Dr. Muijen, who is editor of this new column, is regional adviser for mental health for the World Health Organization's Regional Office for Europe. Send correspondence, including inquiries about possible submissions to the column, to him at WHO Regional Office for Europe, Scherfigsvej 8 DK-2100, Copenhagen, Denmark (e-mail: email@example.com).
This occasional column for Psychiatric Services will address the status of mental health care in Europe. The term "Europe" encompasses different meanings and groupings, even in a limited subject area such as mental health care. Within Europe there are natural, historic, cultural, and political divisions that carry significance, such as Central or Eastern Europe, but that change constantly over time and are largely meaningless in isolation (1). Anyone challenged to define "European psychiatry" will grasp the point quickly.
Intergovernment agencies that focus on areas such as economics, law, and health all have mandates to shape mental health activities in their various groups of nations. Such agencies include the European Union with 27 countries, the Council of Europe with 47 members, and the European Regional Office of the World Health Organization (WHO) with 53 countries. These agencies generate strategies, declarations, and resolutions, such as WHO's Mental Health Declaration and Action Plan for Europe (2), the European Commission's green paper on mental health (3), and the Council of Europe's Convention on Human Rights and Biomedicine (4).
For the purpose of this column, the membership of WHO Europe will be used to determine the boundaries of Europe. WHO Europe comprises 53 countries, including the usual 48 "European" countries west of the Ural range and the former Soviet Union republics. It is bordered by seas on three sides and by Syria, Iraq, Iran, Afghanistan, and China on the south side. It has a population of some 850 million people, and about 45 official languages are spoken in its 53 member countries. The region is very unequal economically, with a strong gradient from a poor Eastern area to a very rich Western area, particularly the 27 European Union countries. Gross domestic product (GDP) per capita (in U.S. dollars) varies from $322 in Tajikistan to $54,500 in Norway (excluding Luxembourg, which is atypically small and wealthy) (5). Life expectancy ranges for men from 58.9 years in the Russian Federation to 79.5 years in Iceland. Among women life expectancy ranges from 69.8 years in Turkmenistan and 71.7 in Moldova to 83.9 years in France and Switzerland.
Many parts of government have a responsibility for mental health care, with considerable variation across countries. It is not surprising that mental health systems across Europe are diverse in governance, human resources, funding systems, and service delivery. The responsibilities of the public and private sectors differ, and the role of the private sector is generally expanding. However, in every country treatment and care, including medication, is free at the point of access for persons with acute mental disorders, although informal—and sometimes illegal—copayments are expected in many of the poorer countries. There are more differences between the historically and culturally diverse European Union countries than between the more homogeneous countries in the eastern part of the region, many of which were part of the former Soviet Union with its centralized and standardized health care system. Eastern European countries are now creating diverse health care systems, and all are developing mental health policies. The reforms are partly driven by broad political and economic changes, such as market reforms and attempts to cut public spending. They are also inspired by a growing awareness of the inability of the health system to address conditions, such as depression and alcohol misuse, that are responsible for a large proportion of disability and by concerns about heavy reliance on asylums in which patients receive inadequate care. Crucially, all European countries have at least a basic supply of hospital beds and psychiatrists on which they can build reformed programs.
Many of the more developed countries are moving toward community-based mental health services. In poorer countries, however, hospitals still dominate services, absorbing up to 90% of mental health resources (6). The rates of hospital beds across countries hide important differences. First, some countries offer more differentiated forms of hospital treatment than others by providing beds in alternatives to psychiatric hospitals. Generally, but not always, the availability of beds in alternative settings is related to the stage of service development. For example, in most former Soviet Union countries, all beds for treatment of psychiatric disorders are provided in mental institutions. In Italy, Finland, Sweden, and the United Kingdom, all psychiatric hospitals have been closed and replaced by smaller units, mostly in general hospitals. However, in some advanced countries, such as Belgium, the Netherlands, Germany, and France, a large proportion of hospital beds are in psychiatric hospitals.
The hospital bed rates do not include beds in small-scale residential care homes in Western European countries and so-called social care homes in many Eastern European and former Soviet Union countries. Some social care homes are large institutions, typically under the responsibility of a Ministry of Social Welfare, that provide beds for people with any condition that requires long-term care. These homes often house a mix of residents—with mental retardation, dementia, and schizophrenia—and offer minimal and mostly generalist treatment in a highly institutionalized context. The number of people with psychiatric disorders in social care homes may be as large as the number in psychiatric hospitals, but the former are not counted and often not known. An important observation has been the potential transinstitutionalization of patients from the old mental hospitals to new institutions, such as forensic hospitals, prisons, and residential homes (7).
