SSM - Mental Health 3 (2023) 100210

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SSM - Mental Health

journal homepage: www.journals.elsevier.com/ssm-mental-health

Mental health care delivery and quality of service provision in Brazil

Lauro Estivalete Marchionatti a, K
atia Bones Rocha b, c, Natalia Becker d, Natan Pereira Gosmann a,
Giovanni A. Salum a, *
a
Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Centro de Pesquisa Clínica, Faculty of Medicine, Department of Psychiatry and Legal
Medicine, Porto Alegre, Brazil
b
Pontifícia Universidade Cat

olica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
c
Universidad Aut
onoma de Madrid (UAM), Madrid, Spain
d
Developmental Disorders Graduate Program, Mackenzie Presbyterian University (UPM), S~ ao Paulo, Brazil

A R T I C L E I N F O A B S T R A C T

Handling Editor: Dr E Mendenhall Public mental health system in Brazil is structured through “The Psychosocial Care Network (Rede de Atenç~ao
Psicossocial, RAPS)". This coordinated system comprises primary care, specialized mental health care, crisis
Keywords: management services, inpatient units, deinstitutionalization initiatives, and psychosocial rehabilitation programs.
Mental health In this narrative review, we aim to provide an overview of mental health care delivery in Brazil by assessing three
Public health
aspects of the RAPS: structure, operationalization, and current state. For reviewing its structure, we start by
Psychiatry
overviewing the public health system, then examining the psychiatric reform, as well as the law and policy that
Psychology
established the components of the community-based mental health system in the country. Regarding the oper-
ationalization, we review recommendations for how the different components of the system should be coordi-
nated, as well as directions for practices at the assistance level. Finally, we review the results of the mental health
system, including official data and academic publications assessing coverage, funding, and quality of care.
Drawing on the results from this review, we highlight fragilities that indicate three future directions for
strengthening the mental health provision in Brazil: establishing appropriate mechanisms for systematic assess-
ment of the mental health system, improving the recommendations regarding the coordination and integration of
services, and promoting evidence-based practices across the different levels of care provision.

1. Introduction Paulo, which is arguably the state with one of the higher numbers of
services in the country (Borges et al., 2019). Despite the increase in
In just 10 years, mental disorders left the 9th position to become the mental health care services in recent years, it is estimated that 77% of the
3rd cause of disability adjusted life years in Brazil (DALYs), just behind Brazilian population still lives in areas with non-existent or insufficient
cardiovascular disorders and neoplasms (Institute for Health Metrics and mental health assistance (Fernandes et al., 2020).
Evaluation (IHME) 2021). Mental disorders account alone for 7.5% of the Moreover, while access to mental health services is essential, it does
DALYs with an annual change of 0.5% increase per year over the twenty not guarantee the quality of care. In S~ao Paulo, only around 40% of the
years. The lifetime prevalence of mental disorders in Brazil suggests that people with mental disorders that are receiving care are estimated to
57.7% of people in the country will experience a mental disorder meet basic standards of quality (Borges et al., 2019). Also, only 26.1% of
throughout their lives, with around 30% of people experiencing a dis- patients reported being helped by the very first professional to assist
order in a period of 12-months, as estimated from a study conducted a them, and only 22.8% of patients would have persisted in seeing these
decade ago in urban areas of S~ao Paulo (Viana and Andrade, 2012; professionals after repeatedly receiving treatments they considered not
Andrade et al., 2012). The burden is especially higher in women and helpful (Kessler et al., 2022).
migrant men living in most deprived areas (Andrade et al., 2012). All this data highlights the enormous gap to be addressed in the
Nevertheless, only 23.9% of people facing mental health conditions ac- mental health crisis in Brazil. In the following sections, we are going to
cess any type of mental health services in the metropolitan area of S~ao review the structure of the Brazilian mental health system, its historical

* Corresponding author. Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Centro de Pesquisa Clínica, Faculty of Medicine, Graduate
Program in Psychiatry and Behavioral Sciences, Ramiro Barcelos, 2350, Centro de Pesquisa Clínica, Porto Alegre, Rio Grande do Sul, Brazil.
E-mail addresses: [email protected], [email protected] (G.A. Salum).

https://doi.org/10.1016/j.ssmmh.2023.100210
Received 5 February 2023; Received in revised form 29 March 2023; Accepted 4 April 2023
Available online 11 April 2023
2666-5603/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
L.E. Marchionatti et al. SSM - Mental Health 3 (2023) 100210

