Servicios de salud mental: veinticinco años de investigación
- Autores: María Elena Medina-Mora Icaza, Shoshana Berenzon Gorn, M. Asunción Lara Cantú
- Localización: Salud mental, ISSN 0185-3325, Vol. 26, Nº. 5, 2003, págs. 61-72
- Idioma: español
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- Dialnet Métricas: 1 Cita
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Resumen
- español
El propósito de este trabajo es presentar una revisión de las investigaciones que sobre servicios de salud mental se han realizado a lo largo de veinticinco años en la Dirección de Investigaciones Epidemiológicas y Psicosociales del Instituto Nacional de Psiquiatría Ramón de la Fuente (INP). Las áreas de investigación han sido muy diversas, incluyen encuestas de hogares, estudios en poblaciones específicas, como niños de la calle, adolescentes, mujeres, población rural y usuarios de alcohol y drogas. También se han desarrollado proyectos de investigación enfocados a conocer las trayectorias curativas seguidas por pacientes con trastornos mentales y/o el uso de servicios alternativos.
Servicios de salud y adicciones Las encuestas en hogares han permitido conocer las tendencias de utilización de servicios por la población que presenta problemas relacionados con el consumo de drogas. En las diversas mediciones se ha observado que las personas que consumen drogas y alcohol se apoyan principalmente en familiares, amigos o ministros religiosos. Por el contrario, la asistencia a servicios especializados es muy baja; en la medición de l988 fue de 5% y en 1998 sólo ascendió al 6.1%.
El Sistema de Registro de Información en Drogas (SRID) ha proporcionado información sobre casos detectados en centros de salud e instituciones de procuración de justicia. Aproximadamente 60% de los casos registrados provienen de instituciones de salud y 40% de instituciones de procuración de justicia. Gutiérrez y Vega han estudiado a los niños y niñas que subsisten en la calle y consumen sustancias y han encontrado que los recursos para atender a esta población presentan importantes deficiencias. Los factores que subyacen al fracaso de las intervenciones son: la existencia de metas poco realistas y una percepción fragmentada del problema.
El consumo de drogas en mujeres también ha sido estudiado. Los resultados de diferentes investigaciones han demostrado reiteradamente que existen escasos programas diseñados para atender las necesidades de las mujeres adictas. Natera y colaboradores, se han interesado en conocer las barreras que impiden a los familiares buscar ayuda para atender los efectos físicos y psicológicos de tener que enfrentar el consumo de drogas en algún miembro de la familia.
Los servicios de atención a la salud mental Se han realizado diversas encuestas de salud mental, tanto nacionales como locales. Los resultados de estas mediciones han reflejado que los familiares y amigos, la automedicación y los sacerdotes o ministros religiosos constituyen el primer recurso de ayuda. Del mismo modo, se ha visto que es muy baja la utilización de servicios especializados en salud mental. Un patrón similar se ha observado en estudios realizados con poblaciones específicas como mujeres y grupo rurales.
En el INP existe una larga tradición en el estudio de las necesidades y demandas de atención tanto en el primer nivel como en los servicios especializados en salud mental. Se ha observado que la población se dirige en su primera solicitud de ayuda, al médico general, pese a lo anterior, un alto porcentaje de los casos no son detectados, y mucho menos referidos a tiempo, lo que eleva el costo de la atención.
Los datos aportados por las encuestas han servido de base para realizar investigaciones en servicios alternativos. Los principales estudios se han llevado acabo con grupos de Neuróticos Anónimos, templos espiritualistas Trinitarios Marianos, y médicos tradicionales. También se han evaluado los caminos seguidos por los pacientes psiquiátricos en busca de atención. Entre los principales resultados se observa que la población combina y prueba diferentes opciones médicas construyendo múltiples alternativas y estrategias para la búsqueda de salud
- English
The aim of this article is to present a review of the studies on mental health services conducted over the past twenty-five years by the Head Offices of Epidemiological and Psychosocial Research of the Ramón de la Fuente National Institute of Psychiatry (INP) and to propose further lines of research to be developed in this field.
Health services and addictions The study of the types of care needed and the characteristics of the use of services among the population that abuses substances has been an area of interest at INP. The Institute has information drawn from surveys, the Drug Information Registration System and studies focussing on specialized services. It also has results obtained from specific populations such as women and teenagers and groups that are difficult to reach, such as street children and cocaine users.
Since 1974, INP has conducted a series of household surveys that has shed light on trends in the use of services by the population with drug-related problems. Several studies have shown that drug- and alcohol-users rely mainly on relatives, friends and ministers of the Church. The use of home remedies and self-medication are also common. Conversely, users rarely seek specialized services. In the 1988 survey, a mere 5% of this population sought the latter, a figure that had risen only slightly to 6.1% by 1998 (59, 57, 30).
The main aim of the Drug Information Registration System (SRID), in operation since 1987, is to evaluate trends in the use of psychoactive substances, identify the changes that have occurred and estimate the trajectory of use. Approximately 60% of the cases reported came from health institutions and 40% from penal institutions. The main reason why the former had been admitted to health centers was to receive treatment, whereas the latter had been sent to penal institutions as a result of crimes involving robbery or damage to health (39,40,41).
