Financing Mental Health Care in Spain: Context and critical issues

Authentic Self and Last Resort: International Perceptions of Psychiatric Neurosurgery

Psychiatric neurosurgery has resurfaced over the past two decades for the treatment of severe mental health disorders, with improved precision and safety over older interventions alongside the development of novel ones. Little is known, however, about current public opinions, expectations, hopes, and concerns over this evolution in neurotechnology, particularly given the controversial history of psychosurgery. To fill this knowledge gap, we conducted a study with eight focus groups in Vancouver and Montreal (Canada; n = 14), Berlin (Germany; n = 22), and Madrid (Spain; n = 12). Focus group texts were transcribed and analyzed using qualitative content analysis in the language local to each city, guided by the theoretical framework of pragmatic neuroethics. Findings indicate that participants across all cities hold concerns about the last resort nature of psychiatric neurosurgery and the potential impact on the authentic self of patients who undergo these procedures. The views captured serve to advance discussion on the appropriate timing for psychiatric neurosurgery, promote sound health policy for the allocation of this resource, and foster scientific literacy about advances for mental health internationally.

Effects of macroeconomic fluctuations on mental health and psychotropic medicine consumption

Our aim in this paper is to understand the impact of macroeconomic fluctuations on mental health and psychotropic medicine consumption. In order to do that we exploit differences in the fluctuations of business cycle conditions across regional units in Catalonia. Our findings suggest that, in general, economic fluctuations at the local level had no significant effect on the consumption of psychotropic medicines. However, we show that a deterioration in local labour market conditions is associated with a reduction in the consumption of anxiolytics medicines. We also report an increase in the consumption of anxiolytics in regions with a softer deterioration in the economic situation. Although we report mild improvements in both mental and physical health for some sub-groups of the population, we also find significant reductions on the probability of sleeping 6 h or more. Thus, these elements point towards potential negative effects of local labour market conditions on health in the medium/long term.

[On the roller coaster: An abridged history of mental health planning in Spain. SESPAS Report 2020]

Effective mental health change in Spain started in 1985 with the Report of the Ministerial Commission for the Psychiatric Reform that recommended integrating psychiatric care into the general health system, providing care in the patient's context and for specific diagnoses. The SESPAS 2002 Report carried out an analysis of this reform and recommended the creation of a permanent ministerial commission, the design of a national map of socio-sanitary mental health services, the creation of a coordination and promotion agency for and carrying out a financial analysis of resource provision and research. Since 2004, the Technical Committee for the Mental Health Strategy boosted the elaboration of a theoretical and normative framework that unfortunately did not lead to a road map for the improvement of the system. After 2011, during the financial crisis, the Ministry of Health lost the opportunity to lead a second phase of change of the mental health care, which was evidence-based: no key technical reports were published nor was an action plan based on data developed. Currently, the 1985 community mental health model is still the general framework of mental health care with the addition of aspects related to the recovery model and the balance of care model. Significant progress has been made in developing care systems assessment methods and data-based models that could advance mental health planning. The gap between general health attention and mental health care has increased and the expected reform of the mental health system will not take place in the near future.

Attachment-based compassion therapy and adapted mindfulness-based stress reduction for the treatment of depressive, anxious and adjustment disorders in mental health settings: a randomised controlled clinical trial protocol

INTRODUCTION

Depressive, anxiety and adjustment disorders are highly prevalent among mental health outpatients. The lack of funding for mental health problems produces inefficient results and a high burden of disease. New cost-effective group interventions aimed at treating these symptoms might be an appropriate solution to reduce the healthcare burden in mental health units. Mindfulness-based interventions (MBIs) have shown significant reductions in anxious, depressive and adjustment symptomatology. Recent research highlights the influence of compassion as a key mechanism of change. However, MBIs only address compassion implicitly, whereas compassion-based protocols consider it a core aspect of psychotherapy. In this randomised controlled trial, we hypothesise that the provision of attachment-based compassion therapy (ABCT), which is a compassion-based protocol, will be more effective than mindfulness-based stress reduction (MBSR), which is a conventional MBI programme, for the treatment of depressive, anxious and adaptive symptoms in patients in mental health settings.

METHODS AND ANALYSIS

Approximately 90 patients suffering from depressive, anxious or adjustment disorders recruited from Spanish mental health settings will be randomised to receive 8 weekly 2 hours group sessions of ABCT, 8 weekly 2.5 hours group sessions of adapted MBSR (with no full-day silent retreat) or treatment as usual (TAU), with a 1:1:1 allocation rate. Patients in the ABCT and adapted MBSR groups will also receive TAU. The main outcome will be general affective distress measured by means of the 'Depression Anxiety Stress Scales-21' at post-test as primary endpoint. Other outcomes will be quality of life, mindfulness, self-compassion and the use of healthcare services. There will be a 6-month follow-up assessment. Intention-to-treat analysis will be conducted using linear mixed models. Per-protocol and secondary outcome analyses will be performed. A data monitoring committee comprising the trial manager, the ABCT and MBSR teachers and an independent clinical psychologist will monitor for possible negative side effects.

