Mental health research in Brazil : policies , infrastructure , financing and human resources

*Fellowship by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES). Supported by Department of Mental Health and Substance Dependence of World Health Organization. Received on 12/7/2005. Approved on 6/9/2005. Correspondence: Jair de Jesus Mari Departamento de Psiquiatria UNIFESP Rua Botucatu, 740 04023-900 São Paulo, SP, Brasil E-mail: mari@psiquiatria.epm.br


INTRODUCTION
Research is no longer perceived as an discretionary activity, given its critical role in helping countries to reduce the health burden due to mental disorders worldwide.Research-generated information has been identified by the World Health Organization (WHO) as essential to determine needs, propose new cost-effective individual or collective interventions, monitor process implementation and evaluate the changes intended.Also, it is helpful to explore obstacles that prevent recommended cost-effective actions from being carried out.Conceivably, if information systems are indeed implemented and used appropriately, developing countries will be able to better utilize their mental health resources.Research can thus become an instrument for change.
In December 2002, WHO organized a meeting on Research for Change to discuss mental health research in low and middle-income countries.Participants to this meeting included researchers from developing and developed countries, WHO Collaborating Centers, national research institutes and research councils, international research organizations, editors of scientific journals, policy advisors and program planners as well as representatives of funding agencies and donors.The meeting clearly brought out the paucity of mental health research activities and the inadequacy of infrastructure to support such research in these countries.The need for concerted actions for supporting research was recognized and many steps have been taken.One of these was the Atlas-Research Project that aims to obtaining information about mental health-related research (research amount and quality) and mental health research infrastructure (policies, network, manpower) from low and middleincome countries.The project is currently being implemented in 13 countries producing more than 2% of research from low-and middle-income countries: India, South Africa, Brazil, Russia, China, Poland, Mexico, Turkey, Thailand, Pakistan, Hungary, Nigeria, and Croatia.
An important action to improve mental health in Brazil is to provide information about its research infrastructure.These data will be useful to discuss the future of mental health research in the country and the steps proposed for attaining such goals.These findings will serve as a ready reference on Brazil's resources and could help evidence-based advocacy for the government and international organizations aiming at increasing investments in mental health research.Strengthening the system for conducting mental health research would provide input for decision making on policies and strategies that could promote appropriate actions.
This study aimed at obtaining data on the country's policies (vision, mission, goals and priorities), ethical aspects, infrastructure (councils, institutions), financing, human resources (training, researchers and lectures), including the actual research production and dissemination.Relevant issues related to general health and health care will also be addressed since mental health and mental health care are embedded in the former.

DATA COLLECTION
To assess Brazil's mental health research capability information about several aspects of mental health Data on mental health research training opportunities was gathered by means of a questionnaire sent to the heads of the most productive PGPs on psychiatry (5) and psychobiology (3).Other institutions that do not have specific PGPs known by their mental health The number of research and scientific publications was estimated based on the 2000 CAPES Report.To obtain data on general health research and scientific publication, a database was created including all CAPES PGPs in health, which included Nursing, Pharmacy, Dentistry, Physical Education, Public Health and Medicine (biological sciences were not included in this estimate).
Data on the dissemination of mental health research production were obtained by means of surveys at the Instituto Brasileiro de Informação em Ciência e Tecnologia (Brazilian Institute of Information in Science and Technology -IBICT).The number of journals at Literature Latin American Health Sciences (LILACS) was taken from the LI-LACS Database 2002.The relevant journals in Psychology were given by the Ministry of Education psychology consultant.
To obtain data on patents a survey was carried out in the INPI website (National Institute of Industrial Property, Ministry of Development -Ministério do Desenvolvimento).The year under consideration was 2001, because the registration may be published within 18 months of the application.

VISION, MISSION AND GOALS FOR NATIONAL MENTAL HEALTH RESEARCH
The Brazilian Mental Health Policy is essentially based on the Caracas Declaration (1991).The Brazilian Ministry of Health proposed a mental health law, approved by the Congress in 1999, which essentially establishes the progressive substitution of psychiatric beds for Community Social Psychiatric Centers, so-called Centros de Atenção Psicossocial -CAPS.In addition, the law has introduced a program for paying a monthly bonus for families of long-stay patients, so as to encourage them to leave the hospital and return home (Programa de Reabilitação Assistida -PRA, Ministry of Health, 1999).

