More Than 10-Fold Difference In Number Of Psychiatrists Across Europe

Main Category: Psychology / Psychiatry
Also Included In: Mental Health
Article Date: 09 Oct 2008 - 4:00 PDT

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A report by the WHO Regional Office for Europe, co-funded by the European Commission and launched today at a meeting hosted by the Department of Health in London, provides data not hitherto available on mental health policy and practice across the WHO European Region. It also highlights important information gaps.

Policies and practices for mental health in Europe allows for country-to-country comparisons on indicators such as numbers of psychiatrists, financing, community services, training of workforce, prescription of antidepressants, and representation of users and carers. The data were obtained from ministries of health.

More than 10-fold difference in number of psychiatrists

The report reveals large gaps in treatment and services. The rates for numbers of psychiatrists are indicative of the huge differences in mental health care - they vary more than 10-fold across the European Region, ranging from 30 per 100 000 population in Switzerland and 26 in Finland, to 3 in Albania and 1 in Turkey. The median rate of psychiatrists per 100 000 population in the 41 countries that provided information is 9.

The report indicates that a large majority of countries now have mental health policies and legislation, and many, but not all, are making some progress towards implementing community-based mental health services. However, it also shows clearly that treatment - or lack of treatment - depends on where one lives. The diversity of access, availability, acceptability and quality reflected in the report is not only related to prosperity and investment, but also to diversity of policies, mental health systems and practices. The report makes the case for greater clarity and consistency, and sharing of knowledge and experience.

Dr Marc Danzon, WHO Regional Director for Europe, said, "This report shows overall progress but there are clear inequities across the Region. Often, we know what works but still the gaps in treatment and services are so huge. The quality of services a person with poor mental health receives can vary because of economic conditions, but it is unacceptable that it should vary because of a lack of knowledge about or commitment to best practice."

The report concludes that:

- much progress has been achieved in policy development, with a clear trend towards supporting deinstitutionalization and establishing services close to where people live;

- countries are gradually accepting the involvement of service users and carers as good practice, and most countries are establishing programmes for the social inclusion of service users;

- there is great diversity across the large majority of variables;

- there is a lack of precise and comparable information, even fundamental information;

- there is lack of consistency in practice and education.

Readjusting spending - drugs, beds or community services?

The 128 tables and figures in this report demonstrate the diversity across the European Region, and the different interpretation of some data. For example, two clusters of countries have the fewest beds. The first seems to group countries with low levels of investment in mental health care and low supply of services, such as Albania and Turkey. The second group, comprising Italy, some provinces of Spain, and the United Kingdom, are in the post-hospital stage, having replaced beds with community services. Some countries such as Belgium, France, Germany and the Netherlands combine a high level of beds with community services. Whether this is the best or worst of both worlds is an important debate.

The report gives powerful arguments for carefully assessing spending priorities for people with mental disorders in residential and social homes. Conditions in some of these places, a lifetime home for some of the most vulnerable people in society, can be shocking. A slight readjustment in spending from, for example, expensive and not always effective prescription drugs to providing care could make a great difference.

The report also gives a clear message about the growing implementation of community-based mental health services. There is a convergence towards supporting deinstitutionalization and establishing services close to where people live. Undeniably, there is still a long way to go, as illustrated by some of the examples of poor institutional practices in this report, but countries now agree that these are no longer acceptable and are introducing alternatives.

Promoting mental health and preventing mental disorders

The findings show that interventions have been introduced to raise awareness and to tackle stigma and discrimination in almost all countries. However, evaluations of impact and effectiveness are rare.

Training and workforce for mental health care

There are striking variations in staff numbers, differences in education and a lack of reliable information available from countries in many areas.

- For nursing education, it is surprising how many countries cannot provide data about numbers. In addition, the training and levels of education differ vastly, raising questions about variation in competences in some countries.

- At a time of great change in service delivery and knowledge, continuing education is important, but the picture is not reassuring. No one would like to be operated on by a surgeon educated 25 years ago who has had no more recent updated training. Continuing education seems to be taking place, but there is little control over content or providers, with a strong reliance on informal self-regulation. Where more formal processes have been put in place, the emphasis seems to be on the process rather than the outcome.

Human rights - neglect and abuse

Findings on monitoring, the existence of protocols and the availability of national data on involuntary admission, restraint and seclusion show considerable variation. Further efforts are needed to collect basic data to allow more in-depth analysis of comparative good practices related to safeguarding the human rights of people with mental disorders. This could include reviewing procedures to prevent poor practices and abuse related to involuntary admission and involuntary treatment, and reviewing the availability and effectiveness of alternatives to restraint or seclusion.

The overall picture

Some European countries lead the world in the vision and quality of activities. Most countries are creating an increasingly diverse and competent workforce. Countries are gradually accepting the involvement of service users and carers as good practice, and most countries are establishing programmes for the social inclusion of service users, if often initially on a small and local scale. The role of primary care in the care of people with mental health problems is growing, and partnerships with other agencies are being established.

Dr Matt Muijen from the WHO Regional Office for Europe said: "This report indicates the need for action. It reveals the lack of reliable indicators and valid information that should support the shaping of progressive mental health programmes and the creation of a competent workforce. The challenge is now to address this need in partnership with our Member States and other intergovernmental agencies."

For more detail and extracts from the report, see the fact sheet below.

Fact sheet

New Who Report Policies And Practices For Mental Health In Europe - Meeting The Challenges

A report published by WHO Regional Office for Europe and co-funded by the European Commission provides data not hitherto available on mental health policy and practice across the European Region. It also highlights important information gaps. Extracts below give an indication of the kinds of data the report presents from 42 Member States.

