Reform of mental health care in Serbia: ten steps plus one

Abstract

Disastrous events in the country and the region caused a 13.5% increase in the prevalence of mental and behavioral disorders in Serbia in the last few years, thus making them the second largest public health problem. Due to prolonged adversities, the health system has deteriorated and is facing specific challenges. However, the reform of mental health care has been initiated, with a lot of positive movements such as the preparation of a national policy for mental health care and a law for protection of mentally ill individuals. The transformation of mental health services has started, with an accent on community care, antistigma campaigns and continuing education. Based on an assessment carried out by the National Committee on Mental Health, service provision, number of professionals working in services, funding arrangements, pathways into care, user/carer involvement and other specific issues are reported.

In the past decade, Serbia has been exposed to many stressors, such as civil war in the surroundings, United Nations (UN) sanctions which have lasted for 3.5 years, and a collapse of the former state. There are approximately 500,000 refugees and internally displaced persons in the country. In addition to this, many Serbian people live in either forced or voluntary exile: about 100,000 of them in European Union member states and about 200,000 in other countries.

The mental health care system has been seriously affected by the above events. The overall quality of services has deteriorated. On the other hand, the prevalence of mental disorders has increased by 13.5% from 1999 to 2002, so that they are now the second largest public health problem after cardiovascular diseases.

The incidence of stress-related disorders is high, but also that of depression, psychosomatic disorders, substance abuse and suicide, as well as that of burnout syndrome among physicians who shared adversities with their patients (1,2).

The economic situation of the country can be briefly described by the following indicators: the gross domestic product (GDP) per capita is US$ 1,400; the national debt is US$ 9 billion; the percentage of the GDP spent on health care is 5.1%. According to the UN data, 29.0% of the population was unemployed in 2002. Most likely the percentage is even higher this year, considering the serious transition problems that the country is facing. A lot of people lose their job in the prime of their lives; many are socially deprived and frequently lack the essential resources necessary to fulfill basic survival needs. Recently, the suicide rate increased among people who had lost their jobs.

Another issue is the lack of appropriate information of the general public and the widespread stigma related to mental disorders, as well as a lack of interest by the media in mental health issues, unless they serve their sensationalistic purposes.

PSYCHIATRIC SERVICES

There are 46 inpatient psychiatric institutions in Serbia (specialized hospitals, psychiatric institutes, psychiatric clinics, clinics for child and adolescent psychiatry, and psychiatric departments in general hospitals). Furthermore, there are 71 outpatient services in the municipal health centers. The entire mental health sector has a total of 6,247 beds at its disposal, 50% of which are in large psychiatric hospitals. There are 12.6 psychiatrists, 2.3 psychologists, 1.6 social workers and 21.6 nurses/technicians per 100,000 population. The total number of psychiatrists (neuropsychiatrists) in the country is 947. However, 336 psychiatrists work in the capital. In addition to that, most of the specialists in the provinces deal with neurological, in addition to psychiatric problems (3). General practitioners seldom treat patients with severe mental disorders. Only 39.5% of patients treated in psychiatric institutions have been seen by a general practitioner.

There are a lot of non-governmental organizations, both international and national, dealing mainly with refugees and internally displaced persons, gender problems, torture victims, domestic violence and human rights.

Health care is free of charge. The services are financed by the state through the Republic Office of Health Care. Every institution signs a one-year contract with the Office, and the remunerations are received monthly (for medication, medical supplies, food for the patients, energy consumption, employees' salaries, etc.). The funds depend on the number of beds and provided service. Preventive and psychotherapeutic activities are not funded.

TOWARDS SOLUTIONS

Since 2000, eight countries entered the Stability Pact for South-Eastern Europe (SEE): Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Macedonia (FYROM), Moldova, Serbia and Montenegro (4). The international community decided to take a proactive attitude rather than intervening during crises only, and initiated the mental health project entitled "Enhancing social cohesion through strengthening community mental health services". The project started in 2002 and is supported by donor countries, such as Greece, Italy and Belgium. The World Health Organization (WHO) is closely involved in the project.

