The State and suicide: the resources that cannot be added up

We searched the stem "suicid" in the enacted text of seven consecutive laws. They are two budget laws and five accountability laws, between 2020 and 2025. The word appears zero times in all seven.

Ley 20.446, the 2025-2029 National Budget, has 717 articles. None of them names it. The expression «salud mental», mental health, does appear: eleven times in that law, and with a different count in each of the other six.

Zero mentions is not zero pesos. Prevention spending exists inside mental health budget lines and inside ASSE salaries. What the count proves is that no budget line is labelled by the problem. Because of that, the spending cannot be isolated from the law itself.

The measurement covers the enacted text, not the budget volumes. Tomo II, the planning and evaluation volume, does name suicide three times. The next section is about that.

The Health Ministry publishes an annual National Health Accounts bulletin. The 2024 edition has 22 numbered pages. The expression «salud mental» appears zero times, the stem "suicid" zero times and the stem "psiqui" zero times.

The Uruguay country profile in the WHO Mental Health Atlas 2020 has three financing boxes. All three are empty. The 2017 profile does not report the figure either.

The same 2020 profile asks two consecutive questions about the national mental health plan. One asks whether human resources are estimated and allocated. The other asks the same about financial resources. Uruguay answered "No" to both.

The State set itself the target of getting to measure. Milestone 4 of the Health Ministry in Tomo II reads "Contar con un sistema de monitoreo de indicadores de salud mental en el país" — have a national mental health indicator monitoring system, with baseline 0 and cumulative target 4 for 2029.

None of this proves that no internal register exists. It proves that the figure was not declared and is not published.

The WHO publishes an indicator of public mental health spending over public health spending. It has 78 rows in the whole world, and all of them are from the same year: 2011. Nineteen rows come from the Americas region. None comes from Uruguay.

Two statements follow, and both go together. The first: no country has a recent figure, so the regional comparison cannot be built from this source. The second: in the only year that exists, six South American countries reported and Uruguay did not.

The articles of Ley 20.446 that name mental health add up to 224,250,000 pesos for the 2026 financial year. From 2027 they add up to 234,250,000 a year. The largest line belongs to ASSE: 170,000,000 a year.

Only four of the five articles say "Asígnase", hereby allocated, which is the wording of new money. Counting only those, 220,000,000 remain for 2026 and 230,000,000 from 2027. The 4,000,000 of the national university are a reallocation from another budget head.

Article 393 gives 10,000,000 to the Health Ministry for "los cometidos en salud mental y adicciones", its duties in mental health and addiction. Of that, 9,768,240 pesos are transfers to non-profit institutions. That is 97.68% of the line.

For magnitude: the 170,000,000 of ASSE equal 0.29% of the 57,988,000,000 that ASSE executed in 2023. The arithmetic gives scale, not a share of the current budget. It compares a credit valued at January 2025 prices against spending executed in nominal 2023 pesos.

This is allocated credit, not executed spending. Execution by line is not published.

Since 2024 follow-up after discharge is a care target that is paid for. It is indicator 5 of Component 5 of the Health Ministry instruction, and it is called "Seguimiento inmediato de afiliados con intento de autoeliminación" — immediate follow-up of members after a suicide attempt.

It is worth 15.51 pesos per month per FONASA user, out of the 217.08 the whole target is worth. That is 7.14% of a target with 21 indicators. The scale of amounts per indicator has three steps, 5.16, 10.34 and 15.51, and follow-up sits on the highest one.

The compliance objective the State sets itself is 70%. Payment starts at 50%. Both values apply milestone by milestone, not to a single percentage of completed cases.

Said without arithmetic: the State plans to meet the protocol in 7 of every 10 cases, and starts collecting from 5 of every 10.

The indicator has four milestones with different weights. The one that weighs most alongside the face-to-face consultation is the call at 2 days. The instruction says "2 days", not "48 hours".

The milestone of the face-to-face consultation at 7 days is worth 30%. The instruction expressly allows the provider to replace it with a call if the consultation does not happen. That call counts even when it is with the emotional referent and not with the person. The milestone closes without seeing the person, and it can close without speaking to them.

