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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">A CRISIS WITHIN THE CRISIS: THE MENTAL HEALTH SITUATION OF REFUGEES IN THE WORLD DURING THE 2019 CORONAVIRUS (2019-nCoV) OUTBREAK</title><author><name sortKey="Junior, Jucier Goncalves" sort="Junior, Jucier Goncalves" uniqKey="Junior J" first="Jucier Gonçalves" last="Júnior">Jucier Gonçalves Júnior</name><affiliation><nlm:aff id="aff0001">Department of Internal Medicine, Santa casa de Misericórdia de Fortaleza, Fortaleza, Ceará, Brazil</nlm:aff></affiliation></author><author><name sortKey="De Sales, Jair Paulino" sort="De Sales, Jair Paulino" uniqKey="De Sales J" first="Jair Paulino" last="De Sales">Jair Paulino De Sales</name><affiliation><nlm:aff id="aff0002">Department of Production Engineering, Catolic University, Quixadá, CE, Brazil</nlm:aff></affiliation></author><author><name sortKey="Moreira, Marcial Moreno" sort="Moreira, Marcial Moreno" uniqKey="Moreira M" first="Marcial Moreno" last="Moreira">Marcial Moreno Moreira</name><affiliation><nlm:aff id="aff0003">School of Medicine, Universidade Federal do Cariri (UFCA), Barbalha, Ceará, Brazil</nlm:aff></affiliation><affiliation><nlm:aff id="aff0004">School of Medicine of Juazeiro do Norte (FMJ/Estácio) – Juazeiro do Norte, Ceará, Brazil</nlm:aff></affiliation></author><author><name sortKey="Pinheiro, Woneska Rodrigues" sort="Pinheiro, Woneska Rodrigues" uniqKey="Pinheiro W" first="Woneska Rodrigues" last="Pinheiro">Woneska Rodrigues Pinheiro</name><affiliation><nlm:aff id="aff0005">Regional University of Cariri – URCA, Crato, Ceará, Brazil</nlm:aff></affiliation></author><author><name sortKey="Lima, Carlos Kennedy Tavares" sort="Lima, Carlos Kennedy Tavares" uniqKey="Lima C" first="Carlos Kennedy Tavares" last="Lima">Carlos Kennedy Tavares Lima</name><affiliation><nlm:aff id="aff0006">Postgraduate Program in Health Sciences, School of Medicine of ABC, Santo André, São Paulo, Brazil</nlm:aff></affiliation></author><author><name sortKey="Neto, Modesto Leite Rolim" sort="Neto, Modesto Leite Rolim" uniqKey="Neto M" first="Modesto Leite Rolim" last="Neto">Modesto Leite Rolim Neto</name><affiliation><nlm:aff id="aff0003">School of Medicine, Universidade Federal do Cariri (UFCA), Barbalha, Ceará, Brazil</nlm:aff></affiliation><affiliation><nlm:aff id="aff0004">School of Medicine of Juazeiro do Norte (FMJ/Estácio) – Juazeiro do Norte, Ceará, Brazil</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmc">7156944</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7156944</idno><idno type="RBID">PMC:7156944</idno><idno type="doi">10.1016/j.psychres.2020.113000</idno><idno type="pmid">NONE</idno><date when="2020">2020</date><idno type="wicri:Area/Pmc/Corpus">000507</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000507</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">A CRISIS WITHIN THE CRISIS: THE MENTAL HEALTH SITUATION OF REFUGEES IN THE WORLD DURING THE 2019 CORONAVIRUS (2019-nCoV) OUTBREAK</title><author><name sortKey="Junior, Jucier Goncalves" sort="Junior, Jucier Goncalves" uniqKey="Junior J" first="Jucier Gonçalves" last="Júnior">Jucier Gonçalves Júnior</name><affiliation><nlm:aff id="aff0001">Department of Internal Medicine, Santa casa de Misericórdia de Fortaleza, Fortaleza, Ceará, Brazil</nlm:aff></affiliation></author><author><name sortKey="De Sales, Jair Paulino" sort="De Sales, Jair Paulino" uniqKey="De Sales J" first="Jair Paulino" last="De Sales">Jair Paulino De Sales</name><affiliation><nlm:aff id="aff0002">Department of Production Engineering, Catolic University, Quixadá, CE, Brazil</nlm:aff></affiliation></author><author><name sortKey="Moreira, Marcial Moreno" sort="Moreira, Marcial Moreno" uniqKey="Moreira M" first="Marcial Moreno" last="Moreira">Marcial Moreno Moreira</name><affiliation><nlm:aff id="aff0003">School of Medicine, Universidade Federal do Cariri (UFCA), Barbalha, Ceará, Brazil</nlm:aff></affiliation><affiliation><nlm:aff