Mental Health Care In Brazil Research Articles

Challenges facing the psychiatric reform and mental health care in Brazil: Critical unmet needs and prospects for better integrating the public and university sectors

In Brazil, two main mental health care sectors (public and academic) coexist, interact, and tension each other with distinct, antagonistic views and ethos, producing a scenario of distancing and mistreatment. All the leading players involved need to take a new stance to openly discuss the roots of their divergences and accept the challenge of formulating a minimally joint and integrated project for the Brazilian mental healthcare system policy and practices.Here we present and discuss five critical unmet needs of the mental health system that should be tackled through more integrated work between the public and university sectors aiming at: 1. Providing better emergency care, including, when required, inpatient treatment in general hospital psychiatric units for patients with severe mental disorders in acute episodes; 2. Optimizing the use of clozapine, granting a trial for all patients with treatment-resistant schizophrenia and other severe psychoses; 3. Updating the list and protocols of use of psychiatric drugs available in the Brazilian Unified Health System; 4. Updating psychosocial rehabilitation interventions; 5. Implementing a two-way collaboration between the network of mental health services, especially the CAPS, and Primary Care Centers to offer integrated healthcare, addressing thus the high physical morbidity of patients with severe mental disorders.Psychiatric reform in Brazil has gone a long way in the past few decades toward community-centered mental health care. It was never an easy process, proper funding was always a challenge, and the risk of political drawbacks loomed, particularly in the last years. We believe the country has the necessary resources to deliver high-quality and accessible mental health care. Now is the time to better integrate the public and university sectors to address the critical issues and move forward with the psychiatric reform agenda.

Realising the future: Health challenges and achievements in Brazil

In the present paper, we take a critical public health perspective that accounts for social determinants of health and health inequalities to explore the challenges of healthcare — including mental healthcare — in Brazil. Brazil, which has been described as a country of continental dimensions, a country of contrasts, and the country of the future, was built on principles of exploitation of the land and of its people, and has faced many social, economic, and political challenges throughout its history. The creation of Brazil's Unified Health System (Sistema Único de Saúde — SUS), providing universal healthcare free of charge at point of use, attests to the country's resilience. Despite many advances, several issues remain in the promotion, prevention, and care for physical and mental health problems. Particularly for mental health, the recent increased demand for services following the Covid-19 pandemic has exposed the system's vulnerability in terms of coverage and reach, with underserved groups including youths, females, LGBTQIA+, non-white, and low-income individuals. By taking advantage of the SUS installed infrastructure and strengthening the primary care model on which the system is based, the SUS can become the blueprint to consolidate and expand mental healthcare in Brazil.

Atuação de terapeutas ocupacionais na Rede de Atenção Psicossocial em um estado do nordeste brasileiro

Abstract Mental health care in Brazil has been changing throughout history, establishing new practices, forming the Psychosocial Care Network, affirming the protagonism of users in the production of care, their social rights and their citizenship. Among the professionals involved in these changes are occupational therapists. This qualitative research aimed to understand the performance of these professionals in this Psychosocial Care Network in the Paraíba state, Brazil. Thirteen occupational therapists were interviewed using a semi-structured questionnaire, applied remotely. These professionals are mostly women, with professional experience and interest in working in Mental Health, as well as work in Psychosocial Care Centers I. A low number of professionals in state services was evidenced, being only 17 in a Network of 124 services. As for the actions developed, they listed: individualized care, reception/screening, groups, Unique Therapeutic Projects, participation in team meetings, crisis management and workshops. The precariousness of working conditions was perceived, in particular, by the lack of resources to carry out the interventions. Only occasionally they feel supported by the representative entities (class council, union, and state professional association). The service coordinators understand the professional performance, but it is the users who value it the most, followed by family members, teams, and service coordinators. This appreciation and recognition by the main agents involved in the production of community life demonstrates that occupational therapists are an integral and active part in this process of reception, coexistence and inclusion of vulnerable and fragile people facing their condition of mental suffering.

Effectiveness of Agreement Criteria and Flows of Collaborative Care in Primary Mental Health Care in Brazil.

