Current state and recent developments of child and adolescent psychiatry in Greece
Psychiatric reform in Greece started in 1984 with the Commission of the European Communities Regulation 815/84 which provided financial and technical assistance for the modernization of the Greek mental health-care system, with an emphasis on the deinstitutionalization of the long-stay patients and improvement of conditions in public mental hospitals and the development of community-based services. Subsequently, a national strategic and operational plan named “Psychargos” was developed by the Greek Ministry of Health and Social Solidarity to make possible the transformation of mental health care. The “Psychargos” programme, which became almost synonymous with the psychiatric reforms in Greece, was implemented in two phases: “Psychargos I” (1997–2001) and “Psychargos II (2001–2010), also known as “National Action Plan Psychargos 2001–2010”, which was jointly funded by the EU and the Greek State. The main targets of the reform programme, i.e. the closure of some long-stay mental hospitals, the deinstitutionalization of the majority of patients, the establishment of psychiatric services in general hospitals (inpatient and outpatient units), community mental health centres (CMHC) in several parts of the country, different types of residential provision, day centres and hospitals, and psychosocial rehabilitation units, as well as the geographical and administrative sectorization of the public mental health services aiming at increasing the accessibility and continuity of care patients from an identified area were partially achieved [1, 2], as regrettably the second phase of the programme was not completed, and the goal for an effective, comprehensive, integrated and sustainable mental health system was also not fully completed [3,4,5]. The last revised phase was scheduled to cover the period from 2011 to 2020. In 2012, there were over 60 NGOs providing mostly residential care, day care and outreach teams known in Greece as “mobile units” . Despite substantial service transformation towards developing community-based mental health services, important service gaps remained for child and adolescent mental health services and psychiatric geriatric and specialist services for people with autism, intellectual disabilities, eating disorders and forensic psychiatric services .
Regarding the mental health care for children and young people, one of the greatest achievements of the “Psychargos” programme was the closure of the large mental health institution (asylum-like) “Children’s Psychiatric Hospital of Attica” (PNA), which had been operating since 1960, and in which the majority of hospitalized children, many of whom had reached adulthood by the time of the closure, were diagnosed with severe intellectual disabilities and psychiatric or behaviour disorders . Two clinics from the PNA were transferred to general hospitals and one to a paediatric hospital in Athens, where child and adolescent psychiatry (CAP) departments (inpatient and outpatient units) were established, and the adjacent medico-pedagogical centres based in the community were further developed as independent CAMH services. Unfortunately, the development of services for young people did not follow at the same rate as in the case of adult mental health care, as only 30% of the planned CAMHS materialized [5, 6]. The outbreak of the profound financial recession, with cumulatively a 17.4% decline of its GDP in real terms between 2008 and 2012 , found the Greek mental health system in transition. From 2010 onwards, as a response to the economic crisis, governments implemented horizontal budget cuts instead of health reforms  with the mental health policy being set low on the priority agenda. Having to operate within severely constricted fiscal limits, the development of new services ceased and many community and rehabilitation units have suspended their operation .
In this paper, we aim to give a brief account of the current state of child mental health care within the context of severe financial crisis, and highlight recent changes and new developments that may improve the CAMH care from clinical and organizational perspective, as well as the future position of CAP in Greece.
Current state of child and adolescent mental health care
The health-care system in Greece is a mixed one; the private sector, apart from the public one, is significantly involved in the provision of health-care services. The cost of private treatment for children with psychiatric and specific/pervasive developmental disorders is only partially covered by the national insurance fund (EOPYY), thus the family often has to pay out-of-pocket money for the child’s treatment.
The long-term recession, the loss of income and high unemployment have put a lot of strain on the public health sector in Greece. The number of referrals and public demand for CAMH services have substantially increased in recent years. This is certainly not unique to child and adolescent psychiatry, as it is occurring across many other specialities and areas of the public National Health System (NHS) of new Law 4368/2016 , which guarantees provision of health-care services to uninsured people and vulnerable social groups, including the third-country nationals (e.g. immigrants, refugees) .
