Community-Based Mental-Health Services in Mexico

Abstract

Objective:  This article describes the general characteristics of community-based mental health care in Mexico.

Method: It uses data from national surveys, special studies and statistics from the national information system for the period 2001-2017. It reviews available information on health systems, new regulations and innovations implemented and research on psychosocial interventions conducted in the country.

Results: Data show a fragmented health system with services for workers, people without social security or private care; a treatment system still heavily based on tertiary health care and not integrated into the general health system with a significant treatment gap and delay in first treatment. At the same time, a slow but steady increase in care provided at the primary health care level and in specialized community services is observed. This trend has been accompanied by an increase in the number of medical doctors, psychologists and to a lesser extent psychiatrist incorporated into primary care health services. At the same time, no new psychiatric hospitals have been built and there has been a proportional reduction in psychiatric beds but no increase in mental health services or beds allocated in first contact hospitals. Research initiatives have analyzed the barriers to a reform and efficient interventions have been developed and tested for the community and primary health care level, special interventions are available for populations in vulnerable conditions with no formal efforts for their implementation.

Conclusions: Evidence is available for implementing the transition from reliance on tertiary health care to a reinforced primary care. At the same time, parity, financial protection, quality and continuity of care remain major challenges.

Full Text

Introduction

The inclusion of mental health in the UN Sustainable Development Goals and the universal health coverage commitment adopted by countries re-opened the debate on best practices to close the treatment gap.  The challenge posed in Alma Ata in 1978, universal health coverage through primary care [1], has not been met around the globe [2] and Mexico is no exception. The prevailing treatment paradigm based on tertiary health care has failed, there is a large treatment gap (for example, only 19% of people with a mental condition and 49% persons with substance use dependence, have access to care [3, 4]). This situation is compounded by the fact that people at the highest risk of mental health problems are usually those with least access to services (i.e. families living in poverty, children exposed to abuse or neglect, minority groups, or elderly people). Accordingly, a significant part of the population is excluded from mental health care [5, 6].

General health system

The Mexican health system comprises two sectors: public and private. Public services include social security institutions, which provide services to workers in the formal sector of the economy (IMSS) and the government (ISSSTE, PEMEX and others), and institutions that deliver services to the population without social security. The private sector provides services to the population with the capacity to pay. 

Social security institutions are financed by government, employer and employee contributions [7]. Services for the population without social services are funded by federal and state governments through the Popular Insurance Scheme established in 2003. It provided services to 40% of the population without medical insurance [8]; a small contribution was paid by users when receiving care (recovery fees) [7]. This system was substituted in 2019 by a new Institute of Health for Wellbeing (INSABI), which still is in development. The private sector is financed through payments made by users when they receive care and private health insurance premiums [7]. 

The last available national health survey [9] reported that 61% of outpatient consultations were provided by the public sector and 38.9% by the private sector whereas only 17% of users of inpatient hospital services, received services at private hospitals. 

A recent report on Public Health and Primary Care [10], shows that despite significant reforms, key challenges remain. The National Health Survey [9] showed that 21% of the population had no insurance, while a subsequent survey revealed that 87% of the population from the lowest socio-economic level lacked access to health services. It has also been estimated that 49% of health expenditure is private and that over 90% corresponds to out-of-pocket expenses, mainly for out-patient care and medicines. 

Mental Health Services

Mental health services have been provided at psychiatric institutions since 1566. For many years, treatment was based in psychiatric hospitals with little investment in rehabilitation or community care [11]. Mexico is one of the few countries to participate in the World Mental Health Survey [12], which demonstrated that it is one of the countries with more people seen in the tertiary care level than at the primary care level [13]. Thus, latency in receiving care is high: 14 years for depression as opposed to one year in Spain [14, 15].  

Primary care services for mental health also have a long history. The Mexican Institute of Social Security (IMSS) recognized the need for family doctors in 1954 but it was not until 1971 that the specialization of family medicine was created with a focus on primary care (86% of its services). Psycho-affective disorders are among the ten leading reasons for consultation [16]. 

For persons not affiliated to the IMSS, primary care services were formalized in 1959 after the Ministry of Health established the General Directorate of Neurology, Mental Health and Rehabilitation, which created Mental Hygiene Services incorporated into primary care centers in Mexico City with preventive actions and first contact care, with a referral system to specialized services. The staff was multidisciplinary with a psychiatrist, psychologist and social worker. This initiative was not widespread and by 1964, only 16 such services had been installed, 10 in Mexico City and six in various  states. In the 1980s and 1990s, the federal authorities overhauled the health sector, reducing the budget and the range of services, including  mental health care [17, 18]. 

