Abstract

Global Mental Health and the Brazilian context

Global Mental Health is a field of teaching, research, and practice whose goal is to improve access to mental health and to reduce inequalities in mental health for people worldwide ¹1. Patel V, Prince M. Global Mental Health: a new global health field comes of age. JAMA 2010; 303:1976-7.. The Global Mental Health agenda features situational diagnoses, methodological proposals for research and evaluation, measures to deal with the mental health gap, and advocacy of the rights of persons with mental disorders and their families on a global level ²2. Patel V. Global mental health: from science to action. Harv Rev Psychiatry 2012; 20:6-12.^,33. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, et al. No health without mental health. Lancet 2007; 370:859-77.^,44. Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: scarcity, inequity, and inefficiency. Lancet 2007; 370:878-89.^,55. Patel V, Araya R, Chatterjee S, Chisholm D, Cohen A, De Silva M, et al. Treatment and prevention of mental disorders in low-income and middle-income countries. Lancet 2007; 370:991-1005.^,66. Jacob KS, Sharan P, Mirza I, Garrido-Cumbrera M, Seedat S, Mari JJ, et al. Mental health systems in countries: where are we now? Lancet 2007; 370:1061-77.^,77. Saraceno B, van Ommeren M, Batniji R, Cohen A, Gureje O, Mahoney J, et al. Barriers to improvement of mental health services in low-income and middle-income countries. Lancet 2007; 370:1164-74.^,88. Lancet Global Mental Health Group. Scale up services for mental disorders: a call for action. Lancet 2007; 370:1241-52.. The agenda also recommends follow-up of persons with mental disorders within the community by primary care services and health teams, with evidence-based and collaborative interventions that are consistent with local characteristics and that can be scaled up as intervention strategies for expanding access to mental health ³3. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, et al. No health without mental health. Lancet 2007; 370:859-77.^,44. Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: scarcity, inequity, and inefficiency. Lancet 2007; 370:878-89.^,55. Patel V, Araya R, Chatterjee S, Chisholm D, Cohen A, De Silva M, et al. Treatment and prevention of mental disorders in low-income and middle-income countries. Lancet 2007; 370:991-1005.^,66. Jacob KS, Sharan P, Mirza I, Garrido-Cumbrera M, Seedat S, Mari JJ, et al. Mental health systems in countries: where are we now? Lancet 2007; 370:1061-77.^,77. Saraceno B, van Ommeren M, Batniji R, Cohen A, Gureje O, Mahoney J, et al. Barriers to improvement of mental health services in low-income and middle-income countries. Lancet 2007; 370:1164-74.^,88. Lancet Global Mental Health Group. Scale up services for mental disorders: a call for action. Lancet 2007; 370:1241-52..

Another key characteristic of Global Mental Health is the effort to bring international partners together through the Movement for Global Mental Health in order to strengthen mental health, research initiatives and the elaboration of practices of care ⁹9. Collins PY, Patel V, Joestl SS, March D, Insel TR, Daar AS. Grand challenges in global mental health: a consortium of researchers, advocates and clinicians announces here research priorities for improving the lives of people with mental illness around the world, and calls for urgent action and investment. Nature 2011; 475:27-30.^,1010. Jain S, Orr DM. Ethnographic perspectives on global mental health. Transcult Psychiatry 2016; 53:685-95.^,1111. Cooper S. Global mental health and its critics: moving beyond the impasse. Crit Public Health 2016; 26:355-8.. Studies indicate that shortages in the supply of mental health services partially reflect gaps in scientific knowledge concerning the provision of such care in resource-poor settings, as well as the small volume of mental health research focusing on populations in low- and middle-income countries (LMICs) ¹²12. Becker AE, Kleinman A. Mental health and the global agenda. N Engl J Med 2013; 369:66-73..

This situation perpetuates health inequalities and leads to fewer research opportunities. The urgent establishment of a platform for science-sharing and a common research agenda, as some authors have proposed, would promote an evidence base capable of guiding strategic planning and the implementation of interventions, integrating local cultural characteristics with practice in primary care services ¹²12. Becker AE, Kleinman A. Mental health and the global agenda. N Engl J Med 2013; 369:66-73.^,1313. Beran D, Byass P, Gbakima A, Kahn K, Sankoh O, Tollman S, et al. Research capacity building - obligations for global health partners. Lancet Glob Health 2017; 5:e567-8..

It is important to learn how this agenda for research and interventions has impacted Brazil, and in turn, how the agenda may have been influenced by Brazil’s research production and health policies. Brazil’s case is unique. Although Brazil can be classified as a low-income or middle-income country, the measures that are recommended for the African and Asian countries are not applicable here. Unlike African and Asian countries, Brazil has a well-structured national health system, the Brazilian Unified National Health System (SUS) ¹⁴14. Ortega F, Wenceslau LD. Dilemas e desafios para a implementação de políticas de saúde mental global no Brasil. Cad Saúde Pública 2015; 31:2255-7., that resulted from historical processes in Health Reform and reorientation of the primary care model. In mental health, the national system has been impacted by the Psychiatric Reform and the replacement of asylums with community-based mental health services, based on Law n. 10,2016/2001 and other guidelines for integrated care in the Community Mental Health Network.

