Les décisions d'hospitalisation et de soins psychiatriques sans le consentement des patients dans des contextes clinique et judiciaire: une étude du pluralisme normatif appliqué

Thèse de doctorat réalisée en cotutelle avec l'Institut du social et du politique de l'École Normale supérieure de Cachan.

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.

Endoscopy for repeatedly ingested sharp foreign bodies in patients with borderline personality disorder: an international survey

The general guidelines on the management of ingested foreign bodies (FBs) do not address specific aspects raised by psychiatric patients, particularly in patients with borderline personality disorders (BPD) who repeatedly ingest FBs. The aim of this survey was to collect data on experience and opinions on the management of FBs in psychiatric patients with BPD and to review the relevant literature.

THE DISCHARGED PSYCHIATRIC PATIENT: POST-HOSPITAL ADJUSTMENT AND FACTORS AFFECTING REHOSPITALIZATION

Discharged psychiatric patients were studied six months post-discharge to determine those demographic, social and clinical characteristics affecting positive or negative adjustment and the degree to which the use of mental health services and medication compliance mediated the effects. With the exception of those with primary or secondary diagnoses of OBS, substance abuse or mental retardation, sixty-three psychiatric subjects between the ages of eighteen and sixty-four were chosen from all admissions into the hospital and interviewed six months after discharge using a specially designed questionnaire.^ The subjects' adjustment to community living was found to be marginal. Although not engaged in destructive activities, over half were living with their family members who supported them financially and emotionally. Most were unemployed and had been so for a long time. Others worked sporadically and frequently changed residences. Most did have substantial social ties with extended family and with friends with whom they interacted regularly, but one-fourth were socially isolated. Almost three-quarters continued to obtain regular mental health services after discharge and followed medication instructions under the supervision of their physician. The use of mental health services after discharge and the use of medication did not appear to affect the subjects' community adaption or their rate of rehospitalization.^ Forty percent of those discharged were rehospitalized by the end of the follow-up period. Four levels of risk of rehospitalization emerged. The highest risk was associated with a history of five or more prior hospitalizations, living alone, and social isolation. One third or more of the subjects expressed a need for more counseling, leisure time activities, case-manager assistance, vocational guidance, supervised housing, and placement into a transitional residential treatment program.^ Recommendations were made to enhance the ability to predict recidivism, to develop interorganizational casework management programs linking the patient and family to the community mental health system and to create computerized tracking and monitoring programs that systematically report patient treatment regimen and progress cross-sectionally and longitudinally. ^

Burden of care and general health in families of patients with schizophrenia

Background De-institutionalization of psychiatric patients has led to a greater emphasis on family management in the community, and family members are often overwhelmed by the demands that caring for a patient with schizophrenia involves. Most studies of family burden in schizophrenia have taken place in developed countries. The current study examined family burden and its correlates in a regional area of a medium income country in South America. Method Sixty-five relatives of patients with schizophrenia who were attending a public mental health out-patient service in the province of Arica, Chile, were assessed on Spanish versions of the Zarit Caregiver Burden Scale and SF-36 Health Survey (SF-36). Results Average levels of burden were very high, particularly for mothers, carers with less education, carers of younger patients and carers of patients with more hospitalisations in the previous 3 years. Kinship and number of recent hospitalisations retained unique predictive variance in a multiple regression. Burden was the strongest predictor of SF-36 subscales, and the prediction from burden remained significant after entry of other potential predictors. Conclusions In common with families in developed countries, family members of schizophrenia patients in regional Chile reported high levels of burden and related functional and health impact. The study highlighted the support needs of carers in contexts with high rates of poverty and limited health and community resources.