routes, its law and policy, and its composing services. Then, we will services from other centers.
debate the guidelines for operationalizing the structure, including rec- While the law creating the SUS and its principles was established in
ommendations for coordinating services and delivering care. Finally, we 1990, the operationalization of the system and the relationship between
will assess the current state of the Brazilian mental health system, administrators were later addressed through Ministerial Decrees of the
including services coverage and quality of care. Drawing on those sec- Ministry of Health, the Basic Operational Standards of the SUS (Norma
tions, we discuss possible directions to improve the mental health system Operacional B
asica - NOB), the Operational Standards of Health Assis-
nationwide, especially focusing on the importance of the systematic tance (Normas Operacionais da Assist^encia a Saúde, NOAS), the Man-
measurement of standards of care. agement Pacts (Pactos de Gest~ao), and a Constitutional Amendment
(Emenda Constitucional) (Government of Brazil, 1990b, 2000, [a] 2012,
2. Structure 1991, 1993, 1996, [b] 2001, [b] 2002). In sum, this series of regulatory
acts and further legislation determined how these principles should
2.1. The Brazilian Unified Health System operate, defining attributes of each government level, and details of
funding, and popular participation. Popular participation is established
The public mental health care system in Brazil is part of the Brazilian through the Health Council (Conselho de Saúde), a locally-established
Unified Health System (Sistema Único de Saúde - SUS), sharing the same council that must involve members of the community, health pro-
principles and structure. Among the largest public systems in the world, fessionals, and politicians. In terms of regional coordination, the
the SUS aggregates all health services provided by federal, state and Regional Inter-Management Commissions (Comiss~ao Intergestores
municipal governments through direct and indirect administration, as Regional) are responsible for regional planning. Furthermore, the
well as foundations supported by public authorities (Mendes, 2013; Inter-Management Bipartite Commission (Comiss~ao Intergestores Bipar-
Paim, 2020). The private sector is also allowed to be part of SUS under tite), comprising of municipalities and their corresponding federal state,
contract, although public authorities retain the power to govern, control and the Inter-Management Tripartite Commission (Comiss~ao Inter-
and inspect the services being provided. The Ministry of Health is gestores Tripartite), comprising of municipalities, federal state and the
responsible for monitoring and directing all activities related to health, federal union, are responsible for coordinating and articulating the
including mental health. The foundation of the SUS occurred alongside different levels of government. At the federal level, the National Health
the democratization process of Brazil and the establishment of the 1988 Council (Conselho Nacional de Saúde), composed of professionals, poli-
Federal Constitution, which laid the basis for human rights, considering ticians, and community members, establishes the guidelines for elabo-
health as a right of all citizens and a duty of the state (Government of rating the Health Plan (Plano de Saúde), a document that analyzes the
Brazil, 1988). Building on that, the 1990 Law nº 8080 created the SUS, health needs and presents goals and objectives for the health of the
defining its attributes, principles, and guidelines in the form of a set of nation.
foundational doctrinal and organizational elements to be followed, Regarding funding, the legislation establishes a minimum percentage
including the principles of universality, equity, integrality, autonomy, of specific taxes that each level of government must allocate to the health
information sharing, decentralization, regionalization, popular partici- system, as well as criteria for the distribution of funds among different
pation, and the use of epidemiology (Government of Brazil, 1990a). health programs. For example, 15% of all municipal government income
Among doctrinal principles, universality relates to the free access, for and 12% of state income must be directed towards the SUS, based on
every individual, to all public health services (and the private ones specific taxes such as the ones on housing and vehicles. Additionally,
serving the public system). The principle of equity determines that access criteria are established for municipalities and states to receive funding
to health services is provided without discrimination or privileges. For its from the federal government, such as population size and the health
turn, the principle of integrality determines that all individual and col- services provided at the local level. The SUS also maintains a National
lective health needs of people should be addressed, coordinating and List of Health Actions and Services (Relaç~ao Nacional de Aç~
oes e Serviços
integrating assistance across all levels of complexity. Autonomy refers to de Saúde, RENASES) and a National List of Essential Medicines (Relaç~ao
the right of people to make informed decisions about their own health, Nacional de Medicamentos Essenciais, RENAME), which are periodically
including knowing their conditions, treatments, and available options. updated to reflect current needs and best practices and list all services,
Relatably, we have the principle of divulgation of information, in which actions, and medications provided within the system.
the health system should promote and divulgate knowledge regarding According to hierarchization and regionalization, the system is
health and available services. For its turn, the principle of participation organized using a community-based organization, with increasing levels
establishes the involvement of the community in determining actions and of complexity that are coordinated at the primary care level. Regions of
directions for the system, as well as supervising its activities. health are established using mechanisms that involve the discussion of
At the more operational level, the SUS determines the principles of different managers and providers. Each region of health should contain
decentralization, regionalization, and hierarchization of the health primary health care, emergency and urgency, psychosocial assistance,
network. Decentralization is the redistribution of power and re- ambulatory (secondary level) care, hospital beds, and surveillance in
sponsibility among the three levels of government, aiming to ensure health. For accessing the system, there are gatekeepers of universal ac-
control and determination at the local level according to its own neces- cess, which are determined to be primary health care units, emergency
sities. This responsibility must be decentralized down to the municipality and urgency, and psychosocial attention. Indigenous populations have
level, providing municipalities with the necessary managerial, technical, special access, which should be compatible with their own specificities
administrative, and financial conditions to fulfill this role. The principle and needs and consider their necessity for integral assistance of health.
of hierarchization refers to the organization and delivery of healthcare As an example of how a service is determined to be, a minimal primary
services in a hierarchical manner, based on the level of complexity and health care unit should consist of at least one doctor, one nurse, one
urgency of the health condition. This aims to ensure that patients receive nursing assistant, and four to six community health agents (members
the appropriate level of care based on their needs, and that resources are from the local community that help in articulating the health providers
used efficiently, from primary health care to third-level hospital-based with the population). Such a unit should be responsible for providing
care. Finally, regionalization aims to create a network of care that takes assistance to 3000 to 4000 people. Some units, as the amplified units,
into account the specific needs of the local population while also ensuring may have additional staff such as dentists or nutritionists. The Family
access to more complex levels of care when necessary. It is based on the Health Support Center (Núcleo de Apoio a Saúde da Família - NASF) is an
concept of integration of services, rather than fragmentation, by pro- element that provides support to primary health care units. It is staffed by
moting cooperation between municipalities, with small municipalities professionals such as psychologists or physical therapists and helps to
providing basic services to their population yet reaching more complex improve the overall quality of care provided by primary health care units.

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L.E. Marchionatti et al. SSM - Mental Health 3 (2023) 100210

Additionally, special modalities of primary health care, such as the Street 2002a). It established Psychosocial Mental Health Services (Centros de
Mobile Unit, which serves homeless individuals, are also part of the Atenç~ao Psicossocial, CAPS), which serve as the cornerstone of Brazilian
primary care system. community mental care. According to this regulation, the CAPS were
intended to function as daily outpatient services for individuals with
2.2. Mental health services: the transition to a community-oriented model mental health problems, operating within the regions where residents
live, following a territorialization of care. They were responsible for
Alongside the establishment of the SUS and the democratization organizing the demand for mental health care in the region, regulating
process and social justice of the country, Brazil began its psychiatric re- access to the healthcare network, coordinating and training primary care
form, inspired by the Italian reform (Pitta, 2011). Prior to this reform, the teams on mental health demands, and supervising the activities of hos-
Mental Health System was primarily based on psychiatric asylums and pital units that provide mental health services. In terms of care provision,
outpatient care. A social movement led by patient associations and CAPS should offer individual services such as psychotherapy, consulta-
healthcare workers (Movimento dos Trabalhadores de Saúde Mental) tions, medication, social support, home visits, as well as group services
challenged the psychiatric hospital model, highlighting human rights such as workshops led by professionals and community activities, aiming
violations within these institutions, and sparking a movement for psy- to integrate patients into their communities and families. The minimum
chiatric reform and social justice for people with mental health condi- composition of a CAPS included one mental health specialist physician,
tions. This movement started in the end of the 70's and coincided with the one nurse, three professionals in specialties such as psychology, social
establishment of social participation in Constitution and healthcare, work, occupational therapy, and education, and four additional pro-
which paved the way for gradual changes in the mental health policy of fessionals such as nursing assistants and administrative assistants.
the Brazilian state, through a series of laws and policies developed with Another important step for the reform was the 2003 Law 10.708,
the participation of healthcare professionals, users, stakeholders and which established The Back Home (Volta para Casa) program as a means
researchers. The new policy made Brazil widely recognized interna- of contributing to the social integration of individuals who have a long
tionally as one of the first countries not in the group of high-income history of institutionalization in psychiatric hospitals (Government of
countries to establish a national mental health policy and implement it Brazil, 2003). The program provides a monthly rehabilitation allowance
successfully (de Almeida and Horvitz-Lennon, 2010). of R$ 320 to its beneficiaries, many of whom had difficulty finding means
As a significant historical marker of the psychiatric reform process in of subsistence after years of institutionalization. To be eligible for the
Brazil, the “Bauru Manifesto for a Society Without Mental Disorder allowance, an individual must have been discharged from a Psychiatric
Asylums” was released in 1987, following an event organized by mental Hospital or a Psychiatric Custody and Treatment Hospital after 2 years of
health care workers in the city of Bauru and involving the participation of continuous stay. In addition to the financial support, these patients are
health counselors. The manifesto publicly declared that asylum in- also ensured access to a case management program provided by the local
stitutions violated the rights and excluded individuals suffering from community mental health centers (CAPS), including support for resolving
mental illness and served as a public call for reform, in partnership with civil documentation issues.
the community and healthcare workers. In 1990, the Pan-American Finally, a 2011 Regulatory Act (the Portaria n 3.088) established the
Health Organization (PAHO) released a document entitled “The Psychosocial Care Network (Rede de Atenç~ao Psicossocial, or RAPS), as a
Restructuring of Psychiatric Care in Latin America: A New Policy for way of integrating all mental health-related services in the SUS, including
Mental Health Services,” commonly referred to as the Caracas Declara- primary health care (PHC), CAPS, emergencies, ambulatory care, and
tion (Pan American Health Organization, 1990). This document focused hospitals (Government of Brazil, 2011a). This network is designed to
on safeguarding the civil rights of individuals with mental health con- consider the complexity of services and the target users, and it aims to
ditions, decentralizing psychiatric care from psychiatric hospitals to reduce user segregation and improve community integration, while
community services, and replacing psychiatric beds with inpatient ser- respecting the principles of autonomy. The network is planned to
vices in general hospitals, providing a foundation for psychiatric reform consider local territories and regionalization, and it will also monitor and
in Brazil. In tandem with these movements, the Federal Constitution of evaluate the effectiveness of the services. The RAPS is organized in seven
1988 established the constitutional basis for Brazilian democracy and components: basic care, strategic psychosocial care, hospital care,
protection of human rights, whilst the Law 8.080 created the Unified emergency care, temporary residential care, deinstitutionalization stra-
Health System (SUS) and outlined principles of universality, equity, tegies, and psychosocial rehabilitation. These components include ser-
integrality, and popular participation, providing the basis for subsequent vices such as the Unidades de Saúde da Família (USF) [Primary Health
reform laws for a new mental health policy in the country. (Government Care Units], Núcleos de Apoio a Saúde da Família (NASF) [Family Health
of Brazil, 1988, [a] 1990). Support Centers], Centros de Atenç~ao Psicossocial (CAPS) [Psychosocial
The Brazilian Mental Health Law, officially known as the Law of Mental Health Services], Serviços Residenciais Terap^euticos (SRT) [Resi-
Psychiatric Reform (Law n 10.216), was enacted in 2001, providing a dential Therapeutic Services], hospital beds for comprehensive care, and
legal framework for the ongoing transformation of the country's mental others. In 2017, another Regulatory Act (Portaria n 3.588) was issued to
health system and paving the way for funding and creation of new ser- further complement the RAPS by placing emphasis on the care of in-
vices (Government of Brazil, 2001a). This law guaranteed the rights of dividuals with needs resulting from the use of crack, alcohol, and other
individuals diagnosed with mental disorders, emphasizing the impor- drugs (Government of Brazil, 2017). It further defined the constitution
tance of providing care with humanity and respect, and promoting re- and physical structure of CAPS, established new modalities for the ser-
covery through social integration in the family, work, and community. vice, including those specialized in alcohol and drug use disorders, with
Additionally, the law highlighted the importance of ensuring that in- some required to be open 24 h a day and coordinated with mobile
dividuals have access to information about their disorder and treatment, emergency services. Additionally, it expanded the admission criteria for
and emphasized the preference for community-based mental health housing programs and defined the action provision of short-term inpa-
services as a means of improving social reintegration. The law also tient treatment in specialized beds of general hospitals. It also established
recognized the autonomy of individuals with mental disorders, and the Multiprofessional Teams Specialized in Mental Health (Equipe Mul-
reinforced the principle that they are citizens with the right to access tiprofissional de Atenç~ao Especializada em Saúde Mental), which should
public health services. work in secondary-level care and be articulated with primary care teams.
To operationalize this law, a regulation was established in 2002 in the The implementation of the mental health reform and its associated
form of a Regulatory Act (Portaria 336), outlining guidelines for the laws in Brazil led to significant changes in the country's mental health
implementation of the community psychosocial care model in Brazil and services. There was an increase in federal funding for mental health,
directing funding towards its implementation (Government of Brazil, which was directed towards the creation of community-based services