id="aff0004">School of Medicine of Juazeiro do Norte (FMJ/Estácio) – Juazeiro do Norte, Ceará, Brazil</nlm:aff></affiliation></author><author><name sortKey="Pinheiro, Woneska Rodrigues" sort="Pinheiro, Woneska Rodrigues" uniqKey="Pinheiro W" first="Woneska Rodrigues" last="Pinheiro">Woneska Rodrigues Pinheiro</name><affiliation><nlm:aff id="aff0005">Regional University of Cariri – URCA, Crato, Ceará, Brazil</nlm:aff></affiliation></author><author><name sortKey="Lima, Carlos Kennedy Tavares" sort="Lima, Carlos Kennedy Tavares" uniqKey="Lima C" first="Carlos Kennedy Tavares" last="Lima">Carlos Kennedy Tavares Lima</name><affiliation><nlm:aff id="aff0006">Postgraduate Program in Health Sciences, School of Medicine of ABC, Santo André, São Paulo, Brazil</nlm:aff></affiliation></author><author><name sortKey="Neto, Modesto Leite Rolim" sort="Neto, Modesto Leite Rolim" uniqKey="Neto M" first="Modesto Leite Rolim" last="Neto">Modesto Leite Rolim Neto</name><affiliation><nlm:aff id="aff0003">School of Medicine, Universidade Federal do Cariri (UFCA), Barbalha, Ceará, Brazil</nlm:aff></affiliation><affiliation><nlm:aff id="aff0004">School of Medicine of Juazeiro do Norte (FMJ/Estácio) – Juazeiro do Norte, Ceará, Brazil</nlm:aff></affiliation></author></analytic><series><title level="j">Psychiatry Research</title><idno type="ISSN">0165-1781</idno><idno type="eISSN">1872-7123</idno><imprint><date when="2020">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><title>Highlights</title><p><list list-type="simple" id="celist0001"><list-item id="celistitem0001"><label>•</label><p id="para0001">Refugees faced several challenges due to their condition. With the COVID-19 pandemic, Refugees encounter several difficulties: adapting to the language while trying to obtain reliable information; the unhealthy spaces in which they live, overcrowded, without access to water, basic sanitation, food are also factors that aggravate their condition. Lack of human resources due to quarantine and the lack of infrastructure of support agencies in countries that have received refugees also mitigates assistance.</p></list-item><list-item id="celistitem0002"><label>•</label><p id="para0002">All of these factors associated with fear and uncertainties about the future are consistent risk factors for an increase in cases of COVID-19 infection as well as psychiatric illnesses such as depression, anxiety, and post-traumatic stress disorder.</p></list-item></list></p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Moreira, E B" uniqKey="Moreira E">E.B. Moreira</name></author><author><name sortKey="Goncalves Junior, J" uniqKey="Goncalves Junior J">J. Gonçalves Júnior</name></author><author><name sortKey="Sant Anna, A L" uniqKey="Sant Anna A">A.L. Sant'Anna</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Hvass, A M" uniqKey="Hvass A">A.M. Hvass</name></author><author><name sortKey="Wejse, C" uniqKey="Wejse C">C. Wejse</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Triantafyllou, K" uniqKey="Triantafyllou K">K. Triantafyllou</name></author><author><name sortKey="Othiti, I" uniqKey="Othiti I">I. Othiti</name></author><author><name sortKey="Xylouris, G" uniqKey="Xylouris G">G. Xylouris</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Shokri, A" uniqKey="Shokri A">A. Shokri</name></author><author><name sortKey="Sabzevari, S" uniqKey="Sabzevari S">S. Sabzevari</name></author><author><name sortKey="Hashemi, A S" uniqKey="Hashemi A">A.S. Hashemi</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Phillbrick, A M" uniqKey="Phillbrick A">A.M. Phillbrick</name></author><author><name sortKey="Wicks, C M" uniqKey="Wicks C">C.M. Wicks</name></author><author><name sortKey="Harris, I M" uniqKey="Harris I">I.M. Harris</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Silva, A A M" uniqKey="Silva A">A.A.M. Silva</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Morina, N" uniqKey="Morina