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

Asistencia de salud mental a pacientes ingresados en institutos psiquiátricos brasileños: scoping review

ABSTRACT

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.

Descriptors:
Mental Health Care; Prisoners; Inpatients; Institutes of Psychiatry; Review Literature

RESUMEN

Objetivo:

identificar y mapear la atención de salud mental ofrecida a los pacientes ingresados en los institutos de psiquiatría forense en Brasil.

Método:

esta es una revisión de alcance guiada por el JBI Institute Reviewer’s Manual. Las búsquedas tuvieron lugar en febrero de 2019, en seis bases de datos, utilizando descriptores y sinónimos. El análisis se realizó utilizando estadísticas descriptivas simples.

Resultados:

se incluyeron 12 estudios, predominantemente disertaciones, publicados en 2014, realizados en la región sureste de Brasil. Se destacó la investigación cualitativa en el área de psicología y derecho, con énfasis en las declaraciones de los profesionales de la salud y que no especificaron la metodología del análisis de datos.

Consideraciones finales:

la asistencia ofrecida a los pasantes de estas instituciones tiene un carácter punitivo, se basa en una medicalización excesiva y difiere de la legislación actual, lo que dificulta la reintegración social de estos sujetos.

Descriptores:
Atención de Salud Mental; Prisioneros; Pacientes Internos; Institutos de Psiquiatría; Revisión de Literatura

RESUMO

Objetivo:

identificar e mapear a assistência em saúde mental ofertada aos pacientes internados nos institutos de psiquiatria forense no Brasil.

Método:

trata-se de uma scoping review norteada pelo JBI Institute Reviewer’s Manual. As buscas ocorreram no mês de fevereiro de 2019, em seis bases de dados, por intermédio dos descritores e sinônimos. A análise ocorreu por estatística descritiva simples.

Resultados:

foram incluídos 12 estudos, que eram predominantemente dissertações, publicadas no ano de 2014, realizadas na região sudeste do Brasil. Destacaram-se as pesquisas qualitativas, na área da psicologia e direito, com ênfase nas falas dos profissionais de saúde e que não especificaram a metodologia da análise de dados.

Considerações finais:

a assistência ofertada aos internos destas instituições tem caráter punitivo, pauta-se na medicalização excessiva e diverge da legislação vigente, o que dificulta a reintegração social desses sujeitos.

Descritores:
Assistência em Saúde Mental; Prisioneiros; Pacientes Internados; Institutos de Psiquiatria; Literatura de Revisão

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 & Allied Health Literature (CINAHL) of the main descriptors and their synonyms in English, Medical Subject Headings (MeSH). Mapping was carried out in the Latin American & Caribbean Literature in Health Sciences (LILACS) of the main descriptors and their synonyms in Brazilian Portuguese, Health Sciences Descriptors (DeCS - Descritores em Saúde), used in studies that addressed the theme of interest.

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.

RESULTS

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 pre-selected studies to be read in full (Figure 1).

Figure 1
Flowchart of data collection steps

Characterization of these studies is shown in Chart 1 according to title, year of publication, database, federative unit of origin, and type of study.

Chart 1
Characterization of publications according to title, type, database, year, federative unit, and type of study (n=12). Natal/RN, 2019

Title	Type/Database	Year	Federative Unit	Type of Study
Justiça, cidadania e saúde: reflexões sobre limites, possibilidades e desafios para a implementação da reforma psiquiátrica nos hospitais de custódia e tratamento psiquiátrico no estado de São Paulo ( 16 )	Dissert. /CAPES Catalog	2013	São Paulo	Qualitative
Reinternação e recidiva nas medidas de segurança: um estudo no hospital de custódia da Bahia ( 17 )	Dissert. /CAPES Catalog	2014	Bahia	Qualitative
The relationship psychiatric diagnosis and crimes committed by internals of a forensic psychiatric prison(18)	Artigo/CINAHL	2014	Paraíba	Quantitative
Entre o delito e a loucura: a enfermagem em manicômio judiciário ( 19 )	Dissert. /CAPES Catalog	2014	Rio Grande do Sul	Qualitative
Loucos sob medida: compassos e descompassos entre a reforma psiquiátrica e os manicômios judiciários ( 20 )	Dissert. /CAPES Catalog	2014	Rio de Janeiro	Qualitative
O caso do manicômio judiciário Heitor Carrilho": relatos de uma experiência de desinstitucionalização manicomial ( 21 )	Dissert. /CAPES Catalog	2015	Rio de Janeiro	Qualitative
O manicômio judiciário e seus pacientes na visão dos trabalhadores: atenção à saúde e equipamento prisional ( 22 )	Tese/CAPES Catalog	2015	Minas Gerais	Qualitative
Health professionals experiences in a judicial asylum and their view about the patients(23)	Artigo/CINAHL	2015	Minas Gerais	Qualitative
Cartografia da desinstitucionalização do hospital de custódia e tratamento psiquiátrico Heitor Carrilho ( 24 )	Tese/CAPES Catalog	2016	Rio de Janeiro	Qualitative
Right to mental health in prison system: reflections on the process of deinstitutionalization of the HCTP(25).	Paper/Thematic number	2016	Federal District	Qualitative
Além da medida: uma etnografia do "tratamento" previsto na medida de segurança em um manicômio judiciário do Estado do Rio de Janeiro" ( 26 )	Dissert. /CAPES Catalog	2017	Rio de Janeiro	Qualitative
The performance of health professionals in a custody and psychiatric treatment hospital: the perspective of the psychosocial rehabilitation(27)	Paper/Web of Science	2018	Alagoas	Qualitative

