¿Cuántos somos? ¿Dónde estamos? ¿Dónde debemos estar? El papel del psiquiatra en México. Análisis preliminar
- Autores: Maria del Carmen Lara Muñoz, Claudia Fouilloux Morales, Minou del Carmen Arévalo Ramírez, Yuridia Santiago Ventura
- Localización: Salud mental, ISSN 0185-3325, Vol. 34, Nº. 6, 2011, págs. 531-536
- Idioma: español
- Títulos paralelos:
- How many are we? Where are we? Where should we be? The psychiatrist's role in Mexico. Preliminar analysis
- Enlaces
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Resumen
- español
Una de las limitantes más importantes que explican la diferencia entre las personas que necesitan servicios de salud mental y las que acceden a éstos, es el insuficiente número de psiquiatras. La media mundial de psiquiatras por cada 100 000 habitantes es de 3.96 (DE 5.94), la distribución de psiquiatras varía de una región a otra; existe un promedio de 0.06 en los países de bajos ingresos y de 9.0 en los de altos ingresos. La psiquiatría, como especialidad médica, es relativamente reciente. Es hasta el siglo XIX cuando el tratamiento de los trastornos mentales empieza a ser objeto de una especialidad médica. En México, la enseñanza de la psiquiatría como especialidad independiente se inicia en 1950. En 2010 se abrieron 137 plazas para la realización de la residencia en psiquiatría en diferentes partes de la República Mexicana. A pesar de esto, el número de psiquiatras es insuficiente además de que el ámbito de su actividad no corresponde a las recomendaciones de la Organización Mundial de la Salud. El objetivo del presente trabajo fue determinar el número y la distribución de los psiquiatras en la República Mexicana y proponer nuevos campos de acción del psiquiatra.
Metodología Se realizó un estudio descriptivo, transversal, heterodémico. Se revisaron las siguientes fuentes de información: el Directorio de la Asociación Psiquiátrica Mexicana (APM) de 2008, el Directorio del Consejo Mexicano de Psiquiatría (CMP) de 2008, el Censo de 1990 y el II Conteo de Población y Vivienda 2005.
Resultados En el Directorio de la Asociación Psiquiátrica Mexicana se encontraron 1397 socios activos. En el Directorio del Consejo Mexicano de Psiquiatría están anotados 1430 psiquiatras certificados. En los últimos 20 años hubo un incremento de psiquiatras del 29%, pues pasaron de 1108 a 1430. Para el 2005 la población aumentó de 81.2 a 103.3 millones de personas, es decir hubo un incremento del 27%.
Esto indica que la cantidad de psiquiatras se ha mantenido constante respecto al número de habitantes. Observamos que, en total, hay más psiquiatras certificados que miembros de la APM.
En cuanto al segundo objetivo, a excepción del Distrito Federal, en el resto del país el número de psiquiatras por número de habitantes es notablemente inferior a la media mundial de 3.96/100 000 habitantes. En promedio, hay 1.3 psiquiatras/100 000 habitantes.
En 22 Estados hay menos de un psiquiatra/100 000 habitantes. No se identificó ningún psiquiatra adscrito al primer nivel de atención y casi la mitad estaba adscrita a hospitales psiquiátricos. Conclusiones En México el número de psiquiatras es insuficiente para atender las necesidades de la población por lo que la opción es, como ha propuesto la OMS, reestructurar la atención a los trastornos mentales. En el modelo propuesto se establece un continuo desde la atención que se proporciona directamente en la comunidad, hasta la que se proporciona en los llamados centros de «alta especialidad», los hospitales psiquiátricos. Este continuo ha sido descrito de manera piramidal, por lo que en la base, en la que se concentran la mayoría de las acciones, está el autocuidado, y en el vértice, la atención especializada.
En esta pirámide de atención, ¿donde deberíamos estar los psiquiatras? A primera vista pareciera que el ámbito natural de actividad del psiquiatra estaría en los servicios de psiquiatría como tales, en el hospital general y en los hospitales de especialidad. Sin embargo, en una estructura piramidal como la descrita, la mayoría de las intervenciones corresponden a la base: autocuidado, atención informal en la comunidad y atención de salud mental por medio de los servicios de atención primaria. Actualmente los servicios de salud mental son extremadamente limitados, especialmente en el primer nivel, donde practicamente no hay psiquiatras laborando en ellos.
- English
The recently modified General Law on Health (Ley General de Salud) establishes in article 74b, section VII, that any individual with mental or behavioral disorders will have "The right to be treated and cared for within his community or as closely as possible to his family's or friends' place of residence"; this leads us to the questions titling this article.