Mental health is particularly vulnerable to rapid economic fluctuations  and the first available data reveal worrisome trends (increase in unemployment rates, in the number of families facing economic hardship, increase in the rate of children living in poverty, worsening of mental health of adults as indicated by increase in suicide attempts and completed suicides, rise in the prevalence of major depression) [12,13,14,15] affecting the family functioning and social cohesion, with an adverse impact on child mental health. At the same time, the refugee crisis brought to Greece a large number of unaccompanied minors as well as migrant children with their families, with many of them having increased needs for mental health services . Recent survey comparing CAMH care services across European countries revealed that there are 45 public CAMHS operating in Greece (2.4/100.000 young people) . However, there are huge variations in the availability of CAMH services and their organization. The majority of them are located in large cities and the metropolitan area of Athens, leaving most rural areas without even a single child and adolescent psychiatrist working either in public or private sector. The existing public CAMHS operate with 30–40% fewer employees, whose salaries have been cut by 40%. A large portion of the experienced professionals have retired without being replaced due to the severe cuts in the public expenditure for health system. Consequently, teams have been poorly staffed and stretched . At the same time, the demand for public CAMH has considerably increased because of the rise in rates of psychological problems among children and adolescents as an effect of the crisis on the family functioning as well as due to family financial situation, which does not allow seeking help or continuation of treatment in the private sector. A recent survey in both public and private child psychiatric institutions compared data from 2007 to 2011 (2 years before the recession and 2 years after the implementation of austerity measures). Findings revealed an increase of 39.8% for children and 25.5% for adolescents seen in public outpatient as opposed to a decrease by a total of 35.4% of young people seen in the private sector . Complex and more severe psychopathological presentations that were not so prevalent before the financial crisis, such as serious suicide attempts, self-harming behaviours, severe mood dysregulation difficulties, and alcohol and substance abuse, are among the most frequently referred cases requiring multilevel intervention . While efforts are made to effectively manage cases with severe mental health problems and complex family needs in the community, for some hospital level of care remains appropriate and necessary. Currently, there is national shortage of psychiatric beds. Specifically, there are 34 psychiatric beds for children up to the age of 15 years (24 in Athens and 10 in Thessaloniki) and 28 beds for 14–17 years old adolescents (10 in Athens, 10 in Crete, and 8 in Thessaloniki). The increased demand for inpatient care, combined with the shortage of adolescent beds in particular, means that in “extreme emergency” the 16–17 years olds are admitted to adult mental health units.
Recent developments in child and adolescent mental health care
In June 2018, the Ministry of Health (MoH) published the national report: “Plan of sectorization for the development of Mental Health Structures. The current situation and the needs on Mental Health infrastructures and personnel” . According to the report it is estimated that for the “smooth” functioning of the mental health-care system and the implementation of the reform, there is a need of more than 1200 new personnel and the creation of more than 208 new structures, including 28 specialized services for children and adolescents . The increased awareness of the importance of child and adolescent mental health, alongside the limited access to public CAMH care, led the MoH to developing a new national strategic plan for CAMH care. It focuses on: (a) empowering the understaffed already existing CAMH services, (b) developing new services in the areas of increased need (e.g. deprived areas of Athens), (c) expanding innovative services such as mobile units and telepsychiatry to deliver specialized mental health care to remote communities, (d) establishing one inpatient unit per Regional Health Authority, so that children will not need to be hospitalized miles away from family home, with all repercussions of such a practice (e.g. increasing the young person’s vulnerability), and (e) opening at last an inpatient adolescent unit in Athens (suspended plan since 2010).
To meet the above objectives (at the time of writing), the MoH secured funding to cover the vacancies and advertised more than 20 CAP posts in the public sector, which are expected to be filled within the next few months. In addition, the necessary steps were taken to expand the services provided by the Hellenic Centre for Mental Health and Research (formerly known as Center for Mental Health Hygiene, which was set up in 1956 as the first community mental health service in Greece), not only in terms of securing creation of new posts, but also in planning to start the immediate operation of seven CAMHS in the rural areas of Greece.
