Mental health care provided to patients admitted to Brazilian psychiatric institutes: a scoping review.

OBJECTIVE
to identify and map the mental health care offered to patients admitted to forensic psychiatry institutes in Brazil.


METHOD
a scoping review was guided by the JBI Institute Reviewer's Manual. Searches took place in February 2019, in six databases, using descriptors and synonyms. Analysis was performed using simple descriptive statistics.


RESULTS
twelve studies were included, which were predominantly dissertations, published in 2014, carried out in the southeastern region of Brazil. Qualitative researches in the field of psychology and law stood out, with emphasis on the speeches of health professionals, and which did not specify the methodology of data analysis. Final considerations: the care provided to interns of the institutions has a punitive character, is based on excessive medicalization and diverges from the current legislation, which makes social reintegration difficult.


INTRODUCTION
In all societies and in the most diverse eras, insanity has been found and often associated with difference, with the abnormal and with what is not within the sphere of the acceptable (1) . Even though over the years there have been changes in the way insanity is perceived, the social imaginary still persists in understanding the person with mental disorder as being incapable, irresponsible and violent, which reinforces their social segregation (2)(3) .
Among this historically stigmatized and socially excluded portion, in total institutions or in extra-wall spaces, people with mental disorders who commit crimes stand out, which demand differentiated attention (3)(4) .
From a legal standpoint, people with mental disorders who commit a crime, given the inability to distinguish the illicit nature of their actions, cannot be judged by their act. In these circumstances, the application of a Security Measure (SM) is determined for an indefinite period. This measure has a preventive and care character and can be carried out on an outpatient basis or hospitalization in a judicial asylum, to protect society and the individual against the presumed threat of mental disorder (5) .
Thereby, SM differs from the penalty (a measure imposed by justice for individuals who are in common chains) for some reasons: the penalty has a punitive character; it occurs through the understanding of the individual's guilt; it has a pre-established duration, while SM presents itself preventively; it operates due to the danger, due to the lack of understanding that people have in relation to the illicit character of their criminal act; and it has its indefinite time, because it depends on the evolution of the person's treatment, therefore it is subject to annual renewal (6) .
SM, therefore, is configured as a legal instrument, imposed on individuals considered incomputable, namely, one who, due to mental illness, incomplete or delayed mental development, or even due to mental health disturbance, does not answer in court for their acts (7) . In this way, specific places were created to guard/treat this segment of the population: judicial asylums (8) .
The birth of judicial asylums dates back to the end of the 19 th century, in England, through the intersection between psychiatry, positive law and criminal anthropology, in the search for a typology for the insane that could serve as a prevention for violence and were spread by all western countries. In the past, there were only special attachments to some prisons for imprisonment and treatment of "insane offenders" or convicts who went insane in prisons (9) . In Brazil, from 1984 onwards, in compliance with the Criminal Law Reform, mental asylums became known as custody and psychiatric treatment hospitals (HCTP -hospitais de custódia e tratamento psiquiátrico). Later, in 2002, they were called forensic psychiatry institutes (10) .
Such institutions, historically neglected and forgotten, have come under criticism with the advent of Psychiatric Reform (PR). PR occurred in Brazil in the mid-1980s, when the proposal to replace the asylum model with a network of community-based psychosocial care services emerged. This network was able to overcome the dichotomy of the individual/society binomial, safeguarding human rights through deinstitutionalization (8) .
In this context, the maintenance of people with mental disorders who are guilty of crimes in asylum institutions directly violates the rights constitutionally guaranteed to them through Law 10.216/01. Moreover, it can be considered a crime of torture, since it is imputable and has no right to authorship of one's own words and actions is to be condemned to the grave of silence in eternal social exile. This fails to meet the requirements imposed by human rights, which is to give the right to answer for crimes and receive treatment (11) .
However, contrary to the deinstitutionalization proclaimed by PR, there is a growing process of "psychiatrization" directed, above all, at young offenders diagnosed with mental disorders, which promotes the construction and/or maintenance of judicial asylums in Brazil (12) .
Thus, forensic psychiatry institutions are, notoriously, complex institutions that manage to articulate, on the one hand, two of the most depressing realities of modern societies -the asylum for the alienated and the prison -and, on the other, two of the most tragic ghosts that "chase" everyone: the criminal and the insane (13) . Overcoming this reality requires structural and cultural changes of an intersectoral nature, which have their primary basis in the restructuring of mental health care for people with mental disorders who have committed crimes.
Recognizing the difficulties in ensuring the rights to health of this population, the Brazilian Unified Health System (SUS -Sistema Único de Saúde) instituted, in 2014, the service of evaluation and monitoring of therapeutic measures applicable to people with mental disorders in conflict with the Law and linked to the Brazilian National Policy of Comprehensive Health Care for Persons Deprived of Liberty in the Prison System (PNAISP -Política Nacional de Atenção Integral à Saúde das Pessoas Privadas de Liberdade no Sistema Prisional) (14) .
When considering that the social reintegration targeted by PR is directly related to mental health care provided to people with mental disorders, it becomes relevant to know the mental health care offered to patients admitted to forensic psychiatry institutes. In addition, there are few studies in the literature that address this issue in the Brazilian context. The findings of the study may affect improvements in mental health care, both in the care and in teaching fields. Therefore, the present study has as a guiding question: how is the mental health care offered to patients admitted to forensic psychiatry institutes?

