic resources during treatment for chemical dependence.

Another positive aspect observed is the fact that TCI offers moments of freedom - for participants undergoing treatment that is more guided by more strict norms and routines in an inpatient environment - and this facilitates adherence to the established therapeutic project, because, the TCI is a form of humanitarian therapy that provides inmates with the possibility of pleasant moments, with more stimuli, respecting human rights, by accepting the suffering and demands of users, and being absent from restrictions.

It was observed that, in fact, community therapy can be a therapeutic resource that can be used separately or in a complementary way, in order to provide support and foster sociability among users in a healthy way, favoring the free expression of their patients feelings, which showed that it is possible to deconstruct the idea of using only conventional biomedical models in the treatment and recovery of these users.

In the present study, community therapy was developed by three trained nurses and proved to be an effective care tool when applied by these professionals. The use of this therapy broadens the view of nursing for the use of a low-cost intervention that can help to recognize the needs, fears and insecurities of these individuals undergoing treatment, also proposing to the team a health care that allows individuals the opportunity to share your story and feelings, to be heard and welcomed during treatment.

These results draw attention to the need for ever-expanding offer of multidisciplinary approaches, such as community therapy, that meet the mental health demands of these users, regardless of where they choose (or are referred to) for care and or as they expand health care.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

This study confirmed that integrative practices, such as TCI, can and should be used in health promotion of psychoactive drug users, to complement or improve indicators of the possible presence of mental disorders such as depression and anxiety, concomitant with use of these substances. The evidence pointed to a positive impact of TCI in reducing symptoms of depression and anxiety when compared to the initial state among these users, becoming an important tool focused on mental health care of people in a situation of chemical dependence.

The findings showed that the more TCI yarning circle the user participates in, the better their results may be, suggesting in this study a protocol for the application of this therapy of at least six TCI yarning circles in research to be conducted with drug users undergoing treatment, considering the results achieved.

The results of this study support the importance of implementing complementary practices in the process of treatment and rehabilitation of psychoactive drug users, meeting the different demands of this population, revealing the need for qualification of people involved in this care, as community therapists, as well as the need offering other complementary practices that may meet the demands arising from the use of psychoactive substances.

As limitations, it is highlighted the fact that the population is exclusively of men in a situation of chemical dependency residing in therapeutic communities, the type of study and the sample size, which is in agreement with the characteristics of the studied population, which presents high turnover and also because this type of service does not support large numbers of users in the residential system. Another limitation to be highlighted is the use of the Beck Anxiety Inventory, as it does not establish a difference between the individual's anxiety trait and their current state of anxiety at the time of data collection.

Therefore, it is suggested that further studies be conducted in different groups of drug users, as well as in other types of health services that host these individuals and use of other research tools, to determine the extent of the effects of this intervention with more equity.

ACKNOWLEDGMENTS

To users and managers of the therapeutic communities participating in the study. To the volunteers of the Mental Health Research Project of University Federal of Mato Grosso (UFMT), University Campus of Araguaia (CUA), for assistance in the data collection phase. To the psychologist Eduardo dos Santos Vieira for supporting the research.

• FINANCIAL SUPPORT The Coordination for the improvement of higher Education Personnel (CAPES) for offering the doctoral scholarship “New Produceral” in partnership with the Federal University of Mato Grosso (UFMT) to Alisséia Guimarães Lemes (Process No 1,762,375).
• a
  Article extracted from doctoral thesis “Integrative Community Therapy as a strategy for psychosocial intervention for psychoactive drug users”, written by Alisséia Guimarães Lemes. Graduate Program in Psychiatric Nursing. University of São Paulo at Ribeirão Preto, Nursing School. 2020.

