Country Reports
Implementation of Mental Health Promotion and Prevention Policies and Strategies in the EU member states and appplicant countries
(EMIP)
Volume II
Austria
3 Gerlinde Rohrauer1 EMIP Project - National Coordinator Fonds Gesundes Österreich (Austrian Health Promotion Foundation) Mariahilferstraße 176 1150 Vienna E-Mail Mail: [email protected]
Report on the
Expert workshop on “Mental Health – Health Promotion and Prevention Strategies in Austria”
as part of the project
“Implementation of Mental Health Promotion and Prevention Policies and Strategies in EU Member States and Applicant Countries (EMIP)”
Vienna, 17. February 2006
1 Thanks to Christian Scharinger and Christina Dietscher for inputs and comments on this report 4 Table of Contents
1. Introduction ...... 6
2. Facts and figures about mental health...... 6
2.1 Epidemiological data...... 6
2.2 Workforce for mental health...... 7
3. Organisations, policies and legislation in the field of MHP/MDP...... 8
3.1 Organisations in the field of MHP/MDP ...... 8
3.2 MHP/MDP policies and programmes ...... 10
3.3 Legislation related to health promotion and prevention ...... 10
4. Expert workshop on mental health in Austria ...... 11
4.1 Preparation...... 11
4.2 Implementation ...... 11
4.3 Working group results ...... 14
A Early childhood, family, parenting...... 14
B School and out-of-school setting ...... 15
C Workplace setting ...... 16
D Healthy ageing...... 17
E Addiction prevention ...... 18
F Mental disorder prevention and reduction of discrimination and stigma...... 19
G Research, education and further training in the field of MHP in Austria ...... 20
5. Summary and outlook...... 22
6. List of participants ...... 24
7. References ...... 27
5
1. Introduction
This report is intended to provide an overview of the field of Mental Health Promotion (MHP) and Mental Disorders Prevention (MDP) in Austria, and documents the results of the expert workshop “Mental Health – Health Promotion and Prevention Strategies in Austria“. This national workshop was held in Vienna on 7 November 2005 within the framework of the project “EMIP - Implementation of Mental Health Promotion and Prevention Policies and Strategies in EU Member States and Applicant Countries“ by the Austrian Health Promotion Foundation (FGÖ) and in collaboration with the Ludwig Boltzmann Institute for the Sociology of Health and Medicine/WHO Collaborating Centre for Health Promotion in Hospitals and Health Care (Prof. Pelikan, Christina Dietscher).
2. Facts and figures about mental health
Below is a short overview of facts and figures which, owing to a lack of data on dimensions of positive mental health, is based primarily on mental disorders statistics. For a comprehensive treatment please consult the reports cited (especially the reports issued by the Federal Ministry for Health and Women and Statistics Austria). In addition, the professional workforce involved in the field of MHP and MDP is listed below.
Epidemiological data
Only sparse information is available on the epidemiology of mental disorders in Austria. According to a representative health survey (General Health Questionnaire – GHQ-12) conducted in 1991, which gathered information on psychological complaints, among other things, 16.3 % of the Austrian population experienced anxiety or symptoms of depression within a four-week period, with the percentage of women affected (17.5 %) somewhat higher than that of men (15.1 %).1
In a survey assessing people’s experience of mental health that was conducted in the European countries in 2003 (Eurobarometer 58.2), 21.2 % of the Austrian women and 17 % of men reported experiencing mental health problems. 64.3 % of the Austrian men and 62.1 of women reported psychological wellbeing, measured by the energy and vitality scale (EVI)”.2
WHO’s Health Behaviour in School-Aged Children study reports the incidence of psychological and/or psychosomatic complaints among young people at the ages of 11, 13 and 15. According to the study’s results, between one-fourth and one-third of Austrian schoolchildren regularly suffer from headaches, irritability, nervousness and insomnia. Nearly half (45%) of schoolchildren experience tiredness and/or exhaustion.3
6 Austria’s suicide rate has traditionally been high, although it has dropped significantly since 1986, when it had reached a level of more than 28 per 100,000 inhabitants. Since 1997 it has remained below 20 per 100,000, for the first time since 1945.1 In 2004 the rate was 17 per 100,000 inhabitants.4
Statistics on the utilization of hospital beds offer an indication of the prevalence of mental disorders. In 2002 ten percent of all 2.3 million episodes of in-patient episodes in Austria result in a psychiatric diagnosis (episodes with and without psychiatric diagnosis as main diagnosis). The absolute number of discharges with a psychiatric diagnosis rose considerably between 1996 (155,922) and 2002 (233,853) (+50%), while the percentage of such discharges relative to all hospital discharges increased from 7.8% to 10.1%. For 4.6% of all discharges a psychiatric diagnosis was reported as the main diagnosis (approximately one in twenty discharges). This percentage remained nearly unchanged between 1997 and 2002, with levels of 4.6% and 4.8%.5
After musculoskeletal diseases, psychiatric disorders are the most common causes of illness-related retirement in Austria. Some 19 % of all early retirements among women and men are the result of psychiatric disorders.1
Between 1990 and 1999, psychiatric disorders as a cause of sickness leave days increased by 50% (from 307 to 460 sickness leave days per 1,000 workers), while most other illness categories declined slightly as a cause of sickness leave days.1
Apart from statistics of in-patient episodes or work disability records, no regular, systematic data are available for mental disorders.
In the past few years a sizeable increase in expenditure for psychotropic drugs in Austria has been observed. In 2003 these drugs accounted for costs of 187 million Euro in Austria (data from social insurance institutions), since 1995 the cost have increased by just under a factor of three. Doctors in private practice prescribed psychotropic drugs some 7 million times in 2003, primarily antidepressants (53%) and tranquilisers (22%), followed by neuroleptics at 15%. Over the last 10 years tranquiliser prescriptions have declined, while prescriptions for antidepressants have increased dramatically. Expenditures for health insurance funded psychotherapy have also risen substantially, amounting to some 38 million Euro in 2003, while spending on psychotropic drugs by the statutory health insurance companies amounts to five times that figure.5
Workforce for mental health
A variety of different professions are involved in activities related to mental health promotion/mental disorder, which does not mean, though, that there is any common self- understanding of the involved professional groups as a “mental health promotion/prevention workforce”. The most important occupational groups are the following (based on a summary by Dietscher & Pelikan6, for a comprehensive summary see also Katschnig1):
7
• Psychologists: Since 1991, there is the state certified profession of “clinical” and “health” psychologists. There were 3,902 clinical and health psychologists registered in Austria in 20021. • Psychotherapists: The psychotherapy act (1991) regulates training of psychotherapists and the possibility for reimbursement of psychotherapeutic care by health insurance in some cases. In 2002, there were 5,632 trained psychotherapists (a ratio of 7 per 10,000 population)1. • Psychiatrists: In 2002, Austria had 893 certified psychiatrists (which is one per 9,000 inhabitants)1. • Psychiatric nurses (a specific nursing diploma which is available since 1997).
Further important professions include occupational health experts and centres, occupational psychologists, social workers, teachers, health scientists and public health experts. However, it is difficult to determine the extent to which members of these groups are involved in the field of MHP/MDP.6
3. Organisations, policies and legislation in the field of MHP/MDP
Organisations in the field of MHP/MDP
Dietscher and Pelikan6 have compiled a list of relevant organisations concerned with the development of policies and programmes in the field of MHP/MDP. They noted, however, that given the federal system in Austria where many responsibilities rest with the nine Austrian regions, it is almost impossible to provide a complete list of the relevant involved players.
“On the policy level, at least four Austrian ministries are of relevance: • Federal Ministry for Health and Women: responsible for treatment oriented aspects of MHP and MDP, including co-operation between health care sectors, but also for health promotion; • Federal Ministry for Social Affairs and Generations: responsible for policies and programmes for families, for youth work outside schools, for specific risks groups, and for senior citizens; • Federal Ministry for Education, Sciences and Culture: responsible for policies and programmes in schools; • Federal Ministry of Justice: responsible for policies and programmes like “probation support” for delinquents, “therapy instead of penalty” for drug addicts.”
At the level of implementation, the Austrian Health Promotion Foundation (FGÖ), gets available € 7,25 million annually (based on the Health Promotion Act from 1998) for funding activities and projects in the field of health promotion and comprehensive primary prevention in Austria. “Mental health“ is one of the priority topics in the current three-year programme.7
8 In the federal states, there are six organisations that regionally implement prevention and health promotion programmes and projects (aks Vorarlberg, avomed Tirol, AVOS Salzburg, PGA Oberösterreich, Gesundheitsforum Niederösterreich and Styria vitalis). These six organisations have joined together to form the “Forum österreichischer Gesundheitsarbeitskreise“ (aks Austria) [Forum of Austrian Working Groups on Health], which sees its role as providing an active contact for institutions that initiate nationwide activities to promote health.8
In the field of addiction prevention there exists a institutionalised, statute-based cooperation in the form of the Bundesdrogenforum [Federal Drug Forum]. Every Austrian state has an office whose primary responsibility is addiction prevention and which is responsible for putting in place interventions to prevent addiction as well as, in most cases, coordinating such activities. These offices have joined together in a voluntary association called the Österreichische Arbeitsgemeinschaft Suchtvorbeugung (ARGE Suchtvorbeugung) [Austrian Working Group for Addiction Prevention].9
Several social health insurance institutions (e.g. OÖGKK, SGKK, KGKK and VAEB in Styria) play a major role in health promotion and primary prevention.
Austrian health promotion networks (cities and communities, hospitals, schools, workplaces) carry out at least some activities in the area of MHP/MDP.6
Throughout Austria, a number of NGOs (pastoral care, associations, foundations, self help groups, and others) conduct activities related to MHP/MDP.6 Particular mention should be made “pro mente” and “Caritas”. Both of these organisations are active in all of Austria’s federal states.
Self-help organisations are well on the way toward establishing themselves in the field of mental health. Particular mention should be made of the following federal-level associations in Austria: HPE-Österreich (providing aid to family and friends of people suffering from mental illness), “Club D & A“ (society to encourage self-help for depression and anxiety states) as well as the association for “families of persons suffering from Alzheimer’s disease and dementia in Austria“ (AAA).10
There is a substantial need for research and training in Austria. The field of public health is becoming established in the Universities of Graz and Vienna; some “universities of applied sciences” are also offering training in health management. It is unclear what role MHP and MDP play in this context. Research is conducted at the Klinische Abteilung für Sozialpsychiatrie und Evaluationsforschung [Clinical Department of Social Psychiatry and Evaluation Research] (Medical University of Vienna), the Ludwig Boltzmann Institut für Medizin- und Gesundheitssoziologie [Ludwig Boltzmann Institute for the Sociology of Health and Medicine] at the University of Vienna, the Research Institute of the Vienna Red Cross, the European Centre for Social Welfare Policy and Research, and the Institute for Social Medicine and Epidemiology in Graz, amongst others.
9 MHP/MDP policies and programmes
There are no specific national policies on MHP and MDP in Austria. However, several policies address a range of areas concerning the promotion of MHP or MDP; similarly, in the area of implementation there are numerous relevant activities/programmes, although they are not explicitly associated with the field of health promotion or with MHP or MDP.
An initial description of these policies and programmes may be found in Dietscher & Pelikan (2005).6
Legislation related to health promotion and prevention
Since 1998 Austria has a law on promoting health (BGBl. No. 51/1998).11 The Austrian Health Promotion Act (federal law on measures and initiatives to promote health and provide health education and information) is based on a comprehensive view of health and the principles contained in the Ottawa Charter of the World Health Organisation (WHO, 1986). The Austrian Health Promotion Foundation (FGÖ) was charged with the implementation of this law. The work of the Austrian Health Promotion Foundation consists in funding practical and scientific projects, the creation of structures for health promotion, the provision and support of initial and continuing training and education offerings, networking, information and public education.
Furthermore, health promotion and prevention are defined in the Allgemeines Sozialversicherungsgesetz [general law on social insurance] as services to be financed through the social insurance system. Prevention in problem areas specific to young people is regulated by the Jugendförderungsgesetz [law providing support for young people] while prevention and health promotion for workers are regulated by the ArbeitnehmerInnenschutzgesetz [labour protection law]. However, none of these laws explicitly refers to MHP/MDP.
Regulations governing the training of physicians, psychologists, health care workers and nurses include health promotion and prevention as areas with which these occupations are concerned.
An additional legal framework for health promotion is found in the statutory agreement on the organisation and financing of the health care system (Art.15a B-VG [Federal Constitutional Law]). This agreement between the federal government and the states, valid for a respective period of four years, defined health promotion as a responsibility of the health care system for the period 2005-2008. The preamble to the agreement explicitly mentions the importance of health promotion. The states are required to set up health funds to carry out their responsibilities under this agreement. Moreover, specific reference is made to developing projects to promote health, although no further detail is given on their content. Parallel to the agreement on financing, in 2005 the Qualitätsgesetz [health quality law] was drawn up requiring health services to be provided in an “environment supportive for health”.
10 4. Expert workshop on mental health in Austria
Preparation
Since not only health promotion and prevention in general, but MHP and MDP in particular are extremely complex and diverse fields, the overall subject was broken down into specific target groups and settings, with seven topics to be addressed by working groups.
The policy document “Mental Health Promotion and Mental Disorder Prevention – A Policy for Europe“12 as well as the European Action Plan for Mental Health13 and WHO’s European Declaration on Mental Health14 served as a basis for selecting these topics.
Moderators with concrete knowledge and experience in their respective areas were chosen to provide some initial input on the subject matter and lead the discussions.
Information on the EMIP project was provided to the moderators; they were given a briefing paper containing relevant questions from the EMIP Manual for the purpose of carrying out a “mapping exercise“ as well as a number of documents on MHP and MDP at the European and international levels.
After a preliminary list had been drawn up, experts and the moderators of the working groups were asked to name relevant specialists who might be appropriate participants in the workshop. About 160 people were invited to participate.
Implementation
A one-day expert workshop entitled “Mental Health – Health Promotion and Prevention Strategies in Austria“ was held on 7 November 2005 in Vienna. Its aim was to develop a profile of the current status of MHP and MDP in Austria and to define relevant action areas in this field.
Following welcoming statements by Mr. Dennis Beck, Managing Director of the Austrian Health Promotion Foundation (FGÖ), and Ms. Gerlinde Rohrauer, FGÖ specialist in the area of mental health, Prof. Pelikan and Ms. Dietscher, introduced the subject matter of the workshop with their talk on “Mental Health Promotion as a Chance and Challenge – European and Austrian Perspectives“. Dr. Regula Rička of the Federal Ministry for Health in Bern reported on the development of a national mental health promotion strategy in Switzerland.
Following these talks the seven working groups were convened. The moderators first offered an introduction on the topics, then the current status of MHP and MDP was discussed and an analysis of strengths and weaknesses was carried out. Steps were identified to further MHP and MDP in Austria. The results of the working groups were presented in the final plenary session.
11 Documents such as the European Action Plan for Mental Health, the European Declaration on Mental Health and the IMHPA document “Mental Health Promotion and Mental Disorder Prevention: A Policy for Europe“ were made available to the participants.
A total of 63 participants were involved in the working groups, with backgrounds that can be classified roughly as follows:
• Health promotion networks • Representatives of occupational groups (psychologists) • Organisations for health promotion and prevention in the federal states (aks Austria) • State governments and/or departments • Spokespersons on health for the political parties • Institutions for addiction prevention • Health insurance institutions • Research institutions in the fields of public health/health promotion, psychology, social medicine, psychiatry • Providers of services aimed at health promotion • Women’s health centres • Self-help organisations • Chamber of Labour • NGOs in the social and health fields
The workshop’s agenda was organised as follows:
12 Expert Workshop on Mental Health
Welcome 10:00 a.m. Dennis Beck, Managing Director, Austrian Health Promotion Foundation
Gerlinde Rohrauer, Austrian Health Promotion Foundation
10:15 a.m. Mental Health Promotion as a Chance and Challenge for Health Promotion – European and Austrian Perspectives Prof. Dr. Jürgen Pelikan/Christina Dietscher, Ludwig Boltzmann Institute for the Sociology of Health and Medicine
Development of a national strategy to protect, promote, maintain and restore mental health for the people of Switzerland Dr. Regula Rička, Federal Office of Health, Bern
11:30 a.m. Working Groups on Mental Health
A Early Childhood, Family, Parenting Moderator: Prof. A. Rotraud Perner, Institut für Stressprophylaxe und Salutogenese
B School Setting and Community-Based Youth Work Moderator: Gerald Koller, Büro VITAL
C Workplace Setting Moderator: Dr. Thomas Diller, AVOS Arbeitskreis für Vorsorgemedizin, Salzburg
D Healthy Ageing Moderator: Karin Reis-Klingspiegl, M.A., Styria vitalis, Institut für Sozialmedizin und Epidemiologie, Medical University of Graz
E Addiction Prevention Moderator: Martin Hefel, Stiftung Maria Ebene
F Preventing Mental Disorders and Reducing Discrimination and Stigma Moderator: Dr. Werner Schöny, Landes-Nervenklinik Linz, pro mente austria
G Research, Education and Training in the Field of Mental Health Promotion in Austria Moderator: Dr. Maria Schmidt-Leitner, MPH, MSC
12:30–1:30 Lunch p.m.
1:30–3:30 Working groups p.m.
4:00-5:00 p.m. Summary, conclusion
13
Working group results
Each of the moderators provided a short report of the working group’s results. The limited scope of this report permits only an abbreviated version of their findings. The complete and unabridged versions may be accessed on the home page of the Austrian Health Promotion Foundation (http://www.fgoe.org/der-fonds/inhaltliche-schwerpunkte/seelische-gesundheit). A list of the experts who participated in the various working groups is found in the Appendix.
A Early childhood, family, parenting
Moderation and report: Prof. A. Rotraud Perner
In the working group on “Early childhood, family, parenting“ the focus was on defining action areas. There was little discussion of the status quo, perhaps because there are few MHP or MDP programmes relating to family, parenting and early childhood. According to Dietscher & Pelikan,6 MHP and/or MDP activities in this context include courses for parents financed by the Ministry for Social Affairs; the option for specifically vulnerable expecting mothers to give birth anonymously, which was decriminalised when the penal law was changed in 2001; support and counseling for socially disadvantaged families provided by youth welfare institutions; and a project in Vienna to prevent postpartum depression. In the area of addiction prevention, mention should be made of the project “Spielzeugfreier Kindergarten” [Preschool without toys], which has been implemented in the preschool setting.15
The following action areas/developmental steps were identified:
• (Male-appropriate) training courses for parents, grandparents, experts in working with parents, others (members of the clergy, politicians) • Particular attention should be paid to migrants • Standardisation of training of preschool teachers (EU standard) • Healthy communities and relevant associations should be encouraged to set priorities (in this field) • PR and media relations, videos, informational forums, brainstorming competitions • Models of good practice should be put into practice • Assignment of relevant thesis and dissertation topics • Development of a best-practice book • Support for the adoption of a national action plan
14 B School and out-of-school setting
Moderation and report: Gerald Koller
The analysis of the status quo by the working group on “School and out-of-school setting“ showed that the informal educational sector – i.e., youth work and youth welfare outside the school setting – is strongly represented in the area of preventive interventions. Programs offered by a variety of social-work institutions are available to provide help to children and youth with psychological problems. The Austrian states’ departments of youth affairs have a long tradition of devoting portions of their support programmes for children and youth to preventive goals (addiction and violence prevention programmes, sect prevention, sex education). For a number of years the youth section of the Federal Ministry for Social Security and Generations has emphasised peer group education. With regard to MDP in the school setting, particular mention was made of the offices for school psychology that are found throughout Austria, as well as the work of advisor-teachers who devote themselves to the mental health of needy pupils or young people seeking advice.
In the area of promotion, the school setting in particular has already launched a number of initiatives. The programme “Health Promoting Schools“ represents a focus of such promotion efforts. More action is needed to develop social and environmental conditions and settings which are supportive for mental health.
The following action areas/developmental steps were identified:
• Structured programmes need to address the specific needs of various groups. • Helping institutions are not yet available in enough locations. • Culture-specific problems require the development of specific strategies (for example in the area of migration). • In the gender area, particular attention should be paid to working with boys and men. • Projects should be set up in intermediate and secondary as well as elementary schools. • It should be examined whether the content and methods of MHP projects address the determinants of health in terms of the social and environmental conditions which impact on health and if the projects are sustainable. • Certain spheres of society need to be provided with information to make them aware of their responsibility for and contribution to mental health. • Standards must be developed in both the political and the educational sphere. • The importance of cultural conditions for mental health should also be emphasised by the media. • Solid structures ensure long-term efforts to promote the mental health of children and youth. • In order to promote mental health, the workplace climate must nurture the mental health of those working there. • The main goal is to establish intersectoral networks and to link decision makers and actors: E.g. there are few links between the formal and informal educational sectors.
15 Labour-market services targeted toward specific groups as well as measures to support trainees are associated with labour sector rather than the educational sector. Therefore the working group recommends action that brings these sectors together under the heading “Lebenswelten Jugendlicher” [life-worlds of adolescents].
C Workplace setting
Moderation and report: Dr. Thomas Diller
The analysis of the working group “Workplace setting“ shows that many Austrian companies have ongoing projects to promote health, supported by the Österreichisches Netzwerk betrieblicher Gesundheitsförderung [Austrian Network for Workplace Health Promotion] and largely co-funded by the Austrian Health Promotion Foundation, all of which address aspects of mental health, even if they are not the primary focus. Quality-tested instruments and collections of good-practice standards are available through the network. In addition to the important and increasingly established activities of the network supported by the health insurance companies, concentrated efforts are being made to improve mental health in the context of labour protection. One significant positive development, among others, was the reform of the labour protection law (Arbeitsschutzgesetz), which made it possible to engage organisational psychologists within the prescribed prevention periods. In practice, however, acceptance of context- oriented work performed by organisational psychologists is slow in coming.
The working group identified a barrier in the split between “labour protection” and “workplace health promotion” which is caused by the Austrian laws. This split leads to a lack of cooperation between the two areas. Limited funds and a negative attitude toward the “psyche” as a topic were also mentioned as problems in the workplace setting.
The following action areas/steps for development were defined:
Practical tools and process designs exist; experiences and examples of good practice have been collected. A wider public needs to be made aware of this know-how through • an organised exchange of experiences; • the development and expansion of inter-company networks; • promotion of models of good practice; • a demonstration of the effectiveness of health promotion interventions by providing statistics and facts, thus raising consciousness.
• With regard to services in the area of workplace health promotion, more transparency is needed; in addition, it is important to develop and consolidate certain quality criteria. It would be helpful to have multi-professional providers. • The legal provisions governing labour protection should serve as a basis for activities in the area of workplace health promotion, and experts in this field should be included in such activities.
16 D Healthy ageing
Moderation and report: Karin Reis-Klingspiegl, M.A.
The working group on “Healthy ageing“ took stock of the organisations and institutions that are implementing concrete projects for healthy ageing as well as the studies that have addressed this topic in Austria. Some health promotion projects on “healthy ageing in the workplace“ are currently underway, such as those conducted by the IBG Vienna (Institut für humanökologische Unternehmensführung) [Institute for Human Ecological Business Management], ZSI (Zentrum für soziale Innovation) [Centre for Social Innovation), the partners ÖSB (ÖSB Consulting GmbH), pro mente, the Research Institute of the Vienna Red Cross (“Stressimpact”) as well as AUVA (EQUAL project AEIOU on life-long learning).
There are also individual regional health promotion projects dealing with the issue of “healthy ageing“. These include, for example, the models of good practice “Plan 60“ and “Lebenswerte Lebenswelten für ältere Menschen” [Life-Worlds Worth Living for Older People] (intervention study), initiated by the Austrian Health Promotion Foundation. Other projects are “Anders Altern in Radenthein” [Ageing Differently in Radenthein], “Geh ma“ [Let’s Go] in Mölltal, Gesunde Stadt Wien [Healthy City of Vienna] with “Aktiv ins Alter” [Active into Advanced Age], “Sichere Josefstadt” [A Safe Josefstadt] (which also touches on the target group of older people). Activities in the field of primary care were also brought up, such as programmes for caregivers. Explicit studies on the topic of “healthy ageing“ are rare, whether they are general or more specifically address the field of mental health. The bottom line was that the target group of older people is fundamentally underrepresented in the field, and there are gaps in health care, particularly in the “non-physical“ realm. Deficiencies were also identified in the field of interface management and community care.
According to the working group the action areas are well defined in the basic statements on mental health in Europe. The group saw problems rather in a lack of structures and capacity building, both at the federal level and among the social insurance agencies, so that those carrying out projects and studies find themselves constantly “swimming upstream“. Further issues include “inadequate integration and linkages in the field, for example between practice and evidence, as well as a lack of transsectoral treatment of these matters at all decision- making levels, from the EU on down“.
The following action areas/developmental steps were identified:
• The group proposes integrating and linking practice and evidence between sectors, in the form of regular and well-founded dialogue (with the Austrian Health Promotion Foundation as a possible organiser); • the development of a knowledge platform on the website of the Austrian Health Promotion Foundation to support those active in the field (with basic documents, articles, presentations, links); • it would be very helpful to take advantage of the broad-based position of the Austrian Health Promotion Foundation to establish sustainable alliances for the central
17 concerns in this area, health promotion and primary prevention, and to find further capital for relevant activities.
E Addiction prevention
Moderation and report: Martin Hefel
The working group on “Addiction prevention“ compiled an overview of how addiction prevention efforts are structured in Austria. Under the law there is an institutionalised form of cooperation in Austria in the form of the “Bundesdrogenforum” [Federal Forum on Drugs]. Because of how it is constituted, this forum devotes only little attention to prevention. However, it is a very important body, with Österreichische ARGE Suchtvorbeugung [Austrian Working Group for Addiction Prevention] the only NPO represented among its members. Austria is unique among German-speaking countries in that each of its states has a specialised office devoted to addiction prevention; these offices have joined together in a voluntary association, the Österreichische Arbeitsgemeinschaft Suchtvorbeugung (ARGE Suchtvorbeugung) [Austrian Working Group for Addiction Prevention]. In addition, each state has a drug coordinator who is the official representative of that state.
The field of addiction prevention in Austria is characterised by a variety of separate projects; only four programmes have been implemented nationwide (an internet event calendar;16 It`s up to you“, a flyer for young people; “Becoming independent“, a model aimed at enhancing life competence at the elementary school level; “Step by step“, a programme for early recognition and intervention in schools; the annual meeting of ARGE Suchtvorbeugung [Working Group for Addiction Prevention]).
The report by the working group on addiction prevention was quite extensive; as mentioned above, the complete analyses of the status quo may be found on the home page of the Austrian Health Promotion Foundation and/or parts of them may be contained in the following discussion of action areas.
The following action areas/developmental steps were identified:
• One goal is to establish a national policy on addiction to serve as a strategic concept at the federal, state and community/city level (with the aims of addiction prevention and regulation of the distribution of costs among the federal government, states and communities). • Coordination of preventive measures at the federal level, but also taking into account the states. Making use of existing professional and regionally based structures when carrying out federal activities in the field of addiction prevention. • Consolidating the working group structure (ARGE Suchtvorbeugung [Working Group on Addiction Prevention]) and providing support for this network. • The aim is to achieve a clear commitment on the part of the federal government to the work of addiction prevention and to providing financial support for this structure, so that nationwide programmes, at least, can be carried out at a high-quality level.
18 • Interdisciplinary networks which, through dialogue, coordinate the tasks assigned to them (by an addiction-prevention policy that is not yet in place) as well as developing and disseminating joint proposals for improvement. • Funds are needed for carrying out evaluation and/or assigning research contracts for the Federal Ministry. It is also important to guarantee and fund continuing cooperation with interdisciplinary research in all phases of development and implementation. • Development of curricular training for addiction prevention specialists. • Harmonisation of laws, for example uniform “Jugendgesetz” [juvenile law] throughout Austria. • In the public arena, it is important to start introducing the technical terms that are used internationally. They are clearer and more precise, and avoid confusion. • Long-term and lasting financing of cross-state prevention programmes. Improved support for research and standardisation of funding structures for preventive work.
F Mental disorder prevention and reduction of discrimination and stigma
Moderation and report: Dr. Werner Schöny
In analysing the current state of affairs, the working group on “Mental disorder prevention and reduction of discrimination and stigma“ concluded that a number of preventive measures are already in place in Austria, but they are not being implemented in a coordinated fashion; depending on the federal state and the institution, preventive measures are being carried out in the areas of addiction programmes, suicide prevention, gender-specific activities, youth work as well as programmes for the elderly.
The working group identified positive developments in this area, among others, in the inclusion of these issues in the agenda of the Ministry and the Austrian Health Promotion Foundation; the development of psychiatric plans; the establishment of health goals with psychosocial components in two federal states; and the programmes carried out by “Gesunde Gemeinde” [Healthy Community] in Upper Austria and by the “Österreichisches Netzwerk Betrieblicher Gesundheitsförderung” [Austrian Network for Workplace Health Promotion]. Also favourably noted were the information that is currently being provided on the internet, media work (to some degree) and the inclusion of affected individuals in relevant efforts. Continuing barriers and obstacles include stigmatisation and discrimination, insufficient or inconsistent financing, the lack of uniform, binding minimum planning as well as a lack of basic epidemiological data.
The following action areas/developmental steps were identified:
• The establishment of a nationwide psychosocial emergency and crisis service staffed by trained personnel and providing mobile aid in acute cases. • Further support for mental health promotion in the workplace, taking into consideration labour and labour-protection law. Strategy development in this area. • Enhanced information in schools, particularly through further training for teachers, going through textbooks, teacher supervision, establishing principles and crisis management.
19 • Information, education and further training for physicians in general practice, persons employed in the health and social fields, media personnel/journalists, attorneys, executives. • Improved and accurate information for the public, particularly aimed at correcting misconceptions by conveying the facts. • Including these issues in preventive health care, better information on mental problems and disorders. • Focus group work with those affected to determine how these programmes should be carried out and where the emphasis should be placed. • Inclusion of persons affected, as well as experts on implementation, and experts with personal work experience, in order to enhance credibility and define programme value. • Develop trained multipliers • Increased attention in the sense of a tetralogue, particularly among the general public, politicians and administrators, aimed at making this subject “acceptable” for discussion. • It is crucial to use and implement the action plans initiated by the EU.
G Research, education and further training in the field of mental health promotion in Austria
Moderation and report: Dr. Maria Schmidt-Leitner, MPH, MSC
The working group on “Research, education and further training in the field of mental health promotion in Austria“ identified a fundamental gap in funding for applied public health research in Austria as well as a specific lack of MHP activities in the Austrian research, education and training landscape.
In the interest of capacity building, the development and promotion of research, education and training are priorities in implementing a national mental health promotion policy.
The following action areas/developmental steps were identified:
• In the interest of an effective and efficient establishment of a research, educational and training landscape for mental health promotion in Austria, a “Mental Health Promotion Alliance“ should be set up, staffed by intersectoral and interdisciplinary personnel. This MHP alliance should ensure lobbying for the MHP movement and lay the groundwork for encouraging scientific “innovation packages”. A feasibility study should be conducted prior to the establishment of such an alliance. • The implementation of a mental health monitoring system • Training workshops for journalists (destigmatisation), decision makers (e.g. social insurance, Ministry of Economic Affairs) • An MHP training module for preschool and elementary school teachers (during their teacher education, on-the-job training) • Integration of MHP into Austrian public health training programmes • Adapt the manual for general practitioners (IMHPA project) to Austria’s situation and offer it as a further training program conducted by the Austrian medical association.
20 • “Train the Trainer“ workshop with the experts involved in the IMHPA network • Adapt the Australian/German “ Mind Matters“ concept to Austria’s situation and integrate it into the Austrian school system
Possible contents for research projects/“Innovation packages“ include the following:
o Mental health literacy o Interdisciplinary lines of argumentation (e.g. 4% of GDP) o Mental health promotion glossary o Gender-specific programmes o Target group-specific strategies o Models of good practice (e.g. violence prevention in schools) o Healthy drinking (culture of daily life and alcohol) o Development of concepts and quality standards for MHP in preschools o Mental health indicators (as a basis for the mental health monitoring system) o Mental health promotion and older people o Healthy ending
21 5. Summary and outlook
The working group reports presented here give a complex view of MHP and MDP in Austria.
In various areas, such as school- and community-based youth programmes, workplace health promotion and addiction prevention, good structures are already in place and numerous activities are underway in the areas of MHP and MDP. Only a few MHP or MDP activities (whether research, education and training or practical activities) were identified in the preschool/family setting/for the early life years. Similarly, although some very promising research and practice-oriented projects are under way for the target group of older people or related to the topic of “healthy ageing“, but as a whole this target group and this subject are underrepresented. If we look specifically at the prevention of mental disorders (MDP), a number of programmes are in place, but they are not always coordinated with one another. People suffering from mental disorders continue to be stigmatised and discriminated against.
Numerous action areas and steps to develop MHP and MDP were defined by the working groups.
Most of the groups spoke out in favour of exchanging experiences and establishing a network at various levels, even a “mental health promotion alliance“.
There was also critical discussion of the lack of binding planning as well as the dearth of basic epidemiological data. Several working groups also addressed the topic of insufficient funding for measures in the field of MHP and MDP. Particularly in the areas of research, education and training, it was noted that there is a lack of financing and of structures and programmes in Austria. Proposals included, for example, adoption of a national mental health action plan, long-term and permanent funding for national programmes, a harmonisation of financing structures and increased support for research.
Concrete suggestions were developed for creating effective and efficient education and training programmes in the field of MHP/MDP, such as integrating MHP in Austrian public health training programmes or in the training of preschool and school teachers. Moreover, it was considered important to provide courses offering information or sensitization training to a range of multipliers.
Moreover, several working groups proposed that quality standards be developed and that models of good practice be promoted.
A number of working groups also supported measures to meet the needs of specific target groups, especially the mentally ill and socially or physically disadvantaged people (such as migrants), in a gender-appropriate manner.
Overall, participation in the workshop was excellent, and feedback was very positive.
22 Where do we go from here? Several new projects and networking initiatives in the area of mental health are in the planning stages (e.g. networking in the area of out-of-school youth programmes). The results of the workshop are being disseminated by the Austrian Health Promotion Foundation and made available to the public on its home page and in its magazine.
The Austrian Health Promotion Foundation, as a national contact and funding institution in the field of health promotion, will continue to support MHP and MDP. The Fund will take into account these workshop results in developing its new three-year programme for 2007-2009. Of course, this is only possible within the framework of its statutory structure and mission.
The experts and stakeholders mentioned in Chapter 3 also bear responsibility for supporting MHP and MDP in Austria.
In order for far-reaching national developments to occur, however, a commitment at the political level is necessary. In this regard the European Commission might provide support by developing binding European guidelines. Such guidelines might be, for example:
- recommendations for priority intervention areas in Europe - guidelines for indicators that enable a comparable mental health monitoring in Europe
The European Commission might also provide support for implementation through the following measures (while they were not explicitly discussed in the workshop, they follow from the results): Support for education and training (e.g. development of an MHP/MDP curriculum, training of experts), support for the transfer of evidence into practice (drawing up best-practice examples, developing a knowledge platform e.g. offering basic documents, review papers) as well as determining quality criteria for various areas.
