Mental health profile of Greece.

Since the mid-1980s, a profound reform in the organisation of mental health provision has been taking place in Greece (Madianos & Christodoulou, 2007; Christodoulou, 2009). The aim has been to modernise the outdated system of care (Christodoulou, 1970), which was based on inpatient asylum-like treatment, the beginning of which can be roughly dated to the second half of the 19th century (Christodoulou et al, 2010).

Two major programmes of financial and technical assistance from the European Union, Regulation 815/1984 (1984–94) and Psychargos I and II (1999–2007), greatly contributed to the implementation of the reform. Their main targets were the following:

the provision of community psychiatric services in sectors (‘sectorisation’)

a progressive reduction in the number of traditional hospitals, in parallel with the creation of a network of housing units

the creation of psychiatric units in general hospitals

the creation of mobile units in rural areas and the islands

the establishment of a network of units for psychosocial rehabilitation

the establishment of pilot units for psychogeriatric patients and people with autism.

Mental health policy and legislation

Law 1397 of 1983 on the National Health System provided the legal framework for the psychiatric reform.

Law 2071 of 1992 aimed to modernise the conditions of care in Greece, especially regarding involuntary hospitalisation, and introduced the principle of ‘sectorisation’ (the establishment of sectors of 250 000–280 000 inhabitants) in the provision of services.

Law 2444 of 1996, especially articles 1666–88, offers broad legal guarantees to persons under court protection orders.

Law 2716 of 1999 defined the principles of mental health practice in Greece (article 1) and identified the ‘units of mental health’ (articles 4–12). Sectorisation was again a key principle. This law also introduced the concept of ‘social cooperative units’ (Κοι.Σ.Π.Ε), which give people with mental health problems and other disabilities the opportunity to engage in work.

Mental health service delivery

Mental health services are provided by the public sector, by non-profit units and by the private sector.

Sectorisation has yet not been systematically organised. There are also deficiencies in primary care and in follow-up, creating increased demand for beds (because the filters that would prevent admission to hospital do not work well).

The dysfunctional aspects of the system are manifest in:

the high rates of involuntary hospital admissions (over 50% of admissions in public psychiatric hospitals and 35–40% of those to psychiatric units in general hospitals in Athens, although in other cities the rates are lower – see Tables 1 and 2)

Table 1

Public psychiatric hospitals in Greece

	Number of beds for acute patientsa	Number of admissions per yearb	Proportion of admissions that are involuntary
Psychiatric Hospital of Athens	250	2800	52–55%
Dromokaition Psychiatric Hospital (Athens)	180	1560	50–52%
Psychiatric Hospital of Thessaloniki	120	3300	26–29%
Psychiatric Hospital of Tripolis	100	1015	59–63%
Psychiatric Hospital of Leros	20–22	190	31–32%

There are additional beds occupied by chronic patients and also in housing units outside the hospitals.

The Psychiatry Department of Athens University (Eginition hospital) additionally admits approximately 500 voluntary patients per year.

Table 2

Psychiatric units in general hospitals

	Number of units	Total number of beds	Number of admissions per year (approximate)	Proportion of admissions that are involuntary
Athens	8	150–160	2700	35–40%
Other cities	12	200	5200	22–23%b

They generally have 20 beds, but some of these are not always in use, mainly due to insufficient nursing staff.

This figure is approximate and we have not included six units that do not admit involuntary patients.

the frequent use of ‘auxiliary beds’ in public units, especially in the psychiatric units of general hospitals in the Athens area.

Sectorisation – networking of psychiatric services

There are 13 sectors for the Athens area and three for the area of Thessaloniki. Each sector has in principle the responsibility for out-patient and in-patient care within the sector, but few of them are sufficiently developed to satisfy this requirement. Each sector is regulated by a sectoral committee of mental health (Τ.Ε.Ψ.Υ), a body whose responsibility it is to coordinate the out-patient and in-patient units, which usually belong to a variety of mental health facilities run by various organisations. It is felt that in order to fulfil their mission, the sectors must be adequately funded and be entrusted with sufficient authority for decision making.

Hospital admissions

Data from 2006 and 2007, collected by a committee established by the Hellenic Psychiatric Association (Ploumpidis et al, 2008), indicate the following:

Public psychiatric hospitals

Admissions to the nine public psychiatric hospitals have steadily diminished since the late 1970s (Madianos & Christodoulou, 2007). Four of them (the psychiatric hospitals of Petra-Olympus, Corfu, Crete and the child psychiatric hospital of Attiki) have practically closed down, although they still provide administrative services to the hostels, out-patient units and psychosocial rehabilitation centres in their areas.

The five fully functioning public psychiatric hospitals maintain many hostels, rehabilitation units and out-patient units. There is a high rate of involuntary admission to them.

Psychiatric units in general hospitals

Fifty-four hospitals have out-patient facilities and liaison psychiatry, but only 20 of them also have in-patient units. Six more units in general hospitals will start admitting patients as soon as they resolve their staff shortages (mainly nursing).

The majority of these units have been created in the last 25 years. Their contribution to the implementation of psychiatric reform has been substantial. Many of them house university departments of psychiatry.

In the Athens area, many of these psychiatric units are overcrowded and ‘auxiliary beds’ are used to accommodate the patients. In the rest of the country, conditions are better.

Out-patient care

The largest social security organisation (Ι.Κ.Α) offers primary care through its out-patient services. Practically all in-patient psychiatric facilities also offer out-patient services.

