London School of Hygiene & Tropical Medicine

The study team, which involved researchers from the London School of Hygiene & Tropical Medicine and was led by the National Institute of Mental Health in the Czech Republic, assessed the development of mental health services in 24 countries across the former Soviet Union and Eastern Bloc and the Southeast European countries over the last 25 years.

Profound socio-economic and political changes have taken place since the fall of communism in CEE. However, after reviewing research on mental health services across the region the team showed that despite many promising policy documents, in practice mental health services are still reliant on large psychiatric hospitals with inadequate conditions. Many facilities are run-down and lacking in privacy.

The researchers found that underdevelopment of community care and lack of alternatives to hospital treatment in some countries led to unnecessary psychiatric admissions and long-term hospitalisations, in some cases for over 20 years. Stigma and discrimination against people with mental disorders were shown to be widespread, and human rights violations continue to occur.

The research highlights the need for mental health to be recognised as a public health priority and to be allocated resources that are proportional to the burden of these conditions. CEE countries apportion an estimated 3% of their health care budgets to mental health (equivalent to US$18.70 per person), which is far below the average in EU countries outside of the former eastern bloc, with an average of 7% (equivalent to US$293.70 per person). The team found a lack of economic evaluations and epidemiological evidence to support the allocation of these scarce resources.

Dr Arlinda Cerga-Pashoja from the Centre for Global Mental Health at the London School of Hygiene & Tropical Medicine and co-author of the study said: “More than 25 years ago the Berlin wall fell and the countries of Central and Eastern Europe emerged from decades of political and economical isolation. Mental health services were mostly, or completely, built on biological approaches, and were hospital-based, highly stigmatised, underfunded and under-resourced. Some services were limited to a few psychiatrists and a handful of psychologists and social workers. More than two decades later, mental health remains neglected by CEE governments and the international community.

“Mental health legislation has been passed and introduced in several CEE countries. However, in many countries this was mostly due to external pressures in order to meet EU standards, rather than as a result of genuine attempts to modernise the services. In Albania and Kosovo, for example, the mental health legislation remains largely unimplemented, services underfunded, and stigma still very high.”

The researchers found some positive developments since 1989-1991. Local champions, with the help of international organisations, have developed some excellent examples of community services in nearly all countries of the region. There has also been a rise in the number and activities of voluntary, patient and family organisations, and a lot of small-scale projects and improvements.

However, the team highlight that these initiatives have not been scaled-up and integrated into routine mental health care systems. This means that they are not accessible to the majority of the population and their sustainability depends on external funding schemes, which are very often limited in time and geographical coverage.

Dr Krupchanka from the National Institute of Mental Health in the Czech Republic said: “This region has the highest proportion of disease burden due to mental and substance use disorders in the world, the highest rates of suicide worldwide, and extremely high – and rising – levels of alcohol consumption. Despite all these facts, the attention devoted to mental health and mental health care in the region is very limited.”

The researchers also note that public mental health research activity in the region is scarce. This is due to a combination of internal and external factors such as ‘brain drain’, lack of public health training for mental health leaders, and mental health not being seen as a priority by local and international funders. They also urge policymakers and service managers to give greater weight to the voices of service user and family organisations, in order to address quality issues, stigma and human rights violations.

Publication

Petr Winkler, Dzmitry Krupchanka, Tessa Roberts, Lucie Kondratova, Vendula Machů, Cyril Höschl, Norman Sartorius, Prof Robert Van Voren, Oleg Aizberg, Prof Istvan Bitter, Arlinda Cerga-Pashoja, Azra Deljkovic, Naim Fanaj, Arunas Germanavicius, Hristo Hinkov, Aram Hovsepyan, Prof Fuad N Ismayilov, Sladana Strkalj Ivezic, Marek Jarema, Vesna Jordanova, Selma Kukić, Nino Makhashvili, Brigita Novak Šarotar, Oksana Plevachuk, Daria Smirnova, Bogdan Ioan Voinescu, Jelena Vrublevska, Graham Thornicroft. A blind spot on the global mental health map: a scoping review of 25 years' development of mental health care for people with severe mental illnesses in central and eastern Europe. Lancet Psychiatry. DOI.org/10.1016/S2215-0366(17)30135-9