Latin American and Spanish-speaking perspectives on the challenges of global psychiatry

The multi-faceted phenomenon known as globalization has a particular impact on the conceptual and practical development of mental health disciplines in general, and psychiatry in particular, across different world regions. To be theoretically and functionally effective, global psychiatry requires an integration of its different components. To such objective, and after a brief review of continental European and Anglo-Saxon contributions, this article examines the history, characteristics, and contributions of Latin/Iberian American and Spanish-speaking psychiatry, in order to substantiate its role in world psychiatry. The Latin American proper (including Portuguese-speaking Brazil), Spain, and U.S.-based Hispanic components are described, revealing an identity that is based on a humanistic tradition, a value-based, culturally-determined clinical approach to patient care, and a pragmatic adaptation of different treatment resources and techniques. These may constitute supportive elements of an instrumental inter-regional bond in the present and future of our discipline.

Latin American and Spanish-speaking perspectives on the challenges of global psychiatry.

The multi-faceted phenomenon known as globalization has a particular impact on the conceptual and practical development of mental health disciplines in general, and psychiatry in particular, across different world regions. To be theoretically and functionally effective, global psychiatry requires an integration of its different components. To such objective, and after a brief review of continental European and Anglo-Saxon contributions, this article examines the history, characteristics, and contributions of Latin/Iberian American and Spanish-speaking psychiatry, in order to substantiate its role in world psychiatry. The Latin American proper (including Portuguese-speaking Brazil), Spain, and U.S.-based Hispanic components are described, revealing an identity that is based on a humanistic tradition, a value-based, culturally-determined clinical approach to patient care, and a pragmatic adaptation of different treatment resources and techniques. These may constitute supportive elements of an instrumental inter-regional bond in the present and future of our discipline.

Global Mental Health: challenges for a global ethics / Salud Mental Global: retos para una ética global / Saúde Mental Global: desafios para uma ética global

This paper aims at presenting a perspective on a global ethics useful for conducting and evaluating research on global mental health. It includes the proposal of expanding the scope of "global" to include different aspects of cultural diversity and a plea for a "differential ethics" approach that accepts diversity and sociocultural determinants of health. The contention is advanced that ethics is a linguistic justification of moral norms based on customs, beliefs, and traditions. Besides its foundation on rational or religious beliefs, ethics should also be conceived of as a way of attaining human fulfillment of interests and expectations in the context of different forms of humanity.

Este texto se propone presentar una perspectiva sobre una ética global útil para conducir y evaluar investigaciones sobre salud mental global. Incluye la propuesta de expandir el significado de "global" para incluir la diversidad cultural y la demanda por una "ética diferencial" que acepte la diversidad y considere los determinantes socioculturales de la salud. Se sugiere que la ética constituye una justificación lingüística de las normas morales basadas en costumbres, creencias y tradiciones. Además de fundarse en convicciones religiosas o racionales, la ética también debe concebirse como una forma de alcanzar plenitud humana en intereses y expectativas en el contexto de diversas formas de humanidad.

Este texto se propõe apresentar uma perspectiva sobre uma ética global útil para conduzir e avaliar pesquisas sobre saúde mental global. Inclui a proposta de expandir o significado de "global" para incluir a diversidade cultural e a demanda por uma "ética diferenciada" que aceite a diversidade e considere as determinantes socioculturais da saúde. É sugerido que a ética constitui uma justificação linguística das normas morais baseadas em costumes, crenças e tradições. Além de fundamentar-se em convicções religiosas ou racionais, a ética também deve ser concebida como uma forma de alcançar a plenitude humana em interesses e expectativas no contexto de diversas formas de humanidade.

The basic discipline of psychiatry as metatext / La disciplina básica de la psiquiatría como metatexto / A disciplina básica de psiquiatria como metatexto

Several disciplines converge on current psychiatric practice and research. Each one is a discourse with its defining objects, its audience and its socialization as specialized text. The psychophysiological triad includes studies of mentation (language), behavior and physiology. Each text is a context for the others. Thus, in and by itself, each one in isolation lacks explanatory power. The basic science of psychiatry is a metatext including those partial texts in a constructive fashion. Such an attempt is more a linguistic enterprise than an empirical one. It should supersede all reductionisms, including those presented in the form of juxtaposition of disciplines (bio-psycho-social, psycho-somatic, etc.).

