The International Journal of Psychosocial Rehabilitation
Preparing Mental Health Reform in Slovenia
 

Vesna Švab, MD, PhD
Assistant Professor
Rehabilitation Unit in Psychiatric Hospital Ljubljana, Slovenia, Studenec 48, 1260, Ljubljana.
President of the National Association for Mental Health ŠENT, Cigaletova 5, 1000 Ljubljana, Slovenia
 

Address for correspondence: Vesna Švab, Psychiatric Clinic Ljubljana, Studenec 48, 1260 Ljubljana, Slovenia.
Tel.: 00386 41 913766   Fax: 00386 1 5284618
e-mail: vesna.svab@psih-klinika.si
 
 

 Citation:
Švab, V. (2003)  Preparing Mental Health Reform in Slovenia.
International Journal of Psychosocial Rehabilitation. 8, 5-9.



Abstract
The article describes major mental health problems in Slovenia and describes the steps done to change present inadequacy of mental health system organization. Psychosocial rehabilitation services organized in non government organization are stewarding the process of reform through promotion of rehabilitation values and through involvement of users and carers. Further development of services is to be enhanced with integration of psychosocial rehabilitation in educational curricula for mental health professionals with involvement of users as teachers in educational process.
Mental Health Reform in Slovenia

Mental Health Situation
Slovenia is a central European county with 2 million inhabitants, the northern part of former Yugoslavia. It is a country in transition with the national product of 760 USD per capita; 7.7% of it is used for health. Mental health care is institutionalised prevailingly in hospitals and asylums,  with  the exception of wide-spread and easily accessible outpatient psychiatric clinics .
The main Slovene mental health problems are: high alcohol  abuse, high suicidal index, increasing outpatient clinics visits and overcrowded hospitals (Table 1, Table 2).

Table 1: Mental health indicators in Slovenia


Source: WHO: Slovenia HFA Data basis 1998

Indicator
1985
1990
1995
1997
1998
Share of pop. 0 -14 years (%)
21.9
20.5
17.9
17.1
16.7
Share of pop. ? 65 years (%)
10.0
10.8
12.5
13.1
13.5
Rate of unemployment (%)
1.5
4.7
7.4
7.1
7.9
Suicides 0-64 years/ 100,000 inhabitants
30.7
25.1
25.3
25.7
26.5
Cirrhosis of the liver/100,000 inhabitants
42.8
34.0
34.1
29.2
29.1
No. of hospital beds/ 100,000 inhabitants
632
604
575
567
562
No. of doctors/ 100,000 inhabitants
187
205
212
224
228
Mean duration of hospitalization (all hospitals)
12.4
11.4
10.4
10.0
9.5
Share of expenditures for health of GDP (%)
4.2
5.6
7.8
7.7
7.7
Notes: Psychiatry receives approximately one third of hospital health funds. The suicide rate is three times higher for men, in the age period around 50, among retired people and among the unemployed. People who commit suicide are often without psychiatric diagnosis; among diagnoses, alcohol dependence and psychotic disorders are prevailing. 20.9% of people who commit suicide have already attempted it previously.
Regarding care for patients with severe mental illness (SMI), Slovenian mental health system can be (shortly described) characterized by  the following statements (Švab&Tomori, 2002):
- services for patients with severe mental illness are predominantly institutionalised;

- non-government organisations (NGO) that provide social support, employment and housing are growing;
- there is no community psychiatry available;

- privatisation of services is  rapidly increasing, however, it actually does not contribute to outreach, comprehensiveness of treatment and registration of patients. These things were organized better in the previous (socialistic) system.

A national program for mental health  has not yet been accepted in Slovenia. National programs for preventing suicide and  dependence on alcohol and drugs, however, have been developed.

