LITERATURE REVIEW Joint Action on Mental Health and Well-being TOWARDS COMMUNITY-BASED AND SOCIALLY INCLUSIVE MENTAL HEALTH CARE Situation analysis and recommendations for action MENTAL HEALTH AND WELLBEING REPORT | 1 Co-funded by the European Union AUTHORSHIP JM Caldas Almeida, Pedro Mateus and Gina Tomé coordinated the preparation of the Report with the participation of: Heinz Katschnig (Austria) Hristo Hinkov (Bulgaria) Indrek Sooniste (Estonia) Lajos Simon (Hungary) Angelo Fioritti (Italy) Aideen McDonnell, Terry Madden, Eithne O’Donnell (Ireland) Álvaro de Carvalho, Miguel Xavier, Graça Cardoso (Portugal) José Rodriguez, Isabel Saiz (Spain) Helen Killaspy (UK) Guadalupe Morales (ENUSP) Alfonso Montero, Kim Japing (ESN) John Saunders (EUFAMI) Pedro Montellano (GAMIAN) Maria Nyman, Josée Van Remoortel (MHE). Heinz Katschnig, Helen Killaspy, Benedetto Saraceno and Miguel Xavier gave important contributions to the structuring of the Report and the development of the questionnaires. Chiara Samele coordinated the literature review and reviewed the Report at various stages of development. ISBN: 978-989-98576-3-6 The views expressed in this report are those of the contributors and do not necessarily represent those of Government Ministries or employers. ACKNOWLEDGEMENTS We would like to thank all the National Networks members that participated in the data collection, specially to: Austria - Alexander Grabenhofer-Eggerth, Joachim Hagleitner, Gisela Hagmair, Herbert Heintz, Christian Horvath, Günter Klug, Susanna Krainz, Edwin Ladinser, Joy Ladurner, Ullrich Meise, Georg Psota, Sophie Sagerschnig, Werner Schöny, Anton Sinabell, Sonja Valady Bulgaria - Vladimir Nakov, Zahari Zarkov Hungary - Zsofia Lehoczky Italy - Antonella Piazza Spain - Mª Jesús San Pío and Institutional and Technical Committees of the National Strategy on Mental Health, its scientific coordinators, and the national expert group. INDEX 01 EXECUTIVE SUMMARY 05 I. INTRODUCTION 05 II. METHODS 11 III. LITERATURE REVIEW • Historical background to the transition from institutional to community MH services • Successful closures of psychiatric hospitals • Case example - Italy • Legislating deinstitutionalisation • Outcomes of Italian psychiatric reform • Impact on the family • Current situation • Case example - England • Case Example - Spain • Creation of community based services • Community care models and effectiveness • Supportive housing and residential care • Cost benefits and cost-effectiveness of community based mental healthcare • Challenges to the closure of psychiatric hospitals and development of community mental health services • Facilitators and strategies to closures of psychiatric hospitals and development of community alternatives • Social inclusion and transition • Ingredients of success • Health policy implications 35 IV. TRANSITION FROM INSTITUTIONAL CARE TO COMMUNITY-BASED CARE IN EU 1. Mental health services reforms 2. Mental health policy, plans and legislation 3. Mental health services 4. Human Resources in EU countries 5. Financial resources in EU countries 6. Human rights and compulsory treatment 7. Support towards social inclusion for people with mental health problems 8. Representation of users and carers 83 V. ACHIEVEMENTS, BARRIERS AND FACILITATING FACTORS 90 VI. SWOT ANALYSIS 92 VII. PAST AND UNDERGOING EUROPEAN PROJECTS RELATED WITH TRANSITION FROM INSTITUTIONAL TO COMMUNITY BASED CARE 101 VIII. KEY FINDINGS AND POLICY RECOMMENDATIONS • Benefits of community-based mental health care • Further developments and advancements are needed • Key findings • Policy recommendations 1. Generating political commitment for mental health system development 2. Developing or updating mental health policies and legislation 3. Mobilising the shift from mental hospitals/psychiatric hospitals to a system based on general hospitals and community mental health services 4. Improve the use and effectiveness of mechanisms to monitor the implementation of mental health reform 5. Promote the use of relevant EU instruments 111 IX. ANNEXES Annex 1. Swot analysis for 9 wp5 participanting countries Annex 2. Good practices EXECUTIVE SUMMARY EXECUTIVE SUMMARY Community-based mental health care is a well-recognized approach to addressing effectively and efficiently the challenges associated with the burden of mental disorders and promotion of mental health in the population. A strategy to shift away from a traditional model of care based on large psychiatric institutions to more community-based services is therefore essential. There are today many reasons why the development of community-based mental health services is central to improving mental health systems. Community care contributes to improved access to services, enables people with mental disorders to