The Brazilian experience has required the creation and improvement of mental health policies and practices to ensure the right to health in all its dimensions. The mental health field in Brazil is also the result of a diverse and complex set of influences ¹⁴14. Ortega F, Wenceslau LD. Dilemas e desafios para a implementação de políticas de saúde mental global no Brasil. Cad Saúde Pública 2015; 31:2255-7., with a tradition in the national health debate and practices that have mirrored changes in the internationally tested model of care. However, although Brazilian studies in mental health have contributed to knowledge on reforms in mental health care, the studies still lack sufficient diversity and scope to develop health indicators, to identify successes, and to correct gaps in the system ¹⁵15. Delgado PG. Limites para a inovação e pesquisa na reforma psiquiátrica. Physis (Rio J.) 2015; 25:13-8.^,1616. Gregório G, Tomlinson M, Gerolin J, Kieling C, Moreira HC, Razzouk D, et al. Setting priorities for mental health research in Brazil. Rev Bras Psiquatr 2012; 34:434-9..

Encouragement for scientific research and comprehensive and systematic assessments can assist decision-making processes and progress in the Health and Psychiatric Reforms ¹⁵15. Delgado PG. Limites para a inovação e pesquisa na reforma psiquiátrica. Physis (Rio J.) 2015; 25:13-8.^,1616. Gregório G, Tomlinson M, Gerolin J, Kieling C, Moreira HC, Razzouk D, et al. Setting priorities for mental health research in Brazil. Rev Bras Psiquatr 2012; 34:434-9.^,1717. Furtado JP, Onocko-Campos RT, Moreira MIB, Trapé TL. A elaboração participativa de indicadores para a avaliação em saúde mental. Cad Saúde Pública 2013; 29:102-10.. Thus, knowledge on the ways in which the international debate impacts Brazilian research can provide backing for mental health researchers, administrators, and practitioners to engage in a critical dialogue with the field of Global Mental Health.

This article thus analyzes the current status of the Brazilian mental health literature and its relationship to the discipline of global mental health, seeking to describe how the Brazilian studies address the key arguments, proposals, policies, and practices in Global Mental Health, such as increased access, reduction of the treatment gap and inequalities, the fight against stigma, and the production of scientific evidence.

Method

The study takes a qualitative and descriptive approach, with an integrative literature review method based on an article search. The integrative review method was chosen because it is comprehensive and allows combining data from the theoretical and applied literature, e.g., including experimental and non-experimental studies to achieve a broad understanding of the phenomenon. The methodology thus provides a synthesis of the knowledge and the applicability of significant study results in practice, besides generating a consistent and comprehensive review of complex concepts, theories, and relevant health problems ¹⁸18. Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein (São Paulo) 2010; 8:102-6..

Data collection: building the sample through a literature search

To begin mapping the Global Mental Health field and identify the Brazilian research production, we initially performed preliminary searches in SciELO, BIREME/BVS, and PubMed. The search started with the keywords “saúde mental global” and “global mental health”, using the advanced search mode with the title, abstract, and subject headings. The term “Brazil” was added to increase the search strategy’s specificity in order to guarantee that the results found in international databases actually referred to the Brazilian context.

The preliminary searches yielded only two articles, suggesting low penetration of the Global Mental Health debate in Brazil. A sample of only two articles was also insufficient for a review. The search scope was thus expanded by eliminating the term global and adding other keywords. Keywords were selected in Portuguese and English that corresponded to the principal topics emphasized by Patel ²2. Patel V. Global mental health: from science to action. Harv Rev Psychiatry 2012; 20:6-12. in defending an action strategy for the Global Mental Health field: access; primary care (plus the variants basic care and family health); social determinants of health; human rights; equity; and evidence. Using these descriptors together with the keywords “mental health” and “Brazil”, new searches were performed in the same databases, always in the “advanced search” mode, in the title, abstract, and subject headings in Portuguese and English (Box 1).

The final search strategy yielded more than 3,000 articles, narrowed to 996 after eliminating duplicates. Although this was a representative example of the Global Mental Health field, it was unfeasible to analyze such a large initial sample of articles. A time filter was thus applied. Considering that global mental health emerged as a discipline in 2007 and that the key ideas would likely take some time to appear in Brazilian studies, we opted to review the most recent articles, selecting a period of nearly two years, from January 2014 to October 2015, immediately prior to data collection.

The inclusion criteria were: articles published in Portuguese and English in Brazilian and international journals indexed in the above-mentioned databases. Exclusion criteria were: dissertations, theses, monographs, and book chapters, besides articles that were not available as full texts or that were not relevant to the study theme, based on the abstracts. After applying the exclusion criteria, 88 articles remained that comprised the analytical base for the current review.

Distribution and analysis of the articles

To orient the articles’ conceptual analysis, some of the same Global Mental Health topics already indetified in the previous literature search were used as analytical categories: access, primary care, social determinants of health, human rights, and equity. After reading the abstracts, community mental health services (Portuguese: atenção psicossocial) was added, since it proved relevant as an analytical category in Brazilian mental health research and as a key guideline in the country’s mental health policy. We also analyzed the study methods (Figure 1) and the articles’ characteristics, including the profiles of the lead authors and periodicals and regions of publication.