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%).

Concerning the type of study research, there was a predominance of qualitative studies (11; 91.6%), with an emphasis on ethnographic studies (4; 33.3%). The research subjects were mostly health professionals (4; 33.3%), followed by interns (3; 25.0%). As for data collection procedures, 6 (50.0%) researches used interviews, followed by documentary research (4; 33.3%), use of image (1; 8.3%) and a form (1; 8.3%).

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%).

With regard to data analysis procedures, 7 (58.3%) studies did not specify the methodology used for such analysis, followed by content analysis (3; 25.0%), discourse analysis (1; 8.3 %), and descriptive statistics (1; 8.3%).

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.

As for the professionals responsible for care, psychiatrists predominated (7; 58.3%), followed by a multidisciplinary team (4; 33.3%) and a nursing team (1; 8.3%).

The tools used to provide care mentioned in the publications were: psychotropic (7; 58.3%), interdisciplinary meetings (1; 8.3%), Singular Therapeutic Project (PTS - Projeto Terapêutico Singular) (1; 8.3%) and padlocks and cells (1; 8.3%). Two studies (16.6%) did not mention any care tools.

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).

Chart 2
Facilities and difficulties in providing care to interns of forensic psychiatry institutes in Brazil

Facilities	Difficulties
Concerning interns: • Low level of aggressiveness; • Affected bonds preserved; • Cooperative; • Stable mood; • Artistic expression developed; • Preserved memory, language and cognition; • Documentary situation defined; • Rich historical record.	Concerning interns: • Aggressiveness; • Fragmented family links; • Impaired memory, cognition and language; • Absence of clear references about your past; • Undefined documentary situation; • Without territory; • Stigmas; • Long institutionalization.
Concerning structure: • Current legislation; • Have an organizational chart and deinstitutionalization schedule; • Alliances produced between technicians and the existing devices of the psychosocial network; • Commitment of professionals and commitment of technical teams to keep Singular Therapeutic Project updated;	Concerning structure: • Professional devaluation and reduced staff; • Increase in prison mass, especially increase in the number of drug users in compliance with Security Measure; • Clashes between security officers and health professionals; • Stigmas related to the construction of dangerousness as inherent to the insane (Fear of the intern's relapse); • Fragility or lack of Psychosocial Care Network;
Concerning structure: • Creativity of health professionals, including changes in technical terms to "humanize" the care process; • Inspiration through successful deinstitutionalization initiatives.	Concerning structure: • Structural deficiency (absence of parliament, expired medicines, unhealthy conditions); • Aggressiveness of security agents in the penal system; • Absence of parameters for the treatment of inmates (which is subjectively established by each professional); • Lack of specific training to work with this people; • Absence of teamwork.

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 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.

