On World Mental Health Day, celebrated on October 10, it is worth remembering a simple and powerful idea: in Brazil, mental health care was built alongside democracy. The Brazilian Psychiatric Reform did not originate in the doctor’s offices. It came from the streets, from services and social movements, and to this day it still needs to be defended.

A reform born of democratic struggle

At the end of the 1970s, during the full reign of dictatorship, mental health workers denounced the inhumane conditions in Brazilian psychiatric hospitals: overcrowding, abandonment, violence, and deaths. The Movement of Workers in Mental Health, and later the Antimanicomial Struggle Movement, under the motto “For a society without manicomials,” brought together professionals, users, family members, and activists. The goal was to go beyond changing the services: it was to transform the way society deals with madness and difference.

This struggle went hand in hand with the Sanitary Reform and the democratization of the country. The 8th National Conference on Health (1986), the Constitution of 1988, which recognizes health as “a right of all and a duty of the State,” and the creation of the SUS (Laws 8.080 and 8.142/1990) formed the basis of this change. The Bauru Conference (1987) and the intervention at Casa de Saúde Anchieta in Santos (1989) marked the turning point towards a model of care in freedom.

After 12 years of being debated in Congress, Law 10,216/2001, known as the Paulo Delgado Law, guaranteed the rights of people with mental disorders and redirected the care model towards community-based services. Since then, hospitalization has become the exception, never the rule.

The democratic nature of the reform is also evident in social participation. Health and mental health councils and conferences ensure that users, families and workers help decide the direction of public policies. The reform is at the same time a health policy and a project of citizenship.

SUS: universal, integral and equitable

Mental health care in Brazil is based on the principles of the SUS:

• Universality: all people have the right to receive care, without paying and without any prior condition.
• Integrity: care looks at the person as a whole (body, mind, relationships and living conditions), and not just at a diagnosis.
• Equity: those who need it the most receive more attention, recognizing inequalities based on class, race, gender, and territory.
• Decentralization and social participation: management is close to the territories and has the control of the population.

In mental health, these principles add to the values of the Reform: care in freedom, respect for human rights, autonomy, combating stigma, the protagonism of users and family members, and social reintegration.

RAPS: care in the network, on the territory

Created by Ordinance No. 3,088/2011, the Network of Psychosocial Care (RAPS) organizes the mental health services of the SUS. The central idea is that no service can take care of everything alone: care takes place in a network, close to where the person lives. RAPS is composed of:

• Primary Health Care: Basic Health Units, Family Health Teams, multidisciplinary teams (former NASF), Street Clinics and Community Centers.
• Specialized psychosocial care: the Psychosocial Care Centers (CAPS), in their various modalities (CAPS I, II and III, CAPS for children and adolescents and CAPS for Alcohol and Drugs, including 24-hour operation).
• Emergency and emergency: SAMU 192, 24-hour emergency care units, emergency rooms and stabilization rooms.
• Residential care of a temporary nature: Shelters for adults and for children and adolescents.
• Hospital care: mental health beds in general hospitals, for short stays and well-indicated cases.
• Deinstitutionalization strategies: Therapeutic Residential Services and the Return Home Program for people who have spent long periods in hospitals.
• Psychosocial rehabilitation: initiatives to generate employment and income, solidarity economy and social cooperatives.

How the network is organized

Primary care is the preferred entry point and the one who coordinates care. Family Health Teams know the territory, follow up on people over time, and take care of many cases of mental distress such as anxiety, depression, and grief. With matrix support, CAPS professionals discuss cases and provide joint care with the teams from the primary care units, which increases the ability to provide care without having to refer patients.

CAPS supports people who are experiencing intense and persistent suffering, such as psychosis, severe crises, and problematic use of alcohol and other drugs. Together with each person, they develop a unique therapeutic project.

Emergency and urgent care services address acute crises. After that, they ensure that the person returns to the CAPS and to primary care without losing the link with the territory. When hospitalization is necessary, it takes place in a general hospital, in the shortest possible time and in coordination with the network.

How to access mental health care in the SUS

1. Find the Primary Health Care Unit (health post or Family Clinic) closest to your home. It is the main entry point. You do not need a referral; just bring your document and, if you have it, your SUS Card.
2. Go directly to a CAPS. CAPS operate on a “door-open” basis: anyone can come without an referral to be admitted, including concerned family members.
3. In a crisis or risk situation, call the SAMU (192) or seek help from an UPA or emergency room.
4. For emotional support and suicide prevention, the CVV provides assistance via 188, free of charge and 24 hours a day, in partnership with the Brazilian Health System.
5. People in street situations can be assisted by the Street Clinic teams.
Asking for help is a right, and not a sign of weakness.

Advances of recent years

After a period of setbacks between 2016 and 2022, with the strengthening of psychiatric hospitals and therapeutic communities and the loss of funding for community services, national policy has once again aligned itself with the Psychiatric Reform. Among the advances are:

• Reorganization of the Department of Mental Health, Alcohol, and Other Drugs within the Ministry of Health (2023) and repeal of regulations that contradicted the anti-psychotic logic.
• Expansion and readjustment of RAPS funding, with the authorization of new CAPS, Care Units and Therapeutic Residential Services, and the readjustment of transfers that had been frozen for years.
• Strengthening primary care, with the resumption of multiprofessional teams (eMulti) and the expansion of mental health care in primary care units.
• 5th National Conference on Mental Health (2023), the first in over a decade, which reaffirmed care in freedom with broad public participation.
• Anti-Institutionalization Policy of the Judiciary (CNJ Resolution No. 487/2023), which determines the closure of Custodial Hospitals and guarantees people in conflict with the law access to care in the RAPS.
• Adjustment of the Return to Home Program and further incentive for deinstitutionalization.
• Greater attention to the mental health of children, adolescents and vulnerable populations, with intersectoral actions involving education and social assistance, and with care for issues of race, gender and territory.

The challenges are still great. Coverage is uneven across regions, teams are overloaded, underfunding continues, the medicalization of suffering grows, and there are constant pressures to return to shelter models. The involvement of users and families through associations, collectives, and networks of mutual support remains essential to keep the Reform alive.

Mental health is a right

On this 10th of October, we celebrate a collective achievement: a public, universal and free healthcare network that cares freely and understands suffering as part of life in society. Defending RAPS and the SUS is defending democracy, dignity, and the right of every person to live, be cared for, and participate in ordinary life.

For a society without mental hospitals. Caring freely is a right.

Related articles:

Decolonizing the gaze: why mental health in the Global South needs a popular science Bridge over the ocean: how popular science can transform mental health in Mozambique. When the community takes control of mental health. Mental health and decoloniality: for an antimanicomial struggle in Brazil.