Towards a community mental health care for people with schizophrenia in Colombia

Mental health care based on the community has shown to be effective and successful for the health care service to people with severe mental disorders such as schizophrenia, evidence that is less clear in the health care system in Colombia, where weaknesses are present, both for prevention and rehabilitation, although national guidelines give importance to the social context in relation to the disease. As a contribution to the discussion on providing care for people living with schizophrenia, a topic review was conducted with the aim of identifying experiences in community mental health care services, in relation to their relevance to these people at the national level. Articles were searched on Scientific Electronic Library Online (SciELO) Medline with Full text, Science Direct and documents of the World Health Organization, Pan American Health Organization and the Colombian Ministry of Health and Social Protection. Few experiences in community care for people with schizophrenia in Colombia were found and given its importance to public health worldwide, a call for attention is made towards the construction and implementation of these models in the Colombian context.


Introduction
The increasing prevalence of mental illness in the world has increased the gap in health care that can be provided to people with this type of problem, in addition to the fact that there are still difficulties in care processes managed from health systems, especially in low and middle-income countries 1 . In this situation there have been many calls on governments to expand and strengthen community mental health care as an alternative to reduce the difficulties that occur in relation to health care services for the entire population, specifically for people with mental and behavioral disorders 2,3 .
People who are diagnosed with schizophrenia represent a challenge not only for professionals in the area of health, but also for their families and society in general 4,5 . For example, at the early onset of symptoms, which affect young people in the phase of training and getting their basic education and involve decreasing productivity and inclusion in the community 5,6 and on the other hand, its recovery potential, which requires the active participation of health personnel, the person with the disease and their family towards a greater adherence to treatment and inclusion in society 7 . In this regard it is worth noting the increase in life expectancy of people with the disease, which means more investment and higher costs in health systems for their care 4,8 .
In contrast to the above, a high prevalence of suicide attempts are present. It was found that 20% to 50% of people with schizophrenia attempt suicide and 10% to 13% die from this cause 9 , thus this group of people are 20 times more likely to die than general population 10 . Thus, the family burden is increased so that the deterioration of relations and fatigue of caregivers are some of the conditions that complicate the care, attention and respect towards these persons 11,12 . Faced with this complex situation, which demands permanent research and management, it has been evident that in Colombia studies on schizophrenia are scarce, even with respect to their magnitude. The most recent data is from 1997, when the national study of mental health and psychoactive substances use recorded higher prevalence of this disease in the states of Guajira, Córdoba, Quindío and Magdalena, and morbidity of 1.4% in the total Colombian population 13 . In the state of Antioquia, in 2009, of all consultations in institutions of mental health care, 10.7% of them were for schizophrenia, schizotypal and delusional disorders 14 . Even more significant data when there are contextual conditions that are not conducive to mental health, such as violence. The limiting of access to psychiatry and psychology services quite notorious of the Colombian health system, economic barriers and understaffed personnel 15,16 .
In Colombia, there has traditionally been a model of care focused on the disease, which in the case of people with mental problems has been characterized by the search for diagnosis, treatment and prevention of serious consequences, always with the help of drugs and hospitalization in mental health units 17 .
The difficulties of access to mental health services have remained despite the advances in regulations aimed at protecting people with these diseases. Among the best known are the National Mental Health Policy in 1998 18 and the Law 1616 of Mental Health in 2013 19 . The first one was not implemented, despite its reference point that the development of mental illnesses is linked to context and socioeconomic conditions of persons 20,21 , and to seek, among other things, to improve the quality of care and comprehensiveness in rehabilitating individuals and communities 22 . Meanwhile, the law has not been regulated after more than two years after its approval.
Based on these elements and those found in the review on care from a community perspective that is provided to people with schizophrenia, as discussed below, it aims to generate discussion and critical reflection on the need to implement models of community mental health care services for people living with schizophrenia in Colombia.

Methods
A review of the topic was made by searching databases such as Scientific Electronic Library Online (SciELO), Medline with Full text and Science Direct using descriptors: schizophrenia, mental health care, community mental health and community psychiatry, taken from the Health Sciences Descriptors (DeCS for its initials in Spanish), with their respective terms in English. As selection criteria were used periods between 2000 and 2014 that had abstract, written in English, Portuguese or Spanish (Figure 1). The search focused by including "Colombia" in each of the descriptors, which means that 12 papers were selected. Likewise, the search engines of the World Health Organization (WHO) and the Pan American Health Organization (PAHO) were used and there were five documents selected.
From the few findings in Colombia, unlike what was found in the international arena and the recommendation of key documents in the field, by experts in mental health care services for people with schizophrenia, 34 articles were selected because of their relevance and contribution to the contrast of the specific findings in Colombia. For a total of 51 documents (Chart 1).
The three groups of texts selected allowed contextualizing the problem from both national and international levels and identifying official recommendations in the treatment of these cases. The relevance of articles and documents found, so that conceptually and methodologically contributed to meeting the objective, was taken into account.

