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Mexico is a culturally, socially and economically heterogeneous country, with a population of over 100 million. Although it is regarded as a country with a medium–high income according to World Bank criteria, inequality continues to be one of its main problems. In addition to this, the country is going through a difficult period. Large parts of the population face economic insecurity, as a result of which feelings of despair, fear and impotence are common. It is hardly surprising, then, that mental disorders should constitute a major public health problem: depression is the main cause of loss of healthy years of life (6.4% of the population suffer from it), while alcohol misuse is the 9th (2.5%) and schizophrenia the 10th (2.1%) most common health problem (González-Pier et al , 2006).
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actively involved in the work of the European Federation of
Psychiatric Trainees and thus the UEMS, and in the existing
networks of young psychiatrists within the WPA and the
European Psychiatric Association.
The World Health Organization (WHO) has an office
in Zagreb. Croatia has a mental health representative in
the WHO and collaborates with the WHO on many joint
programmes, such the Stability Pact Initiative for the Develop-
ment of Community Mental Health Centres, which resulted
in the opening of the aforementioned Mental Health Centre
and the Community Rehabilitation Centre in Zagreb.
On the other hand, few non-governmental organisations
working in the field of mental health have participated in
international programmes on stigma and human rights.
Conclusion
Despite the initiatives for the improvement of overall mental
healthcare in Croatia in the past two decades, there is a need
for organised mental health services in the community.
Sources
Naroden Novine (People’s Newspaper) is the official gazette of the
Republic of Croatia. The following are available in Croatian:
Zakon o zdravstvenoj zaštiti [Health care law]. Narodne Novine (2008), 150.
Fig. 2. Number of publications by Croatian residents, 2006 (n = 66, 89% of all psychiatric trainees in Croatia).
0 5 10 15 20 25 30 35
0
1
2
3
4
5
Over 5
Frequencies
Other publications
Current Contents publications
Plan i program mjera zdravstvene zaštite [Healthcare measure plan and
programme]. Narodne Novine (2006), 126.
Zakon o obveznom zdravstvenom osiguranju [Obligatory health insur-
ance law]. Narodne Novine (2008), 150.
Croatian National Institute of Public Health (2008) Croatian Health
Service Yearbook 2007. CNIPH.
Croatian Psychiatric Association, Croatian Medical Association, Croatian
Society for Clinical Psychiatry, Psychiatric Department, University of
Illinois, USA (2001) Plan reorganizacije službe za mentalno zdravlje u
RH. [The re-organization plan for the mental health services based on
the model of community pychiatry.]
Gater, R., Jordanova, V., Maric, N., et al (2005) Pathways to psychiatric
care in eastern Europe. British Journal of Psychiatry, 186, 529–535.
Gruber, E. N., Kajevic, M., Agius, M., et al (2006) Group psychotherapy
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Social Psychiatry, 52, 487–500.
Ivezic, S. (2002) Nacionalni program borbe protiv stigme psihicke bolesti.
42. [National programme against the stigma associated with mental
illnesses.] Medunarodni neuropsihijatrijski simpozij.
Ivezic, S., Muzinic, L. & Vidulin, I. (2009) Program koordiniranog lijecenja
(case managment) u rehabilitaciji osoba s psihoticnim poremecajem. [The
program of coordinated treatment (case management) in the rehabilia-
tion of people with psychotic disorders.] Socijalna psihijatrija (in press).
Rojnic Kuzman, M., Bolanca, M. & Rojnic Palavra, I. (2009a) General
practice meeting the needs for psychiatric care in Croatia. Psychiatria
Danubina (in press).
Rojnic Kuzman, M., Jovanovic, N., Vidovic, D., et al (2009b) Problems in
the current psychiatry residency training program in Croatia: residents’
perspective. Collegium Antropologicum, 33, 217–223.
Strkalj Ivezic, S., Folnegovic Smalc, V. & Bajs Bjegovic, M. (2003) Procjena
programa specijalizacije iz psihijatrije [The evaluation of the psychiatry
residency programme.] Lijec Vjesn, 125, 36–40.
CouNtry Profile
Mental health services in Mexico
Shoshana Berenzon,1 Héctor Sentíes2 and Elena Medina-Mora3
1Researcher, National Institute of Psychiatry ‘Ramon de la Fuente Muñíz’, Mexico City
2Education Director, National Institute of Psychiatry ‘Ramon de la Fuente Muñiz’, Mexico City
3General Director, National Institute of Psychiatry ‘Ramon de la Fuente Muñiz’, Mexico City, email medinam@imp.edu.mx
Mexico is a culturally, socially and economically hetero-
geneous country, with a population of over 100
million. Although it is regarded as a country with a medium–
high income according to World Bank criteria, inequality
continues to be one of its main problems. In addition to this,
the country is going through a difficult period. Large parts
of the population face economic insecurity, as a result of
which feelings of despair, fear and impotence are common.
