Παραδόθηκε Στον Εκπρόσωπο Του Ευρωπαϊκού Γραφείου Του ΟΗΕ Για Τα Ανθρώπινα Δικαιώματα κ. Γιαν Γιαραμπ, Κατα Την Επίσκεψη Του Στην Αθήνα Και Τις Συναντήσεις Του Με Τον Υπουργό Υγείας Και Τον Συνήγορο Του Πολίτη Στις 29/3/15
Brief Report on the situation and problems of Mental Health Care in Greece
Mental Health Care is offered in Greece both by the public and the private sector. The Greek state-funded National Health Service owns a number of special psychiatric hospitals for the provision of secondary and tertiary care. Tertiary care is also offered by several private hospitals and the university affiliated clinics in the regions where medical schools exist.
Greece has been overhauling an outdated mental health system, which was based on institutional care, over the last 20 years, by developing community-based mental health care. The mental health reform in Greece is currently entering its third phase and is entitled the “Psychargos programme”. In this context various forms of community-based mental health services have been developed including supported living facilities, community mental health centres. Moreover, the last decade a number of Psychiatric departments in General Hospitals have been developed in the major cities of Greece in order to a wide provide a range of services including inpatients services. Primary care and outpatients services are offered in Greece by the few Community Mental Health Centers, doctors in private practice and in the outpatients’ clinics of the psychiatric departments of the general hospitals.
However, due to the absence of a coherent strategy on mental health coupled with the recent austerity measures imposed on the public sector that have largely affected health care, the aforementioned mental health reform and its provisions exist only in paper with mental patients not being able to cover even the expenses of their medication. The Greek state appears to have abandoned the social security policy and health care in general with mental health being the first victim of this situation.
The main weaknesses of the “Psychargos programme” and the mental health reforms as emphasized by NGOs, independent bodies, mental patients and families and carers’ associations include in brief: (a) an overall impression of patchy, ill-coordinated and often inadequate provision on the ground with weak implementation of agreed policies; (b) a lack of a population-based approach to the mental health system, without clear evidence for assessing the needs of local populations and no clear understanding at the local level of what components are necessary for a comprehensive system of care; (c) inequity in the development of services between different areas around the country as there are huge inequalities in mental health care provision between different regions of Greece, inefficient organization of primary care and insufficient number of psychiatric beds; (d) important services gaps are to be noticed for child and adolescent mental health services, services for older adults and specialist services for people with autistic spectrum disorders, those with intellectual disabilities, eating disorders and forensic psychiatric services; (e) no quality assurance mechanisms and systems for clinical governance; and service users’ involvement and participation of families and caregivers at the decision-making level as well as advocacy remain underdeveloped despite the efforts by the family associations.
Key problems faced by mental health patients and their carers/families
Mental health problems and mental illness affect a large segment of the Greek population. Despite the fact that schizophrenia and bipolar disorder are chronic diseases, they are not included in the list of chronic diseases as set by the Greek healthcare and welfare system producing thus a series of problems and injustices for the mentally ill who are not entitled to a state lifelong allowance and have to be periodically examined by committees that certify disability which on many occasions do not even comprise a psychiatrist. Moreover, the prevailing situation is that mental patients reside primarily with parents and / or siblings, who have been left alone in trying to provide the best possible care. The independent living of the mentally ill is simply not encouraged or assisted almost not at all in the current way the community exercises the provision of psychiatric care. People who suffer from mental illness and need help are far more that only the few who participate in daily programs at mental health centers or attend support groups of day centers (most of which run programs with specific time duration and once a mentally ill has participated in an program there is no continuity of service and the majority just return to the family home without the right to join the program again and without any prospect of continuity in their psychosocial rehabilitation in the community).
There is also a large number of mentally ill who simply never receive such services due to the withdrawal and helplessness caused by the mental illness itself that makes the sufferer unable to seek help or go to a mental health center. And here lies a serious shortcoming and failure of mental health services. With the exception of very few cases community mental health services do not provide home support services to patients with serious mental illness.