The Ramón de la Fuente National Institute of Psychiatry, a national health institute with research, education and clinical services was inaugurated in 1979. Research on the epidemiology of mental disorders, neurosciences, and clinical and psychosocial aspects led to culturally-adapted interventions. Emphasis was placed on the population in conditions of vulnerability, and new models were tested in communities, primary care and specialized services [19, 20].

Mental health was included in the Popular Insurance scheme. In 2007, prevention (e.g. early detection and brief advice for addictions) and screening and treatment (pharmacological and psychotherapeutic) for   various mental health disorders were included. The number of disorders covered increased over time and by 2018, the scheme covered autism, depression and other mood disorders, and psychosis [21]. Unfortunately, this was not fully implemented, among other reasons, because it required a primary care referral to the tertiary level, with limited hospitalization days and a re-referral to primary care for the continuity of care; severe depression was only covered at general hospitals, but the institutions were not ready to identify or treat people with mental disorders.  Although the new government has announced a new program to replace the former Popular Insurance Scheme and has committed to universal coverage, since 2019 there has been a significant reduction in the health budget and patients with mental disorders do not have access to free medication  https://ciep.mx/presupuesto-para-salud-mental-relevancia-ante-la-covid19/).

The trend is shifting care delivery from psychiatric institutions to community-based services, and there has been a growing involvement of primary health care [22]. In 2012, 42 specialized medical units for ambulatory care were opened in 20 states; In 2018, before the COVID-19 pandemic, 51 units are currently operating in 22 of the 32 Mexican states [23]. Three hundred and ten centers were also opened for the prevention and treatment of substance use disorders, yet despite the common comorbidity [24], initially mental health care was not included in their mandate [25] but in 2019 a reform mandated treatment of mental and substance use disorders in both systems. A third organization, Juvenile Treatment Centers (CIJ) for substance use disorders, with 120 community centers, also included mental health treatment. Today the three organizations are united in a network that amplified significantly health coverage.

Unfortunately, there is still no formal referral system for mental disorders within the different levels of care. Persons seen at the primary care level are often referred to the tertiary level without treatment. Among other reasons, this is because primary level medical consultations are usually brief and focused on treating somatic symptoms, making it difficult to detect and treat chronic disorders. This is compounded by the lack of collaboration between primary care staff and mental health specialists and the low proportion of trained resources to deliver mental health care including psychiatrists [5, 26].  

The country has also made significant progress in formulating laws, policies and programs to improve community mental health care; which comply with  international human rights guidelines and are periodically reviewed. However, they have only partially been implemented. In this respect , the seventh chapter of the General Health Law stipulates the characteristics of mental health care. Likewise, some states, including Mexico City, have a specific state mental health law stating that the prevention and care of mental illness is a priority. In recent years, various initiatives have been submitted to the Senate and the Chamber of Deputies to establish a National Mental Health Law that will promote community services, strengthen primary health care, outpatient care and coordination with hospitalization systems. 

General characteristics of community-based mental care in Mexico: interventions

Delivery settings for community-based mental care include schools, workplaces, families and populations in vulnerable conditions. Those developed and tested by the National Institute of  Psychiatry (INPRFM) include programs for persons with lived experiences and their families [27], on-line interventions for depressed females not seeking help [28] and reducing substance use and depression symptoms [29], interventions for families with alcohol problems in indigenous populations [30],  the prevention of violence among youth [31] survivors of violence, street children and youth, prison populations, sex workers, migrants, people living in unsafe communities, indigenous groups and communities in poverty [32]. 

The principal evidence-based psychological interventions that have proven to be effective in Mexico include cognitive-behavioral techniques (such as behavioral activation, relaxation training for anxiety, and identification and modification of automatic thoughts related to depression and anxiety) implemented in rural community health settings [33], as well as problem-solving therapy [34, 35], stress reduction based on mindfulness training [36] and stress management for mental health professionals [37]. 

There have also been local efforts to complement pharmacological and psychological interventions with those designed to address the contextual sources or social determinants of mental health problems (such as underemployment, inadequate housing, food insecurity, and violence) though the collaborative work of PCPs and promotoras (trusted community members, who deliver health-related services) [38].

Initiatives to help general practitioners overcome the barriers of lack of time and expertise to the evaluation and management of common mental disorders observed in primary care setting (i.e. depression, anxiety and unexplained medical symptoms) have been also implemented and evaluated in Mexico (including very brief screening tools, training packages on WHO-mhGAP guidelines, and manualized psychological interventions) [39, 40].  

