Componentes do apoio matricial e cuidados colaborativos em saúde mental: uma revisão narrativa

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.

Matrix support in specialized care backed by the care model for chronic conditions: evaluative research

OBJECTIVE

To analyze the matrix support for health teams in Specialized Outpatient Care, according to the Chronic Conditions Care Model.

METHOD

Qualitative evaluative research, conducted by the Chronic Conditions Care Model, carried out from February to July 2020. For data collection, interviews were carried out with 21 health professionals, assistance observation and document analysis of the service. Data were analyzed by data triangulation, with the aid of the MAXQDA software, respecting all ethical aspects.

RESULTS

The matrix support provided approximation between Primary and Secondary Care; implemented case management and qualified comprehensive care for people with chronic conditions. Weaknesses in communication and understanding of the theoretical bases of matrix support were obstacles to the proper implementation of matrix strategies.

FINAL CONSIDERATION

Matrix support for specialized health teams qualified the professional care given to people with chronic conditions treated at the service.

Effectiveness of Agreement Criteria and Flows of Collaborative Care in Primary Mental Health Care in Brazil

The supply of mental health processes in primary care has gaps. This study aims to analyze the association of agreement criteria and flows between primary care teams and the Family Health Support Center (NASF) for mental health collaborative care, considering the difference between capital and non-capital cities in Brazil. This cross-sectional study was conducted based on secondary data from the Primary Care Access and Quality Improvement Program. Agreement criteria and flows were obtained from 3883 NASF teams of the matrix support or collaborative care. The Chi-square test and multiple Poisson regression were used; p < 0.05 was considered statistically significant. Prevalence ratios of negative associations demonstrated protective factors for support actions: follow-up at Psychosocial Care Center, management of psychopharmacotherapy, offer of other therapeutic actions, care process for users of psychoactive substances, and offer of activities to prevent the use of psychoactive substances. Collaborative care in primary care was effective, and capital cities were a protective factor compared with non-capital cities.

International perspective on integrated care models in child and adult mental health

The dearth of child and adolescent mental health services (CAMHS) is a global problem. Integrating CAMHS in primary care has been offered as a solution. We sampled integrated care perspectives from colleagues around the world. Our findings include various models of integrated care namely: the stepped care model in Australia; shared care in the United Kingdom (UK) and Spain; school-based collaborative care in Qatar, Singapore and the state of Texas in the US; collaborative care in Canada, Brazil, US, and Uruguay; coordinated care in the US; and, developing collaborative care models in low-resource settings, like Kenya and Micronesia. These findings provide insights into training initiatives necessary to build CAMHS workforce capacity using integrated care models, each with the ultimate goal of improving access to care. Despite variations and progress in implementing integrated care models internationally, common challenges exist: funding within complex healthcare systems, limited training mechanisms, and geopolitical/policy issues. Supportive healthcare policy, robust training initiatives, ongoing quality improvement and measurement of outcomes across programs would provide data-driven support for the expansion of integrated care and ensure its sustainability.

Paradoxos e limites da colaboração interprofissional: análise de um Núcleo Ampliado de Saúde da Família e Atenção Básica

Resumo Este artigo analisa as possibilidades e os limites da colaboração interprofissional no âmbito do cuidado em saúde mental, considerando-se as articulações entre as equipes do Núcleo Ampliado de Saúde da Família e Atenção Básica e da Estratégia de Saúde da Família em um município do estado do Rio de Janeiro. Trata-se de uma pesquisa qualitativa, baseada na abordagem hermenêutica filosófica, que se pautou em um estudo de caso, utilizando como estratégias metodológicas a observação participante, grupos focais narrativos e entrevistas semiestruturadas. Os resultados indicam a indissociabilidade dos elementos estruturais, organizacionais e intersubjetivos na colaboração interprofissional, com fortes tensionamentos no que diz respeito à organização dos processos de trabalho tanto em sua dimensão formal quanto intersubjetiva. Identificou-se que o compartilhamento de alguns objetivos do cuidado, como a desmedicalização, fomentava a construção de parcerias entre as equipes. Por outro lado, a partir do diálogo com os referenciais utilizados, compreendeu-se que regras construídas com o intuito de induzir a cooperação tiveram efeito paradoxal, gerando participação desimplicada em parte dos trabalhadores. Conclui-se que as relações de confiança no trabalho mostraram-se um elemento fundamental para a colaboração, o que exige a configuração de um ambiente organizacional capaz de aglutinar interesses e lidar com conflitos.

