Saúde mental na atenção básica em casinhas-PE: Um estudo de caso em um município de pequeno porte

Abstract

In Brazil, basic care assumes a strategic position within the scope of the Unified Health System (SUS), as it represents, through the Family Health Strategy (ESF), the gateway to this system. In this context, the development of actions in mental health in basic care is driven by the inclusion of the Psychiatric Reform in the Brazilian agenda for the implementation of public health policies. Basic care and Psychiatric Reform share principles and guidelines, aiming at overcoming the limitations of the biomedical model and the construction of a dynamic, complex and non-reductionist model of health care. It is recommended that mental health programs and actions be incorporated into basic health services in an articulated way to specialized services. However, in small cities with a population of no more than 20,000 inhabitants, mental health care must be structured from the basic care services, especially from the ESF. Thus, this research had as general objective to analyze how mental health care is characterized at the level of basic care in the municipality of Casinhas/PE. The specific objectives were: to characterize the network of mental health care in the municipality of Casinhas/PE; to understand how basic care has received and attended the demand in mental health in the municipality; to analyze the meanings that professionals, relatives and users construct about mental health care at the level of basic care in the municipality; and to identify, in the discursive practices of professionals, relatives and users, the evaluations and the expectations that they produce about mental health care at the level of basic care in the mentioned municipality. The theoretical reference adopted was the proposal of a study of the productions of meanings from the analysis of the discursive practices. To develop this research, we chose a qualitative approach, outlined as a single case study, by delimiting the discursive practices of professionals, relatives and users as subunits of analysis. The methodological procedures adopted were consultation in public domain documents, daily observations, semi-structured interviews and field journaling. We interviewed 31 people, 14 (fourteen) professionals, 9 (nine) users and 8 (eight) relatives. To analyze the discursive practices, we use the dialogical maps as an analysis technique, as proposed by the adopted theoretical framework. In the process of analyzing discursive practices, three analytical axes were defined: characterization of mental health care in basic care; evaluations on mental health care in basic care and expectations on mental health care in basic care. With regard to the first axis, it is emphasized that the service develops from practices such as identification of the demand in mental health and referral to specialists, especially, psychiatrists and home visits. The articulation between professionals, health services and social assistance are guided by specialism and the use of medicines. The reports poorly valorize the use of socio-community strategies. Regarding the second axis, the evaluations point to positive aspects of the offered care related to the interaction, to the development, provided to the users participating in a mental health group that existed in the municipality, the multiprofessional work, the proximity of the service and the access to the medication. However, in the reports, limitations are related to the lack of human and institutional resources. The relatives and the users are responsible for the effectiveness of the care. It is also worth noting the little governmental investment in the development of mental health actions. Concerning the third axis, the expectations are related to the maintenance of the hegemonic medical model. Nonetheless, senses are produced in a perspective that approaches building a broader understanding of mental health care in basic care. Although, in the reports of our interviewees, there is a timid sign of a process of incorporation of some aspects of the psychosocial model (which are not yet reflected in the practical field), the results of this research converge to the understanding that assistance in mental health in the municipality of Casinhas/PE is characterized by an emphasis on the hegemonic medical model and, by extension, on Psychiatry. Therefore, still far from what the National Mental Health Policy (PNSM) and the National Primary Care Policy (PNAB) advocate.