MENTAL HEALTHIN AUSTRIA

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TABLE OF CONTENTS

Table of contents

Foreword by the Minister of Health and Women Maria Rauch-Kallat 1

Foreword by the Secretary of State for Health Professor Reinhart Waneck, M.D. 2

Introduction and overview 3

A. Mental health indicators 5

A1 Anxiety and depression 6

A2 Disability pensions and sickness leave days due to psychiatric disorders 8

A3 Suicide 10

A4 Dementia 12

B. Mental health professionals and mental health services 15

B1 Psychiatrists 16

B2 Psychologists, psychotherapists, psychiatric nurses and other professionals 18

B3 Psychiatric hospital beds 20

B4 Community psychiatric services 22

C. Utilization of psychiatric hospital beds 25

C1 In-patient episodes without and with a psychiatric diagnosis as main

diagnosis in all hospitals 26

C2 In-patient episodes in psychiatric hospitals and psychiatric departments of

general hospitals by main diagnostic groups 28

C3 In-patient episodes in traditional vs. new psychiatric hospitals/departments

by main diagnostic groups 30

C4 In-patient episodes with a psychiatric diagnosis as main diagnosis in non-

psychiatric departments of general hospitals by main diagnostic groups 32

C5 Compulsory admissions and detained mentally ill offenders 34

D. Pharmacological and psychotherapeutic treatments 37

D1 Number of prescriptions and costs of psychotropic medication in out-patient

services by type of medication 2002 38

D2 Prescriptions of psychotropic medications by type of medication 1995-2002 40

D3 Prescriptions of psychotropic medication by type of medication

and type of physician 1991-2002 42

D4 Costs of prescriptions of psychotropic medication 1995-2002 44

D5 Costs of health insurance funded psychotherapy 1997-2000 46

Acknowledgements 48

1

FOREWORD

Mental Health in AustriaMental Health has become a major issue globally, notonly within the European Health Policy and not onlybecause of the World Health Day 2001, which was en-titled with "Stop exclusion - Dare to Care" and commit-ted to the 400 million human beings with mental disor-ders. Mental disorders today represent five of the tenleading causes of disability and are closely linked tooverall quality of life.

The Federal Ministry of Health and Women isproud to present this report, which is the summary ofthe Austrian Mental Health Reports 2001 and 2003.

In the 1970ies we had thirteen mental hospitalsand university departments, which were responsible for

in-patient treatment. Altogether they had around 12.000 beds, this means 16 bedsper 10.000 population. Thirty years later, the situation has fundamentally changed.The system has mutated into a multifaceted picture with more than 40 smaller psy-chiatric in- and day-patient services funded by social security, and numerous com-munity based residential, day structure, ambulatory and other services funded main-ly by the social service system. Psychiatric beds could be reduced to below 5.000,corresponding to roughly 6 beds per 10.000 population.

The number of social security reimbursed psychiatrists working in solo prac-tices is still rather low, but a large variety of new state certified professions, such aspsychiatric nurses, clinical psychologists and psychotherapists has been created.

Mental health problems constitute a major burden on individual sufferers,their families and friends, and on society as a whole. The prevalence of anxiety anddepressive symptoms in the Austrian population demonstrates this, as there is onein six persons suffering from such symptoms over a four week period and it is alar-ming that psychiatric disorders are the second most important cause among all dis-eases for disability pensions.

The major goal in our Health Policy is the support and enforcement ofHealth Promotion and Health Prevention. Therefore we are also working on a"Mental Health Centre of Excellence", together with the author of the report,Professor Heinz Katschnig, M.D., which will be the most important step after havinganalysed the situation now. Useful cooperation with other structures of our HealthCare system and effective strategies of our "Centre of Excellence" should enable usto reduce the suffering of the patient, the stigmatisation as well as the incidence andprevalence of mental disorders. Mental and physical health must be given equalimportance, this as one commitment to "Stop exclusion - Dare to Care".

Maria Rauch-KKallatFederal Minister for Health and Women

2

FOREWORD

Mental Health in Austria

TThheerree iiss nnoo hheeaalltthhwwiitthhoouutt mmeennttaall hheeaalltthh!!

"Mental Health" does not only describe mental disor-ders, but also prevention and therapy. This term is acentral element of Health and has to become one inHealth Care as well.

Today mental disorders represent a global bur-den, as it is shown by the disease "depression", whichis rated as number 4 within the most common diseasesnow and will become number 2 within the next 20years.

In 2001, when WHO announced the "World Health Day on Mental Health",we presented the first Austrian Mental Health Report. It shows all available data onthe structure of the care for patients with mental disorders.

Together with the analysis, which will be presented in the second AustrianMental Health Report, we will have a close and complete study of the psychiatricand psychososocial care for people with mental disabilities and disorders in Austria.This report will be a basic element for all further developments in the field of pre-vention, diagnosis and therapy.

I want to thank the authors of both Austrian Mental Health Reports, my col-league Heinz Katschnig and his co-workers, for this brief summary as well as fortheir ambitious contributions and for their engagement against stigmatisation ofpeople with mental disorders.

This engagement, which enables us more and more to understand theexpectations and needs of patients and their families, has to be increased. Alsopatient initiatives and other innovative projects with and for patients have to be sup-ported.

"Mental Health" is a challenge for a Health Care System - nation wide, aswell as internationally. We have to face it without exclusion.

Professor Reinhart Waneck, M.D.Secretary of State for Health

3

INTRODUCTION AND OVERVIEW

The mental health statistics presented and discussed here in English are selectedfrom the Austrian Mental Health Reports published in 2001 and 2003, which areonly available in German. These statistics pinpoint certain areas for which data wereavailable and which constitute a challenge for health policy. It was not intended todraw a comprehensive picture in this short brochure. For complete information on"Public Health in Austria" a separate publication is available in English from bro-schuerenservice@bmgf.gv.at.

Austria is a rather small country, with 8 million inhabitants and large ruraland mountainous areas. It is a federal country with health and social service provi-sion being the responsibility of its nine provincial governments. These means thatdata on health and mental health services - with the exception of hospitals due tothe nationwide DRG-System - are not available for the country as a whole, but onlyon the provincial level. Also, such data are usually not collected in a uniform way.For these reasons the mental health statistics contained in this brochure represent acompromise between the desirable and the available and do not draw a represen-tative picture of the situation as far as mental health and mental health care inAustria is concerned. Large sectors, such as the use of out-patient services, the so-called complementary facilities (e.g. residential, day structure), and the advocacyand self-help movements are either underrepresented or not represented at all,because no or only insufficient nation-wide data are available.