It is hardly surprising, then, that mental disorders should
constitute a major public health problem: depression is
International Psychiatry Volume 6 Number 4 October 2009
94
International Psychiatry Volume 6 Number 4 October 2009
the main cause of loss of healthy years of life (6.4% of the
population suffer from it), while alcohol misuse is the 9th
(2.5%) and schizophrenia the 10th (2.1%) most common
health problem (González-Pier et al, 2006).
The Mexican health system
The Mexican health system is divided into three types of
service provision.
First, social security provides services for the formal,
salaried sector of the economy and covers 47% of the
population. This type of security guarantees free access to
healthcare and is financed through contributions from both
employers and employees.
Second, those not covered by social security (45% of the
total Mexican population), who are also the poorest, were
long regarded as a residual group, for whom the Health
Secretariat provided a poorly defined benefits package. In
2000, the Popular Insurance Scheme was created to provide
protection for this vulnerable population. The intention
was to expand the coverage of this insurance only gradu-
ally. Two kinds of mental health service are included under
this scheme: preventive medicine and external consultation
services. Beneficiaries of the Popular Insurance Scheme are
entitled to receive treatment for the diseases included in the
Universal Catalogue of Essential Health Services (CAUSES),
which covers all the medical services provided at primary
health centres and associated medication. In relation to
mental health, CAUSES include: attention deficit disorder,
eating disorders, alcohol misuse, depression, psychosis,
epilepsy, Parkinson’s disease and convulsive crises.
Third, there is a heterogeneous group of private service pro-
viders who attend non-insured families who are able to afford
them and the population which, despite having some form of
social security, is dissatisfied with the quality of services; this
group accounts for just 4% of the population (Frenk, 2007).
Mental health services
Mental health policy and legislation
The main axes of the legislative and political actions related
to mental health, formulated in 1983, were promotion,
prevention, treatment and rehabilitation. In order to restruc-
ture these policies, consultations were carried out in 2001
with the participation of politicians, government officials,
professionals, non-governmental organisations (NGOs) and
patients. On the basis of these consultations, the 2001–06
Mental Health Programme of Action proposed an integrated
care model. That programme, in addition to psychiatric
hospitals, community health centres, day hospitals and inter-
mediate residences, emphasises patients’ rights and their
social inclusion. Its main components are: strategies to
reform existing services, mental health promotion and pre-
vention, improving mental health training programmes for
staff, and the encouragement of research work in this field.
The most recent National Health Programme (2007–12)
proposes five social policy objectives:
m improve the population’s health conditions
m provide efficient health services, guaranteeing quality,
warmth and safety for the patient
m reduce health inequalities
m prevent the impoverishment of the population for health
reasons
m guarantee that health will contribute to overcoming
poverty.
On the basis of these objectives and in order to reinforce
and lend continuity to the care model formulated in 2001,
a proposal was made to create a national mental health
network, comprising specialist units within primary care
(UNEMES), organised on the basis of a community model. The
aim is for these specialist units to offer out-patient services
for timely detection, care and rehabilitation, while offering
the necessary services for effective treatment. The aim is for
UNEMES to function as the axis around which out-patient
and community mental healthcare will function. They must
therefore consist of multidisciplinary teams offering integrated
care. In addition to their welfare functions, they will be an im-
portant space for health prevention and promotion, as well as
offering training opportunities for other levels of care.
Although major efforts have been made in Mexico to
advance the care of patients with mental disorders, the main
challenge at present is to achieve the integration of mental
healthcare into general healthcare programmes. This is the
only way the gap between care and treatment needs will be
bridged.
Mental health service resources
The Mexican mental health system has 0.667 psychiatric
beds for every 10 000 inhabitants. There are 0.51 beds in
psy chiatric hospitals plus 0.051 beds available at general
hospitals for this same population rate. As for human re-
sources, it is estimated that for every 100 000 inhabitants
there are 2.8 psychiatrists, 44 psychologists, 0.12 psychiatric
nurses, 1.5 neurosurgeons, 1.2 neurologists and 0.20 social
workers specialising in psychiatry (World Health Organiza-
tion, 2005). As Fig. 1 illustrates, Mexico has a significant
shortfall in resources compared with other countries on the
American continent.
