Saúde Mental Global e Atenção Primária à Saúde no Brasil: um estudo de caso sobre os cuidados às pessoas com sintomas depressivos na Estratégia Saúde da Família da cidade do Rio de Janeiro.

Abstract

This PhD thesis is an ethnographic case study on the assessment of people with depressive symptoms by residents of family medicine in the city of Rio de Janeiro. The results of the fieldwork were analyzed in dialogue with the "cultural critique" to Global Mental Health (GMH). Through a narrative literature review, I identified four uses of the category "culture" present in critical studies of GMH: culture as a non-biological dimension of reality, as a territory of human moral grammars, as non-Western symbolic systems, and as a social structure. I proposed to put aside the false oppositions that permeate these uses and reconfigure them through a semiotic conceptualization of culture and the investigation of the circulation of "moral economies" in the form of "cultural" and "social" phenomena. Thus, I developed a theoretical framework for the dialogue between the empirical field of research and GMH. During three months, I followed the visits of six family medicine residents in a Family Health Strategy practice in the northern zone of Rio de Janeiro. My interest was to investigate how those professionals approach patients who presented symptoms that could be diagnosed as depression. Patients and residents, while sometimes referring to aspects of the conventional psychiatric diagnosis, made local reinvention of "depression" and "depressive symptoms" as idioms of distress. Residents worked with a categorization of depression between "hill" and "asphalt", whose correspondences with patients' experiences became one of the focus of the study. I interviewed and followed the assessment and treatment of 22 patients, 12 dwellers of the "hill" and 10 of the "asphalt". Although I identified evidence of patterns associated with hill / asphalt categorization, the study of individual trajectories presented several elements that contradicted a homogeneous replication of these patterns. "Life" emerged as a category able to bring together the meanings of both patients '"lives in suffering" and the residents' clinical practices of "reengagement with life." The "hill" and "asphalt" categorization proved to be a source of tensions in the field, especially when the moral stakes of physicians and patients around these categories were evident. These "moral economies" were reconfigured into different approaches to the depressive symptoms of "hill" and "asphalt" dwellers. These approaches, in turn, unfolded in "elective affinities" between family medicine residents and dwellers of the hill and greater restraint in attention to the asphalt population. The impacts of these issues on the life of the residents and on patient care are discussed. This research pointed to the need, on one hand, to deviate from the false oppositions present in the uses of "culture" in Global Mental Health and, on the other, to explore the circulation of epistemic orientations, social determinations and moral values as inseparable phenomena when human suffering is at stake ". Thus, I could map both powers and difficulties experienced by patients and professionals in a scenario of expansion of public mental health care in Brazil.