Abstract

Introduction

Issues related to mental health (MH) have become a worldwide health problem, totaling approximately 12% of the global burden of disease. Common mental disorders alone affect one third of the population, being one of the most prevalent psychological morbidities in the world¹1 Knudsen AK, Harvey SB, Mykletun A, Overland S. Common mental disorders and long-term sickness absence in a general working population. The Hordaland Health Study. Acta Psychiatr Scand. 2013; 127(4):287-97. Doi: https://doi.org/10.1111/j.1600-0447.2012.01902.x.
https://doi.org/10.1111/j.1600-0447.2012... . In Brazil, it is estimated that this prevalence ranges between 29.6% and 47.4%²2 Patel V, Saxena S, Lund C, Thornicroft G, Baingana F, Bolton P, et al. Comissão Lancet sobre saúde mental global e desenvolvimento sustentável. Lancet. 2018; 392(10157):1553-98. Doi: https://doi.org/10.1016/S0140-6736(18)31612-X.
https://doi.org/10.1016/S0140-6736(18)31... ^,33 Fernandes L, Basílio N, Figueira S, Nunes JM. Saúde mental em medicina geral familiar – obstáculos e expectativas percecionados pelos Médicos de Família. Cienc Saude Colet. 2017; 22(3):797-805..

In view of these data, the question is: How can the health services deal with this prevalence and build a new reality? The World Health Organization (WHO) mentions reasons why MH care should be integrated into Primary Health Care (PHC): the burden of mental disorders is high; mental and physical health problems are interconnected; the treatment deficit concerning mental disorders is huge. The document also emphasizes that primary care for MH improves access to care, promotes respect for human rights, has a good cost-benefit ratio and generates better health outcomes⁴4 Organización Mundial de la Salud. mhGAP. Programa de acción para superar las brechas en salud Mental. Mejora y ampliación de la atención de los trastornos mentales, neurológicos y por abuso de sustancias. Genebra: OMS; 2009.. Therefore, professionals in PHC teams should absorb this demand, conducting MH promotion actions and preventing and treating mental illness, in an individual and collective way.

In Brazil, the Movement of Mental Health Workers, whose purpose is the reformulation of psychiatric care, is an abundant source of historical and social possibilities, promoting activities and producing legal texts that legitimize the entire political, ethical, institutional and scientific process called the Brazilian Psychiatric Reform. The change promoted by the Brazilian Psychiatric Reform shifts the focus from hospital care, centered on the biomedical model, to psychosocial care, provided for users in the community⁵5 Amarante P, Nunes MO. A reforma psiquiátrica no SUS e a luta por uma sociedade sem manicômios. Cienc Saude Colet. 2018; 23(6):2067-74..

Thus, the challenge is to inhabit the circuits of exchanges in society’s territories, instead of creating parallel and protected life circuits for users. This takes the challenge of including MH actions in PHC beyond the Brazilian National Health System (SUS): to achieve this, society needs to open itself to its own diversity⁶6 Portela GZ. Atenção Primária à Saúde: um ensaio sobre conceitos aplicados aos estudos nacionais. Physis. 2017; 27(2):255-76..

Studies carried out in Norway⁷7 Fredheim T, Danbolt LJ, Haavet OR, Kjønsberg K, Lien L. Collaboration between general practitioners and mental health care professionals: a qualitative study. Int J Ment Health Syst. 2011; 5:13. Doi: https://doi.org/10.1186/1752-4458-5-13.
https://doi.org/10.1186/1752-4458-5-13... and Brazil⁸8 Souza MLP. Registro de distúrbios mentais no Sistema de Informação da Atenção Básica do Brasil. Epidemiol Serv Saude. 2016; 25(2):405-10. have shown that, despite several innovative initiatives in care provided for people with mental illness in PHC, aspects like problems related to the organization of the working process, insufficient professional education, the precarious structuring of the services network, and the incipient infrastructure and human resources, hinder the inclusion of MH actions in PHC. These weaknesses are barriers to care provision in PHC, as they promote the reproduction of the asylum and biomedical model, lack of focus on users and their families, duplicity of care models, unnecessary referrals, and absence of co-accountability.

