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Article: Good intentions, bad habits: Reforming mental healthcare in Latin America and the Caribbean

Marc Yates, February 2018

Good intentions, bad habitsIn the second of a series of articles exploring mental health in emerging markets we take an in-depth look at the situation in Latin America and the Caribbean.

The Latin America and Caribbean (LAC) region is a vast patchwork of countries, cultures and ethnicities, with a total population of more than 645 million, ranging from 209 million-plus in Brazil to islands with fewer than 100,000 inhabitants. The diversity is also economic. Recent years have seen marked improvements in income distribution and a burgeoning middle class, particularly in countries such as Argentina, Bolivia, Ecuador, Peru and Nicaragua. Yet Latin America and the Caribbean remains the region with the highest levels of income inequality worldwide.  All of this has a significant bearing on the state of mental health in Latin America, where good intentions and genuine progress in reforming infrastructure and attitudes are clouded by treatment gaps, inadequate funding, over-centralisation, meagre human resources and persistent stigmatisation.

The burden of illness remains substantial. Mental, neurological, and substance use (MNS) disorders account for an estimated 21% of all disability-adjusted life years (DALYs) and for 34% of years lived with disability (YLDs) across Latin America. Worldwide, MNS disorders are responsible for 10% of all DALYs and 29% of YLDs. Depressive and anxiety disorders are the main contributors. According to the World Health Organization, depressive disorders are the leading cause of YLDs in its Region of the Americas (which includes the US and Canada), accounting for 9% of the total – well above the global figure of 8%. Anxiety disorders rank third, with 6% of all YLDs across the Americas (3% worldwide).

Underlying problems

These data mask extensive underlying problems with implications for mental health, such as:

  • High levels of alcohol/substance abuse
  • Domestic and gang violence
  • Cultural, family and religious attitudes that can either stigmatise or enhance acceptance of mental-health conditions
  • The impact of natural disasters   
  • A deep legacy of political instability and armed conflict
  • A fast-rising tide of neurological conditions as populations age.
  • The stresses of work and raised expectations associated with an expanding middle class

Transition to democracy

That mental-health systems today are better equipped to deal with these challenges owes much to the political transition to democracy across Latin America during the 1980/90s. This encouraged a focus on social reform, human rights and remedying past abuses, including those of long-term residents in the large psychiatric hospitals that were the hub of national mental-health systems.  A turning point was the Caracas Declaration, adopted in 1990 by the Pan American Health Organization (PAHO)-convened Conference on the Restructuring of Psychiatric Care in Latin America. This confirmed the primacy of human and civil rights within member-country mental-health systems.  In parallel, it called for restructuring and retraining to shift the focus from a dominant psychiatric-hospital model in Latin America to one based on participatory, multidisciplinary, integrated primary care, delivered at community level.   

Slow transition

These commitments began to trickle down into health reforms and legal instruments at national level across Latin America. Nonetheless, the transition to community-based mental healthcare has been slower and more sporadic than PAHO might have hoped. According to the association, 81% of member countries now have a stand-alone mental-health policy or plan, and 85% updated these between 2005 and 2015. Moreover, 81% report full or partial implementation of mental health policies/plans, while a further 81% claim high compliance with human-rights standards.  

In terms of dedicated legislation and its translation into palpable improvements on the ground, though, the picture is a lot more mixed. A study published in 2012 found that Latin American countries scored better on introducing mental-health policies and plans than other countries classified as low and middle income (LMIC) – 67% versus 55%, and 72% versus 66% respectively). Yet a lower percentage of LAC countries had introduced specific mental-health legislation (47 % versus 54% in LMICs globally).

Even where laws promoting decentralisation, human rights and community integration of mental healthcare are in place, implementation may be an uphill struggle. In Argentina, the Centre for Legal and Social Studies (CELS) was among the human-rights groups that helped push through one such law in 2010. Two years on, CELS reported persistent human-rights violations of psychiatric patients, resistance from doctors to granting patients legal autonomy, and over-zealous application of deinstitutionalisation programmes, without the safety net of intermediate care facilities and services.

Across the whole LAC region, treatment gaps of up to 80% have been identified for conditions such as major depression, mania and generalised anxiety. The gaps are likely to be even wider in rural areas, among the young or elderly, and in indigenous communities with limited access to healthcare. Moreover, the continuing growth of the middle class in Latin America will bring a heavier burden of non-communicable diseases – including mental-health conditions – associated with changing diets, values, lifestyles and stress levels.  

Considerable progress

This is not to overlook that several countries in Latin America, such as Brazil, Cuba, Costa Rica, Nicaragua, Guatemala, Columbia and Peru, have made considerable progress in integrating mental-health services into primary care, with an emphasis on prevention, health promotion and psychosocial rehabilitation   . Brazil’s mental-health reforms, for example, created a network of community-based Centres for Psychosocial Care, equipped with outpatient and partial hospitalisation services. The volume of psychiatric-hospital beds in Brazil fell by one quarter in the early 2000s, while the share of the national mental-health budget allocated to psychiatric hospitals shrank from 96% in 1995 to 49% in 2005. Over the same period, the proportion of mental-health funds going to community services increased from 0.8% to 15%.

