ORIGINAL ARTICLE

 

Mental Health in the Unified Health System: Mapping the Contributions from the Psychosocial Care Centers

 

Salud Mental en el Sistema Único de Salud: Identificación de las Contribuciones de los Centros de Atención Psicosocial

 

 

Geysa Cristina Marcelino Nascimento^I; Fabio Scorsolini-Comin^II; Rodrigo Sanches Peres^III

^IUndergraduate student in Psicology, Departamento de Psicologia, Instituto de Educação, Letras, Artes, Ciências Humanas e Sociais, Universidade Federal do Triângulo Mineiro, Uberlândia, MG, Brazil
^IIPhD, Adjunct Professor, Departamento de Psicologia, Instituto de Educação, Letras, Artes, Ciências Humanas e Sociais, Universidade Federal do Triângulo Mineiro, Uberlândia, MG, Brazil
^IIIPhD, Adjunct Professor, Instituto de Psicologia, Universidade Federal de Uberlândia, Uberlândia, MG, Brazil

Correspondence

 

 

---

ABSTRACT

This article aims to present a review of the scientific literature on the Psychosocial Care Centers (CAPS). A search in the LILACS, SciELO-Brazil, and PePSIC databases returned 10 articles. These articles, in general, show that the CAPS have been essential for the consolidation of the psychiatric reform in Brazil. There is a predominance of qualitative studies conducted with patients, their families, and health professionals. Some of the challenges relate to the need for greater coordination between mental health and primary care; thus, establishing a collaborative relationship between patients and health professionals, in addition to qualification requirements, and performance evaluations of these professionals.

Descriptors: Mental Health Services; Mental Health; Unified Health System; Public Policies.

---

RESUMEN

Este artículo tiene como objetivo presentar una revisión de la literatura científica sobre los Centros de Atención Psicosocial (CAPS). Por medio de una busca en las bases de datos LILACS, SciELO-Brasil y PePSIC, fueron recobrados 10 artículos. Tales artículos, en líneas generales, revelan que los CAPS vienen prestando contribuciones esenciales para la consolidación de la Reforma Psiquiátrica en Brasil. Predominan estudios cualitativos realizados con usuarios, profesionales de salud y familiares. Algunos de los desafíos a ser superados se refieren a la necesidad de mayor articulación de la salud mental con la atención básica, además del establecimiento de relaciones colaborativas entre usuarios y profesionales de salud, siendo que, para tanto, la ejecución de procesos de evaluación y la calificación de eses profesionales se revelan esenciales.

Descriptores: Servicios de Salud Mental; Salud Mental; Sistema Único de Salud; Políticas Públicas.

---

 

 

Introduction

The current public health policies cannot be discussed without a brief historical incursion. It should be noted that the VIII National Health Conference, held in March 1986, was a milestone for the establishment of the guiding principles of the health care reform. At that time, there was an intense mobilization from the political parties, unions, health professionals, among others, in favor of an extension of the concept of health and the definition of the corresponding institutional acts⁽¹⁾. Thus, in 1987 it was created the Unified and Decentralized Health Systems (SUDS), which a year later became the Unified Health System (SUS).

The Federal Constitution of 1988 establishes, with the implementation of the SUS that health is the right of every citizen and a duty of the State. Therefore, the access to health services must be universal, free, and public. The comprehensiveness, equity, and decentralization were defined as the SUS doctrine, aspiring to treat each citizen as a unique person who needs specific care. The fulfillment of these principles is socially provided by the Municipal, State and National Health Councils, which include the participation of the patients, workers, service providers, civil society organizations, and educational institutions⁽²⁾.

It is the SUS responsibility to enhance the prevention, and promotion of health, seeking to reduce the probability of certain diseases affecting any given population; thus, empowering individuals and communities to increase control over the health determinants through the creation of policies, and educational components in a broad dimension of interlinked interpretations and systems. The SUS had brought considerable advances in public health when it established decentralization as one of its organizing principles. However, the decentralization faces several obstacles, such as the absence of tax reforms, implementation of an effective policy dealing with drugs and equipment, adjustments from the universities and public participation⁽³⁾.

