Mental Health Service provision in remote areas in Greece: the experience of the Mobile Mental Health Units in Cyclades islands

1 Uni e sidade NOVA de Lisboa NOVA Medical School Faculdade de Ciências Médicas Mas e ’s Disse a ion in Men al Heal h Policy and Se ices Ti le: Men al Heal h Se ice p o ision in emo e a eas in G eece: he expe ience o he Mobile Men al Heal h Uni s in Cyclades islands S uden Name: Geo gios Chadoulis Supe iso : P o . Benede o Sa aceno Yea o Comple ion: 2016 2 ABSTRACT The aim o his s udy was o iden i y i and how he ope a ion o he men al heal h mobile uni s in he Cyclades in G eece has had an e ec on he men al heal h o he local popula ion. The Cyclades islands, al hough e y popula as a summe des ina ion globally, had an almos inexis en sys em o men al heal h se ices. Due o he comple e lack o such se ices, 2 mobile uni s we e ounded 10 yea s ago in o de o co e o his lack. We gi e a sho desc ip ion o he s uc u e and wo king mechanisms o he mobile uni s. We hen p esen he cu en si ua ion and how i has e ol ed ac oss ime. We p ocessed he da a in o a unique da abase o he use s o he Mobile Men al Heal h Uni s in a pe iod o 10 yea s. We used quan i a i e me hods and desc ip i e analysis o a se o a iables and indica o s o help us each a conclusion o how o measu e he impac o he p o ision o se ice, along wi h a sho ocus g oups discussion in ol ing he key playe s in he communi y. The sample o he p esen s udy is he clinical popula ion o 6,884 adul s, who we e e e ed o he mobile psychia ic uni s o EPAPSY in Wes and No h-Eas Cyclades be ween he yea s 2003 and 2014. The cu en s udy has ocused on he iden i ica ion o posi i e e ec s o he se ice p o ision o he uni s o he local popula ion, as well as he ba ie s and limi a ions du ing he 10 yea expe ience in he Cyclades. In addi ion, we ackled some p esen obs acles (such as he socio-economic c isis and how hese ha e a ec ed se ice p o ision and use s’ men al heal h s a us. We iden i ied he main easons behind he luc ua ion and change in he numbe o use s pe yea o e he decade, he numbe and sou ce o e e als, he ini ial eques s o he pa ien s o se ices and how hey e ol ed ac oss ime. We concluded ha he se ices o e ed by he Mobile uni s had a posi i e impac in educing he ea men gap and inc easing awa eness o men al heal h issues. We also iden i ied a ew indica o s ha could poin owa ds a educ ion o s igma in he communi ies. We sugges ed some key s eps o wa d o he imp o emen o se ices and, e en ually, hei e alua ion, in o de o examine he o e all impac on he men al heal h o he popula ion o he islands. Keywo ds: mobile uni s, se ice p o ision, communi y ne wo ks, men al heal h p omo ion 3 SINOPSIS El p opósi o de es e es udio ue iden i ica el posible e ec o que podía ene el es ablecimien o de cen os mó iles pa a el cuidado de la salud men al en los habi an es del a chipiélago de las Cícladas en G ecia. Las islas Cícladas, aunque muy popula es como des ino u ís ico a ni el mundial, poseen un sis ema de salud men al casi inexis en e. Con el p opósi o de a ende es a necesidad de la población, dos unidades mó iles ue on undadas hace diez años. En es e es udio p esen amos una desc ipción de la es uc u a y los mecanismos que han pe mi ido el uncionamien o de las unidades mó iles, así como un análisis de cómo dicho uncionamien o se ha ido desa ollando has a la ac ualidad. Como pa e de es e es udio, p ocesamos los da os ecopilados en una base de da os que con iene in o mación de los usua ios de las unidades mó iles du an e sus diez años de uso. U ilizamos mé odos cuan i a i os, desa ollamos discusiones con g upos ocales compues os po indi iduos que poseen oles impo an es den o de la población de las Islas, y p odujimos un análisis desc ip i o que nos pe mi ie on es ablece las a iables y los indicado es necesa ios pa a llega a una conclusión basada en la medición del impac o que los cen os mó iles han enido en la población. La mues a de es e es udio es á compues a po la población clínica de 6,884 adul os que ue on e e idos a las unidades de se icios psiquiá icos de EPAPSY en el oes e y no es e de las Cícladas du an e los años 2003 y 2014. Nos en ocamos en iden i ica los e ec os posi i os que el o ecimien o de se icios de salud men al median e el uso de unidades mó iles a la población local, así como las ba e as y limi aciones du an e sus diez años de uncionamien o en las Cícladas. Además, ambién analizamos algunos obs áculos igen es (ej. la c isis socio-económica y su e ec o en el o ecimien o de se icios, el es ado de salud men al de los pacien es e e idos a las unidades mó iles, e c.). Iden i icamos las azones p incipales de ás de la luc uación en el núme o de usua ios po año, luga de e e ido, y las solici udes iniciales de se icios y cómo es as cambia on du an e un pe iodo diez años. Concluimos que los se icios o ecidos po las unidades mó iles u ie on un impac o posi i o en la educción de la b echa de se icios de salud men al o ecidos en las Cicladas. Las unidades mó iles han enido un ol muy impo an e en la concienciación en emas de salud men al y en la educción de es igmas en las comunidades. Culminamos 4 es e es udio o eciendo