Psychiatry career in Brazil: Regional disparities,differences and similarities in an international context

Abstract

This review explores the literature related to career choice of psychiatry in Brazil through selection of scientific articles published in the period from 1999 to 2013 in the MEDLINE and SciELO databases. There are currently 145 medical schools in Brazil, the highest concentration being in the more developed areas. In 2005, there were 6,003 psychiatrists working in Brazil, a rate of 3.3 psychiatrists per 100,000 inhabitants, with unequal distribution across the geographical regions of the country: a rate of 4.5 psychiatrists/100,000 inhabitants in the southern region, and less than one psychiatrist per 100,000 inhabitants in the northern region. The south and south-east regions comprise 56% of the national population and 76% of the residency posts in psychiatry. In 2013, 27% of the residency posts in psychiatry were not filled, particularly in the north and north-east areas, where the shortage of professionals is more pronounced. The number of specialized doctors is far below what is needed to cover the burden attributed to neuropsychiatric disorders in the country. The main hypotheses to explain this imbalance in Brazil are the relatively low exposure to the speciality during undergraduate coursework, the stigma attached to mental disorders, and the poor organization of mental healthcare services.     

Psychiatry and the military: an update.

The United States has historically been concerned about the successful adjustment of its military members returning from war. These concerns are based on the recognition that war-zone exposures may have considerable negative emotional or behavior consequences. As the global war on terror continues, the United States military medical system will be required to address issues at the interface of psychiatry and the law. Despite clinical advances within the theater of war and at tertiary facilities in the United States, some military members will develop chronic and disabling mental illness as a result of traumatic exposure and exacerbated by the demands of the austere and dangerous operational environment. The extent to which violent and aggressive behavior in the aftermath of deployment can be attributed to combat experience remains an area of debate and ongoing investigation. However, experience suggests that a very small subgroup of the hundreds of thousands of war veterans deployed in conjunction with the current conflict in Iraq has already been involved in violent crimes. For this group, military forensic psychiatrists will be called on to make determinations of competency and criminal responsibility and to inform the courts about the potential contributions of war-related distress or disorder to criminal behavior.Though the overwhelming majority of war veterans will not be involved in criminal proceedings, a minority will develop career-ending (and in rare instances, life-ending) disabilities as a result of mental illness. For those who are no longer fit for duty, the military Physical Disability Evaluation System must make determinations of the extent to which future military performance and future civilian social and occupational function have been compromised. For a small yet highly visible minority of returning veterans, questions about the cause, precipitants, and manner of death will necessitate psychological autopsies.This article highlighted recent updates in military forensic psychiatry and the mechanisms through which answers to questions of disability and criminal culpability, and motivation underpinning self-injurious behavior, are determined within the United States military. As the global war on terror progresses, further experience and study of our country's judicial processes, disability system, and the policies and procedures governing psychological autopsies must evolve to meet these increasing demands.     

Viewpoint: Methodological Issues in Psychiatry: Psychiatry as an Empirical Science

The paper reflects the empirical position of psychiatry as a research discipline. Principles of empirical research are discussed, such as the generation of empirical hypotheses, the falsification of hypotheses, the logical structure of theories, etc. It is discussed to what extent these principles can be transferred to psychiatric research.

Articles published in the Viewpoint section of this Journal may not meet the strict editorial and scientific standards that are applied to major articles in The World Journal of Biological Psychiatry. In addition, the Viewpoints expressed in these articles do not necessarily represent those of the Editors or the Editorial Board.     

Psychiatry in Africa: an overview

The authors review the practice of psychiatry in Africa today. They describe the similarities as well as the differences between psychiatry in Africa and in the Western world in the rates, presentations, and treatment of neurosis, depression, schizophrenia, and suicide and drug- and alcohol-related problems. Child psychiatric services and research in biological psychiatry are rare in Africa, and sociocultural problems confront epidemiologic studies and the use of psychotherapy. The authors conclude that to achieve the goal of mental health care for all Africans, psychiatry should be included in the primary health care program, regional postgraduate medical centers are needed, and a means of gathering statistics and funding research should be fostered.     

Course of hypochondriasis in an international primary care study

Hypochondriasis is frequently defined as a chronic condition distinct from anxiety and depressive disorders. Consecutive primary care attenders (n=25,916) were screened using the General Health Questionnaire and a stratified random sample (n=5447) completed a baseline diagnostic assessment. All patients with significant psychiatric symptoms and a random sample of remaining patients (n=3201) were asked to complete a follow-up diagnostic assessment 12 months later. Of patients meeting an abridged definition of hypochondriasis at baseline, 18% continued to do so at follow-up and an additional 16% continued to report hypochondriacal worries. 45% of those with hypochondriasis at follow-up also met criteria for DSM-IV anxiety or depressive disorder. Follow-up anxiety or depressive disorder was significantly associated with both onset and persistence of hypochondriasis. Hypochondriasis is moderately stable over time. The clear distinction between hypochondriasis and anxiety/depressive disorders suggested by ICD-10 and DSM-IV may be difficult to accomplish in practice.     

