Implementing the Community Mental Health Care ...

International Journal of Mental Health

ISSN: 0020-7411 (Print) 1557-9328 (Online) Journal homepage: http://www.tandfonline.com/loi/mimh20

Implementing the Community Mental Health Care Model in a Large Latin-American Urban Area Rafael Sepúlveda , Jorge Ramírez , Pedro Zitko , Ana María Ortiz , Pablo Norambuena , Álvaro Barrera , Cecilia Vera & Eduardo Illanes To cite this article: Rafael Sepúlveda , Jorge Ramírez , Pedro Zitko , Ana María Ortiz , Pablo Norambuena , Álvaro Barrera , Cecilia Vera & Eduardo Illanes (2012) Implementing the Community Mental Health Care Model in a Large Latin-American Urban Area, International Journal of Mental Health, 41:1, 62-72 To link to this article: http://dx.doi.org/10.2753/IMH0020-7411410105

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62 INTERNATIONAL JOURNAL OF MENTAL HEALTH

International Journal of Mental Health, vol. 41, no. 1, Spring 2012, pp. 62–72. © 2012 M.E. Sharpe, Inc. All rights reserved. Permissions: www.copyright.com ISSN 0020–7411 (print)/ISSN 1557–9328 (online) DOI: 10.2753/IMH0020-7411410105

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Rafael Sepúlveda, Jorge Ramírez, Pedro Zitko, Ana María Ortiz, Pablo Norambuena, Álvaro Barrera, Cecilia Vera, and Eduardo Illanes

Implementing the Community Mental Health Care Model in a Large LatinAmerican Urban Area The Experience from Santiago, Chile ABSTRACT: This article outlines the development of the Barros Luco General Hospital’s Psychiatry Service since its creation in 1968. Initially, some historical and political background is provided followed by a description of how our service has endeavored, over the last 10 years, to put the community mental health care model into practice. Subsequently, we describe the growth of a network of locally based mental health services. Another process running in parallel has been the acquisition, by the local primary care teams, of skills that have enabled them to manage, on an ambulatory basis, patients with severe and enduring mental illness. In this regard, some data are provided in order to illustrate the effect of the changes that are taking place, including a reduction in the proportion of emergency psychiatry consultations at the casualty department. Finally, current and future challenges are Rafael Sepúlveda is the head of Psychiatry at the Barros Luco Hospital, professor of psychiatry at Universidad Mayor, and senior lecturer at the School of Public Health, Faculty of Medicine, University of Chile, Santiago, Chile. Jorge Ramírez is a specialist in public health at the Mental Health Department, Ministry of Health, Santiago, Chile. Pedro Zitko is an epidemiologist at the Research Unit, Barros Luco General Hospital, Santiago, Chile. Ana María Ortiz is an occupational therapist at Barros Luco General Hospital, Santiago, Chile. Pablo Norambuena is a psychologist at the Mental Health Department, Ministry of Health, Santiago, Chile. Álvaro Barrera, MRCPsych, M.Sc., Ph.D., is a consultant psychiatrist at Oxford Health NHS Foundation Trust, Oxford, England. Cecilia Vera is a psychiatrist and head of the Outpatient Psychiatry Department, Barros Luco General Hospital, Santiago, Chile. Eduardo Illanes is a psychiatrist and deputy head at Barros Luco General Hospital Psychiatry Services, Santiago, Chile. 62