Results
The findings presented below show various elements that related indicate the importance of community mental health care for people with schizophrenia in Colombia ( Figure 2). First, it is clear that this condition corresponds to a visible problem for public health, which requires a high burden of care and causes stress within the family, with obvious social discrimination and clear convenience of community-based treatment and rehabilitation. Experiences and practices that in Colombia are recommended but have been poorly documented a fact that is consistent with the low presence of mental health care services.

Schizophrenia, a public health problem
Schizophrenia has been for many years one of the most recognized mental illnesses in the world, given its psychopathological features and its high degree of chronicity 23,24 . According to WHO, in the world, mental and behavioral disorders represent 12% of the burden of illnesses 1,24-26 . In 2004, this same organization estimated that more than 26 million people worldwide were suffering from schizophrenia, making it one of the 20 leading causes of disability worldwide, Figure 1. Search criteria and selection of the texts found.

Beginning of the search
Descriptors (schizophrenia, mental health care, community mental health care services, community psychiatry).

Scientific Electronic Library
Online (SciELO)

Science Direct (Descriptors in English)
Schizophrenia (639) growing to 1.1% of the total DALYs and 2.8% of years lost due to disability, with a prevalence of 0.5 to 1.2% 27 . It is said that the risk of schizophrenia over a lifetime is 1%, with the same probability of suffering it, both men and women 11,12,23,28 . In Colombia these data have not been updated since 1997, when a National Study of Mental Health was performed, taking as its starting point the concept of mental health as the absence of disease 21,29,30 . In 2003, although another mental health study was conducted, schizophrenia was not seen as specific object of it 31 . However and following the guidelines of other studies again it was sought to identify the prevalence of psychotic symptoms in some population groups, which can be very general and confused with other diseases that have these symptoms as a diagnostic criterion 21 . Meanwhile, although the costs of health care for people with schizophrenia is high in both the public and the private sector, due to prolonged hospitalization and treatment 8,23 not only talking about funding as one of the difficulties enabling comprehensive care, lack of trained health personnel increases the gap of health care for people with mental diseases 36-38 . In Colombia, this situation has been the subject of discussion by health professionals, especially psychiatrists who exercise their practice in the country 39 .

Community care and schizophrenia
In the world there have been advances in what refers to increased community mental health care services 25,40,41 . For example, in European countries 42 . The rehabilitation that starts in the community has allowed people living with the disease to express they are keeping their quality of life, despite presenting symptoms of the pathology 43,44 .
From models of community mental health care have been developed experiences of social inclusion and rehabilitation that have shown very good results, allowing people living with the disease to feel productive and able to live within society 3,45,46 .
Various experiences of community health care for people with mental illnesses show how a narrow therapeutic relationship between health personnel and users, public policies for expansion of community services and the development of labor skills in people living with the disease, increase their perception of recovery and decrease their psychotic symptoms 47 . In addition, this type of interventions to people with schizophrenia who also have other comorbidities, have shown improvement in access and care quality perception [48][49][50] .
Although reported experiences of models of community care for people with schizophrenia were not found, an experience on domestic violence, documented by Luis Hernández in Bogotá 51 , although not focused on sick people, shows the importance of this type of models for the benefit of the mental health of the community. Little mental health care qualified personnel in the services

Stigma and discrimination in schizophrenia
Undoubtedly, stigmatization is one of the problems that hinder social inclusion and the implementation of community programs for people with mental illnesses in the world 23 . Studies in different countries have shown the influence of sociocultural contexts in consolidating such discrimination 52,53 , as well as the influence of stigma on the treatment 54 . To try to reduce levels of discrimination have been launched multiple campaigns, which despite having a positive impact on the prevention of this phenomenon in society, do not seem to be very effective in reducing stigma, as they should be aware that the historical and cultural context of each community plays a major role in the acceptance of people with this type of diseases 23,55 .
Discrimination and stigma not only fall on the person who has the disease, their family and friends, but also affects the treatment. Thus, the literature shows four types of stigma: the internalized, the family, the health personnel and the social one. Studies of the latter with health personnel have shown that it requires much more obvious interventions through plans and programs that promote the humanization towards people with mental diseases 53 . Some studies in Colombia have found that in the case of mental illnesses, discrimination and exclusion presented by the community to people who have been diagnosed with these diseases, even if provided for in the legislation respect and social inclusion of people living in disability 15,56 , even shown how this situation affects not only the person who has the disease, but their families and the community that shares space with them 56 . This displays an obstacle for people with mental illnesses to be able to freely access health care services within a community setting, something disturbing especially if what is sought is social inclusion and rehabilitation for people who have mental disease 15,57 .