These categories oriented the two stages in the analysis (comprehensive and specific). In the first stage, the authors divided into two-person groups, and the articles were randomly distributed among them. Each author analyzed the articles to determine whether the categories were present or absent in the article’s objectives or in the discussion of the results and then drafted a summary of the article’s main arguments for each key category that was found to be present. The evaluations were compared and summaries were recorded in text and spreadsheet format, and later compiled in a master spreadsheet and a master text.

The second stage featured an analysis of the specific categories, distributing the categories among the authors. The master text was subdivided according to the analytical categories for an in-depth analysis of the results from the first stage. All the analyses were assessed by the group, and any disagreements were debated collectively to reach a consensus.

Ethical aspects and financing

This study is part of the research line Dilemmas and Challenges of Global Mental health Policies, of the Institute of Social Medicine/State University of Rio de Janeiro, in collaboration with the Rio Center for Global Health. The study received financial support from the CNPq Call for Projects, n. 443137/2014-5 and PhD scholarships (CNPq 140379/2014-2 and FAPERJ 2017.01612.2).

Results

The current review identified 88 articles (Table 1) that were examined according to the authors’ profiles, periodicals and regions of publication, methods, and analytical categories.

Characterization of articles as to authors and periodicals and regions of publication

Most of the lead authors were psychologists (31), physicians (20), or nurses (18), followed by occupational therapists (4), biologists (2), dentists (2), pharmacists (2), speech therapists (2), and other professionals (one lead author each), including an attorney, medical anthropologist, social scientist, economist, physical education professional, journalist, and nutritionist.

The 88 articles were distributed across 54 periodicals, both Brazilian (32) and international (22); 38 were written in Portuguese, 34 in English, and 16 in other languages.

There was a geographic concentration of the regions studied and the origin of the publishing institutions. Of the 88 articles, the region of Brazil most extensively studied was the Southeast (34), followed by the South (17), Northeast (16), and Central (1). Nineteen studies had a nationwide scope, while one focused on the experience in an international study.

Of the 32 Brazilian periodicals, 24 are published by institutions in the Southeast (São Paulo: 14; Rio de Janeiro: 10), the leading region in terms of publications, followed by the Central (Federal District: 3), South (Rio Grande do Sul: 2; Paraná: 1), and Northeast (Ceará: 1; Pernambuco: 1). Of these 32 Brazilian periodicals, 22 are published by universities, mostly in the Southeast (São Paulo: 11 of 14, Rio de Janeiro: 6 of 10), partly in the Central (Federal District: 1 of 3) and Northeast (1 of 2). In the South, academic institutions published all the periodicals (3). The 10 remaining periodicals were published by professional societies, legal entities, other teaching and research institutions, and charitable hospitals. No studies were found on the North of Brazil, nor are any of the periodicals that appeared in the review published in that region.

Twenty of the 22 international periodicals are from the Northern Hemisphere, heavily concentrated in the United States (12) and United Kingdom (4), followed by Portugal, Canada, Switzerland, and Belgium with one article each. Two Latin American countries, Chile and Colombia, each had one article in the sample.

The fields of knowledge that concetrated the largest number of periodicals were Public Health/Collective Health (14), Nursing (9), Psychology (9), and Psychiatry (4). Together, these 36 periodicals published 64 articles, or 73% of the material analyzed. Other areas included Health Anthropology, Health Law, Speech Therapy, Geriatrics and Gerontology, Medicine, Pediatrics, Occupational Therapy, and Global Mental Health.

The journals that contained the largest number of articles were: Cadernos de Saúde Pública and Physis (6 articles each); Revista de Saúde Pública and Ciência & Saúde Coletiva (5); PLoS One (4); and Revista de Pesquisa: Cuidado é Fundamental (3); totaling 29 of the 88 articles.

Types of studies

The quantitative studies (40) (Figure 2) were nearly all observational studies (39), with just one intervention study. The observational studies were mostly cross-sectional (33), with some longitudinal studies (5) and ecological studies (1).