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discussed, including the need for a mental health law, clinical governance issues, and the provision for people with developmental disorders and those with highly complex mental health needs. Mental and neurological disorders are a significant public health problem worldwide. It is estimated that they account for 23.2 percent of the burden of illness in Chile [1]. In the face of this epidemiological reality, the patchy and largely insufficient provision of mental health care led the World Health Organization (WHO) to emphasize the importance of countries to develop consistent mental health services [2]. In order to provide a framework to undertake such a task, WHO has proposed some guiding principles that mental health services development should follow, specifically, the so-called community care model has been advocated because it ensures that patients’ needs are at the center of the service development. The community mental health care model emphasizes the importance of services being located close to where patients live with a range of services available to people with mental and behavioral disorders, including alternatives to hospital admission, such as home treatment and access to acute inpatient care as well as local accommodation placements for patients that require more prolonged residential care. The model also emphasizes the importance of treatments and support being tailored to the individuals’ needs as well as clinicians working with and addressing the needs of caregivers. Similarly, clinical interventions must consider not only symptomatic remission, but also should address any associated disabilities with close collaboration between mental health professionals and community resources. Finally, last but not least, the provision of mental health care must take place within the context of an effective legal framework [3]. Services delivered along these lines are considered by WHO as providing community mental health care [4]. In the case of Chile, with the creation of the National Health Service in 1952, the country saw a gradual and significant improvement in the health standards of its population, becoming one of three countries in Latin America and the Caribbean region with improving health care indicators [5]. However, at the time of the return to democratic rule in 1990 after 17 years of military dictatorship, the nation’s mental health service was in a deplorable condition, even more so than the other areas of health care [6]. Since then gradual and significant changes in the provision of mental health care in Chile have taken place, and these changes have attempted to follow the above-mentioned model of community mental health care advocated by WHO. Initially, some changes started to occur between 1990 and 1996 [7], but their scope increased with the momentous publication of the National Plan of Mental Health in the year 2000 [8], which provided a route map for the work and efforts of mental health professionals over the following decade. The gradual implementation of the National Plan of Mental Health encouraged the transition from mental health care revolving around the four large psychiatric hospitals located in the geographical center of the country to a network of regional mental health services distributed around the country (Figure 1). It goes without


Figure 1


Stages of Developmental Psychiatry Service, Barros Luco General Hospital, 1968–2009

saying that this change in itself has led to improvements in people’s access to mental health care [9]. Currently, each one of the main regional hospitals has general psychiatry services that are embedded in a network of mental health community services as well as primary health care units [10]. Unfortunately, these changes in the way mental health care is provided in Chile have not been adequately communicated or documented. We believe that more detailed knowledge of these processes may be helpful both for those who are just preparing to embark on such changes as well as for those who are already in the process of change. The present article describes the development of psychiatric services in the south of Santiago, Chile’s capital city, where we have at least tried to follow the community mental health care model. The Barros Luco General Hospital in Southern Santiago, Chile: Some History and Context The Santiago South Health Service currently provides services for almost 900,000 people who live in eleven communes, and it includes thirty-one primary care centers and seven community hospitals with the Barros Luco General Hospital being the largest hospital providing specialist (secondary and tertiary) medical care. For decades, and following the priorities set at the foundation of the National Health Service in 1952, the focus of the Barros Luco General Hospital centered on the control of infectious diseases as well as improvements in maternal and child health. In other wards, mental ill health was not at the top of the agenda at the time. Psychiatric