3
L.E. Marchionatti et al. SSM - Mental Health 3 (2023) 100210

and a gradual reduction in the number of psychiatric hospitals (Macedo general hospitals and community-based services such as the CAPS
et al., 2017). By 2006, the amount allocated to community services (Ministry of Health, 2016).
exceeded the expenditure on hospital beds. (Onocko-Campos, 2019).
Changes in the profile of psychiatric hospitals have been observed as a
result of this shift. Asylums were phased out of the public healthcare 2.3. Service structure and key componentes
system and federal funding was redirected towards the development of
psychosocial rehabilitation strategies, such as work, culture, and social In this section, we present an overview of the organization of the
inclusion programs, as well as initiatives to empower users and their mental health system, highlighting the main components as established
families (Sampaio and Bispo Júnior, 2021). Between 2002 and 2014, by the laws and regulations discussed in the preceding sections. These
there was a reduction of 25,405 beds in psychiatric hospitals accredited services are organized into five levels of care, namely primary care,
to operate under the SUS, which were replaced by mental health beds in specialized outpatient care, inpatient units, emergency care, and resi-
dential care. In Table 1, we describe each service offered by the mental

Table 1
Key components of the mental health system.
Level of care Service Details

Primary Health Care Basic Health Unit (UBS) A health clinic for primary health care with minimal composition of one doctor, one nurse,
one nursing assistant, and four to six community health agents. The minimal composition
stands for a unit responsible for providing assistance to 3000 to 4000 people.
Basic health teams for populations with Example: the ‘Street Consultory’ practice, with mobile teams offering care for people
special needs experiencing homelessness.
Family Health Support Centers (NASF) A facility that provides assistance to primary health care units, counting on specialized
professionals, such as psychologists, nutritionists, physical therapists.
Community Centers Public services offering social inclusion and cultural initiatives.

Secondary Level (specialized care for Multi-professional team for specialized Multi-professional teams counting on mental health specialists which should provide care
mental health or psychosocial assistance in mental health (AMENT) for individuals diagnosed with disorders of moderate complexity or living in cities without
assistance) CAPS I. These teams should be directly associated with outpatient services of hospitals or
clinics.
Multi-professional outpatient services for Composed of psychiatrists, psychologists, social workers, speech therapists, nurses and
specialized assistance in mental health other professionals working in mental health assistance at secondary-level, in outpatients
services. These services should provide integrated multi-professional mental health care to
individuals diagnosed with disorders of moderate severity.
Center of Psychosocial Care I (CAPS I) Centers of Psychosocial Care for individuals diagnosed with persistent and severe mental
disorders with no restriction for age or diagnosis. Indicated for cities with at least 15.000
residents.
Center of Psychosocial Care II (CAPS II) Centers of Psychosocial Care for individuals diagnosed with persistent and severe mental
disorders with no restriction for age or diagnosis. Units composed of more professionals
than assistance teams of CAPS I and indicated for cities with at least 70.000 residents.
Center of Psychosocial Care infancy Centers of Psychosocial Care for children and adolescents diagnosed with persistent and
(CAPSi) severe mental disorders with no restriction for diagnosis. Indicated for cities with at least
70.000 residents.
Center of Psychosocial Care Alcohol and Centers of Psychosocial Care for individuals diagnosed substance use disorder in need for
Drugs (CAPS AD) specialized mental health support, with no restriction for age. Indicated for cities with at
least 70.000 residents.
Center of Psychosocial Care III (CAPS III) Centers of Psychosocial Care for individuals diagnosed with persistent and severe mental
disorders with no restriction for age or diagnosis and with up to five beds for overnight
mental health support. Indicated for cities with at least 150.000 residents.
Center of Psychosocial Care Alcohol and Centers of Psychosocial Care for individuals diagnosed substance use disorder in need for
Drugs III (CAPS AD III) specialized mental health support, with no restriction for age, with eight to 12 beds for
overnight mental health support and 24 h operation. Indicated for cities with at least
150.000 residents.

