Community-Based Psychiatric Care Provision in Hungary: Trends and Steps towards Progress

Psychiatric care has undergone several cycles of profound changes in the past centuries all over the world. In Hungary, community-based outpatient care has been showing signs of evolution since the 1950s. Initially, the system centered on assertive outreach and family involvement, especially for those with serious mental health problems. Such services remain available throughout the country, but the emphasis in the past decades has shifted towards mass care provision. In many places, community-based services are no longer provided, and where they are the approach is biomedical and less asuming of recovery. In other centers, the services provided are conceived with the eventuality of rehabilitation in mind and in close cooperation with community-based care providers.

Community-based services providers, as part of the social fabric, offer as many psychiatric and rehabilitation services as possible for those with mental disorders within their communities. The main objective of community-based care is to achieve community re-integration and recovery from mental disorders. Today in Hungary, deinstitutionalisation and the introduction of community-based psychiatric care have been adopted even by large inpatient institutions. The replacement of institutional bed space and the provision of subsidised housing further underscore the importance of community-based psychiatric care provision. There is the opinion that, as a further course of development, the emphasis needs to now shift towards the nurturing of a community of experienced experts and creastion of user-led programs. In this new paradigm, the ability of a person with a mental disorder to make decisions and the bolstering of that ability are seen as vital. In order to achieve these objectives, it is essential that health and social seervices professionals cooperate. Hands-on experience is key in the provision and development of such services.

INTRODUCTION

The psychiatric care system has undergone profound changes in the past centuries in many countries. The aim of this review was to identify the main trends in the development of community-based psychiatric care in Hungary, its characteristics and place in the mental health care system, as well as the direction in which the wind blows in the way of progress. Сommunity-based care was provided in a multidisciplinary team (psychiatrist, social worker, nurse), with the involvement of a peer support worker.

IMPORTANT MILESTONES IN THE DEVELOPMENT OF COMMUNITY-BASED PSYCHIATRIC CARE IN HUNGARY

Community-based psychiatry (CP) has a solid tradition in Hungary: most of the inpatient wards have existed in general hospitals. A humanistic tradition has always been part of psychiatry, and, beginning in the 1920s, the first pilot community-based outpatient clinics started to appear. From 1950, these outpatient services providers began multiplying and their best practices included the CP approach.

The comprehensive pilot program of CP was implemented by the Awakenings Foundation, the Community Psychiatry Center of Semmelweis University, Budapest (in short: AF). From 1994, under the leadership of the psychiatrist Judit Harangozó, AF adopted and implemented the Assertive Community Treatment, one of the international best practices, by Leonard Stein [1], and the Optimal Treatment Program by Ian Falloon [2]. We created the principles of community addictology under the leadership of Andrea Bodrogi, MD, head of the addictology team at our center. The Supported Employment Program [3] was adapted by Tünde Bulyáki [4]. We published handbooks and booklets on these topics [4, 5].

Soon after 1994, we launched our community psychiatry and addictology service in Budapest, Hungary. The key characteristics of our service are as follows: recovery-oriented, family involvement, psychoeducation, assertive outreach, monitoring of early warning signs to prevent relapse, optimal and individualized pharmacotherapy, skills training, stress management, assertivity, and supported employment.

Primarily, the rehabilitation plans are based on the personal life goals of patients and family members, before an assessment is made of the difficulties that interfere with those personal goals and a reaction to these is prescribed, with the involvement of a multidisciplinary team that includes peers support. Emphasis is put on nonviolent means of treatment and rehabilitation by offering to our staff training in communication and negotiation skills and in de-escalation strategies to handle aggression [2]. Great results have been achieved. After one year of community-based care, the employment/learning rate among patients has gone from 15–20% to 55–65% in every diagnostic group.

We have joined efforts with the Antistigma group of the World Psychiatric Association, and Norman Sartorius has provided training for the Antistigma volunteers. We have also joined the research on stigma led by Graham Thornicroft of Kings’ College London. There is close cooperation with Agnes Rupp from NIMH (US) in the field of mental health policy and economics. More than 300 of our publications are related to these activities. The staff of the AF participates in graduate and post-gradual training programs for medical professionals, nurses, social workers, and psychologists.

