Review A blind spot on the global mental health map: a scoping review of 25 years’ development of mental health care for people with severe mental illnesses in central and eastern Europe Petr Winkler*, Dzmitry Krupchanka*, Tessa Roberts, Lucie Kondratova, Vendula Machů, Cyril Höschl, Norman Sartorius, Robert Van Voren, Oleg Aizberg, Istvan Bitter, Arlinda Cerga-Pashoja, Azra Deljkovic, Naim Fanaj, Arunas Germanavicius, Hristo Hinkov, Aram Hovsepyan, Fuad N Ismayilov, Sladana Strkalj Ivezic , Marek Jarema, Vesna Jordanova, Selma Kukić, Nino Makhashvili, Brigita Novak Šarotar, Oksana Plevachuk, Daria Smirnova, Bogdan Ioan Voinescu , Jelena Vrublevska, Graham Thornicroft Just over 25 years have passed since the major sociopolitical changes in central and eastern Europe; our aim was to Lancet Psychiatry 2017 map and analyse the development of mental health-care practice for people with severe mental illnesses in this region Published Online since then. A scoping review was complemented by an expert survey in 24 countries. Mental health-care practice in May 8, 2017 the region differs greatly across as well as within individual countries. National policies often exist but reforms remain http://dx.doi.org/10.1016/ S2215-0366(17)30135-9 mostly in the realm of aspiration. Services are predominantly based in psychiatric hospitals. Decision making on *Contributed equally resource allocation is not transparent, and full economic evaluations of complex interventions and rigorous Department of Social epidemiological studies are lacking. Stigma seems to be higher than in other European countries, but consideration Psychiatry, National Institute of human rights and user involvement are increasing. The region has seen respectable development, which happened of Mental Health, Prague, because of grassroots initiatives supported by international organisations, rather than by systematic implementation Czech Republic (P Winkler PhDr, of government policies. D Krupchanka PhD, L Kondratova MSc, V Machů BSc, Prof C Höschl DrSc); Introduction illnesses. These initiatives have been largely in line with Department of Population 2016 marked a quarter of a century since the dissolution the principles enshrined by the Universal Declaration of Health, London School of of the Soviet Union, which was the symbolic end of Human Rights6 and Alma Ata Declaration,7 and included Hygiene & Tropical Medicine, London, UK (T Roberts MSc, communist rule in central and eastern Europe (CEE). For the UN Principles for the Protection of Persons with A Cerga-Pashoja PhD); Health 8 this Review, CEE is defined as the 23 countries included Mental Illness and later the Convention on the Rights of Service and Population in the UN Eastern European Group1 plus Kosovo, which Persons with Disabilities,9 as well as documents by the Research Department contain approximately 342 million people.2 For most of European Regional Office of WHO, such as the Mental (P Winkler, D Krupchanka, Prof G Thornicroft PhD) and the 20th century, mental health systems in CEE developed Health Declaration and the Mental Health Action Plan Department of Psychological 10,11 under the influence of communist and socialist for Europe. Medicine (V Jordanova MD), ideologies. However, unfavourable news about mental health care Institute of Psychiatry, This ideological influence differed across the region, in CEE has continued to emerge. Mental health care Psychology and Neuroscience, King’s College London, however. Whereas the countries of the former Soviet reforms, so often announced in the region, remain largely London, UK; Institute of Global Union were fully dominated by the Moscow school of unimplemented.4,12 The burden of mental and substance Health, University of Geneva, psychiatry and had restricted contact with the international use disorders in CEE is one of the greatest in the world,13 Geneva, Switzerland community, the countries of southeast and central Europe the prevalence of post-traumatic stress disorder and other (D Krupchanka); Association for the Improvement of Mental were more open to the outside world, and in some of mental health problems seems to be considerably elevated Health Programmes, Geneva, them there were even examples of community-based in countries that have seen recent conflict,14 suicide rates Switzerland care models (eg, in former Yugoslavia).3,4 Despite their are medium to high,15 and alcohol consumption is (Prof N Sartorius PhD); Ilia State heterogeneity, CEE mental health systems shared many excessive.16 Despite some success in deinstitutionalisation University, Tbilisi, Georgia (Prof R Van Voren PhD); 17 similar characteristics. People with severe mental illnesses and changes in legislation, there is evidence of Vytautas Magnus University, were almost exclusively