Myths and prejudices of ‘madness’ hinder dignified treatment in Brazil

It’s been 36 years of studies in electrotechnics, physics, philosophy and psychopathology, but sometimes it’s still through the prism of 38 years of schizophrenia that Jorge Assis is seen. It is a polite but distant look, it describes, if not derogatory or pious.

“The worst thing about stigma is what people don’t talk about,” he says, recounting the imprint he left when, as a young man, he saw his popularity and that of his friends evaporate after word of his second psychiatric hospitalization spread through the university.

The example, one of several in his life, shows how myths and prejudices about what society understands as “madness” exclude, hinder access to effective treatments and, ultimately, leave mental health in the background in public investments.

The area continues to be surrounded by debates and taboos that include electroshock, now called electroconvulsive therapy (ECT), the rejection and at the same time the exacerbated use of medication and even compulsory hospitalizations determined by the Courts.

These issues affect a considerable portion of Brazilians: 7% said they had a diagnosis of schizophrenia, bipolar disorder, another psychosis or OCD (obsessive-compulsive disorder) in 2019, according to the IBGE, joining the 10% with depression and a further share. greater number of anxious and chemical dependents.

You have to go back to the 19th century to understand that people with mental disorders were once seen as the degeneration of the human race, explains Jorge, who has been teaching the subject to medical students at Unifesp (Federal University of São Paulo) for 10 of his 58 years. ).

The asylums where they were imprisoned only began to be questioned in the 1970s. Even so, he says, “there is still the idea that the person is violent, that he cannot fulfill commitments like any other and that one should not maintain a friendship with Is it over there”.

“This is another huge stigma. The treated mentally ill is not dangerous”, adds Antônio Geraldo, president of the Brazilian Psychiatric Association (ABP), who also emphasizes the self-stigma generated by these views. “‘You said I’m inferior, I believed that’. This is destructive, it mistreats, it makes the person not seek treatment.

One of the treatments that is perhaps linked to the greatest of these stigmas is electroconvulsive therapy, an evolution of electroshock, used for decades as an instrument of torture or punishment by asylums and dictatorships and always portrayed in a brutal way in the movies.

“We had this idea of ​​’One Flew Over the Cuckoo’s Nest’ [longa estrelado por Jack Nicholson]that violence, but it’s completely different”, says lawyer Marco Aurélio Cunha, 51, who in 2019 saw his father reemerge from a state of catatonia after the procedure.

Luiz Henrique’s depression worsened to the point that the retired judge stopped eating. He was just “skin and bones” when he arrived for an appointment with neuropsychiatrist José Gallucci, director of ECT at the USP Psychiatry Institute (IPQ). He left there having hours of philosophical debates with the doctor.

The unit is a reference in the treatment, always consented and indicated for specific cases: patient with depression or severe schizophrenia, who did not respond to medication and other alternatives.

The method consists of placing two electrodes on the head and applying an electrical stimulus for a few seconds that generates a seizure in the brain. It is only done with the person anesthetized, monitored and under the effect of a muscle relaxant.​

Possible side effects include mental confusion and loss of recent memory (can’t remember the procedure, for example) or biographical memory (forgets things from the past). In the case of Luiz Henrique, the forgetfulness lasted a month, says his son.

Depression returned after a year, but part of the family opposed further sessions recommended by the doctor. The retired judge had other treatments, but later decided to stop them all. He died in April of kidney failure, without eating. “I’m sure he lived these three extra years through ECT, and with a good quality of life”, says Marco.

The debate on the subject today revolves mainly around the inclusion or not of the procedure in the SUS. On the one hand, it is argued that the rich have access, while the poor dies. “There is a discourse that there is an overuse of ECT in Brazil, but it is not true. The IPQ is an island and is getting small for the demand”, says Gallucci.

On the other hand, it is argued that expanding it is not a priority and would create a risk of misuse. “It is not a question of being against or in favor, we are talking about management. It is incongruous to defend such a restricted and expensive strategy to the detriment of the rest of the network”, says psychiatrist Ana Paula Guljor, researcher at Fiocruz and president of Abrasme (Association Brazilian Institute of Mental Health).

Another discussion that takes shape in mental health concerns medication. If going to the psychiatrist and taking psychotropic drugs is still seen by many as a “crazy thing”, which prevents those who need it from seeking treatment, contradictorily a large part of Brazilians ingest these drugs incorrectly.

About 9% of the population said they had already used anxiolytics, sedatives, hypnotics and other over-the-counter substances, according to a 2015 survey by Fiocruz.

Among the 16 million people who claimed to have a diagnosis of depression in 2019, almost half took medication (48%), but only a fifth were on some form of psychotherapy (19%), according to IBGE data.

Inequality also counts at this point: Brazilians with a monthly income above five minimum wages have much more access to therapies (29%) and medicines (54%) than the other extreme, who earn up to a quarter of the minimum wage (17% and 41%). Variety at Popular Pharmacy is scarce, and it is not uncommon for them to be lacking, psychiatrists say.

“It’s not just taking medicine, of course, but there are cases in which it is very difficult without the medicine”, points out Jorge, from Unifesp. “Well medicated and assisted, the person has a long and quality life.”

A third controversy that comes up against the stigmas of mental illness is compulsory psychiatric hospitalizations, determined by a judge. They are different from involuntary ones, made at the request of third parties such as health professionals or relatives.

These are more common and have to be communicated to the Public Ministry within 72 hours. There were 11.9 per day in the city of São Paulo alone this year (2,507 in total). Compulsory requests had 3.4 requests per day to the courts across the state (718), without being able to know how many were accepted or not.

They are a thermometer of the lack of services and investments in them. The stronger the mental health network, the less compulsory it will be, assesses psychologist Eduardo Gomes, who coordinated the area in two cities in Rio de Janeiro and currently heads the Caps 3 (Psychosocial Care Center) in Rocinha.

The national law that instituted them, from 2001, says that the court’s decision must follow a medical report. In practice, however, it ends up depending on a personal view of the magistrate, moved by the despair of families, as shown by a survey carried out by judge Isabel Pinto Coelho in cases of crack users in Rio in 2018, by Fiocruz.

“The compulsory hospitalizations that I treated were contraindicated by the doctor, usually at the request of the family or the surrounding community, or the judge only received the diagnosis report”, says Eduardo.

Another problem is that, in these cases, the discharge is also in the hands of the judge and depends on the time of the process, which can extend the hospitalization, in addition to not having an effective follow-up that actually makes the patient improve, according to the psychologist.

For him, the solution is to demystify the psychic suffering in the surroundings of the Caps, for example. “The further madness is, the more fear it generates.”

Jorge Assis also defends campaigns to combat stigma, with athletes and artists linked to the cause. He learned to do this on a daily basis from his own experience: “It’s not that we’re going to invade the oil rig like Greenpeace, it’s something we have to do day by day,” he says.

HOW TO FIGHT STIGMA?

open (Brazilian Schizophrenia Association)

Informs and fights for the rights of people with schizophrenia: www.abrebrasil.org.br

Abrata (Brazilian Association of Family, Friends and People with Affective Disorders)

Informs and supports people with depression and/or bipolar disorder, family members and friends: www.abrata.org.br

ABP (Brazilian Association of Psychiatry)

Promotes campaign against prejudice: www.psicofobia.com.br

WHAT IS SERIES BRAZIL ON THE DIVAN

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.