Addressing Severe Mental Illness Rehabilitation in Colombia, Costa Rica, and Peru
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SPECIAL ARTICLE
Addressing Severe Mental Illness Rehabilitation
in Colombia, Costa Rica, and Peru
Leonardo Cubillos, M.D., M.P.H., Juliana Muñoz, B.A., M.A., July Caballero, M.D., M.H.C.D.S., María Mendoza, R.N.,
Adriana Pulido, M.D., M.P.H., Karen Carpio, M.A., Anirudh K. Udutha, B.S., Catalina Botero, B.A.,
Elizabeth Borrero, M.D., M.A., Diana Rodríguez, M.A., Yuri Cutipe, M.D., Rebecca Emeny, Ph.D., M.P.H.,
Karen Schifferdecker, Ph.D., M.P.H., William C. Torrey, M.D.
Many Latin American countries face the challenge of subsidies that create conflicting incentives, lack of dein-
caring for a growing number of people with severe men- stitutionalized models, and lack of reimbursement for
tal illnesses while promoting deinstitutionalization and evidence-based psychiatric rehabilitation interventions.
community-based care. This article presents an overview Policy reforms in these countries have promoted the use
of current policies that aim to reform the mental health of medical interventions to treat people with severe
care system and advance the employment of people with mental illnesses but not the use of evidence-based re-
disabilities in Colombia, Costa Rica, and Peru. The authors habilitation programs to facilitate community integration
conducted a thematic analysis by using public records and and functional recovery. Because these countries have
semistructured interviews with stakeholders. The authors other supported employment programs for people with
found evidence of supported employment programs for nonpsychiatric disabilities, they are well positioned to pilot
vulnerable populations, including people with disabilities, individual placement and support to accelerate full com-
but found that the programs did not include people with munity integration among individuals with severe mental
severe mental illnesses. Five relevant themes were found illnesses.
to hamper progress in psychiatric vocational rehabilitation
services: rigid labor markets, insufficient advocacy, public Psychiatric Services 2020; 71:378–384; doi: 10.1176/appi.ps.201900306
Over the past 4 decades, many Latin American countries have association between poverty and poor mental health is
experienced political and social transformations that have led substantial (5). In Latin America, 82% of people with a dis-
to efforts to minimize fragmentation of health care services, ability live in poverty, and about 90% are unemployed or
end differential care to citizens on the basis of socioeconomic outside of the workforce (6). The Caracas Declaration (7)
status, and realize the rights of vulnerable populations (1). As a
result, many Latin American countries have increased public
investments in the health and social protection of their
communities. Increased use of general government revenue HIGHLIGHTS
instead of payroll taxation and out-of-pocket spending has
• Individual placement and support (IPS), an evidence-
increased equity in financing, decreased impoverishment due based intervention that aids the employment aspirations
to out-of-pocket health care spending (1), and supported new of people with severe psychiatric illnesses, helps service
health policies that now cover millions of additional individ- providers focus on supporting patients’ strengths, func-
uals (2). Subsidized universal coverage for vulnerable groups tional capacities, and community integration.
has improved access to diagnoses and pharmacotherapy for • Colombia, Costa Rica, and Peru have implemented
people with severe mental illnesses. supported employment programs for some populations
with disabilities but not for people with psychiatric
Although Latin American countries have improved health disabilities.
care access, the disability-adjusted life years related to
• Current system capacity allows for pilot testing of IPS
mental illness have increased by more than 10% over the past through the community-based mental health system in
25 years. Between 1990 and 2017, mental illnesses moved Peru and as an extension of existing supported employ-
from the 10th to the sixth leading cause of disability-adjusted ment services for individuals with disabilities in Colombia
life years (3). Rising rates of mental disorders have also had and Costa Rica.
a significant impact on the economy (4). Additionally, the
378 ps.psychiatryonline.org Psychiatric Services 71:4, April 2020CUBILLOS ET AL.
and the Brasilia Consensus (8) represent nonbinding in- medication management and emergency services in the
ternational commitments under which Latin American na- community (21). Table 1 summarizes the regulatory frame-
tions express the intent to pursue a person-centered, work and the programs described in this section.
community-based approach to mental health care with an Colombia has a regulatory framework that advances a
emphasis on primary care and psychosocial rehabilitation (9). deinstitutionalized approach to mental health care and
stipulates the need for community-based care and evidence-
based interventions, such as assertive community treatment
EVIDENCE FOR INDIVIDUAL PLACEMENT AND
(ACT) teams and IPS supported employment (22, 23).
