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Revista Colombiana de Psiquiatría

versão impressa ISSN 0034-7450

rev.colomb.psiquiatr. v.41 n.1 Bogotá jan./abr. 2012

 

Editorial

Psychiatry and Mental Health in the Framework of Act 1438 and Agreement 029


We had to wait since 1993 up to the end of 2011 to update drugs and procedures registered in the compulsory health plan allocated to psychiatry and mental health. Through Act 1438 of 2011, Agreement No. 029 was issued to integrally define, clarify and update the Compulsory Health Plan (CHP). Let's welcome then, the Reform to the Compulsory Health Plan that, for the first time, highlights the need to work in the field of mental health as stipulated in Article 66 of this new agreement we waited for so long and for whose attainment we have unflaggingly struggled from different instances of the Colombian Psychiatry Association.

Among modifications it is worth analyzing Articles 6, 17, 18, 22, 24, and 73-77:

Article 6th regarding exclusions that leave aside educational, instructing or training activities on social or labor rehabilitation, which is clearly against the satisfaction of one of the fundamental needs to be met for psychosocial and community rehabilitation, key in Primary Mental Health Attention.

Article 17th defines up to a total of 30 sessions (a year) for individual psychotherapy in psychiatry and psychology, and up to 30 sessions (a year) for group, family or couple psychotherapy in psychiatry and psychology. These are important changes, taking into account the limitations from previous agreements. However, we at the Association must be on the alert since many health intermediaries pretend to cover this modality with psychologists, generally less costly than psychiatrists. Gradually, this has led to transferring biological and psychopharmachological issues to us at the expense of leaving psycotherapies aside which are the basis of our profession. It is worth to be on the alert on this issue.

Article 18th includes as compulsory psychiatric and psychological attention to women who are victims of violence. It had not been defined whose this responsibility was and the routes and networks for rendering this service are still to be defined - a pressing need for such vulnerable population.

Article 22nd addresses mental health emergency attention. The Compulsory Health Plan includes emergency attention of patients with mental disorders in the emergency and observation service. This covers the first 24 hours if threatening patient's life and integrity or the life and integrity from his / her relatives or community. This does not actually modify the situation we had. The everyday situation we see in emergency services trying to refer psychiatric patients to other institutions without bed availability for admission is a diffculty that remains. This will take us to continue "fighting" for payment whenever a patient requires staying two or more extra days in the emergency service, waiting to be admitted for hospitalization. On the other hand, the Article still has the faws of yesteryear... I wonder, what does it mean danger for the patient's integrity? Can a patient with a major moderated or severe depression, without suicidal risk but requiring admission, be considered as being in danger of affecting his/ her own integrity? Could s/he stay in the emergency services? These sort of questions still remain unanswered.

Article 18th includes compulsory psychiatric and psychological attention to women who are victims of violence, a service not stipulated before in terms of responsibility; however, the routes and networks to render this service to such vulnerable population are still to be defined.

Article 24th refers to admission for mental disorder management up to 90 days a year. However, the Article states that it should preferably be managed within the partial hospitalization program. This increase in the hospitalization days could benefit some of our most severely affected patients requiring sometimes more than the 30 authorized days, which was the valid term before the above mentioned agreement. However, this issue is still a loosen wheel when considering that the norm adds all previous hospitalizations in general, including partial as well as total hospitalizations. In spite of this, it is clear that as long as it is clinically pertinent, this service could be requested from sources different to the Compulsory Health Plan. It is also important to take into account those patients that, due to their pathology as well as to their poor support network and social situation, do require institutional management. Although currently this service is being rendered by some EPS*, up to which point does it remain in the socio - sanitary limbo? It is still unclear whose responsibility it is.

Article 55th deals with the transition coverage and the benefits for the population affiliated to the subsidized non-unified regime where there is mental health coverage. Definitely, this is a fundamental step of great impact for the population with mental pathologies who have been affected by so much inequality in every regime.

Title 4th defines services for the population under 18, emphasizing mental pathologies coverage, and Articles 73 to 77 define activities for this population in reference to victims of intra-family violence, sexual harrassment, food disorders, and use of psychoactive substances. This highlights the importance of making visible the work on mental health for population under age, which is a wise decision that allows early treatment leading to cure or chronicity prevention. What happens in terms of continuity when patients become of age? We surely would like the inclusion of all services for all the population within the framework of universality, but limitations are clear. Nevertheless, such limitations for this population that becomes older as well as other populations is an issue to worry about.

Article 77th refers to psychological or psychiatrical attention for disabled patients under age. The CHP for population under age covers outpatient psychologic and psychiatric attention for disabled population under age, and the Obligatory Health Plan for patients under age covers outpatient and hospitalized patients, provided every disabailabity is duly acknowledged by a compentent authority. There are also coverage forms established in Articles 17 and 24. According to the International Classification of Functioning, Disability and Health, are all patients with mental health problems mentally disabled? Then, what does disability mean in the framework of this Article?

The list of drugs includes: risperidone, sentraline, olanzapine and rivastigmine. It is important to note that each drug has been defined for a pathology in particular; for instance, risperidone is exclusively for paranoid schizophenia. Therefore, if the patient has a schizoaffective disorder or a maniac episode, s/he will require a non- CHP format thus passing by a Technical Scientifc Committee by which we expect the patient to be rapidly evaluated by our peers, that is, by ourselves as psychiatrists.

Regarding sertraline, we consider it is a wise decision, in spite of the fact that we consider a mistake the inclusion of the 25 mg presentation, since in the first instance it will not be used so much and as far as I know, it does not exist in our country.

In the case of olanzapine, we consider that other alternatives with less methabolic effects could have been considered, i.e., quetiapine and aripiprazol, which maybe due to such reason could possibly be more cost-effective.

There has been a long need for a drug in the line of Alzheimer Dementia, and Rivastigmine is a drug that surely will benefit these patients in their early stages. Now, we do not know reasons behind the decision in favor of this drug instead of galantamine, donepecile, memantine or any other. Besides, very useful drugs in our clinical practices such as lamotrigine for epilepsy do require that we continue resorting to the Non- CHP mechanism.

Summarizing, we consider that Act 1438 of 2011, as well as Agreement 029, constitute a step forward and we do hope that, as stipulated, every year a thorough review must be made of this Manual of Technologies (as it has been called), so as to allow refinement of obsolete ones as well as inclusion of those technoloigies bearing enough evidence for the benefit of our patients.

Carlos Gómez-Restrepo
Director RCP
cgomez_restrepo@yahoo.com

Note: I thank Dr. Lina María González for comments on this editorial.

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