N">N. Morina</name></author><author><name sortKey="Hoppen, T H" uniqKey="Hoppen T">T.H. Hoppen</name></author><author><name sortKey="Priebe, S" uniqKey="Priebe S">S. Priebe</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Slewa Younan, S" uniqKey="Slewa Younan S">S. Slewa-Younan</name></author><author><name sortKey="Uribe Guajardo, M G" uniqKey="Uribe Guajardo M">M.G. Uribe Guajardo</name></author><author><name sortKey="Heriseanu, A" uniqKey="Heriseanu A">A. Heriseanu</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Bulik, K J" uniqKey="Bulik K">K.J. Bulik</name></author><author><name sortKey="Colucci, E" uniqKey="Colucci E">E. Colucci</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="letter"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Psychiatry Res</journal-id><journal-id journal-id-type="iso-abbrev">Psychiatry Res</journal-id><journal-title-group><journal-title>Psychiatry Research</journal-title></journal-title-group><issn pub-type="ppub">0165-1781</issn><issn pub-type="epub">1872-7123</issn><publisher><publisher-name>Elsevier B.V.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmc">7156944</article-id><article-id pub-id-type="publisher-id">S0165-1781(20)30786-1</article-id><article-id pub-id-type="doi">10.1016/j.psychres.2020.113000</article-id><article-id pub-id-type="publisher-id">113000</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>A CRISIS WITHIN THE CRISIS: THE MENTAL HEALTH SITUATION OF REFUGEES IN THE WORLD DURING THE 2019 CORONAVIRUS (2019-nCoV) OUTBREAK</article-title></title-group><contrib-group><contrib contrib-type="author" id="au0001"><name><surname>Júnior</surname><given-names>Jucier Gonçalves</given-names></name><xref rid="aff0001" ref-type="aff">a</xref></contrib><contrib contrib-type="author" id="au0002"><name><surname>de Sales</surname><given-names>Jair Paulino</given-names></name><xref rid="aff0002" ref-type="aff">b</xref></contrib><contrib contrib-type="author" id="au0003"><name><surname>Moreira</surname><given-names>Marcial Moreno</given-names></name><xref rid="aff0003" ref-type="aff">c</xref><xref rid="aff0004" ref-type="aff">d</xref></contrib><contrib contrib-type="author" id="au0004"><name><surname>Pinheiro</surname><given-names>Woneska Rodrigues</given-names></name><xref rid="aff0005" ref-type="aff">e</xref></contrib><contrib contrib-type="author" id="au0005"><name><surname>Lima</surname><given-names>Carlos Kennedy Tavares</given-names></name><xref rid="aff0006" ref-type="aff">f</xref></contrib><contrib contrib-type="author" id="au0006"><name><surname>Neto</surname><given-names>Modesto Leite Rolim</given-names></name><email>modesto.neto@ufca.edu.br</email><xref rid="aff0003" ref-type="aff">c</xref><xref rid="aff0004" ref-type="aff">d</xref><xref rid="cor0001" ref-type="corresp">⁎</xref></contrib></contrib-group><aff id="aff0001"><label>a</label>Department of Internal Medicine, Santa casa de Misericórdia de Fortaleza, Fortaleza, Ceará, Brazil</aff><aff id="aff0002"><label>b</label>Department of Production Engineering, Catolic University, Quixadá, CE, Brazil</aff><aff id="aff0003"><label>c</label>School of Medicine, Universidade Federal do Cariri (UFCA), Barbalha, Ceará, Brazil</aff><aff id="aff0004"><label>d</label>School of Medicine of Juazeiro do Norte (FMJ/Estácio) – Juazeiro do Norte, Ceará, Brazil</aff><aff id="aff0005"><label>e</label>Regional University of Cariri – URCA, Crato, Ceará, Brazil</aff><aff id="aff0006"><label>f</label>Postgraduate Program in Health Sciences, School of Medicine of ABC, Santo André, São Paulo, Brazil</aff><author-notes><corresp id="cor0001"><label>⁎</label>Correspondence author: Modesto Leite Rolim Neto, School of Medicine, Federal University of Cariri, UFCA, Barbalha, Ceará, Brazil <email>modesto.neto@ufca.edu.br</email></corresp></author-notes><pub-date pub-type="pmc-release"><day>15</day><month>4</month><year>2020</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="epub"><day>15</day><month>4</month><year>2020</year></pub-date><elocation-id>113000</elocation-id><history><date date-type="received"><day>5</day><month>4</month><year>2020</year></date><date date-type="rev-recd"><day>8</day><month>4</month><year>2020</year></date><date date-type="accepted"><day>8</day><month>4</month><year>2020</year></date></history><permissions><copyright-statement>© 2020 Elsevier B.V. All rights reserved.