saúde mental global no Brasil Dilemmas and challenges for implementing global mental health policies in Brazil

Em 2007, a primeira série sobre saúde mental da revista The Lancet foi publicada como parte de um esforço maior para ressaltar a escala global de problemas de saúde mental e instar parceiros internacionais a se juntarem a este “novo amplo movimento social” para fortalecer a saúde mental 1. Os autores argumentaram que a saúde mental tem sido majoritariamente negligenciada nas agendas globais de saúde, e destacaram estimativas epidemiológicas mostrando a extensão da carga dos transtornos mentais nas famílias, comunidades, nações e sistemas econômicos internacionais 2. É apontada a existência de uma grande “lacuna de tratamento” (treatment gap) entre a necessidade e a disponibilidade de serviços de saúde mental, e ressaltam os custos individuais e sociais da doença mental não diagnosticada e não tratada, além da demanda por intervenções eficazes e acessíveis, especialmente em países de renda baixa e média 3. A ascensão do Movimento de Saúde Mental Global (Movement for Global Mental Health – MGMH; http://www.globalmentalhealth.org) – que conta atualmente com aproximadamente 10 mil membros individuais e 200 instituições – tem, no entanto, conferido um novo significado a controvérsias antigas sobre a universalidade ou especificidade cultural de transtornos mentais e seus sintomas. Os críticos acusam o movimento de exportar um modelo ocidental de doença e tratamento, prejudicando o papel dos praticantes de terapêuticas tradicionais, desconsiderando a variabilidade cultural na compreensão e nas respostas ao sofrimento mental, além de medicalizar a angústia e ignorar suas causas sociais e econômicas em países de baixa e média renda 4. Líderes do MGMH rejeitam essas críticas 5. Defendem que o MGMH é permeado por uma preocupação pelos direitos humanos e uma sensibilidade pós-colonial para colaborações entre o Sul global e o Norte global. São estimulados programas que sejam sensíveis às tradições culturais locais e resultem de uma atuação conjunta e colaborativa com os praticantes de terapêuticas tradicionais. Apoiam-se na literatura sobre os determinantes socioeconômicos dos transtornos mentais e salientam que esta literatura estabeleceu uma base empírica multidisciplinar para subsidiar as intervenções. Ao mesmo tempo, algumas preocupações no MGMH convergem com as preocupações dos críticos. Baseados em uma versão do “universalismo”, alguns pesquisadores do MGMH afirmam que, por motivos pragmáticos, abordar um desafio desta magnitude requer a adoção de pacotes de intervenção padronizados, que apresentem uma boa relação custo-benefício, possam ser globalmente replicáveis, e pareçam viáveis e financiáveis para os patrocinadores/doadores (donors) e os governos. Contudo, outros pesquisado-