Extramural services are mainly provided by several thousand doctors insolo practices (general practitioners and specialists). Extramural mental health servi-ces - other than psychiatrists in solo practices - are publicly funded but available onlyfrom a large variety of private and charitable providers. 99% of the population arecovered by obligatory health insurance, which gives virtually free access to medicalhelp with a small amount of financial participation.

The statistics selected here illustrate challenges for mental health policies.Examples are: The need for early recognition of mental disorders in general practi-ce and anti-stigma activities in order to make access to psychiatric help more accep-table (A1); attention to the problem of mental health and the work place (A2); sui-cide prevention (A3), and the ever increasing burden of dementia which shall soonovertax care facilities (A4). Furthermore: The coordination between private psychi-atrists in solo practices and publicly funded community psychiatric services (B1, B4),the issue of adequate reimbursement for psychotherapy (B2, D4) and redefining therole of psychiatric beds vis-a-vis other types of care, especially also under the aspectof the fragmentation of financing of services, which has to be overcome by theindroduction of global budgets (B3, B4, C1-C4). In view of the rising numbers ofcompulsorily detained psychiatric patients, the compulsory detention act has to bere-evaluated (C5). Also the rising numbers of mentally ill offenders in institutionsshould be a cause for concern of politicians (C5). Medication issues create a num-ber of challenges (D1-D4): The rising numbers of prescriptions, and above all therising costs of these prescriptions, constantly create new isolated debates, which usu-ally do not consider the whole system of mental health care, for which costs of medi-cation are only a fragment of the total costs. Better medications might prevent relap-

4

INTRODUCTION AND OVERVIEW

se and hospital admissions; but, because of the fragmentation of the financingsystem, there is no way to monitor this.

It is noteworthy that all nine provincial governments have produced reformplans for mental health care over the last few years and that the their philosophy isthe same, namely a change from the traditional hospital based and centralised to adecentralised and diversified community oriented mental health care system. Thelatter development of a diversification of services in the community poses a newchallenge to mental health informatics. It is certainly necessary that data collectionand informatics in the health field are much more coordinated and integrated in thefuture, both on a country and on an international level, in order to render healthcare planning more rational and to better inform those allocating the ever scarcerresources. In the meantime the collection and publication of the available data, asin this brochure and the Austrian Mental Health Reports, can be regarded as a use-ful compromise on the way towards this aim.

Heinz Katschnig, MD,Professor and Chairman, Department of Psychiatry, University of Vienna,

Director, Ludwig-BBoltzmann-IInstitute for Social Psychiatry, Viennaheinz.katschnig@univie.ac.at

5

A Mental health indicators

What has been impressively documen-ted recently by the World HealthOrganization in its "World HealthReport"1 is also true for Austria: Mentalhealth problems constitute a majorburden on individual sufferers, theirfamilies and friends, and on society asa whole. Large international surveyshave shown life time prevalence ratesfor mental disorders of 40 and morepercent, with affective and anxietydisorders as the most frequent diagno-ses. In the "Global Burden of Disease"report depression was the leadingcause for disease related disabilities(somatic as well as psychiatric disor-ders) in the age group 15-44 in indu-strialized countries.

In this section estimates of the pre-valence of anxiety and depressivesymptoms in the Austrian populationare presented - they are as high as onein six persons suffering from suchsymptoms over a four week period(A1).

It is also alarming that psychiatricdisorders are the second most impor-tant cause (among all diseases) fordisability pensions and that their num-bers have been dramatically increasingsince the mid-eighties; in a similardevelopment the numbers of sicknessleave days have been constantly on

the rise during the nineties (A2). Austria has always belonged to the

group of high suicide rate countries,with well over 20 per 100.000 of thepopulation (and a peak value of 28.3in 1986). It came as a surprise that, forthe first time in history, suicide ratesfell below 20 per 100.000 in 1997 andhave remained below that mark untiltoday (A3). It is remarkable that thisdecline coincides with the expansionof community psychiatric services(B4), the enactment of a psychothera-py act (B2), improvements in therecognition of depression and theincrease in prescriptions of antidepres-sants (D2), especially by general prac-titioners (D3). However, whether theseor other factors are responsible for thereduction of suicide rates, cannot bedecided post hoc.

Finally, the by now well knownfact of a demographically driven dra-matic increase in the prevalence ofdementia over the next 50 years isrelated here to the also demographi-cally determined decline of the workforce. While in 1951 for each personsuffering from dementia 120 personswere in the work force, this numberwill decrease in the year 2050 to below17.

6

A1 Anxiety and depression

In a representative survey of the non-institutionalized Austrian population(N = 1.408) the "General HealthQuestionnaire" (GHQ-12) was used toestimate the prevalence of anxiety anddepressive symptoms during the fourweek period before the survey2. Usinga cutoff of 2/3, a prevalence rate of17,5% for women and 15,1% for menwas found. The rates were decliningwith age, in men more so than inwomen. There was a non-significanttrend for unemployed persons to havehigher rates. Married persons had thelowest rates, never married and divor-ced persons the highest. The resultsare comparable to those of surveysusing the same questionnaire in othercountries.

Using more stringent diagnosticcriteria, the US National ComorbiditySurvey (NCS) found a one year preva-lence rate of 17,2% for anxiety, 11,3%for affective (mainly depressive) and11,3% for substance use disorders,with a high comorbidity between thesediagnostic groups, yielding a one yearprevalence rate for any disorder of29,5%3. With 0,5% schizophrenia wasmuch less prevalent. The "GlobalBurden of Disease" report4 showed

that in the economically active seg-ment of the population (15-44 years)of industrialized countries depression,schizophrenia, bipolar and obsessivecompulsive disorders are among theten leading diseases (somatic as wellas psychiatric) as far as disabilities indaily life are concerned (with depres-sion being number 1). Furthermore, ithas been repeatedly shown (also in anAustrian study5) that persons who arehospitalized for a somatic disease, staylonger in hospital, if they also sufferfrom a psychiatric condition, thanthose who don't, which is an economi-cally extremely relevant finding.

Anxiety and depressive disordersare under-recognized and under-trea-ted, although powerful pharmacologi-cal and psychotherapeutic treatmentsare available today. It follows that bet-ter training of non-psychiatric physici-ans, especially of general practitioners,in order to enable them to recognizethese disorders at an early stage, isnecessary. Anti-stigma activities, whichshould lead to better acceptance ofpsychiatric diagnoses and of peoplesuffering from these conditions, shouldalso help in this respect. Activities inboth areas are under way in Austria.

