Spotlight
on Bulgaria
Population: 6,9 MIL.
Depression included
in the health plan
Goverment lead on mental health with cross-ministerial responsibility
Systematic data collection
on depression
Data on mental health
used for planning
Patients involved
in national plan or strategy
Access to financial aid
for carers
Access to remote support
for patients
Remote prescriptions
renewal
The paradox in the development of the psychiatric system in our country is that during the totalitarian health care system some form of bio-psycho-social approach has found expression in the complexes of the hospital-dispensary and developed occupational therapy - the so-called occupational health farms (TLS), although strongly subject to the principles of isolationism and stigmatization of people with mental disorders. In the 1990s, these complexes were dismantled and largely looted (especially TLS) due to a lack of a clear concept of reform and resistance to change by various stakeholders. As a result of all this, mental health services are currently chaotic, of poor quality, inefficient and do not meet the requirements for modern psychiatric care. Isolated examples of good practice of individual structures with a developed rehabilitation and occupational therapy base do not guarantee sustainability, but are rather the result of individual efforts and favorable local conditions.
New technologies for the treatment of mental disorders go far beyond pure medical intervention, which in psychiatry is mainly limited to drug therapy and some non-drug methods - transcranial magnetic stimulation and electroconvulsive therapy. They involve coordinated actions of different groups of specialists in their competence and organization - doctors, nurses, psychologists, social workers, as well as the introduction of new positions and even professions such as. leading to the case, etc. The lack of a comprehensive concept for reform also leads to uncoordinated actions in sectors that, by definition, need to cooperate in one area. To achieve this, a change in the regulatory framework, funding and training is needed. So far, there is still no clear political will for change, despite a series of strategic documents, programs and action plans developed and adopted.The population of Bulgaria is about 6.5 million, and the number of psychiatrists is about 500, very unevenly distributed, concentrated mainly around the cities with medical universities (Sofia, Plovdiv, Varna, Pleven, Stara Zagora).
Psychiatrists are unevenly represented by gender. The number of psychiatrists who have contracted with the National Health Insurance Fund (NHIF) is about 400, and 25% of them are on the territory of Sofia.3 At the same time, for the period 02. 2018 - 05. 2021 the number of contract psychiatrists has decreased by nearly 10%.4
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Integrated care – that is, a patient-centred system that supports the person with depression throughout their lifetime and with continuity across the health system – is essential to delivering adequate support and treatment.
Integrating mental health services into wider health and social care services is convenient and can increase treatment rates, improve comprehensiveness of care and reduce overall costs.
Reading time 7 minMental Health care services in Bulgaria, by common consensus amongst the Ministry of Health, the Bulgarian Psychiatric Association, medical, nursing and other staff, and patients and families, are currently in an unsatisfactory situation and there is a pressing need for reform. Health Reform implemented by the government in 2000 has not led to significant improvement in mental health services.5
A small number of psychiatrists are entirely in private practice /about 1% of all psychiatrists in Bulgaria/. Practically these are all psychiatrists who provide outpatient services /about 400 psychiatrists/. Almost all also work in inpatient psychiatric services. All psychological services are entirely private. Everyone who needs psychological help is forced to pay for it. The price of this service varies from 15 to 60 euros per visit. The minimum wage in Bulgaria is 305 euros. Unfortunately, the Ministry of Health and Social Welfare does not interact fully enough.
Professionals show low awareness of ongoing projects in the field of depression management. Innovative methods for the treatment of mental disorders go far beyond pure medical intervention, which in psychiatry is largely limited to drug therapy and some non-drug methods - transcranial magnetic stimulation and electroconvulsive therapy. They involve coordinated action by different groups of professionals - doctors, nurses, psychologists, social workers, as well as the introduction of new jobs and even professions, such as „mental health case manager“ and others. The lack of a comprehensive concept for reform also leads to uncoordinated action in sectors that by definition need to cooperate. To achieve this, there is a need for a change in the legal framework, for the provision of funding and training. So far, Bulgaria still lacks a clear political will for change, despite a number of strategic documents, programs and action plans. None of these documents focus on depression. They are all political and apply to all mental illnesses.6
Is depression included in either the national health plan or a specific plan for mental health?
Is there a government lead on mental health, with cross-ministerial responsibility to support a ‘mental health in all plans’ approach?
