Introduction

Thanks to the mental health policy launched in the 1980s, Brazil gained a unique place in the global mental health field. This outstanding position, widely acknowledged at the international level, results from the fact that Brazil was one of the first countries outside the group of wealthier nations to establish a national mental health policy and to have implemented that policy with considerable success for more than 30 years ¹1. Caldas de Almeida JM, Horvitz-Lennon M. Mental health care reforms in Latin America: an overview of mental health care reforms in Latin America and the Caribbean. Psychiatr Serv 2010; 61:218-21.. Thus, not surprisingly, Brazil’s case has sparked major interest worldwide and has been one of most widely studied and discussed experiences in the mental health field.

A systematic literature review within the scope of an assessment of Brazil’s psychiatric reform, conducted in 2015 by the Oswaldo Cruz Foundation (Fiocruz), the Gulbenkian Foundation, and the World Health Organization (WHO) ²2. Fundação Oswaldo Cruz; Fundação Calouste Gulbenkian. Inovações e desafios em desinstitucionalização e atenção comunitária no Brasil. Seminário Internacional de Saúde Mental: documento técnico final. Rio de Janeiro: Fundação Oswaldo Cruz/Fundação Calouste Gulbenkian; 2015., shows that this process was not without difficulties. From the beginning, the reform faced numerous forms of resistance: for example, the Mental Health Law was first proposed in 1989 but was not passed until 2001. Even so, over the course of more than 30 years, it was always possible to build the necessary political consensus to ensure the initial policy’s continuity and even to diversify its objectives. While the policy was first centered on replacing the psychiatric hospital-based model with a new system of community-based services and protecting the human rights of persons with mental disorders, as it gained momentum, the process was extended to other objectives such as the prevention of mental disorders, mental healthcare for children and adolescents, and strategies to deal with alcohol abuse and other forms of drug addiction.

The assessment of the reform in 2015 revealed that Brazil now has an important critical mass in the mental health field that involves representatives from all the sectors and is strengthened by a significant number of high-level research groups with excellent scientific research output.

Various publications identified in the review point to gaps in the new mental health system’s implementation, underlining the need to rethink some of its strategies. However, there is an extremely broad consensus as to the fundamentals, the main objectives, and the results of the mental health policy developed until 2016 ²2. Fundação Oswaldo Cruz; Fundação Calouste Gulbenkian. Inovações e desafios em desinstitucionalização e atenção comunitária no Brasil. Seminário Internacional de Saúde Mental: documento técnico final. Rio de Janeiro: Fundação Oswaldo Cruz/Fundação Calouste Gulbenkian; 2015..

The positions taken by the Brazilian government since 2016 represent a break with this perspective. Although the official documents on the current government’s strategy are scarce and largely self-contradictory, by all indications the strategy that the government intends to implement has many objectives that run counter to the previous policy ³3. Ministério da Saúde. Nota Técnica nº 11/2019-CGMAD/DAPES/SAS/MS. http://pbpd.org.br/wp-content/uploads/2019/02/0656ad6e.pdf (acessado em 08/Jun/2019).
http://pbpd.org.br/wp-content/uploads/20... .

In this context, any discussion that helps us understand what is truly at stake (in conceptual and scientific terms, in terms of values, principles, and results for the mental health of populations), in the current confrontation in the field of Brazil’s national mental health policy is of particular importance not only for Brazil, but also for global mental health.

The Brazilian mental health policy launched in the 1980s

Origins and evolution

In the late 1970s, Brazil urgently needed to develop a national mental health policy. The country’s scandalously archaic psychiatric system was based mainly on a large number of psychiatric hospitals with typically low quality of care and frequent human rights violations. A reform in the country’s mental health services was absolutely indispensable.

The first reforms were implemented in some cities (Santos, São Paulo State, for example) and played a decisive role in the development of a model adapted to the specificities of the Brazilian context, with valuable contributions to the first steps in building a national mental health policy. The national policy came about in the 1980s, part of the re-democratization process started in that decade and steadily strengthened at the legislative, administrative, and financial levels.