The information provided by SRID has served as the basis for conducting studies that analyze in greater depth the characteristics of services designed to deal with problems of drug dependence.
One example of this is the project carried out to study the patterns of cocaine use, associated problems and perceptions and attitudes towards treatment services (37).
Other research projects have been designed to assess or analyze the way specialized services operate in the treatment of addictions. Two examples of this are the Center of Assistance for Alcoholics and their Relatives (CAAF) (61, 62, 35) and the Alcoholics Anonymous movement (AA) (49, 44, 50, 51).
For over a decade, Gutiérrez and Vega have studied children that live on the streets and consume substances and they have found that the resources available for dealing with this population are extremely limited. The lack of success of the interventions implemented can be attributed to unrealistic goals, a fragmented perception of the problem and therefore of its solution and failure to consider the perceptions and needs of the children whom these programs are intended to benefit (16, 28, 63).
Since the early 1990s, the study of drug use among women has attracted the attention of a group of INP researchers. The results of various studies have repeatedly shown that there are hardly any programs specifically designed to deal with the needs of female addicts (45, 46, 47, 27, 31, 32). The few types of treatment offered at specialized centers only cover part of women’s needs. For example, patients undergo detoxification or receive pharmacological treatment, while others problems are ignored (27).
Natera, Mora and Tiburcio (34) analyzed the obstacles that prevent relatives from seeking help to deal with the physical and psychological effects of having to cope with a family member’s drug use. On the basis of the information obtained from 100 interviews, the authors observed that only 50% of the interviewees had sought some kind of assistance while only 20% had found it useful. The reasons for failing to seek assistance were related as much to cultural values and norms as to the lack of financial resources, fear, shame and lack of information.
Mental health care services The information presented below is drawn from household surveys and studies on populations attended at the primary health care level and in mental health service facilities. It also analyzes research conducted on special groups such as children, teenagers, women and the rural population and studies focussing on issues such as curative trajectories and the use of alternative services.
As part of the 1988 National Survey on Addictions, a mental health survey was carried out on a fifth of the urban population selected (n=2,025). The results of this study show that friends and relatives constituted the first source of help (54%), followed by self-medication (15%) and priests or ministers (10%). Only 5% resorted to general medical services, while a similar percentage used centers specializing in mental health. The main reasons for not requesting assistance were lack of knowledge about the services, prejudice towards the latter and lack of time and financial resources (27). Similar results were reported in subsequent surveys (7,9,10,29).
INP has a long tradition of studying the needs and demands for care at the primary health care level. The earliest projects focussed on the adaptation, modification and standardization of instruments used for detection and diagnosis (2,11). These instruments subsequently permitted the detection of psychiatric disorders among the population that made appointments to see their local GP. The most common disorders were depression and anxiety (26, 42, 22, 3). Subsequent studies have shown that although the population initially seeks help from a GP (27, 29, 14, 8), a high percentage of cases are not detected, far less referred in time, which in turn increases the cost of care (23, 42, 43).
Since 1978, studies have been undertaken to determine the characteristics of specialized mental health services. The earliest studies showed that the main reasons for a patient’s admission were relapses caused by discontinuing treatment, the inability to survive on their own and aggressiveness (12, 52). In 1992, a national survey was carried out on 4,539 hospitalized psychiatric patients (6). In general, almost half the cases could be treated as outpatients.
The use of health services by the child and adolescent population has been studied by Zimmerman and collaborators (64) and by Caraveo and collaborators (10). The first two studies showed that there is a low perception of mental health care among children and youth and that even less formal assistance is provided.
The use of services by the female population has also been widely studied. Results have shown that women tend to seek professional help because of emotional disorders whereas men do so because of problems related to alcoholism and drug dependence (43). Data yielded by various studies show that friends, relatives, priests or ministers and home remedies are the main resources used by women (27, 59, 29, 53). Very few women seek specialized mental health care services. The main reasons why women do not seek them are that they do not feel anyone can help them, they are ashamed to talk about their problems and they do not know where to go.
Snyder and collaborators have found that although the presence of emotional malaise such as depression or “nerves” is common among the female rural population, there is a lack of specialized services in rural settings. Consequently, women resort to other sources of support such as friends or relatives, priests, local healers and self-medication (53, 54, 55).
Data yielded by various surveys have served as the basis for carrying out studies to analyze the characteristics of alternative services in greater depth. The main studies have been carried out with groups of Neurotics Anonymous (25), spiritualist churches such as the Marian Trinitarians (24) and traditional doctors (1).
The paths followed by psychiatric patients in search of care have also been evaluated. One of the most striking results is that in comparison with other countries, Mexico shows the greatest lag between the emergence of symptoms and the first attempt to seek help. As for the characteristics of the trajectories followed, people resort mainly to their GPs, traditional doctors, healers or ministers and priests (15,5).
Discussion The information reviewed in this article highlights the need for further research on treatment, prevention and health promotion programs. Studies should include an analysis of various related factors such as the beliefs, attitudes and behavior of patients and providers, the type of disorder involved, the complexity of the therapeutic regime, the system of service provision and certain determinants of health and mental illness.
- español
