Norwegian Financial Mechanism Public Health Programme Area Network of Mental Health Coordinators István Bitter Dept. Psychiatry and Psychotherapy Semmelweis University, Budapest Budapest, 5th June 2013

Final report on Improved community-based mental health services and suicide prevention interventions Project based on the Biennial Collaborative Agreement (BCA) between the Ministry of Health of Hungary and the Regional Office for Europe of the World Health Organization 2010/2011

I. Development of a community based psychiatric program in the 9th district of Budapest II. Suicide prevention program Why did we start these programs? Major cuts in psychiatric services and research in 2007 – Growing rehospitalization rates – Decreasing outpatient capacity – Still high (2nd in Europe) suicide death rates – Social community services for people with psychiatric disorders are not adequately integrated with health care services AND: – We did not want to wait until we can afford one case- manager/10-15 patients

Main features of the project Employment of a coordinator Establishment of a district database with – a full list of health and social services and associated institutions, – a description of the types of services offered, – details of contact persons in the 9th district who could be potential partners in a community-based treatment program. Contact with all pts from the 9th district hospitalized in the Dept of Psychiatry (catchment area!)

Main features of the project (2) Offer of individually selected services to pts Contact with services – Networking with services Our support for „participating” services: supervision, education, regular meetings with case discussions

Main tasks of the coordinators, who will be trained social workers 1. case management from hospital, 2. facilitation of community-based care, 3. coordination among healthcare providers in micro-regions, 4. coordination between healthcare providers and social services.

Type of institution Number of patients treated Number of patients remaining in treatment (by Oct 25 th, 2009) Centre for Family Support2413 Child Welfare Services36 Day Clubs for Addictive Patients 2115 Day Clubs for People with Mental Disorders 1816 Community Services4034 Guardianship Office5552 Mayor’s Office4034 Centre of Community- based Social Services 158 Centre for Labour Affairs3823 Asylum25 Rehabilitation Institutes75 Homeless shelter34 Community Outpatient Service Halfway houses33 Day Clubs for Disabled11 Other health services6238 Type of services – number of patients ( )

Outcome of the coordination activity: Lower rehospitalization rates of patients from the 9th district as compared to district with no coordinator

Main target groups of the mental health coordination Patients with severe mental disorders requiring hospitalization, however do not need long term care (i.e. can be discharged from a psychiatric unit back to their home, communities).

Main tasks during the project Developing a training material and curriculum for coordinators Selection of participating sites - contracting Selection of the site coordinators + project coordinator (full time!) Training of the coordinators Supervision of the coordinators Data collection – analysis (efficacy and cost effectiveness) Supporting sustainability of the project Progress and final reports

Expected major outcomes Improved community care Decreasing rehospitalization rates Decreasing suicide attempts/death

Main „drivers” of the project Semmelweis University, Dept Psychiatry and Psychotherapy GYEMSZI

THANK YOU FOR YOUR ATTENTION!

Norwegian Financial Mechanism Public Health Programme Area Secure Mental Health Unit István Bitter Dept. Psychiatry and Psychotherapy, Semmelweis University, Budapest Budapest, 5th June 2013

Why was a secure unit proposed? Hungary has ca high security beds in a prison environment for those mentally ill, who were committed to compulsory treatment because of a criminal act. Hungary has no units for violent patients, who have not committed a criminal act which would result in arrest.

Hungarian psychiatrist reported an alarming increase in violence of psychiatric patients. The increase of violence by mentally ill patients in Hungary does not come unexpected, as similar developments have been observed in other countries with an opening of the borders: – On one side the influx of drugs hits the mentally ill a little later than many other drug users but much more harmful; – On the other side adopting a less paternalistic attitude towards the mentally ill has drawbacks on those evading the system. Both developments are major factors for the development of violence by mentally ill.

The general psychiatric units responsible for large catchment areas admit, diagnose and treat the most violent patients. These units are unable to cope with this task, some accidents already resulted in death.

The history of the proposal (1) The Section for Forensic Psychiatry of the European Psychiatric Association in 2006 helped with a course in Budapest. The program included lectures/workshops with the participation of the past chair of the section Dr. Harvey Gordon (UK), the past secretary Prof. Cosyns (Belgium) and such distinguished members of the Section as Prof Nedopil (Germany) and Prof. Silfen (Israel and Hungary; past WHO advisor)

The history of the proposal (2) We also regularly consult Prof. Silfen, who agreed to work as a volunteer for the Department of Psychiatry and Psychotherapy of the Semmelweis University. An informal survey was performed among the heads of psychiatric units in order to estimate the need for the diagnosis and treatment of violent patients, who cannot be properly managed on their units.

The proposed unit The plan includes a unit with 3 levels of security: high, medium and low, each consisting 15 beds with appropriate personal. The unit would be located in Budapest, considering that 2.5 million out the 10 million inhabitants of the country live in or around Budapest.

External expertise is needed in planning, building up and starting the secure unit A training program for the staff of the unit will be created with significant support from international experts. The European Psychiatric Association provided two letters of support (one the President of the Association and another one the Chair of its Forensic Psychiatric Section) and their experts are willing to provide professional, expert help for building up this much needed service.

Mental Health Secure Unit (MHSU) Action 1. Preparatory study tour for Hungarian expert/s. Action 2. External supervision of the development of the project. Action 3. Training programs for MHSU staff. Action 4. Professional protocol development for the MHSU. Action 5. Operational and performance indicator set development for the MHSU. Action 6. Patient documentation system (medical and legal) elaboration. Action 7. Professional communication on MHSU for the Hungarian medical community, police, ambulance; special focus: psychiatry / addictology Action 8. Preparing publications (journal manuscripts, text books, handout materials)

Proposed first steps Selection and training of the future head of the MHSU. Contact with EPA, WHO and other international organizations and ask for well defined help. Local (in Hungary) meetings with stakeholders (ministries, NGOs, police, ambulance, other medical professions, e.g. emergeny medicine, toxicology) Selecting the site of new unit

Main „drivers” of the project GYEMSZI, Nyírő Gyula Hospital - National Institute of Psychiatry and Addictology, Future head of the unit, Representatives of the future site.

THANK YOU FOR YOUR ATTENTION!