Anxiety and depressive symptoms in a representative sampleof the Austrian population (aged 15+; N = 1.408)

7

8

A2 Disability pensions and sickness leavedays due to psychiatric disorders

The number of so called disability pen-sions, i.e. premature retirements dueto work incapacity, was 24.836 in1999. Psychiatric disorders were thesecond largest cause for disability pen-sions (18,9%) after musculoskeletaldiseases (39,5%)6. Such prematureretirement because of psychiatricdisorders is much more prevalent inthe younger age groups - in thoseaged less than 40 between 40% and50% of all disability pensions are gran-ted because of mental disorders. If thedevelopment of new disability pen-sions is regarded from 1985 to 1999, itis evident that psychiatric disorders arethe only cause for disability pensionwith a clear increase, with a factor of2,5 times over the fifteen year period,while most other causes show a decli-ne, corresponding to the absolutedecline of all granted disability pen-sions from 28.346 in 1985 to 24.836in 1999. The granting of disabilitypensions is a complex phenomenonand cannot be regarded as a direct

prove for the increase of mental dis-orders. It is also possible that mentaldisorders are more readily appreciatedas causes for granting a disability pen-sion, both by sufferers, their familymembers and the authorities. In anycase, the increase of the economicburden on society through mentaldisorders is evident.

In 1999 all together 14.431sickness leave days were registered per1.000 employees in Austria, whichcorresponds to a slight decrease since1990 (14.431)7. Psychiatric disordersare not among the main causes.However, if the development since1990 is regarded, sickness leave daysbecause of psychiatric disorders are onthe increase, while they are rather onthe decrease for most other causes(except for pulmonary diseases).Again, sickness leave is a complexphenomenon, an cannot be taken as aone to one prove for the increase ofmental disorders.

9

New disability pensions 1999(N=24.836)

Changes in the frequencies of newdisability pensions 1985-1999

(1985=100%)

Sickness leave days per 1.000employees 1999

(N=14.431)

Changes in sickness leave days 1990-1999 (1990 = 100%)

10

A3 Suicide

Traditionally Austria belonged to thehigh suicide rate countries. Long termtime series show rather high suiciderates between the first and thesecond world war and rates above20/100.000 for the first 25 years afterthe second world war. In the 1970iesthese rates started to rise and reacheda value of just under 30/100.000 in1986.

Over the last fifteen years suiciderates have steadily decreased and areconstantly below 20/100.000 since1997.8 Female rates have droppedmore than male rates. It is difficult tointerpret these changes, but it is noti-ceable that over the same period com-munity psychiatric services expanded(B4), a clinical psychology andpsychotherapy law was enacted in1990 (B2) and the prescription of anti-depressants increased while those oftranquilizers decreased (D2), especial-ly by general practitioners (D3).

As in most countries suicide ratesare very different for men and womenand for different age-groups. In Austriathe female suicide rate is less than half

as big as the male rate and rates incre-ase with age. Men above the age of 85years have a suicide rate of120/100.000, the female rate in theseage-group is around 33/100.000. Asfar as marital status is concerned inboth men and women the suicide ratesare lowest in the married and highestin the divorced, which is especiallytrue for men (120/100.000). Also therate of never married (above the ageof 20) is clearly higher than the rate ofthe married. The most frequent suicidemethod used by men is hanging(50%), followed by shooting (20%)and self-poisoning (10%). Also inwomen hanging is the most frequentmethod used (40%), followed by self-poisoning (25%) and jumping (14%).

A national suicide prevention pro-gram has been developed and is awai-ting implementation. A specific suicideprevention project, carried out sincemany years in Vienna, is based on anagreement with the press not to reportabout suicides in the subway, whichhas led to a reduction of suicides bythis method.9

11

Suicide rates per 100.000 population 1913-2002,no data are available for 1940-1945

12

A4 Dementia

The actual political discussions inindustrialized countries on how tofinance the system of pensions in thecoming decades, with the ever gro-wing numbers of old people anddecreasing numbers of young people,has a specific aspect in terms of how tofinance health care for an increasinglyaging and therefore increasingly sickerpopulation. As far as mental disordersare concerned it is not only organicbrain disorders, but also affective andanxiety disorders, which are prevalentin old age. However, since organicbrain disorders are specifically relatedto old age, they warrant specific atten-tion.

In a model calculation based oninternational prevalence data and theexpected demographic changes, it wascalculated for Austria that 35.500 per-sons suffered from dementia in 1951and that this figure had increased to90.500 in 2000 and will rise to233.800 in 2050, mainly because ofthe well known change in the agepyramid10. Because the prevalence ofdementia increases drastically beyondthe age of 80, the total prevalence ratein those aged 60 and above will alsoincrease (from 3,28 to 8,28%). Sincethe working population will declinefrom 2000 to 2050, the number ofpersons working per one person suffe-

ring from dementia will decrease dra-matically. It was 120 in 1951, 56 in2000 and will be below 17 in 2050.When the actual number of dementiacases in 1951 is set 100% it will rise to658% in 2050. For the working popu-lation the same calculation shows aslight increase until 2000 (118,8) anda decrease until 2050 (91,6). If theratio of dementia cases per 100 of theworking population is set 100% for1951, it will increase to over 700% in2050.

These calculations show the dra-matic increase of the burden ofdementia on Austrian society over thenext 50 years. It is to be feared thatthere might simply not be enough per-sons - family members or professionals- who care for demented persons.Furthermore the financial burden willbe enormous. Austria has a nursingcare scheme, which provides "nursingbenefits" to persons in need of nursingcare in seven grades according to thedegree of disability. The affected per-son can buy nursing care with thesebenefits. By the end of 2002, altoget-her 257.013 persons received nursingbenefits (slightly more than 3% of thetotal population) and the costs werearound 1,3 million Euro. The increa-sing burden of dementia will presshard upon this nursing care scheme.

13

Year Work Force Prevalence ofdementia

Rate: cases ofdementia per

100 work force

Number of working personsper one person suffering

from dementia

1951 4.262.800 35.500 0,83% 119,92000 5.064.900 90.500 1,79% 56,02050 3.905.600 233.800 5,99% 16,7

The development of the prevalence of dementia and itsrelationship to the working population 1951-2050

14

References for part A: Mental Health Indicators in theGeneral Population

1 World Health Organization: World Health Report 2001: Mental Health - NewUnderstanding, New Hope. Geneva 2001 (www.who.int/whr/whr2001)

2 Katschnig H, Etzersdorfer E, Muzik M: Final report to the "Austrian ScienceFund" on the project "Attitudes of the Austrian population towards psychiatryand psychiatric patients". Vienna 1993

3 Kessler, R: The National Comorbidity Survey. Int Rev Psychiatry 6 (1994) 365-376

4 Murray C, Lopez A(Eds.): The Global Burden of Disease: A ComprehensiveAssessment of Mortality and Disability from Diseases, Injuries and Risk Factors in 1990 and Projected to 2020. Harvard University Press, Cambridge Mass. 1996

