"If I don't get my medication, I will just drink cachaça!"

As part of the Department of Global Health & Social Medicine's internship programme, I was able to get a unique insight into the way mental healthcare was approached and delivered across a variety of city districts in São Paulo.

The benefit for us as social scientists came in the opportunity to compare the Brazilian system to that which we are familiar with, in the UK. Although the Brazilian national health service (SUS) was modelled to a large extent on our NHS, there are key differences in the way mental healthcare is provided and in the kind of cultural barriers to health that must be overcome.

Daniel Mair navigating the São Paulo metro system

Examining the challenges of mental healthcare delivery in Rio de Janeiro

Upon visiting a number of clinics across the city, the structure of the local primary healthcare delivery system soon became clear. Family doctors – who would generally be described as General Practitioners in the British health system – are often not in this position on a permanent basis.

Most have their sights set on a particular specialist field but are completing residencies as family doctors as a necessary step in order to reach these positions. Due to the temporary nature of these positions and the specialist nature of their training, their scope to deal with specific and complex cases in areas such as mental health is understandably limited.

We discovered quickly that this problem is offset by the assistance of psychiatrists and psychologists who attend patient consultations and offer advice and guidance based on their expertise in the field of mental health. Additionally, a weekly meeting is held with family doctors and mental healthcare specialists, specifically to discuss complex cases and to decide the next best course of action.

It transpired that many doctors were filling out repeat prescriptions of antidepressants without any follow-up consultations to measure the patients’ progress and to determine further treatment. This acted in both the patients and the doctors' short-term interest, in that it saved time for doctors, and patients could get their pills with minimal fuss. However, for many years mental health generally did not improve, and patients were not being properly treated.

During one of our visits to the Hospital Universitário Pedro Ernesto (HUPE), we learnt how this issue was dealt with. The medical professionals at the hospital realised quickly that a cut-off point, where medication would be denied to patients unless they attended their consultations, would risk a fall in overall patient adherence.

To avoid this pitfall, a Medication Awareness Group was formed. This group would serve to close the information gap between the doctor and the patient by informing patients of the purposes of taking medication, the risks and benefits, and ultimately give them a better sense of control of their own medical path.

The need for awareness-raising

We had the privilege of sitting in for one of these group meetings, and the need for such awareness-raising about medication became abundantly clear in just the first twenty minutes. Patients did not fully grasp the need for further consultations and did not want to ‘drag up’ painful memories from their past.

The idea of receiving counselling to discuss previous traumatic events was dismissed as irrelevant, as they would rather place their focus on the future. The words of one particular patient epitomised the information gap between patient and doctor in a very succinct way: “If I don’t get my medication, I will just drink cachaça”.

Cachaça being a popular spirit in Brazil, this patient viewed alcohol as treatment just as antidepressants were treatment, with there being little to no understanding of mental health medication as a long-term course of treatment with long-term benefits.

This awareness group now appears to be vital in keeping patient adherence high and to ultimately empower patients to make their own informed choices about their health.

Visiting a mental health stall at the market

The differences between Brazil and the UK

The most striking difference to the system we have grown to know in the UK was the frequency and the way in which group meetings were run to deal with mental health issues. Group sessions were seen not only as a way of engaging the community in understanding and managing each other’s issues, but it was also viewed as a form of treatment in itself.

The sessions created an open space where members could discuss problems of a personal nature, but also those that affected the family or the community. Unlike similar groups taking place in the UK, members were encouraged to respond to each other with songs or poems or even works of art that they felt related to the individual’s issue – and physical comforting was commonplace between patients and with group leaders.

Dr Sandra Fortes, a psychiatrist who kindly showed us around one of the policlinics, highlighted this community spirit by telling the story of a British student in one of the Rio de Janeiro policlinics who offered a suggested course of action in the event a group member breaks down in tears.

Their suggestion: to make sure they are alright before asking them to go to the restroom to compose themselves before re-entering the space. The staff at the policlinic replied that this would result in half of the members leaving the room to console the person, and the other half remaining to reprimand the student for sending the person out in the first place!

This kind of communal sentiment came naturally to all members and was clearly a wider part of Brazil’s more collective culture. In cases such as these groups, this helped to create a very welcome and comfortable environment for members and surely went a long way to improving mental health for the individuals involved.

While in some ways this seems to be a cultural advantage over our own system of dealing with mental health issues, which primarily focuses on private counselling and fewer communal solutions, there can be instances where a group mentality can encroach on the rights of the individual.

It was reported to us that it was very common for doctors to tell family members about a diagnosis of another member of the family without telling the individual in question. It would then be up to the family members as to whether this diagnosis would ever be made apparent to the individual to whom it pertained.

While this appears to be commonplace in Brazil, similar occurrences in the UK would be seen as a tremendous breach of confidentiality and an undermining of the autonomy of the patient. Despite accepting the positive impact that community involvement can have in improving health, especially mental health, these cases still raise the major question of how much control the community should be given over the individual, and at which point individual autonomy becomes overshadowed.

The added value of internships

While on this internship programme, Professor Francisco Ortega, who instructed us while we were there, made sure to also cater to our academic interests outside of the realm of primary mental healthcare.

Francisco kindly introduced me to other academics at the Institute of Social Medicine at UERJ, including Professor Sérgio Carrara who is a pioneer in the field of gender and sexuality research in Brazil. He offered valuable insight into the general health state of queer people living in Rio de Janeiro following studies he conducted on the subject of violence and oppression.

As my dissertation focuses on the overall health and wellbeing of local LGBT communities in both London and Rio de Janeiro, this was extremely useful.

We were also invited to attend a seminar at the Pontifical Catholic University of Rio de Janeiro (PUC-Rio), on the subject of forced migration in Latin America, with particular emphasis on those fleeing Venezuela into the North of Brazil.

Here we learnt about the use of different discourses to describe fronts or borders, the demographics of those who are forced to flee and the kind of mental health issues that refugees are bound to suffer from as a result.

This whole experience can only be described as eye-opening. So much of the theoretical knowledge that I have accumulated over the first two years of my degree in Global Health & Social Medicine began to find its place in real-world examples.

Issues such as retaining patient adherence, balancing family and individual consent, shortening the information gap between patient and doctor; these all seem much more tangible to me now. My respect for the health practitioners who have a daily responsibility over these complex challenges, has increased dramatically. I would highly recommend any student to take full advantage of this internship!