Analysis of Nursing Dissertations and Theses on Mental Health , Brazil , 1979-2007

This bibliographic study analyzes scientific texts published in the CEPEn database in the mental health field (1979-2007). A total of 280 abstracts were investigated, of which 208 were Master’s theses. The individuals investigated in these studies were professionals (57), patients (50), and professors and/or students (18). Among the themes addressed between 2000 and 2007 were the following: Nursing Care in Mental Health (40), Perception in Mental Health (37); and Transversality in Mental Health Care (27). This study provided an overview of the scientific research produced in the mental health field in Brazilian nursing graduate programs. We expect this study to elicit reflections concerning mental health care practice and enable new approaches for nursing promoting health and the prevention of diseases in order to enable patients to recover their citizenship, autonomy and quality of life.


Introduction
The institutionalization of psychiatry was established in the mid 17 th Century during the Enlightenment era.
The use of reasoning as exemplified by ancient Greeks was recovered by philosophers during this time and irrationality, represented by insane individuals and "disturbers of the peace", was contained and corrected in prisons, schools, workhouses and madhouses that emerged throughout Europe in the 18 th and 19 th centuries (1) .
Classical psychiatry was developed with the creation of asylums, considered an efficacious therapeutic model, viewing isolation and abusive practices as a necessary evil for achieving a cure.After psychiatry, movements contrary to this instituted knowledge and practice emerged aiming to reform the model current at the time.
In Brazil, psychiatric reform was triggered in a political context of struggle to re-democratize the country and was strongly influenced by movements of reform in psychiatric care in Italy and the United States at the end of the 1970s.The internal conditions of psychiatric facilities that included maltreatment of inpatients were exposed in the Brazilian social process of "democratic opening" (2) .Therefore, the transition of the mental health paradigm occurs with the transition from hospitalization to deinstitutionalization.The hospital paradigm reveals an inability to institute spaces to help and welcome patients, while the psychosocial field adopted by the deinstitutionalization paradigm no longer accepts that the disease has a single explanation or the proposal to Silva KVLG, Almeida ANS, Monteiro ARM, Silveira LC, Fialho AVM, Moreira TMM.
treat it uniquely based on the biological and scientific references.Hence "psychiatric deinstitutionalization" proposes a transformation in the knowledge, professional, and educational fields and institutional mental health practices (3) .
Currently, mental disease is explained not only by biological causes, but also psychological and social ones, and appropriate care seeking to enable patients to be reinserted into society and to provide appropriate support for patients and family members is necessary (4) .The practices developed in the nursing field are influenced by human relationships and nursing's focus goes beyond disease's physical/biological aspect and considers the context of interpersonal relationships in which the professional is an instrument of care (5) .
An analysis of the articles published by the Latin American Journal of Nursing in the last five years reveals that only one study consisted of a systematic review of knowledge produced in the mental health field (6) .

Method
This is a bibliographic study with a quantitative approach, the methodology of which is based on exploratory and selective readings of the study's material, which contributed to the process of synthesis and analysis of results.We stress that in this type of investigation, the studied material must have been published in the form of books, articles in periodicals, and currently, as material available on the internet (7) .

Results
Data concerning the theses' and dissertations' abstracts are presented according to year of publication, graduate program, distribution regarding its category, subject matter and settings where they were carried out.The abstracts analyzed according to the thematic categories that ground this study are presented as follow.