SUPPORT IN THE REHABILITATION OF PATIENTS
Nevertheless, implementation is far from reaching the
WITH SERIOUS MENTAL ILLNESS
standards set by these regulations with regard to meeting the
Individual placement and support (IPS) is a psychosocial population’s needs. A recent national mental health policy
intervention with a considerable body of evidence demon- focused on coordinating networks of existing health care
strating improvements in health, employment, and income providers and promoting community-based recovery-
among people with severe psychiatric disorders (10). IPS oriented interventions (24).
increases employment, income earned in competitive jobs, In Costa Rica, mental health policy establishes standards
self-esteem, and community integration among people with for deinstitutionalization, community-based care, and the
even the most severe mental disorders. It also decreases development of recovery-oriented programs (25). In prin-
hospitalizations, dependence on public systems of care, and ciple, implementation efforts center on embedding mental
stigma in the community (11, 12). Most people with psychi- health units in general hospitals and integrating behavioral
atric illnesses want competitive employment, and IPS sup- health into primary care. However, progress has been slow
ports their aspirations to pursue this aspect of a full life. IPS because of insufficient funding, poor stakeholder co-
also transforms the attitudes, goals, and roles of clinical ordination, resistance to change, and workforce shortages.
teams. The intervention’s focus on successful outcomes and In Peru, a new mental health policy that stipulates funds
patient’s preferences shifts the role of clinicians from care- earmarked by Congress, explicitly prioritizes community
takers to professional consultants and partners and keeps over institutional care and provides instructions for a
service providers focused on the strengths, rather than the recovery-oriented community-based model of care (26–29).
deficits, of the people they are serving. IPS has been proven As a result, Peru had developed 100 community mental
cost effective and has saved on costs of care in cases in six health centers, 10 sheltered homes, and 20 short-stay in-
European countries (13) and the United States (14). The in- patient units in general hospitals as of December 31, 2018,
tervention has been widely adopted in more than a dozen and the utilization of community mental health services had
high-income countries to support, successfully, the recovery increased. Some of these centers offer additional evidence-
of individuals with severe mental illnesses. More recently, based interventions, such as ACT teams, intensive case
IPS has been researched for treatment in other populations, management, and acute crisis management.
such as those with posttraumatic stress disorder (15), In summary, these three mental health care systems are
chronic pain (16, 17), and spinal cord injury (18). moving, to varying degrees, toward deinstitutionalizing pa-
This study aims to present and discuss the progress and tients and adopting variations of community-based care.
challenges of implementing supported employment programs However, they continue to invest heavily in non-recovery-
for individuals with severe mental illnesses in Colombia, oriented models of care for patients with severe mental ill-
Costa Rica, and Peru as one of the steps necessary for the nesses, such as office-based management of psychiatric
rehabilitation of patients with severe mental illnesses. We medication and inpatient care in psychiatric hospitals (30).
conducted semistructured interviews with 12 key stake-
holders in each country (N=36), including patients, family
SUPPORTED EMPLOYMENT AND
members, health system academics, human rights advocates,
VOCATIONAL REHABILITATION
and policy makers. Additionally, we conducted a desk review
of the regulatory framework of the health systems, extracted Mental illness can undermine household finances as well
from pertinent laws, health policies, ministerial technical as personal dignity. Supported employment programs
documents, gray literature, peer-reviewed articles, and pub- are central to transforming hospital-based systems into
lications from multilateral organizations. We also specifically community-based, recovery-oriented systems (31).
searched for supported employment experiences that did not In recent years, each country in this study has developed
target individuals with serious mental illness (19, 20). supported employment programs for individuals with a
disability. Although these programs represent a significant
step toward recovery-oriented interventions for people with
MENTAL HEALTH CARE SYSTEMS IN COLOMBIA,
disabilities, our findings suggest they have not reached indi-
COSTA RICA, AND PERU
viduals with severe mental illnesses. Below, we provide a brief
Mental health care in Colombia, Costa Rica, and Peru is review of the current employment services and vocational
predominantly hospital based with only discrete episodes of rehabilitation programs offered in these three countries.
