Abstract
According to official data, there was in Brazil an increase of almost 87% in the amount of immigrants between 2000 and 2010 (Brazilian Institute of Geography and Statistics (IBGE), 2010), and this number continues to rise (Department of Justice of Brazil, 2012, 2013). Probably, these governmental statistics underestimate the very real number of foreigners since, according to evaluations of the Pastoral Service for Migrants (2008), there are approximately 600,000 illegal immigrants in Brazil. The fact is that transcultural care has become increasingly frequent in the Brazilian medical practice. However, the emphasis on research, training and development of services with cross-cultural competence is still small in Brazil (Medeiros, Sampaio, Sampaio, & Lotufo-Neto, 2014).
The available data from the Department of Justice of Brazil (2012, 2013) suggest that foreigners who come to Brazil can be divided in three different groups: (1) The largest amount apparently are immigrants from developing countries (mainly Haiti and Bolivia) who come for economical reasons, (2) refugees from countries with significant political or social issues such as Colombia and Democratic Republic of Congo and (3) a smaller number of Immigrants from developed countries (especially from Western Europe and United States) affected by the 2008 International Economical crisis (Department of Justice of Brazil, 2012, 2013). Improving access to health care is a core requirement of foreigners in Brazil, as evidenced by the recent report of the 1st Conference of Municipal Policies for Immigrants in São Paulo (2013).
It is known that immigrants, particularly refugees, have a substantially higher risk for developing a variety of mental disorders (Medeiros, Sampaio, Sampaio, & Lotufo-Neto, 2014). Lindert, Ehrenstein, Priebe, Mielck, and Brahler (2009) conducted a meta-analysis that found a prevalence of 20% of depression and 21% of anxiety disorders in labour immigrants, what is significantly above general population. Refugees had an even higher prevalence: 44% of depression and 40% of anxiety disorders (Lindert, Ehrenstein, Priebe, Mielck, & Brahler, 2009). There are evidences suggesting that chronic pain, somatic and psychotic symptoms are also more common in these populations (Wheeler & Danesh, 2005; Tarricone et al., 2009). Moreover, the practice of Psychiatry and Psychology is heavily dependent on communication and on the mental state examination, but a good portion of the foreigners have limited proficiency in Portuguese, and this, together with cultural differences, prejudices the recognition and treatment of mental health problems (Kirmayer et al., 2011). Evidence shows that people who have difficulties with the language of the destination country have a higher risk of medical errors and complain more often of health services (Crosby, 2013). This possibly shows that the traditional medical assistance when applied to this population tends to be not so effective and therefore needs adjustments to be more efficient. There are several papers suggesting this need for cultural adaptations in other countries such as the United Kingdom – as, for example, the works conducted by Bhui and Bhugra (1998) and Mastrogianni and Bhugra (2003) – and Canada, as, for instance, the works conducted by Kirmayer (2012, 2013).
Current research indicates the relevance of mental disorders and their social impact if not properly treated. For example, neglecting mental health needs can create serious problems such as unemployment, substance abuse and crime (Ngui et al., 2010). Thus, immigrants and refugees with mental health problems without assistance not only do not generate wealth for the country but also could harm public health and safety. Therefore, treatment with cross-cultural competence is probably cost-effective.
Unfortunately, we have two problems in delivering a transculturally competent mental health care in Brazil. The first one is the heterogeneity of the immigrant profile: a significant number of foreigners from locations such as South America, North America, Africa and Europe (Department of Justice of Brazil, 2012, 2013), what is probably associated with distinct social and cultural backgrounds and an additional need for adjustments. The second point is that, from our knowledge, there are no reliable data approaching the cross-cultural differences between immigrants and Brazilian Citizens. Anyway, there are evidence-based recommendations for the appropriate mental care of immigrants and refugees from other countries. For example, the presence of a trained interpreter improves communication and decreases the amount of medical errors (Crosby, 2013). Moreover, a cross-culturally competent service should pay attention on several cultural factors (Kirmayer et al., 2011) as ethnicity, religious practices and habits in the country of origin. These cultural barriers can be reduced using a ‘culture broker’ (according to Jezewski and Sotnik (2001), an individual who makes the connection and mediation between groups or persons of different cultural contexts). It can be used for this purpose a community leader, a religious leader or an immigrant/refugee more adapted to local culture. With proper training, the ‘culture broker’ can also play the role of interpreter.
These cross-culturally adjusted Mental Health centres could be initially deployed as low-complexity services in the areas of highest density of foreigners and also on key high-complexity hospitals where it is required detailed medical investigation. In short, the installation and expansion of mental health services cross-culturally prepared must be a core concern because if we do not properly address the mental health of this population we could harm the Brazilian society as a whole. Further research on the profile of immigrants and on the effectiveness of these mental health services is needed.