Nine out of ten Brazilian municipalities have less than one psychologist and psychoanalyst in the SUS for every thousand inhabitants. The lack of professionals restricts access to psychological care and occurs despite the increase in disorders, which can worsen the mental suffering of the population.
Brazil has around 439 thousand psychologists, according to the CFP (Federal Psychology Council), which results in an average of 2 professionals for every 1,000 inhabitants. In the public network, Iaras (SP) and Olaria (MG) are the only cities to reach this rate.
There are 5,050 cities with a figure below 1. The data shows that there are no official records of the presence of psychologists in the public network in at least 400 cities.
At a national level, the average number of psychologists in the public network per thousand inhabitants drops to 0.18. In England, whose public health system inspired the SUS, the rate is 0.52, according to 2023 data from the National Health Service.
The information comes from Instituto República.org, dedicated to improving people management in the Brazilian public service, based on data from January 2021 from the National Registry of Health Establishments.
The distribution of Caps (Psychosocial Care Centers) is also low in the states. Sixteen have an average number of centers below the national average, and seven have less than one Caps per 100,000 inhabitants, according to 2022 data from the Ministry of Health.
The ministry states that it increased the budget of the mental health care network in the SUS by 27% compared to last year, reaching R$200 million. Next year, the investment will be R$414 million.
Only the richest had access to psychologists when the profession was regulated in Brazil, in 1962. According to Pedro Paulo Bicalho, president of the council of psychologists, this occurred because private practice care was the only model of practice.
“It was an elitist psychology, of listening to the problems of those who could pay,” he says.
The introduction of the area to public policies occurred throughout the 1980s, with the advances of the anti-asylum movement. In 2001, psychiatric reform changed the way people with mental disorders were treated, leading to the closure of asylums and, later, leading to the creation of Caps.
Raps (Psychosocial Care Network) was established in 2011, encompassing Caps, UBS (Basic Health Units) and other mental health care points.
But the reduced number of psychologists persists due to several factors, including remuneration and professional structure, according to Mariana Rae, project coordinator at Instituto Cactus, an organization dedicated to mental health.
There is often a lack of working conditions, such as salary and career plans and mechanisms for psychologists to develop. These mechanisms include emotional support, since the therapeutic process is long and requires extensive dedication.
“It’s not a one-off thing, where one session solves the person’s problem, and this also reduces availability to serve more people”, says Rae.
Today, anyone who wants a consultation with a psychologist must go to a UBS and report their case to the general practitioner, responsible for the referral.
The number of people who can receive care in psychology is restricted, due to the high demand and the reduced number of professionals. Thus, those who have access are, in general, at a more advanced stage of the problem.
“We wait for the person to become very seriously ill to start offering this service, when we needed to provide care while they still have autonomy and are able to leave the house”, says the president of the CFP.
Even when the patient is referred, the queue to be seen is usually long. In Rio, for example, the average waiting time for a psychologist appointment is three and a half months, according to data from this year’s city Regulation System.
Larissa Weber is a psychologist at a Caps clinic in Guaíba (RS), in the metropolitan region of Porto Alegre. At the unit, the team discusses the possibility of treating those who were not referred by a UBS doctor and are in a less serious stage.
She says that the center offers care according to the case, considering factors such as the support network and the patient’s socioeconomic conditions.
“There is a gap of people who would benefit from psychological care, but are unable to access it. The patient even asks: ‘So do I have to get worse to receive care?'”, he states.
According to Larissa, the city now has psychologists in some outpatient clinics for milder cases, which can expand access. “It depends on the municipality’s understanding of putting psychologists as a priority,” she says.
The Caps take more care of serious cases, when the disease affects autonomy. This includes, for example, patients who cannot get out of bed due to severe depression. Anyone suffering from alcohol or drug abuse is also supported.
At the center, the patient has access to individual consultations, participates in therapeutic groups and is monitored by other health professionals, including psychiatrists.
Despite the benefits, Caps are still poorly distributed across the country, according to Caroline Ballan, a researcher on public mental health policies at the Institute for Advanced Studies at USP.
The rule is that, in cities with 20 thousand inhabitants, there must be at least one service center. However, in practice, many municipalities lack these structures.
The picture is reflected in the distribution of centers by state. The average of Caps per 100 thousand inhabitants in São Paulo (0.99), in the Federal District (0.42) and in Rio de Janeiro (0.88) is lower than the national figure (1.33), according to data from 2022 from the Ministry of Health.
“We are very far from the ideal number, so we don’t have coverage. This shows the precariousness of the service when it reaches the end”, says Ballan.
PROFESSIONAL TRAINING CAN BE A SOLUTION
In general, UBS professionals are the first to treat patients with disorders. Therefore, experts argue that training on mental health can improve reception.
According to Mariana Rae, from the Cactus Institute, community agents, for example, can play a listening role and facilitate referrals to specialized professionals.
She cites the case of Banco da Amizade, a project in Zimbabwe that brings together people from local communities to care for patients with some mental suffering. Rae says the success rate is high, with an improvement in psychopathology.
“But it’s not a way of saying that we don’t need a specialist. On the contrary: by doing this, we dedicate this professional to those cases that really need it.”
In a note, the Ministry of Health states that mental health care is multidisciplinary in nature. According to the ministry, primary care provided 10.9 million mental health consultations in the first half of the year, and 28 Caps were enabled. The ministry says that, although it finances programs, states and municipalities establish their priorities.
DISCOVER PLACES WITH LOWER PSYCHOLOGIST AND CAPS FEES
Cities with lower numbers of psychologists per thousand inhabitants are concentrated in the North and Northeast; more than half are in Pará
Portel (PA): 0.014
The face (PA): 0.015
Muana (PA): 0.016
happy mountain (PA): 0.016
Tutóia (MA): 0.018
São Bento do Una (PE): 0.020
Brejo da Madre de Deus (PE): 0.020
São Mateus do Sul (PR): 0.022
Pacajá (PA): 0.022
Our Lady of Glory (PA): 0.024
Caps have a lower concentration in states in the North, Southeast and Center-West of the country; Northeast leads the list with the highest number of centers
Federal District: 0.42
Holy Spirit: 0.8
Rio de Janeiro: 0.97
São Paulo: 0.99
Mato Grosso do Sul: 1.13