Lessons learned in developing community mental health care in Europe
Authors: MAYA SEMRAU, ELIZABETH A. BARLEY, ANN LAW, GRAHAM THORNICROFT
Journal: World Psychiatry (2011)

This paper is part of a series which describes the development of community mental health care in regions around the world (see 1). It is one of the products of the Task Force appointed by the WPA, as part of its Action Plan 2008–2011 2,3, to produce a Guidance on Steps, Obstacles and Mistakes to Avoid in the Implementation of Community Mental Health Care. The purpose, methods and main findings of this Task Force have been previously published in this journal 4. In this article, we describe these issues in relation to the World Health Organization (WHO) European region. The WHO European Region consists of 53 countries and over 886 million people 5. It includes the former EU-15 countries (the fifteen countries that have been part of the European Union (EU) since before 2004), the 12 countries that joined the EU from 2004 onwards, the 11 countries of the Commonwealth of Independent States (CIS) (which incorporates most of the former Soviet Union's member states), eight countries from South-Eastern Europe, and seven non-EU high income countries (see Table 1). Generally speaking, there is an economic divide across Europe, with most of the high income countries (n=30) amongst EU (especially EU-15) countries and other primarily Western countries, all of the low income (n=3) and lower-middle income countries (n=7) in the non-EU Eastern parts of the region (most of which are CIS countries), and many of the upper-middle income countries (n=13) in the post-2004 EU countries and South-Eastern Europe 6. Mental health problems are common and have a huge economic and social impact across Europe, with at least 25% of people in the region experiencing a mental disorder over their lifetime 7. In 2004, neuropsychiatric disorders accounted for 19.1% of all disability-adjusted life-years (DALYs), and 39% of all first-ranked cause of years lived with disability (YLD) 8. Unipolar depression alone was the third leading cause of DALYs (after ischaemic heart disease and cerebrovascular disease), accounting for 5.6% of DALYs in the region 9. Suicide rates are also high across the region, with a prevalence rate of 14.01 per 100,000 population in 2007 5, and contributing 2% of total DALYs and 1.6% of all deaths in 2004 8. Following various mental health treaties, action programmes and plans within the EU throughout the 1990s and early 2000s 9, a significant milestone in the development and reform of mental health policies across Europe was the Mental Health Declaration for Europe 10 and the Mental Health Action Plan for Europe 11 in 2005. Here all European health ministers acknowledged mental health as a priority area, recognized the need for evidence-based mental health policies, defined a broad scope for these policies, committed themselves to the development, implementation and reinforcement of such policies, and proposed twelve action areas and milestones to be implemented by 2010. This included a commitment to develop community-based mental health services, to downgrade large mental institutions, and to integrate mental health services into primary health care. Most countries in Europe (around 83%) now have a mental health policy in place (see Table 1), with around 89% of the population in the region covered by 2005 13. Similarly, almost all countries (over 95%) now have mental health legislation in place (see Table 1), with around 90% of the population covered by 2005 13. Specific policies, strategies or plans for the development of community mental health services, as well as for the downgrading of large mental hospitals, and an integration of mental health into primary care, have now been developed in at least two thirds of European countries (see Table 1). However, there are still large differences in policies between countries, and whilst in many countries policies have been updated in recent years to fit in with changing ideals of mental health service provision (with around half of the countries with mental health policies in place having either adopted new, or updated existing, policies since 2005), others are out-of-date and in need of improvement 17. What is more, although around 40% of countries with mental health legislation in place have updated their legislation or adopted new legislation since 2005, around one quarter of countries still have legislation in place that is over 10 years old (see Table 1). Research evidence from systematic reviews and randomized controlled trials (RCTs) evaluating community mental health services across the region is displayed in Tables 2 and 3. Overall, this evidence suggests that, in principle, community-based mental health care is effective. There is some evidence for the effectiveness of an integration of mental health into primary health services across different models of care, as well as for community mental health teams, assertive community treatment, intensive case management, crisis intervention, and supported employment. However, high-quality evaluative evidence for other mainstream or specialized community mental health services is inconsistent or missing. In fact, for most European countries, there is a dearth of high-quality research on community-based mental health services, with most RCTs in the region having been conducted in the UK (around 80%) and a few other high-income countries. Findings may therefore not be applicable to other countries. Moreover, results may be difficult to compare across studies due to a lack of clarity about the model of care 18,19, differences between control treatments 18, or an overlap of components of community-based treatment with standard treatment (and therefore differences in outcomes being reduced) 19. Further issues are that services assessed in studies are often not sustained 19, and that there is a lack of studies assessing cost-effectiveness of services. Other than trials of effectiveness, there have been some observational and qualitative studies conducted in Europe (mostly in the UK). These have shown that home treatment is viewed positively by service providers 44, and that specific community mental health services, such as women's crisis houses, are highly valued by service users 45. Some of the processes that may be important to the effectiveness and sustainability of community mental health services have also been identified in this way, including staff satisfaction 47, views on interdisciplinary working 46,47,48,49,50,51, and involvement of service user views 52,53,54,55,56,57,58,59,60. Generally, a