The Intersectorial Committee for Coordination in Mental Health ICCMH

1
The Intersectorial Committee for Coordination in
Mental Health ICCMH

• Constitutive meeting
• Bucharest
• 9 January 2006
• Hilton Hotel, Regina Maria 2 room, 13 00 hr

2
Agenda

• Welcome speech and the objectives of the meeting
• Mr. Eugen Nicolaescu, Ministry of Health
• Introduction
• Mr. Jonathan Scheele, EU delegation
• The present situation and the stage of the
  legislative adjustment
• Prof. Dr. Dan Prelipceanu
• European Directives in the area of mental
  health
• Dr. Daniela Valceanu, INCDS
• Directions of actions short term and long term
  proposals
• Dr. Radu Teodorescu

3
Agenda

• Speech from the patients associations
• Mr. Stefan Bandol, President of the Wings
  Association
• From hostility towards normality, through the TV
  cable
• Val Valcu, Senior editor - Adevarul, President
  of Association of Journalists in the Medical
  Field
• Examples of good practice in the area of
  community care
• Dr. Radu Teodorescu, Dr. Alexandru Paziuc
• Project of an Epidemiologic Study - Harvard
• Dr. Silvia Florescu, INCDS
• Project of resolution of the CICSM first session

4
The situation of the psyciatric assistance in
Romania

• Prof. Dr. Dan Prelipceanu, MoH

5
Statistic data

• 38 psychiatry hospitals (4 are of psychiatry and
  safety measures)
• 66 LSM?? (out of which a limited number are
  functional)
• Total chronic patients in 2004 206,555 (CCSS)
• Total number of beds for psychiatry 15,700
  (CCSS)
• Place in Europe
• Total number of psychiatry doctors 975 (2004)
• The deficit of psychiatry doctors at national
  level is about 750 (2004)

6
Psychiatric hospital beds per 100000
2003
7
Statistic data

• Standard for staff in hospitals
• acute - 1 doctor position/ 12-16 beds
• chronic - 1 doctor position / 30-40 beds
• Psychiatry doctors in ambulatory
• Standard 1 at 60,000 inhabitants
• Total needed 373
• Total existing 256
• The relation hospital/ambulatory doctors
• Actual 31
• Ideal 1 1.5

8
Infrastructure (I)

• Types of existing units of psychiatric care
• Psychiatry hospitals,
• Sections and departments of psychiatry / other
  types of hospitals,
• Daily stationeries,
• Public and private psychiatry cabinets and mental
  health laboratories,
• Units of the ministries with own network
  (transportation, justice, army, labor, internal
  affairs, etc.)

9
Infrastructure (II)

• Assesment
• The buildings of the psyciatry units are morally
  and phisically used,
• E.g. the last psychiatry hospital from Romania
  was built in Bucharest, about 85 years ago,
• The investments and the rehabilitations have been
  insuficient, sporadic and isolated,
• Same location for the psychiatry, TB,
  deramtology, infectious diseases and neurology
  sections,
• Over-crowded services in hospital and in
  ambulatory.

10
Human resources

• Specialization of personnel
• In hospitals from the rural area are hired
  general practitioners or doctor with other
  specialities
• The medium level personnel are not trained in
  care services for the patient with a mental
  disorder
• Out of 4450 medical assistants only 300 graduated
  a nursing school of psychiatry
• The quasi-complete lack of social assistants and
  occupational therapists, major deficit of
  psychologists

11
The beneficiaries of mental health services

• The hospital acute disorders, emergencies, and
  chronics
• 20-30 with dominant social problems
• Abandoneded by family or by legal representatives
• Lack of alternatives to hospitalization
  determines the excesive use of these services

12
Legislation (I)

• Mental Health Law (2002)
• Publication on the site of the Ministry of Health
  of the final form of the enforcement regulations
  of the Law of Mental Health and of Protection of
  the Persons with Mental Disorders.
• Order of the Minister of Health 639/2005 The
  National Strategy regarding the mental health
  services