ecomendaciones cla es pa a el mejo amien o de los se icios en las unidades mó iles, así como mé odos de e aluación pa a medi p og eso y la e iciencia de los se icios o ecidos. Palabas cla es: unidades mó iles, o ecimien o de se icios, edes comuni a ias, p omoción de salud men al. 5 RESUMO O obje i o des e es udo oi iden i ica se e como a a uação das unidades mó eis de saúde men al nas Cíclades, na G écia e e um e ei o sob e a saúde men al da população local. As ilhas Cíclades, embo a mundialmen e popula es como des ino de e ão, inham um sis ema quase inexis en e de se iços de saúde men al. De ido à al a de ais se iços, 2 unidades mó eis o am undadas há 10 anos, a im de cob i es a lacuna. O e ecemos uma b e e desc ição da es u u a e dos mecanismos de uncionamen o das unidades mó eis. Em seguida, ap esen amos a si uação a ual e sua e olução ao longo do empo. Os dados o am p ocessados em uma única base de dados dos usuá ios das Unidades Mó eis de Saúde Men al, em um pe íodo de 10 anos. Fo am u ilizados mé odos quan i a i os e análise desc i i a pa a um conjun o de a iá eis e indicado es, pa a ajuda a chega a uma conclusão sob e como medi o impac o da p es ação de se iço, bem como uma b e e discussão em g upo ocal en ol endo os p incipais a o es na comunidade. A amos a do p esen e es udo é a população de 6.884 adul os, que o am encaminhados pa a as unidades psiquiá icas mó eis de EPAPSY do Oes e e No des e de Cíclades en e os anos de 2003 e 2014. O p esen e es udo cen ou-se na iden i icação dos e ei os posi i os da p es ação de se iços das unidades pa a a população local, bem como das ba ei as e limi ações du an e a expe iência de 10 anos nas Cíclades. Adicionalmen e, abo damos alguns obs áculos a uais (como a c ise socioeconômica e de que o ma em a e ado a p es ação de se iços e o es ado de saúde men al dos usuá ios). Iden i icamos as p incipais azões pa a a a iação e a mudança no núme o de usuá ios po ano du an e a década, o núme o e on e dos encaminhamen os, os pedidos iniciais dos pacien es aos se iços e como eles e oluí am ao longo do empo. Concluiu-se que os se iços o e ecidos pelas unidades mó eis i e am impac o posi i o na edução da lacuna de a amen o e aumen o da sensibilização pa a as ques ões de saúde men al. Iden i icamos, ainda, alguns indicado es que pode iam apon a pa a a edução do es igma nas comunidades. Suge imos alguns passos undamen ais pa a a 6 melho ia dos se iços e, e en ualmen e, sua a aliação, a im de es uda o impac o ge al sob e a saúde men al da população das ilhas. Pala as-cha e: unidades mó eis, p es ação de se iços, edes comuni á ias, p omoção da saúde men al. 7 ACKNOWLEDGEMENT I would i s like o hank my hesis ad iso P o esso Benede o Sa aceno. He consis en ly allowed his pape o be my own wo k, bu s ee ed me in he igh he di ec ion whene e he hough I needed i . I am g a e ully indeb ed o him o his e y aluable commen s on his hesis I would also like o hank S ella Pan elidou, who was in ol ed in his esea ch p ojec o he passiona e pa icipa ion and suppo . I would also like o acknowledge P o esso S elios S ylianidis o he mo i a ion and ad ice he o e ed h oughou he yea . Finally, I mus exp ess my g a i ude o my colleagues a wo k, as well as my ellow s uden s a he uni e si y, who p o ided me wi h un ailing suppo and con inuous encou agemen h oughou he p ocess o w i ing his hesis. This accomplishmen would no ha e been possible wi hou hem. Thank you. 8 Con en s 1. In oduc ion G eek psychia ic e o m – Backg ound .......................................................................... p 11 Mobile uni s – basic p inciples ......................................................................................... p 13 Link wi h PHC ................................................................................................................... p 14 MU in he Cyclades ........................................................................................................... p 15 Resea ch: backg ound, pu pose and objec i es ............................................................... p 18 2. Me hodology Resea ch Sample ............................................................................................................... p 20 P ocedu es & Da a Collec ion .......................................................................................... p 20 Ins umen s & Va iables ................................................................................................... p 21 S a is ical Analyses ........................................................................................................... p 21 3 Resul s Adul s ................................................................................................................................ p 22 Child en and adolescen s .................................................................................................. p 34 4. Discussion Clinical .............................................................................................................................. p 38 In eg a ion wi h PHC ......................................................................................................... p 41 P omo ion and communi y ne wo ks ............................................................................... p 42 5. Limi a ions, conclusions and ecommenda ions ........................................................ p 45 6. Bibliog aphy & Re e ences ........................................................................................... p 47 9 Tables & Figu es Figu e 1 Numbe o pa ien s (adul s) ............................................................................... p22 Figu e 2 Numbe o pa ien s pe yea pe island Figu e 3 SEX ...................................................................................................................... p23 Figu e 4 coun y o o igin Figu e 5 ma i al s a us ...................................................................................................... p24 Figu e 6 Numbe o child en Figu e 7 employmen ........................................................................................................ p25 Figu e 8 employmen ype Figu e 9 P e ious isi o men al heal h p o essional ..................................................... p26 Figu e 10 se ious heal h p oblem Figu e 11 ch onic physical ailmen s .................................................................................. p27 Figu e 12 Psy hospi aliza ion Figu e 13 co-mo bidi y ..................................................................................................... p28 Figu e 14 Mean sco es in he Global Assessmen o Func ioning Figu e 15 Diagnos ic ca ego ies acco ding o he c i e ia o he ICD-10 Classi ica ion o Diseases, as se by he EPAPSY psychia is s ................................................................... p29 Figu e 16 ea men ecei ed Figu e 17 Numbe o pa ien s pe yea ............................................................................ p30 Figu e 18.1 ini ial eques Figu e 18.2 ini ial eques s pe yea ................................................................................. p31 16 Bo h mobile uni s ope a e wi h speci ic asks, lis ed unde nea h:  In- ime diagnosis - in e en ion o p e en he onse o disease o a emission.  Home in e en ion o deal wi h and manage c ises.  Home ea men and moni o ing o medica ion, ollow-up o he cou se o he illness a egula in e als, and o ensu e he con inui y o psychia ic ca e o he pa ien .  Help and suppo o he pa ien in mee ing his p ac ical needs wi h emphasis on eaching him skills and p epa ing him o he end goal, which is an independen li e.  Counselling – suppo o he amily o he pa ien o ensu e be e communica ion, and educe s ess o bo h he amily and he pa ien .  T aining key playe s in each se ing (doc o s, local au ho i ies, olun ee s, police o ice s, p ies s, eache s)  Comba ing social s igma h ough communi y aining p og ammes. The e a e ou majo a eas in which he mobile uni s ac : assessmen o needs, clinical p ac ice, in eg a ion wi h p ima y heal h ca e and men al heal h p omo ion. Howe e , he e a e special cha ac e is ics in he eali y o he islands. The e is a g ea con as be ween he way o li ing du ing summe and du ing he win e . As mos o he islands ha e become among he mos popula ou is a ac ion his pe iod o he las 15 yea s, hey become c owded and he local popula ion wo ks mainly in ou is ic en e p ises. In con as , du ing win e he islands gi e he image o isola ed communi ies, many people do no wo k du ing his pe iod, social e en s become less and gene ally social li e o locals is e y es ic ed. Wea he condi ions du ing win e in some cases do no pe mi a elling, gi ing he eeling o e en g ea e isola ion. This g ea change has a signi ican impac in he way o li ing, he cul u e, he pa e ns o hough and beha iou , e en in he way men al heal h demands a e o med and exp essed. Mos o he local communi ies a e in o e . Conce ning heal h and social se ices in he egion, in e e y island he e is a Heal h Cen e (excep o some e y small islands whe e he e is only a Pe iphe al medical o ice 17 wi h one o wo gene al p ac i ione s). The capi al o Cyclades is Sy os (wi h a popula ion o o e 20.000 esiden s), whe e he e is a Gene al Hospi al. In e e y island he e a e also social se ices o elde ly people, p og ammes p o iding help a home unded by Municipali ies (se e e dys unc ion du ing he las h ee yea s due o lack o unding), p og ammes conce ning he p e en ion o subs ance use (in some islands) and some se ices o people wi h special needs in Sy os and Pa os (a olun a y se ice). These se ices ha e been de eloped o e he las 10 yea s. The e a e no men al heal h se ices in he islands wi h he excep ion o a psychia is in he Gene al Hospi al o Sy os. As a esul , o many yea s a lo o people su e ing om men al diso de s did no seek o help and had o a el o A hens o ge psychia ic ca e. S igma and p ejudice owa d men al heal h issues is also a g ea ba ie o seeking help and should be in o conside a ion by a communi y men al heal h eam s a ing wo king in a egion wi h no sensi iza ion in he ield. To sum up, all o he abo e can be ansla ed, in e ms o men al heal h s a egy, as he inadequa e de elopmen o PHC sys em, he insu icien numbe o well- ained GPs in espec o he popula ion needs, he low le el o