Organisation of services
There are three types of service at the primary healthcare
level: mental healthcare modules integrated into general
hospitals; health modules integrated into health centres; and
psychiatric units integrated into general hospitals. However,
many of these units or modules lack sufficient minimum per-
sonnel to be able to cover the demand for treatment; also,
they are not uniformly distributed geographically.
At the secondary healthcare level, the Health Secretariat
only has eight specialised mental healthcare units designed
for out-patients and the provision of specialised psycho logical
medical care. At this level of care, 41% of all institutional psy-
chiatrists and psychologists are concentrated in Mexico City.
Lastly, there are the psychiatric hospitals. Mexico has 31
public institutions, distributed unevenly throughout 23 of
the country’s 31 states. The units operate on the basis of two
main schemes: short and long hospital stays. Although these
are their main activities, in recent years they have largely been
devoted to specialist out-patient care, because of the high
demand for and the limited supply of services of this nature.
‘Day hospital management’ is a concept that is currently
being implemented at certain institutions. The experience has
been satisfactory, since this form of management reduces the
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95
number of relapses and increases patients’ social inclusion
(Secretaria de Salud, 2004).
In rural areas there are no local specialist mental health-
care institutions. A visit to the psychiatrist or psychologist
may involve a day’s travelling as well as considerable expense.
Consequently, the rural population often consults traditional
doctors and other informal agents.
Psychiatric training
The teaching of psychiatry in Mexico is relatively recent. The
earliest psychiatry hospital residences began in 1948. In 1951
a clinical course was established at the National Autono-
mous University (Universidad Nacional Autónoma de México,
UNAM); it is now a 3-year programme. Since 1971, the UNAM
has offered specialist courses in the different areas of psy-
chiatry and provides master’s degree and PhD programmes.
In 1994, the UNAM with the National Academy of
Medicine and other institutions created the Single Medical
Specialisation Programme. This has been taught at all schools
of medicine and medical faculties, which ensures that the
academic course is standardised.
There is only one specialisation in psychiatric social work,
taught at the National Institute of Psychiatry and coordinated
by the UNAM. There are two formal courses for psychiatric
nursing, one taught at the UNAM National School of Nursing
and another at the Instituto Politecnico Nacional (IPN) School
of Nursing. Courses are also taught after the basic nursing
degree at Mexico’s largest psychiatric hospitals and at the
National Institutes of Neurology and Psychiatry.
Mental health research
Mental health research in Mexico faces difficulties due to
the shortage of trained professionals and a lack of high-
technology equipment. Despite this, various Mexican
institutions undertake research in the clinical, neuroscience,
epidemiological and social spheres of mental health.
The main clinical areas researched are genetics, clinimetry,
neurochemistry, psychopharmacology, immunology, phyto-
pharmacology, brain cartography and imaging. The most
important fields of research in the field of neuroscience are:
neurophysiology, chronobiology, neurobiology, bioelectron-
ics, ethology and comparative psychology. The main lines of
research related to the epidemiological and social areas are:
psychiatric epidemiology, health systems, drug dependence,
suicide, violence, mental health in vulnerable groups and
evaluation of intervention models.
Human rights and future
challenges
In 1995, an official Mexican regulation for the provision of
psychiatric services in medical care hospital units was issued.
This regulation focuses on two areas: quality specialised
medical care and the preservation of the user’s human rights.
This regulation fits in with the United Nations’ Principles for
the Protection of Persons Suffering from Mental Illness and
for the Improvement of Mental Health Care (1991). One of
the shortcomings of the Mexican regulation is that it fails to
mention the rights of children and teenagers with mental
illness, and it therefore needs revision.
Important advances have included increasing the budget
to treat mental illness and the creation of innovative primary
mental healthcare approaches. Nevertheless, the propor-
tion of people suffering from mental diseases who receive
treatment remains low. The greatest challenge is to expand
coverage and achieve universal mental healthcare services,
in order to reach the most neglected groups, but also to
develop new, improved, culturally sensitive treatments that
can meet the population’s needs, fostering help seeking and
treatment compliance.
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Secretaría de Salud.
World Health Organization (2005) Mental Health Atlas: Mexico. Avail-
able at http://www.who.int/mental_health/evidence/atlas/ (last
accessed July 2009).
Fig. 1. Mental healthcare human resources per 100 000 inhabitants
(does not include psychologists because the data are not available in Mexico) (World Health Organization, 2005).
