Abstract

Mental health care based on the community has shown to be effective and successful for the health care service to people with severe mental disorders such as schizophrenia, evidence that is less clear in the health care system in Colombia, where weaknesses are present, both for prevention and rehabilitation, although national guidelines give importance to the social context in relation to the disease. As a contribution to the discussion on providing care for people living with schizophrenia, a topic review was conducted with the aim of identifying experiences in community mental health care services, in relation to their relevance to these people at the national level. Articles were searched on Scientific Electronic Library Online (SciELO) Medline with Full text, Science Direct and documents of the World Health Organization, Pan American Health Organization and the Colombian Ministry of Health and Social Protection. Few experiences in community care for people with schizophrenia in Colombia were found and given its importance to public health worldwide, a call for attention is made towards the construction and implementation of these models in the Colombian context.

Schizophrenia; Community mental health care services; Community psychiatry; Mental health care; Colombia

Introduction

The increasing prevalence of mental illness in the world has increased the gap in health care that can be provided to people with this type of problem, in addition to the fact that there are still difficulties in care processes managed from health systems, especially in low and middle-income countries¹1. Organización Mundial de la Salud (OMS). Informe de Salud en el Mundo 2001 Salud mental: nuevos conocimientos, nuevas esperanzas. Geneva: OMS; 2001.. In this situation there have been many calls on governments to expand and strengthen community mental health care as an alternative to reduce the difficulties that occur in relation to health care services for the entire population, specifically for people with mental and behavioral disorders ²2. Organización Mundial de la Salud (OMS). Promoción de la Salud Mental. Ginebra: OMS; 2004.^,33. Asociación Española de Neuropsiquiatría. Hacia una atención comunitaria de Salud Mental de calidad. Madrid: Asociación Española de Neuropsiquiatría; 2000..

People who are diagnosed with schizophrenia represent a challenge not only for professionals in the area of health, but also for their families and society in general⁴4. Organización Mundial de la Salud (OMS). Schizophrenia and public health. Geneva: OMS; 1997.^,55. Mueser KT, McGurk SR. Schizophrenia. Lancet 2004; 363(9426):2063-2072. . For example, at the early onset of symptoms, which affect young people in the phase of training and getting their basic education and involve decreasing productivity and inclusion in the community⁵5. Mueser KT, McGurk SR. Schizophrenia. Lancet 2004; 363(9426):2063-2072.^,66. Organización Mundial de la Salud (OMS). Schizophrenia Information for families. Geneva: OMS; 1992. and on the other hand, its recovery potential, which requires the active participation of health personnel, the person with the disease and their family towards a greater adherence to treatment and inclusion in society⁷7. Zipursky RB, Reilly TJ, Murray RM. The myth of schizophrenia as a progressive brain disease. Schizophr. Bull. 2013; 39(6):1363-1372.. In this regard it is worth noting the increase in life expectancy of people with the disease, which means more investment and higher costs in health systems for their care⁴4. Organización Mundial de la Salud (OMS). Schizophrenia and public health. Geneva: OMS; 1997.^,88. Rangel HC, Castro LD, Arredondo A. Costo-efectividad de intervenciones para esquizofrenia en México. Salud Ment 2011; 34(2):95-102..

In contrast to the above, a high prevalence of suicide attempts are present. It was found that 20% to 50% of people with schizophrenia attempt suicide and 10% to 13% die from this cause⁹9. Colombia. Ministerio de la Salud y Protección Social (MSPS). Guía de práctica clínica para el diagnóstico, ratamiento e inicio de la rehabilitación psicosocial de los adultos con esquizofrenia. Bogotá: MSPS; 2014., thus this group of people are 20 times more likely to die than general population¹⁰10. Jablensky A. Epidemiology of schizophrenia: The global burden of disease and disability. Eur. Arch. Psychiatry Clin. Neurosci. 2000; 250(6):274-285.. Thus, the family burden is increased so that the deterioration of relations and fatigue of caregivers are some of the conditions that complicate the care, attention and respect towards these persons¹¹11. Pinikahana J, Happell B, Hope J, Keks N. Quality of life in schizophrenia: a review of the literature from 1995 to 2000. Int. J. Ment. Health Nurs. 2002; 11(2):103-111.^,1212. Chan SW. Global perspective of burden of family caregivers for persons with schizophrenia. Arch. Psychiatr. Nurs. [Internet]. 2011 Oct [cited 2013 Nov 15];25(5):339-349. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21978802
http://www.ncbi.nlm.nih.gov/pubmed/21978... .

