Patterns and innovations in the unfolding of Latin American psychiatry and mental health

The 24th World Congress of Psychiatry, held in Mexico City in November 2024, hosted a Presidential Symposium entitled “Past, present and future of Latin American psychiatry”, dealing with patterns and innovations in Latin American models and programs for diagnosis and care in clinical psychiatry and public health, within a broad international framework. Here we summarize some highlights of that Symposium, focusing on the areas of conceptualization of health, diagnosis and health care. Concerning conceptualization of health, the World Health Organization (WHO), in its 1948 inaugural constitution, proclaimed that health is a state of complete physical, emotional and social well-being, and not merely the absence of illness or infirmity. Quite notably, the Andean cosmovision held that health is a state of harmonious equilibrium among the person's interior, social and natural worlds1, a definition of stunning post-pandemic value. Concerning diagnosis, the WHO assumed responsibility for decennial revisions of the International Classification of Diseases (ICD) in 1946. However, the complexity and particular vicissitudes of disease classifications in the field of psychiatry and mental health have stimulated the design of more detailed and comprehensive diagnostic models. In these efforts, some Latin American colleagues have been pioneers, such as the Venezuelan D. Curiel, developer of the first national collaboration center for the ICD; the Peruvian H. Delgado, as systematizer of psychopathology and clinical psychiatry; the Chileans J. Horwitz and J. Marconi2, who published in 1966 the world's first structural and operational definitions of mental disorders; and the Brazilian J. Leme Lopes, who put forward a multiaxial conception of psychiatric diagnosis as early as in 1954. Another breakthrough has been the Third Cuban Glossary of Psychiatry, which represents both a systematically constructed adaptation of ICD to national reality and needs and an application of the multiaxial approach3. The WPA International Guidelines for Diagnostic Assessment (IGDA), based on an international survey of all WPA Member Societies and published in 2003, also exemplify this comprehensive approach. In 2010, the WPA Classification Section and the International College of Person-Centered Medicine published a theoretical model for Person-Centered Integrative Diagnosis (PID), providing an integrated assessment of the totality of health, including ill and positive health, risk and protective factors, and experience and values at stake when seeking clinical care. The PID model, along with ICD terms and codes for identifying mental disorders, were applied as a Latin American practical guide for psychiatric diagnosis (GLADP-VR)4. It has been found through surveys5 that Latin American psychiatrists who used this guide preferred this option to the original ICD-10 as well as to the DSM-IV and DSM-5. Concerning health care, the Andean cultures have promoted – since early times – accompaniment, social commitment and solidarity in the care for health issues and general well-being. This has been expressed in Quechua and Aymara terms meaning “let's go all together, nobody is to be left behind” and the continued validity of ancestral medicine as shown by the Andean Health Organization6. Such cultural tenets are, however, seriously threatened and undermined by the prevalent dehumanization and commercialization of modern societies. Current health care throughout Latin America, including both mental and physical health, is plagued by the fragmentation of health services, their severe underfunding (in reference to the standards of the Organization for Economic Cooperation and Development), and the grossly unequitative distribution of health services and health professionals across socio-economic and ethnic groups and rural vs. urban areas. This ongoing challenge is consistent with the recognition by the United Nations of Latin America as “the most unequitative region of the world”7. Psychiatric care in Latin America, as in many areas around the world, was asylum-based until the middle of the 20th century. Since then, quite slowly and irregularly, the settings and purpose of mental health care have been evolving towards community-based care and the clinical and social recovery of psychiatric patients. The fragmentation, underfunding and unequitative distribution of health services, however, remain active and strongly limit progress. At the same time, intriguing conceptual and strategic health developments have been emerging in Latin America, perhaps more intensively than in other world regions. The major WHO Conference on Primary Care in Alma Ata (1978) has had its key message powerfully reformulated by one of its architects and WHO Deputy Director General, the Peruvian D. Tejada de Rivero, as “integral care of all by all”. Recent conferences of the Latin American Network of Person Centered Medicine have enriched and further developed this health strategy by centering it on people and adding inter-care or mutual care to it8. In terms of horizons envisioned for the future emerging from the Mexico City Symposium, one may list the following: a) strengthening the diagnostic value of identified disorders through person-centered, contextualized and development-related information; b) broadening the scope of diagnostic models through the diagnosis of whole health status (both ill and positive health) and the elucidation of risk and protective factors as well as experience and values pertinent to seeking care; c) potentiating care activities by adding to the pointed treatment and alleviation of disorders the stimulation of internal resources, the engagement of contextual supports, and the promotion of longitudinal personal development (from personal history to personal life project); and d) consideration of the heuristic value of the person-centered approach to enhance the understanding of and actions in health, education and other social activities, and of the emerging concepts of whole person, whole health and whole care. Some of these horizons have been recently outlined by the Pan American Health Organization9. They are quite consistent with the 2015 United Nations Sustainable Development Goals, anchored on five Ps (Person, Planet, Peace, Prosperity and Partnership).