Mental healthcare for older adults in rural Greece

First-contact patients with a community mental health service in rural Greece: A 3-year prospective study of treatment attendance and its co-relations

BACKGROUND

Treatment continuation is essential for the optimal management of patients with mental disorders in the community, but treatment and outcome are often undermined by the high rates of service disengagement and treatment non-adherence across all psychiatric diagnoses. The phenomenon may be even more relevant in rural settings.

AIMS

The aim of the present study was to explore attendance to treatment in first-contact patients in a community-based treatment setting in rural Greece and to explore the associations of treatment attendance with demographic and clinical factors.

METHOD

Data were collected prospectively over a 3-year period, with 1-year follow-up interval. All first-contact cases with the Mobile Mental Health Unit of the prefectures of Ioannina and Thesprotia (MMHU I-T), Northwest Greece were considered, but only clinical cases were processed.

RESULTS

The sample size consisted of 446 patients, with a mean age 65.4 ± 18.8 years. The rate of 12-month attendance to mental health treatment was 13.5% (60 out of 446 patients). Treatment attendance was found to be correlated with younger age, the diagnosis of schizophrenia-spectrum disorder, and patients' referral by other psychiatric services. First examination over the year 2019 had been significantly inversely associated with treatment engagement.

CONCLUSION

Rates of subsequent attendance after initial assessment in a rural community mental healthcare setting were rather low in the present study. Several variables that have been previously associated with service engagement were found to be related in this study too, whereas other were not. Research on treatment engagement in rural treatment settings should be ongoing to reveal all associated factors.

Mobile Mental Health Units in Heraklion Crete 2013–2022: Progress, Difficulties and Future Challenges

Mobile mental health units (MMHUs) have been proposed as an effective model to serve the mental health needs of remote underserved areas. In 2013, the Department of Psychiatry, University of Crete, started a pilot MMHU to cover the needs of remote rural areas of the Heraklion Prefecture. The main objectives were early detection, prevention and therapy of patients with severe psychiatric disorders, without access to regular psychiatric care. In addition to regular visits to primary care health centers, a community support network was established. During this 10-year period, the MMHU has evaluated 3343 patients and performed 19,935 visits. The most frequent diagnoses are depression and anxiety (52.7%) whereas psychosis and bipolar disorders are the third (12.7%) and fifth most frequent diagnoses (4.7%). Half of the patients with depression/anxiety were older than 65 years and one third were living alone. Furthermore, the first visit with the MMHU of severely mentally ill was about 15 years later from the self-reported onset of psychotic symptoms. We discuss how to improve our ability to detect and intervene earlier in patients with severe mental illness, and how to address effectively, both pharmacologically and psychosocially, the depression and loneliness of older individuals living in small remote communities.

Community Psychiatry in Rural Greece: The Role of the Mobile Mental Health Units

Almost a decade ago, an article published in the official journal of the Hellenic Psychiatric Association, concerning the state of Greek mental health reform, referred to the significant shortages of mental health staff and services in rural areas of the country [...]

A comparative study of two Mobile Mental Health Units in different catchment rural areas in Greece

BACKGROUND

Mental healthcare service delivery in rural and remote areas in Greece is challenging due to socioeconomic and geographical reasons, and distant facilities. To address the needs of the underserved areas, the Greek state has launched a number of Mobile Mental Health Units (MMHUs).

AIM

The objective of the present study was to explore the differences among two MMHUs, one being run by a university general hospital (MMHU UHA) and the other being run by a nongovernmental organization (MMHU I-T).

METHODS

The two MMHUs deliver services in rural areas of northeast and northwest Greece, respectively. Both MMHUs use the infrastructures of the primary healthcare system and have the potential for domiciliary visits.

RESULTS

Medical and nursing staff is much more in the MMHU UHA, whereas MMHU I-T has more psychologists, social workers and health visitors. Patients attended the MMHU I-T were significantly older than the patients attended the MMHU UHA (mean age 64.5 vs. 55.3 years) and the percentage of the elderly patients in treatment with the MMHU I-T (56.5%) is significantly higher than the corresponding percentage of the MMHU UHA (20%). The proportion of patients that received home-based care by the two MMHUs was almost identical. The percentage of patients with schizophrenia spectrum disorders that attended the MMHU UHA was significantly higher. Patients with affective disorders, anxiety disorders and organic brain disorders that attended the MMHU I-T were significantly more.

CONCLUSIONS

Despite the similarities among the MMHUs in rural Greece, this study recorded some important differences. The differences in staffing may be accounted for by the availability of resources. The differences in the patients' population may be explained by the fact that the MMHU UHA was designed from its beginning to treat patients with severe mental illnesses, mainly psychoses, and it accepts loss of referrals within the general hospital's network of psychiatric services. The MMHU I-T is an independent, locally based service that may be better perceived as an expansion of the primary care system. The results of the study could inform service practice and mental health policy.

Decrease of hospitalizations and length of hospital stay in patients with schizophrenia spectrum disorders treated in a community mental health service in rural Greece

BACKGROUND

The treatment of severe and chronic mental disorders, such as schizophrenia and related syndromes, is largely based on community mental health services.