OBJECTIVE
To identify and map the mental health care offered to patients admitted to forensic psychiatry institutes in Brazil.

METHODS
This is a scoping review, a type of literature review aimed at mapping the main concepts and limitations of a given research area, as well as the evidence for professional practice. It was guided by the assumptions of the JBI Institute Reviewer's Manual (15) and presented according to the PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation recommendations. Its protocol was registered at the Open Science Framework at the link: NN [deleted for peer review purposes].
The research question was developed based on the PCC strategy (P -Population; C -Concept; C -Context). Therefore, it was defined as P: interns; C: mental health care; and C: forensic psychiatry institutes.
The study population consisted of researches referring to the inmates of the forensic psychiatry institutes. Research published in full, in Portuguese, Spanish, and English, produced by Brazilian researchers, which aimed to identify the mental health care provided to inmates in forensic psychiatry institutes was included. Editorials, experience reports, theoretical essays and integrative reviews were excluded. No time limit was defined.
Prior to data collection, a preliminary search was performed in the JBI COnNECT + and Cochrane Library databases, and no protocols and reviews with a similar theme were identified.
Prior to the elaboration of the research strategy, a mapping was carried out in the PubMed and Cumulative Index to Nursing Thus, the following were used: Population -"Prisoners" OR "Convicts" OR "Persons deprived of their liberty" OR "Incarcerates" OR "Inmates" OR "Insane offender"; Concept -"Mental health care"; Context -"Forensic Psychiatry Institute" OR "Mental Health Service" OR "Hospitais de Custódia e Tratamento Psiquiátrico" OR "Judicial asylum". For the combination of descriptors, we used Boolean operators "AND" and "OR", composing the search formulas in the referred databases and research platforms.
Searches took place, in February 2019, in PubMed, CINAHL, Scopus, LILACS, Web of Science. Gray literature search was carried out in the Theses and Dissertations Catalog of the Coordination for the Improvement of Higher Education Personnel (CAPES -Coordenação de Aperfeiçoamento de Pessoal de Nível Superior). Moreover, searches were carried out on the following thematic issues that addressed prison health and/or mental health: Revista Brasileira de Enfermagem -v.71, Suppl. 5, 2018 and Revista Ciência & Saúde Coletiva -v.21, n. 7, 2016.
Open access filters and countries/regions (Brazil) were used in the databases. The search occurred at the CAPES Catalog through the combination of descriptors and synonyms of the last element of the PCC mnemonic of this research -(C) forensic psychiatry institutes, HCTP, and judicial asylums. As inclusion criteria, the following were established: dissertations and theses published in full online. No time limit was stipulated. However, as the database used has undergone recent updates, abstracts of works published since 2013.
After applying filters, 4,370 publications were found, including theses, dissertations and papers. Titles and abstracts were read to identify possible studies to be included in the review, which were analyzed in full.
The studies of the final sample were organized based on the following data: type of study, year of publication, academic background of the author, federative unit, objective, type of research, research subjects, mental health care, professionals responsible for care, care tool and results (difficulties and/or facilities for carrying out care). The data were analyzed using simple descriptive statistics. There was no need for ethical appraisal, as it works with public-domain studies.