</copyright-statement><copyright-year>2020</copyright-year><copyright-holder></copyright-holder><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions><abstract abstract-type="author-highlights" id="abs0001"><title>Highlights</title><p><list list-type="simple" id="celist0001"><list-item id="celistitem0001"><label>•</label><p id="para0001">Refugees faced several challenges due to their condition. With the COVID-19 pandemic, Refugees encounter several difficulties: adapting to the language while trying to obtain reliable information; the unhealthy spaces in which they live, overcrowded, without access to water, basic sanitation, food are also factors that aggravate their condition. Lack of human resources due to quarantine and the lack of infrastructure of support agencies in countries that have received refugees also mitigates assistance.</p></list-item><list-item id="celistitem0002"><label>•</label><p id="para0002">All of these factors associated with fear and uncertainties about the future are consistent risk factors for an increase in cases of COVID-19 infection as well as psychiatric illnesses such as depression, anxiety, and post-traumatic stress disorder.</p></list-item></list></p></abstract><abstract id="abs0002"><sec><title>Background</title><p>68.5 million people around the world have been forced to leave their houses. Refugees have mainly to face their adaption in a host country, which involves bureaucracy, different culture, poverty, and racism. The already fragile situation of refugees becomes worrying and challenged in the face of the new coronavirus (COVID-19) epidemic. Therefore, we aimed to describe the factors that can worsen the mental health of refugees.</p></sec><sec><title>Method</title><p>The studies were identified in well-known international journals found in three electronic databases: PubMed, Scopus, and Embase. The data were cross-checked with information from the main international newspapers.</p></sec><sec><title>Results</title><p>According to the literature, the difficulties faced by refugees with the COVID-19 pandemic are potentiated by the pandemic state. There are several risk factors common to coronavirus and psychiatric illnesses as overcrowding, disruption of sewage disposal, poor standards of hygiene, poor nutrition, negligible sanitation, lack of access to shelter, health care, public services, and safety. These associated with fear and uncertainty create a closed ground for psychological sickness and COVID-19 infection.</p></sec><sec><title>Conclusions</title><p>There should be not only a social mobilization to contain the virus, but also a collective effort on behalf of the most vulnerable populations.</p></sec></abstract><kwd-group id="keys0001"><title>Keywords</title><kwd>Coronavirus Infection</kwd><kwd>Mental Health</kwd><kwd>Refugees</kwd></kwd-group></article-meta></front><body><p id="para0007">68.5 million people around the world have been forced to leave their houses (<xref rid="bib0001" ref-type="bibr">Moreira et al., 2018</xref>) because of war, violence, or oppression. Nearly 21.3 million of these are refugees. In addition, 40.8 million are internally displaced. Globally, 6% of the world's displaced people are hosted in Europe and 12% in the Americas (<xref rid="bib0002" ref-type="bibr">Hvas; Wejse, 2017</xref>).