Mental Health Collaborative Care in Brazil and the Economy of Attention: Disclosing Barriers and Therapeutic Negotiations.

The introduction of mental health collaborative care (MHCC) is one of the strategies to scale up access to mental health care in primary health care in Brazil. This article investigates an experience of mental health collaborative care in the city of Rio de Janeiro, Brazil. It is a qualitative study involving interviews with physicians and mental health professionals working in primary health care units located in the northern part of the city of Rio de Janeiro, Brazil. The aim is to examine the various strategies and negotiations that primary health care professionals deploy to identify mental distress and plan health care interventions. We discuss the results within the economy of attention framework. We argue that divergences in diagnostic design and therapeutic planning carried out by professionals and users or observed in MHCC meetings illustrate the health-disease-care seeking phenomenon as a negotiated process, entangled in complex interactions. Our results evince that those interactions are not always evident and configure 'what is at stake' in mental suffering. The incorporation of cultural and structural determinants in collaborative care may enable the expansion of mental health initiatives sensitive to local needs and realities.

[Reflexive groups with medical students from the mental health league as a strategy for change]. / Grupos reflexivos com estudantes de medicina da liga de saúde mental como estratégia de mudanças.

This paper set out to present the outcomes of qualitative research conducted with medical students of a Mental Health and Psychiatry League (LASMP). Its objectives were to sensitize them to perceive themselves as people and provide them with other rationales different from biomedical ways of thinking. The reflexive groups, within the culture circle, provided an opportunity for an exchange of ideas, time for reflection and sharing of fully formed daily experiences. They were configured as a strategy of change and awakening to rethink models of health more focused on healthcare than on diseases. Participant observation enabled revealing, through the narratives, particularities of the experiences, discourses and culture of the group itself. The analyses were carried out using the reflexivity method (Bourdieu, 2001; 2004), as it permits the systematic deepening of the contents of the narratives. Without any pretension of synthesis, the reflexive course on the narratives started from the assumptions of thought and actions to arrive at the constructed and shared meanings. They offered possibilities of transforming the way of perceiving the world of work, themselves, and the people around them; of changing the understanding of mental health beyond the individual level.

O trabalho apresenta os resultados de uma pesquisa qualitativa realizada com estudantes de medicina de uma Liga de Saúde Mental e Psiquiatria (LASMP). Teve como objetivos sensibilizá-los para perceber a si mesmos como pessoas e instrumentalizá-los com outras racionalidades distintas das formas de pensamento biomédicas. Os grupos reflexivos, por meio do círculo de cultura, ofereceram espaço de livre circulação da palavra, tempo para reflexões e compartilhamento de experiências cotidianas vividas em plena formação. Configuraram-se como estratégia de mudança e um despertar para repensar modelos de saúde mais voltados para o cuidado do que para doenças. A observação participante permitiu descortinar, por meio das narrativas, particularidades das experiências, dos discursos e da cultura do próprio grupo. As análises foram realizadas pelo método da reflexividade (Bourdieu, 2001; 2004), por permitir o aprofundamento sistemático dos conteúdos das narrativas. Sem pretensão de síntese, o percurso reflexivo sobre as narrativas partiu dos pressupostos do pensamento e das ações para chegar aos sentidos construídos e partilhados. Ofereceram possibilidades de transformação do modo de ver o mundo do trabalho, a si mesmos e as pessoas a sua volta; de mudança na compreensão da saúde mental para além do plano individual.

Grupos reflexivos com estudantes de medicina da liga de saúde mental como estratégia de mudanças / Reflexive groups with medical students from the mental health league as a strategy for change

Resumo O trabalho apresenta os resultados de uma pesquisa qualitativa realizada com estudantes de medicina de uma Liga de Saúde Mental e Psiquiatria (LASMP). Teve como objetivos sensibilizá-los para perceber a si mesmos como pessoas e instrumentalizá-los com outras racionalidades distintas das formas de pensamento biomédicas. Os grupos reflexivos, por meio do círculo de cultura, ofereceram espaço de livre circulação da palavra, tempo para reflexões e compartilhamento de experiências cotidianas vividas em plena formação. Configuraram-se como estratégia de mudança e um despertar para repensar modelos de saúde mais voltados para o cuidado do que para doenças. A observação participante permitiu descortinar, por meio das narrativas, particularidades das experiências, dos discursos e da cultura do próprio grupo. As análises foram realizadas pelo método da reflexividade (Bourdieu, 2001; 2004), por permitir o aprofundamento sistemático dos conteúdos das narrativas. Sem pretensão de síntese, o percurso reflexivo sobre as narrativas partiu dos pressupostos do pensamento e das ações para chegar aos sentidos construídos e partilhados. Ofereceram possibilidades de transformação do modo de ver o mundo do trabalho, a si mesmos e as pessoas a sua volta; de mudança na compreensão da saúde mental para além do plano individual.