13
Legislation (II)

• Order of the Minister of Health 661/2005 for the
  Constitution of a Consultative National Group in
  the area of psychiatric issues.
• Projects/Programs shall be the basis for the
  improvement of the psychiatric legislation
• Phare Twinning Light Program with Dutch technical
  assistance (2005)
• MATRA Project for the improvement of the
  hospitalization conditions in psychiatry and
  safety measures hospitals

14
European Directives

• Dr. Daniela Valceanu

15
Documents

• Helsinki Conference - 12-15 January 2005
• Of the WHO European Regional Bureau and of
  European Commission for health and consumers
  protection - 52 ministers of health from European
  countries have signed the Declaration of the
  Helsinki Conference and the Action Plan for
  Europe in the area of Mental Health.
• EU The country report of RO for 2004 and 2005
• Signals for health in general and for mental
  health in particular
• Amnesty International 2004
• 12 points to follow

16
Helsinki - I

• Basically, the following have been agreed upon
• The priorities in the area of mental health are
  promotion, prevention, treatment, rehabiltation,
  care and re-integration in society.
• It was re-affirmed the adhesion to
• The Resolution EUR/RC51/R5 regarding the Athens
  declaration on mental health, human provoked
  disasters, de-stigmatization and community care
  from Sept. 2003, and the Resolution EUR/RC53/R4,
  Mental Health in the WHO European Region, adopted
  by the WHO Regional Office for Europe, where was
  expressed the concern for the continuous raise of
  the burden determined by the mental illnesses in
  Europe, and for the fact that many people with
  this type of problems do not receive the needed
  treatment and care, despite the development of
  efficient therapeutic solutions.

17
Helsinki - II

• At the WHO Resolution WHA55/10 from May 2002 that
  requests the member states to increase the
  investments in the mental health of population,
  and the same time to establish policies, programs
  and legislation in the area, in fully agreement
  with the human rights and after consultation with
  all the involved factors in the society that have
  a say in this field.
• It was reaffirmed the need to insure appropriate
  funding according to the prior status of mental
  health, and the elimination of inequities and
  discriminations which arises from the diminishing
  of beneficiaries access to treatment.
• Even more, it is recognized the importance of
  the active promotion of mental health role by all
  means, and the negative consequences of the
  association of mental suffering and social
  exclusion, lack of chances in finding a job, lack
  of a home, drug and alcohol abuse, as depicted by
  the documents of the European Council and WHO
  since 1975.

18
Helsinki - III

• The same time with the main document, studies
  referring to the burden of the disease, the
  minuses of treatment, the evaluation of social
  and economic implications have been presented
  (ESEMeD - epidemiology on mental disorders in EU,
  examples)
• Up to 20 of the population experienced one form
  of mental illness during the past 12 months, half
  of them being of moderate to severe intensity,
  and being responsible for major losses in
  productivity (social economic costs up to 3-4
  of the GDP according to the ILO).
• The diagnosis did not involve treatment 33 of
  the countries do not insure incentives and
  training for general practitioners in prevention
  and diagnoses 20 of the patients do not receive
  any treatment, only 33 of the target patients
  received psychotropic medication, and only 21
  received anti-depressive medication.
• 25 of the countries do not insure the
  development of the community care and among 10 to
  60 do not insure special programs for
  children/adolescents, aged people, minorities,
  refugees, disaster areas.

19
Country report 04

• 2004 - pg 98, 100, 153, 158
• immediate measures must be taken in order to
  improve the health status of the population,
  which is much under the EU average, despite
  multiple actions of promoting the health related
  activities. Increase of resources, more efficient
  allocation and improvement of management in the
  health sector are needed further on
• The appropriate attention must be given to
  promote the social dialogue and to improve the
  health status of the population, which is much
  under the EU average. The administrative capacity
  regarding the management of the European Social
  Fund must be improved with priority .