Tertiary level Inpatients Units in Hospitals Services for short term mental health support of individuals during unstable clinical states.
Indicated for individuals presenting high risk of aggression, of self injury or suicide, severe
disability for self care or risk of social exposure. One psychiatric bed is indicated for each
23.000 residents.
Day Hospital Services for diagnostic of therapeutic interventions of intermediate complexity. Short term
stay of up to 12 h.

Emergency and urgency support Mobile Emergency Service (SAMU 192) Services for immediate support of individuals diagnosed with mental disorders during
crises situations.
Emergency Care Units (UPA 24h) Health care units that operate 24 h 7 days a week to provide immediate medical attention
to patients with acute illnesses or injuries that require prompt medical attention, including
mental health conditions.
Emergency departments Emergency support in hospital services or other facilities.

Temporary Residential Attention Therapeutic Residential Services (SRT) Habitations for long term mental health care of individuals diagnosed with severe mental
disorders, with no social support or in social vulnerability and with previous long term
admissions.
Care Units (UA) Habitations for up to six months mental health care of adults diagnosed with severe
substance use disorders, with no social support or in social vulnerability. One Care Unit is
indicated for every 10 psychiatric beds.
Care Units for Children and Adolescents Intended for children and adolescents with 10–18 years old.
(UAI)
Therapeutic Communities Services for continuous, but temporary, residential health care of adults diagnosed with
severe substance use disorders during stable clinical state.

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L.E. Marchionatti et al. SSM - Mental Health 3 (2023) 100210

health system, according to levels of care. specialized units within hospitals as well as specialized emergency units
At the initial level of care, Primary Health Care Units serve as the for mental health care, all of which should be closely coordinated and
primary point of contact and entryway into the healthcare system, integrated with other levels of care within the system.
responsible for addressing a wide range of general health needs, As for the transitory residential care components, the Transitory
including those related to mental health. Primary Health Care teams are Residential Units (Unidades de Acolhimento) are voluntary reception
typically composed of a general practitioner, nurse, nursing assistant, and services and offer continuous care for up to six months for people who
community health agents. The majority of mental health conditions are make harmful use of drugs and who are in severe social vulnerability. The
managed at this stage, including common disorders such as depression Residential Therapeutic Service (Serviço Residencial Terap^eutico, SRT)
and anxiety that are responsive to initial interventions, and referrals to and the Return Home Program (Programa Volta para Casa, PVC) are
higher levels of care are made in cases of increased complexity. In in- aimed at people who have gone through the experience of long-term
stances where patients require care from other levels of care, Primary hospitalization in psychiatric hospitals. The SRT are houses for up to
Health Care teams continue to coordinate and integrate the necessary 10 people, located outside psychiatric hospitals, while the PVC deals with
services. The Family Health Support Centers (Núcleo de Apoio a Saúde da the payment of a financial benefit to materially contribute to the
Família - NASF) are supplementary services that support Primary Health reconstruction of autonomy and reintegration into the community. There
Care teams and may include specialized professionals such as psychia- are also Therapeutic Communities, which are facilities that provide
trists, psychologists, or social workers, with specific composition deter- temporary accommodation and treatment for individuals experiencing
mined based on local needs. They are responsible for matrix-based severe substance use disorders, exclusively on a voluntary basis, although
support, a multidisciplinary approach in which a team of specialists with extensive criticism for promoting isolation (and not integration) and
provide support to primary health care teams in addressing mental health often leading to violation of rights (Ribeiro and Cecília de Souza Minayo,
cases of increased complexity (Chiaverini and Helena, 2011). 2015; M. P. G. dos Santos, 2016).
The second tier of services within the mental health system is
specialized care, which receives referrals from primary health care. These 3. Practices and processes: operationalizing the structure
services include both outpatient secondary-level care at clinics or hos-
pitals, as well as the CAPS. CAPS services are divided into various mo- 3.1. Integrating key components
dalities to best meet the needs of specific populations, such as adults with
mental disorders with functional impairment, children and adolescents, The general principles of the mental health structure are specifically
or individuals with substance use disorders. As defined by the regulatory established, including key elements of composition of services according
documents, CAPS should operate as “open door” services, allowing in- to population size, at which level of care they operate, and professional
dividuals to be received and evaluated by the health team without the composition. However, the regulations regarding the integration and
need for a referral or prior appointment - nevertheless, this recommen- coordination of services are relatively imprecise, merely providing broad
dation is not followed in multiple services The structure and minimum guidance on their implementation.
staffing of CAPS is determined based on the size of the municipality and The 2011 Regulatory Act 7.508 outlines the continuity of care within
the kind of CAPS. Considering both CAPS and outpatient care were the hierarchical network of services (Government of Brazil, 2002c). It
responsible for caring for people considered to have severe mental con- mandates that primary entry points into the hierarchical and regionalized
ditions, the Specialized Mental Health Care (Atenç~ao Especializada em network should consist of primary healthcare facilities, emergency de-
Saúde Mental, AMENTs) were established as clinic-based teams to partments, and RAPS. Additional entry points may be established within
address the needs of individuals with mental health conditions of mod- each region, subject to proper justification. Subsequently, hospital care
erate intensity that exceed the complexity of primary health care (Gov- and specialized outpatient care, along with other services of increased
ernment of Brazil, 2017; Government of the State of Rio Grande do Sul technology, can be accessed through referral from the entry points, based
2020). on a determination of the individual and collective severity of risk and
The third tier of the mental health system is hospital-based care the order of request. Moreover, specific access rules are recommended for
(Government of Brazil, 2012b). This type of care is provided in general the indigenous population, in light of their unique care requirements.
hospitals, preferably through specialized mental health beds, and is The 2017 Regulatory Act 3.588 also mandates that the CAPS should be
intended for short-term hospitalizations. It is primarily aimed at the integrated with other elements of the network, such as primary health-
management of acute situations resulting from psychoactive substances, care and SAMU (Mobile Emergency Service), however it provides no
such as withdrawal and severe intoxication, as well as the management of further guidance on this (Government of Brazil, 2017). Hospital care,
crisis situations in mental health, such as suicide risk, mania, or acute when necessary, should take into account the individual therapeutic plan
psychosis. This type of care should be provided in coordination and for each patient, as a means of having articulated services.
co-responsibility with CAPS services and other points of care within the Regarding the planning of services within regions, the Inter-
RAPS. Additionally, it includes the Day Hospital (Hospital Dia), which is Management Commissions (Comiss~ oes Intergestores) are responsible
an intermediate level of care between inpatient and ambulatory care, for directing and coordinating the flow of actions and services, moni-
where patients can undergo procedures that require a maximum stay of toring access to health services, and providing health services at the
12 h. However, it is important to notice that Day Hospitals available are regional level. Meanwhile, the Ministry of Health is responsible for
scarce in mental health provision. establishing guidelines and procedures to assist states and municipalities
Another level of the mental health system is the emergency care, in fulfilling these responsibilities. The Regionalization Director Plan
addressing crisis situations and serving as a point of entry for mental (Plano Diretor de Regionalizaç~ao, PDR) provides the framework for
health assistance (Government of Brazil, 2002c). This level of care en- regionalization by defining concepts such as Region of Health (Regi~ao de
compasses a variety of services, including the SAMU 192 (Mobile Saúde), a contiguous geographical area composed of adjacent munici-
Emergency Service), which are mobile units responsible for responding palities with shared cultural, economic, and social identities and inter-
to emergency situations outside of healthcare settings and providing connected transportation infrastructure and communication networks,
transportation to care facilities. Additionally, it includes Emergency Care intended to integrate the organization, planning, and execution of health
Units, such as Unidades de Pronto Atendimento (UPA), which are general actions and services (Government of Brazil, 2002b, [b] 2001). The 2011
health care units that provide immediate medical attention to patients Decree 7.508 also established the Health Map (Mapa da Saúde), a
with acute illnesses or injuries that require prompt medical attention, geographical description of the distribution of human resources and
including mental health conditions. These units are typically open 24 h a health actions and services offered by the SUS and private sector, taking
day, 7 days a week. Furthermore, emergency care also includes into account existing capacity, investments, and performance as

