Opinion – Public Health: Mental Health Policies: everyone’s right and the State’s duty

In Brazil, cases of depression have already surpassed cases of diabetes and anxiety attacks in school environments have been recorded in recent months. Long neglected, these are just two examples of how Brazilians’ mental health is doing in a context that is still pandemic. Given the relevance of the theme and seeking to understand what are the services and programs of the Executive Branch offered to the population, the IEPS and the Cactus Institute prepared a document with unpublished data.¹ and updated on the mental health policy scenario in recent years, which also serves to bring people closer to the services available in the Unified Health System (SUS) and to clarify their functions.

Although the Ministry of Health puts some information on the Psychosocial Care Network (RAPS) on its website, this service is not easily found and not easily understood. Thus, abbreviations such as UBS, CAPS, SRT, PVC and UA make up the alphabet soup that is served timidly and is easy to understand only for managers or specialists in the subject.

Faced with the difficulty of accessing consolidated and updated information in a single space, all the results were gathered in a single document, the “Scenario of National Mental Health Policies and Programs”. The report presents information on existing services in a simple and transparent way to facilitate access by the population and the work of managers and researchers, and thus strengthen the construction of policies based on data and evidence. The document also has a glossary with the main terms and abbreviations on the subject.

According to the Brazilian Federal Constitution, it is up to the Executive Power to govern the people and manage public interests, which, in the field of Mental Health, is mainly carried out by the Ministry of Health, but also by other Ministries such as the Ministry of Citizenship, the Ministry of Education – since interdisciplinarity is the principle of the area.

recent changes

This Scenario aims to provide a complete, but not exhaustive, view of the mental health landscape in Brazil. The Executive’s policies and programs continue to be updated and it is important that this information continues to be monitored. An example of this is that, on June 20, the Ministry of Health reconfigured its operation, bringing some relevant changes in governance and organization, such as the end of the General Coordination of Mental Health, Alcohol and Other Drugs. The same happened with the Coordination dedicated to health policies for people with disabilities, and for the first time the folder’s regiment does not mention this policy.

Having as a guiding principle the importance of bringing quality and up-to-date information, as tools to guarantee participation and social control, the construction of evidence-based policies and access to public services, it is important that participatory and democratic discussions remain alive so that mental health policies are made with quality. The Scenario can be a tool for this and we highlight, below, some of the main considerations and reflections that the document consolidates.

Services with the same function are receiving different investments

Transitory Residential Care aims to offer voluntary reception and continuous care for people with needs related to the use of crack, alcohol and other drugs, in situations of social and family vulnerability and/or who require therapeutic and protective monitoring. The service must guarantee the rights to housing, education and family and social coexistence and, currently, it can be provided through the Shelter Units or Therapeutic Communities (TC) – the Shelter Units are located in the Ministry of Health and the TCs are civil society entities linked to the Ministry of Citizenship, although they also carry out psychiatric hospitalizations.

However, the investments directed towards these services differ: the Scenario found that, between 2017 and 2021, 13 states did not even have a Shelter Unit, while, to perform the same type of service, the TCs received an increase of more of 100 million reais in the last 3 years. According to the Ministry of Citizenship, BRL 34,051,239.74 was allocated to TCs in 2019; BRL 117,875,652.63 in 2020; and, in 2021, BRL 135,816,631.90 was spent.

Monitoring psychiatric hospitalizations is not centralized in the Ministry of Health

When asked about the TCs, the Ministry of Health replied, via the Access to Information Law, that “the National Secretariat for Drug Care and Prevention – SENAPRED, linked to the Ministry of Citizenship, became responsible for the accreditation, inspection and financing of vacancies in Welcoming Therapeutic Communities”. When asked about the number of people admitted to Psychiatric Treatment and Custody Hospitals, which are intended for people with a mental disorder in conflict with the law, but who are unimputable or semi-imputable (that is, who could not understand that the act they committed was a crime), the Ministry of Health also redirected the question: “The Mental Health Policy does not advocate the Norms of Custody and Psychiatric Treatment Hospitals. )”.

