Rafael Sepúlveda

Development of Community Care for People with Schizophrenia in Chile

Chile has greatly reformed its approach to psychiatric care in the last two decades, having transitioned from a model centered around a psychiatric hospital to one in which mental health care is based in the community. During this period, patients were moved from large psychiatric hospitals into ambulatory clinics, and the number of people who were in hospitals for extended periods decreased. At the same time, mental health service networks—consisting of ambulatory clinics, day hospitals, rehabilitation centers, and community group homes—were created, each responsible for a specific population. The reform process, however, has occurred in different, unequal degrees throughout the country. The purpose of this investigation is to compare the characteristics, resources, and results of the mental health service networks that have successfully transitioned to and developed in the community with respect to those that are still centered in a hospital. The structural aspects were evaluated with the EvaRedCom-TMS (Evaluación de Redes de Servicios Comunitarios para Trastornos Mentales Severos), and the level of functioning was measured with World Health Organizations International Classification of Mental Health Care. Area networks with higher levels of community-based services show better indicators of geographic and financial accessibility, use less human resources (particularly psychiatrists and nursing assistants), have an equal level of specialization, and yet show better treatment adherence among the patients (84.2 percent versus 41.8 percent), despite the fact that the patients have worse socioeconomic and clinical indicators than area networks with lower levels of community-based services. In conclusion, the community-based psychiatric care model is more effective than the hospital-centered model.

Implementing a Community Model of Mental Health Care in Chile: Impact on Psychiatric Emergency Visits

OBJECTIVE The community model of mental health care (CMMHC) is recommended as the best way to organize mental health care, but evidence of its successful implementation and effectiveness is scarce, particularly in resource-poor settings. This study aimed to evaluate the impact of CMMHC on the rate of psychiatric emergency visits in Santiago, Chile. METHODS The rate of psychiatric emergency visits from 2006 to 2011 was compared between two health care administrative districts: district 1 (D1), in which CMMHC was being systematically implemented, and D2, where CMMHC implementation was very limited and inconsistent. In addition, rates of psychiatric emergency visits in ten D1 municipalities were compared by the degree to which they had implemented CMMHC. RESULTS Compared with D2, D1 had higher rates of psychiatric emergency visits during the observation period. In D1, the rate of visits per 100,000 inhabitants declined from 541 in 2006 to 414 in 2011. In D2, the rate increased from 104 in 2006 to 130 in 2011. In D1 municipalities, the reduction in the rate of psychiatric emergency visits was greater in those with well-implemented CMMHC compared with those with partially implemented CMMHC. When distance to the emergency room was taken into account, the 2011 rate of emergency visits in the ten D1 municipalities was 21% (p<.01) lower in those with well-implemented CMMHC than in those with partially implemented CMMHC. CONCLUSIONS CMMHC implementation leads to reduction in psychiatric emergency visits, which are burdensome to both users and providers. Results support CMMHC implementation in resource-poor settings.

Implementing the Community Mental Health Care Model in a Large Latin-American Urban Area

This article outlines the development of the Barros Luco General Hospitals Psychiatry Service since its creation in 1968. Initially, some historical and political background is provided followed by a description of how our service has endeavored, over the last 10 years, to put the community mental health care model into practice. Subsequently, we describe the growth of a network of locally based mental health services. Another process running in parallel has been the acquisition, by the local primary care teams, of skills that have enabled them to manage, on an ambulatory basis, patients with severe and enduring mental illness. In this regard, some data are provided in order to illustrate the effect of the changes that are taking place, including a reduction in the proportion of emergency psychiatry consultations at the casualty department. Finally, current and future challenges are discussed, including the need for a mental health law, clinical governance issues, and the provision for people with developmental disorders and those with highly complex mental health needs.