Hidden Lives in Hidden Patients : an Analysis of Custody Hospitals in Brazil revIew

There are important limitations regarding the Brazilian Custodial Psychiatric Hospitals or Judicial Psychiatric Hospitals situation. They way how they are administrated, as prisons and non as hospitals, could make the health of their patients worst than when they were admitted. These limitations are not just in the hospitals, but on current Laws of the Brazilian Unified Health System. In addition, patients with mental disorders suffer a complex process of stigmatization, prejudice and social reclusion. Despite the existing Laws to the adequate caring and treatment of mentally ill patients and the advances in the psychiatric and mental health field, radical changes should be made on the Judicial Psychiatric Hospitals and on the Judicial and Health Systems in Brazil in order to achieve better results in the life quality of people with mental disorders. Hidden Lives in Hidden Patients: an Analysis of Custody Hospitals in Brazil revIew

The knowledge limitations about the profile of people in safety measurement is an obstacle for planning and for improving custody policies and the mental health care in Brazil (Rossini, 2011) [1].Therefore, a radical change must be conducted on the Brazilian custody system, and this depends on reforms on the current Laws of this system [2].According to Reis (2010) [3] The Custodial Psychiatric Hospitals (CPH), or Judicial Psychiatric Hospitals remains, in large part, primitive, uncivi-lized and inhospitable.These institutions are in fact barriers to the better understanding of the mental illness treatments.In addition, the, complicate rather than facilitate their patient's recovery.
Diniz (2014) [2] says that besides aforementioned changes on the legislation, modifications on the public policies for the custody and psychiatric treatment are required.The person who is suffering of a mental disorder and commits a crime should be treated [2].Nowadays, the security measures, which are the legal way for the establishment of compulsory treatment, are still interpreted as imprisonment sentence.However, little is known about the individuals living inside these institutions, how is conducted their treatment and which are their future prospects [4] .
Through the first mapping of custody hospitals and psychiatric treatment in Brazil, the researcher Diniz (2014) [2] says: "I saw a lot: from contention by force, patients tied to beds, patients trapped in solitaries or walking naked by lawns and corridors.I just did not see care".
According to Cordioli, Borenstein and RibeiRo (2006) [4] the issue of security measure was poorly detailed in the Brazilian Psychiatric Reform.CPHs, as well as other hospitals, remained at the margin of the changes advocated by the new paradigms for the care of mentally ill patients.
Judicial Psychiatric Hospitals are complex institutions that can articulate, two of the most depressing realities of modern societies: the asylum and the imprisonment.Additionally, these hospitals put together two of the most tragic ghosts that "haunt" everyone: the criminal and the insane [5].CPHs are a reflection of something we cannot deal yet: people with mental disorders who committed crimes [2].The current security measure system in Brazil violates the rights of the people with mental disorders6.More importantly, this creates a conflict with the current law.Although CPHs have been created to treat patients, their operation has been confused with the prisons' operation [2].This includes the precarious-ness and violations of the human rights.Unfortunately, this is still overlooked by our institutions.
Judicial Psychiatric Hospitals, today known as CPHs, are yet places with important contradiction in terms of classification; these establishments are destinations to which are sent people on defining situation: those who are waitng for the expert medical report [7].Diniz (2014) [2] classifies CPHs as hybrid institutions of criminal confinement and psychiatric hospitalization.They are the home of poor, illiterate, black and mental ill individuals.(Figure 1) [8]  Thus, CPHs are also considered not only custody prison units, but also hospitals for the caring and treatment of mental ill patients, whom are in a peculiar situation, and specific regulations are needed [6].MaMeDe (2006) [9] forewarns that the literature (still limited in Brazil) about Judicial Psychiatric Hospitals, expose their ambiguity (prison versus hospital), their inefficiency and their inability to reach a consensus among law, medicine and psychology.
Diniz (2014) [2] emphasizes that the danger is obscured by the psychiatric diagnosis, or by the criminal history of these individuals.Moreover, Diniz (2014) [2] also points out that the psychiatric reform of the 2000s have not reached these institutions and the madness is kept under detention for social protection.Health and care policies planned for these populations have not been guaranteed.These individuals are in perpetual scheme of abandonment.Finally, CPHs are institutions that replicate what the outside world craves: the desire of these people to be forgotten for the rest of their life [2].Interestingly, the condemnation of asylums and the defense of 'therapeutic freedom' have been broadly debated in the last Mental Health Conferences [10].
Compared to common psychiatric hospitals, the criteria for admission into custody hospitals (better known as Custodial Psychiatric Hospitals) are even more appalling [11].Diniz (2014) [2] notes that under the law, the routing can be temporary when the judge requests a psychiatric report (to assess the mental condition of the individual) then, the person is sentenced to a security measure.Importantly, the psychiatric report may be requested even after the imprisonment.
