Mental Health Services in Cuba

Nick Kates, F.R.C.P.(C) located in the capital city of Ha- cally regulated network of policlin-
vana. Most medical and psychiatric ics (the name derives from the
Despite its limited resources, services were provided by private Greek word “poli” meaning
Cuba has developed an integrat- physicians and were not readily many), each of which provides
ed mental health system that em- available to those who could not comprehensive medical services to
phasizes prevention and commu- afford to pay for them. between 25,000 and 40,000 peo-
nity care. It consists ofthree dis- Following the revolution, the ple (1). The area covered by each
tinct organizations: the government made the improve- policlinic is divided into eight
Committee for the Defense of the rnent of mental health services a smaller sectors. Each sector has an
Revolution, one of many mass priority. This paper presents a internist, a pediatrician, a dentist,
community organizations that broad overview of the way these three nurses, one or two social
strive to protect the revolution; services have been developed. It workers, a psychologist, and a psy-
the policlinics, which provide stems from a two-week visit to chometrist and shares an obstetni-
comprehensive health services to Cuba made by a group of Amen- cian and obstetrical nurse with an-
geographic areas containing can health workers in 1983 to ex- other sector.
25,000 to 40,000 people; and the amine the country’s health and The policlinics provide routine
psychiatric hospitals. All three welfare services. primary care, preventive programs
use treatment approaches that to monitor high-risk groups,
are based on a social systems Organization of services screening programs, and immuni-
model and that emphasize solving Mental health services in Cuba em- zatios. It is the psychologists who
current problems and distur- phasize prevention and community coordinate and organize mental
bances. Behavioral and milder management and are provided by health care. They work primarily
psychiatric problems are treated three distinct organizations: the with behavioral disturbances and
by policlinic psychologists, in the mass community organizations, the milder psychiatric problems, while
community whenever feasible, policlinics, and the psychiatric hos- psychiatrists usually manage major
and major psychiatric disorders pitals. psychiatric illnesses and are based
are treated by psychiatrists at the at the psychiatric hospitals.
hospitals. Services for children The mass organizations Much of the psychologists’ work
and adolescents, research, and The mass organizations are nation- is directed at behavioral and learn-
staff training in Cuba are also wide groups made up of members ing problems in children such as
discussed. of the community who strive to hyperactivity, enuresis, parenting
protect different gains of the revo- and family difficulties, and academ-
Before the revolution in 1959, Cu- lution. The mass organization most ic under-achievement. Other
ba’s mental health services consist- involved with mental health care is groups singled out for special at-
ed of a single psychiatric hospital the Committee for the Defense of tention include pregnant women,
the Revolution, to which 80 per- patients with chronic physical ill-
Dr. Kates is assistant professor cent of the population belongs. Its nesses, parents of premature ba-
in the department of psychiatry members’ varied roles include irn- bies, and couples with marital
at McMaster University in proving literacy rates, helping pnis- problems. A psychiatrist is usually
Hamilton, Ontario, Canada. Ad- oners and psychiatric patients rein- available one day each week to
dress correspondence to him at tegrate into the community (and consult on cases referred by the
East Region Mental Health looking after their families while psychologist or other medical staff
Services, 615 Britannia Avenue, they are away), organizing health of the policlinic.
Hamilton, Ontario, L8H 2A5. and immunization campaigns, and The psychologist’s treatment ap-
This article is part of an occa- supporting members of the com- proach usually follows a social sys-
sional series of articles on for- munity who are in distress. tern or family systems model and
eign psychiatry published in uses short-term individual psycho-
H&CP. Martin Gittelman, The policlinics therapy, group discussions, or fam-
Ph.D., is editor of the series. Cuba is divided into a geographi- ily meetings. A strongly behavioral

