Matrix Support in Mental Health: Achievements and Limits in Primary Health Care

Changes in mental health care in the city of Fortaleza (Northeastern Brazil) have a recent historical and political process. Compared to other municipalities of the State of Ceara, which in the early 1990s were already pioneers in the process, Fortaleza has not implemented the changes due to the interests of psychiatric hospitals, of psychiatric outpatient clinics of the public network, and because of the difficulty in managing the new mental health devices and equipment present in Primary Care. In the municipality, the reorganization of mental health actions and services has required that the Primary Care Network faces the challenge of assisting mental health problems with the implementation of Matrix Support. In light of this context, we aimed to evaluate Matrix Support in mental health in Primary Care Units and to identify achievements and limitations in the Primary Care Units with Matrix Support. This study used a qualitative approach and was carried out by means of a case study. We interviewed twelve professionals from the Family Health Teams of four Units with implemented Matrix Support. The analysis of the information reveals that access, decision making, participation and the challenges of implementing Matrix Support are elements that are, in a dialectic way, weak and strong in the reorganization of services and practices. The presence of Matrix Support in Primary Care highlights the proposal of dealing with mental health within the network in the municipality. The process has not ended. Mobilization, awareness-raising and qualification of Primary Care have to be enhanced constantly, but implementation has enabled, to the service and professionals, greater acceptance of mental health in Primary Care.

The Brazilian National Health Agency and the Mental Health Policy in the Context of the Private Health System: developments and challenges

This work analyses the mental health policy-making activity of the Brazilian National Health Agency (ANS), responsible for controlling health insurance companies. Three points are discussed: a) the framework of an economic and private health assistance regulatory activity, b) the ANS and its regulation activity and c) the rules produced by ANS in the mental health care field. It was concluded that, despite advances like the legal obligation to ensure medical treatment to all the diseases listed in ICD-10, the inclusion of suicidal patient damage and self-inflicted damage care, care provided by a multiprofessional team, the increase in the number of sessions with a psychologist, with an occupational therapist and of psychotherapy sessions, and mental health day hospitals included as part of the services offered, the authors identified specific regulatory gaps in this area. Some issues that ANS has to solve so that it can really play its institutional role of defending the public interest in the private health system are: the regulation of co-participation and franchise mechanisms, the increasing co-participation as a limitation of psychiatric hospitalization, and the limited number of crisis intervention psychotherapy sessions.

Influence of psychosocial risk factors on the trajectory of mental health problems from childhood to adolescence: a longitudinal study

Background Longitudinal epidemiological studies involving child/adolescent mental health problems are scarce in developing countries, particularly in regions characterized by adverse living conditions. We examined the influence of psychosocial factors on the trajectory of child/adolescent mental health problems (CAMHP) over time. Methods A population-based sample of 6- to 13-year-olds with CAMHP was followed-up from 2002–2003 (Time 1/T1) to 2007–2008 (Time 2/T2), with 86 out of 124 eligible children/adolescents at T1 being reassessed at T2 (sample loss: 30.6%). Outcome: CAMHP at T2 according to the Child Behavior Checklist/CBCL’s total problem scale. Psychosocial factors: T1 variables (child/adolescent’s age, family socioeconomic status); trajectory of variables from T1 to T2 (child/adolescent exposure to severe physical punishment, mother exposure to severe physical marital violence, maternal anxiety/depression); and T2 variables (maternal education, child/adolescent’s social support and pro-social activities). Results Multivariate analysis identified two risk factors for child/adolescent MHP at T2: aggravation of child/adolescent physical punishment and aggravation of maternal anxiety/depression. Conclusions The current study shows the importance of considering child/adolescent physical punishment and maternal anxiety/depression in intervention models and mental health care policies.

Methodological contributions towards the study of health care production: lessons from a research study on barriers and access in mental health

This article presents methodological contributions and a conceptual innovation for thinking about the production of health care, stemming from a study on access and barriers in mental health carried out in the municipality of Campinas (Sao Paulo, Brazil). The study used a cartographic approach and, after an initial identification of the most complex cases (on the part of the teams of workers), adopted the users as guides to explore the different levels of production of their lives and to evaluate the possibility of forming a network of existential connections that produce life as a fundamental analyzer of access or barriers to care.

