Denise Martin

Is psychiatric reform a strategy for reducing the mental health budget? The case of Brazil

OBJECTIVE To investigate trends in the provision of mental health services and financing in Brazil. METHOD Data from DATASUS (the Brazilian Unified Health Computerized System) with free access in the web were collected regarding the number of beds, the development of new community centers, the number of mental health professionals, and costs involved from 1995 to 2005. RESULTS In ten years, the number of psychiatric beds decreased 41% (5.4 to 3.2 per 10,000 inhabitants) while community services have increased nine-fold (0.004 to 0.037 per 10,000 inhabitants). Psychologists and social workers have accounted for three and two-fold, respectively, as much hirings as psychiatrists. Psychiatric admissions accounted for 95.5% of the budget in 1995 and 49% in 2005, and the expenses with community services and medication have increased 15% each. As a whole, the expenses in mental health decreased by 26.7% (2.66 to 1.95 US

Utilização dos Centros de Atenção Psicossocial (CAPS) na cidade de Santos, São Paulo, Brasil

per capita). CONCLUSION There has been a clear switch from hospital to community psychiatric care in Brazil, where the system can now provide a diversity of treatments and free access to psychotropics. However, the coverage of community services is precarious, and the reform was not accompanied by an increased public investment in mental health. The psychiatric reform is not a strategy for reducing costs; it necessarily implies increasing investments if countries decide to have a better care of those more disadvantaged.

Fatores de Risco para Problemas de Saúde Mental na Infância/Adolescência

To report on the clientele treated at community mental health services (CAPS) in the city of Santos, São Paulo, Brazil, a census was conducted of the patients examined at the services from June 1, 2001, to June 30, 2001. The patients initial contact with the service was registered, and data were recorded on a standardized form, using the medical case history as a source of information. Among the 1,673 patients, average age was 46 years, 59.0% were female, 58.0% lived with their families, and mean duration of treatment was three years. Some 38.0% were schizophrenic, schizotypical, or in acute delusional states, 31.0% presented mood disorders, and 17.0% were neurotic. Treatment modalities included out-patient psychiatric (81.0%), individual (23.0%), group (13.0%), and psychosocial rehabilitation (4.3%). In Santos, CAPS treat all categories of mental disorders (and frequently those considered the most severe cases) expected at this type of service. The treatment model is that of an out-patient psychiatric clinic.

Primary care and children's mental health in Brazil.

RESUMO – Estudo de corte transversal conduzido em comunidade urbana de baixa renda do municipio de Embu-SP com objetivo de identificar fatores associados a problemas de saude mental em criancas/adolescentes (PSMCA) em amostra probabilistica (N=67, faixa etaria 4-17 anos). Foram aplicados instrumentos estruturados as maes: Child Behavior Checklist (PSMCA); WorldSAFE Core Questionnaire (dados sociodemograficos; violencia domestica; embriaguez do pai/padrasto); Self-Report Questionnaire (problemas de saude mental maternos, ideacao suicida materna). Os resultados do estudo apontaram fatores estatisticamente associados aos PSMCA: crianca/adolescente ser do sexo masculino e sofrer punicao fisica grave; ideacao suicida da mae e violencia conjugal fisica grave contra a mae; embriaguez do pai/padrasto. Concluindo, grupos vulneraveis com caracteristicas individuais/familiares identificadas neste estudo devem ser considerados prioritarios em propostas de prevencao/tratamento. Palavras-chave: saude mental; fatores de risco; crianca; adolescente; estudos transversais. ABSTRACT – A cross-sectional study was conducted in an urban low-income community in the municipality of Embu-SP with the objective of identifying factors associated with mental health problems of children and adolescents (MHPCA) in a probabilistic sample (N=67, aged 4-17 years). Standardized instruments were applied to mothers: Child Behavior Checklist; WorldSAFE Core Questionnaire (demographics, domestic violence, father/stepfather drunkenness); Self-Report Questionnaire (maternal mental health problems and suicide ideation). The results of this study identified factors statistically related to MPHCA: child/adolescent of male gender and severe physical punishment; maternal suicide ideation and severe physical marital violence; father/stepfather drunkenness. As a result, vulnerable groups with individual/family characteristics identified in this study should have priority in prevention/treatment programs. Keywords: mental health; risk factors; child; adolescent; cross-sectional studies.

Impact of the application of neurolinguistic programming to mothers of children enrolled in a day care center of a shantytown

OBJECTIVE Primary care offers opportunities to expand childrens access to mental health (MH) services, but a given practices community context and staff attitudes may influence which integration models are feasible. The aim of this study was to explore the possibility of using community-based primary care to increase access to MH services in low-income communities in Brazil. METHODS A qualitative study was undertaken using focus groups with adolescents aged 11 to 16 (n = 46), parents (n = 40), and primary care clinicians and staff (n = 52) from public-sector health centers in 6 low-income Brazilian communities chosen for their geographic diversity. RESULTS Parents felt they had little support in parenting and attributed much of their childrens behavior and mood problems to life in violent, poor communities. Parents thought that primary care could potentially be a source of MH care, but that clinicians often seemed rushed or uninterested. Clinicians classified many child problems as issues with parenting rather than MH. Nonprofessional staff was more likely to be a source of support to parents, except at one center that had a truly integrated MH service. Adolescents reported little need for MH services. CONCLUSIONS Expanding the role of primary care in child MH may require close attention to how parents, adolescents, and clinicians define their problems and on the causes to which they attribute them. These factors interact with differences in how centers organize MH care, and the extent to which they take advantage of patient interactions with nonprofessional staff.

