ThepresentstateofMentalhealthcareinSlovakia

ŠtefanLaššán

Depressionreducessurvivalinpa;entswithchronicsoma;cdisorder

Prospec(vecohortstudyenrolling376hospitalizedpa(entwithCOPD;medianfollow-up369days

OR1,93

Barrierstotreatment(mentaldisorders)inEU

RespondentstotheEUCompassforAc4ononMentalHealthandWell-being2016surveyindicatedthefollowingbarriers:

•  insufficientfundingformentalhealthserviceswasreportedby19outof22memberstateshavingsome(27.3%),high(18.2%)orveryhighimpact(27.3%);

•  insufficientavailabilityofmentalhealthprofessionalswasreportedby16outof22memberstates,havingsome(31,8%),high(27,3%)orveryhigh(13,6%)impact;

•  aMtudinalbarriers(lackoftrust,willingnesstohandleproblemsbyone’sown,s4gma)wasreportedby17ofthe22memberstates,havingsome(40.9%)high(27.3%)orveryhigh(9.1%)impact.

Animportantpartofmentalhealthcarecouldbemanagedbyinformalorganiza;ons.Whereaddi4onalsupportandexper4searerequiredamoreformalnetworkisneeded.

Theintegra4onofmentalhealthcareinprimaryhealthservicesisacri;calcomponentofacomprehensivementalhealthsystem.Essen4alservicesatthislevelincludeearlyiden4fica4onofmentaldisorders,managementofstabilizedseverementaldisorders,referralofcomplexcasestospecializedservices.

WHOpyramidnetwork

Thespecializedservicesareatthetopofthepyramid:•  aprocessofdeins;tu;onaliza;on,•  limi;ngtheroleofmentalhospitals•  buildinganetworkofcommunityservices(includingcommunitymentalhealthcenters,generalhospitalpsychiatricunits,daycentersandcommunityresiden4alfacili4es)Thatallincreasestheaccessibilityofservices.Actually,hospitaltreatmentisrequiredforaminorityofpeoplewithmentaldisorders,evenincasesofseveredisorders.

WorldHealthOrganiza1on,2010;2011;2014

Problemsofslovakhealthcaresysteminthemanagementofmentaldisorders

•  Ins;tu;onaliza;onofhealthcare.Equipmentandarrangementofins4tu4onalhealthcareproviders(MTS,PS).

•  AbsenceofPsychiatricfacili;eswithspecialdesigna;on.•  Unmetneedsintheareaofpediatricpsychiatry(inpa4entandoutpa4entcare,humanresources...).

•  Insufficientconnec;on/collabora;onbetweeninpa4entandoutpa4entpsychiatriccarewithsocialservices.

•  Insufficientconnec;on/collabora;onbetweeninpa4entandoutpa4entpsychiatriccarewithprimaryhealthservices.

•  Absenceofanetworkofcommunitypsychiatrichealthcareservices:communitymentalhealthcenters,daycentersandcommunityresiden4alfacili4es,early-interven4oncenters,crisiscentersandotherservicesincludingmobile(mul4disciplinary)teams,specializedpsychiatriccommunitynursesetc.

•  Publichealthinsurancepaymentsysteminoutpa4enthealthcare.

Activity I. r.

Number of visits

Patients at outpatient

clinics Domestic

visits

Domes-tic visits perfor-med by nurses

Age group a 1 2 3

0 - 18 01 86 499 4 0

19 + 02 1 702 055 1 019 0

Outpa;entpsychiatriccare(2016)

Ins;tu;onalpsychiatriccare(2016):Hospitalisa;ons

Mental and ehavioural disorders due to alcohol use

Organic, including symptomatic, mental disorders

Mood [affective] disorders

Disorders of adult personality and behaviour

Schizophrenia, schizotypal and delusional disorders

Mental and behavioural disorders due to other psychoactive substance use

Neurotic, stress-related and somatoform disorders Disordersofpsychological

development

43516(3,5%ofallhospitaladmissions)

Howmuchdowespendonmentalhealthdisorders?