Faced with this complex situation, which demands permanent research and management, it has been evident that in Colombia studies on schizophrenia are scarce, even with respect to their magnitude. The most recent data is from 1997, when the national study of mental health and psychoactive substances use recorded higher prevalence of this disease in the states of Guajira, Córdoba, Quindío and Magdalena, and morbidity of 1.4% in the total Colombian population¹³13. Republica de Colombia. Ministerio de Salud. Segundo Estudio Nacional de Salud Mental y Consumo de Sustancias Psicoactivas. Version Preliminar. Santafé de Bogotá: Ministerio de Salud; 1997.. In the state of Antioquia, in 2009, of all consultations in institutions of mental health care, 10.7% of them were for schizophrenia, schizotypal and delusional disorders¹⁴14. Colombia. Gobernación de Antioquia. Tamizaje de salud mental Departamento de Antioquia 2009. Medellín: Gobernación de Antioquia; 2010.. Even more significant data when there are contextual conditions that are not conducive to mental health, such as violence. The limiting of access to psychiatry and psychology services quite notorious of the Colombian health system, economic barriers and understaffed personnel¹⁵15. Henao S, Restrepo V, Alzate AF, Gonzalez C. Percepción sobre el acceso a los servicios de salud mental que tienen los residentes de tres municipios de Antioquia, 2004-2006. Rev. Fac. Nac. Salud Pública 2009; 27(3):271- 281.^,1616. Colombia. Gobernación de Antioquia. Hacia una propuesta de intervención integral en salud mental para las poblaciones de Antioquia. Medellín: Gobernación de Antioquia; 2010..

In Colombia, there has traditionally been a model of care focused on the disease, which in the case of people with mental problems has been characterized by the search for diagnosis, treatment and prevention of serious consequences, always with the help of drugs and hospitalization in mental health units¹⁷17. Jiménez M. Políticas de las instituciones de salud mental: Sus efectos e incidencias en la concepción de la psicosis y la condición del sujeto psicótico. Tesis Psicológica 2012; 7(1):102-125..

The difficulties of access to mental health services have remained despite the advances in regulations aimed at protecting people with these diseases. Among the best known are the National Mental Health Policy in 1998¹⁸18. Ministerio De Salud. Resolucion Numero 2358 De 1998. Por la cual se adopta la Política Nacional de Salud Mental. Bogota; 1998. and the Law 1616 of Mental Health in 2013¹⁹19. República de Colombia. Ley 1616 de 2013 de Salud Mental. Bogotá; 2013.. The first one was not implemented, despite its reference point that the development of mental illnesses is linked to context and socioeconomic conditions of persons²⁰20. Rodríguez AP. Salud Mental: Situación y Tendencias. Rev. Salud Publica 2002; 4(1):74-88.^,2121. Urrego Z. Reflexiones en torno al análisis de la situación de salud mental en Colombia, 1974-2004. Rev. Colomb. Psiquiatr. 2007; XXXVI(2):307-319., and to seek, among other things, to improve the quality of care and comprehensiveness in rehabilitating individuals and communities²²22. Castaño L. El derecho a la salud en Colombia : una propuesta para su fundamentación moral. Rev. Panam. Salud Publica 2005; 18(65):129-135.. Meanwhile, the law has not been regulated after more than two years after its approval.

Based on these elements and those found in the review on care from a community perspective that is provided to people with schizophrenia, as discussed below, it aims to generate discussion and critical reflection on the need to implement models of community mental health care services for people living with schizophrenia in Colombia.

Methods

A review of the topic was made by searching databases such as Scientific Electronic Library Online (SciELO), Medline with Full text and Science Direct using descriptors: schizophrenia, mental health care, community mental health and community psychiatry, taken from the Health Sciences Descriptors (DeCS for its initials in Spanish), with their respective terms in English. As selection criteria were used periods between 2000 and 2014 that had abstract, written in English, Portuguese or Spanish (Figure 1).

The search focused by including “Colombia” in each of the descriptors, which means that 12 papers were selected. Likewise, the search engines of the World Health Organization (WHO) and the Pan American Health Organization (PAHO) were used and there were five documents selected.

From the few findings in Colombia, unlike what was found in the international arena and the recommendation of key documents in the field, by experts in mental health care services for people with schizophrenia, 34 articles were selected because of their relevance and contribution to the contrast of the specific findings in Colombia. For a total of 51 documents (Chart 1).

The three groups of texts selected allowed contextualizing the problem from both national and international levels and identifying official recommendations in the treatment of these cases. The relevance of articles and documents found, so that conceptually and methodologically contributed to meeting the objective, was taken into account.

Results

The findings presented below show various elements that related indicate the importance of community mental health care for people with schizophrenia in Colombia (Figure 2). First, it is clear that this condition corresponds to a visible problem for public health, which requires a high burden of care and causes stress within the family, with obvious social discrimination and clear convenience of community-based treatment and rehabilitation. Experiences and practices that in Colombia are recommended but have been poorly documented a fact that is consistent with the low presence of mental health care services.

