Overview Taiwanese Journal of Psychiatry (Taipei) Vol. 32 No. 3 2018 • 173 •

Mental Health Care in Spain: From Psychiatric Reform to Community-based Care within the “State of Autonomies”

Juan D. Molina, M.D.1,2,3, Manuel Durán-Cutilla, M.D.3,4, Yolanda Pérez-Ros, M.D.1,Gabriel Rubio, M.D.2,5,6,7, Francisco López-Muñoz, M.D.6,7,8,9*

Nowadays Spain where is a country that lives in democracy, is integrated into the European Union and with a universal coverage and free healthcare services. Being carried out from a community model, mental health care has been coordi- nated with social services and the antidrug agency network. But until now the process has been complex. In this overview, the authors are describing the process of psychiatric reform since the late 1970s, when was coinciding with the end of the dictatorship, and the creation of the “State of Autonomies.” As in this peculiarity of the territorial ordination of the country, Spain has had mental health plans of each of the 19 autonomous entities. As an example, we are illustrating two the mental health organizations – one of the richest autonomous communities, Ma- drid, and one of the poorest autonomous communities, Andalusia – to explain and analyze how they have applied the community model and coordination with other services.

Key words: State of Autonomies, psychiatric care system, Madrid, Andalusia (Taiwanese Journal of Psychiatry [Taipei] 2018; 32: 173-187)

Sea; to the north and northeast by France, Andorra, Introduction and the Bay of Biscay; as well as to the west and northwest by Portugal and the Atlantic Ocean. Spain is mostly located on the Iberian Spanish territory also includes two large archi- Peninsula in Europe. The country’s mainland is pelagoes, the Balearic Islands in the Mediterranean bordered to the south and east by the Mediterranean Sea and the Canary Islands off the African Atlantic

1 Faculty of Health Sciences, University Francisco de Vitoria (UFV), Madrid, Spain, 2 Department of Psychiatry, Hospital Universi- tario 12 de Octubre, Madrid, Spain, 3 Biomedical Research Center for Mental Health Network (CIBERSAM), Madrid, Spain, 4 Department of Child and Adolescent Psychiatry, Hospital General Universitario Gregorio Marañón, Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain, 5 Department of Psychiatry, University Complutense (UCM), Madrid, Spain, 6 Hospital 12 de Octubre Research Institute (i+12), Madrid, Spain, 7 Thematic Network for Cooperative Health Research (RETICS), Addictive Disorders Network, Health Institute Carlos III, MICINN and FEDER, Madrid, Spain, 8 Faculty of Health Sciences, University Ca- milo José Cela (UCJC), Madrid, Spain, 9 Portucalense Institute of Neuropsychology and Cognitive and Behavioural Neurosciences (INPP), Portucalense University, Porto, Portugal Received: July 19, 2018, accepted: July 22, 2018 *Corresponding author. C/ Castillo de Alarcón 49, 28692 Villanueva de la Cañada, Madrid, Spain. E-mails: Francisco López-Muñoz <fl [email protected]> or [email protected]> • 174 • MH Care in Spain