Discussion
Figure 1 shows the growing scientific production in nursing mental health with a leap from 22 studies in the 1980s to 87 studies in the 1990s, with a considerable increase also in the number of graduate programs in the decade.This is explained by the expansion led by the restructuring of the Brazilian Education Guidelines Law approved in 1997, which established that higher level education schools should have at least one third of their faculty members with a Master's or doctoral degree (8) .Consequently, several graduate programs were launched with a higher demand for candidates and with a consequent increase in the number of dissertations and theses from the 1990s on.
Greater accessibility to Master's programs is and was the first doctoral program authorized in 1980 (9) .
Nurses seek to deepen their scientific knowledge with a growing interest in research in recent decades.
Scientific concern in nursing dates back to the 18 th century when the emergent model of capitalist production demanded the creation of hospitals to deliver health care (10) .
The Brazilian mental health policies have changed in recent years.After the movement for the psychiatric reform, the structure of mental health services abandoned the restriction to hospitals of psychiatric hospitalization and came to include a community-based network composed of various extra-hospital services (11) .
Psychiatric reform seeks to enable mental patients to recover citizenship, questions the current care model and proposes new strategies to transform it.The following were then proposed: replacement of the "hospital-centered model"; implementation of an extra-hospital network and multi-professional care; the construction of new psychiatric hospitals be prohibited; progressive deactivation of beds; inclusion of psychiatric beds in general hospitals and the integration of mental Silva KVLG, Almeida ANS, Monteiro ARM, Silveira LC, Fialho AVM, Moreira TMM.
health into other health programs, social movements and institutions (12) .
In relation to the addressed themes, an interest in mental health promotion in different health fields and services is apparent, which consolidates the mental health proposals in different care spheres.
The success of psychiatric reform depends on new forms of care and treatment and requires that health professionals be prepared for these activities (13) .For that, nursing practice should be carried out in a humanistic, creative, reflexive and imaginative perspective, considering care as a dynamic, mutable and innovating process (14) .
Among the categories that emerged from the studied material, we found investigations of and reflections on care, knowledge constructed regarding psychiatric reform and the approach to patients with mental disorders and their family members, as well as new therapeutic modalities in work spaces in mental health.
The re-construction of a new action in health in which health professionals are challenged to link technical knowledge with ability in order to deal with diversity and unpredictability is seen in the current care model.It is a paradigmatic, conceptual and ethical rupture (15) .
In relation to the theme "Psychiatric/Mental health nursing teaching", it is believed that changes in the mental health field imposes a transformation in the educational field and require professionals committed to a new way of dealing with knowledge (16) .Mental health teaching in the paradigm of psychiatric reform should reflect the changes experienced in care and become the object of interest and study of those involved.
It is necessary to establish permanent education processes jointly with the mental health nursing team and to establish appropriate professional education to fully implement policies in this sector because the cooperation between services and universities strengthens and develops the workforce in healthcare (17) .
Concerning the studies' participants, patients with psychiatric disorders and their family members are increasingly studied as are the professionals involved in care as active actors of this process of re-constructing new practices of care delivered to patients with mental disorders (18) .Nurses need to know and understand the entire context, offer support and the necessary guidance; they need to help patients to be active participants in the therapeutic process and focus on the family and offer the necessary support (4) .
In relation to the research settings, extra-hospital services are highlighted, with the implementation of new modalities of community-based care and the interrelation of these services and primary care in which the interest for the investigation of the work and strategies developed by health professionals is observed.
It is important to highlight the diverse purposes of mental health services: promotion and prevention actions, cure and rehabilitation associated with the construction of autonomous subjects satisfied with their lives (17) .After all, psychiatric reform aims to transcend the walls of the asylum, creating spaces that focus on the individuals' singularity, collaborating with their autonomy and self-care in the health-disease continuum.For that, conceptions and devices need to be re-elaborated, so that one can better relate with madness, re-constructing it from a perspective more committed toto the interests of those to whom care is delivered (19) .

Conclusion
were collected from the proceedings of Mental Health Researchers and Psychiatric Nursing Specialists Meetings.The content analyzed highlights the prevalence of articles addressing psychiatric nursing care, which reflects nurses' initiative to describe and disseminate their practices.From this perspective, this study contributes to broadening the discussion of studies of psychiatric nursing care, allowing a deeper knowledge of the way nursing studies are being produced in the mental health field.This study was developed as part of the evaluation of a course "Research in Health and Quantitative Methodology" from the Master's program in Clinical Health and Nursing Care at the State University of Ceará.The subject of mental health is the object of this study, since Psychiatric Reform is a landmark for nursing care in mental health.This study analyzes the scientific texts (dissertations and theses) published in the catalogs of the Center for Studies and Research in Nursing (CEPEn) in the mental health field (1979-2007).
Center of Studies and Research in Nursing (CEPEn) were used to collect data and all the abstracts of Brazilian dissertations and theses that met the inclusion criteria constituted the material of this study: abstracts published from 1979 to 2007 available online (site: www.abennacional.org.br)through the link CEPEN or on CD-Rom with the following descriptors: Psychiatric Nursing; Mental Health; Mental Disorder.Data were collected in October and November 2008 and a total of 337 abstracts were found; 57 were excluded due to repetition or because they did not fit the study's theme, totaling 280 abstracts.

Figure 1 -
Figure 1 -Distribution of abstracts published in the CEPEn catalogs from 1979 to 2007 according to year of publication.Fortaleza, CE, Brazil, 2008.

Figure 1
Figure1shows a predominance of theses compared to dissertations.Twenty-two studies were developed between 1979 and 1989 including dissertations and

Figure 2 -
Figure 2 -Distribution of abstracts published in the CEPEn catalogs from 1979 to 2007 according to graduate nursing programs.Fortaleza, CE, Brazil, 2008.