The main objective of cross-sectional observational studies is to characterize the prevalence of health problems and associated factors. Many of these studies aimed to measure the prevalence of mental disorders in different contexts and its relationship to social determinants of health. Among the prevalence studies, four articles integrated the São Paulo Megacity Health Survey, a population-based cross-sectional survey of psychiatric morbidity, assessing a probabilistic sample of household residents in the São Paulo Metropolitan Area, using diagnostic scales and structured psychiatric interviews. The research was part of a set of epidemiological studies with the same methodological approach conducted in 30 different countries, coordinated by the World Health Organization (WHO) in collaboration with Harvard University and the University of Michigan (United States). Besides producing information on the global burden of disease in different cultures, these studies serve as the basis for resource allocation in mental health according to the population’s needs ¹⁹19. Chiavegatto Filho ADP, Wang YP, Campino ACC, Malik AM, Viana MC, Andrade LH. Incremental health expenditure and lost days of normal activity for individuals with mental disorders: results from the São Paulo Megacity Study. BMC Public Health 2015; 15:745.^,2020. Chiavegatto Filho ADP, Wang YP, Malik AM, Takaoka J, Viana MC, Andrade LH. Determinants of the use of health care services: multilevel analysis in the Metropolitan Region of Sao Paulo. Rev Saúde Pública 2015; 49:15.^,2121. Castaldelli-Maia JM, Silveira CM, Siu ER, Wang YP, Milhorança IA, Alexandrino-Silva C, et al. DSM-5 latent classes of alcohol users in a population-based sample: results from the São Paulo Megacity Mental Health Survey, Brazil. Drug Alcohol Depend 2014; 136:92-9.^,2222. Campanha AM, Siu ER, Milhorança IA, Viana MC, Wang YP, Andrade LH. Use of psychotropic medications in São Paulo Metropolitan Area, Brazil: pattern of healthcare provision to general population. Pharmacoepidemiol Drug Saf 2015; 24:1207-14..

Longitudinal observational studies are costlier because they follow a population over time to investigate potential causal relations. In the longitudinal studies identified in this review, the focus varied from the biomedical approach to maternal-child health issues and the assessment of social determinants of health in pediatric populations.

The only ecological study found by the review analyzed variations in social security benefits for mental disorders and the relationship to work.

A single community-based intervention study was identified, The Equilibrium Program, which aims to promote family and social reintegration of vulnerable children and adolescents in the city of São Paulo, victims of trauma and negligence with impacts on their physical and mental health. The program’s interdisciplinary approach includes health services, social services, legal aid, and education. The intervention’s results were described in an article using quantitative and qualitative methods ²³23. Stefanovics EA, Filho MV, Rosenheck RA, Scivoletto S. Functional outcomes of maltreated children and adolescents in a community-based rehabilitation program in Brazil: six-month improvement and baseline predictors. Child Abuse Negl 2014; 38:1231-7., and the setting, proposed innovations, and principal challenges for its implementation were presented in two other descriptive articles using a qualitative approach ²⁴24. Marques AH, Oliveira PA, Scomparini LB, Silva UMR, Silva AC, Doretto V, et al. Community-based global health program for maltreated children and adolescents in Brazil: The Equilibrium Program. Front Psychiatry 2015; 6:1-8.^,2525. Scivoletto S, de Medeiros Filho MV, Stefanovics E, Rosenheck RA. Global mental health reforms: challenges in developing a community-based program for maltreated children and adolescents in Brazil. Psychiatr Serv 2014; 65:138-40..

The qualitative studies identified in the review included 28 case studies, 6 literature reviews, 2 mapping studies, and one ethnographic study (Table 1; Figure 3). In more than half, the data collection relied on interviews, often associated to other techniques, which evinces a variety of methods to gather the empirical material.

The case studies featured themes related to practices and processes in community mental health services and primary care. Some case studies focused on the mental health of specific population groups like homeless people and children and adolescents.

Literature reviews were used in 6 studies with various themes in mental health, such as: research priorities; policy assessment; teaching; organization of the community mental health network; specific population groups; and integration of technologies with primary health care (tele-mental health).

The mapping studies addressed harm reduction, describing challenges for care based on support activities performed by teams at the Community Mental Health Services (CAPS), and evaluative studies on mental health services produced in Brazil from 2004 to 2013.

The only ethnographic study analyzed intersections between health and citizens’ rights in the field of autism, describing controversies between parents’ associations and mental health professionals in the SUS.

Finally, eight studies in essay format mainly addressed advocacy for patients’ rights and implementation of mental health policies, most of which focused on children and adolescents.

Analytical categories

The 88 publications explored a broad range of subjects, such as: prevalence of mental disorders, entry and length of stay in services, development and implementation of policies and strategies to improve community-based mental health care; inter-sector practices and interface with primary health care, focusing especially on inter-consultation; assessment of mental health policies and practices; obstacles to access and quality of care, including questions pertaining to stigma as an index of vulnerability and an aggravating factor for social and health inequalities. The studies also investigated specific population groups, focusing on vulnerable groups with their characteristics and needs. As for the perspective addressed in the studies, many considered the points of view of health services or professionals and, less frequently, of patients or families attending the services.

Of the 88 studies, 54 alluded to the category social determinants of health, 46 mentioned community mental health, 44 approached access, 31 referred to equity, 26 focused on primary care, and 22 were related to human rights (Table 1).

Of the 54 articles corresponding to the category social determinants of health, 35 used quantitative methods, the majority of which were cross-sectional studies, in addition to 16 qualitative studies and 3 essays. The themes and target populations varied widely, with the discussions addressing issues such as income, occupation, gender, age, health conditions, access to health services, education, and justice.

As for the access category, the studies problematized policies that orient the supply of mental health services, the criteria and barriers to entry and length of stay in services, and intervening factors in the availability and quality of care.

As for the category community mental health, the search yielded articles on the specificity of work conducted at CAPS and how some populations relate to such services, highlighting access, as well as interfaces with other programs, reflecting such themes as inter-sector collaboration with a focus on primary care and deinstitutionalization.