5 Wancata J, Benda N, Meise U, Windhaber J: Sind die Aufenthaltsdauern vonpsychisch Kranken an internen, chirurgischen und gynäkologischen Abteilungenlänger? Nervenarzt 70 (2001)810-816

6 Wörister K: Chamber of Labour, Vienna 20007 Wörister K: Chamber of Labour, Vienna 20008 Österreichischer Psychiatriebericht 2001. Federal Ministry of Health and Women,

Vienna 2001; www.bmgf.gv.at/cms/site/berichte.htm?channel=CH0093) 9 Sonneck G, Etzersdorfer E, Nagel-Kuess S: Imitative suicide on the Viennese

subway. Soc Sci Med 38 (1994) 453-45710 Wancata J, Kaupp B, Krautgartner M: Die Entwicklung der emenzerkrankungen

in Österreich in den Jahren 1951 bis 2050 (Increasing number of people suffe-ring from dementia between the years 1951 and 2050). Wien Klin Wochenschr113 (2001) 172-180

15

B Mental health professionals and mentalhealth services

Until the early 1970ies a two tiersystem of psychiatric care existed inAustria: On the one hand ten largemental hospitals (plus three small uni-versity departments) were responsiblefor in-patient treatment. Altogetherthey had around 12.000 beds (i.e. 16beds per 10.000 population; six of theten hospitals had more than 1.000beds and three more than 1.500 beds.A survey in 1974 showed that 85% ofpatients suffered from either schizoph-renia (40%), mental retardation (25%)or dementia (20%), nearly 60% hadbeen in hospital for more than twoyears and more than 90% were com-pulsorily detained. On the other hand,a few dozens of "neuro-psychiatrists"in solo practices treated both neurolo-gical and psychiatric out-patients.Because of the large geographicaldistances there was virtually no com-munication between these twosystems.

Thirty years later, the situation hasfundamentally changed. As far as ser-vices are concerned the two tiersystem has mutated into a multiface-ted picture with more than 40 smallerpsychiatric in- and day-patient servicesfunded by a variety of sources (amongothers health insurance), and nume-rous community based residential, daystructure, ambulatory and other servi-ces funded mainly by the social servi-

ce system (B4). Psychiatric beds arenow down to below 5.000, which isequivalent to roughly 6 beds per10.000 population (B3). In addition,neuropsychiatry has been recentlydivided into two separate medical spe-cialties, neurology on the one hand,and psychiatry on the other (B1). Thenumber of social security reimbursedpsychiatrists working in solo practicesis still rather low.

In addition to psychiatrists, a largevariety of new state certified profes-sions, such as clinical psychologistsand psychotherapists, have been crea-ted, who cooperate with psychiatristswithin institutions, but partly competewith them in the ambulatory field(B2).

The main challenge today is howto cope with the fragmentation offinancing of these services, whichmakes transitions between in-, day-and out-patient, as well as betweenmedical and social services difficult. Inaddition, the federal structure of thecountry has led to uneven develop-ments, with some provinces beingmore advanced and others morebehind in the reform processes. Thefederal structure has also preventedthe establishment of common defini-tions of services and of quality assu-rance criteria outside hospitals.

16

B1 Psychiatrists

Until very recently - and in contrast tomost other countries - "neuropsychia-try" was a single medical specialty inAustria. In 1975 a half-hearted separa-tion took place: formally one could beeither a "psychiatrist and neurologist"or a "neurologist and psychiatrist", cor-responding to a larger proportion oftraining time devoted to one of thetwo disciplines. De facto both types ofspecialists could still practice both neu-rology and psychiatry - which was andstill is relevant for rural areas. Onlythose who have started their trainingin psychiatry or neurology since 1994are now becoming "pure" psychiatristsor "pure" neurologists.

The numbers of "neurologists" and"psychiatrists" have been steadilyincreasing over the last 30 years, psy-chiatrists more so than neurologists.893 certified psychiatrists were registe-red by the end of 2002 which corre-sponds to roughly one psychiatrist per9.000 inhabitants1. As far as ambula-

tory care is concerned, in 2002 twothirds of these worked in private prac-tice, but only 98 had a contract withhealth insurance (i.e. they were acces-sible at virtually no costs). The latterfigure corresponds to only one psychi-atrist per 81.000 inhabitants or to 0,12psychiatrists per 10.000 population. Itwill be necessary to redefine the role ofthese rather few solo practice psychia-trists in relation to the tax fundedpublic out-patient services (B4).

The postgraduate training of psy-chiatrists comprises four years of psy-chiatry, one year of neurology and oneyear of internal medicine. Practicaltraining is basically restricted to hospi-tal settings, which constitutes a majorproblem in view of the development ofpsychiatric services away from themental hospital and back into thecommunity. Since 2002 an examina-tion has to be taken at the end of thetraining.

Number of registered psychiatrists and neurologistsx) 1972-2002

x) Until 1974 "neuropsychiatrists", 1975-1994 "neurologists and psychiatrists" or "psychiatrists and neurologists",since 1994 "psychiatrists" and "neurologists" as separate professions. In 2002 most are still "mixed".

Number of psychiatrists in solo practices with and withoutsocial security contract

17

18

B2 Psychologists, psychotherapists, psy-chiatric nurses and other professionals

In 1991 the "Psychology Act"(Psychologengesetz) established thestate certified professions of "clinicalpsychologist" and "health psycholo-gist". Both have to follow a predefinedpostgraduate curriculum. Health andclinical psychologists may work ininstitutions or in private practices,where they are partly reimbursed bysocial security. Four in six of them arealso certified "psychotherapists". InJuly 2003 they numbered 3.902, cor-responding to 4,9 per 10.000 popula-tion, with more than 90% being quali-fied for both health and clinicalpsychology.2

Also in 1991 the "PsychotherapyAct" (Psychotherapiegesetz) estab-lished a specific curriculum for psycho-therapists (who do not necessarilyhave to be university graduates).Training is delegated to 19 psychothe-rapy associations, representing diffe-rent "schools" (such as psychoanalysis,behaviour therapy, family therapy,hypnosis, etc.). Psychotherapists inprivate practice are partly reimbursed

by health insurance in a complex pro-cedure. The number of psychothera-pists was 5.632 by the end of 2002 (=7 per 10.000 population)3. Since thereis a large overlap between all profes-sions discussed so far, their numberscannot be simply added.

Psychiatric nursing is a specialtype of the nursing profession. The"Health Care and Nursing Act", whichcame into force in 1997, redefined thenursing professions and especially psy-chiatric nursing, including aspects ofcommunity psychiatric nursing.Training takes place at specialist psy-chiatric nursing schools and lasts threeyears. By the end of 2001 there werearound 3,8 psychiatric nurses per10.000 population4. The majority ofthem work in psychiatric hospitals orpsychiatric departments of generalhospitals.

