Child and adolescent mental health services in Brazil: structure, use and
               challenges

Santos, Vagner dos; Fernández, Anna

doi:10.1590/S1519-38292014000400002

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Revista Brasileira de Saúde Materno Infantil

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Sumário

ORIGINAL ARTICLES • Rev. Bras. Saude Mater. Infant. 14 (4) • Oct-Dec 2014 • https://doi.org/10.1590/S1519-38292014000400002 copy

Child and adolescent mental health services in Brazil: structure, use and challenges

Serviços de saúde mental para crianças e adolescentes no Brasil: estrutura, uso e desafios

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objectives:

to examine the state of Child and Adolescent Mental Health (CAMH) services and to compare the availability and use of CAMH services across the five regions of Brazil.

Methods:

the Mental Health Matrix Model was used as a framework to describe the state of CAMH services. Documents and administrative datasets were consulted, covering the whole country and the five Brazilian regions as separate levels. This enabled crossregion comparisons and combination with thethree temporal dimensions (Input, Process andOutcome)

Results:

although there are national policies regulating CAMH, along with an integral protection doctrine, scarcity of services was unequally distributed across the regions. A number of trends relating to social development and mental health (e.g. intellectual disability treated prevalence) were also identified.

Conclusion:

substantial advances in CAMH policy characterize the contemporary Brazilian CAMH system, especially regarding the implementa tion of community based mental health services for children and adolescents. However, the data reveals great inequalities and geographic variation regarding social indicators, service structure and use.

Child; Adolescent; Mental health; Mental health services

Temporal dimension
		Inputs	Process	Outcomes
Geographical dimension	Country / Regions	Policies and regulations	Targeting of special groups	Street children and adolescents
		CAPS-II i coverage rate	Data from the system use	Socio-educational measures
		Expenditure	Hospital use	School dropout and failure
		Non-hospital	Out-Care use	Inappropriate Age/Grade
		Hospital		Suicide rate
				Violent death
				alcohol & tobacco -
				lifetime use/dependence

Information collected		Source	Year
Imputs	Policies and regulations	The Brazilian official legislation browser (www4.planalto.gov.br/legislacao)	1989-2009
	CAPS-II i coverage rate	CAPS-II i : 'Mental Health on Data' (Saúde Mental em Dados)	2009
		Population under 18 years: brazilian institute of geography and statistics (Censo, 2009)
		(rate: 1:100.000- total of CAPS-II i /pop under 18 years old)
	Expenditure	DATASUS: Ministry of Health's department responsible for gathering data provided by health services	2009
Process	Non-hospital	DATASUS: Out-care Information System (SIA/SUS)	2009
	Hospital	DATASUS: Hospital Information System (SIH/SUS)	2009
	Targeting of special groups	Final Reports of the National Forum on Child and Adolescent and Official Documents	2004-2009
	Hospital use information	DATASUS: Hospital Information System (SIH/SUS)	2009
	Out-Care use information	DATASUS: Out-care Information System (SIA/SUS)	2009
Outocomes	Street children and adolescents	Information provided by the Ministry of Social Development and Fight against Hunger (by requieriment)	2009
	Socio-educationalmeasures	National Secretary on Human Rights - division on promotion on the Child and Adolescent rights. (rate: 1:10.000 -measures/pop under 18 years old)	2009
	School dropout, failure and inadequecy age/grade	Ministry of Education (Rates provide by the Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira - in relation to the school pop)	2009
	Suicide rate	DATASUS: TabNet: On line database: (http://www2.datasus.gov.br/DATASUS/index.php) (rate: 1:100.000 - casualties/pop under 18 years old)	2009
	Violent death	Brazilian Institute of Geography and Statistics - IBGE- Series (http://seriesestatisticas.ibge.gov.br/) (%=number of violent deaths/total deaths among adolescents aged 15-19)	2009
	Drug abuse	Brazilian Center for Psychotropic Drug Information (CEBRID)	2005
	Drug abuse	(2nd National Survey of Psychoactive Drug Use)	2005

Type	Scope of population	Work schedule	Days	Population target
CAPS -I	from 20,000 up to 70,000 inhab.	8 am - 6 pm	Monday to Friday	adults
CAPS-II	from 70,000 up to 200,000 inhab.	8 am - 6 pm (Extendible until 9 pm)	Monday to Friday	adults
CAPS-II i	over 200,000 inhab.	8 am - 6 pm (Extendible until 9 pm)	Monday to Friday	Child and adolescent
CAPS-II AD	over 100,000 inhab.	8 am - 6 pm (Extendible until 9 pm)	Monday to Friday	people with alcohol and drug consumption problems
CAPS-III	over 200,000 inha	24 hours	24/7, 365 days a year	adults