In the category primary care, the emphasis was on support through inter-consultation, with some studies focusing on its educational dimension and others on the dimension of care, whether through the Family Health Support Team (NASF) or networking with the CAPS. While the studies highlighted the potential of inter-consultation in mental health and primary care, they also identified important challenges, including: unfair distribution of inter-consultation support between regions of Brazil, precarious work conditions, and difficulties in superseding the traditional mental health model.

Studies that discussed equity in mental health recommended that inequalities should be identified and the necessary adaptations should be made by mental health professionals, services, and administrators whenever planning mental health care in order to deal with such needs as detected. In general, the studies discussed such adaptations, correlating them with the other analytical categories.

On the theme of human rights, stigma emerged as an index of vulnerability and an aggravating factor for social inequalities, access, and inequity, leading to the discussion on advocacy for access and mental health as a human right.

Discussion

Periodicals and regions of Brazil

Brazil’s research production in mental health is addressed mainly to Portuguese-language readers. Some Brazilian authors have endeavored to publish in English in order to reach non-Brazilian readers, although on a smaller scale. The research is also geographically concentrated in the Southeast of Brazil, which reflects and reinforces the country’s regional inequalities ¹⁵15. Delgado PG. Limites para a inovação e pesquisa na reforma psiquiátrica. Physis (Rio J.) 2015; 25:13-8.^,2626. Dantas CR, Oda AMGR. Cartografia das pesquisas avaliativas de serviços de saúde mental no Brasil (2004-2013). Physis (Rio J.) 2014; 24:1127-79..

Although not all the studies showed interaction between academia and mental health services, Brazil’s public universities were clearly participating by producing the knowledge and sharing it through their scientific journals. The universities thus accounted for most of the publications, playing a key role in the development of mental health research.

Study designs and methods

The results suggest a balance in the use of quantitative and qualitative methods in mental health research in Brazil, based on the keywords used in our search. With the exception of the Megacity and Equilibrium Program studies, most of the studies were single initiatives, with little complementariness between studies.

Although cross-sectional quantitative studies formed a large share of this review (except for one of the articles from the Megacity project ²²22. Campanha AM, Siu ER, Milhorança IA, Viana MC, Wang YP, Andrade LH. Use of psychotropic medications in São Paulo Metropolitan Area, Brazil: pattern of healthcare provision to general population. Pharmacoepidemiol Drug Saf 2015; 24:1207-14.), most did not assess the proportion of individuals with mental disorders currently in treatment or other measures of access to care in mental health, thus failing to engage in the debate on mental health gap, a vital issue for Global Mental Health.

Interestingly, only one publication reported on an intervention initiative ²³23. Stefanovics EA, Filho MV, Rosenheck RA, Scivoletto S. Functional outcomes of maltreated children and adolescents in a community-based rehabilitation program in Brazil: six-month improvement and baseline predictors. Child Abuse Negl 2014; 38:1231-7.^,2424. Marques AH, Oliveira PA, Scomparini LB, Silva UMR, Silva AC, Doretto V, et al. Community-based global health program for maltreated children and adolescents in Brazil: The Equilibrium Program. Front Psychiatry 2015; 6:1-8.^,2525. Scivoletto S, de Medeiros Filho MV, Stefanovics E, Rosenheck RA. Global mental health reforms: challenges in developing a community-based program for maltreated children and adolescents in Brazil. Psychiatr Serv 2014; 65:138-40.. However, this study featured an innovative and interdisciplinary approach, including community participation in its planning, consistent with the proposal by Global Mental Health authors to value local community engagement ²⁷27. Campbell C, Burgess R. The role of communities in advancing the goals of the Movement for Global Mental Health. Transcult Psychiatry 2012; 49:379-95..

The predominance of exploratory and descriptive methods and field research as a data source among the qualitative studies contributed to assessing and emphasizing local policies, practices, and work processes, considering both the perspective of health administrators and professionals and patients and their families ²⁸28. Andrade AB, Bosi MLM. Qualidade do cuidado em dois centros de atenção psicossocial sob o olhar de usuários. Saúde Soc 2015; 24:887-900.^,2929. Bleicher T, Freire JC, Sampaio JJC. Avaliação de política em saúde mental sob o viés da alteridade radical. Physis (Rio J.) 2014; 24:527-43.^,3030. Borysow IC, Furtado JP. Acesso, equidade e coesão social: avaliação de estratégias intersetoriais para a população em situação de rua. Rev Esc Enferm USP 2014; 48:1069-76.^,3131. Bosi MLM, Melo AKS, Carvalho LB, Ximenes VM, Godoy MGC. Social determinants for health (mental): evaluating a non-governmental experience from the perspective of actors involved. Rev Bras Epidemiol 2014; 17:126-35.^,3232. Costa NR, Correa SGP, Silva PRF. Considerações sobre a acessibilidade nos Centros de Atenção Psicossocial no Brasil. Ciênc Saúde Coletiva 2015; 20:3139-50.. This mapping furnishes data on the sociocultural reality and the political and organizational impasses in the Brazilian mental health field. Further developments based on these data can orient the development of future academic and scientific studies and culturally sensitive approaches.

