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THE MENTAL HEALTH IN BOLIVIA (draft version)

Guillermo Rivera Arroyo, MD, MSc, PhD.


guillermo.rivera@fultra.org

Abstract
Bolivia is one of the countries in Latin America with the lowest income, and also the Latin
American country with the highest native presence. This poses specific challenges when it is
time to establish mental health services that will cover the needs of the community. There was a
review of the available studies performed in the media; most of them give us indirect
information. An analysis of the epidemiologic situation reveals that the Alcohol Abuse Disorder
is very frequent, just like the Depression Disorder. They emphasize the high rates of suicide.
The amounts of human resources are notoriously insufficient and the services are mainly
oriented to chronic cases. The compliance of the health politics is modest, while ethnicity topics,
cultural differences or forced internment don’t get any attention and there’s no legislation exists
on that matter.
Clue words: Bolivia, Epidemiologic indicators, human resources, public politics, mental health.

Introduction

In the last 20 years, health in Bolivia has evolves in a favorable way, Smallpox and Poliomyelitis
have been eradicated, and Chagas, Malaria and others have been controlled.¹ The Health
Reform² process has developed some advances, one of them is the Basic Health Insurance,
with some modifications: Basic Native Insurance and the Maternal and Child Insurance;
however the results achieved are yet insufficient. Without a doubt, mental health is most
neglected, although the underreporting of cases won’t show us the real situation of the
associated morbidity and mortality.

Amongst the existing failures we can mention that the interventions done in the mental health
area are not registered in the first attention level, there’s no passive nor active epidemiological
monitoring. Remote studies exist about prevalence of the consumption of alcohol and drugs,
information about suicidal attempts in the Emergency Service in hospitals, data of registered
violence in the Advocacy and Protection Brigade to the Family, and data of car accidents
related to the consumption of alcohol from the Bolivian National Police, as well as studies
promoted by the universities.

An analysis of the epidemiologic situation of the mental health in our country shows us that
there is scarce systematized information, from both general and specialized hospitals. Based on
the most prevalent world wide pathologies reported by the OMS and presented in their 2001
world report, a synthesis of the epidemiological information in psychiatry and mental health in
our country is presented subsequently.
____________________________
¹ National Health Politics Nov. 2004
² National Health Politics Nov. 2004
Following the classification by the OMS in terms of mental disorders, figure 1 shows a frequency
distribution of the causes of internment in Specialized Psychiatric Centers in the country.³

HOSPITAL MORBIDITY
PSYCHIATRIC HOSPITAL OF BOLIVIA

Mental and behavioral disorders due to the consumption of psychotropic substances 28.2%
Schizophrenia, schyzotipal disorder and delusions 28%
Organic Mental Disorders, including somatic disorders 17.8%
Mood Disorders (affective) 13.5%
Neurotic Disorders, secondary to stress realted situations and somatoform 6.9%
Personality Disorders and sdult behavior 2.9%
Mental Retardation 1.7%
Epilepsy 0.7%
Anorexia Nervosa 0.2%

It can be observed that the 3 main treated pathologies are depression, mental disorders due to
drugs consumption and schizophrenia.

1. Depressive Disorders

The 2003 survey of demography and health (ENDSA) 4, source of information epidemiologically
dependable in the health community. Its questionnaire included seven questions directed to
identify disorders of emotional character. Though nothing has been published to see the
cumulative incidence of the amount of people with these symptoms, ENDSA comments that “for
both men and women, it is observed significant percentages in the report of crying easily,
feelings of incapacity, difficulty in making decisions, fears without apparent cause, etc., signs of
a tendency to depression.” It also indicates that the presence of symptoms is determined by
economic (quintiles of health) and educational aspects.
____________________________

³ Analysis done by the Mental Health of Prevention and Rehabilitation Program, basing on hospital morbidity data of the
year 2004 according to CIE-10, provided by specialized units of mental health in third level hospitals and psychiatry
hospitals around the country.