The SUS represented a significant victory for the Health Reform movement, but it still needs to consolidate itself as a state policy solid grounded in the social bases⁽⁴⁾. Significant advances have been achieved in spite of the problems inherent with the privatization of the health care system. Several authors highlight the need for supplementary and ordinary legislation to detail and discipline the principles and constitutional guidelines; thus, establishing the possibility of constant communication between teams, government, and society for the creation of public policies that meet the yearnings and needs of the population^(5-8).

One of the challenges facing the SUS today is the effective implementation of the Psychiatric Reform, consolidated with Law 10.216/2001. The Psychiatric Reform guarantees comprehensive care for the patients of mental health services through the structuring of community-based services, which must be configured into care networks, according to the Health Reform principles, able to provide equity in care and promote social reintegration. Among these services, the Centers for Psychosocial Care (CAPS), regulated in 2002, play a central role. In 2010, twenty-three years after the implementation of the first CAPS, there are 1,541 CAPS in operation around the country⁽⁹⁾.

As an elemental part of the SUS network, the CAPS plays a strategic role within the mental health care system as community-based services aimed at the psychosocial rehabilitation. All Brazilians suffering from any mental disorder requiring intensive care are eligible to receive assistance from the CAPS. After all, the CAPS are designed to provide service to the population of its covered area, conducting the clinical follow-up and the social reinsertion of its patients through work, leisure, exercise of civil rights, and the strengthening of family and community ties^(1-2).

Thus, the CAPS were created as a replacement of the traditional hospital model. They provide a moderated and structured environment, with consulting room, group activity and social areas, workshops, cafeteria, and an outdoor area for various recreational activities and sports⁽¹⁰⁾. Moreover, the CAPS should be inserted in the neighborhoods to facilitate the reintroduction of the patient to society. Therefore, they are located in specific physical areas, independent of any hospital structure, often in buildings formerly used as residences.

Prior psychiatric hospitalization is not a requirement to be attended at a CAPS unit. The patients are either walk-ins, or referrals from the Family Health Strategy and/or any other health service⁽¹¹⁾. A patient should be able to go the nearest CAPS for the initial assessment, followed by the therapeutic relationship with the designated health professional; consisting of a treatment plan tailored to meet the needs of each patient.

The CAPS should seek permanent integration with the network of primary care providers in their territory since they play an essential role in the monitoring, training, and support for the care of mental disorder sufferers ^(12-14). The primary care network is formed by the centers or local and/or regional health units and the Family Health, and Community Health Agents in the covered area. These teams are responsible for providing health care to the population in that area^{(5, 15 to 16).}

Seeking greater interaction between public policies of human and mental health rights, the Ministry of Health and the Special Human Rights Office signed in May 2006, the Inter-ministerial Ordinance No. 1055, which established a working group for the creation of a Brazilian Center for Human and Mental Health Rights⁽¹⁾. Furthermore, the psychiatric reform also includes the exploitation of different types of work. In any case, the actions developed in many areas of the CAPS - in partnership with other mechanisms outside the hospital spheres, such as therapeutic residential services (SRT) - have provided a number of benefits to the patients, among them, the reduction of hospitalizations, greater autonomy, and better quality of life⁽¹⁷⁾. Despite the many advances in the mental health area, the transition from the old asylum paradigm to the community psychiatric model has met many obstacles, in addition to not being fully, supported by the patients, their families, and the health professionals⁽¹⁸⁾.

Therefore, this endeavor requires continuous and constant improvements to achieve the connection between the mental disorder sufferers and the community with all the players sharing the responsibilities. After all, the decentralization of care is essential to shift focus from mental illness to mental health⁽¹⁹⁾. An outline of the knowledge thus far accumulated would be essential in the quest to overcome this challenge. Based on this principle, this study aims to present a review of the national scientific literature on the Psychosocial Care Centers.

 

Materials and Methods

Study Type

This is an integrative review of the scientific literature. This study type contributes to the expansion of the existing knowledge based on findings concerning the limits of previous studies while allowing for the identification of gaps and trends in the scientific production⁽²⁰⁾. To obtain meaningful results, it is fundamental to start with a survey of the issues, establish the inclusion/exclusion criteria, analysis, and interpretation of the findings, and finally the presentation of the review itself. One of the central points of a review is the process of choosing the research papers for the analysis, which involves setting the system parameters to encourage a critical reading of the chosen material.