The transition towards an effective community based system envisaged as “sectorization” in the “Psychargos programme” has proven to be problematic in its implementation starting with the continuous lack of information with regard to the location of community mental health centers and the exact services provided by each of them. The Charter of Mental Health Services that under “Psychargos” was supposed to map the sectors-areas of community mental health services is outdated and contains no distinction based on the municipality or area. For Attica, in particular, with a population of over 3,700,000 inhabitants Law N.3852 / 2010 provided for 13 sectors with a mental health center each as the central unit of this sectorization approach that would supposedly provide primary, secondary and tertiary prevention and care with hospital beds, 24hour operation etc. However, according to numerous testimonies by mental health patients, carers and their families, these 13 mental health centers provide inadequate services, operate only in the mornings and are understaffed (in most cases: 1-2 staff psychiatrists, 1 social worker, 1 psychologist and 1 occupational therapist).
Furthermore, hospitalization conditions in psychiatric hospitals and clinics are dire as repressive methods -sedation and restraints- have intensified in the recent years of the economic crisis due to the insufficient number of staff that is used as a pretext. Official reports and denouncements of such incidents by carers and families of mentally ill persons who have been abused while in hospitalization having experience excessive restraints and even violence -both verbal and physical- are almost never taken seriously into consideration. Even in cases when an internal investigation procedure in psychiatric hospitals is ordered, the outcome is always the same justifying sedation and restraints for “safety” purposes despite clear testimonies by carers and family members of the mentally ill reporting the systematic degrading treatment of mental health patients inside psychiatric hospitals and clinics.
In addition, the hospitalization of mental patients has a pre-defined maximum length (as stated in the October conference entitled "Living with Schizophrenia" by the Governor of the psychiatric hospital of Attica) and it shall never exceed 15 days. This practice of "holding mental patients for 15 days and then discharge them in order to have enough psychiatric beds” is a clear violation of the human rights of the mentally ill. The duration of hospitalization must be based on an individual treatment plan consistent with the adequate psychiatric services while the continuity of care after the discharge of the patient must be also ensured. In practice the discharge is never accompanied by clear instructions and/or a referral through communication of the psychiatric hospital’s social service with a mental health center in the community. The discharge is equivalent to a written diagnosis and prescription of medication with a note to return after a month for a new prescription. In this way both mental patients and their family caregivers are left abandoned in a limbo.
The percentage of involuntary admissions and hospitalization is extremely high, as it was thirty years before, 55% of all admissions, with serious injuries even deaths of people with mental illness having been reported. The involuntary hospitalizations in Greece are carried out solely by the police, which results in fact in the arrest of a mental ill person that is one of the most traumatic, frightening and stigmatizing experiences for both the patient and the family. This is an unacceptable practice and a flagrant violation of the rights of the mentally ill who are treated as mere criminals.
Lastly, we would also like mention the right to education of the mentally ill which very little is discussed and addressed as an issue. Mental disorders very frequently make their first appearance during secondary education and/or during university studies. As a consequence the discontinuation of education is prevalent in all ages of people with mental disabilities. The continuation of education should be part of the psychosocial rehabilitation and equal opportunities provided for the mentally ill with interconnection of all Mental Health Centers and the mental health service structures with second-opportunity schools. Regrettably, the current psychiatric reform has not even considered any measure or policy for the support of the mentally ill to continue and complete their studies.
KINAPSI would like to present in brief a number of recommendations and proposals for the alleviation of mental health patients which are widely shared by mental health patients, their carers/families and mental health professionals.
- The involuntary admissions should seize to be performed by the police. Instead it should be performed by the appropriate health services (psychiatrist, nurses) and the police should be called upon only in extremely urgent cases. The legislation regarding the involuntary hospitalization should be implemented effectively (law 2071/92), which stipulates that a case must be heard within 10 days, and the person involved should be able to be present with his/her own expert and lawyer.
- The committees that certify disability and provide the right to a pension or allowance should operate rapidly without delays that leave the people concerned without the means to a decent living. Schizophrenia and bipolar disorder are chronic diseases, and therefore should be included in the list of chronic diseases by the Greek Ministry Of Health.
- Immediate cancellation of the state regulation which allows the withholding of pension for tenants of housing structures for mental patients, but also the so-called welfare of patients (in institutions, structures, etc.) where the withholding has been already put into effect for two years now.