4 ENDSA 2003 Demography and Health National Survey, made by the National Institute of Statistics (INE)
For example, 73% of women and 39% of men say they experience crying easily, reported by 8
of 10 women without school education and 6 of every 10 women with school education.
Unfortunately, EDNSA doesn’t inform about people that have had several of these symptoms all
at once, which could indicate Depression Disorder.

Even though there are no epidemiologic studies about depressive morbidity in the Bolivian
population, from data of the Health and Sports Department, we know that the tenth cause of
consultation of the older adult is depression. Statistics of reported internment by the psychiatric
hospitals of the country, show that the Mood Disorders (CIE-10: F10-F39) occupy the fourth
place of frequency with 13, 5% of the attended cases. (see fig. 1)

As for the external consultation of specialists in mental health, we should consider that probably
depression is the most important morbidity cause and that psychiatric emergencies by suicidal
conduct could be associated to this pathology. But, on the other hand, itself does not count on
current data about depressive comorbidity associated to physical pathologies like infectious
illnesses, cancer o neurological disorders that cause disability.

2.Disorders by consumption of psychotropic substances (alcohol, marihuana, cocaine,


tobacco and volatile solvents)

This category seems to be the most important, by the magnitude of the epidemiologic data that
will be detailed.

The first cause of morbidity in interned patients during the 2004 management, reported by all de
Psychiatric Centers around the country is due to “Mental disorders and behavior due to
consumption of psychotropic substances” (CIE-10:F10-F19). Analyzing the composition of this
group, we find that 88% correspond to alcohol consumption, 7% to cocaine- marihuana
consumption and 5% to the consumption of multiple drugs.

As for the mortality, the SNIS- La Paz reported the year 2002 that the most frequent causes of
death in the Hospital of Clinics (as center of reference of third level of the department of La Paz)
were various diagnoses associated to the chronic consumption of alcohol, such as alcoholic
liver cirrhosis, alcoholic liver disease no specified or mental disorders and de behavior due to
alcohol consumption. Together, they constitute the most frequent cause of mortality, along with
others caused by lethal pathologies much less preventable than alcoholism. The problem of the
sub report of the diagnosis of the condition of drunkenness as a determining or triggering factor
still remains in the darkness.
___________________________
5 ENDSA 2003 Analysis results of Mental Health chapter.
6 Data from the Social Welfare and Health Insurance Directory- Health and Sports Ministry
7 Annual 2002 SNIS of SEDES La Paz
In the year 2004, in the Hospital of Clinics, it was reported that hospitalization due to alcoholic
liver disease is one of the most frequent, and as a matter of fact, it is the group that presents the
highest mortality rate (22by each 100) almost duplicating mortality caused by cervical
malignancy (15 of each 100) that is found in second place.

As for the cost assumed by the Health System, the hospitalized days due to mental disorders
duplicate and even triplicate all the other pathologies, signifying a great expense in health.

Chart 1: Morbidity Causes of Hospital Expenses- Hospital of Clinics 2004

Causes Expenses Death Days of stay Average Days of


Stay
Self–inflicted 158 0 524 3.32
poisoning, 2º cause of
morbidity
Cervical Malignancy 74 14 1117 15.09
Gallbladder Calculus 330 2 2466 7.47
Broken Leg 83 0 1494 18.00
Alcoholic Liver 83 24 2226 26.82
Disease, 8º cause

On the other hand if we consider alcoholic intoxication, each year there are at least 75 deaths
catalogued as “alcoholic intoxication”, reported in the statistics by the Technical Judicial Police.
In the year 2002 the Hospital “Corea El Alto” reported to the SNIS of the health secretary of La
Paz that among its 10 first causes of death, death by alcoholic intoxication was in fifth place.

Drunkenness was reported to be the third most important cause, related to traffic accidents,
after “speeding”. The ENDSA 2003 found that half of the women in Bolivia have suffered
physical violence by the spouse; and that 70% of these victims reported that their spouse had
consumed alcohol some time before the act of violence. The rural area narrowly exceeds the
urban area in violence related to alcohol consumption and comparatively it is in the vallunos
region where a greater magnitude exists (in the department of Cochabamba 77% was reported,
while Beni and Pando reported 53%).