Our mission is to continuously innovate. We have implemented the Hearing Voices approach [6] since 2012, as well as an organizational culture of Coproduction: mental health is a collaboration effort between users and professionals [7]. We train peers as supporters and involve them in every aspect of our action. We offer several online facilities; besides therapy there are online self-help groups, platforms, various applications, and online peer support, as well. Our leader on the professional front is the co-chair of the “Mental Health Economics” panel of the World Psychiatry Association. One of our peer supporters, Peter Kéri, is the board member of the European Psychiatric Association and the President of GAMIAN Europe, an umbrella organization for user-centered organizations.

In the early 2000s, community-based psychiatric care was folded into the renewed Social Act and more than 100 service centers were established by the government, partly for psychiatric and partly for addicted patients, as part of the social services system. The methodological basis of this care is centered on the CP pilot program introduced by the Foundation. Colleagues and peer supporters of the foundation have developed the training programs for the staff of the new services centers, an effort that is also supported by the government.

GENERAL CHARACTERISTICS OF COMMUNITY PSYCHIATRY IN HUNGARY

In Hungary, people living with mental disorders have access to health care and social services. Community-based outpatient services providers and other outpatient facilities and day hospitals constitute community-based psychiatry in the healthcare system (see below), while in the social services system, community-based care and daycare are available and there are a few residential facilities (supported housing) facilities in the community.

There are 91 socially oriented community-based services providers for mental, and 89 for addicted, patients around the country.1 The former serve 5,003; the latter, 4,435 clients with serious mental disorders that, for the most part, belong on the psychotic to affective continum and require intensive, long-term need-based psychosocial rehabilitation and support.2 The services are free of charge and non-coersive.

There are also day-centers for mental (n=108) and addicted (n=95) patients serving 5,583/6,017 clients voluntarily and free of charge in the nation-wide social services system.3 Patients can use other social services as well; i.e., family support services that are available for everybody in the local community, free of charge. Since 2013, the social services system has been complemented with residential facilities in the community. Unfortunately, this service is not available to everyone in need at the moment and many of these facilities require significant co-pays. The methods utilized in these services are similar to those used in the pilot program of the Awakenings Foundation. Day centers in some instances house self-help facilities and incorporate peers support. They organise cultural, leisure or educational activities, training programs, residential or family programs, meetings, all based on the needs of the clients. The purpose of these establishments is to achieve recovery [8]. The professionals providing these services are mostly social workers and a few psychologists, who must undergo a 350-h community-based psychiatry education program based on our pilot program and run by the National Institution for Social Policy.

THE GENERAL FEATURES OF THE HUGARIAN MENTAL-HEALTH SYSTEM

Within health care system, outpatient care is provided by community-based psychiatric outpatient providers available to the whole population, and outpatient care is available in inpatient wards and special clinics. GPs and other specialists can request a consultation from the outpatient psychiatric services provider. Psychiatric inpatient care is provided in the psychiatric wards of general hospitals, psychiatric clinics, or in a mental hospital.

Figure 1. Psychiatric outpatient turnover in the health care system of Hungary: 2012–2023.

Note: These numbers are to be related to the full population of Hungary which changed from 9,931,925 (2012) to 9,689,744 (2023). Data from Hungarian Central Statistical Office: https://www.ksh.hu/stadat_files/nep/en/nep0001.html

Figure 2. Psychiatric inpatient turnover in the health care system (for 10 million people) of Hungary 2010–2022.

There is still an insuffucient number of professionals in the field of psychiatry and mental health care, and its financing is still institution-based. Speaking of health care over all, there are also day hospitals, mostly organized in hospitals (see Tables 1–3 and Figures 1–2). Health care professionals and patients accept this way of treatment in the country. Peers support workers are not involved in the provision of mental health services.