PRIORITIES FOR MENTAL HEALTH RESEARCH
There is no explicit health research agenda in Brazil, which indicates that health research carried out to date has not adequately addressed national health priorities.Resources allocated to health research have been granted through a system of peer review under competitive conditions, but not spe-cifically designed for national priorities.Therefore, there has been continuous inequality and low selectivity, i.e., insufficient capacity to establish and follow health priorities. 4  However, the commitment to approach inequity in the health sector (i.e., increasing equity in the health system) has recently become the basis for developing a new policy.In June 2003, a process of developing an agenda of priority health research issues began with the study of Brazil's health conditions.However, peer health research review competition is usually led by the scientific community, and a document 9 from the Brazilian Academy of Science has raised the following subjects: a) social inequalities in Brazil, the problem of the inverse care law; b) absence of cost-benefit studies in implementing mental health services; c) health coverage, the country does not provide universal access for severe mental disorders; and d) training of primary care physicians in mental health practice.
The change in demographic profiles, which resulted from the move from rural settings to urban environments in the last few decades, with a predominance of housing in cities with populations of over half a million inhabitants, may be correlated to several factors.For example, worsening of living conditions, difficulties in labor insertion, lack of leisure and violence arising from social inequities.The central role of inequities and social exclusion as determinants of poor health conditions is undisputable, leading to a worldwide growing interest for research on this subject-matter, particularly in Latin America and the Caribbean (Almeida-Filho et al, 1 2003).The impact of social inequality and social adversity on a cluster of diseases such as common psychiatric disorders, post-traumatic stress disorders, drug dependence, behavioral disorders and obesity, i.e., the mental health of the urban poor, has been well recognized.The consequences of rapid urbanization may be associated to an excess of common psychiatric disorders (mainly anxiety states), observed in epidemiologic studies carried out in the community (Lima et al, 6 2004).Such a profound social debt in health justifies the needs for future research and the development of efficacious interventions for reducing health burden and sufferance in the country.
Brazil has not yet eradicated health problems associated to poverty, such as intestinal and respiratory infections, and have to face the emerging conditions due to these rapid demographic changes: cancer, cardiovascular diseases and mental disorders.Indeed, the increase in longevity and the reduction in fertility rates resulting from such a demographic transition give way to an increment in mental disorders in senescence (depression and dementia states, among others).The economic and social burden of psychiatric disorders has clearly not been properly assessed in Brazil.The phenomenon of the "inverse care law," in which lower income populations, with an excess of morbidity, do not receive minimum care for mental health, while the more privileged population could be receiving excessive assistance, is clearly a matter of concern for mental health planners (Lima et al, 5 1999).
There has been an increase of psychosocial care centers in the last few years, an evidently positive experience in terms of the humanization of mental health care.Nevertheless, the mental health care system is relatively scarce and poorly distributed among the different regions in the country.Therefore, there is a need for more evaluation studies to comparing the cost-benefits of alternative care models so as to improve coverage.Also, it is necessary to implement training for health managers in mental health.These providers must be knowledgeable in epidemiology, anthropology, biostatistics, health policy, health economy, and planning.
There is a need for more and better data on Brazil's mental health situation.Epidemiological research in the country has experienced a significant improvement in terms of both the number of papers published and the quality of research conducted.Indeed, several cross-sectional studies have addressed the prevalence and risk factor for common mental disorders, and many of them used sophisticated methods of sample selection and analysis.Few cohort, case-control, and randomized controlled studies conducted in South America were exclusively published locally (Lima et al, 6 2004).This may reflect the fact that researchers select their higher quality papers for submission to international journals.There is a need for improving the quality of existing journals, and increasing its distribution and access in the region.However, there is much to be done, considering local needs, cultural/ethnic features of the populations and current relevant issues such as crime, violence, and substance use.

COORDINATING MENTAL HEALTH RESEARCH
Health research in Brazil has been funded by a variety of institutions: a) the health section of the Brazilian Ministry of Science and Technology, and CNPq; b) the health section of CAPES/Ministry of Education; c) the Department of Science and Technology in Health, Brazilian Ministry of Health; and d) the state research funding agencies (the most important is FAPESP).All these agencies are involved mental health research funding, and there is not a formal system for coordinating priorities.However, the vast majority of the scientific production in Brazil is concentrated in the universities' PGPs.

FINANCING OF MENTAL HEALTH RESEARCH
As can be seen in Table 2, the total budget allocation for health research was 303,751,116.70Reais (equivalent to US$101 million).The share for mental health research was 10,238,344.63 (approximately 3.4 million dollars), corresponding to 3.37% of the total budget (1 US$ =3.00 Reais approximately).The main funding sources for mental health research were Fapesp (53.2%) and CAPES (30.2%).