23 6. List of participants
First Postal WS Last name name Title code City Street address Organisation Institut für Suchtprävention/Fonds A Kolar Sabine GSA 1010 Vienna Guglgasse 7-9 Soziales Wien Allmayer- Fischlstrasse Arbeitsvereinigung der A Radich Gabriele Dr. 9020 Klagenfurt 40 Sozialhilfe Kärntens Institut für Suchtprävention/Fonds A Krieger Martina M.A. 1010 Vienna Guglgasse 7-9 Soziales Wien Mariahilfer- A Lins Andrea M.A. 1150 Vienna strasse 176 Fonds Gesundes Österreich A Muschik Elisabeth Dr. 1040 Vienna Grüngasse 1A pro mente Wien
A. Institut für Stress-prophylaxe A Perner Rotraud Prof. Dr. 2243 Matzen Bahnstrasse 24 & Salutogenese B Bauer Sonja Dr. 1040 Vienna Waaggasse 1 GIVE Dr. Theodor- Bruck a.d. Körner Strasse Jugendgesundheitsförderung B Deutsch Eva-Maria M.A. 8600 Mur 37 auf dem Lande Netzwerk GF Schulen B Haller Beatrix Dr. 1014 Vienna Minoritenplatz 5BMBWK Gleinkergasse B Koller Gerald 4400 Steyr 8 Büro Vital Johann B Korn Margret M.A. 5061 Elsbethen Herbststrase 23pro mente Salzburg B Mills Susanna Dr. 9020 Klagenfurt Flurgasse 31 pro mente Jugend Petracek- Josefstädter- Versicherungsanstalt öffentl. B Ankowitsch Martina 1080 Vienna strasse 80 Bediensteter em. Univ.Prof. Universitäts- Institut für Psychologie der B Rollett Brigitte Dr. 1010 Vienna strasse 7 UNI Wien Haideggerweg C Brunner Edith M.A. 8044 Graz 40a VAEB WZ-Josefhof Elisabeth- C Diller Thomas M.A. Dr. 5020 Salzburg strasse 2 AVOS Salzburg Kaplanhof- Ppm Forschung und C Elsigan Gerhard M.Eng. 4020 Linz strasse 1 Beratung Mörwaldplatz C Joanowitsch Sabine M.A. 1040 Vienna 4/4/37 BÖP Sektion AWO Praterstern C Künzl Daniela 1020 Vienna 2/4/9 die partner Löwelstrasse C Lackner Manfred Dr. 1014 Vienna 18 SPÖ Gesundheitssprecher Nottendorfer Forschungs-institut des C Lang Gert M.A. 1030 Vienna Gasse 21 Wiener Roten Kreuzes Praterstern C Neudorfer Ernst 1020 Vienna 2/4/9 die partner Josefstädter- Versicherungsanstalt öffentl. C Praher Melitta 1080 Vienna strasse 80 Bediensteter Mariahilfer- C Ropin Klaus Dr. 1150 Vienna strasse 176 Fonds Gesundes Österreich
24 Hofeneder- C Scheucher Gernot M.A. 1020 Vienna gasse 6/41 Industriepark C Sonderegger Reinhard 6832 Röthis FOCUS Fonds Gesundes Vorarlberg Kundmann- Hauptverband d. Österr. SV- C Spitzbart Stefan M.A. 1031 Vienna gasse 21 Träger (HVB) Faberstrasse Netzwerk BGF, Salzburger C Zeisberger Elisabeth 5024 Salzburg 19-23 GKK IBG - Institut für human- ökologische Mariahilfer- Unternehmensführung D Gabriel Theresia Dr. 1070 Vienna strasse 50/14 GmbH Altmannsdorf- D Klausz Gabriela 1230 Vienna erstrasse 275 Sperrgasse 8- Forschungs-institut des D Pabst Brigitte DSA 1150 Vienna 10 Wiener Roten Kreuzes Reis- Projekt Lebenswerte D Klingspiegl Karin M.A. 8010 Graz Sporgasse 22/1 Lebenswelten Martin, Universitäts- Universitäts-lehrgang Public D Sprenger MPH Dr. 8010 Graz platz 4/3 Health Josefstädter- Versicherungsanstalt öffentl. D Trauner Johannes Dr. 1080 Vienna strasse 80 Bediensteter
Drobesch- Bahnhofstrasse Landesstelle f. Suchtprävent- E Binter Barbara Dr. 9020 Klagenfurt 24 ion Kärnten Europäisches Zentrum f. Eisenbach- Wohlfahrts-politik u. Soz. E Stangl Irmgard Dr. 1090 Vienna Berggasse 17 Forschung Hofsteigstrasse E Hefel Martin 6858 Schwarzach 112 Stiftung Maria Ebene Kaplanhof- E Janout Ursula M.A. 4020 Linz strasse 1 Pga Bastiengasse Frauengesundheitszentrum E Kastenhuber Julia M.A. 1180 Vienna 36-38 F.E.M. Bastiengasse Frauengesundheitszentrum E Kern Daniela M.A. 1180 Vienna 36-38 F.E.M. Mairhofer- Dreihacken- VIVID Fachstelle f. E Resch Gabriele M.A. 8020 Graz gasse 1 Suchtprävent-ion Stmk. Mariahilfer- E Rohrer Eva M.A. 1150 Vienna strasse 176 Fonds Gesundes Österreich Walter-Picard- Task Force on Health Klinik Postfach Promoting Psychiatric F Berger Hartmut Prof. Dr. DE Riedstadt 1362 Services Univ.Prof. F Berger Peter Dr. 1090 Vienna Spitalgasse 23 Med. UNI Wien Maria- Prinz-Eugen- AK Wien, Arbeitnehmer- F Birngruber Anna 1040 Vienna Strasse 20-22 Innenschutz
Univ. F Dantendorfer Karl Prof. Dr. 7100 Neusiedl Hauptplatz 44 pro mente Burgenland
Gutierrez- Univ.Prof. Dr. Karl Institut für Psychiatrie der F Lobos Karin Dr. 1010 Vienna Luegerring 1 UNI Wien
25 Amt der Kärntner Landesreg- F Hassler Ingeborg Dr. 9020 Klagenfurt Arnulfplatz 1 ierung, Abt. 13
Psychosoziale Gesundheits- F Iberer Waltraud Dr. 6850 Dornbirn Färbergasse 15 dienste Vorarlberg Bernardgasse F Ladinser Edwin 1070 Vienna 36/4/14 HPE Österreich
Amt der Kärntner Landesreg- F Rieger Erich M.A. 9020 Klagenfurt Arnulfplatz 2 ierung, Abt. 13
Univ.Doz. Konrad-Vogl- F Schöny Werner Prim.Dr. 4020 Linz Strasse 13 pro mente Austria Müllner Leiter des Sonderauf-trags Hauptstrasse für Psychosomat-ische F Stelzig Manfred Prim. Dr. 5020 Salzburg 48 Medizin Ludwig Boltzmann Institut für Rooseveltplatz Medizin- und Gesundheits- G Dietscher Christina M.A. 1090 Vienna 2 soziologie Mühlschüttel- c/o Medienbüro Dr. C. G Lercher Piero Dr. 1210 Vienna gasse 6 Lercher
Univ.Prof. Universitäts- Institut für Sozialmedizin und G Noack Horst Dr. 8010 Graz strasse 6/I Epidemiologie Ludwig Boltzmann Institut für Rooseveltplatz Medizin- und Gesundheits- G Pelikan Jürgen Prof. Dr. 1090 Vienna 2 soziologie
Schwarzen- Bundesamt für Gesundheit, CH- burgstrasse Sektion Strategie G Ricka Regula Dr. 3097 Liebefeld 153 und Gesund-heitspolitik CH Mariahilfer- G Rohrauer Gerlinde M.A. 1150 Vienna strasse 176 Fonds Gesundes Österreich Schmidt- G Leitner, Maria Dr. M.A. 9631 Tröpolach 136 Fonds Gesundes Österreich Georg Bilgeristrasse G Wintersberger Barbara Dr. 1220 Vienna 60 Teschnergasse Craislheim Birgit Dr. 1180 Vienna 35 Sarleins- Scharinger Christian Dr. 4152 bach Schmidtfeld 1
26 7. References
1 Katschnig H. (2003). Mental Health in Austria. Selected annotated statistics from the Austrian Mental Health reports 2001 and 2003. Vienna: Federal Ministry for Health and Women. 2 The European Opinion Research Group (2003). The mental health status of the European population. European Commission. http://europa.eu.int/comm/health/ph_determinants/life_style/mental_eurobaro.pdf 3 Dür, W., Mravlag, K. (2001). Gesundheit und Gesundheitsverhalten bei Kindern und Jugendlichen. Ergebnisse des 6. HBSC-Surveys 2001 und Trends von 1990 bis 2001. Reihe Originalarbeiten, Studien, Forschungsberichte, Bundesministerium für soziale Sicherheit und Generationen. Wien. 4 Statistik Austria (2006). Statistisches Jahrbuch 2006. 5 Katschnig, H., Denk, P., Scherer, M. (2004). Österreichischer Psychiatriebericht 2004. Analysen und Daten zur psychiatrischen Versorgung der Österreichischen Bevölkerung. Wien: Ludwig Boltzmann Institut für Sozialpsychiatrie, Universitätsklinik für Psychiatrie. Im Auftrag des BMGF. http://www.bmgf.gv.at/cms/site/detail.htm?thema=CH0026&doc=CMS1098965386003 6 Dietscher, C., Pelikan, J.M. (2005) Mental Health Promotion and Mental Disorder Prevention: a snapshot across Europe. Vienna: WHO Collaborating Centre for Health Promotion in Hospitals and Health Care. In: European Commission (publisher) (2005). Mental health promotion and mental disorder prevention across European member states: A collection of country stories. http://europa.eu.int/comm/health/ph_projects/2004/action1/docs/action1_2004_a02_30_en.pdf 7 See http://www.fgoe.org 8 See http://www.aksaustria.at 9 See http://www.suchtvorbeugung.net/ 10 See http://www.fgoe.org/aktivitaeten/selbsthilfe/sigis-datenbank 11 See http://www.fgoe.org/der-fonds/organisation/g-foerderungsgesetz 12 Jané-Llopis, E. & Anderson, P. (2005). Mental Health Promotion and Mental Disorder Prevention. A policy for Europe. Nijmegen: Radboud University. URL: http://www.imhpa.net/fileadmin/imhpa/A_Policy_for_Europe.pdf 13 World Health Organisation (WHO). (2005). European Action Plan on Mental Health. http://www.euro.who.int/mentalhealth2005/press/20050115_1?language=German 14 World Health Organisation (WHO). (2005). European Mental Health Declaration. http://www.euro.who.int/mentalhealth2005/press/20050115_2?language=German 15 See e.g. http://www.praevention.at/seiten/index.php/nav.13/view.79/level.3/ 16 See www.suchtvorbeugung.net
27
Czech Republic
29
National Conference on Mental Health Promotion
National Institute of Public Health, November 22, 2005, Prague, Czech Republic
Report
EMIP 2004 – 2006
Partner: National Institute of Public Health, Prague, Czech Republic Director: Jaroslav Volf, MD., Ph.D Coordinator: Hana Janatová, MD., PhD. Expert: Vladimír Kebza, PhDr., PhD., assoc. Professor
30 I. General information
The National Conference on Mental Health was hold in Prague, at the National Institute of Public Health on the 22. November 2005. Eighty registered participants were present on the conference, among them 2 experts from abroad (Lynne Friedly from Great Britain and Christian Haring from Austria) and one participant from Slovakia (Dušan Selko). The participants were invited by personal letters with information about EMIP project and the aims of the National Conference, and their active participation was continuously discussed by e-mail and/or by phone.. Participants represented a broad spectrum of professions dealing with mental health and mental illness - psychiatrists, psychologists, physicians, public health specialists, public health professionals, University teachers, volunteers from civic organisations and NGOs. The participants also represented different types of organisations : governmental scientific institutes, universities, state organisation for health promotion, professional societies, psychiatric hospitals, NGOs and self health organisation. The detailed information on the conference including the Mental Health Declaration and Action Plan have been placed on the website www.szu.cz/czzp/aktual/konference/index.htm These documents together with the programme of the conference and presentations of speakers have been open for public internet users. A brief press conference was hold before the conference began.
The conference was chaired by Vladimir Kebza, psychologist, one of leading experts in the field of mental health promotion in the Czech Republic and was opened by Jaroslav Volf, director of NIPH. The deputy minister Chief Public Health Officer and vice minister from the Ministry of Health Michael Vít and the director of WHO Liaison office Alena Steflova were among important guest of conference and they presented information about strategies and activities in the field of mental health promotion in the Czech Republic and in a international context, especially about the Mental Health Declaration of WHO. Representants from the Ministry of Education, Youth and Sport and from the Ministry of Employment and Social affair took invitation and were present on the conference.
Invited speakers, leading Czech authorities in the field of psychiatry and psychology have shown a lot of different views on what is mental health and well being, research findings and examples from practice: Jiří Raboch, head of the Czech Psychiatric Society and the chief of the Psychiatric Clinic of the 1st Medical Faculty, Charles University, Jaroslav Šturma, head of the Czech Psychological Society, Ivan David, director of the biggest Prague psychiatric hospital, and former Czech Minister of Health, Václav Břicháček, Professor of psychology from the Faculty of Humanistic Sciences, Charles University, Marek Blatný, Professor of psychology from the Faculty of Philosophy, Masaryk University in Brno, and Barbora Wenigová, director of NGO “Centre for mental health care development” presented perhaps the most important lectures. A one hour discussion that took place the end of conference has indicated a lot of different experience. General consensus was achieved that the Conference was useful as the unique platform for exchange of experience and information and a good basis for other following activities in development of mental health promotion.
31 Conference documents
All documents presentations from the Conference have been placed on the website that has served also as a place for discussion and information exchange before and after conference.
II. Mental health statistic describing national situation
The main sources of statistical data on mental health are rather on mental disorders than on well being and they are regularly published by the Institute of Health Information and Statistic of the Czech Republic. The figures are related to using health care facilities. Few data exists about mental health of people who do not seek health care although they suffer of any mental health problems.
1. Official statistics
Morbidity (2004)
The vast majority of patients with serious mental illness were hospitalised in psychiatric hospitals or in psychiatric wards in general hospitals ( 58 714/year).
Services of day treatment centres were used by 1 484 patients (2.5 % from all patients.
Prevalence of neurotic disorders was 172/ 10 000 inhabitants.
Prevalence of schizophrenia was 39/10 000 inhabitants.
Prevalence of affective disorders was 83 / 10 000 inhabitants.
Cases treated in out patient care for disorders due to use of alcohol were 243/ 100 000 inhabitants.
Cases treated in out patient care for disorders due to use of psychoactive substances were 115/ 100 000 inhabitants.
Cases treated in out patient care for schizophrenia were 391/100 000 inhabitants.
Cases treated in out patient care for affective disorders (including depression) were 832 per 100 000 inhabitants.
Neurotic diseases, schizophrenia and affective disorders were the most frequent diagnosed mental health disorders.
Mortality (2004)
Mortality rate from mental health disorders is 2.8 / 100 000 inhabitants. Mortality rate from intentional self – harm is 15.8/ 100 000 inhabitants. Mortality rate from suicide is 16, 9/100 000 inhabitants, men 3,9x frequently than women.
32 Psychiatric Beds and Professionals (2003)
11, 4 total psychiatric beds per 10 000 inhabitants 9.8 psychiatric beds in mental hospitals per 10 000 inhabitants 1.5 psychiatric beds in general hospitals per 10 000 inhabitants 0.2 psychiatric beds in other settings 12.1 psychiatrists per 100 000 inhabitants 33 psychiatric nurses per 100 000 inhabitants 4.9 psychologists per 100 000 inhabitants
(The numbers trend to decrease each year)
Financing of mental health in 2005
3.8% is a part of the state health care budget on mental health (almost on psychiatric care) 0, 2 % is estimated part of state health care budget for health promotion
2. Figures from surveys
Mental disorders CIDI (1998 – 1999), general population, in age 18 – 79 years, number of respondents: 1535): - 27% reported mental health disorders responding with psychiatric diagnosis (30% women, 24% men). The most frequent were neurotic disorders, disorders from abusus of alcohol and drugs and affective disorders. - 7, 8 % reported symptoms of depression (EU average from the CIDI survey was 8% - 12%). It is probably impacted by will to confess mental health problem - stigmatisation of people with mental health problem is still high in the Czech Republic. - Bullying Survey of the Ministry of Education on bullying (2004): - 41 % of school children 6 – 14 years old experienced bullying - Mental health of elderly (Institute for health education, 2004): 12 – 15 % depression among people 65 + 10 – 15 % dementia among people 65 + (20% of them need to be treated in hospital
III. Identification of Relevant Stakeholders
Parliament Committee for social and health affair
Government: Ministry for Health Ministry for Employment and Social affair Ministry for Education and Youth
Professional societies: Czech Psychiatric Society Czech Psychological Society
33 Organisation ruled by the Ministry of Health: National Institute of Public Health Psychiatric Hospitals Psychiatric Centre Prague Psychiatric Departments within General Hospitals
Organizations ruled by the Ministry of Education and Youth The network of Pedagogical and Psychological Consulting Centres organized in Czech districts and regions as an important source of primary preventive activities in the mental health promotion of children and adolescents
Regional organisation of the Ministry of Health: Regional Public Health Institutes Regional Public Health Authorities
Regional and local organisations: Municipalities Community centres funded by Communities Mental health promotion centres organized by NGO’s
Universities Medical faculties Faculties of Humanistic Sciences Faculties of Philosophy, Departments of Psychology Psychiatric Centres of Medical Faculties Centrum of Neuropsychiatry Studies
Scientific and research institutes Academy of Science, Institute for Psychology
NGOs and Civic associations Czech Association for Mental Health VIDA ESET – HELP FOCUS Centre for Mental Health Care Development Mens Sana GreenDoors and others
National networks Healthy School Network Healthy Cities Network Healthy Company Network
34 IV. Existing Mental Health Policies
There is no specific law on mental health and no specific mental health promotion policy. The legislative regulation in the field of mental health is covered by the Law on Health Care (Act No 20/66 Coll.). This act, adopted in 1966, has been changed and amended by a series of health care reform legislation, most recently in 1999. The Public Health Law was adopted in 2000 (Act No 258/200) and it is a fundamental law for health promotion.
The base for health promotion policy is the document Health 21, a strategy of WHO adopted and adapted for public health in the Czech Republic in 1998. One of the objectives is mental health improvement.
The National Public Health Promotion Programme is a funding program for health promotion. It works since 1999. Some of the projects are aimed on mental health promotion.
Healthy Ageing projects and Projects for Disabled are other funding programmes of the Ministry of health for NGOs working with elderly and disabled, civic organisation, Charity and local authorities.
A policy in a social support field exists : disabled people are under social benefit from the government.
Many NGOs are involved with mental health in the Czech Republic. They are mainly involved in advocacy, promotion, prevention, rehabilitation and education ( e.g. project Matra - Community care in psychiatry for education of professionals in mental health or education programmes for patients and their care givers).
Mental Health Policies in specific fields:
Healthy School Network Healthy Cities Network and their mental health programmes Healthy Company Network and its specific activities Substance abuse policy is a part of a law amended in 1999 (Act No 37/1989). National Therapeutic Drug Policy (Act No 48/1997) National Environment and Health Plan (Governmental decision, 1998) National Programme of Preparation for Ageing (Governmental Decision, 2003)
Reform of psychiatric care
Now the draft of Reform of psychiatric work is under broad discussion and in April 2006 the presentation of the final document is expected. The aim of the process is to define needs of legislative and political changes for transformation of psychiatry. Coordinators of the process are the Ministry of Health, Charles University, 1. medical Faculty, Centre for development of care about mental health ( NGO), WHO/EURO a its advisers. The draft was evaluated by national and foreign experts.
35 V. International Mental Health Policy Documents
Declaration on mental Health for Europe (WHO) Action plan (WHO) Green paper on mental Health (EU) Green paper on demographic changes (EU) Bankog´s Chart (WHO) Health 21 (WHO)
VI. Research
Mental health indicators, mental health determinants National mental health statistics (mental disorders, suicide rate) is implemented by the specific department of the Ministry of Health (ÚZIS). Theoretical and empirical survey of well-being in Czech population was implemented in co- operation of the Institute of Psychology, Czech Academy of Sciences, National Institute of Public Health, and Departments of Psychology of Charles University in Prague and Masaryk University in Brno. The results and conclusions of this survey were presented in the National Conference on Mental Health Promotion mentioned above, and published in the book -Blatný, M., Dosedlová, J., Kebza, V., Šolcová, I. (Eds.): Psychosocial connections of well-being. Brno, Masaryk University & MSD Publishing House 2005. The research grant project concerning the problem of inequalities in health was implemented during the 2003 – 2005 period by National Institute of Public Health (V. Kebza, J, Vignerová et al.) and Institute of Psychology, Czech Academy of Science (I. Šolcová). The main findings are summarized now in the final report (deadline is also January 31, 2006).
VII. NGOs
NGOs are involved with mental health in the Czech Republic. They are mainly involved in advocacy, promotion, prevention, rehabilitation and education ( e.g. project Matra -Community care in psychiatry for education of professionals in mental health or education programmes for patients and their care givers). The list of main NGO’s – see above.
VIII. Community centres for mental health support and prevention
Regional and community centres of social care and service Centres of prevention of addictive behaviour (“Prev-Centres”) Specific centres in selected communities, e.g. Proxima Sociale, organized in Prague 12, EVS – community centre for children and adolescents in Tábor, South Bohemia, Centre for Family Life, organized by regional charity in Brno, etc.
36 IX. Strengths and weaknesses in mental health promotion in the Czech Republic
Strengths:
International documents on mental health promotion signed by government Specific national policy on topics related to mental health (e.g. drugs abuse, ageing,) National policy on health promotion including mental health promotion and the national strategy to support it). A funding programmes of the Ministry of Health ( National Health Promotion Programmes, Projects for Healthy Ageing, Projects for Disabled) National discussion on the new reform of psychiatric care Network of Health promoting school Network of healthy cities NGOs campaigning to increase public awareness to mental health and decrease stigmatisation of people with mental health problems and diseases. Mental health hospitals and their mental health promotion activities Participation on European project aimed on health promotion Community centres for rehabilitation and mental health promotion. A network of Regional Public health Institutes experienced health promotion in practice. High quality of research on indicators and determinants of mental health. High quality of people dealing with mental health promotion.
Weaknesses:
No specific policy on mental health promotion Low financing from health care budget on psychiatric care (3.9%) Low financing from health care budged on health promotion programmes (0.2%) Lack of information on a role of community centres for mental health promotion among professionals and public. No specific quality assurance for health promotion projects. Weak collaboration among community centres for mental health and psychiatric care. Lack of resources (personal, financial) in Regional Public Health Institutes A lack of collaboration and coordination among institutions and agencies acting in mental health. Lack of general understanding on mental health, no clear definition of mental health promotion, Lack of consensus on clear understanding to the term mental health and mental health promotion among professionals. Very slow changes among public in perception of mental health disorders – stigmatisation and marginalisation of mentally ill people. Few projects are aimed on family members and care givers of people with mental problems.
X. Most urgent needs
A specific national policy on mental health promotion. Capacity building for mental health promotion programmes. Including mental health in health promotion projects. Dissemination of international and national documents more flexible among professionals and public.
37
Campaigning to decrease stigmatisation of mentally ill people and increasing awareness to mental health for everybody. Support of collaboration among community centres and psychiatric hospital in a field of mental health rehabilitation. Education on mental health promotion for professionals. Implementation of good practises research findings. Social marketing of mental health project. Sustainability of the process of implementation. Research of mental health determinants
XI. Obstacles and barriers
Lack of resources (financial and personal) in all bodies dealing with mental health. Lack of political will to coordinate activities in promoting mental health. The mainstream definition of mental health is mental illness. The responsibility for dealing with mental health is on psychiatric health care. Statistics on mental health are made only from data from health care facilities. Few surveys were among people without psychiatric diagnosis. The real number on mental health problems among general population is probably underestimated. More research and survey are needed.
XII. Support needed from the European Commission
A regulation, a directive or other documents committing the Czech government to take action and to coordinate implementation of mental health promotion principles.
A specific funding program aimed on mental health promotion – information exchange, sharing experience and research result.
Facilitation of the national process of implementation by the means continuity of the EMIP project in next years.
Conclusion
The national conference on mental health could not solve all problems not even discuss them. The report could not describe all discussed experience of participants because lot of discussion were led outside the plenary, during breaks. The conference and the report should be taken as a beginning of process of implementing European principles on mental health promotion. National Public Health Institute as a partner of EMIP have a good chance to facilitate mental health promotion using experience from current and previous European projects in the field of public health. Information on website, expert’s consultation and training for public health professionals could be good tools for implementation process. The paper prepared by main representatives of mental health promotion in the Czech Republic concerning the current problems, main trends, and national profile of mental health promotion could be one of the useful follow-up steps in this sphere.
38
Estonia
39
EMIP NATIONAL WORKSHOP
REPORT
Estonian-Swedish Mental Health and Suicidology Institute (ERSI) November 2005
Introduction
Two-day EMIP National Workshop in Estonia was hold in October 4-5, 2005. During the preparation time since april 2005, EMIP goals were introduced twice in the Ministry of Social Affairs and had been accepted and valued highly. With the help of Ministry of Social Affairs, EMIP project was supported and co-financed by Estonian Board of Gambling Tax. The organizer of the workshop was Estonian-Swedish Mental Health and Suicidology Institute (ERSI) who has played a substantial role over the 10 years as a catalyst and facilitator of health welfare on alcohol, suicides and mental health related issues in Estonia; lately as a catalyst of policy mental health formulation. The conference was opened by Deputy Secretary General on Health Care of the Ministry of Social Affairs Dr Ivi Normet and Director of Estonian-Swedish Mental Health and Suicidology Institute Prof Dr Airi Värnik. Presentations were made by several specialists from Europe, also by well-know specialists and opinion leaders from Estonia. The conference was planned to be informative rather than exchanging the experiences, therefore the presentations from outside Estonia were highly appreciated. Agenda of the workshop is attached (see annex 1).
Estonian mental health context
Mental health welfare is regulated by the Social Welfare Act and Mental Health Act that regulates the organization of psychiatric care defining the financial obligations of the state and local government. Local governments must guarantee the accessibility of necessary social services for people with mental disorders. The law also provides that in
40 order to get psychiatric care the patient may turn directly to specialist for outpatient consultation without family doctor’s referral. Public Health Act and Occupational Health and Safety Act regulate some general aspects of mental health welfare also. There are waiting lines and insufficient access to the counseling services. Even there are quite many private practices with no waiting line, people may not get the appropriate help in time due to lack of help services (emergency) and the high cost of the psychological counseling, and psychotherapy. Financial resources allocated from the state budget for national welfare of people with mental disorders are divided between county governments based on the number of people who need welfare services and also taking into consideration the extent of services provided in counties. Prevention and health promotion activities are financed from the Health Insurance Fund budget and national programs (public health) belonging to administrative field of the Ministry of Social Affairs. Updated mental health data is available in Mental Health Atlas 2005 (WHO).
Relevant stakeholders
It has been under discussion that Estonian initiatives should seek to promote strategies for improving the health of people with community engagement via many possible settings. In relation to mental health and wellbeing our objectives are to develop and facilitate work with community health care partnerships on how to identify solutions to problems of providing mental health care and promoting well being for communities, addressing the difficult questions as to why settings as workplaces do not engage mental health promotion, why schools are not engaged to mental health prevention as much as they could be? As EMIP’s main goal was develop resources and information and facilitate discussion and planning on process and outcomes on municipalities’ engagement with mental health services regarding to promote improvements in the mental health and wellbeing of people experiencing mental health problems or mental illness, the relevant stakeholders had to be found. As the target of the National workshop, identifying relevant stakeholders and groups, to gather together county health promotion officers and all other local initiatives with the aim to introduce the latest developments in prevention/promotion area and to influence counties
41 towards improving mechanisms for co-ordinating mental health promotion and prevention locally was the main principal. The principal points of the EMIP project overall were the following: 1. Area of the promotion and prevention activities – counties and regions; 2. Key stakeholders and actors – county health promotion officers, also other key persons like social workers, teachers etc; 3. Key stakeholders on professional level – general practitioners and nurses; 4. Key agencies – municipalities; The list of participants is attached (see annex 2).
Strengths and weaknesses in mental health promotion and prevention
EMIP’s main focus is the implementation of promotion and prevention of mental health and to stimulate State to prepare a National Action Plan. At the moment there is not much action in the counties specifically in the area of mental health but health promotion is developing well in the areas of cardiovascular diseases and HIV/AIDS. There is insufficient knowledge among county health promotion officers, teachers, social workers etc about what comes to the question - what and how can be implemented in the area of mental health. Not many schools are involved in health promotion network yet although children and youngsters are the most vulnerable group, which should be taken care from the very early years as there is growing tendency toward poor mental health among children in Estonia. Feedback sheet was asked to fill in (see annex 3). A general problem of Estonian mental health promotion and prevention is its insufficient valuation, inadequate availability and incomplete information regarding the prevention. The enterprises could be encouraged by changes in taxation law to develop and strengthen promotion and prevention activities on workplaces concerning mental well-being.
So far, the network of promotion and prevention has not been developed because of the lack of both specialists and resources. The knowledge, training and refresher courses of health promotion are urgently needed. The draft of mental health policy in Estonia has been prepared a couple of years ago trying to consolidate the key issues in the field of mental health. Different stakeholders were
42 involved in the process of discussion and preparation of the document. Although the initiative was highly appreciated, the policy was not officially launched. In the policy a lot of attention is paid on psychiatric care, less on promotion and prevention possibilities. There are many existing activities and networks to which the mental health issues can be integrated in: working group under the development of environment protection strategy, movement of health promoting cities, hospitals and health promoting schools, activities within the strategy of cardiovascular diseases etc.
The mental health projects on international level and those implemented in cooperation with the EC and WHO have kept mental health in the agenda and in a line with the best practises of all over the Europe. There is a great knowledge and competence for identifying further priorities and actions in the field of mental health.
Existing mental health policies As the mental health is in European agenda and most of the countries are up to implement their strategies in mental health, it is the very good starting point for Estonia to be pulled on the stage to participate in the consulting progress with the Europe stressing the need to allocate all kind of resources regarding to change peoples mental health and well-being for the better. In the context of the Helsinki Declaration and Action Plan 2005 and results from different projects going on in Estonia in the field of mental health, high hope has put the Ministry of Social Affairs to take the initiative of launching a region wide action plan on mental health in the very next future.
What kind of support is needed from the EC to further mental health promotion and prevention in Estonia?
The main challenge Estonia faces in the field of mental health is the need for evidence- based mental health strategy and action plan. For implementing and reinforcing such policies, regarding to achieve mental well-being and social inclusion of people with mental health problems and to promote the mental well-being of the population as a whole, there is a need to pass messages to all settings to allocate resources for it. Mental health matters not only in healthcare and social sector but also in environment, work, education, culture and other sectors. EU can help Estonia in passing the messages that have impact on political field and initiates the development and implementation of mental health promotion strategies at national and local levels across Estonia.
43 In order to develop good practice in improving the mental health of population, the EU can contribute through its own activities and projects involving Estonian Initiatives into it.
Why the seminar was necessary?
The promotion of mental health (and the prevention, treatment, care and rehabilitation of mental health problems) is a priority for WHO and for EU Member States - a priority recognized at the WHO European Ministerial Conference on Mental Health in Helsinki in January 2005 and outlined in the Mental Health Declaration and Action Plan for Europe. The overall aim of the project was to build capacity, knowledge and expertise of mental health promotion strategies in Europe. The key focus was on how collaborative advantage can best produce effective intersectional strategy.
Future activities and developments
1. Support local initiatives to report of the ongoing activities in the area of mental health promotion and prevention; what is the outlook and vision for mental health and mental health promotion and prevention. 2. Support partners in building networks of key regional and local stakeholders who will receive training on the mental health promotion and prevention strategies. 3. Develop training on the local mental health promotion and prevention strategies. 4. Support partnerships to share best practice and agree common standards for the evaluation of mental health promotion strategies (with the methodology developed by IMPHA and with the European Platform). 5. Help local initiatives to work out the needs for action taking account the ten action areas and five common principles of the IMHPA Policy Document and WHO Mental Health Action Plan. 6. Collect the feedback by local initiatives and implement the material. 7. Publish the results in national media channels. 8. Participate in and contribute to the benchmarking conference at the end of the project. Airi Värnik, MD PhD Estonian-Swedish Mental Health and Suicidology Institute (ERSI) Helja Eomois, project co-ordinator Estonian-Swedish Mental Health and Suicidology Institute (ERSI) November 16, 2005 Tallinn
44 ANNEX 1
CONFERENCE: THE POSSIBILITIES TO PROMOTE MENTAL HEALTH
AGENDA 4-5 OCT, 2005
11.00- 11.30 Registration, coffee
11.30- 11.45 Opening Ivi Normet, Deputy Secretary General on Health, Ministry of Social Affairs Prof Dr Airi Värnik, PhD, Estonian-Swedish Mental Health and Suicidology Institute (ERSI)
11.45- 12.30 Eva Jané-Llopis, PhD, Medical Officer WHO Prevention of Mental Disorders
12.30-13.15 Christian Haring, PhD, Austria
Mental Health promotion and prevention: some experiences from Austria
13.15-14.00 Lynne Friedli, PhD, Great Britain Mental health promotion and Public mental health: some experiences from the UK
14.00-15.00 Packed lunch
15.00 -15.15 Prof Dr Airi Värnik, PhD, Estonian-Swedish Mental Health and Suicidology Institute WHO Mental Health Action Plan for Europe: Preparations in Estonia
15.15-15.30 Helja Eomois, local EMIP co-ordinator Linking WHO declaration: Ongoing EU projects in Estonia
15.30- 16.00 Dr Diana Ingerainen, Tallinn City Government The case or the human being
16.00 – 16.30 Merike Sisask, MSc, Estonian-Swedish Mental Health and Suicidology Institute (ERSI) EU project: European Alliance Against Depression
16.30-17.30 Discussion
17.30 Buss to Laulasmaa Resort
20.00 Dinner
45
DAY 2
07.00-09.00 Breakfast, possible to go to morning sauna and swimmingpool
10.00-10.30 Tiia Tulviste, PhD, Tartu University Estonian Mother and Child: based on modern comparative studies
10.30-11.00 Einar Laigna, Estonian Defence Forces Mental Health as a reflection of the culture
11:00-12.00 Dr Andres Lehtmets, President of the Union of Estonian Psychatrists
Management of the developing psychiatric care in Estonia
12.00-12.30 Sirje Vaask, Estonian Health Insurance Fund The role of health promotion in Estonian healthcare system: from perspective of Health Insurane Fund
12.30-13.00 Dr Imre Rammul, Regional Hospital of North Estonia
GP’s advice line
13.00-14.00 Lunch 14.00-14.30 Kristjan Wahlbeck, PhD, Finland Mental Health promotion and disorder prevention policies in Europe
Workshop (ETF grant nr 5349)
The role of alcohol: preventing suicidal behaviour and promoting mental health
14.30-15.00 Lauri Beekman, NGO Alcohol Free Estonia (AVE) Alcoholism, youth and mental health
15.00-15.30 Kairi Kõlves, MA, Estonian-Swedish Mental Health and Suicidology Institute (ERSI) Alcohol as a suicide risk factor: aggregate and individual level studies 15.30-16.00 Registered speeches, discussion
16.00-16.30 Jaanus Rohumaa, Tallinn City Theater On scene: From man to man
46 ANNEX 2
LIST OF PARTICIPANTS 4.- 5. oct 2005
1. Alamaa, Merle Tartu Vangla 2. Amos, Mari Õiguskantsleri kantselei 3. Arumaa, Merike SA Viljandi Haigla Psühhiaatriakliinik 4. Beekman, Lauri Ühendus Alkoholivaba Eesti 5. Eomois, Helja ERSI 6. Friedli, Lynne Suurbritannia 7. Haan, Ülle Erastvere Erihooldekodu 8. Haring, Cristian Austria 9. Harjo, Anu Tervise Arengu Instituut 10. Helde, Talvi Rapla Vesiroosi Gümnaasium 11. Holm, Heli OÜ Tõrva Tervisekeskus 12. Ingerainen, Diana Tallinna linnavalitsus 13. Johanson, Mare Merelahe Perearstikeskus OÜ 14. Jõe- Cannon, Ilvi ERSI 15. Kabin, Eve Haridus- ja kultuuriosakond 16. Kapsta, Kaia Eesti Kirikute Nõukogu 17. Kiplok, Uno Tervishoiuamet 18. Kosula, Kätlin Merelahe Perearstikeskus OÜ 19. Kree, Sirje Tartu Linnavalitsus 20. Kõlves, Kairi ERSI 21. Kütt, Tiina Lääne Laste ja Noorte Nõustamiskeskus 22. Laigna, Einar Eesti Kaitsevägi 23. Lehtmets, Andres Eesti Psühhiaatrite Selts 24. Lemmle, Malle OÜ Tõrva Tervisekeskus 25. Liiv, Anti Sihtasutus Anti- Liew & Hingehooldus 26. Liiv, Krystiine Tervise Arengu Instituut 27. Lopis, Eva- Jané Holland 28. Madisson, Reet SA Viljandi Haigla 29. Mannermaa, Väino Kaitsejõudude Peastaap, Personaliosakond 30. Miller, Liia Murru Vangla 31. Nemvalts, Riina Kaitseliidu Peastaap 32. Normet, Ivi Sotsiaalministeerium 33. Nuut, Ene SA Viljandi Haigla Psühhiaatriakliinik 34. Ojamäe, Karin Merelahe Perearstikeskus OÜ 35. Olt, Katrin Tartu Herbert Masingu Kool 36. Org, Maimu- Ellinoore SA Viljandi Haigla Psühhiaatriakliinik 37. Palo, Ene ERSI 38. Peedu, Galina SA Viljandi Haigla Psühhiaatriakliinik 39. Printsmann, Mairi ERSI 40. Pärna, Maire FIE 41. Rahula, Aino Lääne MV 42. Raidla, Mare ERSI 43. Raja, Karin Leppneeme lasteaed 44. Rammul, Imre PERH Tallinna Psühhiaatriakliinik 45. Rebane, Inge SA Viljandi Haigla Psühhiaatriakliinik 46. Rello, Maie Kaitseliidu Peastaap 47. Rikolas, Tiiu Kaitseliidu Peastaap 48. Rohumaa, Jaanus Tallinna Linnateater
47 49. Saks, Margit SA Viljandi Haigla 50. Samm, Algi ERSI 51. Siimson, Elli SA Viljandi Haigla Psühhiaatriakliinik 52. Sikka, Merle Kaitseliidu Peastaap 53. Sisask, Merike ERSI 54. Soom, Riina Murru Vangla 55. Tabri, Aili OÜ Pirita PAK 56. Teepalu, Kaire ERSI 57. Tihaste, Merle Rahuoperatsioonide keskus 58. Tooma, Aster Tartu Vangla 59. Tulviste, Tiia Tartu Ülikool 60. Täht, Kristina Rahvastikuministri büroo 61. Urbala, Kersti MTÜ Ida- Virumaa Psühholoogiline Abi 62. Vaask, Sirje Eesti Haigekassa 63. Vahermägi, Mari Avatud Piibli Ühing/ Eesti Kirikute Nõukogu 64. Wahlbeck, Kristjan Soome 65. Värnik, Airi ERSI 66. Värnik, Tõnis Külaline 67. Õim, Vilma OÜ Tõrva Tervisekeskus
48 ANNEX 3
EMIP (Implementation of Mental Health Promotion and Prevention Policies and Strategies in the EU Member States and Applicant Countries)
4-5 oct 2005
Feedback sheet
How have you been involved in mental health area (promotion, prevention, cure)?
