Current Concerns in Icelandic Psychiatry Magnus Haraldsson, M.D. Psychiatrist Department of Psychiatry National University Hospital Reykjavik, Iceland Dear colleagues. My name is Magnus Haraldsson and I am an attending psychiatrist at the Outpatient Psychiatry Clinic at the University Hospital in Reykjavik. I received my medical and psychiatric training in Iceland and in the United States. I am going to tell you a little bit about psychiatry in Iceland and what I think are some of the main concerns our profession is facing in Iceland.

Demographics Population of Iceland ~ 290.000 60 % live in the Capital Area (Reykjavik) 1 large University hospital and a few rural hospitals 1 Psychiatric Department in Reykjavik and 1 small Department in the town of Akureyri (pop 35000 in the area) Total number of psychiatrists ~70 So just a little bit of demographic information. As you may know the population of Iceland is very small or a little less than 300000 and it is slowly growing by about 0.5% per year. Most of the inhabitants live in the capital city Reykjavik or in the area around Reykjavik or approximately 60% of the people. In Reykjavik there is one fairly large University Hospital Operating in several buildings around the city. We also have a few small rural hosptials located on each side of the island. There is one psychiatric department in Reykjavik which is part of the University Hospital System. There is also one small Psychiatric unit in a hospital in the town of Akureyri on the north coast of the island draining an area of about 35000 people. The total number of actively practicing psychiatrists is around 70 and the total number of members of the Icelandic Psychiatric Association is around 85. There are 20 practicing female psychiatrists.

Icelandic Psychiatry Most psychiatrists practice in Reykjavik (90%) Most psychiatrists work both in private clinics and state run clinics/hospitals Most psychiatrists are trained in Scandinavia, UK or USA 40% are involved in research Access to psychiatric care is good in the Reykjavik Area but there is lack of services in rural areas The psychiatric services in Iceland are highly centralized. About 90% of the psychiatrists practice in the Reykjavik area. Most psychiatrists have a split practice – working part time in state run hosptitals or clinics and part time in their own private practice. Others are either working full time within the national health care system or working full time in private practice. Most Icelandic psychiatrists received their psychiatric training in Scandinavia (mostly Sweden or Norway), in England or the United States. So Icelandic Psychiatry has been influenced both by America and Northern Europe. Academic interest has gradually been increasing over the years and approximately 40% of Icelandic psychiatrists are involved in research mostly part time. International collaboration has been increasing in recent years. Generally one can say that access to psychiatric care is good in the Capital Area. In Reykjavik we have a busy outpatient clinic providing urgent care and short term follow up. Long term follow up is mostly handled by psychiatrists in private practice and general practicioners. Unfortunately the access is not nearly as good for most rural areas. Large areas of the island have no psychiatrists or psychologists. Telepsychiatry is only on an exprerimental level in few areas and is something we need to pay much more attention to.

Problems Financial - Political Increasing cost of new medications Growing number of people on disability benefits due to psychiatric illness The government has ordered cuts in the health care budget Two different ministries responsible for individuals needing long-term care Department of Health and Department of Human Services No Mental Health Act exists in Iceland Increasing cost is something everyone is concerned about and like in othe countries the cost of new medications is increasing. The amount of psychiatric medications prescribed has more than doubled since 1993. This is mostly due to increased use of SSRI medications. This has attracted a lot af attention from politicians some of whom have critizised the increasing use of antidepressants and questioned the validity of this form of treatment. At the same time the use of lipid lowering drugs has also more then doubled without causing the same fuzz among politicians. Nobody things there is anything wrong with that. The number of people on disability benefits due to psychiatric illness has been increasing rapidly in the past 1-2 decades. The fasted growing group are people with affective disorders and anxiety disorders. The Icelandic government has repeatedly ordered cuts in the health care budget and the University Hospital has had to shut down units and lay off staff. In the past 10 years about one hundred psychiatric hosptital beds have been closed which is around 20% of the total number of beds. Some of this is due to increase in community living support and increased focus on outpatient treatment. But this has also led to shortening of hospital stay and increase in readmission rate. In Iceland the responsibility for health care is carried by two different ministries. The ministry of Health being responsible for the basic health care and specialist care and the ministry of Human services responisble for disability benefits, supported living, half-way houses etc. This has led to problems with providing optimal care for people with long term disability when people are both in need for specialized medical and hospital treatment as well as community support. Another politcal issue and a big one is the fact that there is currently no Mental Health Act in Iceland. This is partly due to some resistance by some leading pscyhiatrists who believe that a Mental Health Act will increase stigma towards people with mental illnesses. In my opinon that is a misunderstanding. In order to provide high quality, consistant care and protect the rights and benefits of people with mental illness we absolutely need a mental health act to set the standards and basis for all mental health professionals to work on.