Diversas disciplinas convergen en la práctica psiquiátrica actual. Cada una es un discurso con objetos que le definen, audiencia y su socialización como texto especializado. La tríada psicofisiológica incluye estudios sobre la enunciación (lenguaje), conducta manifiesta y fisiología. Cada texto es contexto para los otros. Así, cada uno tomado aisladamente carece de poder explicativo. La ciencia básica de la psiquiatría es un metatexto que incluye tales textos parciales de modo constructivo. Tal intento es más una empresa lingüística que una empírica. Debería superar todos los reduccionismos, incluidos aquellos que se presentan bajo la forma de yuxtaposición de disciplinas (bio-psico-social, psico-somático, etc.).

Várias disciplinas convergem para as atuais prática e pesquisa psiquiátricas. Cada uma é um discurso com seus objetos definidos, seu público e sua socialização como texto especializado. A tríade psicofisiológica inclui estudos da atividade mental (linguagem), comportamento e fisiologia. Cada texto é um contexto para outros. Assim, em por si mesmo, cada um isoladamente não tem poder explicativo. A ciência básica da psiquiatria é um metatexto incluindo os textos parciais de uma forma construtiva. Tal tentativa é mais um empreendimento linguistico do que empírico. Ele deverá substituir todos os reducionismos, incluindfo aqueles apresentados sob a forma de justaposição de disciplinas (bio-psico-social, psico-somática etc.).

Salud mental global como bien público: sugerencias para la reflexión ética / Global mental health like a public good: suggestions for an ethical reflection

Luego de establecer en lo posible, claras distinciones entre salud mental internacional (basada en la superación de barreras geográficas) y salud mental global en tanto que orientada a las cualidades esenciales de justicia y reconocimiento pleno de los valores de la humanidad en su conjunto, el artículo examina las brechas éticas que pueden comprometer la integridad de esta última. La realidad de países (e individuos o grupos humanos) ricos y pobres, lasinequidades de logrostecnológicos y del acceso justo a su producción y uso y las diferencias de conceptos como ômedicina basada en evidenciasõ versus ômedicina basada en valoresõ conduce a la consideración de que las consecuencias morales del avance científico no tienen límites geográficos y pueden ahondar diferencias de todo orden. Se examinan luego las dimensiones de una ética global con la vigencia de dos ingredientes fundamentales: solidaridad y reciprocidad. Aquélla puede ser horizontal o vertical pero debe extenderse también a la comprensión del pasado histórico y del futuro de pueblos y naciones, cuanto orientada a objetivos de comunidad y buen hacer. Reciprocidad puede ser un ôimperativo hipotéticoõ, una forma dialógica de la solidaridad que, en conjunto entonces pueden conducir a objetivos de plenitud de vida, justicia social, protección y seguridad, al logro de un genuino ôbien públicoõ.

After making as clear a distinction as possible, between international and global mental health (the former based on overcoming mostly geographic barriers, the latter oriented to essential qualities of justice and full recognition of humanityÆs values), this article examines the ethical breaches that can compromise the integrity of global mental health. The reality of rich and poor countries (as well as individuals or human groups, the inequities of technological achievements and of a fair access to its production and use, and the differences between concepts such as ôevidencebasedõ and ôvalue-basedõ medicine, lead to considering that the moral consequences of scientific advances do not have geographic boundaries and can deepen all kinds of differences. Dimensions of global ethics, with two essential ingredients, solidarity and reciprocity, are then examined. The former can be horizontal or vertical but must extend itself also to the understanding of the historical past and the future of peoples and nations when oriented to objectives of community and ôdoing goodõ. Reciprocity can be a ôhypothetical imperativeõ, a dialogical form of solidarity that, joiny, can then lead to objectives of a plentiful life, social justice protection and security, the accomplishment of a genuine ôpublic goodõ.

