Comment

a developed-world concept, but may be especially felt

in the developing world where mental health care must
thrive.

*Farrah J Mateen, Chencho Dorji

Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA

(FJM); and Department of Psychiatry, Jigme Dorji Wamgchuk
National Referral Hospital, Thimphu, Bhutan (CD)
Farrah_Mateen@hotmail.com

We declare that we have no conicts of interest.

1
2

3
4

Kumar S. Burnout in psychiatrists. World Psychiatry 2007; 6: 18689.

da Silva AT, Menezes PR. Burnout syndrome and common mental disorders
among community-based health agents. Rev Saude Publica 2008;
42: 92129.
Chopra SS, Sotile WM, Sotile MO. Physician burnout. JAMA 2004;
291: 633.
Korkeila JA, Tyry S, Kumpulainen K, Toivola J, Rsnen K, Kalimo R.
Burnout and self-perceived health among Finnish psychiatrists and child
psychiatrists: a national survey. Scand J Public Health 2003; 31: 8591.
Carpenter LM, Swerdlow AJ, Fear NT. Mortality of doctors in dierent
specialties: ndings from a cohort of 20 000 NHS hospital consultants.
Occup Environ Med 1997; 54: 38895.

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ndings. J Formos Med Assoc 2009; 108: 32832.
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a study of risk according to gender, seniority and specialty in medical
practitioners in England and Wales, 19791995.
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Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental
health: scarcity, inequity, and ineciency. Lancet 2007; 370: 87889.
Ndetei DM, Khasakhala L, Ongecha-Owuor F, et al. Attitudes toward
psychiatry: a survey of medical students at the University of Nairobi, Kenya.
Acad Psychiatry 2008; 32: 15459.
Syed EU, Siddiqi MN, Dogar I, Hamrani MM, Yousafzai AW, Zuberi S.
Attitudes of Pakistani medical students towards psychiatry as a prospective
career: a survey. Acad Psychiatry 2008; 32: 16064.
Laugharne R, Appiah-Poku J, Laugharne J, Shankar R. Attitudes towards
psychiatry among nal-year medical students in Kumasi, Ghana.
Acad Psychiatry 2009; 33: 7175.
Mari NP, Stojiljkovi DJ, Mileki B, et al. How medical students in their
pre-clinical year perceive psychiatry as a career: the study from Belgrade.
Psychiatr Danub 2009; 21: 20612.
Boulet J, Bede C, McKinley D, Norcini J. An overview of the worlds medical
schools. Med Teach 2007; 29: 2026.

Chile: an ongoing mental health revolution

The recent report on the call to scale up mental health
programmes in the developing world does little justice
to major initiatives that preceded this call.1 Introducing
changes in mental health care can take a long time.
A movement to improve the mental health of the
population has been evolving for longer than a decade
in Chile. What has been achieved amounts to a silent
revolution, but a long chain of events prepared the
ground for these transformations.
In September, 2004, the most emblematic
programme of the recent Chilean Health reform, the
Regime of Explicit Health Guarantees (AUGE), became
law. This curative health programme was conceived
within a social-guarantee framework. It oers an
explicit subset of guarantees in terms of access,
quality, opportunity, and nancial cover for 56 priority
diseases.2 All citizens have the right to receive timely
and appropriate treatment for these conditions
from their private or state health providers. If these
guarantees are not respected, citizens are entitled
to start legal proceedings to revert this situation.
Each listed disease has a clinical protocol and clear
denitions of the guarantees, including maximum
waiting time, qualications of the providers, and
ceiling for co-payments.
www.thelancet.com Vol 374 August 22, 2009

The treatment of depression for individuals aged

15 years or older is among the 56 priority diseases. Until
now the programme has provided treatment to more
than 530 000 depressed people, 88% of whom had state
health insurance.3 This achievement was not minor in a
country with huge inequalities in access to health care.4,5
The programme oers dierent clinical protocols for
depression of varying severity. Patients with mild to
moderate depression receive an outpatient package,
including drug treatments, psychosocial interventions,
or both. Patients with more severe depression must be
seen by a specialist within 30 days (the time guarantee)
who decides if the patient needs more intensive
services. Most public sector patients (75%) do not pay
anything for these services. The maximum co-payment
for patients in the private sector is around US$18 yearly
for mild to moderate depression and US$75 for severe
depression, including admission to hospital when
needed.
Another key milestone in this process was the
introduction of the National Depression Treatment
Programme in primary care in 2001.6 This was the
rst programme of its kind in a low-income or
middle-income country. Nowadays, the programme
is established and successful, sitting comfortably with
597