REFERENCES

• ¹
  Foucault M. Vigiar e punir: história da violência nas prisões. Petrópolis: Vozes; 1987. 288p.
• ²
  Franceschini E, Fonseca TMG. Art and madness as the threshold for another history. Psicol. USP. 2017[cited 2019 Mar 22];28(1):14-22. doi: 1590/0103-656420160022
  » https://doi.org/1590/0103-656420160022
• ³
  Goffman E. Manicômios, Prisões e Conventos. 9.ed São Paulo: Perspectiva, 2015.312p.
• ⁴
  Cunha CC, Boarini ML. A medicina com o voto de minerva: o louco infrator. Psicol Soc. 2016[cited 2019 Mar 26];28(3):442-52. doi: 10.1590/1807-03102016v28n3p442
  » https://doi.org/10.1590/1807-03102016v28n3p442
• ⁵
  Emerim MF, Souza M. "Ninguém esquece uma coisa dessas": problematizações sobre parricídio e hospitais de custódia. Psicol Soc. 2016[cited 2019 Mar 22];28(1):171-80. doi: 10.1590/1807-03102015v28n1p171
  » https://doi.org/10.1590/1807-03102015v28n1p171
• ⁶
  Diniz D, Brito L. "Eu não sou presa de juízo, não": Zefinha, a louca perigosa mais antiga do Brasil. Hist Cienc Saúde-Manguinhos. 2016 [cited 2019 Feb 19];23(1):113-30. Available from: http://www.scielo.br/pdf/hcsm/v23n1/0104-5970-hcsm-23-1-0113.pdf
  » http://www.scielo.br/pdf/hcsm/v23n1/0104-5970-hcsm-23-1-0113.pdf
• ⁷
  Ministério da Justiça (BR). Lei de Execução Penal nº 7210, de 11 de julho de 1984. Brasília, DF: Ministério da Justiça; 1984.
• ⁸
  Martins LAP, Madalena VF. Evolução do perfil das internações psiquiátricas pelo Sistema Único de Saúde em Minas Gerais, Brasil, 2001-2013. Ciênc Saúde Coletiva. 2019;24(2):659-68. doi: 10.1590/1413-81232018242.14652017
  » https://doi.org/10.1590/1413-81232018242.14652017
• ⁹
  Foucault M. História da loucura. 6.ed. São Paulo: Perspectiva, 2002.608p.
• ¹⁰
  Santos ALG, Farias FR. Criação e extinção do primeiro Manicômio Judiciário do Brasil. Rev Latinoam Psicopatol Fundam. 2014;17(3):515-27. doi: 10.1590/1415-4714.2014v17n3p515-9
  » https://doi.org/10.1590/1415-4714.2014v17n3p515-9
• ¹¹
  Braga CP. A perspectiva da desinstitucionalização: chaves de leitura para compreensão de uma política nacional de saúde mental alinhada à reforma psiquiátrica. Saude Soc. 2019;28(4):198-213. doi: 10.1590/s0104-12902019190125
  » https://doi.org/10.1590/s0104-12902019190125
• ¹²
  Barison MS, Gonçalves RS. Judicialização da questão social e a banalização da interdição de pessoas com transtornos mentais. Serv Soc Soc [Internet]. 2016 [cited 2019 Mar 26];125:41-63. Available from: http://www.scielo.br/pdf/sssoc/n125/0101-6628-sssoc-125-0041.pdf
  » http://www.scielo.br/pdf/sssoc/n125/0101-6628-sssoc-125-0041.pdf
• ¹³
  Lhacer PMV. Transinstitucionalização: caminhos e descaminhos na dinâmica de internações e desinternações de pessoas com transtorno mental em conflito com a lei no Estado de Saúde Paulo [Tese]. São Paulo (SP): Universidade de São Paulo; 2019.
• ¹⁴
  Ministério da Saúde (BR). Portaria nº 94 de 15 de janeiro de 2014. Dispõe sobre a avaliação e acompanhamento de medidas terapêuticas aplicáveis à pessoa com transtorno mental em conflito com a Lei, vinculado à Política Nacional de Atenção Integral à Saúde das Pessoas Privadas de Liberdade no Sistema Prisional. Brasília: Diário Oficial da União; 2014.
• ¹⁵
  Joanna Briggs Institute (JBI). The Joanna Briggs Institute Reviewers' Manual 2015: Methodology for JBI. Scoping Reviews. South Australia: The Joanna Briggs Institute, 2015.
• ¹⁶
  Lhacer PMV. Justiça, cidadania e saúde: reflexões sobre limites, possibilidades e desafios para a implementação da reforma psiquiátrica nos hospitais de custódia e tratamento psiquiátrico no estado de São Paulo [Dissertação]. São Paulo (SP): Universidade de São Paulo; 2013.
• ¹⁷
  Pacheco JA. Reinternação e recidiva nas medidas de segurança: um estudo no hospital de custódia da Bahia [Dissertação]. Brasília (DF): Universidade de Brasília; 2014.
• ¹⁸
