62 INTERNATIONAL JOURNAL OF MENTAL HEALTH

62
Rafael Seplveda is the head of Psychiatry at the Barros Luco Hospital, professor of psy-
chiatry at Universidad Mayor, and senior lecturer at the School of Public Health, Faculty
of Medicine, University of Chile, Santiago, Chile. Jorge Ramrez is a specialist in public
health at the Mental Health Department, Ministry of Health, Santiago, Chile. Pedro Zitko is
an epidemiologist at the Research Unit, Barros Luco General Hospital, Santiago, Chile. Ana
Mara Ortiz is an occupational therapist at Barros Luco General Hospital, Santiago, Chile.
Pablo Norambuena is a psychologist at the Mental Health Department, Ministry of Health,
Santiago, Chile. lvaro Barrera, MRCPsych, M.Sc., Ph.D., is a consultant psychiatrist at
Oxford Health NHS Foundation Trust, Oxford, England. Cecilia Vera is a psychiatrist and
head of the Outpatient Psychiatry Department, Barros Luco General Hospital, Santiago,
Chile. Eduardo Illanes is a psychiatrist and deputy head at Barros Luco General Hospital
Psychiatry Services, Santiago, Chile.
International Journal of Mental Health, vol. 41, no. 1, Spring 2012, pp. 6272.
2012 M.E. Sharpe, Inc. All rights reserved. Permissions: www.copyright.com
ISSN 00207411 (print)/ISSN 15579328 (online)
DOI: 10.2753/IMH0020-7411410105
RAFAEL SEPLVEDA, JORGE RAMREZ, PEDRO ZITKO,
ANA MARA ORTIZ, PABLO NORAMBUENA,
LVARO BARRERA, CECILIA VERA,
AND EDUARDO ILLANES
Implementing the Community Mental
Health Care Model in a Large Latin-
American Urban Area
The Experience from Santiago, Chile
ABSTRACT: This article outlines the development of the Barros Luco General Hos-
pitals Psychiatry Service since its creation in 1968. Initially, some historical and
political background is provided followed by a description of how our service has
endeavored, over the last 10 years, to put the community mental health care model
into practice. Subsequently, we describe the growth of a network of locally based
mental health services. Another process running in parallel has been the acquisi-
tion, by the local primary care teams, of skills that have enabled them to manage,
on an ambulatory basis, patients with severe and enduring mental illness. In this
regard, some data are provided in order to illustrate the effect of the changes that
are taking place, including a reduction in the proportion of emergency psychiatry
consultations at the casualty department. Finally, current and future challenges are
SPRING 2012 63
discussed, including the need for a mental health law, clinical governance issues,
and the provision for people with developmental disorders and those with highly
complex mental health needs.
Mental and neurological disorders are a signifcant public health problem world-
wide. It is estimated that they account for 23.2 percent of the burden of illness in
Chile [1]. In the face of this epidemiological reality, the patchy and largely insuf-
fcient provision of mental health care led the World Health Organization (WHO) to
emphasize the importance of countries to develop consistent mental health services
[2]. In order to provide a framework to undertake such a task, WHO has proposed
some guiding principles that mental health services development should follow,
specifcally, the so-called community care model has been advocated because it
ensures that patients needs are at the center of the service development. The com-
munity mental health care model emphasizes the importance of services being
located close to where patients live with a range of services available to people
with mental and behavioral disorders, including alternatives to hospital admission,
such as home treatment and access to acute inpatient care as well as local accom-
modation placements for patients that require more prolonged residential care. The
model also emphasizes the importance of treatments and support being tailored to
the individuals needs as well as clinicians working with and addressing the needs
of caregivers. Similarly, clinical interventions must consider not only symptomatic
remission, but also should address any associated disabilities with close collabora-
tion between mental health professionals and community resources. Finally, last but
not least, the provision of mental health care must take place within the context of
an effective legal framework [3]. Services delivered along these lines are considered
by WHO as providing community mental health care [4].
