By examining the academic and healthcare landscapes of Mexico and Latin America, it is possible to gain insights into the necessity of a multidisciplinary approach that acknowledges the interplay of sociocultural and biological factors affecting mental health. The prevalent issues in the region encompass major depression, anxiety disorders, post-traumatic stress, addictions, neurodevelopmental problems, chronic mental disorders like schizophrenia and bipolar disorder, and neurological diseases affecting mental health, such as epilepsy, traumatic brain injury, or the degenerative dementias.[1,2] To address these problems, mental health services should be grounded in scientific knowledge, humanistic values, and collaborative multidisciplinary efforts. Regrettably, the reality of mental health services differs markedly, in my view, from this envisioned ideal. I will now delineate some critical points.
The Mental Health Landscape. In Mexico, mental health institutions and services are concentrated in a few cities. These facilities often grapple with technological and infrastructural shortcomings. Numerous psychiatric hospitals across Latin America lack important laboratory studies, and the majority lack the necessary equipment for neuroimaging or electroencephalography studies. These tools are crucial for conducting a comprehensive differential diagnosis, considering that many neurological diseases manifest with psychiatric symptoms. Individuals with mental health issues face an elevated risk of developing physical health problems. Despite this epidemiological fact, many psychiatric services operate in isolation, lacking an efficient connection to address the physical health issues that often coexist with mental disorders. It’s as if the Cartesian separation of the mind and body is reflected in architectural realities, leading to a physical separation of services. Often, psychiatric hospitals are situated outside the main cities, a choice that lacks medical or therapeutic rationale. In my view, this may be a form of discrimination towards individuals exhibiting atypical, divergent, or disruptive behaviors. The structural constraints in mental health provision become evident when examining the number of mental health beds per 100,000 population globally, with a median of 10. In Mexico, this figure is 3. To contextualize within the region, consider the following: Argentina has 40, Brazil has 11, Cuba has 43, and the USA has 18. [3] A similar scenario unfolds when assessing the number of mental health units in general hospitals and mental health outpatient facilities per 100,000 population. Mexico is below the global median, and falls within the lowest range in the Americas.[3]
Shortage of Personnel in the Mental Health System. Comprehensive medical and psychological care should take into account the cognitive, affective, and behavioral aspects that frequently complicate the progression of physical illnesses. It should also address the substantial challenges presented by addictions and primary mental disorders. However, there is a significant shortage of mental health professionals in general hospitals. The number of psychiatrists in Mexico’s mental health sector is 0.2 per 100,000, placing it among the lowest in the region. Comparatively, Argentina has 21, Brazil has 3, Cuba has 9, and the USA has 10 psychiatrists per 100,000.[3] The scarcity of psychiatrists in Mexico helps explain that, while many countries grapple with issues of overdiagnosis and excessive medicalization, a comparative analysis shows that the situation in Mexico is quite different. While the analysis of psychotropic medicine consumption reveals that the UK, USA, and Spain fall within the highest range, Mexico and most Latin American countries register among the lowest levels of consumption.[4] In the case of Mexico, this is also explained by the shortages of essential supplies. Being a clinical psychiatrist working in a public hospital, I have observed for years that patients receive appointments of 20 minutes every 3-6 months. As psychotherapeutic interventions require longer sessions and weekly follow-ups, the shortage of psychiatrists in Mexico is a structural condition that limits the possibility of providing psychotherapeutic care, even though psychiatrists acknowledge the need for this type of treatment. Scientific evidence is clear regarding the effectiveness of psychotherapy for common mental health problems like depression.[5] From my standpoint, it should be incorporated into the public system without hesitation. In Mexico, there is a dramatic shortage of psychotherapists in the public sector, turning psychotherapy into a class privilege. Consider the number of psychologists who work in the mental health sector per 100,000 individuals: in Mexico, the figure is 3. For context, Argentina has 222 psychologists, Brazil has 12, Cuba has 31, and the USA has 29 psychologists per 100,000.[3] Also, Social Work professionals are insufficient in the health systems and often seem to be burdened with administrative tasks, preventing them from focusing on developing effective actions to modify the problematic social circumstances of patients. In summary, it is necessary to move from a model in which the scarce mental health services are isolated and organized around a few medical interventions to the formation of multidisciplinary mental health teams available in two spaces: general hospitals (for the care of acute or complex cases requiring a medical perspective, with hospitalization capabilities) and community services, where care should be closer to the ecological realities of those seeking professional help. These teams should have the knowledge and skills to differentiate between cases that require a medical approach, cases that correspond to states of psychosocial distress, and cases that require both approaches.
Making space for an empathetic and rational assessment in healthcare. In my perspective, the provision of optimal mental and psychological care should take into account factors such as culture, language, and the patient’s system of interpersonal relationships. Unfortunately, many health systems lack mechanisms that strike a balance between clinical attention and treatment that involves respectful, attentive, and careful listening. My observation of the Mexican public institutions is that the lack of resources, as well as the technical and administrative formats, leave little room for open dialogue, spontaneous conversation, and the evaluation of the qualitative and narrative details of the subjective experience, even though these details are often closely linked to the experience of suffering. It’s essential to highlight that healthcare workers cannot effectively address problems without the necessary support to tackle the structural issues of poverty, violence, racism, and sexism that impact the mental health and well-being of Mexican communities. Allocations for prevention, care, and research, unfortunately, fall short, even though global epidemiological studies consistently reveal that psychiatric disorders remain among the top ten causes of disability worldwide, with high prevalence in Latin America.[2] Current government authorities must recognize the epidemiological and social significance of mental health. This acknowledgment is crucial to guarantee the stable operation of services, emphasizing equal access, quality care, financial protection, scientific and technological advancement, and the utmost respect for human rights.
REFERENCES
1 Johansson L, Guerra M, Prince M, et al. Associations between Depression, Depressive Symptoms, and Incidence of Dementia in Latin America: A 10/66 Dementia Research Group Study. J Alzheimer’s Dis. 2019;69:433–41.
2 Collaborators G 2019 MD. Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet Psychiatry. 2022;9:137–50.
3 World Health Organization. Global Health Observatory data repository: Mental Health. 2021. https://apps.who.int/gho/data/node.main.MENTALHEALTH?lang=en (accessed 30 November 2023)
4 Brauer R, Alfageh B, Blais JE, et al. Psychotropic medicine consumption in 65 countries and regions, 2008–19: a longitudinal study. The Lancet Psychiatry. 2021;8:1071–82.
5 Plessen CY, Karyotaki E, Miguel C, et al. Exploring the efficacy of psychotherapies for depression: a multiverse meta-analysis. BMJ Ment Heal. 2023;26. doi: 10.1136/bmjment-2022-300626
Author
Prof. Jesús Ramírez-Bermúdez, MD, PhD
Jesús Ramírez-Bermúdez, MD, PhD, serves as a clinician, researcher, and professor at the National Institute of Neurology and Neurosurgery of Mexico. Additionally, he has authored several books encompassing literary and scientific essays.
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none