However, studies have shown that innovative practices have been experienced in MH care within the Brazilian PHC. A broad review has shown that, in the city of Salvador (Northeastern Brazil), home hospitalization is a possible reality. In the city of Ribeirão Preto (Southeastern Brazil), home visits minimize the incidence of psychiatric readmissions through follow-up of discharged patients, guidance for families, and efforts to avoid the medicalization of mental suffering. In the city of Cuiabá (Central-Western Brazil), the therapeutic group is a way of integrating MH into PHC⁹9 Correia VR, Barros S, Colvero LA. Saúde mental na atenção básica: prática da equipe de saúde da família. Rev Esc Enferm USP. 2011; 45(6):1501-6. Doi: http://dx.doi.org/10.1590/S0080-62342011000600032.
https://doi.org/10.1590/S0080-6234201100... . In São Paulo (Southeastern Brazil), home visits and qualified listening facilitate the process of identifying and meeting the needs of users with mental illness¹⁰10 Frateschi MS, Cardoso CL. Práticas em saúde mental na atenção primária à saúde. Psico (Porto Alegre). 2016; 47(2):159-68..

Other national studies, developed in the states of São Paulo, Rio Grande do Norte, Paraíba, and also in the south region of Brazil, have shown the importance of group practices in PHC, like Community Therapy and MH Groups and Workshops. The studies highlight that people sharing experienced situations is a powerful possibility, indicating that the strengthening of the bonds of trust between users and professionals can be an important tool for MH promotion and preservation⁹9 Correia VR, Barros S, Colvero LA. Saúde mental na atenção básica: prática da equipe de saúde da família. Rev Esc Enferm USP. 2011; 45(6):1501-6. Doi: http://dx.doi.org/10.1590/S0080-62342011000600032.
https://doi.org/10.1590/S0080-6234201100... .

Furthermore, a study carried out in the city of São Paulo has found that the strategy of holding team meetings with case discussion, effective support to workers’ difficulties and development of the Individual Therapeutic Project is used as a way of qualifying teams to tackle the difficulties that arise from including MH practices in PHC¹¹11 Delfini PSS, Sato MK, Antoneli PP, Guimarães POS. Parceria entre CAPS e PSF: o desafio da construção de um novo saber. Cienc Saude Colet. 2009; 14 Supl 1:1483-92..

In the international scenario, experiences of MH actions in primary care are reported by studies developed in England, Australia, Finland and the United States of America. The results of these studies provide some evidences: joint discussion of cases as the main form of articulation between the services; association between improved assistances and the possibility of sharing knowledge¹²12 Byng R, Norman I, Redfern S, Jones R. Exposing the key functions of a complex intervention for shared care in mental health: case study of a process evaluation. BMC Health Serv Res. 2008; 8:274. Doi: http://dx.doi.org/10.1186/1472-6963-8-274.
https://doi.org/10.1186/1472-6963-8-274... ; significant reduction in referrals when the general practitioner is the reference professional¹³13 Perkins D, Hamilton M, Saurman E, Luland T, Alpren C, Lyle D. GP Clinic: promoting access to primary health care for mental health service clientes. Aust J Rural Health. 2010; 18(6):217-22. Doi: https://doi.org/10.1111/j.1440-1584.2010.01159.x.
https://doi.org/10.1111/j.1440-1584.2010... ; significant improvement in the capacity for meeting users’ needs, with shared psychotherapy sessions¹⁴14 Laukkanen E, Hintikka JJ, Kylmä J, Kekkonen V, Marttunen M. A brief intervention is sufficient for many adolescents seeking help from low threshold adolescent psychiatric services. BMC Health Serv Res. 2010; 10:261. Doi: https://doi.org/10.1186/1472-6963-10-261.
https://doi.org/10.1186/1472-6963-10-261... ; continuity of treatment in the primary services that have partnerships with the secondary sector, with high adherence rates¹⁵15 Kessler R. Mental health care treatment initiation when mental health services are incorporated into primary care practice. J Am Board Fam Med. 2012; 25(2):255-9. Doi: https://doi.org/10.3122/jabfm.2012.02.100125.
https://doi.org/10.3122/jabfm.2012.02.10... .

These MH practices, in the context of the Brazilian and international PHC, contribute to improve care provided for people with mental illness, as the included actions innovate and qualify PHC.

In light of these possibilities, this study aimed to understand the practices that are being performed in the PHC of small cities for people with mental disorders. The study was guided by the following question: What practices are performed in the daily routine of PHC in small cities to provide care for people with mental disorders?