To respond to the human rights violations in the psychiatric hospitals at the time, the reforms initially focused on improving the living conditions in these institutions and on promoting deinstitutionalization. The main objectives were thus to progressively replace the psychiatric hospitals with a network of community-based services, focused on the Centers for Psychosocial Care (CAPS in Portuguese), taking inspiration from mental health centers developed in Italy and other European countries.

The development of Brazil’s mental health policy was closely related to the creation of the Unified National Health System (SUS), decentralization of healthcare administration in the country, mobilization of health professionals, and social and cultural changes in Brazilian society as a whole.

Participation by all sectors of society was another important characteristic of Brazil’s reform. National mental health conferences with thousands of participants, including health professionals, patients, and families, played a crucial role in the development of the mental health policy. Social and cultural activists were often decisive allies, and patients were encouraged to participate.

The link to innovative mental health movements at the global level was another constant in Brazil’s reform. Initially influenced by the psychiatric reforms in Europe (particularly Italy), the Brazilian experience was later enriched by developments in the integration of mental health with primary care after Alma-Ata and played an important role in the Initiative for Restructuring Psychiatric Services in Latin America, following the Caracas Declaration¹1. Caldas de Almeida JM, Horvitz-Lennon M. Mental health care reforms in Latin America: an overview of mental health care reforms in Latin America and the Caribbean. Psychiatr Serv 2010; 61:218-21..

As with all innovative processes, Brazil’s mental health policy met with significant resistance from more conservative sectors. However, the developments seen later in the human rights field, particularly the consensus created with the principles of the Convention on the Rights of Persons with Disabilities and the widespread adoption of the principles of Recovery, showed that the Brazilian policy was not only correct in this field, but that it anticipated many of the principles that came to be acknowledged worldwide in the human rights of persons with mental disorders.

The priority focus on community care was also entirely validated by scientific research in recent decades, and there is now a broad consensus concerning the need for a transition from the psychiatric hospital-centered model to an integrated network based on community mental health teams and admission of acute cases to general hospitals, properly linked with primary care and psychosocial rehabilitation services ⁴4. Caldas de Almeida JM. Mental health services and public mental health: challenges and opportunities. World Psychiatry 2015; 14:51-3.^,55. Killaspy H, McPherson P, Samele C, Keet R, Caldas de Almeida JM. Providing community-based mental health services. https://www.lisboninstitutegmh.org/assets/files/EUCompass-Community%20Care%20Scientific%20Paper%20.pdf (acessado em 08/Jun/2019).
https://www.lisboninstitutegmh.org/asset... ^,66. Patel V, Saxena S, Lund C, Thornicroft G, Baingana F, Bolton P, et al. The Lancet Commission on global mental health and sustainable development. Lancet 2018; 392:1553-98.^,77. Delgado P. Reforma psiquiátrica: estratégias para resistir ao desmonte. Trab Educ Saúde 2019; 17:e0021241.^,88. Guljor AP, Vasconcelos E, Couto MC, Silva M, Delgado PG, Cavalcante R, et al. Nota de Avaliação Crítica da Nota Técnica 11/2019 - Esclarecimentos sobre as mudanças na Política Nacional de Saúde Mental e nas Diretrizes na Política Nacional sobre Drogas. http://site.ims.uerj.br/wp-content/uploads/2019/02/Resposta-%C3%A0-Nota-T%C3%A9cnica-Quirino.-Vers%C3%A3o-3.-18.02.19..pdf (acessado em 08/Jun/2019).
http://site.ims.uerj.br/wp-content/uploa... .

Progress, weaknesses, and challenges

Highly significant strides were achieved in the deinstitutionalization process. From 2001 to 2014, there was a drastic reduction in the number of psychiatric hospital beds, from 53,962 in 2001 to 25,988 in 2014 ²2. Fundação Oswaldo Cruz; Fundação Calouste Gulbenkian. Inovações e desafios em desinstitucionalização e atenção comunitária no Brasil. Seminário Internacional de Saúde Mental: documento técnico final. Rio de Janeiro: Fundação Oswaldo Cruz/Fundação Calouste Gulbenkian; 2015.. These changes had actually begun in the previous decade, when audits by authorities led to the closing of numerous psychiatric hospitals that failed to meet the minimum requirements or that had been the object of reports of human rights violations. The movement that developed in the 1980s and 1990s enabled the passage of the psychiatric reform law in 2001; the latter, in turn, together with the political support obtained at the 3rd National Mental Health Conference that same year, allowed the reduction of psychiatric beds, as well as numerous other measures to improve care for chronically institutionalized patients, for example in the development of residential services.