The MMPI-2 Gender-Masculine and Gender-Feminine scales: Gender roles as predictors of psychological health in clinical patients

Previous research measuring various biosocial factors such as age, sex, and marital status has found them to be essentially unrelated to measures of psychological health. Recent empirical studies have revealed that personality constructs may be more significant than demographic variables in the prediction of psychological well-being. The present study assessed the personality constructs of masculinity and femininity and hypothesized that the Gender-Masculine ( GM) scale of the MMPI-2 would be more effective than the Gender-Feminine (GF) scale in predicting psychological well-being. This hypothesis stems from previous research that has indicated the dominance of the masculinity model. It is suggested that previous research supporting androgyny as a primary indicator of well-being was influenced by the masculinity component of this gender orientation. One hundred and seventy-seven psychiatric patients from Australia (N = 107) and Singapore ( N 5 70) completed the MMPI-2. Hierarchical multiple regression revealed significantly stronger masculinity effects, with significance achieved on measures of ego strength and low self-esteem. No significant relationship between psychological well-being and the GF variable was found. Similarly, androgyny did not add any further variance to the model when masculinity was controlled for. Overall, the results are consistent with an interpretation that GM is a better correlate of psychological well-being as compared to the GF scale.

Anthropometric characteristics and the burden of altered nutritional status among neuropsychiatric patients at Zomba Mental Hospital in Zomba, Malawi

Objective To determine the prevalence of overnutrition and undernutrition among neuropsychiatric inpatients and outpatients at Zomba Mental Hospital in Zomba, Malawi. Methods In this analytical cross-sectional study (n = 239), data were collected from psychiatric patients who were either inpatients (n = 181) or outpatients (n = 58) at Zomba Mental Hospital, which is the largest mental health facility in Malawi. Information was collected about patient demographics, anthropometric data, dietary information, and tobacco and alcohol use, among other variables. Data were entered and analysed in SPSS 16.0 (SPSS Inc., Chicago, IL, USA). Means were generated and compared between male and female patients, and between inpatients and outpatients. Results The study recruited 158 male and 81 female patients, with mean ages of 31.24 ± 11.85 years and 33.08 ± 15.18 years (p = 0.328), respectively. Male patients were significantly taller (165.27 ± 7.25 cm) than female patients (155.30 ± 6.56 cm) (p < 0.001); were significantly heavier than females (60.02 ± 10.56 kg versus 55.64 ± 10.53 kg); and had a significantly lower mean body mass index (BMI) than females (21.87 ± 3.21 vs. 23.01 ± 3.78) (p = 0.016). Overweight and obese patients comprised 17.6% of the participants, and 8.8% were underweight. There were no significant differences in the prevalence of overweight, obesity, and underweight between male and female participants, or between inpatients and outpatients. Conclusion Our study—the first one of its kind in Malawi—characterised the anthropometry of neuropsychiatric patients at a major metal health facility in Malawi, and has shown a high proportion of overweight patients and a notable presence of underweight patients among them. Being overweight or obese is a risk factor for metabolic disorders. Being underweight may aggravate mental illness or disturb the effect of medication. There is need, therefore, to include nutrition screening and therapeutic or supplementary feeding as part of a comprehensive care and treatment plan for neuropsychiatric patients.

An examination of the utility of the AUDIT in people with schizophrenia

Objective: To examine the reliability and validity of the Alcohol Use Disorders Identification Test (AUDIT) compared to a structured diagnostic interview, the Composite international Diagnostic Interview (CIDI; 12-month version) in psychiatric patients with a diagnosis of schizophrenia. Method: Patients (N = 71, 53 men) were interviewed using the CIDI (Alcohol Misuse Section; 12-month version) and then completed the AUDIT. Results: The CIDI identified 32.4% of the sample as having an alcohol use disorder. Of these, 5 (7.0%) met diagnostic criteria for harmful use of alcohol, 1 (1.4%) met diagnostic criteria for alcohol abuse and 17 (23.9%) met diagnostic criteria for alcohol dependence. The AUDIT was found to have good internal reliability (coefficient = 0.85). An AUDIT cutoff of greater than or equal to 8 had a sensitivity of 87% and specificity of 90% in detecting CIDI-diagnosed alcohol disorders. All items except Item 9 contributed significantly to discriminant validity. Conclusions: The findings replicate and extend previous findings of high rates of alcohol use disorders in people with severe mental illness. The AUDIT was found to be reliable and valid in this sample and can be used with confidence as a screening instrument for alcohol use disorders in people with schizophrenia.

