Resumo O artigo analisa a rede de saúde mental do município do Rio de Janeiro, objetivando efetuar um balanço sobre a atual situação da implementação da Reforma Psiquiátrica e apontar avanços, limites e desafios. Foi realizada pesquisa documental através de documentos oficiais, portarias, bancos de dados do SUS e informações disponíveis na Superintendência de Saúde Mental do Município do Rio de Janeiro, e revisão de literatura especializada em artigos científicos nacionais e internacionais. Os resultados apontam para importantes avanços na desinstitucionalização da assistência, com substantiva redução de leitos psiquiátricos e aumento dos dispositivos comunitários. Entretanto, permanecem ainda como desafios importantes: o aumento de cobertura dos centros de atenção psicossocial, a implantação de leitos psiquiátricos em hospitais gerais, a integração da saúde mental com a atenção primária, a desinstitucionalização de pessoas em situação de longa permanência hospitalar, a ampliação do quantitativo de dispositivos residenciais e o aumento da provisão dos serviços específicos para pessoas em uso prejudicial de álcool e outras drogas.

Abstract This article analyzes the mental health network in the city of Rio de Janeiro. It provides a report on the current status of the implementation of psychiatric reform and identifies progress, limitations and challenges in this area. Documentary research was carried out by examining official documents, ordinances, SUS databases, information that was available at the Superintendency of Mental Health of the city of Rio de Janeiro, and a literature review of Brazilian and international scientific articles. The results point to important advances in the de-institutionalization of care, with a substantial reduction in the numbers of psychiatric beds, and increased community facilities. However, the following significant challenges remain: the need for increased coverage by psychosocial care centers; the implementation of psychiatric beds in general hospitals; the integration of mental health with primary health care; the de-institutionalization of people who remain in hospitals for long periods; the expansion of the number of residential facilities; and an increase in the provision of specific services for people using alcohol and other drugs.

Resumo O artigo analisa a rede de saúde mental do município do Rio de Janeiro, objetivando efetuar um balanço sobre a atual situação da implementação da Reforma Psiquiátrica e apontar avanços, limites e desafios. Foi realizada pesquisa documental através de documentos oficiais, portarias, bancos de dados do SUS e informações disponíveis na Superintendência de Saúde Mental do Município do Rio de Janeiro, e revisão de literatura especializada em artigos científicos nacionais e internacionais. Os resultados apontam para importantes avanços na desinstitucionalização da assistência, com substantiva redução de leitos psiquiátricos e aumento dos dispositivos comunitários. Entretanto, permanecem ainda como desafios importantes: o aumento de cobertura dos centros de atenção psicossocial, a implantação de leitos psiquiátricos em hospitais gerais, a integração da saúde mental com a atenção primária, a desinstitucionalização de pessoas em situação de longa permanência hospitalar, a ampliação do quantitativo de dispositivos residenciais e o aumento da provisão dos serviços específicos para pessoas em uso prejudicial de álcool e outras drogas.

Abstract This article analyzes the mental health network in the city of Rio de Janeiro. It provides a report on the current status of the implementation of psychiatric reform and identifies progress, limitations and challenges in this area. Documentary research was carried out by examining official documents, ordinances, SUS databases, information that was available at the Superintendency of Mental Health of the city of Rio de Janeiro, and a literature review of Brazilian and international scientific articles. The results point to important advances in the de-institutionalization of care, with a substantial reduction in the numbers of psychiatric beds, and increased community facilities. However, the following significant challenges remain: the need for increased coverage by psychosocial care centers; the implementation of psychiatric beds in general hospitals; the integration of mental health with primary health care; the de-institutionalization of people who remain in hospitals for long periods; the expansion of the number of residential facilities; and an increase in the provision of specific services for people using alcohol and other drugs.

The paper analyzes the situation of psychiatric reform after three decades of development in Spain. The achievements and failures are reviewed and the degree of implementation of the community model and public health, that originally inspired the process, is examinated. It tries to explain the reasons for care, policies and training deficiencies. The strengths are: the great development of alternative resources, and the loss of hegemony of the Psychiatric Hospital; and the threats: the changes in the management of the social and health services, the increasing privatization of services, the theoretical impoverishment and the changes in the demand of the population.

El artículo analiza la situación de la reforma psiquiátrica después de tres décadas de desarrollo en España. Se pregunta por los logros y fracasos; por el grado de implantación del modelo comunitario y de salud pública que inspiraron en su origen el proceso. Trata de explicar el por qué de las insuficiencias asistenciales, normativas y formativas. Las fortalezas, el gran desarrollo de recursos alternativos, y la pérdida de hegemonía del Hospital psiquiátrico; y las amenazas: los cambios producidos en la gestión de los servicios sociales y sanitarios, la creciente privatización de los servicios, la precarización teórica y los cambios en la demanda de la población.

There has been an increased incidence of mental health problems around the world while psychiatry is experiencing a crisis that concerns its own identity and the definition of the scope of its work. After more than half a century of deinstitutionalized community policies, neoliberal globalization is leading to changes that undermine public attention on mental health, particularly of the disorders that require greater social attention. There have been changes in the responsibility of the state and changes in the type of demand and in the way of understanding disease and its treatment. At the time, compared to the medicalization of society that mediates the expression of needs in health, user movements are beginning to emerge demanding autonomy, full citizenship, empowerment, recovery and advocacy.

