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Mental Health in the Republic of Paraguay

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Mental Health in the Republic of Paraguay COUNTRY Mental health in the republic of PROFILE Paraguay Anne Aboaja,1 Alina Wahab,2 Yang Yang Cao,3 Marcelo O’Higgins4 and Julio Torales5 1Consultant Forensic Psychiatrist, the general population and two subpopulations Forensic Service, Tees, Esk & Wear Paraguay is a landlocked country in South that experience mental health inequity. Valleys NHS Foundation Trust, UK America. It is a democratic low-middle-income 2 Medical Student, Faculty of nation, and the Ministry of Public Health and Medicine and Health, University of Leeds, UK Social Welfare is responsible for its healthcare Mental health services and policy 3Medical Student, School of system. Mental health services receive just 1– Medicine, Dentistry, and Nursing, 2% of healthcare budgets, and there are only Mental health services in Paraguay receive just University of Glasgow, UK 3 1.6 psychiatrists per 100 000 inhabitants. 1.84% of the overall healthcare budget, which 4Resident in Psychiatry, There are insufficient resources to adequately is lower than the median values of 2.5% globally Department of Psychiatry, ’ National University of Asunción, assess and treat mental disorders in high-risk and 11.8% for the World Health Organization s Paraguay 5 populations such as children, adolescents and Americas region. Consequently, substantial 5Professor of Psychiatry, healthcare shortages remain an issue, particularly Department of Psychiatry, prisoners. Despite several improvements to 2 National University of Asunción, mental health policies within the past two in rural and marginalised urban areas, and free Paraguay, email jtorales@med. access to psychotropic medication is not available una.py decades, the nation still lacks a Mental Health fi to all those with mental disorders that require Act and speci c policies required to optimise 3 Keywords. South America; mental the mental health of the population. medication. health law; prisoners; adolescents; Mental health services are concentrated in mental disorders. Greater Asunción, where the specialist Psychiatric Hospital is located.3 This leaves a ser- First received 8 Feb 2021 The Republic of Paraguay, one of two landlocked Final revision 26 Apr 2021 vice provision gap for the population living out- Accepted 6 May 2021 nations in central South America, shares borders side of this region, in more rural areas. with three middle-income countries: Argentina, Nationally, outside of general hospitals there are doi:10.1192/bji.2021.24 Bolivia and Brazil.1 It has over 7 million inhabi- two hospitals dedicated to mental healthcare, pro- © The Author(s), 2021. Published tants, most of whom speak Spanish and/or 6 2 viding 5.11 beds per 100 000 population. Even by Cambridge University Press on Guaraní. Almost half of the nation lives in the when combined with psychiatric beds available behalf of the Royal College of capital, Asunción.1 Psychiatrists. This is an Open in forensic, general hospital and residential care Access article, distributed under Following independence from Spain in 1811, settings, the total number of in-patient mental the terms of the Creative the subsequent War of the Triple Alliance, the Commons Attribution licence healthcare beds per capita (6.82)6 remains signifi- (http://creativecommons.org/ Chaco War and a military dictatorship that cantly below the global median of 16.4.5 It is licenses/by/4.0/), which permits ended in 1989, Paraguay is now a democratic unrestricted re-use, distribution, therefore not surprising that in-patient bed occu- middle-income nation.1 Indigenous, colonial and reproduction in any medium, pancy rates above 110% have been reported.3 provided the original work is and African influences have led to a unique cul- properly cited. Despite policy promotion of community-based ture reflected in a multi-ethnic population,1 pre- care,7 relative financial investment remains dominantly identified as ‘mestizo’ (or mixed).3 focused on hospital-based care. However, most Despite this diversity, 90% of Paraguayans mental healthcare is accessed outside of hospitals. describe themselves as belonging to the Roman The median number of visits to adult out-patient Catholic religion.1 Compared with other South and community (non-hospital) facilities per capita American countries, Paraguay has relatively high is 1661,6 which is higher than the median visit income inequality. Despite an increase toward rate for low-income countries (220), but compar- affluence in recent years, over a third of the popu- able to the median rate for upper-middle-income lation still experience poverty, particularly those countries (1993) and much lower than the living in rural areas.1 median for high-income countries (7966).5 The Ministry of Public Health