Gábor Kapócs1,2, *Pèter Balázs3
The Health Policy in Child and Adolescent Psychiatry in Hungary – a review of recent developments
1Department of Psychiatry and Psychiatric Rehabilitation, St. John’s Hospital, Budapest, Hungary
Head of Department: Professor Tamás Kurimay, MD, PhD
2Institute of Behavioral Sciences, Semmelweis University, Budapest, Hungary
Head of Department: Prof. József Kovács, MD, PhD
3Institute of Public Health, Semmelweis University, Budapest, Hungary
Head of Department: Prof. Károly Cseh, MD, PhD
Mental health problems affect 10–20% of the pediatric population worldwide, with the same prevalence in both the high-income countries (HICs) and low-and-middle-income countries (LMICs). Hungary has a relatively high prevalence of psychiatric disorders in children aged 4-17 (15.8%). Psychiatric problems in children are an important public health issue in all countries, as the early diagnosis is important not only for the current well-being of the child, but also for their social and economic development throughout their entire lifetime. This paper reviews the relevant health policy acts of the Hungarian government that have been released during the previous 15 years. All governmental programs followed the current WHO (World Health Organization) and European Union guidelines, indicating the growing influence of the international organizations on the domestic health policy. What is interesting, earlier programs concentrated on local governments and actions, and more recent documents underline the responsibility and role of the state and central government. When analyzing the health policy documents concerning child and adolescent mental health services, a gap between the growing scientific knowledge and its implementation can be seen. The situation of the Hungarian psychiatry has been worsening from 2006 in terms of the capacity of both the in- and outpatient care. Hungary has yet to fulfill the aims of already existing programs in the day-to-day clinical practice.
For the last ten years, multiple policy documents have been issued in Hungary and High Income Countries (HICs), which indicated the rising awareness of the public, international organizations, governments, professional environments and civil organization on the subject of mental health and psychiatric care of children and adolescents.
The proportion of children (0-14 years) in world’s general population has been decreasing from 1966 (38%) and reached 26.11% in 2015 (1, 2). In Hungary, children represented 25% of the population in 1960 and 15% in 2015 (1, 2). Nearly one third (2.2 billion) of the global population are children and adolescents, but 90% of them live in the low- and middle-income countries (LMICs) (3).
Mental health problems affect 10-20% of children and adolescents in the world. A systematic review of studies conducted in LMICs confirmed that the prevalence of mental health disorders in LMICs is equal to the prevalence in HICs (4). Reliability of the epidemiological data is of primary importance, as on their basis, policies and decisions concerning allocating resources are made. However, there is concern that mental disorders might be overdiagnosed in developed countries, resulting in misleading epidemiological data (5). Estimating the real prevalence of mental disorders in pediatric population is particularly challenging because of the different data sources and surveillance methods of pediatric mental disorders. Additionally, cultural differences could have broad implications on the estimates (6). Neuropsychiatric disorders are the leading cause of health-related disability during the first three decades of life, accounting for 15–30% of the loss of disability-adjusted life-years (DALYs) (7). Recent data suggest that currently used approaches underestimate the burden of mental illness by more than a third. Thus, mental illness could be responsible for 32.4% of years lived with disability (YLDs) and 13.0% of disability-adjusted life-years (DALYs) globally (8). According to the Global Burden of Disease Study 2010, mental disorders and substance abuse disorders are among the leading causes of morbidity, being responsible for 7.4% of DALYs and 22.9% of YLDs worldwide, making them the fifth leading cause of DALYs and the leading cause of YLDs (9).
The Atlas Project of the World Health Organization (WHO) on child and adolescent mental health revealed the real global burden of this medical problem. Around 20% of children and adolescents suffer from mental illnesses that end up in disability. Additionally, 50% of all adult mental disorders may be traced back to the adolescence. There were several shortages identified in services concerning pediatric mental health, especially in LMICs, including lacking human resources, services, training, as well as inadequate health economy and policy (10).
The failure to address mental health problems of children and adolescents in most of the countries is an important public health issue. As a substantial part of adults’ mental health conditions has its onset in the early years of life (11), and the early diagnosis is important not only for the current well-being of the child, but also for their social and economic development throughout their entire lifetime (12). Risk factors for mental conditions can present as early as in the preconceptional period, and they include family history, unplanned pregnancy, maternal prenatal and perinatal physical and mental distress, and adolescent parenting (4). Risk factors that appear in the pre-school and school age include: health and nutrition problems, suboptimal psychosocial and educational environment, being orphaned and/or raised in child protection facilities, bullying, perceived obesity, school difficulties, use of tobacco, alcohol, and drugs (4). Risk factors specific for the adult age include career difficulties, unemployment, and other socioeconomic factors (4). Systematic reviews have shown that the prevalence of mental health problems of children in LMICs resembles the prevalence in HICs (4).
Mental health problems are less visible in the society than physical illnesses due to their nature. Their prevalence, as well as their importance, is often overlooked. However, the influence of poor mental health on physical health causes significant costs to the health care. For this reason, health care providers should raise awareness on mental health issues by integrating them into social policies and health programs (13). Primary care physicians play an important role in diagnosing and initiating the treatment of mental health problems in children and adolescents, especially in rural and under-staffed areas, in which the access to psychiatrists is limited. There is need for more systemized and transparent referral process to other specialists, such as pediatricians, psychologists, and social workers (14). Moreover, all the professionals of the mental health care should also cooperate with employees of other social systems (educational, social care, and juridical systems), which should also have a role in promoting mental health (15).
