Abstract

Introduction

Emotional distress (ED)¹1. Fortes S, Villano LAB, Lopes CS. Perfil nosológico e prevalência de transtornos mentais comuns em pacientes atendidos em unidades do Programa de Saúde da Família em Petrópolis, Rio de Janeiro. Rev Bras Psiquiatr. 2008; 30(1):32-7.^,22. Gonçalves DA, Mari JJ, Bower P, Gask L, Dorwick C, Tófoli LF, et al. Brazilian multicentre study of common mental disorders in primary care: rates and related social and demographic factors. Cad Saude Publica. 2014; 30(3):623-32. is a prevalent demand in primary care (PC). In their narratives, individuals often claim they “suffer from nerves” and present diffuse, non-specific somatic complaints with no medicalexplanation, such as: fatigue, chest pressure, palpitations, multiple, incessant pains, shortness of breath, trembling, insomnia, agitations and other symptoms of anxiety and depression¹1. Fortes S, Villano LAB, Lopes CS. Perfil nosológico e prevalência de transtornos mentais comuns em pacientes atendidos em unidades do Programa de Saúde da Família em Petrópolis, Rio de Janeiro. Rev Bras Psiquiatr. 2008; 30(1):32-7..

Epidemiological studies use the nomenclature Common Mental Disorder (CMD)²2. Gonçalves DA, Mari JJ, Bower P, Gask L, Dorwick C, Tófoli LF, et al. Brazilian multicentre study of common mental disorders in primary care: rates and related social and demographic factors. Cad Saude Publica. 2014; 30(3):623-32.^,33. Goldberg D, Huxley P. Common mental disorders: a bio-social model. Londres: Routledge; 1992. to designate these manifestations that encompass issues from ED (which does not fulfill criteria for mental disorder) to cases of depression and anxiety and somatizations, which, though they may spontaneously remit, still require care. In the care process, the complexity of the somatological presentation appears as an important component of ED⁴4. Fonseca MLG, Guimarães MBL, Vasconcelos EM. Sofrimento difuso e transtornos mentais comuns: uma revisão bibliográfica. Rev APS. 2008; 11(3):285-94., and its ambiguity challenges biomedical rationality, requiring broadened approaches that take patients’ experiences into account⁵5. Guedes C, Nogueira M, Camargo KR Jr. A subjetividade como anomalia: contribuições epistemológicas para a crítica do modelo biomédico. Cienc Saude Colet. 2006; 11(4):1093-103..

Both globally and nationally, the frequency of CMD in PC is high and, if not cared for, they may compromise individuals’ lives⁶6. World Health Organization. World Organization of Family Doctors. Integrating mental health into primary care: a global perspective. Geneva: WHO, WONCA; 2008.. In the 1990s, a World Health Organization (WHO) study on general health units⁷7. Üstun TB, Sartorius N. Mental illness in general health care: an international study. Chichester, England: John Wiley & Sons; 1995. in several countries found CMD prevalences between 12.25% and 51%. In Brazil, studies have found prevalences ranging from 52% to 64% ¹1. Fortes S, Villano LAB, Lopes CS. Perfil nosológico e prevalência de transtornos mentais comuns em pacientes atendidos em unidades do Programa de Saúde da Família em Petrópolis, Rio de Janeiro. Rev Bras Psiquiatr. 2008; 30(1):32-7.^,22. Gonçalves DA, Mari JJ, Bower P, Gask L, Dorwick C, Tófoli LF, et al. Brazilian multicentre study of common mental disorders in primary care: rates and related social and demographic factors. Cad Saude Publica. 2014; 30(3):623-32.^,77. Üstun TB, Sartorius N. Mental illness in general health care: an international study. Chichester, England: John Wiley & Sons; 1995.. Although international studies have highlighted the importance of the PC physician in diagnosing, treating and handling patients⁷7. Üstun TB, Sartorius N. Mental illness in general health care: an international study. Chichester, England: John Wiley & Sons; 1995.

8. Valentini W, Levavb I, Kohnc R, Mirandad CT, Mello AAF, Mello MF, et al. Treinamento de clínicos para o diagnóstico e tratamento da depressão. Rev Saude Publica. 2004; 38(4):522-8.^-99. Goldberg D. Reasons for misdiagnosis. In: Sartorious N, organizador. Psychological disorders in general medical settings. New York: Hogrefe & Huber, WHO; 1990. p. 139-45., 30% to 60% of psychiatric morbidities are not recognized¹⁰10. Coyne JC, Schwenk L, Fechner-Bates S. Nondetection of depression by primary care physicians reconsidered. Gen Hosp Psychiatr. 1995; 17(1):3-12.. In Brazil, rates of detection by general practitioners in PC units vary between 21% and 78%¹¹11. Mari JJ, Iacoponi E, Williams P, Oziris S, Silva JBT. Detection of psychiatric morbidity in the primary medical care setting in Brazil. Rev Saude Publica. 1987; 21(6):501-7. and they have difficulty in handling emotional problems, psychosocial issues and mental disorders¹²12. Lyra M. Desafios da saúde mental na atenção básica. Cad IPUB. 2007; 8(24):57-66..

Considering the burden of mental disorders for society, the WHO and authors linked to the Global Mental Health¹³13. Patel V, Prince M. Global mental health: a new global health field comes of age. JAMA. 2010; 303(19):1976-7. field state that “There is no health without mental health” and advocate for an increased access to mental health care services and a reduction in treatment gaps¹⁴14. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR. No health without mental health. Lancet. 2007; 370(9590):859-77.. They thus suggest the integration of mental health into PC⁶6. World Health Organization. World Organization of Family Doctors. Integrating mental health into primary care: a global perspective. Geneva: WHO, WONCA; 2008.^,1515. Wenceslau LD, Ortega F. Saúde mental na atenção primária e saúde mental global: perspectivas internacionais e cenário brasileiro. Interface (Botucatu). 2015; 19(55):1121-32., as well as the dissemination of care packages, especially in low- and middle-income countries (LMIC^(f(f)In the Portuguese version we used the English acronym LMIC, commonly employed in the literature.⁾)¹⁶16. Patel V, Simon G, Chowdhary N, Kaaya S, Araya R. Packages of care for depression in low- and middle-income countries. PLoS Med. 2009; 6(10):e1000159.^,1717. Eaton J, McCay L, Semrau M, Chatterjee S, Baingana F, Araya R, et al. Scale up of services for mental health in low-income and middle-income countries. Lancet. 2011; 378(9802):1592-603.. However, one of the challenges faced in this process is how to avoid the indiscriminate expansion of standardized, decontextualized biomedical interventions. In order to do so, health care must be culturally sensitive and socially relevant and, therefore, it becomes indispensable to consider the patient’s psychosocial dimension¹⁸18. Kirmayer LJ. Rethinking cultural competence. Transcult Psychiatry. 2012; 49(2):149-64.

19. Kirmayer LJ, Pedersen D. Toward a new architecture for global mental health. Transcult Psychiatry. 2014; 51(6):759-76.^-2020. Ortega F, Wesceslau L. Dilemas e desafios para a implementação de políticas de saúde mental global no Brasil. Cad Saude Publica. 2015; 31(11):2255-7..

The difference between physicians’ and patients’ understanding of the health-disease process, summarized in the notions of disease and illness²¹21. Helman C. Cultura, saúde, doença. 5a ed. Porto Alegre: Artmed; 2009., causes disruptions in the physician-patient relationship (PPR). After all, while patients express experiences of illness, subjectively immersed in their sociocultural context, including traditions, beliefs and values, most professionals are still trained to act based on a biomedical rationality focused on disease.