Social workers, physiotherapists,occupational therapists, art and musictherapists are other typical professionsworking in the field of psychiatry inAustria.

19

Postgraduate training in Numbers %

Clinical and Health Psychology 3.556 91,1 %Health Psychology only 158 4,1 %Clinical Psychology only 188 4,8 %Clinical- and/or Health Psychologythereof with additional training in psychotherapy

3.9021.638

100,0 %42,0 %

Psychologists with a postgraduate degree in "Clinical Psychology" and/or"Health Psychology" (July 2003)

Psychotherapists 1991-2002

20

B3 Psychiatric hospital beds

In most industrialized countries thepast decades have seen a decrease inpsychiatric beds and an increase incommunity psychiatric facilities.

Long-term series of statistics ofpsychiatric beds are not very accurate,because the definitions of what consti-tutes a "psychiatric bed", are not consi-stent over time and across countries.In Austria, for instance, there are still“mixed” neuropsychiatric wards andtheir beds may or may not be countedas “psychiatric” beds. Also, there is adifference between “theoretically”available (“systematized”) and actual-ly usable beds. It is therefore notuncommon, that - if different sourcesare regarded - figures for psychiatricbeds for one and the same country dif-fer (which is the case for the figuresreported here from the WHO database).5

With these caveats in mind andallowing for some inconsistencies, onecan note that over the last 30 years thenumber of psychiatric hospital bedshas dramatically decreased in Austria.In a psychiatric hospital bed census1974 altogether nearly 12.000 beds inten large psychiatric hospitals (plusthree university departments) werecounted.6 Six of the ten hospitals hadmore than 1.000 beds, and three morethan 1.500. The number of psychiatricbeds has fallen to 4.696 in 2001 (bedsactually in use), which corresponds toa decrease in the rate per 10.000population from roughly 16 to 5,9, i.e.a reduction to nearly one third of theoriginal value. With this rate Austria is

at the lower end of a list of Europeancountries. Also, in 2001 the 4.696beds were distributed over 29 psychia-tric hospitals and departments in gene-ral hospitals, which are now muchsmaller than thirty years ago7. Todayonly two psychiatric hospitals havemore than 500 beds.

The most recent figures representthe net effect of a reduction of beds inthe traditional large psychiatric hospi-tals and the creation of psychiatricbeds in general hospitals, togetherwith a diversification according toupcoming sub-specialties (such aschild and adolescent psychiatry, geria-tric psychiatry, substance abuse,psychotherapy and others). Thisdevelopment is not evenly distributedover the whole country, with someprovinces being more advanced thanothers. In the province of LowerAustria, for instance, a traditionalmental hospital will be closed by 2007and replaced by four psychiatricdepartments in general hospitals.

The Austrian Hospital and MajorEquipment Plan (ÖsterreichischerKrankenanstalten- und Groß-geräteplan, ÖKAP/GGP) limits the rateof psychiatric beds (including dayhospital places, but excluding childand adolescent psychiatry) with 3 to 5per 10.000 population. The financingarrangements are such that it is moreattractive to have day hospital placesthan beds. In 1999 16 day hospitalsexisted in Austria and their numbershave increased since than.

21

Beds in psychiatric hospitals and in psychiatric departmentsof general hospitals 1997-2001

Psychiatric beds per 10.000 population inWHO-EURO Countries

22

B4 Community psychiatric services

Public community psychiatric servicesare the responsibility of the federalprovinces and nearly all provinces areby now financing such services.

All nine Austrian provinces havedeveloped plans for the reform of psy-chiatric care, some as guidelines only,some with provincial government bak-king. Also for community psychiatricservices there are large regional diffe-rences. For instance, some provincesfollow the principle of sectorization,others don't.

The number of community psychi-atric services has been steadily increa-sing over the last fifteen years. It hasbeen suggested that the reduction ofsuicide rates (A3) might be related tothis increase of community psychiatricservices.

These services are not well syste-matized and can not be easily compa-

red with each other. Some are firmlyestablished, others have the characterof time limited projects. Nearly all aremultiprofessionally stqffed (B2) andoften non-psychatric professionalsdominate.

Comprehensive data are difficultto obtain - in the table only minimumestimates of such tax funded commu-nity services are provided. They inclu-de "out-patient counseling services","vocational rehabilitation services andprojects", "day structure services"(without day hospitals) and "residenti-al facilities and projects". In a recentsurvey 1.014 services/projects werecounted for the whole country.8

The number of providers (usuallycharitable and private organizations) isvery large. For roughly 1.000 servi-ces/projects there are 250 providers.

23

Type of service Number of services/projects Number of providers

Outpatient counselingservices

325 73

Residential facilities andprojects

350 92

Day structure services (without day hospitals)

167 40

Vocational rehabilitationservices and projects

172 48

Total 1014 253 x)

Community psychiatric services and providers 2003

x) total number of providers is smaller than the sum, since some providers offer several types of services.

24

References for part B: Mental Health Professionals and MentalHealth Services

1 Austrian Chamber of Doctors, Statistical Department, Vienna 20032 Federal Ministry of Health and Women, 20033 Österreichisches Bundesinstitut für Gesundheitswesen: Psychotherapeuten,

Klinische Psychologen, Gesundheitspsychologen - Entwicklungsstatistik 1991-2002. Vienna, 2003

4 Statistic Austria, 20035 WHO "Health For All" - database6 Katschnig H, Grumiller I, Strobl R: Daten zur stationären psychiatrischen

Versorgung Österreichs. Teil 2: Prävalenz. Österreichisches Bundesinstitut fürGesundheitswesen. Vienna 1975

7 Österreichischer Psychiatriebericht 2003. Federal Ministry of Health and Women.Vienna 2003

8 Österreichischer Psychiatriebericht 2003. Federal Ministry of Health and Women.Vienna 2003

25

C Utilization of psychiatric hospital beds

The only service use data routinelyavailable on a countrywide basis aredata about hospitalization, originatingin the "performance related hospitalfinancing system" based on "DiagnosisRelated Groups (DRG)". This systemwas introduced in Austria in 1997 andhas become quite reliable in the year2001 for which data are analyzedhere. The DRG-data are reportedwhenever a patient is discharged fromhospital, i.e. whenever a hospital epi-sode ends and a diagnosis is provided.When analyzing these data it has to bekept in mind that the purpose of thesystem is to get financial reimburse-ment and not collect service use dataper se. Some variables, which areimportant for psychiatry, such as"compulsory detention" are not con-tained in this system.

