Voir page 488 le resume en francais. En la pagina 489 figura un resumen en espanol.
Latin America is composed of 22 countries -- the two largest being Brazil and Mexico-- which occupy the Andean zone, the Southern Cone, Central America, and the area known as the Latin American Caribbean. Political and international health agencies consider other Caribbean countries like Barbados to be part of the region. Most of these countries have been politically independent for less than 200 years; a few became sovereign nations only in the first decades of the 20th century. In 1999, the total population of all these countries was nearly 600 million, with a growth rate of about 40% in the last 30 years (1, 2). Almost three-fourths of the population have settled in urban areas, while indigenous groups have been reduced to less than 10% of the total. Nominally, 90% of the population is Catholic, even though the vigorous growth of other Christian denominations is noticeable. The region is composed of a multi-ethnic and multi-racial mosaic, with unique social, economic, political, and cultural characteristics, which have produced marked differences in health and economic development.
Average life expectancy in the region is close to 63 years, with women living about 4 years longer than men do. However, there are two competing tendencies. On the one hand, a decline in death rate in some areas -- reflecting reductions in infant mortality and in the prevalence of infectious diseases -- has increased life expectancy up to 71 years. On the other, deaths related to cerebrovascular disease, homicide and cirrhosis have increased by more than 50% in the last 15 years, particularly in the non-Latin Caribbean countries, and in the Central American and Andean zones. The increase in violent deaths, largely among the male population, surpasses the potential years of life lost because of cancer and gastrointestinal infection (2).
This paper describes the development of mental health policies in Latin American countries, focusing on published data in peer-reviewed journals, and legislative change and its implementation. It presents a brief history of mental health policy developments, and analyzes the basis and practicalities of current practice.
Current mental health situation
In a comparative study on the morbidity of mental disorders in Latin America and the Caribbean, Levav et al. calculated that at the end of the 1980s, 88.3 million people were diagnosed with mood, anxiety, and substance-abuse disorders, schizophrenia, and significant cognitive deterioration secondary to drug and alcohol abuse (2). This represented a 48.1% increase in a period of 15 years, or 28.7 million new cases, with some notable variations, for example, an increase of 69.8% of cases of schizophrenia in Mexico, compared with 53.1% in the rest of Latin America and the Caribbean. The same trend was seen for cognitive impairment and anxiety disorders.
Human resources for mental health programmes in Latin America have always been scarce. Training programmes in psychiatry produce less than 600 new graduates a year, some with only limited technical skills and inadequate training. Less than 10% of psychiatrists in Latin America devote time to educational activities (1, 3). Other mental health professionals -- possibly large numbers of them -- do not find appropriate employment and end up choosing second careers or may practice in a limited fashion. Multidisciplinary teams, sectorization, community services, and primary care programmes have varying levels of success (3, 4).
There are between 130 000 and 140 000 psychiatric beds, approximately 10-15% of all beds, distributed in about 600 hospitals and 1000 outpatient clinics. Out of more than 300 000 physicians, there are 11 000 psychiatrists with varying levels of competence; 80% of these psychiatrists are concentrated in metropolitan areas with high-density populations (more than 100 000). …