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L.E. Marchionatti et al. SSM - Mental Health 3 (2023) 100210

determined by the health system indicators (Government of Brazil, between primary care and the CAPS, as well as a lack of coordination in
2011b). The decree also establishes the Contrato Organizativo da Aç~ao clinical practice (Chiavagatti et al., 2012).
Pública da Saúde (Organizational Contract for Public Health Action), a Considering that practices for articulating services and establishing
collaboration agreement between federal entities aimed at organizing workflows are diverse, we illustrate how those components could be
and integrating health actions and services within the regionalized and coordinated using the model from the municipality of Porto Alegre, a
hierarchical network. It defines that managers should establish health southern capital 2017–2019 (see Fig. 1 for a scheme articulating levels of
goals and indicators, direct financial resources at programs, control and care). In this city, the Federal University of Rio Grande do Sul and the
supervise the execution of the plan, as well as other elements necessary state government developed a project named “Telessaúde” (“Tele-
for the integrated implementation of health actions and services. health”) for enhancing the referral process from primary care to other
The challenges in integrating networks are addressed in a document levels of care, as well as providing a consultation line to connect general
by the Ministry of Health, which tries to clarify a few concepts (Ministry practitioners with specialists (Kolling, 2008; Harzheim et al., 2019;
of Health, 2009b). The document states that the health care network Universidade Federal do Rio Grande do Sul 2018). As an arm of this
consists of a set of health services (such as primary health care units, project, the RegulaSUS initiative (in free translation, Regulating SUS)
hospitals, and CAPS) that are available in a given geographical area. guides the referral process with clear instructions and risk stratification
These services are like the nodes of a network, the construction of which across a state-wide integrated healthcare network (Katz et al., 2020). An
involves more than just offering services in the same geographical area, online program is used to refer cases from primary care, where practi-
but also articulating the relationship between these services. It argues tioners must provide a general description of the case and fill in ques-
that having more services and equipment is crucial, but it is not enough tionnaires that automatically stratify risk. Specialists receive the requests
to build comprehensive care, as it is also necessary to ensure communi- and, following protocols, determine if secondary-level consultation is
cation between services, resulting in more efficient management pro- necessary, or if other strategies are to be placed for managing the case
cesses. To support this process, the document highlights the need for (Universidade Federal do Rio Grande do Sul 2018). The program was
regionalization, popular participation, and integration of health workers later expanded to include inpatient care, offering similar referral pro-
in the building process of the network, starting from primary care. The cesses to distribute specialized beds at hospital tertiary-care. Regarding
Ministry of Health also considers the CAPS as the core element for or- mental health, specific guidelines and protocols were developed to best
ganization of the mental health system, with the goal to create an inte- establish these practices (Government of the State of Rio Grande do Sul
gration of resources from various fields, such as social, health, legal, and and Universidade Federal do Rio Grande do Sul, 2021). Using the
educational, providing comprehensive care and promoting the reinte- instance of depressive disorder, a referral should be made if there is
gration of patients into society (Ministry of Health, 2005). Special persistent suicidal ideation, psychotic symptoms, or insufficient response
attention is devoted to the CAPS location within the population's terri- following two established treatment modalities used for at least 8 weeks
tory, which is considered crucial in producing health at the microlevel each at effective dose. Inpatient care prioritizes cases of mental health
and coordinating available resources. However, specific directions for emergences during pregnancy, psychosis, recent discharge from a mental
accomplishing such coordination are not provided in these documents. health unit, recent suicide attempt, or anorexia with a BMI below 15
A more clearly defined strategy is the one of matrix-based care, as a kg/m2. While results for mental health are not yet available, the Regu-
way of strengthening primary health care and reducing the overload laSUS achieved impressive waiting line reductions to second-level care
upon specialized levels of care. In a document entitled “Practical Guide across many specialists (Katz et al., 2020). For instance, a 75% reduction
for Matrix-Based Care for Mental Health Care”, the Ministry provides of the waiting line was described for neurology, which shortened the
guidelines for specialized teams to support primary health care, including waiting time for specialized consultation in 56 months (Universidade
directions for supervision, brief referral, articulated clinical assessment Federal do Rio Grande do Sul 2018).
and articulated intervention (Chiaverini and Helena, 2011). The guide
also outlines the need for articulation with other levels of the system and 3.2. Provision of care: recommendation for practices
recommend referrals follow a risk stratification process, which takes into
account the biopsychosocial aspects of the user, including their history, In this section, we overview the orientations and guidelines regarding
clinical and psychiatric status, vulnerabilities, and support networks, as practices at the assistance level. Noteworthy, the psychiatric reform in
well as their family and social support. Brazil is vinculated to social justice and aiming at humanizing care.
The guidelines for the mental health network do not provide specific Therefore, a general focus on person needs instead of on the symptom or
instructions for service organization in terms of levels of care, referral disorder is present throughout the development of many guidelines
systems, priority assessments, or waiting lists. This has resulted in a series (Chiaverini and Helena, 2011; Ministry of Health, 2010a). Practices to be
of practical difficulties in implementing the network (Dimenstein et al., developed in the CAPS units are aimed at psychosocial rehabilitation and
2018; A. P. Silva et al., 2021). The arrangements lack standardization and the mental health teams are composed of multidisciplinary professionals
are locally determined, leading to varying criteria for patient flows such that conduct interdisciplinary practices, being also staffed with social
as admission processes and varying levels of coordination across the care assistants pursuing the understanding of social context and its
country (Dias et al., 2020). For instance, a case study on the municipality relation with mental disorders.
of Recife investigated the coordination of care among workers in the The Singular Therapeutic Plan (Plano Terap^eutico Singular) is
CAPS (A. P. Silva et al., 2021). It found that the integration of services considered the central clinical tool for the provision of care throughout
was a significant fragility of the system, being heavily reliant on the the mental health system (Government of Brazil, 2011a). It is a tool
goodwill of healthcare professionals. Similarly, a narrative review on proposed for the management of cases across the different levels and
crisis care for child and adolescent mental health congregated studies facilities of the RAPS, serving as a way of managing cases and organizing
that assessed different local realities across the country, including mu- clinical practices and taking into account the individual needs and pro-
nicipalities from the southern (Porto Alegre), northeast (Mossor
o and moting the patient's involvement with therapeutics. The Singular Ther-
Natal), north (Porto Velho), southeast (S~ao Paulo), and midwest regions apeutic Plan consists of four moments: 1) issues and diagnoses: clinical
(Rio Verde) (Cappi et al., 2021). It concluded that service organization and psychosocial evaluation of the user, seeking to identify risks, vul-
was a challenge, emergency services were often not properly integrated nerabilities, and potentialities; 2) goals: proposals to address the issues
into the network, and the roles of different healthcare professionals and raised in the diagnosis, considering short, medium, and long-term pe-
their collaborations were not adequately established. Additionally, an riods; 3) division of responsibilities: the user and team determine their
evaluation of therapeutic practices in 23 cities across the three federal roles for accomplishing the goals, highlighting their joint responsibility
states in the southern region revealed substantial gaps in the articulation in the therapeutic process; and 4) re-evaluation: an analysis of achieved

