Brazil still has isolated patients and fears ‘hospice culture’

Flavio looked like an animal. He was dirty, toothless, almost naked. The drops ran in a clear line over his black body, revealing that it was the first time he had seen water in a long time, and the smell of rose milk mixed with feces and urine.

Who counts is sister Tânia Messias, 60, who to this day is terrified of the perfume sprayed on her youngest’s shorts whenever she went to visit him at the defunct Psychiatric Clinic of Amendoeiras, in the west of Rio de Janeiro. Diagnosed with severe autism, “Fábio no longer spoke, he just roared”.

The scene is from ten years ago, but it is not so far from the current reality in some places in Brazil. The odor of waste, for example, is the same in the corridor of the infirmary of the main prison in Macapá, the Iapen (Instituto de Administração Penitenciária do Amapá).

There, five inmates live in cells far from the others, with only one mattress, in a constant psychotic episode because, according to officials, there is no medication needed to stabilize them. One of them has been there for two years, and the state doesn’t even know his diagnoses.

If they knew, they would be taken to another property 15 kilometers away, the Custody Center, where 8 of the 16 prisoners are no longer considered dangerous by doctors. Two of them, nicknamed Paulinho and Juju, have been locked up for over 18 years.

Two decades after having decided to end hospices, the country still has people with mental disorders living without decent treatment and isolated in prisons, psychiatric hospitals, therapeutic communities or private clinics.

At the same time, it lacks structures for patients in crisis, such as beds for short-term stabilization and 24-hour Psychosocial Care Centers (Caps 3), whose expansion has not kept up with the speed of closure of psychiatric hospitals in many states.

Amapá is one that is practically off the high-complexity mental health map. Those who enter an outbreak only have the option of going to the Emergency Hospital, where the two beds for the specialty are often filled by other patients.

“Often they are tied up on stretchers in the corridors, without the correct restraint”, says Emília Pimentel, president of Coren-AP (Regional Nursing Council).

When the decision is made for hospitalization, which should be the last option, the person goes to the 14 psychiatric beds at the Hospital de Clínicas, never registered in the Ministry of Health system.

The stay should be brief, at most a few weeks so that he can recover and be referred for follow-up at the Caps, but in practice there are three people living there, one of them for over ten years, abandoned by his family.

“Rondônia is another place where the asylum culture is created. There were hospitals where I entered and said: I’m back. Federal Nursing Department).

The federal government does not have a survey of how many are still permanently living in psychiatric hospitals in the country. In the city of Rio alone there are 35, according to the municipal superintendent of mental health, psychiatrist Hugo Fernandes.

The goal is for these people to leave and be directed essentially to two national policies within the SUS: a monthly allowance of R$ 500 from the De Volta para Casa program and/or therapeutic residences – non-existent in Amapá and with stagnant expansion in the last year in the country. .

That was the trajectory of Flávio Sobreiro, a character at the beginning of this text who spent 27 of his 40 years inside psychiatric institutions. Last October, he became the last of 310 patients at the oldest hospice in Brazil, renamed Instituto Municipal Nise da Silveira, in the north of Rio de Janeiro.

Today, he lives in a house a few kilometers away with five other people with mental disorders, always accompanied by a multidisciplinary team. He goes to the nearest Caps, likes to walk in the square and is now able to form complete sentences.

“Flávio has already been through things that none of us would bear in this life”, says social worker Priscila Hauer, currently deputy director of Nise da Silveira. She refers to things that have also happened on the huge land of the institute, which will soon become a municipal park.

There came to live almost a thousand “chronic patients”, who killed the hours following a rigid discipline, without choices, therapies or names. Shoes were still rare in 1997, when the current director, Érika Pontes e Silva, arrived.

“It’s a very recent history”, says the psychologist. “But now the walls have been torn down. Our users have returned to the city, and the city has occupied the alleys of the institute.”

With the end of asylums and the insufficiency of 24-hour Caps and other devices, in addition to the increase in drug use, another type of service has proliferated across the country: therapeutic communities for drug addicts.

Formally, they are non-profit organizations created to welcome users who choose to be there and participate in decisions. In practice, however, some of them treat addiction as a moral issue in the name of religion and practice human rights violations.

“The estimate is that there are 5,000 host institutions. Many say they are therapeutic communities, but they are not. They use this proposal to make serious distortions of the methodology”, says Ricardo Valente, executive director of Febract (Brazilian Federation of Therapeutic Communities).

About 700 of them are qualified and receive transfers from the federal government. The administration of Jair Bolsonaro (PL) decided to invest in this model, doubling the budget and increasing the number of vacancies funded by the Union by six times.

The most complex legal characteristic of therapeutic communities is that, although they are within the psychosocial care network regulated by the Ministry of Health, they are accredited and financed by the Ministry of Citizenship as a drug policy.

The folder did not respond if it takes actions to monitor them. Inspections are normally carried out by health surveillance, class councils and Public Ministry.

“We have a single unit in Amapá that is close to what is required by law. We found people locked in their room, forced labor under the name of labor therapy, entire families living in unsanitary conditions, reports of aggression”, lists prosecutor Fábia Nilci.

Psychiatrist Rafael Bernardon, general coordinator of mental health at the Ministry of Health, sees communities as a complementary treatment to what is done in Caps and other services, as long as it is voluntary and supervised. They grew up, he says, because psychiatric beds “have been irresponsibly closed.”

“We exaggerated in closing hospitals and in the unique model of Caps, which are one of the links in the network”, defends Bernardon, who compares the 24-hour Caps to “luxury hostels”. “They’re very expensive and they can’t handle it,” he says.

Amapá does not have any of them and claims that it is in the process for its Caps to switch to this modality. It also states that it has already agreed with the capital Macapá to implement the first therapeutic residence in the state, to house patients living in the hospital and in the Custody Center.

Regarding the prisoners in the penitentiary, the state mental health coordinator, Mário Denis Costa, responds that he had already scheduled his psychiatric evaluations, postponed by a death that recently occurred in the unit. “We can’t do everything, we’re trying to expand as much as we can,” he says.

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.