Development of a sustainable community mental health program in a remote region : the Austral Institute for Mental Health

This paper described a community-based rehabilitation program in a remote region of Argentina. The program is located in Neuquén Province, in the Patagonia region. At the time it was initiated, about 20 years ago, the province had an excellent system of primary care, but one in which mental disorders were neglected. There were only a few psychiatrists in the province, and none involved in community care of people with severe mental disorders. Starting from this point, the “Austral” program was developed by making use of the local resources (such as primary care doctors) that were available, and it later earned a reputation as a model program. In 2012, Neuquén became a site of the RedeAmericas, a National Institute of Mental Health funded regional mental health network in Latin America.


INTRODUCTION
This paper describes a community-based rehabilitation program in the province of Neuquén, in the remote Patagonia region of Argentina, which has been sustained for 20 years.Previous publications have described the early phase of the program 1,2 , but this is the first description of how it has evolved and been maintained over such a long period.It is now recognized worldwide as a model program, cited by the World Health Organization Mental Health Division 3 and by the World Federation for Mental Health 4 .Numerous trainees from other places, including the United States and Europe, take electives during which they learn about the program and participate in its work.
One of the authors of this paper was the originator of the program and continues to lead it; and the other was one of three founding members of a group of international consultants who have helped support and shape its development since its initiation.Five members of this group are now also involved in RedeAmericas.Pamela Collins is no longer involved with the Austral, due to the potential for conflict of interest; as a leader in the field of global mental health, she now plays a key role in the development of global mental health initiatives such as RedeAmericas within the National Institute of Mental Health (NIMH) 5 .

CONTEXT
The province of Neuquén is vast, bounded by two rivers fed by the melting snows of the Andes mountain range.It forms a triangle in the Northwest of the Argentinian Patagonia.Neuquén was "national territory" until 1956, when it became a province of the Argentinian Republic.The new one was extremely rich in natural resources, for example, it had major oil and gas fields, large areas of fertile land, and other of dense native jungle.It also had a natural beauty that now attracts tourists from around the world.
Nonetheless, in its early decades, many communities were very poor and a significant number of people was destitute.The population was comprised mainly of indigenous communities, and recent migrants from other Argentinean provinces and neighboring countries who came in search of work.The majority of the population was children and youth.Such population was afflicted by high rates of childhood malnutrition, endemic illnesses like hydatidosis and tuberculosis, and one of the highest infant mortality rates in the Americas (more than one in ten babies).This poor state of population health reflected in part the almost complete absence of a provincial public health program.
By the late 1960s, migrants had become a larger proportion of the population, especially in the city of Neuquén, and the standard of living had improved in many communities as the natural resources were exploited, generating jobs and income.Nonetheless, there had not been a commensurate improvement in population health, for example, infant mortality rates remained very high.At this time, Governor Don Felipe Sapag, responding to demands from mothers to improve child's health, initiated the development of a remarkably innovative public health policy.At the heart of the policy was a universally accessible health care system based on primary care, which was delivered by general doctors, nurses, and paraprofessionals within each local community.Secondary and tertiary cares were available at district level on referral.
Within a decade, the health system and other public health policies had been rapidly transformed.The province had developed an integrated health care system, making use of local resources, under the leadership of cutting edge public health professionals such as Doctors Moreno and Perrone.This in turn was a major contributor to a transformation in population's health.The infant mortality rate has continued to decline.For example, over the 30-year period from 1980 to 2009, the rate dropped from 31.7 to 7.6% 6 .The degree and rapidity of this improvement in public health is unparalleled in the history of Argentina.
Over subsequent years, the health system was further developed and consolidated.It achieved virtual self-sufficiency, that is, it was rarely necessary to refer patients to health care outside the province, with one notable exception.The exception was mental health care, which had not been integrated into the public health system of the province.

MENTAL HEALTH CARE IN NEUQUÉN BEFORE THE AUSTRAL
In 1987, the public mental health system of the province was essentially limited to nine psychiatric beds in a tertiary care hospital (Castro Rendon Hospital) for the entire population of 400,000 inhabitants.Outpatient care was mainly provided by a few office-based specialists in the private sector in the capital city of Neuquén.Jose Lumerman was recruited to Neuquén to work in the public health system, with the mission of changing this situation.It proved difficult to do so due to changes in leadership and general resistance to inclusion of mental health services as a major component.
In 1993, aware of the gap in mental health services in the public sector, the medical director of Neuquén's Social Security Institute (ISSN) asked JL to develop a nongovernmental organization for the care of ISSN members with severe mental disorders.ISSN is a form of social insurance that represents the most important source of funding for health services for most of the population.
Until that time, most patients with severe mental disorders had to be transferred to Buenos Aires (more than a thousand miles away) for specialized care.For those who were not wealthy, this often meant inpatient care in La Borda, a large and crowded asylum in Buenos Aires.It is not known how many people never returned to Neuquén.Those who did received minimal if any follow-up care; many relapsed and were sent back to Buenos Aires for re-hospitalization.This generated high costs for the ISSN, as well as unsatisfactory clinical outcomes for the affected individuals and their families.