An example of good practice is the RECOVER-E project7. Bulgaria is also participating in a project for the transfer of good practices and policies Joint Action Implemental.8
One of the major problems is the fragmentary nature and lack of continuity of both care and therapy and information about a patient. After discharge from psychiatric hospital, the patient does not routinely have referral for follow-up, maintenance therapy or any psychosocial interventions with a view to their recovery and reintegration again into the community. These activities are undertaken chaotically depending on the particular circumstances of the patient, initiatives from their carers and family, or local service conditions.
Complex systems make it very challenging for patients to successfully obtain and continue use of treatment. For example, in order to use services funded by the National Health Insurance Fund (NHIF), the patient is obliged to visit a general practitioner (GP), to get a referral to a specialist, to visit that specialist, then to certify the medication protocol, and if it is for costly medications it must be approved by a special committee, after that to go back to the GP and then visit a pharmacy to get the medicines. This is likely to be too complex for many patients to successfully negotiate, let alone if they have impaired insight or cognitive functioning, or poor motivation and drive resulting from their mental disorder. Drugs for schizophrenia and bipolar affective disorder are reimbursed, but no more than three per patient. Anti-depressants are only partially reimbursed after providing evidence of a depressive disorder. A patient may be referred to a psychiatrist no more than four times a year. This is covered by the fund. The rules are very complicated, there is no specifics on how to interpret them.9
Is collaboration between primary care and mental health services supported and incentivised / encouraged / facilitated?
Are there guidelines on depression care developed jointly by primary care and psychiatry?
Is a range of therapeutic options reimbursed and available to people with depression, such as psychotherapy, counselling and cognitive behavioral therapy?
The European Psychiatric Association (EPA) was invited in 2018 to Bulgaria to send an official team to visit and review mental health services in Bulgaria and advise the Ministry of Health regarding their recommendations for change needed. The aim of this visit was to provide recommendations that will allow much needed reforms in mental health services to be delivered and to help achieve more consensus regarding the reforms required.
Bulgaria has adopted a document that is key to the development of psychiatric care over the next ten years: the National strategy for mental health for citizens of Bulgaria.10 A central priority and at the same time a mechanism for the implementation of the Strategy is the integration of cross-sectoral policies.11
Plans and measures of the National strategy for mental health:
Are depression services available and tailored for at-risk groups?
Young people
Older people
People in the workplace
Homeless people
Collecting and analysing robust and up-to-date data on depression is essential for ensuring the right services are available for everyone who needs them.
Monitoring patient outcomes helps to identify and inform good practice, and may give hope to service users that their mental health can improve.2 Data on services can support clinicians, policymakers and people with depression to better understand what treatment options are available and accessible. More transparent data will also facilitate shared learning across all domains of depression care. New digital tools may have the potential to facilitate documentation for transparency and research purposes while retaining the anonymity of the user.2
Reading time 4 minAccording to the latest nationally representative epidemiological study (2017)14, lifelong morbidity from common mental disorders in Bulgaria is 14.54 %. These data show the relationship between stress levels and prevalence of this group of mental disorders in Bulgaria.
Lifelong illness is common mental disorder is as follows:
Are data on people with depression systematically collected by the health system?
For Bulgaria, the lifetime incidence of affective disorders for both sexes is 6.2% and 12-month 2.8%. The disease leads to problems of different nature - social, psychological, biological. This is the main disease leading to permanent damage and the main cause of death in the age group 18-44 years.
The relative share of patients with depression in Bulgaria hospitalized in psychiatric institutions is about 15% of all hospitalized patients.16 Deaths due to suicide reach 1.5%, while suicide is the 10th leading cause of death in the country.17
There are currently 12 state psychiatric hospitals with 2,225 beds and 128 day care facilities19. Although they are located throughout Bulgaria, the distribution is not always directly related to local needs and is influenced by historical factors.
There are 22 child psychiatrists in Bulgaria. There are two inpatient psychiatric wards for child psychiatry. In the Ruse and the “Prof. N. Shipkovenski ”it is possible to consult children without bed rest.
The number of psychiatrists is about 500, very unevenly distributed, concentrated mainly around cities with medical universities, approximately 1 psychiatrist per 15,000 population. Nearly 80% of them work in psychiatric hospitals and 20% in outpatient services. The number of child psychiatrists with a recognized specialty in child psychiatry in the country is only 22 with extremely uneven territorial distribution. The number of contractors with the NHIF is about 400, and 25% of them are in Sofia (NHIF data, 2018). These indicators put Bulgaria last in Europe.
