Novembro de 2022 – Vol. 27 – Nº 11
Quirino Cordeiro
Rafael Bernardon Ribeiro
Since 2017, with the help and support of several civil society actors, we have been committed to modifying, improving and strengthening the Psychosocial Care Network (RAPS), and bringing to Brazilians, especially the majority who depend on the SUS, dignified, effective assistance. and of quality.
We inherited the consequences of more than 30 years of ideological, anti-scientific, denialist public policies on Mental Health and Drugs, carried by a group without the humility to evaluate their conduct and correct their course. There are many dark indicators: delay in diagnosis and in the beginning of treatment; chaos in emergencies and in crisis response; lack of beds for patients with acute conditions; prisons such as new asylums, full of mentally ill (at least 5% of the prison population is seriously mentally ill, not counting drug addicts); city streets taken over by drug addicts and mentally ill people left to fend for themselves; records of absence from work due to mental disorders and chemical dependence in the INSS; increasing suicide rates in the country in the last 20 years. In fact, in Brazil, suicide has increased both in absolute and relative numbers, contrary to the rest of the developed world and with universal health systems. It is sad and devastating to see the most significant increase in suicides in young people, children and adolescents, people who could not find treatment in a care network that had been organized in an absolutely ideological way and dissociated from effective care models in universal health systems around the world, as in Canada and the United Kingdom, and consequently dissociated from the real needs of patients and their families.
The “bastions of virtues” and “defenders of Human Rights”, with slogans such as “care in freedom” and “craco resists”, radicals of the Anti-Asylum Struggle, dogmatic and rigid, refused to recognize the problems, and insisted on a model merely “capscentric” assistance. CAPS are important equipment that must be part of the treatment network, but they need to be added to many other services, such as multi-professional Mental Health Outpatient Clinics, crisis and emergency services, General and Psychiatric Hospitals, Day Hospitals, Therapeutic Communities and many other places of treatment and care. The “one size fits all” model, of betting all the chips on CAPS, proved to be flawed and responsible for the chaos in Mental Health care that took place in the country. Without a plural, integral and integrated network that meets the needs of patients and families, and not those of militant bureaucrats, it becomes difficult to deal with all the complexity of mental disorders. You don’t change a Network and its culture in a few years. This Network is also not modernized and trained in a short period of time. However, we can highlight here what has been done in recent years to change this reality of inequity in Mental Health in the Brazilian public system.
In December 2017, the Federal Government agreed with States and Municipalities on the “New National Policy on Mental Health”. The Multiprofessional Mental Health Outpatient Clinics (AMENT), Day Hospitals and Psychiatric Hospitals were included in the RAPS; we created CAPS IV, a 24-hour unit, with a medical shift, to serve regions in Cracolândia; the daily rates of Psychiatric Hospitals, which had been frozen for a decade, were readjusted, with the objective of financially asphyxiating these services. Since 2019, under the current administration of the Federal Government, the number of RAPS services has grown by 21% and the number of beds in general hospitals, by 29%.
Deinstitutionalization continued unabated, and 40% of the Therapeutic Residencies (SRTs) in the country today were created from 2017 onwards. However, deinstitutionalization is no longer confused with the closing of beds, nor of Psychiatric Hospitals. In fact, the work has been done precisely in order to exchange beds for residents of Psychiatric Hospitals for beds for acute patients. It is worth mentioning that the devastation of hospital care in Mental Health in Brazil was so great, due to the irresponsibility of the fighting warriors who equipped the old administrations of the Federal Government in these last decades, that, even creating new psychiatric beds from 2017 onwards, the Brazil has proportionally 10 times less of these beds, when compared to OECD countries. Despite being totally against the rest of the world, our Brazilian anti-asylums did not contain their rage in destroying health services and neglecting our population. Closing psychiatric beds in Brazil, in the current shortage, is literally throwing patients with serious mental disorders, including those with chemical dependency, in jail, in the gutter and in the cemetery.
Outpatient Mental Health Teams (AMENTs) began to be implemented in the country, with 224 to date, with the aim of strengthening community-based mental health treatment, making it more powerful and cost-effective.
This measure is of great importance, since, in recent decades, Mental Health Outpatient Clinics have also been closed in droves in Brazil. Thus, the Anti-Asylum Fight and its representatives in the Federal Government bureaucracy not only compromised hospital-based care, but also community-based care.