  Lima EKV, Lima OBA, Ribeiro GS, Fonseca LCT, Rodrigues FA. The relationship psychiatric diagnosis and crimes committed by internals of a forensic psychiatric prison. Rev Enferm UFPE. 2014;8(1):83-9. doi: 10.5205/reuol.4843-39594-1-SM.0801201412
  » https://doi.org/10.5205/reuol.4843-39594-1-SM.0801201412
• ¹⁹
  Cicolella DA. Entre o delito e a loucura: a enfermagem em manicômio judiciário[Dissertação]. Porto Alegre (RS): Universidade Federal do Rio Grande do Sul; 2014.
• ²⁰
  Lira RVC. Loucos sob medida: compassos e descompassos entre a reforma psiquiátrica e os manicômios judiciários [Dissertação]. Rio de Janeiro (RJ): Pontifícia Universidade Católica do Rio de Janeiro; 2014.
• ²¹
  Xavier FC. O caso do manicômio judiciário Heitor Carrilho": relatos de uma experiência de desinstitucionalização manicomial [Dissertação]. Rio de Janeiro (RJ): Universidade Federal do Rio de Janeiro; 2015.
• ²²
  Santana AFFA. O manicômio judiciário e seus pacientes na visão dos trabalhadores: atenção à saúde e equipamento prisional[Tese]. Belo Horizonte (MG): Universidade Federal de Minas Gerais; 2015.
• ²³
  Santana AFFA, Alves M. Vivências de profissionais de saúde em um manicômio judiciário e a visão sobre os pacientes. Rev Enferm UFPE [Internet]. 2015 [cited 2019 Mar 22];9(Supl. 8):9366-75. Available from: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/viewFile/10742/11851
  » https://periodicos.ufpe.br/revistas/revistaenfermagem/article/viewFile/10742/11851
• ²⁴
  Santos ALG. Cartografia da desinstitucionalização do hospital de custódia e tratamento psiquiátrico Heitor Carrilho[Tese]. Rio de Janeiro (RJ): Universidade Federal do Estado do Rio de Janeiro; 2016.
• ²⁵
  Soares Filho MM, Bueno PMMG. Right to mental health in prison system: reflections on the process of deinstitutionalization of the HCTP. Ciênc Saúde Coletiva. 2016;21(7):2101-10. doi: 10.1590/1413-81232015217.08802016
  » https://doi.org/10.1590/1413-81232015217.08802016
• ²⁶
  Franco TM. Além da medida: uma etnografia do "tratamento" previsto na medida de segurança em um manicômio judiciário do estado do rio de janeiro" [Dissertação]. Rio de Janeiro (RJ): Universidade Federal do Rio de Janeiro; 2017.
• ²⁷
  Silva EV, Ribeiro, MC, Souza MCS. O cuidado e os processos de trabalho em um hospital de custódia e tratamento psiquiátrico sob a perspectiva de seus trabalhadores. Cad Bras Ter Ocup [Internet]. 2018[cited 2019 Feb 21];26(2):315-27.Available from: http://www.cadernosdeterapiaocupacional.ufscar.br/index.php/cadernos/article/view/1910
  » http://www.cadernosdeterapiaocupacional.ufscar.br/index.php/cadernos/article/view/1910
• ²⁸
  Langbecker A, Castellanos MEF, Neves RF, Catalan-Matamoros D. Journal coverage on issues of interest to Brazilian Collective Health: a literature review. Interface. 2019;23(e1800095). doi: 10.1590/interface.180095
  » https://doi.org/10.1590/interface.180095
• ²⁹
  Oliveira LV, Coelho AA, Salvador PTCO, Freitas CHSM. Muros (in)visíveis: reflexões sobre o itinerário dos usuários de drogas no Brasil. Physis. 2019;29(4):e290411. doi: 10.1590/s0103-73312019290411
  » https://doi.org/10.1590/s0103-73312019290411
• ³⁰
  Botelho RG, Oliveira CC. Literaturas branca e cinzenta: uma revisão conceitual. Ciênc Inform [Internet]. 2015 [cited 2019 Mar 25];44(3):501-13.Available from: http://revista.ibict.br/ciinf/article/view/1804
  » http://revista.ibict.br/ciinf/article/view/1804
• ³¹
  Geocapes. Sistema de Informações Georreferenciadas CAPES: Distribuição de programas de pós-graduação no Brasi [Internet]. 2017l[cited 2019 Mar 25]. Available from: https://geocapes.capes.gov.br/geocapes/
  » https://geocapes.capes.gov.br/geocapes/
• ³²
  Martin D, Montanari PM, Pereira PPG, Hamburger GG, Silveira C. As contribuições das Ciências Sociais e Humanas no campo da Saúde Coletiva: vinte anos da revista Interface - Comunicação, Saúde, Educação. Interface. 2018;22(67):1029-42. doi: 10.1590/1807-57622017.0219