The supply of mental health processes in primary care has gaps. This study aims to analyze the association of agreement criteria and flows between primary care teams and the Family Health Support Center (NASF) for mental health collaborative care, considering the difference between capital and non-capital cities in Brazil. This cross-sectional study was conducted based on secondary data from the Primary Care Access and Quality Improvement Program. Agreement criteria and flows were obtained from 3883 NASF teams of the matrix support or collaborative care. The Chi-square test and multiple Poisson regression were used; p < 0.05 was considered statistically significant. Prevalence ratios of negative associations demonstrated protective factors for support actions: follow-up at Psychosocial Care Center, management of psychopharmacotherapy, offer of other therapeutic actions, care process for users of psychoactive substances, and offer of activities to prevent the use of psychoactive substances. Collaborative care in primary care was effective, and capital cities were a protective factor compared with non-capital cities.

The woman who chose the terreiro. Lay care and medical landscapes in mental health care in Rio de Janeiro

Brazilian mental health care reform understands mental health as a complex social process. There is a large literature production within the country focused on deinstitutionalization policy, social determinants of mental health and human rights, however, with little recognition beyond Latin American borders. In addition, cultural dimensions of mental suffering have been neglected in Brazilian debates which limits an expanded understanding of health care and users’ inclusion. This paper aims to discuss the role of cultural determinants in mental health care in Brazil. We followed a patient in the city of Rio de Janeiro who opted for therapy based on her religious beliefs—using ayahuasca in the context of the Afro Brazilian religion of Umbanda—over the treatment-as-usual in mental health. We draw on the notions of autoatención (self, domestic, and group-care in lay contexts) and medical landscapes to examine how therapeutic negotiations reflect embodied cultural traits and both social and political determinants shaping therapeutic spaces. We argue that recognizing sociocultural differences and therapeutic negotiations are key elements in making a more inclusive health practice. Moreover, this recognition enables identifying and reasoning the broader social processes framing health practices. This debate is relevant to the Brazilian mental health context and to other scenarios, especially those where local and global knowledge and practices in mental health are entangled.

Dimensional Clinical Personality Inventory 2: antecedents, development, and future improvements

Personality disorders (PDs) are characterized by impairments in the self and interpersonal relationships. People diagnosed with PD present distress in several areas of life. The prevalence of these disorders is 13% in Western countries and around 7% in Brazil. Despite the adverse outcomes related to PDs and its prevalence, these disorders tend to be undertreated in Brazil. One possible explanation is the lack of assessment scales to measure PDs typical traits. To fulfill this gap and improve mental health care in Brazil, the Dimensional Clinical Personality Inventory 2 (IDCP-2) was developed, an assessment tool that follows international guidelines and takes into account for the Brazilian reality. This paper aimed to present the main characteristics of IDCP-2, including its antecedents, development, theoretical and empirical foundations, as well as definitions of its 12 dimensions distributed in 47 factors. We discussed ongoing clinical research, limitations, and future improvements of the IDCP-2. Although IDCP-2 helps in fulfill the gap regarding PDs assessment in Brazil, efforts for the continuity of research focused on the PDs traits assessment is more than desirable, necessary for the advance of the mental health research area in the country.

Mental healthcare in Brazil: a multifaceted study in four large cities

This study aimed to assess characteristics of healthcare networks in four large Brazilian cities (Campinas, Fortaleza, Porto Alegre, and São Paulo), in the provision of mental healthcare. The following outcomes were used: (i) place of identification of the mental health problem; (ii) mental healthcare in primary care; (iii) pharmaceutical care in mental health; and (iv) social rehabilitation. This is a mixed-methods study with a concurrent and sequential approach, conducted with 10 administrators and 1,642 users of Centers for Psychosocial Care (CAPS, in Portuguese) in the four cities. The study showed the persistence of high-complexity services such as hospitals as the site for initial identification of mental health problems in Campinas (40% of users) and Fortaleza (37%); low proportion of mental health treatment in primary care (Fortaleza, 23%); differences between cities in psychotropic medication prescription in primary care (Porto Alegre, 68%; São Paulo, 64%; Campinas, 39%; Fortaleza, 31%) and in shortages of prescribed medication (higher in Fortaleza, 58%; lower in Campinas, 28%); and overall frailty in enabling return to work (lower in São Paulo, 17%; higher in Campinas, 39%), with better overall results regarding religion and leisure activities (higher in São Paulo, 53% and 56%, respectively). The study contributes to the discussion of the Brazilian scenario of mental healthcare, with evidence of persistent inequalities in the national context, pointing to gaps in some mental healthcare network configurations with the potential for better performance and longitudinal follow-up.