The studies in essay format allow investigating the current situation with the implementation of mental health policies and patients’ rights advocacy, consistent with the discussion on human rights emphasized by Global Mental Health.

Analytical categories

Although the article searches with the key words were performed separately, many studies combined more than one category (most with up to three categories). The searches yielded 13 articles with 5 of the 6 categories, 9 articles with 4 categories, 16 articles with 3 categories, 22 with 2, and 28 with only 1 category. This multiplicity and overlapping of categories exemplify the diverse and multifaceted mental health debate in Brazil, signaling the theoretical multidimensionality of practices in this field and the complexity of building knowledge in mental health. However, many articles failed to specify the theoretical definition of the categories addressed by the authors, thus limiting the clarity of the knowledge produced by the studies.

The category access was frequently associated with primary care, community mental health, or both, reflecting the discussion on the use of services and patients’ experiences in securing treatment. The publications showed a clear demand for better access to services and improvement in patient care. As in the field of Global Mental Health, the demand for access to care in mental health appeared as a central theme, although only a few Brazilian publications drew explicitly on the concept of the mental health gap, one of the key concepts in the Global Mental Health literature ²2. Patel V. Global mental health: from science to action. Harv Rev Psychiatry 2012; 20:6-12.^,33. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, et al. No health without mental health. Lancet 2007; 370:859-77.^,44. Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: scarcity, inequity, and inefficiency. Lancet 2007; 370:878-89.^,55. Patel V, Araya R, Chatterjee S, Chisholm D, Cohen A, De Silva M, et al. Treatment and prevention of mental disorders in low-income and middle-income countries. Lancet 2007; 370:991-1005.^,66. Jacob KS, Sharan P, Mirza I, Garrido-Cumbrera M, Seedat S, Mari JJ, et al. Mental health systems in countries: where are we now? Lancet 2007; 370:1061-77.^,77. Saraceno B, van Ommeren M, Batniji R, Cohen A, Gureje O, Mahoney J, et al. Barriers to improvement of mental health services in low-income and middle-income countries. Lancet 2007; 370:1164-74.^,88. Lancet Global Mental Health Group. Scale up services for mental disorders: a call for action. Lancet 2007; 370:1241-52..

The fact that the category social determinants of health was mentioned by more than half of the articles (54 of 88) suggests a keen interest in the discussion of factors related to health status and mental health in Brazil. The social determinants of health category was featured in studies that problematized issues related to stigma, social exclusion, and violence and sought a broader understanding of the health-disease process, identifying a wide range of elements for analyzing health conditions and health care for the Brazilian population. The tendency identified in these articles suggested affinities with the Global Mental Health debate, which recognizes the importance of including social determinants of health in mental health research ¹1. Patel V, Prince M. Global Mental Health: a new global health field comes of age. JAMA 2010; 303:1976-7.^,22. Patel V. Global mental health: from science to action. Harv Rev Psychiatry 2012; 20:6-12.^,1212. Becker AE, Kleinman A. Mental health and the global agenda. N Engl J Med 2013; 369:66-73..

The category primary care appeared in numerous articles, reflecting the growing importance of this level of care for mental health in Brazil. The emphasis on inter-consultation reflects the importance of daily routines in services for the integration of mental health in primary care, similar to the “Collaborative Care” model, one of the principal Global Mental Health strategies for expanding access and improving quality of care ¹²12. Becker AE, Kleinman A. Mental health and the global agenda. N Engl J Med 2013; 369:66-73.. Meanwhile, difficulties reported by Brazilian experiences in developing this model and its effective integration illustrate the barriers to access to adequate mental health care.

The emergence of the category community mental health indicates the relevance of this modality of care in the SUS due to strides in deinstitutionalization ³³33. Fundação Oswaldo Cruz; Fundação Calouste Gulbenkian. Inovações e desafios em desinstitucionalização e atenção comunitária no Brasil: documento técnico final. Rio de Janeiro: Fundação Oswaldo Cruz/Fundação Calouste Gulbenkian/Organização Mundial da Saúde/Ministério da Saúde; 2015., a situation that differs from other LMICs. The articles express both the specificity and the diversity of the Brazilian mental health context. However, although such studies are essential for illustrating the range of mental health practices in Brazil, they are mostly single publications and are limited in their development of health indicators and in the discussion of the system’s successes or shortcomings as whole ¹⁵15. Delgado PG. Limites para a inovação e pesquisa na reforma psiquiátrica. Physis (Rio J.) 2015; 25:13-8.^,2626. Dantas CR, Oda AMGR. Cartografia das pesquisas avaliativas de serviços de saúde mental no Brasil (2004-2013). Physis (Rio J.) 2014; 24:1127-79..

