Censo psicossocial dos moradores em hospitais psiquiátricos do estado de São Paulo : um olhar sob a perspectiva racial Psychosocial census of the residents of psychiatric hospitals in the state of São Paulo : a look from the racial perspective

This study aimed to determine the profile of the residents of psychiatric hospitals in the State of São Paulo, according to race/color. For this secondary data was used from the Psychosocial Census of residents of psychiatric hospitals owned and insured by SUS State of São Paulo, which featured people with a length of stay equal to or higher than one year as of 30/11/2007. When characterizing the profile of this population, it was identified that in regards to race/color, the greater expressiveness was among the white population, which equals 60.29% of total residents. Data on race/color of the 2000 Census reports that out of the total population of the State of São Paulo, 27.4% are black and brown, but when considering the population living in psychiatric hospitals, this number reached 38.36%. It was observed that there is a higher proportion of blacks who are admitted because they have no income or place to live, weak social network, receive fewer visits precarious social life associated with mental disorders or medical conditions. Despite the GM Ordinance 106/2000, which establishes RTSs for former patients of psychiatric long stay, with absent and/or fragile social support networks, it can be assumed that these were not covered by this resolution. The psychosocial effects of racism and the impact of processes of prejudice, exclusion and social separation on mental health are highlighted in the article.

Psychosocial census of the residents of psychiatric hospitals in the state of São Paulo: a look from the racial perspective Censo psicossocial dos moradores em hospitais psiquiátricos do estado de São Paulo: um olhar sob a perspectiva racial DOI 10.1590/S0104-12902014000400010

Introduction
Since the late 1970s, the course of psychiatric reform in Brazil has revealed the presence of individuals with a history of long hospital stays and the association between chronic illness and psychiatric hospital to be significant problems (Amarante et al., 1998;Delgado, 1991).After the creation of residences in the territory (demonstrating the viability and efficacy of this tool for those with a history of being institutionalized (Brasil, 2004;Furtado and Pacheco, 1998;Reis, 1998) in the context of local experiences of reform at the end of the 1980s and the start of the 1990s) and of the process of implementing a new national mental health policy, it was possible to begin to draw up proposals, of which the proposal for the De-hospitalization Support Program, in the 1990s, stands out (Alves, 1996;Brasil, 1994).These initiatives were fundamental in formulating the GM Ordinance 106/2000 that instituted residential treatment services (RTSs) within the ambit of the Brazilian Health System (SUS) (Brasil, 2000).The RTSs are central components in the current SUS mental health policy enabling the asylum model to be overcome.Its implementation has enabled one of the two most basic rights to be restored to institutionalized individuals: that of living in the community (Brasil, 2004(Brasil, , 2005(Brasil, , 2007)).
In 2001, Law 10.216/2001, which "provided protection and rights to those with mental illness and redirects the mental health care model", established, in Article 5, the need for specific, highly planned policies and for the psychosocial rehabilitation of those with long-term stays in psychiatric hospitals or in situations of severe institutional dependence.According to the text of the Law, these situations may result from the clinical picture, as well as from lack of social support, and ongoing treatment should, where necessary, be ensured.In Article 4, it is especially highlighted that "it is prohibited to hospitalize patients with mental illness in asylum-like institutions", defined in the text of the Law as those that do not provide the aforementioned resources to effect comprehensive care and that do not guarantee the rights of those with mental illness (Brasil, 2001).
Federal Law 10.708 from 2003 instituted psycho-social rehabilitation, a financial subsidy paid directly to those discharged from psychiatric institutions (Brasil, 2003).This support, part of the Going Home Program (GHP), is a central component of the rehabilitation processes seeking to make "access and exercise of rights" viable and to empower the contractual power of those with experience of psychological distress (Brasil, 2005;Rotelli, 1999;Saraceno, 1999).
It can then be stated that legal frameworks and normative instrument of the SUS mental health policy currently exist to develop de-institutionalization processes, executing psycho-social rehabilitation projects in the country (Brasil, 2005(Brasil, , 2007(Brasil, , 2009)).
Although drawing up a quantitative and qualitative profile of those who have been hospitalized long-term is considered priority for transforming asylum-based psychological care processes (OPAS, 1992), census studies to discover and characterize those hospitalized in psychiatric institutions on a national level have only recently been verified (Barros and Bichaff, 2008;Gomes et al., 2002;Keusen and Lima, 1994;Pitta et al., 2004;Silva et al., 1999).
In the state of São Paulo, despite diverse experiences in creating residences in different local contexts and paths to psychiatric reform and in establishing the SUS and despite a wide repertoire of knowledge and practice (Furtado, 2001;Furtado and Pacheco, 1998;Guimarães and Saeki, 2001;Livieres and Aranha and Silva, 2006;Reis, 1998;Rosa et al., 2005), state coordinates mental health surveys from 2007 estimated that there were around 6,000 residents in psychiatric hospitals and indicated a lack of a guiding policy for de-institutionalization and psycho-social rehabilitation (Barros and Bichaff, 2008).Although approximately 40% of all RTSsfunctioning and being established -are located in the State of São Paulo, data from the Ministry of Health show that the state has one of the highest concentrations of psychiatric hospital beds in the country, distributed among 58 psychiatric hospitals, 9 of which are public and 49 of which are SUS affiliated (Barros and Bichaff, 2008;Brasil, 2009)