ExpensesofHealthInsuranceCompaniesinMil€onGroupFandXdiagnoses(F*andX6*toX84*)

Year 2014 2015 2016

Outpa;enthealthcare 27,3 27 29,3Medica;ons 51,8 49,2 49Inpa;enthealthcare 62,5 64 71,5Together 141,6 140,2 149,8

OverallexpensesofHealthInsuranceCompanies 3853 3986 4113Propor;onofexpensesonpsychiatricdiseasescompardwithoverallexpensesonhealthcare 3,7% 3,5% 3,6%

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Thelackofphysiciansandnursesinslovakia–compúaredwithEU

AT

BE

BG

HR

CY

CZ

DK

EE

FI

FR

DE

EL

HU

IE

IT

LV

LT

LU

MT

NL

PL

PT RO

SK

SI

ES

SE

UK

EU

0

5

10

15

20

1 2 3 4 5 6 7

Physicians per 1000 inhabitants, 2015 or nearest year

EU: 3.6

EU: 8.4

Physicians Nr. low Nurses Nr. high

Physicians Nr. high Nurses Nr. high

Physicians Nr. high Nurses Nr. low

Physicians Nr. low Nurses Nr. low

Nurses per 1000 inhabitants, 2015 or nearest year

Thenumberofphysiciansandotherhealthcareprofessionalswhoaremissingintheslovakhelathcaresystem

NursePhysicianScrubNurseHealthAssistentMidwivesPhysiotherapeu;stsTechniciansinRadiology

changeHealthcareprofession

NumberofmissingspecialistsinSlovakiaaccordingtoNCHIdata

Deficiencyofphysiciansspecializedinpsychaitry

willrise...

SlovakphysiciansaregeMngolder...

Numberandaverageageofphysiciansac;ngintheareaofpsychiatriccareaccordingtotheirloca;on

Disciplineofmedicine District Numberofphysicians Averageage

Psychiatry

Slovakrepublic 651 46,93 Bra;slavskýkraj 141 48,37 Trnavskýkraj 33 46,15 Trenčianskykraj 66 47,48 Nitrianskykraj 67 47,82 Žilinskýkraj 95 46,53 Banskobystrickýkraj 59 47,95 Prešovskýkraj 76 45,24 Košickýkraj 124 45,55

Disciplineofmedicine District Numberofphysicians Averageage

Pediatricpsychiatry

Slovakrepublic 45 50,93 Bra;slavskýkraj 20 46,10 Trnavskýkraj 0 - Trenčianskykraj 3 51,33 Nitrianskykraj 5 60,80 Žilinskýkraj 4 64,00 Banskobystrickýkraj 6 55,50 Prešovskýkraj 0 - Košickýkraj 7 46,14

Špecializačnýodbor Početabsolventov2006-2015 VydanéOsvedčenieoakreditáciikudňu17.10.2016

Anesteziologiaaintenzívnamedicína 485 JLFUK,UPJŠ,LFUK,SZU,Angiológia 34 SZUDermatovenerológia 106 JLFUK,UPJŠ,LFUK,SZU,Diabetológia,poruchylátkovejpremenyavýživy 84 JLFUK,SZU,Endokrinológia 56 UPJŠ,LFUK,SZU,Fyziatria,balneológiaaliečebnárehabilitácia 115 UPJŠ,SZU,Gastroenterológia 61 JLFUK,LFUK,SZU,Pediatrickágastroenterológia,hepatológiaavýživa 6 JLFUK,LFUK,Geriatria 72 UPJŠ,LFUK,SZU,Gynekológiaapôrodníctvo 284 JLFUK,UPJŠ,LFUK,SZU,Hematológiaatransfuziológia 49 JLFUK,SZU,Chirurgia 231 JLFUK,UPJŠ,LFUK,SZU,Detskáchirurgia 14 JLFUK,LFUK,Infektológia 34 JLFUK,UPJŠ,SZU,Tropickámedicína 5 SZU,Kardiológia 132 UPJŠ,SZU,Pediatrickákardiológia 11 LFUK,Klinickáimunológiaaalergológia 46 JLFUK,Klinickálogopédia 22 SZU,Klinickáonkológia 77 LFUK,Klinickápsychológia 179 FFUK,SZU,Klinicképracovnélekárstvoaklinickátoxikológia 2 Lekárskagene;ka 10 SZU,Nefrológia 64 SZU,pediatrickánefrológia 3 SZU,Neonatológia 23 JLFUK,SZU,Neurológia 240 JLFUK,UPJŠ,LFUK,SZU,Pediatrickáneurológia 8 LFUK,Ozalmológia 192 LFUK,SZU,Ortopédia 130 LFUK,Pediatrickáortopédia 0 Otorinolaryngológia 81 JLFUK,UPJŠ,LFUK,SZU,Pediatria 395 JLFUK,UPJŠ,LFUK,SZU,Pneumológiaazizeológia 66 JLFUK,UPJŠ,SZU,Pediatrickápneumológiaazizeológia 12 JLFUK,SZU,Psychiatria 198 LFUK,SZU,Detskápsychiatria 23 LFUK,Gerontopsychiatria 3 Medicínadrogovýchzávislos{ 6 Rádiológia 245 UPJŠ,LFUK,SZU,Reumatológia 20 SZU,Pediatrickáreumatológia 3 UPJŠ,Úrazováchirurgia 113 UPJŠ,SZU,Urológia 92 JLFUK,UPJŠ,SZU,Pediatrickáurológia 1 JLFUK,Vnútornélekárstvo 286 JLFUK,UPJŠ,LFUK,SZU,

Numberofphysicianswhocompletedtheirspecializa;onstudywithinaperiodbetween2006and2015

198psychiatrists,butonly23pediatric

psychiatristsoveraperiodoflast10years...

