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The reform of the Greek mental health services
ANASTASIA KARASTERGIOU1, ANASTASIA MASTROGIANNI1,
ELENI GEORGIADOU1, SPIROS KOTROTSIOS2, &
KALLIOPI MAURATZIOTOU3
1Psychiatric Hospital of Thessaloniki, 2International Association for Mental Health Services,
Thessaloniki, and 3Ministry of Health and Social Solidarity, Athens, Greece
AbstractBackground: The Greek Psychiatric reforms began in the early 1980s with the introduction of theNational Health System and the financial support of the then European Community.Aims: To describe the ongoing process of psychiatric reforms and the current situation of mental healthservices in Greece.Method: Official reports and relevant publications were used as information sources.Results: The de-institutionalization of patients from psychiatric hospitals has almost been achieved.Psychiatric hospital beds have been reduced, psychiatric units in general hospitals have beendeveloped, a substantial number of community mental health services has been established and thestandards of care have been improved. New legislation has been introduced and the stigma attached tomental illness is gradually reduced. However, psychiatric units in general hospitals and CommunityMental Health Centres have not yet fulfilled their role as principal providers of psychiatric care, whiledecentralization, sectorization and completion of the network of mental health services are still to becompleted.Conclusions: Although the process of the Greek Psychiatric reforms has been slow and laborious, theprogress achieved is undeniable. The identification of problems and gaps together with a strongercollaboration and common efforts with the other European countries will ensure the firmerestablishment of the reforms in Greece.
Keywords: Mental health services, psychiatric reform, Leros, mental health sectors,de-institutionalization.
Introduction
Until the beginning of the 1980s, psychiatric care in Greece was based on nine overcrowded
state and 40 private psychiatric hospitals. Both were inadequately staffed and poorly
equipped asylums with a mixed population of mainly psychotic and intellectually disabled
patients. There were no community mental health services, no provision for those suffering
from less severe disorders and an almost complete absence of services for children and the
elderly. The management of resources was inefficient and there was a complete lack of
qualified administrative and management staff (Madianos et al., 1999). The aim of the
Correspondence: Spiros Kotrotsios, International Association for Mental Health Services, PO Box 7, PC 57018, Melissochori,
Thessaloniki, Greece. Fax: + 30 23940 33015. E-mail: [email protected]
Journal of Mental Health,
April 2005; 14(2): 197 – 203
ISSN 0963-8237 print/ISSN 1360-0567 online # Shadowfax Publishing and Taylor & Francis Group Ltd
DOI: 10.1080/09638230500060516
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present paper is to describe the long and laborious process of psychiatric reforms in Greece
within the last two decades, as well as the current situation of mental health services.
Official records and relevant publications from the Greek and international literature have
been used as information sources. In some cases, data were provided through personal
communication with people actively involved in the psychiatric reform and through contacts
with psychiatric hospitals and the Greek Ministry of Health.
Historical context of the reform plan
The Greek Psychiatric reforms began in 1983 with the passing of ‘‘Law 1397’’ introducing
the National Health System. Two years earlier Greece had become the 10th member of the
then European Community (EC) and, among other areas, the reforms of Mental Health
Services became one of the priorities of the EC. At the request of the Greek government
financial aid was approved and a five-year plan adopted through EEC Regulation 815/84.
The development of a network of community-based services in geographically defined
sectors was the main goal in order to gradually replace the large psychiatric hospitals, which
until that time offered custodial care and were the only public mental health service
providers. The two main community services to be introduced in the new system were the
Community Mental Health Centres and the Psychiatric Units in the General Hospitals. At
the same time, Child Guidance Centres, Adolescent Units, Psychosocial Rehabilitation
Units, Vocational Training Workshops, Mobile Units for remote areas, Social Cooperatives
employing those patients unable to work in the open market, Crisis Intervention Units and
other special services would also be established, according to local requirement.
Leros
Unfortunately, the implementation of these plans was very slow during the initial stages. It
was soon realized that not only was society unprepared for the changes, but also that there
was a limited number of professional people willing and capable, i.e. with adequate training,
to undertake such a serious task. Alongside the various problems that were beginning to
emerge, Greece suffered a serious embarrassment, when the distressing conditions in the
Leros Mental Hospital were exposed to national and international public scrutiny (Bouras et
al., 1992).