INSTITUTIONS SUPPORTING MENTAL HEALTH RESEARCH
The CAPES Report is a yearly report provided by each post-grad program officially operating in the country, where it is given reliable information on research themes, disciplines taught and the scientific production of the research team.The Portal CAPES allows students and academic staff of 97 universities and research institutions in Brazil free, comprehensive and high performance web access to the full-text of over 3,500 scientific and technical international journals from 1995 to the present.This library includes free access to mainstream mental health journals such as Archives of General Psychiatry, American Journal of Psychiatry, British Journal of Psychiatry, and Schizophrenia Research, among others, all over the country (the maintenance of the Portal CAPES costs around US$20 million yearly).The free access is guaranteed as long as an educational institution has at least one pos-graduate course rated as 5.
In the same direction, the Regional Latin American Library of Medicine (BIREME), supported by the Pan American Health Organization (PAHO), offers access to 5,937 national journals and 5,421 international journals.The Scientific Electronic Library (SciELO) linked to the Internet is part of the BIREME/PAHO/ WHO library, which main goal is to contribute for the development of local research, through perfecting and enlarging the ways of dissemination, publication and evaluation of the best available scientific publications in Latin America and Caribbean countries.

MENTAL HEALTH RESEARCH MANPOWER
Data on the distribution of health researchers and service providers is displayed in Table 3.According to the National Medical Board website, as of March 6 2004, there were 289,863 medical doctors legally practicing in Brazil.The number of academic clinicians is a rough estimate.There were 98 medical schools registered in the National Medical Board (2004 March 6).The number of clinicians working in academic settings was estimated by multiplying 98 x 300, 29,400.The total number of doctors involved in research was extracted from the 2000 CAPES Report, using the number of supervisors of all post-grad programs in health (1,721 Medicine I; 1,905 Medicine II, 1,221 Medicine III and Public Health 1,334, leading to a total of 6,181).This estimate does not include medical doctors working in biomedical sciences labs.The total number of psychiatrists (4,546) was provided by the Brazilian Psychiatric Association, and the number of psychiatrists working in academic settings was a rough figure, obtained by multiplying the number of medical schools (98) by an estimate average of 5, equals to 490.By using the 2000 census (population estimated at 169.799.170), the rate of medical doctors is therefore 1,7 per 1,000 inhabitants, and the rate of psychiatrists is 2,7 per 100,000 inhabitants.
As seen in the National Psychology Board website, as of June 13 2002, there were 125,397 professionals.The number of psychologists in academic settings was estimated by means of research data provided by the Ministry of Education psychology consultant.The total number of registered nurses (100,181) was extracted from the National Nursing Board website on March 4 2004.In 2004, there were 394 nursing schools in the country, and the number of nurses in university settings (7,880) was a rough estimate (394 x 20 academics per school).The number of nurses involved in research (368) was extracted from the 2000 CAPES Report, by counting all supervisors of nursing PGPs.

TRAINING POSSIBILITIES
According to CAPES, there were 1,489 Master's degree programs and 857 doctoral programs approved by the Ministry of Education, and the number of scholarships was 13,467 for Master's and 10,181 for doctoral degrees in 2001.The vast majority of the science produced in Brazil is developed in PGPs, a annual production of around 13,000 papers in ISI-indexed journals.CAPES has played an important role in Brazilian scientific growth since it has imple- As it can be seen in Table 4, there were 53 courses for mental health training in Brazil (43 in psychology, six in psychiatry, three in psychobiology and one in psychiatric nursing).In 2002, there were 1,775 students being trained in Brazil and 67 training overseas.In the period 1998-2002, three students trained overseas did not return after completing training, 10 Brazilians left the country to occupy academic positions abroad and two foreign researchers came to work in Brazil.Nine of the 53 PGPs are dedicated to psychiatry, neuropsychiatry, psychobiology and mental health.The PGP name does not necessarily describe its research production.For instance, psychobiological research is developed in psychobiology, psychiatry or even in mental health PGPs.The same is true for epidemiological and clinical research.All but two PGPs are based in state universities located in the south and southeast regions of the country.With the exception of Neuropsychiatry -UFPE, that has only a Master's degree program, all PGPs have doctoral and Master's degree programs accredited by CAPES.PGPs have wide variation in the number of supervisors, indirectly reflecting the size of the programs.The number of supervisors ranged from 6 to 29 (average:13).According to the 2001-2003 CAPES evaluation, six of the nine PGPs dedicated to psychiatry, neuropsychiatry, psychobiology and mental health have scored grade 5 (Table 5), indicating good performance by Brazilian standards, and one psychobiology PGP scored grade 7, i.e. at the same level as the leading world institutions.
During the period, 295 students got a Master's degree and 186 students got a doctoral degree in psychiatry and related sciences (Bressan et al, 2 2005).A total of 481 theses were published, approximately 37 doctoral theses per year.Large PGPs such as Psychiatry -USP, with 29 supervisors, produced more ISI-indexed papers than the majority of other programs, but their productivity (1 ISI-indexed paper per year) was only average. 2  Unifesp and USP/RP psychobiology PGPs had the highest productivity (2.0 and 1.7 ISI-indexed papers per year, respectively).This may reflect a higher concentration on laboratory animal studies, which tend to produce more papers than clinical studies.

