An evaluative survey of the implementation of RAPS was carried out in a representative sample of all municipalities in the state of MG. The areas studied allow for a detailed analysis of the structure and specific activities that constitute the complex range of actions necessary for the satisfactory provision of psychosocial community care2. We were able to demonstrate which advances have taken place in psychosocial care in MG, as well as any limitations that may compromise care and the deinstitutionalization process.
An adequate implementation of services (e.g., ESF, NASF, and CAPS) and actions, such as multidisciplinary and joint casework in mental health care; assistance for common mental disorders by primary health care teams (APS); management of psychiatric crises in CAPS; offer of health promotion actions; case discussions by teams; and basing municipal actions in the National Mental Health Policy, stand for the consolidation of working in line with the national guidelines in the state of MG6,8.
However, despite the advances observed in care actions based on an amplified clinic, community mental health care providers should focus not only on the management of mental health symptoms but also on developing users’ capacities, allowing them to be involved in their care actively and validating their aspirations to maximize their quality of life2,23. We detected difficulties in RAPS of MG with regard to the implementation of ‘Psychosocial Rehabilitation Actions,’ ‘Psychosocial Interventions,’ ‘Productive Inclusion,’ and ‘Users´ Protagonism.’
This finding is consistent with those found in other Brazilian regions12, 24–26 and international reports2,27, reflecting the challenges of changing a logic limited to assistance to a users’ emancipatory scenario, which is necessary for community care in mental health2,23,28. In this sense, a paradigm change, making it possible to break with the positivist principles and traditional psychiatry and find new ways of providing psychosocial care, would require changes in the normal way health professionals work. These changes would need to surpass the traditional healthcare limit by mobilizing community resources in the territory to establish relationships between citizens and city life23T,24. Brazil has been placing the user at the center of the health care system, using several initiatives to reinvent citizenship, such as users and familiar associations, social cooperatives and solidarity economy groups, art and culture projects, participation in policy-making forums and Health Councils, and many other ways of promoting human rights and cultural diversity23. Nonetheless, the analysis of the implementation of the evaluation criteria contained in the subcomponents ‘Psychosocial Rehabilitation’ and ‘Social Participation and Control’ exemplify how these practices are still scarce in RAPS IN MG. Strategies to prevent the use of alcohol and other drugs also need to be improved, such as promoting sports and cultural activities by municipalities.
Moreover, recent qualitative research analyzing the points of view of RAPS users28,29 demonstrated that care processes are still marked by discrimination and limited social participation on a national scale. RAPS and other social services are used when pathologies and the need for guardianship arise. These studies also demonstrate challenges in implementing mental health actions in primary health care (APS) and sections of RAPS, in addition to the fragility in articulating and implementing integrated care in all services, keeping demands on mental health centralized in specialized services. We also found that the follow-up of users with severe mental disorders or secondary to the use of alcohol or other drugs by APS is still below the desired level in MG. A higher DI score for municipalities that have CAPS, or those which are able to use the services of a neighboring municipality, may indicate that this service is an articulator in mental health care, as well as a challenge in incorporating psychosocial care by other RAPS services.
Similarly, even though the ‘Definition of one (or more) reference professional(s) responsible for the user throughout their follow-up’ and the ‘Elaboration of the singular therapeutic project’ were evaluated as being partially implemented, the degree of implementation was lower when analyzing the ‘Connection of actions between different RAPS services,’ the ‘Existence of structured flows for the circulation of users through the various health services of the local RAPS,’ the ‘Existence of discussion among professionals for the articulation of a joint case project in the transition between the RAPS services,’ and the ‘Existence of co-responsibility among professionals from different services in the follow-up of the case.’ This demonstrates that coordination of care is one of the great challenges of the institution of health care networks in Brazil and other countries30. In decentralized public health systems, as in the Brazilian case, areas of concern include limited communication and exchange of clinical data among professionals, access barriers in referrals, and differences in treatment among professionals of distinct services31. With regard to RAPS, this process can be even more complex, as the structuring of an integrated network responsible for a range of areas, going from the care of mild mental disorders to crisis management, as well as deinstitutionalization and psychosocial rehabilitation, presupposes the development of refined coordination, regulation, and planning tools32.
To overcome such problems, the collaborative care model, as proposed by the support matrix in Brazil, has been shown in previous studies to enhance not only the integration and coordination of care in healthcare networks but also the training of professionals13. This proposal, consistent with a network structure, aims to provide a new way of organizing healthcare provision, with workflows that involve different teams in the provision of user care, with joint responsibility for cases, integrating different specialties and levels of care30,33,34. The present results show an adequate implementation of the evaluative criterion ‘Collaborative care actions for mental health in municipal RAPS.’ However, when analyzing in detail the actions that would be expected in this proposal (‘Inclusion of case discussions or joint care in collaborative care actions,’ ‘Weekly attendance of the collaborative care professionals in the matrix unit,’ ‘Network meetings”, ‘Existence of discussion among professionals for the articulation of a joint case project in the transition between RAPS services,’ among others), we found a lower implementation level. This may suggest that practical difficulties exist in implementing this care model in RAPS of MG, as is the case in other Brazilian locations34. Our findings showed that discussions between professionals (“Case discussions by the team that accompanies the user”) occur within the scope of mental health specialized teams. Therefore, they do not include other sections of the network that, precisely because they are not specialized, are the ones that are in most need of actions to enhance their capacity to act in mental health through learning spaces and work. A low level of encouragement for professionals to participate in mental health training activities and a lack of priority for hiring professionals with previous experience or training in the area to work in RAPS was also noted in this study. These results suggest that professionals may have few resources to deal with highly complex problems, such as those that usually require care at RAPS33. In addition to these challenges, we found that few municipalities have a unified electronic medical record for health services, which would allow better coordination of information within the network35.
A low participation of psychiatrists in the discussions and decision-making process was also shown. In other national and international situations36, only a minority of specialized physicians also perceive themselves as jointly responsible for patients during their trajectory through different levels of care and/or participate in anything other than individual medical consultation. The international relevance of this issue prompted the editors of the leading medical journal The Lancet, in a recent publication10, to encourage physicians and governments to do more than just prescribe psychotropic drugs to address mental disorders. They argue that an integrative and holistic approach that would more broadly account for the social determinants of mental illness to advance the field of psychiatry is required since, as previously emphasized, classical treatments, including medications and oral therapy, have limitations in the mental health clinic. The very existence of a specific question regarding psychiatrists in the questionnaire used in this study demonstrates a concept of treatment that is still centered around the physician. Previous research has shown that this is still an issue in MG’s RAPS and needs to be quantified37,38. Nevertheless, in order to achieve the necessary engagement of health professionals (physicians and others) in the new mental health processes, it may be necessary to address factors such as the overvaluation of individual consultations to the detriment of spaces for joint discussion to conduct the case; the lack of clarity about strategies for the practice of collaborative care, case coordination and longitudinal follow-up; the lack of knowledge and/or skills and/or specific training for the development of the work to be performed, lack of time due to work overload, and lack of interest and unsafe working conditions, which all lead professionals to see patient consultation as an isolated act29,31,34,36,39.
Regarding crisis management, the DI of the evaluative criterion “Crisis Management Without Referral to the Psychiatric Hospital” was close to 50%, despite the coverage of CAPS in the MG state being higher than the level stipulated by the MS (DI: 144%) and that respondents reported that crisis care is available in those services. It is important to highlight that the low DI of the ‘Deinstitutionalization’ criteria (36%) may refer to the extent of the process conducted, in the early 2000s, by the National Mental Health System on closing psychiatric long-stay hospitals and the limitation of short-term inpatient hospitalization. On this issue, previous research has shown a scarcity of CAPS aimed at specific populations (CAPS AD-alcohol and drugs and CAPSi-children and adolescents) and CAPS that operate for 24 hours a day. These studies also evidenced the insufficient availability of psychosocial beds in general hospitals for comprehensive community crises management in MG19,37,40,41 and other Brazilian states25,26,42. These data may also explain other difficulties found in our study regarding the incorporation by the MG’s RAPS of clinics that work not just in the suppression of symptoms but also encourage a deeper reflection on the subjective social, family, and relational aspects of crisis. Additionally, as highlighted by Martins (2017)43, the lack of personnel training can compromise the management of crises, as these crises include symptoms that may be confused with strangeness and social disturbance. Such misconceptions pervade health professional circles, as does the ideal of normality still present in our society, once again demonstrating the challenges of transforming the social relationship with insanity and human differences.
The confirmation of our hypothesis that a RAPS in more populous, demographically dense cities with higher IMRS have a better implementation score highlights the importance of regional structuring of RAPS and the sharing of services that are impractical for small rural cities, as they make up the vast majority of the municipalities of MG. Despite this, fewer than half of respondents judged that existing regional service sharing is adequate for the comprehensive care of RAPS users. This difficulty in the regionalization of psychosocial care has already been reported in previous studies in MG19,37 and other states in the country25,26,31. It is possibly linked to insufficient resources and the difficulty of collaboration between municipalities, bureaucratic barriers to accessing federal resources for improving health regionalization, partisan political interests, a lack of qualifications and regional vision by the professionals responsible for these areas at the municipal level, in addition to complications of the state and federal government to plan and organize the coordinated management of regional networks. Furthermore, future studies must investigate if municipalities with large demographic densities, characterized by urban agglomerations and conurbations, should have more widely implemented actions but suffer overload due to the large population assisted.
As previously mentioned, there are few evaluative research on RAPS practices throughout the Brazilian territory, and the low implementation of the evaluation criterion ‘Actions for evaluation and monitoring of mental health care at the municipal level’ highlights the need to expand these practices not only in the scientific sphere but also in the daily practices at the different management levels within MG.
The methodology used in this study was chosen to carry out a primary assessment in the MG state. However, we could not understand all the complexity and tensions involved in developing expanded care in mental health. Elements such as the composition of the multidisciplinary technical team in each municipality, working conditions, professional turnover, the physical structure of services, mapping of other services within the network (living centers, therapeutic residences, reception units, among others), and inclusion of users and other network professionals in the evaluation should be considered in subsequent investigations. It is also important to mention that, since most of the respondents chosen in this study are mental health professionals, their answers reflect their point of view and should be complemented later with research analyzing the view of professionals from other RAPS services (e.g., APS professionals, general hospital workers, among others) in relation to the evaluated criteria. However, the value of an evaluative analysis and the use of a validated instrument for the analysis of RAPS in a representative sample of the municipalities of Brazil's second most populous state stands out.