Balancing Community and Hospital Care A Case Study of Reforming Mental Health Services in Georgia.docVIP

HealthinAction BalancingCommunityandHospitalCare:ACaseStudyof ReformingMentalHealthServicesinGeorgia NinoMakhashvili1,2,RobertvanVoren1,2,3 * 1GlobalInitiativeonPsychiatry,Tbilisi,Georgia,2MentalHealthResourceCenter,IliaStateUniversity,Tbilisi,Georgia,3VytautasMagnusUniversity,Kaunas,Lithuania This case study is part of the PLOS Medicine series on Global Mental HealthPractice. mental health care and of ensuring a balance between providing community- based and hospital-based mental health services. In this article, we provide an overview of the mental health reform process, including its complexities and challenges.Thereformprocessisstillvery muchinprogress,whichmakesitdifficult toassessitsimpact.Nevertheless,thecase ofGeorgiamightprovideinsightsthatcan helpothercountriesthatareembarkingon asimilarmentalhealthreformprogram. was not counterbalanced by the develop- ment of outpatient and community-based services. At present, aside from psychiatric hos- pitals, there are 18 outpatient psychiatric clinics (‘‘dispensaries’’) in the country. However,thereisanunequaldistribution Introduction PsychiatricservicesintheformerSoviet Unionwerecharacterizedbyhighratesof institutionalization and a strong focus on biological treatment. In the post-Soviet states, these features remain—there is strong resistance to the introduction of modern, community-based, and user-ori- ented services [1]. In many cases, psychi- atricreformprogramshavecometoahalt orevenbeenreversed[2].Itisagainstthis backdrop that Georgia began a critical phaseofitsmentalhealthreformprogram almosttwoyearsago. of mental health services across the country: there is less access, and a lower qualityofservices,inpoor,remoteregions. Nearly half (48%) of all licensed psychia- trists are working in the capital city, Tbilisi. TheMentalHealthSituation Thenumberofpeopleregisteredwitha mentaldisorderin2010was79,216(outof atotalpopulationof4.4million)[7].This figure is likely to be an underestimate of the true burden