ECAP Journal, February 2013

Child and adolescent psychiatry in Greece during the crisis: a brief report

Article from the ECAP Journal, Eur Child Adolesc Psychiatry (2013) 22:131–134 DOI 10.1007/s00787-013-0377-y. Presented here with the kind permission of the publisher.

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Dear readers,
Growing international evidence shows that mental disorders and poverty interact in a negative cycle. Below you will find a report from our Greek colleagues on the fundamental impact of the financial crisis on mental health and child and adolescent psychiatry.
Beate Herpertz-Dahlmann, ESCAP Communications Editor.

The state of child and adolescent psychiatry in Greece 
during the international financial crisis: a brief report

Dimitris C. Anagnostopoulos, Eugenia Soumaki

It is a known fact that economic crises have a negative impact on mental health [16 , 19 ]. Since 2009, Greece has been consumed by a socio-economic and cultural crisis due to the international financial crisis. During that time, the national income has decreased by 25 %, and unemployment has tripled, reaching 25 %. Furthermore, among those 24 years old or younger, the unemployment rate is now at 54 %. For the first time, flexible employment dominates the job market, while public sector hiring has practically stopped. Wages and pensions have decreased by up to 40 %, social benefits have decreased, and 30 % of citizens live in poverty. At the same time, due to reserve ‘‘haircuts’’, insurance funds are unable to cover the current medical expenses of insured people. Furthermore, state funding for mental health decreased by 55 % in 2012 compared to 2011, and this funding was also reduced by 20 % in 2011 compared to 2010. No increases are expected for 2013 and 2014.
Factors such as job insecurity, unemployment, increasing social inequalities, poverty, social exclusion (especially for vulnerable groups in society), the inability to control one’s own life, and uncertainty about the future have led the majority of Greeks, both at a personal and a social level, into situations causing deep psychological pain and distress [12 , 18 ]. 