The implementation of CAPS IV also goes ahead so that we have more forceful and resolute actions in cracolândias. In fact, it is not possible to imagine, without bad faith or ideological blindness, that people thrown into cracolândias are effectively helped simply with offers of more “cool” pipes (or something similar), without effective actions to take care of the vulnerable and get them out of the situation. of indigence that flourishes in the streets of our country.
We made lines of care at RAPS based on scientific evidence. We are organizing a great telepsychiatry and teletherapy service in the country. We seek to improve current regulations. We are inducing the planning of regional assistance networks throughout Brazil.
We cut funding for projects that linked nothing to nothing, which consumed millions of reais from the Brazilian taxpayer without delivering anything concrete to society.
The journey is arduous, with multiple “repudiation notes” and boycotts that are not concealed. However, nothing was done without technical support, but we received harsh criticism and opposition from the groups described above, which are eager to return to power, with the aim of resuming their actions, which have caused so much harm to people with mental disorders and chemical dependence in our country. country, especially the poorest.
In the field of alcohol and drugs, the “New National Policy on Drugs” and the “New Drug Law” were instituted, based on scientific evidence and good clinical practices. Clearly the previous model, which ran for many decades in the country, was wrecked. Just look at the streets and viaducts where the cracolândias proliferated. With the new regulations, the Federal Government has recently started to finance 17,500 vacancies in Therapeutic Communities, which work in free reception and in the consolidation of treatment, with a view to abstinence and full recovery of people with chemical dependence. The Federal Government finances and supervises these entities, as there are rules to be followed. The expansion of Therapeutic Communities is the result of society’s own attempt to take care of its chemical dependents, who had been neglected by the State, which adopted silent, ideological and ineffective public policies in the last three decades. Then, from the recent changes in the National Policies on Mental Health and Drugs, the Federal Government also started to give support and support to the important actions that civil society was already carrying out, not only with the Therapeutic Communities, but also with the Groups of Mutual Help and Family Support, which were totally marginalized by former Federal Government administrations. In fact, we have to take advantage of and help this important work of civil society, without, however, denying the need to strengthen other assistance services so that the Treatment and Care Network becomes increasingly stronger and more effective. And that’s what we’ve done. We need all services to help our patients and their families. We know that there is no single answer for the treatment and recovery of psychoactive substance dependence. Care must be centered on the individual, on their needs and particularities.
Another important advance that we had in conducting effective public policies on Mental Health and Chemical Dependency in Brazil was the creation of the unprecedented “National Police for the Prevention of Self-Mutilation and Suicide”, in 2019, through the publication of a Federal Law that began to regulate the theme. This new and unprecedented Public Policy brings several points of intersection with the “New National Policies on Mental Health and Drugs”. As we have already described above, unfortunately, due to problems in the treatment of patients with mental disorders and chemical dependence, Brazil was facing successive increases in suicide rates. Thus, the creation of a specific public policy to deal with the issue, along with the other actions described above, we also started to move forward to reverse the scenario of increased suicide in our country. In this context, the Federal Government created, in 2020, the National Policy Management Committee for the Prevention of Self-Mutilation and Suicide. Since then, in different Ministries, the Federal Government has taken concrete actions to prevent suicide in Brazil.
Since 2017, and especially since 2019, we have been working to implement public policies on Mental Health and Drugs, based on scientific evidence and good international practices, something unprecedented in Brazil, focusing on the real needs of patients and their families. and of the whole society. It is worth mentioning that we are all against asylums, obviously! We do not defend, in the middle of 2022, models of care from the last century or before. We defend and work for ethical, welcoming, effective treatment and care based on the best scientific evidence.
This article presents all the paradigm shifts that we have brought to Public Policies on Mental Health and Drugs, in the last five years, and also draws attention to the concrete risk of setback, real setback, and not rhetorical, as anti-asylum militancy has propagated. The group responsible for the chaotic scenario we have inherited may return, at the risk of nullifying all the advances that have been made recently in Mental Health and Drug Policies. Thus, we can continue to progress, advance and reap good results, consolidating State Policies, or go into reverse gear, blindfolded, towards the abyss from which we are struggling to escape.