Challenges for implementing a global mental health agenda in Brazil: The "silencing" of culture

Mental Health Collaborative Care in Brazil and the Economy of Attention: Disclosing Barriers and Therapeutic Negotiations

The introduction of mental health collaborative care (MHCC) is one of the strategies to scale up access to mental health care in primary health care in Brazil. This article investigates an experience of mental health collaborative care in the city of Rio de Janeiro, Brazil. It is a qualitative study involving interviews with physicians and mental health professionals working in primary health care units located in the northern part of the city of Rio de Janeiro, Brazil. The aim is to examine the various strategies and negotiations that primary health care professionals deploy to identify mental distress and plan health care interventions. We discuss the results within the economy of attention framework. We argue that divergences in diagnostic design and therapeutic planning carried out by professionals and users or observed in MHCC meetings illustrate the health-disease-care seeking phenomenon as a negotiated process, entangled in complex interactions. Our results evince that those interactions are not always evident and configure 'what is at stake' in mental suffering. The incorporation of cultural and structural determinants in collaborative care may enable the expansion of mental health initiatives sensitive to local needs and realities.

Structuralizing Culture: Multicultural Neoliberalism, Migration, and Mental Health in Santiago, Chile

The arrival of Afro-descendant migrants, mainly from Haiti and the Dominican Republic, has led to the emergence of new discourses on migration, multiculturalism, and mental health in health services in Chile since 2010. In this article, I explore how mental health institutions, experts, and practitioners have taken a cultural turn in working with migrant communities in this new multicultural scenario. Based on a multisited ethnography conducted over 14 months in a neighbourhood of northern Santiago, I focus on the Migrant Program-a primary health care initiative implemented since 2013. I argue that health practitioners have tended to redefine cultural approaches in structural terms focusing mainly on class aspects such poverty, social stratification, and socioeconomic inequalities. I affirm that this structural-based approach finds its historical roots in a political and ideological context that provided the conditions for the development of community psychiatry experiences during the 1960s and 1970s, as well as in multicultural and gender policies promoted by the state since the 1990s. This case reveals how health institutions and practitioners have recently engaged in debates on migration and intersectionality from a structural approach in Chile.

Improving patient-centered mental health promotion in primary care in vulnerable communities through mindfulness training in Rio de Janeiro, Brazil

Introduction

Brazilian Primary Health Care (PHC) is responsible for all-sanitary actions for a community-based population, including health promotion and mental health care. Mindfulness Based Health Promotion (MBHP) is an intervention that can promote self-care and psychosocial support in PHC.

Objective

To discuss the effects of mindfulness based psychosocial group interventions for health promotion in primary care units in Rio de Janeiro, Brazil.

Methods

The intervention was based on the MBHP model adapted for SUS. Nine groups were held in Rio de Janeiro. A quali-quanti research was held with two parts: (a) quantitative study, pre and after the 8 weeks intervention, evaluating the effect on mindfulness and self-compassion and their association with levels of anxiety, depression, and quality of life. (b) Qualitative research using Focus Groups with the participants to investigate their experience at the end of the mindfulness groups.

Results and discussion

Sixty-two participants finished the 9 groups where 86% were women, mostly between 30 and 59 years of age and low income, and around 80% under regular medical care in PHC in SUS. In the studied sample 80% had at least one chronic health condition under treatment, including 42% with anxiety and 35% with depression. The effects included significant improvement in Anxiety and Depression and in Quality of Life, mainly in the psychological but also in the physical and interrelation domains. The qualitative study showed that most patients joined the group on the recommendation of health professionals for managing physical and mental health symptoms. Patients reported being able to use the practices taught in the sessions to manage symptoms such as insomnia and emotionally distressing situations in their daily lives. Including family members in mindfulness practices was a strategy to negotiate not only a space at home to meditate, but also to obtain a different approach to health problems. Participants pointed to mindfulness as a complementary therapeutic option to medication and psychotherapy.

Conclusion

Mindfulness-Based Intervention have shown to be a feasible, well-accepted and efficacious method of offering psychosocial support and promoting well-being for low-income patients in primary care in LAMIC.

A Brazilian bottom-up strategy to address mental health in a diverse population over a large territorial area - an inspiration for the use of digital mental health

Brazil is a continental country with a history of massive immigration waves from around the world. Consequently, the Brazilian population is rich in ethnic, cultural, and religious diversity, but suffers from tremendous socioeconomic inequality. Brazil has a documented history of categorizing individuals with culturally specific behaviors as mentally ill, which has led to psychiatric institutionalization for reasons that were more social than clinical. To address this, a "network for psychosocial care" was created in Brazil, that included mental health clinics and community services distributed throughout the country. This generates local support for mental health rehabilitation, integrating psychiatric care, family support and education/work opportunities. These clinics and community services are tailored to provide care for each specific area, and are more attuned to regional culture, values and neighborhood infrastructure. Here we review existing reports about the Brazilian experience, including advances in public policy on mental health, and challenges posed by the large diversity to the psychosocial rehabilitation.  In addition, we show how new digital technologies in general, and computational speech analysis in particular, can contribute to unbiased assessments, resulting in decreased stigma and more effective diagnosis of the mental diseases, with methods that are free of gender, ethnic, or socioeconomic biases.

