PSYCHIATRY IN CENTRAL EUROPEAN COUNTRIES WITHIN THE PROCESS OF AFFILIATION TO THE EUROPEAN UNION

PSYCHIATRY AND MENTAL HEALTH CARE IN POLAND

J. Bomba
Chair of Psychiatry, Jagiellonian University Collegium Medicum, Krakow, Poland

Psychiatry has been developing in Poland into an independent medical specialty and scientific discipline in a specific context, which resulted in changing connections with German, French and recently English language medicine. The process of deinstitutionalisation started since the 1970s. The mental health care system is based on multiprofessional teamwork. The best developed network of facilities is within the bigger urban centers. Treatment is paid by health insurance, but patients pay themselves (more than 50%) for new psychotropic compounds in outpatient care. The mental health act guarantees free choice of service, treatment in the least oppressive conditions and patient consent. As financing of health care is insufficient, one should expect a movement of young specialists to countries of higher standards. Undergraduate training of physicians includes psychology (behavioral sciences) and psychiatry. A national curriculum adapted to European standards is obligatory for medical schools. Postgraduate training of psychiatrists has been changed in the 1990s into a 5-year residency system. Child and adolescent psychiatry requires additional 2 years of residency training. A national board examination is the final stage of training. A continuous education program is now being organized. Nevertheless, the Polish Psychiatric Association has its own system of credits and sponsors additional training in psychotherapy, forensic psychiatry, and gerontopsychiatry. The main areas of research in psychiatry are neurobiology of cognition, molecular genetics, psychotherapy, family therapy, community psychiatry, epidemiology and psychopharmacology.

PSYCHIATRY OF THE 20TH AND 21ST CENTURY IN HUNGARY : A SHORT HISTORICAL OVERVIEW

E Tury
Institute of Behavioural Sciences, Sernmelweis University, Budapest, Hungary

During the first half of the 20th century, Hungarian psychiatry was intensively influenced by German and French literature. A well-known psychoanalytic school, the so-called Budapest School, was established, its main figure being Sandor Ferenczi, one of Sigmund Freud’s best pupils. Sandor Rado, Géza Roheim and Mihaly Mint were also excellent analysts. In this period a high-level neuropathological/biological research can also he mentioned, e.g. the work of Laszlo Meduna and his cardiazol shock treatment based on neuropathological observations. After the Second World War, psychological sciences were suppressed for several decades. An intensive interest in psychotherapies started in the 1970s and the most important psychotherapeutic methods became known : behavioural therapy, family therapy, hypnotherapy. From the 1980s an intensive and high-level biological trend appeared in research with several international collaborations. After the political change at the beginning of the 1990s, the major psychotherapeutic methods became widespread,with vigorous educational activities. At the same time, pharmacotherapy reached a high level, with the availability of the newest psychotropics. In the last decade an integration of biological and social psychiatry can be observed in Hungary. This can be found also in the education of the residents in a four-year system. In everyday practice, the influence of outpatient care has become strong, and the total number of hospital beds has decreased gradually. Nowadays the main problems may arise from the decreasing prestige of the medical profession, resulting in the emigration of good psychiatrists to West-European countries. The presentation will also address the newest prevention programs in mental health care.

BULGARIAN PSYCHIATRY TODAY

L Jivkov
Municipal Psychiatric Dispensary, Sofia, Bulgaria

We present the current state of psychiatry in Bulgaria after the changes which came into effect in 1990, perceived within the economic and social context of the country. We try to show the relationship between psychiatric tradition and the strategy for changes in psychiatric care, as well as the different points of view for the development of both biological and psychosocial therapeutic approaches. The National Program for Mental Health and the forthcoming changes in the legislation concerning mental health are presented. We also present the current state of the educational system and training process of professionals in psychiatry (psychiatrists and psychiatric nurses), having in mind that the education of nurses has just been evolving. The role of non-governmental organizations like the Bulgarian Psychiatric Association, the Association for Private Psychiatric Practice, the organizations of users of psychiatric care, etc. is discussed. The presentation reviews the existing international relations, including those with the Balkan countries and the conditions for their development.