The history of Brazilian Psychiatry and race/color
Amidst the profound changes marking Brazilian society in the later decades of the 19 th century, psychiatry consolidated and institutionalized itself as a field of specialized knowledge.Fruit of a long and contradictory process (triggered in the 1830s with demands arguing the necessity of creating a hospice in the city of Rio de Janeiro) this consolidation was characterized, among other aspects, by the incorporation of a wide variety of topics when setting the boundaries separating 'sickness ' and 'health', 'normal' and 'pathological' in the ambit of mental disorders.
Placing "uncomfortable individuals and sectors of society under suspicion", the psychiatric knowledge essential to drawing up an effective strategy in the sense of placing "personal and social behavior that does not fit in with moral norms or discipline" within a framework (Cunha, 1986, apud Engel, 1999, p. 547).
According to Engel (1999), the connection between race/color and mental illness gives an important clue in evaluating political and social dimensions that psychiatric knowledge and practice have taken on in Brazilian society in the latter decades of the 19 th century.Always zealously safeguarding the extent and imprecision of the defined limits of mental illness, the psychiatrists started from the principle that madness did not choose color, impeding us from covertly constructing close relationships between mental illness and "races" deemed to be inferior.Thus they abandoned the idea, for example, that blacks and, above all, mestizos, were pre-disposed to madness being, by definition, degenerate.However, even when not classified as degenerate, black and mixed race individuals were viewed as intellectually inferior and thus less capable of dealing with and/or adapting to the contingencies of the social environment, and therefore 'more prone' to being degenerate.A good example of this are the considerations of Dr. Henrique Roxo (1904, p. 172, 181-182, 191-192) on mental disturbances in blacks in Brazil, in a communication presented to the 2 nd Latin American Medical Congress and published in Brazil Médico.According to this psychiatrist, blacks should not be considered degenerate but rather "types" that "had not evolved": "They use less of their brains than whites".In this way, the 'scientific racism' expressed by Henrique Roxo is based on a complicated and contradictory mixture of biological determinism and the action of the socio-cultural environment.
The same technical references led Henrique Roxo to believe that the main causes of mental alienation in Brazil's black population were, on the one hand, poor intellectual level and, on the other, the pernicious effects of the ;sudden' abolition of slavery.
Venancio ( 2004) invests in the conceptual universe of well-known psychiatrist Juliano Moreira.The analysis contains contributions for a littleexplored modern field: the crossover between "race/ color", mental illness and sexuality in the classical works of Brazilian psychiatry produced discursive conventions, but whose origin is no longer detected and deserves to be explored.
According to Venâncio (2004), Juliano Moreira's wide-ranging activity in psychiatry reveals the impact of his formulations and the role of an active representative of psychiatric science in the debate on constructing the Brazilian nation.Based on the description and clinical observation of patients' cases, Juliano Moreira stated that mentally ill strangers would be an onus on the public coffers, as well as for future generations, thus defending immigration control based on analysis of individual cases, instead of applying restrictions on a particular people or race.
However, this discourse favorable to immigration as an exit for the Brazilian nation increasingly come to be clothed as "scientific racism" spread by a large group of doctors who saw the "Aryanization" of the Brazilian people as the solution to all its woes, but part of the hygienists and psychiatrists refuted he relationship between illness and the population's racial origin.
In the field of Brazilian psychiatry, Juliano Moreira took part in the theoretical discussion on the relationship between pathos and race.In contrast to Nina Rodrigues, who defended the hypothesis that being mestizo was a degenerative factor (Moreira, 1908), Moreira favored the hypothesis of individual organic units burdened with a nefarious inheritance to which, for him, neither our problematic issue of racial miscegenation or our nationality can be attributed; they are, rather, expressions of universal mental pathos that are expressed in a more recurring way here, and could be healed through education (Venancio and Facchinetti, 2005).
More than 15 years after the abolition of slavery, the association between the slaves' liberty and the proliferation of degeneracies and mental illness are considered anachronistic, although, conveyed in the eminent scientific community of Rio de Janeiro, this association could be used as an important tool to justify and legitimize the deployment of more subtle mechanisms of social control (Engel, 1999).