Moving from theory to praxis on the fly: Introducing a salutogenic method to expedite mental health care provision in disaster situations

Not a lot is known about most mental illness. Its triggers can rarely be established and nor can its aetiological dynamics, so it is hardly surprising that the accepted treatments for most mental illnesses are really strategies to manage the most overt symptoms. But with such a dearth of knowledge, how can worthy decisions be made about psychiatric interventions, especially given time and budgetary restrictions? This paper introduces a method, extrapolated from Salutogenics; the psycho-social theory of health introduced by Antonovsky in 1987. This method takes a normative stance (that psychiatric health care is for the betterment of psychiatric patients), and applies it to any context where there is a dearth of workable knowledge. In lieu of guiding evidence, the method identifies reasonable alternatives on the fly, enabling rational decisions to be made quickly with limited resources.

Suicidal behaviour in bipolar disorder

The Jorvi Bipolar Study (JoBS) is a collaborative ongoing bipolar research project between the Department of Mental Health and Alcohol Research of the National Public Health Institute, Helsinki, and the Department of Psychiatry, Jorvi Hospital, Helsinki University Central Hospital (HUCH), Espoo, Finland. The JoBS is a prospective, naturalistic cohort study of secondary level care psychiatric out-and inpatients with a new episode of Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) bipolar disorder (BD). Altogether, 1630 patients (aged 18-59) years were screened using the Mood Disorder Questionnaire (MDQ) for a possible new episode of DSM-IV BD. 490 patients were interviewed with semi-structured interview [the Structured Clinical Interview for DSM-IV Disorders, research version with Psychotic Screen (SCID-I/P)]. 191 patients with new episode of DSM-IV BD were included in the bipolar cohort study. Psychiatric comorbidity was evaluated using semi-structured interviews. At 6- and 18-month follow-up, the interviews were repeated and life-chart methodology was used to integrate all available information about nature and duration of all different phases. Suicidal behaviour was examined both at intake and follow-up by psychometric scale [Scale for Suicidal Ideation (SSI)], interviewer s questions and medical and psychiatric records. The aim of this thesis was to evaluate prevalence of suicidal behaviour and incidence of suicide attempts, and examine the wide range of risk factors for attempted suicide both, at intake and follow-up, in representative secondary-level sample of psychiatric in- and outpatients with BD. In this study suicidal behaviour was common among psychiatric patients with BD. During the episode when patients were included into cohort study (index episode), 20% of the patients had attempted suicide and 61% had suicidal ideation. Severity of depressive episode and hopelessness were independent risk factors for suicidal ideation, whereas hopelessness, comorbid personality disorder and previous suicide attempt predicted suicide attempts during the index episode. There were no differences in prevalence of suicidal behaviour between bipolar I and II disorder; the risk factors were overlapping but not identical. During the index episode, suicide attempts took place during depressive, mixed and depressive mixed phases. Furthermore, there were marked differences regarding level of suicidal ideation during different phases, with the highest levels during the mixed phases of the illness. Hopelessness was independently associated with suicidal behaviour during the depressive phase. A subjective rating of severity of depression (Beck Depression Inventory) and younger age predicted suicide attempts during mixed phases. During the 18-month follow-up 20% of patients attempted suicide. Previous suicide attempts, hopelessness, depressive phase at index episode and younger age at intake were independent risk factors for suicide attempts during follow-up. Taken altogether, 55% patients attempted suicide before index episode, during index episode or during follow-up. The incidence of suicide attempts was 37-fold during combined mixed and depressive mixed states and 18-fold during major depressive phase as compared with other phases. Prior suicide attempt and time spent in combined mixed phases - mixed and depressive mixed - and depressive phases independently predicted the suicide attempt during follow-up. More than half of the patients have attempted suicide during their lifetime, a finding which highlights the public health importance of suicidal behaviour in bipolar disorder. Clinically, it is crucial to recognize BD and manage the mixed and depressive phases of bipolar patients fast and effectively, as time spent in depressive and mixed phases involves a remarkably high risk of suicide attempts.