Currently,thereare205physiciansinpreparingforthepsychiatricspecializa;on,howeveronly23

physiciansarelistedforpedopsychiatry...

Ins;tu;onalpsychiatriccare(2007-2016).Physicianpostsandbeds–currentsitua;on.

3739beds(Addictologynotincluded)standsfor12%oftheen;reresources

IndicatorsofaccesstocareinEUcountries

(ratesper100,000)

Thenumberofbedsforpedopsychiatricins;tu;onalhealthcare–thepresentstate

Bra1slavaandWestofSlovakiaKlinikadetskejpsychiatrieDFNsPaLFUK,Bra4slava20Pedopsychiatrickéoddelenie,Psychiatrickáklinika,Nitra12Noazer-treatmentbeds!32(-60)MiddleofSlovakiaPedopsychiatrickéoddeleniePsychiatrickáklinikaUKJLFaMFN,Mar4n8PedopsychiatrickéoddeleniePsychiatrickánemocnicaProf.Matulayia,Kremnica30Ʃ38EastofSlovakiaPedopsychiatrickéoddeleniePsychiatrickánemocnica,Stráňany,Michalovce30Detskápsychiatrickáliečebňa,n.o.,Hráň80(95)Significantreduc;onofhospitalbedsinacutehealthacreseMong!Ʃ110Limita;onofaccessability!ƩƩ-180

Source:J.Šuba

Adverseconsequences:-  Lackofpedopsychiatricbeds,theirstructureandoccupancy

arelimi;ngthetreatmentofmentaldisordersinthepediatricandadolescentagegroups.

-  Thenumberofpa;entsdemandingins;tu;onalfollow-uptreatmentisincreasing.Par;curarly,itrefersmainlytoadolescentswithdisordersofpersonality,pa;entswithsuicideriskorself-mu;la;on,pa;entswithmentaldisordersduetopsychoac;vesubstanceuseorwithdisordersoffoodintake.

-  AbsenceofAzer-tretamentbedsandPediatricdaycenters.

Thereareunmetneedsinthefieldofcommunitypsychiatriccareservices

•  ThereisanurgentneedforeffortsaimingatthedevelopmentofStandardpreven;ve,diagnos;candtherapeu;cprocedures.Moreover,accordingtoholis4capproach,thecomplexpa;entmanagementhastobeapplied.Pa4entsarefrequentlyunabletotakecareofthemselvesandmanagetheircommoneverydayac4vi4es.Therefore:

•  Itisnecessarytoimproveoutpa;entpsychiatriccareaswellastoprovidepsychoscialrehabilita;onandresocializa;ontobringpeopleintocommunityandfullyintegratethemsotheyareabletoworkandliveindependently.Thecurrentnetworkofdaycentersandcommunityresiden;alfacili;esisunappropriateowingthedemandsofthementalhealthcare.

•  ItisdesirabletoimprovetheaccesstoLong-termdomiciliaryservicesinordertoavoidprolongedhospitalstays,suicidalbehaviour,nosocomialinfec4onsetc.

Mul;sectorialcrossconnec;on

Healthcare

InternalAffairs

SocialAffairs

Jus;ce

Educa;on

ReformoftheMentalHealthCareintheCzechrepublic–Inspira;onforus?

Maintarget:ImprovingtheQualityofLifeforallpa;entswithmentaldisorders

Developmentofstandardsandmethodology

ImprovementofPsychiatriccarenetwork

Humanisa;onofPsychaitric

care

De-s;gma;za;on

andcommunica;on

Researchandeduca;on.

Legisla;veac;vi;es

Sustainablefinancing

Interdepart-mentalco-opera;on

ReformofPsychiatriccareinSlovakia(1999)

Cocep;onofpsychiatrichealthcareinSlovakia(2006)

EuropeanCommi�eeforthePreven;onofTortureandInhumanorDegradingTreatmentandPunishment(CPT)

•  PastCPTac;vi;esinSlovakia:•  2000–AuditandvisittoSlovakia–thecommimedetectedsevereviola4onsagainsthumanrightsamongresidentswithmentaldisorderslivinginnursing

•  2018–forthcomingvisittoSlovakia•  Member:MUDr.D.Breznoščáková,PhD.

