ORIGINAL RESEARCH

Family health strategy: mental health care actions

Stefânia Mendonça da Silva^I; Antônio Maurício da Silva^II; Adriano Rodrigues de Souza^III; Ana Débora Assis Moura^IV; Guldemar Gomes de Lima^V; Aline Rodrigues Feitoza^VI

^I Nurse of the Santa Casa de Misericórdia of Fortaleza. Graduated from the University of Fortaleza. Ceará, Brazil. E-mail: stefaniaunifor@gmail.com
^II Nurse of the Santa Casa de Misericórdia of Fortaleza. Graduated from the University of Fortaleza. Ceará, Brazil. E-mail: mauricio-souzza@bol.com.br
^III Nurse. PhD in Public Health. Professor at the University of Fortaleza. Ceará, Brazil. E-mail: adrianorsouza@gmail.com
^IV Nurse. PhD student in Public Health. Technical Adviser of Immunizations of the Department of Health of the State. Fortaleza, Ceará, Brazil. E-mail: anadeboraam@hotmail.com
^V Nurse. Specialist in Family Health from the School of Public Health of Ceará. Fortaleza, Ceará, Brazil. E-mail: guldemar@gmail.com
^VI Nurse. PhD in Nursing. Professor at the University of Fortaleza. Brazil. E-mail: alinerfeitoza@hotmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.16926

ABSTRACT

Objective: to examine the mental health care activities performed by primary health care teams at a facility in Fortaleza, Ceará, Brazil. Method: in this qualitative, descriptive study, data was collected in April and May 2013 by semi-structured interviews of seven Family Health Strategy personnel. The data was treated by thematic content analysis. The ethics committee approved the research project (CAAE:13435713.2.0000.5052). Results: personnel were found it difficult to provide care to the mentally ill for lack of time in their schedule, lack of training, as well as challenges in implementing matrix support. Conclusion: provisions and action strategies need to be deployed with technical, ethical and humanistic competence in order to enable Family Health Strategy personnel to provide health care to patients with mental disorders.

Keywords: Mental health; family health; health care (public health); nursing.

INTRODUCTION

Since the Psychiatric Reform in Brazil in the mid-1970s, the country has undergone great changes with respect to the care of patients with psychic suffering. The family health program (FHP) was implemented as an innovative and change-provoking strategy of the municipal health systems, causing an important reorganization of the care model used by the Unified Health System (SUS). Thus, more rationality in the use of care levels was sought, and positive results in the main health indicators of the populations assisted by the family health teams have been produced¹.

In recent decades, there has been a significant increase in the coverage of the family health strategy (FHS) in primary care (PC), and in the new substitutive services in mental health, resulting from the Sanitary and Psychiatric Reform processes. At the same time, mental disorders have been found to represent a significant portion of the demand for PC².

The FHS has as goal to contribute to change the care model for individuals in psychological distress, establishing a further strategic and adequate space to work with mental health. The FHS seeks to establish links between teams and the community in the search for health promotion and education actions with a view to implementing the process of deinstitutionalization advocated by the Brazilian Psychiatric Reform movement.

Practice and knowledge in the Mental Health field have been transformed with changes in the way of conceiving and treating people with mental disorders and in the creation of new community-based treatment devices ³.

In this sense, the matrix support in Mental Health is structured with the objective of promoting the interlocution between specialized mental health services, such as psychosocial care centers (PSCC) and primary care, in a joint action with primary health care (PHC) units ⁴.

Based on this context, the objective of this study was to analyze the mental health care activities developed by the teams of a PHC unit in Fortaleza, Ceará, Brazil.

LITERATURE REVIEW

The Brazilian Psychiatric Reform began with the reformist movement of the workers of the National Division of Mental Health (NDMH) in 1978, when they denounced the poor welfare conditions of Brazilian psychiatric hospitals, putting the psychiatric policy of the country into question⁵. The proposed reorientation of the care model for patients with mental suffering and the de-hospitalization process created the perspective of modifying care structures for these subjects, thus instituting the extra-hospital structures that should be provided to individuals discharged from psychiatric hospitals and provide a filter against new hospitalizations⁶. The construction of an innovative mental health policy is therefore outlined, which offers a diversity of strategies of attention to people suffering from psychic disorders⁷.

This care has been provided through several devices, among which stand out the nuclei and the PSCCs: local/regional units; therapeutic residences; day hospitals; the federal back home program; and the matrix support process, which integrates family health teams and psychosocial care in the follow-up of individuals with mild psychic problems⁸.

