Psychiatryan PsychiatricEpidemiology
Soc PsychiatryPsychiatrEpidemio, (1989)24:151-155
Social
© Spfinger-Verlag 1989
Experiences of a psychiatric outpatient team in Nicaragua Mental health problems seen in a primary care setting Ulises Penayo Department of Psychiatry (Head: Prof. L. Jacobsson), University of Ume~, Ume~, Sweden
Summary. The paper presents experiences from one of the first psychiatric out-patients teams in Nicaragua which was started in 1982. 198 patients consecutively attending the unit were studied thoroughly as regards clinical diagnosis and areas of conflict presented as reason for attendance. Depressive neurosis and anxiety neurosis were the predominant diagnoses, followed by epilepsy and schizophrenic disorders. Almost half of the patients stated that they had family problems.
Since the insurrection in Nicaragua in 1979, there has been a major effort to build a health and medical care system based on the World Health Organization's (WHO) guidelines for the development of mental health programs in the third world (WHO 1980; WHO 1983 a, b; WHO 1984). The main purpose of this program is to create resources at the primary health level, and to integrate mental health care in the local community with the active participation of lay people and voluntary organizations (COSAMPRE 1984). This includes the establishment of a network with local health staff called "brigadistas". Another goal in the national mental health plan is to avoid repeated admissions of patients to the only psychiatric hospital in Nicaragua by offering care at the primary health level through the CAPS (Centros de Atenci6n Psicosocial), which are located in the local community. The National Psychiatric Hospital in Managua was erected in 1932, and had about 500 patients at most. In 1979, the hospital had
about 300 patients, and 1987 the number had been further reduced to about 120. In the National Mental Health Plan, the country is divided into geographic sectors. The goal is to have a psychiatric team with a "CAP" in each sector. The role of the CAPS in these sectors is to try to stop the "revolving: door" of the mental hospital, and to provide alternatives within the community in cooperation with the primary health care. An important part of the Nicaraguan model is a more scientifically-based analysis of the work in the CAPS, Health Centers and the community through simple evaluations of the daily work and other scientifically oriented projects that can be managed by lay people together with professionals from, for example, the mental health team (Le6n 1981). These efforts are periodically reported to the "Jornadas Cientificas" or conferences organized by the Ministry of Health. There is reason to believe that the WHO-inspired planning might be successful in Nicaragua. In spite of the war that is going on, the society continues to participate at a popular level not only in the planning of health care, such as vaccinations and latrine construction campaigns, but also in other areas such as literacy campaigns. The aim of the present study is to present and analyse the experiences of one of the first psychiatric outpatient teams, which was started quite spontaneously with voluntary workers as a result of these national plans (Florez Ortiz 1985). The team started in Ciudad Sandino outside the capital of Managua in 1982 as a pilot project aimed at testing the ideas of a psychiatric team at the primary health care level. Connected to this outpatient unit was a day center
152 Table l. Diagnostic categories ICD-9 in Ciudad Sandino during two months 1984 No 290 293 295 296 300.0 300.1 300.4 300.5 301 302 303 306 308 314 315 319 312 345
Senile and presenile conditions Transitory organic psychotic condition Schizophrenic psychosis Affective psychosis Neurotic anxiety Hysteria Neurotic depression Neurasthenia Personality disorders (psychopatic) Sexual disorders Alcohol dependence syndrome Psychosomatic disorders Acute reaction to stress (war) Hyperkinetic syndrome of childhood Specific delays in development Mental retardation unspecified Disturbance of conduct Epilepsy No mental disorders Total
%
3 1 17 4 22 7 45 8 1 1 14 10 3 4 5 6 3 24 20
1.5 0.5 8.6 2.0 11.1 3.5 22.7 4.0 0.5 0.5 7.1 5.1 1.5 2.0 2.0 3.0 1.5 12.0 10.1
198
100%
(CAPS) described earlier (Penayo and Jacobsson 1987) which aimed at taking care of the psychotic patients who might otherwise have needed treatment at the mental hospital in Managua. It should be noted that the team constructed the buildings of the CAPS with the participation of different community organizations and the patients. It is apparent that the mental health team might benefit in their own work from continuous contact with the popular movements in their community to be able to develop different support programs for their patients. Another aim is to present the psychiatric diagnostic panorama within such a setting. The study was done during a period of two months in 1984, before the war had reached its greatest intensity. The primary intention of the study was to evaluate the daily work. We knew from the statistical report from the area that the team used to see between 80-90 patients per month. The 198 patients interviewed in a period of two months were considered representative of the service at that time. So far, there are only a few studies that give information about the epidemiology of mental disorders in Nicaragua (Kraudy et al. 1987; Penayo et al. 1984).
