Population: 6,9 MIL.
in the health plan
Goverment lead on mental health with cross-ministerial responsibility
Systematic data collection
Data on mental health
used for planning
in national plan or strategy
Access to financial aid
Access to remote support
Despite being a key part of the health and well-being of the whole community, mental health is often seen as a low priority, and a culture of stigmatizing people with mental disabilities is dominant.
In Serbia, there are four special hospitals for psychiatric diseases, psychiatric clinics in four clinical centers, Clinic for Psychiatric Diseases "Dr. Laza Lazarevic", departments in two clinical hospital centers, Institute of Mental Health, 28 territorially distributed general hospitals with bed capacity for inpatient treatment of psychiatric patients, as well as psychiatric clinics in about 70 health centers. In addition, eleven associations of persons with mental disorders have been organized in Serbia. The number of psychiatric beds per 100,000 inhabitants is 60. According to the data of the Institute for Public Health "Dr. Milan Jovanović Batut" from December 2017, there are nine psychiatrists and neuropsychiatrists per 100,000 inhabitants in Serbia.
Public policy on mental health is contained in the Mental Health Protection Program in the Republic of Serbia for the period 2019-2026, accompanied by an action plan for its implementation. The National Commission for Mental Health, responsible for the implementation of the reforms envisaged in this document, was formed six months ago.
The advantages of the current organization of mental health care are the existence of psychiatric services at the level of primary health care, day hospitals and psychiatric departments in general hospitals, high level of education of employees in existing services, the establishment of mental health centers in large psychiatric hospitals, as well as the improvement of the normative framework governing the field of mental health.
Contrary to these advantages, there are disadvantages to the current system. First, there is the lack of national registries for mental health disorders, followed by the insufficient cooperation between the sector and primary, secondary, and tertiary care physicians, insufficient education of primary care physicians in the treatment of mental disorders, a small number of associations dealing with mental health and lack of the involvement of these associations in creating the process of mental health care.
In one part of large psychiatric hospitals and social care institutions where people with chronic disorders stay for a long time, unsatisfactory conditions lead to dissatisfying levels of respect for the human rights of people with mental disorders. Also, there are not enough funds from the budget of the Republic of Serbia that are allocated for the protection of mental health, and there are no data on the percentage of those funds allocated for healthcare.
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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.
The latest Mental Health Protection Program in the Republic of Serbia for the period 2019-2026 only briefly mentions depression but does not offer a clear strategy or plan for treating it. This official RS document highlights the need to reform Serbia's mental health care system. Depression is recognized as a disorder faced by a part of the population. However, it is not considered in detail, but only in the broader context of mental health disorders or within certain statistics. In 2021, the National Commission for Mental Health was formed, which is responsible for implementing the reforms envisaged in this document, and whose president is Prof. Dr. Ivana Stašević Karličić.
In addition to Mental Health Protection Program, the National Guide to Good Clinical Practice for the Treatment of Depression (issued by the Ministry of Health of the Republic of Serbia in 2011) was also formed. It describes depressive disorder, basic principles of depression treatment, special problems and treatment in special populations such as children, adolescents and women.
In the Mental Health Protection Program in the Republic of Serbia for the period 2019-2026 it is stated that it is important to ensure interdepartmental cooperation of the Ministry of Health with the Ministry of Justice, Ministry of Internal Affairs, Ministry of Finance, Ministry of Labor, Employment, Veterans and Social Policy, Ministry of Education, Science and Technological Development, Ministry of Youth and Sports. Cooperation with territorial autonomy and local self-government units, patient associations and their families, the media and social networks is also required. For now, this is mentioned only as a recommendation, but there is no clearly stated plan for the implementation of networking of these line ministries.
The advantage of the current organization of mental health care in the Republic of Serbia is the existence of psychiatric services at the level of primary health care. However, the cooperation of secondary and tertiary psychiatric institutions with primary health care is inadequate. It is emphasized that psychiatrists should be involved in the education of doctors and associates in primary health care and be consultants in that care. What experts recommend is that some depressed patients can be treated by primary care physicians, with additional training.
In general, the advantage of our health care system over others is the availability of mental health services to patients. They can schedule an appointment quickly and see a psychiatrist. Regarding the treatment of depression, almost all psychopharmaceuticals available on the markets of developed countries are available on the Serbian market.18
In health centers and state institutions for psychiatric disorders in Serbia, therapeutic services are available and free of charge for people with depression, including psychotherapy, counseling, and cognitive-behavioral therapy. Also, hospital treatment of depressed patients in Serbia is free of charge.