To establish new programs and develop already existing child and adolescent mental health services, it is essential to understand the decision-making procedures of central governments and the intersectoral competition for financial resources (16). Therefore, there is need to formulate adequate economic arguments to draw the attention of policy makers that can influence resource allocation (16). Studies in HICs have clearly indicated the wide range of long-term consequences of childhood mental health problems, not only concerning the education process (17), but also adult health and labor market conditions (18). Strong economic arguments support the early investment in the mental health of disadvantaged children, for early prevention is often more cost-effective than later remediation (19). Early investments have higher return than those made at a later age (20).
At the beginning of the 2000s, the Atlas of Child and Adolescent Mental Health Resources suggested that governmental child and adolescent mental health policies are rather rare worldwide (21). The United Nations (UN) resolution on a World Fit for Children states that “every child has the right to develop his or her potential to the maximum extent possible to become physically healthy, mentally alert, socially competent, emotionally sound and ready to learn” (1). Unfortunately, this declaration was not followed by the development of specific policies or programs to support the development of pediatric mental health services (22).
The World Report on Violence and Health of the WHO (23) indicated that abuse and negligence in the early life lead to later mental health problems. Following this report, the UN adopted the Convention on the Rights of Persons with Disability in 2007 (24). The Convention included provisions for persons affected with mental illnesses and intended to influence the country-level advocacy for the development of mental health services for children, as well and for the humane treatment of those with mental health problems – including children and adolescents (24).
Although political will is indispensable for the establishment of child and adolescent mental health policies, the education of the public about the need of such services is also vital (25). Reputable international and professional organizations (The World Psychiatric Association Presidential Program on Child Mental Health – a collaboration between the World Psychiatric Association, WHO, and the International Association for Child and Adolescent Psychiatry and Allied Professions) developed an instrument to support the promotion of child and adolescent mental health to develop advocacy programs which could influence the special policies (26).
In spite of growing evidence of the importance of mental health, major international nongovernmental organizations (NGOs) and agencies (except the WHO) seem to pay little attention to the child and adolescent mental health care. The lack of specific interventions may result in long-term negative effects on educational attainment, chronic disability and lost productivity. The policy development depends not only on the mobilization of financial resources, but also on the mobilization of potential stakeholders (27).
In the USA, the child and adolescent mental health services have been significantly developing in the last decades, but in spite of this, only 20% of children and adolescents in need of psychiatric treatment received help, leaving 80% of children and adolescents with psychiatric illnesses untreated (28). It has been pointed out that in the future, more emphasis in the child and adolescent psychiatry should be put on providing services for a larger amount of patients for less money. As the authors of the study formulate it, “patients should flow seamlessly from the community into child and adolescent psychiatric services and back, and from one program to another, with evidence of constant care coordination and an emphasis on quality. Available resources should follow patient demand so that we can be responsive to populations and to immediate clinical need” (28).
Clinical Centers of Excellence support evidence-based care at the national level. They promote mental health and help establish national health policies to raise public awareness and foster public advocacy related to the mental health of children, adolescents and their families (29).
Material and Methods
In order to compare the health policy acts of the Hungarian government with the worldwide trends in child and adolescent psychiatry, we analyzed the governments’ programs. We analyzed four basic programs of successive Hungarian governments:
1. National Program of the Decade of Health (30),
2. Our Children Our Treasures – National Infant and Child Health Program (31),
3. Semmelweis’ Plan for Saving the Health System – Revitalization and Treatment (32),
4. Healthy Hungary 2014-2020 (33).
National Program of the Decade of Health (30)
The program was adopted in 2003 by the new Parliament after the general elections in 2002. It was an improved and updated version of the former Public Health Program of the previous government. The new program emphasized the very poor health status of the Hungarian population, reflected by morbidity and mortality statistics. The description of the program focused on historic facts of the two decades after the fall of the Communism (1989-1990), describing the widening economic gulf of social classes and the wave of unemployment, with male citizens particularly affected. In order to solve these social problems, the government decided to start a general socio-economic program that was supported by all the non-governmental organizations of the Hungarian society. The program also targeted the mental and physical health of children and adolescents, emphasizing the role of the prevention of avoidable mortality and morbidity. Pre-school and elementary school children were concerned a primary target group of health education and promotion programs.
The prevention of mental health diseases was discussed in a separate chapter. It was aimed to improve the mental health status of the general population by improving the quality of life and health awareness. Limited clinical data available indicated the gravity of the situation. Suicidality was the main concern, as with the suicide rate of 45.9/100,000 before 1994, Hungary had the highest suicide rate in the world. Although the rate has been decreased by one third by 2002, the program also indicated that the consumption of alcohol and illegal drugs is causing suicides to be the main cause of death in the 16-24 year-olds.
Based on these facts, seven key objectives were set for the following 10 years: 1) the reduction of general prejudices and misconceptions related to mental illnesses and mental health disorders; 2) primary prevention of mental disorders by health education and promotion; 3) early detection and treatment of psychiatric disorders by sensitizing primary health care providers; 4) development of mental health programs and improving structures and functions of the psychiatric inpatient care; 5) reduction of the suicide rate of children and adolescents by at least 20%; 6) reduction of the general suicide rate to the 20/100,00; 7) increasing the number of registered depression patients by at least 30%.
In order to achieve these goals, the following actions were suggested: 1) primary prevention programs targeting mainly family and school environment; 2) review of structure and function of mental health facilities; 3) the introduction of the recommendations of the community psychiatry model to the inpatient facilities; 4) decentralization of outpatient psychiatric care with the help of financial incentives for local governments and facilities; 5) increasing the number of health professionals by the training of community psychiatric nurses, social workers and rehabilitation experts; 6) supporting local governments participating in pilot projects; 7) developing new outpatient psychiatric units; 8) increasing the number of children and adolescent outpatient care units in close collaboration with children’s right societies.
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