Characterization of studies
The final sample consisted of 12 searches, which represents 0.01% of the initial number of searches and 0.3% of the preselected studies to be read in full (Figure 1). Characterization of these studies is shown in Chart 1 according to title, year of publication, database, federative unit of origin, and type of study.
According to the data presented in the previous chart, dissertations (6; 50.0%) predominated in the sample, followed by scientific papers (4; 33.3%) and theses (2; 16.7%). The time dimension of the investigations analyzed was from 2013 to 2018, with the highest concentration of studies in 2014 (4; 33.3%). The researches were carried out predominantly in the southeastern region (7; 58.0%), with an emphasis on productions from Rio de Janeiro (4; 33.3%) and Minas Gerais (2; 16.7%).
The areas of knowledge in which the authors of the investigations evaluated are demonstrating the multidisciplinary nature of research on this theme, with an emphasis on psychology (3; 25.0%) and law (3; 25.0%).

Characterization of the care provided
As for the objectives of the care provided, 8 (55.6%) studies listed as the only objective SM monitoring. Inclusion in the Psychosocial Care Network (RAPS -Rede de Atenção Psicossocial) was presented as the objective of 2 (16.6%) researches, and intimate "training" was mentioned in 2 (16.6%) studies.
In addition, the difficulties and/or facilities pointed out in the studies were also analyzed, with regard to the care provided to interns of forensic psychiatry institutes (Chart 2).
In general, the facilities are related to strengthening the bonds both between interns and the family/community and between professionals within the RAPS. Difficulties involve structural deficiency, stigmas, and prejudice that permeate the "insane offender", enhanced by the lack of adequate training to work with this people.