In the case of Chile, with the creation of the National Health Service in 1952,
the country saw a gradual and signifcant improvement in the health standards of
its population, becoming one of three countries in Latin America and the Carib-
bean region with improving health care indicators [5]. However, at the time of
the return to democratic rule in 1990 after 17 years of military dictatorship, the
nations mental health service was in a deplorable condition, even more so than
the other areas of health care [6]. Since then gradual and signifcant changes in
the provision of mental health care in Chile have taken place, and these changes
have attempted to follow the above-mentioned model of community mental health
care advocated by WHO. Initially, some changes started to occur between 1990
and 1996 [7], but their scope increased with the momentous publication of the
National Plan of Mental Health in the year 2000 [8], which provided a route map
for the work and efforts of mental health professionals over the following decade.
The gradual implementation of the National Plan of Mental Health encouraged
the transition from mental health care revolving around the four large psychiatric
hospitals located in the geographical center of the country to a network of regional
mental health services distributed around the country (Figure 1). It goes without
64 INTERNATIONAL JOURNAL OF MENTAL HEALTH
saying that this change in itself has led to improvements in peoples access to mental
health care [9]. Currently, each one of the main regional hospitals has general psy-
chiatry services that are embedded in a network of mental health community services
as well as primary health care units [10]. Unfortunately, these changes in the way
mental health care is provided in Chile have not been adequately communicated or
documented. We believe that more detailed knowledge of these processes may be
helpful both for those who are just preparing to embark on such changes as well as
for those who are already in the process of change. The present article describes the
development of psychiatric services in the south of Santiago, Chiles capital city,
where we have at least tried to follow the community mental health care model.
The Barros Luco General Hospital in Southern Santiago, Chile:
Some History and Context
The Santiago South Health Service currently provides services for almost 900,000
people who live in eleven communes, and it includes thirty-one primary care cen-
ters and seven community hospitals with the Barros Luco General Hospital being
the largest hospital providing specialist (secondary and tertiary) medical care. For
decades, and following the priorities set at the foundation of the National Health
Service in 1952, the focus of the Barros Luco General Hospital centered on the con-
trol of infectious diseases as well as improvements in maternal and child health. In
other wards, mental ill health was not at the top of the agenda at the time. Psychiatric
Figure 1
Stages of Developmental Psychiatry Service, Barros Luco General Hospital,
19682009
SPRING 2012 65
services centered on alcohol-related disorders as well as on psychotic disorders; the
care and treatment of the latter focused around large national asylums.
The above situation started to change in 1968 when Professor Juan Marconi and
his team of academics, clinicians, and residents moved from the University of Chile
to southern Santiago, a move probably not unrelated to the process of radical reform
that the University of Chile itself was going through at the time. Professor Marconis
team moved from northern Santiago, where most of the university and public sector
mental health facilities were concentrated, to the southern half of the city, which
did not have any resources at all up until that year; the newly arrived team started
their work both in the outpatient department of the Barros Luco General Hospital
as well as in a primary care center (the Santa Anselma Centre) [11]. Refecting on
their own practice and experiences of engaging with a local community, highly
organized and politically aware, this group of academics and professionals started
to develop what they called the intracommunity psychiatry model (ICPM). The
ICPM was built upon and encouraged community health education and peoples
participation in the defnition of the priorities and the development and implemen-
tation of interventions through what was called a pyramid of delegation. Briefy,
the pyramid of delegation ensured that the interventions, emphasizing health pro-
motion, self-care, and early detection, reached a very wide audience in the local
communities. The pyramid consisted of fve levels, starting at the bottom with the
learning community (D5) level and at the top with the individual responsible for
the program (D1) [12]. Remarkably, the psychiatrists trained within the program
acquired a clear community mental health ethos, and in fact, some of them would
subsequently go on to play an important role in the development of Chilean mental
health. Professor Marconis work, his ICPM, as well as the work of his team are
still widely acknowledged in Latin America.
