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On-line version ISSN 1678-4464
Cad. Saúde Pública vol.24 n.9 Rio de Janeiro Sep. 2008
Maria Tavares Cavalcanti
Instituto de Psiquiatria,
Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil.
Psychiatry was born in association with its own institutional forms of care, and the field's historical beginnings are intimately linked to the emergence of asylums as places to "protect" the insane, to separate them from other "pariahs" of society, as demonstrated by Foucault in his "history of madness".
In Brazil, psychiatric medicine began in the 19th century, and as in Europe, Brazilian mental hospitals were overpopulated, far exceeding their planned capacity. Why did mental hospitals fail as a space for care, becoming places of abandonment? Was it a lack of efficient treatment or professionals sufficiently dedicated to their work? Or is there something inherent to psychiatry that requires more singular and less mass-produced care?
Since World War II, Europe and the United States have witnessed movements to transform psychiatric care, oriented towards decreasing the number of psychiatric beds and implementing territorial and community-based care.
In Brazil, Psychiatric Reform is closely related to the overall Health Reform movement and the country's re-democratization process. The struggles for political freedom and public health care with universal access went hand-in-hand in the search for more humane psychiatric care, focused on improving quality of life by expanding affective and social networks. The debate on health sector directions and guidelines led to the creation of the Unified National Health System (SUS) in 1990. In mental health, opposition to the hegemonic hospital-centered psychiatric model gave rise to the so-called Psychiatric Reform movement, under the impetus of the Anti-Asylum Movement.
The strategy adopted by the Brazilian Ministry of Health to redirect mental health care was to create community mental services nationwide, known as Centers for Psychosocial Care (CAPS). Given the diversity of population size between municipalities (counties) in Brazil, different modalities of CAPS were created, including CAPSad (specific to individuals with alcohol and other drug abuse disorders) and CAPSi (targeted to care for children and adolescents).
In addition to the Centers for Psychosocial Care, the public municipal-based community care network consists of home care services, fellowship centers, mental health outpatient clinics, and general hospitals. The CAPS coordinate and interlink the mental health policy in a given territory; their role is to organize the network of care for persons with mental disorders, providing daily care and promoting the social inclusion of persons with mental disorders through inter-sector actions.
The current challenge lies in different forms of integration and linkage between mental health and primary care, since the coverage by specialized psychiatric services is insufficient for the majority of the population requiring mental health care. Such integration in on the order of the day, and the recent Ministry of Health Ruling no. 154/2008 provides for the creation of Family Health Support Centers (NASFs). Their operational format is still under debate, and time will tell what benefits they will bring in consolidating truly community-based mental health care in Brazil.