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International Journal of Mental Health, vol. 41, no. 1, Spring 2012, pp. 6272.
2012 M.E. Sharpe, Inc. All rights reserved. Permissions: www.copyright.com
ISSN 00207411 (print)/ISSN 15579328 (online)
DOI: 10.2753/IMH0020-7411410105
spring 2012 63
discussed, including the need for a mental health law, clinical governance issues,
and the provision for people with developmental disorders and those with highly
complex mental health needs.
Mental and neurological disorders are a significant public health problem worldwide. It is estimated that they account for 23.2 percent of the burden of illness in
Chile [1]. In the face of this epidemiological reality, the patchy and largely insufficient provision of mental health care led the World Health Organization (WHO) to
emphasize the importance of countries to develop consistent mental health services
[2]. In order to provide a framework to undertake such a task, WHO has proposed
some guiding principles that mental health services development should follow,
specifically, the so-called community care model has been advocated because it
ensures that patients needs are at the center of the service development. The community mental health care model emphasizes the importance of services being
located close to where patients live with a range of services available to people
with mental and behavioral disorders, including alternatives to hospital admission,
such as home treatment and access to acute inpatient care as well as local accommodation placements for patients that require more prolonged residential care. The
model also emphasizes the importance of treatments and support being tailored to
the individuals needs as well as clinicians working with and addressing the needs
of caregivers. Similarly, clinical interventions must consider not only symptomatic
remission, but also should address any associated disabilities with close collaboration between mental health professionals and community resources. Finally, last but
not least, the provision of mental health care must take place within the context of
an effective legal framework [3]. Services delivered along these lines are considered
by WHO as providing community mental health care [4].
In the case of Chile, with the creation of the National Health Service in 1952,
the country saw a gradual and significant improvement in the health standards of
its population, becoming one of three countries in Latin America and the Caribbean region with improving health care indicators [5]. However, at the time of
the return to democratic rule in 1990 after 17 years of military dictatorship, the
nations mental health service was in a deplorable condition, even more so than
the other areas of health care [6]. Since then gradual and significant changes in
the provision of mental health care in Chile have taken place, and these changes
have attempted to follow the above-mentioned model of community mental health
care advocated by WHO. Initially, some changes started to occur between 1990
and 1996 [7], but their scope increased with the momentous publication of the
National Plan of Mental Health in the year 2000 [8], which provided a route map
for the work and efforts of mental health professionals over the following decade.
The gradual implementation of the National Plan of Mental Health encouraged
the transition from mental health care revolving around the four large psychiatric
hospitals located in the geographical center of the country to a network of regional
mental health services distributed around the country (Figure 1). It goes without
Figure 1
Stages of Developmental Psychiatry Service, Barros Luco General Hospital,
19682009
saying that this change in itself has led to improvements in peoples access to mental
health care [9]. Currently, each one of the main regional hospitals has general psychiatry services that are embedded in a network of mental health community services
as well as primary health care units [10]. Unfortunately, these changes in the way
mental health care is provided in Chile have not been adequately communicated or
documented. We believe that more detailed knowledge of these processes may be
helpful both for those who are just preparing to embark on such changes as well as
for those who are already in the process of change. The present article describes the
development of psychiatric services in the south of Santiago, Chiles capital city,
where we have at least tried to follow the community mental health care model.
The Barros Luco General Hospital in Southern Santiago, Chile:
Some History and Context
The Santiago South Health Service currently provides services for almost 900,000
people who live in eleven communes, and it includes thirty-one primary care centers and seven community hospitals with the Barros Luco General Hospital being
the largest hospital providing specialist (secondary and tertiary) medical care. For
decades, and following the priorities set at the foundation of the National Health
Service in 1952, the focus of the Barros Luco General Hospital centered on the control of infectious diseases as well as improvements in maternal and child health. In
other wards, mental ill health was not at the top of the agenda at the time. Psychiatric
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periods, the main activity delivered by the services staff was to intervene during
the postcrisis period of an acute episode of mental ill health and the subsequent
repetition of prescriptions with very limited clinical reviews [13]. In terms of staff
numbers, there was also a reduction over the years so that in 1989 the service had
one nurse, one occupational therapist, two psychologists, seven psychiatrists, one
nurse assistant, and one secretary, resources that were utterly insufficient to meet
the mental health needs of the local population.