in eg a ion wi h specialis se ices, he de alua ed ole o Gene al P ac i ione in managing men al heal h p oblems and, las bu no leas , he isola ion o he a ea. As a esul , hese cha ac e is ics along wi h he amewo k o unc ion o he Mobile Uni s, dic a e he o ma ion o speci ic wo king hypo heses o clinical and communi y wo k ha need o be aken in o accoun : -wo k mus be adap ed o speci ic needs and cha ac e is ics o e e y island -socio-an h opological issues a e aken in o conside a ion in o de o o m an e hno- psychia ic app oach o he communi y: speci ic cul u al codes, a i udes owa ds “ he di e en ”, p ejudice conce ning men al heal h issues, ac o s ha ing a ole in o ming he “psychia ic demand”, he way symp oms a e exp essed di e om one communi y o ano he and should be well unde s ood and di ec wo k in he islands -wo king owa ds he in eg a ion wi h o he se ices, he mobilisa ion o local esou ces and he de elopmen o local heal h sys em a e also necessa y. In o e sion o a se ice in 18 an al eady “in o e ed’ communi y would esul in g ea e agmen a ion o ca e p o ided and would be comple ely ine ec i e in succeeding i s aims. Resea ch: Backg ound, Pu pose and Objec i es To begin wi h, i is impo an o no e ha , al hough he mobile uni s begun hei ope a ion in 2004, i was no un il 2007 ha a la ge scale epidemiological esea ch on he p e alence o common men al diso de s in gene al popula ion o Pa os and An ipa os was conduc ed. This esea ch, in collabo a ion wi h Pan eion Uni e si y o A hens and he Psychia ic Clinic o Uni e si y o Ioannina, wi h he suppo o local au ho i ies (S ylianidis e al 2010), was a s epping s one in ega d o needs assessmen o he islands o Cyclades. In o de o his esea ch o be easible, he mobile uni s had de eloped h ough an empi ical p ocess a eco d p o iding in o ma ion abou ch onic psychia ic condi ions in he communi y and he mos common p oblems in he ield o men al heal h. In o ma ion was ga he ed h ough he eco ds o P ima y Heal h Ca e and social se ices, as well as communi y wo k, such as mee ings wi h key pe sons in he communi ies i.e ep esen a i es o local au ho i ies, doc o s, p o essionals o social se ices, eache s, p ies s e c. This eco d, which was la e en iched wi h in o ma ion, has p o en o be he basic ool in iden i ying he psychia ic and social p oblems managed by heal h and social se ices, as well as un ea ed p oblems e e ed by key pe sons. The indings o he i s epidemiological esea ch, conduc ed wi h a sample o 506 pe sons andomly selec ed om he gene al popula ion, showed ha he p e alence o psychia ic mo bidi y was 22%, while he p e alence o majo dep ession was g ea e in women (4,15%) han men (0,54). Alcohol misuse was ound o be h ee imes g ea e in men (12%) han women (3%). Gene ally, women, unma ied and e i ed we e mo e likely o su e om a common psychia ic diso de . Following his i s esea ch, wo mo e su eys we e conduc ed. The i s , assessing he p e alence o common men al diso de s in 323 high-school s uden s in Pa os (aged 15-17) using CIS-R (Lewis e al 1992). Majo dep ession was ound in 1,6% o s uden s and mild dep ession was ound in 6% o s uden s (almos h ee imes g ea e in gi ls). Dep essi e symp oms we e mo e common in highe le els o school. Subs ance use (alcohol, cannabis, smoking) was highe in s uden s su e ing om dep essi e symp oms. Cannabis 19 use (once) and alcohol use (a leas once in a week) we e g ea e in boys han gi ls (12% s 4% o canabbis use and 31% s 21% o alcohol use), while smoking (a leas once a week) was highe in gi ls, 18% s 13% in boys (Skapinakis e al 2010). The second, conce ning he numbe o compulso y hospi alisa ion o psychia ic pa ien s li ing in Cyclades Islands du ing he pe iod 2000-2005. I was ound ha he e was an inc ease in he numbe o compulso y hospi alisa ions om Cyclades Islands om 2000 ill 2005. O e all, ha ing p esen ed a sho backg ound on he o ma ion and unc ion o he mobile uni s in he Cyclades, along wi h he speci ici ies ha a ise in his geog aphical a ea and he p e alence o men al diso de s in a ep esen a i e sample o he popula ion, we shall now y o ocus on examining he e olu ion and impac o he se ices du ing he en yea s o ope a ion. Ou main a ge is o examine he key a eas in which he ope a ion o he mobile uni s h oughou he en yea pe iod has had an e ec . The main a eas a ound which we shall ocus ou esea ch and analysis a e: a. Clinical wo k b. in eg a ion wi h p ima y ca e c. men al heal h p omo ion and de elopmen o communi y ne wo ks As a as clinical wo k is conce ned, we shall y o iden i y ce ain cha ac e is ics o he popula ion ea ed by he mobile uni s, which can help us d aw some conclusions upon he ea men p og ammes, he eques s and – up o he ex en o which i can be accomplished - ou comes and how hey ha e e ol ed o e ime. In addi ion, we shall y o e alua e he le el o in eg a ion ha has been achie ed wi h p ima y ca e, mainly h ough he e e al p ocess and he coope a ion be ween he uni s and he heal h cen es. Finally, we shall look a he mos impo an men al heal h p omo ion ac i i ies ha ha e aken place o e he las decade and how hese ha e con ibu ed o he u he de elopmen o he communi y ne wo ks es ablished h ough he ope a ion o he mobile uni s in he islands. 