Efforts to advance mental health in Brazil must continue

After a prolonged period of dismantling, the principles of psychiatric health reform appear to be resurging at the forefront of policies in Brazil. However, there is a substantial amount of work ahead to undo the setbacks that have occurred, writes Outra Saúde

July 29, 2023 by Outra Saude
"We fight for the humanization of psychiatric treatment". Photo: Brasil de Fato Recife

On July 3, during the 17th National Health Conference, Brazilian Minister of Health Nísia Trindade announced and signed a decree to resume funding for Therapeutic Residential Services and Centers for Psycho-social Attention. These are the cornerstones of promoting mental health in the Unified Health System (SUS). The announcement took place in the presence of other secretaries of the Ministry of Health, including Sonia Barros, head of the newly created Department of Mental Health, in a strong show of the commitment to improve the right to mental health through better public policies.

However, according to Fernanda Magano, psychologist and member of the National Health Council, there is still much to build and confront. The field of mental health has been strongly affected by the advance of conservatism in Brazil. Ideological and religious groups often use their anti-drug moral discourse to mask specific economic interests, as seen in the so-called Therapeutic Communities. Besides the announcements made during the National Health Conference, this year will be marked by the 5th National Mental Health Conference, which could be a turning point in the production of public policies related to mental health.

“The Conference will be an important moment to reaffirm all the public policies that we defend, including care in freedom, without imprisonment. At the same time, some issues are being processed in the National Justice Council (Conselho Nacional de Justiça, CNJ), specifically those related to ending custodial hospitals and penitentiary treatment, with prisoners to be transferred to the health network. This will remain a hot point in the debate,” Magano said to Outra Saúde.

Read the full interview below.

Outra Saúde: How do you comment on the decree that released about R$ 414 million (USD 87.7 million) for Therapeutic Residential Services and the Centers for Psycho-social Attention (CAPS)? What impact do you think this will have on the public health system?

Fernanda Magano: The availability of these resources is essential because it has been a long time since there was a direct investment in the Psychosocial Care Network (Rede de Atenção Psicossocial, RAPS). With so much time passing without investment, the effect of the network will be diluted over time. We will feel this impact gradually. I believe this is an immediate solution that needs to be supported by other steps.

For example, even before Bolsonaro came into power, during the Temer government, we saw attempts to change the financial incentives that encouraged small municipalities to open CAPS. A focus on humanized care and investment in the mental health care network is important, but we must keep in mind that these measures are now coming almost exclusively to plug a large hole that has appeared over the past years.

OS: What do you think of the approach to mental health by the current government and its Ministry of Health?

FM: There has been progress. First of all, commendably, mental health is no longer treated as just a technical area but as a department. This gives it greater weight and space for building the mental health agenda with more support and relevance. We could say that this is an effect of the electoral process and public positions of some people who even advocated for a dedicated ministry of mental health. While some of these positions differed slightly from the orientation we defend, they helped provide more support for the construction of the department, which now has a more structured team and a mandate to rethink the whole policy of mental health care.

There have still not been any major assessments, and one part of the policy will be forwarded to the 5th National Mental Health Conference, scheduled at the end of the year. This will already reflect the proposals approved at the 17th National Health Conference, which addressed mental health issues. However, there are many situations that need to be addressed in terms of re-introducing some basic principles.

One issue that might seem small but I consider relevant is that until 2015-2016, we had a bulletin for the technical area of mental health called “Mental Health in Data.” This was a crucial and interesting instrument to increase transparency and public participation. The bulletin covered matrix support (the concept of pedagogical-therapeutic monitoring of primary care teams) in mental health, primary care’s role in the strategic psychosocial care network, the number of CAPS opened per year by region, investments in mental health policy as a whole, the relationship with hospital care, hospital beds, and the deinstitutionalization strategy. It was quite important. Unfortunately, it was abandoned, and we hope it will be resumed and adequately valued. Additionally, it is worth monitoring and evaluating the pace of closure of psychiatric beds, as it gives a good idea of the implementation of policies aimed at providing outpatient care and care in the community.

OS: After the pandemic, considering some more recent World Health Organization (WHO) positions, do you believe that we should give more weight to public mental health policies? 

FM: It is fundamental that we have a deeper focus on mental health. There are already statements from the WHO and the Pan American Health Organization (PAHO) on the effects of the pandemic and social isolation, identifying a series of emotional conditions related to depressive traits and the effects of mourning. The WHO has also made a more general assessment of the increase in mental health conditions, not necessarily solely due to the pandemic. Therefore, mental health should be a priority issue.

However, we cannot discuss the restoration of mental health policies and the strengthening of the mental health network without considering other policies. If we do that, we run the risk of oversimplifying the process of becoming ill, as if it only had to do with the internal issues of a person’s experience and emotions. In fact, falling ill is a direct effect of socioeconomic issues, the quality of access to the health network, and other essential factors such as food, work, and leisure. In short, it is related to the objective quality of life. Talking about access to transversal policies is fundamental for the balance of mental health.

Today, we see an attempt to restore important policies in different fields. But we must be careful to make a very qualified reading of everything that constitutes the guarantee of well-being in the area of mental health.

OS: What legacies has the previous period left? For example, what is the status of confrontation with the principles of the so-called psychiatric reform and resumption of funding for so-called therapeutic communities?