PROMOÇÃO E PREVENÇÃO EM SAÚDE MENTAL NA INFÂNCIA: IMPLICAÇÕES EDUCACIONAIS

Nos últimos anos, um novo paradigma em saúde mental vem se consolidando, impulsionado por novas formas de compreender e intervir sobre os processos de saúde. Uma perspectiva mais abrangente, contextualizada e focada nos processos de saúde ganha força, em detrimento de uma abordagem reducionista, institucionalizante e que enfatizava a doença. Nesse contexto, as práticas de promoção e prevenção em saúde mental ganham espaço, as quais objetivam potencializar a saúde psicológica e evitar o surgimento de problemas a ela associados. Assim, este trabalho pretendeu discutir quais as implicações educacionais deste novo paradigma no que diz respeito à saúde mental de crianças e adolescentes. Inicialmente, traça-se um histórico da atenção à saúde mental infantil no Brasil, evidenciando um longo período de descaso e marginalização em relação a essa população. Posteriormente, são discutidos os pressupostos que fundamentam as ações de promoção e prevenção em saúde mental e o papel da escola nesses processos. Finalmente, são discutidos alguns estudos de revisão sobre a implementação de programas de prevenção e promoção em contexto escolar. Acredita-se que a construção de estratégias destinadas à promoção de saúde mental configura-se como um desafio atual, sobretudo, no contexto educacional.

Empathy in Mental Health Nursing Care in Brazil

Background: Empathy, from the Greek empathetic means to enter into the feeling, a term initially used by aesthetic theorists, to designate the ability to perceive the subjective experience of the other. For empathy to occur as a therapeutic process, it is essential that a relationship of mutual respect be developed and that nurses provide individualized care, respecting the culture, beliefs and values of the person. Purpose: This study aimed to determine to know and characterize the scientific production on Empathy in Mental Health Nursing Care in Brazil.Methods: This is a metasynthesis performed in the first half of 2018 that involved five stages: formulation of the problem, data collection, evaluation of the collected data, analysis and interpretation of the data, and presentation of the results.Results: Of the 6 studies that were part of this metasynthesis, the method most used among the forms of treatment among the health professional/patient is the biomedical model, focusing on the disease and not on the human being in a broad and holistic way, consequently, being performed only one punctual care and not a care in order to meet all the biopsychosocial needs of the patient. Conclusion: As a way to improve care and meet the patient's needs, empathy is one of the main tools of mental health care in Brazil, because with it we can gain trust and establish bonds with the patient, thus gaining an effective relationship for both parties, thus being able to perform an affectionate, integrative and productive care

A Política Nacional de Saúde Mental: uma reflexão acerca dos retrocessos nos governos Temer e Bolsonaro

Historicamente, uma série de mudanças tem ocorrido nos padrões de atenção à saúde mental no Brasil, por meio da Reforma Psiquiátrica (RP) e da Reforma Sanitária (RS), representando significativas conquistas para a sociedade civil. No entanto, apesar dos avanços, a mercantilização das políticas sociais tem prevalecido na conjuntura brasileira, dada a ofensiva neoliberal que a acompanha desde a década de 1990. Neste sentido, o presente artigo tem como objetivo discutir acerca das principais tendências da Política de Saúde Mental (PSM) brasileira, fazendo um recorte dos frequentes riscos de retrocessos empreendidos pelos governos Temer e Bolsonaro. Para tanto, o método de análise da realidade que pareceu pertinente para este estudo foi o crítico-dialético. Foi realizado uma revisão bibliográfica das principais categorias do estudo (Contrarreforma e Reforma Psiquiátrica) e uma pesquisa documental das principais legislações da PSM, com abordagem qualitativa. A discussão deste estudo aponta, portanto, que a PSM tem se desenvolvido na realidade brasileira, articulando avanço e conservadorismo, sobretudo a partir das propostas de tais governos, sob a ordem de um neoliberalismo ortodoxo, quando se verifica a volta de uma organização das forças restauradoras da saúde mental contra a RP.