coast, two cities, Ceuta and Melilla, on the African (GDP) and 16th largest by purchasing power par- mainland. With an area of 505,990 km2 (195,360 ity. It is a member of the United Nations (UN), the sq. mi), Spain is the largest country in Southern European Union (EU), the Eurozone, the Council Europe, the second largest country in Western of Europe (CoE), the Organization of Ibero- Europe and the European Union, and the fourth American States (OEI), the Union for the largest country in the European continent. Mediterranean, the North Atlantic Treaty By population, Spain is the sixth largest in Organization (NATO), the Organization for Europe and the fi fth in the European Union. Economic Co-operation and Development Spain’s capital and largest city is Madrid; other (OECD), the Organization for Security and Co- major urban areas include Barcelona, Valencia, operation in Europe (OSCE), the Schengen Area, Seville, Malaga, and Bilbao. Spain’s autonomous the World Trade Organization (WTO), and many communities (CCAAs, comunidad autónoma) are other international organizations. the fi rst level administrative divisions of the coun- try. They were created after the current constitu- The Particularities tion came into effect (in 1978) in recognition of of the Spanish State: the right to self-government of the “nationalities the Constitutional Model and regions of Spain.” Along with the 17 CCAAs, of a State of Autonomies two autonomous cities which are also fi rst-order CCAA territorial divisions – Ceuta and Melilla Constitution and legal system (www.recursostic.educacion.es/secundaria/edad/ Spain is a parliamentary monarchy with a 3esohistoria/para_pdf/quincena12.pdf) [1]. civil law system which is rooted in Roman law Native Spaniards make up 88% of the total and whose main characteristic is that its central population of Spain. After the birth rate was principles are codifi ed into a referable system, plunged in the 1980s and Spain’s population which is the predominant source of law. Spain is a growth rate was dropped, the population was member state of the EU. The Spanish constitution again trended upward, based initially on the return (1978) creates three levels of government – cen- of many Spaniards who had emigrated to other tral, 17 CCAAs, and municipal governments European countries during the 1970s, and more (Article 137) [4]. recently, fueled by large numbers of immigrants Article 43 of the 1978 Spanish constitution who make up 12% of the population. The immi- establishes the rights to health protection and grants originate mainly in Latin America (39%), healthcare for all citizens [5]. Regulation of the North Africa (16%), Eastern Europe (15%), and actions to enable exercise of the rights to health Sub-Saharan Africa (4%) (www.ine.es/prensa/ protection are set out in a set of regulations with cp_2017_p.pdf) [2]. the rank of acts – general health act (1986), act on Spain is a secular parliamentary democracy the cohesion and quality of the national health and constitutional monarchy (www.congreso.es/ system (2003), act on guarantees and rational use consti/constitucion/indice/titulos/articulos.jsp?) of medicines (2006), general health act (2011), as [3]. It is a major developed country and a high well as royal decree-law on emergency measures income country, with the world’s 14th largest for the sustainability of the national health system economy by nominal gross domestic product and improvement of quality and safety (2012). Molina JD, Durán-Cutilla M, Pérez-Ros Y, et al. • 175 •

Five fundamental principles and criteria en- The general health act (1985) establishes co- abling the exercise of the rights are: ordination mechanisms, such as the interterritorial • Public funding, universal coverage, and free council and recognizes the rôle of the NHS in de- healthcare services at the time of use. termining goals or common minimum objectives • Defi ned rights and duties, for citizens and pub- in promotion, prevention, protection and health lic authorities. care, as well as the general establishment of mini- • Political decentralization of healthcare de- mum, basic and common criteria for evaluating volved to the CCAAs. the effectiveness, and performance of programs, • Provision of comprehensive healthcare, striv- health centers and services [7]. ing to attain high levels of quality duly evalu- ated and controlled. Mental Health in the Spanish • Integration of the different public structures National Health Strategy and health services, under the national health system. In 2006, the national health strategy was ap- proved in a consensual manner by all the CCAAs, National health system and a common framework was established for the Spain has a publicly funded health system. improvement of mental health care and for the ad- Publicly funded health care is fi nanced with gen- vances in the implementation of the community eral revenue raised through state, provincial and mental health care model in an equitable way in municipal taxation. Therefore, the Spanish state the country (www.msssi.gob.es/organizacion/ sns/ grants its people the rights to health services by planCalidadSNS/docs/saludmental/MentalHealth relying mostly on the public sector (71%). Hence, StrategySpanishNationalHS.pdf) [8]. this system of fi nancing healthcare results in a But in this sense, the reality of our country universal national health service: every Spanish differs from the situation in other states in the EU. citizen is guaranteed healthcare, as the costs are Although with common objectives, so many covered mostly by the state. The remaining 29% is forms of mental health management coexist as privately funded through “voluntary” payments CCAA. The care processes are different, the name (www.msssi.gob.es) [6]. of the services, their function, their location, and In the Spanish state, as a consequence of the their reception protocols are diverse. The evolu- general health act (1985), the national health sys- tion of them since the psychiatric reform has been tem (NHS) is decentralized, therefore, the compe- varied. They share objectives and a common vi- tences in health matters are transferred to 17 sion, but the way they are developed is uneven. CCAAs, and those of the cities autonomous of Ceuta and Melilla under the coverage of the nation- Spanish psychiatric reform al institute of sanitary management (INGESA), de- The social circumstances that occurred in pendent on the ministry. The NHS is confi gured as Spain in the mid-1960s, with some forward-think- a coordinated set of health services from the central ing cultural trends, constituted the germ of the government administration and the CCAA that in- subsequent psychiatric reform against closed in- tegrates all healthcare functions and benefi ts for stitutions. That included the so-called movement which public authorities are legally responsible. of the “anti-psychiatry.” • 176 • MH Care in Spain

