Challenges and opportunities in the science of research to practice: lessons learned from a randomized controlled trial of a sexual risk-reduction intervention for psychiatric patients in a public mental health system

Objective: Human immunodeficiency virus (HIV) prevention efficacy trials with psychiatric patients have been conducted in research settings in high-resourced countries, establishing short-term efficacy for reducing sexual risk behavior. None has been implemented within systems of care. In the last decade, overcoming this research-to-practice gap has become a focus of implementation science. This paper describes the first and only HIV Prevention intervention trial for psychiatric patients conducted in real-world outpatient psychiatric settings facilitated by trained clinic-based providers. Methods: The HIV Prevention intervention, which uses the Information-Motivation-Behavioral Skills model to achieve sexual risk-reduction, was rigorously adapted to the local context and clinic services' needs. Participants from eight clinics were randomized to HIV Prevention or Health Promotion conditions. Results: HIV Prevention participants showed significant improvement in Information-Motivation-Behavioral domains; in this group, behavioral intentions were associated with significantly fewer unprotected sex occasions, but reduction of unprotected sex occasions was similar in both conditions. Conclusion: Our trial was conducted before implementation studies became widely funded. Transporting an intervention to a new culture or into real-world practice settings may require adaptations. Our results demonstrate that clear guidelines are needed regarding whether to conduct efficacy, effectiveness, and/or implementation research as the most appropriate next step. Clinical trial registration: NCT00881699

Implementación, resultados iniciales y sostenibilidad de la reforma de servicios de salud mental en el Perú, 2013-2018 / Implementation, initial results, and sustainability of the mental health services reform in Peru, 2013-2018

RESUMEN Se analiza la implementación, resultados iniciales y sostenibilidad de innovaciones en la prestación, financiamiento y gestión de servicios de salud mental en el Perú, realizadas en el periodo 2013-2018. Aplicando nuevos mecanismos de financiamiento y estrategias de gestión pública se implementaron 104 Centros de Salud Mental Comunitarios y ocho Hogares Protegidos que muestran ser más eficientes que los hospitales psiquiátricos. El conjunto de los 29 centros creados entre 2015 y 2017, produjeron en el 2018 un número equivalente en atenciones (244 mil vs. 246 mil) y atendidos (46 mil vs. 48 mil) que el conjunto de los tres hospitales psiquiátricos, pero con el 11% de financiamiento y el 43% de psiquiatras. Se está cambiando la forma de atender la salud mental en el Perú involucrando a ciudadanos y comunidades en el cuidado continuo y creando mejores condiciones para el ejercicio de los derechos en salud mental. La reforma en salud mental comunitaria ha ganado amplio respaldo de sectores políticos, internacionales, académicos y medios de comunicación. Se concluye que la reforma de los servicios de salud mental de base comunitaria en el Perú es viable y sostenible. Está en condiciones para escalar a todo el sector salud en todo el territorio nacional, sujeto al compromiso de las autoridades, el incremento progresivo de financiamiento público y las estrategias colaborativas nacionales e internacionales.

ABSTRACT This paper analyzes the implementation, initial results, and sustainability of innovations in the provision, financing, and management of mental health services in Peru, carried out during 2013-2018. By applying new financing mechanisms and public management strategies, 104 Community Mental Health Centers and eight Protected Homes were implemented, which prove to be more efficient than psychiatric hospitals. The set of 29 centers created between 2015 and 2017 produced in 2018 an equivalent number in consultations (244,000 vs. 246,000) and patients attended (46,000 vs. 48,000) than the set of three psychiatric hospitals, but with 11% of financing and 43% of psychiatrists. The way mental health care is being provided is changing in Peru by involving citizens and communities in ongoing care and creating better conditions for the exercise of mental health rights. Community mental health reform has gained broad support from political, international, and academic sectors, and from the media. We conclude that the reform of community-based mental health services in Peru is viable and sustainable. It is in a position to scale up the entire health sector throughout the country, subject to the commitment of the authorities, the progressive increase in public financing, and national and international collaborative strategies.

Avaliação da atenção psicossocial em álcool e drogas na perspectiva dos familiares dos pacientes / Evaluación de la atención psicosocial en alcohol y drogas por familiares de los pacientes / Psychosocial care assessment of alcohol and drug patients from the perspective of family members

Resumo Os métodos de avaliação dos serviços de saúde têm incorporado o relato dos familiares dos pacientes para a elaboração de indicadores de avaliação de resultados. Nesse sentido, o presente estudo, transversal, descritivo e de abordagem qualitativa, avaliou a satisfação e a mudança percebida pelos familiares dos pacientes de um serviço de atenção psicossocial em álcool e drogas. Adotou-se o referencial teórico-metodológico da Avaliação de Quarta Geração adaptado, coletando-se os dados mediante as técnicas de observação, entrevistas individuais com a aplicação do Círculo Hermenêutico-Dialético e entrevistas grupais. A avaliação da satisfação e da percepção de mudança dos familiares apresentou consenso dos participantes em relação à satisfação, considerada positiva, principalmente pelo serviço de proporcionar-lhes um espaço de escuta e oferecer-lhes orientações para compreender e lidar com os pacientes; e dissenso em face da percepção de mudanças observadas na vida dos pacientes, suscitando nos familiares o encaminhamento de pacientes para internação involuntária em instituições psiquiátricas.