In the Survey of Homes, (CELIN, 1998) 9 14.15% of the surveyed adults admitted to have had
accidents due to alcohol consumption. In the survey done in the year 2000, the current
prevalence of the use of alcohol was 47.91% of the population; while in that of the 2004 the
amount was reduced to 42.58% (CELIN, 2005) 10

In the year 2000, in the framework of the study favored by the CICAD-OEA and the Pan-
American System of Uniform Data on Drug Use- SIDUC, to implement an epidemiologic
____________________________
9 National Plan 2005-2009: Prevention and integral care due to traumatism caused by traffic facts.
10 CELIN:Comparative study of the consumption of alcohol, tobacco, cocaine and other drugs in Bolivia, 1992, 1996,
1998, 2000, 2005
surveillance system, the Vice-ministry of Prevention and Rehabilitation carried out the lifting of
data in 7 hospital in the country, finding that 37% of the population treated in hospitals were due
to traffic accidents in emergency centers and 32% of the injuries, were related to the recent
alcohol consumption.

All in all, the excessive consumption of alcohol is an important factor for the public health of the
country, that requires urgent attention to reduce both social and economic impact and of human
suffering.

3. Schizophrefrenia

The ENDSA 2003 found that 18% of women and 10% of men reported “hearing voices that talk
and that other people don’t hear”, nevertheless this high percentage could be slanted by the
animism demonstrations, proper of the native cultures currently in Bolivia, besides the answers
are influenced by the educational levels. In this way it is understood that 20% among the
women without education versus 9% among those with higher education heard voices, and that
15% of males versus 6% with higher education reported hallucinations.

As for the question of the ENDSA “Do you believe that someone can manipulate your mind
without you wanting?”, it was found that approximately 8.8% of women and 5.5% of men said
yes, although these percentages are influenced by the educational level since the percentage
is higher among those who had primary education from those who had higher education.

Psychotic disorders, schizophrenia, schizotypal disorder and delusional disorder; as sub


classification (according to CIE-10), are the second cause of morbidity for internment in
psychiatric services, with a frequency of 28.2%. It is recommendable to seek a consensus to
include definitions of diagnose of schizophrenia to determine the characteristics of these
patients, since the course of the illness from severe cases till chronic cases, will make the
difference in the requirements and the provision of specific services.

On the other hand, there’s no data on the marginal population of the chronically mentally ill that
wander the streets and that could represent and additional number of people that require
attention.

4. Suicide

Isolated studies report that the suicide rate in Bolivia is disproportionately high. Deaths by
suicide would be the cause of 40% of juvenile mortality in the city of El Alto 19, while in the
Pocona community rates of 430 for every 100,000 20. On a worldwide basis suicidal rate goes
from 3.4 for 100,000 in Mexico to 14 for 1,000,000 in China and 34 for 100,000 in Russia (OMS,
2001).

The media of suicide attempt most frequently used in Bolivia is the consumption of insecticides
(organophosphate) and the most frequent way of achieved suicide is through hanging.

The National System of Information in Health (SNIS)* registered 7981 cases♦ the last four
years, of intoxication by insecticides in all the country, which were attended y health personnel.
This corresponds to five cases a day, nevertheless given that there can be occupational or
accidental intoxication, it is unknown exactly how many were by suicidal conduct °. The highest
rates with 36 intoxications for every 100,000 habitants correspond to the years 2001 and 2004,
and the regions distribution in Bolivia registered in the year 2004 shows that the mayor
frequency occurs in the department of La Paz with 41% (Cochabamba 26%, Santa Cruz 11%,
Tarija 10%, Oruro 6%, Chuquisaca 4%, Potosi 2%, Beni 1%).