The discrepancy between physicians’ training and patients’ needs justifies broadening our knowledge of this demand and of therapeutic resources⁴4. Fonseca MLG, Guimarães MBL, Vasconcelos EM. Sofrimento difuso e transtornos mentais comuns: uma revisão bibliográfica. Rev APS. 2008; 11(3):285-94.. Among the aspects that hamper ED identification, some studies emphasize the predominantly physical symptomatological presentation⁴4. Fonseca MLG, Guimarães MBL, Vasconcelos EM. Sofrimento difuso e transtornos mentais comuns: uma revisão bibliográfica. Rev APS. 2008; 11(3):285-94., the disease-centered training model⁵5. Guedes C, Nogueira M, Camargo KR Jr. A subjetividade como anomalia: contribuições epistemológicas para a crítica do modelo biomédico. Cienc Saude Colet. 2006; 11(4):1093-103., and structural problems in the health system⁹9. Goldberg D. Reasons for misdiagnosis. In: Sartorious N, organizador. Psychological disorders in general medical settings. New York: Hogrefe & Huber, WHO; 1990. p. 139-45.. Of the aspects that interfere in the PPR, studies highlight: insipid communication²²22. Kovandžić M, Chew-Graham C, Reeve J, Edwards S, Peters S, Edge D, et al. Access to primary mental healthcare for hard-to-reach groups: from “silent suffering” to “making it work”. Soc Sci Med. 2010; 72(5):763-72.; patients choosing their own physicians²³23. Laugharne R, Priebe S. Trust, choice and power in mental health: a literature review. Soc Psychiatr Psychiatr Epidemiol. 2006; 41(11):843-52.; vulnerability of the population receiving care²⁴24. Patel V, Araya R, De Lima M, Ludermir A, Todd C. Women, poverty and common mental disorders in four restructuring societies. Soc Sci Med. 1999; 49(11):1461-71.; stigma²⁵25. Keeley RD, West DR, Tutt B, Nutting PA. A qualitative comparison of primary care clinicians’ and their patients’ perspectives on achieving depression care: implications for improving outcomes. BMC Fam Pract. 2014; 15(1):13.; treatment decision process²⁶26. Karasz A, Dowrick C, Byng R, Buszewicz M, Ferri L, Olde Hartman TC, et al. What we talk about when we tallk about depression: doctor-patient conversations and treatment outcomes. Br J Gen Pract. 2012; 62(594):e55-63.; processes that shape the therapeutic alliance²⁷27. Gonçalves D, Chazan L, Almeida N, Fortes S. Intervenções psicossociais na atenção primária à saúde. In: Duncan B, Schmidt MI, Giugliani E, organizadores. Medicina ambulatorial: condutas de atenção primária baseada em evidências. 4a ed. Porto Alegre: Artmed; 2013. p. 1189-99., which involve receptiveness, listening, and providing support and clarification about the patient’s heath condition; the population’s trust on public health institutions identified as representatives of the State²⁸28. Hall M, Dugan E, Zheng B, Mishra A. Trust in physicians and medical institutions: what is it, can it be measured, does it matter? Milbank Q. 2001; 79(4):613-39..

Although we recently discussed the experiences of ED and care among female patients of a family health clinic in Rio de Janeiro²⁹29. Athié K, Dowrick C, Menezes ALA, Cruz L, Lima AC, Delgado PGG, et al. Anxious and depressed women’s experiences of emotional suffering and help seeking in a Rio de Janeiro favela. Cienc Saude Colet. 2017; 22(1):75-86., user opinion regarding mental health care in Brazilian PC is still understudied. Thus, in line with the previous study and within the context of the research projects “Dilemmas and challenges for implementing Global Mental Health policies in Brazil”, led by the Institute for Social Medicine of the State University of Rio de Janeiro (UERJ), and “Evaluating mental health care in primary care services within 2.2 Catchment area of the city of Rio de Janeiro”, led by the “Mental Health in Primary Care Research Group” along with the Rio de Janeiro Municipal Health and Civil Defense Secretary, this study seeks to investigate patients’ perception regarding ED and its care in PC.

Methods

Study design and setting

We used an exploratory qualitative narrative study methodology³⁰30. Groleau D, Young A, Kirmayer LJ. The McGill illness narrative interview (MINI): an interview schedule to elicit meanings and modes of reasoning related to illness experience. Transcult Psychiatry. 2006; 43(4):671-91.. Qualitative methods are applicable in health research when one wishes to investigate how people attribute meaning to life in the face of a permanently changing sociocultural context³¹31. Onocko-Campos RT, Furtado JP. Narrativas: utilização na pesquisa qualitativa em saúde. Rev Saude Publica. 2008; 42(6):1090-6.. They are used as a strategy for integrating different contexts, needs and demands present in the clinical act. Thus, studying patient narratives enables us to know their perceptions and, in turn, to make this knowledge available to policymakers so they may plan care interventions that are congruent with a PC³²32. Favoreto CAO, Camargo KR Jr. A narrativa como ferramenta para o desenvolvimento da prática clínica. Interface (Botucatu). 2011; 15(37):473-83. setting.