Hospital and Community Psychiatry July 1987 Vol. 38 No. 7 755

approach, it emphasizes practical Although admissions to the psy- North America, although some
problem solving and exchange of chiatnic hospitals are voluntary, ex- drugs, for example lithium, are
ideas rather than psychodynamic cept for forensic assessments, in hard to obtain because of the
on interpersonal processes. reality patients may have little American blockade. Schizophre-
Whenever possible, the psychol- choice about being admitted to the nia, depression, suicide (Cuba has
ogist works within the community. hospital. The patient who elopes an annual suicide rate of 22 per
Almost halfofCuba’s 750 psychol- or refuses admission becomes the 100,000 people), and homosexual-
ogists may be found in schools or responsibility of the family, and ity are seen as primarily biochemi-
in the workplace, where they help the hospital or the Committee for cal in origin and are treated psy-
workers deal with job-related the Defense of the Revolution may chopharmacologically. Electrocon-
stress. They also provide consulta- strongly pressure the family to en- vulsive therapy is used more
tions to the general hospitals on sure the patient’s speedy return. liberally than in North America,
the emotional aspects of disease. The committee is also active in especially for psychotic patients.
Psychosomatic medicine as we un- facilitating admissions and provid- We were informed, however, that
derstand it is not yet seen as a ing background history on pa- its use with such patients is being
major specialty, but awareness of tients. reevaluated. There is little re-
the impact of psychological factors Psychiatric hospital patients search into developing new drugs;
on people with physical illness arid have an average length of stay of Cuba obtains such drugs from oth-
on their recovery is growing. The three months. Sixty percent of all er countries and manufactures
psychologist’s role also includes admissions are for schizophrenia, them herself in spite of interna-
serving as a liaison between the 10 percent for depression, 10 per- tional patent laws.
community and the policlinic, cent for mental retardation, 10 Psychotherapy. Individual psy-
helping to resolve interpersonal or percent for alcoholism, 5 percent chotherapy focuses predominantly
group issues that may arise within for anxiety disorders, and 5 per- on current problems and distur-
the clinic, and conducting training cent for other problems. Personal- bances in social relationships and
sessions for primarj care workers. ity disorder is not used as a diag- behavior rather than on psychody-
The policlinic social workers are nostic term. Hospital admission namic conflicts. An individual is
primarily caseworkers who pro- rates reflect the island’s racial seen as being shaped primarily by
vide little counseling or therapy. makeup: 75 percent white, 25 per- social forces. In most ofoun discus-
They help with problems such as cent black. Two-thirds of all pa- sions with mental health profes-
residential placement, finances, tients are male, but admissions for sionals, we found they placed very
and adoptions and take social his- depression and anxiety disorders little emphasis on the possible sig-
tories from people attending the are distributed equally between nificance of developmental stages
policinic. Most counseling and males and females. or previous experiences on a per-
support comes from members of The hospitals are staffed by psy- son’s current emotional well-be-
the mass organizations, all of chiatnists, psychiatric nurses and ing. The main precipitants of psy-
whom can potentially fill a part of nursing assistants, social workers, chiatnic problems were repeatedly
the role of a social worker. For psychornetrists (but rarely psychol- identified as being marital and fam-
example, if someone has to be ogists), occupational therapists, ily difficulties (30 percent of mar-
maintained at home, neighbors are and a wide range of general medi- niages end in divorce) and over-
prepared to come to the patient’s cal auxiliary personnel. The hospi- crowded housing conditions.
home and cook meals, administer tals we visited followed a tradition- Family support groups are used
medication, and provide whatever al medical model. Psychotherapy extensively and teach families how
help is needed. was conducted by psychiatrists, so- to manage medications, recognize
cial workers collected information the symptoms of the patient’s ill-
The psychiatric hospitals and took histories, and nurses, al- ness, and reduce stress. Work with
Cuba has seven psychiatric hospi- most all of whom were female, individual families is similar, usual-
tals that manage most psychiatric looked after the patients on the ly lasting for less than six sessions,
illnesses, although most large gen- wards. with the therapist acting as an ad-
eral hospitals have small psychiat- There are three main lines of viser and guide in an educational
nc units. The psychiatric hospitals intervention in the psychiatric hos- role.
have from 200 to 600 beds, with pitals: psychopharmacology, psy- Groups figure prominently in
the exception of the hospital in chotherapy, and rehabilitation inpatient and outpatient therapy,
Havana, which has 3,500 beds. work and occupational therapy. fitting philosophically and politi-
The Havana hospital has become a Psychopharmacology. Cuban cally with the goals of the revolu-
tertiary care facility for difficult psychiatry largely adheres to two tion. They are used for all kinds of
patients from all over the country, models: biological and social sys- patients at every stage of treat-
with 80 percent of its beds filled by tems. Indications for the use of ment, and patients seem to readily
longer term patients. it is also the drugs and physical treatments ap- accept participating in them. The
island’s major research center. pear similar to those found in groups usually focus on realizing

