Česky
Last year he voluntarily left the director's chair of the largest psychiatric facility in the Czech Republic after 14 years and embarked on a greenfield project that has not been explored in the Czech Republic. Martin Hollý, a psychiatrist and sexologist, gained his management experience in state services and will now apply it in the private sector. He is also still committed to the ideas of psychiatric care reform, which he helped to create and promote. Dr. Hollý is part of the team that is launching the unique project of the Mental Rehabilitation Centre in Beroun, which is part of the AKESO healthcare holding. "We want to provide unselected acute psychiatric care while covering the backs of outpatient and community-based care initiatives in the region," he says, adding that the private sector initiative is actually the first to begin to fulfill the state's mental health strategy. In an interview with Zdravotnický deník, Martin Hollý admits that it takes courage to build a psychiatric facility on a greenfield site and explains how they intend to resist the development of institutional "bad habits." He and I discuss in detail the problems of outpatient and inpatient psychiatric care in the Czech Republic and mental health care more broadly, and we also assess progress in health care reform. We then revisit the Beroun centre and its culture of environment, specific programmes and technological "gadgets". In the finale, we touch, among other things, on the increase in the number of gender identity disorders and other diagnoses that Czech psychiatry will have to deal with in the near future.
You were the director of a large state institution, the Bohnice Psychiatric Hospital. Why did you decide to change your workplace?
It was time, or so I felt. The directorship of large institutions should be limited in time. It should be clear when the person in question will quit. It's healthy for the institution and for the person. My idea is that he should stay in office twice for five or six years, with a certain option, unless he has some trouble. That is, there would be no selection process in between, just confirmation of continuation. Five years is sometimes a very short time for a major project. The end should be naturally expected, otherwise it raises terrible uncertainties and questions.
So what was your ending?
I wrote to the Minister about my decision and communicated it internally to the hospital to keep the uncertainty to a minimum. I made arrangements with the current director to see if she would apply for the tender. She was my internal candidate, personally ripe for the job. I made sure that the change was clear to everyone and not a surprise. I had originally wanted to leave two years earlier and wanted to make the move for my birthday, I would have turned 50 in June 2020. But the covid came and I postponed leaving because it didn't seem appropriate at the time.
"Maybe even if I was seventy I would have gone for it. It's a unique opportunity."
Are you the kind of person who closes the door where you leave off and doesn't come back?
I'm the type that can close doors. I don't have any internal problem with that, even though I worked in Bohnice in various positions for 26 years, half of my life. But Bohnice is a huge place. I closed some doors right away so I could focus on new challenges. On the other hand, as an economic migrant, Bohnice is a kind of family for me. I came to Prague from Slovakia once on my own, without any background. So I care about them. I care about sexology there and I try to help where I can be useful. Until December I still had an outpatient clinic there, which I am now transferring to a new location.
But you could have told yourself that after 50 you would slow down and take care of patients in the outpatient clinic. Instead, you embarked on a completely new project, unique in the Czech Republic and untried.
I thought that this might be the last five years, between fifty and fifty-five, when it is possible to take a breath and enter something for the next decade. The project also made sense to me on many levels. If a private entity wants to do something for mental health in such a complex way, it would be a shame to put it behind them. Maybe even if I were in my seventies, I'd go for it. It's a unique opportunity. The other level is the - perhaps a little naive - idea of capitalising on previous experience, building on greenfield sites and trying to change the whole culture of care delivery for people with mental illness too.
We are building a regional system
Is it easier to implement your ideas and concepts in a private or public healthcare provider environment?
More than the public or private axis, it is important that we build something without history. If a public hospital decided to build a psychiatric facility, it would probably be in a similar position. But I don't mean to diminish the difference between public and private. I myself can only compare it with Mr Zavalianis's AKESO company, and here it is indeed possible to convince the owner by argumentation and to prepare a project in a very short time. Bureaucracy does not get in the way here, which is an obvious and great advantage.
There is one more level, why participate in the project of the Mental Rehabilitation Centre in particular. The Beroun region is still a bit of a psychiatric desert, services are lacking there. I don't know if I would go to a project that would be in Ďáblice or Pardubice. We encounter this when we establish relations with the local community. We've had a few seminars there, and everybody there welcomes the fact that outpatient and community care initiatives will have the backing of the inpatient facility. It confirms that there is a hunger for such a service.
"There have been seven major refurbishments under IROP but nowhere has greenfield inpatient capacity been created."
Otherwise, nothing has been created on greenfield sites?