20 2. METHODOLOGY Sample The sample o he p esen s udy is he clinical popula ion o 6,884 adul s, who we e e e ed o he mobile psychia ic uni s o EPAPSY in Wes and No h-Eas Cyclades be ween he yea s 2003 and 2014. I is wo h men ioning ha almos 30% o he pe manen inhabi an s o he islands ha e been eached. A his poin we should men ion ha he mobile uni s ha e also o e ed se ices o child en and adolescen s, he clinical popula ion o which was 2,035. We shall no use his popula ion in ou main esea ch sample, al hough we eel ha i is wo h men ioning ce ain da a which can be o in e es o ou discussion. P ocedu es & Da a collec ion The da a epo ed in he p esen s udy a e de i ed om a e ospec i e s udy o he medical eco ds o all pa ien s e e ed o he mobile psychia ic uni s o EPAPSY be ween he yea s 2003 and 2014. Da a we e ob ained h ough ou majo sou ces: A. a sel - epo ed ques ionnai e adminis a ed p io o he i s session o e e y pa ien e e ed o he uni s. B. he clinical da a en e ed in he pa ien ’s medical eco d by he esponsible men al heal h p o essional assigned wi h he case a e comple ion o he psychia ic e alua ion. C. he eco ds o communi y wo k and men al heal h p omo ion ac i i ies, as well as e iew o he a icles published in he local p ess ega ding he ope a ion o he mobile uni s h oughou he Cyclades D. ocus g oup discussion wi h he key playe s in he communi y, including he head o he medical cen e, he head o p ima y and seconda y educa ion, he head o he police depa men and he head o he social se ices o he municipali y. 21 Ins umen s & Va iables The sel - epo ed ques ionnai e includes 20 i ems asking abou a numbe o socio- demog aphic and socioeconomic ac o s, as well as basic ea u es o he pas and p esen medical his o y o he pa ien . This ques ionnai e is a use ul ool in he p ocess o ga he ing in o ma ion du ing he in ake and has been o g ea assis ance o bo h adminis a i e as well as clinical wo k o he uni s. The socio-demog aphic a iables s udied we e: gende , age, coun y o o igin, amily s a us, while he socioeconomic a iables included: educa ional s a us, which was de ined as he highes educa ional le el a ained, employmen ype, employmen s a us. Basic in o ma ion ega ding he p esen and pas medical his o y includes a ious a iables such as ini ial eques , his o y o hospi aliza ion, p io con ac wi h a men al heal h p o essional, li e e en s, ch onic physical condi ions e c. The clinical da a en e ed by he clinician in he pa ien s’ medical eco ds ha in e es us in he p esen s udy include he ollowing a iables: diagnosis, gene al unc ioning and sugges ed ea men plan. The diagnosis is en e ed acco ding o he c i e ia o he ICD-10 Classi ica ion o Diseases. In he p esen s udy we a e going o in es iga e he diagnos ic ca ego ies o “Chap e V: Men al and Beha iou al diso de s (F00-99)”, as well as hose om “Chap e XXI: Fac o s in luencing heal h s a us and con ac wi h heal h se ices (Z00- 99)”. The gene al unc ioning is assessed using he Global Assessmen o Func ioning (GAF) scale and he sco e is p esen ed as a ange. S a is ical analyses Desc ip i e analyses we e un in o de o p esen ou sample and he popula ion using he mobile uni s o EPAPSY. We pe o med chi-squa e es s o all a iables o in e es . 22 3. RESULTS The sample o he p esen s udy is he clinical popula ion o 6,884 adul s, who we e e e ed o he mobile psychia ic uni s o EPAPSY in Wes and No h-Eas Cyclades be ween he yea s 2003 and 2014. The mean numbe o pa ien s se ed pe yea was 564 ( he ele an igu e anged be ween 324 in 2009 and 949 in 2013) Figu e 1. Numbe o pa ien s (adul s) Figu e 2. Numbe o pa ien s pe yea pe island 0 100 200 300 400 500 600 700 800 900 1000 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 346 633 626 535 493 472 324 507 594 466 949 821 Numbe o pa ien s (N=6884) 0 100 200 300 400 500 600 700 800 900 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Milos Kimolos Si nos Se i os Ky hnos Kea Pa os Sy os Tinos And os 23 Socio-demog aphic cha ac e is ics o he sample Figu e 3 SEX 67.1% o he indi iduals we e women, while only 7.2% o hem had an o igin o he han G eek. Figu e 4 coun y o o igin 31.4 24.5 34.0 31.9 36.4 37.2 34.7 30.1 32.2 36.7 31.7 33.8 32.9 68.6 75.5 66.0 68.2 63.6 62.8 65.3 69.9 67.8 63.3 68.3 66.3 67.1 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 Man Woman 94.3 100.0 91.7 88.6 95.6 83.8 90.3 98.2 95.7 91.6 87.4 97.5 92.8 5.7 8.3 11.4 4.4 16.2 9.7 1.8 4.3 8.4 12.6 2.5 7.2 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 G eece O he 24 The majo i y we e ma ied (56.7%), while 20.9% ha e ne e go ma ied, 10.9% we e widowed, 10% di o ced and 1.5% in a domes ic pa ne ship. Figu e 5 ma i al s a us Mos o he indi iduals (60.5%) had one o wo child en and 17.3% o hem had 3 o mo e child en. Figu e 6 Numbe o child en 18.3 3.3 21.0 27.6 11.0 14.1 23.5 23.2 18.8 20.0 23.9 12.7 20.9 58.5 71.4 59.2 50.8 61.8 67.2 54.5 55.0 56.1 59.4 54.1 67.1 56.7 8.1 4.4 7.1 8.2 7.4 8.5 10.1 13.8 8.7 8.8 12.3 8.9 10.0 13.6 20.9 11.3 12.7 19.1 8.5 10.3 5.8 15.2 11.1 7.6 11.4 10.9 1.6 0.0 1.3 0.8 0.7 1.7 1.6 2.3 1.2 0.7 2.1 0.0 1.5 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Milos