A needs survey among patients in Leros asylum

Τhe Contribution of Mobile Mental Health Units to Community Psychiatric Care in Greece

The implementation of Mobile Mental Health Units (MMHUs) was a decisive step in the psychiatric reform and the development of community psychiatric care in Greece [...]

The adventures of psychiatric reform in Greece: 1999-2019

Psychiatric care in Greece has a long history of traditional in-patient treatment in large public institutions (the public asylum period), which lasted until 1983. European Economic Community (EEC) intervention in 1984 marked a transitional period (1984-1989) characterised by the beginning of the transformation of the mental healthcare system. The current reform era started in 1999 and has included new mental health law, the closure of six public mental hospitals and the establishment of several sectorised mental health services.

Reform of the mental healthcare system in Greece, 1984–2006

Greece joined the European Community in 1981 and, 3 years later, the Commission of the European Communities provided financial and technical assistance under EEC Regulation 815/84 for the modernisation of the Greek mental healthcare system, with an emphasis on decentralisation and the development of community-based services, as well as the deinstitutionalisation of long-stay patients and improvement of conditions in public mental hospitals.

Psychiatric reform in Greece: an overview

Leros became infamous worldwide in the 1980s because of a scandal in its mental institution, the Leros asylum. The scandal provoked universal outrage and the international pressure triggered the Greek mental health reform. Under the reform projects Leros I and Leros II (1990-1994), numerous interventions took place in the Leros asylum as part of deinstitutionalisation. Following that, the Psychargos programme advanced developments for community-based services. Deinstitutionalisation and development of community mental health services have advanced significantly since the 1980s. However, this reform is still incomplete, given that sectorisation, adequate primary care policies, inter-sectoral coordination and specialised services are under-developed. This problematic situation is further complicated by the severe impact of the current financial crisis.

Quality of life of residents of the community hostels of Leros-Greece: clinical and social functioning profile of the ex-patients

BACKGROUND

The quality of life experiences of the chronically mentally ill have received increased attention in outcome research lately and constitute a critical outcome of mental health.

AIMS

This study evaluated the perceived quality of life of the former psychiatric patients (N = 103) who have been moved from the Psychiatric Hospital of Leros to community hostels (N = 19) in Leros Island. In addition, the residents' clinical and social functioning profiles were examined together with the extent of institutional practices by the staff in residents' environment.

METHOD

The present research is a cross-sectional study examining the impact of the transformation programmes Leros I and Leros II on the well-being of long-term psychiatric clients following the move.

RESULTS

The majority of the residents expressed high levels of satisfaction, in almost all variables of quality of life, except the variable of contact with family relations. The level of psychopathology was very low, while the majority of residents expressed low community and social skills. Finally, the staff (N = 64) allowed in a way, the expression of autonomy in the residents' environment.

CONCLUSIONS

This study suggests that even the most chronic psychiatric population of Greece is able to give valid and reliable responses concerning the manner in which they perceive their present life.

Cancer incidence in patients with schizophrenia and their first-degree relatives - a meta-analysis

OBJECTIVE

Controversy concerning cancer incidence in schizophrenia exists because of heterogeneous study findings.

METHOD

A meta-analysis was performed on standardized incidence ratios (SIR) of cancer in patients with schizophrenia and first-degree relatives and compared with general population samples.

RESULTS

The pooled overall cancer incidence in patients was not significantly increased (SIR = 1.05, CI 0.95-1.15). Lung cancer incidence was slightly increased (SIR = 1.31, CI 1.01-1.71), but was reduced after adjusting for smoking prevalence. The incidence of several cancers unrelated to smoking was reduced in patients. Breast cancer rates were significantly increased in female patients. The pooled overall cancer incidence in siblings (SIR = 0.89, CI 0.84-0.94) and parents (SIR = 0.90, CI 0.88-0.93) was significantly reduced. A meta-regression detected a significant relationship between cancer risk in the general population and relative risk in patients.

CONCLUSION

The meta-analysis aided exploration of inconsistent study findings. There is a discrepancy between cancer risk exposure and cancer incidence in schizophrenia consistent with a protective effect.

Greece

The history of mental healthcare offered to people with intellectual disabilities in Greece runs in parallel to that of people suffering from severe psychiatric disorders. Until the early 1980s, it was based on 9 overcrowded and understaffed state and 40 private psychiatric hospitals with a mixed population of patients with psychosis and of those with intellectual disabilities (Madianos et al, 1999). The psychiatric reforms began with Law 1397 in 1983, which introduced the National Health System, and, in the following year, European Council Regulation 815/84, through which financial aid was approved and a 5-year plan adopted. The main goal was the development of a network of community-based services in geographically sectorised areas, to replace the large psychiatric hospitals. Mental health centres, psychiatric units in general hospitals and many other community services were to be established, according to local requirement.

[Needs for care in psychiatric patients: a systematic review. II. Needs for care on individual]

OBJECTIVE

The present paper represents the second part of a larger review on the studies assessing needs for care in mental health field. In the first part, studies assessing needs for services in the general population were reviewed. In this second part studies assessing needs on individual level were reviewed and the role played by the assessment of individual needs in planning mental health care was discussed.

