Greece comes 28th out of 30 in The Economist Intelligence Unit’s Mental Health Integration Index, and fails to place higher than 24th in any given category.This reflects a slow, uneven process of reform often driven by the EU rather than by domestic demand. Greece has closed most of its psychiatric hospitals, and is set to shut the remainder next year, but has been largely unsuccessful in creating effective replacement services in general hospitals or the community.

1. 1 © The Economist Intelligence Unit Limited 2014
Mental health and integration
Provision for supporting people with mental illness: A comparison of 30 European countries
Greece comes 28th out of 30 in The Economist Intelligence
Unit’s Mental Health Integration Index, and fails to place
higher than 24th in any given category.
This reflects a slow, uneven process of reform often driven by
the EU rather than by domestic demand.
Greece has closed most of its psychiatric hospitals, and is set to
shut the remainder next year, but has been largely unsuccessful
in creating effective replacement services in general hospitals
or the community.
The future is not bright, as Greece’s economic troubles have
brought cuts to mental health services at a time of increased
demand.
Mental Health Integration Index Results
Overall: 38.0/100 (28th of 30 countries)
Environment : 46.7/100 (26th)
Opportunities: 33.3/100 (24th)
Access: 24.8/100 (27th)
Governance: 45.4/100 (25th)
Other Key Data
l Expenditure: Mental health budget as a proportion of
government health budget (2011): 4.43% 1
l Burden: Disability-Adjusted Life Years (DALYs) resulting from
mental and behavioural disorders as proportion of all DALYs
(World Health Organisation—WHO—estimate for 2012): 11.4%2
l Stigma: Proportion of people who would find it difficult
to talk to somebody with a serious mental health condition
(Eurobarometer 2010): 32% 3
SPONSORED BY
Greece Country Report
Greece: Austerity hampers halting progress
Highlights
Environment
Opportunities
AccessGovernance
100
100
80
80
60
60
40
40
20
20
0
Mental Health Integration Index:
Results for Greece
Greece Best Average Worst
1
Data from The Economist Intelligence Unit’s Mental
Health Integration Index, which ranks 30 European
countries based on their commitment to integrating
people with mental illness into society and employment
(www.mentalhealthintegration.com).
2
Figures derived from World Health Organisation (WHO)
national figures for individual Index countries for 2012,
available at http://www.who.int/entity/healthinfo/
global_burden_disease/GHE_DALY_2012_country.
xls?ua=1. The WHO estimates do not include dementia
as a mental illness, although it is listed as one under the
WHO’s International Classification of Diseases (ICD-10).
3
Eurobarometer, Mental Health, Special Eurobarometer
345, 2010.

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Mental health and integration
Provision for supporting people with mental illness: A comparison of 30 European countries
A history of slow, sometimes reluctant progress
Greece has some of the poorest results in The Economist
Intelligence Unit’s Mental Health Integration Index, coming
28th out of 30 countries overall and scoring below average in
every category. According to Dr Stelios Stylianidis–professor of
social psychiatry at Panteion University, Athens, and scientific
director of the Greek mental health non-governmental
organisation (NGO), Epapsy–these results seem to reflect
the reality on the ground. The reasons are a combination of
long-standing structural problems with general and mental
healthcare in the country, as well as the more recent impact
of government austerity measures arising out of the recent
financial crisis in the euro area.
Since 1984 the country’s policymakers and health officials have
ostensibly been engaged in a series of reform programmes
designed to turn Greece’s then highly asylum-based provision
into one based on de-institutionalised, community-based
care. Much of this effort, however, has been driven by EU
requirements rather than by domestic considerations. Dr
Stylianidis notes that, over the long term, there has been a
“lack of political will to implement reform and make sustainable
progress.”
As a result, even when reform efforts have been effective to
a degree, they have yielded incomplete and slow results. In
1989, for example, five years after the first reform began, the
Leros scandal broke out. This small Aegean island’s Colony of
the Mentally Ill was revealed to be overcrowded, with low levels
of medical expertise on hand and generally dire conditions
that shocked public opinion in Europe. The discovery drove
more intensive efforts to improve conditions, with some
limited success. A decade later, after a new mental health
law was adopted in 1999, Greece put into place the first two
“Psychargos” National Action Plans on mental health, together
covering the period from 2000 to 2010. Intrinsic to these were
de-institutionalisation efforts involving the development of
psycho-social rehabilitation, housing, and other community-
based mental health services. Psychargos was jointly funded by
the EU and the Greek government.
Progress, however, was so slow that in 2009 the EU briefly
threatened to withhold funding from a range of social
projects. The resulting Spindla Agreement, named after the
then EU commissioner for social affairs, reconfirmed Greece’s
commitment to a number of reform targets, and also called
for an independent, detailed study to evaluate the progress of
Psychargos until the completion of its second phase in 2010.
In addition to presenting the results of the Mental Health
Integration Index, this article draws on the resultant report.4
The mixed results of reform
More positively, Greece has made substantial progress on
shutting down its asylums, closing six between 2000 and 2010
and, in several agreements with the EU, committing to close the
remaining three by 2015. Accordingly, de-institutionalisation—
an Index indicator based on the proportion of service users
in psychiatric or long-stay hospitals—–is one of the very
few indicators for which the country receives full marks. The
independent evaluation also found improvements over time
that the Index was not able to take into account. Notably, the
attitude of the public and of clinicians towards mental health
has improved markedly. Dr Christos Lionis, director of the Clinic
of Social and Family Medicine, University of Crete, even refers
to a “Psychargos effect”, which has led to increased discussion
and awareness of mental health issues.
4
Loukidou et al, “Evaluation of Greek psychiatric reforms: methodological
issues,” International Journal of Mental Health Systems, 2013.

