The state of psychiatry in the Czech Republic

1. Cyril Höschl and Petr Winkler Thestateof psychiatry in the Czech Republic National Institute ofMentalHealth Prague Psychiatric Centre & Charles University, 3rd MedicalFaculty, Prague

2. The state of psychiatry in the Czech Republic CYRIL HÖSCHL, PETR WINKLER & ONDŘEJ PĚČ 278

3. Thestateof psychiatry in the Czech Republic • Background information • Historicalintroduction • Legal framework • Policy – What is needed now? • Finances • WhatistheTrue prevalence and disease burden? • Disability pensions and sick leave • Services • State provided services • Psychiatric hospitals • Psychiatric units in general hospitals • Outpatient psychiatric care • Outpatient 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?

4. Background information Forpsychological&emotionalproblems 2009-2010; explained rather by lower GDP due to crisis than by investments • 14 psychiatrists/100.000 population • FirstcontactwithGPs (73%), Psychiatrists (7%), and psychologists (7%) • Totalhealthexpenditures(HE)reached 7,7% of GDP • MHC expendituresclimbed to 4% HE (0,3% GDP) • 91,5% public healthexpenditurefinancedfrompublic healthinsurance. • Out-of-pockethealthspendingrisingmoderately

5. Historicalintroduction • Origin: Austro-Hungarian empire • Flourishedbetween WW • Declineddue to ideologicalconstraintsoftheSoviet Empire (1948-1989) • Relativelymarginal abuse (in bothways) • Relativelyhighlevelofclinical psychiatry due to outstandingtraditionofuniversitryeducation. • After 1989 – open society, deinstitutionalization Destigmatization, reintegration, public education, internationalresearchcooperation. However, thetransformationof HC systemisslow.

6. Legalframework • Regulation of mental health care delivery is secured via general health care legislation • No special MHC law • No special MHC budget

7. Policy – whatisneedednow? • 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 isfragmented, underfinanced • National mental health policy is missing. and quitepoorlycoordinated As well as plancontainingpriorities, aims, responsibilities, and financialallotments

8. Finances The overall bill for brain disorders in theCzech Republic, however, reached 10.2 billion Euro in 2010 (Gustavsson et al. 2011). • 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

9. 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. • Lifetimeprevalence 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.

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

11. 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 adolescentsin 1990 to 9.881 beds for adults and 485 beds for children and adolescentsin 1995.

12. Services • Staffingand average length of stay - there isalso some improvement. In 1990, HCin 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 daysrespectively.

13. 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 [51per 10.000 inhabitants] and 13.936 women [26 per 10.000] were treated in unitsforalcohol and illicit drug users. • Alcohol use accounted for the majority of all cases [60%]

14. Services Psychiatric rehabilitation being provided by NGO´s in 2007

15. Services • There are onlytwo mobile crisisteamsthatoperateunderrestrictedconditions. Oneoutreachcommunity team began to work in Prague in 2010. From 2006, thehealth care systemallowedparticipationofcommunitypsychiatricnurses in provisionof care [case management and individualrehabilitation in homesofthepatients]. Up to thepresenttime, there are only 3 workplacesforcommunitypsychiatricnursesintegrated in dayclinics.

16. Futureperspectives • 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.). • Adopta mental health plan on a governmental level • Integrate mental healthalso 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.

17. Futureperspectives Mentalhealthplanshouldinclude: • 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, shelteretconditions,and case management teams).

18. Futureperspectives • 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.). • Adopta mental health plan on a governmental level • Integratemental healthalsointo governmental R&D strategy • Training and nurturing of mental health professionals and the provision of better information to attract young people to the field.

19. Cyril Höschl and Petr Winkler Thestateof psychiatry in the Czech Republic Thankyouforyourattention National Institute ofMentalHealth Prague Psychiatric Centre & Charles University, 3rd MedicalFaculty, Prague