Primary care and children's mental health in Brazil

Mental health literacy in children and adolescents in low- and middle-income countries: a mixed studies systematic review and narrative synthesis

Mental illnesses are the leading cause of disease burden among children and young people (CYP) globally. Low- and middle-income countries (LMIC) are disproportionately affected. Enhancing mental health literacy (MHL) is one way to combat low levels of help-seeking and effective treatment receipt. We aimed to synthesis evidence about knowledge, beliefs and attitudes of CYP in LMICs about mental illnesses, their treatments and outcomes, evaluating factors that can enhance or impede help-seeking to inform context-specific and developmentally appropriate understandings of MHL. Eight bibliographic databases were searched from inception to July 2020: PsycInfo, EMBASE, Medline (OVID), Scopus, ASSIA (ProQuest), SSCI, SCI (Web of Science) CINAHL PLUS, Social Sciences full text (EBSCO). 58 papers (41 quantitative, 13 qualitative, 4 mixed methods) representing 52 separate studies comprising 36,429 participants with a mean age of 15.3 [10.4-17.4], were appraised and synthesized using narrative synthesis methods. Low levels of recognition and knowledge about mental health problems and illnesses, pervasive levels of stigma and low confidence in professional healthcare services, even when considered a valid treatment option were dominant themes. CYP cited the value of traditional healers and social networks for seeking help. Several important areas were under-researched including the link between specific stigma types and active help-seeking and research is needed to understand more fully the interplay between knowledge, beliefs and attitudes across varied cultural settings. Greater exploration of social networks and the value of collaboration with traditional healers is consistent with promising, yet understudied, areas of community-based MHL interventions combining education and social contact.

Inclusion of children with disabilities in qualitative health research: A scoping review

Background

Children with disabilities have the right to participate in health research so their priorities, needs, and experiences are included. Health research based primarily on adult report risks misrepresenting children with disabilities and their needs, and contributes to exclusion and a lack of diversity in the experiences being captured. Prioritizing the participation of children with disabilities enhances the relevance, meaningfulness, and impact of research.

Methods

A scoping review was conducted to critically examine the participation of children with disabilities in qualitative health research. The electronic databases PubMed, PsychInfo, Embase, and Google Scholar were searched. Inclusion criteria included qualitative health studies conducted with children with disabilities, published between 2007 and 2020, and written in English. Articles were screened by two reviewers and the synthesis of data was performed using numeric and content analysis.

Results

A total of 62 studies met inclusion criteria. Rationales for including children with disabilities included child-focused, medical model of disability, and disability rights rationales. Participation of children with disabilities in qualitative health research was limited, with the majority of studies conducting research on rather than in partnership with or by children. Findings emphasize that children with disabilities are not participating in the design and implementation of health research.

Conclusion

Further effort should be made by health researchers to incorporate children with a broad range of impairments drawing on theory and methodology from disability and childhood studies and collaborating with people who have expertise in these areas. Furthermore, an array of multi-method inclusive, accessible, adaptable, and non-ableist methods should be available to enable different ways of expression.

Challenges on Diagnoses and Assessments Related to Autism Spectrum Disorder in Brazil: A Systematic Review

Being a continental country, with over 210 million citizens, Brazil is similar to all of those who are part of the LAMIC (Low and middle income countries). It shows a big concentration of wealth, mainly in its south and southeast regions, as well as areas with immense poverty. In that sense, the health system also faces a huge amount of contrast. Inside University hospitals and facilities there are sophisticated tools and trained doctors prepared to assist in any kind of medical subject, including autism. But, unfortunately, at other times, the access to a good health system is made much harder. This results in many issues in the medical community, e.g., looking at the data regarding autism, there is a high average of the age of diagnosis. Another issue is the low number of professionals trained in ASD diagnosis and the few tools translated to Portuguese.

Systematic review of pathways to mental health care in Brazil: narrative synthesis of quantitative and qualitative studies

BACKGROUND

Pathways to care are actions and strategies employed by individuals in order to get help for health-related distress and the related processes of care providers. On several systematic reviews regarding pathways to mental health care (PMHC), studies regarding South American countries were not present. This review synthesizes qualitative and quantitative research about PMHC in Brazil.

METHODS

LILACS, MEDLINE and SCIELO databases were searched for papers regarding PMHC in Brazil. The results were organized in pathway stages, based on Goldberg and Huxley's 'model of Levels and Filters' and on Kleinman's framework of 'Popular, Folk and Professional health sectors'. Analysis also considered the changes in national mental health policy over time.

RESULTS

25 papers were found, with data ranging from 1989 to 2013. Complex social networks were involved in the initial recognition of MH issues. The preferred points of first contact also varied with the nature and severity of problems. A high proportion of patients is treated in specialized services, including mild cases. There is limited capacity of primary care professionals to identify and treat MH problems, with some improvement from collaborative care in the more recent years. The model for crisis management and acute care remains unclear: scarce evidence was found over the different arrangements used, mostly stressing lack of integration between emergency, hospital and community services and fragile continuity of care.

CONCLUSIONS

The performance of primary care and the regulation of acute demands, especially crisis management, are the most critical aspects on PMHC. Although primary care performance seems to be improving, the balanced provision and integration between services for adequate acute and long-term care is yet to be achieved.