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services centered on alcohol-related disorders as well as on psychotic disorders; the care and treatment of the latter focused around large national asylums. The above situation started to change in 1968 when Professor Juan Marconi and his team of academics, clinicians, and residents moved from the University of Chile to southern Santiago, a move probably not unrelated to the process of radical reform that the University of Chile itself was going through at the time. Professor Marconi’s team moved from northern Santiago, where most of the university and public sector mental health facilities were concentrated, to the southern half of the city, which did not have any resources at all up until that year; the newly arrived team started their work both in the outpatient department of the Barros Luco General Hospital as well as in a primary care center (the Santa Anselma Centre) [11]. Reflecting on their own practice and experiences of engaging with a local community, highly organized and politically aware, this group of academics and professionals started to develop what they called the “intracommunity psychiatry” model (ICPM). The ICPM was built upon and encouraged community health education and people’s participation in the definition of the priorities and the development and implementation of interventions through what was called a “pyramid of delegation.” Briefly, the pyramid of delegation ensured that the interventions, emphasizing health promotion, self-care, and early detection, reached a very wide audience in the local communities. The pyramid consisted of five levels, starting at the bottom with the learning community (D5) level and at the top with the individual responsible for the program (D1) [12]. Remarkably, the psychiatrists trained within the program acquired a clear community mental health ethos, and in fact, some of them would subsequently go on to play an important role in the development of Chilean mental health. Professor Marconi’s work, his ICPM, as well as the work of his team are still widely acknowledged in Latin America. In 1973, a military coup interrupted the country’s democratic tradition and established a dictatorship that lasted until 1990. The political conditions that followed—human rights violations, drastic reduction of the size of the state and public spending, massive unemployment, and social breakdown—made it impossible to work on a model that, like the ICPM, emphasized community engagement and participation. In that context, Professor Marconi’s team had no option other than to limit their work to what became the Barros Luco General Hospital Psychiatry Service (henceforth, “the service”). Thus, the service functioned for 17 years basically as an outpatient department in which the opportunities of collaboration amongst professionals of secondary and primary care were very restricted, not the least because of the political environment. One of the first victims of this process of withdrawal into the walls of the hospital was, of course, continuity of care. The result of this was that an increasing number of patients became caught in what could be described as chronic ambulatory psychiatric care, a veritable form of institutionalization not very different from that inflicted on people by large psychiatric asylums. Because not many patients were discharged from the service, it became increasingly difficult to assess and treat new patients. In fact, for long



periods, the main activity delivered by the service’s staff was to intervene during the postcrisis period of an acute episode of mental ill health and the subsequent repetition of prescriptions with very limited clinical reviews [13]. In terms of staff numbers, there was also a reduction over the years so that in 1989 the service had one nurse, one occupational therapist, two psychologists, seven psychiatrists, one nurse assistant, and one secretary, resources that were utterly insufficient to meet the mental health needs of the local population. With the return to democratic rule in 1990, the new local authorities tried to start, not without difficulties and errors, addressing the above situation. In particular, two actions revolving around reestablishing the contact between secondary and primary care units were of particular importance. One step focused on alcoholrelated and emotional disorders with a view to trying to control the flooding of secondary care level facilities by patients whose needs were best met at the primary care level. An associated step was to start a gradual process of referring the abovementioned chronic ambulatory psychiatric patients back to the primary care level with a view of getting them back into their natural local health care network. This process was actively implemented and, despite the limited resources available, some of the psychiatrists started working directly with the primary care teams both to help them to foster their clinical skills to manage the newly received patients as well as to provide as needed direct clinical care for the more complex primary care patients. It was this modality of care, developed out of necessity, that led us to envision the initial stages of the psychiatric consultation model that would later become a distinctive feature of the relationship between primary care and mental health secondary care in Chile. While some of these changes were taking place, Chilean public opinion became outraged in 1993 as the media disclosed the extreme neglect suffered by residents of a publicly funded private residential unit. The authorities responded to this scandal by somehow increasing the resources allocated to mental health. It was within that context that the service was able to make some developments, such as emergency admission beds, psychiatrists working at the Accidents and Emergency department, and the treatment and rehabilitation of addicts at the community level. Subsequently, the launch of the Day Hospital in 1999 was followed by, in 2002, the relocation of the psychiatric outpatient department to a new diagnostic center along with the other medical and surgical specialties. This setting made it possible to start offering a variety of services to the patients. In 2003, change and development continued with newly formed community psychiatry teams and the opening of a new acute inpatient unit in 2004 [13]. Thus, the service has developed a multifaceted profile as the country’s largest general hospital-based psychiatry service. Current Situation The service currently provides mental health care for adults above 18 years of age, including people with addictions, with the staff levels described in Table 1. The

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Table 1 Barros Luco General Hospital, Psychiatry Service Staff, 1976 and 2011 Staff numbers


Staff Psychiatrists (within hours) Psychiatrists (out of hours) Nurses Psychologists Occupational therapists Care assistants Health care assistants Administrative staff

