Women's mental health in Brazil: clinical challenges and perspectives in research
Joel Rennó JrI; César Eduardo FernandesII; João Carlos ManteseIII; Gislene Cristina ValadaresIV; Ângela Maggio FonsecaV; Mara DiegoliV; Silvia BrasilianoI; Patrícia HochgrafI
IInstitute of Psychiatry, Hospital das Clínicas, Escola de Medicina, Universidade de São Paulo (USP), São Paulo (SP), Brazil
IIChapter of Endocrine Gynecology, Family Planning and Climacterium, Gynecology and Obstetrics Disciplines, Universidade do Grande ABC (UNIABC), Santo André (SP), Brazil
IIIHospital Pérola Byington, São Paulo (SP), Brazil
IVWomen's Mental Health Service, Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte (MG), Brazil
VGynecology Outpatients Clinic, Gynecology Medical Division, Hospital das Clínicas, Universidade de São Paulo (USP), São Paulo (SP), Brazil
Women's Mental Health in Brazil remains underserved due to the lack of specialized clinical centers and poor research training or productivity. Nonetheless, there have been some promising initiatives over the last two decades to integrate gynecologic and mental health services and provide more multidisciplinary clinical care. This paper reviews such initiatives and discusses their strengths and pitfalls.
Keywords: Women's health; Mental health; Brazil
Concerns over women's health in Brazil have seen a shift in the last forty years. The concept of birth control has given way to the concept of reproductive health, which encompasses women's health and rights. In the '90s, the Integrated Assistance Program to Women's health (PAISM) was founded, based on the pioneering work of the Pérola Byington Hospital. At that point, the main goals were to:
1) Define priorities on public health issues
2) Integrate service provision to attend the demand driven by symptomatic patients with a system that could be synchronized by time and place with epidemiological and preventative interventions
3) Expand health integrated activities, employing professionals such as psychologists, psychiatrists and nutritionists
4) Cut down on incumbent bureaucracy wherever possible
5) Gain approval for, and encourage, dedication to women's health across all levels of the health system.
This broader concept of reproductive health focused primarily on giving assistanceto the physical and mental health of women, from adolescence to old age, more comprehensively with priorities set according to epidemiologically sound data. However, in a highly diverse country such as Brazil, the practical application of the concept of integrated assistance for the women's health remains problematic. The conditions required include political will, organization of the health system itself according to decentralized models, and appropriate encouragement and training of health staffs enabling the integration of efforts by professionals from different disciplinary backgrounds.
The government policy, except for some efforts in the other sense, remains on organizing campaigns focusing on isolated problems faced by women, such as cervical and breast cancers and sexually-transmitted diseases; there is a lack of more integrated efforts and research with a wider scope. Nevertheless, there are a number of hospitals and academic centers that seek, within their limits, to provide multiprofessional health care for women's health, during the different stages of the feminine reproductive cycle. This paper outlines the main characteristics of a number of these specialized centers supporting women's health in Brazil.
Endocrine/Climacteric gynecology services
1. Pérola Byington Hospital
The idea to create this specialized service stemmed from the fact that around 40% of patients attended at the hospital actually suffered from menopause-related problems.
The team comprises nine medical-doctors, along with nurses, nutritionists and psychologists.
A total of 2,256 appointments were performed representing 720 hours of monthly care.
The attended population had the following characteristics:
1) Average age: 53.5 years
2) Ethnicity : 79% Caucasian
3) Marital status: 94% were either married women or part of a stable couple
4) Schooling Level: 65% of women had less than eight years of education
5) Occupation: 93% of patients were housewives
The model currently adopted at Pérola Byington Hospital for integrated assistance to women's health is costly as it carries out a range of health procedures regardless of the patient's complaint. Some of these procedures could also be performed at health clinics that provide primary health care, but they are rarely performed at those places. Nonetheless, the advantages of the system include reduced number of hospital consultations and early disease detection with increased chances of cure, as well as lower costs on less radical treatment. The incumbent management has tried to provide this type of care for climacteric women whilst also providing the required medicines in collaboration with the State Secretary of Health.
The hospital's psychology team currently undertakes psychopedagogic and psychological studies. The research is facilitated through the medical care, which is based on protocols covering all diagnostic and therapeutic outcomes.
2. ABC School of Medicine
The multiprofessional team working in this sector consists of gynecologists, psychologists, nurses and physiotherapists. There are thirty-six medical residents, drawn from the three-year medical residency in gynecology and obstetrics, who take part in care provision, teaching and research activities.
The main care and teaching unit, located within the Integrated Care Centerfor Women's Health (CAISM), in the city of São Bernardo do Campo-SP, had 3,005 climacteric patients on their register by the end of 2004. The Endocrine Gynecology outpatient clinic handled 365 appointments. The population assisted has a longevity index of 67 years. 95.4% of the population is literate, and 32.5% had completedbetween 4 and 7 years of schooling.
The most common diagnoses at consultations included climacteric syndrome, weight disturbances, mood disorders, premenstrual tension and metabolic syndromes.
Educational courses are organized for those patients using the services. Main difficulties faced by this group include funding shortages to develop research, and scarce interaction with the other services. There is currently little interaction with psychiatry although there is higher involvement of the endocrine gynecology sector with the other disciplines of the ABC School of Medicine.
3. Medical School of the Universidade de São Paulo
The multiprofessional medical team includes ten gynecologists, one endocrinologist, one psychiatrist, four post-graduate students, a physiotherapist and a number of trainees.