………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………
What are the most critical matters regarding health promotion in your county area? ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………
Please list up 5 most positive examples (projects, health promotion initiatives)
………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………
49 What could be health promotion improvements in your county in the future? ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ……………………………………………………………………………… On what health promotion depends in Estonia? ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………
What kind of new ideas did you get from the workshop? ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………
What did you like about the workshop and what you did not? ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ……………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………
50
Finland
51 EMIP - National report FINLAND Draft 31 January 2006 Prepared by Juha Lavikainen and Irma Kiikkala
1. Foreword
The Finnish national workshop was held in STAKES on 31st of October 2005. Approximately 100 invitations were sent and altogether 40 people, representing governmental, municipal, professional and non-governmental organisations, as well as universities and research institutes, took part in the workshop. The programme included presentations by national officials and representatives of NGO's.
Following the EMIP suggestions, the two main headings in the agenda of the workshop were Strategies for obtaining the critical mass and Visions for the future. At the end of the day, the participants were divided into three small groups to discuss the challenges and future visions of mental health promotion in Finland.
The overall atmosphere in the workshop was rather enthusiastic and supportive to the theme of mental health promotion and prevention of mental disorders. Hence, the feedback was for the most part positive, while some concerns were raised as to the sustainability and impact of such a workshop in the longer run.
2. Important mental health figures
The following tables and figures are drawn from a recent publication (Pirkola and Sohlman (eds.), 2005, Atlas of Mental Health - Statistics from Finland) and included in this report with the permission of the authors.
52
As such, the figures show that the prevalence of mental disorders has remained quite stable, and there are no signs of an increase e.g. in the numbers of depressive disorders and anxiety disorders when compared with previous surveys.
Figure 1 shows a decreasing trend in the number of suicides although the number is still quite high.
It has become obvious, that the recent tax reduction in alcohol prices seems to have had an effect on the consumption (Figure 2.).
53 54 55
FIGURE 4. All pension schemes: change in the number of disability pensions in selected diagnostic categories 1996–2003 (Source: Social Insurance Institution)
FIGURE 5. New disability pensions awarded in 2003 by age group (Source: Social Insurance Institution)
56 3. Relevant stakeholders
The following organisations are the most relevant stakeholders in the field of promotion and prevention: - The Ministry of Social Affairs and Health - STAKES, the National Research and Development Centre for Welfare and Health - KTL, The National Public Health Institute - FIOH, Finnish Institute of Occupational Health - WHO Collaborating Centre for Promotion, Prevention, and Policy (operational as of January 2006) - The Finnish Association for Mental Health (Suomen Mielenterveysseura) - Finnish Central Association for Mental Health (Mielenterveyden Keskusliitto) - National Family Association Promoting Mental Health (Omaiset mielenterveystyön tukena keskusliitto ry.) - Finnish Centre for Health Promotion (Terveyden Edistämisen Keskus)
In addition to the above, at the regional level, State Provincial Offices come into play regarding some questions on (mental) health promotion. Furthermore, some universities and research institutes may - and do - have courses in their curricula relevant in this context.
4. Strengths and weaknesses in mental health promotion and prevention
Despite of the international "movement" it seems that mental health promotion and mental disorder prevention have not yet gained enough momentum on national level.
5. Existing mental health policies
Although there exists a general mental health policy (elements of which are included in "Health 2015"-strategy and the governmental Goal and Action Plan 2004-2007) an overall policy of mental health promotion is lacking and an outspoken policy of mental health promotion and prevention does not exist at the national level. Mental health is often taken into consideration in general health promotion policies. One recent example of this is the organisation of a "Health Promotion Tour" (in January-February 2006) in about 20 major Finnish cities. The municipalities are responsible for formulating their own policies as well as for the organisation of the health services. Some municipalities do have specific mental health promotion policies available, mainly at the local level.
National programmes have been carried out on suicide and depression. These programmes were positively evaluated and for example the recently completed large-scale programme, "Meaningful Life", brought together stakeholders across sectors and involved activities on many different areas. With regard to a target group approach, there are specific programmes available for children and adolescents and for the workplaces, but not so much for older people.
6. Existing legislation for mental health promotion and prevention
The Public Health Act has just been revised (in force since 1st of January 2006) to include a stronger emphasis than before on health promotion and prevention of diseases. According to the law, public health work covers measures taken at the level of the individuals, of the population, and of the living environment.
57 In view of mental health, The Mental Health Act (1116/1990) outlines the contents of mental health work.
The legislation listed below is relevant with the provision of mental health services.
• Primary Health Care Act (66/1972), • Act on Specialized Medical Care (1062/1989) • Act on the planning of and State subsidies for social welfare and health care services (733/1992) • Act on Welfare for Substance Abusers (41/1986) and Decree on Welfare for Substance Abusers (653/1986) • Child Welfare Act (683/1983) • Act on the Status and Rights of Patients (785/1992) • Personal Data File Act (523/1999) • Decree on Medical Rehabilitation (1015/1991) • Services and Assistance for the Disabled Decree (759/1987) • Act on Cooperation between Rehabilitation Organizations (604/1991) • Act on Rehabilitative Work (189/2001) • Social Welfare Act (710/1982) • Local Government Act (365/1995).
The legislation is available on the Internet at: http://www.finlex.fi
7. Push and pull factors (e.g. implementation status of national mental health goals)
In a way, the recession of the early 1990's still has a number of repercussions on the Finnish society. For example, a significant amount of promotion and prevention activities were cut down due to the poor economic situation.
Several nongovernmental organisations are active in the field of mental health promotion.
In 2005, several large-scale regional projects on mental health were started. These projects also tackle the issues of addiction. The Ministry of Social Affairs and Health co-funds these projects together with the participating municipalities.
8. Most urgent needs
It would be important to maintain the momentum created by international initiatives such as the WHO Action Plan and the Commission's Green paper on mental health, and to utilise this potential to the full. This links to the urgency of increasing public awareness and knowledge about mental health in general and of effective interventions specifically.
Mental health impact assessment is one of the topics which is foreseen to be important in the near future.
9. Obstacles and barriers
Changes in attitudes are needed and tolerance needs to be increased. Decision makers at local and national levels should be influenced. More sustainable funding - away from a strictly project- oriented approach - should be ensured. There is a lack of resources in the municipalities and at present, there is no body or organisation that would be clearly responsible for the planning and organisation of mental health promotion and mental disorder prevention in the country. More
58 information needs to be provided of e.g. the cost-effectiveness of mental health promotion initiatives.
All in all the debate on mental health still tends to deal with mental health problems and treatment of disorders, at the expense of mental health promotion and disorder prevention.
10. What kind of support is needed from the European Commission to further mental health promotion and prevention?
According to Article 152, there is a need to ensure that health is taken into account in all policies. The Commission could set an example for the member states by achieving this aim within its services.
Structures and funding which clearly exceed the normal project approach (of 2-3 years) need to be set up and adequately supported. This is an investment that would provide to be beneficial in the long run and also supportive to the Lisbon agenda.
The newly established "EU Platform on Mental Health" could be considered as a long-term investment toward reaching such aims.
59 11. List of participants
Kristiina Aminoff Vesa Nevalainen National Family Association Promoting Mental Health Finnish Psychological Association Kaija Appelqvist-Schmidlechner Marja-Liisa Niemi Stakes Ministry of Education Tanja Haarakangas Anu-Katriina Pesonen Stakes University of Helsinki, Department of Psychology Timo Haikonen Jorma Posio The Finnish National Fund for Research and Hospital District of Lapland Development Raija-Leena Punamäki Minna Harjajärvi University of Tampere, Department of Psychology Stakes Mika Pyykkö Jaakko Harkko Finnish Centre for Health Promotion Stakes Matti Rautalahti Tarja Heiskanen The Cancer Society of Finland Finnish Association for Mental Health Anitta Rauvala Teija Honkonen Stakes Finnish Institute of Occupational health Katri Räikkönen-Talvitie Tuula Immonen University of Helsinki, Department of Psychology National Family Association Promoting Mental Health Liisa Saaristo Matti Kaivosoja Finnish Association for Mental Health Pohjanmaa-project Katariina Salmela-Aro Ulla Katila-Nurkka University of Jyväskylä, Department of Psychology Stakes Markku Salo Irma Kiikkala Finnish Central Association of Mental Health Stakes Minna Savolainen Paula Koskinen Stakes Stakes Jouni J. Särkijärvi Lauri Kuosmanen Ministry of Environment The Umbrella project, Vantaa Tytti Solantaus Eero Lahtinen Stakes Ministry of Social Affairs and Health Helmi Tiri Piia Lahtinen Development of mental health services and addiction Mental health, substance abuse and occupational care, Kainuu health-project, Varkaus Sini Toikka Sakari Lankinen Stakes Ministry of Social Affairs and Health Antti Tuomi-Nikula Antero Lassila Stakes Hospital District of Etelä-Pohjanmaa Kristian Wahlbeck Juha Lavikainen Stakes Stakes Maria Vuorilehto Harri Lipponen The Umbrella project, Vantaa Tehy, the Union of Health and Social Care Professionals
60
Germany
61
Prof. A. Schmidtke WHO/EURO Network for Suicide Research and Prevention Department of Clinical Psychology Clinic for Psychiatry and Psychotherapy University of Würzburg Füchsleinstr. 15 97080 Würzburg
EMIP Project 2004 – 2006
Realization in Germany Final Report
62
Table of contents 1. General information 1.1. Population in Germany 1.2. Important mental health figures 1.3. Care of mental health problems 1.3.1. Inpatient treatment 1.3.2. Outpatient treatment 1.4. Conclusion 1.5. Recent Developments: models for comprehensive preventive programmes for mental illnesses 2. The National Workshop: general information, participants and program 2.1. Presentations 2.1.1. Mental Health Promotion and Prevention from a European perspective (Schmidtke) 2.1.2. EMIP (Kuhn) 2.1.3. Mental Health Promotion and Prevention in Germany (Röhrle) 2.1.4. EAAD (Hegerl) 2.2. Feedback 2.3. Post-conference developments 3. Relevant stakeholders 4. Strength and weakness in Mental Health Promotion and Prevention 4.1. Strength 4.2. Weakness 5. Existing mental health policies 6. Existing initiatives 7. How can we address Mental Health Promotion at national level? 8. Most urgent needs 8.1. In general 8.2. In the world of work 9. Obstacles and barriers 10. Support needed from the European Commission 11. Conclusion 12. References
63
1. General information
1.1. Population in Germany
Germany has a population of 40,353,627 males and 42,147,222 females. 9.4 % of the males and 8.3 % of the females are so called “Non Germans”). A special demographic feature is the over representation of elderly people (Figure 1). 21.9 % of the males and 27.8 % of the females are older than 60 years, 9.4 % of the males and 15.1 % of the females are older than 70 years. The average life expectancy for males is 76 years, for females 81.6 years.
85-90 years
70-75 years
55-60 years Female 40-45 years Male
25-30 years 5-year age groups 10-15 years
under 1 year -10,00 -5,00 0,00 5,00 10,00
Figure 1: Distribution of age-groups in Germany, 2004
According to all available forecasts, the percentage of the elderly in the population is increasing. Figures about incidence and prevalence of mental diseases concerning the whole population as well as interpretations of changes are only possible when taking into account these changes of the population structure (e. g. using age-adjusted figures).
1.2. Important mental health figures
In general, “health” has improved in Germany, however lower social status covaries with a more negative health situation.
64
Mental disorders comprise in Germany 9.8% of all illnesses and are, therefore, the 4th most frequent of all illnesses (see Appendix 1). The major groups are “somatoform disorders”, “affective disorders” mainly “depressive disorders”, “anxiety disorders”, “alcohol abuse”, and “psychotic disorders”. The number of dementia is also increasing (Figure 2).
Somatoform disorders 7
Affective disorder 5,8
Anxiety disorders 5,4
Alcohol abuse 2
Psychotic disorder 1,2
012345678 Frequency in Million
Figure 2: Frequency of psychiatric disorders in Germany Mental problems are increasing dramatically: the number of cases (treatments) increased in the last 8 years about 70% (Figure 3).
180 170 160 150 140 130 120 days of disease
number of days/cases cases of disease 110 100 1997 1998 1999 2000 2001 2002 2003 2004
Figure 3: Increase of psychiatric disorders in Germany (1997-2004)
According to a Federal survey (2001) the 12 months prevalence for psychic/ psychiatric illnesses in the adult German population is 30% of the whole population. If one estimates a rate of 25% for the indication of treatment this means a rough number of 5 millions of patients
65
with mental problems. In comparison: the estimated percentage of all mental disorders was world-wide in the year 2001 10.5%. For the year 2020 this percentage is forecasted as 15%. The costs for GNP loss estimated as 3.6%.
The annual rough number of suicides in Germany in the last years is between 10,000 and 13,000 cases. The age structure follows the so called “Hungarian pattern”, the suicide rates increase with age (Figure 4).
90 80 70 60 Female 50 Male 40 30
Suicides/100.000 20 10 0 -19-24-29-34-39-44-49-54-59-64-69-74-79-8485+ Age groups
Figure 4: “Hungarian pattern” in Germany, 2004
For youth and young adults suicides are the second highest cause of death after accidents (see example for males in figure 5).
3000
2500
2000 Others 1500 Car-accident 1000 Suicide
Cases of death 500
0 1-5 years 5-10 years 10-15 15-20 years years
Figure 5: Cases of death in Germany in the younger age-groups for males, 2004
66
According to the WHO multicentre study on suicide attempts the number of suicide attempts in Germany can be estimated between 100,000 and 150,000. The younger age groups (especially females between 15 and 25 years) have the highest rates.
The suicide rates in the last years decrease over time (Figure 6). In comparison to the high rates in the seventies (77 – 80) the rates decreased about ca. 44% (2001 – 2004).
30
25
20 Male 15 Female Both 10 Suicides/100.000 5
0 1990 1992 1994 1996 1998 2000 2002 2004 Year
Figure 6: Decrease of suicide rates in Germany (1990-2004)
On the other hand the rate of death due to drugs stabilised in the last years (see figure 7).
2500
2000
1500
1000
500
Cases of death by drugs 0 1973 1979 1985 1991 1997 2003 Year
Figure 7: Cases of death caused by drugs in Germany, 2004
67
1.3. Care of mental health problems
1.3.1. Inpatient treatment
The number of inpatient treatments per year in Germany is estimated for the year 2004 with ca. 670,000 cases (see figure 8).
800000 676,801 700000 600000 500000 400000 300000 200000 Number of cases 100000 33,522 22,165 0 Psychiatry and Psychiatry and Psychotherapeutic Psychotherapy Psychotherapy for children Medicine and adolescents
Figure 8: Number of inpatient cases per year in Germany, 2004
The number of psychiatric beds decreased during the last years, however, at the same time, the number of “psychosomatic beds” increased in nearly similar proportion (Figure 9).
140000 115,857 120000 100000 80000 54,088 60000 40000 Number of beds of Number 20000 0 12 Year
Figure 9: Reduction of the number of beds in clinics for psychiatry and psychotherapy from 1975 (1) to 2003 (2).
68
In the last years in many psychiatric clinics, there were huge efforts to modernise the building structure. The majority of clinics also introduced special wards (e. g. for depressive disorders, psychotherapy). as well as day clinics.
1.3.2. Outpatient treatment
After the “Psychiatry enquete” there were huge efforts to improve also the out-patient treatment of psychiatric patients.
For the treatment of the patients with mental problems according to an estimation of the DGPPN (German Association of Psychiatrists and Neurologists):
The last available statistic of the KBV (organisation of doctors who are included in the systems paid for by obligatory health insurance companies (GKV) estimated 4,936 specialists for psychiatry and psychotherapy (with medical background, including nerve specialists, that means doctors with double qualification as psychiatrist and neurologists). These doctors care for 1.9 millions of patients per quarter (one patient every 40 minutes).
There are 17,600 psychotherapists with background as psychologists. They treat 520,000 patients per quarter (that means on the average 600 minutes time for treatment).
According to the latest figures the federal chamber for psychotherapists (Bundespsychotherapeutenkammer) had 28,611 as a total number of members in the year 2005 (psychological therapists and psychotherapists for children and youth). In the new provinces the figure approximately is at about 1700 members. The number of doctors with an additional education in psychotherapy is not assessable.
The number of psychiatrist, which became certified by legal authorities increased during the last years (see figure 10).
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900 846
800 742 700 669 589 600 484 500 412 383 400 355 369 374
Number 290 278 300 236 258 204 205 200 137 129 109 94 91 100 54 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Psychiatry and Psychotherapy Psychotherapeutic Medicine
Figure 10: Number of certifications by the Medical Associations in Germany 1994-2004
Also the number of psychotherapists increased during the last years, especially of those who are psychologically educated (see figure 11).
16000 14148 13802 14000 13143 12715 12229 12000 10713 10000
8000 Number 6000
3570 4000 3195 3300 3280 3225 3448 2653 2301 1863 2052 2000
0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Medical Psychotherapist Non-medical Psychotherapist
Figure 11: Expansion of the number of authorised psychotherapists
For 2004 existed a forecast of treatments in psychiatric wards (and polyclinics) estimated ca. 200,000 patients with 500,000 treatments (Spengler, 2004).
According to the psychiatry enquete also the number of “supporting-groups” for psychiatric disorders in Germany increased. The total number is not assessable.
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1.4. Conclusion
The German Association for Psychiatry, Psychotherapy and Neurology (DGPPN) concludes, that despite the increased treatment capacity, there exists still a clear undersupply in treatment of patients with mental problems. 80% of all mental problems stay untreated. This affects especially the patients with severe illnesses such as schizophrenia, severe depression, bipolar disorders, alcoholism and drug abuse or dementia. According to the German network against depression and the European alliance against depression (Hegerl et al., 2006) there are approximately 4 millions of depressive persons in Germany. However supposedly only 360,000 are sufficiently treated (Figure 12).
100%
80%
60%
40%
20%
0% Depression in in family diagnosed as satisfactory compliant total in doctor depression treated 0,24- after 3 month Germany: treatment 2,4- 1,2-1,4 Mio. 0,36 Mio. treatment 0,1- about 4 Mio. 2,8 Mio. 0,16 Mio.
Figure 12: Estimation about prevalence and treatment conditions of depression in Germany
The psychotherapeutic deficit is most obvious in the new provinces (see figure 13).
16000 14311 14000 12000 10000 8000 6000 4621 Number 4080 4000 2000 0 old West newly-formed whole federal German states German states territory
Figure 13: Inhabitants per Psychotherapist in Germany, 2004
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1.5. Recent developments: models for comprehensive preventive programmes for mental illnesses
The legal basis for developing integrated networks to treat and care for psychiatric patients consists out of §140 SGB (Book of the German Social Code) enacted by the Federal Government. The DGPPN create on this basis evidence based comprehensive concepts for the four main psychiatric illnesses (depression, schizophrenia, dementia and alcoholism) (Berger, 2004). In order to do so various working groups were founded.
Some field studies already exist. For example, the ”programme for spiritual health“ is engaged in relapse prevention in Munich. It consists out of patients, 65 psychiatrists, a university clinic, other hospitals and a health insurance company (BKK). There also is a formal co-operation between the clinic and the psychiatrists, such as common meetings for the recidivist prophylactic medication. The programme offers psycho-educative groups, including those for relatives and special therapies as well as support by social workers. It is an open programme and patients can use treatment offers according to their wishes. The participating insurance company pays a special fee for the participating doctors, as well as additional posts for clinics. The communication between clinics and psychiatrists in practice is also paid for. In contravention to the present rules, the patient can already during the inpatient treatment contact the psychiatrist in practice. It is paid for. First can conclusions already show that for patients in the programme only half of the recent costs for inpatient treatment have to be paid (Huber, 2006).
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2. The National Workshop: general information, participants and programme
The National Workshop for Germany was held in Berlin, on November the 4th in 2005. About 70 people of relevant institutions in the field of mental health participated.
2.1. Presentations
2.1.1. Mental Health Promotion and Prevention from a European perspective
After a definition of „mental health“, the role of the EU and the WHO in the field of prevention of mental health was presented. The presentation included epidemiological data for mental health, psychiatric illnesses, suicide and therapy. It also showed the historical development and the legal basis for measures in this field.
2.1.2. EMIP (Kuhn):
13 national partners and networks co-operate in EMIP. Objective of this project is to support the development of a better mental health and well-being on a national level in all participating countries. Therefore, the national activities will be compared and models of best practices taken out. A common action plan (general action plan) will be developed in order to follow political demands of the EU.
2.1.3. MENTAL HEALTH Promotion and Prevention in Germany:
Mental illnesses are the main causes for sick-day (especially among young people). In the treatment of behaviour disorders prevention has only a medium effect size. Studies show that institutions especially created for preventive tasks often change over time their main focus to treatment instead as well as to providing people with information. In Germany especially the prevention of addiction is evaluated. In total in counselling services a neglect of many areas of prevention can be stated.
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Furthermore there orientation often is not evidence-based. In comparison to that, health promotion in schools and day care institutions is better. Yet it is not equally distributed in different regions and in addition often rather model oriented than evaluated. In this field it is necessary to enforce more studies to the state of the art and the co-ordination. In order to do so a co-operation with stakeholders is essential.
2.1.4. EAAD
28% of the inability to work is caused by mental problems. Especially in the field of depression there exists a diagnostic and therapeutic deficit. To improve this the Nuremberg model work action focussed on four levels: GPs, Public sector, multipliers and concerned patients. The effects are significant (Hegerl et al., 2006). In the framework of the German alliance against depression many cities created their local alliance. In the framework of The EU project a co-operation of 16 European countries is successful.
2.2. Feedback
Within in the workshop it was concluded, that in the field of preventing mental diseases a key role should not only be played by formal Governmental organisations and organisations of specialists. Also the European Council and the Agency for Human Rights should be included into the networks, since they have an important impact.
In Germany legal and formal possibilities for prevention already exist. They have been created by the German Government. Their completion should now be fulfilled by specialists. For this purpose international networking activities were proposed.
One major point of the feedback dealt with the financial system in Germany. A key problem is, that most part of the money – if not everything – is foreseen for treating illnesses, and only a very limited amount for prevention. Thus a central question needs to be: what impedes experts from doing prevention? It is recommended to find creative solutions, since the system itself tends to be immobile.
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Some companies in Germany already have tried to find such solutions. For example, the Ford company introduced some product lines for employees, who otherwise would have been pensioned. There are furthermore legal based Disease-Management-Systems in Germany (Sozialgesetzbuch §84: Wiedereingliederungsvorschrift für Arbeitgeber). If a employee has been away from work because of sickness for more than six weeks, the person must be reintegrated at work with the help of such a system.
Mental well-being is of central value within the working world („social capital“). It is critical, how healthy people feel, in order to participate into the competition within the society.
To reach these goals, it is very useful to define high-risk groups. This is already done in some projects. For example within the National Suicide Prevention Programme for Germany there are workshops for high risk groups (police force, train drivers, doctors and nurses). INQA, another project group, is dealing with „traumata“.
Within the workshop participant shared the opinion, that it seems to be essential to already implement steps for improving mental health into the curricula for various professions.
In order to prevent psychological illness at work it is necessary to implement a comprehensive business care and promotion of company culture. A large selection of material is already available to companies for analysing psychological illness. However only hard facts (e.g. lost work days, costs) are in the centre of attention for most businesses. That is why the connection between working conditions, depression and resulting costs must be stated clear. Furthermore depression causing working conditions should be a discussion theme not only at the level of company doctors but also for professional associations.
Mental health prevention in the area of drugs is likewise very important (e.g. psychologically health ex-smokers will presumably have less relapses). Intersections between addictive illness an mental health should be used.
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2.3. Post-conference developments
After the national workshop in Berlin specific workshops were held on the themes „work place“ (24th of January 2006 in Dortmund), „psychiatry“ (16th of December 2005 in Darmstadt) and „total population“ (25th of April in Bonn).
Resulting from it a collection and submitting of suggestions to the “Green Book” at the European Commission was created.
3. Relevant stakeholders
In the following the relevant stakeholders are numerated in the field of MENTAL HEALTH Promotion and Prevention:
► Federal German Health Ministry (Bundesministerium für Gesundheit und soziale Sicherung, BMGS) ► Association of Doctors participating in health security scheme (Kassenärztliche Bundesvereinigung, KBV) ► German Society for psychiatry, psychotherapy and treatment of nervous disorders (Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde, DGPPN) ► National Suicide Prevention Programme (Nationales Suizidpräventionsprogramm, NaSPro) ► German Association for Suicide Prevention (Deutsche Gesellschaft für Suizidprävention, DGS) ► Supporting-Groups (Selbsthilfegruppen)
4. Strength and weakness in Mental Health Promotion and Prevention
4.1. Strength
In Germany tendencies can be stated, that stakeholders are prepared for change. Furthermore awareness is rising, about how important prevention in the field of mental health (influenced also by the EC Green Paper).
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There also are very effective prevention initiatives. However evaluation, registration and nation-wide dissemination is often lacking. In the world of work for example good methods are already available for registering the well-being of workers.
„Company culture“ is encouraged with a direct link to the well-being of workers by the federal ministry of work. Furthermore it is already legally set down that health insurance companies must provide a specific percentage of their budget for prevention measures (2.60 € per person).
Projects sponsored by the EU (i.e. IMPHA) placing surveys and reports on Mental Health Promotion and Prevention were already prepared. They will be a good starting point for further work.
4.2. Weakness
In the area of preventing psychological illness there is basically no specific training offered. Resulting from this there is a lack of human resources in this field. Additionally to the deficit in knowledge and skills there is hardly any research on this topic. Moreover only 16% of researches in Germany are of empirical character and were evaluated within the field of preventing psychological illness between 1993 and 2000 (Röhrle).
Many different institutions work in areas concerning prevention. There are however until now few liaisons between these initiatives.
5. Existing mental health policies
► Within the general law of social insurance V, health promotion is stated obligatory for health insurance funds in Germany. In order to provide this a basic definition of the appropriate provision of health care is necessary (§4(1), §30, §84). ► The general law on social insurance IX states the duty of cost providers in the field of rehabilitation to avoid the occurrence of disability and chronic illnesses.
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► Example for existing programmes: reintegration of employees after 6 weeks of illness (SGB IV, §84). ► The legislation in the field of children and youth already is designed and established as prevention legislation. ► A special prevention legislation is currently in progress (second approach).
6. Existing initiatives
► German network for mental health (register of already existing programmes, sorted by themes) www.gnmh.de ► Programme against stigmatisation (psychotic disorders) ► Comprehensive network for prevention of mental illness (DGPPN) www.dgppn.de ► European and national alliances against depression (EAAD) www.eaad.net, special programmes for persons with migration background ► National programme for suicide prevention in Germany (NaSPro) www.suizidpraevention- deutschland.de ► Initiative new quality in work life: INQA (Initiative Neue Qualität der Arbeit), www.inqa.de ► Non-smoking-campaign for the youth (Antiraucherkampagne der BZGA für Jugendliche) www.rauchfrei.de ► MindMatters – Components of healthy schools (Bausteine einer psychisch gesunden Schule) ► Initiative of the DGSP “patient as a partner” („Patient als Partner“ www.patient-als- partner.de) ► Network of non-smoking hospitals (Netzwerk rauchfreier Krankenhäuser), www.rauchfreie-krankenhaeuser.de ► Network of hospitals with good treatment for migrants (Netzwerk migrantenfreundlicher Krankenhäuser) ► Network for health promotion in hospitals for children (Netzwerk zur Gesundheitsförderung in Kinderkrankenhäusern) ► Task force on health promoting psychiatric services ► Various programmes for the prevention of work related pain (for example OSI Mannheim) ► Various regional initiatives
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7. How can we address Mental Health Promotion at national level?
The already existing “network for mental health” can be used as a platform.
8. Most urgent needs
8.1. In general
► Raising of awareness at all levels (political level, health system level, health research and general population) ► Networking of various areas of health prevention is necessary as well as a stronger co- operation of different networks, in order to create permanent structures. ► The structural lack of a social, political and health care basis needs be worked on. In particular it is necessary to develop a specific prevention and health promoting law, which also is labelled as such. This law should contain initiatives for a comprehensive department collaboration of all political partners that are involved on the federal, province and community level. At present the phrasing of prevention conditions in the social statute book is vague. ► Further financial supporters for prevention measures should be incorporated (in addition to pension, nursing care, accident or illness insurance). Increasing the financial resources for prevention is necessary. ► Not merely social insurance agencies should be responsible for the linking of behaviour prevention with context related measures. ► Prevention should be defined and laid down in the statute book (in addition to primary, secondary and tertiary prevention, the collaboration of individual prevention fields should be made a subject of discussion). ► Co-ordinated health reporting is needed, which is able to provide specific statements for psychological health. This needs to be published for various levels, sectors and treatment fields. ► Specific training should be offered for preventing psychological illnesses. ► Systematic evaluation of already existing prevention measures is necessary, i.e. exhaustive inquiry of the existing offers and deficits.
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► Furthermore already available efficient preventive measures should be integrated into existing psycho-social services. ► A co-ordination of offering-structures in an intersectorial sense is highly recommended (i.e. businesses and schools) ► Preventive nursing care models at a communal level should be established.
8.2. In the world of work
► A legal framework, which lays down that the employer must assess and evaluate the work situation of his workers is highly recommended. ► Norms and standards for the definition of psychological stress at the workplace need to be implied. ► There should be responsible within companies, who are specifically dealing within the field of “prevention”.
9. Obstacles and barriers
One main obstacle in some areas for prevention measures in Germany is the finance structure. There is a strict differentiation between the cost sponsors for the curative measures (secondary and tertiary prevention) and those for prevention measures (Becker, 2003).
The three main cost providers for prevention are health insurance companies, accident insurance companies and pension funds. They consist of a huge number of individual organisations, which more or less autonomously can decide which means will be invested, where and for which preventive measures. For example in most cases the cost sponsors for preventive measures in the field of addiction are institutions as well as sponsors for rehabilitation. In the field of secondary and tertiary prevention the cost sponsors are mainly health insurance companies. In addition to civil servants on federal, province or community levels supporting funds (Beihilfeträger) are providing funds as well.
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In some areas this causes problems, for example when the medical service of the health insurance companies (Medizinischer Dienst) evaluates measures for booster treatments. Despite various studies showing that booster treatments are effective in the prevention of relapse, the payment of this treatment often is discussed about. In many cases it is not paid for by the health insurance companies due to recommendations of the medical service. Since they are not considered as “acute treatments” according to their definition, if costs are covered. A solution is seen in spanning insurance companies, if not an overall insurance branch.
10. Support needed from the European Commission
Financial means for evaluating implementation studies.
11. Conclusion
For the solution of the causality problem (=where does psychological illness come from) an integrated approach is needed. It should take into account many variables, i.e. the leadership style in companies, working-conditions, nutrition, hobbies, socio-political variables like poor- rich gap. All this influences considerations about which form, prevention might be pursued.
The basis for further mental health promotion and prevention is first and foremost the exchange of information. The EMIP Workschops strongly enhanced the necessary linking of various areas of the health service as well as among networks, self-help groups, policy actors and stakeholders.
The next aim should be the linking of partially working network structures in order to encourage further co-operation and establish joint activities to put forward mental health promotion and mental disorder prevention most effectively.
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12. References
Becker, U. 2003. „Präventionspolitische Eckpunkte der Bundesregierung“. Rede des Leiters der BMVA-Unterabteilung „Arbeitschutz, Arbeitsmedizin“, anläßlich der Veranstaltung „Erfolgreiche Prävention durch Zusammenarbeit der Spitzenverbände der UVT und der KK, 6. 11. 2003, Berlin.
Berger, M. Wer behandelt in Zukunft schwer psychisch Erkrankte?. Stellungnahme DGPPN.
Berger, M. 2004. Probleme bei der Versorgung psychisch Kranker in Deutschland am Beispiel der Depression. DGPPN Kongress 2004, Berlin.
Bundespsychotherapeutenkammer. 2005. Keine Gesundheit ohne psychische Gesundheit – Ergebnisse des 5. Deutschen Psychotherapeutentags.
Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde. 2004. Engagement der DGPPN zur Etablierung von Integrierten Versorgungsnetzen für psychische Erkrankungen. DGPPN-Geschäftsstelle, Freiburg. S. 1-5.
Fricke & Pirk, 2004. Defizite in der Arzneimittelversorgung in Deutschland. VFA.
Fritze, J. 2004. Auswirkung der Gesundheitsnetze auf die Versorgung psychisch kranker Menschen. DGPPN Kongress 2004, Berlin.
Fritze, J., Aldenhoff, J., Hohagen, F. Gesundheitsreform 2006: Besonderes Betroffensein psychisch Kranker. Stellungnahme für die Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde (DGPPN) und die Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP).