3. 3 © The Economist Intelligence Unit Limited 2014
Mental health and integration
Provision for supporting people with mental illness: A comparison of 30 European countries
Hospital closures, however, have been accompanied by few
other supportive policies. In the Index, despite high scores for
de-institutionalisation, the complete lack of support for carers
and of state support payments for those disabled by mental
illness, as well as the continued status of mental illness as
grounds for losing custody of children, mean that Greece ranks
26th out of 30 in the “Environment” category—a measure of
policies and conditions allowing those with mental illnesses to
live a stable home and family life.
Efforts to provide integrated, community-based care have been
far from successful. Although the variety of healthcare venues
and community services has increased over the last 15 years,
this was from a very low level and current provision is still poor.
On the healthcare side, Greece scores just 24.8 out of a possible
100 in the Index’s “Access” category, ahead of just three other
countries. According to frequently cited but as yet unpublished
epidemiological research by Professor Venetsanos Mavreas, in
2010 some 75% of individuals with at least one common mental
disorder received no treatment at all. Moreover, Psychargos fell
far short of its own goals on the provision of care. Only a little
over one-half of the hospital-based psychiatric wards planned
under Psychargos have been established, and these are poorly
resourced. According to the independent evaluation, “their
physical infrastructure was rather outdated and unkempt ...
The number of staff (particularly nursing) was not adequate.”
The latter observation is not surprising, as Greece has the
second-lowest number of psychiatric nurses per head of
population in the Index (2.2 per 100,000).
Despite some improvement, poor community-based facilities
are an even bigger problem than insufficient, understaffed
hospital wards. In the Index, Greece is one of the nine
countries with no assertive community treatment teams for
those most at risk. This is part of a wider pattern. For example,
between 2001 and 2010 Greece established just six new
specialist mental health centres in addition to the 28 already
in existence, despite the Psychargos goal to create 52 extra
centres to bring the total up to 80. The lack of any facilities
is particularly acute in rural areas. Dr Stylianidis says that
over one-third of the country’s 52 regions (or departments)
lack “mental health services, especially for children and
adolescents. There is a huge gap between current needs and
facilities after the reform. Community mental health services
have been partially implemented in a fragmented system.”
The record on services beyond healthcare is also mixed at best.
Recent years have seen a substantial increase in the availability
of sheltered housing, but, with a score of 33.3 out of 100 in
the “Opportunities” category of the Index (which measures
the workplace environment), Greece once again performs
poorly. The failings of Psychargos are once more apparent here.
None of the 46 envisaged new socio-vocational rehabilitation
units were opened between 2001 and 2010 and only 18 of
the 55 planned new social cooperatives to provide sheltered
employment were created. Worse still, reports Dr Stylianidis,
two of those 18 stopped offering any kind of service, and
may others stagnated after 2010 because they proved to be
economically unsustainable once EU funds to support them
dried up.
Finally, what services do exist are poorly integrated. Dr Lionis
explains that even the integration of mental health with
primary care is weak, with many general practitioners still
maintaining only a biomedical view of mental illness. He adds
that broader integration of community services, including the
efforts of formal and informal carers, is essential. “This is one
of biggest weak points. Many efforts have been introduced, but

