"I don't need any treatment" - barriers to mental health treatment in the general population of a megacity

Racial inequalities in mental healthcare use and mortality: a cross-sectional analysis of 1.2 million low-income individuals in Rio de Janeiro, Brazil 2010-2016

INTRODUCTION

Mental health inequalities across racial and ethnic groups are large and unjust in many countries, yet these inequalities remain under-researched, particularly in low-income and middle-income countries such as Brazil. This study investigates racial and socioeconomic inequalities in primary healthcare usage, hospitalisation and mortality for mental health disorders in Rio de Janeiro, Brazil.

METHODS

A cohort of 1.2 million low-income adults from Rio de Janeiro, Brazil with linked socioeconomic, demographic, healthcare use and mortality records was cross-sectionally analysed. Poisson regression models were used to investigate associations between self-defined race/colour and primary healthcare (PHC) usage, hospitalisation and mortality due to mental disorders, adjusting for socioeconomic factors. Interactions between race/colour and socioeconomic characteristics (sex, education level, income) explored if black and pardo (mixed race) individuals faced compounded risk of adverse mental health outcomes.

RESULTS

There were 272 532 PHC consultations, 10 970 hospitalisations and 259 deaths due to mental disorders between 2010 and 2016. After adjusting for a wide range of socioeconomic factors, the lowest PHC usage rates were observed in black (adjusted rate ratio (ARR): 0.64; 95% CI 0.60 to 0.68; compared with white) and pardo individuals (ARR: 0.87; 95% CI 0.83 to 0.92). Black individuals were more likely to die from mental disorders (ARR: 1.68; 95% CI 1.19 to 2.37; compared with white), as were those with lower educational attainment and household income. In interaction models, being black or pardo conferred additional disadvantage across mental health outcomes. The highest educated black (ARR: 0.56; 95% CI 0.47 to 0.66) and pardo (ARR: 0.75; 95% CI 0.66 to 0.87) individuals had lower rates of PHC usage for mental disorders compared with the least educated white individuals. Black individuals were 3.7 times (ARR: 3.67; 95% CI 1.29 to 10.42) more likely to die from mental disorders compared with white individuals with the same education level.

CONCLUSION

In low-income individuals in Rio de Janeiro, racial/colour inequalities in mental health outcomes were large and not fully explainable by socioeconomic status. Black and pardo Brazilians were consistently negatively affected, with lower PHC usage and worse mental health outcomes.

Digital mental health interventions for school teachers - A narrative review

AIM

School teachers face the paradox of being in a privileged position to act in youth mental health prevention, but in a vulnerable position for not receiving adequate training and personal support. Digital interventions can provide unexpensive tools and narrow this gap in a large scale without major structural changes. We aimed to synthesize the evidence for digital mental health interventions for school teachers.

METHODS

Studies published from any date until August 2022 were identified through a literature search of the MEDLINE, Embase, ScIELO, and Cochrane Central databases. The studies included evaluated digital interventions targeting school teachers to deal with their own mental health or to assist them in the management of students' mental health. Studies that addressed school-based digital mental health interventions, but directly targeted students, parents, or specifically other professionals were not included.

RESULTS

The literature search retrieved 5626 hits and several interventions were described, but only 11 studies fulfilled the inclusion criteria, none of which focused on teachers' mental health. There was some evidence that these interventions improved knowledge about general or specific topics in mental health, and most studies also reported gains in preparedness, confidence, and attitudes towards mental health.

CONCLUSIONS

The studies identified in this review provide initial support for teacher-focused mental health digital interventions. However, we discuss limitations regarding study designs and data quality. We also discuss barriers, challenges, and the need for effective evidence-based interventions.