AIMS

The objective of the present study was to assess hospital admissions and length of hospital stay in patients with schizophrenia and related disorders, who are engaged to treatment with a Mobile Mental Health Unit (MMHU I-T) in a defined rural catchment area in Greece.

METHOD

Data were retrieved retrospectively for 76 patients with schizophrenia and related disorders. For each patient, comparison was made for the same interval prior and after engagement to treatment with the MMHU I-T.

RESULTS

The average age of patients was 56 years and the mean illness duration was 28 years. The mean follow-up duration was 5.3 years. There was a statistically significant decrease in the annual average of the number of voluntary and involuntary hospitalizations and on days of hospital stay after treatment engagement with the MMHU I-T.

CONCLUSIONS

Treatment of schizophrenia spectrum disorders in rural residents by the MMHUs may contribute to the reduction of patients' admissions and length of hospital stay. Future research should address the cost-effectiveness of such interventions.

Mental Health Care Delivery for Older Adults in Rural Greece: Unmet Needs

Mental disorders may go unrecognized and undertreated in older adults. This is the rationale for the launch of specialized mental health services for the elderly in high resourced settings. Rural areas, however, do not receive adequate mental health care owing to socioeconomic and geographical reasons, and this is the case of rural Greece, where research on mental health of the elderly is scarce. This article discusses the challenges of providing mental health care for older adults in rural Greece and the available options. Care can be delivered through the existing rural mental health services that are the mobile mental health units and through the primary care physicians. Training in psychogeriatrics for the personnel of the former and in mental health for the latter is warranted.

Long-term Benzodiazepine Treatment in Patients with Psychotic Disorders Attending a Mental Health Service in Rural Greece

INTRODUCTION

Long-term benzodiazepine (BZD) treatment in patients with mental disorders is widespread in clinical practice, and this is also the case of patients with schizophrenia, although the evidence is weak and BZD prescription is discouraged by guidelines and medical authorities. Data on BZD prescription are usually derived from national or regional databases whereas information on the use of BZD by patients with schizophrenia and related psychoses in general population-based samples is limited.

MATERIALS AND METHODS

Information for 77 patients with psychotic disorders who were regularly attending follow-up appointments with the multidisciplinary Mobile Mental Health Unit of the prefectures of Ioannina and Thesprotia, Northwest Greece, during 1-year period (2015) was obtained from our database.

RESULTS

From the total of 77 engaged patients, 30 (39%) were regularly prescribed BZDs in the long term, as part of their treatment regimen. Prescribed BZDs were mostly diazepam and lorazepam, in 43.3% of cases each. The mean daily dose of these compounds was 13 mg and 3.77 mg, respectively. Statistical analysis showed a correlation of long-term BZD use with the history of alcohol/substance abuse. Most patients were receiving BZD continuously for several years, and the mean dose was steady within this interval.

CONCLUSIONS

A large proportion of patients with psychotic disorders were regularly prescribed BZD in long term. It appears that when BZDs are prescribed for some period in the course of a psychotic disorder, their use commonly exceeds the recommended interval and then becomes a regular part of the chronic treatment regimen. Future research should address the factors that may be related to the long-term BZD use by patients with psychotic disorders. Interventions for the reduction of regular BZD prescription should target the primary care setting and all those who treat first episode patients.

Mental Healthcare Delivery in Rural Greece: A 10-year Account of a Mobile Mental Health Unit

Introduction:

Patients living in rural and remote areas may have limited access to mental healthcare due to lack of facilities and socioeconomic reasons, and this is the case of rural areas in Eastern Europe countries. In Greece, community mental health service delivery in rural areas has been implemented through the development of the Mobile Mental Health Units (MMHUs).

Methods:

We present a 10-year account of the operation of the MMHU of the prefectures of Ioannina and Thesprotia (MMHU I-T) and report on the impact of the service on mental health delivery in the catchment area. The MMHU I-T is a multidisciplinary community mental health team which delivers services in rural and mountainous areas of Northwest Greece.

Results:

The MMHU I-T has become an integral part of the local primary care system and is well known to the population of the catchment area. By the end of 2016, the majority of patients (60%) were self-referred or family-referred, compared to 24% in the first 2 years. Currently, the number of active patients is 293 (mean age 63 years, 49.5% are older adults), and the mean caseload for each member of the team is 36.6. A significant proportion of patients (28%) receive care with regular domiciliary visits, and the provision of home-based care was correlated with the age of the patients. Within the first 2 years of operation of the MMHU I-T hospitalizations of treatment, engaged patients were reduced significantly by 30.4%, whereas the treatment engagement rates of patients with psychotic disorders were 67.2% in 5 years.

Conclusions:

The MMHU I-T and other similar units in Greece are a successful paradigm of a low-cost service which promotes mental health in rural, remote, and deprived areas. This model of care may be informative for clinical practice and health policy given the ongoing recession and health budget cuts. It suggests that rural mental healthcare may be effectively delivered by integrating generic community mental health mobile teams into the primary care system.