Table 1. Inpatient psychiatric services providers in Hungary (resource: National Dierctorate-General for Hospitals)

Table 2. Mental health services providers in Hungary, 2023 (resource: National Directorate-General for Hospitals)

Table 3. Numbers of professionals in mental health services provision in Hungary, 2023 (source: National Directorate-General for Hospitals)

THE PLACE OF COMMUNITY-BASED MENTAL HEALTH CARE IN HUNGARY

There is an increasing need for CP services in Hungary. Patient turnover in hospital treatment gradually decreases. Professionals and policymakers have insufficient leverage, and not enough resources are vailable in the mostly institutionally financed health care and social services systems to ensure comprehensive, accessible, and acceptable CP care for every patient in need. However, good practices do exist, such as the pilot program at AF, which has yielded a cost-effective model that reduces indirect costs after just one year of optimal care [9]. CP in health care predominantly revolves around medication, but best practices involve сognitive behavior therapies, as well [10]. CP care in the realm of social services provision is only accessible to 10 percent of those with serious mental health problems, while care in boarding-school-type institutions within the community is accessible to just 1% of patients in need who have the resources for co-pays. The quality of care also varies: there are some services which are representative of the quality of the pilot program (Optimal Treatment Project), but others leave much to be desired. Quality assurance is nonexistant, but, on the other hand, there is massive administrative control in the provision of social services. The controls focus mainly on the mandatory documents but not on the professional quality assurance of the services.

THE STRENGTHS AND WEAKNESSES OF COMMUNITY-BASED MENTAL HEALTH CARE PROVISION IN HUNGARY

Most of the existing CP health services provision focuses on symptoms and relapse prevention, while socially oriented CP services in the community are oriented towards recovery, with some application of peer support, as well. That is the strength of socially oriented CP services provision. The system also increases patient access to health care. Achieving this objective requires close cooperation between the professionals working in both sectors [11]. A ministerial professional recommendation issued in 2018 also alludes to close cooperation between the health care and social services sectors in community-based psychiatric care. In addition to the knowledge of one’s own profession, effective cooperation requires everyone to remain open to other professions and to tear down the hierarchies between individual professions. In Hungary, the original dominance of the health care approach in the way care is provided to psychiatric patients can be felt even today [12]. Day hospitals that operate according to the medical model are usually part of a health care institution/hospital system and are primarily staffed by medical personnel (doctors, nurses). In these institutions, the nature of daily programs is structured medical therapeutic interventions, with little attention paid to the value of recovery. This can be regarded as a weakness of the mental health system. At the same time, provision of care also exists in the social services sector. It is much less medicalized and is mainly staffed by social services professionals, sometimes supplemented by a number of health professionals: e.g., a psychologist or a psychiatrist [13]. Home-based long-term community-based psychiatric care is usually provided only by social services providers. Communication between providers of health care and social services is often lacking or non-existent when social workers cannot achieve the cooperation of health professionals [14]. Outside of psychiatric professionals in the health care sector, few health care professionals know about community psychiatry. The vast majority of general practitioners do not have contact with community-based care providers in the social services sector. A further weakness is that the majority of doctors, nurses, and other professionals still treat mental illnesses exclusively as a health problem. Although recovery-based service models have appeared in community-based care provision, the willingness to accept changes is slow among the professionals in the health care system. They don’t believe in the recovery of the mentally ill. In addition to the differences in approach, insufficient allocation of resources can also be identified as a problem in intersectoral cooperation [14, 15]. The strength of the Hungarian system consists in the good employment opportunities offered to patients. The government provides incentives to employ people with disabilities and funds other initiatives as well. Additional strength is the high quality of the professional trainings received and scientific activities persued by Hungarian mental health care professionals.

THE PERSPECTIVES IN COMMUNITY PSYCHIATRY AND PEER SUPPORT

Personalized care with the involvement of families and other important people is a cornerstone of the future of mental health care provision. Tailoring treatment and therapeutic approaches to the needs and circumstances of individual patients and their families improves the chances of recovery.

Digital technology and artificial intelligence will play a pivotal role in shaping the future of mental health care provision. The widespread adoption of eHealth and technology will facilitate more effective communication between patients and healthcare professionals and empower patients to actively monitor their mental health status.