General characteristics of the mental-health system

To serve a population of 129.2 million inhabitants, there are 39 psychiatric hospitals in Mexico, 34 of which funded by the Ministry of Health, and five by the National Institute of Social Security, which provides care for workers and families with mental disorders with an organized referral system yet significant treatment delays.  Services for government workers provided by ISSSTE are delivered by the public sector and 89% of hospitals are located in major cities.  

Psychiatric hospitals have extended outpatient services. Although patients can be referred by other hospitals or primary health care they usually seek outpatient and inpatient care at psychiatric hospitals without a referral. Only 2% of the beds are in general hospitals. There are 1649 mental health community services, 467 developed as part of the initiative to take specialized outpatient services to the community, known as UNEMES and 1169 primary care units with mental health service. 

In 2017, 3.3 million medical consultations were given by the Ministry of Health to the population without social security (1.2 million, nearly a third, were provided by the Popular Insurance scheme) and to persons with social security because mental health services in this sector are limited. Of the total number of medical consultations by the Ministry of Health, 24.8% were given in the outpatient services of psychiatric hospitals and 20.7% by other specialized hospitals, with a total of 45.5% being provided at the tertiary care level. Approximately the same proportion (45.4%) were provided in outpatient mental health services (of which 28.4% were given at general health centers with mental health services and 17% at outpatient mental health clinics), an important shift since 2010 when only 38.3% of medical consultations were provided in outpatient mental health services. In 2017, only 8% were provided in general hospitals with mental health services.  

Trends in mental health services can be observed in units run by the Ministry of Health. Data show a sustained increase in primary health units with mental health services (rising from 0.2 in 2001 to 1.1 in 100,000 inhabitants in 2017), and since 2008, there has also been an increase in mental health community services (from 0.1 in 2008 to 0.4 per hundred thousand inhabitants in 2017). (graph 1). 

The number of psychiatric hospitals has remained stable (with 0.03 hospitals per 100,000 inhabitants). Although beds in psychiatric hospitals decreased from 5.07 to 2.98 per 100,000 inhabitants, psychiatric beds in general hospitals did not increase. (graph 2).

Coinciding with this trend in services, human resources also expanded. From 2001 to 2017, services coordinated by the Ministry of Health, the rate of psychiatrists rose  from 0.5 to 0.7 psychiatrists per hundred thousand inhabitants; GPs  working in mental health services increased fivefold (from 1.9 to 9.5) while the number of  psychologists increased fourfold from 0.9 to 3.9 psychologists per hundred thousand inhabitants (graph 3).

From 2010 to 2017, outpatient mental health in primary care accounted for  38.5% of all outpatient  consultations, reaching 45.4% in 2017 (primary care units with mental health service rose from 22.5 to 28.4%, while  community mental health units increased from 15.8 to 17.0%). Conversely, outpatient care at high specialty hospitals decreased from 21.5% to 20.7% while outpatient care at f psychiatric hospitals fell from 29.3 to 24.8% during this period.

More than half, 62%, of all hospital discharges due to mental and behavioral disorders are from psychiatric hospitals, 24% from general hospitals, 9.1% from specialized hospitals and 4.4% from rural hospitals.

Inpatient care days varied according to the type of disorder and the characteristic of the care services.  Psychiatric hospitals had the longest stays of all services, for all disorders except personality disorders which had the same duration in psychiatric hospitals and specialized hospitals. Intellectual disability involves the lengthiest stays (from 263 days in psychiatric hospitals to 6.6 days in hospitals located in rural communities) (graph 4). 

The place of community-based mental health care in the mental-health system and healthcare system 

About the availability of services and human resources, the proportion of the health budget allocated for mental health services is significantly lower than for other diseases; quality of care is also lower.

Strengths, weaknesses and future developments

While it is true that there are public policies that guide actions designed to care for the community and that significant progress has been made in the development of community-based care services, although some progress has been observed with a greater  participation of primary care,  care for mental disorders remains within specialized services (tertiary care), specifically psychiatric hospitals. These hospitals remain responsible for a large proportion of outpatient care and nearly all hospitalization. The shift towards a paradigm of more community than hospital care has been hampered by the lack  of an integrated policy and an insufficient, poorly optimized budget.

