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Improving the Public Mental Healthcare in Chile: Towards a Mental Health Law - World Federation for Mental Health

Rubén Alvarado Muñoz Ruben Alvarado,Programa Salud Mental. Profesor Asociado, Escuela de Salud Pública, Universidad de Chile

Rubén Alvarado Muñoz Ruben Alvarado,Programa Salud Mental. Profesor Asociado, Escuela de Salud Pública, Universidad de Chile

Carolina González PhD(c), Paulina Larrondo Dr(c), Rubén Alvarado PhD

Chile is a Latin American country with an estimated population of almost 18 million inhabitants [1]. Chile has been categorised with a very high human development (38th in the world rank), which means that it is the country with highest human development in the region [2]. Chile has reached similar positioning in terms of economic development, being categorised as a high-income country, showing economic welfare higher than the world average [3]. Regarding the health of the population, this country has gradually reduced mortality rates in both adult and child populations. Furthermore, the life expectancy at birth has increased 10 years since 1990, positioning Chile in 14th place in comparison to other countries worldwide [4].

According to these international statistics, it seems that Chile is a country growing rapidly to become a developed country. However, there are other social statistics to take into account. Chile is one of the most unequal countries of the OECD, of which it is a member country. Furthermore, if the human development index is adjusted by inequality (inequality-adjusted human development index, IHDI), Chile would lose 18.2% of the value of this indicator, dropping 12 positions in the world rank [5].
In the same way that there is no economic prosperity without social development, there is no health without mental health. Apart from the physical health in Chile, it is important to analyse the state of the mental health of its population. Thus, it is relevant to highlight not only those initiatives aligned to the Mental Health Action Plan of the WHO [6], adopted by Chile; but also pending tasks regarding the provision of the best conditions of care and dignity for the population and their mental health.

Prevalence of mental health disorders and exposure to traumatic events

According to a report of disease burden and attributable burden from the Ministry of Health (MINSAL) of Chile [7], the neuropsychiatric conditions represent 23.2% of the total burden from the disability-adjusted life year (DALY). Thus, these conditions are the highest cause of burden within all causes included in the report, representing the highest burden for women and men, and for adults, children, and adolescents. In terms of specific causes within the neuropsychiatric conditions, the unipolar depressive disorders represented 4.5% of the burden of DALY, followed by 3.4% of alcohol dependency. Although anxiety, schizophrenia, and bipolar disorder have a lower burden than depression and alcohol dependency, they are still within the 20 specific causes with a major burden for DALY.
In an effort to advance data on national prevalence, the third version of the National Survey of Health by the MINSAL [8] included for the first time the administration of the Composite International Diagnostic Interview (CIDI). The outcomes from this interview reported that the prevalence of depression was 6.2% at national level, higher than the 4.4% of the world prevalence [9]. Additionally, data regarding suicide was also reported. The prevalence of suicidal ideation was 2.2%, suicide planning was 1.5%, and suicidal attempt was 0.7% [8]. Regarding suicide, a report from the WHO [10] reported that the age-standardised suicide rate per 100,000 inhabitants in Chile for 2012 was 12.23, which was higher than the world rate. Thus, these rates are concerning considering that the world suicide rate is 1.5%, suicide being within the 20 most common causes of death worldwide in 2015, and the second most common cause of death among young people aged 15-29.
Despite the advance of including the application of CIDI as part of the National Survey of Health, there is no official data regarding the prevalence of other mental health problems at national level. The most important efforts come from Vicente and colleagues [11, 12, 13, 14, 15]. They have reported that 36% of the Chilean population (15 years old and over) have experienced a psychiatric disorder at least once in their lives, and 23% of them have it in the last 6 months. The group of anxiety disorders (16.2%) were the most lifetime prevalent, followed by affective disorders (15%). In terms of specific disorders, the highest lifetime prevalence was agoraphobia without panic (11.1%), followed by major depression (9%), dysthymia (8%), and alcohol dependence (6.4%) [11]. Regarding child and adolescent population, the prevalence of all mental disorders in one year with impairment was 22.5% in this population. Furthermore, this prevalence was higher for disruptive disorders (14.6%), followed by attention-deficit hyperactivity disorder (ADHD, 10.3%) and anxiety disorders (8.3%). The disruptive disorders remain the most prevalent disorders in the last year when they are analysed separately by age groups, 4-11 years y 12-18 years [13, 14].
Regarding exposure to traumatic events, 39.7% of the Chilean population has been exposed to any type of trauma [16]. In general, the most common events have been witnessing another person to be hurt or dying (15.7%), sudden injury/accident (10%), and physical assault (8.8%). The exposure to these and other traumatic events may lead to a wide range of mental disorders [17]; however, one of the most commonly referred sequels is the posttraumatic stress disorder (PTSD). The lifetime prevalence of the PTSD has been estimated at 4.4% [16], and this prevalence is significantly higher in women than in men.