Psychiatric Services 71:4, April 2020 ps.psychiatryonline.org 379ADDRESSING SEVERE MENTAL ILLNESS REHABILITATION IN COLOMBIA, COSTA RICA, AND PERU
TABLE 1. Laws for mental health and supported employment in Colombia, Costa Rica, and Peru
Mental health regulatory framework Supported employment regulation/program
Colombia
Mental Health Law (Law 1616 of 2013) General Disability Rights Statutory Law (Law 1618 of 2013)
National Mental Health Plan 2014–2021 Incentives for hiring people with disabilities (Decree 392 of
2018)
National Mental Health Policy (Ministerial Resolution National Employment Service (Law 1636 of 2013; protection
4886 of 2018) mechanism for unemployed citizens)
Schizophrenia Clinical Guideline (Ministerial Technical Productivity Alliance (Pacto de la Productividad; public-
Document, 2014) private partnership)
Costa Rica
National Mental Health Policy 2012–2021 (Ministerial General Disability Law and Equality of Opportunity Law
Technical Document, 2012) (Law 9379 of 2016 and Law 7600 of 1996)
Technical Secretariat of Mental Health (Law 9213 of 2014) Tax incentives for hiring people with disabilities (Law 7092
of 1998)
Get-Employed and Inclusive Get-Employed Programs
(Empleate and Empleate Inclusivo)
Peru
Mental Health Law (Law 29889 of 2012) General Disability Law and Operation Standards
(Law 29973 of 2012 and Decree 002–2014)
Operation of the community mental health system (Presidential Young and middle-aged adult employment programs
Decree 033–2015-SA) (Programa Nacional de Empleo Juvenil and Programa
Impulsa Peru)
Community Mental Health Centers standards (Resolution
574–2017)
Colombia interact with employment agencies, coaching during the se-
In 2013, Colombia launched the National Employment Ser- lection process, and assistance during the first 6 months after
vice, an agency that aims to both increase job opportunities starting a job. Most beneficiaries are individuals with physical,
for the general citizenry and provide temporary financial hearing, and vision disabilities, followed by individuals with
protection during periods of unemployment. Spearheaded intellectual and developmental disabilities; those with severe
by the Ministry of Labor, this agency seeks to systemati- mental illnesses are rare. Furthermore, we found no evidence
cally connect all public and private sector job opportuni- of collaboration between these programs and the mental
ties with applicants throughout the country by using a health care system for people with severe mental illnesses.
combination of a national employment database, voca- Vocational rehabilitation and supported employment
tional rehabilitation, and local employment agencies (https:// programs targeting individuals with severe mental illnesses
unidad.serviciodeempleo.gov.co/en). Also, the Colombian Na- are scarce. A decade ago, a few mental health clinics part-
tional Learning Services (SENA) offers a wide array of free nered with the Ministry of Labor and SENA to offer voca-
and low-cost vocational and technical trainings (32). Gov- tional rehabilitation services to individuals with psychiatric
ernment data indicate that between 2016 and 2018, nearly disabilities who attended day hospital programs, but the plan
five million Colombians created profiles in the employment was short lived. More recently, a small number of mental
database, including approximately 17,000 individuals with health care providers have offered isolated programs, in-
disabilities. Over this period, although 1.5 million Colom- cluding a vocational rehabilitation program developed by a
bians found employment, only 1,114 individuals with a dis- methadone clinic in a semirural town where patients re-
ability of any kind, and only 30 individuals with a mental ceived training to work construction jobs. To date, no public
health disability, secured a job (33). reimbursement has been disbursed for these efforts.