wide range of community mental health services exists within Europe, with at least some available in every country. However, whilst a few countries lead the way in the successful implementation of community-based mental health services according to an evidence-based "balanced care model" that integrates elements of community and hospital services 4,61,62,63,64,65, in many others access to community-based services is still very limited and may commonly consist of small pilot projects 12. Broadly speaking, consistent with economic differences across the region, the division is mostly between the Eastern and Western countries of Europe. In the EU-15 countries and other predominantly Western high income countries, following a move towards human rights, social inclusion and empowerment over the last few decades, a large array of multidisciplinary community-based services may be available to people with mental health problems, with most patients being treated outside of mental institutions 5. In line with the "balanced care model" approach, the mental hospitals that do exist in these countries are often relatively small, close to communities 12, and usually located in acute wards in general hospitals, with hospital stays reduced as far as possible 9,61. In the low or lower-middle income non-EU countries of Eastern Europe, in particular the CIS countries, access to community-based care tends to be far more limited. Large mental health institutions are commonly still the mainstay of the mental health care system 5, and community mental health services are often restricted to polyclinics or dispensaries attached to a psychiatric office. Where any additional community-based services exist, these are often implemented by non-governmental organizations (NGOs) or international agencies. The range and quality of mental health services in the post-2004 EU countries and other middle income countries tend to lie somewhere between those of the EU-15 and CIS countries. However, the boundaries of this divide are blurry, and no two countries in the region have the exact same mental health system in place. In general, the number of psychiatric beds has been decreasing steadily across Europe and mental hospitals are increasingly being closed down 7. However, in some countries this process has been much slower than in others 9,17. Although inpatient services in mental hospitals still exist in almost all European countries (the exceptions are Italy, Iceland, Andorra, Monaco and San Marino), the number of psychiatric beds and the balance between beds in mental institutions and inpatient community-based facilities varies greatly between countries (see Table 1). Whilst in some countries the small number of inpatient beds is due to the substantial progress that has been made in replacing mental hospitals with community-based care (the UK and Italy for example), in others (such as Albania and Turkey) the small number of beds reflects a lack in funding and a deficit in service provision for mental health overall. Other countries, primarily EU-15 countries such as Belgium, France, Germany, and the Netherlands, have a combination of large numbers of inpatient beds and community services 12. However, in most European countries (in particular those in Eastern parts) institutional care still outweighs community care by far, with around two thirds of all psychiatric beds across the region still located in mental hospitals 7. Whilst all countries in the European Region increasingly have mental health services integrated into primary health care (see Table 1), the extent of this varies widely. In many countries the primary health care system for mental health is still inadequate 12, and even in high income countries the provision of mental health services within primary care has often been found to be less than optimal 66. Mental health training for primary care staff is only available in around two thirds of countries 12, and is often insufficient, which frequently results in mental health problems not being recognized or treatment methods being unknown 7,9. Although there is a definite trend towards an increase in community-based mental health services and a decrease in institutional care 12, the pace and scale at which this is occurring, as well as the quality of services, varies widely throughout the region 7,17. For instance, at least 85% of countries now report having mental health day care, but in some countries such services tend to be attached to long-term mental hospitals or may be very limited in number, while in others there may be a variety of day care services available in a selection of community settings 12. Furthermore, access to such services may be very limited within countries, especially in the Eastern parts of the region 12. Variables such as location, age, gender, ethnicity, employment status, type of diagnosis, educational background or socioeconomic status may determine whether care, and what type of care, is received 7,9,12,67,68. One example of this is that more services tend to be available in urban areas compared to rural settings. We present here an overview of the lessons learned in the implementation of community mental health services across Europe, as well as recommendations for the region in the future. Specific steps on how to facilitate and implement these can be found in the WPA Guidance 4. Clinical experience and research evidence have shown that the implementation of community mental health services according to a "balanced care model" is possible and desirable 4,61,62,63,64,65. However, there is still a gap between population need and actual service provision across Europe, both between and within countries 67,68. To reduce the gap between the Eastern and Western parts of Europe and to scale up services across the region, the focus should be on the development of community-based services in the low and middle income countries, whilst sustaining and improving services in high income settings. Furthermore, equal access for all needs to be ensured within countries, that is across different regions and subgroups of the population 9,12. Changes in service provision should be carefully planned to ensure gradual, balanced and sustainable reform, which takes into account local conditions and resources, as well as the cultural context 61,64. One important factor in making services accessible to whole populations is the continued integration of mental health services into primary health care, and an improvement in the quality of care within these systems. This may be facilitated by ensuring that there are sufficient numbers of primary care staff, regulating