Mental health care reform, apart from the well-known building of CDZs (Mental Health Centres - editor's note) and moving patients into the community, also envisaged moving acute care to general hospitals. Under the last round of the IROP programme, seven major renovations were carried out and the environment in teaching and regional hospitals was humanised. However, nowhere has greenfield bed capacity been created. Nor have any of the smaller hospitals, which have not yet had a psychiatric department or psychiatric clinic, raised the banner of psychiatry and built an acute care unit. Thus, the private sector initiative was actually the first to begin to implement the national mental health strategy. It takes courage to build a psychiatric facility on a greenfield site; it is not easy.
How does this project fit in with the ideas of psychiatric reform, which has deinstitutionalisation in its crest, when an institution is actually being created here?
The communication of the reform has symbolically revolved around the CDZ, with a lot of talk about downsizing or closing down institutions and moving care into the community. The other line of reform, however, is to break up overly large inpatient facilities into smaller units so that acute care, which is often not replaceable by community-based care, even when well run and densified, is close to where the citizen lives. On the map of Bohemia we now see the big Bohnice, the big Dobřany, the smaller clinics in Prague and Plzeň, then also Budějovice, Písek, a few beds in St Petersburg. From this point of view, the creation of an inpatient facility is in line with the ideas of service transformation.
I have come across the view that this is too large a facility. Its internal structure of separate service segments, however, is sufficient to prevent the development of institutional "bad habits". Neither the owner nor the board of directors see psychiatry as a hugely profitable venture that will bring in big money for the whole group, but the project has to make a living. We are making a certain compromise in the number of beds, on the other hand there will be units of specialized care, which is lacking in the regional context. I'm thinking of services for people with borderline personality disorder, obsessive compulsive disorder and other specialised therapeutic programmes including adolescent issues.
What was your professional input into the project?
I went into the project with the idea that we would take a broader view than building a luxury inpatient facility. From the beginning, we are building a regional system that will be tied to the inpatient facility and therefore be able to provide a safer and more coordinated service in the community. And now I don't just mean mental health centres, but out-of-hospital services in general. We will be able to provide long and short inpatient stays efficiently in our facility because we will have some movement of patients prior to hospitalization and then coordinated and follow-up care. That care doesn't have to be in-house, but we will actively interact with regional services, whether that's physicians, clinical psychologists, social services, health and social services. Where those services are not there, we will supplement them with our own initiatives. I don't want to sound grandiose, but we are doing everything we can to be able to say in five years' time that we have succeeded.
"It's good to have inpatient facilities as some kind of backbone that other services can lean on."
What relationship will the centre have with other services in the region?
In 2005, I created a concept for the development of a medium-sized inpatient facility; it was an interesting intellectual exercise for me. I wrote there that an inpatient facility can be very sensitive to whether or not the mental health care system in the region is working. Patients with mental illness partly fall through the filter of services and at the end is the inpatient facility, or now the hospital, which is the litmus test of how services are working in that particular place. To what extent can they capture patients and possibly treat them comprehensively. That is why it is good for the inpatient facility to be some sort of backbone on which other services can lean. Our centre will also have meeting spaces, and these will be more than small in number. Because it is often about practical things like having somewhere to sit down and being able to discuss plans or discuss patients. I would not like to see the system of District and County National Institutes of Health coming back. The ambition is for an informal co-ordinator role that works on some natural attraction. Of course, if there is a need, we will come to colleagues, if there are 50 of us, we will meet at our place.
Are you still talking to your colleagues, perhaps within the psychiatric society or the ministerial team, about reforming psychiatry, regardless of your current position? How do they see your new role?
That's a good question and reflects the uncertainty I had. As I was gradually preparing for my departure from Bohnice, delayed by covid, I was at the same time actively winding down my work in some of the so-called reform structures, or rather my collaboration with the ministry in this area. And after the actual departure, I humbly asked myself how much I was still needed and wanted in the matter of reform, since I no longer had the strength of the director's chair. Although I was not unknown in the professional community, I subjectively felt that the chair suddenly gave a person negotiating and argumentative power. When you say something, it suddenly sounds different when you are the director of Bohnice. I was touched when questions came like: Can we still count on, for example, in psychiatric outpatient clinics, that you would continue to cooperate on some systemic things?
In contrast to the relative comfort of being a director, where there was a lot of work, but in a fairly established pattern, my diary is now much more chaotic. I realise that I have a much harder time planning activities not primarily related to building CDR. Of course, I also have a slightly changed perspective. Maybe I'm over-psychologizing or reflecting on the situation, but I wonder if I'm introducing an unsystematic bias. We're all human, I'm kicking on a different playing field now than I did for Bohnice. But I try to look at this bias and actively counter it.
