Psychiatry in the Czech Republic

Abstract

The profound political, social and economic changes that occurred after the end of communist rule in Central Europe in 1989 had a profound influence on Czech psychiatry. In the socialist Czechoslovakia the healthcare system was fully owned, financed and organised by the state, in so-called regional institutes of healthcare. These had obligatory catchment areas of about 100 000 inhabitants and comprised in-patient as well as out-patient care facilities, including psychiatry. The main trends after 1989 were decentralisation of the healthcare system, rapid privatisation, especially of out-patient services, and financing through the newly established health insurance corporations.

Medical education

In the Czech Republic the system of education is similar to systems in other European states: there are 9 years of primary and 3 years of secondary education; doctors do 6 years of study in medical school. Psychiatry is usually taught during the 4th, 5th or 6th year, mainly in a 3- to 4-week course, totalling about 60–100 hours. Classes typically have about 10 students. There are also obligatory courses in medical psychology and ethics and electives in psychotherapy and in communication skills.

Postgraduate training of physicians was until recently centralised and organised by the Institute of Postgraduate Studies of Physicians, an organ of the Ministry of Health. A law regulating the postgraduate training of healthcare workers, passed by the Czech Parliament at the beginning of 2004, has substantially changed these procedures. Medical schools as well as other accredited institutions are allowed to participate in postgraduate training. Training in psychotherapy became a common part of physicians’ education.

Specialisation in general adult psychiatry includes 5.5 years of practising psychiatry at accredited departments, with rotation in various types of ward and outpatient facilities. Internships in internal medicine and neurology lasting 3 months each are obligatory. There are also special separate courses and specialisations in child psychiatry, old age psychiatry, drug addiction and sexology.

Service provision

We estimate that less than 3.9% of the healthcare budget has been allocated to mental healthcare, which is one of the lowest rates in the European Economic Area (Commission of the European Communities, 2005). In recent years the number of physicians working in psychiatry (Health Statistics, 2004) has been increasing and in the year 2002 there were 1210 (11.8/10 000 population), most (49.8%) working in out-patient clinics. Since 1995 about 80% of psychiatric ambulatory clinics have been in private hands. There is free access to these specialists, who have no catchment areas.

We estimate that less than 3.9% of the healthcare budget has been allocated to mental healthcare, which is one of the lowest rates in the European Economic Area.

There was no period of rapid deinstitutionalisation in the Czech Republic but the number of psychiatric beds was substantially reduced in the 1990s (from 14/100 000 in 1990 to 11.1/100 000 in 2002). However, in recent years this trend has stopped. In the year 2002 there were 21 psychiatric hospitals with a total of 10 045 beds (four of those hospitals specialise in child psychiatry and have a total of 368 beds) and 33 psychiatric units in general hospitals, with 1546 beds (Health Statistics, 2004).

Specialisation in general adult psychiatry includes 5.5 years of practising psychiatry at accredited departments, with rotation in various types of ward and outpatient facilities. Internships in internal medicine and neurology lasting 3 months each are obligatory.

Every psychiatric hospital has a catchment area of about 1 million inhabitants. The distance from a patient’s home is sometimes up to 200 km. Officially, only chronic patients should be hospitalised in these facilities. However, owing to the lack of acute beds in general hospitals about a third of their capacity is occupied by acute admissions. The average length of hospital stay, despite its decline in the last decade, remains high, at 80 days in psychiatric hospitals and 22.5 days in general hospitals. Almost all psychiatric beds (99%) are state owned.

The relatively high number of beds in the Czech Republic can be explained both by the tradition of in-patient care in central Europe and by the fact that psychiatry is substituting for a lack of social care and community services. It is estimated that up to about one-third of the patients are hospitalised for social reasons; these include patients with a learning disability, some with chronic schizophrenia, as well as elderly patients who have no accommodation, relatives or other social support (Raboch, 2003).

For details of the EDEN research project see http://www.edenstudy.com

There are no official statistics regarding community psychiatry but from the European research project EDEN (European Day Hospital Evaluation) we know more about the functioning of day care centres in the Czech Republic (Kallert et al, 2002). There are 35 members of the association of day care and crisis intervention centres. They are located mainly in larger cities; for example, the capital, Prague, has eight. They concentrate on psychotherapy for patients with various types of neurotic disorder and on the rehabilitation of patients with chronic psychiatric illnesses, such as schizophrenia or alcohol and drug dependencies. Programmes for older adults with dementias are still lacking. In the treatment of acute psychiatric disorders, day care centres are not very frequently employed as an alternative to hospitalisation.