The mental health team in Ciudad Sandino
Ciudad Sandino is a suburb of Managua with about 70000 inhabitants. It is a rather poor area, fairly homogeneous in regard to population and occu-
pation. Most inhabitants are workers living in similar simple houses. Most moved to the area after the big earthquake in 1972 which destroyed central parts of Managua and the slums close to it. There is electricity and some communal communication with the city. The "barrio" is very well organized and actively engaged in building the new Nicaraguan society. The psychiatric outpatient team in Ciudad Sandino consisted at the time of the investigation (1984) of one psychiatrist, one psychologist, and one social worker who shared duties with the staff at the "Centro de Salud" or primary health care unit, where the team held consultations. There was also one nurse with special training in psychiatry, and one health brigadista from the local community who later became a sociotherapist within the local CAPS. In total, the team had four full time members (psychiatrist, psychologist, nurse and sociotherapist), and one half time member (social worker). Because of support from Sweden through solidarity organizations, the team was well staffed compared to other teams that were started at the same time. It should also be mentioned that the psychologist in the first period (1982-1983) was a nun from the USA Maryknoll order. The team was in contact with mental health workers from Italy, Mexico, Argentina and Sweden, among others. Frequent discussions took place within the team about the anti-psychiatric movement and the Italian reform movement, and its influence in Europe, as well as the importance of cooperation with healers and local leaders in the community. However, the main point all the time was to work together with the local community in order to integrate and support the patients.
Method
The diagnosis of the patients attending the unit was made by the author and the other members of the team in a group discussion. This also had the function of training other members of the team and give them further education in psychiatric work. The team also had continuous training and supervision from the psychiatric hospiital. According to the experience of the team, a special list with 19 diagnostic categories based on ICD9 was used for this work. The discussions were based on a semistructured clinical interview that the team had developed during the period of 1982-83. Besides a classical clinical history with a list of symtoms, the interview contains questions about
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the influence of the war, recent mourning because of other catastrophes, and the social situation. The team tried in these discussions to find a practical basis for multiaxial diagnosis adapted to Nicaragua. A simple questionnaire was used to collect data on age, sex, civil status, educational level, work and living place. Included at the end of this questionnaire was a list of ten problem areas or conflicts which was intended to cover most of the reasons the patients gave for attending the unit. The patients were thus asked about the subjective experience underlying their attendance. The problem or conflict area that the patient considered most essential was registered.
Results
Diagnosis The diagnosis according to ICD-9 is shown in Table 1. Neurotic syndromes, especially depression and anxiety, were the predominant diagnostic category, followed by epilepsy and schizophrenic disorders.
Background of the patients Of the 198 patients who attended during the period of two months, 42% were men and 58% women. Nearly 70% were younger than 35 years, and only 6% were more than 56 years of age. Half were married, 6% divorced and 4% widowed. 13.5% of the patients were non literate, 50% had an elementary school and 7% were university students. 94 of the patients (47%) came for the first time, the other 104 came for controls and follow-up. 24.5% (48 patients) had earlier been edmitted to the day center - CAPS - in Ciudad Sandino. Before the CAPS was started, 27 of the patients (17 schizophrenics, four affective psychosis, one transitory organic psychosis and five alcoholics) had been in contact with the national Psychiatric Hospital. These patients were able to benefit from being treated in their own community, even in the acute crisis that otherwise would have demanded special care. All psychotic patients had previously been admitted to the National Psychiatric Hospital in Managua. There were no statistical significant differences (Chi2-test) between patients living outside Ciudad Sandino in the rural areas or those living in the main area of the "Barrio". Significantly more married pa-
Table 2, Diagnosis and Civil Status Diagnosis
Not married
Married
Total
Neurosis Psychosis Organic syndroms Alcohol and drug abuse Acute reactions
28 14 25 4 1
65 8 8 11 2
93 22 33 15 3
Total
72
84
166
Z2 ( d f = 4) = 26.26; P < 0.001
Table 3. Problems that cause the consultation No Conflicts within the couple Conflicts with children Conflicts with parents Conflicts with other relatives Conflicts within work Conflicts with neighbours Conflicts relating to the economic situation Conflicts relating to the war Conflicts relating to natural catastrophes Mourning No problems Total
%
33 17 30 16 31 5 4 7 5 4 46
16.7 8.6 15.2 8.1 15.7 2.5 2.0 3.5 2.5 2.0 23.2
198
100%
tients were diagnosed as suffering from alcoholism and neurosis, while more unmarried patients were diagnosed as suffering from psychosis or organic disorders (Table 2).
