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Acta Médica Costarricense

versão On-line ISSN 0001-6002versão impressa ISSN 0001-6012

Acta méd. costarric vol.55 no.3 San José Jul./Set. 2013



Mental health panel 2011, conclusions and future steps

Javier Contreras-Rojas1 y Henriette Raventós1,2

Authors ‘affiliations:

1Research Center in Cellular and Molecular Biology, University of Costa Rica. 2Biology School, University of Costa Rica. *  


Background: Health is a social process that seeks physical and mental wellbeing through every stage of the individual’s life. In spite of great efforts, in Costa Rica the approach to mental health has focused on treatment and very little on prevention and promotion. This work summarizes the conclusions of the Mental Health Panel.

Methods: Adiscussion forum on mental health with participation of health providers, researchers, policy makers and users of health services.

Results: Representatives from 148 organizations and institutions participated. There is a lack of salutogenic indicators and minimal assessment of the impact of prevention and promotion of mental health. Only one program for psychosocial rehabilitation was identified.

Conclusion: The discussion process included users, who, along with other actors identified needs and priority action areas. The difficulties related to the implementation of a specific action plan are the main barrier to achieve effective mental health promotion, treatment and rehabilitation.

There are specific programs, but in the majority of cases, their effectiveness is unknown. It is necessary to establish a leading institution and strengthen its role to ensure the success of a national mental health program.

Keywords: National Mental Health Program, Caja Costarricense del Seguro Social, nongovernmental organizations.

It can be said that health, as a state of complete well-being through the stages of life, is not possible without a healthy, economic, cultural and social environment that includes coverage of basic needs (employment, housing, food, education, recreation).1 There is consensus that the healing model is inefficient, expensive, and produces less wellness than the promotion of prevention.2 The traditional model of medical care (physician-centered) has proven to be inefficient; the patient assumes a passive and irresponsible attitude of his condition, which makes difficult the prevention and control of mental illness. The alternative model includes the addition of three strategies: prevention and health promotion, care and rehabilitation.

1. Prevention and promotion: the individual is the main actor, a subject with rights, but also duties on their own health. Education empowers a person to acquire the compromise on his health.3 The State, in turn, is responsible for ensuring the rights of a job, housing, education, food, health services and a social and work environment free of violence and environmental pollutants. In childhood it is especially important to have a healthy environment, protective factors such as immunization, hygiene and adequate food, and guidance from parents and other adults in charge of the care and formal education.

2. Attention: the user must participate in the process of diagnosis and treatment; he must have full information about his disease, treatment options, the natural history of the disease and indicators that allow early recognition of a decompensation. All people should have access to prompt diagnosis, modern pharmacological and non-pharmacological treatments, evidence-based care and non-institutionalized attention, that is less restrictive of their liberties.4 Ideally, these resources should be available at the community level.

3. Rehabilitation: chronic mental illness (organic psychoses, schizophrenia and bipolar disorder), with an onset in adolescence or early adulthood, usually leads to some level of impairment or disability. The deterioration is less if a proper and prompt treatment is established since the first outbreak, that further may decrease the intensity and frequency of decompensations. Long periods of hospitalization and confinement also increase the deterioration.5 Rehabilitation includes strategies that ensure family involvement and that allow an adequate social reintegration.

Costa Rica has strengths in the field of public health, such as the existence of social security system that covers almost the entire population, mental health programs focused on children and adolescents, and an extensive network of outpatient services and brief hospitalization in general hospitals. However, according to the Report of the Evaluation of the Mental Health System in Costa Rica (WHO 2008), there are significant weaknesses in health mental issues.6

Some mentioned are: 1. the National Mental Health Plan has no funding; 2. poor awareness and empowerment of health teams; 3. attention mainly based on a pharmacological approach; 4. insufficient human resource trained in mental health; 5. 3% of national health expenditures designated for mental health in the CCSS, 67% is for the two psychiatric hospitals and the remaining 33% for other health services and prevention activities; 6. lack of updated prescription drug protocols 7. poor mental health training in primary care; and 8. lack of planning and research in mental health, so there is a big gap in knowledge about the epidemiological profile of mental disorders in the country.

The final report of the specialty in psychiatry, conducted by the CCSS Internal Audit in 2010, identifies specific mental health needs.7 It recommends the following to the medical management: 1. to perform a situational diagnosis of the major mental illnesses nationwide; 2. to adjust the Institutional Plan on Mental Health to what is established by the Ministry of Health in the National Health Plan; 3. to create a strategic timetable for the implementation of this action plan; 4. to develop guidelines of the procedures for psychiatric care at all three levels, 5. to make a disclosure schedule and training plan for the three levels based on these guidelines, 6. according to the Executive Decree No. 20665 -S (October 29th, 1991 ), in which psychiatry is declared as the fifth clinical specialty, to prepare a technical study to assess the availability of human, technological and economic resources for mental health; 7. to assess the appropriateness of removing the hierarchical dependence of psychiatry from the Chief of the Medicine Department, 8. to develop a strategy to strengthen regional mental health services in order to comply with the Declaration of Caracas.8 9. to update the projections defined in the document “Needs of Medical Specialists for the Costa Rican Social Security” (CENDEISSS ). 10. through the participation of the Direction in Development of Health Services, to perform a technical study of the feasibility of extending the time in each psychiatric consultation, 11. to coordinate the country.

