During the covid-19 pandemic, mental health in the Czech Republic has increased threefold and anxieties twofold. Hand in hand with this, the number of people who are not dealing with their problems has grown. This applies not only to common mental illnesses but also to more serious conditions, such as psychoses and bipolar disorders. Poor health literacy is largely at fault since the patient and quite often the people close to them do not reveal the patient’s illness. In addition, programmes focused on mental health in schools or at employers, or projects aimed at the early detection, for example, of serious mental illnesses or dementia, can be helpful in prevention: as said by Petr Winkler, Director of the National Institute of Mental Health, at the international panel of the Permanent Conference on Czech Healthcare held on 22 July in Prague.
“Mental illnesses are highly prevalent and pose an enormous burden – both medical and economic – as they are productive age and childhood illnesses. Prevention, early identification, and treatment are key to limiting their negative impact. Mental health literacy is fundamental for prevention and timely identification,” Petr Winkler states.
Regretfully, literacy in this area is low and many people with serious problems do not receive treatment because they do not realise that something is wrong. As an example, Winkler describes the case of a patient who, for two years, hardly ever left his flat and spent most of his time in bed, seriously considering suicide. He was sent to a psychiatrist by his general practitioner who was to issue a medical certificate for his driver’s licence. It is necessary to increase literacy from childhood – many children have friends suffering from depression or self-harm but they do not know how to react.
Anyway, these are not exceptional cases. Today, one in five children aged between 3 and 17 years suffers from a mental illness, the cost of which amounts to approximately 250 billion dollars per year according to estimates of American experts. Prevention in childhood is important also due to the fact that three quarters of mental illnesses in adults begin before the age of 18 and one half before the age of 15. Unfortunately, another fact is that suicide is one of the most frequent causes of death among children and adolescents.
Over the past years, the rate of mental health problems in children has been growing. “In the Czech Republic, we witnessed an 85 per cent increase in the psychiatric outpatient treatment of childhood and adolescent developmental disorders between the years 2007 and 2017,” claims Petr Winkler.
Prevention in this area is rather complex. It may involve universal or selective interventions in early childhood, such as the screening of mental health disorders during pregnancy and after childbirth, or interventions to promote mental health and prevent emotional or behavioural disorders.
“Programmes implemented in schools prove to be instrumental. In this respect, we differ slightly from our other colleagues, since our competence falls more within the sectors of education, business, and social affairs than healthcare. Such programmes oriented on mental literacy and social learning exist and are effective both in terms of improving the overall well-being symptoms and in the prevention of suicide among children,” Winkler points out.
The National Institute of Mental Health has actually developed such a programme. It is named “Všech pět pohromadě” (On My Mind) and is now in the testing phase. Tests are also ongoing of Triple P (Positive Parent Program), a selective programme focusing on improving the skills of parents, as well as on the emotional and behavioural abilities of children in families with mental illness.
Moreover, there are interventions targeting intellectual disability. These are based, for example, on accident prevention, or oriented on families where social and pathological phenomena may occur, such as child abuse or alcoholism.
Employers do not seem to be very open to mental health programmes
Common mental illnesses in the overall population, such as depression or anxieties, are one of the main causes of disability worldwide (depression ranks first, anxiety disorders rank sixth). In terms of productivity loss, these disorders cost trillions of dollars per year (in the Czech Republic alone, depression-related costs amounted to EUR 1.3 billion and anxiety disorders to EUR 0.9 billion in 2010). Concurrently, depression is the most frequent cause of suicide (around 800,000 occur around the world annually).
“What concerns us far more than other fields is the so-called ‘treatment gap’, meaning the untreated population, which amounts to 60 or even up to 70 percent with depression and anxiety in the Czech Republic. Moreover, in the situation brought about by the Covid-19 pandemic, the lockdowns, and other negative consequences, we saw a dramatic increase in the incidence of common mental illnesses among the population. The number of people suffering from depression tripled as did the number of people at risk of suicide, and the number of people suffering from anxiety disorders doubled and, naturally, the untreated population also grew,” Petr Winkler claims.
