The Czech Republic is experimenting with neighborhood centers where those in recovery after a major psychiatric episode can start rebuilding their lives.
About 1,500 people take their own lives every year in the Czech Republic. Although, like elsewhere in Europe, the suicide rate has been falling for several years, it is concerning that men make up an increasing proportion of suicides – Czech men are four times more likely to commit suicide than women. In a four-part series called “You Are Not Alone,” the Czech news site Aktualne.cz asks why men are so much more likely to kill themselves and asks what can be done to reverse this worrisome trend. Part three of the series describes a new approach to treating patients at high risk of suicide, based on targeted care offered through local mental health centers.
He tried to poison himself with a handful of pills, but they reached him in time, pumped his stomach, and took him to Prague’s largest psychiatric hospital, Bohnice. After a few weeks, Vladimir went back out into the world to face the task of dealing with his problems on his own. The doctors had helped him over the worst of it, now the rest was up to him. Severe depression, with no apparent physical cause, made things even more difficult as he tried to come to terms with divorce and his son’s serious illness.
Once a month, Vladimir attended an outpatient psychiatric clinic, often waiting an hour only to spend just 20 minutes with his doctor. Together they tried to find the right combination of drugs to bring his illness under control – unsuccessfully. Vladimir’s condition deteriorated so badly that he went back to Bohnice. “I felt like I couldn’t go on living,” the 60-year-old says. His name has been changed to respect his request for anonymity.
“However you look at it, a psychiatric hospital is still a hospital, and you know it,” Vladimir says. But there seemed to be no other option, until a psychiatrist suggested a different approach. Instead of periodic checks in the outpatient clinic, he started visiting the new Mental Health Center, a place he could go any time, know that he was not alone with his illness and that if things got bad again there were options other than returning to Bohnice.
In his situation, with a serious illness and a history of prior hospitalizations and a suicide attempt, Vladimir fell into the highest-risk category for potential suicide. Specialists say the worst period is often just after a patient is released from an institution, when they return home only to run head-on into the issues that sent them there in the first place. Yet help is available for people going through these critical days and weeks.
Who’s at risk? Specialists say men with depressive disorders and a prior history of hospitalization and suicide attempts make up the group at highest risk for suicide. About 6 percent of the Czech population suffers from depression. Not all of them have suicidal thoughts, but statistics indicate that a very high proportion of suicides have battled depression.
“We can help some psychiatric patients with targeted prevention,” says researcher Petr Winkler of the National Institute of Mental Health. He is part of a team working on a national suicide prevention strategy set to be unveiled by the end of the year. Parts of the program are already being rolled out, including the mental health centers tasked with stabilizing clients like Vladimir who pose a high risk of suicide.
The centers form part of the evolving reform of mental health care in the Czech Republic. New methods will bring changes to the lives of those with psychiatric illness and those recently released from care. “We don’t talk about mental health much, and when a problem occurs, they take you to an institution,” says psychiatrist Miroslav Pastucha. “But the place could be 100 kilometers (62 miles) away and the journey can be traumatic.” Pastucha helped set up the first center in Bohnice and now is on the staff at the second, in the Prague district of Prosek.
In these centers, staff have the time to work with patients, time that can stave off another hospitalization. For Vladimir, the center changed the course of his life. At the center he is treated for depression but also for its consequences. “They don’t just prescribe drugs, they are also helping me return to things I used to do, but lost interest in because of the depression,” he says. He’s begun visiting galleries and has taken up his painting hobby again.
Client care teams at the centers consist of a psychiatrist, nurses, and social workers. This range of skills translates into a variety of treatment approaches. The goal is for people with serious mental disorders to be able to live as normal a life as possible. “You might say that if we take good care of them, we reduce the risk of suicide,” Pastucha comments.
Pastucha heads a team of 10 specialists at the Prosek center. Their approach to clients differs from the usual procedure in psychiatric clinics, where doctors can devote less than a half hour to each patient during monthly or bimonthly checkups.