Hours per week

1976

2011

1976

2011

2 0 0 5 1 2 0 0

14 6 8 11 10 16 13 5

66 0 0 220 44 88 0 0

220 168 352 286 330 704 572 220

services include an outpatient department, a twenty-eight-bed acute inpatient unit, a day hospital for twenty patients, a rehabilitation unit serving twenty patients, and an outpatient alcohol and substance dependence unit for twenty patients. Moreover, there is a psychiatrist providing cover 24 hours a day/7 days a week at the hospital’s Accidents and Emergency department. In 2009, there were 14,000 consultations (including emergencies) as well as 336 discharges from the acute inpatient unit with an average length of stay of 27 days [14]. We will next briefly outline the components of the service. Outpatient Department This department is organized around community psychiatry teams [15], each of which is in charge of delivering care to the population of its commune within a model of shared care [16] in close liaison with the district’s primary care providers [17]. These teams run outpatient clinics as well as regularly visit the primary care centers, providing psychiatric consultation for the primary care teams. The psychiatric consultation model involves supporting primary care teams to develop their skills in managing both patients with severe and enduring mental illness who are currently stable or those patients who, although unwell, have not yet reached the threshold for referral to secondary care. In 2010, affective disorder (bipolar disorder and depressive disorder) and schizophrenia and other psychotic disorders accounted for just over 70 percent of the patients seen in the psychiatry outpatient department. More recently, outpatient care has started to be transferred from the community psychiatric teams (made up of South Santiago Health Service staff) to district-based community mental health teams (made up of district/council staff); this has taken


place in two districts so far. The district-based community mental health team aim is to try and deal with mental ill health affecting people of all ages with the expectation that they will refer to the secondary care level unit (henceforth, referred to as “the service”) only those more difficult, more severe, or treatment-resistant patients (for whom the day hospital, the hospital inpatient unit, and the psychosocial rehabilitation unit will be available).


Day Hospital The day hospital’s work has developed as an alternative to hospital admission, providing comprehensive care for patients with acute mental ill health. Its functioning has prevented hospitalizations and has also reduced the length of the admissions to the hospital. The day hospital team has acquired experience over time in terms of psychosocial interventions in families with high expressed emotion as well as in the psychoeducation of patients. It has been observed, in accordance with the literature, that these interventions have had a positive effect on the course of the illness as well as promoting patients’ autonomy and self-care, medication concordance, and engagement with psychosocial rehabilitation. Rehabilitation Department This department evolved from the gardening and woodwork workshops that were part of the existing services at the El Peral psychiatric hospital, one of two large psychiatric hospitals in Santiago. The workshops initially evolved into a program that supported the employment of fifty patients as part of the Barros Luco Hospital staff with jobs such as couriers, administrative staff, and cleaning. Unfortunately, patients tended to remain in the same post for long periods, which led to the system being unable to provide more placements for new patients. When the situation was critically reviewed, it was decided to increase the professional input to it as well as to emphasize the transitional nature of the hospital posts and the need to support patients to move toward competitive employment. The results of this new approach have been encouraging, with 120 people having obtained and maintained competitive employment posts. Acute Inpatient Unit This is a twenty-eight-bed unit with bedrooms of up to three beds each that are managed according to the patients’ gender and clinical needs. In 2010, affective disorder (bipolar disorder and depressive disorder) and schizophrenia and other psychotic disorders accounted for just over 75 percent of the patients admitted to the unit. The current average length of stay is twenty-seven days, which has recently increased because of the prolonged stays of patients with developmental disorders whose needs are not yet provided for by other services.

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Teaching and Training Importantly, significant teaching and training takes place at the service, including that of general adult psychiatry trainees as well as medical, nursing, psychology, and occupational health students. It is worth mentioning the general adult psychiatry training program of the Universidad Mayor medical school, which is unique in that it is being developed and embedded within the community mental health care model [18].