Schizophrenia, a public health problem

Schizophrenia has been for many years one of the most recognized mental illnesses in the world, given its psychopathological features and its high degree of chronicity²³23. Caldas de Almeida J, Torres Gonzalez F. Atención Comunitaria a Personas con Trastornos Psicóticos. Washington: OPAS; 2005.^,2424. Millier A, Schmidt U, Angermeyer MC, Chauhan D, Murthy V, Toumi M, Cadi-Soussi N. Humanistic burden in schizophrenia: a literature review. J. Psychiatr. Res. [Internet]. 2014 Jul [cited 2014 Oct 10];54:85-93. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24795289
http://www.ncbi.nlm.nih.gov/pubmed/24795... . According to WHO, in the world, mental and behavioral disorders represent 12% of the burden of illnesses¹1. Organización Mundial de la Salud (OMS). Informe de Salud en el Mundo 2001 Salud mental: nuevos conocimientos, nuevas esperanzas. Geneva: OMS; 2001.^,2424. Millier A, Schmidt U, Angermeyer MC, Chauhan D, Murthy V, Toumi M, Cadi-Soussi N. Humanistic burden in schizophrenia: a literature review. J. Psychiatr. Res. [Internet]. 2014 Jul [cited 2014 Oct 10];54:85-93. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24795289
http://www.ncbi.nlm.nih.gov/pubmed/24795...

25. Kohn R, Saxena S, Levav I, Saraceno B. The treatment gap in mental health care. Bull. World Health Organ 2004; 82(11):858-866.^-2626. Rodríguez J. Los servicios de salud mental en América Latina y el Caribe : la evolución hacia un modelo comunitario. Rev. Psiquiatr. del Uruguay 2011; 75(2):86-96.. In 2004, this same organization estimated that more than 26 million people worldwide were suffering from schizophrenia, making it one of the 20 leading causes of disability worldwide, growing to 1.1% of the total DALYs and 2.8% of years lost due to disability, with a prevalence of 0.5 to 1.2%²⁷27. Organización Mundial de la Salud (OMS). The global burden of disease 2004. Geneva: OMS; 2004.. It is said that the risk of schizophrenia over a lifetime is 1%, with the same probability of suffering it, both men and women¹¹11. Pinikahana J, Happell B, Hope J, Keks N. Quality of life in schizophrenia: a review of the literature from 1995 to 2000. Int. J. Ment. Health Nurs. 2002; 11(2):103-111.^,1212. Chan SW. Global perspective of burden of family caregivers for persons with schizophrenia. Arch. Psychiatr. Nurs. [Internet]. 2011 Oct [cited 2013 Nov 15];25(5):339-349. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21978802
http://www.ncbi.nlm.nih.gov/pubmed/21978... ^,2323. Caldas de Almeida J, Torres Gonzalez F. Atención Comunitaria a Personas con Trastornos Psicóticos. Washington: OPAS; 2005.^,2828. Hickling FW. The epidemiology of schizophrenia and other common mental health disorders in the English-speaking Caribbean [Internet]. Rev Panam Salud Publica 2005; 18(4/5):226-265..

In Colombia these data have not been updated since 1997, when a National Study of Mental Health was performed, taking as its starting point the concept of mental health as the absence of disease²¹21. Urrego Z. Reflexiones en torno al análisis de la situación de salud mental en Colombia, 1974-2004. Rev. Colomb. Psiquiatr. 2007; XXXVI(2):307-319.^,2929. Ardón-centeno N, Cubillos-novella A. La salud mental : una mirada desde su evolución en la normatividad colombiana. Rev. Gerenc. y Polit. salud 2012; 11(23):12-38.^,3030. Organizacion Panamericana de la Salud (OPS). Estrategia y plan de acción sobre salud mental. Washington: OPS; 2009.. In 2003, although another mental health study was conducted, schizophrenia was not seen as specific object of it³¹31. Republica de Colombia. Ministerio de la Protección Social. Estudio Nacional de Salud Mental Colombia 2003. Bogotá: Ministerio de la Protección Social; 2003.. However and following the guidelines of other studies again it was sought to identify the prevalence of psychotic symptoms in some population groups, which can be very general and confused with other diseases that have these symptoms as a diagnostic criterion²¹21. Urrego Z. Reflexiones en torno al análisis de la situación de salud mental en Colombia, 1974-2004. Rev. Colomb. Psiquiatr. 2007; XXXVI(2):307-319..

Unlike Colombia, other Latin American countries like Argentina, Brazil, Chile and Cuba have made progress in the identification and characterization of schizophrenia in the population and have action strategies aimed at solving the difficulties that may arise when living and sharing with a person presenting this disease³²32. Minoletti A, Sepúlveda R, Horvitz-Lennon M. Twenty Years of Mental Health Policies in Chile. Int. J. Ment. Health [Internet]. 2012 Apr 1 [cited 2014 May 15];41(1):21-37. Available from: http://mesharpe.metapress.com/openurl.asp?genre=article&id=doi:10.2753/IMH0020-7411410102
http://mesharpe.metapress.com/openurl.as...