Databases Consulted

The following databases were consulted: Latin American and Caribbean Literature on the Health Sciences (LILACS), Scientific Electronic Library Online - Brazil (SciELO-Brazil) and Electronic Psychology Journals (PePSIC) using the descriptors CAPS, mental health, and SUS.

Inclusion Criteria

It included only articles published from 2000 to 2012, written in Portuguese and whose thematic was compatible with the scope of this study.

Exclusion Criteria

The exclusion included articles prior to 2000 or published in languages other than Portuguese, as well as books, book chapters, reviews, newspaper articles, monographs, dissertations, and theses. The exclusion of such publications is justified because, as a rule, they do not submit to the rigorous peer review process. Furthermore, were excluded articles that mention CAPS and SUS only in a tangential or unrelated manner, in addition to articles, whose subjects are not directly related to mental health.

Procedures for Collecting and Analyzing Data

The abstracts collected using the referred descriptors - alone or combined - were read and analyzed according to the established criteria. The selected articles were retrieved and analyzed in their entirety, followed by a new more detailed selection, culminating in the exclusion of additional items. The final selection was recorded and organized as follows: title, authors, institution, country of origin, study type, general purpose, specific purpose, participants, and main results. Based on this organization, all the main points in each article were outlined in the comparative analysis.

 

Results and Discussion

Table 1 shows that only 10 articles fitted the inclusion/exclusion criteria. Of these, six are empirical qualitative, and four are theoretical studies, both from Brazil. The predominance of qualitative studies among those dedicated to the theme was previously mentioned⁽²¹⁾. It is noteworthy that the drastic reduction in the number of articles retrieved compared to the number of publications found is a result of the inclusion/exclusion criteria used. Therefore, were excluded all articles unrelated to them. Figure 1 shows a detailed identification of the retrieved articles.

The retrieved articles dealt with issues concerning the assistance offered by the CAPS not only for the patients, but also for their families and/or caregivers. Figure 2 shows their objectives. They presented diversity in relation to this aspect the subjects ranged from the representations of mental disorders⁽²²⁾, psychiatric treatments⁽²³⁾, and social inclusion/exclusion⁽²⁴⁾ to the implementation of the Matrix Support as a strategy for regulating the mental health demand⁽²⁵⁾, and the use of methodological tools in the evaluation process⁽²⁶⁾.

In a similar study, focusing on health production⁽²¹⁾, the most frequent objectives were: analysis and evaluation of the proposed CAPS mental health care, analysis of the mental health professionals and their expectations in relation to the services, analysis of the CAPS practices. Identification of the relations established between family members, patients, and CAPS, and identification of the patient view about the disease, treatment, and the CAPS. Thus, the findings of this study hold similarities with those in the review, and the discourses by the professionals, patients, and families corroborate it.

Figure 3 shows the main results reported in the retrieved articles. Based on these results, the CAPS have been instrumental in the consolidation of the Psychiatric Reform by promoting social inclusion as they offer alternatives to the psychiatric hospital^{(24, 27)}. Some of the challenges to be met relate to some political instability⁽²⁸⁾ and the need for greater coordination between the mental health and primary care⁽²⁹⁾, in addition to qualification requirements⁽³¹⁾, and performance evaluations⁽³⁰⁾ of these professionals,

The importance of family in the treatment and quality of life of the patients was highlighted in the articles, in line with other studies⁽³²⁾ also dealing with the clinical treatment⁽³³⁾. A different review⁽²¹⁾ highlighted the need for more research dealing with the relationship between the family and the person with mental disorder. Furthermore, the need for greater coordination with the primary care providers⁽²⁹⁾ and the establishment of a collaborative relationship between professionals and patients in relation to the modality of the care⁽³⁴⁾ provided, could inspire practices that are more in line with the early assumptions of the SUS.

It is also necessary to enable the SUS operations as a network whose territorial entrance way, concerning mental health, is the CAPS at least in theory⁽¹⁹⁾. This network can accommodate other health services - similar to the SRT⁽¹⁷⁾ - neighborhood associations, cultural and sports centers, and churches in the area. Furthermore, the authors warn that mental health should be organized to avoid fragmentation of care, which requires the execution of actions that demonstrate coherence between principles and concepts in the various scenarios of the public health^{(18, 35)}.