There are nine mental health centres in Athens, three in the Thessaloniki area and 22 in the rest of the country (a total of 34). These facilities offer the possibility of combining primary mental healthcare, psychotherapy and day hospital services.

Primary psychiatric care is carried out by general practitioners, healthcare centres and psychiatrists and physicians in private practice, especially in rural areas.

Sectorisation is certainly a prerequisite for the meaningful organisation of services, but in spite of efforts this has not been achieved to the desired extent.

Housing units

The programme of deinstitutionalisation has been based on the creation of a network of housing units. In 2005 there were 377 housing units, 269 state-owned and 108 run by non-governmental organisations (NGOs). These units served 2695 users and employed 3061 professional staff. Recent budgetary problems have affected the operation of these units, especially those run by NGOs.

Rehabilitation units

In the 1990s, psychosocial rehabilitation developed remarkably in Greece. Social and pre-vocational rehabilitation programmes are still active but vocational rehabilitation has regressed, following increasing difficulties in the labour market. The social cooperative units mentioned above have yet to be fully developed.

Private facilities

In the Athens area there are 12 private psychiatric hospitals, with a total of approximately 1700 beds. They have a high proportion of chronic patients and bed occupancy approaching 100%. In Macedonia (northern Greece) there are nine units with a total of 1430 beds and in Thessaly (central Greece) there are nine units with a total of 1175 beds.

Psychiatric training

Undergraduate psychiatric training is carried out in the six medical schools of the country.

There are several available postgraduate degree programmes related to mental health. Postgraduate training is carried out in university and state hospital settings. Specialty training in psychiatry lasts for 5 years and consists of 6 months of training in general medicine, 12 months in neurology and 42 months in psychiatry. There are more than 2000 psychiatrists in Greece.

Child psychiatry was established as a specialty in 1980. Training lasts 4 years 6 months (18 months in adult psychiatry, 6 months in neurology and 30 months in child psychiatry). More than 300 child psychiatrists practise in Greece.

For both specialties, the certificate of specialist training is provided after an oral (and sometimes a written) examination by a committee of psychiatrists appointed by the Ministry of Health. The Hellenic Psychiatric Association has requested greater involvement of the Association in training and examinations as well as harmonisation with the recommendations of the European Board of Psychiatry of the Union Européenne des médecins spécialistes (EUEMS; European Union of Medical Specialists).

Psychiatric subspecialties and allied professions

Psychiatrists regularly collaborate with other mental health professionals (especially psychologists, psychiatric nurses and social workers).

Child and adolescent psychiatry

Law 2716 of 1999 introduced sectorisation of child and adolescent psychiatric services, which was implemented only in the Athens and Thessaloniki areas.

One of the main targets of psychiatric reform in child psychiatry was the closure of the Child Psychiatric Hospital of Attiki, which had operated since 1960, mainly with children with severe intellectual difficulties. Reform was achieved with the creation of modern community services.

There are nine child and adolescent mental health centres – eight in the Athens area and one in the Thessaloniki area. Also, three units (of 10 beds each) are hosted in paediatric hospitals (one in Athens and two in the Thessaloniki area). There has been an adolescent psychiatry unit in Athens since 1985 and one in Thessaloniki since 2009.

Six psychiatric hospitals and 20 paediatric hospitals run child guidance clinics. In addition, eight child guidance clinics are run by the Hellenic Centre for Mental Health and Research and two are run by other non-profit organisations.

Psychiatric nursing and psychotherapy

There are too few nursing staff in the public sector, mainly due to budgetary restrictions. There is a postgraduate, 1-year national training programme for psychiatric nursing, which leads to the Certificate of Psychiatric Nursing.

Training mainly in psychoanalytic, behavioural and cognitive psychotherapies is available at private and university units, affiliated to international organisations.

Budgetary deficits are evident in relation to psychiatric nursing and psychotherapy.

Research

Research is carried out mainly in clinical psychiatry, biological psychiatry, social psychiatry, community-based psychiatry, psychosocial rehabilitation and psychotherapies. Research is also carried out by non-medical professionals, mainly psychologists.

Human rights

There has been progress with respect to the human rights of service users. Ethics committees in research programmes are obligatory. Law 2716 of 1999 introduced the Special Committee for the Control and Protection of the Rights of Persons with Psychological Disorders. Its annual reports of 2007, 2008 and 2009 pointed out omissions in several units.

A wide-ranging anti-stigma programme has been implemented since 2000 (Economou et al, 2005; Ploumpidis et al, 2009) and mental health promotion programmes are being implemented by a number of agencies, notably the Hellenic Psychiatric Association and the Psychiatry Department of Athens University.

International initiatives

The Hellenic Psychiatric Association has representation on many international organisations (e.g. the WPA, EPA, ICPM, PAEEB, WFMH, RCPsych) and is active in initiatives that aim to increase scientific collaboration with psychiatric societies in Eastern Europe, the Balkans (see http://www.paeeb.com) and the Middle East. The Association has mediated locally in Israel, Lebanon and Palestine for the production of anti-war statements, in collaboration with the relevant task forces of the World Psychiatric Association, and has undertaken mental health promotion initiatives in Serbia, Albania, Iraq and Cyprus. Recently it has begun collaborating with the World Health Organization on an ‘advanced psychiatry’ course in Palestine.

Conclusion

The Greek mental healthcare system is now largely based on prevention, community care and limited in-hospital care (Thornicroft et al, 2008). However, there are serious problems, stemming mainly from funding difficulties and the resulting staff shortages.