Mental Health Indicators for the Brazilian Psychosocial Care Network: A proposal

Abstract Objective: to propose Mental Health Indicators aimed at management of the Mental Health Care Network, starting with convergence of their use, in countries with public health organization. Method: an exploratory analysis of the indicators adopted and used in these countries, from the detailed analysis of their respective normative documents, considering the World Health Organization guidelines. After selection of the indicators, the Mental Health Matrix was adopted as a suggestion for their development and application in the Brazilian Psychosocial Care Network. The matrix was prepared in two dimensions, respecting the inclusion and exclusion criteria for the indicators studied, as follows: geographical (national/regional, local, individual), and time (entry, process and results). Results: the analysis indicates 41 indicators that presented diverse evidence regarding their use. All were allocated in the Mental Health Matrix, contributing as a metric to analyze the purpose of the Mental Health services, in the levels and phases of each dimension. Conclusion: the indicators selected, distributed in the different Mental Health Matrix dimensions, are being made available for their use in management and in the clinical practice, as well as for scientific studies and, in the future, to be used as definers of Mental Health policies.


Introduction
According to the World Health Organization (WHO), people with mental disorders have disproportionately high disability and mortality rates. Individuals with major depression or schizophrenia have from 40% to 60% more chances of premature death than the general population, due to physical comorbidities that are not investigated in different situations (tumors, diabetes, cardiovascular diseases, HIV infection) (1) . Worldwide, suicide is the second most frequent cause of death among young people. Based on these facts, the WHO proposed a set of actions and goals for the member countries to adapt to their needs, seeking to change these rates. Thus, the WHO proposal emphasizes that leadership, governance and efficacy in Mental Health (MH) actions are to be strengthened, providing encompassing, adapted and responsive MH and social services at all care levels, strengthened by the information systems and by the results of research studies in this area (2) .
For the WHO, one of the principles of these technologies is how the indicators can significantly synthesize the information for a particular phenomenon, portray a situation and, therefore, be used to evaluate an established and current situation or propose some change.
The overall intentions established by the WHO provide the basis for assessing the Member States' collective actions and achievements in relation to the global goals, but should not prevent establishing more ambitious national purposes (2) .
A recent review study, pointing to the global panorama on the use of Mental Health Indicators (MHIs), analyzed 22 articles that presented the countries' attempts to select or implement MHIs. However, the results shown evidence different uses of these indicators to improve policies, management and services. However, some countries are still committed to the process of discussions, survey and collection of fundamental indicators. Some other initiatives from other countries were in an incomplete implementation process or in the implementation of pilot projects, highlighting that these indicators' capability is still unexplored. It is noteworthy that in low-and middleincome countries, the research studies on MHIs were conducted with many objections, due to the absence of essential MH services, financial conditions, legislation and/ or political disposition, or even lack of guidelines for MH data management and integration (3)(4)(5)(6)(7) .
A study carried out in 2016 sought to identify MHIs to assess effective treatment coverage in MH. The Delphi study method was applied in two rounds (with 93 specialists from different countries, mainly middleand low-income, such as: Ethiopia, India, Nepal, Nigeria, South Africa and Uganda). They initiated selection with a set of 876 indicators, finishing with 15 well-ranked. The study provided data on how the MH service and financial coverage can be assessed in low-and middle-income countries (4) .
In the Netherlands in 2013, a research study sought to develop a set of performance indicators that were executable, expressive and pertinent to assess the quality of the MH public system in Amsterdam. The study was initiated with 330 indicators, reaching the end with 56 indicators selected, based on an international questionnaire and presented to the parties participating in the process (5) . Another similar study was carried out in Germany. The researchers sought to describe the development of quality indicators for a quality-proof procedure for adult patients diagnosed with schizophrenia and schizotypal disorders with delusions (7) .  (8) . The following is evidenced as general purposes of this network: articulation and aggregation of the points of care of the health networks in the towns, evaluating care through welcoming, constant follow-up and emphasis on urgencies (8) .
The SUS scope includes the RAPS, comprised as follows (8)  Despite the important changes that took place in the structure of Brazilian MH organization in the last decades, a recent study (10) showed how MH is discussed in the

Study design
This paper consists of a study of the MHI Exploratory Survey type. This method is aimed at knowledge discovery, without the purpose of evaluating or validating pre-established hypotheses (13) .
Analysis of the results was performed according to the procedures established by the Evidence-Based Practice (EBP), referring to the use of MHIs.
In EBP, it is crucial to provide diverse scientific information on programs and policies that are decisive in health care promotion, in order to produce evaluation research studies and constitute diverse evidences. The intention is to modify science in practices, mapping diverse information on evidence-based interventions from peerelaborated literature for the context of a specific real environment (14) .

The concept of "indicator"
The word "indicator" comes from Latin indicare, which means to discover, point, announce and estimate.
Following the criteria of the semantic knowledge of words, proximity to the words "measure", "inform" and "indicators" or their successors "measurement" and "information" stands out (15)(16) .
The indicators allow performing diagnoses, as well as monitoring and evaluating the individuals and management of the services. Thus, they encompass the search for clinical goals, the quality of professional and managerial care and the results obtained, as well as they assist in taking decisive actions, contributing to the improvement of the processes as a whole (17) .
Elaboration of an indicator is a complex activity, which can range from basic and direct counting of cases of a specific disease to calculation of more elaborate proportions, ratios, rates or indices, such as life perspective at birth (18) .

Mental Health Indicator
In the Action Plan for the 2014-2020 period, the WHO points out the need to develop a basic set of MHIs, in addition to providing guidance, training and technical support aimed at developing surveillance/information systems to obtain the main MHIs and, with this, optimize use of this data to monitor health inequalities and results, as well as extend the information collected by the WHO Global MH Observatory (as a follow-up to the WHO Global Health Observatory); therefore setting up a database to monitor the global MH condition (including the advances regarding the goals determined in the Action Plan) (2) .

Scenario
The data were collected from normative documents and official websites of countries with public health systems, namely: Australia, England and Canada. The  https://consaludmental.org/la-confederacion/ 2. Indicators for the evaluation of Mental Health systems in Spain (35) . http://www.sepsiq.org/file/Noticias/GClin-SEPIndicadores.pdf In the second phase, a set of documents was researched in governmental websites of the health systems from some countries, in order to select those with identification of the indicators effectively used in MH management, which provided diverse information on how these indicators are used in each analysis dimension (30) .

Instruments used to collect the information
After selecting the countries, analysis and selection of the indicators that best referred to the RAPS was initiated, always comparing them with the normative documents.
The first step was carried out with a meticulous search of the national (Ministry of Health) and international (World Health Organization, PAHO) normative documents, taken as a reference for comparison in Figure 1 below.
Both investigation stages of the normative documents took place considering the selection/exclusion criteria of each country and its MHIs (30) .

Selection/Exclusion criteria for the indicators
• 1-Not being part of the Brazilian situation (immigrants, ethnicities, etc.).
• 4-Indicators that require information regarding selfassessment/application of an individual questionnaire.

Data treatment and analysis
Following the steps established for this study, the phase for the Identification of the selected MHI set was reached, establishing the primary characteristics for each indicator. The format determined by the Interagency Health Information Network (RIPSA) (8,18) was resorted to for this purpose, seeking the following items: Definition, Conceptualization, Source, Calculation Method and Category.
The MHM (40) was defined as a fundamental reference, as a heuristic guide in the addition and applicability of the MHIs, at different network management levels.
3 fundamental and inseparable axes are pointed out in this matrix example, namely: ethical conception; evidencebased practices; and accumulation of experiences (41) .
The MHM also refers to a model that can be used to increase the clinical and management benefits. This model suggests two dimensions: a geographical one, divided into three levels: national/regional, local and individual (patient) and a time one, defined by three phases: entry, process and results (40) .
Health policies stand out at the national/regional level; however, at the local level we find the services

Ethical aspects
The study herein presented followed the ethical

Results
The main results of this study were achieved based on the criteria described in the method. Thus, three countries were initially selected, in which 164 MHIs were identified.