Resumen Los métodos de evaluación de los servicios de salud han incorporado el relato de los familiares de los pacientes para la elaboración de indicadores de evaluación de resultados. El presente estudio, transversal, descriptivo y de abordaje cualitativo, evaluó la satisfacción y el cambio percibido por los familiares de los pacientes de un servicio de atención psicosocial en alcohol y drogas. Se adoptó el referencial teórico-metodológico de la Evaluación de Cuarta Generación adaptado, recogiendo los datos mediante técnicas de observación, entrevistas individuales con aplicación del Círculo Hermenéutico-Dialéctico y entrevistas grupales. La evaluación de la satisfacción y de la percepción de cambio de los familiares presentó consenso en relación con la satisfacción, considerada positiva, principalmente por el servicio de proporcionarles un espacio de escucha y ofrecerles orientaciones para comprender y tratar con los pacientes; y disenso frente a la percepción de cambios observados en la vida de los pacientes, suscitando en los familiares el encaminamiento de pacientes para internación involuntaria en instituciones psiquiátricas.

Abstract The methods of evaluation of health services have been incorporating the report of family members of patients in order to elaborate indicators of evaluation of results. The present cross-sectional, descriptive and qualitative study evaluated the satisfaction and the change perceived by family members of patients of psychosocial care service alcohol and drugs users. The theoretical-methodological framework of the adapted Fourth Generation Assessment was adopted, collecting data through observation techniques, individual interviews with the application of the Hermeneutic-Dialectic Circle and group interviews. The evaluation of the satisfaction and the perception of change of the relatives presented a consensus of the participants regarding the satisfaction, considered positive, primarily by providing them with a listening space and offering them guidance to understand and deal with patients; and dissent in the face of the perception of changes observed in the patients' lives, prompting relatives to refer patients for involuntary hospitalization in psychiatric institutions.

Processos de trabalho dos profissionais dos Centros de Atenção Psicossocial: revisão integrativa / Working processes of professionals at Psychosocial Care Centers (CAPS): an integrative review

Resumo Trata-se de uma revisão integrativa da literatura acerca dos processos de trabalho dos profissionais dos Centros de Atenção Psicossocial (CAPS), refletindo sobre as práticas dos serviços, destacando a reinserção social dos usuários, através do cumprimento da perspectiva biopsicossocial. A bibliografia levantada objetiva demonstrar como os processos de trabalho estão sendo desenvolvidos pelos profissionais dos CAPS, e suas repercussões para o usuário desse serviço. A revisão da literatura foi feita nas bases de dados Lilacs, SciELO e PubMed, em Português, Inglês e Espanhol, com o produto de 57 artigos que foram analisados e organizados em planilha Excel. Este estudo mostrou deficiências na quantidade e qualidade dos recursos físicos, humanos e materiais, fragilidade da rede em saúde mental, além de identificar dissonâncias no atendimento aos usuários e seus familiares, o que leva à redução da qualidade nos processos de trabalho. Os desfechos mais pautados foram acolhimento, projeto terapêutico singular e a territorialização como dissonância na proposta de desinstitucionalização. Este trabalho reúne experiência e conhecimentos profissionais espalhados por todo o país, com notas que orientam o redirecionamento das práticas assistenciais.

Abstract This is an integrative review of the literature on the working processes of professionals staffing the Psychosocial Care Centers (CAPS), reflecting on service practices, in particular social reinsertion of service users from the bio-psychosocial perspective. The literature review aims to show how working processes are being developed by CAPS professionals, and the repercussions for service users. This literature review used the Lilacs, SciELO and PubMed databases in Portuguese, English and Spanish, selecting 57 articles that were analyzed and organized using an Excel spreadsheet. This study revealed shortcomings in the amount and quality of physical, human and material resources, a fragile mental health network, and dissonances in the care provided to users and their families, reducing the quality of the working processes. The outcomes mentioned most often were intake, unique therapeutic project and territory as dissonant components of the de-institutionalization proposal. This work combines the experience and knowledge of professionals across the country, with score to guide the re-direction of care practices.

Desinstitucionalização de pacientes de longa permanência de um hospital psiquiátrico no Rio de Janeiro / Deinstitutionalization of long stay patients in a psychiatric hospital in Rio de Janeiro

Resumo A Critical Time Intervention (CTI) é uma intervenção de saúde mental limitada no tempo a períodos considerados críticos, geralmente ofertada a pessoas com transtornos mentais em situação de transição. O presente estudo avalia o impacto da utilização da Intervenção para Períodos de Transição (CTI-BR) sobre o desempenho social e a qualidade de vida em uma população de pessoas em processo de desinstitucionalização, que deixaram um hospital psiquiátrico após longa internação. A população estudada foi dividida em dois grupos e um deles recebeu o programa CTI como intervenção adicional. Os resultados apontaram que nas áreas avaliadas a presença da intervenção CTI não apresentou evidência de vantagens em relação ao programa habitual da instituição realizado isoladamente. Quando o grupo de pacientes é analisado em seu conjunto é evidenciada uma evolução positiva em relação ao comportamento social e melhora da sua percepção sobre a própria saúde mental. Os resultados obtidos indicam a possibilidade de pessoas idosas oriundas de longa internação em hospital psiquiátrico viverem em dispositivos residenciais comunitários supervisionados por equipes de acompanhamento clínico.

