Psychiatric Reforms and Coming off Prescribed Psychotropic Drugs in Brazil, a Global South Country
[In: Peter Lehmann / Craig Newnes (Eds.): Withdrawal from Prescribed Psychotropic Drugs]
In Brazil, the asylum model defines the psychiatric system. Apart from the country-specific characteristics in Brazil, the situation regarding knowledge of risks and harms of prescribed psychotropic drugs and problems with their discontinuation is not significantly different from other countries in the Global South.
From the last decade of the 19th century until the 1950s, dozens of colonies for mad prisoners were created in the country; some were bigger than many cities. One, the Complexo Psiquiátrico do Juquery in Franco da Rocha in the metropolitan region of São Paulo, held almost 30,000 inmates (Farias & Sonim, 2014).
In 1978, the year in which the contemporary psychiatric reform process began in Brazil, 97% of total psychiatric funding was used for psychiatric asylum beds (Cerqueira, 1984). About 80,000 places were on bed-floors, meaning 80,000 people had to sleep on floors. The average hospital stay exceeded years; for example, in the Hospício Nacional de Alienados (National Asylum for the Insane) in Rio de Janeiro, currently Hospício Pedro II, a census was carried out revealing an average stay of 26 years (Andrade, 1982).
Over the years, as a result of the politics of the first non-military government, things changed. Psychiatric reforms lead to a unified health system, which even today defines national health policy founded on the principles of free and universal access, decentralization, social participation and control. Health councils were created with equal participation from municipal, state and federal management bodies holding regular meetings to prepare and monitor health policy. Mental health service users/recipients and family members have become actors in the debates and elect representatives for participation in politics with statements, presentations, and comments on the topics discussed.
In 1987, the Brazilian psychiatric movement identified with Réseau Internacional, a network of critical professionals around the Italian reform psychiatrist Franco Basaglia in the 1960s and 1970s (Elkaïm, 1979), and gave rise to the motto For a society without asylums. Activists from other areas of human rights defence were incorporated, and the concept of the asylum as the social and cultural practice of segregation and discrimination was criticized (Venturini et al., 2020).
In the late 1980s and early 1990s, several initiatives appeared. The first non-asylum and non-outpatient spaces were created, such as the Psychosocial Care Centers and the Social Co-operation and the Co-operation Centers. Among others, the reform movement and social participation grew around a potent National Anti-Asylum Movement. Besides the opening of these new systems, called "substitutes for the asylum model", some asylums were closed. In 2001, the Brazilian Law 10.216 was approved and constituted an important instrument for new Brazilian psychiatric reform. The backbone of this process was the existence of a strong social movement composed of thousands of activists from all parts of society; (ex-) users of psychiatry, human rights activists, professionals, family members, and politicians. Hundreds of asylums have been closed, many thousands of psychiatric beds have been abolished, countless community and territorial services and care centres have been opened. This psychiatric reform was powerful enough to influence a series of cultural initiatives, such as several feature films and theatre plays, marches and public cultural acts, arts exhibitions, diverse cultural events such as a Museum da Loucura (Museum of Madness), a Festival of Loucura (Festival of Madness), political action from the Ministry of Culture for people in psychological distress such as Loucos pela Diversidade (Mad in Diversity) (Torre, 2018). Throughout this period, several music groups, theatre companies, carnival blocks and samba schools, radio stations and community TV were created; all were activities with people calling themselves mad people and (ex-) users or survivors of psychiatry.
However, the application of the principles set out in the laws has been very difficult, partly because of the historical predominance of the asylum model, with roots that penetrate culture and social tradition, and partly because of the strong resistance of the sectors interested in maintaining the system with its use of force and human rights violations. Such sectors are composed, in particular, by psychiatric associations that, very often, are led by psychiatric entrepreneurs themselves, i.e., by organisations that make psychiatric treatment a commercial business. And, not least, the resistance came from mainstream psychiatry's attempts to maintain the medically centered hierarchy. Ith the exception of Brazil, it has been very difficult to close asylum institutions in other countries in Latin America, as well as to open humanistically orientated services and resist the medicalizing and pathologizing model of psychiatry, which is strongly influenced and financed by pharmaceutical firms.
Therefore, in 2017, as a result of an initiative of the Brazilian Mental Health Association, a network of human rights and mental health was organized in Latin America and the Caribbean. Such a network arose from the need to build a body of social support for implementing laws and the creation of new social and political practices in mental health. With the exchange of experiences among network participants, innovative and remarkable experiences have been made possible, especially aimed at the participation and protagonism of (ex-) users and survivors of psychiatry, such as self-help groups, artistic and cultural activities, initiatives to create jobs and earn money, and social participation. But despite all the social movement existing in Brazil, Argentina or Uruguay, the biopsychosocial paradigm of mental illness with its stereotype of public dangerousness, unpredictability and need for treatment, was not criticised.
For several decades, there have been movements in Brazil to criticise psychiatry and medicalisation. Although there have been many events to criticise the latter, such as the various congresses and seminars on the "rational use of medicines", positive results are hardly visible. It is important to highlight important initiatives, such as that of the Brazilian Society of Medicines Vigilance, the "Forum on medicalisation of education and society", the "Support and Monitoring Centre for Learning". The "Despatologiza" (Depathologize) movement, born in the University of Campinas, is the protagonist of important initiatives, amongst which is the establishment of a protocol for the prescription of methylphenidate (trade names Concerta, Medikinet, Ritalin, etc.) many thousands of pills are no longer consumed by children diagnosed with ADHD (Moysés & Collares, 2018).
Experiences of overcoming the use of prescribed psychotropic drugs (psychiatric drugs), and even more the knowledge of how to deprescribe and/or withdraw from them without risk and how to help in the withdrawal process are poorly promoted or almost non-existent. As mentioned at the outset, psychiatric reforms in Brazil may differ from reforms in other countries of the Global South: The dominance of biologically oriented psychiatry exists here as well as there, and presumably this is also the case in middle- and high-income countries (Lehmann, 2021). Psychiatric drugs are administered, but no help is offered in discontinuing them.
The proposal known as Autonomous Medicines Management, for example, does not trigger questioning the use of prescribed psychotropic drugs. It can serve, in part, to adapt the users of psychiatric drugs to the controlled use of them, without problematizing the lack of information about their toxic effects, about the risk of physiological and secondary psychological dependence, about withdrawal symptoms, about alternatives, about the higher recovery rates in rural areas of developing countries with their reduced availability of "effective" synthetic psychiatric drugs compared with the rates in the so-called First World with its modern drugs, and about the higher mortality rate by an average of two to three decades of people with severe psychiatric diagnoses (and appropriate treatment) compared with the general society.
Finally, initiatives to support withdrawal from psychiatric medication are practically non-existent, restricted to medication self-management projects; these are mostly dedicated to managing the consumption of psychiatric drugs than ending it. There is no entity or organisation that does this systematically, such as the International Institute for Psychiatric Drug Withdrawal (IIPDW).
However, the growth of the Brazilian Mental Health Association brought the topic of medicalisation to the fore, as it organised several dedicated events, courses and publications. In this same context, prominent initiatives emerged from Fiocruz, a national public research and teaching institution. In 2017, it launched the website "Mad in Brasil", linked to "Mad in America" and started the seminars "The epidemic of psychiatric drugs" (inspired by Robert Whitaker's book Anatomy of an Epidemic). Subsequent developments made it possible for Robert Whitaker and other members of the IIPDW like Peter Groot and John Read to come to Brazil and establish the first step to a debate about psychiatric drugs' risks, damages and withdrawal problems and solutions that had not existed in the country until then.