As soon as the end of the Dictator Francisco • Its late initiation after other countries allowed Franco Bahamonde’s regime was approaching, to know the errors and problems of other re- the struggle to change the paradigm of mental forms begun much earlier [11]. That helped in- health care had intensifi ed until the mid-1970s. clude starting the development of the services Some mental health institutions were pioneers of of rehabilitation and social reintegration neces- this deinstitutionalization process (the Mental sary for an adequate integral attention of the Institute of La Santa Cruz, the Psychiatric Hospital mental patient’s problems, and looking for the of Conxo and the Psychiatric Hospital of Oviedo) necessary coordination with the social services (www.pestadistico.inteligenciadegestion.msssi. (LGS, Art. 20) [12]. es/) [9]. One of the most important milestones of the After the Dictator Franco’s death in 1975, the reform is the integration of all mental health ser- political transition to democracy began in Spain. vices into specialized care in a single network in The fi rst local elections took place in 1979, mak- each health area, in connection with primary care ing possible for cities such as Barcelona, Madrid, (gateway to the system), and coordination with lo- Valencia, or Seville to join this movement and cal services of social attention. In addition, there subsequently some of the newborn CCAAs began is a change in the care organization with objective to take the lead. being to shift the focus of mental health care to This psychiatric reform was conceived in six community teams: services are now called “men- stages. Starting from psychiatry centralized in tal health services” instead of psychiatric services. asylum, it would be necessary to generate a moti- The community is considered not only as a user, vation for such reform. The next stage would fo- but as an active agent in the planning-programing cus on seeking political initiatives that promote it process and as a generator of resources that must and thus unlock the system based on institutional- be in line with the specifi cally technical ones. ization to develop a progressive implementation Specifi c public health criteria are assumed, such of community services. While health care focused as community diagnosis, positive discrimination, on the community model is generalized, programs work with populations at risk, continuity of care, would be developed to fi nally reach the consolida- and consideration of hospitalization as an excep- tion of the model [10]. tional moment of treatment. One of the remarkable characteristics of the The development of the reform has been tre- psychiatric reform in Spain is that it coincides in mendously unequal, due to the characteristics of time with three favorable factors: the Spanish regional map and the mental health • As we mentioned before, it took place in a con- subsystem (competences, transfer calendar, re- text of transformation of society, after a civil gional political wills, professional commitment): war (1936-39) and 40 years of dictatorship, that A “fast track” process was implemented in “his- devastated the intellectual, scientifi c and tech- torical CCAAs” with health care responsibility nical landscape, especially the psychiatric one. transferred to Catalonia in 1981, Andalusia in • It was carried out within the reform of social 1984, the Basque country and Valencia in 1987, welfare benefi ts and the general health act Galicia and Navarra in 1990, as well as the Canary (LGS, 1986), which established an NHS, uni- Islands in 1994. A “slow process” was used else- versal and decentralized in the CCAA. where, so it was not until 2002 that the process Molina JD, Durán-Cutilla M, Pérez-Ros Y, et al. • 177 •

