Volume 11 - Março de 2006
Editor: Giovanni Torello
Julho de 1997 - Vol.2 - Nº 7
Mental Health Priorities in Brazil
As Desjarlais, Eisenberg, Good and Kleinman stated in their book published in 1995, "World mental health is first and foremost a question of economic and political welfare". By 1989, one out of five people in the world was living in "absolute poverty", more than one billion people lack adequate food, clean water, elementary education, and basic health care.
Economic disparities within countries divide rich and poor social groups. In Brazil, the top 20% earn more than twenty times what the bottom 20% earn (James Brooke, The New York Times, June 6 (C20) and July 25 (I10), 1993).
Among the Brazilian poor, "sofrer dos nervos" (nerves suffering) is used to reflect the bodily and psychological distress associated with chronic hunger or social distress, many times treated by our physicians - usually after just a three-minute consultation - with psychotropic and other medications (Scheper-Hughes, 1992).
Mari (1987), working in the city of Sao Paulo, where spots of high income and modernity coexist with our "favelas" (slums), found that poor families living in irregular housing showed higher psychiatric morbidity than those living in better conditions. Santana (1982) found that the lower the income of residents of a poor-income district of Salvador, the higher the prevalence of psychiatric morbidity, especially for neurotic and psychosomatic disturbances. In another study also done in Salvador, Almeida-Filho (1982) has found that employment status is a clearer indicator of psychiatric morbidity than residential status.
Another important cause of social distress affecting all social classes in Brazil is urban violence. In all large and medium Brazilian cities, family security appears as one of the top everyday life priorities, among employment, health, and education. In Sao Paulo and Rio de Janeiro, our two largest cities, hundreds of people are murdered every month.
Some specific problems on our population mental health needs concern research, access to and quality of care, and human rights of the mentally ill.
Our production of local data is still scarce even considering some academic isles of well-trained people. Besides, our tradition is oral with many interesting experiences just being reported at local meetings and never reaching publication. A general picture of our needs could be estimated from few epidemiological studies showing high rates of psychiatric morbidity in the general population (overall prevalence of 42.5%)(Almeida-Filho et al., 1992) and in general health care settings (38-56%)(Busnello et al., 1983; Mari, 1987; Iacoponi, 1989; Villano et al., 1995).
Many pharmacological studies carried out in Brazil are just phase IV (four), post-marketing strategies from international companies. We still need to know better our reality and there is a growing demand for studies regarding biological and social-anthropological questions such as particularities of diagnostic criteria, psychosocial stressors, quality of life, ethno-psychopharmacology, evaluation of services, family interventions, and so on.
Brazil struggles with the problem of providing adequate care for its medium and low classes people despite the estimated existence of 6,000 psychiatrists and 80,000 psychologists, because of misinformation, mental illness stigmatization, difficult access to health care, regional concentration of professionals and their lack of link to public health needs, besides underdiagnosed and/or subtreated patients conditions.
We are fighting to improve psychiatric care through a specific reform of our health system and legislation. Our psychiatric care system is based on the old insane asylums or large psychiatric hospitals and this situation started to change few years ago. Its international roots rely upon tremendous treatment change in the 1950's with the development of antipsychotic and antidepressant medications and the shift of psychiatric care towards community-based services in the 1960's. But it was not before 1990 that the Pan-American Health Organization and the World Health Organization promoted a Regional Conference on Psychiatric Care where a critical revision of psychiatric hospitals as the center of psychiatric care was proposed in the Caracas Declaration, the final recommendations of that forum.
In 1961, there were 135 psychiatric hospitals in Brazil. Few years later, during the Military Dictatorship, the government policy allied with private health enterprisers change the patient care to a source of profit. So, at the end of the 80s there were 313 psychiatric hospitals with 86,000 psychiatric beds (nearly 20% of all hospitals' beds). At these facilities, there were 450,000 psychiatric internments in 1989 at a cost of 8.5% of the total inpatient health care cost.
This situation began to change in 1989 with a Congressional Law Project (still now in discussion) determinating a progressive extintion of insane asylums and their replacement by other kind of psychiatric services. Between 1991 and 1994, the Ministry of Health promoted the 1st and 2nd Health National Conferences and established a Psychiatric National Reform Committee. In 1994, there were 280 psychiatric hospitals with 69,000 beds (respectively, 10% and 20% less than in 1989), 130 general hospitals' psychiatric units (with 2,150 beds and emergency rooms), 42 day-hospitals, 35 psychosocial care centers, and a non estimated number of outpatient services.
Services are slowly improving but quality assurance is still a challenge to be met. The State provides some care for all through public services or by contracting private services. Most usually, professionals working in these public and private services lack adequate work conditions: they don't have enough training to assist emotionally disturbed people, they see too many patients in a short period of time, and the salary is not enough for their living needs (most physicians in Brazil has three or four jobs). Some companies offer health plans to their employees but their situation is not much different. Even better health insurance plans do not cover any expense related to mental disorders as well as some other illnesses like AIDS. While U.S. psychiatrists are fighting for reimbursement parity between mental and physical disorders, we are still fighting for the non-discrimination of psychiatric patients by insurance companies.
Another important aspect is that in influential academic centers, such as those located in Sao Paulo, Rio de Janeiro and Porto Alegre, there is a gap between what is taught during the residency training and the major needs of our population, which includes child and elderly psychiatry, mental retardation, alcoholism, and psychiatric rehabilitation. Besides diagnostic issues, these training programs currently place emphasis on psychopharmacological treatment and psychodynamic psychotherapy.
Regarding legislation issues, since the Caracas Conference in 1990 many states in Brazil are updating their laws in order to assure priority on communnity care instead of on psychiatric hospitals and also to assure respect to the human rights of the mentally ill.
In conclusion, we could summarize our priorities as follows:
MENTAL HEALTH PRIORITIES IN BRAZIL