A clear example of these conditions is the low availability of psychotropic drugs in primary health care, which forces people to buy them out of pocket, which has a major impact on the family economy and/or prompts the decision not to take the medication.  Low priority is given to mental health because in many cases, it is still considered the exclusive province of specialists in mental health. Many patients with mild disorders or under control, who  can be treated in primary health care are referred to psychiatric hospitals

It is essential to allocate more financial resources and distribute them more effectively to enhance community mental health. Likewise, care models that have successful results should be promoted, taking into account the impact of social, cultural and environmental factors on mental illness.

One of the elements that has worked least well in Mexico is  the participation of patients and the community. Self-management is rarely promoted and actions taken by community members are not fully exploited, such as linking MH services with the population through their recommendation to nearby social networks. It is necessary to promote actions to expand and coordinate the participation of community members and patients on how to take care of their mental health and when to seek services. The World Health Organization also recommends the participation of patients and family members in the planning and implementation of policies, and the monitoring and provision of services.

Likewise, to improve the delivery of community services in Mexico and achieve a model such as the one proposed by the WHO, it is essential to strengthen communication and collaboration between the various platforms [41] and set up continuous monitoring systems. This link between the community and the health system will facilitate the identification of cases, care seeking  and timely referral to treatment.

One of the challenges is to achieve a paradigm shift whereby mental health care is not only the responsibility of psychiatrists and psychologists. The results of various investigations confirm that other health professionals (nurses, social workers) and even people from the same community with more training, supervision and continuous support from mental health specialists could carry out mental health promotion activities as well as the detection and care of certain  mental disorders.

Conclusions

A small but steady increase in services and human resources (more GPs and psychologists) in primary health care and specialized community services was observed.  This shift is an important step towards reducing the treatment gap.  

The challenge for the population that does not have severe psychosocial disability is to assess the scope of these actions to reduce the treatment gap for mental disorders, and ensure quality and continuity of care. We are convinced that Mexico can build a mental health care model that will improve the quality of life of the population, by integrating mental health across the lifespan into the health system  with coordinated actions in various sectors including civil society organizations.

No additional psychiatric hospitals have been built and the number of beds at these institutions has declined. Unfortunately, there has not been an increase of beds or mental health services in general hospitals. A significant proportion of persons with mental disorders are in jail [42].  People with severe intellectual disability and to a lesser extent, schizophrenia and other psychoses, are abandoned at isolation wards in long-stay psychiatric hospitals. This calls for an urgent program for deinstitutionalization to small units with the necessary services to protect the human rights of this population, together with a new system to guarantee continuity of care and include housing and labor facilities to integrate persons with psychosocial disabilities into the community.

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About the authors

María Elena Medina Mora

Ramón de la Fuente Muñiz, National Institute of Psychiatry

Author for correspondence.
Email: metmmora@gmail.com
ORCID iD: 0000-0001-9300-0752

Researcher in the Global Mental Health Research Center

Mexico, Calzada México Xochimilco 101, San Lorenzo Huipulco, Tlalpan, Ciudad de México, CP 14370

Martha Cordero Oropeza

Ramón de la Fuente Muñiz, National Institute of Psychiatry

Email: marthiux1403@hotmail.com
ORCID iD: 0000-0002-9644-6482

Researcher in the Global Mental Health Research Center

Mexico, Calzada México Xochimilco 101, San Lorenzo Huipulco, Tlalpan, Ciudad de México, CP 14370

Shoshana Berenzon

Ramón de la Fuente Muñiz, National Institute of Psychiatry

Email: diepsho19@gmail.com
ORCID iD: 0000-0002-9009-5255

Director of Epidemiology and Psychosocial Research

Mexico, Calzada México Xochimilco 101, San Lorenzo Huipulco, Tlalpan, Ciudad de México, CP 14370

Rebeca Robles

Ramón de la Fuente Muñiz, National Institute of Psychiatry

Email: reberobles@hotmail.com
ORCID iD: 0000-0001-5958-7393

Coordinator Researcher in the Global Mental Health Research Center

Mexico, Calzada México Xochimilco 101, San Lorenzo Huipulco, Tlalpan, Ciudad de México, CP 14370

Tania Real

Ramón de la Fuente Muñiz, National Institute of Psychiatry

Email: taniarealq@gmail.com
ORCID iD: 0000-0002-4920-5838

Researcher in the Global Mental Health Research Center

Mexico, Calzada México Xochimilco 101, San Lorenzo Huipulco, Tlalpan, Ciudad de México, CP 14370

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Copyright (c) Medina Mora M., Cordero Oropeza M., Berenzon S., Robles R., Real T.

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