0
5
10
15
20
25
30
35
40
Psychiatric beds Psychiatrists Psychiatric nurses Social workers
Chile
Cost a Rica
Mexico
USA
Cuba
... Los resultados sugieren la importancia de reconocer el peso de la carga de la enfermedad mental en México, la cual en su conjunto es más alta de lo que presupuestalmente el gobierno mexicano ejerce para su atención 10,15 . Los trastornos mentales se incrementan en momentos de crisis. ...
... Existe una amplia brecha para la atención de los servicios de los TMNS en México, aun por arriba de otros países latinoamericanos 18 . Si bien desde el año 2000 hasta el año 2019 el Seguro Popular cubría aproximadamente el 45% de la población sin seguro social para algunos TMNS (por ejemplo, el trastorno por déficit de atención, trastornos alimentarios, adicciones, depresión, psicosis, epilepsia y crisis convulsivas, enfermedad de Parkinson y dolor crónico) 15,19 , existe evidencia de que los servicios de salud mental son escasos y subutilizados por la población mexicana, especialmente aquella de bajos recursos 18 . Estudios sobre el uso de servicios de salud mental en adultos mexicanos muestra que solo 2 de cada 10 personas reciben atención 18 , lo cual es también común en población adolescente 14 . ...
Article
Resumen Introducción Los trastornos mentales, neurológicos, uso de sustancias, suicidio y trastornos somáticos relacionados (TMNS) tienen un impacto negativo en la calidad de vida de las personas y la economía de México, pero se carece de información actualizada. El objetivo de este trabajo es analizar los Años de Vida Ajustados en función de la Discapacidad (AVAD) de los TMNS en México por sexo, edad, entidad federativa y grado de marginación entre 1990-2019. Métodos Se usan los datos y la metodología del “Global Burden of Disease Group” (GBD). El GBD calcula los AVAD como la suma de dos componentes: los años de vida perdidos por mortalidad prematura (AVP) y los años vividos con discapacidad (AVD). Asimismo, se usan los datos de grado de marginación del Consejo Nacional de Población en México. Resultados Los TMNS representaron en el año 2019 el 16.3% de la carga de la enfermedad en la población mexicana. La tendencia de las tasas estandarizadas por edad de los AVAD de los TMNS ha incrementado poco desde 1990 a 2019. El más alto incremento ha sido para las mujeres. Los trastornos mentales (depresión) y neurológicos (trastornos de dolor de cabeza) son los que más contribuyen a la carga de la enfermedad entre los TMNS. Al interior del país Baja California Sur presentó el más alto incremento del periodo. Discusión Los resultados muestran un panorama complejo de los TMNS y sus subtipos por sexo, grupos de edad y territorio. Mayores recursos son necesario para mejorar la atención de la salud mental.
... Independently, current mental health services for people in Mexico lack infrastructure and trained professionals to vastly implement programs or disseminate resources throughout the republic [17]. The majority of existing mental health services are centered within very large cities, while less populous areas will have limited professional or student mental health providers [17]. ...
... Independently, current mental health services for people in Mexico lack infrastructure and trained professionals to vastly implement programs or disseminate resources throughout the republic [17]. The majority of existing mental health services are centered within very large cities, while less populous areas will have limited professional or student mental health providers [17]. Given these resource-limited and segmented services, the need to fulfill several health needs among people living with diabetes is apparent-specifically related to selfmanagement and mental health services. ...
Article
Full-text available
Background People living with diabetes have an increased risk of developing mental health issues. Mexico has observed a high prevalence of people living with diabetes suffering from mental health issues, such as anxiety and depression. Self-management programs have demonstrated promise in helping participants address and prevent not only physiological health complications but mental health issues as well. This qualitative study aimed to understand the mental health benefits of a diabetes self-management intervention for health centers in Northern Mexico and opportunities for improvement through assessing stakeholder perspectives. Methods Trained research staff used a semi-structured questionnaire guide to conduct all interviews and focus groups from February–May 2018. Individual interviews ( n = 16) were conducted face-to-face at four health center sites among all health center directors and key staff located throughout the state of Sonora. One focus group ( n = 41) was conducted at each of the four health centers among intervention participants. Directed content analysis was used to establish themes by understanding relationships, identifying similar experiences, and determining patterns across datasets. Results In total 57 health center directors, health center staff, and intervention participants were involved in the interviews and focus groups across the four health centers. Overall the analysis identified four themes throughout the data, two were categorized as benefits and two as improvements. The primary themes for participant benefits were an increase in self-efficacy and social support to manage their chronic conditions. These were evident from not only participant perspectives, but health staff observations. Conversely, increased family involvement, and increased mental health integration and services within diabetes care were identified themes for opportunities to improve the intervention to be more inclusive and holistic. Conclusion All stakeholders observed the benefits for intervention participants and opportunities for more inclusivity of the family and integration as well as an increase in mental health services. The themes identified demonstrated a need to more proactively enhance and utilize diabetes self-management as a means to improve mental health outcomes among people living with diabetes in Mexico. This is an opportunity to employ a more comprehensive approach to diabetes self-management, and integrate mental health services into overall diabetes care. Trial registration www.ClinicalTrials.gov, identifier: NCT02804698 . Registered on June 17, 2016.
