Abstinence, anti-drug psychosocial care centers and therapeutic communities: pillars for reorienting the Brazilian Mental Health and Drug Policy

To overcome problems such as crowded psychiatric emergency departments, insufficient psychiatric hospital beds, and substitute services in mental health, the Brazilian Government has dedicated itself to expanding and equipping the psychosocial care network: psychiatric hospitals, day hospitals, specialized outpatient services, anti-drug psychosocial care centers (CAPs AD IV), and therapeutic communities.^1,2 Its aim is to increase financing and the number of psychiatric hospital beds, as well as to ensure provision of all effective treatments for severe refractory mental disorders, including electroconvulsive therapy, which although controversial politically, is considered efficacious in the medical/scientific community.² It is also taking a firm stand against drug legalization and discrimination, developing treatment strategies based not only on damage reduction, but on abstinence, social support, and health education. Abstinence strategies are intended to keep patients away from drugs.^2,3 These initiatives aim to reduce the estimated 23 million Brazilians who require psychiatric assistance, as well as the 75 to 85% of Brazilians with mental disorders who do not have access to good quality psychiatric assistance.⁴

In the global context, Brazil cannot ignore the 2019 United Nations World Report about Drugs,⁵ which highlighted the expanding illicit drug market, including record production of cocaine and opium and the approximately 275 million drug consumers worldwide. Cannabis was cited as the most consumed drug, with 192 million consumers in the last year. Daily drug-related deaths worldwide have increased 60%. The prevalence rates of inhaled and smoked cocaine in Brazil suggest that it has one of the highest rates of annual consumption and is one of the largest cocaine markets in the world.⁶

Heckert et al.⁷ investigated the prevalence of mental disorders among the homeless of Juiz de Fora, a city of 424,479 inhabitants in southeastern Brazilian. Among people aged 18 or older who had been homeless for at least 12 months, 100% had at least one psychiatric diagnostic according to the ICD-10. The most frequently diagnosed disorders were alcohol addiction/abuse (82.0%), mood disorders (32.5%), drug addiction/abuse (31.3%), and schizophreniform psychosis (9.6%), with high comorbidity index (78.3%). These results were ascribed to the nationwide weakness of the homeless assistance system.

The phenomenon of what have been popularly called “Cracolândias” (Cracktowns), i.e. outdoor drug consumption scenes, has been expanding since 1989. One such area in São Paulo was studied by Duailibi et al.,⁸ who determined that Brazil is the biggest crack market in the world. There are 370,000 regular drug users living in the 26 state capitals and the Federal District. Approximately 80% of these drug users have consumed drugs in public places like Cracolândias, the oldest and more populous of which is in the city of São Paulo, with 500 residents and more than 2000 regular visitors.

The new actions and guidelines on mental health and drugs unveiled since December 2017 have promoted a paradigm shift in assistance. Remarkable new points have been incorporated due to worsening indicators, such as increasing suicide rates, high rates of mental disorders among the homeless, the growth of Cracolândias, and increasing numbers of incarcerated severely mentally ill patients.

The creation of a new model of CAPs AD IV, which operates 24 hours a day/7 days a week and provides specialized psychiatric, clinical, and multi-professional care, should be highlighted. These psychosocial care centers are to be located near areas of outdoor drug consumption, i.e. areas with higher social vulnerability.

The approval of Law 13,840/2019⁹ provided for, among other things, the involuntary hospitalization of drug addicts for detoxification when other therapies provided by the health care network are impossible. It should be emphasized that this type of psychiatric hospitalization lasts only the time necessary for detoxification (a maximum of 90 days), and the family or a legal representative can interrupt treatment at any time.

Therapeutic communities to support recovery from drug use are a meaningful alternative for patients with mental and behavioral disorders due to drug consumption. These patients often report a lack of options and overcrowded emergency departments, which results in a significant number who must wait for psychiatric committal. Therapeutic communities, voluntary social institutions that provide shelter to drug addicts, are regulated by the National Drug Policy Council (Conselho Nacional de Políticas sobre Drogas, CONAD) Resolution 01/2015.¹⁰ Treatment in these shelters is transitory and can range from 12 to 24 months, depending on psychiatric diagnostic evaluation.

The Pan American Health Organization advises that health systems have not yet adequately responded to the burden of mental disorders, indicating that there is a great distance between the needed and the provided treatment worldwide. Poor treatment quality is another serious problem in health systems. Beyond health services support, people with mental disorders need help to access education programs adapted to their needs and to find jobs and housing so they can lead active lives in their local communities.⁴

Law 13,819/2019,¹¹ which instituted the National Policy for the Prevention of Self-harm and Suicide, highlights self-inflicted violence and makes it compulsory to report knowledge of it. One of the law’s purposes was to inform and sensitize society about the importance and relevance of self-harm/suicide as a preventable public health issue.

Accordingly, and considering the legal, cultural and scientific aspects involved in the formulation of a new national policy on mental health and drugs, Brazil seems to be progressing toward more acceptable and practical treatment of people with mental and behavioral disorders.

Disclosure

The authors report no conflicts of interest.