[Mental health and organizational quality of primary healthcare services in Brazil]

The study aimed to assess the quality of care for persons with mental health distress in primary healthcare services in Brazil and the association with organizational structure variables. This evaluative study used data from the Brazilian National Program to Improve Acess and Quality in Primary Care (PMAQ-AB), collected in 2018. The study excluded teams that reported not performing this type of care. The sum of the 13 selected mental health indicators produced a score that was classified in three groups of quality: G1 (0 to 5 points - lower quality), G2 (6 to 9 points - medium quality), and G3 (10 to 13 points - higher quality), and the results were associated with nine organizational context variables favoring the teams' permanence in the respective quality groups. The study evaluated 36,384 teams, located in 5,026 municipalities (counties). The score ranged from 1 to 13 points (G1 = 9.7%; G2 = 25.1%; G3 = 65.2%). Having an environment favorable to dispensing medicines and privacy during patient consultations; existence of a medical specialist, psychologist, and pharmacist; inter-consultation with the Expanded Family Health Care Centers (NASF) and Centers for Psychosocial Care (CAPS); and weekly or biweekly team meetings, were more frequent in the teams with higher quality (p < 0.001). In conclusion, structural conditions related to infrastructure and availability of healthcare workers, as well as inter-consultation and spaces for reflection to discuss the (re)organization of work processes in care for patients with mental health distress are factors that influence the quality of care, requiring attention, especially given recent political setbacks.

Mental Health Studies published in the last 25 years in the Journal Ciência & Saúde Coletiva

A systematic review of the 25-year Mental Health production of Journal Ciência & Saúde Coletiva was performed to identify whether this production had changed over time. We investigated whether these changes would have any relationship with the implementation of a new regulatory and legal framework for this field and the expansion of public services and the promotion of public funding agencies' investigation on the subject. A total of 278 original papers were analyzed from the following categories: sociocultural transformations related to madness and its approach; legislative changes; implantation, coverage range and operation of the network of substitute services; clinic/care developed in substitute services; the role and possibilities of primary care; drug use-related problems; mental health of children and adolescents; epidemiological studies/psychiatric categories; and others - which included ethnic-racial issues, violence, about the elderly population, suicide, bullying, and migration. A chronological relationship can be observed between the increase in publications and research notices and the expansion of services, not seemingly in the same way concerning care for people with alcohol and other drug problems.

Bridging the mental health treatment gap: effects of a collaborative care intervention (matrix support) in the detection and treatment of mental disorders in a Brazilian city

Objective

To analyse temporal trends in diagnosis and treatment of mental disorders in primary care following implementation of a collaborative care intervention (matrix support).

Design

Dynamic cohort design with retrospective time-series analysis. Structured secondary data on medical visits to general practitioners of all study clinics were extracted from the municipal electronic records database. Annual changes in the odds of mental disorders diagnoses and antidepressants prescriptions were estimated by multiple logistic regression at visit and patient-year levels with diagnoses or prescriptions as outcomes. Annual changes during two distinct stages of the intervention (stage 1 when it was restricted to mental health (2005–2009), and stage 2 when it was expanded to other areas (2010–2015)) were compared by adding year–period interaction terms to each model.

Setting

49 primary care clinics in the city of Florianópolis, Brazil.

Participants

All adults attending primary care clinics of the study setting between 2005 and 2015.

Results

3 131 983 visits representing 322 100 patients were analysed. At visit level, the odds of mental disorder diagnosis increased by 13% per year during stage 1 (OR 1.13, 95% CI 1.11 to 1.14, p<0.001) and decreased by 5% thereafter (OR 0.95, 95% CI 0.94 to 0.95, p<0.001). The odds of incident mental disorder diagnoses decreased by 1% per year during stage 1 (OR 0.99, 95% CI 0.98 to 1.00, p=0.012) and decreased by 7% per year during stage 2 (OR 0.93, 95% CI 0.92 to 0.93, p<0.001). The odds of antidepressant prescriptions in patients with a mental disorder diagnosis increased by 7% per year during stage 1 (OR 1.07, 95% CI 1.05 to 1.20, p<0.001); this was driven by selective serotonin reuptake inhibitor prescriptions which increased 14% per year during stage 1 (OR 1.14, 95% CI 1.12 to 1.18, p<0.001) and 9% during stage 2 (OR 1.09, 95% CI 1.08 to 1.10, p<0.001). The odds of incident antidepressant prescriptions did not increase during stage 1 (OR 1.00, 95% CI 0.97 to 1.02, p=0.665) and increased by 3% during stage 2 (OR 1.03, 95% CI 1.00 to 1.04, p<0.001). Changes per year were all significantly greater during stage 1 than stage 2 (p values for interaction terms <0.05), except for antidepressant prescriptions during visits (p=0.172).

Conclusion

The matrix support intervention may increase diagnosis and treatment of mental disorders when inter-professional collaboration is adequately supported. Competing demands to the primary care teams can subsequently reduce these effects. Future studies should assess clinical outcomes and identify active components and factors associated with successful implementation.