treated in large psychiatric excessively long or unacceptably short stays in hospital18 Kaunas, Lithuania hospitals;4 mental health care systems were organised and and otherwise inadequate services,19 as well as reports of (Prof R Van Voren); Department funded centrally by the government; many branches of the abuse of psychiatry20 and human rights violations in of Psychiatry and Narcology, Belarusian Medical Academy of 19,21–23 psychiatry-related social science, such as social psychiatry, some countries. The allocation of financial resources Postgraduate Education, psychiatric epidemiology, service research, and mental for mental health care is far below the average of the Minsk, Belarus (O Aizberg PhD); health economics, were largely underdeveloped;4 decision European Union (EU)24 and the vast majority of resources Department of Psychiatry and making in general was the subject of ideological rather are spent on outdated institutional systems.25 The lack of Psychotherapy, Semmelweis University, Budapest, Hungary than scientific scrutiny; and neither staff, patients, and non-biological or non-clinical research in general has (Prof I Bitter PhD); Mental their families, nor citizens were regarded as stakeholders.5 been widespread, with CEE countries having the lowest Health Center, Health Care The profound socioeconomic transformations that publication rate per person in Europe in both public Center Pljevlja, Pljevlja, 26 27 Montenegro (A DeljkovicMD); occurred in 1989–91 theoretically enabled individual mental health research and stigma-related research. Mental Health Center, Prizren, countries to start addressing gaps in mental health care However, the evidence is fragmented, and no systematic Kosovo (N Fanaj PhD); Clinic of without the previous ideological constraints. mapping of development of mental health practices for Psychiatry, Faculty of Since then, numerous political initiatives have emerged people with severe mental illnesses has been conducted Medicine, Vilnius University, Vilnius, Lithuania with the aim to improve care for people with mental in the region as a whole. www.thelancet.com/psychiatry Published online May 8, 2017 http://dx.doi.org/10.1016/S2215-0366(17)30135-9 1 Review (Prof A Germanavicius PhD); We aimed to summarise and analyse evidence about evaluations, and service user and family involvement, or National Center for Public the past 25 years of development and the current state of they can be uninformed. Violations of the human rights Health and Analyses, Sofia, mental health care practice in the countries of CEE. We of service users, when occurring within health and Bulgaria (H Hinkov PhD); Department of Psychiatry, intend to help fill an important blind spot on the global community services, suggest failures in mental health Yerevan State Medical mental health map and shed light on future priorities for care practices. High levels of public stigma indicate University, Yerevan, Armenia the region. societal unwillingness to accept people with severe (A Hovsepyan MD); Department of Psychiatry, Azerbaijan mental illnesses as members of the community, which is Medical University, Baku, Methods likely to influence policy, funding, recovery, help-seeking Azerbaijan, and National We considered the countries of CEE in terms of behaviour, service quality, and quality of life for people Mental Health Centre, Baku, four subregions: the eastern European countries of the with these disorders. Azerbaijan (Prof F N Ismayilov DrSc); former Soviet Union (Belarus, Russia, Ukraine, Armenia, We therefore included articles that focused on: Croatian Medical Association, Azerbaijan, Georgia); the Baltic countries of the former mental health services (inpatient, outpatient, primary care, Zagreb, Croatia Soviet Union (Latvia, Lithuania, Estonia); the central community and residential services for people with severe (Prof S Strkalj Ivezic DrSc); European countries of the former eastern bloc mental illnesses); epidemiological studies of population Croatian Society for Clinical Psychiatry, Zagreb, Croatia (Czech Republic, Hungary, Poland, Slovakia); and the mental health; policy and legislation; involvement of user (Prof S Strkalj Ivezic); southeast European countries (Albania, Bulgaria, and family members in service delivery and planning; 3rd Department of Psychiatry, Romania, Moldova, Bosnia and Herzegovina, Croatia, resource availability and allocation, and economic Institute of Psychiatry and Kosovo, Macedonia, Montenegro, Serbia, Slovenia). evaluations of complex interventions; quality and duration Neurology, Warszawa, Poland (M Jarema PhD); Mental Health We were interested in assessing developments in mental of training for mental health specialists (including the Project in Bosnia and health practice in