Bioethical dimensions of cultural psychosomatics: the need for an ethical research approach.

Contemporary psychosomatics is a research-based technical discipline and its social power depends on how scientific knowledge is obtained and applied in practice, considering cultural contexts. This article presents the view that the dialogical principles on which bioethical discourse is based are more inclusive than professional ethics and philosophical reflection. The distinction is advanced between rule-guided behavior and norm-justifiable acts (substantiation and justification). The practical implications of good practices in the generation of valid, reliable, generalizable and applicable knowledge are emphasized. For practitioners and researchers, the need to reflect on the distinction between patient and research participant can avoid the therapeutic misunderstanding, a form of abuse of the doctor-patient relationship. In addition, in resource-poor settings, the dilemma presented by the know-do gap (inapplicability of research results due to financial or social constraints) is part of the ethics' realm of the profession. Future prospects include a wider use of research results in practice, but avoidance of the know-do gap (the disparity between what is known and what can be done, particularly in settings with limited resources) requires a synthetic and holistic approach to medical ethics, combining moral reflection, theoretical analysis and empirical data.

Ethics in psychosocial and biomedical research - A training experience at the Interdisciplinary Center for Bioethics (CIEB) of the University of Chile().

This paper reviews the experience in training Latin American professionals and scientists in the ethics of biomedical and psychosocial research at the Interdisciplinary Center for Studies in Bioethics (CIEB) of the University of Chile, aided by a grant from Fogarty International Center (FIC) - National Institutes of Health from 2002 to 2011. In these 10 years of experience, 50 trainees have completed a 12-month training combining on-line and in-person teaching and learning activities, with further support for maintaining contact via webmail and personal meetings. The network formed by faculty and former trainees has published extensively on issues relevant in the continent and has been instrumental in promoting new master level courses at different universities, drafting regulations and norms, and promoting the use of bioethical discourse in health care and research. Evaluation meetings have shown that while most trainees did benefit from the experience and contributed highly to developments at their home institutions and countries, some degree of structuring of demand for qualified personnel is needed in order to better utilize the human resources created by the program. Publications and other deliverables of trainees and faculty are presented.

Ethics in psychosocial and biomedical research: a training experience at the Interdisciplinary Center for Bioethics (CIEB) of the University of Chile / Ética en investigación biomédica y psicosocial: experiencia de capacitación en el Centro Interdisciplinario de Estudios en Bioética (CIEB) de la Universidad de Chile / Ética na pesquisa biomédica e psicossocial: eExperiência de capacitação no Centro Interdisciplinar de Estudos em Bioética (CIEB) da Universidade do Chile

This paper reviews the experience in training Latin American professionals and scientists in the ethics of biomedical and psychosocial research at the Interdisciplinary Center for Studies in Bioethics (CIEB) of the University of Chile, aided by a grant from Fogarty International Center (FIC) - National Institutes of Health from 2002 to 2011. In these 10 years of experience, 50 trainees have completed a 12-month training combining on-line and in-person teaching and learning activities, with further support for maintaining contact via webmail and personal meetings. The network formed by faculty and former trainees has published extensively on issues relevant in the continent and has been instrumental in promoting new master level courses at different universities, drafting regulations and norms, and promoting the use of bioethical discourse in health care and research. Evaluation meetings have shown that while most trainees did benefit from the experience and contributed highly to developments at their home institutions and countries, some degree of structuring of demand for qualified personnel is needed in order to better utilize the human resources created by the program. Publications and other deliverables of trainees and faculty are presented.