6
L.E. Marchionatti et al. SSM - Mental Health 3 (2023) 100210

Fig. 1. Role and rules for transition of care between RAPS components in the municipality of Porto Alegre
Note: The mental health services in Brazil are structured in a progressive scheme that takes into account the complexity of the individual's mental health needs. When
the resources available at a particular level of care are insufficient to meet the demands of the individual, a transition to a higher level of care is recommended.
Conversely, when the individual's needs can be met by services offering less complex assistance and continuity of treatment can be ensured, a transition to a lower level
of care is advised. Assisted housing is a special component of the mental health system that provides residency for individuals with mental health conditions who lack
social support, such as those who have been discharged from long-term psychiatric institutions. This parallel component is designed to facilitate the individual's
recovery and integration into society and has specificities on its articulation to other services.

and pending goals, allowing for reestablishing priorities. In the plan, it is recommended treatments and the tools for assessing and following-up
also determined the approaches that will be employed in the case, results and side-effects (Ministry of Health n.d.). They are freely avail-
including pharmacological, psychosocial, or family interventions. For able online and based on scientific evidence for considering the efficacy,
each person accessing the mental health system, the CAPS also count on safety, effectiveness, and cost-effectiveness of the recommended ap-
an official “manager” of the case, or Reference Profissional, which is a proaches, and should be followed within the public health system.
mental health worker who is responsible for following up and coordi- Regarding mental health, Protocols and Therapeutic Guidelines are
nating care for that patient. available for a few conditions, such as bipolar disorder, schizophrenia,
There are some publications reporting practical guides for mental aggressivity in autism spectrum disorder, intellectual disability, Alz-
health assistance in primary care. The HumanizaSUS (in English, Hu- heimer dementia, tobacco use, and attention-deficit/hyperactivity dis-
manize SUS) is a nationwide project to offer tools and methods for sup- orders. Taking the example of the protocol regarding schizophrenia, it
porting the achievement of SUS principles. Among their publications, encompasses the general description of schizophrenia and the diagnostic
there are practical recommendations for regular team meetings to debate criteria, discusses available treatments and provides orientation on their
mental health in primary care settings, and also guidance for effective use, as well as guidance on follow-up (Government of Brazil, 2013). For a
listening, establishing rapport, and considering the individual as a whole specific instance, it states that clozapine should be employed after pre-
(and not looking exclusively at symptoms or conditions (Cunha and vious use of two antipsychotics, at right dosage and sufficient time, with
Figueroa, 2007; Ministry of Health, 2009a). Similarly, publications insufficient results.
focused on primary care professionals often offer guidance regarding Regarding the tools that are available for clinical practice, a list of
mental health practice (Chiaverini and Helena, 2011). They provide in- available drugs is determined by the National Policy of Pharmacological
formation on a range of common mental health conditions, including Assistance (Política Nacional de Assist^encia Farmac^eutica) through the
orientations on how to diagnose, how to assess risk, and the therapeutic National Set of Essential Medications (Relaç~ao Nacional de Medi-
options that are available. camentos Essenciais) (Government of Brazil, 2012c; Ministry of Health,
For specialized health care components, instructions are somewhat 2022b). This is formulated considering scientific evidence, and the Na-
vague, and clear guidance is available only to specific conditions or sit- tional Commission of Technology Implementation in The Health System
uations. In this sense, we have the Clinical Protocols and Therapeutic (Comiss~ao Nacional de Incorporaç~ao de Tecnologias no SUS, Conitec) is
Guidelines (Protocolos Clínicos e Diretrizes Terap^euticas), which are responsible for reviewing the literature and determining which resources
documents published by the government to establish criteria for the will be made available considering cost-effectivity (Ministry of Health,
diagnosis of health conditions, establishing the protocols for 2010b). The list is divided between a basic section (available at primary

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L.E. Marchionatti et al. SSM - Mental Health 3 (2023) 100210