Method

Qualitative study based on ethnomethodology, understood as the empirical study of common sense practices, procedures, methods and knowledge that social actors use on a daily basis to understand and, at the same time, produce the social environments in which they participate¹⁶16 Bispo MS, Godoy AS. A etnometodologia enquanto caminho teórico-metodológico para investigação da aprendizagem nas organizações. Rev Adm Contemp. 2012; 16(5):684-704. Doi: https://dx.doi.org/10.1590/S1415-65552012000500004.
https://doi.org/10.1590/S1415-6555201200... . We chose ethnomethodology due to our aim of investigating the MH practices of Family Health Strategy teams in small cities.

In this methodological approach, the members of a group use natural language in the daily settings that compose the social world, which implies that practical activities and social interactions occur within a common horizon of understanding. To apprehend these dimensions in the reality of MH, we used individual interviews with PHC managers and coordinators and discussion groups with professionals working in PHC teams, based on a script with the guiding request: Tell us how MH actions are organized and developed in your unit.

The study was conducted from July to November 2019 in cities located in Vale do Jequitinhonha, State of Minas Gerais (Southeastern Brazil). The cities were numbered from 01 to 05 according to the chronological order of the interviews and discussion groups. The cities have the following characteristics, among others:

All the cities that accepted the invitation to participate in the study were included. The participants signed a consent document. Theoretical saturation of data was used to delimit the sample, that is, we stopped sampling data when no new element was found and the objective of the research was fulfilled¹⁷17 Nascimento LCN, Souza TV, Oliveira ICS, Moraes JRMM, Aguiar RCB, Silva LF. Saturação teórica em pesquisa qualitativa: relato de experiência na entrevista com escolares. Rev Bras Enferm. 2018; 71(1):228-33. Doi: https://doi.org/10.1590/0034-7167-2016-0616.
https://doi.org/10.1590/0034-7167-2016-0... .

We conducted 11 interviews with PHC managers and coordinators and 10 discussion groups with PHC teams, totaling 85 participants. The number of participants in the discussion groups varied between 6 and 12. The average duration of the discussion groups was one hour. The average duration of the interviews was approximately 30 minutes.

The individual interviews and the group discussions were fully transcribed. All the language was preserved, including the colloquial tone. Then, we listened to the audios repeatedly and read the transcribed discourses in detail.

Data analysis was based on the presupposition of ethnomethodology. Instead of formulating the hypothesis that the actors follow the rules, ethnomethodology is interested in studying the methods employed to update the rules, which makes them observable and descriptive¹⁵15 Kessler R. Mental health care treatment initiation when mental health services are incorporated into primary care practice. J Am Board Fam Med. 2012; 25(2):255-9. Doi: https://doi.org/10.3122/jabfm.2012.02.100125.
https://doi.org/10.3122/jabfm.2012.02.10... . The members’ practical activities in their concrete activities reveal the rules and procedures. Thus, the focus of this study was to investigate the implementation of MH actions in PHC. There is a conceptual framework based on the Brazilian Health Reform that explains the role of PHC in health actions. We aimed to investigate how PHC is related in practice to this process. To achieve this, the analysis of the collected material was organized around three important concepts of ethnomethodology: social actor, social order and social action¹⁷17 Nascimento LCN, Souza TV, Oliveira ICS, Moraes JRMM, Aguiar RCB, Silva LF. Saturação teórica em pesquisa qualitativa: relato de experiência na entrevista com escolares. Rev Bras Enferm. 2018; 71(1):228-33. Doi: https://doi.org/10.1590/0034-7167-2016-0616.
https://doi.org/10.1590/0034-7167-2016-0... .

Concerning the social actor, the point-of-departure was the conception that actors have a set of resources and procedures that enable them to act in their social world. They neither discuss nor reflect on the categorizations and methods they use to face different situations; rather, they employ them tacitly and routinely¹⁸18 Martínez-Guzmán A, Stecher A, Íñiguez-Rueda L. Aportes de la psicología discursiva a la investigación cualitativa en psicología social: análisis de su herencia etnometodológica. Psicol USP. 2016; 27(3):510-20. Doi: https://doi.org/10.1590/0103-656420150046.
https://doi.org/10.1590/0103-65642015004... .

In this aspect, we tried to identify how different workers in PHC teams interact, in their daily routine, with the universe of actions produced in the sphere of MH. We aimed to identify what knowledge and procedures they use as resources in the daily routine of the production of MH actions that enable them to enhance their actions.

