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 same period.

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 free.

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 cases.

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 adolescent psychiatrist.

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 medications."

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." ▪