RESEARCH AND RESEARCH PUBLICATIONS
Over the period studied, 1,719 articles were published in regular journals, 637 of them in ISI-indexed journals and 680 in MEDLINE journals. 2The mean impact factor of ISI-indexed journals where the articles were published was 1.9 (with a range 0.1-30.0).More than 50% of the ISI-indexed papers were published in journals with impact factor higher than 2. Approximately 10% of the articles (63) were published in journals with impact factor 4, and 10 articles (1.6%) in journals with impact factors higher than 8. PGPs that produced more ISI-indexed papers were Psychobiology -USP/RP (n=151) and Psychiatry -USP (n=144).The number of Medline and ISI-indexed articles has progressively increased over the study period. 2The number of articles published in journals not indexed in the Medline has declined from 2000 to 2002, and has reached lower numbers than Medline articles.On average the supervisors from all PGPs have published 5.5 ISI-indexed papers dur- Data reported in this chapter does not reflect the entire scientific production in psychiatry and psychobiology developed in Brazil.A large proportion of research on neurophysiology, neuropathology, psychopharmacology, genetics and molecular biology of psychiatric disorders has been developed in basic research PGPs and were not included herein.Furthermore, the total number of articles evaluated herein was based on the number produced by each PGP individually.There might be collaboration between PGPs and cross-authorship, thus it is possible that some articles have been counted twice.This would introduce an overestimation of the total number of publications, which may well reduce the total by as much as 10%.On the other hand, poor record of the publications in the CAPES reports has lead to the loss of articles.Approximately 10 articles were missed out each year.As this study clearly shows, CAPES audits are a very important instrument for evaluating Brazilian scientific production.In 2002 the number of ISIindexed health papers was 3,302 and as there were 125 ISI-indexed papers in psychiatry, the proportion of psychiatry related to the health area was 3.79%, a figure close to the financing of the mental health research area.The number of scientific papers in the Psychology/Psychiatry section of the Journal of Citation Report (JCR) during the period 1999-2003 was 496, which was lower than that found in the present study (637), probably because some papers were classified in the neuroscience and social sciences sections of the JCR (see Bressan et al, 2 2005 for further details).

DISSEMINATION OF MENTAL HEALTH RESEARCH
The IBICT listed 201 journals under the headings: psychiatry, mental health, psychotherapy, psychol-ogy, psycanalisis.As for the Lilacs Database, 36 journals were found using the same keywords.
The Brazilian Psychiatry Conference, a yearly national meeting sponsored by the Brazilian Psychiatric Association, received more than 4,000 participants in its last gathering (Salvador, 2004).The abstracts are peer reviewed and have been published yearly by the Revista Brasileira de Psiquiatria, the official journal of the Brazilian Psychiatric Association.In addition, there are regional annual workshops organized by the Brazilian Psychiatric Association, and mental health research is also an open topic for the National Conference on Health and National Conference on Mental Health, both held by the Ministry of Health.

CONCLUSIONS
Considering the major education role that research and scientific methodology plays in the physician's training, a significant proportion of Brazilian physicians are educated on the margin of this system and are not prepared to keep up with and absorb breakthroughs in health, which are closely linked to scientific development. 9Between 1998 and 2002, the number of mental health and psychiatric ISI-indexed papers has doubled without significant increase in the number of post-graduate students or academic theses suggesting that PGPs are now more researchoriented resulting in greater scientific quality and productivity.Based on these data, it is plausible to predict a tendency for increasing production over the next few years.However, further sustained investments are essential to keep and even improve this growth. 7 It is expected that the results from this preliminary evaluation study will contribute to form an evidencebased information system on mental health research and the infrastructure supporting it, which will help in harnessing resources available to developing countries towards promotion of mental health and prevention/reduction of mental disorder burden.

Table 1 -
The WHO Atlas Questionnaire for investigating mental health research infrastructure.

Table 2 -
Funds allocated by national government sources to health and mental health research.Brazil, 2002.Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES -Ministry of Education), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq -Ministry of Science and Technology), the state funding agencies: Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG), and Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul (FAPERGS).The Ministry of Health's budget refers to the year 2001.

Table 3 -
Distribution of health researchers and service providers.Brazil, 2002.

Table 4 -
Courses and trainees in mental health.Brazil, 2002.

Table 5 -
Data on post-graduate programs, year of foundation, number of supervisors and Capes evaluation.Brazil, 2001/2003.