As for social order, in ethnomethodology it is perceived in the sphere of practice of the members who participate in society, rather than a set of facts or institutions imposed on the actors and restraining them. Therefore, social reality is understood as a framework of “contingent achievements of common organizational practices”¹⁹19 Rawls AW. Os estudos de etnometodologia de Garfinkel: uma investigação sobre os alicerces morais da vida pública moderna. Soc Estado. 2018; 33(2):443-64. Doi: https://dx.doi.org/10.1590/s0102-699220183302008.
https://doi.org/10.1590/s0102-6992201833... .

Ethnomethodology works with two fundamental concepts to approach social reality as a situated production determined by the various methods (ethno) (resources, practices, procedures, knowledge) that people employ to produce the social order that they inhabit¹⁶16 Bispo MS, Godoy AS. A etnometodologia enquanto caminho teórico-metodológico para investigação da aprendizagem nas organizações. Rev Adm Contemp. 2012; 16(5):684-704. Doi: https://dx.doi.org/10.1590/S1415-65552012000500004.
https://doi.org/10.1590/S1415-6555201200... .

The first concept is indexicality, which refers to the expressions employed by social actors in interactive processes, which have meaning in the moment of the interaction and in the local context where it is produced. Thus, ethnomethodology studies language, giving special attention to new meanings attributed to certain words over the years. In addition, indexicality understands that the new meanings attributed to words are due to the interaction that the individuals establish¹⁸18 Martínez-Guzmán A, Stecher A, Íñiguez-Rueda L. Aportes de la psicología discursiva a la investigación cualitativa en psicología social: análisis de su herencia etnometodológica. Psicol USP. 2016; 27(3):510-20. Doi: https://doi.org/10.1590/0103-656420150046.
https://doi.org/10.1590/0103-65642015004... .

The second concept is reflexivity, which presupposes that actions developed by individuals are provoked by the reflection they make on the actions performed by others and by the individuals themselves. These reflections are made in an instinctive way, that is, the person reflects without deliberate perception or will - it is spontaneous. This reflexivity makes individuals rely on it to generate their own acts¹⁶16 Bispo MS, Godoy AS. A etnometodologia enquanto caminho teórico-metodológico para investigação da aprendizagem nas organizações. Rev Adm Contemp. 2012; 16(5):684-704. Doi: https://dx.doi.org/10.1590/S1415-65552012000500004.
https://doi.org/10.1590/S1415-6555201200... .

We focused on the several modalities of action and practical reasoning that the participants mobilize to recognize, include, produce and sustain their MH actions. In addition, we identified the expressions and contexts in which new meanings have been attributed to MH actions in the reality of PHC.

As for social action, ethnomethodology replaces the investigation of the reasons for an action with the investigation of how a specific field of actions that contains its own intelligibility emerges¹⁶16 Bispo MS, Godoy AS. A etnometodologia enquanto caminho teórico-metodológico para investigação da aprendizagem nas organizações. Rev Adm Contemp. 2012; 16(5):684-704. Doi: https://dx.doi.org/10.1590/S1415-65552012000500004.
https://doi.org/10.1590/S1415-6555201200... . It also focuses on how the field is organized and how different subjects articulate with one another.

Therefore, we investigated how the MH conceptions present in the set of ideas of the Brazilian Health Reform are configured in practice, and how they are expressed in the reality of PHC in the analyzed teams. That is, how are these spaces organized in the daily production of healthcare and in MH? Could it be that new norms are emerging? How are the norms expressed in the daily routine?

The collected material was analyzed based on those outlines. This study complies with Resolution no. 466 of December 12, 2012, of the National Health Council, and was approved by the Research Ethics Committee of the Federal University of Minas Gerais (UFMG), opinion No. 28804.

Results

Various aspects emerged from the MH practices that are being performed by PHC in the analyzed cities, which reflects their complexity. In what follows, we systematized these aspects, categorizing and describing them based on the discourse of the PHC teams and coordinators.

Unveiling the world of intramural mental disorders: the deep meaning of the home visit and of the presence in schools

In the identification of MH problems in the PHC of the analyzed cities, new worlds are unveiled by the practice of the teams. The home and the school emerge as an important field of perception of problems in the MH area. PHC, operating in territories, homes and schools, uncovers problems and enhances the teams’ work.

The presence of the Community Health Agent (CHA) allows the family to inform the problems they are facing.