Strengthening clinical psychologists would relieve the psychiatrists
Let's review the psychiatric services available today. Let's start with the network of outpatient services. Is it sufficient?
I don't know if all outpatient clinicians would agree, because we're going through a difficult communication period in this particular sphere, but for the way the system is built now and the many new challenges the times bring, the network of outpatient mental health professionals is sparse. These professionals are not necessarily outpatient psychiatrists. If we look around the nearby world for inspiration in the mental health service system, we see that our network of contract clinical psychologists is at a third of the number we would need. In recent years, the insurance industry has opened its doors and more than doubled their numbers. Expressed in raw numbers, we have roughly 900 psychiatric outpatient clinics and 250 clinical psychologist clinics, of which there were originally only about 120. However, the number of clinical psychologist outpatient clinics should be at least the same as the number of psychiatric ones. Clinical psychologists mainly provide psychotherapy and cannot have 700 people in their tribe if their work is to be meaningful. Strengthening them would also help and relieve the psychiatrists. But we are now moving in an order of magnitude different capacity. If we increased the number of clinical psychologists to the number mentioned, then perhaps we could validly debate that the number of psychiatrists in outpatient clinics is sufficient. But now it clearly is not.
"The number of clinical psychologists in outpatient clinics should be at least equal to the number of psychiatric ones."
Is the solution better funding, or are there just not the people?
For a long time, health insurance companies were unwilling to expand the network of clinical psychologists, claiming that it was sufficient. They made do with what was there last year and based their decisions on some historical norms rather than looking at the needs of patients and the functionality of the system. This led to the fact that although there were quite a few psychologists in the faculties, relatively few were choosing the direction of clinical psychologist and often remained in the grey area of counselling. Some even trained in one of the psychotherapeutic streams, but did not enter the clinical education system and therefore cannot be health service providers. Attestation in clinical psychology is demanding, taking five years to prepare for, and attestation in psychotherapy is also time consuming. Now that the insurance industry has opened its doors, it has triggered the movement of many clinical psychologists who have been working in inpatient settings into the private sector. Inpatient facilities, and by extension the entire system, are facing a shortage of training positions for young colleagues because of this. Although the number of outpatient facilities with training accreditation is increasing over time, without collaboration with inpatient facilities, training in clinical psychology is not possible. And, for example, in Bohnice, we were completely maxed out for trainees.
"Psychotherapy outside the health care system is a grey area, a no-man's land."
Is the shortage of people a temporary problem, or is it more likely to get worse?
I believe the situation will improve. The door from insurance companies is open. People who, for example, are certified in clinical psychology and knew they would not get a contract are parked with private psychotherapists, a parallel system. Psychotherapy outside the health service is a grey area, a no man's land. We don't just have to wait for new people to be educated, some of them can move from the private sector, paid for by cash, to public health insurance, which doesn't pay that badly today. Better payment for group therapy would also be a quick fix, therapists would be incentivized to do it, and their capacity for care in the system could increase.
There are, of course, regional differences in the availability of outpatient care...
Regional densification of the service network varies. In some more remote areas, psychiatric outpatient clinics are almost unavailable. Even established outpatient clinics are not in demand. This reflects the sometimes fatal shortage of specialists. But this is not only a problem in psychiatry.
It is not easy to open a new outpatient clinic in Prague, but in some areas the insurance company would not object. Psychiatry is uncapped and paid by performance. It is a support for the field and the original fear of its abuse has not been confirmed. But there are only a certain number of hours in a day, and psychiatry is not a field where patient encounters can be significantly shortened.
"Doctors interrupt the patient at the eleventh second; without interruption, the list of symptoms lasts 29 seconds."
A doctor's head full of stimuli needs to rest...
I'm reading a book on decision making right now, and there was research cited that said doctors interrupt patients at the eleventh second after they describe their symptoms because they already know what they need. When doctors weren't allowed to do that, it took 29 seconds to list symptoms. So the time isn't that long, we just don't have a lot of patience. Needless to say, the situation is not conducive to satisfaction on either side.
Psychiatrists should take even longer to listen to a patient, right?
Yeah, we can't do that there. A healthy limit is treating fifteen to twenty patients a day. In psychotherapy, you can't have more than twenty to twenty-five clients a week for long periods of time. The loosening of regulations by insurance companies has helped us, but it hits a limit that can no longer be exceeded.