was completed [11]. It should also be pointed out Social and health services coordination the insuffi ciency of resources for attention to The attention to mental disorders requires in- chronicity and the precariousness of community terventions that are not only health or medical, but programs (continuity of care, attention in crisis, have a social implication (e.g. psychosocial reha- prevention, etc.). bilitation services, supported housing, home care, What objectives have been achieved in these benefi ts). Throughout the nation, there are differ- years of psychiatric reform? On the one hand, a ent mental health care settings with different de- unifi ed service portfolio has been created that nominations that are not always the responsibility guarantees preventive, care and rehabilitation of the health ministries of the different CCAAs. mental health services. Likewise, an NHS mental As in many other European countries, the di- health strategy has been launched with participa- versity of denominations, and functional depen- tion committees that give cohesion and power to dence of this type of services are high among the the community model. They have been imple- different CCAAs [14]. In some cases, there are mented in psychiatric units of general hospitals, differences in the extent to which health and so- acute care units, and emergency 24 hours. cial services are integrated. Some of these servic- The number of beds in monographic hospi- es depend on the ministry of health or health and tals has been reduced signifi cantly. There has also welfare, but in many cases, this does not happen. been an increase in the quality of both structures Sometimes they are responsibility of the social and facilities, clinical practice and novel experi- welfare ministries and are managed through the ences in the management of services. A unifi ed municipal social services by 486 community men- mental health network has been created by pass- tal health centers across the country or arranged ing all existing services to be the responsibility of with private entities. On other occasions, they de- a single administrator, initially INSALUD, in pend on grants to non-profi t entities, or public so- many cases, and as health competencies are de- cial-health foundations [15]. centralized, the CCAA themselves. Creation of an The communication and coordination be- extensive network of mental health centers, en- tween the health and social or socio-health are not hancing available community outpatient resourc- always close. Shared information systems are es and multidisciplinary teams and incorporation rarely available, and the complex range of govern- of other professions (psychology, nursing, social ment structures (regional, provincial, county and work, etc.) [13]. A strong movement of family local) and the absence of a specifi c department for members and users has developed, and special at- mental health within the Spanish ministry of tention has been paid to the accredited speciality health contribute to multiply coordination prob- trainings of doctors, psychologists, and nurses. lems. Regardless of whether mental health ser- But according to the latest data published, Spain vices and social services are coordinated through has 4,862 psychiatrists (in 2016). The ratio is an intersectoral agency, as in Andalusia or operate 10.46 per 100,000 inhabitants), which is one of independently as in Catalonia or Madrid, the coor- the lowest ratios among countries of the European dination diffi culties are still present. But in differ- Union (www.appsso.eurostat.ec.europa.eu/nui/ ent forums, and in normative documents such as submitViewTableAction.do). the mental health strategy of the NHS or in au- tonomous mental health plans, the shortcomings • 178 • MH Care in Spain

in this area are recognized, and work is done to (CISNS) in December 2006 (www.msssi.gob.es/ improve this situation. organizacion/consejoInterterri/docs/actividad- Cisns06.pdf) [19]. The monitoring and evaluation Involvement of other areas committee (CSE) has worked on the implementa- The application of the mental health commu- tion and improvement. This committee brings to- nity model implies the need for intervention from gether the institutional committee (IC) and the other areas that in the Spanish state are adminis- technical committee (TC) in preparing the strate- tered by non-health administrations [16]. This is gy in 2006. the case of the management of welfare benefi ts, The main principles and values of the com- medical care for prisoners, the promotion of em- munity model of mental health care set out in the ployment or housing needs. In the autonomous fi rst edition of this strategy and on which the area, promotion and prevention sometimes de- strategy is based, supported by the general health pend on departments differentiated from those act (1986) and by the ministerial commission for dedicated to health care. psychiatric reform (1985) [7] include autonomy (ability of the service to respect and promote the Mental Health Strategy independence and self-suffi ciency of individu- of the Spanish National als), continuity (ability of the care-providing net- Health Strategy work to provide treatment, rehabilitation, care and support on an uninterrupted basis on a life- In addition to setting common goals, the long basis known as longitudinal continuity, and mental health strategy has provided a space for coherently, among the services of which they are coordination and intercommunication in mental comprised meaning transversal continuity), ac- health among the different agents involved. It has cessibility (ability of a service to provide care to a scientifi c committee in which 19 scientifi c soci- the patients and the family members thereof when eties and two entities of relatives and persons with and where they need it), comprehensiveness (im- mental illness participate. It also has an institu- plementation of all the basic facilities of a service tional committee in which each one of the CCAAs in each health district). Recognition and realiza- participates with a delegate, normally through its tion of the right to receive care within the full departments dedicated to health care in mental range of needs caused by the mental disorder in health. It also includes the home offi ce (holds the question), equity (distribution of the health and competences in penitentiary matters), the institute social resources of adequate quality and propor- for the elderly and social services, and different tional in quantity to the needs of the population in departments of the ministry of health, social ser- accordance with explicit, rational criteria), per- vices and equality (information systems, quality, sonal recovery (includes the recovery of health in public health, action plan on drugs, woman affairs the strict sense and of the consciousness of citi- offi ce) (www.msssi.gob.es/en/organizacion/sns/ zenship despite the disability caused by the disor- docs/ Spanish_National_Health_System.pdf) [17, der in question), accountability (recognition on 18]. the part of the health institutions of their respon- The mental health strategy was approved by sibility to patients, family members and the com- the national health system inter-territorial council munity), quality (characteristic of the services Molina JD, Durán-Cutilla M, Pérez-Ros Y, et al. • 179 •