New worlds are also unveiled by what the CHA perceives in the home.

The presence in schools through shared practices enables dentists to detect problems.

Primary Care moving between distinct universes: the new dimensions that affect mental health arising from the social media

The teams’ professionals also report on the expansion of the spectrum of problems experienced in PHC arising from contacts with the social media. The presence in schools enables professionals to have contact with these new themes, which end up composing the spectrum of action of PHC.

Mental health: expanding the spectrum of approach and support

The Psychosocial Care Network (known by the acronym RAPS in Brazil) has been enhanced by articulation processes involving intersectoral actions with the Child Protective Council, the Prosecution Service and the Military Police. The PHC teams participate in this new process in monthly meetings with the NASF-AB and the CAPS.

This process is a two-way street: both the support network and the teams bring the cases.

The PHC teams mention the decisive importance of the role of the CAPS in the RAPS. Moreover, they highlight the articulation with the CAPS, which share the monitoring of absent patients, hold meetings with the teams and counter-refer people with mild symptoms.

Community Health Agent in action in the mental health field: daily perceptions enabling the provision of quality care

The important role of the CHA is not restricted to helping unravel new cases. Many times, they are able to build longer-lasting bonds, monitoring patients and keeping the team informed.

The transfer of stigmas present in the Psychosocial Care Network: “the CAPS is a place for mad people”

The daily management in the area of MH, still marked by stigmas, has an important impact on the practices of PHC teams and on the difficulty to include the family in the provided care.

Some of the activities are targeted at dealing with stigmas.

Health promotion activities instead of medicines

The PHC teams report the effort to engage MH patients in health promotion activities that are taking place in their territories.

Dedication in the daily routine of Primary Care: attentiveness to mental health medication

The professionals of PHC teams report the need to treat MH patients in a special way, recognizing their experiences and needs. They mentioned changes in the form of work organization to assist these patients, including special attention to the medication.

Issues perceived in Primary Care regarding mental health assistance

The professionals who participated in the research mentioned problems concerning MH care. They highlighted some aspects, like the fact that they do not perform risk assessment nor make records, leaving these activities to the CAPS. Sometimes, they have a folder with the information that has been sent and they monitor the patient based on this record.

Other problems identified by them: the fact that they do not work with drug reduction, the approach to patients with chemical dependency, and the non-formalization of detailed criteria to discharge patients from the CAPS.

[...] it’s been suggested that the NASF-AB professionals should create a group to discuss and try to reduce the use of benzodiazepines, of clonazepam and the like. Many people take them and we know most don’t even need it. Chemical dependency is complicated for us. (G 05)

[...] sometimes, the professionals don’t have available time, logistics, transport, to do everything a mental health service should do. Today, I agree with some discharges but not with others. I don’t think the patient should come ready to us from the service, but I think schizophrenic patients, patients with mental disorders who pose risks to themselves and the others, I think they should first resolve these cases and then discharge and send them back to PHC. (C 04)

Discussion

The different worlds unveiled by managers, coordinators and PHC team workers concerning MH in small cities point to the importance of a care model in which the teams focus on the territory and reaffirm that immersion in this setting enables the integration of MH into primary care, guaranteeing rights and qualifying assistance²⁰20 Wenceslau LD, Ortega F. Mental health within primary health care and Global Mental Health: international perspectives and Brazilian context. Interface (Botucatu). 2015; 19(55):1121-32.^,2121 Moliner J, Lopes SMB. Saúde mental na atenção básica: possibilidades para uma prática voltada para a ampliação e integralidade da saúde mental. Saude Soc. 2013; 22(4):1072-83.. The broad spectrum of problems that PHC encounters regarding mental suffering is revealed in homes and schools. The study shows that the process conceived in the sphere of the Brazilian Health Reform is deepened and becomes real in the daily practices of PHC teams, enabling the provision of comprehensive care and extending it to people with mental disorders²²22 Souza AC, Amarante PD, Abrahão AL. Inclusion of mental health in primary health care: care strategy in the territory. Rev Bras Enferm. 2019; 72(6):1677-83. Doi: http://dx.doi.org/10.1590/0034-7167-2018-0806.
https://doi.org/10.1590/0034-7167-2018-0... ^,2323 Viegas SMF, Penna CMM. As dimensões da integralidade no cuidado em saúde no cotidiano da Estratégia Saúde da Família no Vale do Jequitinhonha, MG, Brasil. Interface (Botucatu). 2015; 19(55):1089-100. Doi: http://dx.doi.org/10.1590/1807-57622014.0275.
https://doi.org/10.1590/1807-57622014.02... .