As representações sociais de profissionais de saúde acerca do paciente psiquiátrico: aspectos descritivos e de zona muda

A presença de pacientes crônicos em instituições psiquiátricas tem se constituído como um desafio humano, político e programático para esta área assistencial. Frente a isto, definiu-se como objetivo geral deste estudo analisar a reconstrução sócio-cognitiva do profissional de saúde mental acerca do paciente psiquiátrico crônico, contextualizando com a sua permanência institucional e o processo assistencial. Como objetivos específicos, descrever os conteúdos e a estrutura das representações sociais do paciente psiquiátrico crônico para os profissionais; identificar a existência de conteúdos implícitos nas formações discursivas dos profissionais de saúde referentes ao paciente crônico institucionalizado; e analisar a perspectiva assistencial implementada na atenção a esses indivíduos no contexto institucional a partir das representações sociais do paciente crônico. Trata-se de uma pesquisa qualitativa, desenvolvida com o aporte teórico-metodológico da Teoria das Representações Sociais em sua abordagem estrutural, em dois hospitais colônias localizados na cidade do Rio de Janeiro. Os dados foram coletados através de evocações livres em dois momentos. No primeiro, com 159 profissionais e no segundo utilizou-se a técnica de substituição com 151 profissionais. Os dados gerados foram analisados pelo software EVOC 2003 e organizados pelo quadro de quatro casas. Utilizou-se, ainda, a análise de similitude. Quanto à representação do paciente psiquiátrico, a mesma foi organizada ao redor das dimensões assistencial-institucional (cuidado), imagética (louco) e afetividade positiva (atenção), que se desdobram nos demais quadrantes, com destaque para a primeira e a segunda. A análise de similitude revelou que o léxico cuidado, obteve o maior número de ligações. Quanto à representação do paciente crônico em contexto normativo, a dimensão assistencial-institucional mostrou-se fortemente presente (cuidado, paciência e dependente), seguida da imagética (abandonado) e da de necessidade (carência). No entanto, na análise de similitude, a afetividade positiva (amor) mostra-se central com maior número de ligações de léxicos. Em contextos contra-normativos, a representação revelou-se negativa (louco, não e medo). A análise de similitude demonstrou uma representação estruturada através de uma imagem e de uma afetividade negativas. Conclui-se que os avanços na área de saúde mental, nos últimos 30 anos, não foram capazes de realizar mudanças representacionais sob fenômenos que ancoram em imagens produzidas desde os primórdios da humanidade. Ressalta-se a possível existência de uma zona muda acerca do paciente psiquiátrico crônico.

Metamorfoses do humano: experimentações etnográficas em um laboratório de neurociência

Este trabalho tem como foco central a análise dos dilemas presentes na produção de conhecimento acerca das emoções e do comportamento humano nas neurociências. Para isso, realizou-se uma etnografia em um laboratório atuante na seara da psicofisiologia ou neurobiologia das emoções. Mais especificamente, trata-se de um centro de pesquisas que atualmente realiza experimentos com universitários, militares e pacientes psiquiátricos no intuito de investigar questões relativas ao chamado transtorno do estresse pós-traumático, o neuromarketing, entre outras questões relacionadas à violência urbana e situações aversivas de um modo geral. Para compreender a centralidade adquirida pelo corpo e em especial o cérebro na definição da Pessoa, buscou-se acompanhar o cotidiano de transformação e atualizações neurocientíficas de problemáticas já postas desde o delineamento histórico do fisicalismo moderno. Buscou-se atentar ainda para as trajetórias dos programas de pesquisas desenvolvidos e da vida acadêmica das/os pesquisadoras/os, assim como para as controvérsias intrínsecas a uma atividade científica que se propõe a discutir uma ontologia para o humano.

An Evaluation of the Dual Diagnosis (substance use and mental health )Strategy in the South Eastern Trust Workers and Service Users Perceptions of Dual Diagnosis Issues

In the UK it is estimated that over 33% of psychiatric patients with enduring mental illness have a substance misuse problem, whilst over 50 % of clients currently accessing drug and alcohol services have a mental health problem. Between 2003 and 2013 in Northern Ireland, there were 741 recorded suicides by patients who were in contact with mental health services. Of this number, 68% (n=501) had a history of either alcohol or drug misuse or both, resulting in an average of 46 patient suicides per year associated with dual diagnosis (University of Manchester 2015).
The current evaluation examined staff attitudes towards working with dual diagnosis (co-existing difficulties) issues, staff confidence in working with clients with dual diagnosis, workers’ perceptions of the South Eastern dual diagnosis strategy and service user perspectives of dual diagnosis service provision.
The purpose of the evaluation was to provide evidence regarding the following in accordance with the current dual diagnosis strategy;
Staff understanding of the concept of dual diagnosis,
Staff attitudes towards working with dual diagnosis,
Staff confidence in working with individuals, who present with dual diagnosis,
Service users’ perspectives of SE Trust provision for dual diagnosis.
Staff views on the South Eastern Trust Dual Diagnosis Strategy.

