Freedom and Mental Health

In the debate on mental healthcare policy in Brazil, the concept of freedom should be used as a criterion. Before defending the elimination of hospital care, one must acknowledge that patients with serious mental illnesses who fail to receive adequate treatment have limited capacity to make decisions or to understand the consequences of their own acts. Mental illness is complex, with various levels of severity.

If health is the right of all citizens and the state’s duty in Brazil (according to the 1988 National Constitution), it is unthinkable to forego necessary and useful therapeutic interventions that can improve the prognosis of patients whose symptoms, if untreated, prevent them from living in community. The evolution of pharmacological treatment and community approaches to mental illness, allowing remission of symptoms in many cases, cannot be used as an excuse to restrict the right to a broad, diversified, and highly qualified mental health system. Open institutions (for volunteer patients with social and family ties) are not the most appropriate option for all cases of mental illness.

The need for hospitalization is obviously not justified on grounds of fear and danger associated with psychiatric patients. Recourse to hospitalization is part of the right to protection and intensive treatment in phases of acute exacerbation of the illness, as in any other health condition. Treatment of mental illness requires adequate time. An antidepressant takes an average of two to four weeks to begin its therapeutic effect. Antipsychotic drugs sometimes take four to eight week to mitigate delusions and hallucinations. One cannot condemn patients to circulating without adequate protection, posing risks to themselves and others. When this happens, the discourse in defense of freedom only serves to legitimize otherwise irresponsible and frivolous attitudes.

In addition, prolonged hospitalizations are (are should be) the vestiges of a time in which therapeutic strategies were either scarce, or else the unwanted consequence of an unsatisfactory response to the only available treatments at the time.

Patients with chronic and severe mental disorders deserve what they have still not received, even after 20 years under Brazil’s Unified National Health System and “Psychiatric Reform”: to be treated with the best and most effective proven treatment as part of special protocols for their illnesses, in addition to programs for social inclusion and treatment hospices in sufficient number, since the vast majority have no social ties or living family members.

Health is the right of all and a duty of the state. Perhaps this explains why we are witnessing a phenomenon referred to erroneously and hastily as the “judicialization of health”. All too frequently in Brazil, the courts order the government to provide treatment to a given citizen, specifying the therapeutic modality or medication to be prescribed. Still, unfortunately, such measures are not based only on the defense of citizenship and individual rights. In practice, they can lead to distortions that generate pecuniary advantages for major economic interests, in addition to overriding and interfering in physicians’ decisions.

We have also seen more sweeping interventions, like that of the Federal Judiciary, ordering the Office of the Mayor of São Paulo (the largest city in Brazil) to expand psychiatric care by creating 57 additional mental healthcare outpatient clinics and 37 more psychiatric hospice services, which are essential for network-based psychiatric care. Such intromission by the judiciary tacitly accepts the premise that the executive branch sustains a discourse of improving therapeutic methods, but that it is not concerned with extending coverage of (or access to) care.

Public prosecutors that are truly concerned with health could follow the example of the Office of the São Paulo State Public Prosecutor, which established a collaborative agreement with the Brazilian Association of Psychiatry to receive scientific arguments and collectively defined technical guidelines to substantiate objective legal rulings, in line with citizens’ demands and interests.

In this process, the legislative branch appears to owe a debt to the Brazilian people. The Brazilian Congress has still not passed Constitutional Amendment 29, which proposes to regulate public health expenditures in the country. How can the healthcare system be expanded without specific funding? Adequate budget allocation is essential to ensure health as every citizen’s right in practice.

Health is the state’s duty, but the responsibilities are collective. Beyond pointing fingers, we seek a time of understanding in which mental health professionals, administrators, society, political representatives, patients, and families can tackle the difficulties of treating mental illness, the limits of therapeutic interventions, and the need for investments to ensure improved quality of care and expand access to more efficient and effective treatments. As every citizen’s right.

Board of Directors, Brazilian Association of Psychiatry

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