Historically, after the Second World War and the Greek Civil War (1946 – 1949) the
Greek society, among other problems, was faced with overcrowded psychiatric asylums. The
way to deal with this was based on the prevailing concept of that era of incarceration and
social exclusion known in Greece as ‘‘exile’’. This appeared to offer a practical solution and
was used in the same way in psychiatry, as indeed with political opponents. This
fundamental principle led to the creation of ‘‘agricultural colonies’’ for people with severe
mental health problems and intellectual disabilities, based mainly on the Swiss model
(Loukas, 1990). Leros is one of the Dodecanese islands in the Aegean with a population of
8207 (2001 census). It was chosen as an exile place for psychiatric patients because it was
geographically isolated. It also presented an affordable solution for the Greek government
because of its huge military Italian barracks available for any use.
The Psychiatric Hospital in Leros was established in 1957. It was designed to
accommodate 650 patients, but the admission number rapidly increased and reached
2600 patients in 1971 (Loukas, 1990). This was the result of significant numbers of patients
eventually transported to Leros from all Greek psychiatric hospitals. The infrastructure of
the hospital was inefficient and the staff inadequate in number, completely untrained and
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without previous experience. The vast majority of them originated from the island. There
was no therapeutic work in any sense and the basic concept underlying any intervention had
to do with containing the patients and barely meeting their basic biological needs inside the
asylum.
In September 1989 a British newspaper, ‘‘The Observer’’, published a front-page article
on Leros under the title ‘‘Europe’s guilty secret – 1300 lost souls left to rot’’. This article,
which actually focused on the unacceptable conditions of a newly established ward for the
most severe cases, naturally evoked extremely negative reactions from the scientific
community throughout the world. This ward alongside another one represented in the most
striking way the lack of any change within this particular hospital functioning as an asylum
and a place for the deported, aims that had led to its development in the first place. This
realization was obviously taken as an indicator of failure of the psychiatric reform itself. As a
result, the European Community demanded immediate action, threatening the Greek
government with withdrawal of the reform funding.
During the years 1989 – 1990 a detailed plan of emergency interventions to the Leros
Psychiatric Hospital was developed. This included the re-housing of a large number of
patients to fully staffed community residential facilities near the areas of their origin and the
modernization of the hospital wards to an acceptable standard. In the following years, the
above goals were achieved with the development in Leros of a large number (25) of
rehabilitation facilities including protected flats, hostels (for 125 people) and workshops.
Within 20 years (1984 – 2004) the number of long stay patients has declined from 1509 to
475 (Brown et al., 1984; Leros Psychiatric Hospital – personal communication). Today
Leros hosts the first social co-operative for the needs of people with mental health problems
in Greece, a Mobile Unit for the Dodecanese area and a Mental Health Vocational Training
Centre.
Implementation of the reform plan
However embarrassing and sad the Leros Psychiatric Hospital story has been for Greece, it
is undeniable that it became the agent for giving new force to the reform efforts and speeding
it up considerably. With all the delays, the original five-year plan extended beyond the
planned period and covered a whole decade, until July 1995. By the end of this period, the
improvement of the infrastructure of mental health services was considerable and several
pilot community projects developed in parallel with staff training projects. In 1996, 388 new
psychiatric facilities including psychiatric departments in general hospitals, community
mental health centres, day hospitals, day centres, child guidance clinics, residential facilities,
and vocational rehabilitation services were in operation nationwide (Madianos et al., 1999).
In 1997 new hope emerged with the planning of the ‘‘Psychargos’’ Programme. This is a
national programme, developing over a 10-year period and aimed at gradually meeting the
needs of the Mental Health Sectors. The period 1997 – 2001 represents Phase I of the
implementation of the programme with emphasis on de-institutionalization of patients,
while 2002 – 2006 represents Phase II concerning the community services required to meet
all the needs of the Mental Health Sector. A total of 66 hostels, 14 boarding houses and 10
apartments have been set up during Phase I. In these facilities approximately 1000 patients
from psychiatric hospitals all over the country have been settled. In addition, a boarding
house for autistic people, a hostel for refugee mental health patients and 35 training
workshops for mental health patients have been set up. Furthermore 1200 professionals have
been employed to staff these services (young Mental Health professionals) and given special
training (Spyraki, 2001). Phase II has so far enriched the services by 68 (3 mobile units, 6
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hostels, 33 boarding houses, 24 apartments and 2 services for autistic people) for the period
2002 – 2004 (Hondros, 2004, personal communication). As a result, the number of long stay
psychiatric patients for the year 2004 is 2362, whereas in 1984 there were 7795 chronic
patients in the eight psychiatric hospitals of Greece (Brown et al., 1984; data provided by the
psychiatric hospitals – personal communication). Many more services have been planned
and it is hoped that will be set up in the near future in the context of the ‘‘Psychargos’’
Programme. One of the psychiatric hospitals (Petra Olympou) has already closed at the
beginning of this year and four more (Attica Mental Health Hospital for Children, Corfu,
Tripoli and Hania psychiatric hospitals) are planned to close by 2006. It is envisaged that by
the year 2015 the final closure of the rest of the psychiatric hospitals (Attica,
‘‘Dromokaiteio’’ and Thessaloniki psychiatric hospitals) will have been achieved (Spyraki,
2001).