This structural diversity of services emerges to direct professional practices according to the psychosocial model, which values ​​interdisciplinary characteristics based on professional responsibility and structured therapeutic link to assist individuals in a comprehensive manner, the promotion of psychosocial rehabilitation and the guarantee of rights of citizenship⁹.

METHODOLOGY

This is a descriptive study with a qualitative approach. The research was carried out in a PHC unit located in the Regional Executive Secretariat VI (RES VI), in Fortaleza, Ceará. Data collection took place between April and May 2013. The research subjects were seven professionals from this unit (three physicians, three nurses and one dentist).

The letter I (Interviewee) followed by random numbers (I1 ... I7) was used to identify the subjects. The selection of participants was based on their involvement in the researched reality, and its final composition was defined by data saturation.

Data collection took place in a single and private room. All interviews were recorded, after authorization of the participants.

The organization and processing of the data was based on the content analysis technique. The thematic categories were: the experience with mental health in the FHS; and mental health: facilities and obstacles.

After data classification, the categories were articulated with the context in appropriate literature. The study respected the ethical precepts and was approved under Opinion nº 316.139, CAAE: 13435713.2.0000.5052.

RESULTS AND DISCUSSION

Seven professionals participated in the research - three physicians, three nurses and one dentist. Four of them were specialized in the area of ​​collective health; the dentist had a specialization on prosthesis; and the other two participants were enrolled in master courses.

The variety of professional categories and multi-disciplinary knowledge made it possible to perceive that the dismantling of the mental asylum as the only model for the care of people suffering from psychological disorders has been incorporated into the new services which have the characteristics of hosting, care and social exchange. The PC is part of this process, providing mental health actions grounded on the principles of the SUS and the Psychiatric Reform, having the networking within the territories as a structural foundation.

The experience with mental health in the FHS

The monitoring of people with psychological distress in the primary care is marked by difficulties and absence of specific service hours for this population. Another factor identified is the absence of experienced professionals, or the lack of training. In the reports obtained, it was noted that the experiences of working with people suffering from psychic disorders were limited.

In our area, there is no qualified training to approach these users. (I2)

Even among the professionals who had received training or performed some activity in the area of ​​mental health, we observed that these were short actions, short courses and/or joint activities with the matrix support team.

I took a weeklong course, morning and afternoon, in the Regional hospital. After that, I had lectures and mini courses with the psychiatrist, once a week, and then it started to be once a month in the Regional hospital. (I1)

Our team provided this service, on Mondays, with the group of doctors and residents who use to come from the Messejana Mental Hospital. (I2)

Among the activities developed, it was observed a predominance of care focused on pharmacological treatment. There were no reports of therapeutic groups or alternative treatment and follow-up activities for these clients.

The interventions still recommended for the users represent a partial care. The initial approaches are replaced by immediate resolutions of transfer and referral to specialized units, mainly to the PSCC.

When I receive mental disorder patients, such as depressive patients, I evaluate them and refer them to the general practitioner of the unit. (I4)

Professionals should recognize that mental health care demands are the responsibility of all levels of complexity, especially primary care, since this is the gateway to the system. Therefore, it is necessary to receive and support these users, not necessarily on a specific day or following a flow of care.

The non-absorption of the psychiatric demand by the health units tends to direct this demand to the services of secondary level, causing long waiting cues in the specialized hospitals¹⁰.

We have several programs for each day of the week now; it is unfeasible to fit another activity. The programs are already determined, making it difficult to separate a specific day. (I5)

It is easy to observe the low availability of time and the excess of demand to justify the non-realization of consultations to individuals suffering from psychological disorders.

Mental health: facilities and obstacles

The activities developed and resulting in greater resolution were carried out by specialized professionals or by those who had some affinity with the theme. The unit under study counted on the collaboration of a psychiatrist who developed activities of matrix support. The presence of this professional promoted the interaction and the provision of service by the teams to the patients.

My experience in the health care center happens from the matrix support action that we do within the regional VI. This is where we take the residents to have this experience, providing a referral service to general doctors and training the team, so that over time they can handle minor cases. (I3)

The matrix support is configured as a specialized technical support of reference to the FHS teams. It is based on the hosting and assistance to attend the cases of psychological suffering and on the presuppositions of psychosocial care recommended by the Brazilian Psychiatric Reform in order to broaden its field of action and qualify its actions. It can be performed by professionals from various specialized areas^11-15.

The experience with matrix support brought learning that surpassed the exchange of knowledge between teams. There has been a movement of recognition of what the others do, and consequently, appreciation of each one's capabilities¹².