756 July 1987 Vol. 38 No. 7 Hospital and Community Psychiatry

collective rather than individual active role in rehabilitation, and of grade 1 identifies the child as
goals or potential. work commissions will seek out having a possible learning disabil-
Work. Cuban patients partici- more suitable work for a patient if ity. If the child is not reading flu-
pate in all aspects of running the necessary, although the patient ently by grade 2, a psychological
psychiatric hospitals and are paid may have little say in the choice or assessment and remedial educa-
for work such as cooking, mainte- location of the new employment. tion, if necessary, are provided.
nance, painting, and gardening. In most communities the psychi- The ages of 11 and 12 are also
Work also figures prominently in atric hospitals have set up residen- seen as key developmental stages
clinical assessments, serving as the tial rehabilitation centers where for Cuban children. Any child hay-
main criteria for progress. Patients patients stay before their return to ing academic or adjustment prob-
are assessed and managed as they their families. Aftercare is moni- lems at these ages receives a full
pass through six stages of rehabili- toned either through hospital-run psychological assessment. In addi-
tation (2). An initial assessment outpatient clinics within the corn- tion, all children who get into trou-
leads to a job within the hospital as munity or through the policlinics. ble with the law receive psycholog-
well as participation in other pro- Each community also has a variety ical assessment.
grams. In the next stages the work of day treatment programs organ-
becomes more complex or de- ized by the psychiatric hospitals or Research
manding, and the patient receives the psychiatric services of the gen- Cuba has little direct access to
greater responsibilities in the hos- eral hospitals. North American journals. The
pital and then within the cornrnuni- The mass organizations play a hospital libraries we visited often
ty under the supervision of an oc- prominent role in community care. consisted of a hodge-podge of
cupational therapist. When ready In addition to helping with the books from the West with some
the patient moves to a residential early identification of problems, neurology and psychiatry journals
rehabilitation center in the corn- they provide support and direction from the 1950s. However, all for-
munity, although some communi- within the local community for eign materials are readily studied
ties do not have sufficient places psychiatric patients who may not and absorbed. Research is centrally
available at these centers. After have a support system and help directed by the Ministry of Health,
participating at a rehabilitation strengthen and support family which approves all projects, and
center, the patient returns to the units in times of stress. Individuals research priorities appear to be in
family and a permanent job. do not feel particularly beholden epidemiology, rehabilitation, and
In addition, every inpatient is to those who help them since the community care.
involved in some kind of physical next time a crisis hits the commu-
activity or team sport to improve nity, they may find themselves in Staff training
fitness and sociability. Each hospi- the supportive role. This interde- Psychiatry residents train for three
tal also has a school for patients pendency is one of the strengths of years in what is described as an
who cannot read or write. the mass organizations. eclectic program and take exams
and write a thesis toward the end
Community care Services for children of the third year. Child psychiatry
Aftercare is seen as a collective and adolescents residents spend another year train-
community responsibility rather Most large cities have specialized ing in pediatrics. All residents ro-
than the responsibility of any spe- services for children, although tate through general and psychiat-
cific agency. However, patients they are limited by available fund- nc hospitals and spend some time
may be hospitalized for relatively ing. Havana has an up-to-date in- in rural areas.
lengthy periods of time, and there patient and outpatient clinic for Psychologists train at Havana
is little pressure to discharge them children, which also serves as a University in a five-year program
into the community. Deinstitu- tertiary care center for children that includes biology, neuroanato-
tionalization is neither a major nor from the entire island. The clinic my, physiology, psychology, and
a controversial issue. Readmission handles a broad range of problems statistics. They do at least one year
rates appear to be as high as 50 from behavior difficulties to psy- of practical work, and their educa-
percent within one year of dis- choses. Judging from the cases dis- tion is also considered eclectic. So-
charge. Economic limitations and a cussed during our visit, treatment cial workers train for three years in
lack of housing make posthospital approaches and attitudes-toward a school for middle-range techni-
residential programs scarce, al- medication, for example-seem cians. However, most employed
though Havana has a well devel- similar to our own. social workers have not yet com-
oped series of residential work- Cuban children start school at pleted their full course and are
shops. age five (less than a third attend working and studying on a part-
Jobs are protected during ill- preschool because of a lack of time basis.
ness, and workers are paid 50 per- openings) and are expected to be Staff appointments are made by
cent of their wages during hospital- able to read by Christmas of their the Ministry of Health, and we
ization. The workplace plays an first year. Failure to read at the end were told that appointments above