FM: This is our Achilles heel, inherited from earlier times when the plan to face the use of crack cocaine was developed when it became a pandemic. The openness to therapeutic communities started then. The mental health department was cautious in setting evaluation criteria to prevent therapeutic communities from becoming part of the health network, as they are private entities and not public or health organizations. They claim to be non-profit and focus on welcoming people with substance use disorders, but this is misleading. They try to infiltrate the mental health network but fail to comply with ministerial ordinances. Thus, they are integrated into the Unified Social Assistance System (SUAS), leading to a complex situation of their legalization within the social assistance network. In reality, they don’t belong in either SUAS or SUS.

This legacy was left by past governments, resulting in a department for therapeutic communities within the Ministry of Social Development and Fight Against Hunger (MDS). The issue is currently avoided even in the government. Despite inquiries made to both the mental health department and the minister, it continues to be treated as if it were another ministry’s problem. No proper confrontation has occurred. Initially, the official position suggested that existing contracts would need to come to an end and that the department would shift under the Ministry of Social Development. However, the Ministry’s decree presented a different story, indicating a continuation of the link with therapeutic communities, which drain substantial public financial resources. We’re talking about millions of reais for organizations that are neither health nor care institutions, but private entities.

This is a significant problem that hasn’t been resolved, even though the propositions from the 17th National Health Conference positioned themselves for the end of therapeutic communities. State-level Mental Health Conferences also recognized the problem as an important issue to address. Currently, the National Health Council approved a resolution envisioning the 5th Mental Health Conference later this year, with the possibility of public, open conferences to allow horizontal election of delegates from the Psychosocial Care Network to attend the conference.

The 5th Conference will be held after a significant gap (the previous one took place in 2010). In comparison to the previous government, the call for the conference is already underway – the Bolsonaro administration did not even commit to carry it out to this extent. Now, under the guidance of Sônia Barros, the department is dedicated to bringing about change. However, there is a profound divide between the municipal and state levels due to the previous government’s refusal to hold the conference and its failure to defend policies based on psychiatric reform law and the principles of the anti-asylum struggle. Instead, it focused on therapeutic communities.

Coming back to your original question – while investing in CAPS and Therapeutic Residential Services is crucial to demonstrate the ministry’s commitment to the principles of psychiatric reform, the power play concerning therapeutic communities remains unresolved. For example, the 4th Mental Health Conference had an intersectoral approach, involving labor policies, solidarity economy, social assistance, support projects on combating hunger, assistance to the family network of users, and housing. This design was implemented by the Haddad administration in São Paulo through the Open Arms program.

Mental health is an interdisciplinary issue. It is a health concern that must integrate other policies, without criminalizing people and handing over authority to the police, as the past administration essentially did. The COVID-19 pandemic also had an impact, introducing various intersectoral decrees between the Ministry of Health and the Ministry of Social Development. Some of these decrees involved hospitalizing homeless populations in therapeutic communities, claiming it was a measure to protect them from COVID. On the other hand, we proposed the use of hotel beds, allowing people to freely come and go, instead of almost compulsory hospitalization in therapeutic communities.

OS: Speaking of the 5th Mental Health Conference and considering everything that was experienced and produced at the 17th National Health Conference, what are your expectations? Do you believe that we will experience a strengthening of the transversality you talked about?

FM: The Conference will be an important moment to reaffirm all the public policies that we defend, focusing on care in freedom, without imprisonment. Concurrently, there are ongoing discussions at the CNJ regarding issues related to ending custodial hospitals and penitentiary treatment, with prisoners being transferred to the health network. This will continue to be a hot topic in the debate. Additionally, the overarching theme of the Conference, “Strengthening and guaranteeing public policies, the SUS, and mental health care in freedom and respect for human rights,” will encompass the issues we have discussed here: outpatient care, the right to citizenship, adequate funding for the mental health network, and the possibility of social participation. It will be about constructing a mental health policy based on universality, integrality, and equity, with the aim of making a real impact on the population and challenging assumptions about psychosocial care in post-pandemic times.

As I mentioned earlier, international organizations stress the need for more attentive mental health care. Another significant concern is the discontinuation of funding for the Family Health Support Centers (Núcleo de Apoio a Saúde da Família, NASF) during the past administration. NASF provided matrix support and comprehensive health care, involving professionals such as psychologists, occupational therapists, and physiotherapists, in a broader health care team.

Currently, NASF is reinterpreted in the policy of Multiprofessional Teams (Emultis), which are linked to the Secretariat for Primary Care through a specific decree. This change raises some concerns for us because it deviates from the principle of matrix support in the region. While it still includes various profiles of professionals, such as doctors and pharmacists, it is more closely tied to basic units of primary care and less connected to the broader territorial approach. This shift is worrisome as the complementing access to the RAPS was a significant aspect of NASFs.

OS: What would be the ideal approach to resolving the existing issues?

FM: The ideal approach would be to maintain the logic of the anti-asylum struggle and ensure the active participation of users and their family members in training courses and defending the system as a whole. The focus should be on establishing a direct relationship of care with the entire family, providing support for deinstitutionalization, care without imprisonment, and extending care to families. It is essential to recognize that changes in a person’s mental health condition can impact broader family dynamics.

The principle of user and family members’ protagonism within the Psychosocial Care Network is crucial. The support for user and family associations, community activities, and Community Coexistence Centers (Centro de Convivência e Cooperativa, CECCO), where the concept of solidarity economy is also embraced, holds significant importance. We should not confine our perspective of care solely to health structures but expand it to involve the family and other spaces, such as building more CECCOs, for instance.

The interview with Fernanda Magano was conducted by Gabriel Brito, and published in Portuguese on Outra Saúde.

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