Mental health policy in Bulgaria

1. Mental health policy in Bulgaria

2. General background • History • Totalitarian period • Organization of the system • Development after 1990

3. Psychiatric services in Bulgaria 1.Psychiatric hospitals 11 2.Mental health centers 12 3.Psychiatric clinics in general hospitals 9

4. Psychiatric beds per 10 000 1. In Psychiatric hospitals 4.1 2.In general hospitals 1.9 3. In other settings 2.3

5. Number of professionals per 10 000 1. Psychiatrists 9 2. Neurosurgeons 1.6 3. Psychiatric nurses 15 4. Psychologists 0.9 5. Social workers 0.3

6. Psychiatric care financing State budget Municipal budget NHIF Private Psychiatric hospitals Dispensaries Group and individual practices Group and individual practices

7. Current shortcomings in the psychiatric care • Institutional model blamed for punishing than helping • Social discrimination and lack of tolerance to the mentally disturbed • The old-fashioned model of stationery-dispensary • Prevalence of the medical model

8. Current shortcomings in the psychiatric care • Current systems of care do not cater for individual needs. • The utilisation of services depends on the capacity of patients to manage their own care, which they mostly lack. • Institutional care encourages dependency. • Agencies do not provide descriptions of their services to enable patients to make choices. • Regional needs are not taken into account in service development. • There is no system, which evaluates the cost effectiveness of services put in place.

9. Amnesty International report

10. Planning and implementing mental health policy • National mental health program • International epidemiological survey • Change of the existing legislation

11. National Health Strategy “Better Health for Better Future for Bulgaria” National Mental Health Policy National drug policy Quality assurance National Program for drug addiction National mental health program Suicidal prevention program National Framework Contract Capacity building SEE Mental health project

12. Milestones of the mental health policy • Changes in the corresponding legislation respecting the patient rights • Defining the real needs and demands of mental care services • Reforming the system of psychiatric care • Change of public attitudes • Establishing a system for mental health information.

13. Legislation • The Act for People’s Health • The Project Law for Public Health • Regulation regarding ECT administration • Regulation regarding patient’s rights

14. Basic principles of the Program • Home services delivering • Interrelation between services and structures • Standards and algorithms for specific cases • Regional programs based on the local needs • Working with the families • Adapting the system to the new legislation • Use of modern technologies • Respect of the human rights by: • incorporating the values of the civil society in the psychiatric activities • procedures of ethical control in the daily practice

15. The main goals of the Program • Decline the rate of morbidity, mortality and other negative effects on the health status • Quality assurance and quality control of the medical care • Improvement the quality of life and changing negative attitude to the mentally sick • Integration in the general health care system • Investigation of the reasons, consequences and care related with the mental disorders

16. The main tasks of the Program • Assessment of the existing psychiatric services according to the local needs • Elaboration of programs for psycho-social interventions in the community • Establishing procedures, rules and organizational basis for a modern psychiatric care • Definition of psychiatric services in the general package of services for primary care • Opening day-care units • Opening psychiatric wards in the general hospitals • Evaluation, and redefinition the profile of the existing psychiatric hospitals and developing programs for closing the hopeless ones • The psychiatric hospitals will be organized on territorial principle and levels of care will be defined • Training the GP’s for dealing with risk groups and cases • Implementing standards for psychiatric care • Design a concept for keeping and exchange the information • Opening shelters for living endorsement and care • Developing a register for people in a risk of offensive behavior or social deprivation • Legislation amendments regarding patient’s rights in the psychiatry

17. Time-schedule of the Program • Initial phase of one year • Implementation phase of four years

18. Management of the Program • Central governing by Executive Council to the MoH • Local councils organized on intersectional basis

19. Financing • By the state budget according to an annual financial plan proposed by the Executive Council and approved by the MoH • Additional sources including foreign donors

20. Sections of the program Section 1: Regional programmes Section 2: Psychiatric service provision Section 3: General practice Section 4: Social welfare Section 5: Suicide prevention Section 6: Substance abuse and dependence Section 7: Training of personnel Section 8: International collaboration Section 9: Continuing education and good practice standards Section 10: Legislation Section 11: Mass media

21. Monitoring and verification of the programme implementation

22. Indicators concerning the resources (“input” indicators)

23. Indicators concerning the activities (“process” indicators)

24. Indicators concerning the results (“outcome” indicators)

25. Current implementation of the Program

26. Pilot project 1

27. Pilot project 2 Day center in urban area (Sofia) It will provide care for people with chronic invalidating psychic disorders in their living place. In the existing mental health system of care, usually these people live in social homes and facilities for disabled people or stationers for chronic patients. The program will give them the opportunity to receive life lasting care along with the possibility to stay at their homes.

28. Pilot project 3 Psychiatric ward in a general hospital.

29. Pilot project 4

30. Pilot project 5 Methodology for assessment of the risk of offensive behavior and social exclusion The project develops methodology for assessment and structure of the psychiatric interview. A network of consultants on national level will be proposed.

31. Pilot project 6 Mobile psychiatric care The project will elaborate procedure for helping people in crisis at home in order to avoid hospitalization.

32. Pilot project 7 Protected homes for mentally disordered people It will describe and demonstrate activities for maintaining the living conditions for these persons within the community, supported by team of social workers, nurses and psychologists

33. Obstacles in implementing mental health policy • The legacy from the past • Traditional cultural attitude • Divided responsibility for the nursing homes and psychiatric hospitals • Administrative inertia • Professional resistance • Media reaction

34. After a press conference about planned epidemiological survey the next day newspapers went out with headlines like these:”They start to count mad people at their homes” and: “They gonna check us if we are crazy”

35. In 2001 a cruel murder of a 6-year boy was reported. The father, taxi driver, organized a group of colleagues protesting to the parliament and shouting “murderers”. The press was largely involved also. Later it was found out that the mother was the killer because of schizophrenic disorder, after an expertise and decision by the court. Although, long after the case was treated by the press as a political affair (as if the prime minister himself had killed the boy). Even now some journalists and public persons don’t believe that the conclusion of the psychiatrists was true.

36. In conclusion it must be underlined that many of the problems in the psychiatric care are common for number of countries of the former Soviet block. Despite the economic crisis and financial restrictions Bulgaria faces last decade, there is a political and professional will the long postponed problems to be solved in accordance with the European standards and good practices, which will contribute for the Bulgarian EC integration