Qualidade de vida e doença mental

Atendendo à conjuntura nacional e internacional que norteia a saúde mental e psiquiatria, a Qualidade de Vida (QDV) das pessoas com doença mental torna-se uma área fundamental de investigação, tendo em conta a sua inquestionável importância na aferição de medidas de intervenção. Um facto observável relaciona-se com um interesse crescente nos últimos anos na QDV da pessoa com doença mental como objeto de investigação. Estudos apontam para que as pessoas com doença mental percecionem a sua QDV inferior às pessoas sem doença mental e/ou com doenças físicas. Esta investigação foi realizada com base em três estudos. O Estudo I pretendeu estudar relações entre variáveis sociodemográficas e clínicas e a QDV de pessoas (n = 39) com doenças do humor (Depressão Major, Distimia, Doença Bipolar e Perturbações Depressivas Sem Outra Especificação). Para isso, foram utilizados o WHOQOL-Bref, o Índice de Graffar, um Questionário de Dados Sociodemográficos e Clínicos e um Guia de Observação. Os dados foram recolhidos no domicílio dos sujeitos. No Estudo II compararam-se diferenças de QDV em duas amostras independentes: sujeitos com doenças do humor (n = 39) e sujeitos sem doença mental diagnosticada (n = 39). Utilizaram-se os mesmos instrumentos do Estudo I exceto o Guia de Observação. Nestes dois estudos os dados foram tratados recorrendo ao IBM SPSS Statistics, versão 19.0. O Estudo III teve como objetivo recolher dados sobre as narrativas dos sujeitos com doença mental e sobre o conhecimento sobre a Rede Nacional de Cuidados Continuados e Integrados de Saúde Mental (RNCCISM). Para esta segunda parte do objetivo foi utilizada uma amostra de profissionais de saúde mental (n = 42) que respondeu a um Questionário sobre a RNCCISM construído para o efeito. Este Instrumento foi validado e do qual resultou uma variável final: “avaliação do conhecimento sobre a RNCCISM”. Os resultados desta pesquisa sugeriram, pelo Estudo I, que a QDV difere em função da doença apresentada pelos sujeitos; encontraram-se também diferenças em relação à idade, sexo, escolaridade, classe social, estado civil e transportes utilizados para a consulta de especialidade. Pelo Estudo II, os resultados indicaram-nos diferenças entre a QDV nos dois grupos, sendo que, o Grupo com doença do humor apresenta scores mas baixos em todos os domínios do WHOOL-Bref que o Grupo sem doença mental diagnosticada. Os dados do EstudoIII sugeriram-nos: i) no primeiro momento, uma reflexão que girou em torno de cinco eixos: o sofrimento; a estigmatização; os eventos de vida perturbadores; o modelo de tratamento adotado pelos profissionais; e o acompanhamento das pessoas com doença mental; ii) no segundo momento, que os enfermeiros são os que, em média, possuíam um score de conhecimento sobre a RNCCISM mais baixo. Esta investigação sugeriu que a QDV das pessoas com doença mental é baixa, indicando algumas relações entre algumas variáveis. Durante o seu desenvolvimento, pretendemos também reforçar a necessidade do envolvimento de todos os profissionais da saúde nas alterações preconizadas, o que permite intervir de forma mais informada. Porque, durante este percurso surgiram dificuldades sérias de acesso à amostra clínica, esta tese chama ainda a atenção para a importância da investigação em saúde mental e psiquiatria e para as formalidades de acesso aos dados que a podem condicionar. De facto, ao assumirmos a QDV como uma medida de resultado em saúde, torna-se importante, por um lado, aprofundar a investigação neste domínio e, por outro, e pelo conhecimento de que já dispomos, equacionar de forma efetiva novas modalidades de intervenção, contribuindo para um plano terapêutico mais amplo, pondo em prática uma filosofia de cuidados mais abrangente e de continuidade, implementando as politicas comunitárias e globais preconizadas para a prestação de cuidados em saúde mental e psiquiatria.