  » https://doi.org/10.1590/1807-57622017.0219
• ³³
  Bosi MLM. Pesquisa qualitativa em saúde coletiva: panorama e desafios. Ciênc Saúde Coletiva. 2012;17(3):575-86. doi: 10.1590/S1413-81232012000300002
  » https://doi.org/10.1590/S1413-81232012000300002
• ³⁴
  Ferreira J, Brandão ER. Challenges in the anthropological education of Healthcare professionals: a teaching experience in graduate studies in Collective Health. Interface. 2019;23(e170686). doi: 10.1590/interface.170686
  » https://doi.org/10.1590/interface.170686
• ³⁵
  Tuzzo AS, Braga CF. O processo de triangulação da pesquisa qualitativa: o metafenômeno como gênese. Rev Pesqui Qualit [Internet]. 2016 [cited 2019 Apr 18];4(5):140-58. Available from: https://editora.sepq.org.br/index.php/rpq/article/view/38
  » https://editora.sepq.org.br/index.php/rpq/article/view/38
• ³⁶
  Silva AH, Moura GL, Cunha DE, Figueira KK, Horbe TAN, Gaspary E. Análise de conteúdo: fazemos o que dizemos? Um levantamento de estudos que dizem adotar a técnica. Conhec Interativo[Internet]. 2017[cited 2019 Apr 10];11(1):168-84. Available from: http://app.fiepr.org.br/revistacientifica/index.php/conhecimentointerativo/article/view/223/221
  » http://app.fiepr.org.br/revistacientifica/index.php/conhecimentointerativo/article/view/223/221
• ³⁷
  Macedo JP, Abreu MM, Fontenele MG, Dimenstein M. A regionalização da saúde mental e os novos desafios da Reforma Psiquiátrica brasileira. Saude Soc. 2017;26(1):155-70. doi: 10.1590/s0104-12902017165827
  » https://doi.org/10.1590/s0104-12902017165827
• ³⁸
  Amarante P, Nunes MO. A reforma psiquiátrica no SUS e a luta por uma sociedade sem manicômios. Ciênc Saúde Coletiva. 2018;23(6):2067-74. doi: 10.1590/1413-81232018236.07082018
  » https://doi.org/10.1590/1413-81232018236.07082018
• ³⁹
  Rocha EN, Lucena AF. Projeto Terapêutico Singular e Processo de Enfermagem em uma perspectiva de cuidado interdisciplinar. Rev Gaúcha Enferm. 2018;39:e2017-0057. doi: 10.1590/1983-1447.2018.2017-0057
  » https://doi.org/10.1590/1983-1447.2018.2017-0057
• ⁴⁰
  Cortez PA, Souza MVR, Oliveira LFA. Princípios de uma política alternativa aos manicômios judiciais. Saúde Soc. 2018;27(4):1206-17. doi: 10.1590/s0104-12902018180409
  » https://doi.org/10.1590/s0104-12902018180409
• ⁴¹
  Oliveira TTSS, Fabrici EP, Santos MA. Estrutura e funcionamento de uma equipe de saúde mental de Trieste na perspectiva de seus integrantes: um estudo qualitativo. Psicol Pesq. 2018;12(2):24-35. doi: 10.24879/2018001200200139
  » https://doi.org/10.24879/2018001200200139
• ⁴²
  Silva KL, França BD, Marques RC, Matos JAV. Análise dos discursos referentes à educação permanente em saúde no Brasil (1970 A 2005). Trabalho, Educação e Saúde. 2019;17(2):e0019222. doi: 10.1590/1981-7746-sol00192
  » https://doi.org/10.1590/1981-7746-sol00192
• ⁴³
  Ministério da Saúde (BR). Resolução nº 32, de 14 de dezembro de 2017. Brasília: Ministério da Saúde; 2017.
• ⁴⁴
  Ministério da Saúde (BR). Decreto nº 9.761, de 11 de abril de 2019. Brasília: Ministério da Saúde; 2019.
• ⁴⁵
  Ferreira TPS. Produção do cuidado em Saúde Mental: desafios para além dos muros institucionais. Interface. 2017;21(61):373-84. doi: 10.1590/1807-57622016.0139
  » https://doi.org/10.1590/1807-57622016.0139
• ⁴⁶
  Monteiro RP. Araújo JNG. Manicômio Judiciário e Agentes Penitenciários: entre reprimir e cuidar. Psicologia: Ciênc Prof. 2018;38(núm.esp.2):144-58. doi: 10.1590/1982-3703000211962
  » https://doi.org/10.1590/1982-3703000211962

Edited by

EDITOR IN CHIEF: Antonio José De Almeida Filho

ASSOCIATE EDITOR: Ana Fátima Fernandes

Publication Dates

• Publication in this collection
  10 July 2020
• Date of issue
  2020

History

• Received
  03 Oct 2019
• Accepted
  27 Mar 2020