Legislation and patients’ rights

Under Czech law there is neither a specific act on mental health nor a comprehensive act regulating involuntary admission, involuntary treatment or use of coercive measures concerning persons with a mental illness. As a principle, diagnostic and therapeutic measures may be carried out only with the consent of the person concerned or if the consent can be anticipated. According to the Healthcare Act, diagnostic and urgent measures without the patient’s consent may be carried out or a patient may be admitted to a medical establishment if, besides other conditions, a person with signs of a mental disorder or intoxication threatens him- or herself or others.

Czech Psychiatric Association: http://www.ceskapsychiatrie.cz

The Czech Republic has recently been criticised by various European bodies and authorities (e.g. the Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment of the Council of Europe) for using cage and net beds. Cage beds are not used any more in Czech healthcare facilities. Net beds, of which there are about 100–200 in the whole country, are still used (and not only in psychiatric facilities), especially in the treatment of emergency states in patients with a learning disability or psychosis and as a safety measure for patients with dementia with night-time confusion. In recent years their number has decreased rapidly.

Every psychiatric institution has transparent and strict rules on how to use restrictive measures, in what situations they should be used, how to document their use and how to supervise these. However, the number of auxiliary nurses and other healthcare personnel is very low in Czech psychiatric facilities (on average 0.36 per bed) and frequently no other technical support, such as modern seclusion rooms, is available (Commission for the Realisation of Reform of Psychiatric Care, 2004).

In order to stress the international and European involvement of Czech psychiatry in this very sensitive part of mental healthcare, we should mention that two Prague psychiatric facilities are participating in the EUNOMIA project (European Evaluation of Coercion in Psychiatry and Harmonisation of Best Clinical Practise) (Kallert et al, 2005). This was set up under the 5th Framework Programme of the European Commission. In the 3-year study period the use of coercive treatment measures in psychiatry in 11 member states of the European Union and in Israel will be mapped on the basis of data collected on two groups of psychiatric patients: those involuntarily admitted and those voluntarily admitted but who feel coerced.

For the EUNOMIA project see http://www.eunomia-study.net

Professional associations and collaboration

The Czech Psychiatric Association is one of the oldest Czech medical societies. It was founded in 1919, after the formation of the independent Czechoslovakia (Czech Medical Society, 2000). More than 1000 of the 1200 physicians working in psychiatry are members. It has 16 sections, the most active of which are biological psychiatry, psychopharmacology, forensic psychiatry, child and adolescent psychiatry, social psychiatry, psychosomatics, eating disorders and hospital psychiatry. The Association has monthly meetings and regular working days at the Psychiatric Department of Charles University in Prague.

A taskforce of the Association has prepared a report on the reform of psychiatric care, which has been approved by the Ministry of Health. This pointed to the need to strengthen the continuity of care for patients with severe mental disorders, to widen the system of community care and acute hospital care, and to find adequate and functional boundaries between chronic psychiatric and social care (Commission for the Realisation of Reform of Psychiatric Care, 2004). A special advisory commission to the Minister of Health was recently established for the realisation of the reform and will push for the advice of the January 2005 meeting of European Ministers for Mental Health in Helsinki to be put into practice.

Czech psychiatrists are also very active internationally, especially in hosting various major international congresses. Prague hosted the regional meeting of the World Psychiatric Association (WPA) in 1993, the conference of the Association of European Psychiatrists (AEP) in 2000, the European Congress on Cognitive Behavioural Therapy in 2003, and a meeting of the European College of Neuropsychopharmacology in 2003. A regional meeting of the Collegium Internationale Neuropsychopharmacologicum (CINP) in 2004 was held in Brno. The World Conference for Social Psychiatry in 2007 and World Congress of Psychiatry in 2008 will take place in Prague.

Conclusion

After 1989, psychiatric care provided in the Czech Republic started to change. New social phenomena appeared that required action (more stressful life, an increasing number of people seeking psychiatric care, drug issues, homelessness, unemployment, etc.) but positive modern trends also emerged, as well as new ways of problem-solving and new programmes. The prevailing institutional psychiatric care is already being complemented by community services and by user and family member programmes. At present, we are looking for political and financial support to be able to realise our very concrete plans.