Slovenia.

Slovenia, with an area of 20 000 km2 and a population of 2 million, is one of the smallest members of the European Union. It gained its independence from Yugoslavia in 1991. The country has a gross domestic product (GDP) of US$27 300 per capita. (Largely because of its historical links with Western Europe, Slovenia has a higher GPD compared with other countries in transition in Central Europe.) The health budget represents 8.4% of GDP. Slovenia has a low birth rate and an ageing population. It is divided into 210 municipalities; however, the reorganisation of government into several separate regions with more administrative and economic autonomy is in progress. The prevalence of mental illness is comparable to that in other European countries, although there are high levels of alcoholism and suicide.

Mental health policy and legislation

Slovenia is a democratic country with a parliamentary form of government. The government must generally endorse all healthcare reforms before they are implemented. The Law of Healthcare and Health Insurance presents the basis for compulsory and voluntary health insurance and also allows for the privatisation of healthcare. The Health Insurance Institute of Slovenia is a public non-profit institution, which is overseen by the state and is bound by the Law on Compulsory Health Insurance. Ministries, government agencies and offices have an administrative and regulatory function and are also responsible for the development of health policy, preventive programmes and health promotion. The state is also the owner and director of public health institutions, such as hospitals and clinics.

Currently the National Programme for Mental Health is in the process of being passed in parliament, as is the new Law on Mental Health. Until now, the provisions of the Non-contentious Procedure Act from 1999 have been used, but these are not in accordance with the constitution. The new Law on Mental Health establishes a network of implementers of mental health programmes and services, defines the rights of people in the network (including the right to a representative or lawyer), establishes the conditions and manner of the appointment of representatives, coordinators of supervisory proceedings and coordinators of services, and regulates the procedure for voluntary or involuntary admission to a psychiatric hospital or social welfare institution. It also contains an innovation, the supervision of patients with psychiatric disturbances in their local community. This would mainly hold true for patients with severe psychiatric disturbances.

Mental health service delivery

The healthcare system and mental health service delivery are both defined by the Law on Medical Services. Mental health institutions are part of the public health network; there are no private psychiatric hospitals or centres for long-term care in the country. Only community care is private, with the majority of providers having contracts with the Health Insurance Institute. Access to psychiatric services is available to everyone and it is paid for by the Health Insurance Institute with funds from compulsory health insurance.

Real deinstitutionalisation of psychiatry has never been achieved in Slovenia. There are four general psychiatric hospitals, one psychiatric clinic and one department of a university clinical centre. This provision amounts to 0.85 beds/1000 inhabitants, which includes beds occupied by patients under compulsory and forensic care. There are 5.4 psychiatrists per 100 000 inhabitants and 5.8 psychiatric nurses per 100 000 inhabitants, who are mainly employed in psychiatric hospitals. Within the Psychiatric Clinic and the University Clinical Centre there are two departments of child and adolescent psychiatry, while another department of child psychiatry is located at the Children’s Hospital. In Slovenia there are 24 specialists in child and adolescent psychiatry.

Adults with special needs or those with severe and chronic mental disorders are treated in five institutions, which are partly financed by health insurance funds and partly from social welfare.

Community psychiatric treatment is provided by psychiatrists who are otherwise employed in psychiatric hospitals, by those in health centres and by private psychiatrists who have contracts with the Health Insurance Institute. There are community care facilities for patients with mental disorders, but a broader system of community mental health has not yet been developed. Psychiatric hospitals and clinics provide professional support and education for those employed in non-government organisations, which are active in rehabilitation, the integration of patients into society, counselling and other forms of assistance, and also play an active role in anti-stigma programmes. Within their framework there are 44 residential groups, 22 day centres and 14 information offices.

Slovenia also has specific programmes for the mental health of minorities, refugees, the elderly and children. Educational programmes are run for general practitioners, and teachers, school counsellors and others for the recognition of suicidal tendencies.

Psychiatric training

In Slovenia there are two medical faculties. Medical studies last 6 years. One faculty is linked to the Psychiatric Clinic in Ljubljana, the other to the Psychiatric Department of the University Clinical Centre in Maribor. After completion of studies and a 1-year internship it is possible to specialise in psychiatry.

The Medical Chamber of Slovenia is responsible for specialisation, licensing, issuing a code of medical ethics and supervising clinical practice. Membership of the Medical Chamber is compulsory for all professionals. A call for applications for specialisation in all fields is made by the Medical Chamber twice a year, according to national needs. Annually there are on average advertisements for 15 vacant positions for specialisation in psychiatry, but the positions remain unfilled because of the severe shortage of doctors throughout the country. Training for specialisation in psychiatry lasts 5 years, as does training in child and adolescent psychiatry. Both specialisations have a common 2-year programme, after which they differ.

Psychiatric sub-specialties and allied professions

Psychotherapy is only partly included in the specialisation programme (4 months); a longer period of psychotherapy training is not compulsory. The specialisation in clinical psychology lasts 4 years, and is advertised by the Ministry of Health. There is no special specialisation for psychiatric nurses, but only additional education, which is run by the two university psychiatric institutions with the assistance of the Nursing Chamber of Slovenia.

Main areas of research

Slovenian psychiatry is rather underdeveloped in the area of research. Only one professional psychiatric journal is published, and this does not have an impact factor. There is no research institute in the field of psychiatry in the country; hence research is left to interested and highly motivated professionals.

The Institute of Public Health of the Republic of Slovenia has carried out research in the field of suicide. Slovenia has one of the highest suicide rates in the world, with 22.7 suicides per 100 000 inhabitants per year. The suicide rate has, though, declined since 1992, when it was 28.9 per 100 000 population. There is a higher suicide rate among men (38.2 per 100 000 population) than among women (9.19 per 100 000 population). Most alarming is the extremely high suicide rate in the over-65 age group, of 48.45 per 100 000, with the rate in males reaching 94.85/100 000 population. This places Slovenia foremost globally for suicides among the elderly.

Other research is being carried out in the field of pharmacogenetics, in collaboration with faculty institutions, and into cognitive functions in some severe physical illnesses.

Workforce issues, resources

There is still too little employment in the field of psychiatry. There is a shortage of doctors in Slovenia and despite increased enrolment in the medical faculties no increase in the number of doctors or psychiatrists can be expected until 2015. The employment of psychologists, psychiatric nurses, occupational therapists and social workers is dependent on the budget of each institution. Perhaps part of the problem will be solved by increased privatisation in health, especially in community care. Private psychiatrists can choose between patients, as they have long waiting lists; this places a heavy burden of patient management onto hospital psychiatrists, who run a 24-hour emergency service. The new national health programme envisages larger work obligations for private psychiatrists.

Human rights issues

Slovenia has a human rights ombudsman, whose office intensively oversees human rights, especially in psychiatric hospitals and prisons. In parliament, a new law on patients’ rights was approved in April this year. This introduces more ombudsmen for patients’ rights throughout the country (previously there had been only one). Also in parliament, a new Mental Health Act is awaiting approval. This will introduce a national plan on mental healthcare, and reform psychiatric services towards a more community-oriented approach.