Abstract Critical Time Intervention (CTI) is a time-limited mental health intervention offered to people with mental disorders during critical/transition periods. This study assesses the impact of CTI-BR on social performance and quality of life within a population in the process of deinstitutionalization, after long-term hospitalization in a psychiatric institution. The study population was split into two groups, one of which received CTI plus the regular care. Results showed no advantage of the intervention compared to the regular programs provided by the institution. When study participants are analyzed as a group, we found positive improvement regarding their social functioning and self-perception of their mental-health. Results show that it is possible for elderly patients discharged from long-term psychiatric care to live in residential facilities in the community, supervised by clinical teams.

Anxious and depressed women's experiences of emotional suffering and help seeking in a Rio de Janeiro favela / Experiências de mulheres ansiosas e deprimidas sobre sofrimento emocional e busca de cuidado em uma favela do Rio de Janeiro

Abstract Taking into consideration issues such as stigma and the mental health gap, this study explores narratives of anxious and depressed women treated in a community-based primary care service in a Rio de Janeiro favela about their suffering and care. We analysed 13 in-depth interviews using questions from Kadam's study. Framework analysis studied Access, Gateway, Trust, Psychosocial Issues, and Primary Mental Health Care, as key-concepts. Vulnerability and accessibility were the theoretical references. Thematic analysis found “suffering category”, highlighting family and community problems, and “help seeking category”, indicating how these women have coped with their emotional problems and addressed their needs through health services, community resources and self-help. Women's language patterns indicated links between implicit social rules and constraints to talk about suffering, especially if related to local violence. High medical turnover and overload are barriers for establishing a positive relationship with family physicians and continuity of care is a facilitator that promotes trust, security and adherence. Concluding, to plan community-based primary mental health care of this population, cultural and social factors must be comprehended as well as the work health teams conditions.

Resumo Considerando o estigma e a lacuna de acesso ao cuidado em saúde mental, o estudo explorou narrativas de mulheres ansiosas e deprimidas, atendidas na Clínica da Família em favela do Rio de Janeiro, sobre sofrimento e cuidado. Analisou-se 13 entrevistas em profundidade a partir das perguntas do estudo de Kadam. Os dados foram dispostos em Framework, tendo Acesso, Porta de Entrada, Confiança, Questões Psicossociais e Saúde Mental na Atenção Primária como conceitos norteadores. Vulnerabilidade e acessibilidade embasaram teoricamente essa leitura. Do estudo temático emergiram as categorias: “sofrimento emocional” onde se destacam os problemas familiares e comunitários e “busca de ajuda” revelando o papel dos serviços de saúde, recursos comunitários e a autoajuda no enfrentamento do sofrimento emocional. Regras sociais implícitas constrangem as mulheres. sendo observados padrões de linguagem específicos ligados à vulnerabilidade e à violência. Alta rotatividade e sobrecarga dos profissionais são barreiras para uma relação positiva com essas mulheres ao passo que a continuidade do cuidado é facilitador da confiança no profissional, gerando segurança e adesão. Conclui-se ser crucial considerar fatores socioculturais e condições adequadas de trabalho das equipes para o cuidado integral dessa população.

Rede de cuidado em saúde mental: visão dos coordenadores da estratégia saúde da família / Red de atención em salud mental: percepción de gestores de la estrategia salud de la familia / Mental health care network: the views of coordinators of the Family Health Strategy (FHS)

RESUMO Objetivo Objetivou-se analisar a visão de coordenadores da Estratégia Saúde da Família (ESF) sobre a conformação da rede de saúde mental no município de Pelotas/RS. Método Estudo descritivo e exploratório, com abordagem qualitativa, realizado com seis coordenadores de ESF no ano de 2012. Para a coleta dos dados, foi utilizada a entrevista semiestruturada, e os resultados foram avaliados por análise temática. Resultados A rede construída pelos coordenadores é composta por poucos serviços formais e focada no Centro de Atenção Psicossocial (CAPS), e a rede informal é descrita com maiores pontos de cuidado. As trocas de corresponsabilidade no cuidado em rede ocorrem de forma frágil, sem o diálogo necessário. Conclusão Os coordenadores demonstram pouco conhecimento da rede formal de cuidado e uma atenção focada nos serviços da ESF e no CAPS. Reconhecem a importância de haver políticas públicas que valorizem e ampliem os espaços informais de cuidado no território.

RESUMEN Objetivo Se tuvo como objetivo analizar la visión de coordinadores de la Estrategia Salud de la Familia (ESF) sobre la configuración de la red de salud mental en el Municipio de Pelotas/RS. Método Estudio descriptivo y exploratorio, cualitativo, realizado con seis coordinadores de ESF en 2012. Se utilizó la entrevista semestructurada y los datos fueron analizados con uso del análisis temático. Resultados La red señalada por los coordinadores posee pocos servicios formales, enfocada en el Centro de Atención Psicosocial (CAPS). La red informal es más diversificada, pero los cambios de corresponsabilidad en el cuidado es de modo frágil. Conclusión Los coordinadores tienen poco conocimiento de la red formal de cuidado, con énfasis en la ESF y en el CAPS. Reconocen la importancia de que haya políticas públicas que valoren y amplíen los espacios informales de cuidado en el territorio, algo necesario en el cuidado en salud mental.