Challenges for implementing a global mental health agenda in Brazil: The "silencing" of culture.

Since its emergence in 2007, Global Mental Health has been a growing and polemic area of study, research and practice in mental health worldwide. Despite having a significant endogenous academic production and innovative policy experiences, the Brazilian mental health field and its actors make few references to, and scarcely dialogue with, the Global Mental Health agenda. This article explores an aspect of this divergence between Global Mental Health initiatives and public mental health care in Brazil regarding the role of culture within mental health policies and practices. Our hypothesis is that part of this difficulty can be attributed to the low relevance of the cultural dimension for the Brazilian mental health field, here referred to as the "silencing of culture." We examine the possible historical roots of this process with reference to theories of "anthropophagy" and "cultural uniformity" in the context of Brazilian cultural matrices. We then describe two recent experiences in public mental health care that incorporate cultural competence through the work of community health workers and the example of community therapy. We argue that the development of cultural competence can be decisive in enabling an improved dialogue between research and practice in Brazilian mental health and global mental health initiatives.

The assistance model in mental health in Brazil: an integrating review

The process of psychiatric reform in Brazil gave way to a crisis of the current assistance model, centered only on the psychiatric hospital, which had a hygienist objective more than care and health promotion. Soon, to change the standard of care for the mentally ill, a struggle was necessary. The present study aimed to make a brief analysis of the care model in mental health in Brazil. The methodology used is an integrative bibliographical review, where 14 articles were selected through the descriptors: Mental Health, Health Care, History of Public Health, between 1997 and 2014 and having as a guiding question: What is the trajectory of the care models mental health? The studies were compared and grouped by content similarity, in the form of empirical categories, and three categories were constructed for analysis, considering the trajectory of models of mental health care in Brazil, as specified: Manicomial Model, Psychiatric Reform and Model of Assistance in Brazil. The manicomial model was the only way of treating the Psychiatric Hospitals and Hospitals. The Psychiatric Reform presents itself in a second moment seeking to reduce the number of psychiatric hospitals and increase the Psychosocial Care Centers (CAPS) to attend the population that manifests some psychic suffering, and finally, the current model that advocates the de-institutionalization in which the CAPS are the reference for mental health care. We conclude that the model of assistance to individuals with mental disorders has evolved significantly and positively in Brazil, abandoning the exclusion model to give place to rehabilitation and integration in society of individuals affected by mental disorders.

Narratives of users of mental health services in an experiment with autonomous management of medication

Numerous studies have highlighted the tendency to chronicity of treatments centered on the use of medications. This study was conducted in a large Brazilian city with users of Centers for Psychosocial Care (CAPS), with the aim of evaluating the effects of experimenting with the personal Guide for Autonomous Management of Medication (GAM) and the users' relationship to their treatments and participation. The instrument, created in Canada and translated and adapted to Brazil, was tested in intervention groups with users of CAPS with severe mental disorders and a history of political participation in the field of health. Focus groups and in-depth interviews were performed. The transcriptions were transformed into narratives, and four analytical categories were defined: subjects with radical experiences of suffering; experiences with medication; users' rights; and participation and political activism. In testing GAM, users expressed a tension between reproduction of illness-centered identity and the legitimate uniqueness of their personal experiences. They showed greater knowledge of the medications they were taking, began to recognize their own expertise in their use of medications, and some sought adjustments to their treatment. They reported the need for support in claiming their rights and strengthening their participation as mental health activists. In conclusion, the Brazilian version of the GAM guide has the potential to contribute to users' empowerment, thus allowing dialogue between the results in mental health care in Brazil and the international scenario.