People with somewhat different backgrounds than we have just discussed are also providing their mental health services. Should their activities be regulated by legislation?
There has been a working group on psychotherapy at the Ministry of Health for two years, and very interesting proposals have come out of it. A three-stage model of psychotherapy has already been published in the Bulletin, which brings nurses, health and social workers and addictionologists into psychotherapy. In fact, for a long time, the cultivation of health care interventions has remained either highly specialized psychotherapy or nothing at all. In between, the lower grades have now been incorporated.
There is also an important proposal that has already gone through the comment process at the Ministry of Health and has been sent to the Ministry of Industry. It defines a tied trade in psychotherapeutic counselling, which could cover a grey area in which the state still has no control over who sticks a psychotherapist sign on their door. Then, when you look at the CVs of some of the people who advertise themselves as psychotherapists, you find that they have attended two weekend training courses. Legislative changes could help capacity but also increase client safety.
Long-term inpatients are being discharged
Moving on to other services. How do you feel about the creation of 30 mental health centres?
As a success and a great distance that has been travelled. Where there are mental health centres, psychiatric care for patients with serious mental disorders looks radically different from what was previously the norm. It reduces the need for hospital admissions, not so much in number as in length. Regionally, however, it is very uneven. Some parts of the country are uncovered. The cause is primarily staffing; there is a need to provide people for the creation of other downstream social services. In terms of health care reimbursement, this has been resolved, thanks to a shift on the part of the health insurance companies, which over the years have several times crossed their shadow, or rather their internal limits on how procedures can be created and what can be reimbursed.
So the healthcare industry has done its part. Insurance companies have changed their thinking and set the necessary payments. On the other side - social services - there is no such progress, for example clients have problems with housing. Does this not threaten the fate of the CDZ?
I agree that this area needs to be improved, although my opinion is not representative. CDZs provide a health and social service, or such an interface. Many social workers, or other people in that multidisciplinary team, can find some form of housing for clients. Often in the regions, it looks like the centre has higher dozens or lower hundreds of people under its care who are from one or two districts, and for every village or township, there are two or three people. Globally, these would be big numbers, but when they are diluted down to the village level, they usually know that they have a person coming back from the hospital. If they get professional support, they can find a council flat more easily. It would undoubtedly be good to make such support more structured, but there is no hard wall in the way, it can be worked with. That's the magic of community work.
What should be the role of stand-alone psychiatric hospitals and what should be the role of wards within mainstream hospitals?
In general, but it has its individual differences in each region, acute care should be linked to the complement of the general hospital. By this I mean a hospital that can cover the imaging, laboratory and somatic investigations and diagnostic needs of patients on a consular basis. Acute psychiatry is an acute medical specialty that belongs to the core and therefore belongs to the hospital. The psychiatric department takes the consular service in the hospital to a whole new level. This is different from having an outpatient psychiatrist come in once a week and write a referral.
"The current psychiatric hospitals that are stand-alone should rather be reduced or focused on medium-term specialized programs."
The current psychiatric hospitals that are stand-alone should be reduced or focused on medium-term specialised programmes, or there should be little or no long-term care. But the current setup is that it's like aftercare, but with a payment benefit until the 120th day of stay. Then we have aftercare, which is long-term. It's up for debate whether that threshold should be the 90th, 120th or 180th day, but we know that it's not two years or five years. In particular, we're dealing with addiction issues, which we can't really replace with community care yet, because there's often an important removal from the natural environment, and also programs for people with more complex needs. We don't have older patients being treated in the system. But they are often polymorbid people, and as soon as they have one psychiatric diagnosis they are immediately put into gerontopsychiatric care, and yet they should be given multidisciplinary geriatric care in the first place. The question is to what extent we can use the current psychiatric hospital premises for such services.
We must not forget about forensic psychiatry, i.e. patients in protective treatment, who are a minority compared to the total number of people living with mental illness, but relatively numerous in hospital care. Their hospitalizations can be similar to long-term ones, as they are often complicated.
How has DRG funding changed psychiatry?
The original idea was: Let's, as we used to say with hyperbole, legalize acute care in psychiatric hospitals, because that's what they do there anyway. We wanted the insurance companies to learn that psychiatry costs something and then on the other side, maybe the directors of the regional hospitals or the private providers would realize that it's not such a bad business and that at least it wouldn't be loss-making. Thanks to the Director of the Reimbursement Department of the VZP Mrázek and the Director General of the VZP Kabátek, it was possible to achieve that the psychiatric DRG is liveable. There is never enough money, but there has been a significant change. The old DRG was frighteningly disadvantageous. I remember in mid-2017 we switched to acute care with 177 beds and then received less money for that than for follow-up care. We discussed it with the insurance companies, and although they didn't give us anything at the time, they realized that it couldn't continue like that. However, I am convinced that without this economic risk, the current system would not be as sophisticated.