20
Country report 05 - I

• 2005 - pg 18, 52-55, 79
• the access to health services, including
  prevention services, must be insured for all
  citizens in order to improve the health status of
  the population
• Access to health services (particularly for
  minorities, e.g. Rroma) needs to be enhanced and
  immediate attention should be paid to the
  improvement of the health status of the
  population and health expenditure. The
  improvement of the treatments for the psychiatry
  units residents must be addressed with
  priority. Unless significant additional effrots
  are made in the field of Public Health, European
  Social Fund and social inclusion, there is a
  serious risk that Romania will not have these
  functional structures in place at the moment of
  the accession

21
Country report 05 - II

• The persistent problem of the ill-treatment
  within the psychiatry hospitals must be
  immediately addressed
• As for the medical care in the psychiatry
  units, the life conditions for the residents are
  inadequate and the allocated budgetary resources
  are limited. Although the staffing level have
  increased, they remain insufficient.
  Overcrowding, lack of activities or medical
  services can be noted. Reports regarding violence
  and ill-treatment continue to be quite common
• The 2002 Law on Mental Health has not yet the
  necessary regulations for its enforcement. Few
  measures have been initiated, related to the
  improvement of living standards, resource
  allocation and specialized training

22
Amnesty International

• During 2004, Amnesty delegations visited many
  psychiatry hospitals, and discussed with the
  professionals in the area, as well as with the
  representatives of the civil society. The
  conclusions of the report can be put in 12 main
  ideas
• Improving the living standards in the hospitals,
  in the area of hygiene, heating and food
• Running inter-sectorial periodic visits for
  monitoring (MoH plus other ministries)
• The constant report of the progress to the MoH
  and civil society
• Wide dissemination of the leaflets containing
  patients rights
• Periodic implication of the public ministry in
  controls

23
Amnesty International

• The consultation and active involvement of the
  civil society
• Finalizing the regulations needed for the
  enforcement of the Law of Mental Health
• Solving the social cases
• Financing psychiatry this are is highly
  under-financed
• The therapy is generally speaking inadequate,
  including pharmacotherapy and alternative
• Pharmacotherapy the government still admits
  that all interviewed psychiatrists declared the
  budgetary resources allocated to pharmacotherapy
  are not enough and they are afraid of new
  reductions
• Lack of coherent policy in drawing continuous
  education and keeping the employees in this field
  is an important factor that contributed to the
  tragic events that took place in 2004.

24
DIRECTIONS OF ACTION IN THE AREA OF MENTAL HEALTH

• DR. RADU TEODORESCU

25
CONTENTS

• THE PRINCIPALS OF THE REFORM
• ACTION PLAN FOR IMPLEMENTATION OF THE REFORM IN
  MENTAL HEALTH
• FINANCING

26
The principals of the reform

• The reform of the mental health services
  according to
• - the principles of the community psychiatry
• - respecting the human rights
• - evidence based medicine

27
The system reform in Romania

• System centered on the patients needs
• Creating a functional unit
• Epidemiologic unit
• Therapeutic team

28
Number of needed units

• 21 000 000 inhabitants
• Epidemiologic unit of 150 000 inhabitants
• 140 units

29
Therapeutic team

• Psychiatrists
• Psychiatry assistants
• Auxiliary personnel
• Social workers
• Clinic psychologists

30
Hospital beds

• Beds psychiatry hospital (30 35 / sector)
• Reference units (specific pathology )
• Trans sectorial units (rare pathology)
• Beds general hospital, psihiatrie de legatura (10
  20)

31
Protected houses

• 1) Shelters for chronic cases
• 2) Protected homes
• a. 8 hours inclusion
• b. Partial inclusion
• c. Without inclusion
• 3) Houses supported by local authorities
• 4) Therapeutic families (?)

32
Hospital
Day hospital
Houses
ICCMH
Consultations
Therapeutic families
Mobile assistance
Rehabilitation/work
CC
33
ACTION PLAN FOR THE IMPLEMENTATION OF THE REFORM
IN MENTAL HEALTH

• Governemental support in the reform
• More active involvement of the patients/beneficiar
  ies and family organisations
• National Institute for Mental Health

34
FINANCING RULE NO. 10

• In 10 years
• The health expenditures shall represent 10 of
  the GDP.
• The costs for mental health shall raise up to 10
  of the total budget of health.

35
FINANCING Internal Sources

• National Health Insurance House
• Specialized medical services
• Medication
• Current repairs
• The Budget of the Ministry of Health
• Subprogram 2.5
• Promotion of mental health
• Continuous training of staff
• Capital repairs and investments
• Other supplementary allocations

36
FINANCING External Sources

• Programs and projects
• - World Bank
• - European Community
• International collaborations (e.g. Belgium, etc.)
  