Problems System issues Strong centralization - only one major psychiatric hospital Lack of community psychiatry Lack of half-way houses and other community support Lack of rehabilitation opportunities (social skills training, vocational rehabilitation etc) As I said earlier there is only one major psychiatric department which belongs to the University Hospital System in Reykjavik. This means that the department has no competition or comparision. In my opinion there is a lack of cooperation with the primary care sector and also with the private sector. Until recently community psychiatry was basically nonexisting in Iceland. In the past few years there has been growing interest in building up this kind of services. Several small agencies have been experimenting with this kind of service i.e. Nurses and social workers working in primary care and also a couple of volenteer and former consumers have also been providing community services. These services are crusial for patients with severe mental illness who are not candidates for and will not come to outpatient clinics and private offices. I received my psychiatric training in Madison Wisconsin where they have a very strong community psychiatry program – a program which has been a prototype for many other community support programs (CSPs) in the United states. What also is lacking in Iceland are more half way houses and supported living housing as well as more rehabilitaton opportunities such as social skills training for patients with severe mental illness and vocational rehabilitation. Fortunately there is gradually increasing awareness of the need for these services but politicians have been slow to respond.

Problems Professional Lack of specially trained mental health nurses, social workers and occupational therapists Lack of organized teams of mental health workers in the community Lack of organized continuing education programs for mental health professionals Stigma among health professionals Iceland has a good number of well trained psychiatrists but there is still a lack of other specially trained mental health professionals. We need to improve the training and education of psychiatry nurses, social workers and occupational therapists. Most people in these professions are working in the hospital setting and we need more of them in primary care and also in the future community programs. Due to the small size of the country there is a lack of continuing education programs for mental helth workers. Icelandic pscyhitrists get financial support to attend international conferences and the role of the pharmaceutical industry in supporting this is highly controversial. The opportunites for other professions is limited. Stigma among health professionals is still high but is gradually decreasing. Psychiatrists can help by strengthening the consultation-liasion services and educating other health professionals about mental illness.

Forensic psychiatry in Iceland 1 forensic unit in Iceland (8 patients) Currently no non-forensic security unit A 6 bed security unit soon to open A small mobile team of mental health professionals will be linked to the unit Lack of psychiatry care within the prison system in Iceland Forensic psychiatry is a rather young profession in Iceland and only a couple of psychiatrists have received training in forensic psychiatry. The first forensic unit was opened in 1990. Forensic patients had been sent to hospitals in other countries mainly Sweden before that time. It is a security forensic unit with 8 beds and most of the patients have commited serious crimes and been found to be incompident to stand trial due to severe mental illness. Currently there is no non-forensic securtiy unit in Iceland. One such unit will open this spring and there has been increasing pressure from the system. Potentially dangerous patients have been admitted to general wards and this has caused tensions both among staff and patients. The new unit will be intended for the most difficult patients who do not belong in the forensic system and not in the general system. The plan is to have a small mobile team working with this patient group in the community and identify as soon as possible the individuals who need admission. Pscyhiatric care within the prison system has long been limited and needs to be improved with more stable and continuous professional staff attending to prisoners suffering from mental illness.

Conclusions Psychiatrists need to inform and influence policy makers The responisbilies of various government agencies for different levels of services need to be clearer We need stronger outpatient services and community support programs Strong need for improving the training and continuing education of mental health workers So a few conclusions: Icelandic psychiatrists need to do a better job of informing and influencing policy makers about the most urgent problems and concerns in Icelandic psychiatry. The responsibilties of the various government agencies for different levels of services need to be clearer. Outpatient and community programs need to be strengthend. There is a strong need for improving the training and continuing education of all mental health workers not just psychiatrists.