health care units) and a specialized section (available at special units), medium and small cities, strong participation in primary care in
and the drugs are recommended to be used following a guideline continued care, and decentralization of psychosocial care beds from large
namedRational Use of Medications” (Ministry of Health, 2015a). cities. However, they detected significant gaps in the provision of ser-
Regarding the central system section of the current list, the basic vices of some regions that only count on primary care devices and do not
component contains lithium carbonate, amitriptyline, clonazepam, have a structure consistent with the minimum standard expected in terms
chlorpromazine, nortriptyline, and long-acting haloperidol, to name a of coverage. Similarly, a 2020 publication evaluated the DATASUS
few. As for the specialized section, drugs listed in specific Protocols and database and the official census database, crossing information on
Therapeutic Guidelines are made available, as lamotrigine for bipolar number of services and population size to ascertain the coverage of the
disorder, or olanzapine for schizophrenia (Ministry of Health, 2022b). mental health system in 5.570 municipalities across Brazil (Fernandes
While protocols for treating specific conditions are based on scientific et al., 2020). They developed a summarizing indicator that summed all
evidence, they are not widely available for most situations encountered services across different levels of care to account for an overall rate of
in mental health settings. Additionally, the principles of the SUS call for service per inhabitant. It was estimated that 77% of the Brazilian popu-
the use of epidemiology to guide policy and practice (Government of lation live in areas with low or non-existent community service coverage.
Brazil, 1990a), but the guidelines and regulations establishing the mental Only 7.9% of the cities had full coverage of the RAPS. A nationwide study
health services and actions lack emphasis on evidence-based practices. using data from 2018 employed a similar methodology, establishing the
This is also reflected in the national academic literature on public mental indicators of each mental health service individually per population area,
health, which often does not integrate evidence-based practices when and further assessing the availability of different professional specialists
researching psychosocial care. per inhabiting (R. M. Alves et al., 2021). Services were unevenly
distributed, as they were considered insufficient in many regions whilst
4. The current state of mental health services in Brazil concentrated on others. Professional distribution was also discrepant, as
the North region was understaffed with mental health specialists whilst
Up to 2022, the Brazilian RAPS was composed of 2836 CAPS units the Southern region presented a concentration among these professional
distributed across 1.910 municipalities, as stated in a brief official report categories. It is also worthy mentioning that many publications assess the
presenting the absolute number of services in the RAPS (Ministry of coverage of the system at the local level, as in specific states of cities
Health, 2022a). Before that, a 2015 publication reported more complete (Coelho, 2022; Leal and De Antoni 2013). They provide valuable infor-
information in the periodic bulletin “Mental Health in Data” (Ministry of mation regarding planning for services following the regionalization
Health, 2015b). It presented data on the coverage of units, as the avail- principle, but are yet to form a comprehensive picture informing the
ability of CAPS. A coverage was classified as good when reaching at least coverage at the national level.
0,5 CAPS units per 100 thousand of inhabitants, which was achieved There are also publications assessing the quality of care of the ser-
across all major regions of the country, although disparities in specific vices. The World Health Organization conducted the World Mental
cities or regions could be unaccounted for. It also evaluates the number of Health Survey in some countries in America, assessing the prevalence of
hospital beds in general hospitals devoted to mental health, as well as mental health conditions, the access to services, and their quality in the
other services, and data on specific programs within the system. How- metropolitan area of S~ao Paulo (Borges et al., 2019). Minimally adequate
ever, data on the quality of care, or more specific assessments, are not mental health care was defined on the basis of follow-up visits during the
provided. treatment (four visits for psychotherapy and two for pharmacotherapy).
According to SUS legislation, the Ministry of Health must monitor and This was met only by about 40% of people with mental disorders
evaluate the services and actions provided within the health system, accessing the mental health system. Another study described the prac-
establishing mechanisms for this assessment, standards of care, and in- tices of mental health care among primary care teams across the country,
dicators of health access, also making this data available (Government of drawing on official databases concerning primary care services and ac-
Brazil, 1990a, [b] 2011). In this sense, the DATASUS is a National Data tions (Dimenstein et al., 2018). Throughout the country, it was found that
System of the Unified Health System, collecting and storing health in- only 32,2% of primary care teams counted on professionals trained for
formation on the availability of services and technologies (Ministry of addressing mental health conditions, only 30,1% of teams provided
Health n.d.). However, most of it requires data processing to be trans- mental health care, and specific actions such as addressing the chronic
lated into indicators, and thus is not readily available for final assess- use of benzodiazepines were only performed by 22,1% of teams. Whilst
ment. Concerning the mechanisms to evaluate the mental health system, 88,5% of the teams counted on matrix-based support to address complex
a review found most of them to be insufficient, outdated, or not imple- cases, only 43,8% of teams employed clinical protocols for addressing
mented (Capistrano, 2016). Indeed, some programs were instituted to common mental health conditions.
evaluate key components of the mental health services, but were not A detailed inspection of 40 Psychiatric Hospitals was performed by
continued and do not provide results concerning recent years. Along the Federal Psychology Council, in a workforce that visited these facil-
them, it is worth mentioning the National Program for the Assessment of ities in 2008 (Conselho Federal de Psicologia, 2018). They examined
Hospital Services and Psychiatry (Programa Nacional de Avaliaç~ao dos aspects such as infrastructure, conditions for overnight beds, basic sup-
Serviços Hospitalares e Psiquiatria, PNASH/Psiquiatria) and the National plies such as food and water, respect to privacy and communication, and
Program for the Assessment of Psychosocial Mental Health Services the practices conducted within these services. The final report docu-
(Programa Nacional de Avaliaç~ao de Centros de Atenç~ao Psicossocial, ments, through photographs, a persistent violation of basic rights of
“Avaliar CAPS”), aimed at evaluating the quality and safety of hospital people facing mental health disorders. Many hospitals presented harsh
services and community care facilities provided within the public system conditions for accommodation and hygiene, often lacking basic pro-
({Government of Brazil, 2002; Government of Brazil, 2005). visions as toilet paper.
As official data is insufficient, many academic efforts have addressed Regarding the services evaluation according to users' perspectives, a
the gap of evaluating the current stage of the mental health system. recent systematic review identified six studies reporting users satisfaction
Regarding availability of services and coverage, a 2017 study took in- on mental health facilities (Ricci et al., 2020). They were conducted
formation from four different official databases to assess the presence of within specific localities or services, and do not provide informative re-
health services from different levels of care across the regions of Brazil sults for a national analysis. For instance, in the municipality of Juiz de
(Macedo et al., 2017). It concluded that significant advances were ach- Fora, in the state of Minas Gerais, the population was overall satisfied
ieved in establishing a regionalized mental health system, as they found a with the model and services provided by CAPS Units (Heckert et al.,
larger number and diversity of services implanted in the regions of the 2006). Similar results were reported for CAPS units and other mental
country, a trend towards the interiorization of mental health care to health services in Pelotas, Rio Grande do Sul (M. A. da Silva et al., 2007).

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L.E. Marchionatti et al. SSM - Mental Health 3 (2023) 100210

