Mental Health in Latin America and the Caribbean
Since the 1960s and 1970s, Pan American Health Organization (PAHO) Member States have striven to improve their systems for delivering mental health services. Still, these initiatives, largely local and isolated, have often failed in attaining the level of reform agreed by regional consensus or addressing challenges in a structural, integrated manner.
A group of countries in Latin America and the Caribbean has nevertheless distinguished itself in recent years with valuable experiences. PAHO has served as a catalyst and played a guiding role by encouraging a fruitful discussion while offering technical assistance that will continue to expand.
Innovative techniques have enabled this PAHO technical-cooperation initiative to strengthen the countries' response capacity, promote mental health, and prevent and treat mental illness. With this support, many Member States are today buttressing the content of their health networks and systems as well as their capacity to address problems in the field of mental health.
Looking back on the steps taken in Latin America and the Caribbean over the past 50 years, the Chief of PAHO Regional Mental Health, Substance Abuse and Rehabilitation Unit, Dr. Jorge Rodríguez, says that from that historical standpoint, the 1990 Caracas Declaration was a major turning point because it formally established the Initiative for the Restructuring of Psychiatric Care in the Region of the Americas.
"Caracas placed special emphasis on the need to integrate mental health services into the general operational framework of primary health care," said Dr. Rodríguez. In their final document, delegates and attendees said that psychiatric hospitals based on the model of the asylum for the insane constituted a clear obstacle to delivering a health service compatible with decentralized, participatory, comprehensive, continuing, and preventive community-based care. Dr. Rodríguez then underscored that Caracas also spelled out the obligation to safeguard the human and civil rights of people with mental illness.
Subsequent to Caracas, PAHO set up a rigorous program to monitor compliance with the guidelines contained in the Declaration. Two resolutions by PAHO Directing Council in 1997 and 2001, reiterated that commitment for compliance and technical cooperation in the ongoing reform of mental health services within PAHO Member States in Latin America and the Caribbean.
The second historic milestone that would catapult the modernization of mental health services and treatment in the Americas came in 2006 in Brasilia during a regional conference organized by PAHO and the Brazilian Ministry of Health.
Mental health organizations, associations, authorities, and professionals gathered in the Brazilian capital reported that countries such as El Salvador, Guatemala and Nicaragua had already made progress in providing care to vulnerable groups; that Chile had promoted the integration of mental health networks into the general public health services systems; that Belize and Jamaica, in the Caribbean, had strengthened their programs for giving nurses specialized training in mental health; and that Brazil already stood out as an important model for cultural mobilization, in addition to having sharply reduced the number of psychiatric beds.
Similar statements were made about Panama, which attendees spotlighted for having created treatment instruments capable of adequately offsetting the effects of decentralization while decisively retreating from the outmoded model of the psychiatric hospital.
Other countries that were mentioned included Cuba, which was praised for its progress in integrating mental health into primary health care and for developing mental health care for children and adolescents.
The Brasilia meeting, however, went farther. "Not only did they talk about eliminating the asylums for the insane as a model of care or about decentralizing the services," noted Dr. Rodríguez. "They cited new challenges that were not brought up in Caracas." The most prominent of these were:
- Psychosocial vulnerability, including the problems of specific groups such as indigenous populations and those living in extreme poverty, and the adverse effects of the lack of urban planning in large metropolis;
- Increased morbidity and psychosocial problems among children and adolescents;
- Greater societal demand for services to facilitate the adoption of effective prevention measures and to address suicidal behavior and drug and alcohol abuse at an early stage, and
- Violence, whose steady increase calls for a response from the health services, especially the mental health services, in order to treat victims.
Words to Action
The theme of the World Health Organization's World Health Report 2001 was mental health. The report noted that, while mental health is as important as physical health for the general well being of individuals, societies, and countries, "only a small minority of the 450 million people suffering from a mental or behavioral disorder is receiving treatment."
PAHO has also stressed its concern about the enormous gaps in care for people with psychological disorders, which is described as "overwhelming". The result of a special study on mental health in Latin America and the Caribbean published at PAHO Pan American Journal of Public Health leaves no room for doubt. The study concludes that in the Americas, "over one-third of individuals with non-affective psychosis, over half of those with an anxiety disorder, and some three-fourths of those with alcohol use, abuse or dependence did not receive mental health care from either specialized or general health services."
In that Journal, PAHO Director Dr. Mirta Roses Periago writes that the number of people with mental disorders in the Region of the Americas is expected to rise from 114 million in 1990 to 176 million in 2010.