Towards measuring effective coverage: critical bottlenecks in quality- and user-adjusted coverage for major depressive disorder in São Paulo metropolitan area, Brazil

BACKGROUND

Major depressive disorder (MDD) contributes to a significant proportion of disease burden, disability, economic losses, and impact on need of treatment and health care in Brazil, but systematic information about its treatment coverage is scarce. This paper aims to estimate the gap in treatment coverage for MDD and identify key bottlenecks in obtaining adequate treatment among adult residents in the São Paulo Metropolitan area, Brazil.

METHODS

A representative face-to-face household survey was conducted among 2942 respondents aged 18+ years to assess 12-month MDD, characteristics of 12-month treatment received, and bottlenecks to deliver care through the World Mental Health Composite International Diagnostic Interview.

RESULTS

Among those with MDD (n = 491), 164 (33.3% [SE, 1.9]) were seen in health services, with an overall 66.7% treatment gap, and only 25.2% [SE, 4.2] received effective treatment coverage, which represents 8.5% of those in need, with a 91.5% gap in adequate care (66.4% due to lack of utilization and 25.1% due to inadequate quality and adherence). Critical service bottlenecks identified were: use of psychotropic medication (12.2 percentage points drop), use of antidepressants (6.5), adequate medication control (6.8), receiving psychotherapy (19.8).

CONCLUSIONS

This is the first study demonstrating the huge treatment gaps for MDD in Brazil, considering not only overall coverage, but also identifying specific quality- and user-adjusted bottlenecks in delivering pharmacological and psychotherapeutic care. These results call for urgent combined actions focused in reducing effective treatment gaps within services utilization, as well as in reducing gaps in availability and accessibility of services, and acceptability of care for those in need.

Experiences of alcohol-dependent elderly: grounded theory

OBJECTIVE

To interpret the experiences of alcohol-dependent elderly people.

METHOD

Qualitative research developed through the theoretical and methodological assumptions of the Grounded Theory in the Straussian version. It was carried out in a small town in the mid-western region of the state of São Paulo. The selection was by theoretical sampling, totaling 25 participants from three sample groups. Semistructured interviews were conducted from March 2019 to January 2020.

RESULTS

The phenomenon "Experiencing alcohol dependence in old age", is conditioned by the category "Initiating Alcohol Consumption", are actions/interactions "Justifying alcohol consumption" and "Coping with alcohol treatment and abstinence" whose consequences are "Experiencing the harms of alcohol dependence" and "Expressing feelings".

CONCLUSION

It was evidenced that the elderly participants consider alcohol dependence as a way to deal with negative emotions, and, in this trajectory, they experience physical, mental, and social consequences. The elderly in abstinence express feelings of loneliness, regret, and desire for a life with quality, and indicate that behavioral change occurs through treatment and awareness of its harmful effects.

Vivências de idosos dependentes de álcool: teoria fundamentada nos dados

RESUMO Objetivo: Interpretar as vivências dos idosos dependentes de álcool. Método: Pesquisa qualitativa desenvolvida por meio dos pressupostos teórico-metodológicos da Teoria Fundamentada dos Dados na versão straussiana. Foi realizada em um município de pequeno porte da região centro-oeste paulista. A seleção foi por amostragem teórica, totalizando 25 participantes a partir de três grupos amostrais. Foram conduzidas entrevistas semiestruturadas entre março de 2019 a janeiro de 2020. Resultados: O fenômeno “Vivenciando a dependência de álcool na velhice”, está condicionado pela categoria “Iniciando o consumo de Álcool”, são ações/interações “Justificando o consumo de álcool” e “Enfrentando o tratamento e a abstinência do álcool” cujas consequências são “Experienciando os danos da dependência de álcool” e “Expressando sentimentos”. Conclusão: Evidenciou-se que os idosos participantes consideram a dependência de álcool como forma de lidar com emoções negativas, e, nessa trajetória, experienciam consequências físicas, mentais e sociais. Os idosos em abstinência expressam sentimentos de solidão, arrependimento e desejo de uma vida com qualidade, e indicam que a mudança comportamental ocorre por meio do tratamento e conscientização de seus malefícios.