Comentários pertinentes sobre usos de metodologias qualitativas em saúde coletiva

CONTEXT Of the members of a family, the mother is without doubt the most important one, which provides justification for including an evaluation of her mental health as one of the variables to be considered as determining factors in each childs level of development. OBJECTIVE To assess the impact of the application of Neurolinguistic Programming (NLP) on child development, home environment and maternal mental health. DESIGN Randomised controlled trial. SETTING The study included children enrolled in the municipal day care center of a shantytown in the City of São Paulo. PARTICIPANTS 45 pairs of mothers and respective children between 18 and 36 months of age. MAIN MEASUREMENTS Childrens development (Bayley scales); home environment variation (HOME); and maternal mental health (SRQ). Comparison between before and after the intervention was made in terms of childrens psychomotor development, home environment and maternal mental health. INTERVENTION Application of the NLP technique to the experimental group and comparison with a control group. 1--Experimental (EG), consisting of 23 children submitted to intervention by NLP; and 2--Control (CG), with 22 children with no intervention. Length of intervention: 15 sessions of NLP. RESULTS 37 children remained in the study (EG = 10, CG = 27). Variations in mental development (OR 1.21, IC 95% 0.0 to 23.08) in their home environment (Wilcoxon): p = 0.96 (before) and p = 0.09 (after); in maternal mental health: p = 0.26, 2 df. CONCLUSIONS There was a trend that indicated positive effects on the home environment from the intervention.

Subjective distress in a representative sample of outpatients with psychotic disorders

Com este texto visamos contribuir para o debate sobre a avaliacao da producao e divulgacao de pesquisas que se baseiam em metodologias qualitativas no campo da saude coletiva. Procuramos relacionar as lacunas teoricas e metodologicas a indicios valorativos que atravessam os processos de pesquisa e avaliacao de artigos publicados. Na ausencia de explicitacao dos valores que conduziram as escolhas imbricadas nas pesquisas, alguns periodicos recomendam recursos de avaliacao que privilegiam procedimentos formais e tecnicos. A avaliacao e complementada com guias de confeccao de artigos, dentre os quais os check-lists, que fornecem os itens valorizados. Estes fatores contribuem para reducionismos teorico-metodologicos e reforcam a crenca na existencia de um unico metodo. Por fim, renovamos o apelo a imaginacao e a diversidade de concepcoes sobre o que pretendemos conhecer.

A avaliação da produção científica nas subáreas da Saúde Coletiva: limites do atual modelo e contribuições para o debate

BACKGROUND The affective burden of psychotic disorder has been increasingly recognised. However, subjective reports of distress and its covariates, especially those related to service use, remain under-investigated in patients with psychosis. METHODS This study investigated subjective distress and its covariates in a representative sample of 401 outpatients with a confirmed diagnosis of psychotic disorders in Brazil. Distress was assessed using the corresponding domain of a standardised measure of need - the Camberwell Assessment of Need. RESULTS Distress was reported as a need by 165 (41%) patients, being met in 78 (20%) and unmet in 87 (22%). Hierarchical logistic regression showed that the presence of distress as a need was predicted by attendance at psychotherapy (OR=3.49, CI=1.62-7.53), presence of suicidal ideation (OR=2.89, CI=1.75-4.79), non-attendance at psychosocial rehabilitation (OR=2.84, CI=1.31-6.19), and higher psychopathology (OR=1.09, CI=1.06-1.12). An unmet need was predicted by family not accompanying patients to treatment (OR=2.60, CI=1.05-6.44) and higher psychopathology (OR=1.05, CI=1.02-1.09). LIMITATION The use of a cross-sectional design and a single questionnaire domain to evaluate distress are the main limitations. CONCLUSIONS Subjective distress is a common unmet need in psychosis, and can be treated. The main clinical implication is that subjective distress in psychosis may be impacted on by family engagement and psychosocial interventions.

Post-Traumatic Stress Disorder and Urban Violence: An Anthropological Study

The aim of this study was to discuss the limits of the quantitative evaluation model for scientific production in Public Health. An analysis of the scientific production of professors from the various subareas of Public Health was performed for 2010-2012. Distributions of the mean annual score for professors were compared according to subareas. The study estimated the likelihood that 60% of the professors in the graduate studies programs scored P50 (Very Good) or higher in their area. Professors of Epidemiology showed a significantly higher median annual score. Graduate studies programs whose faculty included at least 60% of Epidemiology professors and fewer than 10% from the subarea Social and Human Sciences in Health were significantly more likely to achieve a “Very Good” classification. The observed inequalities in scientific production between different subareas of Public Health point to the need to rethink their evaluation in order to avoid reproducing iniquities that have harmful consequences for the field’s diversity.

Uso de drogas entre anestesiologistas no contexto das relações de trabalho -doi:10.5020/18061230.2008.p194

The study aimed to understand how “distress” is experienced by patients with Post-Traumatic Stress Disorder (PTSD) in the social-cultural context of São Paulo, Brazil, an urban environment marked by social inequality and high levels of violence. A qualitative study was conducted between 2008 and 2010 with PTSD patients (F43.1, ICD-10, 1997) who had been victims of robberies and kidnappings in São Paulo. Dense ethnographic observations were carried out, as well as in-depth semi-structured interviews with ten adult patients. The analysis method used was based on anthropology. The results show that it is particularly important to distinguish between perceptions of different forms of the experience of social suffering and perceptions of health and illness held by victims and biomedical experts. The cause of PTSD is more often associated with the personal problems of the victim than with the specific traumatic event. The distress described in terms of what is considered a “normal” reaction to violence and what is considered a symptom of PTSD. The findings indicate that the diagnostic of PTSD can be understood in relation to the different contexts within a culture. The ethnographic approach serves not only to illuminate individual suffering but also the social suffering experienced by the residents of São Paulo.