The current state of psychiatric and mental healthcare in Argentina

Summary

This brief article gives key demographic, socio-economic and health information for the Argentine Republic, with special emphasis in the field of psychiatry and mental health. It also informs about the country's mental health legislation and ongoing epidemiological research projects. It points out deficiencies and obstacles encountered in meeting the population's healthcare needs, and suggests developments to improve this situation.

Demographic, socioeconomic and health data

The population of Argentina (officially the Argentine Republic) is about 42 669 500 (INDEC 2014). Eighty-nine per cent of the inhabitants reside in urban areas, and one-third live in Buenos Aires and its suburbs.

Ethnically, we can notice a near-absolute predominance of White people of European ancestry, mostly Spaniards and Italians, mixed with the indigenous population to give the ‘mixed-race’ or mestizo type. The blend of cultures is reflected in the cosmopolitan atmosphere and the typical Argentine identity, which has a more European influence than the other Latin American countries. The pure indigenous population is only a very small part of the total.

The unemployment rate is 7.07% (INDEC 2014). Despite a marked improvement in the past decade, Argentina's Gini index (a measure of the income distribution of the country's residents) is 0.41 (CEPAL 2013), which indicates a still unacceptable inequality (perfect equality 0, perfect inequality 1). By comparison, that of the European Union in the same year was is 0.35 (Eurostat 2015).

Undoubtedly, urban living and inequality can influence psychiatric morbidity, but the paucity of epidemiological data precludes specific considerations. Among other health indicators, the infant mortality rate is 10.8 per 1000 live births (Ministerio de Salud de la Nación 2015). The overall mortality rate is 7.72 per 1000 population (it is 7.89 worldwide; Index Mundi 2014) and, in general, the country tends towards population ageing.

Human resources in psychiatry and mental healthcare

The literacy rate in Argentina is 97.4%. There are hundreds of university-level institutions, with 15 schools of medicine and 35 schools of psychology (Ministerio de Educación de la Nación 2014). There are 4500 psychiatrists (10.54 per 100 000 inhabitants: a higher rate than in Europe, which has 9.0 per 100 000, and well above the world average of 3.96). On the other hand, the numbers of child and adolescent psychiatrists (around 300) (Barcala 2007) and old age psychiatrists are insufficient.

There are about 56 000 psychologists (154 per 100 000 inhabitants: an extremely high ratio and several times higher than in high-income countries), which makes Argentina the country with the most psychologists per inhabitant in the world (Alonso 2005). Most of them work in the city of Buenos Aires in predominantly psychoanalytic-oriented private or semi-private practice. In sharp contrast, the number of social workers with training in mental health is less than necessary. Also, nurses working in psychiatry are scarce and training for them is deficient. There are no nursing schools in this field, only in-service training of general nurses (Moldavsky 2011). This chaotic picture of the allocation of human resources is a consequence of almost no planning in mental healthcare for decades. Furthermore, there is no government regulation of professional needs and universities have no entry requirements.

Policies and legislation

In the National Ministry of Health, there is a National Department of Mental Health (the DGSM), which issues guidelines and proposals to the Provincial Ministries of Health. However, such guidelines do not have a direct binding effect, since Argentina is a federal country and the provinces have not delegated health sector management to the federal government. Each province allocates little or no money to the mental health sector: usually 0.5–5% of the total health budget, which is clearly insufficient for operation, maintenance of building infrastructure and increased staff recruitment (Moldavsky 2011). In December 2010, the National Congress enacted the National Mental Health Act (Ley Nacional de Salud Mental). The spirit of this legal instrument is essentially intended to regulate psychiatric hospital admissions on the basis of respect for individual freedoms, and it aims to close psychiatric hospitals by 2020. However, there are still no resources planned to care for patients with mental illness who are in psychiatric hospitals today. After some delay, the DGSM released a National Mental Health Plan in 2013. Nevertheless, the lack of funding, the shortage of staff at the DGSM, the absence of epidemiological orientation and lack of power over specific provincial policies have left those initiatives in the field of good intentions for the moment, without the ability to modify the real situation of mental health services. Also, attempts to carry out national mental health plans in the domain of primary care were not successful. Problems of the kind mentioned, among other causes, resulted in great inequality and a significant gap between the demand and supply of primary care services, particularly for poorer people.

The budget for mental health, at both the national and provincial levels, is below the standards recommended by the World Health Organization (WHO 2003). At the national level, 65% of the mental health budget goes to psychiatric hospitals (Pan American Health Organization 2013), leaving insufficient resources for community services and creating big distortions. One of the several consequences is that residents in training in general hospitals or community services have to carry out exhausting healthcare tasks during their 4-year residency, to the detriment of the time dedicated in particular to theoretical learning. Another is the unusual fact, which those in high-income countries might find difficult to understand, that several services in Argentina rely, within their professional staff, on the indispensable participation of young physicians and psychologists who work for free.

The busy life of most Argentinian psychiatrists involves the distribution of their working time among their private office, a public hospital or a private clinic and, in some cases, also a hospital emergency room.

Research

With the exception of some particular epidemiological studies focused on specific areas of certain pathologies (e.g. drug addiction, alcoholism) (SEDRONAR 2010), and only in certain regions of the country, Argentina has always lacked complete and reliable epidemiological data on mental health (Torricelli 2004). In 2015, for the first time in the history of the country, a study of this type was begun in the general population. It is being organised by the School of Medicine at the University of Buenos Aires and the Association of Argentinian Psychiatrists (APSA), with technical support from Harvard University, and is financed by the Argentinian Ministry of Health. In other aspects, research in psychiatry and mental health is scarce. It is expected that preliminary results will be published this year.

New mental healthcare needs

In addition to their usual caseload, psychiatrists are seeing a rise in substance misuse and the consequences of domestic violence. In fact, recorded alcohol and cannabis use has never been higher in Argentina (SEDRONAR 2010). It is estimated that 0.8% of the population use cocaine, with half of users showing signs of dependence. But cocaine users are relatively few compared with the 18% of the population who use tranquillisers and anxiolytics, with about 10% of that consumption acquired without prescription (SEDRONAR 2010) The use of stimulants and antidepressants, whether under medical treatment or not, is less widespread than the use of tranquillisers. Recent or past-year use of stimulants without medical prescription reached 0.1% of the population.

Future challenges

Official figures may paint a gloomy picture of chaos and low quality of care. But what they cannot show is the resilience and dedication of psychiatrists, who compensate for the system's shortcomings with creativity and commitment. These qualities would be better used in a more organised mental healthcare system. To that end, government policies should be aimed at the following goals:

• acquiring up-to-date epidemiological data to allow the scarce resources to be focused on the treatment of prevailing pathologies

• an increase in funding for the mental health sector

• creating institutions in the community (day hospitals, halfway houses, group homes, mental health centres, etc.)

• organising the sector to have specialised psychiatric units with quick bed rotation (to avoid the institutionalisation of the old asylums) and psychiatric units in general hospitals

• a strong boost to the treatment of addictions and alcoholism

• permanent campaigns to inform the general public and fight against the stigma attached to mental illness

• developing specific healthcare policies for the most vulnerable age groups (children, adolescents and the elderly)

• training for specialised psychiatric nurses.