Los problemas de salud mental aumentan su incidencia en todo el mundo mientras la psiquiatría atraviesa una crisis que afecta a su propia identidad y a la delimitación del objeto de su trabajo. Después de más de medio siglo de una política desinstitucionalizadora y comunitaria, la globalización neoliberal está llevando a cambios que socavan la atención pública en salud mental, en especial de los trastornos que demandan mayor atención social. Cambios en la responsabilidad del Estado y cambios en el tipo de demanda y en la forma de entender la enfermedad y su tratamiento. Al tiempo, frente a la medicalización de la sociedad que mediatiza la expresión de las necesidades en salud, empiezan a surgir movimientos de usuarios que reclaman autonomía, plena ciudadanía, empoderamiento, recuperación y "abogacía".

There has been an increased incidence of mental health problems around the world while psychiatry is experiencing a crisis that concerns its own identity and the definition of the scope of its work. After more than half a century of deinstitutionalized community policies, neoliberal globalization is leading to changes that undermine public attention on mental health, particularly of the disorders that require greater social attention. There have been changes in the responsibility of the state and changes in the type of demand and in the way of understanding disease and its treatment. At the time, compared to the medicalization of society that mediates the expression of needs in health, user movements are beginning to emerge demanding autonomy, full citizenship, empowerment, recovery and advocacy.

Los problemas de salud mental aumentan su incidencia en todo el mundo mientras la psiquiatría atraviesa una crisis que afecta a su propia identidad y a la delimitación del objeto de su trabajo. Después de más de medio siglo de una política desinstitucionalizadora y comunitaria, la globalización neoliberal está llevando a cambios que socavan la atención pública en salud mental, en especial de los trastornos que demandan mayor atención social. Cambios en la responsabilidad del Estado y cambios en el tipo de demanda y en la forma de entender la enfermedad y su tratamiento. Al tiempo, frente a la medicalización de la sociedad que mediatiza la expresión de las necesidades en salud, empiezan a surgir movimientos de usuarios que reclaman autonomía, plena ciudadanía, empoderamiento, recuperación y "abogacía".

The paper analyzes the situation of the psychiatric reform 25 years of the General Health Law. The author wonders what has been done and what has been left undone, on the degree of implementation of the Community model that adopts the law and its future sustainability. It highlights, among the strengths, the loss of hegemony of the psychiatric hospital and the great development of alternative resources, and seeks to explain the reason for the inadequacies of care, policy and training, as well as threats: the changes in the management of social and health services, increased privatization of services, the theoretical impoverishment and changing demands of the population.

El artículo analiza la situación de la reforma psiquiátrica a los 25 años de la Ley General de Sanidad. Se pregunta por lo que se ha hecho y lo que se ha dejado de hacer; por el grado de implantación del modelo comunitario que adopta la Ley y por su sostenibilidad futura. Entre las fortalezas se señalan la pérdida de hegemonía del hospital psiquiátrico y el gran desarrollo de recursos alternativos, y se trata de explicar el porqué de las insuficiencias asistenciales, normativas y formativas, así como de las amenazas: los cambios producidos en la gestión de los servicios sociales y sanitarios, la creciente privatización de los servicios, la precarización teórica y los cambios en la demanda de la población.

The paper analyzes the situation of the psychiatric reform 25 years of the General Health Law. The author wonders what has been done and what has been left undone, on the degree of implementation of the Community model that adopts the law and its future sustainability. It highlights, among the strengths, the loss of hegemony of the psychiatric hospital and the great development of alternative resources, and seeks to explain the reason for the inadequacies of care, policy and training, as well as threats: the changes in the management of social and health services, increased privatization of services, the theoretical impoverishment and changing demands of the population.

El artículo analiza la situación de la reforma psiquiátrica a los 25 años de la Ley General de Sanidad. Se pregunta por lo que se ha hecho y lo que se ha dejado de hacer; por el grado de implantación del modelo comunitario que adopta la Ley y por su sostenibilidad futura. Entre las fortalezas se señalan la pérdida de hegemonía del hospital psiquiátrico y el gran desarrollo de recursos alternativos, y se trata de explicar el porqué de las insuficiencias asistenciales, normativas y formativas, así como de las amenazas: los cambios producidos en la gestión de los servicios sociales y sanitarios, la creciente privatización de los servicios, la precarización teórica y los cambios en la demanda de la población.

The symptom acquires sense in the subject's biography, and it's made illness in the collective imaginary. From the symptoms that drew a clinical without anatomical representation, studying by Charcot in Salpêtrière, to fibromyalgia there is a long course of collective narratives. Each historical moment staged its representations, the mental illnesses, how to understand the family, the sexuality or the religious beliefs. Individuals tend to express discontent through meaningful ways to their own culture. There is no semiology of the mental illness building with non-behavioural signs, meaningless. We must escape from the trap of the DSM to work towards achieving a psychopathology to understand mental illness, allowing a clinical of subject in its diversity.

El síntoma cobra sentido en la biografía del sujeto, y se hace enfermedad según el imaginario colectivo. De los síntomas que dibujaban una clínica sin representación anatómica posible, que estudiara Charcot en la Salpêtrière, a la fibromialgia hay un largo discurrir de las narrativas colectivas. Cada momento histórico escenifica sus representaciones, sean las enfermedades mentales, la manera de entender la familia, la sexualidad o los credos religiosos. Los individuos tienden a expresar situaciones de malestar por medio de formas significativas para su propia cultura. No hay una semiología de la enfermedad psíquica construida con signos aconductuales, sin sentido. Hay que salir de la trampa del DSM para trabajar en la consecución de una psicopatología que permita comprender la enfermedad mental, que permita una clínica del sujeto en su diversidad.