DESAFÍOS Y PERSPECTIVAS EN LA POLÍTICA PÚBLICA DE SALUD MENTAL EN CHILE: COMPRENDER EL PROCESO DE SALUD/ENFERMEDAD/ATENCIÓN-PREVENCIÓN DESDE LA MIRADA DE LAS PERSONAS

En Chile, se ha implementado una política pública de salud mental desde 1990 basada en el modelo comunitario de atención. Aunque el país ha recibido reconocimiento internacional y se considera un ejemplo, particularmente por el papel de la atención primaria de salud, no ha habido una disminución en los problemas de salud mental. Se ha observado un importante malestar social y se critica la respuesta insuficiente y poco adecuada del Estado. Este ensayo destaca la necesidad de comprender el proceso de salud/enfermedad/atención-prevención en salud mental desde la perspectiva de las personas y los actores locales, y su relación con la política pública y el modelo comunitario de atención. Se busca contribuir a un plan a largo plazo apoyando iniciativas que cuestionen la pertinencia de la política pública en relación con las necesidades y posibilidades de los usuarios. Para lograr esto, se propone caracterizar el proceso desde el conocimiento de los padecimientos experimentados y reconocidos por las personas a nivel local, e investigar la relación entre la política pública y el modelo comunitario de atención con las representaciones y prácticas de las personas. Por último, se discuten las dificultades metodológicas para lograr esta comprensión sin establecer categorías hegemónicas, y se exploran los relatos de vida como estrategia metodológica para investigaciones cualitativas en este ámbito

Análisis del funcionamiento y rol de los Grupos de Acogimiento en la atención de la salud mental comunitaria. Lima, Perú, 2019.

Objective: The operationalization and the role of a participatory model of diagnostic and therapeutic formulations called Foster Groups, implemented in a Community Mental Health Center in Lima, Peru, are analyzed. Material and Methods: The research was based on the participanting observation by experts in community mental health, public health, communication and social sciences, of a total of 24 Foster Group sessions held at the Nancy Reyes Community Mental Health Center in Chorrillos, Lima Peru, during the years 2018-2019. Results: The Foster Groups are structured in sequential phases that follow a logical process of diagnostic formulations and management plans, concurrently performed by professionals from different disciplines for a small group of users, thus allowing both, diagnoses as plans, to be more comprehensive. An environment of trust is generated, allowing people to share experiences of suffering and intimacy at levels that often exceed those expressed in the traditional doctor-patient relationship. Interdisciplinary dialogue is permanent and users alternate roles of analysands and analysers, showing signs of progressive empowerment. Conclusions: Foster Groups operationalize the fundamental principles of Community Mental Health, are a valuable tool for the expansion of the Comprehensive Care Model as the axis of public health policy in Peru, soften the communication barriers of the doctor-patient relationship, and reduce the social distances between participants, enabling better care and therapeutic alliances.Objetivo: Analizar el funcionamiento y discutir el rol de un modelo participativo de formulación diagnóstica y terapéutica denominado Grupos de Acogimiento (GDA), implementados en un Centro de Salud Mental Comunitario (CSMC) en Perú. Material y métodos: La investigación se basó en la observación participante de expertos en salud mental comunitaria, salud pública, ciencias de la comunicación y ciencias sociales, en un total de 24 sesiones de GDA realizadas en el CSMC Nancy Reyes de Chorrillos, Lima, Perú, durante los años 2018-2019. Resultados: Los GDA están estructurados en fases que siguen un proceso lógico de formulación de diagnósticos y planes de manejo que, al llevarse a cabo de forma concurrente con la participación de profesionales de diferentes disciplinas y dirigido a un pequeño grupo de usuarios, permite que tanto los diagnósticos como los planes tengan un carácter más integral. Se va generando un ambiente de confianza que permite que las personas compartan experiencias de sufrimiento e intimidad en niveles que con frecuencia superan los expresados en ámbitos de la tradicional relación profesional- usuario. El diálogo interdisciplinario es permanente y los usuarios alternan roles de analizados y analizantes, dando señales de un empoderamiento progresivo. Conclusiones: Los GDA operacionalizan los principios fundamentales de la salud mental comunitaria, son una herramienta valiosa para la expansión del Modelo de Cuidado Integral como eje de la política pública de salud en el Perú, diluyen las barreras comunicacionales propias de la relación profesional-usuario y acortan las distancias sociales de los participantes, posibilitando mejores alianzas terapéuticas y de cuidado

Impacto de la consultoría psiquiátrica en atención primaria de salud: estudio de su asociación con las tasas de egresos de hospitalización por causa psiquiátrica, a nivel de comunas del país

Tesis para optar al grado de Magíster en Salud Públic

Stigma and psychiatric care in Latin America: its inclusion on the universal health coverage agenda

In 2014, the Pan American Health Organization (PAHO) approved Resolution CP53.R14, which aimed to provide a framework for universal access to health and universal health coverage. It sets the stage for the inclusion of psychiatric practice within the provision of universal healthcare and highlights the fight against stigma. We propose to concentrate our efforts on changing the model of medical management. To that end, we are promoting the inclusion of mental health patients within the daily routine of primary care centres, thus allowing them to interact with other users of health services on a regular basis