The hosting and bonding in the PC are guiding axes in the assistance. This is especially true in the case of patients with mental disorders, because bonding and qualified listening are intervention tools that ensure comfort, access and accountability, and provide them humanized care.

The user that receives this care in the unit feels accomplished, without the need to look for professionals in another place, where it is much more difficult, as they have to go through long waiting cues and screenings. (I2)

Thus, because there are professionals who facilitate and provide the care for people suffering from mental disorders, others omit this care, referring the patient to another professionals or another municipality without solving the problem.

As I have no experience, I refer to the general practitioner or the next unit. (I5)

When professionals face the impasse of receiving a person in mental suffering, they refer him to a PSCC, revealing a scenario in which the care of people suffering from psychological disorders ends up exclusively on the hands of specialized services¹³. What is interesting is that patients are first hosted in the primary care network, but what happens is divergent: patients are referred to specialized services and often unnecessarily. However, it is easy to see that many obstacles prevent the access to services by these users. One of the first causes mentioned is the excessive demand in the FHS, which often exceeds the possibilities of adequate care, especially to a population that does not fit the characteristics of this service.

What we see is that the family health teams are already overwhelmed with FHS programs, having difficulty to adapt this service, without any free time in the team's agenda. (I3)

Another factor recognized was the issues related to mental health care that mobilized concerns on the part of the interviewees regardless of the functional nature in the team. Such concerns were expressed from the sense of unpreparedness to lack of confidence to deal with psychic suffering.

Mental health preparation for public health ends up being very poor. And without qualification, I'm very insecure to approach a query. I feel insecure, due to this lack of preparation and also lack of time. (I5)

The lack of training and qualification of the professionals in the unit, as generalist doctors and nurses, limit them from providing a more qualified service. (I6)

In spite of courses and opportunities for permanent education offered in the area of ​​mental health in the city of Fortaleza, there is a shortage of training related mainly to crisis management, interpersonal relationships and therapeutic instruments, which are considered as fundamental requisites for mental health work in the PC¹⁰.

Another precursor of the reported problem is the lack of integration of the health network with the nucleus of family health support (NFHS), an indispensable ally of this service chain, which can help in the conjuncture of new activities and implementation of other therapeutic modalities.

The NFHS was created in the country in 2008 aiming to integrate, strengthen and expand the actions developed in the PHC. As a support team, it offers specialized back up to family health teams and uses matrix support as the main strategy for work development^14-15.

The NFHS was abolished by the current management in the municipality, further disturbing this service. Therefore, there was a dismantling of the SUS principles, generating a lack of integral and holistic care to this population.

When there was the NFHS at the health center, despite the difficulties, we were able to make some groups of women, groups of psychological attention, and then I used to identify to which area I should send the patient; if it was for the psychologist, occupational therapist, and there we had this link with them. (I3)

Another very negative problem is that the NFHS was closed; they used to contribute to social group activities. (I7)

Despite the weaknesses, the matrix support action exists as a tool for integrating mental health with the FHS and the NFHS. The matrix support has the potential to allow the construction of new work processes that call into question the need to hold more practical and theoretical knowledge and information on mental health, valuing the multi and transdisciplinary approaches, and questioning the traditional training in this care area ¹⁰.

Matrix support in mental health operates innovative practices and focuses on multidisciplinary action. It represent an integral health care, recognizing the psychosocial field as an indispensable focus in all care and promotion actions, requiring managerial, clinical, ethical and political competences that prioritize the participation and articulation of all professionals. The construction of an integrated health network provides mechanisms favorable to the transformation and overcoming of the fragmented assistance, enabling an integral care, which seeks to promote the health of the individuals, families and communities at various levels of care.

CONCLUSION

We found that the experiences of FHS professionals working with people suffering from psychic disorders limited. We also observed a lack of training in this area.

The matrix support action, despite a recent practice, has already provided advances and innovations in mental health care in the FHS. However, the inclusion of mental health is still something to be organized, with greater investment by managers in human and structural resources, and professional training, towards the articulation of an integral service network and provision of assistance to social demands.

The experiences of the professionals while working with the matrix support action in a health unit revealed the need of practical and dynamic actions to guarantee effective care. Therefore, it is necessary to put into practice the public mental health policies, using these devices and strategies of action with technical, ethical and humanistic competence to overcome the exclusionary model of intervention aimed at people suffering from psychic problems.

Among the limitations of this study, it is important to emphasize that there is a lack of research in the literature on the operational aspects of matrix support action. This is in fact a constant challenge for the discussion of the subject in relation to its applicability. Still, a single scenario and the reduced set of participants prevent the generalization of the findings.

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