• Private sources

37
From hostility towards normality, through the TV
cable

• Dr. Val Valcu
• Senior editor Adevarul
• President of Association of Journalists in the
  Medical Field

38
The Reform in Mental Health the beneficiaries
perspective -

• Dl. Stefan Bandol
• President of Aripi Association

39
Stigmatization

• Establishing standards for representation of
  beneficiaries and , in committees and groups
  responsible for the planning, delivery, revision
  and inspection of mental health activities
  (Helsinki action plan, pt. 3 paragraph VII)

40
Patients rights

• Recognising the experience and the knowledge of
  the beneficiaries as important foundation for
  planning of services (Helsinki Declaration
  priorities chapter, paragraph 5)
• Introduction the personal representative in the
  staff diagram of the specialized institutions,
  according to the Law of mental health
• Patients right to choose the physician that will
  provide treatment (Law of mental health)
• The right to free medicines (Law of mental health)

41
Community psychiatry

• The care for the persons with mental health
  problems to comprise comprehensive and efficient
  services and interventions, involving the
  beneficiaries by offering them the right to
  choose
• Public and private support for the NGOs of the
  beneficiaries of mental health services (Helsinki
  declaration, chapter responsibilities, paragraph
  11)

42
BUDGET

• The financing for the mental health shall be
  done according to the priority status given to
  mental health and to the assessed needs as is
  Mental Health Action Plan for Europe.

43
Examples of good practices in the are of
community care

• Trepte Center/ Obregia Hospital
• Dr. Radu Teodorescu
• Orizonturi Center / Campulung Moldovenesc
• Dr. Alexandru Paziuc

44
The role of the beneficiaries in creating a new
model of social and community care in mental
health in Bucovina

• Dr. Alexandru Paziuc,
• Orizonturi Foundation
• Campulung Moldovenesc
• 2006

45
Orizonturi Foundation

• Charity organization with spiritual character,
  non-governemtnal and apolitical, with activities
  in the area of mental health from 1995, located
  in Campulung Moldovenesc, Suceava county.
• The founding members are beneficiaries of mental
  health services or professionals (Psychiatrists,
  Psychologists, nurses) and persons who understand
  and want to support the mental health reform.
• Its missions is to support the beneficiaries of
  the mental health services in re-gaining self
  trust and in developing those abilities to allow
  them an independent life and the community
  education with view to understand and accept
  them.
• The organization aims at informing and educating
  persons with mental health problems and at
  changing the common mentality towards the mental
  illness concept.

46
ACTIVITIES

• Weekly meetings
• Occupational activities
• Publishing the magazine A FI TO BE
• Club activities
• Starting with 1995 participation at regional
  meetings for the organizations in Central and
  Eastern Europe activating in the area of mental
  health
• 1996 Organizing the first National Conference
  of the Persons with Mental Health Disorders
• Participation at the training New ways of life,
  organized by Hamlet Trust - UK in Hungary and
  Romania (1997) and in Slovenia (1998)
• The participation at the "capacity-building"
  training for organizations involved in the field
  of mental health for organizational development,
  Training of trainers and Forum organized by
  Hamlet Trust and the Romanian League of Mental
  Health
• Implementation of the program Ways to the
  policy in mental health

47
Ways to the policy in mental health

• The program intends to involve the beneficiaries
  in developing alternatives and better care
  services, at regional level, in mental health
• Through the Local and National Policies Forums,
  the beneficiaries and the NGOs have the
  opportunity to speak about what affects their
  lives and the same time to be listened by the
  decision makers in mental health, in this way
  transcending stigma and the handicap of
  psychiatric patient
• The main objectives of the program are
• (1) to bring together beneficiaries of mental
  health services, professionals, local authorities
  and persons from the community in order to
  discuss problems such as the importance of mental
  health policies, human rights, transparency, etc
• (2) to facilitate through trainings and workshops
  conducted by certified persons that all the
  participants, beneficiaries or not, to develop
  abilities and to acquire knowledge in the field
  of mental health
• (3) to offer the frame in which the persons from
  the community, in habitual meetings, to propose,
  plan and implement campaigns and to identify
  efficient ways to influence the mental health
  policies
• (4) to strengthen the voice and the power of
  influence of the NGOs, including of the
  beneficiaries, through national meetings
• (5) to disseminate through Regional Forums the
  results and accomplishments towards other
  countries of the central and eastern European
  region and not only.