Importantly, deinstitutionalization was a planned and progressive process. For example, from 2002 to 2011, psychiatric hospitals with more than 400 beds (which had more than 30% of all the beds), experienced a gradual reduction to 10.5% of the total, while smaller hospitals, with fewer than 160 beds (with only 22% of the total in 2002) gradually increased their share, reaching 52% of all psychiatric beds by 2011 ²2. Fundação Oswaldo Cruz; Fundação Calouste Gulbenkian. Inovações e desafios em desinstitucionalização e atenção comunitária no Brasil. Seminário Internacional de Saúde Mental: documento técnico final. Rio de Janeiro: Fundação Oswaldo Cruz/Fundação Calouste Gulbenkian; 2015..

Meanwhile, community-based services were created to replace the hospital-based services. The CAPS constituted the central focus of these services, having been designed to meet the main needs for care of patients with severe and persistent mental disorders. Starting in 2002, new types of CAPS were created to serve populations with specific needs. The healthcare network in the SUS thus incorporated the “CAPS-I” for children and adolescents and “CAPS-AD” for patients with problems related to alcohol and other forms of substance abuse. As of 2006, there were 673 CAPS for adults and 66 special CAPS for children and adolescents. By 2014 there were 2,209 CAPS in all (2), and by 2017 the total had increased to 2,462 ⁹9. Coordenação Geral de Saúde Mental, Álcool e Outras Drogas, Departamento de Ações Programáticas e Estratégicas, Secretaria de Atenção à Saúde, Ministério da Saúde. Panorama e diagnóstico da Política Nacional de Saúde Mental. Brasília: Ministério da Saúde; 2017..

Residential treatment services housing up to eight patients also became an important resource for deinstitutionalization of chronically hospitalized patients. In 2004 there were 265 residential services with 1,363 residents ²2. Fundação Oswaldo Cruz; Fundação Calouste Gulbenkian. Inovações e desafios em desinstitucionalização e atenção comunitária no Brasil. Seminário Internacional de Saúde Mental: documento técnico final. Rio de Janeiro: Fundação Oswaldo Cruz/Fundação Calouste Gulbenkian; 2015.. By 2017 the total number of residential services had increased to 489 ⁹9. Coordenação Geral de Saúde Mental, Álcool e Outras Drogas, Departamento de Ações Programáticas e Estratégicas, Secretaria de Atenção à Saúde, Ministério da Saúde. Panorama e diagnóstico da Política Nacional de Saúde Mental. Brasília: Ministério da Saúde; 2017..

An especially innovative deinstitutionalization strategy was the program “Volta para Casa” (Going Home), created through a national law passed by the Brazilian Congress in 2003. This program established a financial allowance for deinstitutionalized patients who had previously been hospitalized uninterruptedly for at least a year. These patients also had access to a case management program provided by the CAPS clinics in their area of residence, including care and support to solve problems with their identification papers. In 2003, 206 patients had been enrolled in the program, and by 2014 the number had increased to 4,349 patients ²2. Fundação Oswaldo Cruz; Fundação Calouste Gulbenkian. Inovações e desafios em desinstitucionalização e atenção comunitária no Brasil. Seminário Internacional de Saúde Mental: documento técnico final. Rio de Janeiro: Fundação Oswaldo Cruz/Fundação Calouste Gulbenkian; 2015..

Throughout this process, significant budget resources from the hospital network were reallocated to community services. During the period, the budget for psychiatric hospital care was reduced from 95% of the total to less than 30%, allowing to fund the community services, which increased by 15 times over the previous period. Substantial strides were also made in care for children and adolescents, care for individuals with alcohol and other substance abuse problems, and the approval of a human rights agenda for persons with mental disorders.