As for the funding, a study reports an analysis of the federal budget on to perform a continued assessment, as many evaluation strategies
mental health from 2001 to 2014, using data from official databases employed by the government were interrupted over the course of years.
(Garcia and Figueira 2017). They found an increase in the resources for In this way, many academic publications already developed strategies
outpatient care that occurred as a reallocation of previous expenditure and indicators for establishing standards of cover, and could offer an
from hospital services, whilst the total resources for mental health pro- initial point for such assessment (Fernandes et al., 2020; Bianchini,
grams remained around the mark of 2.54% of the health budget, which is 2017).
about half the recommended percentage. Secondly, our review highlighted the lack of appropriate recom-
Noteworthy, there is also a substantial body of literature employing mendations on how to articulate the different levels of care and the
qualitative methodologies to in-depthly assess the implementation and different services composing the network. This resulted in problems at
practices of mental health services at a local level (Barbosa 2019; Sam- establishing the practices, which are diverse across the country (Dias
paio and Bispo Júnior, 2021; Miranda and Oliveira, 2014; Campos et al., et al., 2020; A. P. Silva et al., 2021; Dimenstein et al., 2018; Cappi et al.,
2009; Bruno Silveira et al., 2018). Yet they do not directly establish 2021). At many locations, the process resulted problematic, with
benchmarks to nationwide assessments, they contribute to understand- important difficulties in articulating primary care with specialized care,
ing how key agents understand and assimilate the principles and prac- or at addressing crisis situations in an integrated manner. As a possible
tices on mental health services, as well as unveiling problems in the direction for addressing the problem, we suggest the instance of the
process of the provision, which can inform directions for effective policy southern capital of Porto Alegre. Therein, a project for regulation across
making. They can also point issues at articulating the services across the different levels of care were developed in partnership with the Fed-
professionals and services, and could potentially reveal nuances that eral University, deriving more clear guidance on how services could
should integrate quantitative assessment. Additionally, they provide coordinate care (Government of the State of Rio Grande do Sul and
significant insight into structural and social barriers to accessing mental Universidade Federal do Rio Grande do Sul, 2021; Katz et al., 2020). It
health services in the Brazilian mental health system, revealing stigma, counts on an integrated resource wherein hospital beds and referral
discrimination, economic disparities, and racism to be key factors consultations are distributed according to risk stratification, which is
contributing to the mental health burdens and limit access to care (David regulated by specialists following protocols developed to the optimal
and Camargo, 2018; M. C. Alves et al., 2015; J. C. dos Santos, 2015; Lima, management of mental health conditions according to level of care and
2017). Consequently, addressing social problems and providing care that availability of services. However, whilst such principles could provide
is tailored to the needs of specific populations are essential in promoting guidance for a rational organization of services, general instructions may
universal, equitable care and reducing disparities in the Brazilian mental not suit all local realities, and regional challenges may require specific
health system. solutions.
Important debate on obstacles in access to services and mental health Finally, our review pointed to a substantial gap regarding guidance
burden due to stigma, discrimination, economic disparities, and racism, for specific healthcare practices at the assistance-level. Specific protocols
highlighting the need for addressing social problems and caring for are developed for a few conditions following evidence-based practices,
specific populations in order to promote universal care. but endorsement of them is lacking, and guidelines do not recommend
treatment according to evidence-based recommendations. Furthermore,
5. Future directions the practices established throughout the country and services are also
expected to be vastly different. In this matter, we suggest the dissemi-
The last decades witnessed enormous achievements in the direction nation of evidence-based practice is pivotal to best addressing the con-
of establishing a community-oriented nation-wide integrated and uni- ditions, as endorsed by literature and provided by other health systems
versal mental health system within the country. Nevertheless, our review worldwide (Gaebel et al., 2012, 2020). In this direction, it would be
highlights many challenges that persist in the ongoing process of estab- necessary to overcome gaps in the medical training in the country, as
lishing mental health provision. In this section, we elicit gaps that were most schools do not contemplate evidence-based practices in their cur-
encountered in the review, which reveals three main points for in- riculum (Atallah et al., 2018; Puga, 2007).
terventions to possibly strengthen the mental health system in Brazil:
systematically assessing the system, providing directions on coordinating 6. Limitations
and integrating services, and the use of evidence-based practices. Worthy
noting, they align with objectives set forth by the WHO mental health The present paper offers an overview of the Brazilian mental health
action plan, which proposes more effective governmental administration; care system, delving into its historical development, structure, coordi-
the provision of comprehensive, integrated, community-based mental nation of services, practices at the assistance level, and results. To ach-
health and social care services; and strengthening information systems, ieve this, a comprehensive literature review was conducted comprising
including the use of evidence and research (World Health Organization, various types of publications, including legal and policy documents,
2013). guidelines, and academic works. The selected sources were evaluated in
As a first concern, we showed that the current state of the mental light of their relevance, historical context, and pertinence to the analysis.
health system is vastly unknown, as official data does not provide crucial By synthesizing this body of literature, the study identified the system's
information on it. Academic publications try to fill this gap, revealing weaknesses, pinpointing areas that could benefit from future
potential pitfalls on many aspects of provision. Issues were most improvement.
consistently detailed in coverage and distribution of services, but are also Although narrative reviews are helpful for overviewing a specific
present in funding and quality of care. Reporting the underfunding is field, they are also susceptible to bias, especially when researching a vast
necessary for demanding the increasing of mental health budgets, which and complex topic such as the Brazilian mental health care system.
is a permanent struggle for strengthening health systems. However, for Considering a multitude of historical events and practices that have
the best allocation of resources and reinforcing the efficacy of the system, evolved over the course of decades, the review is not representative of all
there is a clear demand for a more precise and systematic assessment of local contexts and cannot exhaust the literature on the topic. Thus, this is
its current state, including aspects such as coverage, practices, standards a framed analysis on pieces of research that were selected considering
of quality, and results. This is endorsed by other publications on the their relevance and suitability, in a process that is heavily reliant on the
Brazilian mental health provision, being also a general aim for health viewpoint of the authors. Our results represent a particular lens, and
systems worldwide (Jacob et al., 2007; Trap
e and Campos, 2017). In this different conclusions could be reached by alternative perspectives and
sense, the challenge lies not only in establishing adequate benchmarks to sources of data. Furthermore, the various types of publications do not
reflect the effectiveness of the system, but also asserting mechanisms able allow for a common assessment of methodological strengths and

9
L.E. Marchionatti et al. SSM - Mental Health 3 (2023) 100210

weaknesses. However, many guidelines and publications did not count Americas: a regional report from the world mental health surveys. Epidemiol.
Psychiatr. Sci., 29(August), e53.
on a framework of established benchmarks, but rather offered case
Campos, Teresa Onocko, Rosana, Pereira Furtado, Juarez, Passos, Eduardo, Luiza
studies of a local reality based on the appreciation of authors. Ferrer, Ana, Miranda, Lilian, & Alberto Pegolo da Gama, Carlos (2009). Avaliaç~ao Da
Rede de Centros de Atenç~ao Psicossocial: Entre a Saúde Coletiva E a Saúde Mental.
Revista de Saúde Pública (vol. 43,, 16–22.
7. Conclusion
Capistrano, Ad
elia Benetti de Paula (2016). Revis~ao dos mecanismos de monitoramento,


avaliaç~ao e qualificaç~ao da Política Nacional de Saúde Mental, Alcool e outras Drogas
The Brazilian mental health care system is a notable example of a partir dos princípios da Reforma Psiqui
atrica brasileira e da garantia dos direitos
psychiatric reform, which has resulted in the establishment of a humanos. run.unl.pt https://run.unl.pt/handle/10362/17808.
Cappi, Anna Carla Bento Sabeh, & Machado dos Santos, Edirlei (2021). Desafios Na
community-oriented mental health network that provides universal ac- Atenç~ao a Crise Em Saúde Mental No Contexto Da Rede de Atenç~ao Psicossocial:
cess to mental health services. The system has achieved significant Revis~ao Narrativa. In Saúde Mental No S
eculo XXI: Indivíduo E Coletivo Pand^emico (pp.
progress, particularly within the context of a middle-income country with 115–128). Editora Científica Digital.
Chiavagatti, Gopinger, Fabieli, Prado Kantorski, Luciane, Quinzen Willrich, Janaína,
a vast territory that now counts on a coordinated system comprising Moraes Cortes, Jandro, Maria da Rosa Jardim, Vanda, & Garcia Sinott Silveira
primary care, specialized mental health care, crisis management services, Rodrigues, C^andida (2012). Relationship between psychosocial care centers and
inpatient units, deinstitutionalization initiatives, and psychosocial reha- services in primary health care. Acta Paul. Enferm., 25(1), 11–17.
Chiaverini, Dulce Helena, Daniel Almeida, Gonçalves, Dinarte, Ballester, Luís
bilitation programs. Despite these successes, there are substantial gaps in Fernando, T
ofoli, Luiz Fernando, Chazan, Nali, Almeida, Sandra, Fortes, & Others.
the articulation between different providers, as well as in assessing the (201). Guia pr
atico de Matriciamento Em Saúde mental. Minist
erio da Saúde, Centro de
current state of the system in key aspects such as coverage, funding, and Estudo e Pesquisa Coletiva, 1, 15–210.
Coelho, Vívian Andrade Araújo (2022). An
alise da implantaç~ao da rede de atenç~ao
quality of care. Addressing that, we propose a few directions, as a clear
psicossocial (RAPS) no Estado de Minas Gerais. s.n https://www.arca.fiocruz.br/h
guidance for service articulation and the development of systematic andle/icict/56138.
methodologies to evaluate the system. We also argue that it is essential to Conselho Federal de Psicologia. (2018). Relat
orio de Inspeç~ao. https://site.cfp.org.br/wp
-content/uploads/2019/12/549.3_ly_RelatorioInspecaoHospPsiq-ContraCapa-Final_
promote evidence-based practices across different levels of care provi-
v2Web.pdf.
sion. Countries with similar socioeconomic conditions can learn from the Cunha, Gustavo, & Figueroa, Alba L. G. (2007). Clínica Ampliada, Equipe de Refer^encia E
Brazilian experience to understand the challenges and options in estab- projeto Terap^eutico Singular. {Ministry of Health}. https://bvsms.saude.gov.br/bvs/
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