In 1973, a military coup interrupted the countrys democratic tradition and
established a dictatorship that lasted until 1990. The political conditions that
followedhuman rights violations, drastic reduction of the size of the state and
public spending, massive unemployment, and social breakdownmade it impos-
sible to work on a model that, like the ICPM, emphasized community engage-
ment and participation. In that context, Professor Marconis team had no option
other than to limit their work to what became the Barros Luco General Hospital
Psychiatry Service (henceforth, the service). Thus, the service functioned for 17
years basically as an outpatient department in which the opportunities of collabo-
ration amongst professionals of secondary and primary care were very restricted,
not the least because of the political environment. One of the frst victims of this
process of withdrawal into the walls of the hospital was, of course, continuity of
care. The result of this was that an increasing number of patients became caught
in what could be described as chronic ambulatory psychiatric care, a veritable
form of institutionalization not very different from that inficted on people by large
psychiatric asylums. Because not many patients were discharged from the service,
it became increasingly diffcult to assess and treat new patients. In fact, for long
66 INTERNATIONAL JOURNAL OF MENTAL HEALTH
periods, the main activity delivered by the services staff was to intervene during
the postcrisis period of an acute episode of mental ill health and the subsequent
repetition of prescriptions with very limited clinical reviews [13]. In terms of staff
numbers, there was also a reduction over the years so that in 1989 the service had
one nurse, one occupational therapist, two psychologists, seven psychiatrists, one
nurse assistant, and one secretary, resources that were utterly insuffcient to meet
the mental health needs of the local population.
With the return to democratic rule in 1990, the new local authorities tried to start,
not without diffculties and errors, addressing the above situation. In particular,
two actions revolving around reestablishing the contact between secondary and
primary care units were of particular importance. One step focused on alcohol-
related and emotional disorders with a view to trying to control the fooding of
secondary care level facilities by patients whose needs were best met at the primary
care level. An associated step was to start a gradual process of referring the above-
mentioned chronic ambulatory psychiatric patients back to the primary care level
with a view of getting them back into their natural local health care network. This
process was actively implemented and, despite the limited resources available,
some of the psychiatrists started working directly with the primary care teams both
to help them to foster their clinical skills to manage the newly received patients
as well as to provide as needed direct clinical care for the more complex primary
care patients. It was this modality of care, developed out of necessity, that led us
to envision the initial stages of the psychiatric consultation model that would later
become a distinctive feature of the relationship between primary care and mental
health secondary care in Chile.
While some of these changes were taking place, Chilean public opinion became
outraged in 1993 as the media disclosed the extreme neglect suffered by residents of
a publicly funded private residential unit. The authorities responded to this scandal
by somehow increasing the resources allocated to mental health. It was within that
context that the service was able to make some developments, such as emergency
admission beds, psychiatrists working at the Accidents and Emergency department,
and the treatment and rehabilitation of addicts at the community level. Subsequently,
the launch of the Day Hospital in 1999 was followed by, in 2002, the relocation
of the psychiatric outpatient department to a new diagnostic center along with the
other medical and surgical specialties. This setting made it possible to start offering
a variety of services to the patients. In 2003, change and development continued
with newly formed community psychiatry teams and the opening of a new acute
inpatient unit in 2004 [13]. Thus, the service has developed a multifaceted profle
as the countrys largest general hospital-based psychiatry service.
Current Situation
The service currently provides mental health care for adults above 18 years of age,
including people with addictions, with the staff levels described in Table 1. The
SPRING 2012 67
services include an outpatient department, a twenty-eight-bed acute inpatient unit,
a day hospital for twenty patients, a rehabilitation unit serving twenty patients, and
an outpatient alcohol and substance dependence unit for twenty patients. Moreover,
there is a psychiatrist providing cover 24 hours a day/7 days a week at the hospitals
Accidents and Emergency department. In 2009, there were 14,000 consultations
(including emergencies) as well as 336 discharges from the acute inpatient unit
with an average length of stay of 27 days [14]. We will next briefy outline the
components of the service.
Outpatient Department
This department is organized around community psychiatry teams [15], each of
which is in charge of delivering care to the population of its commune within a
model of shared care [16] in close liaison with the districts primary care provid-
ers [17]. These teams run outpatient clinics as well as regularly visit the primary
care centers, providing psychiatric consultation for the primary care teams. The
psychiatric consultation model involves supporting primary care teams to develop
their skills in managing both patients with severe and enduring mental illness who
are currently stable or those patients who, although unwell, have not yet reached
the threshold for referral to secondary care. In 2010, affective disorder (bipolar
disorder and depressive disorder) and schizophrenia and other psychotic disorders
accounted for just over 70 percent of the patients seen in the psychiatry outpatient
department.
