Ten-Fold Difference In Number Of Psychiatrists Across Europe
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.”