ETHICS AND DISSEMINATION

Approval was obtained from the Ethics Committee of the General University Hospital of Castellón, Spain. The results will be submitted to peer-reviewed specialised journals, and brief reports will be sent to participants on request.

TRIAL REGISTRATION NUMBER

NCT03425487.

Use of an integrated Atlas of Mental Health Care for evidence informed policy in Catalonia (Spain)

BACKGROUND

This paper aims to present the Integrated Atlas of Mental Health of Catalonia (2010) focusing on: (a) the importance of using a taxonomy-based coding and standard system of data collection when assessing health services; and (b) its relevance as a tool for evidence-informed policy.

METHOD

This study maps all the care-related services for people with mental disorders available in Catalonia in 2010, using the 'Description and Evaluation of Services and Directories in Europe for long-term care' (DESDE-LTC). The unit of analysis is the Basic Stable Input of Care (BSIC), which is the minimal organisation unit composed by a set of inputs with temporal stability. We presented data on: (a) availability of BSICs and their capacity; (b) the adequacy of the provision of care, taking into account availability and accessibility; (c) the evolution of BSCIs from 2002 to 2010; and (d) the perceived relevance of Atlas of Mental Health as a tool for evidence-informed policy.

RESULTS

We identified a total of 639 BSICs. A lack of Health services was detected in highly rural areas, although there was moderate availability of Social Services. Overall, more than 80% of the small mental health areas in Catalonia had an adequate core mental health service. Since 2002 the availability of mental health services has increased. Decision makers found the Atlas a useful and relevant tool for evidence informed policy.

CONCLUSIONS

Policy makers can use Atlases to detect gaps and inequities in the provision of care for people with mental health needs.

Inequalities in Mental Health in the Spanish Autonomous Communities: A Multilevel Study

The aim of this study was to analyze inequalities in the prevalence of poor mental health and their association with socioeconomic variables and with the care network in the Autonomous Communities in Spain. A cross-sectional multilevel study was performed, which analyzed individual data from the National Health Survey in Spain (ENS), in 2006 (n = 29,476 people over the age of 16). The prevalence of poor mental health was the dependent variable, measured by the General Health Questionnaire (GHQ-12 > = 3). Individual and contextual socioeconomic variables, along with mental health services in the Autonomous Communities, were included as independent variables. Models of multilevel logistic regression were used, and odds ratios (OR) were obtained, with confidence intervals (CI) of 95%. The results showed that there are inequalities in the prevalence of poor mental health in Spain, associated to contextual variables, such as unemployment rate (men OR 1.04 CI 1.01–1.07; women OR 1.02 CI 1.00–1.05). On the other hand, it was observed that inequalities in the mental health care resources in the Autonomous Communities also have an impact on poor mental health.

An integrative cross-design synthesis approach to estimate the cost of illness: an applied case to the cost of depression in Catalonia

BACKGROUND

Cost of illness (COI) studies are carried out under conditions of uncertainty and with incomplete information. There are concerns regarding their generalisability, accuracy and usability in evidence-informed care.

AIMS

A hybrid methodology is used to estimate the regional costs of depression in Catalonia (Spain) following an integrative approach.

METHODS

The cross-design synthesis included nominal groups and quantitative analysis of both top-down and bottom-up studies, and incorporated primary and secondary data from different sources of information in Catalonia. Sensitivity analysis used probabilistic Monte Carlo simulation modelling. A dissemination strategy was planned, including a standard form adapted from cost-effectiveness studies to summarise methods and results.

RESULTS

The method used allows for a comprehensive estimate of the cost of depression in Catalonia. Health officers and decision-makers concluded that this methodology provided useful information and knowledge for evidence-informed planning in mental health.

CONCLUSIONS

The mix of methods, combined with a simulation model, contributed to a reduction in data gaps and, in conditions of uncertainty, supplied more complete information on the costs of depression in Catalonia. This approach to COI should be differentiated from other COI designs to allow like-with-like comparisons. A consensus on COI typology, procedures and dissemination is needed.

The state of psychiatry in Spain

The 1986 General Health Act and the so-called 'psychiatric reform' were key issues in the development of the mental healthcare system (MHCS) in Spain. The World Health Organization Declaration and Action Plan on Mental Health in 2005 gave it a revitalizing impetus and resulted in the first National Health System (NHS) Mental Health Strategy in 2006. A literature search was performed using MEDLINE, Spanish journals, reference lists, national databases, and European and Spanish official documents to describe the current state of the MHCS in Spain. The main results were: (1) existence of great variability among the autonomous communities with respect to mental health resources and provision of care; (2) lack of national epidemiological information on mental disorders with the exception of substance use disorders and suicide, which comprise powerful longitudinal national data, (3) training in psychiatry is well established, although there is no specialism of child and adolescent psychiatry, and (4) a dramatic increase in scientific productivity in the last decade among research groups, in part due to the creation of the Spanish Mental Health Network, the Centro de Investigación Biomédica en Red en el Área de Salud Mental (CIBERSAM). Quantifiable and reliable indicators are needed to provide efficient monitoring and analysis of epidemiological events and subsequently to understand the status of the Spanish MHCS.