METHODS

Studies published in international literature from January 1980 to June 1999 were reviewed. The studies were located through a computerised search of the databases MEDLINE and PsycLit; in addition, the reference lists of the studies located through the computerised search and the content of main international psychiatric journals were manually scanned in order to avoid possible omissions. Studies assessing needs in the general population and in psychiatric patients were reviewed separately. The latter were reviewed on the basis of the diagnostic category (psychotic and non psychotic patients) and setting of care (outpatients and inpatients). Studies on particular categories, such as homeless, children and adolescents, elderly and patients with aggressive behaviour, have been also reviewed.

RESULTS

Psychotic patients show a wide range of both clinical and social needs. Patients followed by community-based mental health services show similar number of clinical and social needs, while inpatients (with the exception of acute patients) show more social needs. For both community-based mental health patients and inpatients, social needs are most frequently unmet and psychopharmacological treatments are used more frequently than psychotherapeutic or rehabilitative interventions. Non psychotic patients show lower number of needs than psychotic patients; these needs are both clinical and social, with a higher total number of clinical needs, but a higher number of unmet social needs.

CONCLUSIONS

Studies on needs for care provide an interesting perspective on people suffering from mental illness. In the routine clinical practice needs assessment could be a valuable tool for providing specific, individualised and effective mental health care.

[Therapeutic needs in psychiatric patients: a systematic review of the literature. I. General concepts and assessment measures. Needs for services]

OBJECTIVE

In Italy, mental health care is in phase of reorganisation. In this frame the measurement of users' needs may be a useful tool in planning individualised mental health service interventions and in their evaluation. Aims of the present study are (I) to highlight the basic concepts of 'needs for care' and give a brief description of the main needs assessment tools specifically developed for psychiatric patients; (II) to review studies assessing needs for mental health services in the general population; (III) to discuss the role played by the assessment of needs in planning mental health care.

METHODS

Studies published in the international literature from January 1980 to June 1999 were reviewed. The studies were located through a computerised search of the databases MEDLINE and PsycLit; in addition, the reference lists of the studies located through the computerised search and the content of main international psychiatric journals were manually scanned in order to avoid possible omissions. Studies assessing needs for services and studies assessing needs on individual level were separately reviewed. Both groups of studies, in turn, were divided in studies assessing needs for mental health care in the general population and in psychiatric patients.

RESULTS

Although most studies on needs for services used indirect methodologies and employed quite heterogeneous experimental design, they provide at large overlapping results. In the general population, about 60%-70% of patients with anxiety, depression and other neurotic disorders and 30%-40% of psychotic patients do not receive any specialist mental health care, suggesting that the majority of subjects suffering from a psychiatric disorder do not receive the mental health care they need.

CONCLUSIONS

Unmet needs for services show a higher frequency in patients with neurotic and depressive disorders, indicating a shortage in services delivery that should be taken into account both by psychiatrists and mental health planners. Moreover, the finding that a large number of patients suffering from psychotic disorders do not receive any kind of mental health care is of particular relevance for planning mental health services, since these subjects are usually the most problematic and difficult to treat.

Schizophrenia, substance use disorders and medical co-morbidity

OBJECTIVES: This study compared medical treatment costs of adults with schizophrenia to adults with both substance use disorders and schizophrenia. METHODS: This cross-sectional observational study used a paid claims data base to identify 6884 adults treated for schizophrenia. Twenty percent of these also had substance use disorder. We report the costs and likelihood of hospitalization for eight common medical diseases, and the categories of injuries and poisoning, and ill defined conditions. Multivariate analyses were used to adjust rates of treatment for age and sex differences in the comparison groups. RESULTS: There were higher rates of treatment for five of the eight medical disorders, higher treatment costs for two of the medical disorders and much higher costs for psychiatric treatment among those with comorbid substance use disorders. Both groups had high rates of treatment in the categories of injury and poisoning and ill defined conditions. CONCLUSIONS: Closer working relationships among mental health and medical professionals are needed to care for those with schizophrenia and substance use disorders: first, greater attention to the treatment of substance use disorders may improve the health status of those with schizophrenia, reduce their costly medical and psychiatric care and stabilize their psychiatric condition, and second, continuity of care among professionals may promote willingness to seek medical attention or alleviate misunderstandings when adults with schizophrenia present with medical problems.

