The development of psychiatric reform in Slovenia

Abstract

The situation of mental health care in Slovenia is briefly reviewed. The reduction of beds in psychiatric hospitals has started already in the 1970s; a further decrease has occurred in the last few years. The number of admissions to these hospitals has increased recently, while hospitalizations have become shorter. On the other hand, the access to psychiatric outpatient facilities is becoming increasingly difficult. Under these circumstances, it is necessary to enhance community mental health care. Patients and families have great expectations about the new mental health legislation, which is supposed to be associated with a national mental health program.

Slovenia is a central European country with 2 million inhabitants that recently joined the European Union. The care for people with severe mental disorders in this country is traditionally associated with psychiatric institutions, without any obvious political or professional intent to redistribute health resources at the community level or integrate mental health services with general primary care.

The number of beds in psychiatric hospitals has been actually reduced already in the 1970s, but without establishing complementary services in the community: chronic patients were de-hospitalized to asylums or old people homes or returned to their families. A majority of hospital population was quickly discharged 20 years ago, mostly with very little preparation and due to economic pressure. In the central Slovenian psychiatric hospital (University Psychiatric Hospital Ljubljana, PH) there are now only about 2% long-term hospitalized patients.

During the last few years, the number of admissions to PH has been rapidly increasing, while hospitalizations have become shorter, mostly as a result of a further reduction in the number of psychiatric beds (22% from 1998 to 2004). The funding of PH is stable and is not adjusted to the number of admissions. Regardless of greater needs, hospital admissions are restricted to the most severely ill patients.

In Slovenia, there are one psychiatrist and 0.5 hospital beds per 10,000 inhabitants. Seventy-five percent of Slovenian psychiatrists are employed in hospitals, but at the same time they also work in outpatient facilities. Hospital admissions have doubled in the last ten years. According to the World Health Organization (WHO)'s guidelines, inpatient treatment of psychiatric cases should predominantly occur in general hospitals: however, the Slovenian general hospitals have a very limited number of beds available for this purpose. The availability of psychiatric treatment is not uniform: in the Ljubljana region there is one psychiatrist per 6,500 people, while in other regions lacking hospital facilities a single psychiatrist has to cover a population of 25,000. The problem is further aggravated by the fact that the regions with the lowest number of psychiatrists have the highest rate of people with severe mental disorders, which is evident from the suicide statistics (1).

The waiting time for outpatient psychiatric treatment in the central Slovenian region has been increasing, presently being 4 months on average. The access to psychiatric outpatient facilities, which used to be easy in the past even without referral forms, is becoming now increasingly difficult. Social and health care services work each on their own, in terms of both their approach to the clients and their education and training. Interdisciplinary issues, such as for instance psychosocial rehabilitation, are not included in any undergraduate training program, and cooperation between higher education institutions is modest. Education programs at the faculties of medicine, psychology and education and at the college of medical profession are not coordinated and do not contribute to improve the discriminatory attitude of students to psychiatric patients. Rather than program-oriented, the ideas about planning of mental health services are static and bound to the existing institutions.

We believe that under these circumstances it is necessary to enhance preventive activities, which may ensure timely and prompt interventions at patients' homes, as well as further treatment and continuous follow-up in the natural setting (home care, crisis intervention), as suggested in WHO guidelines. The most significant support in this respect can be expected from the rapidly developing private non-profit voluntary associations in the community. These offer their help with the organization of living and self support as well as some possibilities for training and employment. Some of them offer rehabilitation services in the regional centers throughout Slovenia.

Following Thornicroft and Tansella's model (2), it would be advisable to develop in Slovenia primary care units with specialist backup, flexible community mental health teams with case management and long-term community-based residential care, outpatient clinics, and mainstream mental health care, coordinated among them. Harmonization between health services, social services, housing agencies and non-governmental organizations (NGOs) is essential to ensure continuity and quality of care. However, planning of better coordination and availability of continuous and network-integrated activities of psychiatric services have not become a priority in Slovenia as yet. Rehabilitation services have started to develop in hospitals on the initiative of NGOs, which were the first to implement education programs for patients and their families, integrating them into the hospital setting.

Currently, the central Slovenian hospital is preparing new ways to keep record on services and planning of care after discharge. The standards of treatment are defined by different clinical approaches, intended for individual diagnostic groups of patients. These were prepared in order to ensure cooperation with the community services, assessment of patients' needs, individually adjusted treatment modalities and the participation of patients in the treatment and care. In the last months, we have obtained for the first time that some mental health teams perform part of their work at patients' homes. The stress laid on team work and shared definition of treatment objectives have brought about some objective results in chronically ill patients who were discharged to the community (3). Our partners in the implementation of rehabilitation programs are mainly nonprofit voluntary organizations.

With the collapse of outpatient clinics due to service privatization, we tried to transfer part of treatment and care activities to general practitioners. However, they are often overburdened (each of them has an average of 1,800 patients) and thus not ready to take upon themselves the additional care of psychiatric patients.

Patients, and particularly their families, have great expectations about the new Slovenian mental health legislation that has been in the process of being adopted for almost a decade now. The law is supposed to be associated with a national program aiming to ensure that people with severe mental disorders have the same rights as other disabled persons regarding employment and social support. However, it seems that the law, which is being prepared at an inter-ministerial level, will in the first place sort out involuntary hospitalization procedures, and define some new personnel profiles for community monitoring and supervision.

The predominant concern is that the law will define certain rights without ensuring that they will be exercised in practice, since Slovenia lacks the human resources and the trained staff needed to implement supervision and support. The discussion about the law should be joined by psychiatric professionals, users of their services, and patients' families. The first round-table conference on the law was organized by the non-profit voluntary organization "ŠENT" in order to present the Helsinki Declaration (4), in which the promotion of mental health care, treatment and rehabilitation were set out as priorities by the WHO and its member states.

According to this Declaration, mental health policies, programmes and legislations should be established based on current knowledge and considerations regarding human rights, and people with mental health problems should be offered comprehensive care and treatment in a range of settings in a manner that respects their personal preferences and protects them from neglect and abuse. However, the overcrowded and ever less accessible hospitals and social institutions, with a personnel that is neither qualified nor ready for community work, cannot meet these requirements. Some advances may be seen only in the increasingly competent and demanding attitude of the users to our services, in the currently still isolated and non-regulated attempts to carry out community interventions, as well as in the pressure by NGOs to fight against stigmatization of people with mental disorders.