ABSTRACT Objective This study aimed to analyze the opinions of the coordinators of the Family Health Strategy (FHS) on the mental health care network in the city of Pelotas/RS. Method Descriptive and exploratory study with a qualitative approach, carried out with six FHS coordinators, in 2012. Semi-structured interview was used in data collection, and the results were evaluated using the thematic analysis. Results The network designed by the coordinators consists of few formal services and is focused on the Psychosocial Care Centers (CAPS). The informal network has a greater number of care units. Exchange of information related to joint responsibilities in the care is scarce, with lack of dialogue. Conclusion The coordinators have scarce knowledge on the formal care network and on care focused on the ESF and CAPS. They also recognize the importance public policies that value and expand the informal care spaces in the territory.

Propuesta para abordar los problemas de salud mental detectados en el proceso diagnóstico de la Delegación Presidencial para la reconstrucción tras el terremoto del 27 de febrero de 2010 / Proposal to address the mental health problems detected after the February 27, 2010 earthquake

One of the most important topics mentioned by people from places affected by the February 27th, 2010 earthquake to the Presidential Delegation for the Reconstruction, was the urgent need of mental health care. Given the enormous individual and social burden of mental health sequelae after disasters, its treatment becomes a critical issue. In this article, we propose several actions to be implemented in Chile in the context of the process of recovery and reconstruction, including optimization of social communication and media response to disasters; designing and deployment of a national strategy for volunteer service; training of primary care staff in screening and initial management of post-traumatic stress reactions; and training, continuous education and clinical supervision of a critical number of therapists in evidence-based therapies for conditions specifically related to stress.

Reliability and reproducibility of three-dimensional cephalometric landmarks using CBCT: a systematic review

Objective : The aim of this study was to review the reliability and reproducibility of 3D-CBCT (cone beam computed tomography) cephalometric landmark identification. Methods : Electronic databases (Pubmed, Scopus, Web of Science) were searched for papers published from 1998 to October 2014. Specific strategies were developed for each database, with the guidance of a librarian. Two reviewers independently analyzed the titles and abstracts for inclusion. The articles that met the inclusion and exclusion criteria were selected for full-text reading, and the selected articles went through methodological quality evaluation. After the exclusion of repeated articles, the titles of the remaining ones were read and 1,328 of them were excluded. The abstracts of 173 articles were read, of which 43 were selected, read in full and submitted to the inclusion and exclusion criteria. Fourteen articles or studies with reliable methodology and reproducibility remained. The data were collected, organized into figures and analyzed for determination of the reliability and reproducibility of the three-dimensional cephalometric landmarks. Results : Overall, the landmarks on the median sagittal line and dental landmarks had the highest reliability, while the landmarks on the condyle, porion and the orbitale presented lower levels of reliability. Point S must be marked in the multiplanar views associated with visualization in 3D reconstruction. Further studies are necessary for evaluating soft tissue landmarks. .

Child and adolescent mental health services in Brazil: structure, use and challenges / Serviços de saúde mental para crianças e adolescentes no Brasil: estrutura, uso e desafios

To examine the state of Child and Adolescent Mental Health (CAMH) services and to compare the availability and use of CAMH services across the five regions of Brazil. Methods: the Mental Health Matrix Model was used as a framework to describe the state of CAMH services. Documents and administrative datasets were consulted, covering the whole country and the five Brazilian regions as separate levels. This enabled crossregion comparisons and combination with thethree temporal dimensions (Input, Process andOutcome) Results: although there are national policies regulating CAMH, along with an integral protection doctrine, scarcity of services was unequally distributed across the regions. A number of trends relating to social development and mental health (e.g. intellectual disability treated prevalence) were also identified. Conclusion: substantial advances in CAMH policy characterize the contemporary Brazilian CAMH system, especially regarding the implementa tion of community based mental health services for children and adolescents. However, the data reveals great inequalities and geographic variation regarding social indicators, service structure and use...

Analisar a situação dos serviços de saúde mental para crianças e adolescentes ecomparar a disponibilidade e uso dos mesmos entre as cinco macrorregiões do Brasil. Métodos: utilizou-se o The Mental Health Matrix Model como marco referencial para descrever a situação dos serviços de saúde mental para crianças e adolescentes. Analisaram-se documentos e dados originais de bases administrativas do governo federal. Isso permitiu a comparação entre as regiões e em relação ao tempo (investimentos, processos e resultados) Resultados: embora existam políticas e regulamentos nacionais sobre a saúde mental de crianças e adolescentes, alinhadas com a doutrina da proteção integral, verificouse um insuficiente número de serviços com uma distribuição desigual entre as macrorregiões. Adicionalmente, foi possível identificar tendências relacionadas ao desenvolvimento social e a saúde mental (ex. prevalência de atendimentos em deficiência intelectual) Conclusões: avanços substanciais nas políticas caracterizam o sistema brasileiro de saúde mental para crianças e adolescentes principalmente no que se refere à implementação de serviços de base comunitária. No entanto, os dados mostram desigualdade evariações regionais dos indicadores sociais, de estrutura e uso dos serviços...