48
Ways to policy

• VISION
• Beneficiaries of mental health services
• Create long term partnerships with
• Public institutions
• Civil society
• Private sector
• Create new health policies at local and national
  level
• Integrates politics in mental health though a
  learning process

• AIMS at
• Supporting the beneficiaries of mental health
  services and their organizations
• Working together with the representatives of the
  local community
• Influencing at local level the policies,
  practices and procedures in the area of mental
  health
• OBJECTIVES
• To create a support the FLP
• To initiate actions at local level
• To share knowledge and to develop abilities
• To highlight the active and positive side of the
  beneficiaries through mass-media

49
The Structure of the Forum of Local Policies (FLP)

• 33 beneficiaries
• education
• health and health insurance
• police
• justice
• church
• social care
• mass media

50
Problems at local level

• (1) Old mentalities and prejudices that generate
  stigmatization, discrimination and social
  exclusion
• (2) The lack of information amongst the
  population regarding the problems in the field of
  mental health and available services
• (3) The lack of alternative services of community
  care for the beneficiaries of psychiatric
  services
• (4) Defective legislation with enforcement
  difficulties
• (5) Insufficient financial, material and even
  human resources (psychologists, psychotherapists,
  social workers)
• (6) Lack of involvement and poor collaboration of
  the local institutions in problems of mental
  health

51
ACTIONS

• The publication of informational and educational
  materials
• Publication of articles and information about the
  FLP in mass-media (local radio station, local and
  national newspapers)
• Initiation of a program at the local radio
  station
• Organization of meetings aiming at informing
  youth from the urban and rural area in mental
  health
• Organization of meetings between beneficiaries
  and members of the community, especially in the
  rural communities

52
RESULTS at local level

• A more powerful voice of the beneficiaries
• New abilities and knowledge
• Raising awareness upon mental health problems
• New strategic relations for the promotion of
  change
• partnerships with local authorities (counseling
  centers, social enterprises, protected houses)
• one beneficiary in the administrative board of
  the psychiatry hospital
• The evaluation of the care services quality in
  mental heath in the psychiatry hospital by the
  involvement of some beneficiaries and volunteers
  from the community.

53
RESULTS at national level

• Beneficiaries and their NGOs have been admitted
  by the Ministry of Health in groups of
• Discussions regarding the enforcement
  regulations for the Law of mental health
• Development and implementation of the reform in
  Psychiatry
• Two beneficiaries have been selected to initiate
  in Albania the program Ways to the policies
  together with Hamlet Trust and Interactions

54
Conclusions

• The beneficiaries can be involved in the
  improvement of psychiatric assistance services
  and the development of some community
  alternatives.
• The beneficiaries and their NGOs have the chance
  to make their point on what affects their life
  and the same time, to be listened by the decision
  makers in the area of mental health.
• Through their interventions the beneficiaries
  contribute to the fight against stigma and the
  handicap of being psychiatric patient

55
Things arent hard to do. It is difficult to
reach the state for doing them!
Poarta Sarutului
56
Policies in the area of mental health

• Financing Ministry of Health
• Implementation unit National Institute of
  Research and Development in Health Dr. Silvia
  Florescu

57
Information about the study

• Part of the an international study World Mental
  Health Survey Initiative, of the Evaluation,
  Classification and Epidemiology Group within the
  World Health Organization, with technical
  coordination from Harvard Medical School, SUA
• The study took place in 26 country from all the
  WHO regions, during 2000-2005 with a total sample
  of more than 130 000 cases
• In Romania it began in 2005
• The period of the study in Romania 2005-2006
• Financed by the Ministry of Health

58
Justification of the study

• WHO estimates the mental disorders and those
  generated by the alcohol and drug addiction will
  be rising in the next decades.
• Solution WMH Survey Initiative/Politics in the
  field of mental health run investigations
  compellingly inserted in the general population.
• Based on the surveys the prevalence of mental
  disorders is estimated, the risk factors are
  evaluated, the illness pattern as well as the
  barriers in using services are studied.

