Mental health policy in the context of psychiatric hospitals : Challenges and perspectives La política de salud mental en el contexto del hospital psiquiátrico : Desafíos y perspectivas

Objective: To analyze the study participants' opinions on mental health policy, in the context of psychiatric hospitals. Methods: This was a qualitative study with 60 healthcare professionals, all of whom had higher education degrees, undertaken in two large psychiatric hospitals from June to October 2014. Data were collected by means of a questionnaire, transcribed and processed with Alceste software, and interpreted using Bardin's thematic content analysis. Results: In public mental health care policies on psychiatric hospitals, there is a confluence of critical and complex scenarios that directly reflect on the work of mental health care professionals, ranging from institutional macro-political to actual care, developed in the daily life of this service. Conclusion: The results of this study reinforce the need for humanized mental health care, and intersectoral dialogue on the actions developed in this field.


INTRODUCTION
In Brazil, the Psychiatric Reform process began in the 1970s.It was inspired by Italian Democratic Psychiatry, and shared ideals with the Brazilian Health Reform, in a broad and challenging political, economic, legal, social and cultural movement, to change and transition towards a national health care model based on constitutional guarantees.This process led to changes in public policies in the field of mental health, reinforcing deinstitutionalization as an important guiding axis of management in mental health, with a view towards improving the quality of life of people with mental disorders during their rehabilitation, and participation of patients' families 1,2 .
In the course of implementation of new policies, legal instruments emerged that gave value to successful experiences for elimination of the asylum model in the country.In recent years, with law nº 10216/2001 (also known as the Reform Law) and institution of the National Mental Health Policy (PNSM, as per its acronym in Portuguese), a humanized model of comprehensive mental health care in the public network was built, which moved the focus from being solely on hospitalization for treatment of users 1,3 .
In this context, the psychosocial care network (RAPS, as per its acronym in Portuguese) was deployed, composed of strategic outpatient care services, including psychosocial care centers (CAPS, as per its acronym in Portuguese), day hospitals, therapeutic residences and mental health outpatient clinics.The RAPS strives for interdisciplinary care (by nurses, physicians, psychologists, occupational therapists, etc.), with diverse interdisciplinary therapeutic activities aimed at reinserting patients with mental illness into family life and society 4,5 .
To strengthen the process of deinstitutionalization of patients with a long history of psychiatric hospitalization, and reinforce Law nº 10.2016, psychiatric hospitals have been restructured and evaluated through reduced number of beds and admissions, or migration of beds from larger to smaller hospitals 2 .This movement encouraged the expansion of outpatient community-based services in municipalities that replaced the hospital-centric model, with its history, architecture and operation embodying a legacy of suffering, pain, punishment and surveillance, with no psychotherapeutic coherence.
It is recommended that management of crisis and emergency situations for users with acute psychological symptoms occur in psychosocial care centers CAPS III, which provide continuous care, including in emergency situations, or the CAPS for alcohol and drugs (CAPS AD III), and general hospitals, with the support of follow-up care services.Currently in Brazil, there are 3,910 psychiatry beds in 646 general hospitals 2,6 .
In this new understanding, the PNSM emphasizes that crisis and emergency mental health care should be articulated with other strategic partners such as primary care.In addition, it strengthens the work and expansion of the CAPS III and psychiatric beds in general hospitals, in lieu of long-term hospitalization in psychiatric hospitals, considering the need to offer treatment modalities and increasingly qualify services so as to ensure comprehensive mental health care to the population throughout the national territory, in the perspective of psychosocial care 2,4 .
Among Brazilian states and regions, political and economic asymmetries and impasses are circumscribed and even linked to public management, in the process of expansion of specialized services for mental health crises and emergencies 7,8 .This mode of care faces challenges such as shortage of qualified professionals; adherence of mental health professionals in the composition of daily and weekly teams, due to the cost or professional market conditions; and the cost of creating and maintaining this health care service, which involves cooperation between federal and municipal managers 9 .
Faced with the challenges of deploying the crisis and emergency mental health care network, psychiatric hospital beds are used when necessary, the mode of care that still predominates in these hospitals, even though it is less favorable under current policies 1,4 .In this sense, the important role of healthcare professionals working in psychiatric hospitals is recognized, because they live with paradigmatic, structural, operational and doctrinal changes, changes in flow of practices with the adoption of other services, and the idea of the progressive phasing out of this institution, coupled with misunderstanding and lack of professional recognition by other professionals in the public health care network.
Thus, there is a need to broaden the debate on current policies and process of structuring services in the context of the Psychiatric Reform by means of professional experience in the hospital model, by raising the following question: what are the opinions of health professionals on mental health policy in the context of psychiatric hospitals?The aim of this study was to analyze the opinions of mental health care professionals on mental health policy in the context of psychiatric hospitals.