Atenção básica e cuidado colaborativo na atenção psicossocial de crianças e adolescentes: facilitadores e barreiras

Resumo Considerando a lacuna assistencial no campo da atenção psicossocial infanto-juvenil, a articulação da rede intrassetorial se configura como uma importante estratégia para promover fluxos assistenciais menos fragmentados. O estudo analisa os facilitadores e as barreiras para o cuidado colaborativo entre a Estratégia de Saúde da Família (ESF) e um Centro de Atenção Psicossocial intanto-juvenil (CAPSi), no Rio de Janeiro/RJ. Trata-se de estudo exploratório, de abordagem qualitativa, no qual as principais ferramentas metodológicas foram grupos focais e de intervenção. A partir dos eixos temáticos propostos, identificou-se que a percepção dos problemas de saúde mental infanto-juvenil pelos trabalhadores das ESF foi nomeada pelas alterações de comportamento situadas em contexto de vulnerabilidade. As principais barreiras para implementação das ações foram: desconhecimento sobre o modo de cuidado; problemas relacionados ao processo de trabalho; e desarticulação da rede. Ainda que os profissionais da ESF consigam identificar os problemas de saúde mental de crianças e adolescentes, as ações de cuidado são frágeis e a articulação da rede praticamente inexistente. O cuidado colaborativo foi reconhecido como uma estratégia para qualificação da atenção psicossocial infanto-juvenil.

Perceptions of health managers and professionals about mental health and primary care integration in Rio de Janeiro: a mixed methods study

BACKGROUND

Community-based primary mental health care is recommended in low and middle-income countries. The Brazilian Health System has been restructuring primary care by expanding its Family Health Strategy. Due to mental health problems, psychosocial vulnerability and accessibility, Matrix Support teams are being set up to broaden the professional scope of primary care. This paper aims to analyse the perceptions of health professionals and managers about the integration of primary care and mental health.

METHOD

In this mixed-method study 18 health managers and 24 professionals were interviewed from different primary and mental health care services in Rio de Janeiro. A semi-structured survey was conducted with 185 closed questions ranging from 1 to 5 and one open-ended question, to evaluate: access, gateway, trust, family focus, primary mental health interventions, mental health records, mental health problems, team collaboration, integration with community resources and primary mental health education. Two comparisons were made: health managers and professionals' (Mann-Whitney non-parametric test) and health managers' perceptions (Kruskall-Wallis non parametric-test) in 4 service designs (General Traditional Outpatients, Mental Health Specialised Outpatients, Psychosocial Community Centre and Family Health Strategy)(SPSS version 17.0). Qualitative data were subjected to Framework Analysis.

RESULTS

Firstly, health managers and professionals' perceptions converged in all components, except the health record system. Secondly, managers' perceptions in traditional services contrasted with managers' perceptions in community-based services in components such as mental health interventions and team collaboration, and converged in gateway, trust, record system and primary mental health education. Qualitative data revealed an acceptance of mental health and primary care integration, but a lack of communication between institutions. The Mixed Method demonstrated that interviewees consider mental health and primary care integration as a requirement of the system, while their perceptions and the model of work produced by the institutional culture are inextricably linked.

CONCLUSION

There is a gap between health managers' and professionals' understanding of community-based primary mental health care. The integration of different processes of work entails both rethinking workforce actions and institutional support to help make changes.

How to improve the mental health care of children and adolescents in Brazil: actions needed in the public sector

INTRODUCTION

Child/adolescent mental health (CAMH) problems are associated with high burden and high costs across the patient's lifetime. Addressing mental health needs early on can be cost effective and improve the future quality of life.

OBJECTIVE/METHODS

Analyzing most relevant papers databases and policies, this paper discusses how to best address current gaps in CAMH services and presents strategies for improving access to quality care using existing resources.

RESULTS

The data suggest a notable scarcity of health services and providers to treat CAMH problems. Specialized services such as CAPSi (from Portuguese: Psychosocial Community Care Center for Children and Adolescents) are designed to assist severe cases; however, such services are insufficient in number and are unequally distributed. The majority of the population already has good access to primary care and further planning would allow them to become better equipped to address CAMH problems. Psychiatrists are scarce in the public health system, while psychologists and pediatricians are more available; but, additional specialized training in CAMH is recommended to optimize capabilities. Financial and career development incentives could be important drivers to motivate employment-seeking in the public health system.

CONCLUSIONS

Although a long-term, comprehensive strategy addressing barriers to quality CAMH care is still necessary, implementation of these strategies could make.

Psychiatry and politics in Pelotas, Brazil: the equivocal quality of conduct disorder and related diagnoses

The world-wide emergence of categories for diagnosing mental health problems in children and youth such as conduct disorder is often attributed to the globalization of a highly biomedical form of psychiatry. In Brazil, a small group of therapists are resisting biomedicalization by keeping psychodynamic traditions alive and aiming to transform psychotherapy into a resource for politicized youth empowerment. Nevertheless, clinical practices demonstrate an increased use of biomedical diagnoses and therapeutic routines. On the basis of fieldwork with therapists and teachers, and a nine-year-long ethnography of young people, this article explores the localized effects of these potentially contradictory developments. Results show that the growth of biomedical practices alongside politicized therapeutic approaches is not indicative of underlying ambiguities but has, rather, emerged from the purposefully equivocal nature of Brazilian social, medical, and professional life. The article uses this Brazilian case study to critically debate theories of medicalization in the anthropology of psychiatry.