There is no figure for how often the milestone closes by telephone. The instruction also sets that call an objective, which is to reassess risk.

This is not the only mental health indicator of the target. Indicator 2.3 refers first-time mothers with signs of post-partum depression to the same Reception Committee, and is worth 10.34 pesos.

Follow-up after discharge is a duty since 2017, not a recommendation since 2024. The protocol approved by Ordenanza Ministerial 384/017 sets the first outpatient consultation at no more than 7 days, and active follow-up for at least six months, over every user.

The annex to Decreto 305/011 already ordered it in 2011: "En el caso de los IAE, se hará seguimiento los primeros 6 meses, de acuerdo a pautas establecidas al respecto" — suicide attempts are followed up for the first 6 months, according to guidelines set for the purpose. The decree does not define those guidelines. The guidelines arrive only with the 2017 protocol.

There is a tension between the two instruments, and it is worth seeing. The one that obliges runs to six months. The one that pays stops at 30 days.

The doubt is not about the rule: it is about compliance. And compliance is not published.

Spending on psychotropic drugs awarded between 2002 and 2026 is 348,131,404 nominal pesos, across 4,142 purchases and 6,826 lines. The false positive filter removes 1,704 lines and 51,988,860 pesos, 12.99% of the gross: reagents, calibrators, controls, analytical standards, electrodes, tools and batteries.

That filter is asymmetric. It runs from 57.3% on lithium to zero on thirteen molecules. That is why a filter applied to a single molecule breaks any ranking, and why there is no publishable first molecule: aripiprazole and valproate sit 0.66% from each other, and sertraline and escitalopram 0.10%.

By group, antipsychotics are 144,118,808 pesos and antidepressants 53,812,163. That is 2.68 times.

The record is highly concentrated. One single tender, Licitación Pública 1007/2007, moves between 64.43% and 76.95% of the tablets, depending on how they are counted. In money it is 27.75% of the total, and that percentage does use one single rule.

At the other end, in 2025 there are 730 purchases from 40 different bodies, with a median of 27,339 pesos. Over 24 years, 140 different buyers bought psychotropic drugs on their own account.

There is no establishable relation between this series and the suicide rate. The series measures coverage of the procurement record, not national consumption. The central purchasing channel is invisible in amounts. And even if the two curves matched, the match would not be a cause.

Notification of a suicide attempt is mandatory since December 2012. The Health Ministry never published the annual series of the paper form. The mandatory digital register in emergency departments starts in October 2022, so the first full calendar year is 2023.

What exists is not a series: it is a table of measurements with different units. That is why it goes as a table and not as a line.

Two unit traps govern it. The first: an episode is one recorded suicide attempt, and one person can have several. In 2025 the Health Ministry published both units together for the first time: 6,140 episodes by 5,144 people, that is 1.19 episodes per person.

The second: the population base. The implied denominators of 2023 and 2024 sit around 3.57 million. The one of 2025 is 3.49 million. The ministry changed projection vintage between one year and the next, and the base falls 2.57%.

The consequence is concrete. The 2024 rate and the 2025 rate are not compared. The unit changes, from episodes to people, and the base changes.

The ministry itself warned about the quality of its own series. On the 2024 jump it wrote: "Este incremento podría estar vinculado a mejoras en los sistemas de registro, y no necesariamente a un aumento real de casos" — the rise may be linked to better recording systems, and not necessarily to a real rise in cases. That sentence alone rules out reading the series as an epidemiological trend.

The 2021-2025 Strategy acknowledges in writing "el subregistro de IAE a nivel de los prestadores de salud" — the under-recording of suicide attempts at provider level. It does not quantify it. There is no official estimate of how much is missing.

And there are two breakdowns the ministry publishes in no year: the suicide attempt by department, and the count by age band for 2024 and 2025.

The 2021 paper form is the only pre-digital figure the Health Ministry published. It covers only ages 10 to 24 and recorded 1,171 cases. Its two internal checks close.

The EMSE school survey asks students aged 13 to 17 whether they made a suicide attempt in the previous twelve months. It is the only source with two mutually comparable points: 9.2% in 2012 and 12% in 2019.