</p><p id="para0008">Immigration involves several stressful events for youth and their families during the process of immigration and even after the settlement. Refugees have mainly to face their adaption in a host country, which involves bureaucracy, different culture, poverty, and racism (<xref rid="bib0003" ref-type="bibr">Tryantafyllou et al., 2018</xref>). Moreover, settling in crowded shelters without clean water and inaccessibility to health care services makes people more vulnerable to get an infection (<xref rid="bib0004" ref-type="bibr">Shokri; Sabzevari; Hashemi, 2020</xref>). Hence, the already fragile situation of refugees becomes worrying and challenged in the face of the new coronavirus (COVID-19) pandemic that occurred in Wuhan, China, in December of 2019. This has been responsible, until 29 March 2020, for a total of 575,444 cases confirmed in the 202 countries including 26,654 deaths (<xref rid="bib0005" ref-type="bibr">WHO, 2020</xref>). Therefore, we aimed to describe the factors that can worsen the mental health of refugees.</p><p id="para0009">The first difficulty faced by refugees is language and access to information. According to data from the United Nations High Commissioner for Refugees (UNHCR), digital platforms are useful for sharing quality information and keeping contact with local representatives and groups of refugees (<xref rid="bib0006" ref-type="bibr">UNHCR, 2020a</xref>). The great challenge is to screen information on prevention and health promotion about COVID-19 and to adapt them to the routines of thousands of families in refugee camps, while dealing with situations bordering on their physical and psychological health.</p><p id="para0010">The second difficulty refers to the sociocultural differences between refugees and countries that receive them, as well as discrepancies in health care practices that do not align with their cultural or religious beliefs (<xref rid="bib0008" ref-type="bibr">Phillbrick et al., 2017</xref>).</p><p id="para0011">The third difficulty is the overcrowding of fields and intimate human contact, due to the precarious housing situations. In Greece, for instance, there were 38,000 refugees living on 6,200 m<sup>2</sup> in Moria camps (<xref rid="bib0009" ref-type="bibr">AFP, 2020</xref>). A refugee camp in Bangladesh is so cramped that its population density is nearly four times higher than that of New York City, making social distancing impossible (<xref rid="bib0010" ref-type="bibr">Beech; Hubard, 2020</xref>). This situation, as that of several other camps, is worrying, as the most effective methods for controlling COVID-19 are identifying the communicants and quarantining them; protecting health professionals with personal protective equipment; and identifying symptomatic patients, performing tests, giving results quickly and isolating them (<xref rid="bib0011" ref-type="bibr">Silva, 2020</xref>).</p><p id="para0012">The fourth difficulty is the high numbers of refugees that can represent overload and major challenges to health care systems and local refugee voluntary agencies in host societies, especially mental health care (<xref rid="bib0012" ref-type="bibr">Morina; Hoppen; Priebe, 2020</xref>). Clinics in a refugee camp in Kenya have been struggling with only eight doctors for nearly 200,000 people (<xref rid="bib0010" ref-type="bibr">Beech; Hubard, 2020</xref>). <xref rid="bib0008" ref-type="bibr">Phillbrick et al. (2017)</xref> state that voluntary agencies have been given very limited government financial assistance to aid refugees in obtaining food, housing (including furniture), clothing, local language education, employment counseling, education, and medical care in the United States. The UNHCR has been accepting funds to deal with the COVID-19 pandemic throughout the world. It seeks $255 million to provide support to displaced people and migrants in the fight against the disease that affects almost the whole world. Their intention is to provide laboratory equipment for tests and medical supplies for the treatment of patients affected by COVID-19; to disseminate information campaigns; to send supplies to needy regions and to move medical work teams across territories (<xref rid="bib0007" ref-type="bibr">UNHCR, 2020b</xref>).