BRIEFINGS Mental health services in Cyprus Marios Piérides Cyprus has a turbulent history. First occupied Mental health services by the Egyptians in 1450 BC, it was subse quently ruled by Assyrians, Persians, Ptolemies, Staff Romans, and up to 1571 by the Venetians. In Current mental health service personnel number that year the Turks captured the Island. It 469. There are 392 nursing staff including com remained a Turkish province until 1878 when it munity psychiatric nurses (CPNs).Nineteen psy was colonised by the British. In 1925 Cyprus was chiatrists (roughly 3 per 100 000 population), declared a Crown Colony of the British Empire. nine clinical psychologists, three psychiatric Following a four year armed insurrection against social workers, 18 occupational therapists and the British, Cyprus became an independent various administrative and supportive personnel republic in 1960. make up the rest of the numbers. In the United The republic's current troubles date back to Kingdom there are around ten psychiatrists per the summer of 1974 when Turkish troops in 100 000 population (figures supplied by the vaded the island. The Turkish forces currently Royal College of Psychiatrists). occupy just over one third of the northern area of Cyprus. The United Nations Cyprus Force moni tors the 'green line' that divides the island. The Hospitals occupied territories are inaccessible except from The Psychiatric Institution of Athalassa is a 653- Turkey. This report is therefore based only on the bedded mental hospital that serves the whole of Greek-Cypriot government controlled part of the Cyprus and is situated just outside the capital city, Nicosia. All the current (October 1993) 415 island. in-patients are formally detained. Most of the patients are over the age of 50 and have been in Overview of health care in Cyprus the institution for more than ten years. In some Medical care in Cyprus is provided through wards no distinction is made between patients public and private health services. Detailed with physical disabilities, learning difficulties, information for the private sector is lacking. psychotic illnesses or a combination of these These data refer to the public sector health disorders. Nursing staff wear white uniforms. services. Each ward contains around 20 beds. Privacy for Community life is based around the Greek patients is lacking. Orthodox Church and family life around the Patients not limited by physical disabilities grandmother, often a widow who survived her attend an occupational therapy programme at husband after the invasion. The most common the hospital. This consists of basket-weaving or psychiatric syndrome is nevra (or 'nerves') which similar activities. Patients receive nominal re encompasses a range of disorders including muneration for their efforts. anxiety, depression, sexual disorders, epilepsy Although there is no formal government policy and even psychosis. Traditionally, mentally ill requiring a move to community care, over the relatives are cared for at home by their families. last decade psychiatric and allied services have The general standard of health care in Cyprus initiated a process of deinstitutionalisation. Fear compares favourably with that ofother developed of job losses among long-serving nursing staff countries. The infant mortality rate stands at has made for resistance to the decentralisation 11.0 per 1000 live births. Lifeexpectancy at birth programme. Despite these limitations progress is 74.1 years for men and 78.6 years for women. has been made. New admissions to the mental The current total population of Cyprus was hospital have dropped from 435 in 1983 to 128 in estimated to be 589 700 at the end of 1992. 1992. Seven long-stay wards have been closed About a third of the population is below the age of and bed occupancy has fallen by 10% since 17 years. Government expenditure on health 1987. Some nursing staff have joined the services is estimated at C£117.1m,representing community psychiatric nursing team based 4.3% of the gross domestic product. There are in Nicosia. Despite these advances a degree of approximately 457 individuals per doctor on the institutionalism is evident in both staff and island. patients. Psychiatric Bulletin (1994), 18, 425-427 425 BRIEFINGS Fig. 3. A ward bombed during the 1974invasion at Athalassa Asylum. Twenty patients and two members of staff died. Fig. 7. Fear of job lossesamong nursing staff has released or formally certified, allowing for brought resistance to the deinstitutionalisation indefinite detention. policy. The Chemical Dependency Unit was estab lished at the Nicosia General Hospital in 1991. A limited number of psychiatric beds are also Most of the admissions are men suffering from available at the Nicosia and Limassol General alcoholism. Cannabis is thought to be the most Hospitals. Children requiring admission are commonly abused illegal substance. There have treated at the Archbishop Makarios III Hospital been only two recorded cases ofheroin