Os centros de atenção psicossocial infantojuvenis: característicasorganizacionais e oferta de cuidados / The youth and adolescents psychosocial care centers: organization characteristics and care supply

Os objetivos deste artigo são identificar as características gerais do funcionamento e desafios na organização dos Centros de Atenção Psicossocial Infantojuvenis e abordar sob a ótica dos técnicos dos serviços as implicações do funcionamento na qualidade do serviço. O estudo foi desenvolvido em 4 CAPSi do Estado de São Paulo e participaram os coordenadores dos serviços e 17 técnicos com formação em nível superior. Os instrumentos para coleta de dados foram fichas de identificaçãodos serviços, preenchidas pelos coordenadores, e roteiro de entrevista semi-estruturada, para os técnicos. Os dados foram submetidos à análise descritiva e à técnica do Discurso do Sujeito Coletivo. Os resultados evidenciam aspectos gerais da organização dos serviços como tempo de funcionamento, população de abrangência, quantidade de usuários inseridos, composição das equipes de trabalho e principais ofertas de cuidado para as crianças e adolescentes em intenso sofrimento psíquico e apresentam-se discutidos à luz das políticas para o campo. Evidenciou-se que os CAPSi têm atendido uma população maior que a indicada e queos principais recursos oferecidos consistem nos atendimentos individuais, o que pode oferecer ferramentas para o entendimento de que ainda há dificuldades na organização do trabalho tal comopreconizado pelas normativas.

We present a study identifying the general characteristics on the working challenges at the organization of the Youth and Adolescents Psychosocial Care Centers (in Portuguese, Centros de Atenção Psicossociais Infantojuvenis –CAPSi) as well as to approach, under the vision of the technicians, the implications of the working in the quality of the service. It counted on 17 graduated professionals inserted in four CAPSi in São Paulo State. The tools used for data gathering were: identification cards of the services completed by the coordinators and semi-structured interview scripts for technicians. The data was subjected to descriptive analysis and to the Collective Subject Discourse technique (in portuguese, Discurso do Sujeito Coletivo). The results show general aspects of the organization of the services as: working time, attended population, quantity of inserted users,staffing and the main care offerings for youth and adolescentes in intense psychic suffering and are discussed at the light of the policies for the field. We show that the CAPSi have attended a greater population than that preconized and that the main resourceoffered consist of individual attendance, what can offer tools forunderstanding that there are still difficulties in the organization on the work as preconized by the normatives.

Trastornos del desarrollo intelectual en América Latina: un marco para establecer las prioridades políticas de investigación y atención / Intellectual development disorders in Latin America: a framework for setting policy priorities for research and care

Los trastornos del desarrollo intelectual (TDI) son un grupo de alteraciones del desarrollo caracterizadas por una notable limitación de las funciones cognitivas, trastornos del aprendizaje y de las habilidades y conductas adaptativas. Anteriormente agrupados bajo el término discapacidad intelectual, constituyen un problema poco estudiado y cuantificado en América Latina. Los afectados están ausentes en las políticas públicas y no se benefician de las estrategias gubernamentales de desarrollo social y reducción de la pobreza. En este artículo se aporta una visión crítica de los TDI y se describe una nueva taxonomía. Además, se propone reconocerlos como problema de salud pública, promover la profesionalización de la atención, y sugerir una agenda de investigación y acción regional. En América Latina no hay consenso sobre los criterios diagnósticos de los TDI. Pocos programas de rehabilitación cubren una proporción importante de las personas que los padecen, no se ofrecen servicios basados en la evidencia científica y las directrices de atención no se han evaluado. Los manuales de diagnóstico psiquiátrico conceden más importancia a la identificación de los TDI graves, favorecen su subregistro y clasificaciones erróneas. Su estudio no se ha priorizado desde las perspectivas jurídica, de las ciencias sociales y de la salud pública. Por ello escasean las pruebas científicas sobre estos trastornos. Faltan competencias específicas y profesionalización para el cuidado de estas personas y es indispensable realizar intervenciones de prevención, rehabilitación, integración comunitaria e inclusión laboral.

Intellectual development disorders (IDDs) are a set of development disorders characterized by significantly limited cognitive functioning, learning disorders, and disorders related to adaptive skills and behavior. Previously grouped under the term "intellectual disability," this problem has not been widely studied or quantified in Latin America. Those affected are absent from public policy and do not benefit from government social development and poverty reduction strategies. This article offers a critical look at IDDs and describes a new taxonomy; it also proposes recognizing IDDs as a public health issue and promoting the professionalization of care, and suggests an agenda for research and regional action. In Latin America there is no consensus on the diagnostic criteria for IDDs. A small number of rehabilitation programs cover a significant proportion of the people who suffer from IDDs, evidence-based services are not offered, and health care guidelines have not been evaluated. Manuals on psychiatric diagnosis focus heavily on identifying serious IDDs and contribute to underreporting and erroneous classification. The study of these disorders has not been a legal, social science, or public health priority, resulting in a dearth of scientific evidence on them. Specific competencies and professionalization of care for these persons are needed, and interventions must be carried out with a view to prevention, rehabilitation, community integration, and inclusion in the work force.