Kimolos Si nos Se i os Ky hnos Kea Pa os Sy os Tinos And os Mykonos An ipa os To al Unma ied Ma ied Di o ced Widowed/W Domes ic 8.8 1.3 12.2 16.8 8.6 18.5 27.0 28.2 23.7 25.2 23.7 13.9 22.3 73.6 68.8 69.4 75.8 70.1 59.9 53.8 61.1 58.6 59.8 58.0 52.3 60.5 17.6 30.0 18.3 7.4 21.4 21.7 19.2 10.8 17.7 15.0 18.3 33.9 17.3 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Milos Kimolos Si nos Se i os Ky hnos Kea Pa os Sy os Tinos And os Mykonos An ipa os To al None 1 o 2 and mo e 25 Be ween 2003 and 2014 13.9% o he pa ien s e e ed o he mobile uni s we e unemployed, while 9.1% o hem we e on a p eca ious employmen s a us. Figu e 7 employmen Rega ding he employmen ype, 5.2% indi iduals in ou sample had a seasonal job, 5.5% wo ked on a pa - ime basis, 22.8% we e pensione s, 24.3% looked a e he household, while he majo i y (40.7%) had a ull- ime job. Figu e 8 employmen ype 85.9 82.6 83.1 85.2 81.5 81.7 78.0 72.4 73.0 70.6 72.3 72.4 77.0 1.6 5.4 5.7 6.3 8.7 7.1 9.8 14.1 8.3 10.0 11.3 13.2 9.1 12.6 12.0 11.2 8.5 9.8 11.2 12.2 13.6 18.8 19.5 16.4 14.4 13.9 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2003 2005 2007 2009 2011 2013 To al S able P eca ious Unemployed 37.3 14.5 36.4 47.5 24.8 35.4 36.8 47.2 46.8 52.0 36.4 31.6 40.7 3.9 2.4 7.6 4.2 9.6 15.2 5.6 6.6 3.6 4.7 5.9 0.0 5.5 6.2 0.0 6.1 2.5 9.6 5.1 5.0 1.9 3.9 3.5 12.2 10.5 5.2 30.2 51.8 24.8 19.5 17.6 22.2 32.6 23.2 19.2 14.0 10.5 43.4 24.3 1.4 1.2 0.5 0.0 0.8 0.6 1.9 2.4 1.2 1.4 1.6 2.6 1.6 21.0 30.1 24.8 26.3 37.6 21.5 18.1 18.8 25.4 24.5 33.5 11.8 22.8 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Milos Kimolos Si nos Se i os Ky hnos Kea Pa os Sy os Tinos And os Mykonos An ipa os To al Comple e Pa ial Seasonal Household Pupil/S u Pension 32 Table 5. Rele an F equencies o he diagnoses o he adul s se ed in he 1s decade o he NE & W Cyclades Mobile Uni s ope a ion (Ν = 5,021 & 1,863 espec i ely) Diagnosis NE Cyclades W Cyclades O ganic, including symp oma ic, men al diso de s (F00-F09) 7.8% 12% Men al and beha io al diso de s due o psychoac i e subs ance use (F10-F19) 2.4% 1,2% Schizoph enia, schizo ypal and delusional diso de (F20-F29) 6.9% 3,4% Mood (a ec i e) diso de s (F30-F39) 28.2% 27,9% Neu o ic, s ess ela ed and soma o o m diso de s (F40-F48) 18.5% 23,4% Beha io al synd omes associa ed wi h physiological dis u bance and physical ac o s (F50-F59) 0.7% 0,7% Diso de s o adul pe sonali y and beha io (F60-F69) 2.4% 4,7% Men al e a da ion (F70-F79) 1.1% 1,9% Diso de s o psychological de elopmen (F80-F89) 0.2% 0,4% Unspeci ied men al diso de (F99) 0.1% 0,1% Counseling/Medical ad ice (Ζ71) 6.6% 4% P oblems ela ed o social en i onmen and o p ima y suppo g oup (Ζ60-F63) 18.1% 13,8% No men al diso de -Ce i ica es-O he 7.1% 6,5% 33 Figu e 19 Rele an F equencies o he diagnoses o he adul s se ed du ing he 1s decade o he NE & W Cyclades Mobile Uni s ope a ion (Ν = 6,884). Table 6. Rele an F equencies o he e e al sou ces in he 1s decade o he NE & W Cyclades Mobile Uni s ope a ion Re e al sou ces NE Cyclades W Cyclades To al Sel e e al 48.9% 30.6% 44.4% P ima y Heal h Ca e 23.3% 26.6% 24.1% P i a e P ac ice Physician 5% 2.9% 4.5% Social se ice 6.8% 5.1% 6.4% Public au ho i ies 1.5% 3.8% 2.1% Chu ch 0.3% 0.3% 0.3% Educa ional ins i u es 6.1% 22.3% 6.6% O he 8.1% 8,4% 116% 0 10 20 30 40 50 60 70 2003-2006 2007-2009 34 Figu e 20. Rele an F equencies o he e e al sou ces in he 1s decade o he NE & W Cyclades Mobile Uni s ope a ion Child en And Adolescen s The ollowing 4 ables p esen he main demog aphic cha ac e is ic, eques s, e e als and diagnosis o his popula ion. As men ioned be o e, al hough no aken in o accoun in ou sample, he ecen socioeconomic c isis has been he sou ce o a ise in amily p oblems, which, una oidably, a ec child en and adolescen s. We eel i is wo h p esen ing some da a in a a ea which will be o g ea in e es in he nea u u e. Du ing he 10 yea s he mobile men al heal h uni s ha e been in ope a ion hey se ed a o al o 1,339 child en and adolescen s in he NE Cyclades and 567 in he Wes e n Cyclades, whose a e age age was 9.2 yea s old (SD = 4.1, min = 1 max = 2) 0 10 20 30 40 50 60 2003-2006 2007-2009 2010-2014 Sel - e e al PHC P i a e physician Social se ice Public au ho i ies Chu ch Educa ion ins i u es O he 35 Table 1. Demog aphic cha ac e is ics o child en and adolescen s who ecei ed se ices om he mobile men al heal h uni s in he NE and Wes e n Cyclades in he i s 10 yea s hey we e in ope a ion (N = 1906) Demog aphic a iables % Gende : Boy 1,121 58.8 Gi l 785 41.2 Coun y o o igin: G eece 1,728 90.7 Ab oad 178 9.3 P io con ac wi h a men al heal h expe : Yes 391 24.5 No 1,199 75.3 Table 2. Rela i e equencies o sou ces o e e als o mobile uni s in he NE and Wes e n Cyclades in he i s decade in ope a ion (N=1,906) Sou ce o e e als NE Cyclades Wes e n Cyclades To al Sel - e e al 49.3% 34.3% 45.2% P ima y heal hca e 11.6% 8.7% 10.9% P i a e doc o 3.9% 1.3% 3.3% Communi y body 4.6% 2.3% 3.9% Public au ho i ies 0.9% 4.6% 1.5% Chu ch 0.2% 0% 0.1% 36 Educa ional body 22.5% 25% 23.3% O he 6.9% 23.7% 11.8% Table 3. Rela i e equencies o ini ial eques s made o mobile uni s in he NE and Wes e n Cyclades in he