MENTAL HEALTH REFORMS IN MACEDONIA

A. Novotni
University Clinic of Psychiatry, Medical Faculty, Skopje, Republic of Macedonia

The current situation of the Macedonian society is marked by a longterm economical, political and social crisis, unemployment and poverty. The Macedonian family itself is passing through a transitional period : the traditional (multigenerational) family is being disintegrated, but the modern (nuclear) family is still not socially stable. All these factors indicate the increase of the scope and intensity of psychosocial problems and indirectly mental health issues in our country. Evidence-based data and an organized approach concerning various mental health problems are still missing in Macedonia. The mental health reforms are in the initial phase, trying to implement the transition from the « old » system of working within big psychiatric hospitals to community based mental health services. We will report the initial success in establishing a community based mental health centre in Macedonia.

CURRENT TRENDS IN CZECH PSYCHIATRY

J. Raboch
Department of Psychiatry, Charles University, Prague, Czech Republic

Czech Republic had in the year 2002 10,230,060 inhabitants. The health care budget was 7.4% of the gross domestic product. We estimate that less than 3.9% of the health care budget went into mental health care. 52.2% of this amount went to mental hospitals, 22% was spent for drugs, 15.6% went to out-patient clinics, 9.6% to psychiatric departments of general hospitals. Community care is substantially underfunded. We have 1,154 physicians working in psychiatry (11.5/10,000). Most of them (52.2%) work in out-patients clinics. In the last decade, every year, 50-70 young doctors passed the psychiatric board examination. The system of postgraduate training has recently substantially changed. We have separate training programs for adult psychiatry, child psychiatry, old age psychiatry, drug addiction and sexology. We have 30 psychiatric hospitals with 9,616 beds and 33 psychiatric units in general hospitals with 1,546 beds. The overall number of beds decreased from 14/100,000 in 1990 to 11.1/100,000 in 2002. However, in recent years this trend has stopped. The average length of hospitalisation, despite its decline in the last decade, remains high : 73 days in psychiatric hospitals and 23 days in general hospitals. There are no official statistics regarding community psychiatry. Thanks to the European research project EDEN, we know more about the functioning of the 35 day care centres in our country, which are located mainly in bigger towns and mostly provide psychotherapeutic and rehabilitation activities. Protection of the human rights and dignity of people suffering from mental disorder is a hot topic in our country. The detention process is controlled according to our law by independent courts. Two Prague psychiatric facilities are participating in the European project ECONOMIA, which is mapping coercive treatment measures in psychiatry and is trying to find the best way in clinical practice for this very sensitive part of mental health care.

ROMANIAN PSYCHIATRY : THE CHALLENGES OF PRESENT AND FUTURE

T Udristoiu
University of Medicine and Pharmacy, Craiova, Romania

With an area of 237,500 SqKm and a population of 21.7 million people, Romania is geographically the second biggest country in Central Europe. In 1974 and 1980, two important epidemiological studies have been conducted focusing on psychiatric disorders. These studies have shown a general prevalence of 18.34% and 16.33%, respectively. Several but still rather small scale studies have revealed an almost constant increase of the suicide rate, starting in the early 1980s, but without an accurate evidence concerning the real proportion of this phenomenon at the national level. The offer of psychiatric services inpatient, day-care and outpatient ones – was and still is modest : about 4 psychiatrists/ 100,000 people and 0.7 beds/1,000 patients, with very limited possibilities for supporting and supervising the outpatients. The access of people is further reduced by the concentration of this offer in the capital and the major cities. The main problems of the present are the legacy of the communist period, that has pushed psychiatry aside, the economical situation and the mentality of the people, the medical community and the authorities. Somatic medicine still dominates to the prejudice of our specialty. in 2000, psychiatric care consumed only 3% of the health care expenses. The hegemony of somatic medicine is reflected also in undergraduate and postgraduate psychiatric training. Currently, postgraduate training consists of 28 months of training in psychiatry and 32 months in other specialties. Psychiatric care is currently limited to secondary prevention. which is almost fully based on biological therapy. There is a national rehabilitation program, but it is underfunded, small scale and with almost null results. Also, « by tradition », the quality of the patients life is practically not taken into consideration. Scientific research is addressed mainly to the clinical and therapeutic level and scarcely to the epidemiological level. After 1990, some progress has been made : the informational opportunities, the establishment of associations and publications, the appearance of second generation antipsychotics and antidepressants, the law for mental health and for the protection of the persons with psychiatric disorders, the participation in international multicenter trials. The most important priorities are primary prevention and rehabilitation, the life standards in the psychiatric facilities, the care of chronic and forensic patients, suicide prevention and the institutional management. In order to reach the psychiatric standards of the countries in the European Community we need a clear policy, based on a realistic strategy of implementing the experience of the developed countries and adapting it to our culture with decent financial means.

