Back in the 1930s, a Costa Rican named Nazario Chinchilla decided to
undertake a daring venture. Although he had only three years of education and
could not speak English, he traveled to the United States, bought vehicle
chassis, brought them back to Costa Rica, then used them to build the first
intercity buses in his country. Chinchilla became wealthy from this
enterprise. What's more, he raised 10 children and lived to be 101.
It is Chinchilla and numerous other Costa Ricans with a positive, can-do
attitude who have alchemized their little country, tucked between the Atlantic
and Pacific oceans, into one of the gems of Latin America. Costa Rica is a
sound democracy and has no military, and the majority of its citizens enjoy a
fairly high standard of living compared with that in the United States.
According to the World Bank, the combination of steady economic growth and
sustained investment in human development has led to a substantial reduction
in poverty, which fell from 32 percent of the population in 1991 to 18 percent
in 2003, while extreme poverty decreased from 12 percent to 5 percent in the
Under its national health plan, Costa Rica provides care to its citizens
at the National Psychiatric Hospital in San Jose. Joan
In the health realm, Costa Ricans also have much to boast about. With a
government-funded health care system, everyone has access to free medical
care. Costa Ricans' life expectancy is comparable to that of
Americans—76.5 years for Costa Ricans versus 77.6 for Americans."
So that means that we're doing something very right," Andrea
Mesen, M.D., a Costa Rican psychiatrist, told Psychiatric News.
And one of the things being done right in the psychiatric realm is that
psychiatric services are fairly accessible, according to Gary Arce, M.D."
We have psychiatrists in all but seven of the 29 government-run
regional hospitals in Costa Rica," he said.
Arce heads the mental health division of the Caja Costarricense de Seguro
Social (CCSS). The CCSS is the national health care system that operates
medical facilities in Costa Rica and makes medical care available for
Another positive step, Arce said in an interview, is that he and his staff
at the CCSS are in the process of changing from a system that used to be
centered on custodial care of severely mentally ill patients to one based on
community care. That means that while some people with severe mental illness
still live in the National Psychiatric Hospital in San Jose, the capital, or
in an asylum facility outside the city, an increasing number now live at home
and receive care in their communities.
Also on the plus side, Arce reported, he and his staff have set up
community daycare centers where persons with serious mental illness can get
job training, make products to sell, socialize, and even get a free lunch.
They have also established community centers for adolescents with mental
health issues and the first rehabilitation center for youth with substance
abuse problems. They are attempting to help primary care physicians better
identify and treat individuals with depression, except the most severe
During an interview, Mesen also cited two other positive changes:"
The CCSS is making more modern psychiatric medications available to
patients than used to be the case. And family members of patients have
organized into associations—for example, the Foundation of Persons With
Schizophrenia. And yes, these associations are like the mental health consumer
groups in the United States."
"The best thing that is happening in Costa Rican psychiatry these
days," Luis Diego Herrera, M.D., told Psychiatric News,"is that scientific, evidence-based treatments are being
incorporated into practice very soon after they are put into practice in the
United States and other developed countries." Herrera is a child and
But even with numerous aspects of state-sponsored psychiatric care going
well, there is room for improvement, Costa Rican psychiatrists concur.
"Sometimes people have to wait months to get an appointment,"
said Christian Lachner, M.D., purportedly Costa Rica's only geriatric
psychiatrist. A shortage of mental health personnel explains the very long
wait, said Mesen. Costa Rica has some 90 psychiatrists, he estimates, and
could use twice as many.
While psychiatrists are available to patients in 22 out of the 29
government-run regional hospitals, only one—in Limon province on the
Atlantic Coast—has a psychiatric ward, Arce reported. Actually, there
has been an executive decree since 1995 that all hospitals should have such a
ward, but the decree has not been enforced, he added. "We urgently need
more psychiatric wards in the CCSS hospitals," Mesen said.
Even though the CCSS is making more modern psychiatric medications
available to patients than used to be the case, that rarely includes atypical
antipsychotics, Mesen lamented. "The reasons are not altogether
clear," he said. "Maybe psychiatry is not among the authorities'
top priorities, and that is why they don't invest enough in better
Costa Rican mental health personnel, Arce pointed out, likewise need to be
better trained to help people in the aftermath of earthquakes and
floods—two types of disasters that frequently befall their country.
Although crime is not a big problem in Costa Rica, forensic psychiatric
patients do occasionally get admitted to the National Psychiatric Hospital,
Carlos Zoch, M.D., associate director of the hospital, told Psychiatric
News. Yet the hospital has no special facilities for them, which is
problematic, he said.
Not surprisingly, people with severe mental illness in Costa Rica are often
irrationally feared, just as they are in many other countries, said Mesen."
I've actually had patients who have been to magical healers and who
believe that psychotic breaks are due to demons," Lachner said."
So a lot of education needs to be done."
But if there is any pressing psychiatric need in Costa Rica, it concerns
psychiatric education, psychiatrists there agree. "The curriculum of
medical schools needs to be changed to give psychiatry the same weight as
surgery, internal medicine, and other specialties," Mesen asserted."
Psychiatry is like the Cinderella of the health system."
"The aspect of Costa Rican psychiatry that most needs to be improved
is training for psychiatric residents," declared Herrera. "That
means a good, comprehensive training program for residents that is tailored to
Costa Ricans' particular mental health problems—depression,
interpersonal violence, child mental health, and so forth." ▪