Gaebel, W. 2004. Der psychisch Kranke als Fremder und Ausgegrenzter Belastung Betroffener durch Stigmatisierung. DGPPN Kongress 2004, Berlin.
Gesundheitsministerkonferenz (Arbeitsgruppe Psychiatrie). 2003. Bestandsaufnahme zu den Entwicklungen der Psychiatrie in den letzten 25 Jahren. 76. Gesundheitsministerkonferenz 7/2003, Chemnitz.
Huber, H. (2006) “Programm für seelische Gesundheit” reduziert die Rückfallquote. ÄP NeurologiePsychiatrie, 3, 50.
Jacobi, F., Klose, M. & Wittchen, H.-U. 2004. Psychische Störungen in der deutschen Allgemeinbevölkerung : Inanspruchnahmne von Gesundheitsleistungen und Ausfalltage. Bundesgesundheitsblatt – Gesundheitsforschung – Gesundheitsschutz, 8, S. 736 – 744.
Röhrle, B. 2001. Ausgangspunkte und Perspektiven. Denkworkshop zum Thema „Prävention psychischer Störungen und Förderung psychischer Gesundheit“. 11/2001, Fulda.
Rössler, W., Salize, H.-J., van Os, J. & Riecher-Rössler, A. 2005. Size of burden of schizophrenia and psychotic disorders. European Neuropsychopharmacology, 15, S. 399 – 409.
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Stellungnahme betroffener Verbände (GGFP, GNMH, DGSP, DGVT). 2005. Stellungnahme zum Entwurf eines Gesetzes zur Stärkung der gesundheitlichen Prävention. www.bvgesundheit.de/pdf/praevges020205.pdf)
Trabert, G. 2002. Kinderarmut: Zwei-Klassen-Gesundheit. Deutsches Ärzteblatt, PP 1, Februar 2002, S. 61.
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Hungary
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Dr. Richárd Plette
NCPH-NIOH
Report of the “Issues of mental health in Hungary” workshop
1. BACKGROUND – EUROPEAN DATA Definition of mental health: „A degree of well-being, in which the individual can live up to his or her potential, is able to tackle the everyday difficulties of life, is able to carry out effective and productive work and can contribute to his or her community” (according to the WHO definition). Mental disorders: A collective set of self-damaging behaviours, such as depression, suicide, antisocial personality, non-hostile psychosis, generalised anxiety disorder, alcohol abuse and various phobias. These disorders are caused by a complex interaction of physical, psychological, social, cultural and hereditary factors. The incidence of metal disorders is increasing worldwide. ¾ 400 million people worldwide suffer from mood disorders ¾ 340 million have anxiety disorders, ¾ 45 million have personality disorders, ¾ Among those with behavioural disorders, 120 million are alcoholic, 120 million are addicted to drugs, and 1.1 billion are addicted to nicotine. ¾ These disorders are responsible for 30% of all disabilities.
It is estimated that more than 27% of the European adult population has at least one mental disorder annually. Anxiety disorders and depression are the most widespread of disorders observed in the European Union. By 2020, depression is expected to play the largest role in the developed world. Psychic and psycho-social hazards, often called workplace stress (related to work), affect almost a third of the total working population (41.2 million workers) in the European Union. Stress is the second largest occupational health problem in the European Union.
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Intimidation at the workplace is a very serious problem for the European workforce. According to the results of an EU survey, 9% of workers, that is, 12 million, reported that they had been the victims of intimidation during a one-year period. Costs related to this are significant for both the workers and the organisations. Moreover, intimidation should be regarded as unethical and oppressive behaviour, and as such, unacceptable in the working environment. Prevention of intimidation at the workplace is one of the objectives in the announcement of a new European Committee strategy for health and safety at work.
The issue of mental health is one of the priorities of the Public Health Programme of the European Union. An agreement was concluded in 2004 to launch the “EMIP* Project 2004-2006”. The Project was prepared by the Federal Institute for Occupational Safety and Health (FIOSH) with input from other partners (e.g. WHO, STAKES). An Action Plan was prepared at the WHO European Ministerial Conference on Mental Health held in Helsinki, in January 2005. This Action Plan is endorsed in the Declaration for Europe by the ministers of health of the Member States in the European Region of the WHO. They support its implementation in accordance with each country’s needs and resources.
The priorities for the next decade include the following: i. foster awareness of the importance of well-being, ii. collectively tackle stigma, discrimination and inequality, and empower and support people with mental health problems and their families to be actively engaged in this process, iii. design and implement comprehensive, integrated and efficient mental health systems that cover promotion, prevention, treatment and rehabilitation, care and recovery, iv. address the need for a competent workforce, effective in all these areas, v. recognise the experience and knowledge of service users and carers as an important basis for planning and developing services.
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*EMIP (European Mental Health Implementation Project) This Action Plan proposes ways and means of developing, implementing and reinforcing comprehensive mental health policies in the countries of the WHO European Region, requiring action in the 12 areas as set out below. Countries will reflect these policies in their own mental health strategies and plans, to determine what will be delivered over the next five and ten years. The Mental Health Action Plan for Europe defines 12 priority areas:
- Promote mental well-being for all - Demonstrate the centrality of mental health - Tackle stigma and discrimination - Promote activities sensitive to vulnerable life stages - Prevent mental health problems and suicide - Ensure access to good primary care for mental health problems - Offer effective care in community-based services for people with severe MH problems - Establish partnerships across sectors - Create a sufficient and competent workforce - Establish good mental health information - Provide fair and adequate funding - Evaluate effectiveness and generate new evidence
Three priority areas (bolded) deal with mental health promotion and prevention.
Together with the ten action areas and five common principles of the IMHPA** Policy Document, that are presented here below, they offer a selection of implementation areas.
**IMPHA (Implementing Mental Health Promotion Action)
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Ten action areas a. Support parenting and the early years of life b. Promote mental health in schools c. Promote workplace mental health and prevent work related stress d. Support mentally healthy ageing e. Address groups at risk for mental disorders (critical groups) f. Prevent depression and suicide g. Prevent violence and the harm done by substance use (drugs) h. Involve primary and secondary health care i. Reduce disadvantage and exclusion and prevent stigma j. Link with other sectors to create supportive environments
Five common principles 1. Expand the knowledge base for mental health 2. Support effective implementation 3. Build capacity and train the workforce 4. Engage different actors 5. Evaluate and monitor the impact of implemented policies and programmes
2. PROGRAMME OF THE NATIONAL WORKSHOPS
Based on the outcomes of the previous project, it became necessary to consider implementing the strategy of improving mental health in the EU Member States. On the basis of this, the Action Plan for Europe is being developed with the help of National Workshops. Based on the September, 2004 agreement with the Consortium, our Institute became the national representative of the project, as the National Partner, that is tasked with the responsibility of organising the national workshop.
The objectives of the programme of the National Workshop were defined according to the recommendations of the Mental Health Action Plan for Europe. The National Workshop was held in Budapest, on November 4, 2005, with the participation of 35 experts committed to the issue.
When inviting the participating experts, we strived to establish relationships with representatives from other sectors, in order to find solutions to the issues raised together. Hence participants were invited from various areas: ⇒ Health care professionals ⇒ Occupational psychologists ⇒ Labour Safety professionals ⇒ Academia ⇒ Interest advocates (Unions, etc) ⇒ Managers The spokesperson for employees (national level!) and the executive general secretary of the employers (national level) participated at the conference.
The topics discussed at the Workshop were elaborated on the basis of the above aspects:
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¾ Mental Health at the workplace, workplace stress and health care services ¾ Reduction of violence and discrimination, ¾ Education, mental health in schools, ¾ Problems of mental health, role of the family, depression, suicide, ¾ Problems of vulnerable age groups, ageing
During the workshop five 30-minute presentations were held, discussing the main issues related to the above topics. In the afternoon, following the plenary session, the topics were discussed in 5 parallel subgroups. The subgroups worked under the direction of moderators. We tried to find answers to the issues raised in each of the topics.
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3. ASSESSMENT OF THE ISSUES OF MENTAL HEALTH ON THE BASIS OF THE NATIONAL WORKSHOP
1. Situation today: where are we, where are we going? (Important mental health figures)
Regulation in Hungary is adequate; right to health, including mental health, is guaranteed at the highest level, under the Constitution of the Republic of Hungary. This is included in the Labour Safety Act. However, with a few exceptions, preservation of mental health, prevention of mental disorders is not adequately represented in primary prevention.
1.1. Issues of mental health at the workplace Relatively little reliable data is available on the national state of mental health, and these show that the situation is extremely bad. Every other Hungarian worker is exposed to a high level of stress at the workplace. Another 40% suffer from medium level stress. A study performed by national occupational psychologists (Gordio group) showed that the working week of the average Hungarian consists of 44.5 hours worked, which is about 1 hour longer than the recommended 8 hours. Several groups of workers can work significantly longer. It is worth mentioning that doctors occasionally put in 60-70 hour weeks. Agricultural labourers work 12-14 hours a day April to September, 10 hours a day October to Mach; women employed in agriculture work 6-8 hours a day, and there are no days off (Saturday, Sunday, Official Holidays). About 60% of workers take on the extra time because they are expected to. Most find it hard to bear the stress of time, but the excessive workload and work tempo are also often a problem for Hungarian workers. When asked about the cause of stress arising from human relationships, most respondents named the actions of their supervisors, and the lack of support from their supervisors. Financial difficulties lead the list of stress factors outside the workplace, but immediately after these, the general political and economic situation and mood of the country burden the psyche of the Hungarians.
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General exhaustion and backache manifest themselves the most strongly of the physiological symptoms of stress, followed by high blood pressure (27%). Discontentment (dissatisfaction), reduced will to work, and anxiety top the list of psychic symptoms.
1.2. Intimidation at the workplace Few figures are available in Hungary. According to a 1996 survey, about 8% of those polled said that they had experienced this insult during their lifetime. Consequences for the victims of intimidation can be significant. It has been proven that the following can manifest: physical, mental and psychosomatic health problems, e.g.: stress, depression, reduced self-esteem, self-blame, phobias, difficulties sleeping, and problems of the digestive and muscular systems. Post-traumatic stress disturbances, similar to symptoms manifesting following other traumatic experiences, e.g.: catastrophes or attacks, are also generally typical in victims of intimidations. These symptoms can persist even years after the incident. Social isolation, domestic problems, and financial difficulties due to absence from work, or getting laid off, are other possible consequences. There is relatively little data on abuse of power in Hungary, since workplace insecurity is a relatively new problem. In many cases a fear of getting laid off makes abuse of power possible. Typical examples of this: making mothers come to work on Saturday afternoons, or retention of annual vacation time. Some workers do not dare to go on sick-leave, or mothers send their (sick) children to kindergarten after giving them fever medication. On the organisational level, the price of intimidation is frequent absenteeism, fluctuation of the staff, reduced efficacy and productivity, not just by the victims of intimidation, but also by other staff members, who suffer from the negative psychosocial climate of the working environment. Legal damages arising from cases of intimidation can also be significant.
1.3. Discrimination Discrimination, violence can occur at the workplace and outside of the workplace. It can be domestic and non-domestic. Types: due to sex, age,
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education, economic/social state, belonging to a discriminated minority, handicap.
1.4. Education There is no subject linked to issue included in the formal curriculum in secondary education. In the case of tertiary education, the subject of “school mental hygiene” has been included in the curriculum at the gradual level since 1993, in the training of teachers and the specialisation stage of psychologist training. There has been “mental health trained professional’ training in post-gradual form, since the end of Communism (for those working in education, social and health care fields). Occupational health psychologist training – widespread in Western Europe – is non-existent in Hungary.
1.5. Mental disorders In Hungary, Maria Kopp et al. carried out a survey to examine the relationship between physical and mental health in the Hungarian population. Based on the outcome of the survey, they found that the most important psychological background factor behind the worsening physical health of the Hungarian population is the depression syndrome. According to the findings of the survey, the severity of depression is closely related to unemployment and financial status, being left behind socially and low level of education. Those who can expect help during hard, changing times, are much less likely to become depressed, helpless, than those who feel they cannot trust anyone. Depression syndrome is thus a significant health risk factor, diagnosis and treatment of which is important even at the primary care level in order to prevent subsequent behavioural disorders, health consequences. These disorders are responsible for 30% of disabilities. The findings of the Gallup survey: population ratio: 12.8%, 16.3% in women, and 8.8% in men. One in every 6 women and one in every 11 men had had a mental problem within the two weeks preceding the survey. Half of those suffering from these symptoms do not see their doctor, half of those who do, will be correctly diagnosed; the ratio of those getting proper care is barely 20%.
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More women suffer from mental disorders than men; various social deficiencies may play a role: women do not have the same career possibilities as men, women are paid less. Some employers are proven to be less willing to employ women, and they restrict their right to maternity leave. Occupational segregation: while women tend to work more in the public sector (education, health care), men enter the private sector in larger numbers. There are more men than women among the self-employed or private entrepreneurs. Women have multiple burdens (work, family, raising children). Middle-aged women have a reduced chance of being employed. Inequalities within the family striking women, division of power is one-sided. Based on a national representative survey performed on 12 640 subjects, Kopp et al. found that in 1995, 45% of the men and 26.6% of women were smokers, the ratio in those under 45, was 47.9% and 31.9% respectively. The picture is worse in men with a low level of education, both regarding the ratio of smokers and the number of cigarettes per day, and the amount of pure alcohol consumption. This relationship is not so obvious in women. Health promotion campaigns can only be successful if they target the psychological, motivational background of such self-destructive behaviour. The Act for the Protection on Non-Smokers (XLII of 1999.) states that smoking is prohibited in the workplace, in public buildings, on public transportation, during gatherings held in enclosed places – with the exception of specially designated areas. Smoking areas cannot be designated in health care institutions, in areas frequented by students in schools, on local public transportation, on long-distance buses, in sports facilities, in enclosed areas meant for sports activities. Hungarian suicide statistics were among the worst in World until 1994, with 45.9 per hundred thousand. Since then, they have decreased by 40%, which is the highest reduction in the world. However, it is still quite high (27.4/100 000 in 2004). Especially alarming is the number of suicides by juveniles, it is now one of the leading causes of death in the 16-24 age group. It is often interlaced with alcohol and drug consumption.
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1.6. Mental health in seniors. The incidence of depression syndrome is significantly higher in the population above 60 years of age. It is twice as high in women, than in men. Only 7.5% of the sufferers are treated for depression. Depression occurs significantly more often in the presence of chronic diseases. When examining the causes of terminal illnesses that become more frequent at old age, the following was found: health care: 18%, environment: 22%, genetic factors: 25% and life-style: 40% (Gy. Somosi). Follow-up studies show that we utilize just 5-8% of the 40% life-style capacity that we are most able to influence for sustaining health. The impairment of sustainable health in aging, the shifting of the good-health- disease ratio has several consequences. It impairs the liveable life of the individual as a result of dependency, helplessness and defencelessness. His or her personal autonomy, self-sufficiency, self-confidence and value of self decreases, is compromised, his or her personality becomes deprived and isolated, and, secluded. Several follow-up studies confirm that successful ageing is closely related to a person‘s mental, that is psychic health. At the same time, it must be stressed that, the deterioration of mental health, just as physical health, is not a direct consequence of progressing age. According to researchers, they are caused more by the diseases becoming more frequent with ageing, and the symptoms and aches arising from their improper treatment. Incorrectly prescribed spectacles, bad hearing aid, improper medication can, in itself, result in psychic problems, confusion, and even mental deterioration. Emotional and spiritual well-being is a basic condition for healthy ageing, and social interactivity is an important component of emotional health.
2. Relevant stakeholders (competent bodies) • Parliament - legislation • Ministry of Health, Social and Family Matters – allotment of resources for research • OTH – public health, central direction and coordination tasks of health development, professional supervision • NCPH-NIOH • National Institute for Health Development • Ministry of Employment Politics and Labour • Ministry of Education • Ministry of Equal Opportunity
3. Strengths and weaknesses in mental health promotion and prevention Factors behind mental disorders of mental origin in children and youths: – Dysfunctional family, burdened with conflicts – Deviant behaviour of parents, alcoholism Lack of adequate control over the children – Disorganised use of free time – School career full of failures
4. Existing mental health policies – National Programme of Labour Safety – National Health Programme
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– National Geriatric Council – The education system can provide enough professionals. Currently 6 universities train psychologists, and there are even more places taking part in post-gradual training in mental health – Number and activity of civil organisations is increasing
5. Existing laws and statutes Legal, policy background ensuring mental health exists. Laws and statutes to prevent mental disorders: – Constitution of the Republic of Hungary, 70/a.§. – Labour Code – Law no. XI of 1991, on public health – Law no. XLVII of 1997, on the handling and protection of health care and related personal data – Law XLII of 1999, on the protection of non-smokers – Law no CXXV of 2003, on equal treatment and the promotion of equal opportunity
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– Law no. IV of 1978, the Criminal Code – Law no. IV of 1959, the Civil Code – Law no. IV of 1952, on marriage and family
6. Propelling and pulling forces (implementation status) 6.1 at the workplace: i) law, regulation – supervisory control, executive regulations, ANTSZ, OMMF (National Labour Safety and Labour High Inspectorate), MBH (Hungarian Mining Office). A good law and its enforcement is one of the cornerstones of primary prevention in any area. ii) training, awareness, services (occupational health institutes – doctor, nurse, psychological) iii) financial resources (will not work without investment, operating costs) iv) National Programme of Labour Safety, National Health Programme
6.2 Population – beside the above - primary, secondary education - civil organisations - role models (qualifications, conduct) - teachers - doctors - parents - politicians
7. What are the most urgent needs? Even wider promotion of mental health approach. Active relationship between health care institutions, social institutions, civil organisations and schools. Secondary prevention is more effective and faster following the establishment of the dialogue (establishment of the coordination system). Awareness must be raised that lack of resolution of workplace stress (prevention, diagnosis, treatment) causes severe economic drawbacks (to employers, employees and the national economy). Development of tools to prevent and decrease risks (elimination of information barriers and physical obstacles, elimination of isolation).
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Development of unique tools, collection, promotion and dissemination, through the communication channels, examples of good practice. Role of the media in the promotion and influencing of mental health culture. Role of the media in demonstrating workplace intimidation (violence), raising awareness in the society.
Role of the Government in financial, legislative tasks. -Enforcing laws. -Amending the labour protection law: consideration of workplace stress should be part of the risk assessment/analysis. -Identification of mental risks. -Identification of groups exposed to the risk of mental disorders, via epidemiological studies. -Integration of health promotion into the health care system. Strengthening of the social services institution system, mental health support to providers and recipients of mental health services. Reforming the health care system.
Tasks should continue within the framework of the labour protection system (occupational health, occupational hygiene, and labour safety), employer- employee, and workplace hierarchy – e.g.: research tasks, practice, and education: department, vocational and post-graduate training, of the national institution.
Increased promotion of equal opportunity – Development of unique tools to achieve equal opportunity for both sexes, to eliminate differentiation – Strengthening and supporting civil organisations (e.g.: services dedicated to the protection , representation of victims) – Strengthening the protective role of the family.
Teaching the subject (mental health, workplace stress, mental disorders). All those who have tasks in the field (authorities, employees, occupational
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health physicians, human specialists, etc.) must be familiarised with the topic. -Mental hygiene should be included in secondary and tertiary education. -Demonstration of the status of the sexes, analysis should be included in the curricula of both health care and psychology training. -The issue of workplace stress should be included in the syllabus of occupational health care physician training and post-gradual training for doctors. Increase the number of school psychologists -Start specialised occupational health psychologist training Training employers: management should be required to participate in 8 hours of labour safety training per year, which should include the issues of workplace stress.
Increased attention to age-related special issues Adopt a geriatric approach in health care and social care training. The programme of the National Geriatric Council has determined the actions necessary for the improvement of the living conditions of seniors. ο For social security, which also includes making sure that pensions retain their value ο Improving the state of health of seniors. This deal with two areas: the health of seniors, and society as a whole. ο Changing general thinking, preparing suppliers to fulfil the needs of seniors.
Increase the role of the occupational health services – Occupational health services should be involved in secondary prevention also (early diagnosis of depression, anxiety, psychosomatic diseases, referral to specialist) – Increase number of occupational health care centres – Health care should be provided with help from the centres. Minimum personal requirements for occupational health care centres: ο Occupational health care specialist ο Occupational health care nurse, ο Occupational hygienist,
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ο Occupational psychologist
Private (accident) insurance system should be introduced
8. What are the obstacles and barriers? Barriers of approach. Mental health has no office at government level. There is a lack of inter-ministerial cooperation. There is a lack of cooperation between professions. Prejudices, discrimination, public thinking. There is no adequate cooperation between educational institutions, social institutions and health care institutions. The number of school psychologists, who could do a lot for mental hygiene education and care, is low in schools.
A significant problem for the country is the Gypsy population getting left behind. Problems determining the plight of the Roma: – Poverty – Low level of schooling – discrimination – cultural differences
9. What are the hopes and outlooks in the field of mental health? According to local research (Kopp), job security is the most important protective factor against stress and anxiety. Workplace social support is closely related to men’s well-being and subjective health assessment. Thus the responsibility of the workplace is increased. This responsibility is reflected in the regulation. According to the 2001 EU Corporate Responsibility regulation: • Responsibility for the workers’ health is part of the mission statement of companies and their organisational divisions • This is part of the managers’ job descriptions • The issue must be emphasized during manager trainings
The number of those suffering from mental disorders can be reduced by: creating jobs, reducing poverty, reducing the number of poor. With the help of
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social security. By increasing the value of the institution of marriage. By reducing bad life-style habits. The public health programme based on the treatment of mental disorders must emphasize the fight against suicide. The decreasing trend of the number of suicides is a welcome fact. Essential actions in prevention – Prevention projects based on the most recent principles – Promotion of exercise – Education of health improvement – Support for the creation of networks among civil organisations, self-help groups and personnel active in the field of mental health and their actions and cooperation. There have been multi-level stress management programmes in the workplace within the frames of voluntary health reimbursement funds. Institutional establishment: – Governmental/local governmental – Child Protection Services – ombudsmen – non-governmental organisations (NGOs)
One of the priorities of the government is to improve the situation of the minorities, among them, the Roma. To this end, it is necessary to further increase the action programmes targeting the improvement of the situation of Roma. Numerous Declarations by the UN, WHO and the EU emphasize the importance of satisfactory health and quality of life for the whole of the lifetime, with the security of equal opportunity and human dignity in prevention, health preservation, geriatric services and care. Basic gerontology studies, and follow-up human studies worldwide have yielded numerous, useful outcomes. Research and studies performed along the ageing theories are confirming that lifestyle has a decisive role in increasing the “chance years” within the lifespan, or the time spent in good health, with respect to liveable lifetime expected at birth, at 30 and at 60 years of age.
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This basically provides longer life within the human, genetically encoded maximum life capacity, with the possibility of more sustainable health and quality of life – within the directions of previously described Successful Ageing System. Factors pertaining to lifestyle: nutrition, physical and mental activity, choice of roles, social attachments and activities, free time and sports, realisation of belonging to someone-something-somewhere (as the third thing necessary for life), lifetime spent learning, creativity, zest for life, development of aims, strategies and adaptation models driving life (copings), and, last, but not least, the “development of self” to stabilize life in order to achieve a mature personality. An integral part of lifestyle is the avoidance of frustrations, as well as their resolution, development of the ability to solve conflicts, and the personal handling of the changing life periods, especially retirement. The following ways to slow down ageing can be emphasized: Modification of nutritional habits, according to needs, by choosing the composition of nutrients, controlling quantities, division during the day, promotion of psychic effect, reduction of caloric intake, dieting, if needed, satisfying a necessary daily fluid uptake, the necessary protein intake, with plant fibre intake provided by a balanced diet, and favouring plant and fish oils instead of animal fats. The nutritional regimen is extremely important: a little several times a day, proportionately to workload, adjusted to daytime activity, avoiding snacking. Special attention must be paid to alcohol, smoking, coffee, nutrients.
Prevention of the ageing accelerating effects that alcoholic drinks, coffee, tea, stimulants and smoking have, giving them up with professional help, is one of the tasks at every age of life, but they can be qualified as multiple risks due to frailty, vulnerability and multimorbidity that become more prevalent with ageing. “Active lifestyle’ can be proven to have a decidedly decelerating effect on ageing. Modern, fair laws, job security, good social relations, continuous communication between decision makers and stakeholders, and health oriented targeted education are necessary for the development of mental health.
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10. Support needed from the European Commission • Workplace regulation of mental health problems, and recommendations for: ¾ For implementation regulation ¾ For practical execution of implementation ¾ Recommendations for the establishment of “stress-free” workplaces. • Supporting national efforts in the area of mental health promotion/prevention with the EC authority • Co-operation with EC countries on the implementation in Hungary of the mental health promotion and prevention programs that have been evaluated as effective.
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Annex List of participants of the National Workshop:
Name Profession Institute Address Dr. Lajos Béleczki MD NCPH-NIOH 1096 Budapest chief advisor Nagyvárad tér 2.
Zita Blézer environment NCPH-NIOH 1096 Budapest protection Nagyvárad tér 2. manager Gábor Borhidi NGO MEDOSZ 1066 Budapest OMB director, stakeholder Jókai u. 2-4. Employees Dr. Margit Bóta Psychologist Medical University of 4010 Debrecen Adjunct Debrecen, Dept. of Arts Pf. 37. Dr. Antal Bugán Psychologist Medical University of 4010 Debrecen Director, assistant Debrecen, Dept. of Pf. 28. professor, head of Arts, Institute of department Psychology Dr. Tibor Csörget MD MOL Rt. Dunai Refinery 2440 Occupational health PÁNMED Bt. Százhalombatta head doctor Olajmunkás út 2. Dr. Mária Écsy MD NCPH-NIOH 1096 Budapest Department head Nagyvárad tér 2. Dr. Éva Grónai MD NCPH-NIOH 1096 Budapest Head of department Nagyvárad tér 2. Éva Orsós Dr. sociologist Szerencsejáték Rt. 1015 Budapest Hegyesiné Csalogány u. 30- Managing director 32. Prof. László Dr. Iván psychiatrist Semmelweis University 1125 Budapest University professor of Medicine, Kútvölgyi út 4. VI. Kútvölgyi Clinical Block 637. Gerontology Dr. Zita Jeszenszky MD Semmelweis University 1089 Budapest Scientific associate of Medicine Nagyvárad tér 4. Prof. Dr. Mária Kopp MD Semmelweis University 1089 Budapest Director, Psychologist of Medicine Nagyvárad tér 4. University professor Institute of Behavioural Studies Dr. Ferenc Kudász MD NCPH-NIOH 1096 Budapest MD Nagyvárad tér 2. Dr. László Lajtavári psychiatrist Member of the Mental psychiatrist Health Workgroup of the European Commission Krisztina Lakatos psychologist Sports Association of 1139 Budapest International secretary , the Mentally Váci út 99. NGO Handicapped stakeholder (Challenged)
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Name Profession Institution Address
Dr. Imre Lázár MD Semmelweis University 1089 Budapest adjunct Medicine Nagyvárad tér 4. Institute of Behavioural Studies Dr. István Miniska MD ALCOA-KÖFÉM Kft. 1239 Budapest Occupational health Ócsai út 5. physician Prof. Dr. Veronika MD Semmelweis University 1096 Budapest Morvai of Medicine, Nagyvárad tér 2. Head of department, Department of university professor Occupational and Environmental Health Dr. Imre Nagy MD József Fodor National 1096 Budapest Assistant director, Centre for Public Health Nagyvárad tér 2. head doctor Prof. Dr. László MD University of Szeged 6720 Szeged Nagymajtényi Institute for General Dóm tér 10. University professor Health Judit Nosztrai NGO OÉTI Labour Safety director stakeholder Committee Dr. József Pánovics MD Semmelweis University 1082 Budapest Assistant university of Medicine, Urology Üllői út 78/b. professor Clinic Dr. Richárd Plette psychologist, NCPH-NIOH 1096 Budapest Head of department expert for Nagyvárad tér 2. safety Dr. György Purebl MD Semmelweis University 1089 Budapest Assistant university of Medicine, Institute of Nagyvárad tér 4. teacher Behavioural Studies Réka Sáfrány NGO MONA Women’s 1136 Budapest stakeholder Foundation of Hungary Tátra u. 46. Dr. Adrienne Stauder MD Semmelweis University 1089 Budapest Assistant university of Medicine, Institute of Nagyvárad tér 4. teacher Behavioural Studies Orsolya Sugár NGO stakeholder Dr. Zsuzsa Szántó MD Semmelweis University 1089 Budapest University adjunct, of Medicine, Institute of Nagyvárad tér 4. head of department Behavioural Studies Dr. Katalin Székely MD NCPH-NIOH 1096 Budapest Acting head of Nagyvárad tér 2. department head doctor Dr. Judit Szuszky psychologist Dimenzió-Med Kft. 1013 Budapest psychologist Krisztina krt. 32. Mária Bácsi Dr. Health care NCPH-NIOH 1096 Budapest Téglásyné manager Nagyvárad tér 2.
Dr. Szilvia Tőzsér MD 105
Prof. Dr. György MD József Fodor National 1096 Budapest Ungváry Public Health Centre Nagyvárad tér 2. Managing Director, head doctor Dr. Ferenc Viniczay psychologist Magyar Telecom Rt. 1541 Budapest Labour safety office , expert for Labour Safety Office head safety Tünde Tunyi NGO Hungarian Nursing Zimányiné stakeholder Association
Experts delegated by the EMIP Consortium partners
Name Profession Institution Address Dr. John Henderson psychiatrist Mental Health 36 Long Cram Consultant Europe Haddington East Lothian EH41 4 NS Scotland U.K. Dr. Czeslav Czabala psychiatrist Institute of 02-957 Warsaw, Head of Department Psychiatry and Sobieskiego 9. Neurology
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Ireland
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National Mental Health Promotion Seminar
EMIP Project 2004-2006
Ireland
Work Research Centre
Dublin
January 2006
Nadia Clarkin
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Table of contents
1 The Irish National Seminar Participants and Programme 1.2 Conference pack 1.3 Feedback 2 Important Mental Health Figures 2.1 Hospitalisation for psychiatric reasons 2.2 Drug Use 2.3 Alcohol consumption 2.4 Rate of Suicide 2.5 Survey results on Attitudes to Mental Illness 2.6 Ill-health and Psychological distress 2.7 Older people and ill-health 2.8 Public Expenditure on Mental Health 3 Relevant stakeholders 4 Strengths and Weaknesses 4.1 Strengths 4.2 Weaknesses 5 Existing mental health policies 5.1 National Policies 5.2 Regional Policies 6 Seminar Questions 6.1 How can we address Mental Health Promotion at national level? 6.2 Most urgent needs 6.3 Existing initiatives 6.4 Obstacles and barriers
Appendix 1 Seminar participants according to target group
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1. The Irish National Seminar Participants and Programme
The Irish National Seminar on Mental Health Promotion was held on the 29th of November 2005 in Moran’s Hotel, Red Cow Inn, Dublin. It was a one-day event and participation was limited to 50 people. In order to attract a good cross section of participants, invitations were sent to a wide range of groups / individuals with an interest in and or directly involved in health promotion or mental health promotion and also to those groups / individuals who it was considered would benefit from having their awareness of mental health promotion raised. Invitations were forwarded to representatives from a number of government ministries, local public health bodies, occupational health professionals, employer body representatives, trade unions, organisations representing various interest groups and others. A full list of participants can be found in Appendix 1. Of the 50 who registered, 35 people attended on the day.
The seminar considered mental health promotion and mental health / mental illness issues for the population according to the needs of three specific target groups - young people, adults of working age (16-65 years old) and older people. It was divided into two main sessions. A morning session providing information and examples on mental health promotion and an afternoon session consisting of 3 parallel workshops followed by a plenary session. The morning session was presented in 6 main sessions with 9 speakers and the afternoon workshops were each managed by a facilitator and a scribe.
In the morning, the first 3 speakers provided and overview of the area and outlined the background issues. They covered an overview of the EMIP project and aims of the seminar; international, European and national overview of research, practice and policy perspectives on mental health promotion; and an overview of attitudes to mental illness in Ireland. For the remaining morning sessions, 2 speakers addressed each of the 3 target groups. In each session, the first speaker presented information on the national situation regarding mental health promotion, current policy on mental health promotion and provided information on the variety of initiatives available for their target group. The second speaker gave a detailed example of a successful initiative for their target group, outlining how the initiative works, what impact the initiative has had and what they consider is required in the future to support and replicate existing initiatives or to start new initiatives.
For the afternoon workshops participants were allocated to a workshop according to the target group of their interest (young people, adults of working age - both employed and unemployed, older people) and each group led by a facilitator discussed 4 main questions -
y What do people see as the main priorities with regard to MHP y How can we address Mental Health Promotion at national level y Are people aware of other existing MHP initiatives - ideas on how these can be built on y What are the perceived obstacles to the successful introduction to MHP
During the final plenary session, participants provided feedback on the information gathered during the workshops. They were also invited to raise any additional issues and to provide additional comments before the close of the seminar or write their comments on the comment sheet included in their seminar pack.
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1.1 Conference pack
The conference pack contained copies of all presentations, a copy of Mental Health Promotion and Mental Disorder Prevention. A Policy for Europe;1 the European Commission invitation for contributions to the consultation process on Mental Health; the booklet on Healthy Employees in Healthy Organisations: The European Network for Workplace Health Promotion 2, a postcard of Stress Impact Project3, which looks at absence from work due to stress, individual and social perspectives.
1.2 Feedback
Overall, feedback to the seminar was very positive. A number of participants commented that the seminar provided them with a good overview of mental health promotion and that it gave them an understanding of the importance of the topic. Others were interested to find out that there were so many initiatives taking place in Ireland. Many felt that the seminar would be useful to other groups and indicated that they considered it should be run more regularly to help raise awareness and the profile of mental health promotion.
2. Important Mental Health Figures
National figures on the mental health status of the population are not available. To provide an indication of the possible level of prevalence of those with mental health difficulties data was gathered from a number of sources that examine related issues. These include hospitalisation for psychiatric reasons, drug and alcohol use, suicide rates, survey results on attitudes to mental illness, ill-health and psychological distress figures and older people and ill-health.
2.1 Hospitalisation for psychiatric reasons
The number of patients resident in Irish psychiatric hospitals and units has declined considerably since 1963 from 19,801 people to 4321 in 2001. This represents a decline 78%.4 In the last 10 years there has been a 33% decrease in the number of patients resident in hospitals. These changes are due, in part, to the death of older long-stay patients and their non-replacement by new long-stay patients, along with the active promotion and development of community psychiatric services e.g. day hospitals, day centres and hostel accommodation.
In 2003 there were 23,301 admissions to Irish psychiatric units representing a rate of 760.4 per 100,000 population. Three main diagnoses accounted for two-thirds of admissions. Depressive disorders accounted for 33%, schizophrenia accounted for 18% and alcoholic disorders accounted for 16%. Forty-eight percent of discharges took place within 2 weeks of admission.5 Data from 2003 indicates that first admission to hospital constituted less than 30% of all hospital admissions and that admission rates were highest among the 45-54 year old age group and that single, widowed and divorced people had higher admission rates than
1 By Jané-Llopis E. and Anderson, P. (2005), 2 Federal Institute for Occupational Health 3 For more information www.surrey.ac.uk/psychology/stressimpact. Funded under EU 5th Framework Improving Human Potential 4 Daly, A. and Walsh, D (2002) Irish Psychiatric Hospitals and Units Census 2001. Health Research Board 5 Daly, A et al. (2004) Activities of Irish Psychiatric Services 2003. Health Research Board. Dublin 111
married people. Over 90% of admissions were discharged within three months with 29% discharged within one week. Although the data is incomplete, there were clear social class differentials in admission rates, with much higher rates for disadvantaged groups. This finding is consistent since reporting began.
In addition, people with psychiatric illnesses visited and were treated by day hospitals (66 units providing places at a rate of 36 per 100,000 population), community-based residential services (providing places at a rate of 103.9 per 100,000 population), and day care centres (110 units providing places at a rate of 77.8 per 100,000 population). These figures do not include people with less severe mental health problems who were possibly treated by general practitioners, other health professionals or, in the worst case, not treated at all.
2.2 Drug Use
Two national surveys of drug use (SLAN 1998 and SLAN 2003)6 allow for comparisons in prevalence of the use of a variety of drugs. The proportion of those people who had used cannabis at some time during their lifetime has increased from 21.9% to 26.2% for males and from 13.8 to 19.1% for females during this timeframe. Notable increases were also observed in the use of ecstasy and cocaine during this period, while the use of amphetamines had dropped. Estimates put the number of opiate users in 2001 at a rate of 5.6 per 1000 aged 15- 64 years. Opiate usage is still predominantly a Dublin phenomenon. In general, drug use is highest among the 15-34 year old category.
The ESPAD7report shows that there was an increase of 8% in the number of school-going children aged 15 – 16 years reporting lifetime use of any illicit drug between from 1999 and 2003. Among this age group in 2003, Ireland ranked in joint third place for lifetime use of any illicit drug (40%). Drugs included were cannabis, amphetamines, LSD or other hallucinogens, crack, cocaine, heroin and ecstasy.
2.3 Alcohol consumption
Economic prosperity and increases in income per capita have provided increased disposable and discretionary income for many Irish people. Against this backdrop of a fast-growing economy Ireland has experienced the highest growth in alcohol consumption among EU countries at a time when consumption has decreased in almost all other EU countries. These dramatic increases put the consumption of alcohol at 14.2 litres per adult.
Alcoholic disorders continue to be a main cause of admissions to psychiatric hospitals and accounted for 26% of male admissions and 11% of female admissions in 1999. Reports from an Irish general hospital reported that 30% of males and 8% of female patients were identified as having underlying alcohol abuse or dependency problems.8 Alcohol consumption is a significant risk factor in suicides and compounds some other suicide risk factors. Binge drinking (6 drinks per session) is also a major concern in Ireland and went up from 34.7% in 1998 to 41.4% in 2003 for men and from 11.6% in 1998 to 16.2% in 2003 for women.
6 Friel, S. Nic Gabhainn, Kelleher, C. (1999) National Health and Lifestyle Surveys. Department of Health and Children Health Promotion Unit . Kelleher, C et al. (2003) National Health and Lifestyle Surveys. Department of Health and Children Health Promotion Unit 7 . Hibell et al. (2004) The ESPAD Report 2003. Alcohol and other drug use among students in 35 European countries. Stockholm: The Swedish Council for Information on Alcohol and Other Drugs (CAN), Council of Europe, Co-operation Group to Combat Drug Abuse and Illicit Trafficking in Drugs (Pompidou Group). 8 Better Health through Prevention: Fourth Annual Report of Chief Medical Officer (2004) Government of Ireland 112
The economic cost of alcohol-related problems in Ireland was estimated at roughly 2.37 billion Euro in 1999 (1.7% of GDP) 9. This figure encompassed healthcare costs, accidents, crime, absenteeism, transfer payments and lost taxes. It represents 60% of the total revenue from alcohol to the Exchequer for that year.
2.4 Rate of Suicide
The rate of suicide in Ireland has increased from 5.1 per 100,000 population in 1976 to 11.5 per 100,000 population in 2002 with the largest increases in the male population (from 7.9 in 1976 to 19.1 in 2002). 10 Male suicides are more prevalent in the 15-29 age group and it is the commonest cause of death in men in the 15-34 age group.
2.5 Survey results on Attitudes to Mental Illness
A survey on public attitudes to mental illness, carried out by the Mental Health Ireland, found that over two-thirds of Irish people have direct experience of someone with a mental illness, mainly in the extended family (35%) and among friends and acquaintances (23%). Of those with direct experience of people with a mental illness, the following were the main categories of mental illness identified depression (52%), manic depression or bipolar disorder (11%), schizophrenia (10%), anxiety disorder- phobia-panic attacks (7%). Ten percent of those interviewed admitted personally experiencing mental illness. For this group depression was the main illness reported (75%)11.
2.6 Ill-health and Psychological distress
A study analysing the utilisation of GP services in Ireland between 1987 and 2001 reported that those over 65 years are more likely to visit their GP than those aged 16-64 years, those over 65 years also visit more frequently. Females are also more likely to visit than males even when recent maternity experience is controlled for, those living in urban areas and those on medical cards (visit paid for by State) are more likely to visit their GP. Recent findings from 2001 indicate that those aged 25-34 and 35-44 are significantly more likely to have visited their GP in the last two weeks than other age groups under 64 whereas in 1987 it was those aged 54-64 and those aged 35-44 who were more likely to visit.
In this study, figures on the rate of ill-health in the population were taken from Living in Ireland (LII) surveys 1995 and 2000. These surveys indicated that the percentage of the population who reported experiencing ill-health in 2000 was up from 17.2% in 1995 to 19.3% in 2000. They also found 16.4% of respondents reported experiencing psychological distress (as measured by scoring 3 or above on the GHQ12) in 1995 and 15% in 200012. Data from the 2001 Quarterly National Household survey on Health found that 19% of respondents had visited their GP in the last two weeks.
9 http://www.dap.ie/dap_prof/professional_info_current_stats.htm 10 Cited in Daly, A and Walsh, D (2004) Mental Illness in Ireland 1750-2002. Health Research Board. Dublin 11 Pippa Norton (2005) Public Attitudes to Mental Illness. www.healthhub.ie
12 Nolan, A. and Nolan, B. (2002) A Cross-sectional Analysis of the Utilisation of GP Services in Ireland 1987-2001. Working Paper. ERSI Dublin 113
A survey on psychological distress (defined as anxiety, depression or any other mental, nervous or emotional problem) in the Irish population is currently being conducted by the Health Research Board. The survey aims to find out how many people suffered from psychological distress in the last twelve months, whether they used a service for their problems and the willingness to seek help for psychological problems in the future.
2.7 Older people and ill-health
In Ireland as in other European countries the demographic profile of the nation is changing. Life expectancy is increasing and there are more older people and more older old (over 80 years old), more older people are living alone and there are a reduction in family support structures. This reality has implications for mental health of older people and for policy for this target group. Research findings from on the prevalence, incidence and treatment of mental disorders in older Irish people showed that 20-25% have mental disorder of some severity at any one time, 5% suffered from some form of dementia and 15-20% suffered from problems such as depression and anxiety.13 A study on income, deprivation and well-being among older people found that older people at risk of poverty are 1.5 times more at risk of experiencing psychological distress, and those experiencing deprivation with a chronic illness are eight time more at risk of psychiatric disturbance. From the SLAN studies (2004) 25% of those over 55 reported being moderately or extremely anxious or depressed, 7% reported a diagnosis of depression and 3% attended mental health services. The National Council on Ageing and Older People has recommended the development of a national strategy for the future development of mental health services for older people.
In the 2001 census of patients resident in psychiatric hospitals as many as 38% of resident patients were over 65 years old. Statistics on admissions to psychiatric hospitals (2004) 14 show that 44.6% of those aged 64-74 years and 43.5% of those aged over 75 years and over who are admitted suffer from depressive disorders. 11.5% of those aged 64-74 years and 4.8% of those aged over 75 years admitted suffering from alcoholic disorders.
2.8 Public Expenditure on Mental Health
While expenditure on psychiatric service has increased in absolute terms from 196 million Euro in 1988 to 563 million Euro in 2002 as a percentage of total health expenditure the figures have acutally decreased from 12.5% in 1988 to 6.9% in 2002. (Health Statistics,200215)
3 Relevant stakeholders
The relevant stakeholders were identified as: • Appropriate personnel from the following Government Ministries: o Ministry of Health and Children o Ministry of Social and Family Affairs o Ministry of Education and Science o Ministry of Enterprise and Employment • Professional associations representing o GPs, Psychiatrists, Psychologists o Occupational Physicians / Occupational nurses • Representative groups/ Agencies / NGOs for o Older people (these included retirement associations, national organisations and other organisations working for or with older persons, health boards)
13 Keogh,F. and Roche, A. (1996) Mental Disorders in Older Irish People. Dublin: National Council for the Elderly 14 National Psychiatric Inpatient Reporting System (2004) A database recording all admissions and discharges from Irish Psychiatric facilities on an annual basis 15 Department of Health and Children (2003a) Health Statistics 2002. Dubilin: Stationery Office 114
o Young people (these included national orgnaisations, youth organisations and other organisatiosn working for or with young people, health boards) o People of working age (these included employers and trade union representatives, large employers, Civil Service, FAS – state employment agency)
4 Strengths and Weaknesses
4.1 Strengths
• National initiative on health promotion which includes and covers mental health and is aimed at school children. This is delivered through mainstream education under the ‘SPHE programme’ • Focus of Mental Health Ireland (MHI) on young people as their target group over the last couple of years. As part of this they have developed materials and initiatives for older school going children – particularly ‘MIND Matters’ programme • Local initiatives for young people through Youth Clubs • Suicide prevention officers in Health boards • De-stigmatisation of Mental illness through community care of psychiatric patients and admissions to acute general hospitals instead of specialist units • Network of health promoting hospitals • New legislation on Health and Safety for workplaces includes explicit reference to Health Promotion • National Health Promotion Strategy 2000-2005 under which Health promotion officers were established in all local health ministries • Commitment by people working in the area of Mental Health Promotion to further their work • Awareness among National Representative Organisations of the issue of Mental Health and Mental Health Promotion • Existence and strength of NGOs in the sector e.g. Mental Health Ireland, GROW and AWARE – national voluntary organisations offering support and services to those with mental health problems
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4.2 Weaknesses
• No national policy or framework for mental health promotion (Expert Group to report 2006) • Mental health promotion as a concept is not well recognised at governmental level or at organisational level or other levels • Mental health is treated as synonymous with mental illness • Lack of replication of successful initiatives on MHP and on HP due to lack of funding, coherent planning • Lack of co-ordination of services • Mental health promotion generally regarded as a part of Health brief – it is multifaceted and needs a multi-organisational approach • Employers not aware or interested in mental health promotion / prevention • Lack of collaboration between agencies and organisation involved in mental health promotion, lack of exchange of information on activities • Lack of funding for mental health promotion • Lack of resources with specialist knowledge of mental health promotion
5 Existing mental health policies
In Ireland, at present, there is no overall co-ordinated national policy addressing this very important issue. An Expert group on Mental Health Policy was established in 2003 and is due to report in early 2006. The remit of this group is to prepare a new national policy framework for the mental health services to replace the existing policy document – Planning for the Future (1984). There are a number of national policies that address mental health promotion either directly or indirectly and a number of regional policies and strategies in place addressing the issue of Mental Health Promotion directly.
Up until the end of 2004 Ireland was divided into 11 Regional Health Boards and some of these have produced strategy documents on range of mental health related issues e.g. mental health promotion, suicide prevention. The following is a list of policy documents have been included as they address mental health either explicitly or implicitly.
5.1 National Policies
• National Health Promotion Strategy 2000-2005. Department of Health, Health Promotion Unit. Specified specific aims and objectives aimed at improving the overall health of Irish population. It indicated many of the strategic aims and objectives will require an inter-sectoral and multi-disciplinary approach to put the promotion of health on everyone’s agenda. This document was positive to mental health promotion was positive towards mental health
• National Expert Group on Mental Health Policy (established 2003 reporting spring 2006) was set up to prepare a new national policy framework for the mental health services, updating the 1984 policy document - Planning for the Future. This group had a sub group on mental health promotion
• Review of the National Health Promotion Strategy 2004. Department of Health, Health Promotion Unit. This document provides an in-depth review of the progress made in the implementation of the strategy. It is set out according to key areas of population groups, settings and topics.
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• National health Strategy: Quality and Fairness (2001) - emphasised the importance of health promotion and states that there is a need to update mental health policy to take account of recent legislative reform, developments in care and treatment of mental illness and current best practice. It identified that policy and objectives for mental health services need to deal with issues such as: need to integrate mental health care into primary care, concerns about only using traditional medical model of care, developing amore holistic approach to mental health treatment and care. It contained a 121 point action plan to realise the strategy.
• Mental Health Commision (2003) is an independent statutory body established under the Mental Health Act, 2001. to promote quality in the delivery of mental health services, to promote the interests of all persons availing of mental health services and the protection of interests of persons involuntarily admitted under the provision of the Mental Health Act, 2001.
• Mental Health Act (2001) reforms previous legislation and brings Irish mental health law into conformity with the European Convention for the Protection of Human Rights and Fundamental Reforms.
• Suicide Action Plan ‘Reach Out 2005- 2014. This strategy builds on the work of the National Task Force on Suicide. It identifies a number of action points and settings to be targeted. The Strategy suggests practical measures such as the delivery of community education on suicide prevention and mental health promotion, including public lecture series and awareness talks.
• Report of National Task Force on Suicide (1998) Suicide prevention and mental health promotion. This report detailed the various measures which need to be adopted in order to address the high incidence of suicide in Ireland, particularly among recognised risk groups such as young males between fifteen and twenty four years of age. It also recommended a comprehensive approach to tackling the circumstances that can result in persons taking their own lives.
• Strategic Task Force on Alcohol: Second Report (2004) Department of Health, Health Promotion Unit. This report recommends specific evidence-based measures to prevent and reduce alcohol-related harm.
• Health and Well-being for older people – a strategy for 2001 –2006
• An Action Plan for Dementia (2000)
• Adding Years to life and Life to Years (1998) National Council on Ageing and Older People Healthy Ageing Programme.
• Shaping a Healthier Future, 1994 recommended that mental health services should be ‘comprehensive, integrated with other health services, based as far as possible in the community and organised in sectors close to the people being served.
• White Paper on Mental Health (1995)
• The Years Ahead (1988)
• Planning for the future 1984
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5.2 Regional Policies
• Health Promotion Strategy for the North West Region
• Promotion Health in the West – Health promotion Strategy 2003- 2005 (Western Health Board) Goal to develop guidelines on how health promotion initiatives can adress all aspects of health including mental, emotional, spiritual as well as physical and social
• Evans, D. and Jones, J. (2001) Promoting Mental Health in the West – A survey of mental health in the Western Health Board Area (Western Health Board)
• Suicide Prevention Strategy (2004) North Eastern Health Board, Health Promotion Department
6 Seminar Questions
The following sections outline the responses made to the four main questions asked of participants during the seminar workshops.
6.1 How can we address Mental Health Promotion at national level?
Political will / Government Policy
To get Mental Health on the national agenda requires high level acknowledgement and support at a national level. It was suggested that this could be achieved through y High level visible support from the Prime Minister (An Taoisach) y Through Social Partnership agreements - partnership agreements deal with more than wages – example of older people y Going through Social Partnership agreements would mean there would be commitment to work towards same goals y Review of budget for Mental Health, which is declining in recent years (put in MHI figures) y It was felt that presently Mental Health is the last priority in the health area
Education
There is a need to educate the public about Mental Health y For the government – the cost of mental health problems for example amongst employed people the cost of absenteeism vs the cost of Disability Benefit y For employers to education them about what is Mental Health, the cost in terms of Lost days / long term absenteeism y SPIRAL learning system – a coherent and ‘seamless’, ‘lifecycle’ approach to Mental health awareness– i.e. one co-ordinated education system running from primary school to older people.
Rename Concept y Given the stigma associated with Mental Illness, it was felt that to get people to ‘buy into concept’ – may have to rename it ‘Quality of Life’
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Awareness raising y Advertising Campaign - to raise awareness of Mental Health as distinct from Mental Illness y Stigma in relation to Mental Health is a significant issue in Ireland. There are opportunities to reduce stigma, for example the present movement to integrate Mental Health into the General Acute Hospital setting means mental illness and mental health ought to become more acceptable. y Awareness campaign re: positive views of older people and mental health y Employers need to be aware of the impact of working long hours and impact on relationships and on quality of work. (Accord – Marriages in crisis survey found that many men are working in excess of 10 hours over the Working Time Agreement. They found this subsequently placed a lot of stress on relationships)
Acknowledgement
While there is no formal, co-ordinated responsibility for activity in this area, there is a large amount of work taking place in the area. This work should be recognised and acknowledged. • There are a lot of initiatives but there needs to be more awareness/ acknowledgement of them. • There are gaps but we could showcase what is there and what’s going on. • Need to develop a means of ‘building’ upon these initiatives. Too often they are set up as pilot projects, they are very successful, but because the funding runs out they are not continued
Multi-sectoral approach
Mental health is regarded mainly as a health issue. It relates to many aspects of people’s lives, this should be acknowledged and reflected thorough the involvement of other sectors. y An interdepartmental and an integrated approach is required y There is an example of cross-sectoral involvement in the disability area. Where plans being developed across seven government departments. Perhaps mental health could be integrated into this initiative. This was set up by Department of Trade, Enterprise and Employment and the National Disability Authority (NDA) under the Disability Act.
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Involvement of all groups in developing Mental Health Promotion y It is essential to develop an effective national platform covering all relevant organisations. Input should be made both by the public (in all target groups) and by organisations – statutory, voluntary and NGO. Grassroots input is very important.
Co-ordination y There’s a lack of co-ordination regarding older people and mental health promotion. However, given recent developments and a possible change of focus within the Department of Health and Children, now might be the time to address this. y Develop a National Multi-Agency Alliance – Database. This will also provide a way of identification and co-ordination. It should be co-ordinated by an organisation responsible and accountable for its progress. In the context of Youth, the Department of Health and Children or Department of Education was suggested as the most natural organisation. an example was given of where youth organisations are taking the lead in Australia and this is working well and it was suggested that perhaps in Youth Organisations or the Ombudsman Office could be responsible for co-ordination of the young peoples database.
Funding y Funding is seen as the main obstacle. There is often a lot of duplication and replication which leads to further drain on available resources. y NGOs are competing for limited resources. They are working for the same aims but also with the same resources. There’s a tension between agencies. y The Health promotion budget was suggested as a source of funding
Research y National Disability Authority should become more involved in research in MH (they don’t regard MH as a disability). y Lack of research on older people and mental health promotion
Mental health promotion strategy y The current health promotion strategy runs out this year. All of the objectives haven’t been achieved. Do we go back and find out what went before? Health promoting schools was a past objective, which never happened. It wasn’t addressed at all! Do we forget about them and move on to the next idea or go back and try out the old ideas. Just because they weren’t tried out, doesn’t mean they won’t work. y The sub-group on Mental Health Promotion is reporting end 2005 – beginning 2006. The group’s remit extends to older people. It would be a good idea to wait and see what’s contained in their report.
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Set realistic goals
• Set smaller targets – Smaller targets should be set, which can be quantifiably and qualitatively evaluated. More motivation would be generated if these smaller targets were achieved. Smaller steps need to be taken. Instead of trying to have health promotion in primary and secondary schools and colleges. Choose one! Together it is unachievable. Choose one with a transient population, a sustainable group who can access and assess the services. By doing one properly, it would feed into the next. Secondary schools and colleges are similar in a lot of ways. If the process was started in secondary schools it could act as a framework and there would be leakage into colleges.
6.2 Most urgent needs
The question was ‘what do people see as the main priorities with regard to MHP?’
Government support y If mental health promotion is to be treated with the significance it needs to be supported at the highest level
Awareness y Signals of mental health problems y Define good mental health y Young people are aware of the concept of general health – confused about mental health what it is y For young people – create awareness of signals of mental health problems for parents
Culture that promotes mental health y If the culture promotes mental health people will seek help early y De-stigmatisation of mental health problems to encourage people to seek help y Older people – attitudes / combating ageism
Information y for young people have information available through normalised activities y Young people - have information available for parents y Promote positive mental health concepts y Knowledge sharing y Older people – education for older people and service providers y Older people – have a life course strategy regarding mental health
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Services y Provide access to services y Early intervention y Working people – develop more proactive approach to Employee Assistance Programmes and services y Access to services and also back-up teams
Involvement y Involve target groups in planning, consolidation and delivery of services
Initiatives y Young people – buddy system y Older people – build on existing initiatives / mainstream – nation-wide y Provide contact with others who have direct experience of MH problems
Issues specific to target groups
Young people y Strengthen coping skills, build resilience
Working age people y Keep people at work – benefits their mental health, benefits employers in terms of employees experience y Keep people well at work – good HR practice (staff appraisal, person-job fit, provide realistic timeframes/deadlines, good management of staff, design and job control) y Look after the ‘ENGINE’ of society (30 / 40 year olds who provide the main labour / expertise in the economy) they are in the most stressed and productive time of their lives – career, family, y Provide good work-life balance opportunities y Unemployed – review sickness benefit – make It more individual / client based y Need rehabilitation – both social and vocational especially for long term sick who may not go back to work due to mental health issues compounded with original reason for absence y Employers can be instrumental in getting people on disability benefit back to work.
Older people y More research into mental health
6.3 Existing initiatives
Participants were asked if they were aware of other existing MHP initiatives and did they have any ideas on how these can be built on
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Young people
• Irish Society for the Prevention of Cruelty to Children had a number of initiatives – working with children and parents to build up resilience, preventative work. Social inclusion, participation, coping skills, therapeutic services, face-to-face, phone and internet services, anti-drugs, anti-bullying and a mentoring programme. • National youth Council have developed a programme “Good habits of mind” aimed at young people and are presently training young people to become trainers and to delivery the programme. • MHI – An initiative on Public speaking- Primary minds – aimed at 11 and 12year olds is about to start. It will be for young people, by young people and it will be possible to address mental health issues through this. • National Youth Federation – offers ‘Teen Between’, a counselling service for children whose parents are separated.
People of working age y Health Screening. These mainly deal with physical health issues the success of these can be questionable. y Well-being programmes at work y Move to wellness programme y Good screening / rehabilitate absentees into the workplace (this happens in pockets (e.g. some Health Boards) y Prospect – an initiative aimed at getting people with Schizophrenia back to work (funded under Leonardo).
Older people y Positive ageing programme (NCAOP) y Database of healthy ageing projects – for a list of current projects see http://www.health- data.info/search/ncaop/ y Go for Life and PALs project - http://www.olderinireland.ie/physicalactivity/index.htm y Positive Age Cavan – www.positiveage.net y Older Men’s Organisation Cavan –www.positiveage.net/OMO%20HomePage.htm y Federation of Active Retirement Associations – www.fara.ie
Other initiatives y Grow / Aware involved in awareness raising / providing services
Ideas for building on existing initiatives: y Use local authority staff y There are many initiatives out there. To benefit from them they need to be evaluated, replicated and supported y National platform y National database of projects (e.g. build on NCAOP healthy ageing database?) y Develop infrastructure (technology and transport)
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Other Suggestions – y fund a Mental Health Promotion campaign similar to the one on road safety, to illustrate what positive mental health is and to distinguish between positive MH and Mental illness
6.4 Obstacles and barriers
Participants were asked what they perceived to be the main obstacles to the successful introduction to MHP?
Commitment at high level to mental health promotion
Funding y Lack of funding y Resources (there are many existing resources than can be used if there was some commitment) y MHP not high priority for funding
How mental illness / mental health is viewed
• There needs to be a positive slant put on the differentiation between mental ill-health and mental illness.
Lack of co-ordination of services and information y Lack of links between organisations y Lack of sharing of information and initiatives
Lack of information / awareness y Lack of information – what’s out there? Who do you contact? y Services such as the Senior Help Line need to be advertised in local media.http://www.thirdage-ireland.com/helpline.htm 1850 440 444
Younger people
• Volunteer work becoming a thing of the past. – People don’t have time with their own life pressures – Also volunteers not being appreciated. If they were being paid the work would be valued but if unpaid, then it is felt that the the work “Must” be bad. It is assumed they are not qualified to do the job, if they are not getting paid. • Academic role must be recognised in the process. More research needs to be undertaken. Collate evidence from a national perspective.
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Access to vulnerable people y Getting access to older people and older people getting access to services can be difficult, for example due to transport inadequacies, living in isolated areas, there is no way of tracing where vulnerable older people live.
Identifying and targeting those who are not in the usual social / work networks - unemployed - homemakers - those working from home
Some Solutions were offered to the access issue and to identifying those not in the usual networks
Town planning is one way to accommodate these groups is by ensuring that places to connect people are provided e.g. socially oriented services such as - community centres – - Creche - Citizens drop-in-centre
Link the different groups in some way – the community centre, creche, mother and toddler, Parish centre, retirement groups.
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Appendix 1 Seminar participants according to target group
Workshop 1 People of Working Age
John Farrelly ACCORD
Bernadette Lavelle Civil Service Occupational Service
John Burke Civil Service Training and Development Centre
Cathy Lyons Department of Health and Children
Claire Hellen Irish Business and Employers Confederation
Catherine Maguire Irish Business and Employers Confederation
Kevin Farrell Department of Revenue
Patricia Rooney Department of Revenue
Ger Jennings Department of Social & Family Affairs
Fiona Crowley Amnesty International
Ann O’Riordan Health Promoting Hospitals Network
Margaret Hodgins National University Galway
Phil Crotty REHAB
Matthew Hamilliton One Foundation
Alan Chapman FÁS
Michael Coughlan National Learning Network
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Workshop 3 Young People
Chanelle Carlin Childline – Irish Society for Prevention of Cruelty to Children
John McGuire Health Service Executive – NEHB region
Anne Sheridan Health Service Executive – NW region
Deirdre McDonald School Support Services
Jacinta Hastings Mental Health Ireland
Nadine Crotty National Youth Council of Ireland
Ken Keogh National Youth Federation
Matthew Hamilton ONE Foundation
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Workshop 4 Older People
Eilish Redmond Age and Opportunity
Patricia Dawson Age and Opportunity
Martin McMahon Cavan/Monaghan Mental Health Services
Eithne Carey Federation of Active Retirement Associations
Ros Moran Health Research Board
Olga McDaid National Council on Ageing and Older People
Sinead Quill National Council on Ageing and Older People
Hartmut Berger EMIP expert
Organisers
Anne O'Herlihy Work Research Centre
Nadia Clarkin Work Research Centre
Padraic Fleming Work Research Centre
Richard Wynne Work Research Centre
Sarah Delaney Work Research Centre
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Netherlands
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European Mental Health Implementation Project (EMIP)
National Report
Netherlands
Ernst Bohlmeijer Trimbos-institute Postbus 725 3500 AS Utrecht Netherlands [email protected] 0031-30-2971100
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Introduction
On 26 September 2005 a national workshop was held in the Netherlands with twenty participants of relevant organization. This workshop took place as part of the EMIP-project.
Important mental health figures
Youth
Of all the schoolchildren in the 11-to-17 age group, 12.7% are in the clinical area as regards internalizing problems such as depression, anxiety and loneliness and 11.3% are in the clinical area for externalizing problems (Ter Bogt et al. 2003).
Adults
Of all the adults in the Netherlands, 7.6% have had a mood disorder in the past year and 19% have had a mood disorder at some point in their life (Ginneken and Schoemaker 2005). A total of 12.4% of all the adults in the Netherlands have had an anxiety disorder in the past year and 19.3% have had a mood disorder at some point in their life (Ginneken and Schoemaker 2005). A total of 23.5% of all the adults in the Netherlands have had a psychological disorder in the past year. More than a third of them had two or more disorders (Ginneken and Schoemaker 2005). A total of 28% of the people with a mood disorder and 22% of the people with an anxiety disorder needed help but did not take steps to get help (Ginneken and Schoemaker 2005). A total of 63. 8% of the people with a mood disorder and 40.5% of the people with an anxiety disorder reached out for some form of help (Ginneken and Schoemaker 2005).
Elderly people
The prevalence of mood disorders among the elderly in the Netherlands is 3%. Approximately 13% of the elderly people have clinically relevant depressive symptoms (Smit et. al. 2004). The prevalence of anxiety disorders in the general population is 10.2% (Beekman et. al. 1998).
1. State of the art mental health promotion and prevention
Prevention practice is reasonably extensive in the Netherlands. Prevention is mainly implemented at regional mental health care centres, which there are approximately fifty of in the Netherlands. Most of them have separate prevention divisions. The average professional staff capacity is seven full-time staff members. Each prevention division carries out a large number of projects. The main themes are: - Children of parents with psychiatric problems and / or addicted parents - Depression / anxiety disorders - Work-related psychological problems - Social psychiatry, care provided by volunteers and psychology education.
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The Trimbos Institute provides the scientific foundation for the day-to-day practice. In conjunction with the mental health care staff members, the decision was made in 2000 to develop four basic prevention programmes linked to the four themes referred to above. Each basic programme contains at least three standardized and effective preventive interventions. A number of basic programmes were completed in 2004. There are now twelve standardized interventions in the Netherlands that are either promising or in effect. Ample attention is also devoted to innovation within the basic programmes. One example is the development of an Internet group for adolescents with slight to moderate depressive symptoms. Most of the interventions are implemented in more than 50% of the mental health care (GGZ) facilities. Up until 2007, the prevention efforts are to be totally funded by the General Special Illness Costs Act (Algemene wet bijzondere ziektenkosten). This is going to change as of 1 January 2007 (see below). The extent to which prevention is implemented will be the prerogative of each mental health care facility. There are sizable differences between these facilities. The prevention divisions work in close conjunction with the primary health care in implementing prevention projects. In addition to the mental health care facilities, many municipal health services (GGD) also carry out a preventive mental health care policy, be it to a lesser extent. The main themes are the prevention of loneliness among the elderly and school-oriented health promotion. The municipal health services also have a standardized health monitor that includes questions about psychological health. The National Prevention Support Centre (LSP) is part of the Trimbos Institute. Funded by the national government, the National Prevention Support Centre supports the national implementation practice. Every effort is made to coordinate and collaborate the research, policy and practice. For example, the National Prevention Support Centre coordinates nine national work groups. In the framework of an annual work plan, prevention workers are given information about national developments and priorities are set as regards the development, standardization, exploration and innovation of interventions. The National Prevention Support Centre maintains a current overview of the prevention activities in the fields of mental health and addiction care. The data bank of the National Prevention Support Centre passes its data on to a data bank for prevention. Twelve people are employed at the National Prevention Support Centre.
2. Relevant stakeholders
Netherlands Mental Health Care Facilities. The umbrella organization of the state mental health care facilities in the Netherlands.
Netherlands Municipal Health Services. The umbrella organization of the municipal health services in the Netherlands.
Netherlands Care Insurance Companies. Responsible for funding the prevention efforts.
Association of Netherlands Municipalities (VNG). The umbrella organization of the municipalities in the Netherlands.
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The Ministry of Public Health, Welfare and Sports. The ministry responsible for mental health promotion and sports.
Heads of the prevention divisions at mental health care facilities and municipal health services.
The Trimbos Institute (National Prevention Support Centre). Responsible for supporting and providing a scientific foundation for prevention.
Radboud University (Prevention Centre). The most important university in the field of prevention and mental health care promotion.
Almost all the stakeholders were represented at the national workshop.
3. Existing mental health policies
In 2004 the national government published a specific policy paper on health promotion, stipulating the policy in the field for the coming four years. Barely any references are made in this policy paper to mental health promotion and prevention. The theme of depression is an exception though. Its importance is acknowledged and the Trimbos Institute is asked to develop an integral preventive approach. As of 1 January 2007, the prevention of psychological problems is to be funded in a new way. Part of the prevention (individual secondary prevention) is to be regulated by the new and more concise General Special Illness Costs Act (Algemene wet bijzondere ziektekosten). This form of prevention is to be diagnosis-related. Collective prevention is to be part of municipal policy. This will be implemented in the framework of the Social Support Act (Wet op de Maatschappelijke Ondersteuning) and covers the following aspects: - identifying and combating risk factors in the field of public mental health care - reaching and counseling vulnerable groups and high risk groups - serving as a spot where people can report crises or impending crises - providing psychosocial assistance after disasters - stimulating agreements between relevant organization about the implementation of public mental health care.
In the implementation of local health care and the Social Support Act (Wet Maatschappelijke Ondersteuning), the municipalities play the role of director. The recommended way to include partners in the planning and implementation of public mental health care is by formulating and signing agreements. As of 1 January 2006, a new Social Support Act is to go into effect. In the framework of this act, nine achievement fields are described for each municipality including: - Promoting social cohesion and livability at the neighbourhood and district level - Supporting volunteer care and aid workers - Providing support in raising children - Providing facilities to people with chronic psychiatric problems - Providing ambulant addiction care.
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Another relevant development is that for the first time in twenty years, GGZ Nederland, the umbrella organization for all the mental health care facilities in the Netherlands, has made prevention the spearhead of its policy. The aim is to double the prevention efforts in the mental health care facilities in the years to come. To achieve this aim, a transparent financial structure is to be introduced and the steering of prevention activities at the mental health care facilities is also to be organized in a transparent fashion. Another important development is that six years ago, the national government launched a large scientific prevention fund, which can fund scientific effect studies, innovation and implementation. A considerable part of this funding is spent on mental health promotion and prevention. A major contents-related development pertains to the integral approach to depression prevention. As a result of growing worldwide recognition of the dimensions and impact of depressions, a special programme has been developed for an integral approach to the prevention of depression among the elderly. More than 700,000 people a year have a depression. Approximately 15% of the elderly people in the Netherlands have clinically relevant depressive symptoms. People with a depression are seriously limited in their social and societal functioning. The costs to society of depression in the Netherlands are estimated at an annual €1,000,000,000. The WHO expects depression to develop all across the globe into public disease number one. The enormous costs of depression call for a more intensive public mental health care policy. Integral prevention is universally acknowledged as the most effective form of prevention. Integral prevention means a cohesive combination of universal, selective and specifically indicated preventive interventions focused on individuals and the environment, which are implemented by a network of care providers and other services. The programme of integral depression prevention for the elderly is based on the following four aspects: - Insight into national and regional epidemiological research on risk factors for depression among the elderly - Scientific insight into aging successfully and factors that protect people from depression - Based as much as possible on a community approach - Working with promising and effective interventions. The programme of integral depression prevention for the elderly consists of three publications: 1. Introduction and support This publication introduces and supports the prevention programme. The importance of prevention is addressed as regards depression among the elderly. Insight is given into the risk factors for depression among the elderly. A dynamic theory on successful aging is presented and serves as the basis for the programme. 2. Integral approach manual Before achieving an integral approach, it is necessary to go through various stages. The manual gives staff members at municipal health services and mental health care facilities an extensive step-by-step plan. The steps pertain to drawing up a problem analysis, exploring possible solutions and developing, implementing, evaluating and adjusting an action plan. 3. Overview of interventions This publication gives an overview of all the available interventions and discusses the scientific state of the art in the various forms of depression prevention in the elderly.
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4. Strengths and weaknesses in mental health promotion and prevention
The participants cite the following strengths and weaknesses in mental health promotion and prevention in the Netherlands.
Strengths
There is a respectable professional practice in the Netherlands employing approximately 500 specialized prevention workers. There is a professional association in the field of prevention and health promotion. This association carries out an active quality and registration policy. This policy guarantees that prevention workers keep up to date about new development and take whatever extra training courses are necessary. There is ample opportunity for research. The state has launched a large scientific fund, which makes it possible to launch large-scale, scientifically founded innovation, research and implementation projects in the field of prevention and health promotion. Various universities and national knowledge institutes are extremely active in this field. There is a state-funded National Prevention Support Centre affiliated with the Trimbos Institute which sees to nation-wide coordination and consultations. The National Prevention Support Centre is responsible for the development of the basic programmes that have made prevention in the Netherlands visible, standardized and widely implemented. There is quite a tradition in the Netherlands of large-scale, epidemiological population studies. These studies provide insight into the prevalence and incidence of psychological disorders. For some time now, research has been conducted on the prevalence of risk factors and protective factors based on population studies. This provides a sturdy, rational and scientific foundation for prevention efforts. There is a high level of basic care (general practitioners, home care, infant health centres and so forth) in the Netherlands. This provides any number of opportunities to implement preventive and health-promoting interventions. The Netherlands is leading the way in a number of essential fields: e-prevention, epidemiological support and an integral approach.
Weaknesses
In the active policy, prevention and mental health promotion are still relatively low on the state agenda. There are several indications of improvement though (prevention of depression as a key point in the last policy paper), but it will take a great deal of effort and lobbying to put more of a spotlight on prevention. The municipalities play more of a role in the field of collective prevention, but prevention and mental health promotion are still unfamiliar territory for them and are barely the focus of any attention in local health policy. Even though the Netherlands is a small county, any number of parties are active, including universities, knowledge institutes, local mental health care facilities and umbrella organizations. The coordination and collaboration among these parties could be improved. Prevention funding comes from various sides. Particularly at the regional level, this can serve as an obstacle to cooperation.
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There is still not much scientific support and not a very clear perspective on specific mental health promotion efforts. There are some starting projects though in the field of mental health promotion at schools and as regards the elderly. Mental health promotion and prevention are still barely embedded in the more comprehensive health promotion policy. In general, prevention still has a very limited reach. There are numerous good interventions, especially courses, but recruitment does not always go well. Some new experiments have recently been launched to improve the diversification of interventions (adaptations to specific target groups), early detection, community interventions and self-help programmes, and a positive approach to health problems. These are efforts to reach the target groups more effectively.
5. Most urgent needs
The participants agree on the following urgent needs: - The prevalence of psychological disorders among the population needs to be more effectively made visible to the municipalities. - Knowledge on the part of the municipal administration on what mental health promotion and prevention entail needs to be enhanced. - A more positive view needs to be developed on mental health promotion. A theoretical foundation should be created for the interfaces between the prevention of psychological disorders and social and societal determinants. Prevention could thus be more effectively embedded in the local health policy. A view on the collective prevention of psychological problems should be formulated that is attractive to the municipalities. - Collaboration needs to be reinforced among the national parties involved in developing, researching and implementing mental health promotion. This would make it possible to set up a stronger lobby. - More experiments (trial implementations) need to be conducted with community interventions and the integral approach. - An exchange of knowledge, views and culture needs to be put into effect among the various regional agencies.
6. Actions
On the basis of an analysis of the needs, the following actions have been cited. Municipalities are under the obligation to survey the health – including the mental health – of their residents once every four years. The next round is to be in 2007 (?). Standardized monitors have been developed at a national level for this purpose. Numerous questions about emotional problems have also been included in these monitors. This provides ample opportunities for prevention. Regional mental health care facilities are however not adequately aware of the monitors. The action involves bringing the contents and methodology of the monitors to the attention of the regional agencies and advising them on how to use them in setting the municipal agenda. A national prevention network is to be created in which the most important parties are represented. One of the first responsibilities should be to organize a strong joint lobby to pressure the state to give the prevention of psychological disorders a position of significance
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in the new national policy paper on health promotion and collective prevention. The network can also play an important role as regards national and regional collaboration in the field of prevention. Four regional meetings (symposia) are to be organized that important local parties take part in. The aim is to arrive at a further exchange of views, methodologies, interventions and culture. The selected theme is the integral prevention of depression, since it entails a comprehensive, inter-sectoral approach that all the parties can contribute to. The state is to be asked to finance a project in which the linkage between the prevention of psychological disorders and social and societal determinants will be clearly demonstrated to the municipalities. The aim is to make it clear what collective prevention can mean to the municipalities and what contribution the municipalities can make to collective prevention. This policy paper supports the transfer of funding from the General Special Illness Costs Act to the municipal funds. A public relations campaign is to be set up to target the municipalities on the subject of mental health promotion and prevention. A small book was already especially written in 2005 for the municipalities about the prevention of psychological disorders in the Netherlands. This work is to be continued with targeted public relations strategies. A request is to be made for funding to experiment with community interventions and integral prevention. Assistance in raising children certainly provides opportunities, especially in the fields of depression prevention and the prevention of behavioural problems in children. Projects of this kind provide greater systematic insight into the success and failure factors of regional cooperation.
7. List of national workshop participants
− Judith Bierens, Director of Health Promotion and Policy Division, Municipal Health Services, Province of South Holland, North District, Chairman of Public Mental Health Care Department. − Judith Blekman, Director of National Prevention Support Centre, Mental Health Care Facilities and Addiction Care, Trimbos Institute. − Ernst Bohlmeijer, senior academic staff member, Trimbos Institute. − Chris Dekkers, Director of Municipal Health Services, Province of South Holland, South District, Holder of Health Promotion Portfolio, Public Mental Health Care, Municipal Health Policy. − Tine de Hoop, Municipal Health Services, Rotterdam and vicinity, Primary Care Reception Desk. − Clemens Hosman, Radboud University. − Astrid van Jaarsveld, Prevention Division, Rijnmond Regional Mental Health Centre. − Sabine Neppelenbroek, policy worker, Netherlands Municipal Health Services. − Martine Peppelenbos, project staff member, Netherlands Municipal Health Services. − Katrien de Ponti, Netherlands Mental Health Care Facilities. − Marie-José van Rooij, Director of Mental Health Care Facilities, Delft Mental Health Care Facilities. − Greetje Senhorst, Director of Mental Health Care Facilities, Mediant. − Esther Teunissen, policy worker, Association of Netherlands Municipalities.
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− Ineke Voordouw, National Prevention Support Centre, Trimbos Institute. − Toon Voorham, Prevention Development Division Head, Rotterdam Municipal Health Services. − Ada de Vries, Director of Mental Health Care Facilities, Zwolle Regional Mental Health Centre. − Jeroen Zonneveld, Director of Mental Health Care Facilities, Den Bosch Mental Health Care Facilities.
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References
Beekman, A. T. F., Bremmer, M. A., Deeg, D. J. H., Van Balkom, A. J., Smit, J. H., De Beurs, E., van Dyck, R. and Van Tilburg, W. (1998). ‘Anxiety Disorders in Later Life: A Report from the Longitudinal Aging Study Amsterdam’. International Journal of Geriatric Psychiatry 13, 717-726.
Bogt, T. ter, Dorsselaer, S. van and Vollebergh, W. (2003). Psychische gezondheid, risicogedrag en welbevinden van Nederlandse scholieren.
Ginneken, P. van and Schoemaker, C. (2005). GGZ in tabellen. Trimbos Institute.
Smit, F., Bohlmeijer, E. and Cuijpers, P. (2003). Wetenschappelijke onderbouwing van depressiepreventie: epidemiologie, aangrijpingspunten, huidige praktijk, nieuwe richtingen. Utrecht: Trimbos Institute.
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Poland
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Warsaw, 28.11.2005
Barbara Mroziak, Ph.D. EMIP Project - National Coordinator Department of Psychology and Mental Health Promotion Institute of Psychiatry and Neurology (IPiN) Sobieskiego 9 02-957 Warsaw, Poland E-mail: [email protected]
EMIP PROJECT 2004-2006 REALIZATION IN POLANDNATIONAL CONFERENCE - FINAL REPORT
General information
1. The National Conference participants and program
The I National Conference on Mental Health Promotion was held in Warsaw at the Academy of Special Pedagogy in the days 14-15 October. Out of the 108 registered 90 persons actually attended, plus some 20-30 students and staff members invited from the Academy, so in sum there were over 100 participants representing various groups involved in mental health promotion: physicians, psychologists, sociologists, research workers from various universities and research institutes, practitioners working in health care or education resorts, counseling and social services, public health centers, and even sanitary-epidemiological stations, as well as students. The list of participants is enclosed. On the first day of the conference 8 general papers were presented. During the first plenary session outlined were: the current status of mental health in Poland (Cz. Czabała), the Helsinki Declaration and Action Plan for mental health promotion in Europe (P. Miśkiewicz), implementation of mental health promotion – the IMHPA project (E. Jané-Llopis), the EMIP project (B. Mroziak). The second plenary session was devoted to mental health promotion in Poland: new needs, directions and risks to mental health promotion in schools (B. Woynarowska, K. Ostaszewski) and in the workplace (E. Korzeniowska, M. Drabek). The final two presentations dealt with “Home violence and substance dependence as risks to mental health – prevention, intervention, treatment” (J. Mellibruda) and “Preventing stigmatization and reducing exclusion” (K. Prot-Klinger). During a poster session 32 posters were presented, covering a wide range of issues – a number of mental health promotion and mental disorders prevention programs planned or implemented all over the country, among other ones – prevention of substance abuse among children and adolescents, preventing burnout in school teachers, doctors and nurses, programs of stress management for policemen and PTSD prevention in firemen, suicide prevention (a very interesting poster by a histologist who found at pm examinations that a certain type of cerebral tumor is strongly associated with suicide, and postulated inexpensive screening for this condition in depressive patients to prevent their suicide), increasing social integration of the mentally ill, and programs of developing positive psychological resources in young people. The majority of presented projects and programs were spontaneous initiatives undertaken in various, sometimes quite unknown centers, independently from each other. We
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could see for the first time how many and how varied they were. Translation of poster titles is enclosed to the program in the Annex. The last item on the agenda was a dinner for the conference participants. On the second day discussion sessions in 4 subgroups were moderated by the authors who had presented general papers on the previous day. Discussants attempted to summarize the current status of mental health promotion/prevention in Poland and possibilities of implementing the Helsinki Declaration recommendations, as well as these proposed in the Final Report - Mental Health Promotion and Prevention Strategies for Coping with Anxiety, Depression and Stress Related Disorders in Europe. At the final plenary session the moderators presented a summary of discussion in each subgroup (school, workplace, substance abuse/home violence, and stigmatization). The conference was closed by a panel discussion concerning feasibility of and obstacles to implementation a mental health promotion program in Poland.
2. Conference materials
As the conference materials all the participants received a Polish translation of the Helsinki Declaration and Action Plan, as well as a copy of Mental Health Promotion and Mental Disorder Prevention. A Policy for Europe by Jané-Llopis E. and Anderson, P. (2005), copies are enclosed in the Annex.
3. Press conference
A press conference was planned as a benchmarking measure immediately after the National Conference. Invitations and announcements had been sent to about 100 mass media workers (press, TV and radio journalists). Some of them had informed us they did not work on Saturdays, but others had confirmed their attendance. To our disappointment, nobody turned up. However, the conference materials together with a press release prepared by Barbara Mroziak, presenting not only a description of the conference, but also main statistical data, postulates and recommendations, were sent next week to 10 journalists who had declared their interest in the press conference. The conference materials for all journalists were supplemented by a WHO brochure Preventing suicide. A resource for media professionals, published in Polish by the Polish Suicidological Association (a copy is enclosed in the Annex). Moreover, Cz. Czabała and B. Mroziak distributed the same conference materials among journalists at a press conference held at the Institute of Psychiatry and Neurology on October 17th 2005, on the occasion of the World Mental Health Day (the week’s delay was due to the concurrence of our national election with the proper date of the Day). Besides, information about out National Conference and its main conclusions was given. A list of those attending is enclosed in the Annex. On November 3 a journalist from Rzeczpospolita, a serious newspaper, has contacted the conference organizers asking for details, as a coverage on mental health in adolescents is being prepared.
4. Post-conference developments
The conference was documented: all the posters were digitally photographed, discussions were tape registered, and paper presentations were registered on CD. Having obtained permission from the Authors of paper presentations all the files were sent by e-mail to all the
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conference participants after the conference, to popularize the materials and provide an opportunity for thinking them over. We received a very appreciative feedback from the conference participants – people were interested and active during the conference, postulated that such conferences should be held annually, and found the event educative, inspiring and supporting their individual efforts.
Important mental health figures
• The discrepancy between prevalence of neuropsychiatric conditions (NCs) and mental health investments is larger in Poland than in other EU countries: NCs are responsible for 26.7% of total DALYs, and the mental health budget constitutes only 3.3% of the total health budget in Poland (while in the EU - 6%, Eva Jané-Llopis) • For the purpose of a more effective privatization the tax for vodka was reduced by 22% two years ago, in 2002. In the years 2001-2004 the alcohol consumption rate has increased in Poland from 6.9 to 8.2 of pure alcohol per capita. 15% of Poles fall into the latter category of consumers, and it is estimated that the number of alcohol abusers and alcohol dependent persons has increased by about 30% in that period. Before 2002 there was a systematic declining tendency in the alcohol consumption rate. Prior to the tax reduction decision makers had been warned by PARPA (National Agency for Solving Alcohol Problems) about probable consequences. (Joanna Mikuła, Jerzy Mellibruda). The data are particularly dramatic in the light of findings presented by Eva Jané-Llopis: an rise in the price of alcohol by 10% was estimated to reduce the number of alcohol-related mental health disorders by 13,5%, reducing also the number of traffic accidents, suicides, and the rate of family violence. • Psychiatric incidence rate (the number of first admissions due to mental disorders) in Poland has been recently growing by several percent per year: in 1999 the rate increased by 10%, in 2000 by 6%, 2001 by 16%, 2002 by 14%, and in 2003 by 8%. In the years 1998-2002 the number of cases with psychotic disorders has increased by 17% (from 903 to 1061 cases per 100.000 population). In the same period the number of persons treated for non-psychotic mental disorders has grown by 49% (from 727 to 1080 cases per 100.000 population), and of those treated for alcohol dependence - by 36% (from 313 to 424 per 100.000). (Cz. Czabała) • About 11% of junior secondary school students experience high levels of stress, have suicidal thoughts, and assess their functioning as poor due to their ill mental health for at least 14 days a month (Cz. Czabała). • Mental health problems in children and adolescents aged 8-18 – a study carried out by the Institute of Mother and Child in Warsaw, 2003, J. Mazur – KIDSCREEN, SDQ (assessed by parents): abnormalities were diagnosed in 8.7 % of the representative sample, and borderline states in 10.5%. Both these categories included emotional and behavior disorders, as well as inappropriate relations with peers. (Cited by B. Woynarowska) • Social Diagnosis 2005 (a large-scale study repeated on a representative national sample every two years by J. Czapiński, diagnosis of social moods etc.). For the first time a “transformation generation” was investigated, i.e. respondents born in or about 1989. Girls aged 16-18 turned out to differ significantly from their elders, the previous generation: they drink more alcohol, smoke more cigarettes, more often use drugs, and more often feel discriminated. These generational characteristics pertain to girls only, boys did not differ from those born earlier. (Cited by B. Woynarowska) • Another study (Institute of Mother and Child, 2005) indicates increased mental health problems also in 18-year-old girls (the proportion of such girls who reported experiencing negative emotional states frequently, i.e. almost daily or more often than
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once a week, was higher than these of 15-year-old girls and 15- or 18-year-old boys). The ratios were quite high (feeling upset, annoyed and in bad temper, sad, or having difficulty with sleep – from 12% of the youngest boys to 52% of the oldest girls).
Relevant stakeholders
• Parliament – legislation • Ministry of Health – legislation, allotment of resources, • PZH (National Institute of Hygiene) – on commission of the Ministry of Health responsible for the development of the most recent National Health Program and for national monitoring of health (also mental health) • Narodowy Fundusz Zdrowia (National Health Fund), with Department of Health Promotion - resources • Regional Centers for Public Health, Health Promotion Sections (e.g. Mazowieckie / Śląskie Centrum Zdrowia Publicznego, Sekcja Promocji Zdrowia) – choose operational goals from the National Health Program • Local self-governments – funds • Institute of Psychiatry and Neurology (IPiN) with Department of Psychology and Mental Health Promotion – research, monitoring on commission of PZH, coordination of prevention/promotion programs • Council for Mental Health Promotion, multidisciplinary advisory body appointed in 1989 by the Minister of Health. Chaired by Prof. Cz. Czabała. • PARPA (National Agency for Solving Alcohol Problems) • Biuro ds Narkomanii (Bureau for Drug Abuse Prevention) • Departments of Health or Mental Health Promotion at Universities, Medical Academies, research institutes • NGOs – associations of psychiatric service users and their carers.
Strengths and weaknesses in mental health promotion/prevention
Strengths
• A network of 1200 health-promoting schools all over Poland; there are also other networks – of health-promoting hospitals, healthy cities; • An effective mass media campaign for Schools with Class (excellence), a nationwide project inviting creative teachers to develop and implement programs/parts of curricula; • Mental health promotion/prevention programs for schools have been developed and evaluated, some are implemented; including these for substance abuse prevention; • Diagnostic methods for mental health assessment of school students are available; • There are regular stress management programs for the police force and firemen; • National anti-stigmatization campaign “Schizophrenia – Open the Doors” – mass media information, hotels in Cracow run by former or current schizophrenic patients, happenings on the World Mental Health Day; • Mass media campaigns on how to recognize and prevent or deal with depression; • Workshops “Strangers among us” developed for preventing xenophobia can be adapted for preventing stigmatization by mental illness.
Weaknesses
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• No current education system-specific legislation providing legal grounds for implementing elements of mental health promotion/prevention at schools; • There is no universal set of comparable diagnostic dimensions and tools for the assessment and monitoring of mental health; • Decision makers, employers, headmasters are not interested in the issues of mental health promotion/prevention; • A lack of team spirit and collaboration between various institutions/agencies involved in mental health promotion/prevention; lack of information exchange on and coordination of their respective activities; • The self-employed at the moment are beyond the mental health care system – how and where should their mental health problems be dealt with? • The area of the family, and young parents, has received not enough attention so far; developmental perspective should be taken into account and young families should be targeted; • There is no connection between the Council for Mental Health Promotion and either local community or central authorities, a liaison officer for regular contacts is needed.
Existing Mental Health policies
• The Act on Upbringing in Sobriety and Counteracting Alcoholism, of 1982. • The Act on Preventing Drug Dependence, of 1985. • The Mental Health Act of Aug. 19, 1994. • The Ordinance of the Prime Minister on Mental Health Promotion and Mental Disorders Prevention of 1996. The ordinance describes the ways of mental health promotion and prevention implementation, provides information on what types of public institutions are responsible for the implementation, and lists the basic objectives in these two areas. • The National Program of Prevention and Resolving Alcohol-Related Problems, Goals and Action Plan for the Years 2000-2005. The National Program is a basic document of governmental administration providing the key objectives, strategies and methods of State policy regarding alcohol-related problems and specific objectives for several ministries and the district administration. The program sets out eight objectives (e.g. to reduce alcohol consumption by teenagers, to reduce health risks caused by alcohol) and several strategies (e.g. constructing an effective legal and public control over harmful alcohol-related behavior, supporting activities of self-help groups). • The National Program for Counteracting Drug Addiction, 2002-2005, accepted by the Council of Ministers in compliance with the Law of April 24, 1997 on Counteracting Drug Addiction. The National Program for Counteracting Drug Addiction provides the basis for activities in the area of drug prevention, particularly to supply and demand reduction, the issues of coordination and information flow. A separate area is related to research and monitoring carried out in a close cooperation with EU agencies. • The National Program of Social Maladjustment and Delinquency Prevention Among Children and Adolescents. The Program, developed on the initiative of the Prime Minister by a multidisciplinary Task Force in 2003, outlines the framework and directions of activities undertaken by particular ministries, local self-government agencies, and NGOs. The aims are: to prevent further increases in social maladjustment (including delinquency) among children and adolescents, and to reduce effects of social maladjustment, particularly those threatening the health and life of children and adolescents. Juvenile delinquency and social maladjustment prevention in children and adolescents includes a system of integrated activities to eliminate risks to
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the healthy child development by providing children with satisfactory living conditions, supportive education and upbringing, a sense of safety, acceptance, and subjectivity, as well as active participation in culture and healthy leisure time. • National Health Program 1996-2005: a governmental program accepted by the Minister of Health in 1996. National document focused on health promotion and addressed to self-governments and local communities. Operational goal No. 7: Mental health promotion and prevention of mental disorders. • National Health Program for the years 2006-2012, including operational goal No. 11 – mental health promotion and mental disorder prevention (developed by the National Institute of Hygiene without consultation with mental health professionals); • National Mental Health Program developed at the Institute of Psychiatry and Neurology has been proposed to the Ministry of Health to be motioned to the Parliament as an amendment to the Mental Health Act; • Mental Health Promotion and Prevention Program for the years 2001-2004, developed by the Council for Mental Health Promotion, submitted in 2000 to the Minister of Health, with no response and no effect. Never presented and discussed at the Parliament. • Recently an Act on Preventing Home Violence has been developed by the State Agency for Solving Alcohol-Related Problems. • The Green Paper on Mental Health in Polish translation is generally available on the Internet; it was stressed by several conference participants that we are obligated to comply with these regulations as a new member country of the EC. • The network of Health Promoting Schools (HPS) was implemented and tested in 14 pilot schools. The concept was gradually extended and institutionalized in the education system and is now a part of the European Network of Health Promoting Schools (ENHPS), with a national network and several local networks. It is estimated that more than 1200 schools in Poland are in the network. • The National Network of Health Promotion in the Workplace, coordinated by the Nofer Institute of Occupational Medicine in Lodz. • There are also Networks of Health-Promoting Hospitals and Healthy Cities.
Most urgent needs
• Promotion of mental health promotion (also among politicians, mass-media workers, decision-makers, employers, headmasters and directors of schools, and the top police officers – they should be convinced these matters are important); • Experts on social marketing should be invited to help with marketing of mental health promotion/prevention programs. • Lobbying for mental health in the Parliament, creating a political background for good solutions; • Co-operation between various mental health agencies; integration, uniting efforts; • Organization of annual national mental health conferences to popularize and disseminate examples of good practice; • Implementation of the evidence-based mental health promotion and prevention programs based on the existing programs in Poland and in other European countries; • Inclusion of mental health promotion/prevention issues and examples of good practice in the curricula of institutions educating future managers, employers, decision-makers, experts in occupational hygiene and safety; • Obtaining co-operation of trade unions in this respect (they usually are against new training courses);
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• Mental health assessment/diagnosis in the workplace; diagnosing the risk associated with substance use/abuse at school; • Popularization of already existing programs and possibilities, • Collaboration in the area of mental health promotion/prevention with the existing institutions, such as the National Inspectorate of Work, or Occupational Medical Services – also teaching and motivating them during training courses provided by the Institute of Occupational Medicine; • Professional psychological support for teachers at school, and for employees threatened with job loss, or in conflict with their employer; • A coordinator-leader for mental health issues needed at school (not the school director); • Support to schools from scientific research findings; • Prevention of violence at school – beginning with aggressive attitudes and behaviors of teachers (depreciation, neglecting, humiliating); • The major role of interpersonal relations adults-children (mutual respect, trust, closeness, need for contact); • Anti-stigmatization: - education, particularly of teachers, doctors and priests, (also of schoolchildren), to increase their tolerance of mental disorders, by inclusion of mental health problems as a regular element of their university/school curricula; - education of the general public by inclusion of mental health issues in popular TV soap operas so as to reduce anxiety and fear of mental illness (e.g. in one of serials there is a very positive child with Down’s syndrome, or a parent with Alzheimer’s disease); - discussing such films as “Beautiful Mind” on regular sessions for school students, with visiting community half-way houses for the mentally ill; - admission of volunteers among staff members of mental health facilities.
Obstacles and barriers
• There are still no legal regulations concerning the profession of psychologist; a relevant Act is expected to be discussed in the Parliament in an unspecified future. • Knowledge about mental health and its importance is poor in the society, including the level of decision-makers, employers, authorities. Mental health prevention/promotion is disregarded, also in allotment of funds for this area, everything else is more important. This was highlighted in summaries of discussion sessions in all four subgroups. • No funds for the activity of the Council for Mental Health Promotion are available, while it was emphasized repeatedly at the conference that this important body of experts should consult e.g. psychological consequences of legislative acts concerning school prior to their passing by the Parliament, as well as initiate, stimulate and co- ordinate nationwide activities on mental health promotion/prevention. • No Act on the National Mental Health Program has been passed so far by the Parliament.
Support needed from the European Commission
• Funds for a mass media campaign on the nature and importance of mental health promotion/prevention;
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• Funds to support organization of annual national conferences on the subject; the need for such conferences, exchange of experiences, popularization of good practices, opportunity for starting collaboration was emphasized by many participants and all discussion moderators; • Supporting national efforts in the area of mental health promotion/prevention with the EC authority • Co-operation with EC countries on the implementation in Poland of the mental health promotion and prevention programs that have been evaluated as effective.
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ANNEX
List of participants Name and surname Workplace and its address
1. Anna Andruszkiewicz Katedra i Zakład Promocji Zdrowia Collegium Medicum UMK w Toruniu, 85-435 Bydgoszcz ul. Atolowa 2/10 2. Mirella Andryszczak Poznań 3. Bassam Aouil Uniwersytet Kazimierza Wielkiego w Bydgoszczy Instytut Psychologii, ul. Staffa 1, 85-867 Bydgoszcz 4. Małgorzata Basińska Zakład Psychologii Klinicznej Uniwersytet im. Kazimierza Wielkiego, 85-870 Bydgoszcz ul. Ogrody 25/218 5. Alina Bębenek Powiatowa Stacja Sanit. Epid. w Ostrowi Mazowieckiej ul. Sikorskiego 3 07-300 Ostrów Maz. 6. Małgorzata Biadoń Ośrodek Pomocy Społecznej Dzielnicy Bielany m.st. Warszawy, ul. Przybyszewskiego 80/82, 01-824 Warszawa 7. Piotr Bielicki Powiatowa Stacja Sanitarno-Epidemiologiczna we Włocławku, 87-800 Włocławek, ul. Kilińskiego 16. 8. Krzysztof Bobrowski IpiN 9. Anna Borucka IpiN 10. Maria Budner Wojewódzka Stacja Sanitarno-Epidemiologiczna w Łodzi 90-046 Łódź ul. Wodna 40 11. Anna Chorąży Samsel Powiatowa Stacja Sanit. Epid. w Ostrowi Mazowieckiej ul. Sikorskiego 3 07-300 Ostrów Maz. 12. Bogumiła Chrystowska- Wojewódzki Szpital Specjalistyczny im. M. Kopernika, Jabłońska Regionalny Ośrodek Onkologiczny w Łodzi ul. Paderewskiego 4, 93-509 Łódź 13. Czesław Czabała IpiN 14. Krzysztof Czekaj KBPN – Katowice (?) 15. Dorota Daniłowicz NZOZ Hipokrates, Warszawa Pl. Czerwca1976 nr 1 16. Maria Depta Stowarzyszenie Praktyków Dramy STOP-KLATKA 17. Marcin Drabek Instytut Medycyny Pracy, Zakład Psychologii Pracy, ul. Św. Teresy 8, 91-348 Łódź 18. Alina Drozdowicz Poradnia Psychologiczno -Pedagogiczna 64-920 Piła ul. Sikorskiego 19 19. Irena Dziarska Gminny Ośrodek Pomocy Społecznej, 07-230 Zabrodzie ul. Wł. ST. Reymonta 51, woj. mazowieckie 20. Ewa Fersten Klinika Neurochirurgii PAN 21. Alicja Furgał-Borzych Katedra i Zakład Histologii Collegium Medicum UJ w Krakowie 22. Jerzy Gierlacki Główny specjalista w Departamencie Pomocy i Integracji Społecznej w Ministerstwie Polityki Społecznej 23. Alicja Głowacka – Akademia Medyczna im. Karola Marcinkowskiego w Poznaniu Rębała Wydział Nauk o Zdrowiu, 60-179 Poznań ul. Smoluchowskiego 11 24. Krystyna Goliwąs NZOZ, Ośrodek Terapii i Promocji Zdrowia w Szamotułach ul. Powstańców Wlkp. 42 B 25. Krystyna Goździewska XVIII Liceum Ogólnokształcące im. Jana Zamoyskiego 00-375 Warszawa, ul. Smolna 30
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26. Piotr Jerzy Gurowiec Wyższa Szkoła Humanistyczno – Ekonomiczna w Łodzi Wydział Zamiejscowy w Wodzisławiu Śląskim Ul. Wita Hankego 6/15, 41-500 Chorzów 27. Eliza Iwanowicz Krajowe Centrum Promocji Zdrowia w Miejscu Pracy, Instytut Medycyny Pracy im. prof. dra J. Nofera Ul. Św. Teresy 8, 91-348 Łódź 28. Eva Jane-Llopis WHO Kopenhaga 29. Irena Janicka Centrum Promocji Zdrowia i Edukacji Ekologicznej 01-471 Warszawa, Ul. Gen.T. Pełczyńskiego 30 30. Urszula Jaryczewska "Powrót z U" Warszawa ul.Sobieskiego 112 oraz Region Lubuski – Gubin, Pleśno 5, 66-620 Gubin 31. Irena Jelonkiewicz Instytut Psychiatrii i Neurologii, 02-957 Warszawa, ul Sobieskiego 9 32. Katarzyna Jurczak (sama płaci) Eurohealthnet, Bruksela 33. Zdzisław Kapelski Psychiatria ZOZ MSWiA Poznań 34. Ewa Karbowska Powiatowa Stacja Sanitarno-Epidemiologiczna we Włocławku, 87-800 Włocławek, ul. Kilińskiego 16. 35. Wojciech Kłosiński Członek Rady ds. Promocji Zdrowia Psychicznego, Zastępca Dyrektora Departamentu Zdrowia Publicznego w Ministerstwie Zdrowia 36. K Katarzyna Kocoń IpiN 37. Agata Komisarz Mazowieckie Centrum Zdrowia Publicznego ul. Czereśniowa 98, 02-456 Warszawa 38. Iwona Koperwas Poradnia-Psychologiczno-Pedagogiczna w Piekarach Śląskich, Ul. Przyjaźni 48, Piekary Śląskie 41-948 39. Iwona Korpas Środowiskowy Dom Samopomocy, Karczew, 780-90-58 40. Elżbieta Korzeniowska Krajowe Centrum Promocji Zdrowia w Miejscu Pracy, Instytut Medycyny Pracy im. prof. dra J. Nofera Ul. Św. Teresy 8, 91-348 Łódź, Tel: 0-42 63 14 686 41. Katarzyna Kosińska-Dec Instytut Psychiatrii i Neurologii, 02-957 Warszawa, ul Sobieskiego 9 42. Katarzyna Kulik Poradnia-Psychologiczno-Pedagogiczna w Piekarach Śląskich, Ul. Przyjaźni 48, Piekaryśląskie 41-948 43. Elżbieta Lizak Powiatowa Stacja Sanitarno - Epidemiologiczna 06 – 400 Ciechanów; ul. Sienkiewicza 27 44. Monika Majdan- Szpital Powiatowy w Stalowej Woli, Oddział Psychiatryczny i Chmielowiec PZP ul Staszica 4, 37-450 Stalowa Wola 45. Ewa Majsterek Mazowieckie Centrum Zdrowia Publicznego ul. Czereśniowa 98, 02-456 Warszawa 46. Bożena Makowska Akademia Wychowania Fizycznego w Krakowie, Instytut Nauk Humanistycznych Zakład Pedagogiki i Wychowania Zdrowotnego 47. Iwona Zofia Mateuszuk Ośrodek Pomocy Społecznej Dzielnicy Żoliborz m.st. Warszawy, ul Dembińskiego 3, 01-644 Warszawa 48. Małgorzata Maresz KBPN 49. Ewa Maroczkaniec Centrum Pediatrii Zabrze 50. Danuta Matusiak Powiatowa Stacja Sanitarno-Epidemiologiczna (zamiast Wiesławy w Piotrkowie Trybunalskim, 97-300 Piotrków Trybunalski Aleje Kozińskiej) 3-go Maja 8
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51. Joanna Mazur Zakład Epidemiologii Instytut Matki i Dziecka 01-211 Warszawa ul.Kasprzaka 17a 52. Jerzy Mellibruda Instytut Psychologii Zdrowia Polskiego Towarzystwa Psychologicznego, ul. Gęślarska 3, 02-412 Warszawa 601-237-170 53. Joanna Mikuła PARPA, Waszawa 54. Marianna Oddział Oświaty Zdrowotnej i Promocji Zdrowia Mioduchowska Wojewódzka Stacja Sanitarno-Epidemiologiczna w Warszawie ul. Leszno 17, 01-199 Warszawa, tel/fax (22) 632 80 14 55. Paulina Miśkiewicz Biuro WHO w Warszawie, Długa 38/40 56. Ewa Mojs Akademia Medyczna im. K. Marcinkowskiego W Poznaniu Ul. Smoluchowskiego 11,60-350 Poznań 57. Helena Motyka Zakład Pedagogiki Medycznej CM UJ, ul. Kopernika 25, 31-501 Kraków 58. Barbara Mroziak IpiN 59. Katarzyna Okulicz- Kozaryn IpiN 60. Zofia Olszewska Środowiskowy Dom Samopomocy, Karczew, 780-90-58 61. Halina Osińska Polskie Towarzystwo Oświaty Zdrowotnej, Karowa 31, 00-324 WARSZAWA 62. p. Olsińska Urząd Miasta 63. Krzysztof Ostaszewski IpiN 64. Ewa Pawłowska Akademia Rolnicza W Szczecinie, Ul. Żołnierska 47, 71-210 Szczecin 65. Grzegorz Paź Fundacja Homo Domini, ul. Popławskiego 8/12 Kraków 66. Agnieszka Pisarska IpiN 67. Katarzyna Prot-Klinger IPiN, wew. 717 68. Maria Ptak Powiatowy Zespół ds. Orzekania o Stopniu Niepełnosprawności 27-600 Sandomierz, ul. Milberta 8/43 69. Krzysztof Puchalski Instytut Medycyny Pracy, Zakład Psychologii Pracy, ul. Św. Teresy 8, 91-348 Łódź 70. Jacek Pyżalski Instytut Medycyny Pracy, Zakład Psychologii Pracy, ul. Św. Teresy 8, 91-348 Łódź 71. Agnieszka Radzikowska Mazowieckie Centrum Zdrowia Publicznego, ul. Czereśniowa 98, 02-456 WARSZAWA 72. Katarzyna Rataj SP ZOZ Państwowy Szpital dla Nerwowo i Psychicznie Chorych w Rybniku, 44 - 201 Rybnik, ul. Gliwicka 33, woj. Śląskie 73. Agata Rokicka Ośrodek Pomocy Społecznej Dzielnicy Bielany m.st. Warszawy, ul. Przybyszewskiego 80/82, 01-824 Warszawa 74. Krzysztof Rosa Instytut Medycyny Pracy, Zakład Psychologii Pracy, ul. Św. Teresy 8, 91-348 Łódź 75. Katarzyna Sawicka Instytut Profilaktyki Społecznej i Resocjalizacji Uniwersytetu Warszawskiego, Warszawa, ul. Podchorążych 20 Instytut Profilaktyki Społecznej i Resocjalizacji 76. Helena Sęk Instytut Psychologii UAM 77. Henryk Skłodowski Społeczna Wyższa Szkoła Przedsiębiorczości i Zarządzania w Łodzi, Katedra Psychologii Zarządzania i Doradztwa Zawodowego, Ul. Sienkiewicza 9 90-113 Łódź, 042- 631-04-97 78. Grażyna Skoczek Pracownia Promocji Zdrowia Centrum Metodycznego Pomocy psychologiczno-Pedagogicznej, ul. Polna 46A, 00-644
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Warszawa Magdalena Smaś ZOZ Głogów Dzienny Oddział Psychiatryczny 67-200 Głogów ul. Grodzka 51a/7 Maria Sokołowska Centrum Metodyczne Pomocy Psychologiczno – Pedagogicznej ul. Polna 46A 00-644 Warszawa Krystyna Stanach- Małopolskie Centrum Zdrowia Publicznego w Krakowie, 31-123 Pajerska Kraków, Ul. Krupnicza 11a Marek Stankiewicz Gazeta Lekarska
Teresa Szopińska Urząd m. st. Warszawy, Biuro Polityki Społecznej, Wydział ds. Uzależnień. Irena Śliwinska NSZOZ Ośrodek Terapii Uzależnienia od Alkoholu i Współuzależnienia Anon Ul. Monte Cassino 13; 75-414 Koszalin Magdalena Śmilgin Społeczna Wyższa Szkoła Przedsiębiorczości i Zarządzania w Łodzi, Katedra Psychologii Zarządzania i Doradztwa Zawodowego, Ul. Sienkiewicza 9 90-113 Łódź, 042- 631-04-97 Aleksandra Świderska Mazowieckie Centrum Zdrowia Publicznego, ul. Czereśniowa 98, 02-456 WARSZAWA Barbara Świercz Medyczne Studium Zawodowe Nr 14, 00-236 Warszawa ul. Świętojerska 9 Izabela Tabak Instytut Matki i Dziecka, 01-211 Warszawa, ul. Kasprzaka 17a Elżbieta Tomaszek Powiatowa Stacja Sanitarno - Epidemiologiczna 06 – 400 Ciechanów; ul. Sienkiewicza 27 Józefa Trędewicz Towarzystwo Oświaty Zdrowotnej, Toruń 506-08-22-44 Krzysztof Tronczyński Szpital Czerniakowski SPZOZ, ul. Stępińska 19/25 00-739 Warszawa Izabela Turchan Małopolskie Centrum Zdrowia Publicznego w Krakowie, 31- 123 Kraków, Ul. Krupnicza 11a Maria Anna Turosz Akademia Wychowania Fizycznego w Warszawie Zamiejscowy Wydział Wychowania Fizycznego w Białej Podlaskiej ul. Akademicka 2 21-500 Biała Podlaska Jan Tylka Instytut Kardiologii, Alpejska 42 Warszawa, Instytut Psychologii UKSW- Warszawa Ewa Wilczek-Rużyczka Ochrony Zdrowia Collegium Medicum UJ ul. M. Kopernika 25 Kraków 31-501 Patrycja Wojtaszczyk Krajowe Centrum Promocji Zdrowia w Miejscu Pracy Instytut Medycyny Pracy im. prof. dra J. Nofera, ul. Św. Teresy 8; 91-348 Łódź, tel. (+42) 63 14 686, fax. (+42) 63 14 685 Barbara Wolniczek Górnośląskie Centrum Rehabilitacji „Repty”, 42-604 Tarnowskie Góry ul. Śniadeckiego 1 Barbara Woynarowska Wydział Pedagogiczny UW, Warszawa
Helena Wrona – Akademia Pedagogiczna w Krakowie, ul. Podchorążych 2, 30- Polańska 084 Kraków Weronika Wrona-Wolny Akademia Wychowania Fizycznego, Instytut Nauk Humanistycznych, Zakład Pedagogiki i Wychowania Zdrowotnego, 31-571 Kraków, Al. Jana Pawła II 78 153
Krystyna Wyrwicka Dyrektor Departamentu Pomocy i Integracji Społecznej w Ministerstwie Polityki Społecznej Małgorzata Zabłocka Uniwersytet Kazimierza Wielkiego, Instytut Pedagogiki, Zakład Pedagogiki Opiekuńczej z Profilaktyką Społeczną ul. K. Chodkiewicza 30, 85-064 Bydgoszcz Irena Zaniewicz SPZOZ Łuków ul. A. Rogalińskiego 3 Poradnia Terapii Uzależnienia i Współuzależnienia od Alkoholu, Oddział Psychiatrii 21 400 Łuków ul Międzyrzecka 164 Danuta Zaniewska Środowiskowy Dom Samopomocy Olecko Halina Zdebelak Szkoła Podstawowa Nr 40, 41-703 Ruda Śląska ul. Joanny 13 Krystyna Zlewska 13-200 Działdowo, Tylna 4, tel./fax 0236983084 Aldona Żejmo – Stowarzyszenie Praktyków Dramy STOP-KLATKA ul. Kudelska Wilanowska 114 m. 6, 05-520 Konstancin Katarzyna Żmuda Śląska Akademia Medyczna, ul. Warszawska 14, Katowice (studentka) Wyższa Szkoła Pedagogiczna TWP W Warszawie Wydział Nauk Pedagogicznych w Katowicach 40-173 Katowice, ul. Katowicka 27
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2. Poster session – presentation titles
Assessment for the purposes of health promotion in the workplace The Internet in mental health promotion. Slick Tracy and Home detectives. A two-part program of alcohol prevention for primary school students. A re-adaptation program of the “Chance” Association. Aggression at the workplace – the range of risks and prevention. Suicide and adenoma of hypophysis cerebri – collaboration between endocrinologists and psychiatrists Forms of motivating to quitting smoking in programs of mental health promotion for employees. Anti-nicotine programs in the workplace in Poland as a form of strengthening employees’ mental health. A project of anti-stress (AS) prevention program for adolescents. Mental health promotion in the workplace. I know when I cannot. SDQ (Strengths and Difficulties Questionnaire) as an instrument for the assessment of mental health in children and adolescents in population studies. Popularization of psychological knowledge as an element of mental health promotion. Optimism in young people. Health behaviors in young people. Early prevention – program “Candies”. Health as understood by the public opinion – psychological, somatic or holistic? A concept of workers’ health. A questionnaire for the measurement of teachers’ professional stress. Mental health risks in Polish teachers of generally accessible and special education units. SUPRE-MISS in Poland. An international program for the study of suicidal behaviors. Employment of the mentally disabled – realism in EU countries (France, great Britain, Germany, Sweden). Report from an international conference on “The intellectually disabled on the labor market”, Szczecin 2005. Mental health promotion at school – activities of the Methodological Center for Psychological-Pedagogical Assistance. The level of perceived special support and psychological stress in senior secondary school students in Poland. Levels of empathy and burnout in doctors and nurses in psychiatric wards. Social responsibility of firms and mental health promotion. Social responsibility of firms – perspectives of development in Poland. Mental health promotion in social professions. The effect of advertising alcohol on its consumption in adolescents involved in sports. Enhancement of shy children’s psychosocial development as a preventive measure. Various shades of black. “On the edge” – a psycho-educational program of mental disorder prevention.