The Census
The data found by Barros and Bichaff (2008) that, when compared to the general population, the presence of blacks (black or mixed race) resident in psychiatric hospitals in the state of São Paulo is proportionally higher, allowing reflection on the impact of uninterrupted processes of prejudice, exclusion, abandonment and social separation in mental health; on vulnerable populations and mental health and/or on the "psycho-social effects of racism".
Studies show difficulties in ascending socially experienced by the black population and identify the disadvantages created by slavery.The lack of post-abolition public policies and the restrictions on political participation in Brazil were the ultimate expressions of racism and discrimination.Lopes (2005) and Cunha (2010) show that blacks (blacks and mixed race) had poor levels of schooling, low salaries, resided predominantly in neighborhoods on the outskirts of large cities and did not have access to various social rights.The authors indicate that these discriminatory processes conditioned the way of living, falling ill and dying of groups of individuals (Lopes, 2005;Batista, et al., 2004;Cunha, 2010).
For Kabenguele Munanga1 "racism in contemporary Brazilian society is something incorporated in the elitists and is deeply and perniciously rooted in the social fabric" (p.13).And, yet, it would be an error "to ignore difference as an essential element in structuring and classifying problems taken as merely those of market or class, in a society in which racism, although not institutionalized, exists in the culture, the social fabric and in political behavior" (p.13).Barreto (2003) shows us that the dominant medical practice persists in solely looking for visible and measurable disease in the individual's biology, not taking into consideration historical, economic and cultural conditions; social relationships; production methods and way of life; and relationships of domination and submission.
From the hypothesis that there are uninterrupted processes of prejudice, abandonment and social separation of vulnerable populations in Brazilian society, this work aims to describe and characterize the clinical profile of residents in psychiatric hospitals in the state of São Paulo, according to race/color.

Methodology
The text is based on a descriptive quantitative study using secondary data from the Psycho-social census of residents in psychiatric hospitals, henceforth denominated Census.According to Gil (2006), the primordial objective of a descriptive study is to describe the characteristics of a specific population or phenomenon, or to establish relationships between variables.
The Census, coordinated by the work group created by the SES-SP, was conducted in 56 of the 58 psychiatric hospitals existing in São Paulo state, located in 38 municipalities of 15 Regional Health Departments (RHD).For the Census, the subjects of the study were users of all private or SUS affiliated psychiatric hospitals in the state of São Paulo, with a stay equal to or exceeding one year, adopting the date of 30/11/2007 as the baseline (Barros and Bichaff, 2008).
It was the task of the work group to construct a data collection instrument to be used in the field work.The instrument contained three broad topics: Characterization, consulting medical records to characterize the resident (with the possibility of complementing this with an interview conducted by the interviewer/researcher, using the resident and/or the hospital care team as a source); Psychosocial Data, information to be obtained together with the resident and/or hospital care team; and the interviewer/researcher's Observations, relating impressions and noting relevant data.
The partnership between the State of São Paulo Health Secretariat (SES-SP) and the Administrative Development Fund (Fundap) made the process of selecting and accrediting the 69 professional interviewers viable.
The interviewers went through a three-stage training process before the field work.This was conducted between 31 st March and 30 th April 2008.After applying and completing the forms, the interviewers themselves entered the data via the web into a system provided by the Fundap IT administration and a paper copy of the form was subsequently sent to the research/Census coordination.
The Census database, the data obtained through descriptive statistics (simple frequency of the variations) and the recommendations of the Psycho-social Census of residents in psychiatric hospitals, published by Barros and Bichaff (2008) will be analyzed from a racial perspective.