DISCUSSION
Despite the meaningful number of studies previously selected to compose this review, few studies have been identified that have focused on mental disorders in the context of incarceration. A study developed by Langbecker et al. (28) highlighted that the journalistic interest on this theme in collective science in Brazil is minimal, when compared to the high prevalence of these disorders in the Brazilian population.
It is assumed that if mental disorders are neglected in the general population, even more so when they occur in people in conflict with the Law. Therefore, maintenance of all those considered "social lumen" in total institutions, such as prisons, asylums, among others, in which they do not disturb others, tends not to generate major questions or social commotion (3,29) .
The predominance of gray literature (dissertation and theses) studies is a negative aspect. These are documents that have not been published in the usual channels of scientific transmission, nor have they been subjected to prior analysis by an expert or an editorial committee, therefore, without wide visibility (30) .
The publication with an upward trend over the years, with emphasis on the Southeast region of Brazil, is in line with the expansion and quantitative distribution of graduate programs in Brazil (31) . Although the study has not defined a time limit, most of the research found is recent, which may be related to the enactment of the Brazilian National Mental Health Policy (Politica Nacional de Saúde Mental) in 2001, and the need to evaluate its effectiveness.
The multidisciplinary nature of the selected studies is consistent with research by Martin et al. (32) that highlights mental health as one of the main themes produced within the scope of social and human sciences in health (SHSH). Furthermore, these findings also signal the dichotomy between the health and safety paradigms that permeate discussions about people deprived of their liberty in conflict with the Law (12) .
Despite the positivist hegemony, the clinical and biomedical view observed in health research, this research is consistent with other studies that signal the increase in qualitative studies and the use of ethnography in the areas of collective health and mental health, in compliance with the adequacy of the method to objects of study of research in these areas (32)(33) . However, even in graduate school, the teaching of social sciences -and, consequently, of their research methods -is often offered in an instrumental way, favoring the dichotomy between theory and method and the simplification of the fundamentals and the problematization of the objects of study (34) .
It is important to emphasize that most studies have highlighted the speech of health professionals, to the detriment of people with mental disorders in conflict with the Law and their families. The research conducted by Lanbecker et al. (28) points this out, in which the voice of people with schizophrenia is invisible in the setting of health research in Brazil.
The data collection procedures identified in this study correspond to the specificities of the research objects studied. However, complementation of the collected data, using different techniques, called by some scholars of triangulation of methods, would allow to enrich analyzes (35) .
The predominance of studies that did not describe the method of data analysis is a negative aspect, as it makes it difficult to replicate the research in other settings. As for the use of content analysis, it has been quite frequent in qualitative studies, as it is an internationally recognized method, which includes the explanation, systematization and expression of the content of messages, in order to make logical deductions from the analyzed data (28,36) .
It is perceived that the care provided in forensic psychiatry institutes differs from that recommended by the current legislation, because, according to the service of evaluation and monitoring of therapeutic measures applicable to the person with mental disorder in conflict with the Law, the objective of care is to redirect the mental health care model for them, from the asylum environment to community-based services (14) .
Thus, Evaluation and Monitoring of Therapeutic Measures Applicable to the Person with Mental Disorder in Conflict with the Law Teams (EAP -Equipes de Avaliação e Acompanhamento de Medidas Terapêuticas Aplicáveis à Pessoa com Transtorno Mental em Conflito com a Lei) must act in the strengthening of local networks that allow treatment in an open environment, since the beginning of compliance with SM. They must enable the progressive deinstitutionalization of those who are hospitalized, through rescue of family bonds the guarantee of psychosocial care within the scope of SUS, aiming at rehabilitation and social reintegration (14) .
EAP should consist of an interdisciplinary team, composed of five professionals, namely: a nurse; a psychiatrist or doctor with experience in mental health; a psychologist; a social worker; and a professional trained in humanities, social or health sciences, preferably education, occupational therapy or sociology. Therefore, there should not be a professional responsible for care, but co-responsibility and matrixing of the RAPS and EAP reference services (14) .
It is also recommended to prepare the PTS by the network's reference service, with subsidies from EAP, involving, whenever possible, people with mental disorder in conflict with the Law and their family and community references, as a way of establishing articulated therapeutic conducts, in addition to the exclusive use of medicalization or physical restraint (14,37) .
Few fields of knowledge and performance in health are as complex, plural and intersectoral as mental health (38) . This complexity is accentuated when it involves the mental health of people in conflict with the Law. Therefore, it would be pretentious to believe that the points listed in this study include all facilities and/ or difficulties in providing care to interns of forensic psychiatric institutes, but certainly allow for a substantial reflection on them.
Concerning the profile of interns, they must have a low level of aggression, stable humor, developed artistic expression, preserved affective bonds, preserved memory, language and cognition. They must be cooperative and have a defined documentary situation, with a rich historical record, favor care because it facilitates the creation/maintenance of bonds between professionals and interns, as well as corroborating with the construction and implementation of the PTS.
The PTS is a mechanism used to offer users other ways of caring and self-care in mental health and is configured as a device to overcome traditional care. The presence and commitment of family members in the continuity of the actions proposed by the PTS are directly related to the success of the therapeutic proposal employed (39) .
On the other hand, histories of long hospitalization, interns without ties and without territories to return to, and the stigmas that involve the "insane offender" hinder care and, consequently, their social reintegration. Specifically on the territorialization, so necessary for the process of social reintegration of the inmates, there is a disarticulation between the provisions of the RAPS and the courts of justice, which tend to appear in regions outside the territory of the subjects (40) .
The existence of legislation that proclaims the social reintegration of people with mental disorders in conflict with the Law and an organization chart/schedule, to guide the deinstitutionalization teams, in addition to the implementation and updating of the PTS through teamwork, are facilitating aspects in providing care to this people. Successful experiences of deinstitutionalization serve as a model and inspiration for other services.
However, the growth of the prison mass, mainly due to the increase in the number of drug users in compliance with SM, followed by the structural deficiency (physical and human resources), the lack of permanent education actions to train professionals (health and security), weaken the RAPS and hinder teamwork and corroborate the clashes between the fields of safety and health.
It is known that social and medical practices are inseparable from the discourse that establishes them. Thus, contemporary forms of care result from a socio-historical and cultural process consolidated over time. Examples are hegemony of technoscientific and specialized knowledge, to the detriment of teamwork, comprehensive and horizontal essential to replace the practices traditionally consecrated by total institutions (41)(42) .
According to Silva et al. (42) , the power of the positivist and biocentric tradition, absence/presence of a common project, confrontation between specificity and flexibility in carrying out work, communication and the existence of imprecise and/or mistaken concepts of comprehensiveness among health professionals are critical points for interdisciplinary integration in health.
Despite the advances that have taken place since the enactment of Law 10.216/2001, the distortions in the implementation of federal policy in states and municipalities have repercussions on the slow process of total replacement of the asylum model and the coexistence of the asylum park and substitute services. These advances are associated with difficulties regarding the disruption of professional practices that affirm the objectification of the person with mental disorder, the suppression of the symptom, the specialties, the demand for hospitalization, the non-continuity of care, the outpatient care. Finally, work processes that end up maintaining a vigorous asylum culture, even more potent with regard to people in conflict with the Law (37) .
Another aspect that requires reflection is the increase in hospitalizations for SM from other groups made invisible by care actions, as in the case of users of alcohol, crack (42) . This is an increase that is likely to be accentuated as a result of Resolution 32, of December 14, 2017, which inserts psychiatric hospitals in RAPS, as well as encouraging the strengthening of Therapeutic Communities through financing and Decree 9,761, of April 11, 2019. This decree approved the Brazilian National Policy on Drugs (Política Nacional sobre Drogas), and also encouraged confinement spaces as therapeutic strategies, which goes against the grain of PR (43)(44) .
As for continuing and permanent education projects aimed at strengthening the strategy of psychosocial care in services, there was an increase in investment from 2005, although they are still insufficient, mainly because it does not include all the actors involved in the deinstitutionalization process, like security agents (45) .
The basic duties of the security agents in the setting in question are to guarantee order and security inside criminal establishments; to perform internal and external surveillance actions at these locations; to perform escort and custody operations for prisoners. Despite carrying out and promoting security actions that, at the same time, guarantee the intern's access to resocialization activities, the agent is not expected to dedicate himself/herself to this resocialization, which can hinder the practices together with health professionals (46) .
In summary, the great challenge for providing care to inmates of Forensic Psychiatry Institutes concerns the reinvention of this space, abandoning the ambiguity that destines it to the prison act and inserting it within the scope of mental health policies (40) . Thus, successful experiences in recovering the dignity of patients submitted to a SM such as that of the Programa de Atenção Integral ao Louco Infrator (Comprehensive Care Program for the Insane Offender) are replicated throughout the national territory (27) .