According to the responses received, there is an intention to liaise with the Citizenship and Security Departments, but we did not find sufficient records on the monitoring of psychiatric hospitalizations in TCs and Custody Hospitals. If we consider that, in the current policy, hospitalization should be used as a last resort, it is essential that the Ministry of Health make this information available, show how the Law is being applied and thus avoid possible violations, as has already been verified in institutions of this type.

Thus, the Scenario was not able to answer, with information from the Ministry of Health, how many people are hospitalized in these places. In order to implement intersectoral policies, it is essential that information is passed on transparently between the folders, ensuring that all competent bodies have access to the same information and thus manage to carry out a shared and consistent planning.

Social reinsertion stopping midway

Until March of this year, the Ministry of Health had the Deinstitutionalization Program, which was responsible for promoting the psychosocial rehabilitation of people who had been hospitalized for a long time, restoring family ties, for example. In 2003, the Brazilian government created the Serviço Residenciais Terapêuticos, an alternative housing for people with mental disorders who do not have families that want or are able to receive them back. the necessary support for treatment and also for promoting the autonomy of the residents. The Scenario found that, until the beginning of the year, there were 6,074 people living in 801 Therapeutic Residential Services. However, the Federal Government recently ended funding for these teams and, since then, we still do not have information on what will be done with these people.

The health of the homeless population has been neglected

Mental disorders can be the cause and/or consequence of being homeless, and this condition can create and/or worsen health conditions. The service that tries to solve this problem are the Street Clinics, which were established by the National Primary Care Policy, in 2011, and aim to expand the access of the homeless population to health services. Its teams are adapted to this context, carrying out itinerant consultations and developing articulated actions with the Basic Health Units of the locality.

According to the Scenario, in 7 years, only 33 Street Consultancy Teams were installed across the country. However, the context is one of need for investments, as the number of homeless people has more than doubled. The IPEA estimated that, in 2017, more than 101,000 people lived on the streets and, in 2020, this number reached 221,869.

The right to Mental Health can be a gateway to other rights

Promoting mental health or guaranteeing the right of people with mental health conditions is more than promoting well-being. Mental health is a central issue that impacts different spheres of life. When the State increases the reach of public policies from a more inclusive and strategic point of view, the door opens to access other rights, such as housing, food and information.

Despite the large number of studies on Mental Health, important gaps still persist, considering the phases of implementation, monitoring and inspection of public policies in the area. The lack of available, up-to-date and quality data makes it difficult to monitor important and necessary processes to move forward. Know the resource destined to RAPS by equipment; the number of CAPS and Shelter Units enabled in the country and their evolution; the number of residents in SRTs; and the number of hospital admissions and discharges from HCTP are examples of information that could provide evidence for public policies committed to expanding access to mental health care.

With the Scenario, it was possible to reaffirm that the SUS has a wide network of Mental Health services, but this information needs to reach the population in a simple way, being able to identify their needs and which service to access. Likewise, managers and researchers need transparent, descriptive and up-to-date data to improve existing care and services.

For this, interdisciplinarity has to be done in an articulated way and with defined and consistent responsibilities. It is a principle of SUS the exchange between different areas of knowledge and management for the improvement of public policies and also for the understanding of diversities. When it comes to mental health, the existence of this diversity can be so prevalent that the aversion to it, often translated as stigma in our daily relationships and in extreme measures such as exclusion and isolation. Given the seriousness and urgency of the matter, we need comprehensive information and care policies, and the Executive Branch must be transparent about its actions and proudly display everything that SUS has to offer.

For agenda suggestions, partnerships and comments, please contact us at [email protected] and [email protected]. Until the next Mental Health on the Agenda!

1. Part of the data contained in the document was obtained through the use of the Access to Information Law, which regulates the right of citizens to access public information.