The complexity of the health assistance provided in primary care is increased when it encounters the activities performed in MH. These activities encompass old practices characterized by little rooms and their bars, discovered and brought down by the CHA, the systematic monitoring of medical consultations and use of medication for patients who need it, and the current MH theme unveiled by the presence in schools and by the influence of the social media, with two groups presenting a significant growth: youths at school and young women who hurt themselves. An interview conducted with the philosopher Nikolas Rose²⁴24 Carvalho SR, Andrade HS, Marçon L, Costa FD, Yasui S. Nosso “futuro psiquiátrico” e a (bio)política da Saúde Mental: diálogos com Nikolas Rose (Parte 4). Interface (Botucatu). 2020; 24:e190732. Doi: https://doi.org/10.1590/Interface.190732.
https://doi.org/10.1590/Interface.190732... and a study carried out in the state of Santa Catarina - Brazil²⁵25 Peres GM. Limites e desafios da rede de atenção psicossocial na perspectiva dos trabalhadores de saúde mental. Cad Bras Saude Ment. 2018; 10(27):34-52. state that mental disorders have remained consistent in the last 20 years. This means that the new challenges can lead to the structuring of MH care in PHC.

PHC and MH are updated in practice through these social actors, diving into their social realities, interacting with the complexity of their nosological classifications, and employing devices like work in a services network and matrix support. Therefore, we perceive an integrated action between PHC and the psychosocial network, enhanced by the structuring of intersectoral spaces and by an important matrix dynamics between CAPS, NASF-AB and PHC, as other studies have shown²⁶26 Silva JDG, Aciole GG, Lancman S. Ambivalências no cuidado em saúde mental: a ‘loucura’ do trabalho e a saúde dos trabalhadores. Um estudo de caso da clínica do trabalho. Interface (Botucatu). 2017; 21(63):881-92.^,2727 Silva Filho JA, Bezerra AM. Acolhimento em Saúde Mental na Atenção Primária à Saúde: revisão integrativa. Rev Multidiscip Psicol. 2018; 12(40):613-27..

However, important gaps remain in the configuration of the CAPS’ actions, hindering the articulation between services and affecting the provision of care by PHC teams, mainly in moments of crisis. Gaps like deficiency or even absence of matrix support, discontinuity of care on some occasions and the autonomous action of the CAPS configure a two-way street in which PHC needs to make efforts to fulfil its objectives and guarantee the provision of comprehensive and extended care²⁸28 Lima M, Dimenstein M. O apoio matricial em saúde mental: uma ferramenta apoiadora da atenção à crise. Interface (Botucatu). 2016; 20(58):625-35. Doi: https://doi.org/10.1590/1807-57622015.0389.
https://doi.org/10.1590/1807-57622015.03... .

Although the psychosocial network structured in the analyzed cities is relatively homogeneous, we found that the PHC teams function in distinct ways in the relationship with the other units of the psychosocial network. In some situations, PHC is structured to enhance MH care and acts to minimize the gaps that we found. The gaps in the structuring of the psychosocial network stimulates the search for new forms of action to be undertaken by PHC, as the demand for patient care effectively occurs in this level of care.

PHC organizes itself to provide care according to the needs of MH patients, prioritizing the embracement of these patients and putting a special emphasis on adherence to medication²⁹29 Onocko-Campos RT, Vianna D, Diaz AV, Emerich B, Trape T, Gama CAP, et al. Estudos de Saúde Mental publicados nos últimos 25 anos na Revista Ciência e Saúde Coletiva. Cienc Saude Colet. 2020; 25(12):4771-90. Doi: https://doi.org/10.1590/1413-812320202512.27932020.
https://doi.org/10.1590/1413-81232020251... .

The action of the CHA is extremely important in the MH area, as they can build effective bonds, being fundamental to unveil the reality of severe MH patients. The MH practices of the PHC teams show the professionals’ great involvement with the patients, which makes them important actors of the BPR²⁷27 Silva Filho JA, Bezerra AM. Acolhimento em Saúde Mental na Atenção Primária à Saúde: revisão integrativa. Rev Multidiscip Psicol. 2018; 12(40):613-27..