"Of the approximately 8,100 psychiatric patients in the country, ten percent stayed in hospital for more than two years. A terrible number!"
Going back to deinstitutionalization, who does it help the most?
It has succeeded in discharging a large number of people who have been hospitalized for more than two years, or even more than five years. We first had to look the truth in the eye and get a picture of how long patients actually stay with us. We always operated with an average hospital stay, but this was calculated from the patients discharged. For those who stayed, a maximum of 365 days was counted, even if the person in question had lived there for 20 years. I have thought at length about the mechanism by which we came up with an average of 56 days, or 62 days, when that was obviously not enough for the number of people who were staying with us. We saw the first real picture as of January 1, 2018, when we discovered that of the approximately 8,100 psychiatric inpatients in the country, ten percent had been in hospital for more than two years. A terrible number! It was clear that something needed to be done about it. And we did.
So how many patients are in hospital today and how many have been discharged?
Perhaps it's better to express it in terms of the number of days in psychiatric hospitals. Between 2010 and 2019, the annual number fell by 209,000, or almost 590 patient-years. We focused mainly on the group of patients that mental health centres can accept, or people with psychosis. The number of those who stayed in hospital for a long time was reduced to a tenth.
The new centre: culture, comfort and technology
Institutionalisation is not just a question of length of stay, but also of a kind of culture of the environment. Is this an aspect that you want to change in the new project?
When I joined Bohnice, I was quite horrified at how the whole system worked. Patients were being moved between wards according to the main characteristic of the institution, namely that its needs prevail over the needs of the clients. Until then, my experience had been in my native Slovakia. My father was the director of a small hospital on the Slovak-Hungarian border, where he worked without any systemic transformation anchoring. He managed to set up sheltered housing and sheltered employment. Then I worked in Trenčín, where they had a psychotherapy department with its own inpatient ward. In Bohnice, Prague, I joined the sexology department, which had a life of its own, but I thought that it was probably impossible to change the institutional approach. Eventually I became director and saw how difficult it was to put the needs of the patient at the forefront in such a large colossus.
I believe and am doing everything I can to avoid these institutional elements in a project that is smaller and being built on greenfield sites. However, I can imagine that some much smaller facilities and some non-medical facilities still have an institutional culture because it is not just due to size. I believe that the critical experience of Bohnice will help me, even though things have moved on for the better there. The project in Beroun is set up differently from the beginning, which is due to its internal structure and how we set the culture of staff behaviour.
Visualisation of the project of the Mental Rehabilitation Centre in Beroun
A specific element of the new centre may be the level of comfort you will be able to provide to patients. What will it consist of?
In Bohnice, I learned to provide the best possible service for critically little money. Here, I sometimes think about how to make money make sense. I wouldn't say this is a characteristic of the private sector, but rather of how AKESO operates. My paradigm is that every person who comes to us should get more comfort and, let's say, more coordinated service than is common in the Czech Republic. We have double rooms with amenities that are of high quality workmanship, with available television or refrigerator.
Sample room
Controlled lighting will be installed in the building. All the data available to us raises the expectation that the very stay will be therapeutic thanks to the synchronization of human biorhythms by circadian controlled full spectrum biodynamic lighting. And we know that disrupted circadian rhythms are a cause or concomitant of many mental health problems. I don't know of any other similar project in Central Europe at least. I am curious about the results of our research that we are planning in this area.
"We also want to fill a gap in the supply of services for people with mental illness in the area of overdiagnosis."
Most services will be allocated in one location, including a sports hall and swimming pool, which is not generally standard in such facilities, as well as a conference room, gym and general fitness area, and a large area with creative workshops ranging from art and music therapy to woodworking and ceramics. There will also be a shared dining room for staff and patients. Of course, patients who are in a condition where they need their rest and/or have unpredictable behaviour will have their meals on the ward.
We also want to fill a gap in the range of services for people with mental illness in the area of overcare. As the director of Bohnice, we have seen many times that people have asked for the above standard. No one, except the National Institute of Mental Health, has filled this gap. We will have a portion of single rooms and then a portion that will run in suites that can be unashamedly described as luxury. And that's while maintaining high standards of security.
