The fallacy of adequate coverage offered by Psychosocial Care Centers in the state of Rio Grande do Sul: a comment

EDITORIAL

The fallacy of adequate coverage offered by Psychosocial Care Centers in the state of Rio Grande do Sul: a comment

Fernando Lejderman*

*Médico psiquiatra, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil. Ex-presidente, APRS (2008/2009).

Correspondence

According to official October 2009 data from the Brazilian Ministry of Health Office of the Coordinator for Mental Health (Coordenadoria de Saúde Mental), Brazil's network of Psychosocial Care Centers (Centros de Atenção Psicossocial, CAPS) currently numbers 1,467 facilities for a population of 189,612,814 inhabitants, meaning that coverage reaches only 60% of the Brazilian population.¹ Data show that the state of Rio Grande do Sul has 129 Psychosocial Care Centers for a population of 10,855,214, which gives a rate of 0,91 CAPS per 100,000 inhabitants. The state holds the third highest spot on the nationwide ranking of CAPS care coverage, with a rating of "very good."² The CAPS per 100,000 inhabitants indicator considers that Level 1 Centers (CAPS I) provide coverage for 50,000 inhabitants, Level 3 Centers (CAPS III) cover 150,000 residents, and Tier 2 Centers (CAPS II), Child Psychosocial Care Centers (CAPSi), and Psychoactive Substance User Psychosocial Care Centers (CAPSad) each provide coverage for 100,000 inhabitants. The following ranges are adopted: very good coverage (more than 0.70 Centers per 100,000), fair/good coverage (0.50 to 0.69), fair/poor coverage (0.35 to 0.49), poor coverage (0.20 to 0.34), and insufficient/critical coverage (less than 0.20).^3,4

The merit of the study conducted by Gonçalves et al.⁵ with March 2009 data lies in its finding that the mere ratio of Psychosocial Care Centers to inhabitants in the state of Rio Grande do Sul does not suffice for determining the quality of a mental health indicator. As they set out differences in the number of municipalities in each health care region of the state of Rio Grande do Sul and analyzed the distribution of CAPS among these regions, the authors of the study found efficient coverage in only 12 of the state's 19 regions, or 63% of regional health areas. Specific analysis of the population served by Psychosocial Care Centers in each of these regions provides an even bleaker outlook: only 51% of the population of Rio Grande do Sul has adequate CAPS coverage, and 43.5% of the state's inhabitants live in municipalities in which coverage rates are 30% below expected levels.

According to the Brazilian Ministry of Health,⁶ Psychosocial Care Centers constitute the main strategy of the psychiatric reform movement that has been gradually implemented in Brazil over the past few decades. The primary functions of these Centers would be to: 1) provide clinical care for psychiatric patients in the day care setting; 2) prevent institutionalization and admission to psychiatric hospitals; 3) promote the integration of mentally ill individuals into society and into their families; and 4) support the provision of mental health care by the basic health network.

If the state of Rio Grande do Sul, which ranks third best in Brazil in terms of coverage provided by Psychosocial Care Centers, provides insufficient coverage for nearly 50% of its population, as shown by Gonçalves et al.,⁵ what can one expect from the rest of the country? What can be expected of a mental health care reform that, over the past few decades, scrapped approximately 80,000 psychiatric beds without first implementing a countrywide outpatient care network truly capable of providing care and coping with the complexity of mental illness?

The current state of mental health care in Brazil is dire and worrisome. One must understand that a delirious individual or one permanently under the influence of alcohol or drugs will not agree spontaneously to treatment. The number of mentally ill persons living in homelessness has been rising alarmingly in recent years. On the streets, these patients become helpless in terms of their underlying conditions, their psychological status deteriorates, and they find themselves at increased risk for exposure to infectious diseases, such as hepatitis C, tuberculosis, and AIDS, leading to a state of complete physical and mental decay. Prisons are also gradually becoming alternate homes for the portion of mentally ill patients who eventually commit minor offenses or develop combativeness and psychomotor agitation.

Over 20 years have passed since the dawn of the psychiatric reform movement in Brazil - long enough to notice positive outcomes and correct the movement's directions, as initially advised. We must reflect on the remarks made by Gonçalves et al.⁵ in order to obtain a more accurate picture of the real care coverage provided by Psychosocial Care Center teams. Even more significant is the possibility of using these findings in the development and planning of future Ministry of Health policies for mental health.

REFERENCES

• ¹
  Brasil, Ministério da Saúde, Coordenação Nacional de Saúde Mental, Álcool e Outras Drogas. Departamento de Ações Programáticas Estratégicas/Secretaria de Atenção à Saúde/Ministério da Saúde (DAPES/SAS/MS). Brasília: MS; 2009.
• ²
  Brasil, Ministério da Saúde, Coordenação Nacional de Saúde Mental, Álcool e Outras Drogas. Número de Centros de Atenção Psicossocial (CAPS) por tipo e UF e indicador CAPS/100.000 habitantes. Brasília: MS; 2009.
• ³
  Brasil, Ministério da Saúde. Área Técnica de Saúde Mental/Departamento de Ações Programáticas Estratégicas/Secretaria de Atenção à Saúde/Ministério da Saúde (ATSM/DAPES/SAS/MS). Brasília: MS; 2009.
• 4. Instituto Brasileiro de Geografia e Estatística (IBGE). Estimativa populacional 2008. Brasília: IBGE; 2008.
• 5. Gonçalves VM, de Abreu PS, Candiago RH, Saraiva SS, Lobato MI, Belmonte-de-Abreu PS. A falácia da adequação da cobertura dos Centros de Atenção Psicossocial no estado do Rio Grande do Sul. Rev Psiquiatr RS. 2010;32(1):16-8.
• 6. Brasil, Ministério da Saúde. Portal da Saúde. www.saude.gov.br-saude mental. Acessado em 25/02/2010.

Publication Dates

• Publication in this collection
  28 July 2010
• Date of issue
  2010