and Social In the past three decades, key milestones Welfare is responsible for Paraguay’s universal achieved in the development of Paraguay’s men- healthcare system, with delivery occurring pri- tal health policy include the following: marily in family healthcare units.2 Along with the Institute of Social Welfare, they serve 95% of • In 1990, Paraguay signed the Declaration of the population.2 Less than 7% of the national Caracas, signifying a shift in Latin American budget is spent on healthcare.1 Although mental psychiatry from institutionalisation to commu- health inequality in Paraguay has been described nity care. briefly in the literature with respect to the right to • In 2002, the Ministry developed its first health,4 there is an absence of a concise descrip- national policy, which has been criticised for tion of the current mental health profile. This lack of detail and little societal input. paper aims to provide an evidence-based over- • In 2011, a more detailed national policy was view of the mental health system (policies, services created in line with suggestions from the and workforce) and the mental health needs of Inter-American Commission on Human BJPSYCH INTERNATIONAL page 1 of 3 2021 1 Downloaded from https://www.cambridge.org/core. 02 Oct 2021 at 10:59:42, subject to the Cambridge Core terms of use. Rights. This includes an emphasis on universal comparable to that reported in other countries community-based care. in the Americas, whereas the country has the • In 2013, a pathway for mental healthcare was region’s lowest level of disability owing to alcohol developed, integrating primary care and com- use. The contribution of personality disorders to munity mental health teams.7 disability in Paraguay is not known.9 The suicide mortality rate of 9.5 per 100 0006 is lower than To date, major obstacles include the lack of a the global rate of 10.5 per 100 000.5 Mental Health Act, the absence of a suicide pol- icy6 and lack of detailed policy on the rehabilita- tion those who use psychoactive drugs.7 Mental health of prisoners As of 2017, there were 18 prisons in Paraguay, Medical workforce and psychiatric housing prisoners who were pre-trial, post-trial education and on remand. In 2015, 6.5% of the total prison 10 Human resources, including psychiatrists, nurses, population was female. Overcrowding remains psychologists and social workers, are predomin- a serious issue. The occupancy level of 143.1% fi antly skewed in distribution toward facilities in in 2017 (based on the of cial capacity of 9511) Asunción and psychiatric hospitals.3 As of 2018, increased to 176.7% in 2019. Meanwhile, 77.3% there were a recorded 114 psychiatrists and 327 of the total prison population were pre-trial or 10 psychologists working for the Paraguayan popula- on remand, a decrease from 92.7% in 1999. tion of 7 million. Paraguay’s rate of 1.6 psychia- Nationwide, there are 45 forensic mental health trists per 100 000 is lower than the median of beds in specialised prison in-patient units for 2.02 for upper-middle-income countries and inmates with a mental disorder. The minimum 11.87 for high-income countries.5 length of stay in these prison-based facilities is at Because of financial constraints, psychiatric least 1 year, and 54% of all forensic in-patients trainees on Paraguay’s two residence programmes are discharged within 4 years; 38% of patients are – face obstacles, such as limited training tools and discharged after 5 10 years from these forensic 3 time for psychotherapy supervision.8 Resource facilities, and 8% are there for >10 years. limitation has resulted in community research The prison healthcare budget is small and fi being neglected in favour of urban-based hospital insuf cient to meet the cost of psychotropic medi- research. However, research exchange pro- cation needed by prisoners. For this reason, access grammes have begun to fill this gap.8 to medicines is extremely limited in prisons, and Nevertheless, the education division of the medical prescribers often seek medication dona- Latin American Psychiatry Association is unifying tions from external organisations or rely on com- 11 the region’s residency programmes with basic plimentary samples. Addressing the paucity of curricular requirements.8 In 2020, Paraguay prison mental health research would give an indi- began developing a unified psychiatric residency cation of the current level of health inequity and curriculum as part of a wider plan to establish a equality within the prisoner population compared mental health law. The programme includes 3–4 with the general population, and offer direction years of training, opportunities for supervised for improving prisoner mental health. scholarly projects, an oral examination and options to serve underserved areas.8 Mental health of children and adolescents Mental disorders
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