If all discharges from all types ofthe 310 hospitals in Austria are regar-ded, the astonishing fact becomesapparent that year by year far morethan 2 million in-patient episodes arecounted - with a total population of 8million this amounts to over 25% ofthe population. For roughly 5%, i.e.one in twenty, of these in-patient epi-sodes a psychiatric diagnosis wasreported as the main diagnosis (C1). Itwas another surprise that 45% of thesepsychiatric episodes occur in non-

psychiatric hospitals and departments.Whether this is due to fear of stigma ofbeing admitted to a psychiatric unit,due to the sometimes large distancesto psychiatric units or due to other rea-son, is unclear and needs further ana-lysis.

As one contribution towardsunderstanding this phenomenon, thegraphs contained in this section showthe distribution of the main diagnosticgroupsx, also broken down by gender,in all psychiatric in-patient units (C2),in different types of hospital settings,the traditional centralized vs. the newdecentralized psychiatric settings (C3),and, finally, the non-psychiatric hospi-tal settings (C4). It becomes apparentthat the diagnostic spectrum is quitedifferent in these different settings.

Finally, using results from two spe-cific research projects, data aboutcompulsory admissions to psychiatricin-patient units and about detainedmentally ill criminal offenders are pres-ented - in both groups the numbershave increased over the last decade(C5).

If not stated otherwise, all analysesin this sections were carried out by theauthors of the "Austrian Mental HealthReports 2001 and 2003"1 with datafiles provided by the Ministry of Healthand Women.

x) Until 2000 ICD-9 diagnoses were in use in Austria; in 2001 ICD-10 was introduced anddiagnoses were converted back to ICD-9 by a computer program in order to assure comparabilityover time.

26

C1 In-patient episodes without and with apsychiatric diagnosis as main diagnosis inall hospitals

The 2,281.210 hospital in-patient epi-sodes recorded for the year 2001 (allICD diagnoses) amount to nearly 27%of the figure of the total population(8,032.926). Since no record linkage ispossible, it cannot be determined howmany epsiodes were single or repeatedones, in other words, how large thepopulation of "heavy users" was.Anyhow, with these figures, Austria isamong the top countries in Europe, asfar as use of hospital beds is concer-ned.

For nearly 5%, or one in twenty ofthese in-patient episodes (109.043 in2001 = 4,78% of all in-patient episo-des and 1,4% of the total population)a psychiatric diagnosis was reported asthe main diagnosis.

Somewhat surprising is the factthat only 55% of all in-patient episo-des with a psychiatric diagnosis werereported from psychiatric hospitals orpsychatric departments (including"mixed" neuropsychiatric depart-ments) of general hospitals, and that

45% were reported from non-psychia-tric hospitals and departments. In1997, the year of the introduction ofthe DRG system, the latter percentagehad temporarily risen to nearly 50%. Itis not easy to explain this phenome-non, but some hypotheses are discus-sed in section C4, where the diagno-stic spectrum of psychiatric episodes innon-psychiatric hospitals and depart-ments is analyzed.

A more general observation is thatthe number of all hospital episodes hascontinuously increased over the years(+13,8% from 1996 to 2001), but thathospital episodes with a psychiatricdiagnosis rose twice as much over thesame period (+27,4%), even more soin non-psychiatric departments(+30,6%) and somewhat less in psy-chiatric hospitals and departments(+24,9%). Since record linkage is notpossible, there is no way to say whe-ther these increases are more due tothe increase of re-admissions or theincrease of first admissions.

27

In-patient episodes in all hospitals:Non-psychiatric vs. psychiatric diagnoses 1996-2001

In-patient episodes with a psychiatric diagnosis:Non-psychiatric vs. psychiatric hospitals/departments(including neuropsychiatric departments) 1996-2001

28

C2 In-patient episodes in psychiatric hospi-tals and psychiatric departments ofgeneral hospitals by main diagnosticgroups

57.905 in-patient episodes with a psy-chiatric diagnosis were counted in2001 in psychiatric hospitals and psy-chiatric departments of general hospi-tals (including specialized departmentsfor substance abuse, geriatric psychia-try and child/adolescent psychiatry,but excluding mixed neuropsychiatricdepartments). For the sake of simplici-ty the ICD diagnoses were condensedinto six diagnostic groups, with neuro-tic and personality disorders lumpedtogether because of the small numbersof personality disorder diagnoses2.

The leading diagnostic group, withjust over one quarter of all epsiodes, isneurotic/personality disorders, follo-wed by three diagnostic groups withnearly equal percentages (of about

20%): alcohol disorders, affectivedisordersx) and schizophrenia. Psycho-organic disorders (mainly dementia)and drug abuse disorders (other thanalcohol) are less frequent.

While men and women have near-ly equal numbers of episodes, there isa clear gender difference as far as dia-gnosis is concerned. Affective disor-ders and the mixed category neuro-tic/personality disorders are muchmore frequent in women. In contrast,substance (especially alcohol) abusedisorders are considerably more fre-quent in men than in women, withalcohol abuse disorders constituting byfar the largest diagnostic group inmen.

x) As has been noted above that ICD-10 was introduced in Austria in 2001, and a program was used hereto retranslate ICD-10 into ICD-9 diagnoses. This program translates F3 (“affective disorders” in ICD-10)into 296 (affective psychosis in ICD-9). Previous years show much smaller percentages for this category,since it included only "affective psychosis" (while neurotic depression belonged to the category of neuro-sis). Due to the back-translation procedure here all affective disorders of ICD-10 are included in the pre-vious "affective psychosis" category, which gives a slightly distorted picture.

29

In-patient episodes in psychiatric hospitals and psychiatric departments ingeneral hospitals by main diagnostic group 2001, N = 57.905

Same as above by gender;men: N = 29.552, women: N = 28.353

30

C3 In-patient episodes in traditional vs. newpsychiatric hospitals/departments bymain diagnostic groups

In this section the diagnostic spectrumof the ten traditional mental hospitalswhich existed already in 1974 (1974:11.763 beds; 2001: 3.435 beds) iscontrasted with the diagnostic spec-trum of the 19 new psychiatric in-patient units (including specializedsubstance abuse, geriatric psychiatricand child/adolescent psychiatry units)with altogether 1.261 beds in use in2001 (see B3).

In the ten traditional hospitals,which still have the highest case load(41.263 in-patient episodes in 2001),neurotic/personality disorders (24,1%)and schizophrenia (20,3%) are the lea-ding diagnostic groups. They are clo-sely followed by alcohol abuse and

affective disorders. All other groupsare less frequent.

In the 19 new psychiatric in-patient facilities (16.642 in-patient epi-sodes in 2001) schizophrenia (13,9%)is only at the fourth place. With over30% the neurotic/personality disorderscategory is by far the most frequentdiagnostic group and has a higher per-centage than in the traditional hospi-tals. Alcohol abuse and affective disor-ders follow with both over 20%. Allother diagnostic groups are less fre-quent, especially the psychoorganicgroup, with a much smaller proportion(6,1%) than that in the ten traditionalpsychiatric hospitals (11,9%).