During the last 2 years, the National Telemedicine Network, set up by the 2nd Regional Health Authority, has started the implementation of tele-child psychiatry services from the General Hospital of Syros and two general hospitals in Athens in the health units of the Aegean Islands. This represents a novel effort of health care, including CAMH care to remote communities where mental health services are grossly scarce. The gaps in primary health-care services locally in conjunction with the limited human resources in CAMH services providing tele-child psychiatry lead usually to ad hoc evaluations and interventions and do not allow addressing emergencies and complex cases. However, a number of good practices have been identified in the field that give rise to rethinking the way the telepsychiatry service could be implemented to reach its enormous potential.
The recent reorganization of administrative structure of public mental health care and sectorization of mental health services (Law 4461/2017)  is yet another positive development, despite several pitfalls being identified in the document produced by MoH  with regard to its implementation. Although this document provides an overall mapping of the existing public and NGO services (infrastructure and personnel) providing mental health care within the defined geographical areas (sector) and identifies priority needs for development of new services, it does not specify the kind of quality assurance mechanisms that should be built in for monitoring care quality and its cost-effectiveness. Moreover, it does not specify how specific objectives of sectorization will be implemented, as well as the method of assessing the extent to which policy priorities are met.
Given that the sectoral committees of mental health (TEPSI), in practice, had limited co-coordinating functions due to limited administrative capacity and economic resources and had no authority for decision making, the reorganization of the administrative structure to empower decentralization in managing and organizing human resources in the provision of mental health-care services, within the sectors of the Regional Health Authorities, was set up as a high priority. Thus, the new Law 4461/2017  for the sectorization of mental health services was established with 17 sectors for CAMH care across the country . The introduction of the intermediate administrative level aims at achieving planning and developing of new services according to identified needs, and better management of resources within the sector and within the region for the benefit of patients. The Regional Mental Health Committees (responsible for 2–4 sectors) at the level of Regional Health Authorities, with decision-making powers constitute the new intermediate administrative level, between Sectoral Mental Health Committees and the MoH-Mental Health Department. The representation of the service users in the Sectorial Mental Health Committees recognizes the importance of their involvement as partners in designing and monitoring services. The reorganization of sectors, according to socio-demographic indicators of the defined geographical areas, and ensuring of the overlap between adult and child mental health sectors (previously non-existent), is an extremely helpful development as it is expected to improve care through allowing comprehensive intervention if needed (e.g. in case of parental mental illness) as well as to provide continuity of care from childhood to adulthood.
Academic child and adolescent psychiatry
In Greece, as already mentioned above, CAP has been a speciality of its own since 1981, but independent academic departments (university CAP clinics, staffed predominantly by NHS doctors) exist only in two out of the seven medical schools. The National and Kapodistrian University of Athens established in 1995 the first Academic CAP Department which is operating in the largest paediatric hospital “Aghia Sophia”. The second Academic CAP Department will start operating at the University Hospital of Crete. In the remaining four universities, i.e. the Aristotle University of Thessaloniki, the University of Patras, the Democritus University of Thrace and the University of Ioannina, CAP faculty members operate within the departments of adult psychiatry (university psychiatry clinics). At present, the CAP faculty members in Greece are in total 11. The CAP faculty members provide teaching to undergraduate medical students and postgraduate students from the faculty of medicine, and other faculties, such as psychology, nursing, pedagogy, etc., and are involved in research activity. The Hellenic Society of Child and Adolescent Psychiatry (HSCAP) in an attempt to strengthen the position of CAP within medical schools has requested from the Ministry of Education, Research and Religious Affairs to create five more academic CAP posts (2 in Athens, 2 in Thessaloniki and 1 in Crete) within the respective universities.