Twenty years of mental health policies in Chile: lessons and challenges

Over the last 20 years, Chile has increased the mental health share of its public health budget and implemented policies that radically transformed psychiatric services in the country. Both national and international factors have contributed to this process. The implementation of two national mental health plans has led to downsizing mental hospitals and developing community alternatives, such as primary health care, community mental health teams, day hospitals, acute psychiatric beds in general hospitals, and group homes. The annual number of new persons starting treatment for mental disorders in the public sector has increased by 343 percent between 2004 and 2007, with depression being the condition that motivates the highest frequency of visits. The Chilean experience has been successful in terms of increasing availability and accessibility of services and demonstrating that with a modicum of political support, it is possible to implement an effective and efficient community-based network of primary and secondary care facilities. Notwithstanding the progress made in this country, the mental health treatment gap is still significant

Emergency psychiatric consultation and the community mental health care model

Introducción: La evaluación de modelos de atención en salud mental es compleja, existiendo carencias de estudios de impactos de estos servicios; también del Modelo Comunitario de Atención en Salud Mental (MCASM). La Consulta de Urgencia Psiquiátrica (CUP) se utiliza como indicador de resultado: reúne emergencia real y demanda no resuelta. El Complejo Asistencial Barros-Luco (CABL) constituye un modelo naturalístico de comparación: provee CUP a 2 servicios de salud: Sur (SSMS) y Sur-Oriente (SSMSO), el primero con mayor desarrollo del MCASM. Del mismo modo las comunas del SSMS presentan distintos grados de implementación del MCASM. Objetivo: Comparar la variación de tasas de CUP en el CABL, según SS de procedencia y comuna del SSMS. Metodología: Estudio observacional retrospectivo (años 2006-2007). Se compararon comunas del SSMS, categorizándolas por presencia de MCASM y distancia al CABL usando modelos de regresión de poisson. Resultados: Se analizaron 11.760 CUP. Existe caída de tasas de CUP, proporcionalmente mayores en SSMS y en comunas con MCASM. Sin embargo, comunas con MCASM presentan Razón de Tasas de Incidencia (RTI) de CUP mayores al doble. Al ajustar por distancia y años, la RTI disminuye (1,38 [96%IC 1,07-1,77]). Hay diferencias en caída de CUP entre comunas, no explicables por los factores estudiados. Discusión: Mayor desarrollo del MCASM podría asociarse a disminución de CUP. Hay limitaciones: periodo de observación corto, ausencia de ajustes por otros confundentes, categorizaciones poco precisas

Primary care consultation liaison and the rate of psychiatric hospitalizations: a countrywide study in Chile

Objectives. To assess the quality of consultation liaison across all primary health care centers in Chile, and its potential relationship with the psychiatric hospitalization rate. Methods. We carried out a countrywide ecological cross-sectional study on 502 primary health centers in 275 municipalities (87.3% of total primary health centers in Chile) during 2009. We characterized the presence of consultation liaison using four criteria: availability, frequency, continuity of participants, and continuity across care levels. We also created a dichotomous variable called “optimal consultation liaison” for when all four criteria were met. A quasi-Poisson regression model was used to estimate the rate of hospitalization due to different psychiatric disorders, adjusting by population attributes. Results. Of the primary health centers, 28.3% of them had had optimal consultation liaison during the preceding year, concentrated in the poorest and richest municipalities. Continuity of care was the criterion that was met least often (38.3%). The presence of optimal consultation liaison at the municipal level was associated with fewer psychiatric discharges, with the following incidence rate ratios and 95% confidence intervals (CIs): schizophrenia, 0.65 (95% CI: 0.49–0.85); other psychoses, 0.68 (95% CI: 0.52–0.89); and personality disorders, 0.66 (95% CI: 0. 49–0.89). Municipalities with optimal consultation liaison showed 2.44 fewer total psychiatric discharges per 10 000 habitants, although without reaching statistical significance (-0.85 to 5.70). Conclusions. Using a nationally representative sample, we found that consultation liaison in primary care was associated with having fewer psychiatric hospitalizations. More studies are required to understand the role of each component of consultation liaison

Implementing a community model of mental health care in Chile: impact on psychiatric emergency visits

Objective: The community model of mental health care (CMMHC) is recommended as the bestway to organizemental health care, but evidence of its successful implementation and effectiveness is scarce, particularly in resource-poor settings. This study aimed to evaluate the impact of CMMHCon the rate of psychiatric emergency visits in Santiago, Chile. Methods: The rate of psychiatric emergency visits from 2006 to 2011 was compared between two health care administrative districts: district 1 (D1), in which CMMHC was being systematically implemented, and D2, where CMMHC implementation was very limited and inconsistent. In addition, rates of psychiatric emergency visits in ten D1 municipalities were compared by the degree to which they had implemented CMMHC. Results: Compared with D2, D1 had higher rates of psychiatric emergency visits during the observation period. In D1, the rate of visits per 100,000 inhabitants declined from 541 in 2006 to 414 in 2011. In D2, the rate increased from 104 in 2006 to 130 in 2011. In D1 municipalities, the reduction in the rate of psychiatric emergency visits was greater in those with wellimplemented CMMHC compared with those with partially implemented CMMHC. When distance to the emergency room was taken into account, the 2011 rate of emergency visits in the ten D1 municipalities was 21% (p<.01) lower in those with well-implemented CMMHC than in those with partially implemented CMMHC. Conclusions: CMMHC implementation leads to reduction in psychiatric emergency visits, which are burdensome to both users and providers. Results support CMMHC implementation in resource-poor settings