The mental health system in Brazil: Policies and future challenges

Background

The aim of this paper is to assess the mental health system in Brazil in relation to the human resources and the services available to the population.

Methods

The World Health Organization Assessment Instrument for Mental Health Systems (WHO AIMS) was recently applied in Brazil. This paper will analyse data on the following sections of the WHO-AIMS: a) mental health services; and b) human resources. In addition, two more national datasets will be used to complete the information provided by the WHO questionnaire: a) the Executive Bureau of the Department of Health (Datasus); and b) the National Register of Health Institutions (CNS).

Results

There are 6003 psychiatrists, 18,763 psychologists, 1985 social workers, 3119 nurses and 3589 occupational therapists working for the Unified Health System (SUS). At primary care level, there are 104,789 doctors, 184, 437 nurses and nurse technicians and 210,887 health agents. The number of psychiatrists is roughly 5 per 100,000 inhabitants in the Southeast region, and the Northeast region has less than 1 psychiatrist per 100,000 inhabitants. The number of psychiatric nurses is insufficient in all geographical areas, and psychologists outnumber other mental health professionals in all regions of the country. The rate of beds in psychiatric hospitals in the country is 27.17 beds per 100,000 inhabitants. The rate of patients in psychiatric hospitals is 119 per 100,000 inhabitants. The average length of stay in mental hospitals is 65.29 days. In June 2006, there were 848 Community Psychosocial Centers (CAPS) registered in Brazil, a ratio of 0.9 CAPS per 200,000 inhabitants, unequally distributed in the different geographical areas: the Northeast and the North regions having lower figures than the South and Southeast regions.

Conclusion

The country has opted for innovative services and programs, such as the expansion of Psychosocial Community Centers and the Return Home program to deinstitutionalize long-stay patients. However, services are unequally distributed across the regions of the country, and the growth of the elderly population, combined with an existing treatment gap is increasing the burden on mental health care. This gap may get even wider if funding does not increase and mental health services are not expanded in the country. There is not yet a good degree of integration between primary care and the mental health teams working at CAPS level, and it is necessary to train professionals to act as mental health planners and as managers. Research on service organization, policy and mental health systems evaluation are strongly recommended in the country. There are no firm data to show the impact of such policies in terms of community service cost-effectiveness and no tangible indicators to assess the results of these policies.     

Pituitary-thyroid axis, prolactin and growth hormone in patients with acute stroke

The pituitary-thyroid axis, serum prolactin and growth hormone levels were studied in 29 patients within 9 d of onset of acute ischaemic stroke. When compared to a control group of 80-year-old volunteers (n = 33), stroke patients were found to have elevated free thyroxine indices (P = 0.008), after adjustment for age and sex. Seventeen (81%) of the stroke patients showed a paradoxical rise in growth hormone in response to thyrotropin releasing hormone (TRH). In a multiple regression model, disorientation was associated with a low thyrotropin response to TRH (P = 0.02 and P = 0.04; 20 and 60 min after TRH, respectively). Disorientation was also positively correlated with the prolactin response to TRH (P = 0.045 after 60 min). Growth hormone levels were predicted by extensive motor impairment (P = 0.02). In conclusion, changes in pituitary and thyroid hormones were commonly observed after stroke and were closely associated with cognitive and/or motor impairment.     

Complementary use of ultrasound and computed tomography in studies of the pancreas and kidney

113 cases of pancreatic and renal disease studied by both ultrasound and computed tomography (CT) were analyzed retrospectively. CT provided a diagnosis when pancreatic ultrasound was unsuccessful due to overlying bowel gas or obesity and when renal ultrasound was unsuccessful due to obesity, reverberations from ribs, small lesions, or multiple lesions. Conversely, ultrasound provided a diagnosis when CT was unsuccessful due to lack of fat planes or respiratory motion. CT usualy distinguished carcinoma from pancreatitis when ultrasound showed a focal echogenic mass. CT resolved renal cyst from neoplasm when ultrasound showed a mixed echo pattern mass.     

Serum Thyroid-stimulating Hormone in Cerebrovascular Disease

ABSTRACT. A thyrotropin-releasing hormone (TRH) test with serum thyroid-stimulating hormone (TSH) assays was performed in 22 euthyroid stroke patients without thyroid disease and the results were compared with those in 17 age-matched euthyroid controls. Basal and maximum TSH levels after TRH injeciton were significantly lower in the stroke group without elevation of basal serum thyroid hormone levels. There was a tendency towards an inverse relationship betweeen TSH levels and the degree of pareses of the extremities. The test was repeated in 7 stroke patients 3–4 months after the onset of stroke with essentially the same results. The abnormal TSH parameters in stroke patients seem to be the result of the brain lesion per se.     