Field research took place in the Rio de Janeiro 2.2 Catchment Area, between May and July 2013, while the traditional PC model, organized based on medical specialties, was being progressively substituted by Family Health teams centered on patient bonds and comprehensiveness³³33. Mattos RA. Os sentidos da integralidade. In: Pinheiro R, Mattos RA, organizadores. Os sentidos da integralidade na atenção e no cuidado à saúde. 8a ed. Rio de Janeiro: Instituto de Medicina Social/Universidade do Estado do Rio de Janeiro/ABRASCO; 2009. p. 43-68.. We selected services from eight units, three of which where undergoing a phase of care transition.

Data instrument and collection

We chose the McGill Illness Narrative Interview (MINI)³⁰30. Groleau D, Young A, Kirmayer LJ. The McGill illness narrative interview (MINI): an interview schedule to elicit meanings and modes of reasoning related to illness experience. Transcult Psychiatry. 2006; 43(4):671-91. qualitative instrument as our reference because it seeks to investigate patients’ illness experiences , in addition to having already been validated, translated³⁴34. Leal EM, Souza AN, Serpa OD Jr, Oliveira IC, Dahl CM, Figueiredo AC, et al. McGill entrevista narrativa de adoecimento: tradução e adaptação transcultural para o português. Cienc Saude Colet. 2016; 21(8):2393-402. and used in Brazil³⁵35. Souza AN, Rocha HA, Bastos DF, Gomes MK, Bollela VR. A narrativa de adoecimento e as práticas formativas na construção da realidade clínica. Cad ABEM. 2015; 10:47-57..

Although the MINI is meant for individual interviews, since this is an exploratory study, the use of focal groups³⁶36. Barbour R. Grupos focais. Porto Alegre: Artmed; 2009. for data collection enabled us to privilege narrative quantity and variety in order to produce familiarization with the research subject. We chose to recruit participants in waiting rooms because, while people are waiting to be seen by the physician, they are available in the health unit. This required an adapted, shorter and more focused interview guide. Thus, out of the five MINI sections, we selected questions from the two sections that have the greatest affinity with the study’s objectives (titled “Explanatory Model Narrative” and “Services and Response to Treatment”) and we formulated a new interview guide with two dimensions of investigation: perception of ED and perception of mental health care (Table 1).

The invitation was done verbally to all who were awaiting consultations, informing potential participants of the study’s objectives and that they would be able to leave the group at any time. Some refused to participate for fear that they might miss their appointment, and those who agreed were invited to gather in a circle in order to form a group that enabled a dialog amidst the circulation of people in the waiting room. Due to the lack of seats at the health unit, two groups remained standing.

Groups were led by a moderator who posed participants discussion-triggering questions based on the interview guide. Focal group discussions were recorded in audio-recordings that were later transcribed along with the field notes taken by the moderator and the observer. We carried out eight groups, with three to nine members, for a total of 54 participants. Each group lasted in average 30 to 40 minutes. Since the two pilot groups did not lead to significant changes to the interview guide, they were included in the eight groups we analyzed.

Content Analysis

Narratives were treated through the thematic Content Analysis method³⁷37. Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011., following the phases pre-analysis; material exploration; treatment of results, inference and interpretation. Initially, the document corpus comprising the transcriptions and observations was systematized and organized according to rules of exhaustiveness, representativeness, homogeneity and pertinence. From reading the narratives following the dimensions of the interview guide (perception of ED and perception of care), the related contents that emerged were grouped in thematic categories. In the excerpts we present, participants are identified in the following manner: “P” (participant) + participant’s number + “G” (group) + group number.

Ethical aspects and funding

This study was approved by the Ethics Committees of UERJ and of the Rio de Janeiro Municipal Health Secretary. Each participant signed, and was given a copy of, an Informed Consent Form, and their anonymity was guaranteed. We received support from the CNPq Universal Grant (no.43137/2014-5), from FAPERJ (TCT-5 E-26/102.610/2012; CNE 2016. E-26/202.992/2016) and CNPq student grants (PhD 140379/2014-2).