Prevalence of beta-hemolytic Streptococcus in children with special health care needs

Pharyngotonsillitis by beta-hemolytic Streptococcus mostly affects children and imunocompromissed, being Streptococcus pyogenes (Group A) the most common agent in bacterial pharyngotonsillitis. Aim: This work targeted the research of beta-hemolytic Streptococcus Group-A (SBHGA) and No-A (SBHGNA) in the oropharynx of individuals with special health needs from the APAE (Maceio-AL). Method: A prospective study with oropharynx samples from patients with Down syndrome and other mental disorders (test) and students from a private school (control) aged 5-15 years. Cultures in blood agar (5%) were identified through Gram/catalase tests and bacitracin/trirnethoprim-sulfamethoxazole disk diffusion method, applying the chi-squared statistical analysis. Results: A total of 222 bacterial colonies were isolated in 74 individuals from APAE and 65 in the control group. In the test group, previous episodes of pharyngotonsillitis were reported by 36.49% (27/74) and 9.46% (7/74) were diagnosed with symptoms and/or signs suggestive of oropharynx infection. No positive sample of S. pyogenes was confirmed at APAE, being all samples classified as SBHGNA, with 5 SBHGA in the control group. Conclusion: The early identification of beta-hemolytic Streptococcus is important for the fast treatment of pharyngotonsillitis and the absence of S. pyogenes avoid future suppurative or not-suppurative sequels in the group from APAE.

Therapeutic Project at Extra-Hospital Mental Health Services: a critical reflection on the elaboration and management of services' therapeutic projects

Based on a study conducted in Ribeirao Preto, SP, Brazil in extra-hospital mental health services that addressed the organization of these services, therapeutic projects and the inclusion of psychosocial rehabilitation in health actions available, a theoretical-critical reflection concerning the development process of the therapeutic projects by the services' teams is presented. The qualitative study was conducted in an outpatient clinic and a Psychosocial Care Center. Data were collected through semi-structured interviews and focal groups. Data analysis was based on the hermeneutic dialectic philosophy of Jurgen Habermas according to the techniques of reconstruction and interpretation. Data analysis revealed that professionals have difficulty developing and managing therapeutic projects. Health actions are made available without being concretely supported by a proposal guiding the service's practical activities. The therapeutic projects are referred by professionals as the result of guidelines provided by management levels or technical orientations inherent to each profession but not as an activity that represents a philosophy of work of the health team. When the therapeutic project is focused on as a type of consensus that results from a communicative action directed to a mutual and intersubjective understanding among the members of the mental health extra-hospital team, the difficulties of the services' team dialogically organizing themselves to collectively construct the therapeutic project is evidenced.

Basic assistance for mental health in Northeast Brazil

Introduction: Brazilian northeast region is historically affected by socioeconomic problems that made this region more needful for strategies regarding to psychiatric disorders assistance. Methods: This study includes original analysis based on data of secondary level health assistance, extracted from Brazil's Hospitalar Information System, Basic Assistance Information System and Brazilian Institute of Geographic and Statistics. Results: Between 2008 and 2010, more than two hundred million dollars were spent by Brazilian federal government to achieve better quality in the assistance for mental health in Northeast. The service network responsible for the treatment of mental disorders in primary care involves a wide range of professionals and establishments. Conclusion: In northeastern Brazil, socioeconomic and geographic conditions contribute to a particular state of vulnerability for the development of psychopathologies. The association of primary care and an integrated network of public health, however, have improved the attention to mental disordersin this region.

Parent psychopathology and offspring mental disorders: results from the WHO World Mental Health Surveys

Background Associations between specific parent and offspring mental disorders are likely to have been overestimated in studies that have failed to control for parent comorbidity. Aims To examine the associations of parent with respondent disorders. Method Data come from the World Health Organization (WHO) World Mental Health Surveys (n = 51 507). Respondent disorders were assessed with the Composite International Diagnostic Interview and parent disorders with informant-based Family History Research Diagnostic Criteria interviews. Results Although virtually all parent disorders examined (major depressive, generalised anxiety, panic, substance and antisocial behaviour disorders and suicidality) were significantly associated with offspring disorders in multivariate analyses, little specificity was found. Comorbid parent disorders had significant sub-additive associations with offspring disorders. Population-attributable risk proportions for parent disorders were 12.4% across all offspring disorders, generally higher in high- and upper-middle-than low-/lower-middle-income countries, and consistently higher for behaviour (11.0-19.9%) than other (7.1-14.0%) disorders. Conclusions Parent psychopathology is a robust non-specific predictor associated with a substantial proportion of offspring disorders.