4. 4 © The Economist Intelligence Unit Limited 2014
Mental health and integration
Provision for supporting people with mental illness: A comparison of 30 European countries
still the system is fragmented. These efforts are limited to [the
activities of] NGOs, such as the church organisations or other
charities, and they do not coordinate well with the healthcare
services.” Dr Stylianidis agrees: “We have put a lot of energy
into writing a national mental health strategic plan, which
was approved by the European Commission and WHO experts,
but after 20 years of reform provision is still patchy and poorly
co-ordinated.”
Such weak provision has numerous deleterious consequences,
but perhaps the most striking is in the area of involuntary
hospital placements. The protection of human rights afforded
by Greek law in this area is roughly average for Europe,
scoring 75 out of 100 in the Index. Yet over one-half of Greek
admissions to psychiatric wards in general hospitals and to
any remaining psychiatric hospitals are involuntary. This is not
only the highest in Europe, but well above the range of rates on
the continent, which vary between 3% and 30%.
An ongoing research project by Dr Stylianidis found that the
problem is the result of “systemic dysfunction.” In hospital,
these individuals tend to improve sufficiently to be discharged
within a reasonable timeframe, but “about 85% of patients
hospitalised involuntarily are not referred on to community
mental health services, so there is no continuity of care. It
creates a revolving door of involuntary admissions,” which
patients and families are willing to accept since it is seemingly
the only way to get any care.
A cloudy future
In order to find comparable national information in a data-
poor field such as mental health, the Index has often had to
use figures dating back to 2010 or even before. Similarly, the
independent evaluation also looked at progress up to that year.
Since 2010, however, Greece has been subject to an extensive
austerity programme as a consequence of the financial crisis in
the euro area.
Mental health expenditure has been one of the many areas
that have seen significant cuts. Dedicated funding dropped
by nearly two-thirds (64%) between 2010 and 2012, leading
to marked reductions in services and the closure of public
facilities as well as those provided by NGOs.5
Worse still, the
very economic crisis that necessitated these reductions has
also been driving greater levels of mental illness and therefore
a need for these services. For example, the population
prevalence of major depression in Greece rose from around one
in 30 in 2008 to nearly one in 12 in 2011.6
The dangers for mental health provision in Greece, however,
do not come solely from externally imposed austerity policies.
Multiplying the difficulties has been the continuing lack of
focus on reform in this field, a problem that long pre-dates the
crisis. Perhaps the most telling symptom is that, despite a clear
need, the Greek government has failed to spend all the money
provided for these reforms by various European Structural
Funds. In September 2012, for example, about €88m, or
one-quarter of the funds earmarked for the training of mental
health clinicians, was transferred to be used for the reduction
of youth unemployment because the Greek government had
not found ways to use the money for its original purpose.
Moreover, plans for the future are not particularly well-
established. The government is currently implementing the
third phase of Psychargos, called Psychargos C, largely funded
by the EU until 2015. This time, however, the EU has insisted
on an ongoing evaluation, after noting in an April 2013
5
Alexander Kentikelenis et al, “Greece’s health crisis: from austerity to
denialism,” The Lancet, 2014.
6
Marina Economou et al, “Major depression in the era of economic crisis:
a replication of a cross-sectional study across Greece,” Journal of Affective
Disorders, 2013.

5. 5 © The Economist Intelligence Unit Limited 2014
Mental health and integration
Provision for supporting people with mental illness: A comparison of 30 European countries
Memorandum of Understanding with Greece the “dire need to
develop an adequate monitoring system.” The first resultant
report, from May 2013, is not promising. There, the evaluators
state, “although the new policy [Psychargos C] includes
principles, values and practices of international organisations,
it seems to be a visionary text without an apparent trend for
conversion into specific measurable goals and actions towards
the desired directions.” The report then describes a range of
deficiencies in the plan itself, such as a lack of consideration
of the long-term financial sustainability of new services, and
fragmented organisation.7
Another difficulty is that national policies have been drafted
with poor-quality data. Dr Stylianidis notes that there is a lack
of “clear evidence for assessing the needs of local populations,
and no clear understanding at local level of what is needed
for a comprehensive system of care.” He believes that the EU’s
monitoring efforts are unlikely to help. These efforts to gather
data are “top down, without the collaboration of stakeholders.
They monitor financial issues and not the quality of care and
clinical outcomes.”
In fact, given the weakness of community care and services
for the mentally ill, observers are questioning the value of
pressing ahead with the greatest success of Greek psychiatric
reform to date: the closure of psychiatric hospitals. The
government is committed to shutting down the remaining
three by 2015 as part of a broader agreement with the EU to
complete various elements of psychiatric reform. Using past
trends as a guide, the closures are much more likely to occur
than other reforms, however, since they are easily measurable
and immediately reduce costs. Given the current significant
gaps in service provision, the objections to the closures raised
by professionals employed at these institutions are more likely
to be reasonable than self-interested.
7
Έκθεση αξιολόγησης των παρεμβάσεων εφαρμογής της Ψυχιατρικής
Μεταρύθμισης έτους 2012, May 2013.

6. 6 © The Economist Intelligence Unit Limited 2014
Mental health and integration
Provision for supporting people with mental illness: A comparison of 30 European countries
This study, one of a dozen country-specific articles, draws on
The Economist Intelligence Unit’s Mental Health Integration
Index, which compares policies and conditions in 30 European
states for integrating people with mental illness into society,
employment and mainstream medical care. Further insights
were provided by two interviews—with Stelios Stylianidis,
scientific director of a Greek mental health NGO, Epapsy, and
with Dr Christos Lionis, director of the Clinic of Social and
Family Medicine, University of Crete—as well as extensive desk
research. The work was sponsored by Janssen. The research and
conclusions are entirely the responsibility of The Economist
Intelligence Unit.
About the research