The community of child and adolescent psychiatrists is represented by the Hellenic Society of Child and Adolescent Psychiatry (HSCAP), established in 1983 in Athens and currently has approximately 400 members. The HSCAP is a member of the ESCAP (European Society of Child and Adolescent Psychiatry) and IACAPAP (International Association for Child and Adolescent Psychiatry and Allied Professions) and has representation on UEMS-CAP. Apart from the official website (http://www.hscap.gr), HSCAP has also an active Facebook account and recently a YouTube Channel where various keynote lectures and specialized seminars (e.g. psychopharmacology) are uploaded. The HSCAP organizes, every 2 years, a panhellenic (national) child psychiatry conference; the last two (2017, 2019) were organized under the auspices of the ESCAP. The HSCAP is active in contributing to continuing medical education through organizing thematic seminars. During the last 3 years, the HSCAP has organized three seminars on the following topics: psychodynamic psychotherapy, consultation-liaison child psychiatry and paediatric psychopharmacology, which were very well attended despite the fact that they were self-funded. Live video streaming of the psychopharmacology seminar gave the opportunity for our colleagues who live far from Athens to take on the seminar. Moreover, the HSCAP publishes the journal “Child and Adolescent Psychiatry” (accepts also papers written in English) and a Newsletter that informs the members of all activities, changes in legislation and other important topics. At the request of MoH, the HSCAP is involved in producing guidelines for prescribing psychotropic medication (treatment protocols and guidelines) to children and adolescents. HSCAP is officially represented in the Central Board of Health (KESY) and also members of the HSCAP participate in various task force committees or working party groups set up by ministerial decree (Ministry of Health, Ministry of Education, Research and Religious Affairs, Ministry of Justice, Transparency and Human Rights) and provide directions on child mental health issues and CAP training. The HSCAP assistance to various ministries has been instrumental in new developments with regard to service planning, prioritizing needs for CAMH services development, setting up children’s advocacy centres aiming to improve child forensic interviewing following allegations of child sexual abuse, organizing services for young people at risk for re-offending, promotion of mental health in schools and CAP training that ensures harmonization with recommendations of the UEMS-CAP. Finally, the HSCAP has contributed to a committee set up by the MoH on rationalizing financial resource allocation regarding reimbursement of therapies through the national insurance fund (EOPYY) for children with psychiatric and developmental disorders.
New developments in training in child and adolescent psychiatry
Child and adolescent psychiatry (CAP) is a separate medical speciality in Greece since 1981. Previously, it was a subspeciality of adult psychiatry since the early 1960s. Until recently, the training programme including its duration was regulated by the 415/1994 Law  concerning all medical specialities. Training in CAP lasted 4.5 years and included adult psychiatry for 18 months, neurology for 6 months and 2.5 years for CAP rotations (1 year in hospital-based CAP departments and the remaining 1.5 years in community-based CAP service). Recommendations about the training were included in the above law, but there was no mention of structured training in CAP, nor any obligatory research training programme. Exams were obligatory for obtaining certificate of specialist training in CAP.
The Central Board of Health (KESY) is the national institute holding responsibility for every aspect of health policy. Among others, responsibilities of KESY are all matters regarding the educational process of health professionals. Recently, KESY made fundamental changes in training schemes of all specialities. Following the recommendation from the working group on medical specialities, KESY was advised of the following changes in CAP training, which were ratified by the new Law 4138/2018  regulating training in all medical specialities. CAP speciality training lasts 5 years and comprises 2 years of basic training, 12 months in psychiatry and 6 months in neurology, preferably in paediatric departments or hospitals) and 3 years of rotational training in CAP (2 years in hospital outpatient unit, 9 months in an inpatient unit and 9 months in consultation-liaison unit). All trainees are expected to participate in on-call duties throughout their training, as it provides essential and important experience in dealing with emergencies. The introduced changes are important as they fulfil the requirements of the European Union of Medical Specialists Section on Child and Adolescent Psychiatry (UEMS-CAP) . Although the total duration of training was increased by 6 months, the speciality training was increased by 1 year, since adult psychiatry training was reduced by 6 months. Thus, speciality CAP training lasts three-and-half years. UEMS states that the majority of CAP training normally will be carried out in outpatients in community settings. Given that the majority of cases in Greece are referred to outpatient clinics, the training duration of 24 months in this setting ensures that the trainee will have enough time to acquire theoretical knowledge and practical skills as well as to undertake psychotherapies under supervision and to follow up children and adolescents for adequate time. Training in a community CAMHS for 12 months (within the 24 months period outpatient training) exists as an option. The 9 months inpatient training exceeds the minimum of 6 months of inpatient experience recommended by the UEMS. The introduction of obligatory 9 months consultation-liaison training enriches enormously clinical experience (in a setting that makes it possible for children and families to accept help), as this setting provides opportunity for developing skills in communicating, collaborating and working jointly, if needed, with other specialists.