- Immediate application of sectorization of community mental health centers with sectors of 100.000 citizens at most. The point of reference for every sector should be the nursing facility (psychiatric clinic within a general hospital) accompanied by a Center of Mental Health (CMH) as a central sector unit. The CMH should interconnect with the nursing facility and the entire network of structures for mental health within every sector (housing structures). The CMH should function in a 24 hour base, seven days a week as the central point. The CMH should also provide in-house services for those who need it.
- Study of the adequacy of psychiatric beds is essential, since the number of temporary beds in the corridors of the hospitals is due, to some extent, to lack of beds in itself, apart from the total lack of "filtering" through the non-existent integrated network of community services. Establishment of psychiatric clinics in general hospitals in the province where there aren't any (e.g, Central Greece, islands, etc.), and strengthening of those underperforming. Also establishment of psychiatric clinics in some general hospitals of Athens, where there are psychiatrists but without clinics.
- The transfer of the psychiatric clinics of the psychiatric hospitals in suitable and adequate facilities in general hospitals will be followed to the extent that new approaches, practices and institutional functions are consolidated. Only if the development of an integrated network of community services that will fully replace and operate alternative to psychiatric hospital will proceed substantially.
- There should be an end to the orgy of repressive measures, mechanical restraints (which sometimes lead to death) and locked doors. The promotion of equal dialogue and communication, adopting a therapeutic approach and protection that respects freedom is essential. There is urgent need for rights protection mechanisms, but above all processes that open paths to redirect (changing culture and practice) officers - and first of all psychiatrists - to a "different psychiatric paradigm". Otherwise, the "shift towards the community" (through sectorization) will be equivalent to the preservation and reproduction of the dominant (old) "paradigm", the export of institutional brutality from inside out.
- The deinstitutilization should also be implemented in the so called welfare facilities and institutions, not only in the notorious Lechena centre, but also in many others across the country, where conditions are medieval.
- The cancellation of any plans, thoughts, and preparations for establishing judiciary psychiatric hospitals, is also a top priority. The international experience and treatment alternatives to judicial psychiatric hospital should be considered with due seriousness.
- Reinforcement (finance etc.) of existing and creation of new structures and vocational rehabilitation opportunities (KOISPE etc.) that will provide a normal, decent pay for the workers. The KOISPE legal framework must change so that it can be operated from stakeholders (people with psychiatric experience, etc.). The issue of employment integration is a sine qua non for psychosocial rehabilitation and social reintegration. OAED, which is the public authority and central structure managing active labour market policies, should create specified units that will focus on the employment integration for people with psychiatric experience all over Greece. Right now there is only one and understaffed such unit in Athens.
- Vital, throughout this process, is also the active and decisive role of people with psychiatric experience and their carers, families at the decision-making level and also in scrutiny mechanisms and procedures. Until now, despite the intentions and active militant participation, both patients and family associations are commonly used by the dominant system in a decorative way, as so-called stakeholders, but all decisions taken exclude them. It is important to spread further and strengthen movements and collectives of people with psychiatric experience and carers in order to obtain an active and decisive role in the foursomes.
- A critical issue is to address the problem posed by the NGOs in Mental Health, a form of privatization, but, without its own resources as they rely for their survival on government funding. As at the end of 2015 the EU funding for their rescue -in order to achieve the "violent closure of psychiatric hospitals"- comes to an end, it is clear that since 2016, NGOs will face problems of survival and mental health patients will once again become the victims of the absence of a comprehensive state policy.
To conclude with, KINAPSI (Siblings of People with Mental Illness) in its capacity as an association of siblings, families and caregivers of people with mental disorders advocating since 2008 for mental health rights would like to bring to the attention of the UN OHCHR Regional Representative for Europe the grave human rights violations of mental health patients in Greece who due to their medical condition are unable to defend themselves and make their voices heard. As a result these violations remain unaddressed and have formed a vicious circle of injustice, victimization and stigmatization. KINAPSI calls on the UN OHCHR Regional Representative for Europe to support the efforts of mentally ill and family associations and safeguard their rights to medical treatment with dignity as well as their social rights. Therefore, we remain at your disposal for any further information and clarification deemed necessary.