COMMUNITY PSYCHIATRY IN THE MEDITERRANEAN REGION AND THE ROLE OF PSYCHIATRIC ASSOCIATIONS

INTRODUCTION TO PSYCHIATRY AND COMMUNITY PSYCHIATRY IN THE MEDITERRANEAN REGION

L. Küey
WPA Zonal Representative, Zone 8

This presentation aims to outline the main issues to be discussed by the representatives of some of the member societies of the WPA Southern European Zone in this symposium. To provide a contextual framework, the socio-cultural characteristics of the region and the situation of psychiatry in these countries will be reviewed. Practice of psychiatry, especially community psychiatry, has been passing through serious changes in the Mediterranean countries. These countries in transition had witnessed many psychiatric reformist movements in the last couple decades, and the psychiatric associations are trying to develop new policies to promote community mental health in the region ; so, the role of the psychiatric societies will also be another issue of concern.

WHO ARE THE PATIENTS IN RESIDENTIAL FACILITIES ? A NATIONAL SURVEY IN ITALY

G. de Girolamo (1), A. Picardi (2), G. Santone (3), R. Micciolo (4), A. Fioritti (5), I. Falloon (6) for the PROGRES group
1 Department of Mental Health, Health Unit of Bologna, Italy,.
2 National Institute of Health, Rome, Italy ; 3Psychiatric Clinic, United Ancona Hospitals and Marche University, Ancona, Italy ;
4 Chair of Statistics, University of Trento, Italy ;
5 Programme on Mental Health and Substance Abuse, Health Unit of Rimini,Italy ;
6 Department of Psychiatry, University of Auckland, New Zealand

In Italy, residential facilities (RFs) have completely replaced mental hospitals for the residential care of mentally ill patients. We studied all patients resident in 265 randomly sampled Italian RFs (20% of the total). Structured interviews focusing on each patient were conducted with the manager of each RF and with staff ; patients were rated with the Health of the Nations Outcome Scales (HoNOS) and Global Assessment of Functioning (GAF), and their physical disabilities were evaluated. Of the 2,962 patients living in the sampled facilities, most were males (63.2%) who had never been married, more than 70% over 40 years of age ; 85% had a pension, most commonly because of a psychiatric disability, A substantial proportion (39.8%) had never worked and very few were currently employed (2.5%) ; 45% of the sample was totally inactive, and was not involved in domestic activities in the facility. Two-thirds had a diagnosis of schizophrenia ; dual diagnoses and primary substance abuse were uncommon. Twenty-one percent had a history of severe interpersonal violence, but episodes of violent behaviours in the RFs were infrequent. The managers judged almost three-quarters appropriately placed in the facilities and considered that only few had prospects of discharge. In conclusion, Italian RFs provide care to a large patient population of severely mentally ill requiring residential care. Discharge to independent accommodation is uncommon. Future studies should try to identify the best match between RF programs and patients’ disabilities.

TOWARDS COMMUNITY PSYCHIATRY IN ISRAEL : DIRECTIONS, HOPES AND OBSTACLES

Z. Zemishlany
Israeli Psychiatric Association

We are living in an era of rapid changes, which do not spare the health care system, including mental health. The world has become much more interconnected, leading to developments which frequently are global in nature. Therefore, when considering directions for mental health care in the Mediterranean Region and Israel, we should be aware of processes worldwide. The yearly World Health Organization (WHO) report released in 2001 contains, for the first time, an extensive section devoted to mental health. The report’s consensus ivas that there is no health without mental health. It is recommended that mental health services should be based on community care close to home. including admission to general hospitals. In the Israeli mental health system of 2004, the WHO recommendations are far from being implemented. Body and mind are still separated as the national insurance act does not include mental health yet. Mental health care is under the responsibility of the government (Ministry of Health). The mental health system is not integrated in the primary care system and the proportion of psychiatric beds located in general hospitals is only 4.8%. The rest are located in psychiatric hospitals. This discrimination between the general health system and the mental health system contributes to the stigmatization of mental patients. The Israeli Psychiatric Association (IPA) is committed to promote psychiatric care in line with the global changes and directions. The IPA is currently highly involved in two reforms in order to promote community psychiatry. The first is the health insurance reform : mental health should be included in the National Health Insurance Law and the Health Funds should take responsibility for mental health as in other medical fields. This may enable the psychiatric patients to be under the care of the general practitioner in continuity with the psychiatric hospital. The obstacles for the initiation of this reform are budget issues and disagreements between the Ministry of Health and the Health Funds. The second reform is the « structural » one : resources should be transferred from the psychiatric hospitals to the community. This includes a 50% reduction of psychiatric beds (to 0.45 beds per 1000), shortening of hospitalization days to 33 days in average and developing a network of hostels, rehabilitation centers and outpatient clinics in the community. This reform is on its way. We believe that these two reforms are linked and should be performed in parallel. The availability of the psychiatric community services and their links to the general health care system would increase compliance and reduce recurrence, readmissions and the stigma of patients suffering from psychiatric disorders.

