Psychiatry in Spain

Abstract

Spain covers an area of some 506 000 km² and has a population of just over 41 million. It is a high-income country (according to World Bank criteria) and devotes 7.5% of its gross domestic product to health.

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Organisation of healthcare

Spain’s National Health System has universal coverage and is financed through the general budget of the state, although the system is organised territorially. Healthcare has two levels: primary care, which is the gate into the system, and specialised care, which is managed independently of primary care, although some regions are considering unifying the two. Psychiatric care is part of specialised care.

Around 6% of the population have additional health insurance and can be treated privately, which gives them greater choice in their healthcare. The private insurance companies set limits on the length of psychiatric hospital stays and the number of out-patient consultations per year that can be reimbursed.

Mental health policy and service organisation

The budget, planning and provision of health services are taken care of by each of the 17 comunidades autónomas (regions), which are responsible for their own mental health policies under the framework of the 1986 General Health Law and the 1995 Decree for Psychiatric Reform. The Law on the Cohesion and Quality of Healthcare reinforces the uniformity and standards of the care provided in each comunidad autónoma.

Each of the comunidades autónomas has a mental health plan, framed as part of a general health plan. Social reintegration is a key feature of mental health policy. The details of each region’s policy are set out in its plan. There is a specific national plan for drug misuse, which is drawn up by the Ministry of Internal Affairs, since it includes actions pertaining to the control of the traffic in illicit drugs.

For mental health services there is also a general (i.e. national) decree that covers clinical diagnosis and follow-up, pharmacological therapy, individual, group and family psychotherapies and hospitalisation; hypnosis and psychoanalysis are excluded. The cost of all psychotropic drugs is covered by the National Health System.

All comunidades autónomas share the following organisational principles for their mental health services (Reneses, 2003):

• Care is based on the principles of community psychiatry.

• Services are sectorised. Each sector (district) has from 50 000 to 200 000 inhabitants. Mental health services in each sector consist of a multidisciplinary team of psychiatrists, psychologists, nurses, occupational therapists and social workers. Each sector has one or more mental health centres and one or more admission units for acute processes, as well as day hospitals and psychosocial rehabilitation centres.

• People experiencing acute psychiatric episodes are preferably hospitalised in general hospitals. Traditional mental hospitals have been progressively transformed to fit their services to the needs of the population in areas such as rehabilitation, units for sub-acute processes and units for residential care.

• There are specific programmes for the care of children and adolescents in general mental health services or in independent centres. These programmes include out-patient care, day hospitals and admission units, although only some regions have specialist mental health units for minors (in the others they are admitted to general paediatric units).

• The net of social services is tightly coordinated with the healthcare one in different forms in the different comunidades autónomas. In some of them outpatient rehabilitation services are provided by the social services.

• Residential non-hospital care is perceived to be less and less sufficient and is usually provided by social services.

• Specific programmes of psychotherapy, the treatment of alcohol-related problems and rehabilitation are present in all regions but have different degrees of development.

Social reintegration is a key feature of mental health policy.

There are some further differences in the way the comunidades autónomas organise their services:

• Some of them have an independent net for the care of people who misuse drugs.

• Some have non-hospital admission units for the long-stay care of people with sub-acute and chronic processes.

• The number of resources, both structural and human, varies among the comunidades autónomas, as a result of the differing budget allocations for mental health.

Mental healthcare resources

The territorial organisation of health services means that there is no easily accessible national source of information on resources. However, the National Health System publishes online statistics on hospitals (Establecimientos Sanitarios con Regimen de Internado; ESCRI) and these provide the following information. The number of psychiatrists providing out-patient care in public health services varies from 7.2 psychiatrists per 100 000 population in Asturias to 1.6 in Extremadura; the average is around 4 psychiatrists per 100 000. Across the regions, the number of beds in units for acute care in public hospitals is between 7.2 and 12.0 per 100 000 population. The total number of beds, public and private, is 50.4 per 100 000 inhabitants, of which 12.6 are in services for acute processes and 38.6 are for long-stay patients. For acute cases, 60.2% of beds are located in general hospitals.

ESCRI and CMBD statistics are available from the website http://www.msc.es/Diseno/sns/sns_sistemas_informacion.htm

The number of hospital discharges with a main psychiatric diagnosis per 100 000 inhabitants in the year 2002 was 279 (Instituto Nacional de Estadística, 2002).