Current public mental healthcare

Since 1992, the public care of Mental Health in Chile has been aligned to the community mental health model [18], and there are three levels of care depending on the complexity of such mental health problems: primary, secondary, and tertiary care. Thus, the healthcare ranges from the primary level that has more coverage and less complexity focusing on the family health endorsed to neighbourhoods in order to facilitate the access to services, to the tertiary level that has less coverage but a higher level of specialisation. In Chile, these services are often located in urban areas with high population density.
Since 2005, Chile has a health system of Explicit Health Guarantees (AUGE-GES). Out of the 80 health conditions covered by AUGE-GES, only four of them are mental health conditions [19]. These conditions are schizophrenia, depression (15 years and over), bipolar disorder (15 years and over), and harmful alcohol/drugs use in young people (20 years and under). The treatment for all of these conditions includes clinical guidelines providing guidance regarding the direct care following a transdisciplinary approach.
Recently, the National Plan of Mental Health 2017-2025 [20] was updated in order to improve and promote the mental health of all Chilean inhabitants, using preventive strategies within the health system as well as in collaboration with other systems, from a family and community care approach. Thus, this plan focuses on 1) Regulation and Human Rights, 2) Provision of Mental Health Care, 3) Finances, 4) Quality Management, Information Systems, and Research, 5) Human Resources and Training, 6) Participation, and 7) Collaboration.
This plan aims to reduce the gap between mental health needs and treatment, prevention, and early intervention; as well as delays in the provision of such care. However, given the geographic characteristics and the recent social changes of the country, there are new challenges to address. To visualise mental health needs of migrants, older people, and sexual diversity; in addition to ensuring that care reaches remote areas by the use of technology and telepsychiatry [21].

Towards a legal framework for the mental health care

In Chile, the mental health services have advanced significantly towards a model of care in the community, as it was defined in the National Plan of Mental Health and Psychiatry in 2000 [22]. This represents a significant advancement in the accessibility of people who experience mental health care needs to access the care they need. However, several evaluations show that there are remaining deficits in the psychosocial interventions and those addressing the satisfaction with everyday needs (i.e. companionship, couple life, meaningful life) [23, 24]. These needs are there from the diagnosis [25] and, in the same way as stigma, discrimination, and social exclusion are so important to tackle; they are fundamental components of a health care model with emphasis on a community approach [26].
When users and their family members access mental health services, one of the aspects of major concern is the care for their rights. A recent study conducted in Chile, using the WHO QualityRights, showed that there are few achievements in terms of the delivery of support for life within the community, the access to education and work, the respect for the user preferences regarding treatment, and the adequate measures to avoid maltreatment and cruelty [27]. All these aspects should be safeguarded within legislation; however, there is still no Mental Health Law in the country.
In Chile, there are different legal bodies that protect the citizen’s rights, and particularly those experiencing a mental health problem. The country is also subscribed to several international agreements related to mental health, such as the UN Convention on the Rights of Persons with Disabilities. However, Chile is one of the few countries worldwide without specific legislation regarding mental health.
On 10th March 2016, the Bill for Mental Health Law was presented in the Parliament (particularly, Cámara de Diputados de Chile) [28]. From that moment, Chile has advanced significantly regarding this Bill. The First Article defines the aim of this Bill: “To recognise and guarantee the fundamental rights of the people with mental illness or disability, in specific, their right to personal liberty and their right to healthcare”. Thus, this Bill advances in the judicial regularisation of the care, protection, and dignity of the mental health and those facing mental health problems in terms of treatment and hospitalisation. Furthermore, it enhances the care provided by interdisciplinary and trained personnel, with emphasis on primary care, prioritising community settings.

Although this Bill [28] is a clear advancement, there are pending tasks to maximise its imminent enactment:
1. To address the care and protection of child and adolescent mental health,
2. To align the corresponding budget increment of this sector with the implementation of the law,
3. Major empowerment and guidelines for the primary mental health care and community mental health,
4. Clearer guidelines regarding the certified training of professional competencies of mental health personnel and training centres,
5. Major guidelines to improve both evidence-based theory and practice for diagnosis and treatment in mental health.

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CAROLINA GONZALEZ. Psychologist. Master of Mental Health, major in Community Mental Health. PhD candidate, Parenting and Family Support Centre, University of Queensland, Australia. Member of the World Federation for Mental Health and the Chilean Association of Traumatic Stress.
PAULINA LARRONDO, Psychologist. Doctorate(c) in Psychotherapy, University of Chile and Pontifical Catholic University of Chile. Centre of Reproductive Medicine and Adolescent Integral Development, Faculty of Medicine, University of Chile. Department of Psychiatry, Universidad of Chile. Member of the Chilean Association of Traumatic Stress.
RUBEN ALVARADO. Psychiatrist, Master of Public Health, PhD in Psychiatry and Community Care. Head of Institute of Health Sciences in University of O’Higgins, and Head of Unit of Mental Health, School of Public Health, Faculty of Medicine, University of Chile.

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Miércoles 7 de agosto de 2019



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