Hospital and C#{246}mmunity Psychiatry July 1987 Vol. 38 No. 7 757

a certain level, such as the director limited resources. Given its re- sessing the relationship between
ofa psychiatric hospital, have to be sources, Cuba is trying to develop the more individually oriented
approved by the Communist party. an integrated mental health system psychological theories of North
The ministry has also set up a with a strong emphasis on commu- American psychiatry and the col-
mental health group to establish nity care and prevention. lective political philosophy of the
and maintain professional and Rapid changes are occurring in Cuban revolution.
technical standards. Cuban psychiatry, which is increas-
ingly being exposed to North
Conclusions American treatment approaches.
References
While our trip was too short to In many areas Cuba still lags be-
provide anything other than a su- hind North America, but most Cu- 1 . Gittelman M: Sectorization: the quiet
perficial view of mental health care ban psychiatrists and psychologists revolution in European mental health
in Cuba, it is clear that Cuba offers we met were eager to analyze and care. American Journal of Orthopsy-
chiatry 42:159-167, 1972
one model for the development of absorb ideas and developments
2. Michie S: A therapeutic community in
comprehensive mental health serv- from Western psychiatry. They Cuba. International Journal of Thera-
ices in a Third World country with were particularly interested in as- peutic Communities 1:92-99, 1980

Psychiatric Expertise in
Clinical Decision Making
for Psychiatric Inpatients
0. B. Towery, M.D. laboratory procedures, that can Recent antitrust litigation and
lloyd I. Sederer, M.D. be used to determine whether psy- subsequent changes in the stan-
chiatric expertise is needed. The dards of the Joint Commission on
Hospital boards and medical indicators were applied to a Accreditation of Hospitals leave to
staffs are faced with difficult group of ten patients who consti- the individual hospital the ques-
decisions about whether nonphy- tuted all admissions to a treat- tion ofwhether nonphysician men-
sician mental health profession- ment unit in a private, nonprofit tal health professionals should be
au should be given admitting psychiatric hospital in a one- allowed to admit and have primary
privileges to psychiatric hospitals montbperiod. At least half of the responsibility for inpatients. To re-
or treatment units. The authors indicators were relevant to all spond to the issue in an informed
describe the special medical ex- the patients studied, suggesting and responsible way, hospital med-
pertise oftbe psychiatrist and de- the need for management by a ical staff and board members will
fi tie 1 1 indicators, such as a pa- psychiatrist. have to become more familiar with
tient’s needfor new psychotropic the kinds of clinical decisions that
medication or the presence of Changes in the financing and deliv- are made on a psychiatric treat-
symptoms requiring medical or ery of health care services are dra- ment unit.
matically altering clinical decision- In this paper we will demarcate
Dr. Towery is medical director making processes in psychiatric the special expertise of the psychi-
of the Brook Lane Psychiatric hospitals and psychiatric units in atnist and conceptualize the deci-
Center, Box 1945, Hagerstown, general hospitals. Traditionally sion-making process involved in
Maryland 21742, and assistant psychiatrists have been the profes- the care of the hospitalized psychi-
clinical professor of psychiatry sionals exclusively responsible for atric patient. Then we will present
at Georgetown University Med- major diagnostic and treatment a set of indicators for determining
ical School in Washington, D.C. decisions on psychiatric units. Ef- whether psychiatric expertise is
Dr. Sederer is associate chief of forts by other health professionals needed for the hospital treatment
psychiatry at Mount Auburn to gain hospital admitting pnivi- of specific patients or groups of
Hospital in Cambridge, Massa- leges and hospitals’ strategies to patients and will apply the indica-
chusetts, and assistant professor reduce costs can be expected to tons to a small but illustrative sam-
of psychiatry at Harvard Medi- repeatedly challenge the domain of ple of hospitalized patients.
cal School. the psychiatrist. Through these processes we hope

758 July 1987 Vol. 38 No. 7 Hospital and Community Psychiatry