According to WHO, advances in neuroscience and behavioral sciences have demonstrated that, just as with many organic diseases, mental and behavioral disorders are the result of a complex interaction between biological, psychological, and social factors. "While there is still much to be learned, we already have the knowledge and the power to reduce the burden of mental and behavioral disorders worldwide."
Statistics and Realities
In Latin America and the Caribbean, this burden was identified by data contained in the Mental Health Atlas 2005, an unprecedented evaluation effort by WHO to which PAHO and its Member States contributed greatly.
According to the Atlas, 76.5% of the countries in 2005 had national mental health plans. This, Dr. Rodríguez said, is highly significant, given that only 15 years ago such plans were virtually nonexistent. "For both PAHO and the countries the real challenge is to implement these plans, since several assessments indicate that actually fewer than half of the countries of the Region have done so."
The Atlas also indicates that 75% of the Latin American and Caribbean countries have mental health legislation. However, Dr. Rodríguez again invites us to not take this at face value. "The question that we should ask is to what extent this legislation is part of a complete body of law and to what extent they have been brought into line with international standards, and if these laws are in fact being properly enforced in the different contexts."
There can be no programs or services without money. WHO recommends that to meet the challenge of modernizing and restructuring mental health as proposed in the Caracas and Brasilia guidelines, nations should allocate a minimum of 5% of their general health budgets to mental health. Once again, Dr. Rodríguez asks us to look beyond this statistic. "Within the framework of mental health reform as we are envisioning it in the Americas, we also need to see how much of all that money is earmarked or absorbed by centralized psychiatric hospitals, by the large institutions representing those same models that we are in fact trying to eradicate."
Dr. Rodríguez points out that according to studies in the Central American region, many of these countries are below 1% in the general allocation of health budgets to mental health. Between 80% and 90% of these sums is absorbed and spent on centralized hospitals. He acknowledges that this incongruity must be resolved.
Human resources data for mental health in the Region of the Americas in the 2005 Atlas point to an obvious conclusion: there is an enormous need for Latin American and Caribbean countries to invest heavily in training and to work on retaining health workers with specialized education or skills in mental health disciplines. Belize, for instance, is a country singled out for its major accomplishments in strengthening its service capacity with a successful Psychiatric Nurse Practitioners training and implementation program.
According to Dr. Rodríguez, human resources in mental health are a key factor for the reform currently under way. "Mental health plans generally don't require expensive advanced technology; what is needed is a special effort for training and sustained retraining of human resources, based on the principles that are guiding the direction of our structural actions. The idea is to devise service schemes that are not doctor-centered. We must go from 'doctor-centrism' to developing other human resources that can play an important role in promoting health and preventing and treating mental illness. Belize and Panama are two countries whose actions provide the best evidence of the importance given to the role of nurses, for example."
Dr. Rodríguez emphasized that the challenge of human resources in mental health must be faced openly and in the broadest sense. A great number of people with situational symptoms or mild depression can be treated by primary care personnel properly trained in psychosocial issues and thus prepared to handle the emotional issues of many patients.
He also explained the importance of developing specific programs for vulnerable or at-risk groups. PAHO has taken up the challenge of assisting and cooperating with Member States to ensure that they have programs and the ability to properly meet the needs of indigenous populations, communities stricken by disasters, groups living in extreme poverty, and the victims of violence, whether political, social, or gender-based. PAHO is also promoting programs for children and adolescents as well as older adults.
Information and Knowledge
"We still have a long way to go," said Dr. Rodríguez, adding, nonetheless, that he is optimistic about what he views as a regional reform that is gradually progressing and responding to the established guidelines. "A series of efforts must be made and challenges met for mental health, substance abuse, and rehabilitation to become priority areas in the health policies of the appropriate ministries."
Dr. Rodríguez, however, stresses the critical importance of the awakening of this political awareness for bridging the major gaps that still exist in reliable surveillance, recording, and information systems.
"We must give politicians and decision makers evidence justifying a sustained investment, and for this, they must have current and reliable information."
In fact, the search for such appropriate evaluations led the WHO to create an unprecedented tool of more than 150 indicators which provides a baseline for its work. This initiative is known as the Assessment Instrument for Mental Health Systems (AIMS).
"For us at PAHO, the current challenge is for all the countries to adhere to the use of AIMS so that this assessment will clearly identify strengths, as well as weaknesses, in the reform of mental health services, which each country is undertaking with the particular features characteristic of its context but in line with the basic principles agreed on in the Region of the Americas."