To support the work of individuals with any disability, a
partnership between nongovernmental organizations, the na- Costa Rica
tional government, the private sector, and the Inter-American The Ministry of Labor and Social Security launched the
Development Bank launched the Productivity Alliance (34, 35). Get-Employed program (https://www.facebook.com/
This alliance uses the infrastructure of the National Em- EmpleateCR) to advance the employment of vulnerable
ployment Service and leverages existing financial and tax young adults (36). Using a conditional cash-transfer model
incentives for companies hiring people with disabilities. It (37), this program offers supported employment services to
deploys a multistep supported employment model that in- the job candidate as well as to the hiring organization. It also
cludes basic academic training, vocational rehabilitation, provides financial assistance to fund a set of finite living ex-
support to navigate the national employment database and penses and vocational training for a technical degree. To
380 ps.psychiatryonline.org Psychiatric Services 71:4, April 2020CUBILLOS ET AL.
promote the employment of people with disabilities, Costa create access barriers. The experiences and outcomes of
Rica has enacted several laws, including the mandate for these interventions are poorly documented.
companies to employ a minimum number of individuals with
disabilities (5% of their workforce), a mandate for equal pay
FACTORS AFFECTING PSYCHIATRIC
(38), and financial incentives for the employer.
REHABILITATION
Building on the structure and workflow of the Get-
Employed program, in order to support the employment of None of the three countries considered in this study deliver
individuals with any disability, the government launched supported employment services at scale for individuals with
the Inclusive Get-Employed program (39), an alliance with severe mental illnesses. Using the qualitative interviews and
partner technical institutions that offers vocational re- the desk review, we identified five societal and health care
habilitation followed by assistance in finding, selecting, and factors contributing to the absence of this critical psychiatric
applying to job openings. It also supports the employer as rehabilitation service.
well as the new employee during the contracting process and First, the labor markets in these countries are relatively
first months of employment. Over 30 companies are actively rigid and have an oversupply of unskilled labor. For years,
hiring people with disabilities. Although the program has these middle-income countries have grappled with high levels
had eight clients with severe mental illnesses, they were of unemployment and underemployment (e.g., a higher-
unable to join the workforce because of clinical instability. qualified individual employed at a low-paying job) in the in-
The Ministry of Education supports over 30 vocational formal economy. Given this situation, programs such as Get-
rehabilitation centers called Centers for Comprehensive Employed in Costa Rica or the National Employment Service
Treatment of Adults with Disabilities (CAIPADs) across in Colombia are a priority on the domestic agendas. However,
Costa Rica (40). These CAIPADs offer interdisciplinary given the rigidity of these labor markets, employers bear a real
lectures and workshops aimed at increasing the capacity of cost of hiring that can be up to 70% higher than the salary the
individuals with disabilities to find employment, but most employee receives (41). Thus, employers are prone to be risk
beneficiaries of CAIPADs are individuals with physical dis- averse and less inclined to hire people with disabilities, par-
abilities. As in Colombia, Costa Rica’s health sector has ticularly those with severe mental illnesses. Regarding this
limited involvement in psychiatric rehabilitation. The Na- point, one health system academic from Costa Rica stated,
tional Psychiatric Hospital has offered informal and short-
It has been challenging to incorporate [the patients] into
lived sheltered workshops in its hospital day services. society. They have this community organization, but they
aren’t paid enough money. When you ask me about dignity, I
Peru would say we are halfway there because they get a salary that
In Peru, the Ministry of Labor launched two nationwide is lower than the minimum wage just because they have a
supported employment programs to support teenagers and mental illness, but it is an intermediary effort because they
young adults (http://www.jovenesproductivos.gob.pe) as well haven’t been able to incorporate them into the labor market.
as middle-aged adults (http://www.impulsaperu.gob.pe). These Second, advocacy for individuals with severe mental ill-
programs offer vocational rehabilitation, grant a technical nesses is less visible than for individuals with other dis-
degree, and provide employment services. Both programs abilities and has not been as successful in combating stigma.
are open to individuals with any disability. However, individuals People with severe mental illnesses are perceived as lacking
with disabilities—particularly those with intellectual, de- the necessary competence to perform a typically paying job.