Results

The following general categories emerged from our analysis of patients’ perception of ED and its care: 1) “Explaining Distress”; 2) “Communicating Distress to a Physician”; 3) “Communicating regarding Structuring Care”; 4) “Communicating Distress within the Service Context”. A fifth transversal category, termed “Facilitators and Barriers to Care”, permeated categories 2, 3 and 4 and, therefore, will be presented alongside them.

Explaining Distress

The most common way patients’ explained ED consisted of utterances recounting everyday situations and psychosocial experiences in which the causes of ED were attributed to difficult circumstances (diseases, conflicts, unemployment, financial problems and losses):

A striking feature of the narratives were accounts that interwove organic symptoms, mental state and psychosocial problems and that reiterated the connection between physical and emotional distress:

When discussing ED, patients automatically cited coping strategies for dealing with their problems. Work, family and friend networks, which had already been cited as causes of ED, were equally characterized as protective factors:

Communicating Distress to a Physician

Although they were able to explain their ED, patients found barriers and facilitators to communicating it to physicians, which involved perceptions related to patient beliefs, physician attitudes and the service context. Among factors that make communication difficult were patient beliefs regarding the appropriateness of discussing ED and the conviction that physicians are unable to help:

The belief that exams and medications are the only subjects that should be discussed with a physician is another obstacle to communication:

The severity of ED is a facilitator of spontaneous communication. On the other hand, the belief that a patient should only mention ED if questioned by the physician is a barrier:

As to the barriers attributed to physician attitudes, patients mentioned a lack of openness to listening to ED:

Being ironic, changing the subject, prescribing something or suggesting a consultation with a psychologist are physician attitudes perceived as a means to avoiding communication:

The attitude of devaluing physical complaints is another barrier, perceived as a sign that the doctor is unwilling to discuss ED:

Communicating regarding Structuring Care

The way treatments are proposed either stimulates or inhibits communication. Combined with pharmacological interventions, psychosocial recommendations, such as engaging in pleasurable activities and strengthening social bonds, were perceived by patients as helpful:

On the other hand, patients complained when drug interventions were not accompanied by a dialog about the circumstances of ED:

The expectation of dialog, of being heard by the physician, was expressed as an ideal of care:

Lastly, patients, simultaneously noting the importance and limits of medical care for ED, pointed to specialist referrals as part of medical care:

Communicating Distress within the Service Context

When stating their perception of medical care, patients spontaneously commented on the service context. Problems related to working conditions, such as a lack of professionals and overcrowded services, represent barriers both to physicians’ ability to listen adequately and to patients’ ability to expose their ED:

Physicians’ work overload constitutes a barrier that leads patients to question whether they should communicate their ED:

Patients perceive this work overload to be a practically unsurmountable barrier and, consequently, state they expect that other professionals offer them the possibility to discuss their ED:

As for the impact of health service conditions, the lack of consultations is a barrier to communicating ED that worsens the already-present emotional distress:

On the other hand, gaining access to medical attention is a facilitator of care that generates a highly positive emotional impact:

Discussion

These accounts show that patients have singular discursive modes of explaining their experiences that configure illness narratives³⁸38. Kleinman A. The illness narratives: suffering, healing and the human condition. New York: Basic Book; 1988., and in which the category “Explaining Distress” stands out. In this category, patients presented explanatory models²⁸28. Hall M, Dugan E, Zheng B, Mishra A. Trust in physicians and medical institutions: what is it, can it be measured, does it matter? Milbank Q. 2001; 79(4):613-39. which are not limited to mentioning symptoms, but correlate them with biological, psychological, social, cultural and even spiritual issues that permeate their lives. This condensing of multiple dimensions of existence into a single experience confers a totalizing biopsychosocial character to human life, blurring the lines between body-mind. Thus, accounts of experiences that involved pathos, that is, “the direct and concrete feeling of suffering and impotence, the feeling of life gone wrong”³⁹39. Canguilhem G. O normal e o patológico. Rio de Janeiro: Forense; 2009. (p. 96), show that ED affects vital normativity³⁹39. Canguilhem G. O normal e o patológico. Rio de Janeiro: Forense; 2009., restricting patients’ ability to confront their unease and to create new forms of living. This phenomenon helps us to understand the complexity of ED’s symptomatic presentation, which often includes physical complaints⁴4. Fonseca MLG, Guimarães MBL, Vasconcelos EM. Sofrimento difuso e transtornos mentais comuns: uma revisão bibliográfica. Rev APS. 2008; 11(3):285-94. overlapped with psychosocial problems and which, therefore, require comprehensive³³33. Mattos RA. Os sentidos da integralidade. In: Pinheiro R, Mattos RA, organizadores. Os sentidos da integralidade na atenção e no cuidado à saúde. 8a ed. Rio de Janeiro: Instituto de Medicina Social/Universidade do Estado do Rio de Janeiro/ABRASCO; 2009. p. 43-68. care that is sensitive to patients’ life contexts.