In the city of La Paz, in the year 2002♠, the Hospital of Clinics (reference hospital) reported
among its first ten principal causes hospital mortality, auto inflicted poisoning by intentional
exposition to insecticides. In its emergency service, intentional poisoning with insecticides is the
fifth cause of morbidity, with at least 1 patient a day, and during the year 2003 this proportion
was maintained; second place of morbidity in hospitals was due to intentional poisoning with
insecticides.

Behind these figures, there’s the possibility of the existence of under register. There are
suicides are assumed by the family and kept confidential, with a medical certificate that
indicates “cardio respiratory arrest”. Or the corpse is easily buried in non official or clandestine‫٭‬
cemeteries.

Other cases arrive with complication and irreversible damage, to a health post (in the rural
areas) where the personnel does not have the capacity, techniques nor instruments to act
before such emergency and the patient is lost before transferred to a higher level of hospital
____________________________
11 Under the study led by CICAD-OEA with the Interamerican System of Uniform Data about Drugs Consumption-
SIDUC, to implement an epidemiologic vigilance system, made by the Prevention and R ehabilitation Vice Ministry.
* Bolivia counts with a national health information system that performs passive epidemiological surveillance (SNIS),
collects data reported principally by the state system network of health in the whole country (SEDES) and pri vate health
systems.
♦ 2001:2208 cases,; 2002: 1903 cases; 2003: 1700 cases; 2004: 2170 cases.
° SNIS uses the CIE- 10 codification; but when a suicidal patient consults SEDES, they assign as first diagnose
intoxication by pesticides and reports it to the SNIS, in most cases the referred Diagnose to the mental area is omitted.
♠ Information about morbidity and mortality has not been published according to hospitals 2003 and 2004 since the data
reported by the SNIS are still being processed. Some 2003 data have been obtained preliminarily from the SNIS.
‫ ٭‬In the past a register of the causes of mortality didn’t exist, in recent months a death certificate has been introduced in
the health network system, but we still can count on the data.
attention; apparently these patients are not registered or reported by the health post, a system
of specific epidemiological control does not exist and neither a system to control the causes of
mortality•.

Forensic registers are not very dependable, there’s a great reluctance from the population to the
practice of an autopsy and conservation of the corpse in refrigeration, since such procedures
are extremely bureaucratic, expensive for the family and considered contrary to the system of
beliefs and cultural precepts, which causes an important evasion and consequently under report
of information.12 (SNIS, 2003)

Chart 2: Data of Consummated Suicide- National Police 2003

Hanging Rat Poison Women Men 18 to 24 years Other ages


Ingestion
34% 33% 33% 67% 42% 58%

According to the data found in the National Plan of Prevention an Attention of Violence, 53% of
suicides originate by sentimental and family causes.

II. Physical, Human and Economic Resources

Physical Resources

Of the signers’ countries of the Declaration of Caracas, Bolivia is the only country in which the
mental health services have not been integrated to the primary care (21). The existing health
services concentrate in monovalent hospitals and the psychiatry services are scarce in general
hospitals. To date there are:

- 5 monovalent Psychiatric Hospitals


- Mental Health Services in third level hospitals
- 53 Drug Addiction Treatment and Rehabilitation Centers, according to data of the 3º
National Accreditation made in the year 2001.

Paradoxically the actual tendency is to close the mental health services in order to strengthen
the monovalent hospitals.

____________________________
▪ Recently SNIS has introduced a “Clinical epidemiologic register of severe pesticide intoxication” that will help to know
clear epidemiological data, but this register doesn’t let us measure variables of the mental area.
12 The population in the rural area tends to solve their health problems not counting with the conventional medical
services. In the case of the intake of organophosphorus, the community uses the intake of human urine as an attempt to
cure pesticide intoxication; it is administered in quantities between 2 and 4 liters approximately. They also use the intake
of detergents like soapy water. A long time has passed when they discover that the patient got worse and obviously
those procedures introduce the organophosphorous more deeply and rapidly into the digestive system. It is then that the
community decides to go to a hospital or health post, but because of the time that has passed and the previous
procedures, the limited personal resources are insufficient.
Human Resources