33. Ruben A. Cuidemos a los cuidadores: la salud mental de los trabajadores de la salud. Rev. Salud Publica 2006; 10(2):31-37.

34. Pires RR, Morais Ximenes V, Barbosa Nepomuceno B. Práticas de cuidado em saúde mental no Brasil : análise a partir do conceito de cidadania. Av. en Psicol. Latinoam. 2013; 31(3):507-521.^-3535. Rodrigues MA, Facchini L, Piccini R, Tomasi E, Thumé E, Silveira DS, Siqueira FV, Paniz VMV. Uso de serviços básicos de saúde por idosos portadores de condições crônicas, Brasil. Rev Saude Publica 2009; 43(4):604-612..

Meanwhile, although the costs of health care for people with schizophrenia is high in both the public and the private sector, due to prolonged hospitalization and treatment⁸8. Rangel HC, Castro LD, Arredondo A. Costo-efectividad de intervenciones para esquizofrenia en México. Salud Ment 2011; 34(2):95-102.^,2323. Caldas de Almeida J, Torres Gonzalez F. Atención Comunitaria a Personas con Trastornos Psicóticos. Washington: OPAS; 2005. not only talking about funding as one of the difficulties enabling comprehensive care, lack of trained health personnel increases the gap of health care for people with mental diseases³⁶36. Organización Mundial de la Salud (OMS). Mental health ATLAS 2011. Geneva: OMS; 2011.

37. Jacob KS, Sharan P, Mirza I, Garrido-Cumbrera M, Seedat S, Mari JJ, Sreenivas V, Saxena S. Mental health systems in countries: where are we now? Lancet [Internet]. 2007 Sep 22 [cited 2014 Mar 1];370(9592):1061-1077. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17804052
http://www.ncbi.nlm.nih.gov/pubmed/17804... ^-3838. Eaton J, McCay L, Semrau M, Chatterjee S, Baingana F, Araya R, Ntulo C, Thornicroft G, Saxena S. Scale up of services for mental health in low-income and middle-income countries. Lancet [Internet]. Elsevier Ltd; 2011 Oct 29 [cited 2013 Oct 1];378(9802):1592-1603. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22008429
http://www.ncbi.nlm.nih.gov/pubmed/22008... . In Colombia, this situation has been the subject of discussion by health professionals, especially psychiatrists who exercise their practice in the country³⁹39. Arango C. Aspectos conceptuales de la enseñanza de la psiquiatría en Colombia. Rev. Colomb. Psiquiatr. 2012; 41(Supl. 1):11-21..

Community care and schizophrenia

In the world there have been advances in what refers to increased community mental health care services²⁵25. Kohn R, Saxena S, Levav I, Saraceno B. The treatment gap in mental health care. Bull. World Health Organ 2004; 82(11):858-866.^,4040. Padmavati R. Community mental health services for the mentally ill: practices and ethics. Int. Rev. Psychiatry [Internet]. 2012 Oct [cited 2014 Oct 26];24(5):504-510. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23057987
http://www.ncbi.nlm.nih.gov/pubmed/23057... ^,4141. Ferreira-Furegato AR, Aparecida Frari-Galera S, Pillon SC, Ferreira-Santos JL, Araujo-Pitia AC, Cardoso L. Characterizing mental healthcare service teams. Rev. Salud Publica (Bogota) [Internet]. 2010 Oct;12(5):732-743. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21755101
http://www.ncbi.nlm.nih.gov/pubmed/21755... . For example, in European countries⁴²42. Rüsch N, Angermeyer MC, Corrigan PW. Mental illness stigma: concepts, consequences, and initiatives to reduce stigma. Eur. Psychiatry [Internet]. 2005 Dec [cited 2014 Jan 9];20(8):529-539. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16171984
http://www.ncbi.nlm.nih.gov/pubmed/16171... . The rehabilitation that starts in the community has allowed people living with the disease to express they are keeping their quality of life, despite presenting symptoms of the pathology⁴³43. Kate N, Grover S, Kulhara P, Nehra R. Relationship of caregiver burden with coping strategies, social support, psychological morbidity, and quality of life in the caregivers of schizophrenia. Asian J. Psychiatr. [Internet]. Elsevier B.V.; 2013 Oct [cited 2013 Nov 13];6(5):380-388. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24011684
http://www.ncbi.nlm.nih.gov/pubmed/24011... ^,4444. Bröcheler A, Bergmann F, Schneider F. Models of mental health care in psychiatry across sectoral borders. Eur. Arch. Psychiatry Clin. Neurosci. [Internet]. 2009 Nov [cited 2013 Dec 4];259(Supl.):S227-232. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19876683
http://www.ncbi.nlm.nih.gov/pubmed/19876... .