Limitations
In the Census, information concerning race/color and clinical and psychiatric data consider notes on the medical records.

Results and discussion
The patients In total 6,349 institutionalized individuals were identified in the Census.Concerning race/color, 60.29% (3,828) of the residents are white, 16.36% (1,039) black, 22% (1,396) mixed race, 1.24% (79) Asiatic and 0.1% (7) indigenous.Data from the 2000 demographic census show that of the total population of the state of São Paulo 27.4% are black (black and mixed race).In the population of psychiatric hospitals, this number rises 38.36% of the total.
Historically, the black population has suffered from uninterrupted processes of abandonment and social separation.The place par excellence of abandonment and exclusion is the lunatic asylum, as well as other institutions.The consolidated data show that it is the black population placed in the unfair leading position in the ranking of social exclusion in psychiatric hospitals in the state of São Paulo (Barros and Bichaff, 2008).
Likewise, the majority of residents in psychiatric hospitals, the black and mixed race are primarily male (62.17%).
The most commonly reported marital status was single for both men (mean of 84.7% for black and mixed race) and women (mean of 74% for black and mixed race) in the Census total population the percentage was 82.1%.
The organizational logic of total and architectural institutions to prevent meetings, the yards are separated, the sunbathing times are separated, life follows its institutional rhythm, wishes are subjugated to the censorship of the staff.This logic, sustained by the eugenic and prophylactic principles of the late 19 th and early 20 th century in Brazil, silenced the expression of particular forms of existence.
It can be inferred that the data on marital status of those resident in psychiatric hospital can provide elements that confirm that the strategic function of the lunatic asylum is to reduce individuals and their way of living to data reflecting little or nothing of reality, the way they live and with whom they live, confirming that: a.In the lunatic asylum, patients do not improve (Rotelli, 1999): accepting the logic that confers on marital status the form in which an individual's emotional life and relationships are organized, being single can mean not having stable emotional relationships and not procreating and leaving descendants.
b.The lunatic asylum operates along eugenic principles (Costa, 1989): populations organized according to sex in the colonies, pavilions, in the rooms without doors, in the collective washrooms encourages the residents' sterility, at least in theory.This condition does not, however, eliminate the possibility of emotional and sexual relationships, undetected in the Census (Barros and Bichaff, 2008).
Data on the psychiatric hospital residents' schooling show an alarming reality: 62.07% were not literate.Moreover, approximately 9% were merely able to write their names, totaling around 70% of the population (Barros and Bichaff, 2008).This reality was shown to be even more perverse in the case of blacks and mixed race, as in this section of the resident population 64.8% of the 2,435 non-citizens were illiterate.The obstacle of illiteracy further deepens this population's social exclusion, impeding them from exercising the smallest acts of survival, reading and understanding the world.Through reading and writing, it is possible to broaden an individual's repertoire, to judge values and events, participate in political and civil life, to organize oneself as a citizen with rights.
Schooling in the white men and women was distributed between different levels.Among the blacks and those of mixed race, illiteracy prevailed.Literacy is one more right denied to these individuals, and deepens social exclusion, making it difficult to participate in political and civil life.
Table 3 shows that the most common age group for black and mixed race male residents was 35 to 49 years old, whereas for women of the same race/ color, this was 50 to 64.This data raises questions regarding these residents' institutional origins and the hypothesis that they are the fruit of forms of trans-institutionalization, as well raising the issue of whether black and mixed race men are being hospitalized, and remaining hospitalized, at a younger age.
On the national scene, especially in relation to individuals hospitalized for long periods of time, Article 5 of Law 10.216/2001, as mentioned above, determines the need for highly planned policies and psychosocial rehabilitation, ensuring ongoing treatment when necessary (Brasil, 2001).This does not seem to have been realized in psychiatric hospitals in the state of São Paulo.