Currently, various efforts are undertaken, that are aimed at promoting and improving mental health. The draft of the Mental Health Policy is based on the following principles: intersectoral and interagency coordination, allocation of institutional resources as required; updating the legislation, extending coverage to different levels of participation, development of specific action plans; rights approach, risk, gender and diversity, permanent learning team of mental health awareness campaigns to combat stigmatization, increasing the number of mental health professionals, research and impact assessment.

This article aims to present the discussions on mental health issues, taking into account the feedback provided by other equally important stakeholders. In addition to the participation of the State authorities and service providers, it has the participation of patients and families. It briefly describes the methodology of the Forum and the conclusions are discussed, as exposed by the participants.


A forum for consultation and discussion on mental health was organized with the participation of different actors among which are: 1. providers of care, support and rehabilitation 2. researchers 3. persons who define the policies at governmental level, and 4. users and their families through several non-governmental organizations (NGOs). This discussion was held at the headquarters of the Inter-American Institute of Human Rights (IIHR) located in Los Yoses, Montes de Oca, on October 10, 2011, moderated by Dr. Henriette Raventos Vorst, a researcher at the University of Costa Rica.

The goal was to identify gaps in knowledge about the situation and mental health interventions in Costa Rica, and strategies that would improve the quality of life of this population. Table 1 illustrates the process performed.


The forum was attended by 148 representatives of various institutions and organizations. Table 2 summarizes the institutions and organizations represented in the activity.

This document is the second draft mentioned in point 2, which is the working tool for the development of a preliminary action plan. Table 3 summarizes the barriers identified and the possible solutions raised by attendees. Following the recommendations of various international organizations, the findings are grouped according to the health strategy to follow.


As stated by the executive director of IIHR in Costa Rica (Roberto Cuellar Martinez, MD), “the mental health is the basis of ethics of freedom.” There are international treaties ratified at national level, which, in general, guarantee the protection of human rights and the right to health. However, the Defender of the People of Costa Rica (Ofelia Taitelbaum Yoselewich, MSc.) recalls “the ratification is not enough if there is not a national commitment to establish a program of local action, including policies for the prevention, promotion, treatment, social reintegration and reduction of stigmatization.” There are vulnerable populations that are exposed to greater exclusion and inequality, and that you should pay more attention, such as women, indigenous population, economically disadvantaged groups, sexually diverse populations and persons infected with HIV.

Sisy Castillo Ramírez, MD (Viceminister of Health) and Mary Rose Madden Arias (IIDH), mentioned that there are still legal gaps, for example, the Law against Workplace Bullying. Other laws also necessary are those that ensure equal rights for all citizens (for example, laws for corporate cohabitation of same-sex couples, for the regulation of biomedical research, monitoring of tabaco advertising, and in vitro fertilization). In some cases, the existing laws lack additional legal instruments (for example: regulations) to ensure its implementation.

Examples of interventions in prevention and promotion

Among the interventions discussed are: 1. Prevention of drug use (IAFA), 2. Protocols for the prevention of violence in schools (Ministry of Education), 3. Community care of the elderly (National Hospital of Geriatrics and Gerontology Dr. Raúl Blanco Cervantes), 4. Management of moral and workplace bullying (MS), 5. networks for preventing minors in psychosocial risk (Saint- Exupéry Foundation), 6. other interventions such as yoga, art and dance. The only programs that mentioned measurements to determine the impact of the intervention are the drug use prevention programs of IAFA and the networks for preventing minors in psychosocial risk of the Saint- Exupéry Foundation. But only Saint- Exupéry Foundation showed the results. The IAFA still has no data since the first evaluation will be until 2012. Members of the National Police Academy denounced, “the poor training received by the security forces on mental health issues and the absence of protocols to follow when caring mental health related situations.” In the police there are myths about the approach of people with any mental disorder, and it seems that there is not a direct line of communication between officials and institutions like the IAFA and the CCSS.

Prevention and promotion strategies

To set the priority promotion strategies that can be scaled for prevention and promotion, we recommend: to make a list of all interventions being undertaken by different organizations, including but not limited to CCSS, ministries, IAFA, National Children´s Board (PANI), UCR and NGOs; to document the results of such research in order to measure the impact and compare their effectiveness according to cost/benefit issues, and to create/designate an entity with leadership to centralize information from different sectors/ organizations. To have an inventory of the current actions is essential to avoid duplication of efforts and to make more efficient the use of the resources. A specific example, such as school dropout prevention, is also vital to ensure proper growth and access to opportunities. A healthy environment, free from violence, harassment, insults (for example drugs, smoking and other environmental pollutants), is extended from the home, community, school and workplace.