-- Activity in policy and legislation has flourished in recent years. Since 2005, 57% of countries have adopted new mental health policies or updated existing ones, and 47% have introduced new legislation or updated existing legislation. Only four countries do not yet have a strategy. Five of the countries still have legislation that is more than 10 years old.

-- The number of psychiatrists per 100 000 population varies widely: from 30 per 100 000 in Switzerland and 26 in Finland to 3 in Albania and 1 in Turkey. The median rate of psychiatrists per 100 000 population in the 41 countries that provided information is 9.

-- Few countries provide figures on spending on promoting mental health and preventing mental disorders, but the data available are consistently very low, at most about 1% of the mental health budget.

-- Data on the proportion of disabled people who are receiving social welfare benefits or pensions as a consequence of mental health problems are available for 17 of 42 countries. The countries for which data are available report proportions ranging from 44% in Denmark to 8% in the Russian Federation.

-- Social institutions are where care varies most: social institutions for children and adolescents are provided in 31 of 42 countries (74%), in comparable proportions across the groups of countries. This is the area with the largest variation in care. In countries in western Europe, children are often placed in foster homes or small residential facilities. In many countries in south-eastern Europe and of the Commonwealth of Independent States, children with any form of disability are placed in sometimes large and often underfunded social care homes.

-- Prescribing of antidepressants - little information and large variation: the survey enquired about the proportion of the population that had been prescribed antidepressants in the last year available. Many countries (26 of 42) reported that they had no information available. Further, data on prescribed antidepressants are not collected consistently.

-- For the countries who were able to submit the requested information, the proportion of the population prescribed antidepressants varied from 12% in Moldova and 10% in Spain (Catalonia) to 3% in Lithuania and 1% in Bosnia and Herzegovina (Republika Srpska).

-- Visits to mental health facilities show a wide range of differences in access, from 1% to 28% of the population.

-- Rates of admission to inpatient units vary 13-fold. At the high end and, are such countries as Romania, Hungary and Estonia, together with such countries as Germany and Sweden. In some cases, the high admission rates could be due to perverse financial incentives within the health system such as payment per admission or payment for a limited period of admission only, encouraging discharge and readmission. In other countries, a large supply of beds could be a factor.

-- Intriguingly, there is an overrepresentation of women in outpatient services but almost equal sex distribution in inpatient services.

-- Opportunities for the empowerment and representation of service users and carers: the report shows a strong association between trends in mental health expenditure, trends in the development of community mental health services and the involvement of users and carers. These are strongest among the 15 countries that were members of the European Union before 2004 (EU15 countries comprise Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, the Netherlands, Portugal, Spain, Sweden and the United Kingdom). In many countries in the eastern part of the WHO European Region, where the institutional model of care still dominates, user and carer movements are in a developmental stage.

-- The expectations for general practitioners (GP's) vary widely and are not always correlated to the degree of education. For example, in Norway, psychological and psychiatric issues are not very prominent in the education of GPs, who are, nevertheless, expected to provide services for people with common mental health problems.

-- Funds on research sometimes inefficiently spent: there is a major divide across the European Region between countries with well-developed information systems that also invest in research and dissemination, typically the EU15 countries, and the countries that do not. If these data were cross-tabulated with presence of community services and diversity of workforce, a clear association would be found. Considering the few countries that invest heavily in research, most countries probably have no access to original research. This suggests that many countries are analysing identical research, presumably to publish comparable treatment guidelines. Considerable gains in quality and efficiency could be made through a closer collaboration.

The burden of mental health in Europe - some key facts and figures

Most European countries have recognized mental health as a priority area in recent years. Neuropsychiatric disorders are the second leading cause of disability-adjusted life-years (DALYs) in the WHO European Region, accounting for 19.5% of all DALYs.

According to the most recent available data (2002), neuropsychiatric disorders are the first-ranked cause of years lived with disability (YLD) in Europe, accounting for 39.7% of those attributable to all causes. Unipolar depressive disorder alone is responsible for 13.7% of YLD, making it by far the leading cause of chronic conditions in Europe. Alzheimer's disease and other forms of dementia are the seventh leading cause of chronic conditions in Europe (Global burden of disease estimates. Geneva, World Health Organization, 2004 (http://www.who.int/healthinfo/bodestimates/en/index.html, accessed 8 May 2008), and account for 3.8% of all YLD. Schizophrenia and bipolar disorders are each responsible for 2.3% of all YLD.

Suicide rates are high in the European Region. The average suicide prevalence rate in Europe is 15.1 per 100 000 population, with the highest rates in the countries of the CIS (22.7 per 100 000 population) followed by the countries that have joined the EU since 2004 (15.5 per 100 000 population). The countries that have joined the EU since 2004 comprise Bulgaria, Cyprus, the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Romania, Slovakia and Slovenia.

Background to the study

The health ministries of the participating countries were responsible for delivering the data for this report. Forty-two countries in the WHO European Region participated in this project:

-- all 27 EU countries: Austria, Belgium, Bulgaria, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden and the United Kingdom;

-- seven countries from south-eastern Europe: Albania, Bosnia and Herzegovina (Federation of Bosnia and Herzegovina and Republika Srpska), Croatia, Montenegro, Serbia, the former Yugoslav Republic of Macedonia and Turkey;

-- five CIS countries: Azerbaijan, Georgia, Moldova, Russian Federation and Uzbekistan; and -- Israel, Norway and Switzerland.

http://www.euro.who.int