From models of community mental health care have been developed experiences of social inclusion and rehabilitation that have shown very good results, allowing people living with the disease to feel productive and able to live within society³3. Asociación Española de Neuropsiquiatría. Hacia una atención comunitaria de Salud Mental de calidad. Madrid: Asociación Española de Neuropsiquiatría; 2000.^,4545. Suárez MA, Ortiz MB, Fernandez A. Origen y desarrollo de los progamas de seguimiento y cuidados para pacientes mentales graves y cronicos en la comunidad. Rev. Asoc. Española Neuropsiquiatría 2004; 92(24):25-51.^,4646. Araya R, Alvarado R, Sepúlveda R, Rojas G. Lessons from scaling up a depression treatment program in primary care in Chile. Rev. Panam. Salud Publica 2012; 32(3):234-240..

Various experiences of community health care for people with mental illnesses show how a narrow therapeutic relationship between health personnel and users, public policies for expansion of community services and the development of labor skills in people living with the disease, increase their perception of recovery and decrease their psychotic symptoms⁴⁷47. Moreno-küstner B, Mayoral F, Rivas F, Angona P, Requena J, García-herrera JM, Navas D, Moreno P, Serrano-Blanco A, Bellón JA. Factors associated with use of community mental health services by schizophrenia patients using multilevel analysis. Biomed Cent. Heal. Serv. Res. 2011; 11:257.. In addition, this type of interventions to people with schizophrenia who also have other comorbidities, have shown improvement in access and care quality perception⁴⁸48. Killackey E, Alvarez-Jimenez M, Allott K, Bendall S, McGorry P. Community rehabilitation and psychosocial interventions for psychotic disorders in youth. Child Adolesc. Psychiatr. Clin. N. Am. [Internet]. Elsevier Inc; 2013 Oct [cited 2014 Jun 24];22(4):745-758. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24012084
http://www.ncbi.nlm.nih.gov/pubmed/24012...

49. Muir-Cochrane E. Medical co-morbidity risk factors and barriers to care for people with schizophrenia. J. Psychiatr. Ment. Health Nurs. 2006; 13(4):447-452.^-5050. Taylor TL, Killaspy H, Wright C, Turton P, White S, Kallert TW, Schuster M, Cervilla JA, Brangier P, Raboch J, Kalisová L, Onchev G, Dimitrov H, Mezzina R, Wolf K, Wiersma D, Visser E, Kiejna A, Piotrowski P, Ploumpidis D, Gonidakis F, Caldas-de-Almeida J, Cardoso G, King MB.. A systematic review of the international published literature relating to quality of institutional care for people with longer term mental health problems. BMC Psychiatry [Internet]. 2009 Jan [cited 2013 Dec 4]; 9:55. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2753585&tool=pmcentrez&rendertype=abstract
http://www.pubmedcentral.nih.gov/article... .

Although reported experiences of models of community care for people with schizophrenia were not found, an experience on domestic violence, documented by Luis Hernández in Bogotá⁵¹51. Hernández LJ. Evaluación de Resultados e Impactos de un Modelo de Salud Mental basado en la Comunidad en Localidades de Bogotá, DC. Rev. Salud Publica 2003; 5(3):272-283., although not focused on sick people, shows the importance of this type of models for the benefit of the mental health of the community.

Stigma and discrimination in schizophrenia

Undoubtedly, stigmatization is one of the problems that hinder social inclusion and the implementation of community programs for people with mental illnesses in the world²³23. Caldas de Almeida J, Torres Gonzalez F. Atención Comunitaria a Personas con Trastornos Psicóticos. Washington: OPAS; 2005.. Studies in different countries have shown the influence of sociocultural contexts in consolidating such discrimination⁵²52. Fresán A, Robles- García R, Benito L De, Saracco R, Escamilla R. Desarrollo y propiedades psicométricas de un instrumento breve para evaluar el estigma de agresividad en la esquizofrenia. Actas Esp. Psiquiatr. 2010; 38(101):340-345.^,5353. Hanzawa S, Nosaki A, Yatabe K, Nagai Y, Tanaka G, Nakane H, Nakane Y. Study of understanding the internalized stigma of schizophrenia in psychiatric nurses in Japan. Psychiatry Clin. Neurosci. [Internet]. 2012 Mar [cited 2014 Jan 21]; 66(2):113-120. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22353324
http://www.ncbi.nlm.nih.gov/pubmed/22353... , as well as the influence of stigma on the treatment⁵⁴54. Sartorius N. Stigma and mental health. Lancet [Internet]. 2007 Sep 8 [cited 2013 Sep 19];370(9590):810-801. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17804064
http://www.ncbi.nlm.nih.gov/pubmed/17804... . To try to reduce levels of discrimination have been launched multiple campaigns, which despite having a positive impact on the prevention of this phenomenon in society, do not seem to be very effective in reducing stigma, as they should be aware that the historical and cultural context of each community plays a major role in the acceptance of people with this type of diseases²³23. Caldas de Almeida J, Torres Gonzalez F. Atención Comunitaria a Personas con Trastornos Psicóticos. Washington: OPAS; 2005.^,5555. Wagner LC, Geidel AR, Torres-gonzález F, King MB. Cuidado en salud mental : percepción de personas con esquizofrenia y sus cuidadores. Cien Saude Colet 2011; 16(4):2077-2087..