addiction. in Nicosia. Psychiatric out-patient clinics are Dependence on benzodiazepines, other minor held in the general hospitals and the larger tranquillisers and anti-parkinsonian agents are urban centres of Larnaca and Paphos, and in the the other commonly encountered problems. In last fiveyears more have been established in the all, 55 patients have been treated at this unit to rural areas of Paralimni, Polis, Kaimakli and date. Strovolos. All patients admitted to the general hospitals are voluntary. If patients require formal deten Community services tion, application with relative's consent is made The Community Psychiatric Nursing Department to the local magistrate. Detained patients are covering the whole of Cyprus is based in Nicosia. transferred to the Athalassa Hospital. The re The first CPN (UK trained) was appointed in sponsible medical officer must review the appli 1977. To date, the 25 CPNs have a case-load of cation in writing to the magistrate within seven about 35 patients each. Referrals are received days. After three months the patient must be from psychiatrists, social workers, police, neigh bours, relatives and voluntary organisations. Self-referrals are not uncommon since the establishment of a mental health 'hotline' in the CPN offices. The CPNs work closely with the psychiatrists within a multi-disciplinary setting. They are responsible for the supervision of the psychiatric hostel in Nicosia. Following the start of the ward closure pro gramme at the Athalassa Hospital, a day club was started in Nicosia where patients discharged to relatives would gather informally in the after noons once or twice a week. Meetings would be supervised by a community nurse. Since then, client-demand and assistance from voluntary organisations has resulted in the development of a fully-fledged day centre in Ayios Dometios. It is open from 7.30 am to 6.30 pm on weekdays and Fig. 2. ThePsychiatric Ward (top) and the Chemi has a register of 65 patients with long-term men cal Dependency Unit (middle) at the Nicosia tal health needs. Self-referrals are becoming General Hospital. more common. The daily programme is run by 426 Piérides BRIEFINGS five full-time professional staff and lay volun evident with publication of recent research teers. initiatives. The move from hospital-based to community care will be further strengthened when the new day centres planned for Limassol and Paphos are opened. Mobile psychiatric clinics have been Acknowledgements planned for the more remote areas of the island. I am grateful to the Rt Hon Mr Manolis However, a core of patients who were cared for by Christophides, Minister of Health, the Director of their families before the 1974 invasion are diffi Mental Health Services, Dr Vassos Pyrgos, the cult to place since their families form part of the Department of Statistics and Research and to the population of 200 000 refugees created by the invasion. There are no known cases of homeless- mental health service personnel for their time ness since the commencement of the deinsti- and support. tutionalisation programme. It is hoped that Marios Pierides, Research Registrar in Psy resistance to community care from within the chiatry, UMDS of Guy's and St Thomas', South mental health services will lessen once benefits Western Hospital Campus, Pulross Road, London to patients, staff and service become more SW9 The case of the vanishing boiler Ann Gath There has been a series of notorious hospital continues after mid-day, the watershed for scandals from Ely to Ashworth involving gross visits. neglect or abuse of vulnerable people who have The initial visit to the children's hospital took been put away from the sight of the general place at the invitation of the team from Athens public. Suddenly the spotlight is put on them who were involved in a project aimed at improv and then the question is asked why no one has ing the standards of care. On the flight to the bothered before. island, we were accompanied by an extremely Sometimes it is possible to believe for a short smartly dressed lady, whom we learnt was the period at least that such a thing could not pos chairman of the government organisation re sibly happen here - wherever that here may be. sponsible for the institution. When we arrived we When the Observer produced its pictures of the found the place scrupulously scrubbed and all hospital on Leros, that surely was beyond any the patients wearing new clothes - so new that local shortcoming. the creases where they were folded were there in Leros has two hospitals - the larger one caters identical form on each. Beds were covered with for the mentally ill and for some adults with brand new covers and their occupants lay still all learning disability while the other, referred to facing the same direction. After the official visit as a children's hospital, caters for those with was over, the new clothes all disappeared and physical and severe developmental disability once more excrement appeared on the floors.