velopmental, or mental health disabilities—do not often register. We could not identify any advocacy groups representing
Two small-scale models have assisted individuals with persons with severe mental illnesses who were interested in
severe mental illnesses in joining the workforce: patients’ work that had successfully drawn focus to this issue on the
clubs and vocational rehabilitation programs. Patients’ clubs public agenda. This lack of advocacy likely reflects the
are local rural networks of patients and families working unique and persistent stigma associated with mental and
with a mental health care professional or a community behavioral disability. A government official from Peru, dis-
member to create regular structured daytime activities. A cussing the challenges of supported employment programs
typical day includes education on self-care and house- that may lead to increased stigma, said,
cleaning, followed by vocational training and recreational
activities. These clubs are decreasing in number because of There was a case where a young man assaulted his cowork-
ers. We later found out that he had stopped his medication.
insufficient funding and loose coordination with the mental
Due to this, they had to let him go, and this hinders the
health system. Publicly funded rehabilitation centers offer project quite a bit; the employer feels, perhaps, fear or re-
more-formalized vocational training, such as in essential jection against the person.
computer management, tailoring, and cooking. However,
these programs do not provide a degree or employment A government official in Colombia added,
specialists to connect patients to potential employers. We continue to stigmatize mental health patients, [and em-
Moreover, the limited capacity of these centers and the need ployers might think], How am I going to keep [him or her]
to demonstrate at least 6 months of mental health stability inside a company?
Psychiatric Services 71:4, April 2020 ps.psychiatryonline.org 381ADDRESSING SEVERE MENTAL ILLNESS REHABILITATION IN COLOMBIA, COSTA RICA, AND PERU
Third, these three countries use public subsidies to sup- Over the last three years, regarding labor inclusion, we have
port the livelihood of individuals with low income and an not been able to develop a systemic response to labor op-
inability to work because of a general or mental health dis- portunities and employment search. This is the case for our
most advanced medical services for mental illnesses located
ability. Patients and families fear that employment-seeking
at the community centers.
efforts can result in losing these subsidies. A medical pro-
vider in Peru stated, Fifth, evidence-based interventions providing social and
clinical supports (e.g., case manager) are generally not re-
Family views [the patients] as a source of income, even
imbursed by the health care system. Except in Peru, which
though it is very little money. . . .This is where we find the
family and economic problem. [Family members] say, currently offers community-based clinical and some social
“Doctor, don’t take away his/her disability status, he/she is support services, these services are usually not available.
doing better, but we need that income.” Employment agencies and employers in the private sector
who are willing to hire people with severe mental illnesses
A government official in Colombia shared,
expressed concerns about the lack of clinical stability and
Programs tend to be highly based on assistance models, so lack of additional support for this population. Existing pro-
when you reach the community, people are always thinking, grams do not have the resources to follow up with patients
Well, what are we getting in exchange for our participation? in rehabilitation programs, and their tasks are limited to
However, this situation is not true for all patients or helping patients find jobs. A government official in Costa
families. Many patients with severe mental illnesses per- Rica shared,
ceive work as a source of financial stability as well as a Well, our capacity only focuses on helping people with dis-
source of dignity. They not only expect access to high- abilities find jobs. We do not have enough people working
quality health care services but also aspire to attain stable here to do more than that.
employment and to improve their income, no different
A health provider in Colombia said,
from expectations observed in patients with other chronic
conditions. A medical provider in Costa Rica struggled We know about the importance of helping patients re-
with not being able to connect patients to employment habilitate, but these services are not reimbursed by the
opportunities: health system.
A patient was telling me, “I have three children, and I am In summary, supported employment programs for indi-
depressed because I don’t have a job. I come here, and I get viduals with disabilities exist in these three Latin American
pills, but why would I want pills if what I really need is countries, but they do not reach persons with severe mental
money to buy food for my children and me?” illnesses. These employment programs operate in labor mar-
kets with an abundance of job seekers and with rigid hiring
Likewise, a patient in Costa Rica shared,
structures that may affect willingness to employ people with
After discharge, all I wanted was to find employment. I severe mental illnesses. The low level of intersectoral collab-
wanted to feel motivated, I wanted to work. oration inhibits mental health providers from supporting the
Fourth, the health systems are still grappling with de- job-seeking efforts of their patients. Vocational rehabilitation
signing and implementing a reasonable model to de- for individuals with severe mental illnesses remains severely
institutionalize and provide long-term clinical care for limited, existing only in same-day hospital programs, with little
patients with severe mental illnesses. The use of evidence- or no evidence of improved recovery, employment, or income.