REFERÊNCIAS

• ¹
  Devóglio LL, Corrente JE, Borgato MH, Godoy I. Tabagismo em mulheres profissionais do sexo: prevalência e variáveis associadas. J Bras Pneumol. 2017;43(1):6-13. PMid:28380184.
• ²
  Remy LS, Scherer J, Guimarães L, Surratt HL, Kurtz SP, Pechansky F et al. Anxiety and depression symptoms in Brazilian sexual minority ecstasy and LSD users. Trends Psychiatry Psychother. 2017;39(4):239-46. http://dx.doi.org/10.1590/2237-6089-2016-0081 PMid:29160330.
  » http://dx.doi.org/10.1590/2237-6089-2016-0081
• ³
  Marin AH, Peuker AC, Kessler FHP. Sociodemographic characteristics, school performance, pattern of consumption and emotional health as risk factors for alcohol use among adolescents. Trends Psychol. 2019;27(1):279-92. http://dx.doi.org/10.9788/TP2019.1-20
  » http://dx.doi.org/10.9788/TP2019.1-20
• ⁴
  Andretta I, Limberger J, Schneider JA, Mello LTN. Sintomas de depressão, ansiedade e estresse em usuários de drogas em tratamento em comunidades terapêuticas. Psico-USF. 2018;23(2):361-73. http://dx.doi.org/10.1590/1413-82712018230214
  » http://dx.doi.org/10.1590/1413-82712018230214
• ⁵
  Cybulski CA, Mansani FP. Análise da depressão, dos fatores de risco para sintomas depressivos e do uso de antidepressivos entre acadêmicos do curso de medicina da Universidade Estadual de Ponta Grossa. Rev Bras Educ Med. 2017;41(1):92-101. http://dx.doi.org/10.1590/1981-52712015v41n1rb20160034
  » http://dx.doi.org/10.1590/1981-52712015v41n1rb20160034
• ⁶
  Figueiró LR, Bortolon CB, Benchaya MC, Bisch NK, Ferigolo M, Barros HM et al. Avaliação de mudanças na dependência da nicotina, motivação e sintomas de ansiedade e depressão em fumantes no processo inicial de redução ou cessação do tabagismo: estudo de seguimento de curto prazo. Trends Psychiatry Psychother. 2013;35(3):212-20. PMid:25923393.
• ⁷
  Alves DGL, Rocha SG, Andrade EV, Mendes AZ, Cunha AGJ. The positive impact of physical activity on the reduction of anxiety scores: a pilot study. Rev Assoc Med Bras. 2019;65(3):434-40. http://dx.doi.org/10.1590/1806-9282.65.3.434
  » http://dx.doi.org/10.1590/1806-9282.65.3.434
• ⁸
  Pawlina MMC, Rondina RC, Espinosa MM, Botelho C. Nicotine dependence and levels of depression and anxiety in smokers in the processo f smoking cessation. Rev Psiquiatr Clin. 2014;41(4):101-5. http://dx.doi.org/10.1590/0101-60830000000020
  » http://dx.doi.org/10.1590/0101-60830000000020
• ⁹
  Latkin C, Davey-Rothwell M, Yang JY, Crawford N. The relationship between drug user stigma and depression among inner-city drug users in Baltimore. J Urban Health. 2013;90(1):147-56. http://dx.doi.org/10.1007/s11524-012-9753-z PMid:22918839.
  » http://dx.doi.org/10.1007/s11524-012-9753-z
• ¹⁰
  Ministério da Saúde (BR). Glossário temático: práticas integrativas e complementares em saúde. Brasília: Ministério da Saúde; 2018.
• ¹¹
  Souza LPS, Teixeira FL, Diniz AP, Souza AG, Delgado LHV, Vaz AM et al. Práticas integrativas e complementares no cuidado à saúde mental e aos usuários de drogas. Id on Line Rev Mult Psic. 2017;11(38):1-22. http://dx.doi.org/10.14295/idonline.v11i38.775
  » http://dx.doi.org/10.14295/idonline.v11i38.775
• ¹²
  Melo OS, Ribeiro LRR, Costa ALRC, Urel DR. Repercussões da terapia comunitária integrativa nas pessoas doentes renais durante sessão de hemodiálise. Rev Pesqui Cuid Fundam. 2015;7(2):2200-14. http://dx.doi.org/10.9789/2175-5361.2015.v7i2.2200-2214
  » http://dx.doi.org/10.9789/2175-5361.2015.v7i2.2200-2214
• ¹³
  Braga JEF, Chaves No G, Lima AB, Oliveira RQ, Alves RS, Farias JA. Jogos cooperativos e relaxamento respiratório: efeito sobre craving e ansiedade. Rev Bras Med Esporte. 2016;22(5):403-7. http://dx.doi.org/10.1590/1517-869220162205153151
  » http://dx.doi.org/10.1590/1517-869220162205153151
• ¹⁴