There are many cases of patients admitted by the single psychiatric evaluation, but who stayed there for years [2].The Brazilian Psychiatric Reform induced a significant loss in psychiatric beds provoking a diversification in community services.Ultimately, this reform has condemned the society to deal with the complexity of mental disorders and with the usage of psychoactive substances.[10] silva (2010) [7] mentioned that prison-like CPHs and psychiatric infirmary continue to be created around the country.On the other hand, some security measure has been taken into account for a hospital or outpatient treatment.A hallmark of the early twentieth century psychiatric medicine is the recognition of those who committed infractions may need treatment, not punishment.The Brazilian Unified Health System (Sistema Único de Saude-SUS), allows healthcare institutions to be created in defiance of logic integrality and intersectoriality.According to the Brazilian Law N o .10,216, April 6 th , 2001, the protection of the mentally ill's human rights and their redirection to the psychiatric care must be ensured.They should only remain in asylum institutions if there are no outpatient services in their community [12].In this context, the National Health Plan for the Prison System (Plano Nacional de Saúde no Sistema Penitenciário -PNSSP), refers to the National Policy on Mental Health, the outpatient setting network -CAPS -among other Brazilian state actions [13].
Another way to minimize this problem is by the structured treatment, which replaces the closed clinical treatment by the introduction of new technological devices [14].On the other hand, individuals treated by the community have significantly improved their mental conditions if compared to those treated under conditions of liberty limitations [15][16].Additionally, the asylum model has been criticized by the Brazilian state and by the social movements.Moreover, the asylum is a segregating model and filled with bureaucracy.The new project aims on social reintegration and, citizenship lays emphasis on the historical and cultural context of specialized mental health care [17].
The anti-asylum movement, in the context of security measure application, is somehow shielded by the Brazilian Law n° 10.216, pointing to the fact that CPHs were hardly touched by the Psychiatric Reform [7,18].Mental ill patients remain on the "invisibility", even after the Psychiatric Reform [19].The Bra-zilian reform, which has redesigned the treatment guidelines (based on community care networks) has not reached these patients [2].
Security measures should be based on individual recovery, hospitalization and outpatient treatment, unlike imposed imprisonment penalties.However, the 2011 census, alert that people are still being submitted to scheme of abandonment [19].Despite the maximum penalty of thirty years, imposed by the Brazilian law, some individuals are being kept for longer periods in custodial hospitals.These individuals have to overcome the cruel social rules imposed by the State and deserve being recognized as unique individuals with special needs [19].
Furthermore, the census highlights their vulnerability as an alarming scenario.For example, one in four individuals should not be admitted, 47% are incarcerated with no legal and psychiatric reasons, 21% stayed beyond the stipulated in sentence, not counting the hospitalized for more than 30 years [19,20].
The Psychiatric Reform law (number 10.216/2001), is a valid attempt toward more dignity.Additionally, this law also alleviates the social discrimination and economic constraints suffered by these people.On the other hand, the violence, intolerance and humiliation were not eliminated by this law [6].
As stated by silva (2011) [21] the field of legal and sanitary practices links concepts such as "social defense", "disability" and "dangerousness" to the idea of mental illness.In the last 300 years, the decision for the ban, unaccountability, and involuntary or compulsory hospitalization was determined by these presumptions.The right of being responsible for their actions and privacy demonstrate their abilities and also shows that the social bonds have been ignored [21].In fact, the mechanisms of oppression in our society are really present at asylums [22].Diniz (2011) [19] believes that there is no coming back after entering through the heavy iron gates of a judicial asylum.Between walls and omissions, thousands of lives are invisible to the State and society.These individuals are doubly marginalized by the abandonment and stigma of mental ill.The "crazy" represents a face of a sick society, for whom psychiatric reform becomes a civilizing process, directed to social the relationships guided by principles and values [23].Noticeably, the Brazilian Law N o .10.216/2011 has been violated by the Federal and State authorities [6].
More than half of the population in the safety measurement (56%) was been hospitalized for a period longer than the maximum sentence allowed.The table 1 shows the 10 main distortions of these

InternatIonal archIves of MedIcIne
Section: Global HealtH & HealtH Policy Issn: 1755-7682 J system.For example, the table presents an individual who stayed for 32 years due to attempted robbery [24].Diniz (2011Diniz ( , 2014) [19, 24] ) [19, 24] stresses that "since these individuals come into a security measure and this is renewed indefinitely, they become invisible and disappear for an entire support structure of health justice that should take care of them.Nobody cares about the crazy, offenders, it is like if they do not really exist." According to lobosque (2011) [25] actions "beyond health" are the real challenges.These include exchanging homes designed as health systems by homes designed to live in.Additionally, these places should provide protection but no guardianship.Basic needs as education, justice, human rights and social assistance must also be provided.Agreeing with Diniz (2014) [2] no structural changes are seen, even though, there are some efforts by the public authorities.Where Doctors exchange clinical experiences, review their cases and share clinical knowledge.You can also access lots of medical publications for free.Join Now! http://medicalia.org/

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