As occurs in the literature on Global Mental Health ³⁴34. Kleinman A. Global Mental Health: a failure of humanity. Lancet 2009; 374:603-4., the issue of stigma was often associated in the Brazilian literature with human rights advocacy for persons with mental disorders. In the current review, stigma was also associated with vulnerability as an aggravating factor for social inequalities and limited access. As for equity, the studies indicated that when inequalities go undetected, they lead to imbalances in access to health, limiting the use of services by the population. This same logic appeared in the studies dealing with the categories of social determinants of health and human rights, indicating that more stigmatized or vulnerable populations (whose social disadvantage is maintained by the cycle of marginalization and mental illness) lack access to resources to meet their specific needs. According to Global Mental Health ²2. Patel V. Global mental health: from science to action. Harv Rev Psychiatry 2012; 20:6-12.^,44. Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: scarcity, inequity, and inefficiency. Lancet 2007; 370:878-89.^,99. Collins PY, Patel V, Joestl SS, March D, Insel TR, Daar AS. Grand challenges in global mental health: a consortium of researchers, advocates and clinicians announces here research priorities for improving the lives of people with mental illness around the world, and calls for urgent action and investment. Nature 2011; 475:27-30., planning interventions that address the specific needs of vulnerable groups to minimize the disparities and promote equity is a key priority when addressing the main challenges in mental health.

The review thus identified a parallel between the topics emerging from the categories in the studies analyzed in the Brazilian context and those approached in Global Mental Health. Despite this parallel, the review revealed some differences between Brazil’s mental health research and global mental health. The main difference was the importance of the category community mental health (atenção psicossocial) in the Brazilian literature. Other differences related to the way the arguments were conducted in the studies, which can be attributed to the outcomes of Brazilian Health and Psychiatric Reform movements, the geographic concentration of studies (which both reproduces and perpetuates the inequalities), and limitations in the principal methods used in mental health research in the country.

Implications of the results for mental health research and practice

Brazilian research in mental health, based on the descriptors and the target period, showed a rich body of studies that was diversified and balanced in its use of quantitative and qualitative approaches. While the majority of the quantitative studies focused on the prevalence of mental illness, considering the social determinants of health, the qualitative studies concentrated on describing specificities in the local experiences. These findings suggest a strong commitment to understanding the local context, unlike Global Mental Health studies that focus less attention on social conditions ¹⁰10. Jain S, Orr DM. Ethnographic perspectives on global mental health. Transcult Psychiatry 2016; 53:685-95.^,1111. Cooper S. Global mental health and its critics: moving beyond the impasse. Crit Public Health 2016; 26:355-8.^,1313. Beran D, Byass P, Gbakima A, Kahn K, Sankoh O, Tollman S, et al. Research capacity building - obligations for global health partners. Lancet Glob Health 2017; 5:e567-8..

While the contextual scenario attracted studies with various methodologies, the shortage of more comprehensive epidemiological studies limits the ability to develop indicators that could be combined with other evidence from the existing qualitative studies in Brazil in order to support better planning of mental health initiative within primary care and community mental health ¹⁶16. Gregório G, Tomlinson M, Gerolin J, Kieling C, Moreira HC, Razzouk D, et al. Setting priorities for mental health research in Brazil. Rev Bras Psiquatr 2012; 34:434-9.^,3535. Mari JJ. Um balanço da reforma psiquiátrica brasileira. Ciênc Saúde Coletiva 2011; 16:4593-6. and the respective resource allocations.

The Equilibrium Program was an example of the wealth of complementary and mixed methods and the feasibility of incorporating community participation in the planning, a methodology that has been increasingly recommended ¹⁶16. Gregório G, Tomlinson M, Gerolin J, Kieling C, Moreira HC, Razzouk D, et al. Setting priorities for mental health research in Brazil. Rev Bras Psiquatr 2012; 34:434-9. as well for the participatory elaboration of assessment indicators in mental health services, reinforcing the role of other stakeholders such as patients and health care professionals in this process ¹⁷17. Furtado JP, Onocko-Campos RT, Moreira MIB, Trapé TL. A elaboração participativa de indicadores para a avaliação em saúde mental. Cad Saúde Pública 2013; 29:102-10.^,2626. Dantas CR, Oda AMGR. Cartografia das pesquisas avaliativas de serviços de saúde mental no Brasil (2004-2013). Physis (Rio J.) 2014; 24:1127-79.. Such an approach is consistent with the vision of Global Mental Health authors ¹¹11. Cooper S. Global mental health and its critics: moving beyond the impasse. Crit Public Health 2016; 26:355-8.^,2727. Campbell C, Burgess R. The role of communities in advancing the goals of the Movement for Global Mental Health. Transcult Psychiatry 2012; 49:379-95.^,3434. Kleinman A. Global Mental Health: a failure of humanity. Lancet 2009; 374:603-4. when they recommend the development of interventions that prioritize actual contextual experiences as opposed to those transposed from other realities.

Despite the wealth of studies and the balance between qualitative and quantitative methods, the review showed a low level of systematization in the studies, characterized by the description of multiple local realities with little dialogue between the studies, geographic concentration, little linkage, integration, and/or continuity between studies developed in Brazil’s various regions, and finally, short study timeframes.