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Portugal
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Lisbon, 16 March, 2006
Maria João Heitor, MD EMIP Project - National Coordinator Psychiatry and Mental Health Department Directorate-General of Health Alameda D. Afonso Henriques, 45, 7th floor 1049-005 Lisbon E-mail: [email protected]
EMIP PROJECT 2004-2006
PORTUGAL’S FINAL REPORT
1. INTRODUCTION
In Portugal, mental health is integrated in the context of general health and there is a legislative framework which includes a Mental Health Law. Mental Health is a Government and a National Health Plan priority in Portugal. We are preparing a National Mental Health Plan within the framework of the WHO Action Plan for Europe, as well as the EC Green Paper. Among various measures, we are developing three programs, namely on depression, on alcohol related problems and on post-traumatic stress disorder. Mainly since 1995 a reform has been taking place in the reorganization of services under a community care and psychosocial rehabilitation model and, more recently, with an investment on mental health promotion and mental disorder prevention. However, one of the major constraints is the implementation of these Plans and Programs
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.2. IMPORTANT MENTAL HEALTH FIGURES
Portugal is a country with an approximate area of 92.000 km2, a population of 10 million and a sex ratio (men per hundred women) of 93. The population under the age of 15 years old is 17%, and above the age of 60 years old is 21%. The life expectancy at birth is 73.6 years for males and 80.5 years old for females and the healthy life expectancy at birth is 67 years old for males and 72 years for females (WHO, 2004). Based on World Bank 2004 criteria, the country belongs to the high- income group. The health budget is 9.2% of the GDP. The per capita total expenditure on health is 1618 international dollars, and the per capita government expenditure on health is 1116 international dollars (WHO, 2004).
In Portugal, there is only a few data on psychiatric morbidity in the community. However we are now preparing a national study of psychiatric morbidity in the general population. Concerning mental health services, there are, on the public sector:
• 29 Mental Health Local Services, based in general hospitals; • 3 Infant and Adolescent Psychiatry and Mental Health Departments; • 5 Psychiatric Hospitals; • 1 Regional Psychiatric Rehabilitation Centre • 3 Alcohol Regional Centres, and • 23 Social Institutions, on the private sector.
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Our last psychiatric census revealed:
- 1 to 2% of the Portuguese population are users of the psychiatric outpatient clinics. - Total of 17902 patients, 9768 (55%) female and 7942 (44%) male. - 9414 outpatients, 6839 admissions, 1649 emergencies (3rd Psychiatric Census, 2001). In the overall, depression was most prevalent in the outpatient clinics, schizophrenia in the admissions and alcohol related problems was the main reason found in the emergency rooms.
Depression in Primary Health Care: 21,5%
Depression in general psychiatry – outpatient: >40%
Direct / indirect costs of Depression: 17% : 83%
According with recent data referring to mortality rates due to suicide, by gender, in Portugal (in the period of 2003), is 15.7 for male population. In what refers to female population, in 2003, we have a mortality rate of 4the due to suicide. The average of the two groups (men and women) is around 1 0 per 100 000 for Continental Portugal in the same year.
3. RELEVANT STAKEHOLDERS
A nationwide mental health coalition is already constituted (National Council of Mental Health) with representatives of the different sectors relevant for mental health, governmental, non-governmental, health professional, scientific, families and users organizations, involved in the arena of mental health and its improvement, promotion and implementation.
Some of the relevant Stakeholders:
Dr. Maria João Heitor dos Santos, Psychiatrist, Director of the Psychiatry and Mental Health Department, Directorate-General of Health, Ministry of Health
Dr. Jaime Milheiro, Psychiatrist, President of the National Council of Mental Health
Dr. António Leuschner, Psychiatrist, Director of Hospital Magalhães Lemos
Dra. Fátima Monteiro, President of the Association for the Psychosocial Study and Integration
Enfº José Manuel Santos, Supervisor Nurse , College of Nurses
Dr. Manuel Cruz, Psychiatrist, Technical Support Office…
Dra. Maria Júlia Valério, Psychologist, Coordinator of the Psychology Department of the Vila Nova de Gaia Hospital Centre.
Dr. Vítor Cotovio, Director of Casa de Saúde do Telhal, private social sector
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Dr. Gregoria Von Amann, Public Health Physician, Directorate-General of Health, Ministry of Health
Professor Isabel Loureiro, Public Health Physician, National School of Public Health
4. STRENGTHS AND WEAKNESSES IN MENTAL HEALTH PROMOTION/PREVENTION
4.1 STRENGTHS
A new national mental health plan is being prepared within the context of the National Health Plan. Several other programmes, namely for the elderly, children and adolescents, depression, post-traumatic stress disorder (PTSD) and alcohol related problems are also being prepared.
There are some key advances that should take place in the period of 2004-2010 concerning the implementation of evidence-based programmes for the promotion of mental health and the prevention of mental disorders. This will include the implementation of evidence-based programmes during pregnancy and early childhood, in schools, in health care services, in the general public and at the workplace. An advance would also be the performance of cost-effective evaluations of implemented programmes and the implementation of an adequate mental health information system, including the regular use of a set of mental health indicators.
A mental health impact assessment project is being planned within the framework of an European project co-financed by the European Commission and the Portuguese National Health Plan.
For these advances to become possible, some changes need to be made. These include the availability of resources for the implementation of the National Plan for Mental Health, which should incorporate evidence-based programmes. This could be facilitated by a change of policy priorities.
The Portuguese 3rd National Health Survey contains information about mental health and the 4th (in preparation) will strengthen alcohol and mental health information. There is some information about psychiatric service use obtained through the periodical National Psychiatric Census (the latest in 2001). The Directorate-General of Health (Psychiatry and Mental Health Department), within the Ministry of Health, is preparing a national system for mental health information and the first National Psychiatric Morbidity Study, which will allow the gathering of internationally comparable data, in what concerns the assessment and monitoring of mental health and mental disorders.
The country has specific programmes for disaster affected populations, elderly people and children. There are separate clinics for child and adolescent psychiatry. For the elderly, there are outpatient clinics, inpatient services, home visit facilities and old people’s homes. There are three child and adolescent psychiatry departments and 29 services and units (Rede de Referenciação em Psiquiatria e Saúde Mental,
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Direcção-Geral da Saúde, 2004). There are three regional alcohol treatment centres and one centre for psychiatric rehabilitation. This is already an important network of community care with an emphasis on psychosocial rehabilitation, although still not enough for the actual needs. Alcohol related problems are dealt within the context of mental health and are integrated in the general health system. In the field of illicit drugs, there is a vertical institute within the Ministry of Health with a nationwide network of 45 specific care centres, separated from mental health.
Training programmes for health care professionals, which include promotion and prevention in mental health, started in 2005, funded through the National Health Plan.
Programmes or strategies for the promotion of mental health and the prevention of mental disorders are partially available in schools and workplaces, and available in general/family practices. In schools, some training of teachers and students was started. In workplace settings, there are some local programmes on stress management. In general/family practice settings, there are several local experiences on the liaison of mental health teams with primary health care and with representatives of the community. There is also the practice of consultation-liaison psychiatry in general and specialised hospitals.
Mental health promotion and mental disorders prevention are integrated in the professional vocational training of general practitioners and family doctors, public health physicians and nurses or doctors’ assistants working in general practice, and it is compulsory, although not sufficiently developed. There have been studies on how to increase the involvement of primary or secondary health care professionals in the prevention of mental disorders and the promotion of mental health (such as DepCare, secondary prevention of depression in primary health care).
4.2 WEAKNESSES Drug problems and AIDS have been the highest priorities in health. However, there is a shift and at present the main priorities are cancer, cardiovascular diseases, AIDS and the elderly. Mental Health, including Alcohol, is also a priority within the National Health Plan.
Policy and practice guidelines on mental health promotion and mental disorder prevention are now being developed in Portugal. A registry or database of programmes or strategies for the promotion of mental health or the prevention of mental disorders has not been developed yet.
The promotion of mental health or the prevention of mental disorders are not integrated in medical education and in the professional vocational training of health care professionals, namely of those working in chronic diseases care, midwives/obstetric care professionals and geriatric care.
Just a few evaluation studies on the effectiveness or on the cost-effectiveness of mental health promotion or mental disorder prevention programmes implemented in Portugal have been developed or published.
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5. EXISTING MENTAL HEALTH POLICIES
There is a central governmental infrastructure that creates health policies and supports their implementation, with a specific department for mental health. There is a governmental structure for the dissemination of knowledge, programmes and strategies on health issues to health professionals or prevention workers that include the prevention and promotion of mental health. National or regional training programmes for health professionals on prevention and promotion of mental health are being developed. The main bodies involved in developing the knowledge base for mental health promotion and/or mental disease prevention are the Directorate- General of Health (namely its Psychiatry and Mental Health Department), the National School of Public Health, the Medical Faculties (Lisboa, Oporto and Coimbra), the Institute of Quality in Health and some other Faculties, such as the Higher Institute of Applied Psychology and the Psychology and Education Sciences Faculties (Lisboa, Oporto and Coimbra).
In Portugal, policy on mental health (under the framework of mental health legislation), integrates mental health improvement (i.e., promotion and prevention), treatment (through mental health services) and psychosocial rehabilitation (with the involvement of health, social security and other sectors). The Directorate-General of Health at the Ministry of Health, (through its Psychiatry and Mental Health Department) and the five Regional Health Authorities have, respectively, national and regional responsibilities on the definition and implementation of mental health policies in Portugal. Under the framework of the Portuguese National Health Plan 2004-2010, mental health (including alcohol related problems) has been appointed as a top priority. A new National Mental Health Referral Network has been launched during the national conference on the 3 and 4 November 2005 and a National Network for Alcohol problems is being developed.
Since 1989, community care (vocational training, employment support, day centres and residential support) has been progressively developed through cooperation between health services, social services and NGOs. Since 1998, there has been an integration of social support and continuous health care for people suffering from mental and psychiatric disorders in situations of substantial dependency (physical, mental, social) in order to provide for residential and occupational programmes, financed by social security. In 1998, the Ministry of Work and Solidarity defined the framework for recognition and granting of technical and financial support to promote integration within the context of social employment market; the Institute for Employment and Vocational Training sponsored active employment. There is also a national network, involving the Ministry of Defence, the Ministry of Health and the Ministry of Labour and Social Security, for PTSD and other psychological disorders of ex-combatants. An official governmental written policy for mental health promotion and mental disorder prevention is in preparation (National Mental Health Plan). This policy will include a national strategy on training, interventions by primary care professionals, school interventions integrated in the curriculum, interventions for groups at risk and interventions for the general public. Although still in preparation, there will be strong components on:
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Training of primary care professionals and articulation with mental health teams; Development of guidelines for primary care professionals’ interventions and for consultation-liaison psychiatry at the general hospital; Promotion of mental health and prevention of mental disorders in children and adolescents and in older people; National strategies/campaigns against stigma and discrimination of people with mental disorders and for mental health promotion for the general public.
At the national level, in the Directorate-General of Health, the Psychiatry and Mental Health Department is responsible for overseeing and managing mental health, including promotion and prevention strategies. Besides, there are focal points at regional levels with a role in the implementation process.
There is no non-governmental written policy on the prevention of mental disorders or the promotion of mental health.
6. EXISTING LEGISLATION FOR MENTAL HEALTH PROMOTION AND PREVENTION
The Mental Health Law 36/98, dated 1998, although mainly for compulsory treatment, sets the basis of the policy. Other relevant national laws are the Law 35/99 (Organization of Services), the Joint Ruling 407/98 (not specific for mental health), the Order 348A/98 (social firms, not specific for mental health), the Council of Ministers Resolution 166/2000 (Alcohol Action Plan), the Law 281/2003 of Continuity Care Network and the Joint Ruling 502/2004 (PTSD network).
The country has disability benefits for persons with mental disorders. Financial incentives were introduced for disabled employees in 1982. More recently, benefits were announced with the Law 247/89.
In 2000, the Resolution of the National Assembly 76/2000 and the Resolution of Council of Ministries 166/2000 directed a national policy for alcohol related problems. An update on alcohol legislation, a national programme with a new strategy in alcohol policy and a national alcohol care network are being prepared.
7. EMIP’S WORKSHOP: THE NATIONAL CONFERENCE ON MENTAL HEALTH
Regarding the growing importance of the mental health problems worldwide, and taking into account that mental health is one of the priorities of the Portuguese National Health Plan, we organized the “National Conference on Mental Health – Pathways of Change”, in Lisbon, ten years after the 1995 Mental Health Conference. A balance of ten years of reform was made and the priorities for the future were analysed.
It was held on the 3rd and 4th November 2005, promoted by the Psychiatry and Mental Health Department of the Directorate-General of Health, by the National Mental Health Council and supported by EMIP. Policy makers, national stakeholders, healthcare professionals (and from other sectors), NGO’s, users and families, and the general public were involved. An estimated number of 300 people participated in the Conference.
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Prior to the Conference and periodically, in four different periods, there was a general press release announcing the event.
An organizing Committee was created, constituted by the EMIP National Coordinator, the President of the National Mental Health Council and by several members of this Council. An executive committee was also set, integrated by the EMIP National Coordinator, national expert and another collaborator.
The program is included as an attachment of this report, as well as the list of speakers. Two WHO members and an international expert were invited. The National Conference established priorities for the future, recognizing the most urgent needs and the main obstacles and barriers to their accomplishment.
8. MOST URGENT NEEDS • Develop mental health promotion and mental disorder prevention; • Continue the reform concerning the organization of mental health services; • Improve mental health awareness and information; • Improve the care given to children and adolescents; • Improve the care available for elderly people; • Raise the care for people with mental illness in situation of social exclusion; • Develop a broader approach regarding mental health; • Raise awareness of the importance of mental health among other sectors and improve the articulation between (mental) health and other sectors; • Encourage actions against depression and improve intervention capacity for the prevention of suicide; • Improve the available solutions for schizophrenia and other psychotic disorders, namely in what refers to solutions in the community; • Intervene in alcohol abuse and dependence; • Provide a continuous improvement of the access and quality of health care towards people with mental illness; • Develop quality indicators in mental health; • Reduce social exclusion and stigma associated with mental disorders; • Promote media awareness of mental health subjects; • Improve links between primary health care and mental health services; • Continue the integration of mental health in general health services.
9. OBSTACLES AND BARRIERS
Although mental health is slowly becoming a priority, as evidenced by the increased amount of resources put into the field more recently, there have been little changes in resources. The main Obstacles in Portugal are:
• Poor human resources planning; • Poor financial resources planning; • Lack of funding; • Decrease of compliance (poor motivation, less availability of time, etc.) among health care professionals, particularly in primary care;
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• Lack and/or heterogeneity in the distribution of human resources; • Problems in the articulation and organization at several levels; • Information systems and processes of quality control are insufficient; • Stigma associated to mental illness; • Economical and financial constraints.
10. SUPPORT NEEDED FROM THE EUROPEAN COMMISSION
• The Green Paper and the creation of a European strategy towards the improvement of mental health are essential for the national strategy of mental health implementation, either on mental health promotion or on mental disorder prevention.
• International cooperation among member states, to develop mechanisms of implementation concerning mental health policies. To reinforce the relevance of the European Community projects’ funding.
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Romania
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EMIP 2004-2006 PROJECT IMPLEMENTATION IN ROMANIA FINAL REPORT NATIONAL WORKSHOP
Project Team:
Cristina PADEANU, MSc., Project coordinator, Romtens Foundation Mihaela HARATAU, MD, Public Health Specialist, Project coordinator, Romtens Foundation Bogdana TUDORACHE, MD, Specialist in Psychiatry, WHO Mental Health Counterpart
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General information about the workshop 1. The EMIP project has been developed in Romania by the Romtens Foundation. The purpose of the project is to establish a critical mass of specialists interested in the elaboration and implementation at the national level of an integrated countrywide strategy regarding the mental health. The driving ideas within the project are: Mental health is an important public health issue having a great human, social and economic impact. Mental health prevention and promotion should be included in the national strategy of mental health. There are arguments in favour of effective promotion of mental health. The health policy should address all the aspects involved by mental health.
Expected results: Establishing a network of specialists willing to promote the mental health at the international standards Establishing the opportunity for communication of information regarding the mental health, at the national and international levels. Debating on the complex issue of mental health in the workplaces.
The expected results were delivered during the EMIP workshop.
The National Workshop
The Romtens Foundation organised the National Workshop on Mental Health Promotion within the EMIP Project with support from the Romanian League of Mental Health in Bucharest at the Euro Hotels International on the date of January 26, 2006. The workshop mostly focused on Mental Health in the Workplaces. Main objectives of the workshop were presented by dr. Mihaela Haratau, public health specialist that wrote the EMIP project proposal and managed the project. These objectives are: Presenting the state of art in the field of mental health in Romania, an overview of projects and research developed to present; • Establishing and defining the factors that can support or impede the mental health being on the agenda of decision makers and in the strategy and plan of action regarding mental health, recently developed; • Initiating a process of multidisciplinary approach of mental health in the workplaces, in Romania.
Taking into consideration the workshop objectives, there were invited to attend psychiatrists, public health, health promotion and work health specialists, psychologists, and managers of Romanian companies interested in setting up healthy workplaces for their employees.
There were 45 people attending the event, 5 out of them were representatives of the Romtens Foundation, among them the director and members of the board. The participants (see the Appendix 1) were stakeholders in the field of Mental Health, representing District Public Health Directorates, Institutes for Public Health, and
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various NGOs in the field of Mental Health such as the Romanian League for Mental Health, “Aripi” Foundation (the organisation of beneficiaries), Psychiatric Departments, Departments for Child and Youth Psychiatry of Universities. At the event, there were invited and attended, Prof. Armin Schmidtke (as expert rapporteur), on behalf of the EMIP consortium and Francesco Longu, Communications Officer, from the European Public Health, Alliance.
Moreover, the workshop was advertised in the electronic newsletter „Voluntar“ for the organisations acting in the social area that involved a larger participation of persons interested in the field of Mental Health in the Workplaces who were not in the database of the Romtens Foundation. Thus, at the workshop participated representatives of the Workers Union, international donor agencies and medical schools.
Based, also, on the workshop objectives, the agenda included presentations of the representatives working in the mental health, occupational medicine, health promotion and international organizations. (see the workshop agenda-Appendix 2). At the beginning, there was presented information on mental health promotion and prevention of mental disorders in Romania, including policies in the field of mental health, “Overview of the mental health field in Romania” (Dan Prelipceanu, Associate Professor), “Overview of the mental health field promotion and mental health disorders prevention in Romania” (Bogdana Tudorache, MD, WHO Mental Health Counterpart). After the coffee break, other fields such as mental health in children and adolescents, “Mental health promotion for children and adolescents”– (Iuliana Dobrescu, MD, Associate Professor), “Media effects on suicidal behaviours” (Prof. Armin Schmidtke), “Mental Health in Romania – a 2005 study” – (Silvia Florescu, MD) were approached. The later presentation made easier the transition to the field of occupational medicine and the impact of some factors in the workplaces on the mental health which included: “Overview of the mental health at the workplaces in Romania“ (Adriana Todea, MD), “Workplaces with exposure to the electromagnetic fields and the possible impact on health“ (Didi Surcel, MD) and “Mental health pathology related to workplaces – realities and perspectives“ –(Gabriel Popescu, psychologist). The presentations were followed by 2 hour discussions on the agenda topics, mostly on the need of mental health promotion and, specifically Mental Health in the Workplaces.
The participants were provided with a copy of the Green Paper “Improving the mental health of the population. Towards a strategy on mental health for the European Union” translated into Romanian. Francesco Longu, Communications Officer at EPHA, detailed the document during the presentation “The Green Paper and the future EU Strategy on Mental Health” provided.
The Romanian versions of the Green Paper “Improving the mental health of the population. Towards a strategy on mental health for the European Union”is available on the web site of the Ministry of Health: www.ms.ro (see the Appendix 3). On the same site, it is available the legal framework for the mental health field, as well as PHARE and MATRA projects on mental health.
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Workshop materials
All the participants received a folder including the Ministry of Health Strategy on Mental Health, the Action Plan for the Implementation of Mental Health Policy and the presentations of participants copied on the CDs.
Specialists from the Romanian League for Mental Health and the Public Health Directorate Brasov provided information materials about the mental disorders, understanding and challenging stigma related to them.
At the end of the workshop, there were applied questionnaires to evaluate the achievement of the workshop objectives. (see the Appendix 4).
Workshop recommendations The participants at the workshop were concerned about the increasing number of persons affected by the mental disorders (one in three persons has one mental disorders, in the lifetime), and they emphasized that mental disorders represent an important source of disabilities at the global level, according to WHO.
The European Commission established that mental health represents a priority within the Community Programme of Public Health 2003 - 2008, and Romania was invited to adopt the Helsinki Mental Health Declaration for Europe. Facing the Challenges, Building Solutions (issued in January 2005) and the European Plan of Action regarding the Mental Health, and also got involved in the European programs of specific interventions in the field of mental health.
The experts participating at the National Workshop on “Mental Health in the Workplaces” agreed that mental health is a major component of individual and population health, and the mental health promotion represents an important objective of Romanian public health policies.
As a result of discussions at the end of workshop, the following recommendations were issued: Including the mental health promotion, prevention of mental disorders as priorities, together with Mental Health in the Workplaces, in the Ministry of Health Strategy on Mental Health and the Action Plan for the Implementation of Mental Health Policy. Evaluation of the programs and activities of mental health promotion and mental disorder prevention, at the national level (using standardised tools). Elaboration of social, educational, medical and research programs regarding mental health prevention. Development of partnerships among non-governmental organisations and other departments/ institutions focusing on mental health. Establishing a national coalition with the main stakeholders in the field of mental health and those who are interested and acting in this. Cooperation among professionals in the field of mental health and occupational health.
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Mental health and work environment It is widely accepted that people should balance between work and other activities. This aspect is very important for the social and economic areas. Work is expected to fill peoples’ life and have a positive influence on their health status.
Each person should work in good conditions without being exposed to unacceptable level of stress or other aggression. Therefore, professionals attending the National Workshop “Mental Health in the Workplaces” issued the following statements and recommendations to be included on the decision-makers agenda: In order to support people integrating work and other activities in their lives, the stakeholders should be supported to develop campaigns encouraging employers to explore those practices allowing employees to balance the workplace and day-to-day tasks. Moreover, employers should be encouraged to develop anti-stress policies in the workplaces. Also, employers could be stimulated to develop projects on preventing and combating bulling, intimidation and assaults in the workplaces. On the other hand, employees should be informed and educated to recognise and report or use the legislation to combat intimidation and assaults in the workplaces. The comparative analysis regarding Mental Health in the Workplaces could be useful in having the entire picture of public/ private sectors, the situation detailed by gender and geographic areas, a.s.o.
Specific recommendations regarding Mental Health in the Workplaces: Increasing the access of employees to mental health prevention centres at the workplaces and community centres. Informing managers and changing their attitudes regarding the impact of mental health in the workplaces on social/ economic indicators; assistance can be provided to them in order to implement preventive measures of mental ill health in the workplaces. Promoting the preventive measures of mental ill health in the workplaces focused on vulnerable and at risk persons. Multi-sectoral approach of Mental Health in the Workplaces. Prevention of discrimination and stigmatisation related to mental ill health, in the workplaces. Identifying the risk factors for mental ill health in the work environment (e.g. factors related to work management, work environment and psycho-social relationships at the workplace) for avoiding or reducing the impact of these on the nervous central system. Counselling the employers on guidelines to prevent and avoid workplace related stress. Elaborating guidelines on good practices addressed to employers and employees on prevention of stress at the workplaces. Developing the legislation on prevention of stress in the workplaces through adapting and implementing the specific regulations applied in the European Union Promoting mental well-being for the entire population, emphasising on the importance of Mental Health in the Workplaces.
(Pictures from the workshop and discussions regarding the recommendations are available on the Appendixes 5, 6, 7)
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Important mental health figures Statistics on real number of persons with mental disorders is not available at present. According to the data from the Centre for Medical Statistics, number of persons with mental health disorders who addressed to the family doctors was 251.5 / 100000 people and number of new cases was 54.5 / 100.000 people, in 2004. In 2004, 3% of GDP was allocated for the health sector, out of which 3% was distributed to the mental health field. In 2003 , there were 165 000 new cases of mental health disorders diagnosed at the level of dispensaries. (National Institute of Statistics, 2004) Starting from 2005, the National Institute for Research and Development in Health develops a study as part of the international research “World Mental Health Survey Initiative”. The Epidemiology, Classification and Evaluation Group from WHO develops the international research, technical support being provided by the Harvard Medical School, SUA. The study developed in Romania has the objective of gathering data regarding the prevalence of conduct and mental disorders, as well as illegal drugs and alcohol use and abuse. Final data and analysis will be available in the mid 2006.
Characteristics of the mental health care system in Romania o Concentrated in the hospitals and psychiatric departments. o Excessively institutionalised while the reported number of beds is one of the smallest in Europe: 76,1 beds/100.000 people. o The care model is mostly based on drug treatment. o Lack of flexibility and diversity of services provided to people with mental disorders. o Incomplete and not effective care services. o The ambulatory services do not provide a continuum of care, but the continuation of drugs based care. o A few local initiatives to improve the care and support for people with mental disorders. o An official Strategy on Mental Health since 2005.
Organisational structure of the mental health system o Hospitals (provide treatment for acute / chronic patients and patients with associated social problems -20% -) o District hospitals provide services through external departments, as well o The mental health system includes specialized units of the ministries having their own medical network (transportation, justice, defence, labour, internal affairs) o Public psychiatric units (for adults, over 170, and over 100 for infants neuropsychiatry). o Private psychiatric units. o Laboratories for Mental Health. o Day centres.
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Statistics o 38 psychiatric hospitals (out of them, 4 are psychiatric hospitals with security measures) o 66 of Laboratories of Mental Health o Total number of psychiatric beds: 15,700 (CMSI) – approximately 11,5% of the total number of hospital beds o Total number of patients with chronic diseases in 2004: 206 555* (Centre for Medical Statistics and Information) o Total no. of psychiatrists: 975 (2004) o The deficit in number of psychiatrists is of 750, at the national level (2004) o Psychiatrists in hospitals provide care as follows: 1 for 12-16 beds in the department for acute disorders and 1 for 30-40 beds in the department for chronic disorders o Psychiatrists providing exclusively ambulatory services, 1 for 60000 people o The number of psychiatrists needed for providing specialised services in the ambulatory is 373. o The actual number of psychiatrists in the ambulatory is 256. o Number of psychiatrists in the hospitals reported to number of psychiatrists in the ambulatory services is 3:1. Taking into consideration the international standards, the number of psychiatrists in the hospitals against number of psychiatrists in the ambulatory should be: 1: 1.5. o Number of hospitalisations is 258 000 / year which means a number of 12/ bed and year. o Number of consultations: 1,7 million / year o Number of infant neuropsychiatry consultations – 540 000/ year. o Number of ambulatory patients – 100 000/ year.
Specialisation of personnel o In the rural areas, psychiatric services in the hospitals are provided by general practitioners or other specialties o Most of the personnel with undergraduate studies (nurses and hospital attendants) do not have special training in assisting people with mental disorders: 300 out of 4450 nurses graduated the school for psychiatric nurses. o Lack of social assistants and occupational therapists, and only a few psychologists providing services to people with mental disorders.
Infrastructure o The buildings for psychiatric hospitals and other units are not in good conditions (the “newest” psychiatric hospital in Romania was built 85 years ago). o Investment for rehabilitation of psychiatric hospitals was insufficient and rare. o Many of the hospitals provide services for mental disorders and other acute or chronic diseases: tuberculosis, dermatology, infectious and neurological ones. o The services provided at the level hospital or ambulatory are not enough, usually, these institutions are overcrowded.
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Beneficiaries of mental health services: o Services for people with acute, chronic mental health disorders and emergencies are provided in the hospitals. o 20-30% of in-patients having social problems, for example, people abandoned by their families or other relatives. o Lack of alternative services involves the over- utilization of hospital services.
Regional distribution of services o Overlaps the administrative one. o Sometimes, unequal and not in accordance with the request for specialised services. o Some of the hospitals are overcrowded, other are under-utilised. o The lack of services at the community level. The Orizonturi Foundation develops one good example of services provided at the community level.. o More than one reported admission in the hospital for every person. o High costs without consistent improvement of the patient life quality.
The status of security hospitals o These hospitals provide services according to the legislation in place. o At the national level, there are 4 security psychiatric hospitals with a total number of 600 beds. o The personnel lack the specialization regarding care for people with aggressive behaviour due to mental disorders. o An increasing interest of the decision-makers in improving the life conditions of people in the security hospitals, in the last one and a half year. (Source: Presentation of the Associate Prof. Dr. Prelipceanu with the occasion of the EMIP workshop organised in Bucharest on January 26, 2006).
Statistics on illegal drug and alcohol use: o The total number of people demanding medical services for drug addiction in 2004 was 1502. This number included addicts seeking treatment in the three methadone maintenance centers in Bucharest and some cases of addicts registered all over the country in emergency rooms and psychiatric departments. People aged 20 to 24 (28%) and 25 to 29 (20%) represent most of the drug users demanding treatment. Almost a half of the total number of people demanding treatment are heroin users (52%), 94% of them injecting this drug. o Data collection on drug treatment demand will improve due to the newly established system on monitoring in the drug treatment centers implemented by the National Agency Against Drugs and funded by the Global Fund to Fight AIDS and Tuberculosis. o In 2004, the National Anti-drug Agency developed a study on drug use in the general population financed by the Global Fund to Fight AIDS and Tuberculosis. The study sample was based on 3500 people, but the results were extended at the national level. The lifetime prevalence of drug use is, according to the type of drugs: 1,7% for cannabis, 0,4% for cocaine, 0,3% for ecstasy and 0,2% for heroin (National Agency Against Drugs, 2005).
