The last decades we could observe the tendency of closing the large mental health care institutions and developing community based services for people with mental health problems. The elimination of those institutions largely contribute to the reduction of reinforcement of dependency, or in other words, providing mental health care within the community empowers patients to take more control over their lives. On one hand, the value change driven by activist groups advocating for human rights has played a significant role in the process of deinstitutionalisation, drawing attention to patients’ rights and bringing to the public attention the debate of ethics and values behind the treatment of mental health patients. On the other hand, why is this shift/ transition proving to be so difficult ?
There is no such a thing as a ‘natural death’ of mental health care institutions because the transformation has to come through the change of perception of mental health disorders in the society at large. The advocates of change defend the right to the highest attainable standard of physical and mental health for everyone, emphasising the importance to take the patient centred approach in treatment and investing time and resources in health literacy.
For the major improvements to occur it is necessary to have the political commitment not only from the Ministries of Health and Social Affairs but also other state ministries and grass-root level organisations. Unfortunately, the approach of including mental health as a component of all policies is far from being a reality in the EU. However, it has to be acknowledged that there are actions taken at national as well as the European levels aiming to shift mental health higher on the political agenda.
It has been said numerous times that a national mental health policy is essential providing guidance for the effective implementation of community mental health services, because it represents not only a formalisation of values and principles, but also plans for the development of relevant services and programmes. WHO recommends countries to develop mental health policies that outline plans for: limiting the use of psychiatric hospitals; developing community mental health services; integrating mental health services into primary care; and, promoting self-care.
The EU-Compass position paper has cited Italy and Sweden as good examples, where psychiatric hospitals have been fully replaced with psychiatric units within regular hospitals. In some other countries where institutional care is much more present, the deinstitutionalisation appeared to be difficult, said Raluca Nica, Romanian League of Mental Health and a member of GAMIAN-Europe, in her presentation at the EU-Compass Stakeholder Forum in February 2018. Speaking from her experience, she mentioned that four key factors making irreversible changes towards community based mental health services are: favourable context, main stakeholders are involved in the process and they are aware of their responsibilities, available resources, and strong leadership.
At the European level, the European Commission supports action on mental health through the funding of the EU-Compass for Action on Mental Health and Wellbeing (2016-2018) and the Joint Action on Mental Health and Wellbeing (2013-2016). Those two initiatives are major collaborations at the European level encompassing stakeholders from the EU Member States’ governments, health institutes, research centres and non-governmental organisations. The EU-Compass is a web-based mechanism used to collect, exchange and analyse information on policy and stakeholder activities in mental health across the EU. In addition, there are many other smaller scale pilot and research projects funded by the EU aiming to improve mental health literacy, build resilience in children, suicide prevention, etc.
Even though the process of deinstitutionalisation is strongly supported by advocates at the international level, their efforts are not quite enough. What we can observe across the EU is that the implementation of community based mental health care is patchy and many barriers impeding progress still remain. Knapp’s research findings could serve as an incentive to decision makers to take firmer action in the process. In the study published in 201 he confirmed that the community based mental health services are not costlier than hospital based care. However, Knapp also highlights that policy makers should not assume that community based care is cheaper because this could lead to under investment to essential services which are the main pillars of an effective system.
Equally important to mention is that we should not pretend that the community based services will not bring new challenges. For instance, we cannot turn a blind eye on the challenges associated with the insurance packages which fail to include community care and are mainly focused on paying hospital beds rather than home visits. Another challenge signalled by Dr Caldas Almeida, Nova University of Portugal, is the creation of adequate multi-disciplinary teams in community, which are not the mere collection of professionals but a body working as a team. In addition, there are problems connected to data sharing and privacy, ethical issues in relation to treatment in the community, as well as a risk for some patients to become homeless due to reallocation of resources away from institutions.
There are many challenges as well opportunities associated to the community based mental health services. The human rights activist groups have paved the way to a more humane approach to treatment of mental health patients, calling for reintegration of patients into the community life. Now it is up to us to continue raising awareness of mental health issues to reduce stigma and to make sure that mental health problems get the same rights of treatment as the physical health.