Sociodemographic profile of psychiatric inpatients at a center of mental health care in Brazil

BackgroundThe most prevalent disorders between the chronic diseases are the mental health disorders. Almost 650 million of people in the world suffer of some mental health disorders, which cause serious impact on individual abilities, family relationship and social rehabilitation.AimsWe describe and study the sociodemographic characteristics and the diagnosis of a sample of male and female psychiatric inpatients undergoing treatment in a mental health care center in Brazil.MethodsIt is a descriptive cross-sectional study, carried out with 517 psychiatric inpatients from a Brazilian health institution – IMAS Nise da Silveira. Data was collected from January to December 2014 and occurred through consultation of the patients’ hospital notes. Univariate analysis was used for the data collection and analysis.ResultsOur sample was composed by 52.6% (n = 272) of men and 47.4% of women (n = 245); 50.5% were over 40 years old and have a long time of hospitalization. Overall, 64.6% had schizophrenia; 27.2% mood [affect] disorders; 3.7% mental and behavioural disorders due to psychoactive substance use; 1.4% mental retartation; 0.4% personality disorders; 0.2% disorders of psychological development.ConclusionThe profile could advance the mental health care and rehabilitation of these people. Although could improve public policies.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Profissionais de saúde mental e familiares de pessoas com sofrimento psíquico: encontro ou desencontro?

Resumo Este estudo analisa os impasses enfrentados pelos profissionais de saúde mental na inclusão da família nos projetos terapêuticos de atenção à pessoa com sofrimento psíquico. Foram realizadas entrevistas semiestruturadas com profissionais de saúde mental de dois Centros de Atenção Psicossocial da região Sudeste do país. A análise temática do conteúdo apontou regularidades discursivas que delinearam quatro categorias: atender a familiares: insegurança e rivalização; tomada de responsabilidade; foco principal: diagnóstico ou necessidade?; confiança, vínculo e diferença. Tendo como referência o conceito de encontro da ética na filosofia de Spinoza, são apontadas, como questões a ser avaliadas, discutidas e incluídas nas reflexões dos profissionais na orientação de suas práticas e nos atendimentos aos familiares: ideal de família, culpabilização do familiar e responsabilização pelo cuidado da pessoa com transtorno mental.

An analysis of the federal funding for mental health care in Brazil

ABSTRACTThis article analyzes spending on mental health by the Brazilian Ministry of Health between 2001 and 2014. It is documental research of the Brazilian Ministry of Health’s databases. It analyzes the data using descriptive statistical analysis. Total spending on mental health for the period 2001 to 2014 shows a percentage increase in resources destined for outpatient care, but this increase is a reallocation from hospital services to community-based services and total resources for the mental health program remain at an average of 2.54% of the total health budget. Within outpatient expenditure, spending on medications remains high. Professionals committed to psychiatric reform fight to guarantee that a small fraction of the surplus appropriated by the state is directed towards social policies.

A web-based information system for a regional public mental healthcare service network in Brazil

BackgroundRegional networking between services that provide mental health care in Brazil’s decentralized public health system is challenging, partly due to the simultaneous existence of services managed by municipal and state authorities and a lack of efficient and transparent mechanisms for continuous and updated communication between them. Since 2011, the Ribeirao Preto Medical School and the XIII Regional Health Department of the Sao Paulo state, Brazil, have been developing and implementing a web-based information system to facilitate an integrated care throughout a public regional mental health care network.Case presentationAfter a profound on-site analysis, the structure of the network was identified and a web-based information system for psychiatric admissions and discharges was developed and implemented using a socio-technical approach. An information technology team liaised with mental health professionals, health-service managers, municipal and state health secretariats and judicial authorities. Primary care, specialized community services, general emergency and psychiatric wards services, that comprise the regional mental healthcare network, were identified and the system flow was delineated. The web-based system overcame the fragmentation of the healthcare system and addressed service specific needs, enabling: detailed patient information sharing; active coordination of the processes of psychiatric admissions and discharges; real-time monitoring; the patients’ status reports; the evaluation of the performance of each service and the whole network. During a 2-year period of operation, it registered 137 services, 480 health care professionals and 4271 patients, with a mean number of 2835 accesses per month. To date the system is successfully operating and further expanding.ConclusionWe have successfully developed and implemented an acceptable, useful and transparent web-based information system for a regional mental healthcare service network in a medium-income country with a decentralized public health system. Systematic collaboration between an information technology team and a wide range of stakeholders is essential for the system development and implementation.