•  Ongoingac;vi;es:•  Crea;onofDeten;oncentersinSlovakia•  Crea;onofPsychiatricfacili;eswithspecialdesigna;onwithintheframe

ofexis4ngconcurrentpsychiatricfacili4es

Deten;onins;tuteinHronovce

Standardpreven;ve,diagnos;candtherapeu;cprocedures

WhatistheaimofSPDTP?

•  Defini;onofclearguidelinesforallhealthcareproviders.•  Standardisa;onandharmonisa;onofproceduresaimingatprevence,diagnos;csandtreatmentinselectedareas.

•  Specifica;onofthecompetencesforallstakeholders.•  Consolida;onofthequalityappraisalduringhealthacareproviding.•  Preserva;onofequalityduringhealthcareproviding.•  Crea;onofqualifiedes;ma;onofresourcesdemendedforfinancingofhealthcare.

•  Legisla;vechanges.

SPDTPandpsychiatry

•  ProcessingofSPDTPfortheareaofmentaldisordersrepresentsthemodernEurope-wideapproachtopsychiatriccare.

•  Itwilldefinetelycontributetothequalityofhealthcare.•  Itisimportanttorespectandrealis;callyreviewcurrentdiagnos4candtherapeu4cresourcesandcondi4onsinSlovakia

•  ExpertWorkingGroupforthe1stphaseofSPDTP:•  Chairman:assoc.prof..IvanDóci•  Vice-Chairman:prof.JánPečeňák•  Secretary:Dr.Breznoščáková•  Members:Dr.JánDúžek,Dr.ĽubicaFerenčáková,Dr.JanaGrešková,Dr.KatarínaKubašovská,Dr.LíviaVavrušová,Dr.MarekZelman

•  Selec;onofdiagnosesforthe1stphase(ICD):F30-34,F20-25/F40-43/

Na;onalProgramforMentalHealth

•  ThedevelopmentoftheNPMHwasini4atedaccordingtotheWHOrecommenda4onsanddecisionoftheSlovakgovernmentfromJune27th2001.

•  NPMHactasana;onalprogrammedocumentanditrepresentsthemostcomplexprogramdedicatedtothementalhealthcare.Thankstothedocument,mentalhealthbecameoneofthepoli4cpriori4esintheSlovakrepublic.

•  Thedocumenthasbeenpreparedwithrespecttotheholis;cmul;disciplinaryapproachtothementalhealth.Alleffortsshouldbedonetosecureanequalaccesstobothsoma4candmentalhealthservices.

•  Thisstrategicalmaterialdescribestheframeworkofglobalac4onswithin10keyareas.Themainpurposeistheimprovementofmentalhealth.

•  Coopera4onandcollabora;onofmul;pledepartmentsisnecessary–healthcare,socialaffairs,culture,jus4ce,educa4on,finance,internalaffairsetc.

•  TheCouncilforMentalHealthattheMoHisresponsiblefortheprepara4onofthedocument;themembersfromthepsychiatriccommunityare:Ľ.Izáková,I.Dóci(Vice-chairman),D.Breznoščáková,J.ŠubaandĽ.Okruhlica

•  Currently,legisla4veprocessisinprogress.

TheEU-CompassforAc;ononMentalHealth

Theresourcesarestructuredaroundthe5priorityareasoftheEuropeanPactinMentalHealthandWellbeing:•Preven4onofSuicideandDepression•Promo4onofMentalHealthandWell-beingofChildrenandAdolescents•Promo4ngMentalHealthandWell-BeinginWorkplaces•OlderPeople’sMentalHealthandWell-being•Promo4ngSocialInclusionandComba4ngS4gma

hGp://ec.europa.eu/health/mental_health/eu_compass/index_en.htm

ConclusionsfromtheEUCompassforAc;ononmentalHealthandWell-beingscien;ficpaper

•  TheaccesstomentalhealthcareinEuropeanUnionisfarfrombeingsa4sfactory.•  Coverageisbemerforseverementaldisorders,suchaspsychoses,andmuchworsefordepressionandcommonmentaldisorders.

•  Structuralbarriersmaybemoreimportantincountrieswithlimitedhealthcoverageandlessdevelopedcommunitycare,aMtudinalbarriersareimportanteverywhere.However,trendsincontainmentofhealthcostscanraisetheroleoffinancialbarriersevenincountrieswithuniversalhealthcoverage.

•  Lowpercep;onofneedisanimportantaxtudinalbarrier.•  Thelackofcoverageisespeciallyrelevantforpsychologicalandpsychosocialtreatments,despiteindica4onfromguidelinesaboutevidence-basedcaremodels.

Cooperation is the key to success!