From Person to Life: An Anthropological Examination of Primary Health Care Approach to Depression in Rio de Janeiro

Mental illness approaches in public health have resulted in controversies around the adequacy of interpretative and therapeutic models. These controversies engage polarized debates amid understandings of mental illnesses either as brain disorders or as socioculturally determined entities. Aiming to investigate how mental health care is implemented in a Latin American metropolis, we conducted an ethnographic study of the approach to depression in a primary care unit in Rio de Janeiro between 2016 and 2017. "Life" emerged from our fieldwork as the main local category for understanding the experiences of patients with depressive symptoms and the work of reengagement performed by family physicians. With this investigation, we seek to provide insights into an approach to mental illness in primary health care that moves away from polarized interpretive frameworks and remains open to the singularities of patients' experiences of suffering.

Global Mental Health: Interdisciplinary challenges for a field in motion

In recent years, efforts in Global Mental Health (GMH) have evolved alongside critical engagement with the field's claims and interventions. GMH has shifted its agenda and epistemological underpinnings, increased its evidence base, and joined other global policy platforms such as the Sustainable Development Goals. This editorial introduction to a thematic issue traces the recent shifts in the GMH agenda and discusses the changing construct of "mental health" as GMH moves away from a categorical biomedical model toward dimensional and transdiagnostic approaches and embraces digital technologies. We highlight persistent and emerging lines of inquiry and advocate for meaningful interdisciplinary engagement. Taken together, the articles in this special issue of Transcultural Psychiatry provide a snapshot of current interdisciplinary work in GMH that considers the socio-cultural and historical dimensions of mental health important and proposes reflexive development of interventions and implementation strategies.

Encruzilhadas da Democracia e da Saúde Mental em Tempos de Pandemia

Resumo Esse artigo visa abordar a relação entre democracia, saúde mental e pandemia. Para tanto, convida o leitor, na primeira parte do texto, a revisitar o assombro da chegada da pandemia da Covid-19 por meio de um filme, cujas personagens colocam em cena posições subjetivas distintas que carregam a potência de interpelar nosso lugar nos cenários necropolíticos da crise sanitária brasileira. Na segunda parte do texto, algumas encruzilhadas da democracia e da saúde mental na atualidade são explicitadas, a exemplo da propagação de discursos antidemocráticos e do recrudescimento das fragilidades da Rede de Atenção Psicossocial. Na última parte do escrito, compartilha-se uma experiência de Educação Permanente em Saúde em curso junto a trabalhadores da Rede de Atenção Psicossocial e da Atenção Primária à Saúde, e se desenvolve uma tentativa de reposicionar as balizas para a ação ético-política no campo da saúde mental contra a paralisia e a anestesia agenciadas pela lógica capitalista do estado necroliberal, que não raro engessa os afetos, os corpos e os atos dos trabalhadores da saúde no cotidiano das práticas.

Global Mental Health and Pharmacology: The Case of Attention Deficit and Hyperactivity Disorders in Brazil

Global Mental Health (GMH) is the field of study, research, and intervention, which aims at improving access to mental health worldwide. It is based on the global burden of disease research program and on the existence of a large "treatment gap" between the need and availability of mental health services, displaying individual and social costs of undiagnosed and untreated mental disorders, especially in low- and middle-income countries (LMIC). Few academic publications in Brazil dialogue directly with the field of GMH, although several issues drawn from its agenda have been the subject of mental health policies in the country. Brazil can be classified as a middle-income country with a well-structured national health system. This system is oriented toward primary health care, which integrates both community mental health services and the broader health care network. The debate between GMH advocates and critics has unearthed old controversies in psychiatry such as universality or cultural specificity of mental disorders, their expressions, and their relationship with social and economic factors. We intend to examine how these controversies reverberate in the Brazilian mental health scenario, taking as an illustration the debates around Attention Deficit Hyperactivity Disorder (ADHD) in the country. ADHD discussions oppose those who argue that the condition is underdiagnosed and undertreated, and those who claim that there is overdiagnosis and overtreatment and thus, medicalization of childhood. This article presents the current status of the Brazilian mental health literature on ADHD, with emphasis on tensions around diagnosis, prevalence and interventions. Our aim is to highlight how the differential in discourse shapes the debate on ADHD in Brazil and how this may contribute to the GMH agenda. This goal will be undertaken in three steps. First, we will briefly examine studies around GMH and ADHD. Secondly, we address Brazilian studies on this theme, considering the specificities regarding the constitution of the mental health field. Finally, we will examine the debate of treatment gap vs. medicalization in the country in order to underscore the potentials and limitations of each perspective.