The progress achieved by the policy is undeniable. However, as concluded by the assessment performed in 2015, “the Brazilian reform process points to significant strides, but it is far from being considered fully successful” ²2. Fundação Oswaldo Cruz; Fundação Calouste Gulbenkian. Inovações e desafios em desinstitucionalização e atenção comunitária no Brasil. Seminário Internacional de Saúde Mental: documento técnico final. Rio de Janeiro: Fundação Oswaldo Cruz/Fundação Calouste Gulbenkian; 2015. (p. 7). Meanwhile, the available data show that despite these strides, there were various weaknesses in the policy’s implementation, and in 2015 there were still various basic challenges.

Relevant weaknesses were seen in financing. Although the funds were correctly allocated to the community services, many experts considered the funds insufficient to fully implement the reform’s various components. Human resources development was also found to be an important problem. Weaknesses were also identified in the quality of information produced by services, the integration of mental health with primary care, and the sustainability of patients’ associations ²2. Fundação Oswaldo Cruz; Fundação Calouste Gulbenkian. Inovações e desafios em desinstitucionalização e atenção comunitária no Brasil. Seminário Internacional de Saúde Mental: documento técnico final. Rio de Janeiro: Fundação Oswaldo Cruz/Fundação Calouste Gulbenkian; 2015..

The main challenges feature expansion of access and integration of mental health with primary care, the development of solutions for hospitalization of acute cases in general hospitals, and linkage between the system’s various components.

Changes since 2016

The available data on Brazil’s current mental health policy are limited and in some cases are difficult for outside observers to interpret. The only official description of the changes that the current government intends to introduce in the mental health policy and that we were able to access is a “Technical Memorandum” published in February 2019 ³3. Ministério da Saúde. Nota Técnica nº 11/2019-CGMAD/DAPES/SAS/MS. http://pbpd.org.br/wp-content/uploads/2019/02/0656ad6e.pdf (acessado em 08/Jun/2019).
http://pbpd.org.br/wp-content/uploads/20... , announcing the proposed changes with the objective of “making the healthcare network more accessible, efficacious, with greater case-resolution capacity, and more humanistic”, through a reform in the “model of mental health care, which required improvements, without losing the essence of Law 10.216/01”.

Given the Technical Memorandum’s subsequent suspension and the Minister of Health’s publicly expressed doubts on some of its points, it is not clear to what extent the proposed changes will reflect the government’s true position.

However, the mere publication of this document and the measures already taken to support psychiatric hospitals appear to justify the concerns manifested by various sectors of Brazil’s mental health community ⁷7. Delgado P. Reforma psiquiátrica: estratégias para resistir ao desmonte. Trab Educ Saúde 2019; 17:e0021241.^,88. Guljor AP, Vasconcelos E, Couto MC, Silva M, Delgado PG, Cavalcante R, et al. Nota de Avaliação Crítica da Nota Técnica 11/2019 - Esclarecimentos sobre as mudanças na Política Nacional de Saúde Mental e nas Diretrizes na Política Nacional sobre Drogas. http://site.ims.uerj.br/wp-content/uploads/2019/02/Resposta-%C3%A0-Nota-T%C3%A9cnica-Quirino.-Vers%C3%A3o-3.-18.02.19..pdf (acessado em 08/Jun/2019).
http://site.ims.uerj.br/wp-content/uploa... .

Despite the declarations concerning the Mental Health Law, the proposed changes “actually represent the abandonment of the legal and healthcare principles and the strategies for psychosocial care consolidated by Brazil’s Psychiatric Reform, with a real risk of setbacks to the country’s mental health policies” ⁸8. Guljor AP, Vasconcelos E, Couto MC, Silva M, Delgado PG, Cavalcante R, et al. Nota de Avaliação Crítica da Nota Técnica 11/2019 - Esclarecimentos sobre as mudanças na Política Nacional de Saúde Mental e nas Diretrizes na Política Nacional sobre Drogas. http://site.ims.uerj.br/wp-content/uploads/2019/02/Resposta-%C3%A0-Nota-T%C3%A9cnica-Quirino.-Vers%C3%A3o-3.-18.02.19..pdf (acessado em 08/Jun/2019).
http://site.ims.uerj.br/wp-content/uploa... .