</p><p id="para0013">The fifth difficulty, paradoxically, is the shutdown of government services and a considerable decrease in volunteers due to quarantine. These situations are quite unsettling and can be exemplified by camps across Germany, France, Greece, Brazil (O <xref rid="bib0013" ref-type="bibr">Globo, 2020</xref>), Africa, the Middle East and Asia, where there are traumatized and undernourished people with limited access to health care resources and basic sanitation (<xref rid="bib0010" ref-type="bibr">Beech; Hubard, 2020</xref>).</p><p id="para0014">For these various reasons, this population has a high risk of developing psychiatric disorders, which is worsened in the face of the COVID-19 pandemic. Overcrowding, disruption of sewage disposal, poor standards of hygiene, poor nutrition, negligible sanitation (<xref rid="bib0004" ref-type="bibr">Shokri; Sabzevari; Hashemi, 2020</xref>), lack of access to shelter, health care, public services and safety are risk factor for COVID-19 and mental illness that when associated with fear and uncertainty creat a favorable situation for the psychological and biological illness of these communities (<xref rid="bib0015" ref-type="bibr">Bulik; Colucci, 2019</xref>). A Greek study compared the number of psychiatric diagnoses of refugees in Greece with natives, showing a rate almost four times higher (<xref rid="bib0003" ref-type="bibr">Tryantafyllou et al., 2018</xref>). Systematic reviews show that prevalence estimates of mental health disorders for this population vary widely from 20 to 80%: 4 to 40% for anxiety, 5 to 44% for depression, 9 to 36% for posttraumatic stress disorder (<xref rid="bib0014" ref-type="bibr">Slewa-Younan et al., 2015</xref>).</p><p id="para0015">Therefore, during the pandemic of COVID-19, there should be not only a social mobilization to contain the virus, but also a collective effort on behalf of the most vulnerable populations – biologically and psychologically with holistic support for both the humanitarian issues and the containment of the pandemic.</p><sec id="sec0001"><title>Authors’ contributions</title><p id="para0016">MLRN, JGJ, JPS, CKTL, MMM designed the review, developed the inclusion criteria, screened titles and abstracts, appraised the quality of included papers, and drafted the manuscript.</p><p id="para0017">MLRN, JGJ, WRP, CKTL, JPS reviewed the study protocol and inclusion criteria and provided substantial input to the manuscript.</p><p id="para0018">MLRN, JGJ, JPS, MMM, WRP reviewed the study protocol. MMM read and screened articles for inclusion. All authors critically reviewed drafts and approved the final manuscript.</p></sec><sec id="sec0002"><title>Funding</title><p id="para0019">The researchs groups: Statistical Modeling, Simulation and Risk Optimization, Department of Engineer; Scientific Writing Lab, Medicine School – Universidade Federal of Cariri (UFCA) and the Suicidology Research Group from Universidade Federal do Ceará (UFC) and Brazilian National Council for Scientific and Technological Development (CNPq) – institution linked to the Brazilian Department of Science, Technology and Innovation to encourage research in Brazil.</p></sec><sec sec-type="COI-statement"><title>Declaration of Competing Interest</title><p id="para0020">The authors declare that they have no competing interests.</p></sec></body><back><ref-list id="cebibl1"><title>References</title><ref id="bib0001"><element-citation publication-type="journal" id="sbref0001"><person-group person-group-type="author"><name><surname>Moreira</surname><given-names>E.B.</given-names></name><name><surname>Gonçalves Júnior</surname><given-names>J.</given-names></name><name><surname>Sant'Anna</surname><given-names>A.L.</given-names></name></person-group><article-title>. 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