More recently, outpatient care has started to be transferred from the community
psychiatric teams (made up of South Santiago Health Service staff) to district-based
community mental health teams (made up of district/council staff); this has taken
Table 1
Barros Luco General Hospital, Psychiatry Service Staff, 1976 and 2011
Staff
Staff numbers Hours per week
1976 2011 1976 2011
Psychiatrists (within hours) 2 14 66 220
Psychiatrists (out of hours) 0 6 0 168
Nurses 0 8 0 352
Psychologists 5 11 220 286
Occupational therapists 1 10 44 330
Care assistants 2 16 88 704
Health care assistants 0 13 0 572
Administrative staff 0 5 0 220
68 INTERNATIONAL JOURNAL OF MENTAL HEALTH
place in two districts so far. The district-based community mental health team aim
is to try and deal with mental ill health affecting people of all ages with the ex-
pectation that they will refer to the secondary care level unit (henceforth, referred
to as the service) only those more diffcult, more severe, or treatment-resistant
patients (for whom the day hospital, the hospital inpatient unit, and the psychosocial
rehabilitation unit will be available).
Day Hospital
The day hospitals work has developed as an alternative to hospital admission, pro-
viding comprehensive care for patients with acute mental ill health. Its functioning
has prevented hospitalizations and has also reduced the length of the admissions
to the hospital. The day hospital team has acquired experience over time in terms
of psychosocial interventions in families with high expressed emotion as well as
in the psychoeducation of patients. It has been observed, in accordance with the
literature, that these interventions have had a positive effect on the course of the
illness as well as promoting patients autonomy and self-care, medication concor-
dance, and engagement with psychosocial rehabilitation.
Rehabilitation Department
This department evolved from the gardening and woodwork workshops that were
part of the existing services at the El Peral psychiatric hospital, one of two large
psychiatric hospitals in Santiago. The workshops initially evolved into a program
that supported the employment of ffty patients as part of the Barros Luco Hospital
staff with jobs such as couriers, administrative staff, and cleaning. Unfortunately,
patients tended to remain in the same post for long periods, which led to the system
being unable to provide more placements for new patients. When the situation
was critically reviewed, it was decided to increase the professional input to it as
well as to emphasize the transitional nature of the hospital posts and the need to
support patients to move toward competitive employment. The results of this new
approach have been encouraging, with 120 people having obtained and maintained
competitive employment posts.
Acute Inpatient Unit
This is a twenty-eight-bed unit with bedrooms of up to three beds each that are
managed according to the patients gender and clinical needs. In 2010, affective
disorder (bipolar disorder and depressive disorder) and schizophrenia and other
psychotic disorders accounted for just over 75 percent of the patients admitted to
the unit. The current average length of stay is twenty-seven days, which has recently
increased because of the prolonged stays of patients with developmental disorders
whose needs are not yet provided for by other services.
SPRING 2012 69
Teaching and Training
Importantly, signifcant teaching and training takes place at the service, including
that of general adult psychiatry trainees as well as medical, nursing, psychology,
and occupational health students. It is worth mentioning the general adult psychia-
try training program of the Universidad Mayor medical school, which is unique
in that it is being developed and embedded within the community mental health
care model [18].