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The 2003 ESPAD study was carried out on a pattern of 4371 students (born in 1987), from 209 schools at national level, according to the methodology elaborated and developed by Pompidou Group and CAN. o Data from the ESPAD 2003 provided by the National Institute for Research and Development in Health (2004), indicated that prevalence of illegal drugs is still low among Romanian teenagers (3% for cannabis and derivates and less than 1% for other drugs), but compared with 1999 ESPAD data the prevalence increased, especially for synthetic drugs. 55% of the teenagers begin drinking bear before the age of 14 (double compared with 1999); also 50% of them drink wine before the age of 14 and 15% drink “strong” alcohol beverages. The most common places used for drinking alcohol were: at home (38%, three times more than in 1999 ESPAD Study), at the discotheque (18%, three times more then in the previous study), in a friend’s house (15%, 2,5 more than in 1999), in the street/park/beach or other public places (13%, ten times higher percentage than in 1999), at the pub or bar (12%, an increase of three percents) or at the restaurant (more than 5%, a nine times increase). Because of the alcohol, about 2-3% of the teenagers had problems with the police or had poor school results. The data referring to illegal drug abuse revealed increasing trends for: ecstasy (three times increase, although the prevalence was still less than 1%), amphetamines (an 85% increase but also less than 1% prevalence), injectable drugs (50-60% increase, less than 1% prevalence) and LSD/hallucinogens (40-45% increase, less than 1% prevalence).
Relevant stakeholders: Ministry of Health Romanian Parliament National Health Insurance House Ministry of Labour and Social Solidarity Professionals in the field of mental health NGOs in the field of mental health, mainly beneficiary organizations 41 District and Bucharest Public Health Directorates National Institutes of Public Health Public Health Centres Medicine Faculties Sociology, Psychology and Social Assistance Faculties National Agency Anti-drugs Romanian League for Mental Health National Institute for Research and Development in Health Romanian Society “Alzheimer” Mental Health Laboratories Inter-sectoral Committee for Mental Health ALIAT Foundation, Romanian Association against AIDS (ARAS)
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Strengths and weaknesses in mental health promotion and prevention
Strengths Adoption of a Strategy and a Plan of Action in the field of mental health. Establishing a multi-disciplinary committee regarding mental health under the coordination of the Romanian Presidency and the Prime Minister Institution Integration of Romania in the Implementing Mental Health Promotion Action, a network with partners across 28 European countries financed by the European Commission. The existing network of health promotion units within the public health directorates at the 41 districts and Bucharest level “Education for health” program in the Romanian schools implemented by the Ministry of Education and Ministry of Health. This program consists of teaching children about health, including mental health, according to a health education curriculum. The program will become compulsory from the school year 2006-2007 while almost 9000 teachers where trained within a project funded by the Global Fund to Fight HIV/ AIDS and Tuberculosis. A network of health promoting schools (including promotion of mental health) developed under the WHO program "The European Health Promoting Schools". Campaigns and programs of mental health promotion developed by the Romanian League for Mental Health: o “Mental health problems can be solved. How do you interact with people having mental health problems?” project. The main objective of the project providing knowledge regarding mental health problems and improving the attitudes of students from high schools towards persons with mental health problems. o “Now, you know why you should care” – education campaign against stigma and discrimination of people with mental health problems. o “Training for advocating for NGOs developing activities for people with disabilities” o National Conference “Mental health in Romania. From ignoring to acting responsible. o Workshop on “Advocating the mental health”. Programs for prevention of depression and suicide developed by the Anti-Suicide Alliance. Development of harm-reduction related to intravenous drug use programs by the NGOs (e.g. ALIAT starting from 2000, ARAS). Study regarding the qualitative and quantitative evaluation of stigmatisation an discrimination regarding mental health in Romania International assistance and support for developing legislation within the projects in the field of mental health The existing programs for illegal drug use and alcohol use/ abuse developed by the Ministry of Health though the network of Health Promotion Units, National Agency Against Drugs and different NGOs, financed from the Global Fund to Fight AIDS and Tuberculosis in the last 2 years. The Strategy for prevention of drug use according to the European Union one The legislation for prevention and fight against trafficking and using illegal drugs.
8. Weaknesses Lack of organizations enabled to coordinate the activities in the field of mental health, including related activities to this field.
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Lack of human resources (mainly qualified personnel in the field of mental health promotion and prevention of mental disorders) as well as financial resources for supporting the training programs and specific infrastructure in the mental health field. Lack of effective allocation of financial resources in the mental health field. Lack of interest for dissemination of information and knowledge from projects and activities developed at the local level to the communities interested by the topic of mental health. The existence of psychiatric hospital / Laboratories for Mental Health and lack of mental health services at the community level. Lack of cooperation and relationships among professionals from the mental health and occupational health field Lack of approved Norms for applying Law no. 487/2002 regarding mental health and protection of people with mental disorders.
Existing mental health policies In Romania, mental health was approached as a field exclusively related to the health sector for many years. On the other hand, the mental ill health has a great impact on other sectors such as social and economic, therefore, the field needs a complex approach, and mental health should be included as an important topic on the health and other policies agenda.
Ministry of Health, according to the Governmental Decision no. 168/2005 regarding the Ministry of Health organising and functioning, establishes the health policy, including the mental health policy, in Romania. Thus, the mental health prevention and treatment issues are addressed by the health promotion specialists in the public health directorates, primary care services provided by the family doctors, dispensaries, and by the professionals providing secondary care services in the through hospitals, ambulatory and mental health laboratories.
The National Health Insurance House based on the Framework Agreement with the health providers funds the payment for the primary and secondary medical care services. Moreover, Ministry of Health, based on the Health Minister Order issued annually, funds the health sub- programs from the state budget. Funds are allocated for prophylaxis of psychological and psychiatric pathology. In 2005, the Order no. 10 included the regulations regarding he implementation of sub- program 2.5 „The prophylaxis of psycho-social and psychiatric pathology” Objectives: o Shortening the period of acute diseases evolution by 10% o Recovering the self-care abilities and development of some housing activities for 50% of the patients in the psychiatric hospitals Activities: o Occupational therapy. o Rehabilitation of the centers for occupational therapy o Development of an information-education-communication campaign Proposed result indicators: o Decreasing the hospitalisation duration by 10%. o Decreasing the number of patients depending on the support of relatives, by 25%.
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Proposed activity indicators: o Number of patients included in the occupational therapy programs -2912 .
Moreover, Ministry of Health funds, from the state budget, a national subprogram on “Health Promotion and Education” that focuses on information, education and communication campaign and activities addressing the communicable and non-communicable diseases. Thus, in 2005, within the framework of national sub-program on health promotion, there were developed campaigns regarding prevention of illegal drug use, as well as fighting stigmatisation related to HIV/ AIDS. In some districts, there were organised information- education-communication activities for prevention of mental disorders, addressing mostly depression and anxiety. Unfortunately, acceptance of people with mental ill health still represents a problem to overcome, and mental health promotion activities are not constantly organised and sometimes lack the funds.
The Order no. 10/ 2005 regarding the implementation of national health programs and sub- programs funded from the state budget, included the sub-program no. 1.5 „Health promotion and education” with the general objective: o Development of favourable attitudes towards health and healthy behaviours through health promotion and education methods. Activities: o Development and implementation of information-education-communication campaigns addressing the public health problems identified at the local and national level, and celebrating the world health days according to the recommendations of WHO, as well as other specific activities of health promotion. o Specific training and education for the personnel developing health promotion and education activities. o Providing training for the health mediators or other people providing health activities and education at the local communities or disatvantaged communities. o Evaluation of knowledge, attitudes and practices regarding behaviours involving a risk for health, at the level of population.
The national health sub-programs financed from the state budget are implemented through the public health directorates from Bucharest and 41 districts.
These institutions transpose the health policy proposed by the Ministry of Health into practice, and they also provide interventions for public health problems at the district level. Therefore, the public health directorates and designated hospitals develop the activities within the national subprogram on mental health, and when possible specific interventions in the mental health field.
As emphasized in the section of “Weaknesses and Strengths”, Romania was provided with international assistance for improving the policy and activities in the field of mental health. Thus, within the Mental Health Programme developed in the framework of Stability Pact from Dubrovnik for countries in South Eastern Europe, there was performed an evaluation of mental health field, based on which it was developed the Strategy on Mental Health.
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Recently, there was elaborated a Plan of Action for implementing the Mental Health Strategy, as a result of PHARE Twining Light Project RO-2003/005-551.03.03 - RO03/IB/OT 09. The Plan has a section dedicated to the mental health promotion and mental disorders prevention.
Prevention • The “Green paper” on mental health of the European Community will be the starting point for the Romanian policy on prevention. • Prevention of mental diseases is very difficult. However, having in mind that stigma and discrimination of persons with mental disorder have a high prevalence in Romanian society, mental health promotion should be an essential part of the action plan. • In general, primary prevention programmes do not show immediate results. • In prevention the use of new ways of communication like TV and the Internet should be considered. • Secondary and tertiary preventions are feasible and effective.”
The first step for improving the mental health services was setting-up Mental Health Centres based on the Health Minister Order regarding the setting up and organizing of the Mental Health Centres for the purpose of providing support to people affected by mental disorders. Thus, the Centres will provide services at the community level, one becoming accessible for 150000 to 300000 people, according to the location and prevalence of mental health problems in the area.
Moreover, Romania received technical and financial assistance within the international projects such as: o the MATRA Project for European Integration and Assistance from the Netherlanden experts “Reforming the institutional and organisational structures of high security psychiatric hospitals in Romania” is now available. The ultimate objective of the project is establishing a strategy and action plan for reforming the high security psychiatric hospitals, according to the recommendations of the European Union. o PHARE Project Twining Light RO-2003/005-551.03.03 - RO03/IB/OT 09.
The prevention and treatment of drug use
The National Anti-drug Strategy 2005-2012 has a sub-chapter on “Drug use prevention”. This chapter establishes besides general and specific objectives in drug prevention activities, an action plan for education, health and family, police, youth, community, private organizations, mass-media, national and international co-operation areas. The ministries involved in the drugs demand reduction are: Ministry of Health, Ministry of Education, Research and Youth, Ministry of Young and Sports, Ministry of Justice, Ministry of Administration and Interior, Ministry of Labor, Family and Social Solidarity. Each ministry involved in drug prevention has its own action plan, for the time interval 2005-2012.
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The treatment system available for drug addicted in 2004 was not very different from previous years. The therapeutic chain was incomplete, under financed and collected data on demand for treatment were difficult to evaluate. The medical services available in 2004 could be roughly divided in: - Methadone maintenance centers (three, only in Bucharest) - Non-substitutive centers (only a few in Bucharest, Iasi, Timis) - After care (Bucharest, Iasi) - Psychiatric departments of Counties Hospitals - Emergency rooms of Counties Hospitals. The Ministry of Health covers funds for treatment from the state budget through the National Sub-program no. 2.13 ”Treatment for Drug Dependencies”.
Existing legislation for mental health promotion and prevention Law no. 487/2002 regarding mental health and protection of people with mental disorders establishes in the article no. 3 that “ Mental health is a fundamental component of the individual health; mental health promotion represents a major objective of the public health policy. Similarly, within the chapter 7, the issue of mental disorders prevention is approached: “(1) Prevention of mental disorders is provided through research, education, medical and social programs designed to reach: a) the general population, and this is called „general prevention”; b) population at higher risk than general population to develop mental disorders, the „selective prevention”; c) population at risk of mental ill health, the „focused prevention” Health Minister Order no. 639/ /2005 establishes the National Strategy regarding the mental health services and the Action Plan for the Implementation of the Mental Health Policy of the Romanian Ministry of Health - result of the PHARE Project Twining Light RO-2003/005-551.03.03 - RO03/IB/OT 09. Health Minister Order no. 661/ /2005 setting up the National Consultative Group on the psychiatric issues. Law no. 522/ 2004 regarding the changes in the Law no. 143/2000 on combating the traffic and illicit drug use. Governmental Decision no. 73 of January 27, 2005 on the approval of the National Anti- drug Strategy 2005-2012. Action Plan for implementing the National Anti-drug Strategy 2005-2008. Ministry of Health Order no. 10/ 2005 regarding the implementation of national health programs and sub-programs funded from the state budget. The Twinning Light with technical assistance from the Netherlander Government – (2005) MATRA project for the improvement of norms for hospitalisation in the psychiatric and hospitals and hospitals applying security measures The Order regarding the setting up and organizing of the Mental Health Centres which will be approved by the Ministry of Health in the next days.
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Push and pull factors
Push factors
The long term monitoring by the international bodies: European Commission, Amnesty International a.s.o. and conditions imposed by the European Union for the Romania accession to the E.U. (the importance of a “positive report for the country”) The Action Plan for implementing the mental health reform promoted by the Ministry of Health. The Inter-sectoral Committee for Mental Health set up at the proposal of the Minister of Health and under the coordination of the Presidency. The Executive Director of the Committee is the Secretary of State from the Ministry of Health.
Pull factors Stigmatisation at different levels. Lack of interest for the mental ill health at the level of governmental institutions, until recently, and at the level of population. Medical and social institutions for mental health are not in good conditions. Lack of an effective system for management of information in the mental health field. Inappropriate legislation for providing care and support to people with mental disorders. The reduced budget for mental health care and support. Lack of qualified personnel in the fields of psychiatric care, clinical psychology, social assistance and other mental health related fields.
Most urgent needs Development of mental health services in the community. De-institutionalisation followed by the development of alternatives to hospitalisation. Structuring the therapeutic team according to the recently issued Order regarding the setting up and organizing of the Mental Health Centres which will be approved by the Ministry of Health in the next days. Those team should include psychiatrists, psychologists, social assistants, nurses specialised in psychiatry. Including and approving the specialties needed for the therapeutic team in the Classified list of professions (e.g. occupational therapists, art therapists). Development of specific training curricula for nurses, specialist and family doctors, psychologists and social assistants. Continuing the legislative harmonisation process and implementation of the adopted legislation as a result of the harmonisation process. Including the mental health promotion in the health promotion activities and projects developed by the district and Bucharest Public Health Directorates. Finalising the Action Plan for the Implementation of the Mental Health Policy of the Romanian Ministry of Health. Elaborating the secondary legislation as a result of adoption of the Strategy National Strategy regarding the mental health services Accelerating the approval process of the Norms for applying Law no. 487/2002 regarding mental health and protection of people with mental disorders. Setting up a network of mental health community services Changing the attitudes regarding mental ill health through anti-stigmatisation programs Changing the actual mental health care model into one based on the multi-disciplinary team and individual care plan.
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Involving the patient/ beneficiary/ family member organizations in an integrated network Standardised evaluation at the national level of programs and activities developed in the field of mental health promotion and psychiatric disorders prevention. Establishing a national coalition, which will include main actors involved in the field of mental health. Romania integration in the international networks of mental health promotion and mental disorders prevention.
Obstacles and barriers: Lack of the legislative norms regarding the Law no. 487/2002 regarding mental health and protection of people with mental disorders The need for making population aware regarding the mental health, mental ill health and stigmatisation. The shortage of funds allocated in the field of mental health Te need for sustained and rigorous research activity in the field of mental health in Romania.
What kind of support is needed from the European Union to further mental health promotion and prevention in your country? Technical assistance for setting up a National Centre of information, training and education in the field of mental health promotion and mental disorders prevention. Technical assistance for establishing measurable indicators for the projects / programs developed in the field of mental health, monitoring and evaluation procedures (designing the monitoring and evaluation standards to be implemented at the national level.) Supporting Romania integration in the international networks of mental health promotion and mental disorders prevention. Funds for training for the professionals involved in the field of mental health Financing a raising awareness campaign for the target groups regarding the mental health, identifying the mental ill health and early addressing to the specialists, acceptance of people with mental disorders. Supporting the implementation of legislation adopted according to the EC regulations, especially those Funding training of trainers for professionals from the multi-disciplinary teams to provide care and support for mental health promotion and mental disorders at the community level. Cooperation with the European Union Member States for development of effective mental health prevention and promotion programs Support for integration of multi-disciplinary programs into the mental health policy. Workplace mental health programs.
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Slovenia
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Tanja Kamin, Ph.D. EMIP Project – National Coordinator Institute of Public Health of the Republic of Slovenia Trubarjeva 2 1000 Ljubljana, Slovenia e-mai: [email protected]
Ljubljana, 23. 01 2006
EMIP PROJECT REALIZATION IN SLOVENIA National Conference: The World Mental Health Day National workshop: A step forward towards national mental health programme
General information
1. National Conference
National Conference “the World Mental Health Day” was held in Ljubljana, on October the 10th in 2005.
Key speakers at the national conference were: - Andrej Marušič, The Institute of Public Health of the Republic of Slovenia with lecture “Slovenian Public Mental Health in Europe” - Marija Seljak, The Ministry of Public Health, with lecture “Slovenia on the Way Towards National Mental Health Programme” - Gregor Henderson, National Programme for Improving Mental Health and Wellbeing, Mental Health Division, Scottish Executive, with lecture “National Programme for Improving Mental Health and Well-being in Scotland” - Nuša Konec Juričič, Regional Institute for Health Care Celje, with Introductive presentation of the mental health issue in Slovenia.
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Conference was divided into two parts: firstly, lectures on the mental health state and mental health prevention and promotion issues, and secondly, discussion. 80 participants attended the national conference. Participants were asked to evaluate the conference and invited to participate in further activities for promotion of mental health in Slovenia. A lot of interest was shown for participation at the second national mental health promotion event: National workshop for promotion of mental health in Slovenia.
Conference ended just before a pop-rock concert for de-stigmatisation of depression has started. Both events were organized by The Institute of Public Health, they were accompanied with acknowledging amount of public relation activities, including press conference two days before the event, on which the The Minister of Public health Andrej Bručan, the director of The Institute of Public Health Andrej Marušič and director of the NGO Ozara Society Igor Hrast gave talk about mental health promotion in Slovenia. Consequently, both events achieved a lot of attention of all the main national mass media.
2. National workshop: A step forward towards national mental health programme
National workshop was held in Ljubljana, one week after the conference, on October the 19th 2006. Out of 85 registered persons we choose 56 participants, which were representing various groups involved in mental health promotion: psychiatrists, sociologists, social workers, physicians, counselling services, researcher workers from the universities and research institutes, public health ministry, self-help groups, public health centres etc. The list of participants is enclosed.
The activities of the workshop were divided into four main parts: - Introductory lectures on public mental health, mental health promotion and mental disease prevention; o One health only (A. Marušič) o The role of psychiatry in mental health promotion (V.Švab) o Components of national mental health policy (S.Neil) o Aims of the first national meeting for promoting mental health in Slovenia (T.Kamin);
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- Presentations of activities of the 12 main active organizations on the field of mental health in Slovenia and presentation of Scottish National Programme for Improving Mental Health and Well-Being (R. Ellis); - Group assignment and discussion; - Concluding comments in which discussants attempted to summarize the current state of mental health promotion and mental disease prevention in the country, outline the consensus on further steps needed and milestones.
The aims of the national meeting were: - to encourage the placement of mental health issues, including positive mental health, on the priority list on public policy agenda; - to prepare strategic guidelines for national programme for improving mental health in Slovenia; - to identify key aims, priorities and target groups for actions on the mental health area; - to become aware of the process in mental health promotion activities; - to get acquainted with key actors and advocates in the mental health promotion field in Slovenia; - to identify key stakeholders in the mental health promotion process and various interests that need to be respected and integrated in planning and implementation of the national programme.
Materials for the national workshop were consistent of copies of: - all presentations; - initial questions for the group discussions; - introduction of the EMIP project; - Mental Health Declaration for Europe; - Slovenian country story published in Mental Health Promotion and Mental Disorder Prevention across European Union Member states, developed by The European Platform for Mental Health Promotion and Mental Disorder Prevention; - The challenge of developing a national mental health promotion strategy: some thoughts for colleagues in Slovenia, based on our experience in England (L.Friedly); - The list of indicators for monitoring mental health in the EU Member states (MINDFUL project).
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Post-conference and workshop developments:
Participants of both, the conference and workshop were asked to evaluate the events and to write down, in their opinion, the main mental health promotion issues in the country. Feedback was satisfactory. Participants were highly satisfied with the organization of workshop and they look forward to further following events. Particularly they have supported interdisciplinary and cross-sector structured participation. It was for the first time in Slovenia, that so many various interests and views regarding mental health promotion were confronted at the same workshop. This should be taken care for in the future meetings as well. It was decided that such workshops should be held annually.
Main issues are summarized as fallows: - Participants share the same vision on promotion of mental health and well being in Slovenia regardless the expertise, disciplines and sectors. - The need for good national mental health policy, which would strive to establish good legislation on the mental health field, better services for treating mental health disorders and promoting mental health, better life for those already suffering mental health problems, and efficient programme for improving mental health of the population. - Disburden mental health from stigma and discrimination. - Better networking of existent organizations and associations and their activities in the mental health promotion and mental disorder treatment and prevention area.
Organization board has agreed that will by the end of March 2006 develop standardised method for description of an individual mental health promotion and mental disorder prevention programme, which will be the base for evaluation of mental health promotion programmes in Slovenia.
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Important mental health figures
STATE OF MENTAL 1990 1995 2000 2005 or the last HEALTH BY measured INDICATOR AND YEAR
676 564 588 Last data year Suicide rate 515 man 435 man 433 man 2003: 161 women 129 women 155 women 562 (no of suicides in all 440 men population) 122 women 3,6 % of all deaths 2,9%of all 3,2% of all deaths deaths 2,9% of all deaths SDR 1,74 SDR 1,12 SDR 4,31 Last data 2003 Events of SDR 3,61 undetermined intention (crude death rate: 97 cases(ICD-10, 82 cases(ICD-10, number of registered Y10-Y34) Y10-Y34) deaths/ mid-year population (per 100000population). WHO data
3 12 28 39 Drug related deaths
35 41 24 Last data 2003: 27 Alcohol related deaths (no. of people who died by accidental poisoning by alcohol) Last data 2003: Social Phobia 9 cases (among all hospitalised patients) Last data year Major depression 2003: (among all hospitalised F322: 217 cases patients) F323: 120 cases F335: 296 cases F:333:197cases Year 2003: Alcohol Dependance 1561 patients (among all hospitalised hospitalised patients) Last data 2003: Lifetime occurrence of 53 cases( there is suicide attempt no exact number (among all hospitalised because of lack of patients) law defined registers)
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Last data: year Psychological distress 2003: (among all hospitalised F430: 128 patients) F431: 36 F432:316 7931 women 7133 women 12258 women Year 2003: Parenthood training 1377 men 2926 men 6212 men 11585 women (number of 7522 men participants at the *data available also parental classes by sex) for different age groups 1614 beds 1594 beds 1525 beds Year 2003: 777 Number of psychiatric 8,08 beds per 10 000 8 beds per 7,7 beds per 10 beds bed 10 000 000
124 psychiatrists in 130 psychiatrists 169 psychiatrists Year 2003: Number of hospitals and in hospitals and in hospitals and 147 psychiatrists psychiatrists 33 psychiatrists in 53 psychiatrists 67 in hospitals and out-patient specialist in out-patient psychiatrists in 91,7 In hospitals and in out- clinics calculated specialist clinics out-patient psychiatrists in patients specialist from the 66,6 full- calculated from specialist clinics out-patient clinics-full time time equivalent the 83,4 full- calculated from specialist clinic equivalent :number of time equivalent the 85,4 full-time calculated from hours worked divided equivalent full time by 1590hours) equivalent 10966 episodes 10311 episodes 11301 episodes Last data year Number of in-patient 5,48 per 1000 5,20 per 1000 5,72 per 1000 2003: episodes due to mental population population population 11239 episodes health conditions 5.63 per (episodes, aggregated 1000population by diagnoses per 1000 population ) Use of out-patient 32041 patients 38245 63718 patients Last data year services due to mental 4,0 per 1000 patients 32,2 per 2003: health population 3,9 per 1000 1000population 50404 patients conditions(diagnosed population 25,3 per 1000 disease and conditions population in out-patient specialist clinics by ICD 10 chapter per 1000 population)
Use of antidepressants 70.833Rp 97.984 Rp 163.873 Rp Last data year (number of written 50Rp per 1000 83 Rp per 1000 2003: prescriptions per 1000 252.817 Rp population) 127 Rp per 1000 population 589.433 Rp Last data year Use of anxiolytics 298 per 1000 2003: 601.631 Rp 301 Rp per 1000 population
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18.684 Rp 99.244Rp 200.770 Rp Last data Use of hypnotics 51Rp per 1000 102 Rp per 1000 year 2003: 246.824 Rp 124Rp per 1000 population
Proportion of disability Mentally disturbed- Mentally Mentally Last data Year pensions due to mental Children and Youth: disturbed- disturbed- 2003: disorders 6245 Children and Children and Mentally - recipients of social Behaviourally and Youth: Youth: disturbed- welfare services due to personally disturbed 4594 3779 Children and Mental, Personal and - all Behaviourally Behaviourally and Youth: 2213 Behavioural disorder population:17058 and personally personally Behaviourally and disturbed - all disturbed - all personally population: population: disturbed - all 11677 11412 population: 10858
Long stay patients per 4,8 4,99 4,65 Year 2003: 100000 3,71 population(WHO)
Relevant stakeholders: - Governmental level • Ministry of Health • Council for Mental Health at the Government of Republic of Slovenia (acts as an advisory body, consists of 28 members including representatives from non- governmental organizations, users and carers) - The Institute of Public Health of the Republic of Slovenia • Department of Health Promotion Section for Mental Health Improvement (in process of establishment) - 9 Regional Institutes for Public Health Prevention - Institute of Psychiatry - Information unit for illicit drugs, Institute of public health - Faculty of Social work, University of Ljubljana - NGO • Centre for social and work integration • Associations for volunteers; • Self-help groups etc; • Schools; • Work force;
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In Slovenia the workforce involved in mental health activities is drawn from a diversity of settings and sectors including: the National Health Service, The Institute of Public Health, Regional Institutes for Public Health Prevention, NGOs, and the wider public and voluntary sector e.g. community workers, academics, teachers, human resource officers, etc.
Strengths and weaknesses in mental health promotion/prevention
- A network of 130 health-promotion schools (100 primary schools, 25 secondary schools, 5 dormitories); - Regional anti-stigmatisation campaign “Depression” was launched in the year 2005; - Concert for anti-stigmatisation of depression on the World Health Day; - Suicide prevention workshops for teachers and parents; - National mass media campaign s on how to recognize and deal with depression; - Promotion of mental health research and promotion at the Faculty of Social Sciences, University of Ljubljana; - Development of diagnostic methods for mental health assessment among pupils and students.
Weaknesses in mental health promotion and prevention
- the absence of national mental health promotion programme with clear vision, priority areas and action strategies; - too many important stakeholders are still not interested in the issues of mental health; - poor mental health literacy among the general public as well as experts; - prioritisation of the narrow negative side of mental health definition; - lack of cooperation between various organizations involved in mental health promotion and mental disease prevention; - absence of good network of stakeholders in mental health promotion and lack of information exchange on activities of various organizations working in mental health promotion; - absence of educational curriculum on mental health promotion.
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Existing mental health policies and Existing legislation for MH promotion and prevention Mental health promotion and mental health disorder prevention in Slovenia still has not got its own national programme that would include and organize other policy areas, such as public health; education and sport; labour, family and social affairs; special planning; education and sport; higher education; social justice and social inclusion etc. around mental health issues under its own policy umbrella. However, the new National Public Health Prevention Programme is in the stage of preparation, which will set in more detail the Slovene public health priorities and their relations to other policy areas.
The old National Programme for Public Health Prevention, which was operative until 2004, did not specifically include mental health priorities and prevention and promotion actions. The forthcoming National Programme for Public Health Prevention will be the starting base for interdisciplinary and cross-sectional establishment of the National Mental Health Promotion and Mental Disease Prevention Programme of Slovenia. It is already in the process of preparation.
Existing acts from the mental health area or related to the mental health area are: - Act Concerning Social Care of Mentally and Physically Handicapped Persons, - Social Security Act, - Health Care and Health Insurance Act, - Patient Advocacy Act and Protection of Right of Mental Patient (in procedure), - Mental Health Law (in procedure), - National Action Plan on Social Inclusion (NGO)
Most urgent needs
- Challenge poor mental health literacy amongst both the general public, as well as amongst experts and professionals. - Special campaigns at the national level are needed to challenge stigma and discrimination around mental ill-health in Slovenia. - Although actions have been undertaken for mental health promotion, priorities should be explicitly delineated and placed in a wider context.
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- Build a strong network of experts and institutions that are responsible in the field of mental health promotion and prevention. - To intensify effects and to avoid overlaps, there is a need to harmonize programmes with a long term vision, making them concrete through actions across different settings, at different levels, pointed to different target groups. - Experts from social studies and social marketing should be invited to help with mental health promotion programmes. - National advocacy board should be established, which would actively lobby for mental health in the Parliament. - Mental health should be put on the public agenda; therefore media advocates should be invited to help with mental health promotion programmes. - The professionals in psychiatry should recognize and except that there is more to treatment and that other professionals should be included in mental health promotion. - Improve information exchange on mental health promotion activities. - Narrow the gap in mental health promotion activities between the urban and rural area in the country. - Introduce mental health promotion curriculum in the higher educational system.
Obstacles and barriers
- Poor mental health literacy amongst both the general public, as well as amongst experts and professionals. - Underestimation of mental health promotion among medical professionals and the political decision makers. - Absence of the National Mental Health Programme. - Absence of funded Mental Health Promotion Board/ Council that would consistently guide and stimulate national mental health promotion activities.
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Support needed from the European Commission
- Funds for mass media campaign to raise awareness of mental health promotion. - Funds to support continuation of workshops and conferences on the mental health promotion subject. - Funds for building information network for better exchange of information on mental health promotion activities in the country. - Initiative or support from EU authority for introduction of mental health promotion curriculum in national higher education system. - Cooperation between EU countries in implementation of effective mental health promotion programmes. - Supporting national effort in the area of mental health promotion and prevention with EU authority, which would effectively motivate national governments to take political actions towards better organization and regulations of mental health promotion area. Including even distribution of activities for mental health promotion among sectors and disciplines.
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List of participators of the National Workshop
Name and Surname Institution Address Email address Ljubljanska ulica 9, 2000 1 Igor Hrast Society Ozara Maribor [email protected] Grablovičeva ulica 28, 1000 2 Suzana Oreški Society Altra Ljubljana [email protected] 3 Doc.dr. Vesna Švab Society Šent Vrhovci c.XVII/40 [email protected] 4 Mateja Mlakar Society Dam Ilirska 22, 1000 Ljubljana [email protected] 5 Alenka Mavec Society Dam Ilirska 22, 1000 Ljubljana [email protected] 6 Maja Cimerman Society Dam Ilirska 22, 1000 Ljubljana [email protected] Faculty of Social Work, University 8 dr. Mojca Urek Ljubljana Topniška 31, 1000 Ljubljana [email protected] Institute of Public Health of the 9 Doc. dr. Andrej Marušič Republic of Slovenia Trubarjeva 2, 1000 Ljubljana [email protected] Institute of Public Health of the 10 dr. Helena Jeriček Republic of Slovenia Trubarjeva 2, 1000 Ljubljana [email protected] Institute of Public Health of the 12 dr.Tanja Kamin Republic of Slovenia Trubarjeva 2, 1000 Ljubljana [email protected] Institute of Public Health of the 13 Dejan Kozel Republic of Slovenia Trubarjeva 2, 1000 Ljubljana [email protected] Institute of Public Health of the 14 Maja Zorko Republic of Slovenia Trubarjeva 2, 1000 Ljubljana [email protected] Institute of Public Health of the 15 Milan Mirjanič Republic of Slovenia Trubarjeva 2, 1000 Ljubljana [email protected] Regional Institute of 16 Nuša Konec Juričič Health Care Celje Ipavčeva 18, 3000 Celje [email protected] Regional Instittute of Gosposvetska ulica 12, 4000 17 Alenka Hafner Health Care Kranj Kranj [email protected] Ministry of Health of the Republic of 18 Nadja Čobal Slovenia Štefanova 5, 1000 Ljubljana [email protected]
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Ministry of Labour, Family and Social 19 Mag. Borut Grabrijan Affairs Kotnikova 5,1000 Ljubljana [email protected] Centre for the Out- 20 Mag.Urban Groleger patient Psychiatry Studenec 48, 1260 Ljubljana [email protected] Center for Social 21 Mateja Prosen Work Kranj Slovenski trg 1, 4000 Kranj [email protected] Institute of Public Health of the 22 Andreja Drev Republic of Slovenia Trubarjeva 2, 1000 Ljubljana [email protected] Institute of Public Health of the 25 Maja Sever Republic of Slovenia Trubarjeva 2, 1000 Ljubljana [email protected] 27 Maja Šenveter Zavod Emma Trg MDB 14, 1000Ljubljana [email protected] Regional Institute of Health Care Murska Arhitekta Novaka 2/b, 9000 zdenka.verban-buzeti@zzv- 28 Zdenka Verban Buzeti Sobota Murska sobota ms.si 29 Marinka Hribernik Združenje Humana Oldhamska 14, 4000 Kranj [email protected] 30 Nada Šimenc Združenje Humana Oldhamska 14, 4000 Kranj [email protected] Društvo Vezi- Ilirska Tavčarjeva ul. 15, 6250 Ilirska 32 Tina Knap Bistrica Bistrica [email protected] Društvo Vezi- Ilirska Tavčarjeva ul. 15, 6250 Ilirska 33 Mateja Baša Bistrica Bistrica [email protected] 34 Ema Malačič Društvo DAM Ilirska 22, 1000 Ljubljana [email protected] Regional Institute of 35 Petra Šafran Health Care Celje Ipavčeva 18, 3000 Celje [email protected] Institute of Public Health of the 36 mag. Nina Scagnetti Republic of Slovenia Trubarjeva 2, 1000 Ljubljana [email protected] Institute of Public Health of the 37 Mojca Bevc Stankovič Republic of Slovenia Trubarjeva 2, 1000 Ljubljana [email protected] Institute of Public Health of the 38 Helena Koprivnikar Republic of Slovenia Trubarjeva 2, 1000 Ljubljana [email protected] Institute of Public Health of the 40 Laura Šušteršič Zorn Republic of Slovenia Trubarjeva 2, 1000 Ljubljana [email protected] Institute of Public 41 Lucija Demšar Health of the Trubarjeva 2, 1000 Ljubljana [email protected]
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Republic of Slovenia Institute of Public Health of the 42 Matic Meglič Republic of Slovenia Trubarjeva 2, 1000 Ljubljana [email protected] 43 Nataša Usar Student Topniška 31, 1000 Ljubljana 44 Petra Bergelj Student Topniška 31, 1000 Ljubljana 45 Andreja Pučko Student Topniška 31, 1000 Ljubljana Society for Non- violent 46 Klavdija Aničič Communication Miklošičeva 36, 1000 Ljubljana [email protected] Association Feniks- Dobrunjska cesta 28, 1261 47 Zdenko Šibav SI Ljubljana-Dobrunje [email protected] Center for Social 48 Nataša Novak Work Kranj Slovenski trg 1, 4000 Kranj [email protected] Regional Institute of Vojkovo nabrežje 4a, 6000 49 dr. Marina Sučić Vuković Health Care Koper Koper [email protected] 50 Barbara Purkart Society Šent Cigaletova ulica 5, Ljubljana Institute of Public Health of the 51 Mateja Gorenc Republic of Slovenia Trubarjeva 2, 1000 Ljubljana [email protected] Ministry of Labour, Family and Social 52 Tea Obrez Affairs Kotnikova 5,1000 Ljubljana [email protected] Ljubljanska ulica 9, 2000 53 Stanka Končič Society Ozara Maribor Ljubljanska ulica 9, 2000 54 Tanja Velkov Society Ozara Maribor Institute of Public Health of the 55 Katja Pišot Republic of Slovenia Trubarjeva 2, 1000 Ljubljana Institute of Public Health of the 56 Ana Petrovič Republic of Slovenia Trubarjeva 2, 1000 Ljubljana Ministry of Health of the Republic of 57 Mojca Pristavec Đogić Slovenia Office for Drug 58 Nada Glušič Addiction Prevention Resljeva 18, 1000 Ljubljana
198 This report was produced by a contractor for Health & Consumer Protection Directorate General and represents the views of the contractor or author. These views have not been adopted or in any way approved by the Commission and do not necessarily represent the view of the Commission or the Directorate General for Health and Consumer Protection. The European Commission does not guarantee the accuracy of the data included in this study, nor does it accept responsibility for any use made thereof.