Examples of interventions in care

The approaches of the Costa Rican Foundation of Bipolar Disorder (FUCOTBI) and the Costa Rican Association of Recurrent Affective Disorders (REFINE) were presented. Both NGOs provide care for people with mood disorders (for example psychoeducation for patients and family members, individual and group psychotherapy). They also conduct education campaigns through formal and informal means, whose goal is to reduce stigma. Concrete actions were presented, but no instruments are designed to measure its impact. It was also mentioned that care activities undertaken by NGOs are limited to the Central Valley.

The public manifested the following complaints about public services in mental health care: difficulty in getting transportation for a decompensated patient from home to the medical center; the general practitioner has insufficient training or sensitivity for the detection, diagnosis and treatment of such diseases, treatment for adolescents that onset on drug abuse is poor, there is little support for caregivers of the elderly with dementia, the outpatient psychiatrist consultation at the CCSS lasts only 15 minutes, the access to new psychotropic drugs is limited, and these drugs often must be purchased privately, and the availability of psychotherapy in most centers is very limited.

Intervention strategies in attention

To set the priority strategies in the axis of care for people with neuropsychiatric illness, it is essential to have the opinion of the user and family.9 These can provide vital information regarding their needs and expectations of attention at the social security level. Training of primary care level in the diagnosis of mental and behavioral disorders should also be improved. More training at the primary level will allow earlier and better timed diagnosis, that will reduce the risk of complications. Increased efficiency in the management of these patients at primary and community level would decrease the burden of dating in psychiatric services, which is a practical measure to address the current lack of specialists.10These actions should follow international recommendations and algorithms for priority treatment of mental illness. An implementation plan that includes impact measurement is required. Finally, it should be analyzed in a reasonable time, the effectiveness of the proposed changes, and an effective promotion intervention to increase coverage. A possible solution is that impact studies are carried out on a pilot basis by NGOs and then that the CCSS assumes the obligation to implement them if they prove to be successful.

Stigma is the main reason why individuals do not seek professional mental health care.11 Fear of being labeled as “crazy”, makes people not receive early help, the diagnosis is delayed, the disease takes a more torpid course, and there is an increase in management complications and a worse overall prognosis. In other countries, education (both patients and families, and the general population, mental health issues ) and exposure of disadvantaged groups (in this case mental patients) are the most effective measures to combat the stigma.12 In Costa Rica an educational plan that involves mass media and that reaches most of the population is required. More empowered and better self-esteem patients have more chance to fight for their rights, ensuring a better quality of life. Psychotherapy in all its forms should accompany drug therapy. Other complementary therapies that may be incorporated in care include: zootherapy, dance therapy, yoga therapy, art therapy (these are discussed in more detail in the next section).

Examples of interventions in the rehabilitation axis

The day hospital service at the National Psychiatric Hospital presented its program for behavioral, physical and cognitive rehabilitation, which aims to achieve the highest level of performance and autonomy of the individual. This trains people in activities of daily living, coexistence, cognitive and behavioral changes, and the development of job skills. The program was able to significantly decrease the number of people held for long periods in the hospital. The need for intermediate homes, shelters, supportive families and single households to return the user to their community was raised. A job management program, which is intended to form a union, and to achieve a greater impact on the process of reintegration. The AyApresented a program of employment opportunities for people with disabilities, in which physical disabilities with little mention of mental disabilities are emphasized.

It is noted that the only existing rehabilitation program is confined to a hospital room in a single medical center. This makes access to remote areas and users can create resistance in patients with negative experiences at the center. Also unveiled complementary therapies based on interaction with dogs, dance, art, yoga and voice in radio. These are relatively recent forms that do not yet have impact measurement in between.

Intervention strategies on the shaft rehabilitation

In addition to the feedback provided by relatives and patients, it is recommended that these programs are accessible to people around the country. It should important to use the existing community facilities such as educational or religious centers. Social reintegration with more or less autonomy, that depends on each case, must ensure the possibility of obtaining work and haousing.13 It is considered that employability will enhance with information campaigns to reduce stigma and educate employers on the necessary adjustments to people with disabilities or mental illness. Education in general should seek to eradicate myths about people with mental illness, to change the view of the family, the community the media and the same health personnel. It is important to develop training programs to improve the skills of this group and to achieve greater competitiveness in the labor market. In terms of housing, the feasibility of having families, supportive homes or intermediate shelters should be explored.

Mental health is inseparable from the health and general welfare of the people. The most effective strategies are, in general, health promotion, which are collective obligations within an ideological framework of the country, where all citizens have access to a healthy environment, education, housing, food, employment, recreation, so they can carry out their life plans. It is urgent to define an agenda of interventions that they are escalated in a short, intermediate and long period of time. The goal of this effort is to list specific actions prioritized by the participants of the discussion. It is pertinent to ensure respect for the rights and confidentiality of information, the right to appropriate treatment, and the right to free will and informed consent.

Conflict of interest: no conflict of interest.

Acknowledgments: The authors thank all participants of this forum.


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Received: January 7th, 2013 Accepted: May 9th, 2013

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