The self-assessment report also states: “It should be noted that in all state psychiatric hospitals in the country there are dozens of patients who are not in active treatment and are not discharged. In this way, hospitals are forced to take on the role of homes for people with mental disorders, a practice that has existed for decades.“
There is an uneven territorial distribution of the medical establishments for inpatient psychiatric care and of the hospital beds according to the levels of competence. The provision of inpatient psychiatric care in state psychiatric hospitals mainly includes hospital beds of the lowest first level of competence, which presupposes the diagnosis and treatment of patients under the conditions of a minimum requirement for the quality of medical services. For the administrative districts that do not have mental health centers, the Ministry of Health has not issued clear and precise instructions as to which medical institution should perform the legally assigned activities of a mental health center for establishing and maintaining a regional information system for persons with mental disorders, promotion, prevention and improvement of the mental health of the population, as well as for informing the public on the problems of mental health.
The amount of public funds planned for mental health is significant and increased from BGN 53,380 thousand in 2017 to BGN 65,932 thousand in 2019.20
By 2020, the cost per bed in state psychiatric hospitals is up to 5 times lower than the cost per bed in other hospitals.21
The financing of psychiatric hospitals is based on four lines: from the state budget, from contracts with the National Health Insurance Fund, from municipalities and from private payments. Funding from the state budget is carried out according to criteria and order determined by an ordinance of the Minister of Health (Ordinance № 3 of April 5, 2019 on medical activities outside the scope of compulsory health insurance, for which the Ministry of Health subsidizes medical institutions, and the procedure for subsidizing medical institutions), which includes inpatient treatment of patients with mental illness, treatment with substitution and maintenance programs with methadone and daily psychorehabilitation programs. This creates opposition and tension between the different types of medical institutions and reflects on the quality of medical services.
Through Ordinance № 3/2019, subsidies are provided to CPCs, clinics and wards at multidisciplinary hospitals with 1st, 2nd or 3rd level of competence in accordance with the medical standard "Psychiatry". From contracts with the National Health Insurance Fund, the financing is mainly for outpatient psychiatric care - separate offices or open to other medical structures. The revenues in some medical institutions for inpatient care are from the National Health Insurance Fund for dispensary activities. There are no data on out-of-pocket payments for users of mental health services, but it can be assumed that they are significant, given that most of these offices are people with so-called frequent mental disorders, whose prevalence is about 17.5% of all diseases.
In addition, the vast majority of people with severe mental disorders are insolvent and do not reach psychiatric offices that do not have a contract with the NHIF. In general, the costs of inpatient psychiatric care are estimated at about BGN 100 million or about 2.5% of the total health care budget in the country.
In Bulgaria, a lot of data is collected from various institutions - the National Statistical Institute, National Center of Public Health and Analyses, National Health Insurance Fund, Ministry of Health. This information is collected in different forms and with different questionnaires. There are also no specific targets for collecting this information. This creates preconditions for data discrepancies and disrupts planning opportunities.22
Are data on mental health services being used for planning?
Are patient-reported outcomes being measured systematically?
It is essential that people with depression – along with their families, friends and carers – are actively empowered to participate in depression care plans at all stages.
Empowerment involves a person gaining information and control over their own life as well as their capacity to act on what they find important, which in turn will allow them to more optimally manage their depression. Peer support, whereby a person who has previously experienced depression offers empathy and hope to others in the same position, can assist both people with depression and their peer supporter in their recovery. Social systems, patient advocacy groups and other civil society organisations with access to underserved communities are critical in ensuring that mental health services reach everyone, including those who have ‘slipped through the net’.2
Reading time 7 minProfessionals are unanimous that caregivers, and especially patients themselves, are not sufficiently involved in decision-making. Patients and their carers need to be actively involved through various forms at both local and central level in order to be able to actively influence the policies, the work of mental health professionals, the reimbursement of medicines and services and, of course, the quality of care.
While acknowledging that this process is key, professionals believe it is used in a few places. One of the big problems in Bulgaria is the traditional medical model. Patients are not empowered and are not encouraged to participate actively in the treatment process.23 Professionals are adamant that such support is lacking, as no rules and mechanisms have been developed for valuing and paying for such services.
Do guidelines or care pathways for depression recognise the importance of patient empowerment?
Do guidelines on depression recognise the role of families and carers in making decisions on the planning and delivery of care?
Were patient and carer representatives involved in the most recent national plan or strategy covering depression?
Do carers have access to financial aid to help them support their loved ones with depression?