Systematic reviews with national¹⁰10 Frateschi MS, Cardoso CL. Práticas em saúde mental na atenção primária à saúde. Psico (Porto Alegre). 2016; 47(2):159-68.^,2727 Silva Filho JA, Bezerra AM. Acolhimento em Saúde Mental na Atenção Primária à Saúde: revisão integrativa. Rev Multidiscip Psicol. 2018; 12(40):613-27. and international²⁷27 Silva Filho JA, Bezerra AM. Acolhimento em Saúde Mental na Atenção Primária à Saúde: revisão integrativa. Rev Multidiscip Psicol. 2018; 12(40):613-27. studies have shown that, despite the difficulties, several innovations in the MH area are present in the daily routine of PHC teams. The procedures and knowledge that emerge from PHC practices clearly show complex themes present in the making of MH policies: the approach to pathologies deriving from the social media; the complexity of intersectoral actions in common forums with the participation of the teams, involving Child Protective Councils, the Prosecution Service and the Police; the difficult discussion about MH stigmas in private spaces and some confinement practices; the systematization of discharges from the CAPS and the counter-referral to PHC.

In the analysis of the structuring of MH in PHC, conducted in practice, with its potentials and limits, it is possible to see the configuration of realities from which emerge indexical expressions that reflect the daily routine of this work¹⁸18 Martínez-Guzmán A, Stecher A, Íñiguez-Rueda L. Aportes de la psicología discursiva a la investigación cualitativa en psicología social: análisis de su herencia etnometodológica. Psicol USP. 2016; 27(3):510-20. Doi: https://doi.org/10.1590/0103-656420150046.
https://doi.org/10.1590/0103-65642015004... : “the patient wasn’t discharged from the medication, he was discharged from the CAPS”; “fierce active search together with the Child Protective Council, if necessary”; “boys imitating other boys and cutting themselves”. These expressions show a reality that is unveiled, involving the universes constructed in the daily MH practice in PHC.

As for the emergence of new norms or their reconfiguration based on practices, we found that the professionals’ perception updates the dilemmas of the BPR³⁰30 Furtado RP, Sousa MF, Martinez JFN, Rabelo NS, Oliveira NSR, Simon WJ. Desinstitucionalizar o cuidado e institucionalizar parcerias: desafios dos profissionais de Educação Física dos CAPS de Goiânia em intervenções no território. Saude Soc. 2017; 26(1):183-95. Doi: https://doi.org/10.1590/s0104-12902017169101.
https://doi.org/10.1590/s0104-1290201716... : the possibility that the CAPS start to be considered the new madhouse and the efforts made by the teams to prevent this; the wonderful action of the CHA, unveiling the madness stigmas in private spaces and bringing bars down, reaffirming the inclusion enabled in the sphere of the Brazilian Health Reform; the emergence of new pathologies reverberated by the social media. These issues challenge the structuring process of PHC.

This study has limitations. Because we chose ethnomethodology, it is possible that the findings represent micro-events instead of more general approaches related to the process of structuring MH actions in PHC. The option of focusing on small cities with precarious socioeconomic conditions in Vale do Jequitinhonha, state of Minas Gerais, may represent the MH reality of cities with these characteristics, not the reality experienced by the Family Health Strategy in Brazil.

Conclusion

This study revealed important aspects of the configuration of healthcare in PHC practices, which unveil, in the daily routine, the configurations of MH actions through the professionals’ presence in the territory: their presence in homes and schools sheds light on obscure fields in which the MH theme is inserted. PHC teams interacting with MH in homes and schools enables to enhance the power of MH actions, bringing bars down in the household sphere and unveiling severe cases, with significant interventions.

The configurations of intersectoral articulations put new actors on stage, with the construction of forums involving Child Protective Councils, the Prosecution Service and the Police. In addition, we found limits in the action of PHC, involving risk assessment in the MH area, structured follow-up of patients, and policies involving drug reduction. The forms of care that we found point to important flaws in the configuration of the CAPS service. In some situations, PHC is organized to overcome these gaps.

The main thing that emerges from the MH practices is the PHC teams’ commitment to the patients. In the identification of MH problems in cities, new worlds are unveiled by the teams’ practice and become cases to be treated.

In spite of the regressions that threaten the Brazilian Psychiatric Reform in its project of being a humanized and anti-asylum reform, it is possible to see that its principles are rooted in the practice of PHC professionals, which is an important finding of the study. Therefore, there is still hope.

References

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History