Terapia comunitária integrativa: situações de sofrimento emocional e estratégias de enfrentamento apresentadas por usuários / Terapia comunitaria integradora: situaciones de angustia emocional y estrategias de afrontamiento presentadas por los usuarios / Community integrative therapy: situations of emotional suffering and patients' coping strategies

A Terapia Comunitária Integrativa (TCI) surge como uma estratégia de apoio à saúde mental dos usuários do Sistema Único de Saúde. O estudo tem como objetivo identificar os principais problemas apresentados pelos usuários da terapia comunitária e identificar as estratégias que utilizam no enfrentamento das situações que provocam sofrimento emocional. Pesquisa do tipo documental realizada na Secretaria Municipal de Saúde, tendo como fontes de informações fichas de organização de dados da TCI. Os resultados demonstraram que o problema mais frequente é o estresse, que a estratégia de enfrentamento mais utilizada é a espiritualidade, e que através dos discursos dos participantes é possível perceber a opinião positiva que eles têm dos encontros. A TCI é um espaço onde as relações construídas transmitem apoio emocional, fortalecem vínculos e diminuem os casos de exclusão social.

La Terapia Comunitaria Integradora (TCI) se ha convertido en una estrategia de apoyo de salud mental a los usuarios del Sistema Nacional de Salud. El estudio tiene como objetivo identificar los principales problemas presentados por los usuarios de la atención comunitaria e identificar las estrategias que utilizan para afrontar las situaciones que causan estrés emocional. La investigación fue documental celebrada en el Municipal de Salud en el que las fuentes de información fichas para organizar los datos de la TCI. Los resultados mostraron que el problema más frecuente es el estrés, la estrategia de enfrentamiento más utilizada es la espiritualidad, y a través de los discursos de los participantes es posible percibir la connotación positiva que tienen las reuniones. La TCI es un espacio donde las relaciones construidas transmiten apoyo emocional, fortalecen los vínculos y reducen los casos de exclusión social.

Community Integrative Therapy (CIT) has emerged as a strategy to support the mental health of users of the public Unified Health System (SUS). This study had the objective to identify the principal problems presented by patients of group therapy, and to identify strategies that they use to cope with situations that cause emotional suffering. Secondary research carried out at the Municipal Secretary of Health, with information sources being organization forms with data from CIT. The results demonstrate that the most frequent problem [cause of suffering] is stress, the coping strategy most used is spirituality, and through the discourses of the participants it is possible to perceive the positive perception that they have of the meetings. CIT is a space where the relationships that are forged transmit emotional support, strengthen ties and diminish cases of social exclusion.

Ampliando los márgenes de la clínica. Trayectoria de un Programa de Salud Mental Comunitaria para niños, niñas y adolescentes desde una perspectiva de derechos en la Ciudad de Buenos Aires / [Expanding the boundaries of clinics. Development of a community mental health program for children and teenagers from a rights perspective in the City of Buenos Aires].

There are forms of severe suffering in contemporary life that are not accommodated within the mechanisms offered by the mental health care system or that are not described on diagnostics handbooks, which need an appropriate response. This paper deals with the development of a community mental health program that provided care to children and teenagers with severe mental disorders and with a significant subjective suffering in the City of Buenos Aires from 2006 until the beginning of 2012. Pursuant to international standards in force in terms of mental health and human rights, this community, collective and territorial mental health practice suggested an inter-discipline and cross-sector approach that took into consideration the multi-dimension of social health determiners to provide comprehensive care. In order to offer a reply to fragmentation and the repeated traumas to which a large number of these children and teenagers have been exposed to, the program designed individual clinical-community strategies for each child or teenager, based on a network of continuous and reliable institutional supports. Conceived from a psychoanalytical approach, this praxis intended to benefit subjectification processes and the building of social bonds aiming at preventing the growing trends of administering medication and admitting children and teenagers as patients in mental health facilities.

Accesibilidad y derechos humanos: Análisis de los procesos de atención alternativos al modelo asilar en Santa Fe y Tierra del Fuego / Accessibility and Human Rights. Analysis of the Care Processes Alternative to the Asylum-centered Model in Santa Fe and Tierra del Fuego

INTRODUCCIÓN: El tema desarrollado en este escrito se basa en la indagación en la accesibilidad y derechos humanos en Salud Mental. La profundización en el conocimiento sobre la trayectoria de acceso a la atención de los padecimientos mentales desde diversos efectores generales puede contribuir a generar aportes innovadores que pueden ser orientadores en el diseño de políticas públicas. OBJETIVO: Analizar la trayectoria de accesibilidad en salud mental en los efectores generales de salud del subsector público, estudiando los casos de las provincias de Santa Fe y Tierra del Fuego (Argentina) en el marco de los dispositivos alternativos y/o sustitutivos del modelo asilar. MÉTODOS: Diseño cualitativo, de tipo descriptivo-analítico y de corte transversal, con una muestra no probabilística de carácter intencional. RESULTADOS: Con diferencias, las dos provincias analizadas se encuentran consolidando espacios alternativos y sustitutivos al manicomio. La presencia física del hospital monovalente (así esté situado dentro de la jurisdicción o fuera de su territorio) genera trayectorias que aún lo ubican como un efector más en el engranaje de la asistencia. El hospital general sigue generando resistencias para adecuar su dinámica institucional al abordaje de problemáticas vinculadas al padecimiento mental y a situaciones de vida complejas.CONCLUSIÓN: La atención primaria de la salud es un espacio privilegiado para fortalecer trayectorias de acceso con base en los derechos de los usuarios de los servicios de salud mental