Can you mention any other technological advances?
Maybe I don't talk about them so much, I know that we still have a lot of work to do to test and put them into operation. In psychiatry, we must always strike a balance between human freedom and intimacy on the one hand and the safety of the care provided on the other. Often the two views are difficult to reconcile. Technology helps us to do this. For example, rooms will have a handle on the inside and a ball on the outside. So only the patients who live there can get in. This is a common problem, especially in acute wards, where patients enter rooms other than their own. Similarly, RFID (Radio-Frequency Identification - editor's note) technology will help us to open cabinets. We can deal with where a patient can or cannot go in a much more sophisticated way than moving and placing them somewhere.
We are also creating a large project for virtual reality treatment. Here we are in line with the latest global trends. I would also mention the Mindwell project, which is remote, internet-delivered psychotherapy for individual disorders. In a simpler module, we will use it for hospitalised patients. There will be a television in each room, where it will be possible to watch educational programmes related to a particular person's problem and thus support one's own treatment.
"To say that staffing is not a problem and that I am busy would be naive and premature, but our project is attracting people."
Technically and technologically, the project looks very promising. Ultimately, however, its success will come down to the people - the medical staff. Are you recruiting well?
I have key people. To say that staffing is not a problem and that I am busy would be naive and premature, but our project is attracting people. We're hearing from people who are open to change. We haven't had to target recruitment activity yet. We interview potential candidates quite frequently.
Situation on site in August last year
Will there be any limitations on the range of patients you will accept, for example compared to Bohnice?
I would like us to meet the needs of the region in acute care, i.e. not to say that "this is an inappropriate patient for us". So we will provide unselected acute psychiatric care. Obviously, we can't do that without collaboration with other inpatient facilities.
The times are good for psychiatry
Do you think that the years we're going through now - the covid, the lockdowns, the tensions in society, the war on our doorsteps - that this is some sort of reservoir of future patients?
They say that times are good for psychiatry. There's some truth in that, though it's very simplistic. And we haven't touched children's services at all.
I assumed you wouldn't have children at the center.
It seems unfair to open a facility this large and complex without helping child psychiatry. We want to help. I'd like to solve all the problems of the world, but I have to keep my feet on the ground. We are venturing into residential care for children and inpatient care for adolescents, along with specialized programs, especially for eating disorders and self-harm. There is also undoubtedly a huge increase in gender identity disorder. We see this every day and there is as yet no reliable, scientifically verified explanation as to why this is the case.
"Those of us who have been ripped away from our mothers and have not gone through primary bonding are probably making some kind of parenting mistake that we are not even aware of."
There's been a lot of talk about different gender identities lately, but I guess that's not the point?
No, though of course that's some layer that makes up the whole picture. But we don't know much about it. There are several theories, some of which smack of conspiracy, such as hormones in the drinking water. They get there from poorly treated sewage, where hormonal contraceptives have actually been shown to be present. I have a theory of my own that we who were taken away from our mothers and didn't go through primary bonding are probably making some kind of parenting mistake that we are completely unaware of. Like the transmission of holocaust trauma. It goes beyond our perception. Further, as a society, we are creating virtually unattainable role models and increasing social pressure on girls' identities to the point of launching girls into other identities. These role models used to be on the covers of magazines, but now they are constantly in plain sight on mobile phones and girls are escaping into either male or TO identities. We can speculate about this, but we have no prior experience and don't really know much about it.
If the times are favoring psychiatry, does that mean that there will be more patients of certain diagnoses in the coming years?
The incidence of anxiety-depressive disorders is increasing, where we can talk about a disease of civilisation. But I don't foresee a rise in serious mental disorders such as schizophrenia, bipolar disorders, etc., which seem to occur in a certain percentage in every age and culture. I expect an increase in moderate to mild mental disorders.
Primarily this will put a strain on the outpatient system and psychotherapy and psychological services. There will be a need to develop distance care, self-help. We cannot concentrate on calculating how many extra beds we will have, which is the Czech way of dealing with things, that if we do not have care under our roof, it is as if it does not exist. We need to focus on mental resilience, especially in child rearing, creating understandable self-care programmes and involving informal help. Things we cannot change should not be seen as too stressful. We are not going to find two thousand more psychiatrists to cover the entire need for mental health care. What is important is to support a spectrum of services from psychotherapeutic help in outpatient clinics, through stepped psychotherapy to somewhere between psychiatric and inpatient psychiatric help.
Author: AKESO
