The state of psychiatry in the Czech Republic

Cyril Höschl and Petr Winkler

National Institute of Mental HealthPrague Psychiatric Centre

& Charles University, 3rd Medical Faculty, Prague

The state of psychiatry in the Czech Republic

CYRIL HÖSCHL, PETR WINKLER & ONDŘEJ PĚČ 278

THE STATE OF PSYCHIATRY IN THE CZECH REPUBLIC

• BACKGROUND INFORMATION• HISTORICAL INTRODUCTION• LEGAL FRAMEWORK• POLICY – WHAT IS NEEDED NOW?• FINANCES• WHAT IS THE TRUE PREVALENCE AND DISEASE BURDEN?• DISABILITY PENSIONS AND SICK LEAVE• SERVICES• STATE PROVIDED SERVICES

Psychiatric hospitalsPsychiatric units in general hospitalsOutpatient psychiatric careOutpatient care for psychoactive substance users

• NGO PROVIDED SERVICES, DAY CLINICS, CRISIS INTERVENTION CENTERS

• ACCESSIBILITY OF SERVICES AND INVOLUNTARY HOSPITALIZATION

• PERSONNEL, EDUCATION AND RESEARCH• Discussion – what are the Priorities?

Background information

• 14 psychiatrists/100.000 population • First contact with GPs (73%), Psychiatrists (7%), and

psychologists (7%)• Total health expenditures (HE) reached 7,7% of

GDP• MHC expenditures climbed to 4% HE (0,3% GDP)• 91,5% public health expenditure financed from

public health insurance. • Out-of-pocket health spending rising moderately

2009-2010; explained rather by

lower GDP due to crisis than by

investments

For psychological & emotional problems

Historical introduction

• Origin: Austro-Hungarian empire• Flourished between WW• Declined due to ideological constraints of the

Soviet Empire (1948-1989)• Relatively marginal abuse (in both ways)• Relatively high level of clinical psychiatry due to

outstanding tradition of universitry education.• After 1989 – open society, deinstitutionalization

Destigmatization, reintegration, public education,

international research cooperation. However, the

transformation of HC system is slow.

Legal framework

• Regulation of mental health care delivery is secured via general health care legislation

• No special MHC law• No special MHC budget

Policy – what is needed now?

• Concept of Psychiatric Care (CPS 2000; 2008) observes that psychiatric care in the Czech Republic relies mainly on institutionalized services, while community care has not been sufficiently deployed.

• Care is fragmented, underfinanced• National mental health policy is missing.

and quite poorly coordinated

As well as plan containing priorities, aims, responsibilities, and financial allotments

Finances

• In 2006 CZK 9.1 billion (average exchange rate in 2006 was 28,3 CZK for €1) was spent on mental health care, which is app. €322mio (10 mio population); corresponds to 4,1% HE (Dlouhý 2010)

• More than half of that (61,5% labour cost) went to the psychiatric hospitals and psychiatric departments in general hospitals.

Approx. one-quarter of all expenditures was spent on prescribed drugs Anxiety, somatoform disorders and eating

disorders [F40-F48, F50-F59] accounted for nearly one-quarter of all expenditure

The overall bill for brain disorders in the Czech Republic, however, reached 10.2 billion Euro in 2010 (Gustavsson et al. 2011).

What is the true prevalence and disease burden?

• The only study measuring true prevalence of mental illness in the adult population of the Czech Republic was conducted by the Prague Psychiatric Centre (PCP) in cooperation with WHO in 1998-1999.

• Lifetime prevalence of psychiatric disorders reached 27% [30% women, 24% men](Dzúrová et al. 2000)

The most frequent were anxiety and behavioural syndromes associated with physiological disturbances and physical factors [18%], mental and behavioural disorders due to psychoactive substance use [13%], and mood disorders [13%, mainly depression]. 16,7% of respondents reported a single psychiatric disorder, 5,4% a history of 3 or more disorders.

What is the true prevalence and disease burden?

• Nearly 5% of women had a life-time prevalence of suicidal thoughts and 2% attempted suicide, increasing to 12% and 6% respectively for women with some psychiatric diagnosis. Men reported suicidal thoughts less frequently.

• Completed suicide is in the opposite direction [men: 22,7; women: 4,3 per 100.000/year](Dzúrová et al. 2000)

Services• № of beds in psychiatric hospitals was reduced

significantly after the Velvet revolution, from 11.958 beds for adults and 901 beds for children and adolescents in 1990 to 9.881 beds for adults and 485 beds for children and adolescents in 1995.

№ beds0

2000

4000

6000

8000

10000

12000

14000

199019952010

Services• Staffing and average length of stay - there is also some

improvement. In 1990, HC in all psychiatric hospitals was provided by 370 physicians, in 1995 it was 430, and in 2010, 517 physicians. The average length of stay was 101,3 days, 88,7 days, and 79,9 days respectively.

№ physicians0

100

200

300

400

500

600

199019952010

Length of stay0

20

40

60

80

100

120

199019952010

Services• In 2010, the overall number of investigation-treatments

reached 2.665.547 [2.534,5 per 10.000 inhabitants], 30% increase since the year 2000

• Approx. 60% of patients were female.• In total, 26.262 men [51 per 10.000 inhabitants] and

13.936 women [26 per 10.000] were treated in units for alcohol and illicit drug users.

• Alcohol use accounted for the majority of all cases [60%]

Services

Area of support Type of service № of organizations

Living Sheltered housing 13

Supported living 9

Work Sheltered workshops 17

Transitional employment 4

Supported employment 6

Day activity centers 25

Other Case management 12

Supported education 2

Consultancy 16

Psychiatric rehabilitation being provided by NGO´s in 2007

Services• There are only two mobile crisis teams that operate

under restricted conditions. One outreach community team began to work in Prague in 2010. From 2006, the health care system allowed participation of community psychiatric nurses in provision of care [case management and individual rehabilitation in homes of the patients]. Up to the present time, there are only 3 workplaces for community psychiatric nurses integrated in day clinics.

Future perspectives• The transformation of MHC from big institutions toward

community based services must continue.• Preparation of society for an ageing population and

associated psychiatric issues (increased prevalence and burden of depression, neurodegenerative diseases including dementias etc.).

• Adopt a mental health plan on a governmental level • Integrate mental health also into governmental R&D

strategy• training and nurturing of mental health professionals

and the provision of better information to attract young people to the field.

Future perspectives

• Harmonization of legislation• Harmonization of health and social services• Mental health promotion and prevention in the workplaces

and schools• Investments into the non-governmental sector• Social inclusion• De-stigmatization• Special attention to the most vulnerable (child and

adolescent, geriatric) persons• Accessibility of services (day clinics, crisis intervention teams,

community services, psychotherapists, shelteret conditions, and case management teams).

Mental health plan should include:

Future perspectives• The transformation of MHC from big institutions toward

community based services must continue.• Preparation of society for an ageing population and

associated psychiatric issues (increased prevalence and burden of depression, neurodegenerative diseases including dementias etc.).

• Adopt a mental health plan on a governmental level • Integrate mental health also into governmental R&D

strategy• Training and nurturing of mental health professionals

and the provision of better information to attract young people to the field.

The state of psychiatry in the Czech Republic

Cyril Höschl and Petr Winkler

National Institute of Mental HealthPrague Psychiatric Centre

& Charles University, 3rd Medical Faculty, Prague

Thank you for your

attention