Hospital discharges are yet another unit. They count admissions with ICD-10 secondary code X60-X84, not emergency department visits. They add up to 8,554 between 2018 and 2021.

Of the 4,723 suicide attempts recorded in 2023, 2,392 records state a previous attempt. In the nine-month window the proportion was 1,346 of 2,896.

The Health Ministry study on adolescent suicide worked on 149 death certificates and 54 clinical histories of people aged 19 and under. Of those 54 histories, 29 had consulted the system in the previous three months and 38 in the previous six months.

The previous attempt is self-declared on the form. The 54 histories are not extrapolated to the country. And it cannot be slipped in that the system saw them and did not act: the figure is descriptive and no source states that cause.

The register of licensed qualifications of the Health Ministry, at 31 July 2026, lists 628 people with a psychiatry qualification and 183 with child and adolescent psychiatry. Only 8 people hold both, so the union is 803.

The same register lists 14,616 psychologists. And it lists 91 people with a mental health specialisation qualification, of whom 77 are registered nurses and 14 nursing auxiliaries. That the group is a nursing group comes from the cross-reference, not from the title of the qualification.

The register does not say where any of those people work. It carries no department column. That the territorial figure of psychiatrists does not exist is something we cannot state: we can state that we did not find it in public sources.

The same register lists 27,834 licensed doctors of medicine. The WHO indicator gives 45.51 doctors per 10,000 people for Uruguay in 2023, which against the population of the 2023 census is some 15,700 practising doctors.

That is 1.8 qualifications per practising doctor. The register accumulates qualifications and removes none on death, retirement or emigration. It is a ceiling, not a count of who practises.

Converting the rate into an absolute number is our own arithmetic. We publish it because it is the argument that holds up the whole quality control of the method.

In 2016, the last year with a comparable figure, Uruguay declared 14.13 psychiatrists per 100,000 people. Argentina declared 21.71 and the United States 10.54.

That year Uruguay came second among the 23 countries of the region that reported, and ninth among the 104 countries of the world with a figure. Not among the 35 countries of the region, and not among the 194 member states.

The medians of the same indicator are 1.835 in the Americas and 1.231 in the world. The figure is ten years old.

The WHO publishes medians, not targets. None of the eight targets of its Comprehensive Mental Health Action Plan is a staffing target.

The psychiatrist medians of the Atlas 2024 are 1.5 in the world, 1.7 in the Americas, 7.0 in the high-income countries and 9.9 in Europe. Comparing them against the Uruguayan 15.7 mixes 2020 with 2024.

The consequence matters: there is no official threshold against which to measure Uruguay. That closes the door on any figure of the "the WHO recommends this many" kind.

The Uruguay country profile of the Atlas 2024 is not published. Uruguay answered the questionnaire and appears in the list of contributors. The expected address returns 404, and the 2020 one responds. The last complete portrait of the Uruguayan system holds 2020 data.

The 1st National Census in Psychology, from 2014, counted 7,543 psychologists. That is 77.1% of the census universe, not the national total.

Of those, 5,488 lived in Montevideo and 2,055 outside it. Montevideo had 240.4 inhabitants per psychologist and Artigas 2,530.3.

The figure is twelve years old. It measures declared residence, not place of work. The inhabitants come from the 2011 census. There is no later census, and for psychiatry no equivalent exists.

The other territorial figure available covers doctors of all specialties, from 2011: 78.8 per 10,000 people in Montevideo against 21.7 outside it. The stem "psiquiatr" appears zero times in that report.

The government reported that 30,000 users were waiting for a psychiatry appointment at ASSE at the start of the term. It also reported a reduction of 15% over seven months, to November 2025.

The two figures do not go together. The 30,000 are attributed to "los servicios de psiquiatría", the psychiatry services, of ASSE. The minus 15% is attributed to "los servicios de salud mental del prestador público", the mental health services of the public provider. The government does not say that they measure the same thing, and the absolute value of November 2025 is not published.

There is a maximum waiting time for a specialty appointment, of 30 days. It is a decree, not an act, and it does not name psychiatry. The waiting-time targets the government set itself cover the whole system: none is about mental health.