Clinical data
In the Census, information concerning clinical and psychiatric data used notes from medical records and, therefore, no clinical or psychiatric evaluations of the residents were conducted.Current psychiatric diagnoses were recorded, as were associated diseases and disabilities and, as the data collection instrument allowed more than one alternative to be recorded, the medical record analysis led to identifying the frequency with which these data were present in the resident population (Barros and Bichaff, 2008).The data, then, allow the frequency with which a specific clinical condition is present in the total population of residents.
In the case of psychiatric diagnoses, the data collection instrument includes notes according to the International Statistical Classification of Diseases and Related Health Problems (ICD-10), in relation to some diagnostic groups: it was observed that 5,770 (90%) of residents had one psychiatric diagnosis, whereas 409 (6.44%) had two and 26 (0.41%) more Ballone (2008) warns that although there is some reluctance to debate racial and ethnic prejudice in the context of mental health in certain social sectors, psychological, sociological and anthropological research shows that racism is related with perpetuating mental health problems.To judge by available indices, those who are targets of racism for much time are at more risk of presenting or aggravating existing mental health problems.Psychiatrists who study the relationship between racism and mental health have observed that having experienced racism can accentuate depression, for example.

Motives for institutionalization
Social precariousness -considered to be the resident lacking a place to live outside of the hospital and/ or not having an income -, associated with mental or clinical illness was the motive for remaining institutionalized for 65.30%.In contrast, for 519 individuals (8.2%) social precariousness was the only motive for remaining in the institution, with no mention of mental or associated clinical illness, revealing their potential for living in the community.These proportions differ between white and black men (11.4% of black, 9.3% of white and 8.0% of mixed race male residents).For the women, these percentages were 8.2% for black women, 6.3% for white and 4.7% among those who reported themselves to be mixed race.
When we analyzed the frequency of visits, we found that 3,341 residents did not receive family visits.Among men, the highest percentage was in black males, 62.3% of whom did not receive visits, the percentage was 59.5% among the mixed race, 44.7% for white men, 44% for Asiatic and 100% for the indigenous.Among women, 66.1% of the black women, 61.8% of mixed race 50.6% of the white women, 33.3% of Asiatic women and 25% of indigenous female residents did not receive visits from family members.
Even when social precariousness is defined as a lack of social and/or family ties, the fact that some residents receive income, either from benefits or pensions, enables them to obtain hospital discharge and live in the community, demonstrating some successful examples of social re-integration through psycho-social rehabilitation projects that have been conducted for many years in the state of São Paulo.
Considering that Ordinance GM 106/2000 established RTSs for those leaving long term psychiatric hospital stays and with no and/or poor social support networks, it is supposed that these services are an appropriate strategy for meeting this group's needs and, therefore, it appears important to investigate the reasons impeding de-institutionalization.

Conclusions
Data from the Psychosocial Census of Residents of Psychiatric Hospitals in the State of São Paulo reveal that it is the black population which holds the number one position in the social exclusion ranking in the psychiatric hospitals in the state.
The age group of black and mixed race hospitalized individuals in concentrated between 35 and 49 years old.This datum raises the hypothesis that black and mixed race individuals are hospitalized at a younger age and stay hospitalized.
Among the clinical data, the proportion of schizophrenia, schizotypal and delusional disorders (F20-F29) among black and mixed race men and women is noteworthy.
When the group of mental and behavioural disorders due to psychoactive substance use (F10 to F19) is analyzed, there is a small difference between white and black men and women.It would be interesting to undertake new investigations into mental and behavioural disorders due to psychoactive substance use in psycho-social care networks and the racial and ethnic issue.
In this study, the black population residing in psychiatric hospitals in the state of São Paulo, identified as black and mixed race.Much data remains to be uncovered, especially those relating to these individuals' process of institutionalization, their trajectory, resources and needs for de-institutionalization projects and the needs of these individuals and of other residents in order to care for themselves and participate in life in the community.
It is essential that the Psycho-social Census recommendations are implemented by administration, civil society, associations and all who defend the rights of those with mental health disorders.However, racial inequalities in Brazil have been shown to be persistent and to require public policies and action to change the situation of adversity experienced by the black population.
The psycho-social effects of racism is a recent line of interpreting mental health in Brazil.It must be asked to what extent eugenic thinking still pervades the area of health care, contributing to professionals' social representation of madness and the mad.
Thus, the influence of racism on the collective and mental health of groups and society can also be considered.

Table 2 -of residents in psychiatric hospitals in the state of São Paulo according to marital status, sex and race/ color, 2008
Source: Database of Psychosocial Census of Residents in Psychiatric Hospitals, 2008.

Table 4 -Number and percentage (%) of residents in psychiatric hospitals in the state São Paulo, according to psychiatric diagnosis (ICD-10), sex and race/color, 2008
Source: Database of Psychosocial Census of Residents in Psychiatric Hospitals, 2008.