Abstract This paper set out to present the outcomes of qualitative research conducted with medical students of a Mental Health and Psychiatry League (LASMP). Its objectives were to sensitize them to perceive themselves as people and provide them with other rationales different from biomedical ways of thinking. The reflexive groups, within the culture circle, provided an opportunity for an exchange of ideas, time for reflection and sharing of fully formed daily experiences. They were configured as a strategy of change and awakening to rethink models of health more focused on healthcare than on diseases. Participant observation enabled revealing, through the narratives, particularities of the experiences, discourses and culture of the group itself. The analyses were carried out using the reflexivity method (Bourdieu, 2001; 2004), as it permits the systematic deepening of the contents of the narratives. Without any pretension of synthesis, the reflexive course on the narratives started from the assumptions of thought and actions to arrive at the constructed and shared meanings. They offered possibilities of transforming the way of perceiving the world of work, themselves, and the people around them; of changing the understanding of mental health beyond the individual level.

Rethinking structural competency: Continuing education in mental health and practices of territorialisation in Brazil.

Brazilian mental health focuses on the social determination model within mental health policies and interventions to address mental and social suffering as resulting from social exclusion and structural violence. Structural concerns focused on class stratification and socioeconomic inequalities overweight cultural ones in Brazilian mental health. In this article we examine, first the role of culture and interculturality in mental health practices and mental health guidelines for health professionals continuing training in Brazil. Second, we explore interviews with health professionals around Continuing Education in Health provided by mental health collaborative care initiatives within primary health care as illustration of a local practice of structural competency in mental health. Finally, we examine the central role played by the practices of territorialisation in shaping health care training and care interventions. The focus on the territory can promote critical apprehensions of the intercultural and structural factors that shape health practices, enrich health professional education oriented towards the basic tenets of social medicine and provide global discussions around structural competency with innovative ways of thinking about health education, health care and spatiality. We believe that our results may be useful for comparing structural competency training initiatives in global health.

Repensando a competência cultural nas práticas de saúde no Brasil: por um cuidado culturalmente sensível / Rethinking cultural competence in healthcare practices in Brazil: towards cultural sensitivity in care

Resumo O planejamento e a implementação de políticas e práticas de saúde em países com sistemas orientados para a Atenção Primária em Saúde devem reconhecer e manejar as questões de desigualdade social em saúde que interferem no cuidado integral e equânime. Uma estratégia amplamente defendida para detectar e lidar com tais desafios é a noção de competência cultural (CC). Neste artigo, apresentaremos a noção de CC, suas críticas e alternativas teórico-práticas e, em seguida, uma revisão narrativa dessa noção em publicações brasileiras relacionadas à assistência em saúde na Estratégia Saúde da Família. O reconhecimento da diversidade sociocultural no planejamento de intervenções em saúde no Brasil é fundamental, dado que se trata de um país extremamente diverso, cujo sistema de saúde é organizado a partir das premissas da Reforma Sanitária, mas que, ainda assim, apresenta importantes iniquidades. Argumentamos que a inclusão e a negociação das diferenças socioculturais nas práticas de saúde se beneficiariam da observação do contexto histórico-social e da reflexão acerca das experiências brasileiras de assistência em saúde e das práticas cotidianas de cuidado utilizadas nas comunidades.

Abstract Planning and implementing health policies and practices in countries with Primary Health Care-oriented systems must recognize and manage social inequality issues in health, which hinder comprehensive and equitable care. A widely advocated strategy for detecting and dealing with such challenges is the notion of cultural competence (CC). In this article, we will present the notion of CC, its criticisms, and theoretical-practical alternatives and, then, a narrative review of Brazilian publications related to healthcare in the Family Health Strategy. Recognizing sociocultural diversity in planning health interventions in Brazil is essential, given that it is an extremely diverse country, whose health system is organized on the premises of the Health Reform but that presents important inequities still. We argue that the inclusion and the negotiation of sociocultural differences in health practices would benefit from the observation of the social-historical context and the reflection on the Brazilian health care experiences and the everyday care practices within the communities.