i s decade in ope a ion Ini ial eques NE Cyclades Wes e n Cyclades To al Psychia ic symp oms 18.8% 15% 17.5% Lea ning p oblems 15.3% 29.1% 19.8% Beha iou al p oblems 27.6% 20.6% 25.2% Subs ance dependence / abuse 0.2% 0% 0.1% P oblems wi h amily ela ions 16.4% 14% 15.6% Speech p oblems 5.8% 6.2% 5.9% De elopmen al diso de s 1.9% 1% 1.6% Ea ing diso de s 1.1% 1.2% 1.2% Men al e a da ion 0.4% 0.8% 0.5% Ce i ica es, e c. 1% 2.3% 1.5% Social su eys 11.4% 9.9% 10.9% O he 0.1% 0% 0.1% 37 Table 4. Rele an F equencies o he diagnoses o he Child en and Adolescen s se ed in he 1s decade o he NE & W Cyclades Mobile Uni s ope a ion. (Ν = 1339 and 567 espec i ely) Diagnosis NA Cyclades W Cyclades O ganic, including symp oma ic, men al diso de s (F00-F09) 0.3% 0.2% Men al and beha io al diso de s due o psychoac i e subs ance use (F10-F19) 0.1% Schizoph enia, schizo ypal and delusional diso de (F20-F29) 0.3% 0.9% Mood (a ec i e) diso de s (F30-F39) 4.1% 5.7% Neu o ic, s ess ela ed and soma o o m diso de s (F40-F48) 11.4% 13.4% Beha io al synd omes associa ed wi h physiological dis u bance and physical ac o s (F50-F59) 1.8% 1.4% Diso de s o adul pe sonali y and beha io (F60-F69) 1.7% 1.1% Men al e a da ion (F70-F79) 2.4% 3.9% Diso de s o psychological de elopmen (F80-F89) 25.2% 19.6% Beha io al and emo ional diso de s wi h onse usually acc uing in childhood and adolescence (F90-F98) 22.2% 21.6% Unspeci ied men al diso de ((F99) 0.1% P oblems ela ed o social en i onmen and o p ima y suppo g oup (Ζ60-Ζ63) 25.9% 26% No men al diso de -Ce i ica es-O he 4.7% 6.2% 4. Discussion 38 The clinical wo k o he Mobile Uni s (MU) includes psychia ic and psychological assessmen and diagnosis, pe sonal, g oup, amily and couple counseling and psycho he apy, coo dina ion o a social club o people wi h se e e psychosocial p oblems, social in es iga ions in cases o child abuse, suppo o amilies wi h mul iple psychosocial and medical p oblems, as well as home ca e. As i is easily unde s andable, while he e we e no such se ices o e ed ac oss he islands – wi h he excep ion o sy os island, whe e he e is a child psychia is a he gene al hospi al – he ope a ion o he mobile uni s has played an impo an ole in he e e yday day li e o he popula ion su e ing om men al heal h p oblems. Be o e he mobile uni s s a ed hei ope a ion, he e we e only wo op ions: ei he a ange a isi a he gene al hospi al in Sy os (which can be e y di icul in e ms o wo k load o he psychia is , means o anspo – as in e island connec ions a e no e y easy, o a el o he capi al o A hens and a ange a isi a one o he psychia ic hospi als. As a esul , ha ing he p o essionals o e ing se ices a he islands, was no only sa ing ime and money o he inhabi an s, bu also ga e people he ad an age o ha ing hei “pe sonal” he apis , a no cos and a he p oximi y o hei home. E iden ly, apa om he ob ious ad an ages in cos and ime sa ings, wha appea s o be he g ea es bene i o he popula ion ea ed by he mobile uni s is he po en ial “sa ings” in psychological cos , o hem and hei amilies, no ha ing o endu e he a el o a psychia ic hospi al, which, in mos o he cases, esul in hospi aliza ion. In addi ion, i is wo h men ioning ha , e en i elapses we e di icul o p edic , i was much easie o bo h use s o he se ices as well as p o essionals o p e en hem, since he e was a close moni o ing o each case (wi h a equency o wice o once a mon h). Moni o ing he change in new cases o e ime, as shown in igu e 17, du ing he i s yea s in ope a ion he e was a g adual inc ease in new cases. This is a he common wi hin any communi y in e en ion whe e he e a e no o he men al heal h se ices. This ise was ollowed by a d op in he p eceding yea s, which can be a ibu ed o in e nal unding 39 p oblems o he Minis y O Heal h owa ds he se ices. Then, one can no ice a g adual ise, which is p obably associa ed wi h he impac s o he socio-economic c isis as well as wi h he ac i i ies unde aken ela ing o p e en ion and awa eness aising o he psychosocial heal h o adolescen s and hei amilies, igge ed by he aise o ini ial eques s. The a ious ypes o he ini ial eques as p esen ed by he pa ien s e e ed o he mobile uni s o EPAPSY. The h ee majo easons o e e al, i.e. s ess, dep ession and ela ionship/social p oblems, a e equally common and oge he hey ep esen h ee qua e s o all ypes o eques s. Looking a igu e (18.2), whe e ini ial eques s a e examined pe yea , i is wo h aking a no e o he apid inc ease o social ela ed and ela ionships p oblems du ing 2012 and especially 2013, when he pe cen age o ini ial eques o his cause eached an absolu e highes o all eques s h oughou he whole decade o ope a ion o he mobile uni s (40,2%). As he socio-economic c isis had eached i s peak, he le el o unemploymen was inc easing, along wi h he di icul ies aced in e e yday li e amongs ela ionships, amilies and communi y li e. Conce ning he diagnoses ( able 5), he mos equen ones a e hose ela ed o mood diso de s, neu o ic and s ess ela ed diso de s, as well as p oblems ela ed o social en i onmen and p ima y suppo g oup. Following he same pa e n, as one can no ice om igu e 19, he dec ease o all ypes o diagnoses du ing he yea s 2007-09, e lec s mos