A National Committee for Mental Health was established in January 2003 by the Ministry of Health of the Republic of Serbia, which has become the research team of the SEE mental health project. The Committee prepared the national policy and action plan (3), and drafted the law on the protection of rights of persons with mental disorders. Both documents were discussed in public debates in 16 towns and reviewed by distinguished international experts. The national strategy was approved by the government in January 2007 and the law is expected to be approved by the parliament soon. The strategy is based on the WHO recommendations as stated in the World Health Report (5). It is in accordance with the WHO Helsinki Declaration and harmonized with the mental health policies of the region.

The national policy and action plan for the next decade has ten steps plus one and incorporates several domains: legislation and human rights; organization of services; prevention of mental disorders and mental health promotion; work force development; research; evaluation of services; improvement of quality; information system; intersectoral cooperation (partnership for mental health); advocacy and public representation; reform of psychiatry and psychiatrists (6). The reorganization of services, such as reducing the length of hospitalization especially in the old-fashioned psychiatric institutions, has started and some hospitals are being slowly downsized. Prevention of mental disorders and mental health promotion have been marginalized, but still there are many preventive programs, especially for vulnerable groups, such as refugees and torture victims (3).

There is only one pilot independent community mental health centre, which was opened last year in Nis, a university town in the South of Serbia, as part of the SEE mental health project. Residential facilities in the community are lacking. However, in most of the health centres throughout the country, there is a mental health team, integrated in primary care.

Mental health reform entails workforce development and continuing education of professionals, especially of general practitioners, which is what we have been doing for the last five years. We have developed packages for continuing education in mental health care of general practitioners, which were applied in Sarajevo and Belgrade, supported by the Norwegian Medical Association. However, it is not easy for primary care physicians to accept taking care of psychiatric patients, since they are already overburdened with a high daily number of patients.

The involvement of patients and their families in decision making process is not developed. However, in Belgrade there are clubs of treated alcoholics, the first one of which was established 44 years ago, which function quite well.

Multicentric studies that include several countries of the region are of particular importance, and might serve as tools for reconciliation. We are involved in two international multicentric studies of post-traumatic stress in refugees and in general population supported by the European Commission (7,8).

Destigmatization of psychiatric patients is a significant step in our reform of mental health care. This process already began two years ago, when we organized the campaign "United colours of soul". The campaign included psychiatrists, general practitioners, non-governmental organizations and patients. The "Wednesday culture circle" has been organized for our patients at the Institute of Mental Health in Belgrade as an important antistigma activity: once a month concerts and meetings with public figures are regularly organized for our inpatients.

The reform of psychiatric services and mental health care is not easy in countries facing social transition, due to many problems such as economic difficulties, as well as resistance and marginalization of psychiatry in the society (9). The implementation of the new national policy will take time. It needs competent workforce development, evaluation of services and interventions, as well as a long-term investment and commitment by government (10).

The reform implies transformation, and the transformation should start within our profession and ourselves, not from outside. Individualization and humanization of treatment could be reached even without huge resources. Integrative treatment, good clinical practice based on values and not only on evidence as demanded by modern science, is essential, and it does not need a lot of money. Psychiatrists and other mental health professionals should treat persons and not diseases, following the ancient Aristotle's medicine of personality and in accordance with the WPA Institutional Program on Psychiatry for the Person (11).

This is not easy and might sound unfeasible when low motivation of staff is prevailing due to apathy, chronic stress, poor conditions of work, and low salaries. Many professionals left the country and found shelter in developed countries; some have established non-governmental organizations or opened private services. In addition to that, many show resistance to changes and reform, which is a natural reaction.

Therefore, we believe that, in addition to transformation of services, the reform of mental health care requires another step - the reform of psychiatry and psychiatrists, which involves restoring the dignity of our noble discipline. Destigmatization of psychiatrists, who are often stigmatized together with their patients, is one of the important steps in this direction.