Investment, personnel

Among the remaining barriers to implementation of community-based mental healthcare in Latin America are lack of targeted investment and shortages of trained healthcare personnel. Funding for mental healthcare remains low-priority, even in countries that have introduced progressive reforms, while the supply and distribution of mental-health professionals is badly out of step with demand.    

In 2013, a WHO review found the proportion of total health budgets allocated to mental health by eight countries in South America was 2% on average. In six countries across Central America, Mexico and the Caribbean, the average share was just 1%.  Moreover, of the 27 countries in the study with psychiatric hospitals, 20 spent over 50% of their mental-health budget on these institutions, and 14 of the 20 countries more than 80%. 

The WHO’s data showed a median 1.5 psychiatrists per 100,000 population in Central America, Mexico and the Caribbean, and 3 per 100,000 in South America. As a comparison, the EU15 countries have a median 13 psychiatrists per 100,000 population.

What pharma can do

The still tentative mental-health reforms in many Latin American countries, and the limited budgets underpinning them, are something pharmaceutical companies must bear in mind as they assess unmet need for psychiatric medicines. There is variable progress in the integration of drug therapies into community-based mental healthcare. Pharmaceuticals for mental-health conditions are more readily available in psychiatric hospitals, further hindering progress towards deinstitutionalisation.

Brazil introduced a decree in 1999 that guaranteed users of public ambulatory health services access to basic medicines for psychiatric conditions. The WHO’s review in 2013 found that in Costa Rica and Cuba, 81%–100% of primary healthcare clinics had at least one psychotropic medicine in each therapeutic category (antipsychotic, antidepressant, mood stabilizer, anxiolytic and antiepileptic medicines).  In Mexico, on the other hand, only between 21% and 50% of physician-based clinics and 1-20% of non-physician-based clinic offered these medicines.

Availability and affordability of drug therapies are key considerations for companies active in mental health across Latin America and the Caribbean. As in other countries with limited resources for mental healthcare and marked economic disparities between population groups, expensive innovative drugs may require flexible pricing and evidence of long-term cost-effectiveness.  

Fostering awareness of, and training in, therapeutic options is likely to facilitate access, particularly in shifting prescribing responsibility from specialist down to primary/community level. Getting primary care more involved in treatment pathways will help to address demand for drug therapies and broaden access hampered by the aforementioned shortages of mental-health specialists. At the same time, pharmaceutical companies can contribute to a more rational, efficient and responsive infrastructure for mental healthcare by offering diagnostics and advice to guide appropriate patient referrals to secondary care.   

Need for evidence

Information and evidence to track the efficiency and effectiveness of reform programmes are also in short supply. This presents opportunities for pharmaceutical companies with data-integration and analysis expertise to help systems redesign mental healthcare pathways for better outcomes. There is also continuing demand for robust epidemiological studies to quantify disease burdens as well as risk or protective factors for mental-health conditions.

Wrap-around services, such as funding for psychiatric nurses, educational initiatives or adherence programmes, will ease the transition to community care and de-stigmatisation. At the same time, companies should remain sensitive to cultural particularities such as family dynamics or preference for traditional medicine.

One finding of a recent study evaluating mental-health service needs in Latin America was that the first point of contact for indigenous people with health problems in Nicaragua is the traditional healer or doctor. In Mexican folk medicine, numerous plant species are used to treat ‘nervios’, or states of ‘bodily and mental unrest’, as well as depression and anxiety. Integrating traditional healing into mainstream healthcare provision can enhance receptivity to modern medicine, particularly in areas such as mental health where diagnosis and treatment may be complicated by folklore and superstitions.                     

In Guatemala, Sanofi has partnered with local non-governmental organisation ALAS to implement global programmes aimed at training frontline healthcare professionals to diagnose and treat mental disorders, combating stigmatisation in the community, and improving access to psychiatric medicines through equitable pricing. Digital technology, apps and telemetry are other means by which pharmaceutical companies can improve understanding of mental-health conditions, optimise limited human resources (mental health is particularly amenable to virtual intervention), and steer care into the community.

LAC countries have come a long way in shedding the legacy of outmoded, poorly resourced and repressive mental-health systems. Many challenges lie ahead. With the right broad-based and locally-tailored approach, though, pharmaceutical companies can make sure their products and services are part of the solution.

In particular, raising awareness and understanding of mental-health issues in both the medical community and the general population will help to tackle stigmatisation and neglect. Pharmaceutical companies can facilitate modern, culturally sensitive mental-health strategies by working with healthcare providers to ensure conditions are appropriately diagnosed and care plans developed in consultation with patients and their families. And providing effective treatments will do much to address both historical failings and the more recent stresses on mental health that are a cost of economic development and urbanisation in Latin America and the Caribbean.

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