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Mental Health Priorities in Brazil
Miguel R. Jorge, M.D., Ph.D.
* Professor Associado do Departamento de Psiquiatria da UNIFESP (Federal University of São Paulo, 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
mental health as a priority of national health and social policies;
epidemiological research and cross-cultural studies;
community psychiatry through primary health care services;
development of psychiatric units in general hospitals rather than continued support for
large psychiatric hospitals;
closure of old insane asylum with its dehumanizing treatment and many of their practices
of basic human rights violations;
community-based psychiatric rehabilitation services;
improvement of the quality of all mental health services;
improvement of the amount and adequacy of mental health training;
improvement in mental health services for children, adolescents, and elderly people;
development of prevention, early detection, and effective treatment programs for mental
disorders and alcohol and drugs abuse and dependence;
- updating of laws through specific legislation.
Denise Razzouk e Giovanni Torello
Data da última modificação:23/08/00
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