The mental health care delivery system in greece: regional variation and socioeconomic correlates

BACKGROUND: In Greece, the functional capacity of the mental health care system until 1980, was totally inadequate to meet the increasing mental health needs of the population and to provide efficient and community-based services. This situation was brought to the attention of the Commission of European Communities and a special EEC Regulation No 815/84 provided the financial technical support for an extended psychiatric reform programme. The psychiatric reform programme initiated in 1984 and ended in 1995. AIMS OF THE STUDY: This study compared the geographical distribution of neuropsychiatrists and the mental health care delivery system structural components (psychiatric beds, extramural mental health units and places in rehabilitation services), according to the regional socioeconomic development for the years 1984, 1990 and 1996. Additionally the possible effects of the operation of community-based mental health services on the psychiatric hospitalizations were examined. METHODS: Data on the geographical distribution of neuropsychiatrists in the previously mentioned years were drawn from local Medical Association from each of 54 prefectures of the country. The corresponding distribution of the mental health care delivery system components was made available from the database of the Monitoring and Evaluation of Mental Health Services Unit. Pearson product moment correlations of the regional distribution of neuropsychiatrists and the various components of the mental health care system, as population-based ratios, with the corresponding socioeconomic development in the form of the general index of development were performed. Mental hospital age standardized rates were collected from the Hospital Central Register for the periods 1984-1987 and 1990-1993. Discharge rates were elaborated according to the existence of mental health services in specific regions. RESULTS: A wide regional variation in neuropsychiatrists per 100000 population was found in all three years, with the majority of them working in the greater Athens and Thessaloniki areas. In the geographical distribution of health regions, there is an uneven significant decrease in psychiatric beds between 1984 and 1996. However in almost all regions an increase in extramural services between the two critical periods was noticed, as part of the implementation of the psychiatric reform programme. A parallel and more dramatic increase in the places of rehabilitation in 12 out of 13 regions has been observed during the implementation of the reform programme. At the level of prefectures, the changes across time, in the mean ratios of beds, extramural services and rehabilitation places were not found to be significant. A significant decrease of discharges in prefectures covered by newly established extramural services for the period 1990-1993, compared to discharge rates during the period 1984-1987, when none of these services were in operation in these prefectures, was noticed. The intercorrelation matrix between the various mean values (1990-1996) of the mental health care system components in the 54 prefectures and the local general index of development scores produced statistically significant correlation coefficients. It seems that the greater the level of local socioeconomic development the higher the degree of mental health care delivery system growth. DISCUSSION: Our results have shown uneven regional distribution of neuropsychiatrists, as well as extramural mental health units and rehabilitation places, despite the current reorganization of the whole mental health care delivery system. The positive correlation between the various structural components of the system in the 54 prefectures and the local socioeconomic conditions could be interpreted as follows. Urban areas of higher socioeconomic growth had a long history of development of inpatient services in mental hospitals. In these several community-based alternatives have been established for their transformation into modern ones. Urban areas exhibit also higher psychiatric morbidity and therefore increasing mental health needs. Additionally in several cities local University Psychiatric Departments have developed a variety of mental health and rehabilitation services. Many new services highly specialized and complementary to existing mental hospitals were established in urban areas. Rural areas are mostly uncovered by mental health care facilities. However it seems that the establishment of community-based services could have an effect on mental hospital utilization. CONCLUSION: It becomes evident that after the implementation of the psychiatric reform programme in Greece significant progress in the areas of decentralization of mental health and rehabilitation services has been observed. However there are still areas in many prefectures, mainly rural or semirural, lacking the appropriate delivery of mental health care. IMPLICATIONS FOR HEALTH CARE AND POLICY FORMULATION: Our results suggest that flexible models of services should be introduced for the benefit of population living in areas lacking the necessary socioeconomic resourses. IMPLICATIONS FOR FUTURE RESEARCH: Mental health services research in Greece should focus on quasi-experimental studies on the effectiveness of various models of mental health care in areas of different socioeconomic growth.

Changing patterns of mental health care in Greece (1984-1996)

Greece joined the European Community in 1981 and, three years later, the Commission of the European Communities provided financial and technical assistance under EEC Regulation 815/84 for the modernisation of the traditional psychiatric care system, with the emphasis on decentralisation of mental health services and the development of community-based services, as well as on deinstutionalization of long-stay patients and improvement of conditions in public mental hospitals. Over the last 11 years, the implementation of the EEC Reg. 815/84 programme contributed to a significant shift towards extramural care and rehabilitation. The role of the large mental hospitals has gradually been diminished and a large number of long-stay patients have been deinstitutionalised. It is commonly accepted that the EEC-funded psychiatric reform programme, despite inadequacies and constraints, had an impact on the changing mental health scene in Greece.

From Leros asylum to community-based facilities: levels of functioning and quality of life among hostel residents in Greece

The pattern of mental health care in Greece is undergoing a major transformation. The Leros Projects I and II supported the development of 13 community hostels located throughout the Greek mainland. These hostels provide residential care to more than 100 former psychiatric inpatients, mainly from Leros asylum. The present study evaluates the impact of the resettlement process on the residents' perceived quality of life (QoL) together with an examination of the residents' psychiatric and behavioural functioning four years after the move from hospital. The target sample (n = 99) comprised of individuals who may be considered 'chronic' psychiatric patients with a long history of institutionalisation and many are socially deprived with few family ties. The residents' functioning profile indicates a range of different levels of abilities. The QoL findings show that the majority of residents (70%) perceived the movement from the traditional hospital regime to the community hostels as being a positive change and expressed their satisfaction (74%) with the new living situation. This study demonstrates that even the most dependent, chronic psychiatric patients in Greece can be maintained in community settings and are able to articulate generally reliable and valid responses concerning the impact of service changes.