PSYCHIATRY IN GREECE : ADVANCES, PROBLEMS AND PERSPECTIVES

G.N. Christodoulou, V Alevizos, D. Anagnostopoulos, V Kontaxakis
Hellenic Psychiatric Association

Public psychiatry in Greece is currently in a transitional period from the traditional inpatient management to community psychiatry. Attempts aiming at this transformation have occurred in the 1950s with, for instance, the establishment of the mental health center (which later has developed into the most extensive service facility for outpatients in Greece), but the most systematic interventions have been carried out since the 1980s, with an extensive reform implemented with local and European Union funding. As a result of these interventions, the total number of inpatients in Greek public mental hospitals from 1984 to 2004 has decreased and this has been associated with increase in extramural facilities. Much remains to be done with respect to primary care, creation of alliances in the community, mental health promotion and qualitative improvement of extramural services.

PSYCHIATRY, COMMUNITY PSYCHIATRY AND THE ROLE OF PSYCHIATRIC ASSOCIATIONS IN TURKEY

P Gökalp (1), B. Ulug2, L. Küey (3)
1 Turkish Neuropsychiatric Society,
2 Psychiatric Association of Turkey
3 WPA Zonal Representative. Zone 8

In this presentation, the mental health profile of Turkey, a country which is not only a geographical bridge between Asia and Europe, but also faces the challenge of belonging to cast and west at the same time, will be reviewed. After outlining the socio-demographic, socio-economic, and cultural characteristics of the society, basic data reflecting the general health status of the population will be provided. The epidemiology of psychiatric disorders. and the financial, institutional and human resources in the mental health field, along with the relevant policies, research and training activities, will be discussed. The negative effects of the lack of a national mental health program, particularly on the issues of community psychiatry, will be underlined. As a conclusion, the psychiatric associations, in respect to their roles in the development of mental health policy and programs, the improvement of professional collaboration, and the Promotion of mental health, will be discussed.

PSYCHIATRY IN SPAIN : THE REAL MANAGEMENT OF THE CHRONIC DISORDERS

M. Roca (1), L. Caballero (2)
1 Hospital Juan March, University of Balearic Islands, Palma de Mallorca
2 Hospital Puerta de Hierro, Madrid, Spain

Is there any evidence of a new approach in the Mediterranean psychiatry after the implementation of community psychiatry ? To discuss this question we studied the clinical management of chronic mental disorders in Spain, a Mediterranean country with a public health system that covers 98% of the population. We conducted a descriptive, cross-sectional, multi-centered study in outpatient mental health centers and private offices. A total of 500 psychiatrists recruited 1969 patients with a primary diagnosis of schizophrenia. Our objective was to find the real provided care of a large population sample of schizophrenic patients in order to identify actual needs and future directions to provide an adequate health care.

COMMUNITY PSYCHIATRY IN CYPRUS

Y Kalakoutas
Psychiatric Association of Cyprus

In Cyprus, psychiatric reform was introduced in an organised form in 1996. The objective was to move from the medical asylum model of therapy to the biopsychosocial one and the provision of services from the mental hospital to the community. During these years the number of inpatients has decreased from 436 in 1992 to 130 in 2003. A network of community mental health services has been developed all over the island for the management and follow-up of patients in the community securing the continuity of management. Day centres have been established and multidisciplinary teams are actively involved both in the management of cases and in the introduction of mental health promoting programs.