Some Evidence of the Effect of the Implemented Changes
The structure described earlier has resulted in a reduction in the demand for emer-
gency psychiatric care at the Barros Luco Hospitals Accident and Emergency de-
partment [19, 20]. Just over 70 percent of patients requiring emergency psychiatric
care at the Accident and Emergency department come from the hospitals catchment
area, but the rest of the patients come from adjacent areas that have less developed
mental health community services. The proportion of emergency psychiatry patients
consulting at the Barros Lucos Accident and Emergency department coming from
its allocated catchment area compared to emergency psychiatry patients coming
from the adjacent catchment area has consistently dropped over the last 5 years
(down from 4.27 to 3.02 during the period). We interpret this fall in the ratio as
suggesting a preliminary positive impact of the implementation of the community
mental health care model with the associated close work between the service (i.e.,
the secondary care level) and the primary care level of this catchment area. Although
these fgures may in part be accounted for by defciencies in data collection, it is
our view that they support the above point, that is, the effectiveness of the commu-
nity mental health care model to at least reduce unmet needs and therefore reduce
unplanned emergency psychiatric consultations. Similarly, some evidence seems to
suggest that implementing the model has also been associated with a reduction in
the number of acutely unwell patients attending the day hospital [21]. Specifcally,
the day hospital sees fewer acutely unwell schizophrenic or bipolar patients and has
been able to provide support to patients with severe depressive episodes, personality
disorder patients in acute crisis, and patients with comorbid disorders (i.e., dual
diagnosis). At any rate, there are a considerable number of patients with highly
complex unmet psychosocial needs who remain a signifcant challenge [22] and who
until recently probably had no access to services at all. In particular, we have faced
an increasing number of patients with comorbid psychoses and substance misuse,
comorbid signifcant learning disabilities and substance misuse, and patients with
organic brain damage and severe behavioral disturbances. Many of these patients
did not come to the attention of services because their families and/or government
agencies had given up on them; they suffer a high degree of social exclusion and
are highly vulnerable, and some of them pose a high risk to others. Our approach
to these patients has included elements of promoting engagement with services,
70 INTERNATIONAL JOURNAL OF MENTAL HEALTH
building continuity in their care, providing psychoeducation to their relatives and
caregivers, and incorporating them into rehabilitation. Some preliminary evidence
appears to indicate that these efforts may be improving their outcomes [23].
Over the last 2 years, the service has started to gather evidence regarding the impact
of the community mental health care model. In order to do that, a multidisciplinary
research unit has been created with input from a psychiatrist, public health specialist,
psychologist, occupational therapist, and epidemiologist. It is expected that this unit
will be able to provide evidence regarding the cost-effectiveness of the services work.
Its main aims are to gather data to quantify the changes in terms of readmission rates
and emergency consultations, and to develop instruments to map how the model is
being introduced in the different areas of the services catchment area.
Challenges Ahead
We envisage three challenges that will need to be addressed in the near future.
First, the service, as any complex organization, has at times been torn between
the need, on the one hand, to develop different departments and expertise and, on
the other hand, the need to ensure the continuity of care, an essential part of the
community mental heath care model. This is a creative tension that we hope will
provide energy to the growth of the different teams. Second, we need to continue
transferring skills and responsibilities from the secondary level unit (the service)
to the district-based community mental heath teams while at the same time the ser-
vice develops its skills and expertise to allow it to care for more complex patients.
These two related processes will necessitate changes in the way the local primary
care level and the community at large deal with an increasing number of patients
who will require more long-term and specifc care and support. Third, we need to
be able to gather reliable data at the different levels of the model to demonstrate
cost-effectiveness; this is a crucial issue if we are going to persuade authorities
and skeptics that beyond the values that underpin the community care approach to
mental health it also offers value for money. Finally, we hope that by addressing the
above challenges the service will become a center of training and innovation that
makes it possible for the model to be adopted in other regions of our country.
Conclusion
Regardless of whether the Barros Luco General Hospital has promoted the de-
velopment of the community mental health care model or it has been gradually
colonized by the ideas and practices of that model, our service aspires to be part
of a mental health care network that goes beyond what is strictly considered health
care and, in collaboration with the wider community, promotes recovery from and
fghts the stigma associated with mental illness. We are aware that our service faces
signifcant challenges ahead and that further growth and development are required
not the least in terms of human resources and quality of the care delivered. Simi-
SPRING 2012 71
larly, we realize that further local progress will depend on clear leadership from the
central government, in particular providing evidence-based and patient-centered
policies and also making sure that such policies are consistently implemented across
the country. Finally, we believe that a mental health law that regulates the practice
of clinical psychiatry at all levels will be crucial if the quality of care is going to
improve, dignity and rights of patients are going to be protected and promoted, and
the stigma associated with mental illness is going to be defeated.
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