Problem diagnosis The problems which the patients presented as the reason for their attendance are shown in Table 3. Conflicts in the family were the most frequent (48.5%), but 23.2% stated that they had no problem. Out of 21 patients with functional psychosis, eight did not mention any problem at all. Eleven mentioned problems in the family and two said they had problems at work. Of the 93 patients with a neurosis, 47 mentioned problems in the family, and 18 at work, seven mentioned the ongoing war with the contras, three had conflicts with their neighbours and eleven said that they had no special problems. There were 33 patients with organic disorders and half of them said they had no problems. Of the 15 patients with alcoholism, only seven admitted they had problems - five in the family and two with their job. Of the twelve children who came to the unit, eight said they had problems with their parents and two with some other relative. One of the children
154
said he had problems in school. The one with mental retardation did not recognize any problems at all.
Comments
It is apparent that the diagnostic panorama in a psychiatric outpatient unit in Nicaragua does not differ essentially from other countries in the third world (Jacobsson 1985) and from elsewhere in Latin America (APAL 1981). The proportion of alcoholics is not higher than in other countries where alcohol is not prohibited. Alcohol dependence is nevertheless considered an increasing problem by the Health authorities (Jacobsson 1988). Neurotic patients comprise the majority, especially those with depressive characteristics. This seems to be a common feature in the Latin American culture (Jacobsson 1988). For the planning of psychiatric services in Nicaragua it is important that the out-patient team provides care for predominantly neurotic patients. This is known from many other studies in developing countries, as well as from industrialized countries, and has implications for the training and staffing of these outpatient teams. It is also clear that the number of people seen by such a service is small compared to the total psychiatric morbidity in the community. Mari (1987) has shown that a very high proportion of patients attending primary medical care clinics in Sao Paulo suffer from "minor psychiatric morbidity". Further studies on the psychiatric morbidity in primary care settings in Nicaragua are needed. The concept of "problem diagnosis" is imprecise, but might be useful as an indication of possible causes of mental disturbances and of their possible effects on social relationships. Supplementary assessment of this type provides information about t h e social situation which could be used in psychiatric practice. It could also assist in the development of a multiaxial diagnosis adapted to Nicaragua. We later found similar ideas and techniques in the evaluation of the "Nacka sector" in Stockholm, Sweden (Stefansson 1985). Altogether in almost 40% of cases conflicts in the family were mentioned. This figure should be used as a justification for more family oriented work and research by Primary Care Mental Health teams in Nicaragua. The results in this study do not show essential differences from previous studies in the third world (Giel et al. 1983). Nicaragua is now experiencing fundamental changes in the social system which will possibly be seen very clearly in the situation of the family. There
is a change from a colonial-Indian family model to a more modern "revolutionary sandinistic" model which is still not clearly defined. There is, among other things, a change in the power relations between men and women, in the sense that women have a greater role in decisions than before, and this of course causes conflicts (ENVIO 1984). Another important factor is the war with the "contras" which imposes a great stress on almost every family. However, it is interesting that only 3.5% of the patients mentioned 1Lhewar as the main cause of their problems. It could be that the pressures imposed by the war situation transform themselves into conflicts within the family, as they are perceived by the interviewed. These observations add strength to the applicability of the WHO's guidelines for preventive work in the field of Mental Health which hinge on the development of care geared towards the family in the third world. It is thus necessary that the mental health team should get a more family oriented training to be able to deal with problems and support the families of mentally disturbed people. As regard schizophrenia, the relatively small number of schizophrenic patients (17 individuals) in contact with the service, in a population of about 70 000 inhabitants gives an approximate prevalence rate of 0.3-0.4 per 1,000. This is a quite low figure that raises questions. Is schizophrenia uncommon in this community, is care provided elsewhere, or are there unmet needs? Only further epidemiological studies can give the answer. From our results, it might be concluded that the principles which the Ministry of Health has accepted and which stress the development of primary health care including the establishment of centers for psychosocial intervention (Centros de Atenti6n Psicosocial - CAPS) are in accordance with the problems identified in the pilot study. The mental health teams should actively participate and cooperate with other health programs at the primary care level, such as childrens' clinics and mothers' clinics, and in this way support the families, which are the basis for mental health work in the third world. It is also apparent that it is of value for the mental health team to make simple investigations of their own work, as in this study. This gives a better insight into the problems which patients have and which the mental health team has to deal with in their community. Acknowledgements. I am grateful to Professor Lars Jacobsson for his support and to the Mental Health Team in Ciudad Sandino: Cra. Mafia Jarguin, Maura Otero, Man:a Ramirez, Sofia Velazquez, Felipe Sarti, July Miller and Camilla Lundgren.
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Accepted November 9, 1988
U. Penayo, MD Department of Psychiatry University of Ume~t S-901 85 Umeg Sweden