As previously mentioned, several authors^(5-8) emphasize the need for additional legislations - such as the Inter-ministerial Ordinance No. 1055 - to fulfill the SUS and the Psychiatric Reform regulations. Moreover, it seems appropriate to point out that the SUS is permeated by contradictions that threaten its foundations⁽⁴⁾, in that health is progressively becoming a valuable commodity not only in Brazil, but also in other capitalistic nations. Such contradictions can certainly influence the work performed in the CAPS throughout the country, which fosters the need for a psychosocial care that recovers the values of community, family, and the identity of the patient⁽³³⁾. Such assumptions are addressed in all the retrieved articles^{(24, 26)}.

One way to reverse this trend is to employ the ESF as a tool to consolidate the SUS: establishing a dialogue of changes within the teams, which can be multiplied in a harmonizing manner throughout the community in line with the co-responsibility principles⁽¹⁵⁾. After all, the teams from the CAPS must act in an interdisciplinary way, seeking thereby a broader understanding of the demands presented by the patients, because they will need to interact with the primary care teams in the territory⁽¹⁰⁾.

It is noteworthy that the assessment of the articles retrieved in this review suggests the need for further studies aimed at the development of innovative care models under the expanded clinical perspective. Arrangements of this nature could be added to those traditionally offered in the CAPS, such as therapeutic workshops in its various forms, such as expressions (bodily, verbal, musical, etc...), the generation of income, or literacy. However, these therapeutic projects should always be individualized considering the particularities of each patient⁽⁴⁾.

Incidentally, a survey of over 300 psychologists linked to the CAPS from various regions of the country lists some care modalities, which according to the concept of the participants can be considered as innovative. Among them is the availability of computer courses considering the digital inclusion of the patients as a practice of therapeutic monitoring aimed at fostering their integration into the social environment⁽³⁶⁾. Care modalities such as these are able to broaden the dialogue between the CAPS and the community and it can be the subject for future research. However, such strategies should be used to broaden the dialogue between mental health professionals, patients, and their families⁽⁹⁾, and prevent the CAPS from replicating previous models of fragmented care without any interface with the social, historical, economic, political, and cultural context encompassed in the proposals of the mental health area.

It is essential that studies depart from the assumptions that public health policies are still under revision^{(9, 21)} so that new findings may trigger the adoption of different positions and greater improvement in mental health practice, notably in the CAPS. Thus, the CAPS and the SUS should be inserted in the same discussion, and they should be presented in an integrated manner, allowing for the creation of a schedule of study, evaluation, and continuous updating. As shown, this discussion should also be coordinated with the primary care^{(11, 25, 29, 34, and 37)} in seeking to build more collaborative models of care, meet the assumptions of a psychosocial, democratic, and potentiate care of the most appropriate health practices as recommended in the SUS.

 

Conclusion

The articles retrieved for this review provide indicators to define several ranges and limitations from both the CAPS and the SUS. Some of the limitations are determined by the neoliberal influence that permeate the public health policies in the country; thus, requiring constant infusion of funds, and above all the need for changes beyond an administrative and financial reform and that require deeper transformations. Health, more than the classic definition found in official documents and proclaimed as a slogan, should indubitably be a right guaranteed by the state. With universal and equal access to actions and services, which provide protection and recovery of the well-being.

Now regarding the CAPS, it is evident that its patients benefit mainly from the interactive relationship of therapy, which is established through the diverse modalities of health care offered; thus, promoting the continuity of care under the perspective of deinstitutionalization. However, such benefits require a deeper assessment, in the form of new studies, developed from a more diverse theoretical and methodological approach, with the ability to add plurality to the issue of mental health in the SUS.

From the results of this review and in line with the production redeemed in other studies, there is a need for projects developed outside the southern and southeast areas of the country, so that the new experiences are correlated with their limitations and advances. There is a pressing need for the construction and monitoring of public health policies that address the prospects of a more democratic and interactive care, which accounts for the context and its community relationships to foster changes in the care and understanding of mental health. Moreover, the constant evaluation of SUS policies and the Caps performance is essential to achieve these objectives.