CREATION OF THE AUSTRAL INSTITUTE OF MENTAL HEALTH
The challenge that JL confronted was to develop a program for mental health care in a province that had virtually no psychiatrists providing care for people with severe mental disorders.Furthermore, the program had to be established outside the provincial public health system, though it would also need to maintain strong ties with that system.His previous experience in the public health system of the province enabled him, however, to identify other kinds of local resources, and to envision a community based mental health care that could be built with these resources.Clearly, primary care teams consisting of general practitioners, nurses, social workers and community health workers were providing adequate care for people with chronic diseases such as diabetes.Why could they not do the same for people affected by chronic psychiatric disorders?At the same time, other kinds of local resources were potentially available to fulfill the roles usually played by occupational therapists and others in psychiatric rehabilitation.Why not use artists, dancers, actors, authors, and sculptors?
The Austral Institute was developed as a novel approach to the use of these local resources for community mental health care.A central guiding concept since the initiation of the program has been "alta simplicidad" (high simplicity, in English).This meant the distillation of complex concepts of care into basic principles that could be conveyed to all stakeholders in the community, including service users, their families, journalists, policy makers, teachers, judges, and others.Indeed, it was apparent from the start that for the program to be sustained, it would need to be understandable to the entire community.Alta simplicidad also defined the elaboration of corresponding mental health care practices that could be implemented by nonspecialist workers, an approach that nowadays would be considered as a form of "task shifting".
Following this principle, the new Institute used teams led by general practitioners who learned to recognize the basic symptoms of mental disorders, and the appropriate treatment.Treatment included the key elements of the healing process: outreach and support delivered at home and/or at a welcoming locale (the Institute); support for family members; a recovery orientation (in current terminology); advocacy in the community to allow patients to participate in civic life; and medications.

SERVICES OF THE AUSTRAL INSTITUTE
The program has evolved a great deal, and now includes nurses, psychologists, and other mental health professionals.Nonetheless, the central elements of the team structure have remained in place.For example, the general practitioner is the overall team leader and monitors physical health and medications as well.The community mental health worker spends more time than other members of the team providing services to the patient and family and has the most intimate knowledge of their circumstances.A psychiatrist is available for consultation.The team meets regularly to share experiences and plan treatment strategies.
Over a period of about 20 years, in conjunction with this general approach, a wide spectrum of outpatient services were developed.We describe three of them briefly here; others, not described, include services for children.
The Day Hospital is the highest intensity outpatient service.For the creation of the Day Hospital, a comfortable house was chosen in the center of the city of Neuquén, and renovated by a local architect, to provide an open and cozy space.In its center, there is a prominent kitchen run by a chef who cooks delicious meals and interacts with patients.For patients in a state of crisis who cannot manage with the Day Hospital alone, there is also intensive home care which helps prevent the need for hospitalization.In addition, all patients receive home visits as part of assessment and ongoing work.Patients are assessed and monitored by their general practitioner and have psychiatric consultations.They participate in "Basic Needs and Functioning" groups, in groups for planning the weekends, in recreation workshops, and in multifamily meetings, usually led by the community mental health workers.They also discuss ways to socialize and participate in the broader Neuquén community during their free time, both in one to one meetings with staff and in the various groups.The average length of stay in the Day Hospital is four months.
The Half-Day Hospital is a service of medium intensity where patients are offered therapeutic activities similar to those of the Day Hospital, but less intensive, and with more emphasis on groups.Often patients move from the Day Hospital to the Half-Day Hospital as they improve, but they can also start in the Half-day Hospital, depending on their condition and needs.The average stay is three months.
A third key component service is rehabilitation.Although rehabilitation was always central to the mission of the Austral, the services available have increased gradually over time, and especially in the last few years.The rehabilitation process begins in the Day Hospital, continues in the Half-Day Hospital, and finally becomes the main type of activity.Key to the rehabilitation process are the groups run by artists and agricultural technicians and other non-mental health professionals.These groups take place out in the community with the support of the community mental health workers of the Austral.Recently patients from the Austral have been admitted to courses in agricultural methods that are offered by the Province to the entire community.They participate as regular trainees, with no distinction made between Austral referrals and other trainees.Also, patients have set up various kinds of small businesses (e.g., making crafts out of wood to sell at the artisan fair on weekends), initially with the assistance of Austral staff, and later becoming virtually independent (staff still visit and offer some practical help when needed).There is no specified time limit to the rehabilitation process.
Since its creation, the Austral has treated over 5,000 patients and their families.Very few have required hospitalization.Following treatment, the great majority has been able to live in decent accommodation in the community, and have maintained enduring ties with their families.Often a family was initially disconnected from, or critical of a patient, and/or vice versa, but over time the family became a solid and welcome source of support.Many former patients have obtained employment.Thus, Neuquén has been transformed from a province in which community mental health issues were largely ignored into a province where people with mental disorders receive adequate help.