We still lack  consensus on planning of mental health services for persons with SMI. Care plans for patients with SMI are  poorly coordinated among psychiatric institutions, social services and non-government organizations that provide rehabilitation services (Švab& al., 2002). Moreover, there are some additional problems that have been discovered only recently:

1. The number of admissions of patients with SMI to the greatest psychiatric hospital in Slovenia,  i.e. University Hospital of Psychiatry Ljubljana-Polje, which provides care for approximately 700,000 population is rapidly increasing  Table 2: Number of hospitalizations: admissions and rejections of patients from 1995 to 2002

Table 2: Number of hospitalizations: admissions and rejections of patients from 1995 to 2002
YEAR
ADMISSION
REFUSAL
TOGETHER
DIFFERENCE REGARDING PREVIOUS YEAR
DIFFERENCE REGARDING 1995 (%)
1995
2319
340
2659
1996
2457
275
2732
+73
73 (2.7)
1997
2422
305
2727
-5
68 (2.5)
1998
2589
308
2897
+70
238 (8.9)
1999
2599
281
2880
-17
221 (8.3)
2000
2710
344
3054
+174
395 (14.8)
2001
2870
380
3250
+196
591 (22.2)
2002 – first 6 months
1424
324
1748 (annual expectancy =3496)
+246 (expected)
873 (31.4%)
(expected)
 
Diagnostic structure of admitted patients is  presented in Table 3.  Differences between diagnostic groups regarding admission increase have not been evaluated. yet, but  we can assume  that social factors influence frequent re-admissions as well.
Table 3: Diagnostic structure of patients admitted to University Hospital of Psychiatry Ljubljana Polje in 2001
Diagnostic group (ICD 10)
MEN
WOMEN
N (%)
N (%)
Organic mental disorders
94 (9.4%)
145 (12.3%)
Psychoactive substance abuse related disorders
323 (32.4%)
89 (7.5%)
Schizophrenia
274 (27.5%)
316 (26.7%)
Other psychoses
133 (13.4%)
252 (21.3%)
Moood Disorders
95 (9.5%)
264 (22.3%)
Neurotic Disorders
77 (7.7%)
117 (9.9%)

 
2. It also became apparent that  mean duration of hospitalizations is relatively long (60 days) in the largest hospital department  intended  for people with severe mental disorders. The health insurance does not cover  the total hospital costs and does not pay  for patients staying in the hospital for more than 50 days any more. Therefore, the  duration of hospitalization was administratively reduced to 48 days within a couple of months, due to a financial crisis of the hospital. The number of hospital beds has been  decreased by 12% in a years’ time. This actually means that many chronic patients were (quickly) discharged prematurely, most of them with no preparation.

The process of de-institutionalisation has started in Slovenia already 40 years ago when the majority of mentally ill patients were discharged to their families,  asylums and old peoples’ homes. The  new de-hospitalisation is different only  in terms of better public and users’ knowledge about  human rights and possibilities of rehabilitation. Education of patients, carers and professionals was implemented by ŠENT, the largest NGO service in Slovenia, and by some enthusiastic professionals who took part in the anti-discrimination campaign launched by ŠENT (Švab, 2000).

3. The number of outpatient clinic visits has  increased by 100% in the last four years (Ministry of Health, 2002). The number of general practice visits due to mental health problems is rising as well.

4. We are witnessing major dissatisfaction of patients, their families (gathered in the National Forum of Relatives) and public (media) with mental health services. Psychiatric hospitals and asylums are often regarded as out-dated institutions violating human rights of patients.

Planning
The conference on Psychosocial Rehabilitation in the Community held in the capital of Slovenia in May 2002 was  aimed to provide an overview of the present situation regarding mental health services for patients with SMI in Slovenia and to prepare a platform for development of co-ordinated  mental health reform. It was organised by the NGO ŠENT and the Government Office for the Sick and Disabled. A large public event was prepared to enable discussion and search for possible solutions. It was opened by prominent politicians and attended by leading Slovene experts. In the first part several distinguished guests from World Association for Psychosocial Rehabilitation (WAPR) and World Health Organization (WHO) presented mental health reforms in Western and Eastern countries. The opening speech was held by Prof. Norman Sartorious, president of World Psychiatric Association. He stressed that stigmatisation of people with mental disorders is the primary  cause of the low priority of mental health services all over the world and that governments, as the ultimate stewards of mental health, need to assume the responsibility for ensuring that these complex activities are carried out. One critical role in stewardship is to develop and implement policy.