31

Traditional psychiatric hospitals (N = 41.263)

New psychiatric in-patient facilities (N = 16.642)

32

C4 In-patient episodes with a psychiatricdiagnosis as main diagnosis in non-psy-chiatric departments of general hospi-tals by main diagnostic groups

As has been pointed out above, 45%of all hospital episodes with a psychia-tric diagnosis are reported from non-psychiatric departments of generalhospitals. Two thirds of theses epi-sodes are reported from internal medi-cine departments. With 48.710 epi-sodes in 2001 this amounts to morethan 2% of all in-patient episodes innon-psychiatric hospitals. One canonly speculate, why this figure is sohigh. Possible explanations are the fearof stigma of being admitted to a psy-chiatric hospital, large geographicaldistances, and somatic comorbidity.

The diagnostic spectrum in thesenon-psychiatric departments is clearlydifferent from the psychiatric ones.While neurotic/personality disordersdominate again (with well over onethird of all episodes), psychoorganicdisorders constitute the second largestgroup with one quarter of all episodes.Alcohol abuse and affective disordershold an intermediate position, with17,1% each. Schizophrenia (2,7%)and non-alcoholic substance abuse

disorders (2,7%) are relatively unim-portant.

In view of the enormous numbersof episodes (48.710 in 2001) it comesas no surprise that more in-patient epi-sodes with neurotic/personality disor-ders are treated in non-psychiatricdepartments of general hospitals(17.142) than in psychiatric in-patientfacilities (14.963). The same is true fordementia: In fact, two thirds (12.052)of all in-patient episodes with demen-tia (17.986) are treated in non-psychi-atric departments of general hospitals.

There is a clear gender difference.First of all - and in contrast to the fin-ding in psychiatric in-patient facilities -the numbers of in-patient episodes innon-psychiatric departments of gene-ral hospitals is much larger for women(28.237) than for men (20.473).Secondly, the diagnostic spectrum isagain different, with women domina-ting in neurosis/personality, affectiveand psychoorganic disorders, andmen overwhelmingly dominating inalcohol abuse disorders.

33

In-patient episodes with a psychiatric diagnosis innon-psychiatric departments of general hospitals by main

diagnostic groups 2001, N = 48.710)

Same as above by gender;men: N = 20.473, women: N = 28.237

34

C5 Compulsory admissions and detainedmentally ill offenders

The compulsory admission act("Unterbringungsgesetz") of 1991regulates the compulsory admissionand detention (in psychiatric hospitalsand departments) of persons who suf-fer from a mental illness and pose athreat for their own or other people'shealth or life. The emphasis is on thesafeguarding of personal liberty. So-called patient's lawyers were establis-hed, who are based in psychiatrichospitals and departments and repre-sent the patient's rights vis a vis thehospital. Also the courts are intensive-ly involved in the detention procedure.

A recent study has shown that thenumber of compulsorily detained psy-chiatric patients has continuouslyincreased since the new act becameeffective, while the numbers of invo-luntary detentions in psychiatric hospi-tals had constantly fallen during thedecades before3. However, if related tothe increase in psychiatric in-patientepisodes, the proportion of involunta-ry admissions/detentions has remai-ned constant, at the rather high levelof 17%, over the decade from 1991 to2000.

Why the intention of the compul-sory admission act to reduce involun-tary hospitalizations has failed,remains unclear, and different expla-nations are brought forward by diffe-rent quarters. Psychiatrists tend to

assume that patients are prematurelydischarged and have to be readmittedcompulsorily. Another possible expla-nation is that, with the closer scrutinyby the courts, "gray" situations, whichmay not have been brought to exter-nal attention formerly, now result informal detention. Basically the findingremains unexplained.

Mentally ill persons who havecommitted an offense against thepenal law fall under two main catego-ries, those who are regarded as fit tostand trial (mostly personality disorde-red sex offenders) and those who arenot (mostly psychotic patients). Bothgroups are detained in special institu-tions in the prison system; those whoare not regarded as fit to stand trialmay also be detained in psychiatrichospitals (in fact more than half ofthem are). In the graph the numbers ofpersons detained because of these twoconditions is shown (in addition to thenumbers of offenders with a drug pro-blem)4. As can be seen, the former twocategories have been on the rise overthe last decade - in fact the number ofdetained persons in these two cate-gories has more than doubled since1990. This increase does not necessa-rily reflect an increase in offenses - thereasons are most probably complexand include, among others, a possiblechange of court practices.

35

Compulsorily detained psychiatric patients 1971-2000

Detained mentally ill offenders 1984-2002

36

References for part C: Utilization of psychiatrix hospital beds

1 Österreichischer Psychiatriebericht 2001. Federal Ministry of Health and Women.Vienna 2001 (www.bmgf.gv.at/cms/site/berichte.htm?channel=CH0093), andÖsterreichischer Psychiatriebericht 2003. Federal Ministry of Health and Women.Vienna 2003

2 Österreichischer Psychiatriebericht 2001, Annex B. Federal Ministry of Healthand Women. Vienna 2001

3 Forster R, Kinzl H: Statistische Informationen zur Vollziehung desUnterbringunggesetzes. Teil 4: 2000. Institut für Rechts- und Kriminalsoziologie.Wien 2002

4 Katschnig H, Gutierrez K: Evaluation des Massnahmenvollzugs nach § 21(2)StGB. Federal Ministry of Justice. Vienna 2000; and Federal Ministry of Justice. Vienna 2003

37

D Pharmacological and psychotherapeutictreatments

While details for specific in-patienttreatments are not available on acountry-wide basis (due to the lump-sum approach of the DRG system),data for pharmacological and psycho-therapeutic treatments in out-patientsare. Sources are the "Main Associationof Austrian Social InsuranceInstitutions" (for medication paid forby health insurance) and the "Instituteof Medical Statistics (IMS)", which car-ries out regular prescription surveysamong doctors in private practice andin pharmacies.

For all types of medication 93,3million prescriptions were paid for byhealth insurance in 2002, with totalcosts of 1.788 million Euro. Cheapmedications are not included, sincepatients have to pay a prescription feeof 4,14 Euro and it might be cheaperfor them to buy the medication them-selves. 6,5 million prescriptions, i.e.

7% of all prescriptions, concernedpsychotropic medication, with costs of167,3 million Euro, or 9,4% of thecosts for all drugs.

In 2000 health insurance paid28.6 million Euro for psychotherapy.While this is less than 20% of the costsof pharmacotherapy during that year,it has to be acknowledged that the tar-get populations for these two types oftreatments only partly overlap andthat a direct comparison betweenthese two treatments is not meaning-ful. Also, it is proven for many psychi-atric conditions that a combination ofboth treatments is superior to the sin-gle treatments.