Relationships between gender, age, family conditions, physical and mental health, and social isolation of elderly caregivers

Background: In an aging population an increasing number of elderly caregivers will be called upon to provide care over a long period, during which time they will be burdened both by caregiving and by the physiological effects of their own aging. Among them there will be more aged male caregivers, who will probably be less prepared than women to become caregivers. The aim of this study was to investigate the relationship between caregivers' gender, age, family income, living arrangements and social support as independent variables, and depressive symptoms, comorbidities, level of frailty, grip strength, walking speed and social isolation, as dependent variables. Methods: 176 elderly people (123 women) were selected from a sample of a population-based study on frailty (n = 900), who had cared for a spouse (79.3%) and/or parents (31.4%) in the past five years (mean age = 71.8 +/- 4.86 years; mean monthly family income in minimum wages = 4.64 +/- 5.14). The study used questionnaires and self-report scales, grip strength and walking speed tests. Results: 65% of participants evaluated caregiving as being very stressful. Univariate analyses of regression showed low family income as a risk factor for depression; being female and low perceived social support as a risk for comorbidities; being 80 years of age and above for low grip strength; and being male for social isolation indicated by discontinuity of activities and social roles. In multivariate analyses of regression, poverty arose as a risk factor for depression and being female for comorbidities. Conclusions: Gender roles, age, income and social support interacted with physical and emotional health, and with the continuity of social participation of elderly caregivers. Special attention must be given to male caregivers.

Bioethics and Mental Health: The Rights of Patients With a Disorder

Bioethics can be included in the context of psychiatric patients' recovery of dignity and rights, creating a therapeutic interface of social rehabilitation, respect and closeness between professionals and the treated persons. The completion of the analysis of the facts occurred by reviewing 22 articles dated between 1999-2011, from a prior reading, selecting the ones that mention bioethics and mental health. Before the Psychiatric Reform, often, a lack of commitment to the mentally ill was noticed, isolating the patient from a social life. Before the Psychiatric Reform, often, a lack of commitment to the mentally ill was noticed by isolating the patient from a social life. After the Reform, the person with mental illness began to receive a more attentive care. It can be concluded that the Reform tried to bring life to those who had no respect and attention, these patients who needed to be included in a social and urban interaction.

Mental Disorders in Megacities: Findings from the Sao Paulo Megacity Mental Health Survey, Brazil

Background: World population growth is projected to be concentrated in megacities, with increases in social inequality and urbanization-associated stress. Sao Paulo Metropolitan Area (SPMA) provides a forewarning of the burden of mental disorders in urban settings in developing world. The aim of this study is to estimate prevalence, severity, and treatment of recently active DSM-IV mental disorders. We examined socio-demographic correlates, aspects of urban living such as internal migration, exposure to violence, and neighborhood-level social deprivation with 12-month mental disorders. Methods and Results: A representative cross-sectional household sample of 5,037 adults was interviewed face-to-face using the WHO Composite International Diagnostic Interview (CIDI), to generate diagnoses of DSM-IV mental disorders within 12 months of interview, disorder severity, and treatment. Administrative data on neighborhood social deprivation were gathered. Multiple logistic regression was used to evaluate individual and contextual correlates of disorders, severity, and treatment. Around thirty percent of respondents reported a 12-month disorder, with an even distribution across severity levels. Anxiety disorders were the most common disorders (affecting 19.9%), followed by mood (11%), impulse-control (4.3%), and substance use (3.6%) disorders. Exposure to crime was associated with all four types of disorder. Migrants had low prevalence of all four types compared to stable residents. High urbanicity was associated with impulse-control disorders and high social deprivation with substance use disorders. Vulnerable subgroups were observed: women and migrant men living in most deprived areas. Only one-third of serious cases had received treatment in the previous year. Discussion: Adults living in Sao Paulo megacity had prevalence of mental disorders at greater levels than similar surveys conducted in other areas of the world. Integration of mental health promotion and care into the rapidly expanding Brazilian primary health system should be strengthened. This strategy might become a model for poorly resourced and highly populated developing countries.