El presente artículo revisa la experiencia de capacitación en ética de investigación biomédica y psicosocial a profesionales y científicos latinoamericanos en el Centro Interdisciplinario de Estudios en Bioética de la Universidad de Chile, con el apoyo de un grant del Centro Internacional Fogarty de los Institutos Nacionales de la Salud de Estados Unidos, de 2002 a 2011. En estos 10 años de experiencia, 50 profesionales han completado una capacitación de 12 meses, que combina actividades de aprendizaje en línea y presenciales con apoyo vía email y tutoría. La red, formada por los académicos del programa y los participantes, ha publicado extensamente en temas relevantes para el continente y ha sido instrumental en promover cursos de nivel de magíster en diferentes universidades, proponer regulaciones y promover el uso del discurso bioético en la atención de salud y la investigación. Los encuentros de evaluación han demostrado que, aun cuando la mayoría de los participantes se beneficiaron de la experiencia y contribuyeron grandemente al desarrollo en sus instituciones y su país, se necesita algún grado de estructuración para la demanda de personal calificado que pueda utilizar mejor los recursos humanos creados por el programa. Se presentan las publicaciones y otros productos de académicos y participantes en el programa.

O presente artigo revisa a experiência de capacitação em ética da pesquisa biomédica e psicossocial a profissionais e cientistas latino-americanos no Centro Interdisciplinar de Estudos em Bioética da Universidade do Chile, com o apoio de bolsa do Centro Internacional Fogarty dos Institutos Nacionais de Saúde dos Estados Unidos, de 2002 a 2011. Nestes 10 anos de experiência, 50 profissionais completaram uma capacitação de 12 meses, que combina atividades de aprendizagem “on line” e presenciais com apoio via e-mail e tutoria. A rede formada por acadêmicos do programa e participantes publicou extensamente temas relevantes para o continente e foi instrumental em promover cursos em nivel de mestrado em diferentes universidades, propor regulamentações e promover o uso do discurso bioético na atenção à saúde e à pesquisa. Os encontros de avaliação têm demonstrado que, mesmo que a maioria dos participantes tenha se beneficiado da experiência e contribuido grandemente para o desenvolvimento de suas instituições e seu país, ainda necessita de algum grau de estruturação para a demanda de pessoal qualificado que possa utilizar melhor os recursos humanos criados pelo programa. São apresentados publicações e outros produtos de acadêmicos e participantes do programa.

THE TOPIC OF RESEARCH INTEGRITY IN LATINAMERICA.

Present article narrates the experience of trainees of the ethics of biomedical and psychosocial research program of the Interdisciplinary Center for studies on bioethics (CIEB) of the University of Chile on the topic of research integrity in Latin America. The following problems are covered: integrity of publications, reporting of scientific research misconduct, definitions of research integrity, scientific ethical review committees functioning, international multi-centric clinical trials monitoring and norms for scientific integrity and ethical oversight.

Psychiatry and human rights in Latin America: ethical dilemmas and the future.

This paper addresses the context in which ethical and human right issues as they pertain to psychiatry are discussed in Latin America. Dependency and institutional instability are singled out as pervading characteristics influencing the analysis of issues and the design of mental health policies. According to the landmark 1990 Declaration of Caracas all countries in the region have progressed towards implementing measures designed to improve the condition of the populations regarding mental health care and research. Several principles are now universally accepted and, while there is still room for improvement, provision of services and better contexts for scientific development make it possible to expect advances in the future.

Situación de la psiquiatría en tiempos de crisis / Situation of psychiatry in times of crisis

Este artículo examina la situación de la psiquiatría como profesión que cohesiona diversas racionalidades en un contexto que parece objetar su legitimidad disciplinaria. Destacando las ventajas y desventajas de su inserción en la mentalidad y el ethos médicos, se examina la influencia de algunas prácticas clásicas (el asilo y las terapias biológicas) que antecedieron a su configuración sistemática conceptual. La solidez del oficio de psiquiatra, que en algunos círculos pudiera ser eliminado por la neurología, la medicina, la psicología o el trabajo social, debe encontrarse en la virtud moral de la prudencia. Gracias a ella, es posible pensar en una armónica constelación de saberes diversos y prácticas no siempre avaladas por evidencia empírica.

This paper examines the situation of psychiatry as a profession harmonizing different rationalities in a context that seems to question its disciplinary legitimacy. Stressing advantages and disadvantages of its insertion into the medical mentality and its ethos, some practices antedating its conceptual systematization are examined, like asylums and biological therapies. Sustainability of the psychiatric trade, which some would like to be eliminated by neurology, internal medicine, psychology or social work, must be found in the moral virtue of prudence. This permits considering a harmonic constellation of diverse forms of knowledge and practices not always supported by empirical evidence.

