Latin America and the Caribbean (LAC) recently celebrated 30 years from the Caracas Declaration, which, in 1990, set forth the principles to transition from hospital-based mental health care into community mental health services . Since then, significant efforts have been made to reduce the number of psychiatric hospital beds, increase mental health teams within general hospitals, integrate mental health into primary care, implement outpatient mental health facilities, and encourage the participation of community members in the provision and implementation of mental health care . Nonetheless, progress has been uneven across countries . Many large psychiatric hospitals (PHs) still exist and consume most of the scanty national mental health budgets . Moreover, PH residents in LAC were poor and socially excluded even before the COVID-19 pandemic hit. The COVID-19 pandemic has worsened the living conditions of these people, especially in resource-constrained settings.
LAC is one of the most affected regions by the pandemic, with large countries, such as Brazil, Mexico, and Peru, reporting the highest death rates per capita worldwide . Moreover, the Pan-American Health Organization (PAHO/WHO) has reported considerable disruptions in the delivery and quality of mental health services, which will likely have lasting effects on PH residents. In this commentary, we describe the situation of PH before and during the COVID-19 pandemic in LAC. We then address current and future challenges for supporting PH residents, including inequalities in the distribution of COVID-19 vaccines for this population. Our knowledge on this topic is based on regional reports and input from policymakers, local health authorities, and members of PAHO/WHO.
Before the pandemic
PHs are still the main mental health facility in LAC. Out of 39 LAC countries, only seven did not have a PH in 2017 . Despite PAHO/WHO recommendations, these kinds of health facilities absorb over 60% of the total budget allocated for mental health services and about 97% of inpatient facilities’ budget . Moreover, more health professionals (e.g., psychiatrists, nurses) work in PHs compared to outpatient clinics. For instance, for each mental health provider in outpatient services, on average, there are 1.4 working in PHs .
Furthermore, there is still a stark difference between the proportion of psychiatric beds in PHs (4.3 per 100,000) compared to other inpatient services such as psychiatric wards at general hospitals (1 per 100,000). Recent data show that over 30% of PH residents have been hospitalized for more than a year, and, in some cases, more than 5 years . Globally, LAC is the region with the longest stays in PHs compared to other WHO regions . Due to a lack of regulations on coercive measures (e.g., involuntary hospitalizations), several PH residents were at a high-risk of mistreatment and human rights violations before the COVID-19 pandemic. Additionally, many PH residents were older people, who were, on average, in poor health and had various risk factors (e.g., chronic physical conditions) for COVID-19.
During the pandemic
On June 3 2020, WHO director, Dr. Tedros Adhanom, declared that COVID-19-related cases and deaths in LAC were rising faster than in other countries, a pattern that has been sustained since then. As of December 2020, the LA region accounted for 1/3 of all COVID-19 cases globally and 34% of COVID-19 related deaths, and this was before the devastating current wave . This huge outbreak has caused a significant disruption in the organization of health, social, and educational systems, seriously affecting the delivery, quality, and extent of mental health care and related services. Most LAC countries declared that mental health and psychosocial support were part of their national COVID-19 response. However, only 7% (2 of 29) of these countries have fully funded their mental health response .
Increased rates of COVID-19 cases have been reported among PH residents in several LAC countries [6, 7]. Moreover, in countries such as Brazil, El Salvador, Guatemala, and Mexico, people with COVID-19 have been treated in PHs, increasing the odds of spreading the virus among residents and staff. For instance, 100 out of 355 PH residents from Bolivia tested positive for COVID-19, and among them, 14 died . Unfortunately, as vaccines for COVID-19 begin to roll out, we are not aware of any LAC country prioritizing this group. In fact, due to global (e.g., lack of support from high-income countries and international pharmaceuticals) and local (e.g., social exclusion) inequalities, the reach of COVID-19 vaccines among PH residents is likely to face serious barriers in LAC.
Furthermore, in some PHs, communication between inpatients and their significant others (e.g., relatives) has been disrupted, increasing the feelings of isolation among residents. Moreover, continuity of care from PHs to outpatient services has also been affected. As of November 2020, outpatient services in general hospitals were partially or fully closed in 13 out of 26 LAC countries (50%). Further, 11 of 28 LAC countries (39.3%) have reported disruptions in diagnostic and laboratory services, which are essential for monitoring antipsychotic use among people with severe mental illness .
This situation requires short- and long-term actions by local governments and other institutions. The former includes developing guidelines on how to proceed when a resident is infected; screening of PH residents prior to admission and during their hospitalization; ensuring physical isolation in case of residents with suspected or confirmed COVID-19; improving competencies among PH staff to manage physical illnesses related to COVID-19; and monitoring potential human rights violations. However, these actions are unlikely to be fully implemented, especially in large, crowded PH where physical distancing is virtually impossible. Hence, long-term actions are warranted and should entail substantial transformations of mental health services in LAC, to develop person-centered, human-rights-based mental health care. These long-term transformations need to be started now and continued once the COVID-19 pandemic is under control.
Challenges and opportunities
The COVID-19 pandemic will have lasting effects on PH residents in LAC. Moreover, due to pervasive social inequalities and systematic discrimination, the reach and uptake of COVID-19 vaccines might be limited among these individuals. We encourage high-income countries (where most vaccines are produced) and LAC governments to mobilize resources for vaccines and prioritize this population. Additionally, due to the profound disruptions of the mental health system, it may take years until outpatient and other inpatient services, such as wards in general hospitals and daycare hospitals, will be fully functional again. Many people may end up in PHs due to a lack of a better alternative.
However, this disadvantageous scenario may offer a unique opportunity, as seen in previous natural disasters and emergencies , to reorganize mental health systems in LAC, by developing an integrated network of health and social services that is able to effectively and sustainably replace traditional psychiatric hospitals . As seen in several LAC settings, the care of patients requiring short- and mid-long admissions can be successfully provided by other mental health facilities, especially psychiatric units in general hospitals and halfway homes for those who do not have available caretakers. Therefore, the existence of PHs is as this point unwarranted. Moreover, the reforms to PHs should have taken place decades ago, but now, considering how vulnerable the PH population is to COVID-19 pandemic, and no doubt future pandemics, implementing these reforms is imperative and a matter of human rights. While we acknowledge that several governments and agencies from LAC have started to recognize the disadvantageous PH residents' situation and have recommended several of the aforementioned short-term measures, we firmly believe that more should be done for those living in PH.
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The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.
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Mascayano, F., Alvarado, R., Martínez-Viciana, C. et al. 30 years from the Caracas Declaration: the situation of psychiatric hospitals in Latin America and the Caribbean prior, during and after the COVID-19 pandemic. Soc Psychiatry Psychiatr Epidemiol 56, 1325–1327 (2021). https://doi.org/10.1007/s00127-021-02100-1