by Dr Lucienne Aguirre, Core Trainee Psychiatry (CT3) South West London & St George’s Mental Health Trust
The health care system in Ecuador is state funded, through the Ministry of Health. The first line of contact with the health care system is through the primary care physician who is responsible for the implementation of the government’s health care policies.
Ecuador is one of the few countries in Latin America that does not have a mental health policy[1]. In the public sector mental health is focused on psychiatric care. In the primary care sector, 7 out of the 23 provinces from the secondary and tertiary care provide mental health services in general hospitals. Another 7 provinces have psychological care provided by psychologist and only 1 has full psychiatric care at all levels. In total 15 out of 23 provinces in Ecuador have mental health services.
Ongoing efforts are focused on strategic implementation of preventative health screening or physical illness, but currently there is no policy for screening for depression and other psychiatric disorders. However, in the last 5 years, there have been some changes in some psychiatric hospitals around the country in the implementation of new mental health policies and pathways for patients. The discharge of very long-stay patients back to the community after many years of being institutionalised is one of the biggest changes in the country.
Depression is one of the most common mental illnesses in Ecuador, followed by anxiety, stress and poly-substance misuse[2]. The stigma around mental health is still a big problem across the country and this can impact the level of support and treatment that people receive. Most of the care is provided in the private sector rather than in the public sector. People may be reluctant to see mental health professionals when experiencing symptoms of depression. This is due to stigma around mental illnesses, lack of resources in mental health, low socioeconomic status and poor education.
‘Nervios’ (meaning ‘nerves’ in Spanish), is a powerful word of distress used by Hispanics/Latinos from a variety of Caribbean, Central and South American countries to express concerns about physical distress, turbulent emotional states, and adverse life changes. ‘Nervios’ is not necessarily pathological but is seen as a natural consequence of the human condition. Depression could be described or experienced in many different ways around the country according to their demographic areas, social background and economic social class. ‘Ataque de Nervios’ (nervous attack) is one of the most common ways of describing depression, ‘sadness’ and somatization are also ways of expression when people are in distress.
Depression can be manifested somatically through symptoms such as headaches, gastrointestinal disturbances, or complaints of ‘nervios’ rather than commonly recognized symptoms. Clinical data suggests that women suffering from depression have a higher prevalence of somatic manifestations than men[3]. An appreciation of cultural manifestations of depression and social factors is necessary to ensure better detection of depression in the public, to assist in formulating psychosocial interventions and the allocation of resources for mental health needs.
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[1] Politica Nacional de Salud Mental 2014-2024, Version 6.2, Febrero 2014, p. 9
[2] Politica Nacional de Salud Mental 2014-2024, Version 6.2, Febrero 2014, p. 17
[3] Politica Nacional de Salud Mental 2014-2024, Version 6.2, Febrero 2014, page 18