Comment

300 000

250 000

Number of people

200 000

150 000

100 000

50 000

0
2002

2003

2004

2005
Year

2006

2007

2008

Figure: Number of people receiving treatment in the Chilean public health-care sector, 200208

more traditional primary care programmes for the

management of hypertension and diabetes within
a network of 520 primary care clinics throughout
the country. The programme is led by psychologists
and general practitioners, and follows clinical
guidelines similar to those tested in a trial,7 with the
addition of support from specialists for patients with
severe disease. The programme has been growing
steadily since its introduction, with more than
200 000 patients receiving treatment every year since
2006 (gure).8 Together with this programme, there
has been a three-fold increase in the past decade in
the number of ambulatory mental health centres,
often attached to general hospitals.9 Each centre has a
specialist multidisciplinary team and is linked to three
to ten primary care clinics. A member of the team
visits each primary care clinic at least once a month
to provide help with the management of dicult-tomanage patients. Nowadays 84% of all patients with
depression are managed exclusively in primary care
clinics. All these achievements are in line with the
goals set on the National Mental Health Programme
approved in 2000.9
The introduction of all these great improvements
has not been problem free. For instance, one of the
challenges of targeted programmes is the incentive
for resources to be shifted to cover priority diseases
across dierent sectors. As a result some psychiatrists
have moved to the private sector, which is now legally
bound to cover this demand, or shifted their clinical
598

practices to concentrate on these programmes.

Notwithstanding, only 7% of those patients with
depression seeking treatment in the programme
had not received treatment within the prespecied
target times, which was only second best after hip
osteoarthritis.10 Because the programme is curative, it
has taken away resources from traditional preventive
actions. However, these programmes provide a
formidable base to oer equitable access to treatment
to those patients with depression. In the process a
fair amount of knowledge has been accumulated that
could be of use to other low-income or middle-income
countries. A more formal evaluation, including clinical
outcomes, is underway.
All too often we hear only depressing reports from
low-income or middle-income countries. We hope that
our uplifting news encourages others in such countries
to press for more resources for their own mental health
revolutions, many of which have been waiting for far
too long.
*Ricardo Araya, Ruben Alvarado, Alberto Minoletti
Academic Unit of Psychiatry, University of Bristol, Bristol BS6 6JL,
UK (R Araya); Department of Public Health, Faculty of Medicine,
Universidad de Chile, Santiago, Chile (R Alvarado); and Ministry of
Health, Santiago, Chile (AM)
R.Araya@bris.ac.uk
We declare that we have no conicts of interest.
1
2

4
5

7
8
9

10

Patel V, Garrison P, de Jesus MJ, Minas H, Prince M, Saxena S. The Lancets

series on global mental health: 1 year on. Lancet 2008; 372: 135457.
World Bank. Realizing rights through social guarantees: an analysis of new
approaches to social policy in Latin America and South Africa. February,
2008. http://siteresources.worldbank.org/EXTSOCIALDEVELOPMENT/
Resources/244362-1164107274725/3182370-1164107324437/
Realizing_Rights_through_Social_Guarantees-web1.pdf (accessed
Aug 11, 2009).
Superintendencia de Salud, Ministerio de Salud. Estadsticas de Casos GES
(Julio 2005Marzo 2009). 2009. http://www.supersalud.cl/568/article5138.html (accessed Aug 11, 2009).
Unger JP, De Paepe P, Cantuarias GS, Herrera OA. Chiles neoliberal health
reform: an assessment and a critique. PLoS Med 2008; 5: e79.
Araya R, Rojas G, Fritsch R, Frank R, Lewis G. Inequities in mental health
care after health care system reform in Chile. Am J Public Health 2006;
96: 10913.
Ministerio de Salud. Gua Clnica para la atencin primaria: La depresin,
deteccin, diagnstico y tratamiento. Santiago, Chile: Ministerio de Salud,
2001.
Araya R, Rojas G, Fritsch R, et al. Treating depression in primary care in
low-income women in Santiago, Chile. Lancet 2003; 361: 9951000.
Ministerio de Salud. Avance Programa Depresin y GES. Santiago, Chile;
2009.
Minoletti A, Narvaez P, Sepulveda R, Caprile A. Lecciones aprendidas en la
implementacin de un modelo comunitario de atencin en salud mental.
In: Pan American Health Organization, ed. Salud Mental en la Comunidad.
Washington: Paltex (in press).
Superintendencia de Salud. Informe de Fiscalizacin N 02 Cumplimiento
Garanta de Oportunidad por Fonasa, Regin Metropolitana. Santiago,
Chile:. Superintendencia de Salud, Ministerio de Salud, 2009.

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