59
The aim of the study

• To acquire information at national level about
  the prevalence of behavioral, mental and alcohol
  and drugs related disorders.

60
Methodology

• Target population people of 18 and above. The
  institutionalized persons are not eligible.
• Multiphase probabilistic households sample.
• At national level a sample of 6500 households
  (5000 filled up questionnaires) from which there
  are approached, in an initial phase, 2500
  households (1800 filled up questionnaires)

61
The used instrument

• It is standardized.
• It is used WMH CIDI (Composite International
  Diagnostic Interview) structured interview for
  mental disorders and their treatment evaluation,
  CAPI version computer assisted
• The inquiry contains nearly 1000 questions,
  divided in two parts
• part I the evaluation of the main diagnostic
• part II information about different
  correlations and affections of secondary
  interest.
• The first part is administrated to all the
  respondents and to those meeting all the criteria
  for mental disease the second part is
  administrated too.

62
The considered disorders

• Are those
• Related to anxiety agoraphoby, anxiety,
  obsesive-compulsive disorders, panic attacks,
  posttraumatic stress disorders, social phobias,
  specific phobias
• Related to disposition bipolar disorders,
  disthima, major depresions
• Related to impulsions control boulimia,
  attention and concentration disorders,
  hyperactivity
• Related to drugs and alcohol consumption and
  addiction.

63
Data collection

• Face to face interview, with field operators
  that participated at a 5 days training.
• The enumeration of all adults in the households
  shall be done, no matter their age.
• For each person in the household the following
  data shall be collected age, gender, relation
  with the selected person.
• From the household an adult shall be randomly
  chosen. Because the probability to choose the
  adult depends from one household to another, the
  balance shall be applied in order to prevent
  these discrepancies.
• The balance is based on the enumeration of all
  members in one household.
• The national data base implies the filling of
  5000 questionnaires using CAPI.
• In 10 of the households, the legal partner of
  the selected respondent shall be interviewed. The
  respondent shall be selected with Kish procedure.

64
Evaluation of disorders

• By the operation of clinical calibration based on
  P"Diagnostic and Statistical Manual of Mental
  Disorders, Fourth Edition (DSM-IV)" and "ICD-10
  Classification of Mental and Behavioral
  Disorders".

65
What was done until now

• The training and certification of the NIRDH
  trainers at the Ann Arbor University, Michigan,
  SUA
• Certification by WHO/Harvard Medical School of
  the institutional capacity of NIRDH to implement
  the project
• Translation, adjudgement, revision of the tool
• The acquisition of the necessary elements (soft,
  PC, operators, establishing the sample)
• Training the field operators
• In the near future starting data collection

66
Attractive aspects

• International study
• The methodology is standardized
• Collection assisted on computer (minimizes the
  errors)
• It is a study of prevalence that is basis of
  health and services policies equalizes with the
  evaluation of needs and the analysis of
  utilization

67
Why is the study very important?

• Because there is no representative study at
  national level regarding this problem
• Because it is impossible to elaborate policies,
  strategies, interventions, to plan and evaluate
  services without knowing the real needs of the
  population and the intensity of morbid phenomena
• Because it is a prestigious collaboration that
  can offer scientific upstanding

68
Resolution

• Establishing the CICSM organization aimed at
  facilitating and strengthen the communication
  and decisions between the involved factors
• Claudia Dima
• Finalize the legislative ground (enforcement
  regulations for the Law of mental health, Law of
  community centers, intersectorial harmonization,
  Law of community medical care?)
• The working group
• Starting the Mental Health Community Centers
  pilot phase
• Dan Prelipceanu
• Increase the financing resources allocated for
  the psychiatry national programs, funds
  re-allocation from the World Bank programs,
  access to alternate resources (the Belgian
  proposal), access to new structural funds,
  identification of other resources.
• Virgil Paunescu