The dearth of policies to induce large-scale and long-term studies, combined with the lack of guidelines, which could otherwise support mental health research collaboration and priorities with the necessary methodological plurality ³3. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, et al. No health without mental health. Lancet 2007; 370:859-77.^,1515. Delgado PG. Limites para a inovação e pesquisa na reforma psiquiátrica. Physis (Rio J.) 2015; 25:13-8.^,2626. Dantas CR, Oda AMGR. Cartografia das pesquisas avaliativas de serviços de saúde mental no Brasil (2004-2013). Physis (Rio J.) 2014; 24:1127-79., apparently explains the studies’ low systematization. Although Brazil has a universal health system with a solid history in mental health care ¹⁴14. Ortega F, Wenceslau LD. Dilemas e desafios para a implementação de políticas de saúde mental global no Brasil. Cad Saúde Pública 2015; 31:2255-7.^,1515. Delgado PG. Limites para a inovação e pesquisa na reforma psiquiátrica. Physis (Rio J.) 2015; 25:13-8. (distinguishing it from many other LMICs), obstacles within the SUS itself hinder collaboration between studies and the flow and integration of information between health services, administrators, professionals, and researchers. The reasons for these obstacles include the limited ability of the SUS to foment research ¹⁵15. Delgado PG. Limites para a inovação e pesquisa na reforma psiquiátrica. Physis (Rio J.) 2015; 25:13-8., plus the decentralization and municipalization of services ³⁶36. Ribeiro JM, Inglez-Dias A. Políticas e inovação em atenção à saúde mental: limites ao descolamento do desempenho do SUS. Ciênc Saúde Coletiva 2011; 16:4623-34. and the limited interaction between services and academia.

In order to overcome such obstacles and improve the development and systematization of mental health research in Brazil and guarantee consistent growth in the field’s expertise, a number of initiatives are needed, negotiated in public forums with representatives from multiple associations and institutions from the mental health field ¹⁶16. Gregório G, Tomlinson M, Gerolin J, Kieling C, Moreira HC, Razzouk D, et al. Setting priorities for mental health research in Brazil. Rev Bras Psiquatr 2012; 34:434-9.. Brazilian researchers also need to respond to the challenges ¹⁵15. Delgado PG. Limites para a inovação e pesquisa na reforma psiquiátrica. Physis (Rio J.) 2015; 25:13-8.^,2929. Bleicher T, Freire JC, Sampaio JJC. Avaliação de política em saúde mental sob o viés da alteridade radical. Physis (Rio J.) 2014; 24:527-43. with greater methodological diversity, including approaches that allow assessing interventions and their impacts on the availability and quality of care ¹⁵15. Delgado PG. Limites para a inovação e pesquisa na reforma psiquiátrica. Physis (Rio J.) 2015; 25:13-8.^,1616. Gregório G, Tomlinson M, Gerolin J, Kieling C, Moreira HC, Razzouk D, et al. Setting priorities for mental health research in Brazil. Rev Bras Psiquatr 2012; 34:434-9.^,1717. Furtado JP, Onocko-Campos RT, Moreira MIB, Trapé TL. A elaboração participativa de indicadores para a avaliação em saúde mental. Cad Saúde Pública 2013; 29:102-10.^,2626. Dantas CR, Oda AMGR. Cartografia das pesquisas avaliativas de serviços de saúde mental no Brasil (2004-2013). Physis (Rio J.) 2014; 24:1127-79.. A pluralistic body of evidence would certainly enrich mental health care in Brazil, contributing in turn to the debate in Global Mental Health.

Strengths and weaknesses

One of the review’s limitations was the short timeframe. Settling the differences of opinion between the authors increased the time spent in the analytical stage. The use of the same literature search strategy in different languages may have introduced a selection bias. In order to ensure that the studies actually referred to the Brazilian reality, the term “Brazil” was added to all the searches, including those in Portuguese, and it is possible that a few Brazilian studies that did not explicitly refer to “Brazil” (in the title, abstract, or keywords) were not located. The overlapping of analytical categories meant a loss of clarity in the data analysis, although it reflected the field’s epistemic and methodological complexity. Despite these limitations, the review highlighted the amount and variety of articles and the diversity of methods. The analysis of articles in both Portuguese and English is another merit of this review. Another strength was the unprecedented comparison of Brazilian research production with research in global mental health, a discipline that has still received relatively little attention in Brazil.

Final remarks

Based on the key categories emphasized in Global Mental Health, this review examined how these categories appear in recent mental health research in Brazil and identified parallels between the Brazilian research production and that of Global Mental Health.

According to the review’s results, in order for LMICs like Brazil to participate actively in the field of Global Mental Health, they must be capable of setting their own research agendas and mental health practices, in keeping with the population’s needs and the local context, alongside the establishment of partnerships with international groups and organizations.

Despite efforts to generate knowledge, the barriers to the expansion and deepening of methodological approaches may be limiting Brazil’s participation in the international debate on Global Mental Health.

Acknowledgments

The authors wish to acknowledge the Brazilian National Research Council - CNPq (Call for Projects n. 443137/2), the Brazilian Graduate Studies Coordinating Board - Capes (Master’s grant), CNPq and the Rio de Janeiro State Research Foundation - FAPERJ (PhD grants), and the Institutional Scholarship Program of Scientifc Research - PIBIC/CNPq (introductory scientific research grant).

References

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