Discrimination and stigma not only fall on the person who has the disease, their family and friends, but also affects the treatment. Thus, the literature shows four types of stigma: the internalized, the family, the health personnel and the social one. Studies of the latter with health personnel have shown that it requires much more obvious interventions through plans and programs that promote the humanization towards people with mental diseases⁵³53. Hanzawa S, Nosaki A, Yatabe K, Nagai Y, Tanaka G, Nakane H, Nakane Y. Study of understanding the internalized stigma of schizophrenia in psychiatric nurses in Japan. Psychiatry Clin. Neurosci. [Internet]. 2012 Mar [cited 2014 Jan 21]; 66(2):113-120. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22353324
http://www.ncbi.nlm.nih.gov/pubmed/22353... . Some studies in Colombia have found that in the case of mental illnesses, discrimination and exclusion presented by the community to people who have been diagnosed with these diseases, even if provided for in the legislation respect and social inclusion of people living in disability¹⁵15. Henao S, Restrepo V, Alzate AF, Gonzalez C. Percepción sobre el acceso a los servicios de salud mental que tienen los residentes de tres municipios de Antioquia, 2004-2006. Rev. Fac. Nac. Salud Pública 2009; 27(3):271- 281.^,5656. Restrepo MU, Mora OL, Cristina ANA, Rodríguez C. Voces del estigma Percepción de estigma en pacientes y familias con enfermedad mental. Univ. Médica 2007; 48(3):207-220., even shown how this situation affects not only the person who has the disease, but their families and the community that shares space with them⁵⁶56. Restrepo MU, Mora OL, Cristina ANA, Rodríguez C. Voces del estigma Percepción de estigma en pacientes y familias con enfermedad mental. Univ. Médica 2007; 48(3):207-220.. This displays an obstacle for people with mental illnesses to be able to freely access health care services within a community setting, something disturbing especially if what is sought is social inclusion and rehabilitation for people who have mental disease¹⁵15. Henao S, Restrepo V, Alzate AF, Gonzalez C. Percepción sobre el acceso a los servicios de salud mental que tienen los residentes de tres municipios de Antioquia, 2004-2006. Rev. Fac. Nac. Salud Pública 2009; 27(3):271- 281.^,5757. Arias B. Los derechos civiles de las personas con discapacidad mental en Colombia: una actualización tardía y restringida. Rev. Colomb. Psiquiatr. 2010; 39(2):405-414. .

Caregiver fatigue, a pending task

Family plays an important role in the recovery of the person with schizophrenia. One of the tasks presented is precisely to serve as support for the return to society⁵⁸58. Chou K-R, Liu S-Y, Chu H. The effects of support groups on caregivers of patients with schizophrenia. Int. J. Nurs. Stud. [Internet]. 2002 Sep; 39(7):713-722. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12231028
http://www.ncbi.nlm.nih.gov/pubmed/12231... ^,5959. Chien W-TW-T, Norman I, Thompson DR. A randomized controlled trial of a mutual support group for family caregivers of patients with schizophrenia. Int. J. Nurs. Stud. [Internet]. 2004 Aug [cited 2013 Dec 4]; 41(6):637-649. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15240088
http://www.ncbi.nlm.nih.gov/pubmed/15240... .

Family as a primary network responsible for the direct care to these people, not only supports through taking medications or through accompaniments to control appointments, but it is precisely through their care in aspects that are not so notorious for society, that the success of treatment has a balance point⁵⁸58. Chou K-R, Liu S-Y, Chu H. The effects of support groups on caregivers of patients with schizophrenia. Int. J. Nurs. Stud. [Internet]. 2002 Sep; 39(7):713-722. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12231028
http://www.ncbi.nlm.nih.gov/pubmed/12231... ^,6060. Silva G. Álbum De Família E Esquizofrenia : Convivência Em Retrato Family Album And Schizophrenia. Picture of Life. Psicol. em Estud. 2009; 14(1):83-91..

