Brazil still struggles to take mental health to extremes 20 years after reform

If a “normal” car crosses your path, it’s a good sign. It means that the improvised stones in the mud holes along the road will work, the truck will not get stuck and, without any problems, the trip will only last 8 to 10 hours.

It would be worse if you were on the bus, because when it breaks it takes up to two days. It’s just that the asphalt track under construction for four decades has been left in the middle, and the last hundred kilometers have to be covered on earth, soaked by rain.

The recommendations are from those who take the highway every month: Carlos Estevão, from Rio de Janeiro, the only psychiatrist who works in Oiapoque, Amapá. The last city in the North of the country symbolizes the long journey that Brazil has to go through to take mental health to all its extremes.

Even after more than 20 years of construction and capillarization of the public network, with the closure of asylums and a psychiatric reform that is a reference in the world, we still have unequal and underfunded services to face an explosion of psychic disorders.

Mental health is in the dust, summarizes the social worker of one of the Caps (Psychosocial Care Centers) in Amapá. Only about 1% of the national health budget goes to the psychosocial care network, well below the 6% prescribed by the WHO (World Health Organization).

The value is negligible in the face of a problem that affects more than a quarter of the population throughout their lives and is one of the main causes of absence from work. It is also insufficient to deal with unexpected factors back then, such as the Covid pandemic and the increase in crack use.

Amid the old difficulties, there is a debate that has lasted about five years. On the one hand, workers in the area accuse the governments of Michel Temer (MDB) and Jair Bolsonaro (PL) of dismantling the network. On the other hand, the Ministry of Health and especially groups of psychiatrists argue that it is necessary to strengthen highly complex equipment.

For the patient, the first bottleneck arises in a basic network that does not prevent or absorb cases of depression and anxiety as it should, the bulk of the demand. Of the adults in the first group who say they received medical care in 2019, only a third did so in primary care, according to the IBGE.

​The training and preparation of teams to deal with mental health cases at this stage are often flawed, added to a stigma that this type of patient has. As the professional thinks he has no capacity, he prefers to stay away, say officials from different regions of the country.

In Oiapoque, the psychologist Torricha de Souza, 29, is divided between the five basic health units (UBSs) during the week, including the one in Vila Vitória, a dirt neighborhood that connects Brazil to French Guiana. “Usually the schedule is full. Ideally, I work four per shift, but sometimes I work five in the morning and seven in the afternoon.”

There, Osmarina Francalino takes care of Cosme and Damião, the twins who for 24 years have been suffering from a psychosis that she cannot name. “The doctor wrote it down on paper for me, it looks like schizophrenia,” says the 67-year-old seamstress.

The supply of certain medicines in the city depends on “pirateiros”, men who charge to travel the 600 km to Macapá in a 4×4 vehicle. “I haven’t missed it yet, but I’m afraid because he can’t stop taking it. On the 10th they promised at the pharmacy”, she says.

The capital, which accumulates demand from all over the state, only gained psychologists in the basic units last year. Even so, many of the patients who arrive are referred to the Caps, which should treat only cases of psychosis or dependence on alcohol and drugs through consultations, workshops and conversation groups.

That’s because now they have a place to serve. Until a few months ago, the reception of the main center was done under a tree, the fan threatened to burst, and the ceiling flew when it was windy.

With medical records still handwritten, little monitoring and no 24-hour unit or shelter, most patients end up lost in the system or on the streets. “We say it’s a gateway to nowhere”, criticizes Karol Duarte, representative of the Amapa Anti-Asylum Movement.

State mental health coordinator, psychologist Mário Denis Costa admits that the network is far behind, but cites advances in the last year. It provides for the creation of two new municipal Caps in the capital by 2023 and says it guides cities in the interior to make agreements with neighbors and open more units – it takes at least 15,000 inhabitants for that, according to federal rules.

“We are trying to change this culture that it is the state that has to do this funding to have Caps, the prerogative must be of the municipalities”, argues Costa, who “sees a very big setback” in federal policies. “We weren’t able to access resources as easily as we used to.”

The stoppage in the authorization of new Caps by the Ministry of Health is the main criticism of those who point to a breakdown of mental health in the SUS in recent years. They argue that the increased budget for hospital beds should be invested in treatment in the territories, as recommended by the psychiatric reform.

In Oiapoque, the only unit allowed by its 28,000 inhabitants is unable to mix psychotics, drug users and children. “It’s scary. In 26 years of public health, I still don’t know how to do that”, says the carioca psychiatrist Carlos, who has traveled all over Amapá in an itinerant project created by him, but which was not carried out by the state.

“Brazil needs to work on the idea that some cities with specific characteristics, and I guarantee that Oiapoque has all of them, should receive a different look in terms of funds and equipment”, he defends, citing particularities of the border such as isolation, trafficking, prostitution , mining and large indigenous community.

Today, there are 2,796 Caps registered in the country and about 450 more in the queue. If approved, they receive an initial low incentive to implement and then a steady amount that varies from location to location. Without registration, they have to be funded solely by the municipalities and/or states.

Psychiatrist Rafael Bernardon, general coordinator of mental health at the Ministry of Health, counters that he has suspended new requests for the folder to evaluate and enable those already inserted. He argues that before this was done without planning and the platform was open, creating the illusion that there would be resources for everyone.

“We are demanding regional planning from municipalities: define which ones are most important”, he says. This, however, is not your priority. The ministry’s view is that Caps is one of the links in the network, not the main one, and that the big hole is in crisis care, therefore in hospitals.

Bernardon also bets on telemedicine for distant places and on the model of mental health clinics to heal the limbo in which patients with depression and anxiety are. They are open-door units aimed at chronic cases, but not emergencies, which usually exist in larger cities.

He denies that this represents a dismantling of the psychiatric reform: “The whole world is seeing the drop in suicides, which are growing in Brazil. This is inseparable from the model we have, which needs to be improved. Nobody wants to go back to the 1970s.” .

It is still difficult, however, to guarantee what works or not. The country does not have a consistent assessment system for the thousands of services that have been created in recent decades. “I think it’s time to talk about quality, and not the name of things”, analyzes psychiatrist Giovanni Salum, a professor at UFRGS (Federal University of RS).

The researcher is coordinating a large census on the structures, processes and results of the network, which was commissioned by the Ministry of Health and should be completed by the end of the year. “The discussion is at a very ideological and non-technical level”, he evaluates.

For the time being, in such a heterogeneous country, the quality of services remains largely dependent on the dedication of each health professional. Nurse Regiane Picanço, 48, for example, has already become “mother, father, daughter and niece” for those who attend Caps do Oiapoque.

“Everything you see here came out of my pocket. How am I going to do art therapy if there’s no material?”, she asks, while one of her patients glues bead by bead on a large red strawberry outlined on the sulphite sheet. “You have to love your mental health, otherwise you can’t.”

Where to look for assistance?

Psychosocial Care Network

Map shows the network units enabled by the Ministry of Health until September 2020

Mental Health Map

Site maps different types of service: www.mapasaudemental.com.br

CVV (Life Appreciation Center)

Volunteers answer toll-free calls 24 hours a day at number 188: www.cvv.org.br.

What is the Brazil series on the couch

Depression, anxiety, burnout, schizophrenia, suicide: the explosion of mental disorders was cited exhaustively during more than two years of pandemic. However, little has gone into the capacity of the public mental health system, which has been undergoing major psychiatric reform for more than 20 years. The Brasil no Divã series discusses the size of the problem, the capacity of the SUS, the end of asylums, myths and prejudices that dominate the subject and possible solutions.