Caregiver fatigue, a pending task
Family plays an important role in the recovery of the person with schizophrenia. One of the tasks presented is precisely to serve as support for the return to society 58,59 .
Family as a primary network responsible for the direct care to these people, not only supports through taking medications or through accompaniments to control appointments, but it is pre-cisely through their care in aspects that are not so notorious for society, that the success of treatment has a balance point 58,60 .
Given the characteristics of this disease, which produces a profound change in family relationships, it was pointed at some time, by psychoanalysts doctors, that one of the reasons why a person could generate schizophrenia was an inadequate upbringing 61 . However, this hypothesis has been abandoned and it is generally mentioned a genetic transmission rather than due to trauma in childhood 62,63 .
And it is that perhaps, one of the situations that causes more complexity in the care of people living with this disease, is that the symptoms are reactivated in unexpected periods in which the disease worsens and can cause separation from society and detachment of the household, besides the fatigue that is reflected in the caregiver 60,64 .
In Colombia, there has been some research showing the impact of the constant care of family caregivers of people with mental illness, also highlighting the enormous physical and emotional exhaustion that brings this with the passage of time 64-67 . Some of them report that the health care system does not provide adequate assistance to their physical ailments, which in most cases arise from these care given 66 .
For models of community care, support and coordination established with family caregivers is essential for monitoring the therapeutic processes outlined from the beginning of diagnosis 57,66 , somewhat visible in models of traditional psychiatric care.

Discussion
Despite normative progress made by Colombia in relation to the mental health of its population, difficulties in access to services remain an obstacle for people with mental illnesses to benefit from quality care 15,68 .
WHO has been emphatic on seeking that health care systems in the world promote social inclusion and create strategies to reduce discrimination and social stigma 23,26 . However, the few experiences that have arisen regarding community care models in Colombia regarding mental health and the null finding regarding schizophrenia show the ambiguity of the system and evidence the lack of opportunities to implement strategies to shape the truth of the implementation of the strategy for primary care for people with mental diseases 69,70 .
Quality health services can generate huge difference in achieving adherence to treatment because it has been established that in those services where better treatment is given, there is greater ease of access and less bureaucracy for users, it considerably reduces the risk of relapse 71,72 . In this type of services it has been identified an increased demand for care of the mentally ill and their families 30,36,73 . To this end, WHO has developed practical tools that can help professionals and non-professionals in health, in improving attendance and decreasing the difficulties around the diagnosis of mental diseases 74 .
It is a social responsibility of human resources in mental health to promote a better quality of care in these services, and involving not only the people who have been diagnosed with a disorder, but also their families and the community in general 23 . This adds to the need to understand that these people even with a diagnosis such as schizophrenia, have rights and need to live in society without the pressure of stigma and discrimination that falls on them 75 .
The importance of creating social networking that provide a support and participate in the care of people with schizophrenia and other mental illnesses, is becoming more noticeable in countries that have implemented community strategies in their health care systems 44,76 .
Although timidly, in Colombia, services for mental health care are being increasingly recognized, not only because of the problems related to mental health that occur, such as depression and aggressions 70 , but also because of the expectation that generates the recent Law of Mental Health 19 , the focus of Primary Health Care promulgated by the Ministry of Health and Social Protection of the country seeking to ensure the care of people who have such disabilities, improving circumstantially with these actions the quality of life of the whole population 21 .

Recommendation: towards a community mental health care
The move toward mental health care services based in the community is a challenge for the Colombian health care system, which demands a strong work towards overcoming the difficulties mentioned above. Greater sensitivity is required in general to the issues concerning the mental health of the population and interdisciplinary work. The importance of the family in the recovery and rehabilitation of people with mental illnesses, as in the case of schizophrenia, seen from the evidence reviewed, it is essential to improve the quality of life of people diagnosed. The use of tools such as mhGAP Intervention Guide can make it easy to detect potential cases and facilitate the work of workers in the area of health. The recent national regulations could also become a key point for future interventions to improve the results of the actions of health personnel. 14.

Collaborations
The authors express their full contribution to the development of both the text and the research that precedes it. DR Zaraza-Morales was involved in the initial writing of the text, search for bibliographical sources and also going through the correction, editing and Portuguese translation of the abstract. DM Hernández-Holguín was involved in editing the text, bearing in mind the suggestions given by the publisher, the English translation of the summary and the subsequent delivery of the text.