The progressive steps towards the dissemination of good practices in community-based psychiatry in Hungary are as follows:

• shifting of resources from institutions to quality-controlled CP services provision;
• quality assurance;
• evaluation of good practices and their dissemination using public money;
• subsidized employment for people with a lived experience in the health care and social services sectors, and the education of professionals;4
• training of managers, leaders, and other staff, as well as peer support and emphasis on a person-centered and value-based approach, including de-escalation of aggression, and organizational development towards a system of cooperation [7];
• training of professionals on ethics and human rights based on CPRD (Convention on the Rights of Persons with Disabilities) and WHO protocols;
• eradicating “violent” practices radically in psychiatry;
• improving public awareness of mental health and mental health institutions;
• involvement of primary care professionals in the prevention and management of noncomplex cases of mental disorders; and
• the integration of digital technology and AI.

In the future, there is great potential for peer support to play a vital role in value-based, cost-effective mental health care provision. As we look ahead, several key factors can shape the future of peer support in the mental health field. Mental health is a coproduction involving users and professionals. The integration of people with lived experience should ensure that peer support workers are valued as equal members of the team, contributing their distinct perspectives towards improving overall care provision. People with lived experience should be involved in the education and training of professionals, as well. Programs involving students offer a glimpse of the potential impact of exposing future mental health professionals to peer support early in their training. Expanding these initiatives and ensuring that they are an integrated part of mental health education can foster greater understanding and cooperation between peers and clinicians and decrease stigma.

The stigma and discrimination associated with mental disorders needs to be targeted both within the mental health care community and in the society at large. Meeting with people with lived experience can play a significant role in challenging stereotypes and dispelling myths about mental illness. By sharing their stories and offering hope, they can contribute to the creation of a more accepting and compassionate society. Technology and innovation also hold promise for the future of peer support. Online platforms can provide accessible avenues for people to connect with peer support specialists regardless of their location. As technology continues to advance, there are opportunities to develop more tailored and effective digital interventions that complement traditional face-to-face support.

Additionally, research and evaluation are essential to demonstrate the effectiveness of peer-supported interventions. Gathering data on outcomes, such as improvements of mental health, reduced hospitalization cases, or increased quality of life can help secure funding and bolster support for these programs. It’s crucial to build an evidence basis that highlights the value of peer support in achieving positive mental health outcomes.

The prospects for peer support in mental health care look promising, with the potential to transform how we approach and deliver mental health services. This transformation hinges on the integration of peer support into the system, education and training, stigma reduction, technological innovations, and robust research.

CONCLUSION

Hungary possesses good practices in community-based psychiatry, but the structure and funding of health and social services remain institution-based. There is continuous development of community services. Their quality varies, as quality insurance is missing. By working in cooperation and embracing the unique contributions of peer support specialists, we wish to create a mental health care system that is more holistic, person-centered, and effective in achieving recovery and well-being.

¹ Hungarian Central Statistical Bureau. Available at: https://www.ksh.hu/stadat_files/szo/en/szo0025.html

² Hungarian Central Statistical Bureau. Available at: https://www.ksh.hu/stadat_files/szo/en/szo0025.html

³ Hungarian Central Statistical Bureau. Available at: https://www.ksh.hu/stadat_files/szo/en/szo0025.html

⁴ Harangozó J, Rupp Á, Kéri P et al. Peer support involvement: Practice models and costs. Presentation at the 23th World Congress of Psychiatry; Sept 28 – Oct 1 2023; Vienna.