Inserção dos temas de humanidades e ética em curriculo médico integrado em escola pública no distrito federal, Brasil / Ethic and humanities themes insertion in medical integrate curriculum at public school of medicine in federal district of Brazil / Inserción de temas de humanidades y ética en currículo médico integrado de escuela pública en el distrito federal, Brasil

Objetivo: Realizar uma análise da inserção da ética e humanidades no currículo do Curso de Medicina da Escola Superior em Ciências da Saúde - ESCS, escola pública do Distrito Federal, Brasil, de forma a contribuir com o processo de gestão curricular. Metodologia: O Estudo é de coorte e documental. Foram pesquisados 37 termos relacionados à ética e 36 referentes à humanização nos objetivos educacionais e conteúdo dos módulos temáticos, habilidades e atitudes e interação ensino-serviço-comunidade, de 1a a 4a série e no programa do internato no currículo (ano 2006) e no projeto pedagógico do Curso de Medicina (2001). Resultados: Maior inserção da humanização, ética e bioética na 1a e 2a série, quando comparado à inserção na 3a e 4a série e no internato, (IC95 por cento-a=0,034, pvalue=0,007). Unidade de habilidades e atitudes: freqüência das 3 temáticas no currículo da 1a a 4a séries (IC95 por cento-a=0,026, pvalue=0,013). Quando comparada a inserção entre o internato e as quatro primeiras séries, observa-se que nestas a inserção da temática humanização é superior (IC95 por cento-a=0,042, pvalue=0,029). Conclusão: O currículo desenvolvido no ano de 2006 na ESCS apresentou correlação com o projeto pedagógico do curso e contemplou a temática de forma abrangente, em todas as séries e internato.

Objetivo: Realizar un análisis de la inserción de la ética y de las humanidades en el currículo del Curso de Medicina de la Escuela Superior en Ciencias de la Salud-ESCS, escuela pública del Distrito Federal, Brasil, para contribuir con el proceso de gestión curricular. Metodología: El estudio es de cohorte y documental. Se investigaron 37 términos relacionados con la ética y 36 referidos a la humanización en los objetivos educacionales y en el contenido de los módulos temáticos, habilidades, actitudes e interacción enseñanza-servicio-comunidad, de 1a a 4a serie, en el programa del internado del currículo (año 2006) y en el proyecto pedagógico del Curso de Medicina (2001). Resultados: Mayor inserción de la humanización, ética y bioética en la 1a y 2a serie, comparada con la inserción en la 3¬ y 4¬ serie y con el internado, (IC95 por ciento-#945; =0,034, pvalue=0,007). Unidad de habilidades y actitudes: frecuencia de las 3 temáticas en el currículo de 1a a 4a series (IC95 por ciento-#945; =0,026, pvalue=0,013). Cuando se compara la inserción entre el internado y las cuatro primeras series, se observa que en éstas la inserción de la temática humanización es superior (IC95 por ciento-#945; =0,042, pvalue=0,029). Conclusión: El currículo desarrollado en 2006 en ESCS presentó correlación con el proyecto pedagógico del curso y contempló la temática de forma abarcadora, en todas las series e internado.