Psychiatry and internal medicine resident education in an acute care medical-psychiatry unit

A Medical-Psychiatry Program has been developed at the University of Iowa. It includes a medical-psychiatry unit, a medical-psychiatry lecture series, a medical-psychiatry residency program, and a medical-psychiatry fellowship. The program enables residents pursuing straight psychiatry or internal medicine training to participate in a rotational experience requiring that they evaluate and treat patients for illnesses in both specialties under the supervision of both a staff psychiatrist and internist. During the rotation the resident learns how psychiatric and medical disease in the same patient complicates patient care and the skills needed to diagnose and treat such patients in the climate of their own specialty. The rotation is considered a valuable training experience by the majority of residents going through the rotation.     

Psychiatry and primary care medicine in Canada

Summary Primary care medicine has developed rapidly in Canada as elsewhere during the last 25 years. It is a natural sequela to the trend to specialization following World War II and primary practice itself has now reached the status of a specialty. The result has been a longer and more thorough educational process and this process has invited psychiatry to introduce the bio-psychosocial model to medical practice. Although Canadian psychiatry has not itself developed a primary practice frame of health care delivery, it has contributed to primary care residency education. The Canadian national health insurance scheme has facilitated the development of the non-psychiatric physician's interest in the psychological and social issues of health and illness by offering medical coverage in most provinces for psychotherapy. In addition, the generally unlimited payment for all forms of psychiatric care allow ready consultation by physicians to psychiatrists.     

Consultation-liaison psychiatry: an international perspective.

Consultation-liaison (C-L) psychiatry is the specialty of physical/psychiatric comorbidity and somatization. As such, it addresses the commonest forms of psychiatric presentation in the community; it is mainstream psychiatry. Its name reflects the fact that most of the patients seen by C-L psychiatrists have to be managed jointly with a non-psychiatrist doctor and other professionals. Because of this, the degree of development of the specialty and its mode of operation differ from country to country, depending on the organization of health services and the varying attitudes towards the disorders in which C-L psychiatry specializes. These differences permit a refreshing opportunity to re-examine the ways in which patients with physical/psychiatric comorbidity and somatization can be helped. The International Organization for Consultation-Liaison Psychiatry was formed to facilitate this process. It has identified challenges that are universal, and which if not met rapidly and efficiently will damage our ability to provide appropriate care for the patients whom we serve.     

Psychiatry and primary care integration: challenges and opportunities

Health systems across the world remain significantly fragmented, affecting access, quality and costs of the care delivered. Strengthening health systems is a global health challenge for all countries: low, middle and high income. According to the World Health Organization the key components of a well functioning health system, namely, leadership and governance, health information systems, health financing, human resources for health, essential medical products and technologies, and services delivery are sine qua non for health systems functioning and strengthening (WHO, 2010). Psychiatry and primary care integration are contributions the house of medicine can make to address fragmentation, access, quality and costs.     

Psychiatry and primary care integration: Challenges and opportunities

Health systems across the world remain significantly fragmented, affecting access, quality and costs of the care delivered. Strengthening health systems is a global health challenge for all countries: low, middle and high income. According to the World Health Organization the key components of a well functioning health system, namely, leadership and governance, health information systems, health financing, human resources for health, essential medical products and technologies, and services delivery are sine qua non for health systems functioning and strengthening (WHO, 2010). Psychiatry and primary care integration are contributions the house of medicine can make to address fragmentation, access, quality and costs.     

Collaboration can be elusive: Virginia's experience in developing an interagency system of care

States are attempting to improve services for children with mental health needs and their families by using interagency service approaches. This article chronicles two approaches used by Virginia to implement an interagency planned, funded, and managed statewide system of community care. The conceptual base of each approach is examined and service data is used to illustrate their benefits and weaknesses.     

Delivering patient-centered care in Parkinson's disease: Challenges and consensus from an international panel

An international panel of movement disorders specialists explored the views and perceptions of people with Parkinson's disease (PD) about their condition and its treatment, including the potential mismatch between the clinician's view of the patient's condition and their own view of what aspects of the disease most affect their daily lives. The initiative was focused on Asian countries, so participants comprised experts in the management of PD from key centers in Asia, with additional insight provided by European and the North American movement disorders experts. Analysis of peer-reviewed publications on patient perceptions of PD and the factors that they consider important to their wellbeing identified several contributing factors to the mismatch of views, including gaps in knowledge of PD and its treatment, an understanding of the clinical heterogeneity of PD, and the importance of a multidisciplinary approach to patient care. The faculty proposed options to bridge these gaps to ensure that PD patients receive the personalized treatment they need to achieve the best possible outcomes. It was considered essential to improve patient knowledge about PD and its treatment, as well as increasing the awareness of clinicians of PD heterogeneity in presentation and treatment response. A multidisciplinary and shared-care approach to PD was needed alongside the use of patient-centered outcome measures in clinical trials and clinical practice to better capture the patient experience and improve the delivery of individualized therapy.