which is aimed at continuously heightening the hand, debts and housing payment problems lead probability of achieving the desired outcomes by to an increased risk of suffering from common using tested procedures). mental disorders [21]. The preparation of the strategy document In Spain, the report of the Spanish society of has been based on the 2005 Helsinki Declaration public health and health administration (SESPAS) and Action Plan which was endorsed by all mem- (www.sespas.es/informe2002/cap15.pdf ) [22, 23] ber states of the World Health Organization of 2014 states that, according to the IMPACT (WHO) European Region, and European com- study, the most common mental disorders have mitment, which is in line with European policies increased signifi cantly in primary care (PC) con- [20] in this area as settled in the European Green sultations between 2006 and 2010: 19.4% in ma- Paper as response to the Declaration and a fur- jor depressive disorders, 8.4% in generalized ther WHO policy and practice report. When es- anxiety disorders or 7.0% for disorders of alcohol tablishing priority contents, Spain has consid- dependence or abuse. There is also a considerable ered the latest recommendations of the committee increase in the consumption of psychotropic of ministers to member states of the EU regard- drugs, especially antidepressants, whose con- ing the need to implement measures to reduce sumption was increased by around 10% in four social discrimination of the mentally ill, encour- years, between 2009 and 2012. age the promotion of the physical health of the The SESPAS report shows an important con- mentally ill and the mental health of the popula- troversy regarding the evolution of mortality due tion, encourage training in the fi eld of mental to suicide in the period of crisis in Spain. For ex- health of non-health professionals (social work- ample, in the CCAA of Andalusia, the adjusted ers, social leaders, people from the area of citi- suicide rates obtained from the statistics of deaths zen security and civil protection, teachers, etc.) according to the cause of death of the national sta- and fi nally to generate social awareness about tistics institute (INE) have varied little between those negative consequences derived from the 2002 and 2012 without appreciating a signifi cant mental disorder on which we can intervene ef- increase, although in men the values of the fectively and effi ciently from areas that are not Andalusian series are considerably larger than specifi cally sanitary. relative to the nation’s global.

Economic Crisis and The Organization of Mental Mental Health in Spain Health Care System Explained by Two Very Different One of the characteristics of any economic Autonomous Communities: crisis is the empowerment of socio-economic fac- Madrid and Andalusia tors that are associated with poorer mental health (poverty, low educational levels, fragmentation To try to explain the organization of mental and social inequality or unemployment). Thus, health care within the state of the autonomies of people in situations of unemployment or poverty Spain, we will take as example two CCAAs with present a risk, greater than the general population, differentiated characteristics. First of all, one of of depression, alcoholism or suicide. On the other the richest communities, with a high density of • 180 • MH Care in Spain