Mental illnesses are traditionally linked with the failure of acceptance by the society, fear and stigma. Stigmatization of persons with mental health issues constitutes to be a serious problem, the consequences of which are numerous and they are manifested both in experiencing one’s own illness and in the reduced motivation to request professional assistance. Stigma due to mental illnesses is so strong that it creates a wall of silence in relation to this problem, worsens the underlying illness and makes it even more unbearable and difficult. Anti-stigma campaigns are isolated, sporadic and non-governmental. Suicide prevention and anti-depression campaigns by PR Care are good examples.24
Civil society organizations, established and registered under the Non-Profit Legal Entities Act, are involved in the problems of mentally ill people and protect the rights and interests of the groups they represent. Their goal is to provide the necessary support to people with mental health problems and their loved ones to cope better. Organizations protect the rights of these people by requiring the state to change systems adequately and ensure that their rights and interests are respected.
One of the major problems is the fragmentary nature and lack of continuity of both care and therapy and information about a patient. After discharge from psychiatric hospital, the patient does not routinely have referral for follow-up, maintenance therapy or any psychosocial interventions with a view to their recovery and reintegration again into the community. These activities are undertaken chaotically depending on the particular circumstances of the patient, initiatives from their carers and family, or local service conditions.
Is peer support recommended in depression care guidelines?
Are peer support roles reimbursed?
Are there national associations advocating for the rights of:
people living with depression?
carers of people living with depression?
Digital platforms such as those which facilitate remote therapy sessions and online prescription requests, as well as other depression-focused software, smartphone applications and virtual platforms, can allow greater choices of treatment for people with depression while supporting them to take more control of self-managing their condition.
While virtual sessions cannot replace in-person therapy, they may be a flexible option to support people with depression between regularly scheduled visits. Health and social services may also use digital tools to facilitate data collection and monitor care. In addition, people with depression may find it helpful to use digital tools to connect with others and reduce feelings of isolation.
Reading time 5 minThe experts highlighted the low level of familiarity with digital technologies and the idea of how these technologies can be applied in the field of mental health.
Again, there is almost no knowledge of ongoing projects and initiatives in the field of digital technologies.
There is no idea of reimbursing this type of service in public policy. In Bulgaria, the electronic prescription was officially introduced in mid-2021. However, there is no clear regulation for its use. A proposal is made to improve the gaps and improve by creating regulations that would allow the valuation and payment of this type of services. In the first 10 months of 2021, psychiatric visits were about 23,000 more than in 2019. For the same period in 2020, about 15,000 fewer examinations were conducted than in the same nine months of 2019. For 2020 (during the pandemic of COVID-19), this can be explained by the restrictive measures introduced at the beginning of the pandemic, with the drastic reduction in the demand for psychiatric care due to people‘s fear and/or the postponement of “planned” visits. In addition, it is also possible that this is a result of the restriction of outpatient work by psychiatrists. For the increased number of sessions in 2021, the hypothesis is that the fear and anxiety of the pandemic is growing, and the demand for help from a psychiatrist is growing. From the beginning of 2021 until the end of October 2021, psychiatric consultations are almost as many as in the whole of 2019.25
Experts in Bulgaria report that digital platforms exist26, but they are a private initiative27, not a government policy.22 One example is chatbot via Viber platform – revolutionary first in Bulgaria, containing comprehensive information for mental diseases, geolocation for determining psychologists and emergency centers, as well as interactive tests and questionaries. It currently has more than 25 000 subscribers.
Can patients access depression support remotely (via telephone or the internet) in addition to services delivered face-to-face?
Do professional societies or guidelines recommend the use of remote services alongside face-to-face services?
Is remote support for depression reimbursed?
Are people with depression able to use telephone or online platforms that allow them to renew their prescriptions from home?
Reading time 7minThe mental health strategy is key to the future of the psychiatric network in Bulgaria and to the development of care for people with depression. The main priorities of the Strategy are:
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There are many challenges to the strategy such as:
At this time psychotherapy can be practiced only in psychiatric institutions. This means that the practice of private service is semi-illegal.
Implementation of the Mental Health Strategy.
Continuing training for specialists in primary health care.
Funding for alternative treatment methods - hardware and evidence-based psychotherapy.
In Bulgaria, a lot of data is collected from various institutions - the National Statistical Institute, National Center of Public Health and Analyses, National Health Insurance Fund, Ministry of Health. This information is collected in different forms and with different questionnaires. There are also no specific targets for collecting this information. This creates preconditions for data discrepancies and disrupts planning opportunities.24
Financing the collection of data on depression.