  Chan YY, Lo WY, Li TC, Shen LJ, Yang SN, Chen YH et al. Clinical efficacy of acupuncture as an adjunct to methadone treatment services for heroin addicts: a randomized controlled trial. Am J Chin Med. 2014;42(3):569-86. http://dx.doi.org/10.1142/S0192415X14500372 PMid:24871652.
  » http://dx.doi.org/10.1142/S0192415X14500372
• ¹⁵
  Silva PPC, Santos ARM, Santos PJC, Rodrigues EAPC, Freitas CMSM. Práticas corporais no Centro de Atenção Psicossocial de Álcool e Drogas: a percepção dos usuários. Rev Bras Ciênc Esporte. 2019;41(1):3-9. http://dx.doi.org/10.1016/j.rbce.2018.08.004
  » http://dx.doi.org/10.1016/j.rbce.2018.08.004
• ¹⁶
  Ontiveros-González ML, Casique-Casique L, Muñoz-Torres TJ. Auriculotherapy as nursing care to decrease the consumption of marijuana and cocaine. SMAD Rev Eletrônica Saúde Mental Álcool Drog [Internet]. 2018; [citado 2019 jun 19];14(3):136-43. Disponível em: https://www.redalyc.org/articulo.oa?id=80358709003
  » https://www.redalyc.org/articulo.oa?id=80358709003
• ¹⁷
  Angelim SMAV, Valladares-Torres ACA. The design “rain metaphor” as an instrument of therapeutic communication of problematic drug addiction. Rev Cient Arteterapia Cores Vida [Internet]. 2019; [citado 2019 jun 19];26(1):1. Disponível em: https://www.researchgate.net/publication/332734980_O_desenho_%27metafora_da_chuva%27_como_instrumento_de_comunicacao_terapeutica_da_problematica_drogadicao
  » https://www.researchgate.net/publication/332734980_O_desenho_%27metafora_da_chuva%27_como_instrumento_de_comunicacao_terapeutica_da_problematica_drogadicao
• ¹⁸
  Taets GGC, Jomar RT, Abreu AMM, Capella MAM. Effect of music therapy on stress in chemically dependent people: a quasi-experimental study. Rev Lat Am Enfermagem. 2019;27:e3115. http://dx.doi.org/10.1590/1518-8345.2456.3115
  » http://dx.doi.org/10.1590/1518-8345.2456.3115
• ¹⁹
  Lemes AG, Nascimento VF, Rocha EM, Moura AAMM, Luis MAV, Macedo JQ. Integrative Community Therapy as a strategy for coping with drug among inmates in therapeutic communities: documentary research. SMAD Rev Eletrônica Saúde Mental Álcool Drog. 2017;13(2):101-8. http://dx.doi.org/10.11606/issn.1806-6976.v13i2p101-108
  » http://dx.doi.org/10.11606/issn.1806-6976.v13i2p101-108
• ²⁰
  Giffoni FAO, Santos MA. Community therapy as a method to address the problem of alcohol abuse in primary care. Rev Lat Am Enfermagem. 2011;19(spe):821-30. http://dx.doi.org/10.1590/S0104-11692011000700021
  » http://dx.doi.org/10.1590/S0104-11692011000700021
• ²¹
  Resolução CONAD nº 01/2015 (BR). Regulamenta, no âmbito do Sistema Nacional de Políticas Públicas sobre Drogas (SISNAD), as entidades que realizam o acolhimento de pessoas, em caráter voluntário, com problemas associados ao uso nocivo ou dependência de substância psicoativa, caracterizadas como comunidades terapêuticas. Diário Oficial da União, Brasília (DF), 28 ago 2015.
• ²²
  Creswell JW. Research design: quantitative, qualitative and mixed methods approaches. 4^th ed. Thousand Oaks: Sage Publications; 2014.
• ²³
  Cunha JA. Manual da versão em português das Escalas Beck. São Paulo: Casa do Psicólogo; 2016.
• ²⁴
  Barreto AP. Terapia Comunitária passo a passo. 3. ed. Fortaleza: Gráfica LCR; 2008.
• ²⁵
  Silva MZ, Martins SAK, Dallalana TM, Tinti DL, Rodrigues GKF, Macohin LF et al. Práticas integrativas impactam positivamente na saúde psicoemocional de mulheres? Estudo de intervenção da terapia comunitária integrativa no Sul do Brasil. Cad Naturol Terap Complem. 2018;7(12):33-42. http://dx.doi.org/10.19177/cntc.v7e12201833-42
  » http://dx.doi.org/10.19177/cntc.v7e12201833-42
• ²⁶
  Carvalho MRS, Silva JRS, Gomes NP, Andrade MS, Oliveira JF, Souza MRR. Motivações e repercussões do consumo de crack: o discurso coletivo de usuários de um Centro de Atenção Psicossocial. Esc Anna Nery Rev Enferm [Internet]. 2017; [citado 2019 mar 13];21(3):e20160178. Disponível em: http://www.scielo.br/pdf/ean/v21n3/pt_1414-8145-ean-2177-9465-EAN-2016-0178.pdf