Implementation progress of mental health services in Rwanda: Bugesera district case

RESUMO: O Ministério da Saúde do Governo do Ruanda identifica a saúde mental como uma área de prioridade estratégica para a intervenção em resposta à alta carga dos transtornos mentais no Ruanda. Ao longo dos últimos 20 anos após o genocídio, o sector público reconstruiu sua Resposta Nacional de Saúde Mental com base no acesso equitativo aos cuidados, através do desenvolvimento de uma Política Nacional de Saúde Mental e novas estruturas de saúde mental. A política de Saúde Mental do Ruanda, revista em 2010, prima pela descentralização e integração dos serviços de saúde mental em todas as estruturas nacionais do sistema de saúde e ao nível da comunidade. O presente estudo de caso tem como objetivo avaliar a situação do sistema de saúde mental de um distrito típico de uma área rural no Ruanda, e sugerir melhorias, incluindo algumas estratégias para monitoras as mudanças. Os resultados do estudo permitirão ao Ruanda reforçar a sua capacidade para implementar o Plano Nacional de Saúde Mental ao nível dos distritos. O relatório também será útil para monitorar o progresso da implementação de serviços de saúde mental nos distritos, incluindo a prestação de serviços de base comunitária e a participação dos usuários, suas famílias e outros interessados na promoção, prevenção, assistência e reabilitação em saúde mental. Este estudo também procurou avaliar o progresso da implementação dos cuidados de saúde mental a nível descentralizado, com vista a compreender as implicações em termos de recursos desses processos. Foi realizada uma análise situacional num local do distrito, baseado em entrevistas com as principais partes interessadas responsáveis, usando o Instrumento de Avaliação de Sistemas de Saúde Mental da Organização Mundial da Saúde (WHO-AIMS). Os resultados sugerem que os recursos humanos para a saúde mental e serviços de base comunitária de saúde mental no distrito continuam a ser extremamente limitados. Os profissionais de saúde mental são adicionalmente limitados na sua capacidade para oferecer intervenções de emergência a pacientes psiquiátricos e garantir a continuidade do tratamento farmacológico a pacientes com condições crônicas. Para planejar efetivamente, de acordo com as necessidades da comunidade, sugerimos que o sistema de saúde mental deve envolver também os representantes das famílias e dos usuários no processo de planificação de modo a melhorar a sua contribuição no processo de implementação das atividades de saúde mental. Este estudo de caso do Distrito de Bugesera oferece a primeira análise de nível distrital dos serviços de saúde mental no Ruanda, e pode servir como uma mais-valia para a melhoria do sistema de saúde mental, incluindo a advocacia para a melhoria da qualidade dos cuidados de saúde mental a este nível, aumentando o financiamento para a implementação de serviços clínicos de saúde mental e os recursos humanos disponíveis para a prestação de cuidados de saúde mental, principalmente a nível dos cuidados primários.--------------------- ABSTRACT: To deal with the high burden of mental health disorders resulting from consequences of the 1994 genocide against Tutsis, the Rwanda Ministry of Health (MoH) considers mental health as a priority intervention. For the last 20 years, Ministry of Health focused on rebuilding a national and equity-oriented mental health program responding to the population needs in mental health. Mental health services are now decentralized and integrated in the national health system, from the community level up to the referral level. This study assessed the situation of mental health services in one rural district in Rwanda. It was aimed at assessing the progress of implementation of mental health care at the decentralized level, focusing on resource implications and processes. This study is based on interviews conducted with key stakeholders, using the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS). Findings show that human resources for mental health care and community-based mental health services of the assessed district remain extremely limited. Mental health professionals face limitation regarding the ability to provide emergency management of psychiatric patients and to ensure continuity of psychopharmacological treatment of patients with chronic conditions. To improve the implementation process of mental health interventions and activities, a planning process based on community needs and the involvement of representatives of families and users in planning process should be considered. The Bugesera case study on the situation of mental health services can serve as a baseline for improvement of the mental health program in Rwanda, in terms of quality care services, infrastructure and equipment, human and financial resources.