INTRODUCTION: The main focus in this paper is related to the exploration of accessibility and human rights in mental health. Deepen the knowledge about access trajectory related to assist mental suffering of the different general services may contribute to generate innovative inputs to design public policies. OBJECTIVE: To analyze the accessibility in general health services of the public sector, considering the cases of the provinces of Santa Fe and Tierra del Fuego (Argentina), with in the context of schemes which are alternative and/or substitutive to asylum-centered model. METHODS: Qualitative descriptive, analytical and cross-sectional design, combined with an intentional and non-probabilistic sample. RESULTS: Although with differences, both provinces are consolidating alternative and substitutive services to the insane asylum. The physical presence of monovalent psychiatric hospital(whether located with in the jurisdiction or outside its territory) generates trajectories that still place it as a valid service in the health care scheme. The general hospital still generates resistance to adapt its institutional dynamics to dealing with issues related to mental suffering and complex life situations. CONCLUSIONS: Primary health care is a privileged space to strengthen access trajectories based on the rights of mental health services users

Lessons from scaling up a depression treatment program in primary care in Chile / Enseñanzas derivadas de la ampliación de un programa para el tratamiento de la depresión en atención primaria en Chile

In Chile, the National Depression Detection and Treatment Program (Programa Nacional deDiagnóstico y Tratamiento de la Depresión, PNDTD) in primary care is a rare example ofan evidence-based mental health program that was scaled up to the national level in a low- ormiddle-income country. This retrospective qualitative study aimed to better understand howpolicymakers made the decision to scale up mental health services to the national level, andto explore the elements, contexts, and processes that facilitated the decision to implementand sustain PNDTD. In-depth semistructured interviews with six key informants selectedthrough intentional sampling were conducted in August–December 2008. Interviewees weresenior officers at the Ministry of Health who were directly involved in the decision to scale upthe program.Results yielded four elements pivotal to the decisionmaking process: scientific evidence,teamwork and leadership, strategic alliances, and program institutionalization. Each elementcontributed to building consensus, securing funding, attracting resources, and gaining lastingsupport from policymakers. Additionally, a review of available documentation led the authorsto consider sociopolitical context and use of the media to be important factors.While research evidence for the effectiveness of mental health services in the primary caresetting continues to accumulate, low- and middle-income countries should get started on thelengthy process of scaling up by incorporating the elements that led to decisionmaking andimplementation of the PNDTD in Chile.

En Chile, el Programa Nacional de Diagnóstico y Tratamiento de la Depresión(PNDTD) en atención primaria constituye un raro ejemplo de programa de saludmental basado en la evidencia ampliado al nivel nacional en un país de ingresos medioso bajos. Con este estudio retrospectivo cualitativo se buscó conocer más a fondola forma en que los responsables de las políticas tomaron la decisión de ampliar losservicios de salud mental al nivel nacional e investigar los elementos, contextos y procesosque facilitaron la decisión de implementar y mantener el PNDTD. Entre agostoy diciembre de 2008, seis informantes clave seleccionados mediante muestreo intencionalllevaron a cabo entrevistas en profundidad semiestructuradas. Los entrevistadoseran funcionarios de alto nivel del Ministerio de Salud directamente involucradosen la decisión de ampliar el programa.Los resultados arrojaron cuatro elementos fundamentales para el proceso de tomade decisiones: las pruebas científicas, el trabajo en equipo y el liderazgo, las alianzasestratégicas y la institucionalización del programa. Los cuatro elementos contribuyerona la creación de consensos, la obtención de financiamiento, la captación derecursos y la obtención de un apoyo duradero por parte de los responsables de laspolíticas. Además, la revisión de la documentación disponible llevó a los autores aconsiderar al contexto sociopolítico y el uso de los medios factores importantes.Mientras se siguen acumulando datos de investigación sobre la eficacia de losservicios de salud mental en la atención primaria, los países con ingresos medios ybajos deben comenzar el largo proceso de ampliación incorporando los elementos quecondujeron a la toma de decisiones y la implementación del PNDTD en Chile.

Integrating mental health into primary care: an integrative collaborative primary care model - the Jamaican experience / Integrar la salud mental en la atención primaria: un modelo de integracional de la atención primaria - la experiencia jamaicana

Many low-income countries face enormous constraints which limit the development of mental health services. The World Health Organization (WHO) made ten recommendations to facilitate the development of mental health services; among these is the integration of mental health into primary care. Jamaica developed an integrated collaborative system of mental health care through the adoption of a primary care model which is central to the delivery of mental health care. This model emphasized the integration of mental health into primary care and, in expanding the role of the mental health team, made it more collaborative. Mental health services were mainstreamed into primary care and several strategies facilitated this process. These included the training of staff in primary care, the availability of psychotropic medication in primary care facilities and the provision of mental health beds at the community level. Furthermore, focus was placed on human development and the involvement of consumers in the policy development and service delivery. This has resulted in a reduction in the population of the mental health hospital and expansion in the community mental health services.