maintain family relationships, friendships, and employment while receiving treatment, so facilitating early treatment and psychosocial rehabilitation1. Community mental health care is associated with continuity of care, greater user satisfaction, increased adherence to treatment, better protection of human rights, and prevention of stigmatisation2. Community mental health care aids the establishment of a structured collaboration with primary health care services, which plays an important role in the identification and treatment of people with mental disorders. These collaborative models of care are particularly effective in the treatment of people with mental and physical co-morbidities3,4. Under the framework of the EU Joint Action on Mental Health and Wellbeing, key stakeholders from participating countries (Austria, Bulgaria, Estonia, Hungary, Ireland, Italy, Portugal, Spain and UK) worked together with representatives of relevant European mental health organisations to develop a framework for action on community-based and socially inclusive approaches to mental health. Their work gave a special emphasis to the transition from institutional to community-based care for people with severe mental disorders, and was part of a commonly endorsed action framework on mental health and wellbeing in Europe. The specific objectives of the workgroup were: 1-analysing the situation of community-based and socially-inclusive approaches to mental health in participating countries, as well as in EU countries at large; 2- mapping the scientific evidence, best practices and the available technical resources relevant for the implementation of community-based and socially-inclusive approaches to mental health in Europe; 3- developing recommendations for action at EU-level and in Member States for this work package; 4- supporting the engagement and commitment of Member States and other stakeholders in effective action to develop community-based and socially-inclusive approaches to mental health in Europe. The methods used included a literature review, the analysis of existing data on a selected set of indicators related with the transition to community-based care in EU, the analysis of original and more extensive data related to this process collected in the nine countries participating in the workgroup with the support of a questionnaire specifically developed for this purpose, a SWOT analysis (to evaluate achievements, barriers and challenges in MS) in six participating countries, and the selection and description of good practices. MENTAL HEALTH AND WELLBEING REPORT | 1 EXECUTIVE SUMMARY What is the situation in Europe? Across Europe, much effort has been made over recent decades to shift away from institutional to community-based mental health care. However, despite all these efforts, much more has still to be done if we want to provide accessible, effective and social inclusive mental health care to all people with severe mental disorders in Europe. The key findings of this project show that: Deinstitutionalisation and the development of community-based care is accepted by more than half of EU countries as a major goal of their mental health policies. Many countries have developed or initiated some type of mental health reform in the last few decades. Most countries have undergone important transformations in psychiatric hospitals but for a number of countries these hospitals continue to play a central role in mental health systems and consume the vast majority of resources allocated to mental health care. The reduction of beds in mental hospitals/psychiatric hospitals, and the transfer of patients to community services and residential facilities have played a key role in deinstitutionalisation, followed by the veto of new admissions. The involvement of different stakeholders in the planning of deinstitutionalisation has gradually increased in the last 15 years. Despite many significant advances in the development of community care across Europe, community- based services networks have only partially been developed in most countries, with many not introducing timely transfers from traditional services to community-based systems of mental health care. Beds in community-based facilities, including general hospitals, have become an important part of the mental health systems in most of the EU countries. Although in a less systematic way, residential facilities in the community have also increased significantly across many EU countries. Few EU countries offer home treatment and community-based rehabilitation. Primary mental health care also remains very limited in many countries, particularly in relation to severe mental disorders. According to stakeholders perception, the highest levels of achievement were found in the development