training, organizing adequate and ongoing supervision of primary care staff by mental health professionals, addressing staff attitudes, and by developing and managing co-ordinated support networks with specialized community mental health services and other relevant sectors (such as social welfare, health, housing and employment, as well as NGOs and the private sector) 7. The lack of adequate community mental health services in some parts of Europe may lead to the social isolation of people with mental health problems, or even a violation of their human rights through neglect and abuse 12. Even in high income countries (where community services tend to be more established), people with mental health problems may still be subject to stigma, prejudice and discrimination 7. National programmes and plans should therefore be implemented to ensure that the human rights of people with mental disorders are upheld, their social inclusion and full integration into society (including in the workplace) is encouraged, and stigma and discrimination are reduced. These may include public mental health promotion, advocacy and awareness-raising programmes, both for the general population (for instance through media campaigns) as well as for health staff and personnel in the other relevant sectors mentioned above 7,9,10,11,12. Furthermore, care services should be monitored and reviewed regularly to ensure that human rights standards are upheld 12. Importantly, the views of service users, their families and carers (as well as any other stakeholders) should be included in the planning and implementation of policies, and in service development, monitoring and provision 7,9,12,61,64. Currently, service user involvement is highest amongst EU-15 and other EU countries, but is only in the early stages of development in most Eastern European countries 12. One of the first steps in ensuring fair access to services for all is the formulation of carefully planned mental health legislation and policies that take into account a wide range of stakeholders' views 9. Even though there has been much progress in recent years, several countries in the European Region still do not have adequate mental health legislation and policies in place. Comprehensive new national policies and legislation (including mental health promotion, prevention and advocacy) should be developed where these are absent, and older existing mental health policies and legislation should be up-dated. This needs to consist of a commitment not just by health ministries, but also by the other sectors already mentioned which may be relevant to mental health care 7,9. To address challenges in the implementation of these policies and to reduce the gap between mental health policy and practice, in particular in some of the Eastern and South-Eastern countries of the region 12, detailed, feasible (though ambitious), sustainable and highly practical implementation plans and programmes should be developed. A common challenge in implementing mental health policies is the lack of adequate funding mechanisms for mental health, in particular in much of Eastern Europe 17. Related to this is a shortage of human resources. Mental health staff numbers have increased in several EU countries 9, but most of the mental health workforce in Europe is concentrated in a few high income countries, and human resources for mental health are still lacking in many other parts of the region 12. For example, whilst some of the high income countries such as Belgium, Finland and Iceland have over 20 psychiatrists per 100,000 population, other countries such as Turkey or Tajikistan have less than 2 (see Table 1). This shortage typically results in mental institutions being retained and staff being assigned to mental institutions 7, which in turn leads to community mental health facilities being hugely understaffed 17. Moreover, mental health workers are often underskilled due to insufficient resources for training 7,12. Since community mental health care overall has been shown to be cost-neutral compared to institutional care 61,62,64,65, one solution in optimizing the use of available resources is to gradually shift financial and human resources from large mental institutions to community services 9,61,62,64,65. This requires a changing of staff roles, responsibilities and expertise, for instance through mental health workforce strategies 12, as well as new ongoing mental health training programmes and an inclusion of mental health into general health care education programmes 7,9,12,61,64. Staff anxieties and uncertainties due to changing roles and service structures should also be addressed 61,64, and working conditions and pathways for career development should be improved to reduce staff turnover 7. An evidence base is vital to determine the effectiveness of community mental health services. However, this is still lacking for most countries in the European Region, in particular outside the UK and other high income (primarily EU-15) countries. High-quality and well-defined evaluative research is needed across countries to strengthen the evidence base for clinical outcomes and cost-effectiveness of community mental health services, as well as the relative effectiveness and efficiency of policies and programmes 12. To avoid duplicating information unnecessarily, this should include standardizing data collection systems and indicators across the region (for instance through the publishing of data collection guidelines) 7,9,12, and forming a consensus on definitions of service components 12. This, together with adequate dissemination systems, may enable evidence-based comparisons of services and programmes to be made, which may in turn inform policies 7,9,12 and allow for a more informed allocation of limited resources 7. The authors wish to thank the other members of the WPA Task Force on Steps, Obstacles and Mistakes to Avoid in the Implementation of Community Mental Health Care, namely A. Alem, R.A. Dos Santos, R.E. Drake, G. Gregorio, C. Hanlon, H. Ito, E. Latimer, J. Mari, P. McGeorge, R. Padmavati, D. Razzouk, Y. Setoya, R. Thara and D. Wondimagegn. Dr. Thornicroft is funded in relation to a National Institute for Health Research (NIHR) Applied Programme grant awarded to the South London and Maudsley NHS Foundation Trust, and in relation to the NIHR Specialist Mental Health Biomedical Research Centre at the Institute of Psychiatry, King's College London and the South London and Maudsley NHS Foundation Trust. Dr. Semrau is funded by a PhD studentship grant of the Medical Research Council (UK). All opinions expressed here are solely those of the authors.