population and that includes the country’s capital, Madrid in accordance with the general health zon- Madrid. Second, we will explain how to organize ing. This makes possible a greater accessibility to mental health management in another autono- the services and a guarantee in the continuity of mous community, Andalusia, which is one of the the sanitary and social health care throughout the largest, but also with a per capita income lower illness process. than many other regions. There are similarities Outpatient mental health services are the ac- and differences between the two, especially in the cess route to services by the population. Except in integration and coordination of social services and cases of urgent need for care, they are usually anti-drug agencies with the mental health network. through the primary mental health centers (CSM). These services are distributed throughout the Autonomous Community of health districts of the community of Madrid with Madrid one or more points of consultation, covering both the adult population, as well as children and ado- The CCAA of Madrid is located in the center lescents care. of the peninsula, and it is the third most populous Based on a clinical evaluation by a qualifi ed in Spain with 6,549,979 (2018) inhabitants. Its professional, a treatment plan for the disorder is capital is the city of Madrid, which is also the established, which may include ambulatory care, capital of the country. day hospitalization for both adults and children / It is also the most densely populated CCAA. adolescents or psychiatric hospitalization for chil- Madrid’s economy is of roughly equal size to dren, adolescents and adults. Throughout the care Spain’s fi rst, Catalonia. Madrid thus has the high- process, depending on the need of the clinical sit- est GDP per capita in the country (32,723 euros) uation, these modes of attention can be used (www.comunidad.madrid/publicacion/1354547 interchangeably. 577692) [24], far ahead of the largest Spanish re- For those patients who need it, a specifi c pro- gion, Andalusia, and was the main receptor of for- gram of rehabilitation and social reintegration is eign investment in the country. The community available in each district and health area. It has ranks 34th amongst all European regions (evalu- specifi c assistance units such as day centers, reha- ated in 2002), and 50th among the most competi- bilitation centers or social clubs. There is an im- tive cities-regions worldwide (www.madrid.org/ portant collaboration of the CCAA of Madrid de- cs/Satellite?blobcol=urldata&blobheader=applica partment of social services, which has a network tion%2Fpdf&blobheadername1=Content-) [25], of rehabilitation resources coordinated with men- ahead of Barcelona and Valencia. Its citizens have tal health services. diverse origins, and Madrid is the province with Urgent care is covered in two ways. On the the highest number of residents born outside its one hand by the mental health outpatient services territory and with the largest foreign population in their normal operating hours and by the emer- (13.32%). gency services of the reference hospitals of the health area, where there is always specialized per- Structure and resources in mental health sonnel 24 hours a day. The set of mental health The mental health services network provides care resources is part of an integrated network that specialized care to the population of the CCAA of allows the fl ow of patients between the different Molina JD, Durán-Cutilla M, Pérez-Ros Y, et al. • 181 •

Figure 1. Outline of the Mental Health Network and its relations with social health resources in the Autonomous Community of Madrid. Source: Mental Health Strategic Plan for the Community of Madrid 2018-2020

units and programs, both outpatient and partial Creation of a “regional mental health and complete hospitalization [26]. coordination offi ce” In recent years there has been a process of It was created by virtue of Decree 1/2002, of moving mental health services to hospital. But un- January 17, 2002, which established the organic til that moment, the psychiatric and mental health structure of the ministry of health of the commu- care devices were structured at two levels – care nity of Madrid. The function of the coordination unit and resources shared by various health care offi ce is to provide scientifi c and technical support units in matters of mental health assistance to the Each functional care unit should organize the Madrid health service. It does so through the func- structure and mechanisms necessary to ensure ad- tions of advising, planning and evaluating the ser- equate coordination with the centers and social vices with the development of standards and es- care resources dependent on the public social care tablishment and monitoring of indicators common network for people with severe and lasting mental to the entire system. All this must be done taking illnesses of the ministry of family and social into account the current mental health plan and the affairs. guidelines that the health authority determines at • 182 • MH Care in Spain