METHODS
This was an exploratory and descriptive qualitative study, approved by the research ethics committee of the Federal University of Rio Grande do Norte under protocol nº 508.43/2014,CAAE: 25851913.7.0000.5537.The study adhered to ethical principles in research, and the Council of National Health Resolution Nº 466, 12 of December 2012, by which all participants signed a free and informed consent form.
Data were collected from June to October of 2014, in two public psychiatric hospitals in the northeastern Brazilian state of Rio Grande do Norte.One of the hospitals was located in the capital city Natal, and had 130 beds, and a mean admission rate of 764 patients per month.The other hospital was located in the interior of the same state, had 200 beds, and admitted a mean of 160 patients per month.In order to include a greater number of study participants, in all professional categories with higher education degrees in both hospitals, 60 professionals participated in the study, including 22 nurses, 9 social workers,
A self-applicable questionnaire was used for data collection, which contained questions on social, political and demographic aspects of mental health and psychiatric reform in care (comment on national policy in the institutional context; talk about work relationships and work by professionals).Inclusion criteria for participants were being a professional with a higher education degree, with an effective association with the public mental health service, and at least six months of experience, and who provided care to users and their families.
A database was compiled with the participants' responses to the questionnaire, which were processed using Alceste 4.8 10 software, by means of preparation of the corpus required by the informational program that performs lexical analysis of a set of texts, according to the five steps described in Figure 1.

RESULTS
The majority of study participants were female, aged 50 to 59 years, with 34 years of training and 35 years of work in mental health.Moreover, 12 participants had an educational major in mental health (Table 1).
In the process of structuring and organizing data, two main themes were developed to present the findings (Tables 2 and 3).In Theme A, Aspects of mental health policy in the psychiatric hospital, two sub-themes were obtained: A.1 Institutional policy management; and A.2, Political barriers for the team, as shown in Table 2.
In the subtheme A.1, Institutional policy management, the aspects linked to the political field and health care management reflected in psychiatric hospitals were identified, such as: lack Classes 1 and 4 were used for this study, as they specifically have content on mental health policy in the hospital context.In the phase of treatment by the software of the findings obtained, the phases of content analysis were followed 11 : i) pre-analysis: moment of reading and development of the analysis plan; ii) treatment of the material: coding of statements relevant to the purpose of the study through use of Alceste 4.8; iii) interpretation of the findings, categorizing them for final analysis.In the final analysis, the data were subjected to exhaustive and interpretive reading according to Bardin's thematic content analysis 11 .In order to ensure anonymity and confidentiality of participants, excerpts of their statements were identified with the capital letter P, followed by the sequential numbering of study participants.

Thematic axis A -Aspects of mental health policy in the psychiatric hospital Theme A.1 -institutional policy management Theme A.2 -political barriers for the team
The state does not provide conditions necessary for the work of professionals (P6).

The psychiatric reform has not occurred in the institution (P41).
There is a lack of physical and outpatient infrastructure, and materials and medicines; the unit is overcrowded (P2).
Collaborate so that psychiatric reform guidelines are implemented in the institution (P18).
The lack of human resources hinders implementation of the policy (P12).
No, the internal political of the institution impede the interdisciplinary process from occurring, and also make it so that the psychiatric reform doesn't flow (P52).
As there is no therapeutic design of the institution, which adheres to the National Policy, it is often clumsy, and for this reason does not continue (P22).

We have isolated practices that contribute to strengthen the Brazilian psychiatric reform (P1)I think the relationships between professionals are still lacking (P26).
There is no assisted discharge, and no guarantee of continued care (referral), which causes the revolving door phenomenon.Effectively, network care does not exist (P31).
There are difficulties with integration, specification of roles and functions, in addition to work in multidisciplinary teams (P28).

Promote greater interaction between patient and family members/community (P16).
There is still a need for greater interaction with the primary care network, as well as intensification of actions to demystify mental illness in society (P24).

Specialized listening, welcoming subjectivity, family orientation, responsible referrals aimed at improved adherence to treatment (P3).
There could be a better connection with the substitute services (care network), which would reduce the need for hospitalizing patients (P4).

Meet the demands of patients and their families (P9).
There is an overload of patients in search of vacancies (P43).

Work with the patient and family for the patient's resocialization and continuity of treatment after discharge (P6).
Despite being a psychiatric hospital, there is a movement of networking (P1).