Objective: To establish a diagnosis of the insertion of bioethics, ethics and humanistic values and attitudes to the program of the Medical School of ESCS - Escola Superior em Ciências da Saúde, public school of medicine, Distrito Federal, Brazil, in order to contribute to the process of curricular management. Methodology: The study is cohorte and documental. Thirty-two indicators to the thematic on ethics and twenty-four related to humanization were utilized. The educational purpose and contents of activities in modules such as thematic, abilities, interaction and attitude towards the community for teaching and services, from first to senior years as well as in boarding schools programs were all analyzed in the Medical School curriculum of ESCS (2006) and about the pedagogic project of the Course (2001). Results: It was observed a greater insertion of thematic related to ethics and bioethics in the initial levels of the course, Freshman and Sophomore including boarded students, when compared to the insertion in Junior and Senior clerkship years (IC95 percent-a=0,034, pvalue=0,007). The unit on abilities and attitudes was the axle which presented greater recurrence of the thematic on humanization in programs of 1a and 4a years (IC95 percent-a=0,026, pvalue=0,013). It was observed an increase in the recurrence of the thematic on humanization developed in thematic modules and interaction community-teaching/service in the 2a year and decline in the subsequent ones. The results were very low in the 3a and 4a years. When compared with the clerkship it was observed that the first four series had greater insertion of such thematic (IC95 percent-a=0,042, pvalue=0,029). Conclusion: The academic program developed in the year of 2006 at ESCS presented improvements when compared to the pedagogical project of the course.

Ethical Conduct in Research Involving Human Beings In Brazil: Diagnosis of Research Ethics Committee.

OBJECTIVE: Diagnose ethical conduct in research involving human beings in Brazil and the last 10 years of activity by the Human Research Ethics Committee of the Health Department - Federal District - CEP/SES/DF. METHODS: This work was based on a documentary research, descriptive and retrospective. It examined the database containing records of cases brought before the CEP/SES/DF, corresponding the period of June 1997 to December 2007. Results were generated in Excel program, version 2007. RESULTS: CEP/SES/DF has presented increasing number of research projects submitted to appreciation (n = 1129), composing: 90.4% approved 1.7% disapproved, 7.4% removed/filed and 0.5% excluded. Of these projects, 83% belonged to Group III, 18% multi-centered projects and 10% protocols with foreign participation. Time for approval has decreased over the years (30 to 60 days). Frequent pendencies: End of Free and Informed Consent (30%), Cover Sheet (25%), Methodology (20%), Curriculum vitae (12%), Budget (9%), and Others (4%). CONCLUSION: The assessment of the CEP/SES/DF activities, during a ten-year period has shown its commitment to the legitimacy of research ethics review and scientific production SES/DF. There were some weaknesses such as difficulty in monitoring the accompaniment of the research; interruption of works due to adverse drug reaction; gaps or errors in the protocol submitted by the researcher. These situations are the achieving targets for the elaboration of specific criteria.

ANALISE DA INSERCAO DOS TEMAS DE HUMANIDADES E ETICA, COM METODOLOGIA DE APRENDIZAGEM BASEADA EM PROBLEMAS, EM CURRICULO MEDICO INTEGRADO EM ESCOLA PUBLICA NO DISTRITO FEDERAL, BRASIL.

OBJECTIVE: To establish a diagnosis of the insertion of bioethics, ethics and humanistic values and attitudes to the program of the Medical School of ESCS - Escola Superior em Ciências da Saúde, public school of medicine, Distrito Federal, Brazil, in order to contribute to the process of curricular management. METHODOLOGY: The study is cohorte and documental. Thirty-two indicators to the thematic on ethics and twenty-four related to humanization were utilized. The educational purpose and contents of activities in modules such as thematic, abilities, interaction and attitude towards the community for teaching and services, from first to senior years as well as in boarding schools programs were all analyzed in the Medical School curriculum of ESCS (2006) and about the pedagogic project of the Course (2001). RESULTS: It was observed a greater insertion of thematic related to ethics and bioethics in the initial levels of the course, Freshman and Sophomore including boarded students, when compared to the insertion in Junior and Senior clerkship years (IC95%-alpha=0,034, pvalue=0,007). The unit on abilities and attitudes was the axle which presented greater recurrence of the thematic on humanization in programs of 1 and 4 years (IC95%-alpha=0,026, pvalue=0,013). It was observed an increase in the recurrence of the thematic on humanization developed in thematic modules and interaction community-teaching/service in the 2 year and decline in the subsequent ones. The results were very low in the 3 and 4 years. When compared with the clerkship it was observed that the first four series had greater insertion of such thematic (IC95%-alpha=0,042, pvalue=0,029). CONCLUSION: The academic program developed in the year of 2006 at ESCS presented improvements when compared to the pedagogical project of the course.