Challenges and successes
Psychiatric reforms in Greece faced difficulties and challenges, relating to specific socio-
cultural and political factors. Although experience gained from similar reforms in other
European countries has proven valuable for the development of services, still there have
been problems and gaps in the planning and implementation of the Mental Health Reforms
in Greece that require further exploration and analysis.
The reforms in mental health care relied mostly on state initiatives and policies mainly
under pressure from the EC. In Greece, local community networks are generally weak
(citizens do not usually participate actively in community matters through users’
organizations, charity groups, lobbies etc) and community services remain fragmented
and poorly organized. This poses a serious barrier to the implementation of a community-
based reform plan in the first place.
On the other hand, family has always been and still is the core element of the Greek society
and in most cases is willing to embrace and care for a member with mental health problems if
properly supported. The exposure of Greek families to the consequences of the modern
Western society (increased financial needs, urbanization, changes in women’s role, etc.)
threatens their traditional function and weakens family bonds. Families of people with mental
health problems should have been more encouraged to participate actively in the planning
and implementation of the reforms by being offered financial benefits and practical support.
Another element of the local communities in Greece is the Church and its affiliated
charitable organizations. Unfortunately, they have so far played no active role. It is firmly
believed that their involvement and the use of their resources could have proved
advantageous in the implementation of the Mental Health Reforms at a local level.
People with severe mental health problems are still among the most socially excluded and
discriminated groups of people in Greece. This is perhaps a situation not that dissimilar to
many other countries. Attitudes to mental illness among the public are often negative and it
is commonly believed that mentally ill people, especially those suffering from schizophrenia,
are violent and dangerous. In contrast to other European countries, there are still no
powerful users’ and carers’ organizations that could have influenced public opinion.
Unfortunately, the development of services within the community has not been properly
supported by campaigns for the information and education of the public and for the
reduction of stigma and discrimination. As a result, it is not rare for whole communities to
react negatively whenever a new service for the mentally ill is about to be developed in their
area. This leads to a conflict between local authorities and government and causes delays in
the development of services.
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Both planning and implementation of the Mental Health Reform in Greece are directly
influenced by conditions in the National Health System of the country. This is to a great
extent still characterized by fragmentation, uneven development, centralization, bureau-
cracy and lack of adequate primary care services. Co-ordination and co-operation of services
is poor and as a result, the integration of mental health services suffers the most. Moreover,
poor co-ordination between the public and the private sector in the whole of the health
system sets a barrier to the full use of the resources of the latter for the implementation of the
mental health reform.
The sectorization of mental health services remains incomplete. The reasons are mainly
the unwillingness and reservation of health service administrators and even mental health
professionals who fail to see the importance of having defined catchment areas as part of the
mental health reforms. As a result, the network of services remains fragmented and uneven,
leaving whole regions (especially rural ones) with little or no access to psychiatric care. Lack
of co-ordination and collaboration among the existing and newly reformed services is also a
problem that needs to be addressed.
Although de-institutionalization of large numbers of long stay hospital patients is an
undeniable achievement, the re-provision of community-based services for those with severe
mental illness is not yet adequate and there have been serious delays (‘‘Monitoring and
Support Unit for the Implementation of Psychargos B Phase Programme’’ – personal
communication). In addition, most of the psychiatric units in general hospitals – with the
support of the administration of these hospitals in most cases – are reluctant to admit
‘‘difficult patients’’ (involuntary admissions, agitated or suicidal patients, patients with
increased social needs). As a result, psychiatric hospitals are still the principal providers of
psychiatric care, the number of admissions has not yet been reduced substantially and the
process of their closure is very slow.
A system of Community Mental Health Centres was chosen originally for the provision of
primary mental health services. Their role was to undertake the co-ordination of community
mental health care. However, there are examples of such centres that have been turned into
psychotherapy centres fulfilling professional interests rather than offering a comprehensive
community care service. In Greece, due to the lack of adequate primary care service, it is
common for patients to access secondary and even tertiary care services for minor health
problems. The implementation of a community-based network of services for mental health
patients is a great innovation for the Greek National Health System and it may take quite
some time to be fully accepted by the public that is used to a hospital-based health care. At
present, the possibility of primary mental health care being provided by ordinary Health
Centres is being reconsidered.
Finally, evaluation of services, especially in the public sector, is not a common practice in
Greece. This will be one of the future challenges. Regular appraisal of Mental Health
services will inform quality assurance and cost effectiveness.
It is vital that problems do not overshadow successes. Among others, the political
commitment of all Greek parties is of major importance. Moreover, Mental Health
Reform itself has brought mental health issues to the centre of public and state
attention. New legislation has been introduced (the sixth section of Act 2071/92, on
‘‘Modernization and Organization of the Health System’’ and Act 2716/99 on
‘‘Development and Modernization of the Mental Health services and other
provisions’’) to ensure and promote both the implementation of the Mental Health
Reform and the rights of the mentally ill.
Along with the network of services in the community, the planning for the Mental Health
Reform also addresses the needs of the changing Greek society: it introduces services for
Reform of the Greek mental health services 201
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minorities and refugees, for people with alcohol and drug dependence and for people with
psychogeriatric and autistic behavioural disorders.
During the Mental Health Reform a range of new therapies (both psychological and
pharmacotherapies) have been introduced. In contrast to other European countries, the
provision of these therapies is not restricted by financial or insurance factors (The World
Health Report, 2001); they are available to anyone in need (i.e., extensive use of atypical
antipsychotics). At the same time, the education and training of mental health professionals
has improved, new specializations have emerged and their approach to the mental health
patient has become more patient-centred and holistic. Young mental health professionals
have been employed for the staffing of the new community services. Apart from their formal
professional qualifications, they undergo special training in community care and
rehabilitation. This, together with their enthusiasm, dedication and compassion ensure
the optimal functioning of these services.
Finally, although social exclusion and discrimination still exist, the mentally ill in Greece
are no longer in ‘‘exile’’. Due to the Mental Health Reform, slowly but steadily they are
regarded by both the State and the public as equal members of the community, their rights
are being acknowledged and respected, their needs are being addressed and the stigma
attached to mental illness is being gradually reduced.
The outlook in a European context
Future directions in implementing the psychiatric reform in Europe include integration
and collaboration of psychiatric services with social services and primary care,
development of emergency services in the community, sufficient support (psychological
and financial) to families and their involvement in planning of services, focus on
patients’ needs especially in areas of social relations, daily activities and work, and
collaboration with non-governmental and non-professional groups (Brand, 2001;
Johnson et al., 2001; Stefansson & Hansson 2001). The above-mentioned directions
are also important for the future of the reform in Greece. In addition, areas of special
interest for this country should include service evaluation, research on cost-
effectiveness of different approaches, patients’ rights and empowerment, amendment
to Mental Health legislation to include involuntary community treatment and other
measures.
There is much to be gained in this country by the development of stronger collaboration
with other European countries, which more than ever in the past, are now moving closer to
each other. Common efforts to develop ethical standards and practice guidelines are
expected to be made, as well as common programmes to combat stigma and discrimination,
which are the most serious obstacles in social integration of people with mental health
problems. Efforts should be made to ensure that Greece is included in collaborative health
service research projects to promote evidence-based practice.
Acknowledgements
We would like to thank the University Mental Health Research Institute (EPIPSY) in
Athens, the ‘‘Monitoring and Support Unit for the Implementation of Psychargos –B’ Phase
Programme’’ and the psychiatric hospitals of Greece for all the information they provided.
Also, Prof. Nick Bouras, Professor of Psychiatry in Learning Disabilities, Division of
Psychiatry, Guy’s-King’s-St. Thomas Medical School and the Institute of Psychiatry, King’s
College London for his valuable comments and suggestions.
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