With the return to democratic rule in 1990, the new local authorities tried to start,
not without difficulties and errors, addressing the above situation. In particular,
two actions revolving around reestablishing the contact between secondary and
primary care units were of particular importance. One step focused on alcoholrelated and emotional disorders with a view to trying to control the flooding of
secondary care level facilities by patients whose needs were best met at the primary
care level. An associated step was to start a gradual process of referring the abovementioned chronic ambulatory psychiatric patients back to the primary care level
with a view of getting them back into their natural local health care network. This
process was actively implemented and, despite the limited resources available,
some of the psychiatrists started working directly with the primary care teams both
to help them to foster their clinical skills to manage the newly received patients
as well as to provide as needed direct clinical care for the more complex primary
care patients. It was this modality of care, developed out of necessity, that led us
to envision the initial stages of the psychiatric consultation model that would later
become a distinctive feature of the relationship between primary care and mental
health secondary care in Chile.
While some of these changes were taking place, Chilean public opinion became
outraged in 1993 as the media disclosed the extreme neglect suffered by residents of
a publicly funded private residential unit. The authorities responded to this scandal
by somehow increasing the resources allocated to mental health. It was within that
context that the service was able to make some developments, such as emergency
admission beds, psychiatrists working at the Accidents and Emergency department,
and the treatment and rehabilitation of addicts at the community level. Subsequently,
the launch of the Day Hospital in 1999 was followed by, in 2002, the relocation
of the psychiatric outpatient department to a new diagnostic center along with the
other medical and surgical specialties. This setting made it possible to start offering
a variety of services to the patients. In 2003, change and development continued
with newly formed community psychiatry teams and the opening of a new acute
inpatient unit in 2004 [13]. Thus, the service has developed a multifaceted profile
as the countrys largest general hospital-based psychiatry service.
Current Situation
The service currently provides mental health care for adults above 18 years of age,
including people with addictions, with the staff levels described in Table 1. The
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Table 1
Barros Luco General Hospital, Psychiatry Service Staff, 1976 and 2011
Staff numbers
Staff
Psychiatrists (within hours)
Psychiatrists (out of hours)
Nurses
Psychologists
Occupational therapists
Care assistants
Health care assistants
Administrative staff
1976
2011
1976
2011
2
0
0
5
1
2
0
0
14
6
8
11
10
16
13
5
66
0
0
220
44
88
0
0
220
168
352
286
330
704
572
220
place in two districts so far. The district-based community mental health team aim
is to try and deal with mental ill health affecting people of all ages with the expectation that they will refer to the secondary care level unit (henceforth, referred
to as the service) only those more difficult, more severe, or treatment-resistant
patients (for whom the day hospital, the hospital inpatient unit, and the psychosocial
rehabilitation unit will be available).
Day Hospital
The day hospitals work has developed as an alternative to hospital admission, providing comprehensive care for patients with acute mental ill health. Its functioning
has prevented hospitalizations and has also reduced the length of the admissions
to the hospital. The day hospital team has acquired experience over time in terms
of psychosocial interventions in families with high expressed emotion as well as
in the psychoeducation of patients. It has been observed, in accordance with the
literature, that these interventions have had a positive effect on the course of the
illness as well as promoting patients autonomy and self-care, medication concordance, and engagement with psychosocial rehabilitation.
Rehabilitation Department
This department evolved from the gardening and woodwork workshops that were
part of the existing services at the El Peral psychiatric hospital, one of two large
psychiatric hospitals in Santiago. The workshops initially evolved into a program
that supported the employment of fifty patients as part of the Barros Luco Hospital
staff with jobs such as couriers, administrative staff, and cleaning. Unfortunately,
patients tended to remain in the same post for long periods, which led to the system
being unable to provide more placements for new patients. When the situation
was critically reviewed, it was decided to increase the professional input to it as
well as to emphasize the transitional nature of the hospital posts and the need to
support patients to move toward competitive employment. The results of this new
approach have been encouraging, with 120 people having obtained and maintained
competitive employment posts.
Acute Inpatient Unit
This is a twenty-eight-bed unit with bedrooms of up to three beds each that are
managed according to the patients gender and clinical needs. In 2010, affective
disorder (bipolar disorder and depressive disorder) and schizophrenia and other
psychotic disorders accounted for just over 75 percent of the patients admitted to
the unit. The current average length of stay is twenty-seven days, which has recently
increased because of the prolonged stays of patients with developmental disorders
whose needs are not yet provided for by other services.
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spring 2012 71
larly, we realize that further local progress will depend on clear leadership from the
central government, in particular providing evidence-based and patient-centered
policies and also making sure that such policies are consistently implemented across
the country. Finally, we believe that a mental health law that regulates the practice
of clinical psychiatry at all levels will be crucial if the quality of care is going to
improve, dignity and rights of patients are going to be protected and promoted, and
the stigma associated with mental illness is going to be defeated.
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