Saúde mental e os planos de saúde no Brasil

O artigo analisa o regime de regulação da assistência à saúde mental implantado pela Agência Nacional de Saúde Suplementar. Descreve as condições observadas entre a provisão de serviços de saúde mental no setor de planos privados de assistência à saúde em relação à experiência internacional e ao Sistema Único de Saúde (SUS). O artigo demonstra que a assistência à saúde mental do setor apresenta as falhas associadas ao mercado de seguro saúde. As empresas de planos de saúde adotam mecanismos de copagamento, estabelecem limites de utilização para consultas ambulatoriais, enfatizam o tratamento dos casos graves por internação hospitalar de curta duração e oferecem residualmente serviços de suporte ao paciente após a alta. Existem evidências de um descompasso entre o processo de desinstitucionalização em curso no SUS e a regulação implantada pela ANS. Em fins da década de 2000, foi observada a expansão da quantidade das internações psiquiátricas que resultaram em taxas elevadas de admissão se comparadas ao setor público no Brasil.

Meeting the challenge of funding and allocating resources to mental health across Europe: developing the Mental Health Economics European Network

Aims – There is growing demand for economic analysis to support strategic decision-making for mental health but the availability of economic evidence, in particular on system performance remains limited. The Mental Health Economics European Network (MHEEN) was set up in 2002 with the broad objective of developing a base for mental health economics information and subsequent work in 17 countries. Methods – Data on financing, expenditure and costs, provision of services, workforce, employment and capacity for economic evaluation were collected through bespoke questionnaires developed iteratively by the Network. This was augmented by a literature review and analysis of international databases. Results – Findings on financing alone suggest that in many European countries mental health appears to be neglected while mechanisms for resource allocation are rarely linked to objective measure of population mental health needs. Numerous economic barriers and potential solutions were identified. Economic incentives may be one way of promoting change, although there is no one size fits all solution. Conclusions – There are significant benefits and synergies to be gained from the continuing development of networks such as MHEEN. In particular the analysis can be used to inform developments in Central and Eastern Europe. For instance there is much that can be learnt on both how the balance of care between institutional and non-institutional care has changed and on the role played by economic incentives in ensuring that resources were used to develop alternative community-based systems.

Declaration of Interest: none of the authors have received any financial support that presents a conflict of interest.

Development and spatial representation of synthetic indexes of outpatient mental health care in Andalusia (Spain)

INTRODUCTION

There is a need to develop composite indicators to monitor mental health care in countries such as Spain, where there is wide variability of care systems in 17 different regions. The aim of this study is to generate and to test the usability of synthetic indexes in Andalusia (Southern Spain).

METHOD

Seven mental health indicators were selected by expert opinion from a previous list of simple indicators used to compare mental health care systems across Spain (Psicost-74). A Geographical Information Systems (GIS) was used to delineate 71 sectors based on the catchment areas of the mental health centers in Andalusia. Synthetic indexes were obtained through linear combinations of simple indicators via Principal Components Analysis (PCA), using activity data from the Mental Health Information System of Andalusia (SISMA). Maps of these indexes were drawn for 71 catchment areas.

RESULTS

Two synthetic indexes were obtained and showed high consistency in the PCA. The Care Load Index (component 1) related to population size and total outpatient care provided within the area. The Case Load Index (component 2) related to assisted morbidity in relation to the population size. The care load index was higher in populated urban areas, whereas the case load was higher in rural areas.

DISCUSSION

Care and case load indexes show a different pattern in urban and rural areas. This may be related to a different underlying model of care related to the degree of urbanisation. Geographical Information Systems (GIS) improved recognition and assessment of the spatial phenomena related to the mental health care system, and support policy decision making process in mental health.

Spatial analysis to identify hotspots of prevalence of schizophrenia

INTRODUCTION

The geographical distribution of mental health disorders is useful information for epidemiological research and health services planning.

OBJECTIVE

To determine the existence of geographical hotspots with a high prevalence of schizophrenia in a mental health area in Spain.

METHOD

The study included 774 patients with schizophrenia who were users of the community mental health care service in the area of South Granada. Spatial analysis (Kernel estimation) and Bayesian relative risks were used to locate potential hotspots. Availability and accessibility were both rated in each zone and spatial algebra was applied to identify hotspots in a particular zone.

RESULTS

The age-corrected prevalence rate of schizophrenia was 2.86 per 1,000 population in the South Granada area. Bayesian analysis showed a relative risk varying from 0.43 to 2.33. The area analysed had a non-uniform spatial distribution of schizophrenia, with one main hotspot (zone S2). This zone had poor accessibility to and availability of mental health services.

CONCLUSION

A municipality-based variation exists in the prevalence of schizophrenia and related disorders in the study area. Spatial analysis techniques are useful tools to analyse the heterogeneous distribution of a variable and to explain genetic/environmental factors in hotspots related with a lack of easy availability of and accessibility to adequate health care services.