Given the characteristics of this disease, which produces a profound change in family relationships, it was pointed at some time, by psychoanalysts doctors, that one of the reasons why a person could generate schizophrenia was an inadequate upbringing⁶¹61. Daly O. Trauma and psychosis. Psychiatry [Internet]. Elsevier Ltd.; 2009 Aug [cited 2013 Oct 7]; 8(8):315-318. Available from: http://linkinghub.elsevier.com/retrieve/pii/S1476179309000895
http://linkinghub.elsevier.com/retrieve/... . However, this hypothesis has been abandoned and it is generally mentioned a genetic transmission rather than due to trauma in childhood⁶²62. Jerónimo SR, Diego C. DLVS, Patricia SP. Bases neurobiológicas de la Esquizofrenia. Clínica y Salud [Internet]. 2010 [cited 2014 Jan 16]; 21(3):235-254. Available from: http://www.copmadrid.org/webcopm/resource.do?recurso=4000&numero=20101102130418609000
http://www.copmadrid.org/webcopm/resourc... ^,6363. Gejman P V, Sanders AR. Etiología de la esquizofrenia. Med. (Buenos Aires) 2012; 72:227-234..

And it is that perhaps, one of the situations that causes more complexity in the care of people living with this disease, is that the symptoms are reactivated in unexpected periods in which the disease worsens and can cause separation from society and detachment of the household, besides the fatigue that is reflected in the caregiver⁶⁰60. Silva G. Álbum De Família E Esquizofrenia : Convivência Em Retrato Family Album And Schizophrenia. Picture of Life. Psicol. em Estud. 2009; 14(1):83-91.^,6464. Torres AM. Vivencias de los cuidadores de enfermos mentales. Investig. en enfermería Imagen y Desarro. 2004; 6(1 y 2):20- 25..

In Colombia, there has been some research showing the impact of the constant care of family caregivers of people with mental illness, also highlighting the enormous physical and emotional exhaustion that brings this with the passage of time⁶⁴64. Torres AM. Vivencias de los cuidadores de enfermos mentales. Investig. en enfermería Imagen y Desarro. 2004; 6(1 y 2):20- 25.

65. Corredor Rozo ZL, Sánchez Espinosa MP, Rondón-Lagos M, Páez Rojas PL, Cortés Duque C, Forero Castro RM. Descriptive study of 20 patients with schizophrenia in Boyacá, Colombia. Iatreia 2013; 26(3):245-256.

66. Torres AM, Pinilla M. Perfil de cuidadores de enfermos mentales. Investig. en enfermería Imagen y Desarro. 2003; 5(1 y 2):11- 17.^-6767. Hernando M, Hernández B, Victoria M, Correa B. Las condiciones del cuidado en familias antioqueñas con un miembro con trastorno afectivo bipolar. Iatreia 2013; 26(4):419-429.. Some of them report that the health care system does not provide adequate assistance to their physical ailments, which in most cases arise from these care given⁶⁶66. Torres AM, Pinilla M. Perfil de cuidadores de enfermos mentales. Investig. en enfermería Imagen y Desarro. 2003; 5(1 y 2):11- 17..

For models of community care, support and coordination established with family caregivers is essential for monitoring the therapeutic processes outlined from the beginning of diagnosis⁵⁷57. Arias B. Los derechos civiles de las personas con discapacidad mental en Colombia: una actualización tardía y restringida. Rev. Colomb. Psiquiatr. 2010; 39(2):405-414.^,6666. Torres AM, Pinilla M. Perfil de cuidadores de enfermos mentales. Investig. en enfermería Imagen y Desarro. 2003; 5(1 y 2):11- 17., somewhat visible in models of traditional psychiatric care.

Discussion

Despite normative progress made by Colombia in relation to the mental health of its population, difficulties in access to services remain an obstacle for people with mental illnesses to benefit from quality care¹⁵15. Henao S, Restrepo V, Alzate AF, Gonzalez C. Percepción sobre el acceso a los servicios de salud mental que tienen los residentes de tres municipios de Antioquia, 2004-2006. Rev. Fac. Nac. Salud Pública 2009; 27(3):271- 281.^,6868. Vargas J, Molina G. Acceso a los servicios de salud en seis ciudades de Colombia : limitaciones y consecuencias Access to health services in six Colombian cities : limitations. Rev. Fac. Nac. Salud Pública 2009; 27:121-130..

WHO has been emphatic on seeking that health care systems in the world promote social inclusion and create strategies to reduce discrimination and social stigma²³23. Caldas de Almeida J, Torres Gonzalez F. Atención Comunitaria a Personas con Trastornos Psicóticos. Washington: OPAS; 2005.^,2626. Rodríguez J. Los servicios de salud mental en América Latina y el Caribe : la evolución hacia un modelo comunitario. Rev. Psiquiatr. del Uruguay 2011; 75(2):86-96.. However, the few experiences that have arisen regarding community care models in Colombia regarding mental health and the null finding regarding schizophrenia show the ambiguity of the system and evidence the lack of opportunities to implement strategies to shape the truth of the implementation of the strategy for primary care for people with mental diseases⁶⁹69. Arango-dávila CA, Carlos J, Fernández R, Moreno M. Análisis de los aspectos asociados a la enfermedad mental en Colombia y la formación en psiquiatría. Revista Colombiana de Psiquiatría 2008; 37(4):538-563.^,7070. Morales L. Los pacientes psiquiátricos en la ley 100 de 1993 (Sistema General De Seguridad Social En Salud). Rev. Colomb. Psiquiatr. 2003; 1993:13-20..