Muchos países de bajo ingreso enfrentan enormes restricciones que limitan el desarrollo de los servicios de salud mental. La Organización Mundial de la Salud (OMS) hizo diez recomendaciones para facilitar el desarrollo de los servicios para la salud mental. Entre estas recomendaciones, se encuentra la integración de la salud mental a la atención primaria. Jamaica desarrolló un sistema integracional colaborativo de atención a la salud mental a través de la adopción de un modelo de atención primaria de crucial importancia para el ofrecimiento del cuidado de salud mental. Este modelo puso el énfasis en la integración de salud mental en la atención primaria, y la expansión del papel del equipo de la salud mental, haciéndolo más colaborativo. Los servicios de salud mental fueron introducidos de manera regular en la atención primaria, y se trazaron varias estrategias a fin de facilitar este proceso. Éstas incluyeron el entrenamiento de personal en atención primaria, la disponibilidad de medicamentos psicotrópicos en los centros de atención primaria, y suministro de camas para la atención a la salud mental a nivel comunitario. Además, se puso énfasis en el desarrollo humano y la involucración de los consumidores en el desarrollo de políticas y el ofrecimiento de servicios. Esto ha traído consigo una reducción en la población hospitalaria atendida por salud mental, en tanto que por otra parte, ha producido una expansión en los servicios de salud mental en la comunidad.

Deinstitutionalization and attitudes toward mental illness in Jamaica: a qualitative study / Externamiento psiquiátrico y actitudes hacia las enfermedades mentales en Jamaica: estudio cualitativo

OBJECTIVE: To consider whether or not deinstitutionalization and the integration of community mental health care with primary health care services have reduced stigma toward mental illness in Jamaica. METHODS: A qualitative study of 20 focus groups, with a total of 159 participants grouped by shared sociodemographic traits. Results were analyzed using ATLAS.ti software. RESULTS: Participant narratives showed that stigma had transitioned from negative to positive, from avoidance and fear of violent behavior during the period of deinstitutionalization to feelings of compassion and kindness as community mental health services were integrated with Jamaica's primary health care system. The Bellevue Mental Hospital and homelessness were identified as major causes of stigma. CONCLUSIONS: Attitudes toward the mentally ill have improved and stigma has decreased since the increase of community involvement with the mentally ill. This reduction in stigma seems to be a result of the rigorous deinstitutionalization process and the development of a robust community mental health service in Jamaica.

OBJETIVO. Evaluar si el externamiento psiquiátrico y la integración de los servicios comunitarios de salud mental con los servicios de atención primaria de salud han reducido el estigma respecto de las enfermedades mentales en Jamaica. MÉTODOS. Estudio cualitativo de 20 grupos de opinión con un total de 159 participantes agrupados según sus características sociodemográficas. Se analizaron los resultados con el software ATLAS.ti. RESULTADOS: Los relatos de los participantes revelaron que, cuando los servicios comunitarios de salud mental se integraron con el sistema de atención primaria de salud de Jamaica, el estigma había pasado de negativo a positivo y de la evitación y el temor a un comportamiento violento durante el período de externamiento a sentimientos de compasión y amabilidad. Las principales causas de estigma identificadas fueron el modelo de atención del hospital mental Bellevue y vivir en las calles. CONCLUSIONES: Las actitudes hacia los enfermos mentales han mejorado y el estigma ha disminuido desde que aumentó la relación de la comunidad con los pacientes. Esta reducción del estigma parece deberse al proceso riguroso de externamiento psiquiátrico y al desarrollo de un servicio comunitario de salud mental sólido en Jamaica.

Relações do cotidiano: a pessoa com transtorno mental e sua rede de suporte social / Everyday life relationships: people with mental health problems and their social network

O presente estudo buscou conhecer a vida cotidiana de egressos de hospitais psiquiátricos que foram reinternados num período inferior a seis meses. Teve como objetivos conhecer a rede social desta população e analisar suas possibilidades de inclusão social. Foi utilizado o conceito de cotidiano de Agnes Heller como referencial teórico e o conceito de Reabilitação Psicossocial como categoria analítica da pesquisa. Foram realizadas 22 entrevistas semiestruturadas com pessoas com transtorno mental reinternadas em hospitais psiquiátricos e seus familiares, buscando investigar o cotidiano desta população no período entre internações. As entrevistas foram então submetidas à análise do discurso, que revelou que os usuários encontram dificuldades de inclusão social mesmo quando fora do hospital psiquiátrico. Foram relatadas a dinâmica de exclusão e inclusão dos usuários no núcleo familiar e as possibilidades e apoios sociais encontrados na comunidade. Recomenda-se um cuidado especial na atenção aos familiares, o combate ao preconceito e a atuação dos serviços em saúde mental, para facilitar a participação dos usuários em espaços comunitários.

This study analyzed everyday life of patients who had been discharged from a psychiatric hospital and were readmitted in a period of less than six months. It aimed to know this population's social network and analyze their possibilities of social inclusion. The everyday life concept of Agnes Heller was used as a theoretical basis and the Psychosocial Rehabilitation concept was used as an analytic category. It comprised 22 semistructured interviews with people with mental health problems readmitted in a psychiatric hospital and their relatives, seeking explore the everyday life of this population in the period between admissions. The interviews were submitted to discourse analysis, which revealed that the users find difficulties in social inclusion even when they are outpatients, it expresses the users social exclusion and inclusion dynamic in the family and the possibilities and social support found in the community. It recommends especial attention to patients' family care, fighting prejudice, and the work of mental health services to facilitate the user participation in community spaces.