While the category “Explaining Distress” showed that patients are able to explain their ED in their own manner, the categories “Communicating Distress to a Physician”, “Communicating regarding Structuring Care” and “Communicating Distress within the Service Context” showed that there are factors that interfere in the possibility of communicating ED and in getting physicians to listen – facilitating or obstructing ED communication.

The narratives have shown that the severity of ED is a condition that leads patients to express it spontaneously. Physician attitudes which put patients at ease to discuss the problems that cause distress, in particular, also stimulate communication. Obtaining access to medical care in the face of precarious service conditions, in addition to being a facilitator, also generates a positive emotional impact on patient self-esteem. Thus, offering patients space to discuss psychosocial aspects and displaying a welcoming, counseling attitude are factors that enable ED communication.

As to the barriers to communication, narratives indicated that patients have preconceived thoughts regarding what to inform physicians in PC and the latter’s role in ED care. Constrained by these beliefs not to expose their ED, especially when there are psychosocial problems, patients carry out their own selection process and communicate only what they understand physicians to be able to address, which is usually associated with physical symptoms.

Certain physician attitudes also do not favor communication, such as: showing themselves to be unavailable and unwilling to discuss, or actively inquire into, ED, or, if patients mention it, dodging the subject, giving them a prescription or referring them to specialists. Given this semantic distance and the asymmetry of the PPR, the embarrassment patients feel when exposing their problems is added to the difficulty of being listened to by the professional. The narratives suggest that, beyond treating disease, physicians are not prepared to offer a broadened attention to ED and to commit themselves to addressing illness²¹21. Helman C. Cultura, saúde, doença. 5a ed. Porto Alegre: Artmed; 2009., and, consequently, to offer a comprehensive care as established in the Unified Health System (SUS) and National Primary Care Policy guidelines⁴⁰40. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília, DF: Ministério da Saúde; 2007..

Although the psychosocial dimension of ED is constitutive of patients’ explanatory models, there was no reference to other PC professionals (nurses, technicians or community agents), which suggests that care is physician-centered. If, on the one hand, the perception of the centrality of medical care may indicate a medicalizing perspective in legitimating ED, on the other, this highlights physicians’ responsibility in developing the comprehensiveness of ED care.

Although the care process basically involves two people – patient and physician –, a third agent interferes in that relationship: the health service. The narratives show that the perception of ED care does not depend only on what happens in the PPR microcosm, but also involves the perception of the institutional context. To paraphrase the psychoanalyst D.W. Winnicott⁴¹41. Winnicott D. Natureza humana. Rio de Janeiro: Imago; 1990., narratives signal that the service setting does not constitute a “good enough environment”. In other words, working conditions put pressure on professionals, who restrict themselves to examining physical symptoms, without investigating their association with subjective affects, and who carry out consultations within the biomedical mold, that is, strictly focused on diseases and symptoms, in the offer of pharmacological interventions and in specialist referrals (when available in the service network). Since it is unfavorable to communication, this environment does not offer a space for dialog and safety that supports the development of a salutary therapeutic alliance between physicians and patients, based on which patients are able to express themselves and find new ways of confronting their ED²⁷27. Gonçalves D, Chazan L, Almeida N, Fortes S. Intervenções psicossociais na atenção primária à saúde. In: Duncan B, Schmidt MI, Giugliani E, organizadores. Medicina ambulatorial: condutas de atenção primária baseada em evidências. 4a ed. Porto Alegre: Artmed; 2013. p. 1189-99.. On the contrary, this tumultuous context undermines patients’ trust on their physicians and disturbs the PPR²⁸28. Hall M, Dugan E, Zheng B, Mishra A. Trust in physicians and medical institutions: what is it, can it be measured, does it matter? Milbank Q. 2001; 79(4):613-39.^,2929. Athié K, Dowrick C, Menezes ALA, Cruz L, Lima AC, Delgado PGG, et al. Anxious and depressed women’s experiences of emotional suffering and help seeking in a Rio de Janeiro favela. Cienc Saude Colet. 2017; 22(1):75-86.. This restricts physicians’ ability to listen to patients and inhibits the expression of ED, reiterating patients’ conviction that physicians are not there to discuss ED and that it is not worthy of being shared, which may accentuate the stigma²⁵25. Keeley RD, West DR, Tutt B, Nutting PA. A qualitative comparison of primary care clinicians’ and their patients’ perspectives on achieving depression care: implications for improving outcomes. BMC Fam Pract. 2014; 15(1):13. surrounding mental health and even worsen patients’ illnesses. Under these conditions, the service context itself is an obstacle to the full use of services and becomes a barrier to the access it should enable.

