Since 1984, when the EEC Program 815/84 was introduced, the term “psychiatric reform” was made synonymous to the imperative change of the asylic psychiatry towards a decentralized and community based psychiatric care. This program presented various stages of non absorption of funds, stagnation and finally a developmental phase until the completion of the program in 1995. A total of 250 new services and programs have been developed. In 1999, the most progressive Mental Health Law 2716 was passed. In 2000, the “Psychargos” program continued the psychiatric “reform” project, with 700 million euros funding for a ten years period. Its goal was the completion of the reform, the deinstitutionalisation of the remaining long stay patients, in the eight mental hospitals and their closure, the development of psychosocial rehabilitation and housing services as well as the further development of community based mental health services. Four mental hospitals have been closed down until now. Forty three Community Mental Health Centers are in operation (instead of the needed 94). However, there are no evaluative data on their effectiveness and efficiency. Regarding the rest of the types of services, 57 Day Care Centers with 855–900 places (1500 places are needed), 25 Mobile Units, 37 Outpatient Psychiatric Clinics, 28 Psychiatric Departments in General Hospitals, with 650 beds, have been developed in the country. The latter number is insufficient. There is a need of 2900 short stay beds to cover 40,000 admissions per year in order the remaining public mental hospitals to be closed down. Additionally, 343 hostels, sheltered apartments have been developed with 3100 beds as well as 2000 places in various rehabilitation services for the support of the deinstitutionalised patients. To overcome the bureaucratic and rigid public accounting system the intervention of the NGO’s was introduced. In 2012, 65 NGO’s were involved with 220 units (30% of the total mental health units) covering 50% of the deinstitutionalisation beds and a total budget of 45 million euros in 2010. The Ministry of Health had no provision for their evaluation or their requirement to provide fiscal annual reports publicly. It should be noted that the first NGO’s were established by dedicated mental health experts in the eighties, for the fulfilment of the 815/84 program. In the coming years decades of NGO’s were developed under rather unclear criteria by several non mental health professionals for the completion of the Psychargos projects. With respect to the private sector in 2007 there were 4207 inpatient beds.

The evaluation of the whole process of these significant changes in Greek psychiatry during the last 28 years did not prove that these changes constitute a true reform for the bellowing reasons: (1) These changes were made not by a public demand or the majority of mental health professionals. They were a result from “above”, mainly the European Commission under the pressure of the Leros Asylum scandal. (2) There was not a scientific design starting from the catchmentation of the country which was introduced 20 years later in 2004, providing 58 sectors (instead of the needed 94) on the basis of epidemiological data. (3) No specific mental health ideology was prevailed among the personnel in contrast to the Italian psychiatric reform. (4) There has been no real system of care, to be coordinated toward the maintenance of continuity of care. The existing CMHC’s are not operating on 24 hours basis. They are not connected to the Emergency Medical System. This problem is causing the loss of emergency cases and the hospitalization of the patients outside their catchment area. The Sectorized Mental Health Committees are not connected with the Public Health Regional Committees. (5) The role of community (local authorities, resources, families and relatives of patients, active citizens for human rights) is absent from the legislative and delivery of care levels. (6) There is a lack of coordination between public health and welfare system and mental health care. The newly established National Organization of Delivery of Health Services (N. 3918/11) might help the improvement of this coordination.

In this rather pessimistic climate, while these changes are still in progress, the current great economic crisis “invaded” the country with a loss of 25% of NGP, 26% unemployment rate (more than 50% among the young adults), 40% draw backs in salaries and pensions. The magnitude of NGP is synonymous to the global prosperity of society and the achievements of social state. As a result of this crisis, human dignity, human rights, the beliefs in democracy, institutions, the respect of the “other”, the feeling of social cohesiveness and security are undermined. The first “victims” are the young, the poor and the disabled. The economic crisis has caused and continued to produce adverse psychological indicators such as a 35% increase in the consumption of antidepressants as well as an increase by 62% of new HIV cases. It was also found a dramatic increase by 185% of persons who had attempted suicide (0.6% in 2008 and 1.5% in 2011). In 2008, the prevalence of major depression was found 3,3% in a nationwide general population survey, while the corresponding prevalence rate was 8,2% in 2011. The above findings are drawn from systematic epidemiological studies on the impact of crisis on mental health of the population conducted by the University Mental Health Research Institute. The most disturbing finding is that of the significant correlations between public debt, unemployment rates and the age specific suicide rates between 2001 and 2011. The current crisis influencing every area of delivery of care, especially mental health, with first “victim” the deinstitutionalisation project involving the NGO’s resulting budget cuts by 50% of all expenses including suspension of salaries for six and more months. Several mental health services are understaffed and they are forced to stop some specialized programs. This picture is completed with the increasing trends of homeless persons in urban centers, in their majority being chronically mentally ill. With the current crisis the limits of social state are diminished with thousand of uninsured persons due to their unemployment, the abolition of collective jobs agreements and lack of protection from job losses. The intrusion and strengthening of neoliberalism as an antidote to crisis, given the fact of the collapse of the Keynesian social policy, brings out the risk of a destruction of psychosocial protection with the introduction of managerial ideology of cost benefit in the prevention, treatment and rehabilitation of mental illness and the human suffering. The “Managed Care” approach is a true example of this kind of policy.

It is becoming clear that the future of this even incomplete psychiatric reform is at serious risk. The defense of the social state and the mental health apart from the austerity measures and policies is imperative. It is perhaps a solution, the acknowledgment and the empowerment of the multiple roles and resources of the community, in the defense of mental health of its members, to overcome this crucial phenomenon. 

Michael G. Madianos
Emeritus Professor of Psychiatry, University of Athens

References

• Ministry of Health and Social Solidarity. Evaluation report of intervention in the applications of psychiatric reform for the period 2000–2009. Ministry of Health and Social Solidarity Athens, 2011
• Madianos M, Economou M, Alexiou T, Stefanis C. Depression and economic hardship across Greece in 2008 and 2009: two cross-sectional surveys nationwide. Soc Psychiatry Psychiatr Epidemiol 2011, 46:943–952
• Economou M, Madianos M, Theleritis C, Peppou LE, Stefanis C. Suicidality and economic crisis in Greece. Lancet 2012, 380:337–338
• Economou M, Madianos M, Peppou L, Patelakis A, Stefanis C. Major depression in the era of economic crisis: a replication of a crosssectional study across Greece. J Affect Disord 2012, http//dx.doi.org/10.1016/J.Jad.2012.08.008
• World Health Organization-Regional Office for Europe. Impact of Economic Crisis on Mental Health. Copenhagen, WHO, 2011
• Sareen J, Affifi T, MacMillan K et al. Relationship between household income and mental disorders. Arch Gen Psychiatry 2011, 68:419–427

Full article in pdf