As regards prevention, the key partners are employers along with mental health programmes at the workplace. Based on available evidence, these programmes are effective in reducing depression, anxiety, and stigmatisation.
“In the Czech Republic, the business sector does not seem to be very open to this idea. They know that the topic concerns them, yet they think that they will solve it by making psychological care available to their employees. But what will the employee think? ‘The bastards are trying to catch and identify me as a weak point of the organisation. I am not going there.’ We need to work with the entire culture of the organisation so that people accept such care,” Winkler explains. At the same time, we need to improve the approach towards employees with mental health problems. This is also an aspect that preventive programmes help improve.
Promoting such preventive programmes is actually paying off. According to cost-effectiveness studies, one dollar invested in this area generates four or five in return. Another means that helps promote mental health are e-mental health tools. During the Covid-19 pandemic, NIMH launched the Czech screening website opatruj.se where more than 50,000 people have already screened themselves. The website has been visited by over 120,000 users, most returning on a regular basis.
Serious illnesses remain untreated for a long time
The prevalence of serious mental illnesses, such as psychoses and bipolar affective disorders, is lower than with depression and anxieties – and they affect 1.5 to 3.0 percent of the population. Concurrently, these illnesses are associated with higher disability and social costs, whereas around EUR 1.3 billion were attributable solely to psychoses in the Czech Republic in 2010.
“There is also a high treatment gap and a long period of untreated illnesses. These people wait for many years. They often think that what they are experiencing is normal. And they are not the only ones, often their intelligent and educated parents share their view. Another problem associated with serious mental illnesses is the high institutionalisation in the Czech Republic, as well as in other countries of Central and Eastern Europe. During the Communist regime, the diagnosis of schizophrenia meant that the individual was sentenced to lifetime confinement at psychiatric hospitals, which, of course, increased costs expended on care,” Petr Winkler describes.
Prevention in this area mainly consists in averting severe progress, as well as the relapse of an illness. Early detection and intervention programmes serve this purpose and they are not only efficient, but also cost-effective compared to follow-up treatment costs.
“If our country had functioning early detection programmes, the costs per patient would drop by 25 percent, if we had early intervention programmes, the costs would drop by 33 percent, and if we had both, costs would drop by 40 percent. In response to this, we are piloting severe mental illness early intervention teams within the framework of psychiatric care reform in three Czech regions,” Winkler states.
Lack of systematic cost-effectiveness assessments
Another chapter that we should focus on within prevention is Alzheimer’s disease and similar illnesses. Around the world, dementia occurs in 5 to 8 percent of individuals over 60 years old, which roughly amounts to 50 million people. In 2030, it should be 82 million and 150 million in 2050. About nine percent of cases occur before the age of 65. The worldwide costs are estimated at USD 800 billion and in the Czech Republic alone they amounted to EUR 0.9 billion in 2010.
Prevention consists in reducing risk factors, e.g. low physical activity, alcohol, obesity, smoking, unhealthy diet, high blood pressure and cholesterol, mental inactivity, poverty, depression and social isolation.
Secondary prevention involves early detection. “A modelling study allowed us to estimate that lifelong costs expended on the care of an individual suffering from dementia in our country would be reduced by EUR 27,000 among women and by EUR 23,500 among men, if we had functioning early interventions,” comments Winkler.
As evident from the data above, many calculations have already been made in the area of mental health and they are supported by Czech data. The good news is that healthcare payors and other authorities are genuinely interested in these data. “Such levels as we see in the United Kingdom, Canada or the Netherlands, where they have institutes systematically evaluating the cost-effectiveness of interventions and where they ensure that the invested means – not only financial but especially human – provide maximum benefit, are still beyond our reach. I consider it one of the most important steps to be taken in the area of public health,” Petr Winkler emphasises.
To summarise, there are still considerable gaps that we need to overcome in mental health prevention. “Although the availability of preventive programmes is on the rise, there is plenty of room for improvement,” Winkler concludes.
Michaela Koubová
