1. Twenty-twenty European policies for mental health Piazza Armerina, September 2013 The Mental Health System in Andalucía (Spain) Marcelino López Álvarez Psychiatrist and sociologist Director of Programs, evaluation and research Andalousian public foundation for social integration of people with mental illness (FAISEM) Sevilla SPAIN

2. Introduction : Spain don’t have “one” mental health system In fact we have 17, because we have 17 regions (Autonomous Communities), each of one has their specific mental health system Psychiatric hospitals – community services Health – social services Public – private services Organizational models and professional orientation (biological – community and psychosocial) Role of associative movements (Family and Users) They have only some little common aspects Some general legislation Formal integration of health services in the National Health System Negative effect of the current restrictive policies to manage the economic crisis

4. Spanish Psychiatric Reform (1982 -...) Not specific Mental Health Law Concrete articles in civil and penal legislation (1983) General Health Law (1986) Mental health system Very different situations in the 17 regions Psychiatric Hospitals: Decrease of the number of beds (from 32.500 to 16.000) But not general closure: 30% of the admission are still in PH Only 3 Regions closed their public PH Andalucía (8) Asturias (1) Navarra (1)

5. Hospitals and ClinicsBeds Reduction (%) 197512044.034 19869832.49326,2 % 20079916.02850,7 % (1986) 63,6 % (1975) Psychiatric Institutions and beds in Spain 1975, 1986 Y 2007

6. Community Mental Health Services Mental health Teams or Centers, linked with Primary health care services Psychiatric units in General hospitals Little and different Rehabilitation Services Little and different social services (residential and day support) and employment programs A formal Common “Mental Health Strategy” from the National Health System Usually there is not separate funding in Health services Usually not public provision in social and employment services and programs Andalucía: public provision Madrid: public founding but private provision Usually partial public founding and provision by the family associative movement Without accurate common information

7. Andalucía is one of the 17 Regions (Autonomous communities) of Spain 8 provinces 18% of the territory and the population Traditionally «less developed» Psychiatric Reform 1984: Closure of the 8 Public psychiatric hospitals: Mental Health services integrated in the Andalousian Health Service (SAS) Social support resources in a public foundation (FAISEM) AndalucíaSpain Territory87.561 Km 2 504.540 Km 2 Population8.400.00047.000.000

8. The closure of the public psychiatric hospitals in Andalucía (1984-2005) Hospitals closed (!984-1999) 8 (2.987) Long Stay Residents in January 1985 2.672 30% “Elderly “ (>65 years) 30% “Mental Disability” 40% “Chronic” Admissions 1985-1999 315 Dead during the period (19852005) 813 Discharges includes in the study 2.174 Own and family home 5,3 % Nursing homes for elderly people 37,4 % Residential homes for people with Mental Disability 26,8 % Specifics accommodations 24,0 % Private Psychiatric Hospitals 0,6 % Penitentiary Psychiatric Hospital 0,4 % Homeless 0,6 % Others 1,1 % Unknown 3,8 %

9. Private and Penitentiary Psychiatric Hospitals

10. The Mental Health System in Andalucía PERSON FAMILY COMMUNITY USMI UHSM CT HD URA UCSM PRYMARY HEALTH CARE TEEMS COMMUNITY SOCIAL SERVICES LITTLE RESIDENCE APARTMENT HOME SERVICE SOCIAL CLUB WORKSHOP SOAE S FIRMS FAISEMFAISEM SSPASSPA COORDINATION COMMITEE. UGCMENTAL HEALTHUGCMENTAL HEALTH TRAINING SERVICIO ANDALUZ OF EMPLOYMENT SPECIALISED SOCIAL SERVICES

11. The organization of Mental Health system into the Andalousian health “Mental Health Departments” (Clinical Management Mental Health Units) that depends from the Medical Direction of one General Hospital Community M H Unit Director Clinical Management Mental Health Unit M H Hospitalization Unit Child and adolescent Unit Rehabilitation Unit Therapeutical community Day Hospital Community M H Unit

12. Mental Health Services in the General Health Service 24 Mental Health «departments» Community Mental Health Units: 76 (1 /108.000) Hospital (short stay) Units (General Hospitals) : 19: 560 beds (6,8 / 100.000) Therapeutic Communities: 14: 240 beds (2,9 / 100.000) 420 day places (5,1 / 100.000) Child and adolescents Units: 14: 40 beds (0,4 / 100.000) 250 day places (3,1 / 100.000 ) Day Hospitals: 11: 264 places (3,2 / 100.000 ) Rehabilitation Units: 9 :305 places (3,7 / 100.000) Mental Health Emergences Services in 19 General Hospitals

13. Servicios de Salud Mental (SAS) Actividad 2010 Personas atendidas: 198.995  Primeras consultas: 97.214  Total consultas : 842.356  Distribución diagnóstica:  Neurosis/ T. de Personalidad: 46%  Esquizofrenia y ots. Psicosis 14%  T. Afectivos: 27%  T. Infancia y adolescencia: 6 %  T. Orgánicos /Disc. Mental/ ots: 5%  Drogodependencias 2% Hospitalización de corta estancia (USMHG):  Ingresos totales: 10.262  Estancia Media: 15’9 días  Indice de Ocupación: 94,0%  Distribución diagnóstica:  Psicosis : 60%  T. personalidad: 12%

14. Social support services in FAISEM (1) FAISEM: Public Foundation (Regional Government of Andalucía Health Social Services Employment Economy Participation of Associative movements Family Users Professionals Social support programs and services Housing Occupation Employment Support for the Family and Users Associations Training Research Technical cooperation

15. Housing “Home- House:” (20 places, 24 hours) 57 ( 940) (10,2 /100.000) Apartments (3-4 places) 197 ( 753) (9,1 / 100.000) Home support: 585 (7,1 / 100.000) Employment Vocational Guidance and support teams: 8 (2.400) Training Courses: 53 (261) Supported employment 321 Social Firms 10 (305 workers with SMD) Occupation Day Centres, Workshops, and Social Clubs: 156 (3.250) Social support services in FAISEM (2). 2012

16. FAISEM Budget 2013 Regional Minister of Health and Social Services: 7.670.522 Andalousian health Service: 21.612.313 Dependence Agency (Social Services): 3.874.624 Andalousian Employment Service: 1.150.000 Minister of Education: 400.000 Users contributions (“Taxes”): 3.890.784 Others: 734.125 TOTAL: 39.332.368 Social Firms (2012) Total income: 12.741.110 % from subsidies: 16,7 Balance: + 1.023.121

17. Coordination (Mental Health services and FAISEM) Andalousian Mental Health Plan Severe Mental Disorder Care Protocol Personal care protocol SMD Coordination Commission in every Mental Health “department” Provincial and Regional Coordination Commission Mental health Departments FAISEM Social Services