A second substantial difference between richer and poorer countries that is hidden by statistics is the condition of care. Although we cannot be complacent about conditions in some hospitals in Western Europe (8), they bear no resemblance to conditions in hospitals in the central and eastern part of Europe. Organizations such as Mental Disability Rights International and the Mental Disability Advocacy Center produce regular reports about institutional care of patients with mental illness in countries with less developed mental health systems. The reports describe appalling conditions, including neglect and abuse, sometimes of a very disturbing nature, such as tying patients to beds for days or administering unmodified electroconvulsive therapy. In poorer countries the hospitals are typically neglected old buildings, with wards holding 60 patients, 12 in a room, little space for recreation, and a minimal level of hygiene. The staffing level can be one physician and two nurses per ward. In the worst of these institutions, patients are dressed in old hospital clothes and have no personal belongings; they spend most of their time in bed or aimlessly wandering the wards. A main contributing factor is very poor funding for hospitals. In Latvia, a new European Union country of average wealth, a hospital director reported that the total budgeted amount for a hospital day was $22 (U.S. dollars), or about a fifth of the needed amount. The director explained that the low budget results in poor staffing numbers and low levels of therapeutic activity. In the poorest countries, a hospital's medication supply, which consists of a small variety of first-generation antipsychotics and antidepressants, is sufficient for only half the patients. Some hospital directors struggle to buy food.
The lack of funding can result in surprising degrees of self-sufficiency; some hospitals have set up farms to grow some of their own food. An astonishing example is a large hospital in Tajikistan that on orders from Stalin was placed in the middle of a village. There is now complete integration: houses and schools are spread over the hospital grounds, villagers are employed in the hospital, and patients work on the land. Obviously, this arrangement raises major concerns about the potential for abuse and exploitation. It also typifies the challenges faced when a hospital closure is planned, which puts the local economy at risk. The contrast between psychiatric hospitals and general hospitals can be sobering, especially flagship state university hospitals that are found in some of the poorest countries. These university hospitals are often built with aid money and can stand comparison with modern hospitals in wealthy Western countries. No psychiatric hospital can.
A third factor to consider when comparing hospital data from various European countries is the reduction in the number of psychiatric beds, which has been almost universal in Europe over the past 25 years. Although such reductions are generally interpreted as a step in the right direction, the reality is more complex. The assumption is that a reduction in hospital beds represents development of community services, which is indeed the case in most of the richer European countries, such as Italy, all the Nordic countries, and the United Kingdom. However, the reduction is less a cause for celebration in many countries in the eastern part of the region, where hospital beds have not been replaced with alternative services. In such countries cuts in beds may mean cuts in mental health care budgets and therefore services.
Mental health care budgets are not available for all European countries, and those that are available are imprecise and difficult to compare because of variations in what is covered by the mental health care budget. On average, spending for mental health care accounts for 5.9% of health care budgets in European countries, with a range from less than 1% in some of the poorest countries to more than 12% in Luxembourg and the United Kingdom (7). Because the proportion of the GDP invested in mental health care is lowest in the poorest countries, spending on mental health care in poor European countries can be worryingly low. Only 1% of a very small health care budget means that the gap between need and supply is serious and unbridgeable without substantial investment, which is often heavily reliant on foreign grants or loans.
A resource in every European country is the large number of psychiatrists by world standards, which in some countries is a legacy of the Soviet era. Training and competencies vary considerably; some countries in the eastern part of Europe require only one to two years of specialization, compared with four years in most Central and Western European countries. Many countries are struggling to develop and sustain their psychiatric training and workforce. For example, in Tajikistan no higher academic degrees can be awarded because the country has not yet created the necessary academic capacity after the breakup of the Soviet Union, which had a centralized infrastructure and relied on academic institutes in Moscow.
In the Soviet Union psychiatrists shared a common language and training curriculum, which means that they can now easily find employment in any of the former Soviet countries. For example, an exodus of psychiatrists from Kyrgyzstan to the Russian Federation has been stimulated by a mixture of nationalism (many psychiatrists are of Russian descent) and a desire for financial gain. A psychiatrist in Russia earns about ten times more than one in Kyrgyzstan. This salary differential is dwarfed by extremes around the European region. A psychiatrist in Tajikistan can expect to earn $600 (U.S. dollars) annually—perhaps twice as much if copayments are involved—and a psychiatrist in the United Kingdom earns $200,000, more than 300 times more. Of course, the cost of living is considerably higher in London than in Dushanbe, but the difference is not as high as the salary differential: there is a 90-fold difference between the GDP of Tajikistan and the United Kingdom. This partly explains the movement of psychiatrists and other physicians from poorer to richer countries in a gradual western direction, which has caused major shortages in many countries.
