Mental Health Care Reforms in Latin America: An Overview of Mental Health Care Reforms in Latin America and the Caribbean

This new column in Psychiatric Services will address topics related to mental health services in Latin America and the Caribbean. This is a region with diverse geographic, sociocultural, and economic characteristics. It includes South American, Central American, and Caribbean countries, as well as Mexico. Most are low- or middle-income countries, and poverty afflicts large swaths of the population even in middle-income countries. In addition, many of these countries have recently experienced violent social conflicts and severe natural disasters.

Significance of mental disorders in the region

Mental disorders are highly prevalent in Latin America and the Caribbean. A review of the major epidemiological studies on mental disorders conducted in the region in the past 20 years found annual prevalence rates in the adult population of 5.8% for anxiety disorders, 5.7% for alcohol abuse and dependence, 4.9% for major depression, 1.7% for dysthymia, 1.0% for nonaffective psychotic disorders, and .8% for bipolar disorders ( 1 ). In addition, a high annual prevalence of any mental disorder was found in national surveys recently conducted in the region in the context of the World Mental Health Survey Initiative; for example, the rate in Mexico was 12.2%, and in Colombia it was 17.8% ( 2 ).

Mental health problems are also widespread in the younger age groups. A recent study in Brazil to assess the prevalence of psychiatric disorders among children and adolescents aged seven to 14 in a medium-sized city and its surrounding rural areas in the state of São Paulo found an overall prevalence rate of 12.7% ( 3 ). A survey of adolescents aged 12 to 17 residing in Mexico City indicated prevalence rates of serious, moderate, and mild mental disorders to be 9%, 20%, and 10%, respectively ( 4 ).

The prevalence of mental disorders in Latin America and the Caribbean exacts a high toll on affected individuals, their families, and the larger society. In 1990, 8.8% of the overall burden of diseases in the region resulted from psychiatric and neurological disorders. By 2002, this burden had grown more than two-fold to 22% ( 1 ).

Mental health policy and legislation

By 2005, 77% of the countries reporting in the region had a national mental health plan, and 75% had enacted mental health legislation ( 5 ). Most of this progress took place in direct response to the Caracas Declaration, which was issued at the Regional Conference for the Restructuring of Psychiatric Care in Latin America, held in Caracas, Venezuela, in November 1990 ( 6 ). The Caracas Declaration, a landmark in the mental health reform process in the region, called for integration of mental health into primary care, shifting from hospital-based care to community-based care, and protection of the human rights of people with mental disabilities ( 6 ).

The Caracas Declaration was the culmination of a process set in motion by several developments. One of them was the recognition that traditional psychiatric hospitals failed to meet the complex needs of people with mental disorders and engaged in frequent violations of patients' human rights. In addition, epidemiological studies dispelled the notion that mental disorders are a direct consequence of socioeconomic development and are thus unique to developed countries. These studies also revealed that the spectrum of mental health problems leading to impairment is broader than previously assumed and includes problems associated with disasters, violence, and other social ills of high prevalence in the region. Finally, in the late 1980s the end of political regimes that paid little attention to mental health and systematically violated human rights led to a wave of democratic governments whose firm commitment to respecting human rights focused attention on the plight of psychiatric patients ( 7 ).

The Initiative for the Restructuring of Psychiatric Services ( 6 ), launched shortly after the Caracas Declaration by the Pan American Health Organization (PAHO) and the World Health Organization (WHO) in collaboration with a large number of countries, international organizations, and experts, actively promoted and supported mental health reform efforts in Latin America and the Caribbean, contributing to the development of national mental health policies in several countries. In addition, starting in the 1990s many countries in the region formulated or revised mental health legislation with the goal of enhancing human rights protections for people with mental health problems. With adoption by several countries of the Recommendations to Promote the Protection of the Rights of the Mentally Ill issued by the Inter-American Commission on Human Rights of the Organization of American States ( 8 ), the region recently embraced a new era characterized by the integration of international recommendations into national legislation and the creation of mechanisms for monitoring human rights in mental health services.

Beginning in 2001, propelled by mental health initiatives launched by WHO that were related to World Health Day and World Health Report 2001, several countries in the region started formulating and implementing mental health policies and plans. For instance, several of the English Caribbean countries initiated a joint effort to attain this objective with technical support from PAHO and WHO ( 9 ). Similarly, several Central American countries embarked on revisions of their mental health plans: Panama (2003), Costa Rica and Nicaragua (2004), El Salvador (2005), Dominican Republic (2006), and Honduras (2007) ( 10 ).

Impact of reform initiatives

Because of the above policy and legislative efforts, successful and innovative reform processes have taken place in most Latin American and Caribbean countries. At the national or provincial level, countries in the region have developed community-based services and have downsized and improved psychiatric hospital services. Integration of mental health into primary care with a strong focus on health promotion and prevention has been a major component of mental health reform processes in many countries of the region ( 11 ), including Brazil, Cuba, Chile, El Salvador, Nicaragua, Guatemala, and Panama, among others.

The Cuban reform process was the first to integrate mental health care into primary care as the foundation of the new mental health system and to implement this strategy at the national level. The existence of a primary care network covering the entire population greatly facilitated integration. However, a more critical factor in successful integration was the existence of a detailed mental health plan that made it possible to develop new mental health facilities in the community, create specific mental health programs, and train mental health professionals ( 12 ).

Chile's national mental health reform, which also sought to expand access to mental health care through the development of mental health expertise at the primary care level, led to profound changes in the mental health system ( 13 , 14 ). Between 1999 and 2006, the fraction of the health budget allocated to mental health increased almost twofold, from 1.2% to 2.1%. In the same period, the percentage of the mental health budget allocated to psychiatric hospitals decreased from 57% to 33% ( 15 ). Implementation of a comprehensive mental health plan led to significant advances. Not only was access to mental health care substantially improved through the creation of a national network of community mental health centers staffed with teams of mental health professionals, but access to essential psychotropic drugs was also guaranteed for the entire population. By 2004, Chile's public mental health network included an impressive array of services: 472 primary care centers with mental health professionals, 38 community mental health centers, 58 outpatient clinics, 40 day hospitals, 18 psychiatric units in general hospitals, 25 day centers in the community, and 96 group homes for people with severe mental illness ( 15 ). Innovative large-scale initiatives, such as the national program on depression, have led to substantial progress in the identification and treatment of people with mental illness who would otherwise not seek care ( 9 , 16 ).

Brazil's mental health reform—developed with strong support from the government and the civil society—included passage of mental health legislation at the national and state levels, development of community-based services throughout the country, decentralization of the mental health system, and development of national programs in some strategic areas. In little more than a decade, Brazil developed hundreds of new community-based services and redesigned traditional services in accordance with reform-inspired guidelines, with the number of psychiatric hospital beds dropping by one-fourth in the early part of the 2000s. Compared with 1995, the share of the 2005 mental health budget allocated to psychiatric hospitals was slashed from 95.5% to 49.3% while the share of the budget allocated to community services increased more than 15-fold, from .8% to 15% ( 17 ). One of the main policy goals of Brazil's mental health plan involves strengthening community-based services by creating Centers for Psychosocial Care (CAPS), which are mental health centers equipped with outpatient and partial hospitalization services ( 18 ). In 2006, 673 CAPS for adults, 66 special CAPS for children and adolescents, and 476 group homes for people with severe mental illness had been created throughout the country ( 17 ).

Jamaica was the first English Caribbean country to develop a national plan aimed at reforming the mental health care system. In the 1980s, a national network of mental health professionals started providing mental health care in their communities, just as the treatment of acutely ill psychiatric patients was beginning to occur in the medical units of general hospitals ( 19 ). Mental health plans implemented by Barbados and Saint Lucia after 2002 have already improved conditions at the main psychiatric hospitals in these countries and have spurred development of alternative community-based services. Belize has made important progress toward creating alternatives to the psychiatric hospital and strengthening the network of community-based services ( 20 ). Guyana, for its part, developed a plan to train health professionals and improve psychiatric services.

In Argentina and other countries in the region, mental health care delivery was reformed not at the national level but at the state or provincial level. The emblematic reform undertaken by the Rio Negro province in Argentina replaced the psychiatric hospital with psychiatric beds in general hospitals and a network of community-based services, including mental health centers and psychosocial rehabilitation programs distributed throughout the territory ( 21 ). New community-based services were also implemented in the province of Buenos Aires, Argentina ( 9 ).

Other countries in the region are also taking steps to improve mental health care. El Salvador, Guatemala, and Nicaragua implemented several innovative projects designed to bring mental health services to the community ( 22 ). In Paraguay, a fledgling reform process predicated on respect for human rights is just beginning to take hold. Likewise, Peru's main impetus to develop a national mental health plan came from the disturbing findings of an investigation of human rights violations among people with mental disorders ( 23 ).

Conclusions and challenges for the future

The reform processes undertaken in Latin America and the Caribbean since the signing of the Caracas Declaration in 1990 have led to important progress ( 24 ). Valuable lessons may be learned from the collective experience of a region that has faced multiple obstacles in its quest for reform. Much remains to be done to effectively meet the mental health needs of children, adolescents, adults, and the growing number of older adults in the region. The resources available are as insufficient as they are inequitably distributed. In at least five countries in the region, 1% or less of the health budget is allocated to mental health, and in only one in four countries is the share larger than 5% ( 25 ). Even countries with more fully developed mental health reform processes continue to devote extremely small proportions of their health budgets to mental health; Brazil's is 2.35% and Chile's is 2.14% ( 15 , 17 ).

Although limitations in mental health information systems prevent the systematic monitoring or evaluation of the reform process, available information indicates generally low levels of implementation of mental health plans. Furthermore, in many countries mental health legislation does not meet international standards and is grossly inadequate. In most countries the majority of mental health care resources continue to be allocated to psychiatric hospitals, and community-based services are insufficiently developed. In Central American countries, for instance, .54 beds per 10,000 people are in psychiatric hospitals, whereas only .12 are in general hospitals and .77 are in residential facilities ( 10 ). Further, although more than 90% of the countries have declared that they provide mental health at the primary care level ( 5 ), in most countries the integration of mental health in primary care is utterly insufficient. For instance, in Central American countries a very small percentage of primary care doctors and nurses have been properly trained in mental health, primary care doctors do not usually interact with mental health professionals, and psychotropic drugs are not regularly available at primary care centers ( 10 ).

That reform has yet to bear its fruits is demonstrated by studies that indicate that a severe treatment gap still exists in Latin America and the Caribbean. Based on epidemiological evidence, 59% of people with depression, 64% of people with bipolar disorder, 63% of people with anxiety disorders, and 37% of people with nonaffective psychoses do not have access to any kind of mental health treatment, either in primary or specialty care settings ( 1 ). In Mexico, fewer than one in five respondents with a psychiatric disorder had used health services during the previous year ( 26 ).

Therefore, implementation of the ethical, legal, political, and technical principles included in the Caracas Declaration continues to be a priority in Latin America and the Caribbean. Further, as stated at the Regional Conference on Mental Health Services Reform held in Brasilia in 2005, countries in the region face mounting challenges that need to be addressed with appropriate policy and clinical responses. Some of these challenges are the greater psychosocial vulnerability of indigenous communities and other disenfranchised populations, the increasing frequency of psychiatric morbidity and psychosocial problems among children and adolescents, the greater awareness of the burden associated with suicidal behavior and alcohol abuse and the greater demand for appropriate services, and ever-increasing levels of violence in the society ( 24 ).

Addressing challenges old and new will require effective policy responses. In this new century, the region needs to embrace an ambitious reform agenda focused on expanding access to the continuum of mental health services, including promotion, prevention, and rehabilitation, with a special emphasis on the most vulnerable populations. Another important target of reform efforts is improvement of the quality of mental health care. Finally, demographic trends suggest that the region needs to start planning for the complex mental health needs associated with an aging population.

Acknowledgments and disclosures

This work was supported by grant P50-MH073469 from the National Institute of Mental Health. The authors are grateful to Alberto Minoletti, M.D., for helpful comments on an earlier version of this column.

The authors report no competing interests.