SUSTAINABILITY OF THE MODEL
Although there are many models of "task shifting" in global mental health, some distinctive features differentiate the Austral program from other models.We have already described one, that is, the reliance on general doctors as team leaders.The most distinctive (and possibly unique) feature, however, is that it has been maintained for nearly 20 years, in a remote area of a middle income country.We think there were three key factors that contributed to its sustainability.
The first factor is the strength of the relationship with stakeholders in the community.This has been achieved by ongoing efforts to maintain the ties of the Austral to a wide range of groups, such as government sectors and community groups and media.The government sectors alone include health, education, social security and justice.An enormous amount of time and energy has been devoted to these relationships, some of which are inherently unstable, for example, the periodic change of the political party in control of the provincial government always requires some reshaping of relationships.
The second factor is internal to the Austral itself, that is, the continuity of people who contribute to the institute in general, and the continuity of the Austral team in particular."Continuity" does not mean constancy, but rather, that turnover of staff is gradual, so that a core with experience remains; new staff can be introduced and trained as replacements or to lead the extension of services.This continuity is owed in part to the way the program was designed.Each team member's contribution is recognized as important in the team meetings where the evolution of the patients and families in the various therapeutic areas is discussed.Team members are encouraged to develop and increase their responsibilities, and further, to propose new initiatives.Furthermore, the team shares a commitment to the approach used, and above all, to the overall wellbeing of patients and families.These and other factors help foster enthusiasm and initiative, and thus prevent "burn-out".
The third factor is its ongoing relationship with international advisors in psychiatry, epidemiology and community mental health, who have made periodic visits to provide training.As noted earlier, one of the authors was intimately involved throughout this process from the beginning.The involvement of international advisors turned out to be important to sustainability for several reasons.First, it had a positive impact on morale of both staff and patients.International advisors who met with both staff and patients, and were impressed by the work being done, offered a kind of validation that something important was being achieved.Second, international advisors could provide guidance in some areas where expertise was lacking, and connect the Austral to related work being done across other regions of the globe.Third, their ongoing involvement led to international friendships that still help maintain morale, partly through direct contact, and partly through trainees, as described later.Fourth, it helped to raise the prestige of the work in the eyes of various stakeholders, such as government agencies.Fifth, it facilitated access to local and national media, which helped to disseminate the work of a program in a remote province to a broad audience across the country, and to some extent, to other countries.Finally, it created the potential to do research to gauge the effectiveness of the program in a rigorous way, although this potential is not yet fully realized.

RECIPROCITY
It would be very misleading to represent the interaction with the international advisors as a one-way process.In fact, our impression is that the international advisors learned as much from the Austral as vice versa.Many people who later became prominent in what is now called "global mental health" were part of the international advisory team of the Austral at a formative stage in their careers.Three examples are Pamela Collins, Graham Thornicroft, and Ezra Susser, each of whom had longstanding relationships with the Austral.These advisors participated not only in the development of the Austral per se, described here, but also in province-wide efforts to introduce mental health care into routine practice in the primary care system of the province.They were profoundly influenced by these experiences, and drew upon it in their subsequent work.
Furthermore, the Austral has served as a "practicum" experience for students in high-income countries to learn about the possibilities and challenges for mental health programs in a remote area of a middle-income country.The staff and patients alike have warmly welcomed trainees from the United States, the United Kingdom, the Netherlands, and other countries.At present, approximately 50 trainees have had this experience, and the number continues to grow.They include young psychiatrists, other mental health and public health trainees, medical students, and motivated undergraduates.

CONCLUSIONS
The experience of the Austral suggests that good community mental health care is feasible and sustainable in remote settings in middle income countries where there are few psychiatrists and few psychiatric inpatient beds.The program has also had a broad impact on the region that goes beyond the individual patient care provided.Through its alliances with media and other sectors, mental health has become a theme of interest for the people in general, and for policy makers in particular, which is of crucial importance for the struggle against stigma and for increased investment in mental health services.As a result of related work with primary care doctors in the province, mental health has gradually become part of routine primary care and of medical training.In this context, the Austral has become a center of training for doctors, psychologists, nurses, social workers and advanced students who later assume positions in the primary care system of the province.Also, some of the former general doctors of the Austral are now key figures in the Neuquén Ministry of Health, where they facilitate the integration of mental health into primary care.Thus, one small program in a remote province has over the long term had a profound impact within the province, as well as an appreciable impact across the globe.Now, as one of the sites of RedeAmericas, we expect that the influence of the program across Latin America will grow, and at the same time, that the program will introduce new ideas from other sites of RedeAmericas.Being part of RedeAmericas may also allow for a full evaluation to document how the program influences the lives of the patients it serves, and to examine in more depth the reasons for its sustainability.