Other important changes to the training in CAP include the introduction of a structured training curriculum developed on the basis of the UEMS-Logbook  that, apart from the areas of knowledge to be covered and the range of skills to be acquired, also ensures the minimum caseload and that trainee’s needs for supervision are met. The certificate of specialist training in CAP is provided after a written and an oral examination (including a case report presentation of a patient followed up during the training) by an examination committee of CAP appointed by the MoH. Examinations take place every other month at the local level; however, this will probably change to minimum three times per year at the national level.
Another important development has been the change of the speciality’s name from “child psychiatry” to “child and adolescent psychiatry”, which has been a long-standing demand made by the HSCAP. This is considered an important step to strengthening the position of CAP speciality, as semantics of the word “child psychiatry” (a single word in Greek) may imply subspeciality of either psychiatry or paediatrics, and misleadingly be thought that child psychiatrists help only children up to the age of 14 (cut off age for paediatrics, which recently has been extended to 16), leaving the “adolescents” in the grey area as to which speciality serves their needs; indeed in the public service, it is clear that CAP specialists are responsible for the assessment and treatment of mental health disorders in children and young people up to the age of 18 years, but in the private sector adolescents frequently are seen by adult psychiatrists.
Despite these positive steps, there are still things to be done to improve CAP training in Greece. First of all, CAP training includes awareness in psychotherapy through theoretical seminars on different psychotherapeutic approaches (psychodynamic, cognitive–behavioural, systemic family) and supervised therapies, but does not integrate formal psychotherapy training. The psychotherapy training is self-funded and can be obtained from Greek psychotherapy associations or institutes that are members of respective European or international associations (e.g. EFPP, EACBT, EFTA). Moreover, HSCAP is planning to develop specific guidelines on implementing tele-child psychiatry and a training module that could be optional during CAP training.
Research training in CAP also is not highly developed in Greece. A study in 2017 from the ESCAP Research Academy Meeting highlighted the importance of overcome the barriers and difficulties for a dual clinician–scientist career in CAP .
Finally, CAP also is facing some other problems in Greece, such as few training centres and limited number of available CAP training posts. Despite the brain drain in Greece, most of our young colleagues choose training at home; thereof, there are long waiting times to enter the training scheme (most trainees start their training at the age above 35 years). Minimum standard requirements were set up to ensure the quality of the training, and following the recent evaluation it is anticipated that the number of certified training CAP centres will increase, alongside the training posts.
Greece is still facing the consequences of profound financial and humanitarian crisis. Child mental health care has been undoubtedly affected. The move towards community-based mental health care, despite its problems, has been partially achieved in Greece. CAMHS needed to serve the populations’ increased demands with staff shortages and funding difficulties. Moreover, social changes with their impact on families and social institutions as well as the refugee crisis have brought new challenges to CAMH services in Greece. However, much has been achieved in the field of CAMH care, during these difficult times for our country, in terms of service planning and development, particularly in rural areas. Acquiring new knowledge through clinical experience has been enlightening in thinking about innovative approaches to delivering mental health services and about how the services should be reorganized so as to reach their potential. Changes introduced to the structure of CAP training ensure harmonization with the UEMS-CAP and empowers our junior colleagues, with potential benefit for children and their families who are in need of high-quality treatment. This seems extremely important as the impacts of the nearly 10-year financial and humanitarian crisis are more than obvious on children and their families. Finally, we would like to highlight the growing need and the importance of close collaboration and coherence of all ESCAP Society Members to overcome the barriers in further development of CAP as a speciality across Europe through convergence of training, and exchange of experience and knowledge, which is greatly needed considering the global socioeconomic changes of our era.
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Kotsis, K., Giannopoulou, I., Anagnostopoulos, D. et al. Communications of the European Society for Child and Adolescent Psychiatry. Eur Child Adolesc Psychiatry 28, 1005–1010 (2019). https://doi.org/10.1007/s00787-019-01315-7