1. Stein LI, Test MA. Alternative to mental hospital treatment. I. Conceptual model, treatment program, and clinical evaluation. Arch Gen Psychiatry. 1980;37(4):392–7. doi: 10.1001/archpsyc.1980.01780170034003
2. Falloon IRH, Montero I, Sungur M, et al. Implementation of evidence-based treatment for schizophrenic disorders: two-year outcome of an international field trial of optimal treatment. World Psychiatry. 2004;3(2):104–9.
3. Drake RE, Bond GR. Supported employment: 1998 to 2008. Psychiatr Rehabil J. 2008 Spring;31(4):274–6. doi: 10.2975/31.4.2008.274.276
4. A közösségi pszichiátria kézikönyve [Handbook of Community Psychiatry]. In: Bulyáki T, Harangozó J, editors. Awakenings foundation; 2018. 398 p. Hungarian.
5. A közösségi addiktológia kézikönyve [Handbook of Community Addictology]. In: Bodrogi A, Harangozó J, Bulyáki T, Falloon IRH, editors. Awakenings Foundation; 2014. 152 p. Hungarian.
6. Spencer LH. Living with voices: 50 stories of recovery. In: Romme M, Escher S, Dillon J, Corstens D, Morris M, editors. PCCS Books; 2009. 346 p.
7. Clark M. Co-production in mental health care [Editorial]. Mental Health Review Journal. 2015;20(4):213–9. doi: 10.1108/MHRJ-10-2015-0030
8. Bulyáki T. Utazás a mentális zavarból a felépülés irányába. [The journey from mental disorder to recovery]. Eötvös Kiadó; 2023. 313 p. Hungarian.
9. Harangozó J, Bodrogi A, Nemessuri J, Bulyáki T. A semmelweis Egyetem Közösségi Pszichiátriai Centrum és az Ebredések Alapítvány tevékenységének bemutatása [Activities of the awakenings foundation and the community mental health centre of Semmelweis University of Medicine]. Psychiatr Hung. 2008;23(4):224–30. Hungarian.
10. Kovács ZA, Váradi E. Rehabilitációs szemlélet a pszichiátriai gondozásban: bio -behaviour módszerek és a kognitív rehabilitáció távlatai. [Rehabilitation approach in psychiatric care: bio - behavioral methods and cognitive rehabilitation perspectives]. In: Váradi Enikő: Pszichiátriai gondozási kézikönyv. [Handbook of Psychiatric Care]; Budapest, Oriold és Társai Kiadó; 2012. P. 29–68. Hungarian.
11. Endre S. Integrált közösségi ellátások szerepe a felépülésben — egy hatékonyságvizsgálat tükrében [The role of integrated community care in recovery - in the light of an effectiveness study]. Doktori (Ph.D.) értekezés, Doctoral (PhD) thesis; PTE-BTK Pszichológia Intézet; 2020. 198 p. Hungarian.
12. Ács A, Petri G. Szemléletbeli különbségek a pszichiátriai betegek megítélésében és a szektorközi együttműködések szerepe. [Attitudinal differences in the judgment of psychiatric patients and the role of intersectoral cooperation]. In: Perlusz A, editor. Kutatási beszámoló a pszichoszociális fogyatékos személyek társadalmi helyzetét feltáró országos kutatásról. [Research report on national research on the social situation of psychosocial disabled persons]; Budapest: A Gyógypedagógia Fejlesztéséért Alapítvány; 2017. P. 43–58. Hungarian.
13. Budai I. Az interprofesszionális együttműködés és a szociális munka [Interprofessional cooperation and social work]. Esély. 2009;5:83–114. Hungarian.
14. Ács A, Bányai B, Bugarszki Z, et al. A mentális problémával küzdő emberek és a magyar pszichiátriai ellátórendszer bemutatása [People with mental health problems and the Hungarian psychiatric care system]. Perlusz A, editor. A pszichoszociális fogyatékossággal élő személyek társadalmi helyzetét feltáró országos kutatásról [Research Report on National Research on the Social Situation of Psychosocial Disabled Persons]. Budapest: Gyógypedagógia Fejlesztéséért Alapítvány; 2017. P. 58–66. Hungarian.
15. Gomory T, B. Erdős M, Kelemen G. Kényszer vagy együttműködés? Vitatott kérdések a közösségi pszichiátriai
16. ellátás gyakorlatában [Coercion or cooperation? Contentious issues in community psychiatric care practice]. Esély. 2006;5:101–29. Hungarian.