Regulation and finance

Seeking to meet the health needs described above, Guatemala has a stand-alone national mental health plan which partially meets human rights standards.⁶ Although under discussion, at the time of writing, there is no dedicated mental health legislation; the care and protection of persons with mental disorders falls within generic health and disability legislation. The overall healthcare budget, which is 2.3% of the gross domestic product (GDP),² leaves only a small allocation for mental health services.¹

Provision

In-patient mental healthcare is provided through one mental health hospital, a psychiatric unit within a general hospital and one forensic psychiatry unit. No formal arrangements currently exist for the provision of mental healthcare in prisons, although the proposed mental health legislation calls for reforms to create dedicated mental health centres inside prisons. There is a disproportionately high number of out-patient facilities in Guatemala City, with relatively few in rural areas and regions with high indigenous populations.^{Reference Rodriguez, Barrett, Narvaez, Caldas, Levav and Saxena7}

Services are delivered mainly by psychologists (46.15 per 100 000 population).⁶ In comparison, the number of psychiatrists and mental health nurses is extremely low (0.49 and 1.07 per 100 000 population, respectively).⁶ The number of psychiatrists working specifically with children and adolescents is even lower (0.04 per 100 000 population).⁶

Social factors

Non-Spanish monolingualism among some indigenous groups presents a challenge to accessing mental health services delivered by professionals who speak only Spanish.² Effective access to mental health services will be improved by working with indigenous communities to reorient the service delivery process and structure to the community; for example, ensuring healthcare professionals can adapt to and communicate in the patient’s language; including religious guides as supplementary mental healthcare providers; acknowledging different understandings of mental health; translating medicines information leaflets into all 25 languages; and providing opportunities for members of the indigenous community to train as psychiatrists and mental health nurses.^{Reference Healey, Stager, Woodmass, Dettlaff, Vergara and Janke8}

Among the most impoverished communities, digital exclusion remains a barrier to accessing online mental health information. However, where Wi-Fi is available to underserved communities, a social media-based health campaign has been used to disseminate cognitive–behavioural therapy (CBT)- and dialectical behaviour therapy (DBT)-based psychoeducation to almost 85 000 individuals.^{Reference Alonzo and Popescu9} Having demonstrated feasibility, research is now needed to test the effectiveness of this intervention.

Economic

Poverty is a key barrier to accessing mental services in Guatemala. Primary care staff managing common mental disorders among rural indigenous communities report a lack of local specialist mental health services and describe the logistical and financial challenges of low-income patients travelling long distances to receive care at the national psychiatric hospital.^{6,Reference Rodriguez, Barrett, Narvaez, Caldas, Levav and Saxena7,Reference Stryker, Kishton, Nichols, Hargraves, Goodnow and Doarn10} In a country where 29% of the daily minimum wage is required to purchase a daily dose of an antipsychotic and 17% is required for an antidepressant, the cost of psychotropic medication is another barrier to receiving mental health treatment.^{1,Reference Rodriguez, Barrett, Narvaez, Caldas, Levav and Saxena7}

According to a systematic review of poverty and mental health in low- and middle-income countries, food insecurity has a stronger association with mental health outcomes, compared to other poverty markers such as family income,^{Reference Lund, Breen, Flisher, Kakuma, Corrigall and Joska11} yet it is highly plausible that increased family income would improve mental healthcare access. The complex interplay of socioeconomic factors, the prevalence of mental health conditions and limited access to services points to policy-level solutions to address the wider determinants of mental health as well as the implementation of affordable universal mental health coverage as mentioned in the proposed mental health legislation.^{Reference Ciudadana12}

Workforce

A barrier to accessing mental healthcare is the lack of mental health nurses and psychiatrists, especially in rural communities. Globally, similar shortages have been addressed in higher- and lower-income countries through: (a) integrating mental healthcare in primary care systems, (b) task-shifting or sharing, such as redistributing mental health-related tasks to trained non-specialists, including lay people, (c) telepsychiatry and (d) implementing workforce retention strategies.^{Reference Jinah, Adnan, Bakit, Sharin and Lee13}

In Guatemala, a mental health curriculum developed to build capacity and improve access to mental healthcare in rural areas was used to train primary care physicians to offer brief alcohol interventions using motivational interviewing.^{Reference Rissman, Khan, Isaac, Paiz and DeGolia14} In response to the elevated suicide risk among young people,⁶ task-shifting schoolteachers in Guatemala have been trained to identify at-risk students, undertake assessments and provide community-level interventions.^{Reference Alonzo, Popescu and Zubaroglu-Ioannides15} Serving as a link between the lay community and mental health workers, these teachers also facilitate young people and their parents accessing specialist care.^{Reference Alonzo, Popescu and Zubaroglu-Ioannides15} Teachers who participated in the study found training acceptable and reported increased knowledge; however, a larger-scale, controlled evaluation is required to demonstrate overall effectiveness in increasing knowledge and achieving benefits for young people over time, before the intervention can be scaled up.

Effective strategies used to retain doctors in other countries could protect against shrinkage of the existing workforce. For example, providing educational opportunities to collaborate with academics alongside clinical work and awarding financial benefits for those who work in rural and other underserved areas.^{Reference Jinah, Adnan, Bakit, Sharin and Lee13}