The work is developed by professionals individually, where actions are fragmented, and most professionals don't have an overall vision (P14).
The substitute services don't receive the demand as it should, in addition to the stigma that is exposed to the patient, family and the professionals (P8).
A best practice of humanization would also be necessary, since many professionals are "stuck" in older systems (Q6).

The referral does not work for substitute services (P7).
of management in public health; scarcity of material, financial and input resources; lack of professionals; inadequate physical infrastructure; high user demand; and psychiatric rehospitalization.Subtheme A.2, Political barriers for the team, strengthens the findings from the previous theme, and complement what the professionals emphasized, i.e., that the guidelines proposed by the psychiatric reform were not implemented, and there was a lack of interdisciplinary teamwork in these services (Table 3).
As with the previous axis, thematic axis B, Aspects of mental health policy in professional care, is divided into two sub-themes: B.1 -Embracing users and their families; and B.2 -Difficulties for professional work in the mental health care network (Table 3).
In subtheme B.1, Embracing users and their families, from the understanding of professionals as strategic points for such a tool, the formation of a bond between professionals and users; active listening; continuity of treatment; humanization of care; and, fragmentation of care practices stood out.
In subtheme B.2, Difficulties for professional work in the public mental health care network, the main challenges to effective participation of the hospital in the network are cited: lack of articulation with the basic network, unmet demand and lack of referrals and counter-referrals in care.

Mental health policy in psychiatric hospital
Pessoa JM, Santos RCA, Clementino FS, Oliveira KKD, Miranda FAN

DISCUSSION
The historical and political scenarios of professional work in mental health in Brazil, from the adoption of a legal and official framework such as law nº 10.216/2001 and the National Mental Health Policy, point to implementation of the model of psychosocial care and community-based, outpatient treatment of mental disorders.In this sense, the proposed configuration of work in the network defined the CAPS in its various modalities, as an strategic reference for care for users with mental disorders, and the process of gradual reduction of the number of psychiatric hospitals [2][3][4] .
Through changes implemented during the national psychiatric reform, psychiatric hospitals have significantly reduced the number of beds available, an aspect of the process of deinstitutionalization, which ultimately foresees the phasing out of these services.This process is exemplified in GM/MS Ordinance Nº 25, of January 31, 2002, which established standards and guidelines for psychiatric hospital care, as regards the classification of hospitals and the structure and psychiatric hospitalizations by the Unified Health System (SUS, as per its acronym in Portuguese).Thus, these hospitals are classified according to the National Hospital/Psychiatric System Evaluation Program (PNASH, as per its acronym in Portuguese) and the number of beds 4,6 .
Adding to the precepts of Ordinance 251/2002, in 2004, the Annual Program of Psychiatric Hospital Care in the SUS-PRH was established by GM Ordinance Nº 52/04, which aimed to progressively reduce the size of psychiatric hospitals (to a size of up to 160 beds), in order to ensure better clinical functioning and greater articulation with the outpatient mental health network in municipalities 4 .
Recognizing the current context of ressignification of the role of psychological hospitals based on the guidelines of the psychological reform, there are important challenges to be overcome, as pointed out by the study participants.The data presented in tables 2 and 3 refer to aspects of institutional health policy of the hospitals, specifically related to management of work and care processes, where problems such as lack of public investment, the reduced number of professionals and the phenomenon of psychiatric rehospitalization are listed.As for political obstacles for the team, the participants mentioned the shortage of professionals in the field, which intersects with the need for implementation of guidelines of the reform.
It is agreed that in recent years, in several regions and states, there has been an expansion in the network of specialized psychosocial care services, however, in some municipalities, the amount of mental health care services remains low and insufficient to meet the demand 3,7 .There are also difficulties to install and properly maintain this network, either due to the shortage of specialized professionals, or to political-economic reasons linked to public administration, thereby increasing non-implementation of these services in their territories.This problem is reflected in the reality of psychiatric hospitals 7 .
The phenomenon of frequent psychiatric rehospitalization, known as the "revolving-door", was indicated as a consequence of the lack of continuity of treatment by users, and configuration of the care network in the territory, given its incidence among patients of psychiatric hospitals.The repetitive cycle of hospitalization/ discharge/hospitalization can trigger difficulties in the process of socialization of patients and ruptures in family bonds, marked by stigma and prejudice.It is therefore understood that admission be judicious, and strictly for necessary cases, in an attempt to avoid chronicity of the individual and the mental illness 12 .
Corroborating this discussion, one study 13 on common characteristics among people who were recently discharged from a psychiatric hospital, performed at the Mental Health Center of the Ribeirão Preto Medical School, pointed out that psychiatric hospitalization is a necessary resource for crisis, and is part of maintaining psychiatric treatment and the appropriateness of treatment in community care services.In this sense, reduction of the length of stay and the user in the hospital is called for.
Assuming the political obstacles mentioned by the professionals of the study, it is observed that the quality of care developed by the services of the mental health care network still lacks major investments by the government, as mentioned by the study participants, and therefore should not be compromised by outside influences, whatever the nature, whether political, organizational or even financial 14 .Considering, therefore, the fulfillment of its basic precepts in response to the demands of public health, clinical care should be provided based on embracing patients and preserving their human subjectivity and uniqueness 15,16 .
Thus, participants pointed out aspects of mental health policy in the hospital setting of professional work, and reinforced the need for mental health care based on embracement, bonds and shared responsibility for patients, with emphasis on light technologies that enable expression and subjectivity of patients and their families (Table 3).These relational devices are understood as fundamental to organize health care, capable of making health care practices more democratic and horizontal, to the extent that they build affective ties, trust, respect and exchange/sharing of knowledge among users, families and healthcare professionals 17 .To this end, interdisciplinary professional work is required to establish comprehensive health care actions that embrace patients in crisis, and evaluate them according to their needs.
As observed, psychiatric hospitals, considered "open door" services, are in a critical situation due to excessive demand of users, partly reflecting lack of dialogue among the services that provide various levels of care.This reality affects directly the performance of the professional in this service.Primary health care stood out for its lack of coordination with the hospital and other equipment that make up the network of psychosocial care.
It is understood that, in the context of the intersectoral approach in the network of psychosocial care, primary care in the setting of the family health strategy (FHS) acts as an important foothold in the development of mental health actions.In the reality of Brazil, composed of municipalities with small and medium