Some Evidence of the Effect of the Implemented Changes The structure described earlier has resulted in a reduction in the demand for emergency psychiatric care at the Barros Luco Hospital’s Accident and Emergency department [19, 20]. Just over 70 percent of patients requiring emergency psychiatric care at the Accident and Emergency department come from the hospital’s catchment area, but the rest of the patients come from adjacent areas that have less developed mental health community services. The proportion of emergency psychiatry patients consulting at the Barros Luco’s Accident and Emergency department coming from its allocated catchment area compared to emergency psychiatry patients coming from the adjacent catchment area has consistently dropped over the last 5 years (down from 4.27 to 3.02 during the period). We interpret this fall in the ratio as suggesting a preliminary positive impact of the implementation of the community mental health care model with the associated close work between the service (i.e., the secondary care level) and the primary care level of this catchment area. Although these figures may in part be accounted for by deficiencies in data collection, it is our view that they support the above point, that is, the effectiveness of the community mental health care model to at least reduce unmet needs and therefore reduce unplanned emergency psychiatric consultations. Similarly, some evidence seems to suggest that implementing the model has also been associated with a reduction in the number of acutely unwell patients attending the day hospital [21]. Specifically, the day hospital sees fewer acutely unwell schizophrenic or bipolar patients and has been able to provide support to patients with severe depressive episodes, personality disorder patients in acute crisis, and patients with comorbid disorders (i.e., dual diagnosis). At any rate, there are a considerable number of patients with highly complex unmet psychosocial needs who remain a significant challenge [22] and who until recently probably had no access to services at all. In particular, we have faced an increasing number of patients with comorbid psychoses and substance misuse, comorbid significant learning disabilities and substance misuse, and patients with organic brain damage and severe behavioral disturbances. Many of these patients did not come to the attention of services because their families and/or government agencies had given up on them; they suffer a high degree of social exclusion and are highly vulnerable, and some of them pose a high risk to others. Our approach to these patients has included elements of promoting engagement with services,



building continuity in their care, providing psychoeducation to their relatives and caregivers, and incorporating them into rehabilitation. Some preliminary evidence appears to indicate that these efforts may be improving their outcomes [23]. Over the last 2 years, the service has started to gather evidence regarding the impact of the community mental health care model. In order to do that, a multidisciplinary research unit has been created with input from a psychiatrist, public health specialist, psychologist, occupational therapist, and epidemiologist. It is expected that this unit will be able to provide evidence regarding the cost-effectiveness of the service’s work. Its main aims are to gather data to quantify the changes in terms of readmission rates and emergency consultations, and to develop instruments to map how the model is being introduced in the different areas of the service’s catchment area. Challenges Ahead We envisage three challenges that will need to be addressed in the near future. First, the service, as any complex organization, has at times been torn between the need, on the one hand, to develop different departments and expertise and, on the other hand, the need to ensure the continuity of care, an essential part of the community mental heath care model. This is a creative tension that we hope will provide energy to the growth of the different teams. Second, we need to continue transferring skills and responsibilities from the secondary level unit (the service) to the district-based community mental heath teams while at the same time the service develops its skills and expertise to allow it to care for more complex patients. These two related processes will necessitate changes in the way the local primary care level and the community at large deal with an increasing number of patients who will require more long-term and specific care and support. Third, we need to be able to gather reliable data at the different levels of the model to demonstrate cost-effectiveness; this is a crucial issue if we are going to persuade authorities and skeptics that beyond the values that underpin the community care approach to mental health it also offers value for money. Finally, we hope that by addressing the above challenges the service will become a center of training and innovation that makes it possible for the model to be adopted in other regions of our country. Conclusion Regardless of whether the Barros Luco General Hospital has promoted the development of the community mental health care model or it has been gradually “colonized” by the ideas and practices of that model, our service aspires to be part of a mental health care network that goes beyond what is strictly considered health care and, in collaboration with the wider community, promotes recovery from and fights the stigma associated with mental illness. We are aware that our service faces significant challenges ahead and that further growth and development are required not the least in terms of human resources and quality of the care delivered. Simi-

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larly, we realize that further local progress will depend on clear leadership from the central government, in particular providing evidence-based and patient-centered policies and also making sure that such policies are consistently implemented across the country. Finally, we believe that a mental health law that regulates the practice of clinical psychiatry at all levels will be crucial if the quality of care is going to improve, dignity and rights of patients are going to be protected and promoted, and the stigma associated with mental illness is going to be defeated.