ly he p oblems conce ning he unding o he MU. Conce ning he longi udinal occu ence o each diagnosis, psychoses and o ganic me al diso de s a e mos equen du ing he i s yea s o he MU’s unc ion. A e he e up ion o he socioeconomic c isis in G eece, all ypes o diagnoses, bu in pa icula a ec , neu o ic, s ess ela ed as well as p oblems ela ed o socioeconomic condi ions and he p ima y suppo g oups we e inc eased. As a esul and in esponse o his pa icula end, he e we e a se ies o ac ions unde aken by he mobile uni s in o de o espond o he needs o he popula ion, which will be p esen ed a a la e s age. O e all, one could a gue ha he mobile uni s, h ough he e alua ion o ini ial eques s, ha e a s a egic plan o de elop ac i i ies adap ed o he changes in he socioeconomic en i onmen o e ime. 40 Taking in o conside a ion able 6 , sel - e e al, being he mos equen sou ce o e e al and ac ually inc easing o e ime, e lec s on one hand he ac ha he MU ha e c ea ed s ong ies wi h he local communi ies so ha people may e e on hei own o hem. On he o he hand, i unde lines ha PHC is no being he mos equen sou ce o e e al, as expec ed, due o he lack o such se ices in u al a eas in a o o ex emely la ge Te ia y Heal h Ca e se ices in A hens. Wha becomes clea om he able abo e is ha sel e e al is he mos common sou ce by a amongs all o he s. Ce ainly, his shows no only he need ha was exis en bu no se ed be o e he ope a ion o he uni s, bu also he ac ha , a high le el o awa eness was achie ed h ough communi y wo k and social mobilisa ion; people would mo e easily each ou o ask o assis ance han be o e. This can also be a gued i we ake in o accoun he ise in sel e e als a e he i s ew yea s o ope a ion, as shown in igu e 20. The nex sou ce o e e als was p ima y heal hca e p o ide s. Al hough he second highes , as we can see in he ollowing g aph, he e is a d op a e he i s yea s o ope a ion. This can be explained in wo ways: on one hand, one can a gue ha he ope a ion o he mobile uni s o e ed he people he se ice hey needed, so as no o e e o he p ima y heal h se ice. On he o he hand, his could be a p oblem in he p ocess o in eg a ion wi h PHC, as some people who could be ea ed he e, p e e ed o e e s aigh o he mobile uni ins ead. Looking mo e deeply a he issue o sou ces o e e als, i is clea ha o e ime he e is a clea s a is ically signi ican di e ence, especially in he wo mos common sou ces o e e als, as p e iously discussed. Ne e heless, i appea s ha he inc ease o sel e e als is a he equi alen o he dec ease in e e als om PHC (chi-squa e s a is ical e i ica ion (18) = 295.69, p< 0.001). O e all, om a clinical poin o iew, al hough we canno assess whe he he ac ual men al heal h o he popula ion has i sel imp o ed o e he yea s, one could a gue ha he se ices o e ed om he mobile uni s ha e imp o ed he o e all quali y o li e o people wi h men al heal h p oblems li ing on he islands o he Cyclades. 41 In eg a ion wi h P ima y Heal h Ca e Ne e heless, his does no seem o be he case as a as he in eg a ion wi h p ima y heal h ca e is conce ned, as he e a e se ious p oblems in he ope a ion o p ima y heal hca e in he Cyclades, mainly due o he lack o s a and esou ces, especially a e he yea s o he socioeconomic c isis. Apa om he lack o s a , he e is also a lack o aining among doc o s in he in e ace be ween p ima y heal hca e se ices and men al heal h and ch onic wel a e cases. Despi e he ac ha he e is a sys em o liaisons wi h p ima y heal hca e p o ide s ope a ing wi hin he e i o ial emi o he mobile uni s ha been buil up, one canno be sa is ied wi h he o e all le el o in eg a ion wi h PHC. The mobile uni s ha e unde aken a se ies o ac ions wi hin he con ex o achie ing a sa is ac o y coope a ion wi h P ima y heal h ca e o he bene i o he people li ing on he islands. To begin wi h, he e ha e been many wo kshops ocusing on aining p ima y heal hca e p o essionals in how o p e en , ecognise and manage men al diso de s. These wo kshops we e held locally on each island and we e aimed a all doc o s and nu ses in ol ed in p ima y heal hca e in he Cyclades. In addi ion, he WHO’s MhGap guide (WHO, 2010) has been ansla ed in o G eek and is being used in aining. Wha appea s o be he p oblem in his “ ela ionship” is he ac ha he sho age o p o essionals wo king in he PHC is c ea ing a wo k-case o e load o hem, which, in e u ns, is ansla ed as an unwillingness o become an ac i e pa o he in eg a ion model. In ou discussion wi h he head o he Heal h Cen e o Pa os, al hough i was mu ually ecognised ha he e is a e y good ela ionship ha has been buil du ing he yea s, i is qui e common in eme gency se ings o a doc o o e e he pa ien o he mobile uni s, a he han o e ing assis ance. In addi ion, many doc o s will no s ay o mo e han wo o h ee yea s on an island, which una oidably c ea es ano he need o con inuous aining, which some imes canno be unde aken by he p o essionals o he mobile uni s. This ci cle o unde s a ing, lack o esou ces and consequen ly lack o aining, leads o an unde mined le el o in eg a ion wi h PHC. On he o he hand, we ha e o admi ha he job u no e in he mobile uni s is also ela i ely high. 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