Mental health policy in psychiatric hospital
Pessoa JM, Santos RCA, Clementino FS, Oliveira KKD, Miranda FAN sized populations, the FHS plays the central role in psychiatric care, although it continues to be a segment of public health with little financial investment, and which suffers from a shortage of qualified human resources to work in this field 14 .
With a view to overcoming these inequalities, the matrix reference teams seek to qualify and strengthen mental health actions carried out in primary health care, through joint articulation between the mental health care teams and family health units, in a process of shared responsibility of care for users with mental disorders 2,6 .Through organization strategies and the Family Health Support Center (NASF, as per its acronym in Portuguese), which offers specialties such as psychiatry, psychology and therapy, among others, FHS teams began to make diverse professional support available, aiming to improve interventions performed and reduce referrals in most of the cases 7,9,14 .
Thus, the need is reinforced for intersectoral dialogue among the various services that make up the network of psychosocial and mental health care among Brazilian municipalities, such as CAPS, outpatient care clinics, therapeutic residences and psychiatric hospitals, given the few advances achieved in recent years 17 .Efforts towards new demands for care emerging from the increase in population and the little investment directed to this field should also be mentioned 2,18 .
Thus, monitoring of specific cases such as alcohol and abuse of other drugs, or demands such as medical prescriptions, require greater coordination with other network services such as CAPS, outpatient clinics and primary health care.From this reality, there is clearly a need to rethink construction of a network of alternatives to psychiatric hospitalization, taking into consideration the real needs of users, because sometimes they return to family and social life without the necessary treatment or effective care.

CONCLUSION
Among challenges and prospects, the current political and mental health care scenarios in Brazil face problems, especially difficulties in management of services, frequent rehospitalizations, reduced number of services and available equipment, as well as the high demand of users, disarticulation of the psychosocial care network, and shortage of qualified human resources to work in these services.Although this study depicts a specific context, this experience, in various political, economic, legal, social and cultural aspects, approaches the reality of other states in the country as regards the situation of crisis and emergency, which coexist with challenges to implement improvements in the quality of life of mentally ill people, and interference of the political party will to which they are subjected.
In the sphere of public policies and follow-up in mental health in the scope of the psychiatric hospital, the confluence of critical and complex scenarios in the work of professionals is recognized, which range from aspects of the institutional macropolicies to actual care provided by this service.Therefore, this study reinforces the need for humanized care in mental health, along with the intersectoral dialogue on the set of actions developed in this area, as able to contribute in the reintegration process of patients with mental illness into society and family life, and increasingly strengthen the process of psychiatric reform underway, as demonstrated by the evidence of new studies on work in psychiatric crisis and emergency, in the context of the psychosocial care network.

Figure 1 .
Figure 1.Description of the steps of corpus analysis by Alceste.Natal, 2014.Created by the authors.

Table 1 .
Sociodemographic characteristics and training of psychiatric hospital professionals.Rio Grande do Norte, 2014