People experiencing acute psychiatric episodes are preferably hospitalised in general hospitals. Traditional mental hospitals have been progressively transformed to fit their services to the needs of the population in areas such as rehabilitation, units for sub-acute processes and units for residential care.

Information systems

The national minimum data-set (CMBD) facilitates the collection of basic healthcare data. It covers the whole of public hospital care and collects data on all hospital discharges, and includes information on mental health. The Questionnaire on Hospital Morbidity (Instituto Nacional de Estadística, 2002) and the ESCRI provide statistical information on the structure, activity and finances of all public and private hospitals.

The specific information systems for mental health are decentralised, each comunidad autónoma having its own system. At least five comunidades autónomas have information systems based on cumulative case records; the rest have systems based on group activity (Ministerio de Sanidad y Consumo, 2003). There is no specific national information system for mental health.

Patients’ rights

The national civil and penal codes have been modified to protect the rights of psychiatric patients and improve conditions of detention for offenders with a mental illness. As a part of these reforms, prison hospitals were closed and special units within the National Health System were opened.

The latest civil legislation relating to mental illness was enacted in 2000; this regulates all involuntary admissions and treatments, which can be carried out only after judicial authorisation and with supervision.

Training and education

Training of specialists

The training of psychiatrists, clinical psychologists and psychiatric nurses is regulated at state level; services have to be authorised to undertake training (Ministerio de Sanidad y Consumo, 1996). There is no specialisation in child psychiatry or in geriatric psychiatry. A limited number of residency posts are offered, again organised at state level. There is a state examination common to all medical disciplines. (In the case of psychologists and nurses, the examination is specific to each specialty.) The attainment of a residency post depends on the results obtained in the selective examinations.

The specialty of child psychiatry does not exist, officially, and this has impeded the organisation of psychiatric care for children and adolescents.

The training of psychiatrists takes 4 years and includes: psychiatric in-patient and community care, liaison psychiatry, child psychiatry, day-hospital care, neurology and internal medicine (Ministerio de Sanidad y Consumo, 1996).

The training of clinical psychologists takes 3 years and includes hospital and community care, care of children and adolescents, and psychosocial rehabilitation.

Training in psychotherapy is in preparation. At present it is not carried out in a systematic way nationally, although some hospitals do provide their own.

Undergraduate training

Two mental health disciplines generally feature in the curricula of medical schools: medical psychology in the preclinical, basic curriculum; and psychiatry during the clinical period. Some medical faculties have a third discipline, psychopathology, which is otherwise taught as part of either the medical psychology or the psychiatry curriculum. Several non-compulsory disciplines are also included, among them drug dependence and eating disorders.

Mental health professions

Professional practice is regulated at national level by the 2003 Law for the Regulation of Healthcare Professions. The specialty of child psychiatry does not exist, officially, and this has impeded the organisation of psychiatric care for children and adolescents.

The practice of psychotherapy is not regulated in Spain. Normally training in psychotherapy is carried out by psychiatrists and clinical psychologists in the private sector.

Clinical practice is not allowed to psychologists not qualified as clinical psychologists.

Psychiatric associations

The two best-established national associations are the Sociedad Española de Psiquiatría (SEP), a scientific medical association of psychiatrists, and the Asociación Española de Neuropsiquiatría (AEN), whose membership consists of all mental health professionals. In the past it also included a significant number of neurologists and neurosurgeons. The SEP holds a national congress every year jointly with the Sociedad Española de Psiquiatría Biológica (SEPB), which is a smaller, mainly research society. The AEN also organises annual congresses. There are various regional associations, most of which are linked to the SEP or to the AEN.

Other national scientific associations cover more specific fields, such as child psychiatry, psychogeriatrics, psychiatric epidemiology, alcoholism and drug addiction and forensic psychiatry.

Scientific journals

The oldest Spanish psychiatric journal still published is Archivos de Neurobiologia. Actas Españolas de Psiquiatría is the most widely distributed psychiatric journal in the Spanish-speaking world and is among those with the highest impact factor of all non-English psychiatric journals. Another widely distributed journal is the Revista Española de Psiquiatría Biológica.