The impact on mental health
In a nationwide, cross-sectional study, Economou et al. [5 ] reported that in 2011, the 1-month prevalence rate of major depression was found to be 8.2 %, which was up from 3.3 % in 2008. A significant increase in prevalence rates was also observed in the youth (\ 24 years) population subgroup. A recent Panhellenic survey found that there was a 36 % increase in the number of individuals who reported that they had attempted suicide in the month prior to the survey from 24 (1.1 %) in 2009 to 34 (1.5 %) in 2011. The survey also found that a significantly higher proportion of respondents who had high economic distress, had attempted suicide and shown suicidal ideation in the month prior to the survey [6 ]. These findings are in accord with those of Stuckler et al. [15 ], who reported a 17 % increase in suicides in Greece, suggesting that the way in which economic distress is experienced by the population might be revealed through increased suicidality. The Ministry of Public Order and Civil Protection reported that 3,124 new cases of serious suicide attempts and suicides were recorded by the police between 2009 and August 2012 [11 ]. Eur Child Adolesc Psychiatry (2013) 22:131–134 DOI 10.1007/s00787-013-0377-y Giotakos et al. [9 ] investigated the possible impact of the current economic crisis on mental health in Greece, exploring the association between two economic indicators (unemployment and average income) and mental health variables (psychiatric clinic admittance, visits to outpatient departments and emergency units, suicides, homicides, mortality rates, and divorces). A significant correlation was identified between unemployment and visits to outpatient departments (R2 = 0.40, p = 0.001) and emergency units (R2 = 0.49, p = 0.0002). In addition, the unemployment rate during the period of 1981–2008 was positively associated with the number of homicides (R2 = 0.16, b = 0.000049, p = 0.03) and the number of divorces (R2 = 0.20, b = 0.005, p = 0.02) during the same period. The average income showed a positive association with visits to both outpatient departments (R2 = 0.55, p\ 0.001) and emergency units (R2 = 0.37, p = 0.004). According to a statement made by the Ministry of Health Directorate for Mental Health, patient visits to emergency units, outpatient departments, and mental health clinics in the National Health Care general hospitals have increased by 120 % in the last 3 years [10 ]. More specifically, in terms of the mental health of children and adolescents, negative consequences can be seen both in the child psychiatric services provision system and the broader environment in which the children and adolescents are raised (family, school, social models and values) [1 , 13 ]. In terms of the provision of child and adolescent mental health services (CAMHS), the ex-post evaluation of the National Action Plan Psychargos, which covered the period of 2000–2009, showed that the development of psychiatric services for children has followed a different course compared to that for adults, as only 30 % of the planned services have actually been created. Furthermore, the distribution of child psychiatric services has been uneven, as there tend to be more in the Attica Prefecture (to which the city of Athens belongs). In some prefectures, there are no child psychiatric services [17 ]. Because of the financial crisis, the plan to develop child psychiatric services, which has been in place within the framework of the psychiatric reformation since 2000, has been effectively cancelled. Furthermore, a large number of community centres, psychosocial rehabilitation units, and highly specialised establishments have suspended their operation. The impact was particularly severe for units dealing with special categories of disorders, such as pervasive developmental disorders and learning disabilities. Typical examples of the situation include the following: (a) in the city of Piraeus, all community CAMHS (n = 6) have suspended their activity; (b) the Hellenic Centre for Mental Health and Research (1956), which is the largest and most comprehensive outpatient institution and the first community psychiatric service for children and adolescents in Greece, was forced to merge its services in Attica (as has been seen with the Autistic Children Unit and the Special Education Service for Mentally Disabled Adolescents), to cancel einstitutionalisation programmes, and to shut down accommodation units for deinstitutionalised patients, while it is also planning to suspend branch operations outside Attica; (c) the Sikiarideio Foundation (1941), which is the oldest institution for mentally disabled children, has suspended all services; and (d) the Perivolaki (1983), a leading institution for autistic child-care, has shut down two of its three community units, including day-care centres, short-term accommodations for children, and diagnosis and support units. The existing National Healthcare System CAMHS, which forms the core of the service provision system, now operates with 10–40 % fewer employees, who are not paid regularly and whose salaries have been cut by 40 %. A large portion of the more experienced personnel has been forced into retirement. At the same time, the number of new cases has increased, and the demand for supportive work within the community (due to the collapse of social services) and schools (due to insufficient psychological services) has also increased. The fact is that child psychiatric services are now called upon to substitute and assume the work of others. Furthermore, an increasing number of patients is leaving the private sector to seek care within the public system. A recent survey in a representative sample of both public and private child psychiatric institutions in Athens, Piraeus, and Thessaloniki compared data from 2007 and 2011 (two years before and two years after the implementation of austerity measures). Findings revealed a 39.8 % increase in new cases in public outpatient services for children and 25.5 % for adolescents, while percentages have dropped by a total of 35.4 % in the private sector between the years 2007 and 2011 [2 ]. As a result, both the waiting list and waiting time are now longer. In most CAMHS, the waiting time for ordinary cases has tripled and is now longer than a month, while in special cases, it can be up to 1 year. Thus, negative factors for the quality of services provided continue to accumulate [4 ]. The situation is further aggravated by the impact of the crisis on families. Changes in socio-economic conditions, the disintegration of institutions, continuous frustration, the lack of boundaries, the confusion of roles, serious conflicts, and discord in family life undermine the enabling/supportive role of the family framework [1 , 13 ]. Equally severe is the impact of the crisis on schools, which are being constantly undermined and devalued, both at a material level, with the lack of necessary funding and its consequences on school operation, and through the vicious disparagement of educators. 132 Eur Child Adolesc Psychiatry (2013) 22:131–134 The combination of all of these factors has led not only to the multiplication of new cases, which therefore leads to a rise in demand for child psychiatric services, but also to a qualitative change in the severity of psychopathology dealt with in everyday clinical practice. Findings from the survey [2 ] mentioned above showed that cases of psycho-social problems have risen by 40 %, cases of conduct  disorders have risen by 28 %, cases of suicide attempts have risen by 20 %, cases of school refusal have risen by 25 %, cases of bullying have risen by 22 %, cases of the use of illegal addictive substances have risen by 19 %, and cases of family discord have risen by 51 % (due to parental unemployment, serious financial problems, and exorbitant debts). Data from adolescent inpatient units showed an admission increase of up to 84 %, with diagnoses on admission of borderline conditions, severe behavioural disorders, acute psychotic crises, self-harm behaviours, and other similar conditions constituting 78 % of the total cases in 2011, compared to only 48 % in 2007 [2 ]. Borderline states are now more common, and generalised substance abuse has spread throughout the majority of schools, along with bullying and racist behaviours. Acting out behaviour is commonly the main mechanism for the expression of adolescent psychopathology, both at an individual and a social level. Finally, what is most disconcerting is the acceptance of raw violence against the ‘‘other’’ (for example, the immigrant, the mentally vulnerable, and the disabled) by a clearly defined, albeit still limited, portion of adolescents and youth [1]. Faced with this situation, the community of child psychiatrists has intensified its efforts to support public services by offering additional services, developing common actions with other health workers, consolidating its alliances with other social parties (the Church, insurance organisations, patient associations, etc.), enhancing its advocacy role so that decision makers might change health policies, and using its scientific tools to promote further research and substantiate data on the current state of child mental health.

We strongly believe that the imminent backtracking of child and adolescent mental health in our country must be dealt with by the Greek society itself, both in regards to its general causes and its domestic particularities. However, we also agree with the WHO/Europe and EU experts who have underlined the danger of the decline and backtracking of the European mental health state because of the austerity measures implemented due to the financial crisis [7 , 8 , 14 , 19 ]. In this situation, the advocacy role of academic and professional organisations of child and adolescent psychiatrists, at both a national and a European level, is crucial to maintain the good practice of child psychiatry for the benefit of children and their families [3 ].  

Dimitris C. Anagnostopoulos MD
Associate Professor of Child and Adolescent Psychiatry, 1st Psychiatric Department, Medical School, National and Kapodistrian University of Athens, Greece. 

Eugenia Soumaki MD
Child Psychiatrist, Academic Director, Children’s Mental Health Foundation ‘‘Spyros Doxiadis’’, Athens, Greece.


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134 Eur Child Adolesc Psychiatry (2013) 22:131–134