all times. The operation of the regional mental ernment of Spain (www.comunidad. madrid/sites/ health coordination offi ce is carried out with its default/ fi les/doc/sanidad/asis/12_junio_plan_de_ own team with the support of expert committees. salud_mental_2018-2020.pdf) [28]. One of the In the Mental Health Strategic Plan (2010- main objectives of the successive mental health 2014) (www.comunidad.madrid/publicacion/1142 plans is to maintain the global coordination be- 669081933) [27] one of its main objectives was tween the health network of mental health servic- the rational use of psychotropic drugs through the es and the public network of “Social Care for development of strategies that increase the quali- People with Severe and Lasting Mental Illness” of ty, effectiveness and safety of psychopharmaco- the regional ministry of social policies and family. logical treatments. In addition, the pursuit of a It is intended in this way to achieve comprehen- signifi cant number of objectives of the Plan was sive health care for people with serious mental pursued. Especially those related to organizational disorders. changes in the mental health care structure, with full integration into the general health network. Community-based long-term mental The “Prevention of Suicide in the Community of health care plan (PCC) Madrid” Program was also promoted and the It is aimed at the care of patients with severe foundations for the “Fight against Stigma and mental illness (SMI) and is organized as a multi- Discrimination associated with people with professional and longitudinal care process for pa- Mental Illness” were established. tients who present deterioration, defi cits or dis- ability in relation to their mental illness. These Coordination with social services patients require, or are expected to require, con- In addition, the health resources network of tinuous multidisciplinary care and/or the simulta- mental health is coordinated with specifi c resourc- neous or successive use of several health and so- es for the treatment of addiction disorders of the cial resource units. Among its main objectives is anti-drug agency and the Madrid Health Institute to overcome or reduce the symptoms and disabili- of Madrid City Council. ties of these patients and reach the highest possi- The public social network for people with ble level of personal autonomy and social mental illness had, at the beginning of 2015, a to- participation. tal of 6,064 places in 204 centers and specialized The adaptation of resources to the needs of social care resources. These resources work to the patients, through the improvement in coordi- support the care, rehabilitation and integration of nation both intra and inter-institutional, has led to people with severe and lasting mental illness. the growth of the number of discharges of patients They work in close coordination and in a comple- to the community. But the cumulative “bottleneck mentary way with the health network of attention phenomenon” has not been completely eliminated to mental health, with the aim of ensuring com- over the years and the addition to the waiting list prehensive care. exceeds the number of discharges. This lag can be Some of these resources are managed by the estimated at an average of 18 patients per year. health service of the CCAA of Madrid and others The development of the social care network, have administrative dependency of the Ministry with the sustained growth of resources, and the of Social Policies and Family of the central gov- creation of “socio-community support teams” Molina JD, Durán-Cutilla M, Pérez-Ros Y, et al. • 183 •

(EASC), in coordination with the psychosocial tion in the CCAA was established at different lev- care centers (PCCs) of the CSMs, has meant a re- els, as opposed to the model before the psychiatric inforcement for the continuity of care and the reform of a single institution, and includes the fol- home care. Unfortunately, after more than 20 lowing units: years with hardly any increase in the number of professionals assigned to the social teams of the Community mental health units (USMC) CSMs, there is an overfl ow situation. This is hav- They are the basic units of specialized atten- ing a negative impact on the coordination of com- tion to mental health, constituting their fi rst level prehensive care of the cases and creates a diffi - of attention. The rest of the mental health care culty for the adequate optimization of the Social units of the USMC are coordinated, providing Care Network centers and resources [29]. comprehensive care to patients within their popu- lation in ambulatory or domiciliary. Autonomous Community of Andalusia Child and adolescent mental health units (USMI-J): Andalusia is located in southern Spain. It is They provide specialized care, both in the the most populous (8,379,820, in 2017) and the outpatient setting and in full or partial hospitaliza- second largest in area of the CCAA in the country tion, to the child and adolescent population under (Institute of Statistics and Cartography of age, derived from the community mental health Andalusia) but the GDP per capita of Andalusia units in their sphere of infl uence. (17,651 euros) remains the second lowest in Spain. The population is concentrated, above all, in the Mental health rehabilitation units provincial capitals and along the coasts, but is ag- (URSM): ing although the process of immigration is coun- Its objective is the recovery of social skills tering the inversion of the population pyramid. and the social and labor reintegration of patients with severe mental disorder in an outpatient set- Organization of mental health care in ting. They are derived from their USMC. Andalusia Specialized care for people with mental Mental health day hospitals (HDSM): health problems is carried out through a network They are mental health care units, confi gured of health units, distributed throughout the CCAA as intermediate resources between the UMSC and and structured, in 15 mental health areas, whose the mental health hospitalization units. They pro- portfolio of services includes ambulatory and vide specialized care, in a day hospitalization re- home care, day care programs and hospitalization. gime, to patients referred from the community After Decree 77/2008 [30], of administrative and mental health units in their area of infl uence. functional management of mental health services in the scope of the Andalusian Health Service, the Inpatients units in general hospitals mental health units are organized in clinical man- (UHSM): agement units depending on the different hospital The inpatients units provide specialized care areas or areas of health management the organiza- in full hospitalization and short stay. • 184 • MH Care in Spain