Study limitations
Noteworthy is the time limitation for searches in the CAPES Catalog, which, after updating, does not provide summaries of dissertations and theses prior to Plataforma Sucupira (Sucupira Platform), so only abstracts of works published since 2013 were available. Thus, it is possible that the sample analyzed in this research is underestimated and, therefore, should be analyzed from this perspective. There is incipience of research, in this sense, field studies are necessary in different spaces to confirm the generalization of the results to the national context.

Contributions to nursing, health and public policies
The paths of technical and scientific development on mental health care offered to people in conflict with the Law need to be socially referenced. The recognition of their specific health needs, the creation of public policies to meet them, as well as the indicators of prejudice, violence and discrimination require health professionals to produce knowledge and practices that are responsive to this situation. Furthermore, by signaling the of Mental health care provided to patients admitted to Brazilian psychiatric institutes: a scoping review Oliveira LV, Salvador PTCO, Freitas CHSM.
importance of teamwork in the context studied, this research reinforces the importance of the insertion of nursing professionals to improve the care provided to this population. The present study contributes to the reflection on this theme, especially in the current context, in which there are numerous setbacks regarding PR. For this, it is indicated the inclusion of this theme in the curricular components of the courses in the health area and in the internship activities, with a view to guarantee training of skills and competences for a comprehensive and human professional approach. In addition, extension actions and research focusing on people with mental disorders in conflict with the Law are indicated.

FINAL CONSIDERATIONS
The study allowed to identify and map the mental health care offered to patients admitted to forensic psychiatry institutes in Brazil. In this sense, it was found that the researches that addressed this theme were predominantly dissertations, published in 2014 and carried out in the Southeast region of Brazil. Qualitative researches in the area of psychology and law stood out, with emphasis on health professionals' speeches, and which did not specify the methodology of data analysis.
It is important to highlight that the care offered to interns at these institutions has the primary objective of monitoring SM. It is not performed by a multidisciplinary team, and is based, above all, on psychotropic drug use. Thus, it is concluded that such care has a punitive character, is based on excessive medicalization and is in breach of the current Brazilian legislation, which hinders social reintegration. Therefore, it is suggested articulation of the various actors involved in the investigated setting, such as health professionals, justice professionals and relatives of inmates, to discuss and implement care actions in territorial-based devices.