 

References

1. Ministério da Saúde (BR). Sistema Único de Saúde. Brasília: Conselho Nacional de Secretários de Saúde; 2007.         [ Links ]

2. Ministério da Saúde (BR). Saúde mental no SUS: Acesso ao tratamento e mudanças do modelo de atenção. Brasília; 2006.         [ Links ]

3. Cordeiro H. Sistema Único de Saúde. Rio de Janeiro: Ayuri/ABRASCO; 1991.         [ Links ]

4. Elias PE. Estado e saúde: desafios do Brasil contemporâneo. São Paulo Perspec. 2004;18(3):41-6.         [ Links ]

5. Fortuna CM, Matumoto S, Pereira MJB, Mishima SM, Kawata LS, Camargo-Borges C. Nurses and the collective care practices within the family health strategy. Rev. Latino-Am. Enfermagem. 2011;19(3):581-8.         [ Links ]

6. Silva RC. O trabalho do psicólogo em centros de saúde: Algumas reflexões sobre as funções da psicologia na atenção primária à saúde. [tese]. São Paulo: Instituto de Psicologia da Universidade de São Paulo; 1988.         [ Links ]

7. Spink MJ. Os psicólogos na saúde: Reflexões sobre os contextos da prática profissional. In: Spink MJ, organizadora. Psicologia social e saúde: Práticas, saberes e sentidos. Petrópolis (RJ): Vozes; 2003. p. 77-159.         [ Links ]

8. Traverso-Yépez M. A interface Psicologia Social e Saúde: Perspectivas e desafios. Psicol Estud. 2001;6(2):49-56.         [ Links ]

9. Barroso SM, Silva MA. Reforma Psiquiátrica brasileira: o caminho da desinstitucionalização pelo olhar da historiografia. Rev. SPAGESP. 2011;12(1):66-78.         [ Links ]

10. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Saúde mental no SUS: os centros de atenção psicossocial. Brasília: Ministério da Saúde; 2004.         [ Links ]

11. Camargo-Borges C, Mishima SM. A responsabilidade relacional como ferramenta útil para a participação comunitária na atenção básica. Saúde Soc. 2009;18(1):29-41.         [ Links ]

12. Leonello VM, Oliveira MAC. Competencies for educational activities in nursing. Rev. Latino-Am. Enfermagem. 2008;16(2):177-83.         [ Links ]

13. Machado MFAS, Vieira NFC. Health education: the family health teams' perspective and clients' participation. Rev. Latino-Am. Enfermagem. 2009;17(2):174-9.         [ Links ]

14. Marin MJS, Oliveira LR de, Ilias M, Higa E de FR. Community contributions to a FHU team work. Rev. Latino-Am. Enfermagem. 2007;15(6):1065-71.         [ Links ]

15. Camargo-Borges C, Cardoso CL. A psicologia e a estratégia saúde da família: Compondo saberes e fazeres. Psicol Soc. 2005;17(2):26-32.         [ Links ]

16. Silva NHLP, Cardoso CL. Programa de Saúde da Família: Sentidos construídos com agentes comunitárias de saúde acerca do HIV/AIDS. In: Pasian SR, Romanelli G, Cunha MV, organizadores. Investigação científica em Psicologia: Aplicações atuais em saúde. São Paulo: Vetor; 2009. p. 43-68.         [ Links ]

17. Vidal CEL, Bandeira M, Gontijo ED. Reforma psiquiátrica e serviços residenciais terapêuticos. J Bras Psiquiatr. 2008;57(1):70-9.         [ Links ]

18. Barroso SM. Caminhada histórica pela saúde mental. In: Barroso SM, organizadora. Vivências em saúde mental: teoria, práticas e relatos. Curitiba: Juruá; 2011. p. 19-30.         [ Links ]

19. Angelini CFR. Os sentidos construídos acerca do cuidado ao portador de transtorno mental grave por uma equipe de saúde da família na cidade de Araraquara-SP. [dissertação]. Ribeirão Preto (SP): Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo; 2007.         [ Links ]

20. Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm. 2008;17(4):758-64.         [ Links ]

21. Cordeiro LRO, Oliveira MS, Souza RC. Produção científica sobre os Centros de Atenção Psicossocial. Rev Esc Enferm USP. 2012;46(1):119-23.         [ Links ]