Presentation of the mental reforms in some Eastern European countries (Romania, Bosia and Herzegovina, Croatia) has shown that the institutional model is largely preserved and that these models are mostly inadequate. West Europe and the United States have developed a community care model with very different evaluation outcomes. De-hospitalisation is successful only with a highly integrated and politically supported reform implementing sectorization and definition of  responsible actors at the individual and systemic level.

In the second part of the conference the Slovenian system of care was described by presenters from social work services, NGOs, user organisations, psychiatric hospitals, asylums and  general practice (GP). The GPs state that mental health should be included in their training curricula to improve the effectiveness of the management of mental disorders in general health services and that the lack of GPs in Slovenia does not allow shift to community care yet. The Government Employment Office representative stressed that employment opportunities should be maximized regarding  some successful  programmes already established by NGOs.

Work should be used as a mechanism to reintegrate persons with mental disorders into the community. Users and carers stated their needs for support, education, financial needs and need for rehabilitation services and adequate information system.
The conference was concluded with a round table of participants representing psychiatric hospitals, Ministry of Family, Work and Social Affairs, Ministry of Health, Ministry of Education, The Government Office for the Disabled and Chronically Sick of the Republic of  Slovenia, users’ representative, carers’ representative and a member of the government’s group preparing mental health legislation.

The conclusions:

1. Psychiatric hospitals should take part in the process of de-institutionalisation with their staff, expertise and resources.

2. Ministry of Education is going to support educational programs for teachers and pupils to promote anti-discrimination and to provide programs for improving mental health of children and adolescents.

3. Ministry of Labour, Family and Social Affairs has already prepared a reform for developing community based social services and a reform in the system of financing that should be individualized and  consistent with clients’ needs.

4. Ministry of Health will gather a professional group to influence presently low accessibility and locality of mental health services and to influence an improvement in rehabilitation services.

5. The Government Office for the Disabled and Chronically Sick of the Republic of Slovenia, will coordinate the actions and support anti-discrimination programs.

6. Users appeal for development of employment services and for improvement of financial situation of the mentally ill.

7. Carers demand a comprehensive information system and participation in the process of reform.

8. The new mental health law that is now exclusively concerned with outpatient commitment will also implement  patients’ rights for rehabilitation (ŠENT, 2002).


Conclusion
Psychosocial rehabilitation movement in Slovenia is therefore actually leading the path to mental health reform in the country. The consequences of economically triggered de-institutionalization are to be buffered through establishment of rehabilitation services and with involvement of users in the process of reform. Further steps are in the hands of politicians, but public pressure is currently rising through media. We are aware that similar process has already happened in most western countries. The development of community based mental health reform should be therefore supported by international counselling. A parallel process of educational reform is needed as well..  Mental Health Europe and ŠENT are  preparing an International Conference on Education for Mental Health: Education for Change in May 2004 to assess and plan education and training of professionals, users and carers in Slovenia.  We believe that psychosocial rehabilitation knowledge, mission and experience should be integrated in educational curricula of social, medical and pedagogical schools and in educational programmes for users and carers.



References:

1. ŠENT, The Governmental Office for the Disabled and Chronically Sick of RS. (2002). Conference on Psychosocial Rehabilitation with international participation. Ljubljana.

2. Švab, V. (2000). Anti stigma program in Slovenia. Psychiatria Danub., 12, 152-153.

3. Švab, V., Tomori, M.(2002). Mental Health Services in Slovenia. Int. J. Soc. Psychiatry, 78(3), 177-188.

4. Švab, V., Tomori, M., Zalar, B., Ziherl, S., Dernovšek, M. Z., Tav?ar, R. (2002). Community rehabilitation service for patients with severe psychotic disorders:the Slovene experience. Int. J. Soc. Psychiatry, 4 ( 2), 156-160.
 


_____________________________________________________________________________________


Copyright © 2003 Hampstead Psychological Associates, Ltd - A Subsidiary of Southern Development Group, SA.
All Rights Reserved.   A Private Non-Profit Agency for the good of all, published in the UK & Honduras.