	Brazil	Regions
	Brazil	North	Northeast	Southeast	South	Central-West
Population under 18 years	62,494 (32.%)^* * %relative to the total population-in million;	6,209 (9.9%)^ %relative to the total populate under 18 years old-in millon;	19,368 (31%)^ %relative to the total populate under 18 years old-in millon;	24,067 (38.5%)^ %relative to the total populate under 18 years old-in millon;	8,241 (13.2%)^ %relative to the total populate under 18 years old-in millon;	4,613(7.4%)^ %relative to the total populate under 18 years old-in millon;
INPUTS
Policies and Regulations Integral Protection Doctrine; Universal Healthcare System; Psychiatric Reform and the Forum Recommendation
CAPS-II i (n)	105	2	27	46	25	5
CAPS-II i coverage rate^a a Calculated based on the availability of CAPS II -i and the population under 18 years old;	0.17	0.03	0.14	0.19	0.30	0.11
Total Expenditure^b b Total expenditure in Brazilian Real, in 2009;	45,798,836.4	1,080,137.66	18,513,861.01	14,791,661.55	8,720,239.9	2,692,936.26
%	-	2.36	40.42	32.30	19.04	5.88
$/Pop under 18 years	0.73	0.17	0.96	0.61	1.06	0.58
Outpatients	37,502,501.38	895,989.97	16,779,682.37	11,571,273.08	6,434,844.86	1,820,711.51
%	81.9	82.9	90	78.2	73.7	67.6
Hospital	8,296,334.59	184,147.69	1,734,178.64	3,220,388.47	2,285,395.04	872,224.75
%	18.1	17.1	10	21.8	26.3	32.4
PROCESS
Targeted groups CA living under some process of institutionalization, such as shelter, reformatory, psychiatric institutions, and so forth
Hospital Use (SIH)∞
Admissions (n)	13,510	361 (2.7%)	2,531(18.7%)	5,402 (39.9%)	3,813 (28.2%)	1,403 (10.4%)
Relative number admission^□ □ Number of admission/Pop. Under 18years*1.000;	0,21	0.06	0.13	0.22	0.46	0.30
Diagnosis registered (%)
Organic mental disorders	6.0	11.8	4.94	7.90	3.96	5.63
Substance Abuse	40.91	9.97	27.02	34.19	59.98	47.97
Schizophrenia. Acute psycho,	29.41	46.81	51.80	27.45	15.71	29.29
Mood [affective] disorders	11.13	17.73	6.40	11.18	13.64	10.91
Neurotic. somatoform disorders	1.6	3.32	0.79	1.83	1.55	1.85
Behavioral syndromes	1.2		0.79	1.87	1.0	0.21
Disorders of adult personality	1.74	1.11	1.15	2.94	1.05	0.21
Intellectual disability	6.5	8.59	6.80	10.44	2.12	2.14
Dis, of psychological development	0.67	0.83	0.24	0.94	0.42	1.07
CA Behavioral and emotion disor,	0.24	0.28	0.04	0.46	0.05	0.29
Unspecified mental disorder	0.52	0.28	0.04	0.78	0.52	0.43
Outpatients Use (SIA)^∞ ∞ Relative to the attribute cause of attention in the year of 2009 according with ICD-10; (E)Elementary School; (H)High School;
Outpatients (n)	6,556,003	137,235 (2.1%)	1,691,814 (25.8%)	3,409,944 (52.1%)	1,028,087 (15.6%)	288,953 (4.41 %)
Diagnosis registered (%)
Organic mental disorders	0.39	1.88	0.91	0.11	0.23	0.53
Substance Abuse	2.15	2.55	2.29	1.07	5.36	2.57
Schizophrenia. Acute psycho,	80.43	79.48	64.24	90.81	72.04	83.13
Mood [affective] disorders	2.29	7.86	3.10	0.80	5.24	2.14
Neurotic. somatoform disorders	2.36	2.51	4.32	0.96	3.89	2.12
Behavioral syndromes	0.30	0.16	0.78	0.05	0.30	0.44
Disorders of adult personality	0.12	0.22	0.22	0.04	0.22	0.11
Intellectual disability	3.35	3.42	9.60	0.83	1.86	1.88
Dis, of psychological development	4.13	0.30	6.19	3.44	4.04	2.30
CA Behavioral and emotion disorders	3.86	1.63	7.32	1.55	5.89	4.79
Unspecified mental disorder	0.61	0	1.02	0,35	1.03	0
OUTCOMES
Socio-Educational Measure^≈ ≈ Rate-1:100.000;	2.71	1.75	1.88	3.51	3.51	2.82
Admission	1.9	1.19	1.25	2.56	2.08	1.88
Provisional admission	0.56	0.38	0.46	0.61	0.66	0.74
Conditional parole	0.25	0.19	0.17	0.34	0.27	0.2
School^Σ Σ Rates provided by the Ministry of Education;
Dropout rate (E)	3.7	6.2	6.2	1.7	1.6	3.1
Dropout rate (H)	11.5	16.4	16.4	7.4	9.2	12
School failure (E)	11.1	13.5	13.8	8.7	10.9	9.5
School failure (H)	12.6	10.6	9.3	14.8	14.1	13.9
Inappropriate Grade/Age (E)	23.3	33.2	31.6	15.9	17.9	21.6
Inappropriate Grade/Age (H)	34.4	48.5	45.1	26.4	25.9	33.9
Suicide rate^≈ ≈ Rate-1:100.000;	1.03	1.36	0.88	0.62	0.62	1.97
Violent death (%)^‡ ‡ %based on the total death of the population aged 15-19 years;	60.	46.97	57.18	73.29	73.29	61.34
Alcohol & Tobacco ^* ***** Based on the population aged 12-17 years.
Lifetime prevalence of alcohol use	54.3	25.5	43.6	60.8	58.8	55
Dependence alcohol	7	2.9	6.5	6.3	6.5	7.7
Lifetime prevalence of tobacco use	15.2	17.9	9.6	15.3	21.3	18.4
Dependence tobacco	2.9	5.5	0.5	3.3	3.6	2.5

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[1] Adapted version of The Mental Health Matrix Model; CAPS= Community Psychosocial Centers.