22. Cirilo LS, Oliveira P Filho. Discursos de usuários de um Centro de Atenção Psicossocial e de seus familiares. Psicol Ciênc Prof. 2008;28(2):316-29.         [ Links ]

23. Mostazo RR, Kirschbaum DIR. Users of a psychosocial care center: a study of their social outcomes about psychiatric treatment. Rev. Latino-Am. Enfermagem. 2003;11(6):786-91.         [ Links ]

24. Leão A, Barros S. Inclusão e exclusão social: as representações sociais dos profissionais de saúde mental. Comum Saúde e Educ. 2011;15(36):137-52.         [ Links ]

25. Bezerra E, Dimenstein M. Os CAPS e o trabalho em rede: Tecendo o apoio matricial na atenção básica. Psicol Ciênc Prof. 2008;28(3):632-45.         [ Links ]

26. Onocko-Campos RT, Furtado JP. Entre a saúde coletiva e a saúde mental: um instrumental metodológico para avaliação da rede de Centros de Atenção Psicossocial (CAPS) do Sistema Único de Saúde. Cad Saúde Pública. 2006;22(5):1053-62.         [ Links ]

27. Lobosque AM. CAPS: laços sociais. Mental. 2004;5(8):53-60.         [ Links ]

28. Reis AOA. Saúde mental, democracia e responsabilidade. Rev Bras Cresc Desenv Humano. 2010;20(1):11-5.         [ Links ]

29. Vieira NG Filho, Nóbrega SM. A atenção psicossocial em saúde mental: contribuição teórica para o trabalho terapêutico em rede social. Estud Psicol. 2004;9(2):373-9.         [ Links ]

30. Schmidt MB, Figueiredo NA. Acesso, acolhimento e acompanhamento: três desafios para o cotidiano da clínica e saúde mental. Rev Latinoam Psicopatol Fundamental. 2009;12(1):130-40.         [ Links ]

31. Dimenstein M, Severo AK, Brito M, Pimenta AL, Medeiros V, Bezerra E. O apoio matricial em unidades de Saúde da Família: experimentando inovações em saúde mental. Saúde Social. 2009;18(1):63-74.         [ Links ]

32. Gomes MS, Mello R. Sobrecarga gerada pelo convívio com o portador de esquizofrenia: a enfermagem construindo o cuidado à família.
SMAD, Rev. Eletrônica Saúde Mental Álcool Drog. (Ed. port.) 2012;8(1):2-8.

33. Rocha THR. Costuras da construção identitária de um jovem psicótico usuário de um CAPS. Rev SPAGESP. 2012;13(1):79-88.         [ Links ]

34. Souza LV, Santos MA. Group process and psychologist work in primary health care. Rev Bras Cresc e Desenv Humano. 2012;22(3):388-395.         [ Links ]

35. Freitas ME. Tecendo a clínica: princípios e diretrizes. In: Lobosque AM, organizador. Caderno Saúde Mental: a Reforma Psiquiátrica que queremos por uma clínica antimanicomial. Belo Horizonte: Escola de Saúde Pública do Estado de Minas Gerais; 2006. p. 97-100.         [ Links ]

36. Conselho Federal de Psicologia (BR). Práticas profissionais dos(as) psicólogos(as) nos Centros de Atenção Psicossocial. Brasília; 2009.         [ Links ]

37. Onocko-Campos RT, Campos GWS, Ferrer AL, Corrêa CRS, Madureira PR, Gama CAP, et al. Nascimento R. Avaliação de estratégias inovadoras na organização da Atenção Primária à Saúde. Rev Saúde Pública. 2012;46(1):43-50.         [ Links ]

 

 

Correspondence
Fabio Scorsolini-Comin
Universidade Federal do Triângulo Mineiro. Instituto de Educação, Letras, Artes, Ciências Humanas e Sociais
Departamento de Psicologia
Av. Getúlio Guaritá, 159
Bairro: Nossa Senhora da Abadia
CEP: 38025-440, Uberaba, MG, Brasil
E-mail: scorsolini_usp@yahoo.com.br

Received: Jan. 7^th 2013
Accepted: Apr. 5^th 2013