Given their importance, factors that intervene in the perception of care are summarized in Table 2.

According to the treatment decision stages (symptom presentation, physician request for information and offer of intervention), communicating problems to the physician is the basis from which the care process will be established²⁶26. Karasz A, Dowrick C, Byng R, Buszewicz M, Ferri L, Olde Hartman TC, et al. What we talk about when we tallk about depression: doctor-patient conversations and treatment outcomes. Br J Gen Pract. 2012; 62(594):e55-63.. However, the narratives have shown that the interaction between the embarrassment patients feel when expressing themselves, physicians’ lack of training for addressing ED and the context of overloaded health services creates a dynamic that obscures ED communication at the seminal moment of consultation. As they feedback on and intensify each other in a vicious cycle, these barriers form an anti-therapeutic loop (Figure 1) that is extremely pernicious to health and, as a result, the potential of access to comprehensive care³³33. Mattos RA. Os sentidos da integralidade. In: Pinheiro R, Mattos RA, organizadores. Os sentidos da integralidade na atenção e no cuidado à saúde. 8a ed. Rio de Janeiro: Instituto de Medicina Social/Universidade do Estado do Rio de Janeiro/ABRASCO; 2009. p. 43-68.^,4242. Favoreto CAO. Obstáculos à ampliação da competência dialógica e interpretativa da clínica de médicos atuando na atenção primária. In: Pinheiro R, Mattos RA, organizadores. Razões públicas para a integralidade em saúde: o cuidado como valor. Rio de Janeiro: CEPESC-IMS, UERJ-ABRASCO; 2007. p. 213-29. is unfulfilled.

Implications for access to care

According to WHO and Global Mental Health recommendations¹³13. Patel V, Prince M. Global mental health: a new global health field comes of age. JAMA. 2010; 303(19):1976-7., the integration of mental health actions within PC is a guideline for increasing care for CMD⁶6. World Health Organization. World Organization of Family Doctors. Integrating mental health into primary care: a global perspective. Geneva: WHO, WONCA; 2008., including ED. However, the narratives we have analyzed in this article point to barriers that still hamper this access. On the other hand, knowledge of these obstacles provides subsidies to guide strategies directed at the many dimensions of care⁴³43. Assis M, Jesus W. Acesso aos serviços de saúde: abordagens, conceitos, políticas e modelo de análise. Cienc Saude Colet. 2012; 17(11):2865-75..

In review, the narratives indicated that enabling ED communication is paramount, which requires a clinical-service space that facilitates PPR. An indispensable strategy in ensuring that PC is a safe environment for this is the improvement of working conditions. This may be done by addressing both the organizational dimension⁴³43. Assis M, Jesus W. Acesso aos serviços de saúde: abordagens, conceitos, políticas e modelo de análise. Cienc Saude Colet. 2012; 17(11):2865-75. (related to services’ capacity to establish flows and processes; regulate vacancies and articulate service network in order to meet patient demands); and the political and socioeconomic dimensions of access⁴³43. Assis M, Jesus W. Acesso aos serviços de saúde: abordagens, conceitos, políticas e modelo de análise. Cienc Saude Colet. 2012; 17(11):2865-75. (i.e., those that guarantee pacts and investments according to levels of service complexity).