An additional challenge is that psychiatric recruitment is low in many countries. Reportedly, only three of every 600 medical students in Kyrgyzstan choose psychiatry, because earning opportunities and status for psychiatrists are poor compared with other medical specialties. In addition, many medical students do not complete their training or never practice, because medical salaries are significantly lower than salaries in some nonmedical professions, including positions with the pharmaceutical industry. The same factors apply to nurses, an aging and diminishing staff group across Europe that has been affected by a combination of low salaries and low status. Equally low in status are social workers and psychologists, who are almost nonexistent in many Eastern European countries.
Analysis and comparison of the status of mental health care in European countries are seriously hindered by the lack of available information. Even when information exists, the reliability of some sources is uncertain. Most international databases include data provided by governments, and only the advanced Western European countries have the systems and resources necessary to collect and analyze data that are meaningful to clinicians, managers, and policy makers. Data on routine outcome indicators are rare anywhere; such information is only occasionally produced by evaluations and surveys. No standard data set has been agreed upon by member states of either the European Union or WHO, although regular attempts have been made to create one. The lack of agreement means that comparisons can be challenging, because categories such as "psychiatric beds" may include different types of services even in neighboring countries.
Most information on activities relies on international research studies, which have increased in number and quality over the past decade, largely as a result of major grants from the European Commission. For example, the European Study of the Epidemiology of Mental Disorders (ESEMed) reported on epidemiology, comorbidity, service use, and prescribing patterns in six Western European countries (9,10). Considerable differences were reported in patterns of service use and drug prescribing. It is not yet clear whether the differences are attributable to supply or demand. However, if wealthy countries with comparable levels of accessibility and services and with relatively homogeneous cultures show such differences in consumption patterns, one can only wonder about the state of care in poorer countries that have less diverse and sophisticated services and where high levels of stigma affect use of mental health care. No studies have examined patterns of service use in poorer countries.
Service research is conducted in a small number of centers in England, Italy, Germany, and the Nordic countries. Most service research focuses on the effectiveness of local service models and national policies. Thus it is uncertain whether conclusions drawn from sophisticated service models in rich parts of the world can be applied to scenarios in middle- and low-income countries. An example is the finding that community services in England can be funded largely from cost savings from hospital closures (11). These studies have been used as evidence to recommend hospital closures in countries such as Ukraine and Georgia. Although closures should indeed be pursued on human rights grounds and for health reasons, the very different economic and resource context cannot be ignored. In poorer countries, factors such as low land value, poor staffing levels and competencies, lack of investment, rejection of patients by families, and absence of any community infrastructure—all in the shadow of corruption—mean that shifting of resources may risk their disappearance altogether, unless such shifts are supported by a strong commitment and investment from ministers of health.
Variations in reforms and resources across Europe mean that exciting initiatives in psychiatry can be found in some parts of Europe, whereas other parts appear to be quite bleak. Below the surface, examples of progress are emerging in most of the poorer countries in Europe. Some are small-scale model services that are set up by charities or the WHO and gradually adopted by governments. Others are centrally driven by policies and legislation. Examples of the former that have produced positive clinical and social results are the creation of a community mental health team in Tirana, Albania, and the transfer of some patients from a hospital to a residential hostel in Elbasan, Albania. The Albanian Ministry of Health is monitoring these activities closely and is showing increasing signs of support. An example of centrally driven change is the ambitious reform of community care in Romania, which is being coordinated on behalf of the Romanian Ministry of Health by the National Centre for Mental Health. A network of community-based mental health centers is currently being developed and will replace the old outpatient services—the so-called mental health laboratories. The government's commitment has been demonstrated by its allocation of funds for mental health care reform over the next few years, which are to be used both for setting up the first 20 centers and to train staff in new ways of working in community settings. This initiative followed a critical report about conditions in Romanian mental hospitals. Improvements were linked to Romania's conditions of accession into the European Union, which spurred its government into action.
In the past few years many countries in Europe—as far apart geographically and culturally as Portugal and Uzbekistan—have drafted impressive policies on community-based mental health services. The signing of the 2005 Helsinki Mental Health Declaration for Europe, which established action plans and milestones, has acted as an incentive for some countries. The challenge is how to implement these reforms in the light of the challenges summarized above. Financing is crucial, but equally important are sustained leadership by policy makers and the psychiatric profession, workforce reform, involvement of the general population, and empowerment of families and service users. It is particularly to be hoped that the commitment expressed over the past few years to address stigma and discrimination will remain on the policy agenda and that mental health will continue to be viewed as a genuine public health priority in Europe.