Quality health services can generate huge difference in achieving adherence to treatment because it has been established that in those services where better treatment is given, there is greater ease of access and less bureaucracy for users, it considerably reduces the risk of relapse⁷¹71. Cardoso L, Frari S. Internação psiquiátrica e a manutenção do tratamento extra-hospitalar PSYCHIAT. Rev. Esc. Enferm. USP 2011; 45(1):87-94.^,7272. Ruben A, Torres F, Moreno B. Factores asociados a mejores resultados en la calidad de vida de personas con esquizofrenia. Rev. Psiquiatr. del Uruguay 2008; 72(2):130-141.. In this type of services it has been identified an increased demand for care of the mentally ill and their families³⁰30. Organizacion Panamericana de la Salud (OPS). Estrategia y plan de acción sobre salud mental. Washington: OPS; 2009.^,3636. Organización Mundial de la Salud (OMS). Mental health ATLAS 2011. Geneva: OMS; 2011.^,7373. Kohn R, Levav I, Miguel J, Almeida C De, Vicente B, Andrade L, Caraveo-Anduaga JJ, Saxena S, Saraceno B. Los trastornos mentales en América Latina y el Caribe: asunto prioritario para la salud pública. Rev. Panam. Salud Publica 2005; 18(401):229-240.. To this end, WHO has developed practical tools that can help professionals and non-professionals in health, in improving attendance and decreasing the difficulties around the diagnosis of mental diseases⁷⁴74. Organización Mundial de la Salud (OMS). Guía de Intervención mhGAP: para los trastornos mentales, neurologicos y por uso de sustancias en el nivel de atención no especializada. Ginebra: OMS; 2010..

It is a social responsibility of human resources in mental health to promote a better quality of care in these services, and involving not only the people who have been diagnosed with a disorder, but also their families and the community in general²³23. Caldas de Almeida J, Torres Gonzalez F. Atención Comunitaria a Personas con Trastornos Psicóticos. Washington: OPAS; 2005.. This adds to the need to understand that these people even with a diagnosis such as schizophrenia, have rights and need to live in society without the pressure of stigma and discrimination that falls on them⁷⁵75. Organización de las Naciones Unidas (ONU). Convención Sobre Los Derechos De Las Personas Con Discapacidad Preámbulo. Nueva York: ONU; 2006..

The importance of creating social networking that provide a support and participate in the care of people with schizophrenia and other mental illnesses, is becoming more noticeable in countries that have implemented community strategies in their health care systems⁴⁴44. Bröcheler A, Bergmann F, Schneider F. Models of mental health care in psychiatry across sectoral borders. Eur. Arch. Psychiatry Clin. Neurosci. [Internet]. 2009 Nov [cited 2013 Dec 4];259(Supl.):S227-232. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19876683
http://www.ncbi.nlm.nih.gov/pubmed/19876... ^,7676. Sepúlveda R. Un modelo intracomunitario de rehabilitacion para personas discapacitadas de causa psiquiatrica.pdf. Cuad. Med. Soc. 1994; XXXV(3):25-29..

Although timidly, in Colombia, services for mental health care are being increasingly recognized, not only because of the problems related to mental health that occur, such as depression and aggressions⁷⁰70. Morales L. Los pacientes psiquiátricos en la ley 100 de 1993 (Sistema General De Seguridad Social En Salud). Rev. Colomb. Psiquiatr. 2003; 1993:13-20., but also because of the expectation that generates the recent Law of Mental Health¹⁹19. República de Colombia. Ley 1616 de 2013 de Salud Mental. Bogotá; 2013., the focus of Primary Health Care promulgated by the Ministry of Health and Social Protection of the country seeking to ensure the care of people who have such disabilities, improving circumstantially with these actions the quality of life of the whole population²¹21. Urrego Z. Reflexiones en torno al análisis de la situación de salud mental en Colombia, 1974-2004. Rev. Colomb. Psiquiatr. 2007; XXXVI(2):307-319..

Recommendation: towards a community mental health care

The move toward mental health care services based in the community is a challenge for the Colombian health care system, which demands a strong work towards overcoming the difficulties mentioned above. Greater sensitivity is required in general to the issues concerning the mental health of the population and interdisciplinary work. The importance of the family in the recovery and rehabilitation of people with mental illnesses, as in the case of schizophrenia, seen from the evidence reviewed, it is essential to improve the quality of life of people diagnosed. The use of tools such as mhGAP Intervention Guide can make it easy to detect potential cases and facilitate the work of workers in the area of health. The recent national regulations could also become a key point for future interventions to improve the results of the actions of health personnel.

References

Publication Dates

History