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International Psychiatry logoLink to International Psychiatry
. 2013 Feb 1;10(1):3–5.

The financial crisis and the future of mental health in Greece

Nikos G Christodoulou 1, Dimitris C Anagnostopoulos 2
PMCID: PMC6735103  PMID: 31507710

Abstract

The recent financial crisis in Greece has affected the mental health of the population as well as mental health service provision and planning. These new adverse circumstances call for the profession’s swift response. In this paper we make evidence-based suggestions for urgent, as well as longer-term, mental health reform. We consider psychiatric prevention and mental health promotion to be the central principles to abide by in the long term. We also offer suggestions for important current issues, including the devolution and coordination of decision-making, the further development of community psychiatry and the implementation of sectorisation, support for service user involvement, the reform of psychiatric education and the creative integration of mental health service provision with Greek culture. We conclude that enhanced participation of the profession in decision-making and service planning can result in cost-effective, evidence-based reform.


In recent years Greece has been experiencing a financial catastrophe, which has already affected mental health service provision and the mental health of the population. The financial crisis has primarily affected the most vulnerable members of Greek society, people with mental illness being among those worst hit (Christodoulou & Christodoulou, 2013). Studies show an association between income reduction and out-patient visits, acute psychiatric referrals, suicide rates, homicide rates, divorce rates and death rates (Giotakos et al, 2011; Kentikelenis et al, 2011).

The current state of the Greek mental health system

There is an ongoing mental health reform in Greece, for which credit is due; deinstitutionalisation and the development of community services have progressed (Christodoulou et al, 2011). In addition, attitudes have changed; mental health promotion, anti-stigma and a person-centred approach have been promoted and incorporated in the ethos of mental health service provision (Christodoulou et al, 2010; Thornicroft et al, 2011).

However, there are still important challenges in the development and management of mental health services. Underfunding has been a threat to reformed services since before the recent financial downturn, and effective reinstitutionalisation beckons. Similarly, sectorisation and the development of mental health trusts have not been implemented adequately, rendering the reform incomplete (Christodoulou et al, 2012). Additionally, there are deficits in service coordination and planning, equitable resource allocation, clinical governance and quality assurance. There is also sparse epidemiological evidence to guide evidence-based service development (Thornicroft et al, 2011).

Suggestions on the management of mental health in Greece in view of the financial crisis

Urgent priorities

Urgent priorities for mental health at the moment include raising awareness of crisis-associated psychiatric morbidity factors. For instance, in view of the alarming increase in unemployment – which reached 25.4% in August 2012 (and 32.9% for those aged 24–35) (Hellenic Statistical Authority, http://www.statistics.gr) – policy-makers need to be made aware of the potential link between unemployment and suicide (Stuckler et al, 2009). Also, the effect of the rapid dissolution of the social matrix on the mental health of the population needs to be stressed (e.g. the increase in borderline behaviours observed in young people).

Importantly, we need to avoid the de facto reinstitutionalisation of chronic patients, and ensure basic care (medications and service access) for community patients. The rash removal of the autonomy of mental health services needs to be challenged.

Meaningful reform, not just cuts

There is a real need for further mental health reform in Greece and cost improvements are a pragmatic necessity. The profession’s duty is to ensure that there is cooperation between the profession and policy-makers and that rational, evidence-based policies are implemented. We also need to safeguard a political commitment to mental health and to ensure savings are reinvested in mental health rather than used elsewhere (e.g. for debt servicing).

Advocacy and representation

People with mental illness who cannot voice their concerns or defend their rights are easy targets for austerity policies. Our profession has to facilitate effective advocacy for them. The suggested development (Thornicroft et al, 2011) of relevant psychiatric subspecialties (e.g. intellectual disabilities, old age psychiatry) should sustain representation for these groups in the future. The involvement of persons with mental illness and their families in mental health service governance can be supported by the Hellenic Psychiatric Association.