Article
Full-text available
Explicit priority setting presents Mexico with the opportunity to match the pressure and complexity of an advancing epidemiological transition with evidence-based policies driven by a fundamental concern for how to make the best use of scarce resources to improve population health. The Mexican priority-setting experience describes how standardised analytical approaches to decision making, mainly burden of disease and cost-effectiveness analyses, combine with other criteria -eg, being responsive to the legitimate non-health expectations of patients and ensuring fair financing across households- to design and implement a set of three differentiated health intervention packages. This process is a key element of a wider set of reform components aimed at extending health insurance, especially to the poor. The most relevant policy implications include lessons on the use of available and proven analytical tools to set national health priorities, the usefulness of priority-setting results to guide long-term capacity development, the importance of favouring an institutionalised approach to cost-effectiveness analysis, and the need for local technical capacity strengthening as an essential step to balance health-maximising arguments and other non-health criteria in a transparent and systematic process.
Article
Full-text available
During the past six years, Mexico has undergone a large-scale transformation of its health system. This paper provides an overview of the main features of the Mexican reform experience. Because of its high degree of social inequality, Mexico is a microcosm of the range of problems that affect countries at all levels of development. Its health system had not kept up with the pressures of the double burden of disease, whereby malnutrition, common infections, and reproductive health problems coexist with non-communicable disease and injury. With half of its population uninsured, Mexico was facing an unacceptable paradox: whereas health is a key factor in the fight against poverty, a large number of families became impoverished by expenditures in health care and drugs. The reform was designed to correct this paradox by introducing a new scheme called Popular Health Insurance (Seguro Popular). This innovative initiative is gradually protecting the 50 million Mexicans, most of them poor, who had until now been excluded from formal social insurance. This paper reports encouraging results in the achievement of the ultimate objective of the reform: universal access to high-quality services with social protection for all.
Article
Durante los últimos seis años, México ha llevado a cabo una profunda transformación de su sistema de salud. Este artículo presenta una visión general de las principales características de la experiencia de reforma mexicana. Como resultado del alto grado de desigualdad social, México es un microcosmos de la diversidad de problemas que afectan a los países de todos los niveles de desarrollo. Su sistema de salud no estaba a la altura de las presiones impuestas por la doble carga de enfermedad, en donde la desnutrición, las infecciones comunes y los problemas de salud reproductiva coexisten con las enfermedades no transmisibles y las lesiones. Con la mitad de su población sin acceso al aseguramiento en salud, México enfrentaba una paradoja inaceptable: si bien la salud es un factor clave en la lucha contra la pobreza, un gran número de familias se empobrecía como consecuencia de los gastos para la atención de su salud, incluyendo los medicamentos. La reforma se diseñó para corregir esta paradoja mediante la introducción de un innovador esquema denominado Seguro Popular, a través del cual se protege de manera gradual a 50 millones de mexicanos, la mayoría de ellos pobres, que hasta ahora habían sido excluidos de la seguridad social formal. Este artículo presenta una serie de resultados alentadores para lograr el fin último de la reforma: el acceso universal a servicios de salud de alta calidad con protección social para todos.
Información para la rendición de cuentas. [Health Mexico
  • México
Lineamientos para la Preservación de los Derechos Humanos en los Hospitales Psi quiátricos. [Guidelines for the Preservation of Human Rights in Psychiatric Hospitals
  • Comisión Nacional De Derechos Humanos
Comisión Nacional de Derechos Humanos (1995) Lineamientos para la Preservación de los Derechos Humanos en los Hospitales Psi quiátricos. [Guidelines for the Preservation of Human Rights in Psychiatric Hospitals.] Comisión Nacional de Derechos Humanos.
Información para la rendición de cuentas
  • Salud Secretaría De
Secretaría de Salud (2004) Salud México 2004. Información para la rendición de cuentas. [Health Mexico 2004. Accounting Information.] Secretaría de Salud.
Mental Health Atlas: Mexico
World Health Organization (2005) Mental Health Atlas: Mexico. Available at http://www.who.int/mental_health/evidence/atlas/ (last accessed July 2009).