PERSPECTIVAS PERSPECTIVES
In 2007, the first series on mental health in The Lancet was published as part of a larger effort to highlight the global scale of mental health problems and to urge international partners to join this "broad new social movement" to strengthen mental health 1 .The authors argued that mental health has been largely neglected by the global health agendas and pointed to epidemiological estimates on the burden of mental disorders for families, communities, nations, and international economic systems 2 .The series identified a major treatment gap between the need for and availability of mental health services and emphasized the individual and social costs of undiagnosed and untreated mental illness, in addition to the demand for effective and accessible interventions, especially in low and middle-income countries 3 .
However, the rise of the Movement for Global Mental Health (MGMH; http://www.globalmentalhealth.org), currently with some 10,000 individual members and 200 affiliated institutions, has lent new meaning to old controversies on the cultural universality or specificity of mental disorders and their symptoms.The critics accuse the movement of exporting a Western model of illness and treatment, underrating the role of practitioners of traditional therapies, ignoring cultural variability in comprehending and re-sponding to mental suffering, and medicalizing distress and ignoring its social and economic causes in low and middle-income countries 4 .
Leaders of the MGMH refute such criticisms 5 on grounds that the movement adheres to a concern for human rights and post-colonial openness to collaboration between the global South and the global North.The movement encourages programs that are sensitive to local cultural traditions and result in collaboration with traditional therapists.Such programs are supported by the literature on socioeconomic determinants of mental illness and highlight that this literature established a multidisciplinary empirical basis to back the interventions.
Meanwhile, MGMH and its critics agree on several points.Based on a version of "universalism", some MGMH researchers contend that for pragmatic reasons, addressing a challenge of such magnitude requires adopting standardized intervention packages with a favorable costbenefit ratio and that are universally replicable and appear feasible and fundable to donors and governments.However, other MGMH researchers counter-argue that effective interventions in diverse contexts cannot be developed in standardized fashion using a database largely derived from research in developed countries, but that such interventions should be adapted to local http://dx.doi.org/10.1590/0102-311X00145315cultural specificities, the characteristics of existing local health systems, and the particular needs of given population groups.
This international debate has underscored the need to assess how this research and intervention agenda has impacted Brazil, or inversely, how it may be influenced by Brazil's academic output and health policies.Brazil's classification as a middle-income country is insufficient justification to apply the underlying arguments and scale-up strategies for expanding access to mental health care as tested mainly in African and Asian countries that lack well-structured national health systems.On the other hand, the Brazilian agenda is partially impervious to this global movement, thereby avoiding some of its biases but also missing important advances potentially offered by critical participation in these discussions.
The organization of mental health services in Brazil is shaped by a diverse and complex set of influences and is far from being a recent or neglected field in Brazil's health debate and practices.The existence of a unified and universal public health care system (Brazilian Unified National Health System -SUS) for more than 25 years has required the proposal and enhancement of policies to guarantee the social right to health, including its physical, mental, and social dimensions.Following the changes on a global scale, the Brazilian psychiatric reform has promoted the abandonment of the institutional model and the option for community care, the principal strategy of which has been the expansion of Centers for Psychosocial Care (or CAPS, in the Portuguese-language acronym) 6 .
Meanwhile, the SUS also provides a setting for the prioritization and growth of primary care through the Family Health Strategy (ESF).In the last ten years, the demand for mental health care within the ESF has become increasingly evident and is the target of specific policies for the implementation of to Family Health Support Nuclei (NASF).In parallel, the recognition of substance abuse (especially involving crack) as a serious public health problem has revived the wager on long-term institutionalization models, featuring the dissemination of distorted versions of therapeutic communities 7 .Given the emergence of these various health interventions and the involvement of diverse health care professionals, the integration of mental health services has also been the object of official measures such as the creation of Psychosocial Care Networks.
Brazil has thus witnessed at least 25 years of "endogenous" accumulation of laws, large-scale policies, and local experiences that converse with relevant themes in the MGMH, although not al-ways going by this name.This transformation of public mental health care in Brazil has also been the field for a large number of studies, resulting in extensive research production 8 .However, some priority issues for the MGMH could receive more attention in mental health policies and research in Brazil, and we intend to highlight some of these issues.
As stated previously, there are normative instruments that situate the ESF as the locus for the supply of mental health care.However, the strategy's role needs to be defined more precisely, in addition to increasing its autonomy vis-à-vis specialized components such as the CAPS and NASF.Although primary care is responsible for the system's portal of entry and coordination, such functions are usually assigned to the CAPS, even though the latter are a specialized service.This secondary position of the ESF can be explained by the historical construction of its work process, determined by characteristics such as the lack of university-trained health professionals (physicians and registered nurses) specialized in primary care and an emphasis on the supply of services in packages, such as for hypertension, diabetes, and prenatal care 9 .Such packages limit users' access and do not include mental disorders.The ESF's role is thus often limited to referring patients to the specialist.
The NASFs were intended to modify this situation but were faced again with health care professionals in the ESF that mostly lacked specialization in primary care and thus had insufficient skills to manage the most prevalent mental disorders.Meanwhile, mental health specialists have little training to offer integrated treatment within primary care and lack more objective lines of care for mental disorders in keeping with this level in the system and for orienting the dialogue and treatment approaches by these professionals.
One argument used by the MGMH to defend the adoption of protocols to address these disorders on a large scale is to gather scientific evidence demonstrating that mental disorders have effective and easily accessible specific treatments.The applicability of these protocols in Brazil merits analysis and research, especially considering the possibility of mixed quantitative-qualitative pragmatic trials that evaluate interventions in representative scenarios for their expected conditions of application.Thus far, for the SUS and at the nationwide level, there are few available references for addressing and managing mental disorders; the existing references focus largely on broad principles 10 , with little guidance for the rational use of psychoactive drugs or more specific and standardized psychosocial interventions.
Members of the MGMH have increasingly assumed as a central issue the study of cultural aspects of large-scale mental health interventions.To deny access to diagnosis and treatment of mental disorders violates the human rights of persons with mental suffering, but to reduce the intervention to the replication of protocols and especially to the supply of medicines also reproduces an approach that is negligent, harmful, and lacking in evidence on mental disorders.Hence the interest in studies that objectively, subjectively, and qualitatively assess these interventions, for example involving community-based leaders, groups, and health workers and adaptation of protocols to specific local characteristics.
Although Brazil boasts an important production of qualitative studies in mental health 11 , since there have been few standardized, large-scale therapeutic interventions, the field is still not open to studies on the cultural interfaces of such measures.
We believe that the recognition that "every culture has its own popular idioms of distressculturally sanctioned modes for expressing suffering that are intelligible to others within a community" 12 (p.47) is not opposed to the observation that mental disorders (especially the most severe ones) share elements across different cultures and affect individuals in all societies.This assumption allows considering the social and structural determinants of mental illness, highlighting the usefulness of diagnostic tools and protocols that are both locally derived and internationally standardized 13 , thus permitting the development of therapeutic strategies especially for interventions in areas lacking resources in mental health.These questions have the potential to permeate and enrich the reflections and proposals on the expansion of public mental health services in Brazil, meanwhile helping to open the international debate to unique contributions from the Brazilian experience.

Contributors
The two authors contributed equally to all stages of the article.