The population assisted is composed primarily of women in reproductive ages with endocrine disturbances, along with women in transition to menopause. The treatment offered includes clinical (hormone therapy), psychiatric and even surgical care. Amongst the main difficulties encountered are problems of treatment compliance, medicine shortages under the SUS scheme (National Integrated Health System), an overload of patients and the lack of suitable care facilities. Despite the difficulties, post-graduate students and assistant medical-doctors have carried out a number of research projects.
Mental health services for women
1. Institute of Psychiatry, Hospital das Clínicas, Medical School, Universidade de São Paulo
There are two specialized centers: The Pro-Mulher (Project for Attention to Women's Mental Health), and the PROMUD (the Project for Attention to Women's Drug Addiction).
The Pro-Mulher was founded in 1993, initiated by a psychiatrist, Dr. Claudio Soares. The innovative initiative to create a service devoted to the women's mental health was driven by a high demand of female reproductive-related cases seen during the work carried by Dr. Soares at the Consultation-Liaison Group, at the same institution. Initially, the Pro-Mulher was structured to accomplish clinical, teaching and research activities. Currently, this group has a multiprofessional team of four psychiatrists, six psychologists and three nutritionists. There are medical consultants in the areas of gynecology, obstetrics and endocrinology. The group provides collaboration in clinical care and research projects involving female reproductive cycle-related disorders, such as premenstrual dysphoric disorders, prenatal and postnatal mood and anxiety disorders, and menopause-related disorders.
Treatment offered includes medication and individual and group psychotherapy, where patients are grouped based on age range and major complaint. The most common physical complaints are headaches, breast tenderness, sleep changes, menstrual cramps, changes in sexual drive or desire and sweating. The most frequent psychological and cognitive complaints are mood lability (82%), anxiety (80.5%), irritability (79%), lack of energy (70.5%), low self-esteem (63%), impulsiveness (60%), social withdrawal (60%) and memory difficulties (59%).
Difficulties faced by this group include lack of financial resources, and lack of research experience - despite the vast clinical experience of all team members - as well as the absence of a more consistent support from gynecologists. However, a formal agreement has recently been made with the Obstetrics Service at the same Medical School, for collaboration on assistance and research.
The population assisted by the PROMUD consists of women with psychoactive substance dependence (according to the DSM-IV), aged 18 years or above. PROMUD combines cognitive-behavioral approaches for some aspects of treatment such as relapse prevention, with psychodynamic approaches to help women to understand their emotions and pains. The program offers psychiatric treatment, individual psychotherapy, family psychotherapy, individual occupational therapy and nutritional guidance for women with associated eating disorders. Seventy per cent of women seen at the PROMUD show full or partial recovery of overall functioning, as well as a reduction in the use of, or abstinence from, alcohol and other drugs. Obstacles faced are lack of financial resources and insufficient physical space suitable to treat the groups.
2. Psychiatric Service of the Hospital das Clínicas of the Universidade Federal de Minas Gerais
The team consists of one psychiatrist, two psychologists, a music therapist and a sculptor.
Patients are referred by the Gynecology and Obstetrics Service of the Hospital das Clínicas of the Universidade Federal de Minas Gerais as well as by other public hospitals. An average of one hundred patients per month are treated, mean age around 35 years. Main problems detected among these patients are lack of self-esteem, sexuality and work-related gender discrimination. The service offers psychiatric, individual and group psychotherapeutic care, as well as music therapy and art therapy, in twelve-week programs.
Psychiatric disorders commonly seen at this service include premenstrual dysphoric disorder, pregnancy and puerperal-related disorders, disorders related to infertility as well as to abuse or violence against women. Difficulties remain related to institutional issues and prejudiced individuals who discriminate against gender-specific services. Finally, the current lack of academic titles of those providing the service remains an obstacle to obtaining funds for research projects. There is little integration with other similar services.
Support Center for Women with Premenstrual Tension, Hospital das Clínicas, Medical School of the Universidade de São Paulo
This center, linked to the Gynecology Clinic of the Hospital das Clínicas of the Medical School of the Universidade de São Paulo, was initiated in 1993 and comprises a gynecologist, with support and collaboration of a psychologist and a social worker from the same service.
There is extensive collaborative work with Pro-Mulher, already described. Patients are women aged between 15 and 55 years. An average of twenty patients per week are seen. The most frequent symptoms are the psychological ones, such as depression, irritability, low self-esteem, aggressiveness and anxiety. When symptoms occur exclusively during the premenstrual period, a gynecologist manages them. Should problems persist throughout the menstrual cycle, patients are referred to Pro-Mulher.
Therapeutic interventions most employed involve the use of hormones to suppress menstruation, symptomatic medications, antidepressants, anxiolytics and phytotherapies.
Guidance on behavior is offered covering advice on how to cope with symptoms, some physical exercises to be undertaken, as well as care concerning diet during the pre-menstrual phase. Patients requiring psychotherapy are referred to the Institute of Psychiatry. The key problems include the reduced size of the multiprofessional team and lack of funds.
Women's health care in the public health sector, despite limited financial resources and bureaucratic issues, has several care centers of excellence, integrating health care and preventative activities for various periods of a woman's reproductive life. There is growing concern amongst such centers, as well as amongst gynecology services at academic institutions, about the need for greater integration with services devoted to mental health.
Although providing high-quality clinical care, the few existing centers in Brazil which are specialized in women's mental health, remain limited due to lack of financial resources, and poor research training or productivity. There is an absolute need for more collaborative work with other national/international centers, for the development of clinical services, and research and post-graduate activities.
Conflict of interests: None
Publication in this collection
09 Dec 2005
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