Preparation of normative documents based on evidence.
Creation of a unified information system.
Patient organizations were established in Bulgaria as early as 1944-1989, but they were always "infiltrated" by professionals who "directed" patients in the "right" direction. After the changes in 1989, various patient organizations were established, but due to the lack of a state policy to ensure sustainability, they gradually ceased their activities.23
Creating a sustainable organization of patients with mental disorders, funded and supported by the state.
Engage "experienced experts" in the treatment of depression.
Creating conditions to support relatives, caring for patients with depression.
Bulgaria has been working on information technology, e-prescription and diagnostically related groups since 2001. Unfortunately, the whole process of a unified, integrated information system, with a patient file, failed to materialize.10
Administrative regulation of digital consulting.
Reimbursement of digital services.
Promotion of digital platforms.
1. В. Наков, Депресия, MEDINFO, кн. 6 2021г.
2. Ng CWM, How CH, Ng YP. 2017. Depression in primary care: assessing suicide risk. Singapore Med J 58(2): 72-77
3. National Health Insurance Fund, February 2022
4. Bulgarian Medical Union – register, August 2021.
5. EPIBUL-2- conducted by a team of NCPHA, 2016
6. A Implemental – Situation analysis of Bulgaria, 2020-2022
7. Situation analisis of Bulgaria. Project RECOVER-E, 2019
8. Interview with Dr Vladimir Nakov participant in the visit of the European Psychiatric Association, 2018
9. https://www.nhif.bg/
10. Menthal health 2-2 National strategy.pdf (stenobooks.com)
11. Interview with Dr Vladimir Nakov participant in the visit of the European Psychiatric Association, 2018
12. https://www.mh.government.bg/bg/politiki/strategii-i-kontseptsii/strategii/nacionalna-strategiya-za-psihichno-zdrave-na-grazhdanite-na-repu/)
13. JA Implemental – Situation analysis of Bulgaria, 2019, part 2
14. EPIBUL-2 conducted by a team of NCPHA, 2017
15. Menthal health 2-2 National strategy.pdf (stenobooks.com)
16. В. Наков, Депресия, Медикарт, “Неврология и Психиатрия”, бр.4/2014: 45-46
17. https://ourworldindata.org/
18. https://ourworldindata.org/grapher/happiness-cantril-ladder?region=Europe
19. https://www.nhif.bg/page/hospitals
20. https://www.strategy.bg/PublicConsultations/View.aspx?lang=bg-BG&Id=5493
21. https://ncpha.government.bg/
22. Interview with Dr Vladimir Nakov, 2022
23. Interview with Dr Maria Petrоva Dimitrova, 2022
24. Interview with Dr Michail Okolijski, 2022
25. З. Зарков, В. Наков, Р. Динолова-Ходжаджикова, М. Люцканова, Д. Стоилова, М. Околийски, Х. Хинков ВЪЗДЕЙСТВИЕ НА ПАНДЕМИЯТА ОТ COVID-19 ВЪРХУ ПСИХИЧНОТО ЗДРАВЕ НА ГРАЖДАНИТЕ НА Р БЪЛГАРИЯ “Българско списание за обществено 7здраве”. София, Том ХIV, кн. 1 2022.: 45-67
26. https://www.healee.com/bg
27. https://ifightdepression.com/bg/start
28. Beezhold J., Destrebecq F., grosse Holftorth M., et al. 2018. A sustainable approach to depression: moving from words to actions. London: The Health Policy Partnership
29. European Patients Forum. 2015. EPF Background Brief: Patient Empowerment. Brussels: EPF
30. Repper J., Carter T. 2011. A review of the literature on peer support in mental health services. J Ment Health 20(4): pp. 392–411
31. European Commission. 2018. Tackling depression with digital tools. [Updated 04/06/18]. Available from:https://ec.europa.eu/research-and-innovation/en/projects/success-stories?id=/research/headlines/news/article_18_06_04_en.html?infocentre&item=Infocentre&artid=48877 [Accessed 06/11/20]
32. Hallgren KA, Bauer AM, Atkins DC. 2017. Digital technology and clinical decision making in depression treatment: Current findings and future opportunities. Depression and anxiety 34(6): pp. 494 – 501
33. Prescott J, Hanley T, Ujhelyi K. 2017. Peer Communication in Online Mental Health Forums for Young People: Directional and Nondirectional Support. JMIR Ment Health 4(3): e29–e29