Another factor indicated by the narratives to increase care resoluteness was the need to negotiate therapeutics that are congruent with patient perspectives, incorporating the comprehensiveness of the ED experience and the hermeneutic understanding of the meaning they attribute to ED⁴²42. Favoreto CAO. Obstáculos à ampliação da competência dialógica e interpretativa da clínica de médicos atuando na atenção primária. In: Pinheiro R, Mattos RA, organizadores. Razões públicas para a integralidade em saúde: o cuidado como valor. Rio de Janeiro: CEPESC-IMS, UERJ-ABRASCO; 2007. p. 213-29.. Thus, another strategy is to act upon the symbolic dimension of access⁴³43. Assis M, Jesus W. Acesso aos serviços de saúde: abordagens, conceitos, políticas e modelo de análise. Cienc Saude Colet. 2012; 17(11):2865-75., including patients’ views and the characteristics of their context within clinical care, in order to enable care that is culturally sensitive and socially relevant¹⁸18. Kirmayer LJ. Rethinking cultural competence. Transcult Psychiatry. 2012; 49(2):149-64., and to avoid the spread, in LMIC countries such as Brazil, of standardized intervention packages that exclusively use biomedical approaches which ignore local contexts¹⁹19. Kirmayer LJ, Pedersen D. Toward a new architecture for global mental health. Transcult Psychiatry. 2014; 51(6):759-76..

Another essential strategy for Brazilian PC is to act on the technical dimension of access⁴³43. Assis M, Jesus W. Acesso aos serviços de saúde: abordagens, conceitos, políticas e modelo de análise. Cienc Saude Colet. 2012; 17(11):2865-75., ensuring the construction of practices based on the comprehensiveness of care and to intensify therapeutics based on ‘soft technologies’⁴⁴44. Merhy EE. Saúde: a cartografia do trabalho vivo. São Paulo: Hucitec; 2002. . These therapeutics are commonly used in psychosocial interventions⁴⁵45. Menezes ALA. Intervenções psicossociais para transtornos mentais comuns na atenção primária à saúde [dissertação]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2012.^,4646. Chiaverini D. Guia prático de matriciamento em saúde mental. Brasília, DF: Ministério da Saúde, CEPESC; 2011. and involve relational and communicative approaches, which, without ruling out medication interventions, when needed, emphasize dialog and strengthening of the PPR, which is in and of itself a therapeutic action²⁷27. Gonçalves D, Chazan L, Almeida N, Fortes S. Intervenções psicossociais na atenção primária à saúde. In: Duncan B, Schmidt MI, Giugliani E, organizadores. Medicina ambulatorial: condutas de atenção primária baseada em evidências. 4a ed. Porto Alegre: Artmed; 2013. p. 1189-99.. They thus enable physicians to explore the complexity of patient experiences and to incorporate it into the act of care.

Strengths and limitations

The study’s greatest strength is that it is an exploratory investigation that produced a set of narrative evidences regarding ED and barriers to its care in PC. Another virtue is that it informs on cultural perspectives and local discursive modes of understanding ED in order to enrich Global Mental Health approaches¹⁴14. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR. No health without mental health. Lancet. 2007; 370(9590):859-77.. Another highlight is that the study exemplifies that the narrative approach may be used both as a research strategy and as an instrument for improving actions of clinical care.

Among its limitations, there is the fact that conducting research in the waiting room, immediately before medical consultations may have biased some of the information provided by participants. Additionally, the interruption of participation, when patients went into their consultations, made data collection difficult.

Final thoughts

This study explored patient narratives regarding their perception of ED and of the mental health care offered in PC in Brazil and concluded that patients present a comprehensive view of ED and face barriers to communicating it which limit its care. This shows that PC is not totally prepared to contemplate the amount of individuals with ED who often turn to this sector. To deny ED communication is to deny the full use of services and, therefore, to deny access to health.

Seeking to reduce human suffering, this study, by establishing a dialog with the field of Global Mental Health, pointed out strategic institutional actions to guide the structuring of comprehensive, culturally sensitive and socially relevant PC in Brazil.

Acknowledgments

We are grateful for the invaluable comments made by Laurence Kirmayer, Professor and Director of the Division of Social and Transcultural Psychiatry at McGill University, and Danielle Groleau, Professor at the Division of Social and Transcultural Psychiatry at McGill University, authors of the McGill Illness Narrative Interview instrument, on which we based the research guide used in this study.

References

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