Figure 2
Figure 2 shows that a large majority of the studies are in the Southeast.The graduate programs that stood out were: University of São Paulo (USP); Federal University of Rio de Janeiro (UFRJ); Federal University of Santa Catarina

Figure 3 -
Figure 3 -Distribution of the abstracts published in the CEPEn catalogs from 1979 to 2007 according to the categories evidenced in this study.Fortaleza, CE, Brazil, 2008.
Silva KVLG, Almeida ANS, Monteiro ARM, Silveira LC, Fialho AVM, Moreira TMM.To facilitate analysis, the studies were divided into thematic areas: Nursing care in mental health; Perception in mental health; interconnections in mental health care; Psychiatric/Mental Health nursing teaching; Extra-Hospital services; Psychiatric Reform; and Therapeutic modalities.The studies were also allocated into intervals that reflect historical and political periods experienced in the country.The first period(1979-1989) is characterized by the beginning of Brazilian psychiatric reform; the second (1990-1999) refers to the period when redemocratization was consolidated in the country; and the last period (2000-2007) is when the new law governing mental health was enacted.Under the theme "Nursing Care in Mental Health" were included the abstracts that presented aspects related to nursing care, historical analysis of nursing practices and the 'doing' and 'knowing' of psychiatric nursing.The theme "Perception in Mental Health" included the studies addressing the perception and experience of family members, students, patients and professionals concerning mental disease, treatment and experiences in the mental health process.The studies that related mental health to other related fields were included under the item "Transversality of Mental Health Care".The thematic "Psychiatric/Mental Health Nursing Teaching" included studies addressing the learning-teaching process and the experience of students/professors in the psychiatric discipline based on the new mental health care paradigm.The theme "Extra-Hospital Services" included the studies that reported the new spaces available in mental health care (Therapeutic Residences, Shelters, Psychosocial Care Centers (CAPS), Day Hospitals, Mental Health Outpatient Centers), addressing experiences, the patients' psychosocial profiles and situations, evaluation of services, structure, and therapeutic processes developed concomitantly with deinstitutionalization.The studies addressing mental health policies, Psychiatric Reform, the psychosocial care model and the planning of actions in mental health in certain settings were included in the theme "Psychiatric Reform".Finally, the item "Therapeutic Modality" included the studies that discuss the relationship and individual and group therapeutic projects.

Figure 4 -
Figure 4 -Distribution of abstracts published in the CEPEn catalogs from 1979-2007 according to the subjects included in the studies.Fortaleza, CE, Brazil, 2008.
The individuals addressed in the investigated studies comprised mostly professionals, patients and family members, of particular interest for researchers over the studied periods.www.eerp.usp.br/rlaeRev. Latino-Am.Enfermagem 2010 Sep-Oct;18(5):1031-8.

Figure 5 -
Figure 5 -Distribution of abstracts published in the CEPEn catalogs from 1979-2007 according to the setting where the studies were carried out.Fortaleza, CE, Brazil, 2008.
Data presented in figure5reveal a relevant interest in studies carried out in the following settings: extrahospital, university and primary health care.
observed since there are fewer doctoral programs distributed in the national territory, with a lower number of slots.Research in the studied subject is also more frequent in graduate programs of some Brazilian states, most of them in the state of São Paulo, given that a Master's program in Psychiatry was implemented in USP in 1975, which at the end of the 1970s and beginning of the 1980s focuses on psychiatric nursing (Figure 2).The 1960s and 1970s were marked by growth in the theory of the nursing profession with the emergence of the first graduate program that provided a degree in 1972 at the Anna Nery Nursing School at the Federal University of Rio de Janeiro (only the Master's program), Among the graduate programs, the Psychiatric Nursing Graduate Program -Master's and doctoral programs -at the University of São Paulo is highlighted.It has developed activities since 1975 with a growing and significant interest of its researchers in mental health.It is remarkable that the analyzed studies show a tendency in the last seven years to address extrahospital mental health services, revealing an interest in the praxis of these care settings from the perspective of patients, professionals and family members.From this perspective, one needs to reflect on the risk of the medicalization of the problem, defending the understanding of other factors that contribute to psychological suffering, and not reducing it to the biological and individual sphere.This study presents an overview of the current state of scientific research in mental health in Brazilian nursing graduate programs, guiding the development of further research on the theme.It aims to challenge health professionals to reflect on transformations arising from the modern world and their reflections on the mental health field, taking into account the principles of deinstitutionalization, citizenship, social reinsertion and family support, with a view of themes that arises from scientific nursing research as an instrument that confirms and encourages this practice.