An Assessment of the
Hungarian Mental Health Care
March 2014
WHO HQ and
WHO Regional Office for Europe
An Assessment of the Hungarian Mental Health Care
March 2014
The mission took place between 25-28 March 2014. The programme is attached (Annex 1).
Members of the expert team were:
1. Dr. Shekhar Saxena, Director, Department of Mental Health and Substance Abuse
World Health Organization, Geneva.
2. Dr. Matt Muijen, Programme Manager Mental Health and Neurodegenerative Disorders, WHO Regional Office for Europe, Copenhagen.
3. Dr. Dan Chisholm, Health Systems Adviser, Department of Mental Health and Substance Abuse, World Health Organization, Geneva.
4. Professor Martin Brown, University of York, UK.
The team was supported by technical staff from the WHO Country Office:
Dr. Zsófia Pusztai, Head of Country Office.
Szabolcs Szigeti, National Professional Officer, Hungary Country Office.
We would like to thank Hungarian colleagues for their support in preparing and conducting this assessment mission. Particularly the assistance of Dr.Tamas Kurimay, WHO national counterpart on mental health has been much appreciated.
1. Background
During a bilateral meeting between the Hungarian Prime Minister, Mr. Viktor Orbán and the Director General of the WHO, Dr. Margaret Chan, a request was made for information about the Global and Regional mental health situation, and to explore a partnership between WHO and Hungary in this field. Following a briefing for the Prime Minister prepared by WHO, further coordination of activities with the State Secretariat for Health was proposed. It was agreed that a WHO expert team would visit Hungary to assess and evaluate mental health services and provide recommendations on priorities for action within the context of the planned Hungarian Mental Health Strategy.
During 2013, the 8 different sectors under the Ministry of Human Resources had started a preparation of an overall Mental Health Strategy Plan 2014-2020, also including NGOs and professionals. The basis for this Strategywereboth the Global and European Mental Health Action Plans. The State Secretariat for Health coordinated this process jointly with the Social Affairs sector.
The objectives of the assessment, complementing the Strategy, were agreed as follows:
I. The main focus is the evaluation of the effectiveness and efficiency of the current service model in the context of governance, financing and workforce in Hungary and considering the necessary coordination between health and social sectors on mental health care, with the aim to offer recommendations on how to improve community based mental health services and primary care. Priority areas are:
1. Wellbeing of the population and prevention and early intervention of mental disorders and prevention of suicide,
2. Coordinated care for severe mental disorders,
3. Decent living for long term patients,
4. Communication with patients and families.
II. The delivery of a report considering the status and challenges related to:
· Service delivery;
· Human workforce, including the capacity of community teams and primary care;
· Financing system issues;
· Mental health promotion in the light of the Norwegian grant proposals.
2. Introduction and context
The Hungarian State Secretariat and mental health specialists demonstrated during the visit that they are well aware of the mental health situation in Hungary and the challenges facing the system. The sections in this report provide an analysis of the services that together formthe mental health system, followed by some cross-cutting challenges. This introductory section provides a brief international comparison to placethe Hungarian mental health situation in a broader context.
The Hungarian government is concerned about mental wellbeing and the consequences of mental ill health. The Mental Health Strategy Plan Hungary 2014-2020 is being prepared, and focuses extensively on health promotion, development of health, happy childhood, supporting families and communities, positive work life balance, healthy aging, inequalities and stigmatization. We only received a brief summary, so we are not able to comment on the details of the plan. Some issues related to promotion and prevention are addressed later in the report.
Concern about population mental health is dominated by the awareness of the relatively high suicide rates as well as social disparities in mental health. The annual suicide rate now stands at around 24 per 100,000 population, which is about half of the rate it was 20 years ago but still the second highest rate in the European Union (after Lithuania). The Eurobarometer 2011(73.2) also indicates that Hungarian respondents expressed a negative emotional experience that was a bit below the European average.
No recent population-based depression rates are available, but a report from 2006 showsan annual rate of clinical depressive symptoms of 16.8% (Kopp 2011). The treatment gap of depression in the Hungarostudy of 2002 was 80%. In the 10 years since then, prescribing of anti-depressants has doubled, as has occurred in most European countries, and is now 27.6/ DDD/1000/daily (Rihmer 2013). This is low compared to other European countries. However, the Eurobarometer found that 7% of Hungarians used anti-depressants in the previous year, precisely the European average. The explanation for the discrepancy between the low prescribing but average level of reported use of anti-depressants as compared to either countriesis not known. It could be caused by wrong data, could indicate shorter-term use of the medication or sharing of prescriptions due to cost factors.
The aims of the Strategy also include the provision of accessible, integrated and affordable mental health services.When service provision in Hungary is compared with other countries in the European Region, a picture emerges that anticipates some of the challenges that will be addressed in later sections of this report. In 2013, Hungary had a total of 9.8 beds per 10,000 heads of population (10% higher than the data reported to WHO in 2011). This rate is somewhat above the European average. Number of admissions, at about 120 per 10,000 population, is also relatively high. Number of visits to outpatient clinics is also high (about 2,000 per 10,000 population). Details are provided in a later section of this report.
The high use of services is not reflected in high staffing levels, relative to other European countries. Hungary has about 8 psychiatrists (including private psychiatrists) and 20 nurses per 100,000 population as reported by health service providers. Numbers vary somewhat depending on the sources, but numbers are low by European standards.
All these figures need to be interpreted with some caution due to differences of definition and data collection in some countries.
Psychiatric beds per 10,000 (2011).