References 1. Ministerio de Salud de Chile. (2008) Informe final estudio de carga de enfermedad y carga atribuible, Chile 2007 [Final study of the disease burden and attributable burden, Chile 2007]. Santiago. Available at http://epi.minsal.cl/epi/html/invest/cargaenf2008/Informe%20final%20carga_Enf_2007.pdf, accessed April 2, 2012. 2. Chan, M. (2010) Closing the mental health gap: Address at the Mental Health Gap Action Programme Forum. Geneva: World Health Organization. Available at www.who .int/dg/speeches/2010/mhGap_forum_20101007/en/index.html, accessed April 2, 2012. 3. Rodríguez, J. (2009) Salud mental en la comunidad [Community mental health]. Washington, DC: Organización Panamericana de la Salud, serie PALTEX. 4. World Health Organization. (2001) The world health report 2001. Mental health: New understanding, new hope. Available at www.who.int/entity/whr/2001/en/whr01_ en.pdf, accessed April 3, 2012. 5. Becerril-Monteiko, V.; Reyes, J.; & Annick, M. (2011) Sistema de salud de Chile [Chile’s health system]. Salud Pública de México, 53(2), 132–143. Available at http://bvs .insp.mx/rsp/articulos/articulo.php?id=002617, accessed April, 4, 2012. 6. Medina, E.; Riquelme, R.; & Figueras, T. (1990) Informe sobre recursos de salud mental y psiquiatría del sistema nacional de servicios de salud [Report on mental health resources and psychiatry of the national health service]. Revista de Psiquiatría Clinica, 7, 595–638. 7. Pemjean A. (1996) El proceso de reestructuración de la atención en salud mental y psiquiatría en Chile (1990–1996) [The restructuring process of mental health care and psychiatry in Chile (1990–1996)]. Cuadernos Médico Sociales, 37(2), 5–17. 8. Ministerio de Salud de Chile. (2001) Plan nacional de salud mental y psiquiatría, 2000 [National mental health plan and psychiatry, 2000]. Santiago: Unidad de Salud Mental, Ministerio de Salud. 9. Minoletti, A., and Zaccaria, A. (2005) Plan nacional de salud mental en Chile: 10 años de experiencia [National mental health plan in Chile: 10 years of experience]. Rev. Panam. Salud Publica/Pan American Journal of Public Health 18(4/5): 346–358. Available at www.scielosp.org/pdf/rpsp/v18n4-5/28097.pdf, accessed April 3, 2012. 10. Minoletti, A.; Narváez, P.; Sepúlveda, R.; & Caprile, A. (2009) Chile: Lecciones aprendidas en la implementación de un modelo comunitario de atención en salud mental [Chile: Lessons learned from the implementation of a community model of mental health care]. In J. Rodríguez (Ed.), Salud mental en la comunidad [Community mental health] (pp. 339–348). Washington, DC: Organización Panamericana de la Salud, serie PALTEX. 11. Mendive, S. (2004) Entrevista al Dr. Juan Marconi, creador de la psiquiatría intracomunitaria: Reflexiones acerca de su legado para la psicología comunitaria Chilena [Interview with Dr. Juan Marconi, intracommunity psychiatry program creator: Reflections about his legacy for the Chilean psychology community]. PSYKHE, 13(2), 187–199. Available at www.scielo.cl/scielo.php?pid=s0718-22282004000200014&script=sci_arttext, accessed April 3, 2012.



12. Marconi, J. (1971) Asistencia psiquiátrica intracomunitaria en el área sur de Santiago: Bases teóricas y operativas para su implementación (1968–1970) [Intracommunity psychiatric care in the area south of Santiago: Theoretical and operational basis for implementation (1968–1970)]. Acta Psiquiátrica y Psicológica de América Latina, 17(4), 255–264. Available at https://sites.google.com/site/saludmentalumayor/bibliotecajuan-marconi/MARCONI-1972-ASISTENCIA.pdf?attredirects=0&d=1, accessed April 3, 2012. 13. Servicio de Psiquiatría Hospital Barros Luco. (2011) Nuestra historia breve [Our brief history]. Psiquiatría Barros Luco, descripción e historia breve [Psychiatry Barros Luco, brief description and history]. Available at http://psiquiatriabarrosluco.blogspot .com/2006/07/nuestra-biografia-breve.html, accessed April 3, 2012. 14. Servicio de Psiquiatría Hospital Barros Luco, Unidad de Apoyo a la Gestión. (2010) Informe de actividad del servicio de psiquiatría del complejo asistencial Barros Luco, 2009 [Activity report of the psychiatry service, Barros Luco Hospital, 2009]. Santiago: Servicio de Psiquiatría, Complejo Asistencial Barros Luco. 15. Vera, C. (2009) Manual de trabajo para equipos de psiquiatría ambulatoria en el modelo comunitario de salud mental [Workbook for outpatient psychiatric teams in the community mental health model]. Available at http://sites.google.com/site/drrafaelsepulveda/Manualltimaversin.doc?attredirects=0, accessed March 31, 2012. 16. Gask, L.; Sibbald, B.; & Cree, F. (1997) Evaluating models of working at the interface between mental health services and primary care. British Journal of Psychiatry, 170(January), 6–11. 17. Mitchell, A.R.K. (1985) Psychiatrists in primary health care settings. British Journal of Psychiatry, 147, 371–379. 18. Universidad Mayor. (n.d.) Programa de formación de médicos especialistas en psiquiatría adultos [Specialist training program in adult psychiatry]. Santiago: Universidad Mayor, Facultad de Medicina, Dirección de Postgrado. Available at http://psiquiatriauniversidadmayor.blogspot.com/, accessed March 30, 2012. 19. Ramírez, J.; Sepúlveda, R.; Zitko, P.; & Ortiz, A.M. (2010) Consulta de urgencia psiquiátrica y modelo comunitario de atención en salud mental [Emergency psychiatric consultation and community model of mental health care]. Revista Chilena de Salud Pública, 14(1), 18–25. Available at www.revistas.uchile.cl/index.php/RCSP/article/viewFile/8364/8157, accessed April 2, 2012. 20. Ortiz, A.M.; Ramírez, J.; Sepúlveda, R.; & Zitko, P. (2011) Cuatro años de urgencia psiquiátrica: Hacia una evaluación del modelo comunitario de salud mental [Four years of psychiatric emergency: Towards an evaluation of community mental health model]. Revista Chilena de Salud Pública, 14(2–3), 519–520. 21. Servicio de Psiquiatría, Complejo Asistencial Barros Luco. (2011) Presentación del equipo de hospital de día en la reunión de evaluación 2010 y proyección 2011 [Presentation of the day hospital team in evaluation meeting 2010 and projected 2011]. Santiago, Chile. 22. Sepúlveda, R.; Zitko, P.; Ramírez, J.; Ortiz, A.M.; & Norambuena, P. (2012) Seis años de evolución de la demanda de urgencia psiquiátrica como impacto del modelo comunitario de atención en salud mental. [Six years of evolution of psychiatric emergency demand and impact of community care model in mental health]. Article under review. Santiago: Servicio de Psiquiatría, Complejo Asistencial Barros Luco. 23. Servicio de Psiquiatría, Complejo Asistencial Barros Luco, Unidad de Apoyo a la Gestión. (2011) Informe de actividad del servicio de psiquiatría del complejo asistencial Barros Luco, 2010 [Activity report of the psychiatry service, Barros Luco Hospital, 2010]. Santiago, Chile.