based social supports (e.g., supported housing or employ-
ment) that are essential to improve patient outcomes is not DISCUSSION
mainstream in the health policy agendas of these three Investing in Recovery-Oriented Models
countries. As such, psychiatric rehabilitation is not a priority Although these three middle-income Latin American
for their health systems. Additionally, existing rehabilitation countries have demonstrated a commitment to advance
programs for patients with disabilities mostly focus on pa- policies targeting recovery of individuals with disabilities,
tients with physical disabilities and not on those with mental these efforts have not benefited individuals with severe
health disabilities. Discussing the rehabilitation model, a mental illnesses. Furthermore, the health care systems of
medical provider in Costa Rica said, Colombia, Costa Rica, and Peru continue to invest in out-
There is not an established network. All we do are informal dated vocational rehabilitation day programs that segregate
efforts where, for example, if I think a person could benefit people with severe mental illnesses despite well-established
from a particular program or education advantage that is evidence that these programs are inferior to the standard of
being offered by the education system, then I recommend the care, supported employment interventions (42).
patient to the program, but the institutions are not obliged to
Latin American countries could adopt current evidence-
accept my recommendation.
based practices by learning from the experiences of coun-
A government official from Peru commented, tries that started deinstitutionalization five decades earlier
382 ps.psychiatryonline.org Psychiatric Services 71:4, April 2020CUBILLOS ET AL.
(43, 44). Interventions such as day treatment programs, AUTHOR AND ARTICLE INFORMATION
sheltered workshops, and incarceration of people with Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Leb-
mental disorders have proved harmful in many high-income anon, New Hampshire (Cubillos); Department of Behavioral and Com-
countries, whereas evidence-based interventions, including munity Health, University of Maryland School of Public Health, College
Park (Muñoz); Ministry of Health (Caballero, Mendoza, Cutipe) and Na-
supported housing, ACT, and IPS supported employment, tional Institute of Mental Health (Caballero), Lima, Peru; Department of
have provided clear benefits (45, 46). Public Health, Fundación Santa Fe de Bogotá, Bogotá, Colombia (Pulido,
Despite some barriers, Latin American countries have the Botero, Borrero); Regional Office for Central and North America and the
financial resources, organizational capacity, and professional Caribbean, International Organization for Migration, San José, Costa
expertise to pursue innovative health solutions for people Rica (Carpio); Department of Psychiatry (Udutha, Torrey) and the Dart-
mouth Institute for Health Policy and Clinical Practice (Emeny, Schif-
with severe mental illnesses. A model built around the de- ferdecker, Torrey), Geisel School of Medicine at Dartmouth, Hanover,
livery of evidence-based interventions can streamline the New Hampshire; Ministry of Health and Social Protection, Bogotá,
organization of services, with potential positive externalities Colombia (Rodríguez). Send correspondence to Dr. Cubillos
on capacity building, staffing, and payment mechanisms. (leocubillos@post.harvard.edu).
The authors would like to thank Robert E. Drake, M.D., Ph.D., and Matthew
Friedman, M.D., Ph.D., for their guidance during the research and the
Piloting IPS preparation of this article. This article is the result of a collaborative re-
Peru seems ripe to implement and study IPS in a community search project between the following institutions: Dartmouth–Hitchcock
clinic because it has already made significant reforms to its Medical Center; the Ministry of Health and Social Protection of Colombia;
mental health system and the community mental health the Ministry of Health of Peru; the International Organization for
Migration—Regional Office for Central America, North America and the
care system is already adopting evidence-based recovery-
Caribbean; the National Institute of Mental Health of Peru; and the Fun-
oriented interventions for individuals with severe mental dación Santa Fe de Bogotá of Colombia. These views represent the
illnesses. In Costa Rica and Colombia, active community opinions of the authors and not necessarily those of their affiliated
mental health services may take more time to develop. institutions.
Nevertheless, these two countries have accrued experience The authors report no financial relationships with commercial interests.
using public-private partnerships to deliver supported Received June 17, 2019; revision received October 6, 2019; accepted
employment services to people with physical and sensory November 1, 2019; published online January 3, 2020.
disabilities. A collaboration with mental health care organi-
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