Time Dimension: Entry Phase (A)
Six indicators from those selected were allocated in the National (or Regional) Level of Entry Phase 1A axis, serving as measures for evaluating the MH services at this level. The contents proposed for this phase refer to the governmental guidelines and policies, MH laws, costs for MH services and budget relocation, organization of MH contingent and employee training, and protocols and guidelines for treatments and referrals, as shown in Figure 3.

A) Entry Phase
(1) National/Regional Level for individual patients are identified (32) .

Time Dimension: Results (C)
This phase questions the evaluation of the results and should take place accurately and regularly, as a team practice, as the goal of the services is to improve

Geographical Dimension
Time Dimension

B) Process Phase
(1) National/Regional Level 1B 1. Students with social, emotional and mental health needs: % * of these students (High School age). 2. Hospital admission due to mental and behavioral disorders resulting from alcohol consumption: rate per 100,000 inhabitants † .

Finally, 1 indicator was defined in the Individual
Level, Results Phase, 3C. The following is sought in this phase: reduction of symptoms, impacts on the caregivers, satisfaction with the services, quality of life, disabilities and needs (32) . In order to broaden the discussion, it is worth mentioning the Donabedian Model, which provides a general structure to investigate health services and measure care

Geographical Dimension
Time Dimension

2C
1. Prevalence of depression and anxiety in the participants (aged over 18 years old). 2. Estimated prevalence of common Mental Health disorders (% of the population aged between 16 and 74 years old). 3. Estimated prevalence of Mental Health disorders in children and young people (% of the population aged between 5 and 16 years old). 4. Record of the prevalence of severe mental illness (% of the practice recorded in all age groups). 5. Emergency hospital admissions due to intentional self-harm. 6. Hospital admissions due to self-mutilation, standardized admission rate. 7. Depression: prevalence recorded (individuals aged over 18 years old). 8. Change in the consumers' results. 9. Post-discharge community care rate.
(3) Individual Level 3C 1. Successful outcome of the treatment for alcoholism.
Source: Adapted (32) ; *100,000 inhabitants = Data from the Brazilian Institute of Geography and Statistics (43) ; † % = Percentage Figure 5 -Allocation of the MHIs: Results Phase the results for people with mental disorders, as well as management of the MH system in general (42) .
In quality (46)(47) . It is interesting to note that, according to this model, similarly to the approach outlined in the MHM, the best way to evaluate care quality is to select a set of representative indicators from three approaches, namely: "structure", "process" and "results" (32) . The Donabedian Model is cited here as another example of a matrix, in which the characteristics of the health practices and social organization are defined, namely: equality, coverage, user satisfaction, effectiveness, efficiency and accessibility (46)(47) .
In his several health research studies on health, the author did not specifically propose a model for MH; however, his work supported constitution of the domains of the Australian MHI set (39) , as well as it inspired the organization of the MHI set in England (38) .  (48) . Indeed, this set of indicators has application in producing evidence on a health scenario and its trends, based on experience, to identify populations with greater health needs, establish epidemiological risk and identify critical areas. In this way, it contributes as an important tool to establish policies and their priorities, to improve the quality of the services and to adapt care protocols and measures that can provide diverse information for MH promotion programs, as well as prevention and treatment of diseases with psychosocial rehabilitation of the chronic cases, seeking to better meet the needs of the population (49)(50)(51) .
Analyzing and biomedical aspects of this area and relates them to managerial processes of the care networks (52)(53) .

This fact intensifies our interest in improving this
proposal and to test it in the services, seeking consensus and accompanied by research studies and publications.
As a future paper, we will submit the indicators selected in this study to the application of the Delphi Study to validate the results.
Rev. Latino-Am. Enfermagem 2022;30:e3533. Due to non-use of official MHIs in Brazil, it is expected that the results herein presented will be a stimulus for new research studies, as well as an aid for establishing policies aimed at the priorities, specific laws, quality of the services, adaptation of care protocols and measures that can provide diverse information to the MH programs, always seeking to better meet the needs of the population.