Negotiating human rights narratives in Global Mental Health: Autism and ADHD controversies in Brazil.

Promoting evidence-based treatments and the human rights of people living with mental illness are the two pillars of Global Mental Health (GMH). Critics counter that human rights narratives must also include social justice frameworks. We draw on the cases of autism and ADHD in Brazil to discuss the role of human rights in mental health in the context of GMH. A human rights perspective involves citizenship rights for individuals living with mental distress and provides a framework to problematise the logic of GMH centred on individual rights and rights to treatment. We begin with an overview on human rights discussions in GMH and examine the introduction of human rights discourses in the Brazilian psychiatric reform. We then explore how autism and ADHD became priorities of GMH interventions as well as the constitution of two styles of activism and mobilisation of human rights around these conditions. One follows the universal public health logic and promotes health as a social right. The other follows the logic of parents' associations that redefined those conditions as forms of disability to advocate for specialised services and interventions. Finally, we discuss these forms of human rights mobilisation and their implications for Brazilian mental health and GMH.

Saúde Mental dos Acadêmicos de Medicina na Quarentena ­ isolamento e enfrentamentos individuais / Mental Health of Medical Students in Quarantine ­ isolation and individual confrontations

O isolamento domiciliar e o distanciamento social têm sido sugeridos como estratégias a serem adotadas em estágios mais avançados de pandemias. Até recentemente tais medidas, geralmente, eram aplicadas somente para grupos de risco e/ou para contactantes de pessoas infectadas. A pandemia atual é a primeira experiência de implementação deste tipo de medida em larga escala. É fundamental avaliarmos as diferentes consequências que tanto a pandemia, como suas medidas de enfrentamento (isolamento domiciliar e distanciamento social), podem vir a ocasionar em territórios e estratos sociais distintos. Nesse estudo, buscou-se observar os efeitos da quarentena na saúde mental dos estudantes de medicina de uma faculdade particular, os fatores que influenciam, os recursos utilizados para lidar com essas dificuldades e quais as especificidades de ser estudante de medicina na quarentena. Para tanto, foram aplicados questionários semi-estruturados on-line analisados por meio de análise do conteúdo. Apresenta-se aqui os resultados preliminares e específicos quanto às estratégias utilizadas pelos acadêmicos para lidar com o sofrimento e os contratempos cotidianos. Os estudantes privilegiaram atividades de auto-cuidado e atividades de lazer experimentadas individualmente. Discutimos esses achados, considerando a carga do isolamento e seus efeitos para o processo de socialização dos acadêmicos.(AU)

Isolation and social distance have been suggested as strategies to be adopted in more advanced stages of pandemics. Until recently, such measures were generally applied only to groups at risk and / or to contact persons infected. The current pandemic is the first experience of implementing this type of measure on a large scale. It is essential to assess the different consequences that both the pandemic and its measures of coping (home isolation and social distance), may have in different territories and social strata. In this study, we sought to observe the effects of quarantine on the mental health of medical students from a particular college, the factors that influence it, the resources used to deal with these difficulties and what are the specifics of being a medical student in quarantine. For that, semi-structured questionnaires were applied online and analyzed through content analysis. Preliminary and specific results regarding the strategies used by academics to deal with daily suffering and setbacks are presented here. Students favored self-care activities and leisure activities experienced individually. We discussed these findings, considering the burden of isolation and its effects on the students socialization process.(AU)

Se ha sugerido que el aislamiento del hogar y la distancia social son estrategias a adoptar en las etapas más avanzadas de las pandemias. Hasta hace poco, estas medidas se aplicaban generalmente solo a grupos en riesgo y / o para contactar personas infectadas. La pandemia actual es la primera experiencia de implementación de este tipo de medidas a gran escala. Es fundamental evaluar las diferentes consecuencias que tanto la pandemia como sus medidas de afrontamiento (aislamiento domiciliario y distancia social), pueden tener en diferentes territorios y estratos sociales. En este estudio, buscamos observar los efectos de la cuarentena en la salud mental de los estudiantes de medicina de una universidad en particular, los factores que influyen en ella, los recursos utilizados para hacer frente a estas dificultades y cuáles son las particularidades de ser un estudiante de medicina en cuarentena. Para ello, se aplicaron cuestionarios semiestructurados online y se analizaron mediante análisis de contenido. A continuación se presentan resultados preliminares y específicos sobre las estrategias que utilizan los académicos para afrontar el sufrimiento y los retrocesos cotidianos. Los estudiantes favorecieron las actividades de cuidado personal y las actividades de ocio experimentadas individualmente. Discutimos estos hallazgos, considerando la carga del aislamiento y sus efectos en el proceso de socialización de los estudiantes.(AU)

Global Mental Health and Pharmacology: The Case of Attention Deficit and Hyperactivity Disorders in Brazil.