Devolution and coordination

A recent evaluation report on psychiatric reform in Greece yielded two useful findings: firstly, it confirmed that mental health workers in Greece have good leadership skills; secondly, it ascertained that central coordination is deficient (Thornicroft et al, 2011). These two facts suggest that administrative devolution from central government to local mental health authorities may have several benefits, including the introduction of an effective accountability framework, quality assurance and locally relevant service development. Crucially, cost-effective resource allocation and equitable budgeting can start taking place. It needs to be stressed that the success of future service development depends on its disentanglement from political confounders.

The organisational and coordinating role of the Hellenic Psychiatric Association needs to be reinforced at this critical conjuncture. In addition to educational responsibilities, it needs to enhance its role as the government’s scientific advisor and increase its leverage on reform decision-making and planning.

Taking advantage of Greece’s culture

Greek society has traditionally depended on local communities and the family institution for mental healthcare in the community. Supporting this model of community mental healthcare has many advantages: carer empowerment and increased advocacy, cost-effectiveness and stigma reduction are just a few. Nevertheless, there are significant barriers to its implementation. Firstly, the family institution is itself in crisis at the moment due to an increasingly ‘Western’ way of life. Secondly, the family is a dynamic part of society and is therefore also affected by the current crisis (Anagnostopoulos & Soumaki, 2011). Lastly, moral support is not enough; considerable financial investment in this model is required.

Another traditional institution of Greek society, the Church, caters for niche populations and is often the first port of call when mental illness emerges. Priests have developed their own pastoral therapeutic approach when dealing with mental illness, but need the contribution of informed mental health professionals in order to ensure the delivery of safe and holistic care.

Prevention of mental illness and promotion of mental health (preventive psychiatry)

Probably the most important mental health principle for Greece to commit to at this critical conjuncture is that of preventive psychiatry. In recent years it has become clear not only that preventive psychiatry is imperative from an ethical point of view, but also that it has a robust evidence base to support its effectiveness. It is our profession’s duty to persuade policy-makers that the prevention of mental illness and promotion of mental health are not just important, but necessary, even if their results may not be immediately tangible. Using humanitarian arguments, for example the transgenerational effects of the crisis on the mental health of children, is probably not enough to persuade policy-makers. Thankfully, we can now speak the policy-makers’ language in doing so, as preventive psychiatry has been shown to be cost-effective and has already been endorsed by the World Health Organization (2004) and the European Parliament (2009).

Preventive psychiatry is sometimes difficult to advocate, given that preventive policies are broad and may often lie outside the remit of mental health. For instance, if we assume that the inequality gap is a causal factor in mental illness (Pickett & Wilkinson, 2010), then tackling the gap would be a valid preventive strategy; but is it the role of psychiatry to promote social justice and socialist ideas? Or, similarly, if we assume that a society’s maladies are a causal factor, then would it be our duty as a profession to promote a change of political culture? Professional humility demands further debate on these roles.

From a service development point of view, primary care mental health services would be the best platform for preventive psychiatry in Greece, particularly for younger people (Anagnostopoulos & Soumaki, 2011).

Education, specialisation, revalidation

The reform of psychiatric training is long overdue in Greece. Responsibility for quality assurance for the professional development of psychiatrists should lie with the scientific advisor of the government (i.e. the Hellenic Psychiatric Association). Quality assurance should begin with meritocratic recruitment for specialist training, extend to certification of specialist training and expand longitudinally beyond that to professional revalidation. Such a reform would be cost-effective and ultimately benefit service users.

A final word on optimism

The Chinese term for crisis (Wai Chi) means ‘danger and opportunity’. On the other hand, ‘crisis’ is etymologically a Greek word meaning ‘judgement’ (hence the uses of ‘critical’ in English). The Sino-Hellenic confluence yields an optimistic message: with good judgement, crisis can be turned into opportunity.

It is our profession’s duty to exercise leadership and prudence (Aristotelian phronesis) in delivering this good judgement, by suggesting evidence-based, rational change. There is no doubt that change is needed in mental health in Greece, and this may be the best time to make it happen.

References

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