The graphs on the following pagesbasically show that prescriptions andcosts for antidepressants and antipsy-chotics are on the rise - also as far ascosts are concerned - and that tranqui-lizers are on the decline.

38

D1 Number of prescriptions and costs ofpsychotropic medication in out-patientservices by type of medication 2002

In 2002 all together 6,540.253 pres-criptions for psychotropic medicationswere issued by doctors (general practi-tioners, psychiatrists and other specia-lists) who had contracts with healthinsurance. Over 50% of these prescrip-tions were for antidepressants, lessthan 25% for tranquilizers and 15%for antipsychotics.

The costs for these groups - in total167,3 million Euro - are not proportio-

nate to the number of prescriptions.Antipsychotics are relatively expensive(accounting for one quarter of the totalcosts, but only for 15% of prescrip-tion). In contrast, tranquilizers, whileaccounting for more than every fifthprescription, create only 4% of thetotal costs. The costs for antidepres-sants are related to the percentage oftheir numbers of prescriptions.

Out-patient prescriptions of psychotropic medication 2002by type of medication, 100% = 6,540.253 prescriptions

Costs of out-patient prescriptions of psychotropic medication 2002by type of medication, 100% = 167,331.000 Euro

39

40

D2 Prescriptions of psychotropicmedications by type of medication1995-2002

The total number of prescriptions ofpsychotropic medication rose from4,77 million in 1995 to 6,54 million in2002. The increase is not monoto-nous, since a leveling off can be obser-ved since 2000 with only a small in-crease from 6,46 million to 6,54 mil-lions (+1,2%), while in the years befo-re increases were much higher. Onepossible explanation is that the pre-scription fee was increased substantial-ly in 2002 and that since then morepatients pay for their medicationthemselves.

As far as type of medication isconcerned, antidepressant prescrip-

tions have more than doubled bet-ween 1995 and 2002 (with yearlyincreases of between 2 and 3%).Some argue that the reduction of sui-cide rates (A3) might be related to theincreased prescription of antidepres-sants, especially the new ones whichare less toxic.

Antipsychotic prescriptions increa-sed by a factor of 1,5. Tranquilizerprescriptions decreased, especiallysince 2000, which might be in connec-tion with the above mentioned mecha-nism in relation to the increase of theprescription fee (since tranquilizers areusually cheap).

41

Total Antipsychotics

Antidepressants Tranquilizers

Proportions of antipsychotics, antidepressant and tranquilizer prescriptions

Prescriptons of psychotropic medication 1995-2002

42

D3 Prescriptions of psychotropic medicationby type of medication and type of physi-cian 1991-2002

It is somewhat surprising at first sightthat general practitioners are the lea-ding group among all physicians as faras the number of prescriptions ofpsychotropic medication is concerned.Of course, this is not really astonishing,since general practitioners are muchmore numerous than psychiatrists.

What is in fact astonishing is thatgeneral practitioners are the leadinggroup for all three main types ofpsychotropic medication. It has beenwell known for some time that generalpractitioners have always tended toprescribe tranquilizers, but they do cle-arly less so in 2002 than they did adecade earlier. It seems that antide-pressants, for which two million pres-criptions were issued in 2002 by gene-ral practitioners, have taken over therole of tranquilizers. Their increasefrom 1991 to 2002 mirrors the decre-

ase of tranquilizer prescription bygeneral practitioners.

It is noteworthy that psychiatristsnever prescribed much tranquilizersand remained stable in this respectover the period 1991-2002 on a lowlevel. Psychiatrists also prescribedmore antidepressants in 2002 thanthey did 1991, but the rise was by farnot as pronounced as that in generalpractitioners.

As far as antipsychotic prescrip-tions are concerned the situation wasrather stable until 2000, when thenumber of prescriptions started to rise,especially so prescriptions by generalpractitioners. All together, antipsycho-tics are the smallest sector in the field(which does not show in the graph,since the scale is different from that forantidepressants and tranquilizers).

43

Antidepressants

Antipsychotics

Tranquilizers

44

D4 Costs of out-patient prescriptions ofpsychotropic medication 1995-2002

The costs of prescribed psychotropicmedication have more than doubledbetween 1995 and 2002. The rise isexclusively due to the prescription ofantidepressants and antipsychotics,with the latter showing an especiallydrastic increase, which is out of pro-portion if compared with the increase

of prescriptions. The reason is proba-bly the increasing proportion of pres-criptions of atypical antipsychotics.

It is noteworthy that in 1995 tran-quilizers and antipsychotics had cau-sed nearly identical costs and that in2002 antipsychotic costs were 6 timesas high as costs for tranquilizers.

45

Costs of prescriptions of psychotropic medication by type of medication1995-2002

46

D5 Costs of health insurance fundedpsychotherapy

Psychotherapy is a state-certified pro-fession with a standardized curriculumsince 1991 (see B2). By the end of2002 altogether 5632 psychothera-pists were registered - a number seventimes as large as that of psychiatrists.

Psychotherapists may practicepsychotherapy either in institutions orin solo practices, where the costs arepartly borne by health insurance in acomplex manner - either by contractor by reimbursing the patient, who hasto pay the psychotherapist directly.The latter mechanism also applies topatients of psychiatrists who haveundergone a specific psychotherapeu-tic training.

The total costs of health insurancefunded psychotherapy increased from22,6 million Euro in 1997 to 28,6 mil-lion Euro in 2000, the year for whichthe latest figures are available. This isaround 20% of the costs of psychotro-pic medication paid by health insuran-ce. Some regard this as a small, othersas a large amount; sometimes a pole-mic is carried out around these figures.It has to be clearly stated, however,that the target populations of thesetwo types of treatments only partlyoverlap and that a combination maywell be superior in some conditionsthan just applying one of the two treat-ments alone.

47

Costs of health insurance funded psychotherapy 1997-2000(in million Euro)

48

ACKNOWLEDGEMENTS

This publication would not have been possible without the help of many persons.Not all can be mentioned here, but special thanks go to: Werner Bohuslav, PeterDenk, Hubert Hartl, Margot Haslinger, Edwin Ladinser, Theresia Maly, MichaelScherer, Peter Scholz, Gernot Sonneck, Günther Stefanits, Eva Trappl, JohannesWancata and Barbara Weibold.

Heinz Katschnig

Published bythe Federal Ministry of Health and Women, Section III, Radetzkystr. 2, 1030 Vienna,

based on a draft prepared by Professor Dr. Heinz Katschnig, University of ViennaEditor-iin-cchief: Dr.Hubert Hrabcik, M.D., CMO

Vienna, September 2003All rights reserved.

Layout: Günther STEFANITS