There is a broad international consensus today on the vital importance of replacing psychiatric hospitals with an integrated and territorially based network of community-based services. This is one of the four pillars of the Global Mental Health Action Plan of the World Health Organization ¹⁰10. World Health Organization. Mental health action plan 2013-2020. Geneva: World Health Organization; 2013., and the Lancet Commission Report ⁶6. Patel V, Saxena S, Lund C, Thornicroft G, Baingana F, Bolton P, et al. The Lancet Commission on global mental health and sustainable development. Lancet 2018; 392:1553-98. explicitly recommends that closing of psychiatric hospitals should be started in low-income countries, consolidated in middle-income countries, and completed in high-income countries. Interrupting this transition and backstepping to the psychiatric hospital-centered mental health model, as determined by the above-mentioned Technical Memorandum, will inevitably result in decreased access to decent quality care, increased human rights violations, and increased social exclusion of persons with mental disorders. All previous efforts at redistributing the budget funds will be annihilated, and the available funds for community-based services will inevitably become scarcer.

For reasons of a different order, the proposal to create “Specialized Psychiatric Units” in general hospitals and “Specialized Outpatient Units”, as announced in the memorandum, also raises serious concerns. Although both types of services can play an important role in a mental health system, their creation disconnected from a specific territory and without adequate integration with CAPS and other community-based services will inevitably lead to the system’s fragmentation and discontinuity of care. Meanwhile, the possibility of establishing specialized outpatient units targeted to treating “persons with the most common and prevalent mental disorders” in hospitals does not appear to make much sense. Such units should be geographically close to the people and to the primary care services with which they would hopefully collaborate.

These and other proposed changes, such as those citing the creation of inpatient services for children and adolescents and strategies in the area of alcohol and other drugs, ultimately reveal an emphasis on institutional approaches and systematic relegation of integrated community-based approaches, which are totally discordant with the purpose repeatedly expressed in the Technical Memorandum of basing all the activities related to prevention, health promotion, and treatment on scientific evidence.

This contradiction is one of the more glaring aspects in the Technical Memorandum. Although constantly proclaiming respect for scientific evidence, the text that purports to present a new mental health policy does not include a single reference to the numerous contributions in recent years from psychiatric epidemiology, research on mental health policy and services, and implementation science, which are now the conceptual and scientific basis for mental health policies. The proposed changes completely ignore the evidence on the need to base mental health promotion and prevention and treatment of mental disorders on a public, systemic, and inter-sector health approach ⁶6. Patel V, Saxena S, Lund C, Thornicroft G, Baingana F, Bolton P, et al. The Lancet Commission on global mental health and sustainable development. Lancet 2018; 392:1553-98.^,99. Coordenação Geral de Saúde Mental, Álcool e Outras Drogas, Departamento de Ações Programáticas e Estratégicas, Secretaria de Atenção à Saúde, Ministério da Saúde. Panorama e diagnóstico da Política Nacional de Saúde Mental. Brasília: Ministério da Saúde; 2017.^,1111. World Health Organization; Calouste Gulbenkian Foundation. Policy options on mental health: a WHO-Gulbenkian Mental Health Platform collaboration. Geneva: World Health Organization; 2017.. Rather, their central tenet, now totally outdated, is that a mental health policy can be built on a strictly clinical perspective, ignoring all the current debate on the mental health of the future.

Conclusions

Brazil’s experience with the implementation of a mental health policy led to a profound transformation in the national mental health system and significant improvements in access and quality of mental health care.

Despite all the progress achieved, important challenges still exist. These can only be confronted with a policy centered on the population’s priority needs, based on the most current scientific knowledge and aligned with international human rights instruments, and at the same time if it is possible to engage all the relevant actors in the field of mental health in the policy’s implementation. In this context, all efforts should be made to build a broad consensus that allows continuity in the progress already achieved on the basis of the country’s mental health law and the technical and scientific recommendations by the relevant international organizations in this field.

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History