In Mexico, according to the National Psychiatric Epidemiology Survey, 28.6% of the population has presented one of the 23 IDC disorders at some point in their lives. Only one out of 10 patients with a mental disorder had access to specialized care.
One of the most important limiting factors explaining the difference between subjects requiring services and those being provided for is the insufficient number of available psychiatrists. The worldwide mean number of psychiatrists per 100000 individuals is 3.96 (SD 5.94) and their distribution varies from one region to another; they average 0.06 in low–income countries and 9.0 in those with high incomes.
As a medical specialty, psychiatry is relatively new. Not until the XIXth Century did the treatment of mental disorder become part of the medical realm. In Mexico, the teaching of psychiatry as a specialty begins in 1950. In 2010, 137 positions for Psychiatry residency were made available throughout the country: Campeche, Coahuila, Jalisco, Mexico City, Nuevo León, Puebla, Sonora, San Luis Potosí, Tabasco, Tamaulipas and Yucatán. Most openings (and educational venues) providing specialization in Psychiatry are in Mexico City. Regardless, the number of psychiatrists remains scarce and the scope of their activity does not fulfill the World Health Organization's recommendations.
The purpose of this paper was to determine the number and distribution of psychiatrists in Mexico and propose new fields for their activities.
Methods A descriptive, cross–sectional, heterodemic study was conducted. The following data sources were reviewed: the 2008 Directory of the Mexican Psychiatric Association (MPA), the 2008 Directory of the Mexican Council of Psychiatry (MCP) and the II Assessment of Population and Housing (2005).
Results In the Directory of the Mexican Psychiatric Association, 1397 active members were reported. In the Directory of the Mexican Council of Psychiatry, 1430 certified psychiatrists are tallied. We noticed that in total, there are more certified psychiatrists than members of the MPA.
In terms of the second objective, we established that except for Mexico City, the number of psychiatrists vis–à–vis the number of inhabitants is notably inferior to the worldwide mean of 3.96/ 100 000, throughout the rest of the country. In 22 states, there is less than one psychiatrist per 100 000 inhabitants.
Discussion In Mexico, the number of psychiatrists is insufficient to attend the population's needs; hence, as proposed in 2001 by the WHO, the option is to restructure the management of mental disorders via specific actions. In the model proposed for mental health, a continuum is established whereby care is provided directly in the community and progresses into that offered in the so–called "highly specialized" centers, psychiatric hospitals.
This continuum follows a pyramidal pattern whereby the base, where most actions are concentrated, includes self–care and the apex represents specialized care.
Where should psychiatrists be in this pyramidal context? At first glance, it would appear that the psychiatrist's expected activity realm would be within psychiatric services per se, such as in general or specialized hospitals. However, following the described pyramidal structure, most interventions take place at the base: self–care, informal care within the community and mental health care at the primary care level.
It is interesting to mention that in another state, among all certified psychiatrists not one was assigned to primary care and only 18% were active in a general hospital.
In the context of pyramidal care, who will provide the necessary information required for the encouragement of self–care? Informal care in the community refers to that provided by individuals without formal training and that should be trained in order to become the first contact point for patients with mental health issues. Mental health care at the primary care level has been broadly reviewed but the identification of a successful model depends not only on a particular country's circumstances but also on specific regions within that country. Until now, training primary care physicians has not proven to be an effective strategy in increasing mental health care coverage unless they are directly integrated within formal mental health services. An effective strategy is supervision and support of primary care physicians by psychiatrists. A possible schema could include the programming of case reviews and constant feedback to the primary care personnel such as physicians and psychologists.
The community should be at the forefront in terms of the practice of psychiatry. From said position, the psychiatrist can: 1. support self–care and informal care programs, 2. supervise and offer support to primary care providers, 3. provide direct attention to mental health issues requiring specialized attention and 4. act as a link between the different care levels.
A psychiatrist's activities within a general hospital allow: 1. integration with medicine, 2. the appropriate management of non–psychiatric co–morbidities due to more available resources and 3. blunting of stigmatization.
Other forms of care for patients with mental health disorders deserve a paragraph; although their usefulness has been proven they have not been evaluated in our country and their application has not become commonplace. We are referring to daytime hospitalization and homecare provided by a team specialized in the management of crises. These models also require a psychiatrist as part of the team.
The purpose of this study was to provide an overview of the activity of psychiatrists in Mexico without intending to exhaustively review the current situation. Its limitations are obvious since only certified and/or MPA members were included. Although we included all psychiatrists that at some point were certified and not only those with active current certification, it is evident that there are colleagues that belong to neither professional organization although these two include the greatest number of the country's psychiatrists.
- español