Global Mental Health (GMH) is the field of study, research, and intervention, which aims at improving access to mental health worldwide. It is based on the global burden of disease research program and on the existence of a large "treatment gap" between the need and availability of mental health services, displaying individual and social costs of undiagnosed and untreated mental disorders, especially in low- and middle-income countries (LMIC). Few academic publications in Brazil dialogue directly with the field of GMH, although several issues drawn from its agenda have been the subject of mental health policies in the country. Brazil can be classified as a middle-income country with a well-structured national health system. This system is oriented toward primary health care, which integrates both community mental health services and the broader health care network. The debate between GMH advocates and critics has unearthed old controversies in psychiatry such as universality or cultural specificity of mental disorders, their expressions, and their relationship with social and economic factors. We intend to examine how these controversies reverberate in the Brazilian mental health scenario, taking as an illustration the debates around Attention Deficit Hyperactivity Disorder (ADHD) in the country. ADHD discussions oppose those who argue that the condition is underdiagnosed and undertreated, and those who claim that there is overdiagnosis and overtreatment and thus, medicalization of childhood. This article presents the current status of the Brazilian mental health literature on ADHD, with emphasis on tensions around diagnosis, prevalence and interventions. Our aim is to highlight how the differential in discourse shapes the debate on ADHD in Brazil and how this may contribute to the GMH agenda. This goal will be undertaken in three steps. First, we will briefly examine studies around GMH and ADHD. Secondly, we address Brazilian studies on this theme, considering the specificities regarding the constitution of the mental health field. Finally, we will examine the debate of treatment gap vs. medicalization in the country in order to underscore the potentials and limitations of each perspective.

Competência Cultural no Matriciamento em Saúde Mental / Cultural Competence in Mental Health Collaborative Care

O Matriciamento ou cuidado colaborativo, adotado no Brasil e defendido pela Organização Mundial de Saúde (OMS), permite a detecção precoce dos transtornos mentais, o tratamento e a continuidade de cuidado na comunidade. Incorporar um olhar sobre a cultura pode ser útil para lidar com os desafios suscitados nos encontros clínicos. Pretendeu-se, então, observar se e como a diversidade cultural e as configurações culturais específicas dos serviços e de suas comunidades são reconhecidas como impasses e/ou potencialidades ao planejamento terapêutico negociado entre profissionais de saúde da família e matriciadores de saúde mental. Para tanto, realizou-se pesquisa qualitativa, entrevistando-se profissionais de saúde da família e matriciadores, por meio de entrevistas episódicas, analisadas segundo referencial da Análise do Discurso. Embora os profissionais percebam os condicionantes socioculturais relacionados aos casos clínicos e às interações com usuários, comunidade e entre profissionais, a noção de competência cultural se mostrou insuficiente para uma compreensão ampliada e crítica da diversidade cultural, demonstrando a necessidade de estimular o debate em torno da dimensão sociocultural, a partir das particularidades das reformas sanitária e psiquiátrica brasileiras

The collaborative care, adopted in Brazil, and defended by the World Health Organization (WHO) allows the early detection of mental disorders, treatment and continuity of care in the community. Incorporating a culture outlook can be helpful in dealing with the challenges raised in clinical encounters. It was then sought to observe if and how cultural diversity, materialized by the specific cultural configurations of services and their communities are recognized as obstacles and / or potentialities for the therapeutic planning negotiated between family health professionals and mental health supporters. For that, a qualitative research was conducted, interviewing family health professionals and mental health supporters through episodic interviews, analyzed according to the discourse analysis framework. Although professionals observe sociocultural determinants related to clinical cases and interactions with users, community and professionals, the notion of cultural competence has proved insufficient for a broad and critical understanding of cultural diversity, demonstrating the need to stimulate the debate around of the socio-cultural dimension, considering the particularities of the Brazilian sanitary and psychiatric reforms

Dengue / Dengue

Os autores realizam uma breve discussão sobre a infecção pelo vírus dengue, como forma de proporcionar um melhor panorama do estado atual do problema.