Despite challenges, Brazil has changed a paradigm in mental health

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“Mental health without a network is not mental health,” says nurse Roberta dos Reis, pointing to a tangle of colored wires on the map hanging on the wall. It’s so much string that you can barely see the streets of Campinas, in the interior of São Paulo.

The lines connect labels with the names of the health units in the region, pinned on the board in the middle of the corridor: “Everyone has to look at this all the time”, says the coordinator of Caps AD (Center for Psychosocial Care) Southwest.

The municipality takes seriously the need for integration between services, one of the pillars of the SUS (Unified Health System). Therefore, it is cited as “an example of how a country can implement services on a large scale” by last year’s WHO (World Health Organization) best practice guide.

The city shows how, despite the numerous challenges it still faces in the area, Brazil managed to change in two decades, at the national level, the paradigm of mental health treatment, taking the patient out of the asylum and placing him at the center of public policies.

At the same time, it was filling up with independent initiatives to solve the problem in its neighborhoods, companies and schools, in addition to building centers of excellence in research and teaching of psychiatry that are a reference around the world.

Now, it needs to advance in the debate of how to evaluate, improve and expand the solutions for the escalation of psychic disorders, still far from a consensus. Putting more weight and money on the basic network, in Caps, in outpatient clinics or in crisis beds are among the changes discussed.

Campinas, in this case, is recognized for its territorial model. It closed its only psychiatric hospital in 2017, reduced the average length of stay in a general hospital from 60 to 15 days, expanded the menu of services and invested 9% of its health budget in the psychosocial care network, compared to a federal mark of 1% .

Today, with teams spread across all regions, the municipality of 1.2 million inhabitants knows almost all the users of the system by name. “When João gets here, everyone will already know who he is, what his case is and the context of the place where he lives”, exemplifies Roberta.

The first strategy is to go to “your João”. That is why they prioritize policies such as the Consultório na Rua, which works where most people with mental disorders or chemical dependence live. That’s how they convinced Thiago Martins, 27, to be treated at a Caps on a June morning.

“I don’t want to use drugs anymore, look how I look, I’m not like that”, he says after being medicated through the vein in the program’s tent, showing his dirty clothes, broken teeth and his right hand swollen from a spider bite.

Any reason is an opportunity for the user to sign in and then continue with the services, the team explains. The Caps in the region where Thiago lives is then notified by telephone and later informs those involved that he has indeed arrived there.

“It’s no use giving you a piece of paper and saying ‘go’. Next week I have to go to your UBS [Unidade Básica de Saúde] or even the hospital where you were admitted to discuss what worked, what didn’t, your risk factors, your family relationships”, says Marcelo Bruniera, municipal mental health coordinator.

This is how the psychologist describes the so-called “matriciamento”, a health concept dear to the city, also put into practice through periodic meetings at various management levels and even with other areas, such as educational institutions and the Judiciary.​

At the base of the treatment is still the protagonism and autonomy of the patients. In the 14 Caps, kept open during the pandemic, they meet in assemblies and choose a council to work with managers.

“We need an urgent meeting with the secretary”, demands representative Valter Eustáquio, 75, who at 11 am at the Southwest unit says that, if he hadn’t been there, “he would have had more than one bottle of pinga”.

At the Work Workshops Nucleus, they also learn crafts such as cooking, woodworking or agriculture, receiving a grant for what they sell. The building is the former hospice, where Benedito Dias, 66, was hospitalized with severe depression. “If I were in a hospital, until today it was not so good”, he says, showing the stained glass windows he made.

When the patient freaks out, he goes to the emergencies, the 72 beds in Caps 24 hours or another 20 in the general hospital. “For now, we don’t need to open any more,” says Bruniera. “But with the increase in cases in the pandemic, we have been discussing how to strengthen the rear. The network is very well structured, which does not mean that it is not debated all the time.”

In addition to this formal psychosocial assistance —and often in its vacuum—, initiatives created in parallel have proliferated in Brazil, whether by companies, non-profit organizations, schools, professionals or by patients and their families.

A movement that has expanded in mental health is “recovery”, which consists of helping people with mental disorders to regain control of their own lives, especially with the support of those who have gone through similar experiences.

José Alberto Orsi, 55, is one of the references on the subject in Brazil, at the head of Abre (Brazilian Association of Relatives, Friends and People with Schizophrenia). He sidestepped all the prophecies of a Miami doctor who, in his second bout, claimed he would have to be warded until he died.

“In this crisis I thought I was the biblical Adam, I went out naked in the pool, I was arrested by the police”, says he, the third generation of the family with the disease. He quit his job, broke off his engagement and didn’t finish his master’s. The fourth outbreak, in mid-2000, “didn’t destroy anything because everything was already destroyed.”

He then had the diagnosis closed, corrected the medicines and therapies and started to rebuild his life with the help of courses and people he met at Abre, which emerged at Unifesp (Federal University of São Paulo). Now, she is doing her PhD on the subject there.

Orsi wants to expand rehabilitation through education with the Recovery College project, the first in Latin America to offer tailored scholarships in partnership with foundations and colleges. “Caps is an important model, but it is an asylum. The ideal is that one time the person is discharged and the rituals of life are lived, something that today is the privilege of the rich”, he opines.

Part of the riverside communities of the Amazon in the region of Belterra (PA), for example, only saw psychologists and psychiatrists for the first time a few months ago, when the NGO Zoé took professionals by boat to attend and train local teams, in partnership with the city hall.

Psychiatrist Giovanni Salum, a professor at UFRGS (Federal University of Rio Grande do Sul), sees the spread of such diverse initiatives as the result of an opposition between humanized care and technical care that was created in mental health in the country.

“On the one hand, this gave value to inventing very cool techniques: radios, vegetable gardens, cooperatives. Brazil is full of these. On the other hand, it made us not evaluate which measures actually work. This dichotomy should not exist, technique is the instrument for to be human and give the best treatment to a person”, he analyzes.

And technique is an advantage in Brazil, which has an excellent scientific production in the area. “We have four postgraduate programs at an international level: USP, USP Ribeirão Preto, Unifesp and UFRGS”, quotes Jair Mari, coordinator of the postgraduate course in psychiatry at Unifesp and the Center for Integrated Attention to Mental Health (Caism).

In the laboratories of the neighboring Institute of Psychiatry, at USP, for example, researchers are working to try to find ways of diagnosing mental illnesses at an early stage, through “biomarkers” in blood, urine or saliva, and not just through clinical evaluation.

In 2018, the scientific journal Brazilian Journal of Psychiatry achieved the highest score of publications in medicine in Brazil and in the specialty in Latin America, according to the Brazilian Association of Psychiatry (ABP).

It remains for the country to use these advantages to amplify what already works and change what has prevented us from preventing 14,000 suicides a year and the illness of more than 28 million people with depression. “Mental health is the holy grail of the 21st century,” recalls Orsi.

WHERE TO SEEK HELP?

Psychosocial Care Network

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

Mental Health Map

Website brings together 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 SERIES BRAZIL ON THE DIVAN

Depression, anxiety, burnout, schizophrenia, suicide: the explosion of mental disorders has been debated for more than two years of the pandemic, but little has been done about our public mental health system, which has been undergoing major psychiatric reform for more than 20 years. . The Brasil no Divã series discussed the size of the problem, the capacity of the SUS, the end of asylums, myths and prejudices surrounding the subject and possible solutions.

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