  » http://www.scielo.br/pdf/ean/v21n3/pt_1414-8145-ean-2177-9465-EAN-2016-0178.pdf
• ²⁷
  Bisch NK, Moreira TC, Benchaya MC, Pozza DR, Freitas LC, Farias MS et al. Telephone counseling for young Brazilian cocaine and/or crack users. Who are these users? J Pediatr. 2019;95(2):209-16. http://dx.doi.org/10.1016/j.jped.2017.12.016 PMid:29526482.
  » http://dx.doi.org/10.1016/j.jped.2017.12.016
• ²⁸
  Danieli RV, Ferreira MBM, Nogueira JM, Oliveira LNC, Cruz Emirene MTN, Araújo Fo GM. Perfil sociodemográfico e comorbidades psiquiátricas em dependentes químicos acompanhados em comunidades terapêuticas. J Bras Psiquiatr. 2017;66(3):139-49. http://dx.doi.org/10.1590/0047-2085000000163
  » http://dx.doi.org/10.1590/0047-2085000000163
• ²⁹
  Paiva CB, Ferreira IB, Bosa VL, Narvaez JCM. Depression, anxiety, hopelessness and quality of life in users of cocaine/crack in outpatient treatment. Trends Psychiatry Psychother. 2017;39(1):34-42. http://dx.doi.org/10.1590/2237-6089-2015-0065 PMid:28403321.
  » http://dx.doi.org/10.1590/2237-6089-2015-0065
• ³⁰
  Poudel A, Sharma C, Gautam S, Poudel A. Psychosocial problems among individuals with substance use disorders in drug rehabilitation centers, Nepal. Subst Abuse Treat Prev Policy. 2016;11(1):28. http://dx.doi.org/10.1186/s13011-016-0072-3 PMid:27528233.
  » http://dx.doi.org/10.1186/s13011-016-0072-3
• ³¹
  Soares I, Esswein GC, Benetti SPC. Motivação para mudança em homens e mulheres dependentes de crack. Psicol Saude Doencas. 2017;18(2):567-80. http://dx.doi.org/10.15309/17psd180223
  » http://dx.doi.org/10.15309/17psd180223
• ³²
  Chan GCK, Butterworth P, Becker D, Degenhardt L, Stockings E, Hall W et al. Longitudinal patterns of amphetamine use from adolescence to adulthood: a latent class analysis of a 20-year prospective study of Australians. Drug Alcohol Depend. 2019;194:121-7. http://dx.doi.org/10.1016/j.drugalcdep.2018.08.042 PMid:30419406.
  » http://dx.doi.org/10.1016/j.drugalcdep.2018.08.042
• ³³
  Marel C, Sunderland M, Mills KL, Slade T, Teesson M, Chapman C. Conditional probabilities of substance use disorders and associated risk factors: progression from first use to use disorder on alcohol, cannabis, stimulants, sedatives and opioids. Drug Alcohol Depend. 2019;194:136-42. http://dx.doi.org/10.1016/j.drugalcdep.2018.10.010 PMid:30439610.
  » http://dx.doi.org/10.1016/j.drugalcdep.2018.10.010
• ³⁴
  Galvão A, Pinheiro M, Gomes MJ, Ala S. Ansiedade, stress e depressão relacionados com perturbações do sono-vigília e consumo de álcool em alunos do ensino superior. Rev Port Enferm Saúde Mental [Internet]. 2017; [citado 2019 mar 13];5:8-12. Disponível em: http://www.scielo.mec.pt/pdf/rpesm/nspe5/nspe5a02.pdf
  » http://www.scielo.mec.pt/pdf/rpesm/nspe5/nspe5a02.pdf
• ³⁵
  Lemes AG, Rocha EM, Nascimento VF, Volpato RJ, Almeida MASO, Franco SEJ et al. Benefícios da terapia comunitária integrativa revelados por usuários de substancias psicoativas. Acta Paul Enferm. 2020;33:1-8. http://dx.doi.org/10.37689/acta-ape/2020AO0122
  » http://dx.doi.org/10.37689/acta-ape/2020AO0122
• ³⁶
  Ferreira Fa MO, Lazarte R, Barreto AP. Impacto y tendencias del uso de la Terapia Comunitaria Integrativa en la producción de cuidados en salud mental. Rev Eletrônica Enferm [Internet]. 2015; [citado 2019 set 13];17(2):176-7. Disponível em: https://revistas.ufg.br/fen/article/view/37270/19517
  » https://revistas.ufg.br/fen/article/view/37270/19517

Edited by

ASSOCIATED EDITOR:

Ivone Evangelista Cabral

Publication Dates

• Publication in this collection
  09 Apr 2020
• Date of issue
  2020

History

• Received
  11 Nov 2019
• Accepted
  07 Jan 2020