THE NATIONAL MENTAL HEALTH PROGRAMME IN SLOVAKIA

I. Vavrusova A. Mayer, P Breier, P Nawka, J. Vranova
Department of Psychiatry, University Hospital Ruzinov, Bratislava. Slovak Republic

The National Mental Health Programme, a complex and multisegment programme, has been developed according to the recognition of the situation of mental health care in Slovakia and with the help of the Report of Assessment mission of the World Health Organization WHO). The WHO performed an audit in Slovakia in June 2003 and pointed out some most important topics. Expenditures on mental health are at present only 2% of health budget, a large proportion of the funding goes into psychotropic drug prescription ; there is a lack of substantial communication, cooperation and cofunding from health and social services at ministerial, regional and local levels ; here is an absence of community-based mental health care ; mental health care delivery is heavily influenced by health insurance companies and this imposes limitations on multi-disciplinary cooperation ; there is no adequate implementation of the biopsychosocial approach in medical training programmes ; there is no credible professional psychiatric nurse training ; there is a severe lack of nursing staff in inpatient mental health care ; day hospital functioning is limited by system restrains and shortage of funding. In the National Mental Health Programme detailed plans with time span are proposed. This includes planning of mental health delivery, promotion and prevention strategies. This programme was formulated in collaboration with representatives of mental health professionals, user and family representatives and other relevant non-governmental organizations. The National Mental Health Programme includes national-regional-local participation. It includes a clear description of tasks to be taken by involved ministries and local governments. It includes a timetable of actions for implementation and a statement on resources required for programme implementation. Special attention is given to needs of children and adolescents and of the elderly with mental disorders. A community psychiatry based approach will be developed. The National Mental Health Programme raises awareness, strengths tolerance pluralism and equity for people with mental disorders.

MENTAL HEALTH CARE IN SERBIA AND MONTENEGRO : THE PROBLEM OF REFUGEES

0. Zikic (1), G. Grbesa (1, 2), D. Lecic-Tosevski (2, 3)
(1) School of Medicine, University of Nis ;
(2) National Committee for Mental Health ;
(3) School of Medicine, University of Belgrade, Serbia and Montenegro

War in the region of ex-Yugoslavia has caused the forced migration of a huge number of people. At present, there are 702,000 refugees living in Serbia and Montenegro. Most of them have experienced multiple traumas, which caused significant distress. According to our studies 29.2% of refugees manifest chronic post-traumatic stress disorder, while 40% of them have an adjustment disorder. 1.300 refugee families do not know the destiny of their members. This severe trauma prevents them from completing the process of mourning. In addition to post-traumatic stress disorder, refugees suffer from other mental and somatic disorders, which represent a huge burden for health services of the country. The organization of mental health care has to adjust to specific needs of the refugee population. In a first stage, programs of psychosocial assistance were undertaken by many governmental and non-governmental organizations. Future programs of mental health care for refugees should take care of demographic and cultural specificities of this population, originating from various regions of ex-Yugoslavia. The National Committee for Mental Health has identified the mental health care of refugees in the community as one of the targets, with their social integration as one of the objectives.