Factors Associated with Providers' Perceptions of Mental Health Care in Santa Luzia's Family Health Strategy, Brazil.

Brazil has a unique mental health care system, characterized by universal coverage delivered by interdisciplinary teams both in the community and in specialized centros de atenção psicossocial (CAPS—psychosocial care centers). Provision of patient-centered mental health care is an important principle of Brazilian mental health care, but this topic has not been well-studied. We analyzed data from a cross-sectional survey of 151 community health workers (CHWs), nurses, and physicians in Santa Luzia, Minas Gerais State, Brazil. Chi-squares, t-tests and multivariate regression analyses examined differences in socio-demographics, caseload, engagement in evidence-based practices (EBPs), and transdisciplinary collaboration between providers who reported providing high levels of patient-centered mental health care and those who did not. In multivariate regression models, components of transdisciplinary collaboration were significantly associated with providers’ perceptions of patient-centered mental health care (p < 0.05). CHWs were also significantly more likely to report providing patient-centered care than physicians and nurses. EBP engagement and sociodemographics were not associated with perceptions. Results suggest that training efforts to improve patient-centered mental health care in Brazil could build upon CHWs’ skills and focus on transdisciplinary collaboration. Findings may inform practice in other countries with similar health care systems.

Use of psychotropic medications in São Paulo Metropolitan Area, Brazil: pattern of healthcare provision to general population.

We estimate the proportion of psychotropic medication use (PMU) among adults in São Paulo Metropolitan Area, Brazil. We investigated whether socio-demographic factors, comorbidity, and disease severity influence PMU among individuals with psychiatric disorders. Data are from the São Paulo Megacity Mental Health Survey, a cross-sectional, population-based study, the Brazilian branch of the World Mental Health Survey Initiative. Trained lay interviewers face-to-face assessed psychiatric disorders and PMU through the Composite International Diagnostic Interview. Respondents were asked about use of healthcare service and prescribed medications for mental disorders in the previous year. Information on PMU was collected for 2935 adult residents in the area and among those with disorders who received treatment. Around 6% of respondents reported PMU in the past year: hypnotics or sedatives were used by 3.7% and antidepressants by 3.5%. Among individuals with 12-month disorders, only 14% reported past year PMU. Gender, age, education, income, occupational status, comorbidity, and severity were significant predictors for PMU. Among those with 12-month DSM-IV disorders who obtained treatment in healthcare settings, almost 40% received medication only. Among those treated in specialty mental health service, around 23% received combination of medication and psychotherapy. Our study has pointed out that the recent trend of access to mental healthcare in Brazil depicts unmet needs, characterized by a low prevalence of PMU among individuals with psychiatric disorders. Policies that improve appropriate access to prescribed drugs for those most in need are urgent public health priority.

Biolegitimacy, rights and social policies: New biopolitical regimes in mental healthcare in Brazil

This paper discuss biolegitimacy as an instrument and device for the production of rights, recognition and access to services and care from the state, as a means to demand and conquer rights and as an expression of a new biopolitical regime. Biolegitimacy is articulated with a broader context of political shift, with an emphasis on the processes of pathologization, medicalization or biologization of social experiences, particularly concerning the production of public policies and actions of the state in the field of rights and citizenship. Despite the breadth of the issues that can be addressed through this concept in its formulation by Didier Fassin, the focus of this article is mental health policies in Brazil in the context of Brazil's Psychiatric Reform program, particularly those policies aimed at women. If on one hand the Psychiatric Reform is based on the principles of the human rights of the ill and of psychiatric patients, and on the democratization and universalization of access to healthcare, on the other hand, in various aspects these same policies reproduce the device of biolegitimacy. The focus is the notion of the "life-cycle" of women, a principle widely used in the documents and guidelines mainly in those specifically aimed at women's health.