Community Mental Health Care in Serbia: Development and Perspectives

Community mental health care was developed in Serbia in 1982 at the Belgrade Institute of mental health. Treatment was provided through the primary health care system, with each health centre having its own mental health care team. However, in the process of psychiatric reform and deinstitutionalization, dedicated community centres had to be established, in accordance with the National Strategy for the Development of Mental Health Care. The first community-based mental health centre opened in the southern area of Serbia in 2005 and subsequently, other centres were established. The centres are organized independently of psychiatric hospitals and are located in local, self-government units, providing psychosocial treatment and the continuation of mental health care. In relation to the ongoing reform of psychiatry in the country, there are positive and negative issues. There are 41.41 beds per 100,000 of the population in psychiatric hospitals and 18.33 beds per 100,000 of the population in the psychiatric departments of general hospitals. Day hospitals, established throughout the country, provide patients with good quality care. Mental health care professionals are educated to a high standard and integrative, person-centred treatment is applied in most services. However, the level of stigma directed towards those with mental illness is still high and constitutes a barrier to treatment. Well-developed screening and early detection programmes to identify persons requiring mental health care are lacking, as are the records of patients with mental disorders. The future goal is to further reduce the number of beds in psychiatric hospitals, establish new community mental health care services throughout the country and ensure the prevention of mental disorders, as well as mental health promotion.

MENTAL HEALTH CARE IN SERBIA

The oldest psychiatric institution, “Home for the Insane People” in the Balkans, was established in Belgrade (capital of Serbia) in 1861, with 25 beds. The number of beds in psychiatric hospitals continued to increase until the last decade when, in accordance with national policy, the number began to decrease, primarily in “large” psychiatric hospitals.

According to data acquired in 2002, there were 46 psychiatric hospitals with 7,000 beds; 3,000 of these were in large psychiatric hospitals and the average duration of treatment was 153 days. However, this period was much shorter in university tertiary clinics (around 30 days). The total number of doctors (psychiatrists and neuropsychiatrists) was 947, with 336 of these working in the capital, Belgrade.1,2

In 2016 there were seven psychiatric hospitals, 36 psychiatric departments in general hospitals and four community mental health centres.3,4 There were еight outpatient facilities for children and adolescents (e.g., day care), with departments for developmental disorders, as well as 39 other outpatient services for children and adolescents, and six inpatient facilities for children and adolescents. The total number of mental health care workers (governmental and nongovernmental) in Serbia in 2016 was 2,643 (29.86 per 100,000 of the population3 (Table 1).

Inpatient care (per 100,000 of the population) included 41.41 hospital beds with 127.07 annual admissions and 18.33 psychiatric unit beds in general hospitals, with 209.97 annual admissions. The number of child- and adolescent-specific inpatient beds per 100,000 of the population was 0.86, with 3.02 annual admissions. More than 75% of discharged inpatients received a follow–up outpatient visit within one month.

COMMUNITY-BASED MENTAL HEALTH CARE

Community-based mental health care in Serbia is under development.5,6 It began as part of the reform of psychiatry in 2007, along with a process of deinstitutionalization and de-stigmatization. However, community mental health care was developed in the country many years ago. It was organized through the primary health care system, each health centre having its own mental health care team. The activities aimed at bringing mental health care services closer to patients was already in existence in previous decades in certain psychiatric institutes and clinics. The day hospital for substance abuse treatment (community centre) was founded in 1978 as a part of the Institute of Mental Health (IMH), which was the first psychosocial psychiatric institution in Serbia, established in 1963 in the centre of Belgrade and currently recognized as an institution of excellence.7 This was essentially a community centre, transferred to another municipality in 1982 (from the Institute). It consists of two elements, one for treating alcohol abuse in adults and pathological gamblers, the other for the treatment of young, poly-substance abusers, between 12 and 18 of age.8 In addition to these services at the IMH, there are clubs for specific groups of patients (those suffering from psychotic disorders or alcoholism, elderly patients (we refer to this group as the “third age”, in order to overcome stigmatization), families of adolescents, etc.), organized as outpatient services.7,8

Table 1. Mental health care staff in Serbia

In 2003, Serbia was involved in the Stability Pact Mental Health Project of South-Eastern Europe, along with another eight countries within the region. The project was entitled, “Enhancing social cohesion through strengthening community mental health services”, with the primary aim of standardizing mental health care in the region.1,5 It was coordinated by the World Health Organization (WHO) and by national committees, responsible for mental health. The national policy, “Strategy for the Development of Mental Health Care”, was prepared as part of the project and was approved by the government of the Republic of Serbia in January 2007. The policy is in accordance with the WHO recommendations from 2001 concerning mental health care, and with the Declaration on Mental Health for Europe, approved at the European Ministerial Conference in Helsinki, in January 2005. As a key obligation of the project, the first centre for mental health care in the community in Serbia, was established.