Admissions to all inpatient units per 100 000 population
Visits to outpatient facilities per 100 000 population
Psychiatrists per 100.000 population, 2011
Nurses in mental health per 100 000 population
3. WHO Service Model
The model of care used as a benchmark for this assessment is the one endorsed by WHO Member States in both the Comprehensive Mental Health Action Plan and the European Mental Health Action Plan.
The Action Plans put forward a range of activities to optimize wellbeing and build resilience across the lifespan. Such activities require initiatives and partnerships across all sectors of governments.
In order to prevent and treat mental disorders and offer social inclusion for people with mental disorders, minimizing stigma and discrimination, the Global and European Action Plans propose a spectrum of services responsive to population needs. This spectrum of community and hospital services is interdependent, relying for acceptability, accessibility, effectiveness and efficiency on their integration. These services include: information and means to help oneself or support family members; primary care linked services for common mental health problems; community mental health teams for severe and/or complex mental health problems; beds in community settings such as health centres or District General Hospitals for persons requiring intensive care; and some regional/national services for special conditions including eating disorders and forensic services.
Primary care remains the first point of access for the large majority of people with mental health problems. Up to 50% of persons attending primary care suffer from a mental health problem, often not identified. The stigma of accessing primary care is low, settings are accessible and brief interventions can be delivered efficiently, particularly for people with common mental health problems such as anxiety and depression. Primary care staff require training and support from mental health staff to identify, diagnose, treat and when required to refer people with mental health problems to specialist care.
Community services need to be located close to the populations they serve, in settings with good access and low stigma. Multidisciplinary teams have proven their effectiveness at: prevention through early intervention at times of crisis thus preventing hospital admissions; providing assessment and treatment of people with severe and enduring mental health problems 24 hours a day; and, engaging persons with severe mental health problems at high risk of relapse, including homeless people. Teams can struggle to meet demand because of high expectations and limited resources. Their objectives and the scope of services thus need clear specification and communication with the population and referring agencies. Mental health services need to work closely with primary care and hospital services and must be locally co-ordinated, minimizing fragmentation and facilitating collaboration.
Many patients present with multiple problems, and services need to be prepared by offering expert interventions or establishing partnerships. Substance misuse disorders are so frequent in many European countries that some multi-disciplinary community teams will benefit from integrated expertise and specialist treatment and care for people with combined mental health and substance misuse problems.
Hospital beds need to be available for complex care and the provision of a place of safety for the briefest necessary period when community support is insufficient. Wards should be small scale, not more than 20-30 beds, balancing the requirements for individual care programs and efficient care and protection. Men and women should have separate sleeping, washing and toilet facilities. Children and young people and elderly people require their own units. Information must be available about procedures and rights, particularly for people who are forced to stay against their will. All hospital design, procedures and actions should be considered from a therapeutic perspective.
Some specialist centres need to be available for conditions requiring expert care such as eating disorders, mother and baby units, severe personality disorders or forensic care, subject to resources. Mental health care in places such as prisons, care homes or children’s homes is the responsibility of mental health services and should be of high standard.
Service gaps are challenging for socially marginalised groups such as certain minorities, the homeless, refugees and travelling communities. People from such groups have more difficulties accessing services because of stigma, lack of information about services, mistrust in staff or a perception that services are inappropriate for their needs. Specific efforts including outreach work that is aware of the consequences of socio-economic and cultural differences are required to overcome these barriers and provide care equally for everyone in need.
Partnership with the social care sector and other non-health sectors is essential, particularly for people with long term mental disorders who rely on these sectors for occupation, housing and benefits.
Children and young people and old people can present with age related developmental or neuro-psychiatric problems that require specialist interventions and care. Child psychiatric and old age services are each specialist services, staffed by specialist staff who work closely with families and the social sectors.
Mental health service delivery depends on a sufficient number of competent staff. Changes in service structure and style require changes in workforce numbers and skill mix within multi-disciplinary teams, not relying on traditionally staff roles. Financing systems need to be in place that create incentives for efficient prevention, treatment and care, aiming to shift resources downwards towards the most accessible and effective services.
The next sections of this report will evaluate whether the present service model and the delivery of care meets these expectations as set by the WHO Action Plans.
4. Mental health services and system components in Hungary
Primary care
In Hungary, as in all other EU countries, General Practitioners (GPs) function as gate keepers to specialist services. They are expected to identify, diagnose and treat the majority of cases of common mental disorders such as mild and moderate depression and anxiety, and refer to mental health services people with severe disorders such as schizophrenia and bipolar disorders or complex cases. In mental healthcare such a gate keeper role is essential, since the prevalence of common mental disorders requiring interventions can be expected to be about 8-10% of the population annually. Most of these people attend primary care. Missing these cases can cause suffering and deterioration. However, if most of these are referred to specialist care, mental health services will collapse under the burden. In order to safeguard adequate interventions at primary care level, GPs need to be able to offer treatment and receive support when required.
Exploration of these issues with GPs raised questions about their ability to manage. GPs in Hungary, similar to Germany and Austria, work as single-handed practices, only supported by a nurse. Training in mental health is very limited. Typically, a GP looks after 1,500-2,000 patients. We were informed by GPs that they have on their books between 15-20 patients with schizophrenia, or about 1% of their patient population. This is about 50% higher than the national data on primary care show. It indicates that most people with schizophrenia will be known to primary care.
Numbers of referrals to specialist services were very low, only 1-2 patients monthly. The important point made by GPs was that referred patients mostly will not attend psychiatric service anyway, due to stigma associated with the hospitals. GPs only prescribed anti-depressants if advised by psychiatrists, since this reduced the cost to patients. This may explain the low prescription rate of anti-depressants mentioned in the introduction.
This combination of low referral numbers and reluctance to treat independently suggests a large pool of untreated common mental disorders, confirming past research indicating an 80% treatment gap. It also indicates: