Mental health and integration Provision for supporting people with mental illness: A comparison of 30 European countries Romania Country Report Mired in an unhealthy past Mental Health Integration Index Results Mental Health Integration Index: Results for Romania Romania Best Average Worst Environment Governance 100 80 60 40 20 Overall: Environment : Opportunities: Access: Governance: Overall: 34.7/100 (29th of 30 countries) 51.7/100 (24th) 16.7/100 (29th) 11.0/100 (30th) 52.2/100 (16th) Other Key Data 20 40 60 80 100 Access Opportunities l Spending: Mental health budget as proportion of government health budget: Not available l Burden: Disability-adjusted life years (DALYs) resulting from mental and behavioural disorders as proportion of all DALYs (World Health Organisation—WHO—estimate for 2012): 7.2% l Stigma: Proportion of people who would find it difficult to talk to somebody with a serious mental health problem (Eurobarometer 2010): 22% Highlights Mental healthcare is poorly resourced, institution-based, and predominantly biomedical rather than psychosocial The Ministry of Labour, Family and Social Affairs runs a parallel system of long-term care facilities, many of the residents of which are people living with mental illness, where inhabitants receive little or no care, and where the most common way of leaving is death Community-based social and employment services are largely absent and those available are the work of non-governmental organisations (NGOs) reliant on international funding Politicians have shown little interest in changing the system, only taking steps when put under international pressure to so, and even backtracking once the pressure has subsided Conditions in the Ministry of Health’s psychiatric hospitals are poor, leading to frequent criticism by human rights bodies Such progress as has occurred is the result of the work of NGOs and dedicated individuals Romania finishes 29th out of 30 in the Economist Intelligence Unit’s Mental Health Integration Index, with low rankings in all categories SPONSORED BY © The Economist Intelligence Unit Limited 2014 Mental health and integration Provision for supporting people with mental illness: A comparison of 30 European countries Romania ranks very low in the Mental Health Integration Index, coming in 29th overall out of 30 countries Its weaknesses are substantial across the board The country finishes 24th in the “Environment” category (which measures the extent to which government policy makes it possible to live a fulfilling home and family life), 29th in “Opportunities” (which looks at the existence of policies that support finding and keeping employment), and last in the category that measures access to medical care Even its highest ranking, 16th in the “Governance” category, is partly the result of the existence of a number of good laws that in practice are not enforced Romania’s performance in the Index comes as no surprise to any of the experts interviewed for this report As Alina Zlati— director of Open Minds: Centre for Mental Health Research, a research institute in Cluj-Napoca— puts it, “the paradigm shift from social exclusion to inclusion has not been made yet.” Instead, Romania’s mental health provision is stuck in the past, which is all too often a dark one As closer examination shows, care for people living with mental illness in Romania is a catalogue of gross deficiency which, on occasion, has proved fatal A poorly resourced system Romania’s last-place score in the “Access” category is in part the result of a lack of specialised services, such as assertive community treatment, prison support, or patient advocacy schemes for service users Each of these is so rare that the Index gives the country zero points The most glaring problem, though, and one that complicates all other efforts to improve provision, is the very small size of the mental health workforce Overall, in the Index, Romania scores just 4.8 out of 100 on this indicator, which is not only the lowest score of all ranked countries, but less than half that of the next-lowest-ranked country Romania has just 4.1 psychiatrists per 100,000 people (in 29th place) and 8.9 psychiatric nurses per 1000,000 people (26th) Even these numbers overestimate the capability of the workforce Ms Zlati notes that emigration of trained psychiatrists is an ongoing problem, especially among those who are more capable and therefore find it easier to get a job abroad “We not only have few psychiatrists,” she says, “they are also not necessarily the most well-equipped to foster change within the system or within society” Moreover, the large majority of psychiatric nurses receive no specialist training because little has been available beyond a single NGO-supported programme Between 1993 and 2008 that programme was able to graduate only 250 students.1 The few available professionals are also not evenly spread around the country Dr Alexandru Paziuc, a practising psychiatrist and president of the Romanian Social Psychiatry Association, says that most are concentrated in the major cities, especially at university centres “In university centres”, he says, “there is one psychiatrist for every five or 10 beds In some places in the provinces, you have one for every 80 or 100 beds.” The countryside is in even worse shape than provincial cities “Rural and remote areas are completely off the grid, with virtually no mental health professionals”, says Ms Zlati The reasons for these low numbers are easy to find Stefan Bandol, president and founder of Aripi, a Bucharest-based psychiatric service users’ organisation, explains that “psychiatrists are the worst-paid personnel in the medical system To pay them more would mean properly valuing their Cristian Vlãdescu et al, Romania: Health System Review, 2008 © The Economist Intelligence Unit Limited 2014 Mental health and integration Provision for supporting people with mental illness: A comparison of 30 European countries work.” Psychotherapists, meanwhile, have only been paid by the government health insurance system since 2011, and not particularly well More generally, Ms Zlati adds that “it is quite hard to make a living out of providing mental healthcare”, and that poor working conditions also discourage people from entering the field or trained individuals from staying in the country Such low pay and poor conditions are a symptom of a broader lack of spending on mental health Romania already puts less than many of its European neighbours into healthcare as a whole (4% of GDP in 2012) Figures on mental health spending are hard to find or are out of date, but most point to around 3% of total healthcare expenditure before 2008 and less than 0.5% in that year2, which would make it one of the lowest figures in the Index In short, Romania’s mental health services are possibly the least supported in Europe, making maintenance of existing structures difficult and large-scale reform nearly impossible Institutions from a different age Medical care for those living with mental illness in Romania remains heavily dominated by psychiatric and other hospitals In the Index, the country ranks 29th out of 30 for policy and success in the field of deinstitutionalisation, and is the only one in the Index to lack even a notional strategy in this area This may seem at first confusing when looking at psychiatric hospital bed numbers: Romania’s roughly 78 psychiatric hospital beds per 100,000 people, although stable over the last decade, now more or less matches the European average Cristian Vlãdescu et al, Romania: Health System Review, 2008; Emilia Chiscop, “Ce se ascunde in spatele unor orori”, Ziarul de iasi, December 15th 2008, (translation at http://www.cartercenter.org/health/mental_health/archive/ documents/romanian_system_chiscop.html) This has mental health budget figures for 2007 and 2008 compared with national spending on health available from Eurostat The problem is that there is an almost total absence of outpatient care to balance this institutional provision Ms Zlati notes that the existing situation is an improvement: “we have some community mental health services now, but they are very underdeveloped” Romania has had some form of outpatient provision since the 1970s when the government set up so-called mental health laboratories Very few had actually been established by the time of the revolution in 1989, and in 1996 those that were became integrated with hospitals In recent years the government has tried to reform them as community mental health centres In 2013 there were 52 of them, but a 2006 survey (the latest information available) found that over half of those that did exist could not function at full capacity because of a lack of staff, and that care consisted almost entirely of psychiatrists prescribing medication Instead, healthcare for people living with mental illness is largely dominated by inpatient hospital provision Of the roughly 17,000 beds available, most are in specialist psychiatric facilities All of the beds in psychiatric wards of general hospitals—a little under one-third—are for acute care, as are about half of those in specialist psychiatric hospitals.3 Care in these facilities is highly medicalised Psychiatrists are far more common than psychologists and social workers, and only 72% of these hospitals conduct psychosocial evaluations, while all provide psychotropic drugs.4 This is consistent with the underlying institutional culture pervasive in the hospitals In a small 2011 survey, over 80% of doctors were not even familiar with a WHO integrated care model for mental healthcare.5 Mr Bandol notes that clinicians “are Transylvanian Review of Administrative Sciences, 2009; Cristian Vlãdescu et al, Romania: Health System Review, 2008 Veronica Junjan et al, “The Provision of Psychiatric Care in Romania—Need for Change or Change of Needs?” Transylvanian Review of Administrative Sciences, 2009 For bed numbers see Adriana Mihai and Ileana Botezat-Antonesc, “Romania”, in Chiara Samele et al, Mental health Systems in the European Union Member States, 2013; Veronica Junjan et al, “The Provision of Psychiatric Care in Romania—Need for Change or Change of Needs?” Violeta Manasi and Daniela Vâlcean, “Survey on the Need for Developing and Implementing an Optimal Care Model Based on An Integrated Mental Health Services in a Romanian Psychiatric Medical Ward”, Management in Health, 2012 © The Economist Intelligence Unit Limited 2014 Mental health and integration Provision for supporting people with mental illness: A comparison of 30 European countries taught to take care of the patient within the hospital system” He recalls asking a professor from a university clinic about deinstitutionalisation and social psychiatry only to be told, “as a psychiatrist, why should I have to run down the street in order to give people medicine”—an attitude that he finds all too common Even more alarming are the conditions in these hospitals Ms Zlati calls them “very degraded Ceilings are collapsing; pipes are bursting.” Ministry of Health data from 2007 indicates that on average there were five beds per room and 13 beds per toilet.6 The average obscures some extreme cases In 2012 the European Court of Human Rights agreed with one patient’s complaint that he suffered from “inhuman and degrading” conditions when he was involuntarily admitted to an overcrowded ward where head lice was common, two or three people had to share each bed, and all 70 patients had to share two to three showers during a limited time period.7 Far worse still is the notorious case of Poiana Mare Psychiatric Hospital where, in 2004, 17 patients died in suspicious circumstances, apparently of malnutrition and hypothermia The explanation is that the country has been slow to adopt legislation enforcing treaty provisions, and the law on involuntary placement is poorly understood by patients and frequently not followed by institutions As one service user told an investigator from the European Agency for Fundamental Rights, “being detained in a hospital and thinking that you can benefit from legal assistance is absolutely utopian”.9 Indeed, Romania’s psychiatric institutions regularly face criticism from human rights bodies, most recently in a report from the Council of Europe which, inter alia, lists several court cases that the country has lost.8 This may seem inconsistent with Romania’s maximum marks in the Index for its laws on involuntary commitment, and its score of 67 out of 100 for adhesion to relevant human rights treaties, which help to explain its relative strength in the “Governance” category Formal psychiatric hospitals, for all their faults, however, are not the main contributor to the country’s poor level of treatment Dr Paziuc notes that the government has been reducing the number of acute psychiatric beds of which, perhaps ironically, there are not enough to meet current need, especially given the low level of community provision At the same time, it has been increasing the number of beds in a parallel system run by the Ministry of Labour, Family and Social Affairs These facilities, although called centres for psychosocial rehabilitation, are in fact large dormitories for individuals considered incapable of living on their own in society—often those with mental illness or mental disability, but sometimes merely the homeless According to data provided to the Council of Europe some 17,123 people live in these centres, slightly more than all the beds in the country’s psychiatric hospitals.10 Many have been admitted involuntarily If two-thirds11 of these individuals are in rehabilitation centres as a result of mental illness, and if their numbers are added to the number of institutional psychiatric beds overseen by the Ministry of Health, that would give Romania the third highest number of such beds in Europe—a better reflection of its degree of institutionalisation 10 Veronica Junjan et al, “The Provision of Psychiatric Care in Romania—Need for Change or Change of Needs?” Transylvanian Review of Administrative Sciences, 2009 Affaire Parascineti contre Roumanie, Arrêt Définitif, June 2012, European Court of Human Rights Nils Muižnieks, “Report by Commissioner for Human Rights of the Council of Europe Following His Visit to Romania From 31 March to April 2014”, Council of Europe CommDH(2014)14, July 2014 Mihaela Dumitrescu1 and Maria Ladea, “Mental Health Law in Romania— Its Awareness Among the Population”, Romanian Journal of Psychiatry, 2011, European Agency for Fundamental Rights, Involuntary placement and involuntary treatment of persons with mental health problems, 2012 For information on these institutions, see Nils Muižnieks, “Report by Commissioner for Human Rights of the Council of Europe Following His Visit to Romania From 31 March to April 2014”, Council of Europe CommDH(2014)14, July 201,4 and Institute for Public Policy (IPP) Bucharest, Monitoring report on Romania’s readiness to enforce the UN Convention on the Rights of Persons with Disabilities Third edition: Article 9, Article 13, Article 19, Article 24, Article 27, 2013 11 Data on the specific causes for entry into these institutions is not available, but the report by the commissioner cited above notes that “most” people living in this system were described by the government as having “intellectual and psychosocial disabilities.” The two-thirds figure is used to illustrate the implications for Romania’s formal level of institutionalisation that inclusion of the uncertain, but large, number of people living with mental illnesses would have © The Economist Intelligence Unit Limited 2014 Mental health and integration Provision for supporting people with mental illness: A comparison of 30 European countries Worse still, those living in rehabilitation centres—known as “social cases”—receive no appropriate medical therapy at all says Dr Paziuc The data certainly show that, despite the names of these institutions, little rehabilitation takes place Of those leaving specific centres, two-thirds so as a result of dying, and another 15% are transferred to similar institutions within the same system Only 14% are reintegrated with their families.12 Ms Zlati recalls talking to someone committed to such an institution “She says that she feels like she is waiting in the antechamber of death It is quite grim They provide a bed and three hot meals a day and that is pretty much it—the very basics—and even that is not of a high standard.” Non-medical services are absent Along with the poor level of medical care for people living with mental illness in Romania, the Index found other services severely wanting Its data show that programmes to help such individuals find and retain employment are nearly completely absent, with the country being one of only four to score no points for indicators covering both back-to-work and workplacement schemes According to Mr Bandol, “There are a few initiatives by two or three NGOs, but they are like a drop in the ocean There are no government programmes.” Nor are even these efforts effective, adds Dr Paziuc: “nobody is returning to real employment.” Romania’s Law on the Protection and Promotion of the Rights of Disabled Persons requires organisations with more than 50 employees to have a workforce that includes at least 4% disabled people—a group that includes those with mental illness Ms Zlati describes this as “the only step that has been made across the country in terms of social inclusion” However, she adds, “it does not really work” A survey of companies found that about one-half prefer to pay a fine instead of hiring disabled people, most of the rest hire well below the quota (the average is 1% of the workforce), and 7% simply ignore the law completely.13 This is consistent with the deep reluctance among employers to hire people with mental health problems Dr Paziuc recalls speaking to a group of small-business owners to encourage them to employ staff with mental health issues only to be told “Look, we have a lot of unemployed people [to choose from], so we prefer to employ people who not have any mental disability” At the same time, those with mental illness are reluctant to search or apply for employment because there is a complete absence of support to help them keep their jobs, should they secure employment, and working could lead to the loss of their disability benefits, notes Ms Zlati A lack of success stories increases attitudes of dependency and fear of taking risks adds Dr Paziuc, “We tried to organise a social enterprise, but people prefer to receive money from state.” Other social provision is rare or non-existent The European commissioner for human rights reported that at end-2013 only 1,669 disabled people—including the mentally disabled as well as those living with serious mental illness—were receiving long-term non-residential community care.14 This is roughly one-tenth the number of psychiatric hospital beds Also, for all disabilities, only around 100 small protected housing units existed.15 As Mr Bandol points out, however, those for individuals living with mental illness are only provided by NGOs, which rely on EU rather than Romanian government funding According to Mr Bandol: “There is not one statefunded house for persons with mental health problems” Furthermore, what little care is available is far from easy for those living with mental illness to access Ms Zlati explains that “medical and social services are not integrated at all” 12 Institute for Public Policy (IPP) Bucharest, Monitoring report on Romania’s readiness to enforce the UN Convention on the Rights of Persons with Disabilities Third edition: Article 9, Article 13, Article 19, Article 24, Article 27, 2013 Nils Muižnieks, “Report by Commissioner for Human Rights of the Council of Europe Following His Visit to Romania From 31 March to April 2014”, Council of Europe CommDH(2014)14, July 2014 13 Veronica Junjan et al, “Labor Integration of Persons with Disabilities in Public Institutions in Romania”, Transylvanian Review of Administrative Sciences, 2011 15 Institute for Public Policy (IPP) Bucharest, Monitoring report on Romania’s readiness to enforce the UN Convention on the Rights of Persons with Disabilities Third edition: Article 9, Article 13, Article 19, Article 24, Article 27, 2013 14 © The Economist Intelligence Unit Limited 2014 Mental health and integration Provision for supporting people with mental illness: A comparison of 30 European countries She cites as an example Cluj-Napoca, which with a population of over 400,000 people is Romania’s second largest city The psychiatric hospital—which is better than most in the country—has just one psychologist and no social workers, while the city’s mental health centre has only one of the latter “They not have money to hire psychologists or social workers”, she explains The absence of psychologists and social workers, in turn, makes it more difficult for affected individuals to gain access to services to which they have a legal right Dr Paziuc says that by law, “those with mental illness have a right to protected housing and sheltered employment, but if you ask service users or mental health professionals, you will find it is difficult to say that the legislation has been put into practice by officials.” neither law nor policy saw any sort of implementation, despite repeated reports of human rights abuses Finally, in 2006, the European Commission in its pre-accession report on human rights flagged mental healthcare as an issue in need of reform, forcing the government to act and publish a national mental health programme.16 In 2007 Romania joined the EU, at which point progress ground to a halt Although the overall health budget rose in 2008, funding for mental health dropped from €23m to just €3m, making any real change in provision impossible.17 The poor level of health and social-service provision for those living with mental illness, along with the ongoing lack of progress in these areas, reflects not just a dearth of resources, says Mr Bandol: “Resources can be redirected The major weakness is a lack of political will due to a misunderstanding, or failure to realise the gravity, of the problem.” Even apparent progress on non-budgetary matters lacks substance Mr Bandol notes that his service-user organisation worked with the government on drafting important amendments to the 2002 mental health act, which, among other things, increased the rights of those subject to involuntary treatment and imposed stricter limits on the use of forcible restraint Although the resultant law was passed in 2012, it remains inoperative, just as the original act did between 2002 and 2006, because the government has not published the associated rules required for implementation—a necessity under Romanian law “So”, says Mr Bandol, “the law does not apply, but if somebody from outside Romania asks, the authorities can say that we have a good mental health act.” This is a longstanding issue, with the total lack of activity on the policy front only intermittently punctuated by international pressure In the years after the Romanian revolution, mental health issues received little attention A draft mental health law existed in 1996, but it was not ratified by parliament until 2002 Similarly, a draft national mental health policy was promulgated in 1998, but was not adopted until 2004 In both cases, eventual movement was the result of pressure by the EU during the accession process Nevertheless, An even bigger problem, explains Ms Zlati, is “that enforcement of legislation is even poorer than the legislation itself It does not necessarily translate into daily practice.” This is true of Romanian mental healthcare policy as well Although it officially favours community-based, integrated care with a focus on recovery, greater use of mental health centres, and even the creation of mobile treatment teams, little or no shift has occurred away from under-resourced, institutional, biomedical provision Mr Bandol notes, “the authorities have Politicians have little interest in the limited care available 16 Programul National de Sanatate Mintala, 2007, http://www.ms.ro/ documente/7_51_328_b.htm 17 Emilia Chiscop, “Ce se ascunde in spatele unor orori”, Ziarul de iasi, December 15th 2008, (translation at http://www.cartercenter.org/health/ mental_health/archive/documents/romanian_system_chiscop.html) © The Economist Intelligence Unit Limited 2014 Mental health and integration Provision for supporting people with mental illness: A comparison of 30 European countries stopped the programme of reform; it exists only on paper” Dr Paziuc adds that “when we joined the EU we signed a lot of papers but nobody is putting them into practice We have some good legislation, but it is all theoretical and does nothing in real life for people with mental illness.” Part of the problem is administrative: there have been nine different ministers of health in the last decade, one of whom, Eugen Nicolaescu, served for two periods, several years apart “We have to have clear and consistent policy in mental health”, complains Dr Paziuc, “rather than each new government changing the strategy” The bigger problem, though, is a lack of interest in official circles Ms Zlati says that “in order to move forwards, policy makers need to recognise the role that mental health plays in the overall scheme of things, but the concept of ‘no health without mental health’ is not acknowledged here” Mr Bandol agrees He recalls once asking a senior official why mental health was “always the Cinderella of funding The man replied, ‘Have you ever met a minister of health who is a psychiatrist? Until that happens, you will not have proper funding.’” Popular opinion, meanwhile, is unlikely to drive politicians to change Among the general public, “stigma and discrimination is quite high and dominates every part of life of people living with mental illness,” says Ms Zlati These feelings are sufficiently strong and widespread to make people reluctant to seek treatment, or even for carers and families to form associations The media is also generally hostile, in most cases portraying those with mental illness as dangerous.18 This in particular, believes Mr Bandol, has further decreased sympathy for those with these conditions in rural areas “People [there] were very tolerant before They saw them as the ‘village madman’ and helped them with food and work Now even that perception has changed because of the tabloid press.” Lighting candles in the darkness The results of poor access, high levels of stigma, and lack of focus are predictable Not only does Romania have a substantial treatment gap for mental illness, the median time between onset and first contact with the medical system for most such conditions is measured in decades rather than years.19 There are, though, a very few bright spots amidst the gloom, provided by a number of NGOs, which struggle to provide a variety of medical, social and housing services for people living with mental illness Even within the healthcare system, committed and innovative individuals can accomplish a surprising amount, although sometimes using unorthodox methods Dr Paziuc works in the small city of Câmpulung Moldovenesc in northern Romania He was originally in charge of the psychiatric ward of the local hospital, but struggled to deal with the poor conditions and the few resources available He therefore obtained permission in 1999 to take the inpatient service out of its existing quarters and move it to a newly created, stand-alone psychiatric hospital with independent management Rather than a step towards further institutionalisation, this became a platform for transformation The new 80-bed hospital was able to hire two psychologists, two social workers, and two occupational therapists, and replace a large number of underqualified staff It has since created a day hospital and a mobile team that provides home care to accompany its inpatient provision One of Dr Paziuc’s most unusual steps was to establish a chapel and hire a priest as a social worker The latter engages in community relations and works with service users—in an NGO called Horizons—on a magazine, which they produce and publish as part of their therapy; this gives the patients a voice and enables them to learn about rehabilitation and their rights The priest also conducts religious services 18 Alina Beldie et al, “Fighting stigma of mental illness in midsize European countries”, Social Psychiatry and Psychiatric Epidemiology, 2012 19 Silvia Florescu, “The Romanian Mental Health Study: Main aspects of lifetime prevalence and service use of DSM-IV disorders”, Management in Health, 2009 © The Economist Intelligence Unit Limited 2014 Mental health and integration Provision for supporting people with mental illness: A comparison of 30 European countries which—especially on important religious holidays—might include not just those who use the hospital, but other members of the community This, notes Dr Paziuc, helps service users feel more connected to the rest of society and less stigmatised These efforts, amongst others, point to how progress could occur, but they are far too little properly to address the serious failings in mental health provision Ultimately, for progress to take place, the Romanian government will have to shoulder the burden of providing appropriate medical care and services for people living with mental illness in the country © The Economist Intelligence Unit Limited 2014 Mental health and integration Provision for supporting people with mental illness: A comparison of 30 European countries About the research This study, one of a dozen country-specific articles on the degree of integration of those with mental illness into society and mainstream medical care, draws on The Economist Intelligence Unit’s Mental Health Integration Index, which compares policies and conditions in 30 European states Further insights are provided by three interviews—with Stefan Bandol, president and founder of Aripi, a Bucharest-based psychiatric service users organisation; Dr Alexandru Paziuc, a practising psychiatrist and president of the Romanian Social Psychiatry Association; and Alina Zlati, director of Open Minds: Centre for Mental Health Research, a research institute in Cluj-Napoca—along with extensive desk research The work was sponsored by Janssen The research and conclusions are entirely the responsibility of The Economist Intelligence Unit © The Economist Intelligence Unit Limited 2014 ... Psychiatric Care in Romania Need for Change or Change of Needs?” Transylvanian Review of Administrative Sciences, 2009 For bed numbers see Adriana Mihai and Ileana Botezat-Antonesc, Romania , in Chiara... the European Agency for Fundamental Rights, “being detained in a hospital and thinking that you can benefit from legal assistance is absolutely utopian”.9 Indeed, Romania s psychiatric institutions... for Developing and Implementing an Optimal Care Model Based on An Integrated Mental Health Services in a Romanian Psychiatric Medical Ward”, Management in Health, 2012 © The Economist Intelligence