Figure 2. Outline of the Mental Health Network and its relations with social health resources in Andalusia. EBAP, Primary Care Unit; USMC, Community Mental Health Unit; UHSM, Psychiatry Inpatient Unit USMI-J, Child and Adolescent Mental Health Unit; URSM, Mental Health Rehabilitation Unit; HDSM, Mental Health Day Hospital; CTSM: Mental Health Therapeutic Community; UTS, Social Work Unit; FAISEM: Andalusian Public Foundation for the Social Integration of People with Mental Illness. Source: NHS Primary Care Information System (2009)

Mental health therapeutic communities Social support (CTSM): In Andalusia, social support resources for They are mental health care units aimed at people with SMIs are managed by the Andalusian the intensive treatment of patients with severe Public Foundation for the Social Integration of mental illness, derived from the community men- People with Mental Illness (FAISEM). This tal health units of their sphere of infl uence, which public institution was created in 1993 and is require specialized mental health care, under full linked to the Ministries of Health, Equality and or partial hospitalization, half stay. Social Welfare, Employment and Economy and Molina JD, Durán-Cutilla M, Pérez-Ros Y, et al. • 185 •

Finance and fi nanced through the budgets of the grams and ways of applying the strategies as dif- CCAA. ferent regions has the nation Its objective is to develop programs that are Among the diffi culties in carrying out the oriented to cover the diffi culties or shortcomings mental health strategies at the national level and in of people with serious mental disorders. They fo- the CCAA, a series of factors appear. First, the cus on accommodation, employment, daily activ- history and the peculiar circumstances of each ity and social relations (residence, occupational- community. Second, the resistance to change of occupational, leisure and free time, promotion and some mental health professionals. support for tutelary entities and the associative The “political will” of the governments of movement, and care for people with SMIs in situ- the CCAA in their relationship with the central ation of marginalization/homeless and prison pop- government of the nation, with the ideology of the ulation with SMIs. They are also in charge of so- party in government and the pressure exerted by cial support activities in coordination with public the associative movement mental health services and with the different ser- Perhaps due to the economic crisis and the vice networks existing in the autonomous com- diffi cult coordination between autonomous com- munity (social services, employment, education, munities, the new update of the strategy (assumed etc.) [31]. for the period 2015-2019) (www.msssi.gob.es/ gabinete/notasPrensa.do?id=3789) [33] that will Health care for drug users establish the priorities for mental health for the In Andalusia, the general directorate under next fi ve years is still pending ratifi cation. the Ministry of Equality and Social Welfare has Specifi cally, the new national strategy for mental been assigned the powers relating to action in health introduces the fi ght against suicide as one the field of drug addiction. Since 2002, there of the main strategic lines, with the aim of reduc- was a joint action protocol between the commu- ing this behavior with efforts in prevention and nity mental health Units dependent on the early detection. It includes other lines of action Andalusian health service and the outpatient that involve a novelty, such as attention and inter- drug addiction treatment centers, which was re- vention with families, improvement of informa- viewed and updated during the validity period tion systems, autonomy and patient rights or the of the II comprehensive mental health plan of participation of social agents and institutions. Andalusia 2008-2012, and continued in the III comprehensive mental health plan in Andalusia Acknowledgement 2016-2020 [32]. All authors declare no confl icts of interest in Conclusion writing this article.

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