Characterization of nonlymphoid cells derived from rat peripheral lymph

Mesenteric lymphadenectomy in rats is followed by union of peripheral and central lymphatics, allowing the collection of intestine-derived peripheral lymph cells via the thoracic duct for several days. These cells include a proportion of nonlymphoid cells (NLC) that show irregular and heterogeneous surface morphology including long pseudopodia and veils. They stain variably for nonspecific esterase and acid phosphatase and are ATPase-positive. Their nuclei are irregular and some contain cytoplasmic inclusions, some of which show peroxidase activity and/or contain DNA. NLC have a range of densitites generally lower than that of lymphocytes. Freshly collected NLC express the leukocyte-common antigen (defined by monoclonal antibody MRC Ox 1) and Ia antigens (I-A and I-E subregion products defined by monoclonal antibodies) but they show a relative lack of other surface markers normally found on rat B or T lymphocytes (W3/13, W3/25, MRC Ox 12 (sIg), MRC Ox 19) or rat macrophages (FcR, C’R, mannose R, W3/25). In general NLC are only weakly adherent to glass or plastic. Although a subpopulation of NLC appear to have had a phagocytic past, freshly collected NLC fail to phagocytose a variety of test particles in vitro. NLC also appear incapable of pinocytosis in vitro. This heterogeneity may represent distinct subpopulations of NLC or different stages in the development of a single cell lineage. Direct cannulation of mesenteric lacteals shows that the majority of NLC are derived from the small intestine and their precursors appear to be present both in lamina propria and Peyer's patches. Kinetic studies, following irradiation or intravenous tritiated thymidine, show that the majority of NLC turn over rapidly in the intestine with a modal time of 3-5 d. Studies with bone marrow chimeras show that they are derived from a rapidly dividing precursor present in normal bone marrow. NLC occur at very low frequencies in normal thoracic duct lymph at all times following cannulation. The evidence presented suggests that NLC closely resemble mouse lymphoid dendritic cells. This conclusion is supported by evidence already obtained showing that NLC are potent stimulators of the semi-allogeneic rat primary mixed leukocyte reaction. In addition to the ceils resembling dendritic cells rare monocytoid cells are found in thoracic duct lymph of lymphadenectomized specific pathogen-free rats. The proportion of these cells increases greatly when the animals are conventionally housed. It seems probable that the physiological function of NLC is to act as accessory cells in the lymph nodes to which they normally drain. Methods for enriching NLC and thus facilitating analysis of their functions are discussed.     

Role of Surgery in Infective Endocarditis

ABSTRACT. One-hundred-and-thirteen patients with endocarditis and valvular insufficiency were studied retrospectively with special regard to indications for operation and the optimum time for cardiac valve surgery. Thirty patients (group I) had acute, 63 (group II) subacute and 20 (group III) prosthetic valve endocarditis. Group I: Eleven patients underwent surgery in the acute stage, 8 while bacteremic; 5 of the latter died perioperatively. Of the 19 patients treated medically, 16 died. Group II: All patients underwent operation in a bacteria-free state. The mortality was 5%. Group III: Eight patients had early (<60 days postoperatively) and 12 late endocarditis. Total mortality was 40% (71 % early and 25% late mortality). Ten patients underwent reoperation, with a mortality of 20%, compared with 60% in the medically treated group. The results support the indication for early operation in acute endocarditis with progressive cardiac failure and renal failure and prosthetic valve endocarditis, even during bacteremia.     

A cytokine switch induced by human seminal plasma: an immune modulation with implications for sexually transmitted disease

The immunosuppressive activity of human seminal plasma may be one factor in the aetiology of sexually transmitted disease and could be particularly important for the spread of human immunodeficiency virus (HIV). The advent of virus that can preferentially infect Langerhans cells of the genital mucosa underscores the relevance of seminal plasma effects. Virally infected cells are eradicated by the killing activity of T cells and natural killer (NK) cells and this cytotoxicity is stimulated by IL-12 (previously known as natural killer cell stimulatory factor) and partly inhibited by IL-10 (previously known as cytokine synthesis inhibitory factor). We have examined the effects of human seminal plasma on the production of these key cytokines. Cytokine production was measured in rapidly diluted, fresh, lipopolysaccharide (LPS)-stimulated, whole blood since this provided leukocytes with minimal exposure to prostaglandin. Prostaglandin concentrations and cytokine release were measured by ELISA. Addition of human seminal plasma diluted up to 100,000 times (0.001%) to blood cell cultures led to a marked increase in the IL-10/IL-12 ratio (P <0.02). A dose- dependent increase in the ratio was observed in five separate experiments, from a control value of 1 (no seminal plasma) to a mean value of 80 (1% seminal plasma). This cytokine switch was also seen when seminal plasma was substituted by pure prostaglandin E (PGE) and 19-OH PGE (the main prostaglandin constituent of human seminal plasma). Lipid-extracted seminal plasma was considerably less active at high dilutions than whole seminal plasma at the same dilution. However, its activity could be restored by the addition of synthetic PGE and 19- hydroxy PGE. A stimulation of IL-10 and a decrease in IL-12 in host- defence cells of the lower female reproductive tract will seriously affect the ability of cytotoxic T cells and NK cells to recognise and destroy virally infected cells. In addition, the stimulation of IL-10 will inhibit the release of the anti-HIV activity from CD8+ve cells. The cytokine switch reported here, activated by semen deposition, would exercise a key inhibitory control over vital immune defences in the lower genital tract, with ablation of cell-mediated responses and immunosurveillance.      

Vitamin K in preterm breastmilk with maternal supplementation

Six healthy lactating mothers who gave birth to preterm infants at a median post conceptional age of 29.5 (range 26-30) weeks were given 2.5 mg phylloquinone (vitamin K1) orally daily for 2 weeks beginning at a median postconceptional age of 31.5 (range 28–32) weeks. Phylloquinone was measured in the breastmilk daily for 14 d. Trough plasma phylloquinone concentrations were also determined on four occasions. Phylloquinone levels in the breastmilk increased from a baseline of 3 ± 2.3ngml^-1 to 22.6 ± 16.3 ng ml^-1 (mean ± SD) after the first dose ( p < 0:05); a gradual increase was noted until phylloquinone levels reached a plateau of 64.2 ± 31.4ng ml^-1 after the sixth daily dose.