“When someone has severe depression, often they just lie in bed and aren’t able to leave home,” says Pastucha. “They don’t even appear for their checkup. At the center, we provide what is known as assertive care – we organize activities and don’t leave everything to the patient.” If a client misses an appointment, center staff try to locate her or him on the phone or even go to the client’s house.
All team members are involved in client care. Not every client always needs to see the psychiatrist, and the others have the skills and education to provide whatever care is needed. The team meets with Pastucha daily. The center currently has 50 clients, half its maximum capacity. Team members talk with them, try to encourage outside interests and return them to normal life – even help them find a job.
“The relationship with the client is all-important,” Pastucha says. “We work to build trust. Clients participate in treatment – along with the physician in charge, they decide what kind of treatment works best for them.” Vladimir visits the center once a month, or more often if his condition worsens. In case of need, clients can spend up to several days in the center.
Five mental health centers have opened since the program began last year. By July, the Health Ministry plans to increase the number to 20. Eventually there will be 100 centers, as one arm of the psychiatric care reform launched with the help of money from the European Union in 2013.
The centers are guaranteed funding for 18 months. “What comes after that, no one knows yet. Discussions are being held. The first center in Bohnice has been running for more than three years, but it’s losing money. Bohnice Hospital finances the center from its own budget,” Pastucha says.
Statistical gap: Records of suicide attempts stopped being compiled in the 1990s, so Czech specialists lack current data on the numbers of attempts and the population size of groups at risk. Suicide attempts are not even recorded in patients’ medical charts.
The Swedish System
The centers provide so-called secondary care. Their mission is to assist clients who have previously been hospitalized or treated in a crisis center and gotten over the most severe phase of their illness. Secondary care is seen as crucial in helping prevent suicides among high-risk groups. Experiences from abroad are helping guide the Czech suicide-prevention strategy.
One example is Sweden. In the 1960s, Sweden recorded the highest suicide rate in Western Europe, yet now it experiences no more suicides per 100,000 people than the European average. In the mid-1990s, Swedish experts recommended measures to reduce the suicide rate but not until 2008 did the government authorize a program based on secondary care for recently released psychiatric patients.
Invisible helpers: Six years after the psychiatric care reforms began, inadequate funding means that information about new treatment methods is failing to reach those in need. The mental health centers are left to their own devices, using Facebook and other social media to spread the word.
According to Vladimir Caroli of Sweden’s National Center for Suicide Research and Prevention of Mental Ill-Health, the program owes its success to its multi-pronged approach and sufficient funds from the state. “It works in the real world, not just on paper,” he says.
After hearing out the experts, the Swedish government freed up money to establish a client-centered preventive care system. Working out of barrier-free centers so they are in close contact with clients, doctors are able to catch suicidal thoughts in time to help those in most need of intervention.
An Imperfect Safety Net
Even with the opening of new mental health centers, help is not available to all who need it. One reason is lack of public awareness of the centers. Center staff have to improvise, visiting psychiatric wards to speak with patients who could transition into outpatient care at the centers.
The centers do not automatically accept anyone with a history of suicide attempts. They target clients with serious mental illness, primarily depression and schizophrenia. Those who attempt suicide from other causes such as trauma during a difficult life episode are typically treated with psychotherapy.
Psychiatric reform: A key goal of the strategy launched in 2013, and the starting point for the network of mental health centers, is to reduce the number of people treated in psychiatric hospitals. “Psychiatry was undervalued for a long time. The priority for the Czech health system was better equipment and new technology for hospitals,” Deputy Minister of Health Roman Prymula explains.
The centers are going through teething troubles across the country. Chomutov, a city near the German border, opened its mental health center two years ago, yet the staff are still working to convince psychiatrists to steer their patients there. They post flyers in doctors’ offices and public buildings hoping to attract potential clients.
As Pastucha puts it, “We have to work on presenting and selling ourselves. We don’t have a PR department.”