Nº of Psychiatrists: 95
Nº of collegiate Psychologists: 122

The number of specialists recommended for a country, by the World Health Organization, is of
one psychiatrist for every 100,000 inhabitants, it is so that the Bolivian population requires 900
psychiatrists, and however we just count with 1 psychiatrist for every 100,000 inhabitants. The
alarming picture doesn’t change much considering the group of professionals in mental health
(psychiatrists and psychologists) 1 in mental health for every 50,000 inhabitants. While the
annual production of psychiatrists is from 4 to 5, which indicates that there are not enough
specialists, and there is no clear increase in the coming years.

Chart 3. Human and Material Resources in Mental Health


Total number of psychiatric beds x 10,000 inhabitants 0.791

Psychiatric beds in mental hospitals x 10,000 inhabitants 0.51

Psychiatric beds in general hospitals x 10,000 inhabitants 0.004

Psychiatric beds in other devices x 10,000 inhabitants ---

Number of psychiatrist x 100,000 inhabitants 0.9

Number of neurosurgeons x 100,000 inhabitants 0.8

Number of psychiatric nurses x 100,000 inhabitants ---

Number of neurologists x 100,000 inhabitants 0.5

Number of psychologists x 100,000 inhabitants 5

Number of social workers x 100,000 inhabitants ---

The median of nurses who work in the psychiatric settings ranges around 0.16 for every
100,000 inhabitants. Most are general nurses that work in psychiatric services as psychiatric
nurses, although they have not received the appropriate specialized training.

Half of the mental health professionals in the country work in public services.
Economic Resources

In quantitative terms Bolivia destines the 02% of the budget destined to mental health; it
signifies about 600,000 Bs. (approximately $75,000) annually for the National Mental Health
Program, Prevention and Rehabilitation, which 45% is destined to operating expenses.

The bulk of resources are destined to some mental asylums that are in charge of a small
fraction of the people who need treatment. Frequently also this institutions offer poor attention
and even inhuman attention. Since budgetary allocations are principally dedicated for the
chronic cases, what is left leaves us with insufficient resources for ambulatory attention.

These resources are more than insufficient, and the precarious Bolivian mental health system
only survives thanks to the cooperation of religious organizations, which are the ones that
handle the monovalent hospitals, and the help of non-governmental organizations.

III. Instruments of Public Politics

The Mental Health National Program was made in 1972 and revised in the year 2001. Only 10–
25% of the program has been implemented. These searches to reform, promote, prevent and
integrate the mental health services to the primary care, and also to develop specialized
services.

Special programs for child and senior population exist, not so for ethnic minorities, nor of genre.

Mental health legislation dates from 1978, and it was revised in 2001. It focuses on promotion
and prevention, human rights and regulates mental health services. But it doesn’t mention
forced internment or treatments.

IV. Conclusions

Mental disorders are universal, but in zones where life conditions are deficient there is a greater
concentration of mental pathology. The rate of mental disorders is two times higher among the
poor than among the rich. (23) It is estimated that mental disorders constitute one of the
epidemics of this century, because of the increment of adverse factors both in low-income
countries like in first world countries.

As is well known, poverty is linked to unhygienic and insecure living conditions, hunger and
malnutrition, inadequate access to health care, lack of educational and employment
opportunities. What public health officials and the makers of public policies don’t know is that if
mental disorders are not treated, this contributes to the increase of the poverty cycle (25) in
diverse ways.

While mental disorders generate costs by long-range treatments and loss of productivity, it can
be argued that these disorders contribute considerably to poverty. At the same time, insecurity,
low educational level, inadequate housing and undernourishment have been considered factors
linked to common mental disorders (OMS, 2004). Both appear united in a vicious circle affecting
diverse dimension of the individual and social development.

There is evidence that investing in mental health now could generate enormous benefits in
terms of reduction of the disability and prevention of premature deaths. These priorities are well
known and the projects and activities that are required are clear and possible (OMS, 2004).

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