This pilot project in Serbia consisted of the opening of the first community-based mental health centre in October 2005 in Niš (in the southern region of Serbia).9 The centre formed part of the Special Hospital for Mental Disorders “Gornja Toponica”. Its establishment was a result of the collaboration of the Serbian Ministry of Health, the Stability Pact for South-Eastern Europe and the NGO, Caritas Italiana.10

The mental health centre in Kikinda, a city in the autonomous province of Vojvodina (in the northern region of the country) opened at the end of May 2015, as an organizational unit of the Special Hospital for Mental Disorders, “Sveti Vračevi” in Novi Kneževac.11 The third community-based mental health centre in Serbia opened in 2015 in Vršac (in the north-eastern region of the country), associated with the Special Hospital for Mental Disorders “Dr. Slavoljub Bakalović” in Vršac.12 All the centres are situated outside the psychiatric hospitals and are located within local self-government units. They are led by multidisciplinary teams, consisting of case managers, psychiatrists, psychologists and social workers, who provide psychosocial treatment and the continuation of mental health care. The funding of the project for the centre in Kikinda totalled 141,645.14 EUR. Part of this fund was provided by the Provincial Secretariat for Finance, and part by the Provincial Secretariat for Health, Social Policy and Demography.11 An amount of 155,000.00 EUR was approved for the realization of the project for the mental health centre in Vršac, 85% of which was a donation from the European Union, while the remainder of the money was transferred from the funds of the hospital or from the two provincial secretariats.12 The establishment of these centres formed part of the project entitled, “Improving the position of users of residential institutions with intellectual and mental disorders, creating conditions for their inclusion in society and the local community – Open Hug” in collaboration with the Ministry of Health. The partners in the project were the local municipalities and the Provincial Secretariat for Health, Social Policy and Demography. The project was also supported by the NGO, “International Aid Network – IAN” in Belgrade.11,12

STRENGTHS AND WEAKNESSES

The mental health care system in Serbia demonstrates many positive characteristics, such as the provision of a number of day hospitals, providing patients with high quality mental health care. The involvement of persons with mental disorders and their family members in mental health policies, laws and service development, is increasing. Mental health care professionals are educated to a high standard and integrative, person-centred treatment is applied in most services, especially in university clinics. Specialization in both adult and child psychiatry requires a four-year training period and is developed in accordance with European standards.1 Postgraduate psychiatry training includes subspecialties in psychoanalytical psychotherapy, forensic psychiatry, clinical pharmacology and substance abuse. Psychotherapy has a long tradition in the country with various approaches – psychoanalytical, group analysis, systemic family treatment, cognitive–behavioural, etc.13 Continuing medical education is obligatory for all mental health care workers. Professionals from Serbia publish in the leading psychiatric journals, books and textbooks of international publishing houses.1 All the institutes, clinics and psychiatric departments have ethical committees and are obliged to apply ethical codes in their treatment and research. The health care service is financed by the state through the Republic Office of Health Care (health care is free of charge).

As an example of good clinical and research practice in Serbia, the Institute of Mental Health was designated as the WHO Collaborating Centre for Mental Health in 2009 (renominated in 2018). The government recognized its importance and supported the IMH programmes, aimed at the prevention of suicide and violence among children and young people, child abuse, as well as substance abuse and alcoholism.1 During the past decade national guidelines for good clinical practice were developed and published for the treatment of schizophrenia,14 depression15 and alcoholism,16 as well as protocols for the prevention of child abuse.

However, certain weaknesses exist, such as a high level of stigma directed towards those with mental disorders among the general public, which constitutes a barrier to treatment.17 Screening and early detection programmes to identify persons requiring mental health care are needed, and there is a lack of an integrated information system for registering and monitoring mental disorders, as well as limited records of mental disorders. The collaboration between primary, secondary and tertiary health care is not satisfactory, similarly between psychiatric and social welfare institutions. The network of mental health community centres should be expanded. It is well known that the importance of community mental health care may have even greater relevance in low- and middle-income countries (LMIC) compared to high-income countries (HICs).18

PERSPECTIVES

The future perspective of mental health care in Serbia is inextricably linked to the social, economic and legal transition of the country. This goal has ten steps plus one and incorporates several domains: legislation and human rights; organization of services; prevention of mental disorders and mental health promotion; work force development; research; evaluation of services; improvement of quality; information systems; intersectoral cooperation (partnership for mental health); advocacy and public representation; reform of psychiatry and psychiatrists.5

As previously noted, the mental health care system in Serbia needs to be adjusted to meet many different challenges. It should be stressed that the establishment of new community centres is not the only development that will improve the treatment of mentally ill persons. Humanization and individualization of treatment, as well as person-centred psychiatry, are also significant and are already applied in many psychiatric services in Serbia.8

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