Services are insufficiently developed and adapted for risk groups. In the Mental Health Protection Program in the Republic of Serbia for the period 2019-2026 a recommendation was given for the development of programs specifically designed for different social groups. These groups include school children, the elderly, refugees, or members of minority groups. It is necessary to develop prevention programs and programs for the improvement of mental health for these groups.
All psychiatric hospitals in Serbia are open for emergencies, which means that without referral the patient can get access to any health institution. The standard process of access to these services is for the patient to first contact a general practitioner in order to be referred to a psychiatrist at the Health Center and, if necessary, to tertiary level sectors. Patients have access to psychiatric services in the departments of emergency, primary, secondary care, the justice system, which works very well at the level of consultations. However, in practice it often happens that when a somatic medicine doctor recommends a patient to go to a psychiatrist, the patient does not do so, because of the fear of psychiatry and psychiatric therapy, which indicates a great impact of stigmatization in society. The services provided by primary and specialist health care for people suffering from depression are coordinated so that there is an integrated information system, and the general practitioner can immediately schedule an examination with a psychiatrist and thus refer the patient for further treatment.
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?
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?
The set of therapeutic options for people with depression is available within the system of funded health services, but not sufficiently for the expressed needs. In most smaller centers, when we exclude clinical centers and large cities, this type of treatment is very scarce. Like everything else, health care in large centers is more accessible and the options are wider.18
Combined health care could be much better. And above all, a larger number of experts in institutions is needed - psychiatrists, psychologists, etc.
Is a range of therapeutic options reimbursed and available to people with depression, such as psychotherapy, counselling and cognitive behavioral therapy?
In general, the procedure between primary and specialist (psychiatric) care is not established. The services provided by primary and specialist health care for people with depression are not well coordinated - the only thing that GPs or primary care doctors can do is to refer you to other examinations. There is no coordination other than scheduling appointments. The process of scheduling before the coronavirus epidemic was quite complicated because the personal presence of the fifth day of the month was necessary to schedule an examination or consultation for the next month. That was the only date for scheduling appointments, which caused big crowds. Due to the emergency caused by the coronavirus, it is now sufficient that patients call and ask if the psychiatrist who treats them is at work that week for an appointment to be scheduled in accordance with the doctor's timetable.21
Experts believe that this set of services is not available in all parts of the country, because there is an insufficient number of educated therapists on the local level. Mostly, patients receive the integrated therapeutic approach that any psychiatrist with completed education and specialization can provide. This involves a combination of pharmacotherapy and some superficial methods of supportive psychotherapy, but structured cognitive-behavioral and other therapies require additional education. Psychotherapy itself is not well structured in the country while the education is conducted by certain associations with a questionable license. This segment is problematic, but the Law on Psychotherapy is being drafted, which should regulate this area.20
Are depression services available and tailored for at-risk groups?
People in the workplace
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
The Institute of Public Health "Dr Milan Jovanović Batut" is an umbrella institution responsible for monitoring, assessing and analyzing the health and health literacy of the population, the state and quality of the environment and the impact of environmental factors on health, monitoring and studying health problems and risks, population health, causes, occurrence and spread of infectious diseases and other diseases of socio-medical significance and proposing measures for their improvement. To a certain extent, this institution collects data on mental disorders, but they are not collected systematically nor on the territory of the entire country.
Are data on people with depression systematically collected by the health system?
Given the inadequate functioning of the information system and the lack of national registers for mental disorders, it is not possible to obtain reliable epidemiological and statistical data necessary to assess the mental health of the citizens of the Republic of Serbia.
Primary, secondary, and tertiary care institutions are obliged to keep data on all patients at the local level, but these data are no longer systematized nor used for other purposes. Databases are mostly concentrated regionally and by institution, except for research conducted by certain organizations.18
According to the data from the Mental Health Protection Program in the Republic of Serbia for the period 2019-2026, patient associations (service users) and their family members are not sufficiently involved in creating mental health protection processes. Insufficiently developed information system for registration and monitoring of mental disorders makes it difficult to monitor mental disorders in society. Data stored in health care facilities are not used to systematically improve the treatment conditions of patients with depression. The lack of a central registry negatively affects people who may need help, and who are not covered by the scope of work of mental health professionals, and then are not treated adequately.18
Are data on mental health services being used for planning?
Are patient-reported outcomes being measured systematically?
Data collection is quite difficult, and that what is available is mostly outdated.21 Databases are mostly concentrated regionally and by institution, while more comprehensive data do not exist except at the level of research conducted by certain organizations.
The state does not collect adequate data on depression to support effective health care planning and monitoring. There is no research at the level of the Republic of Serbia on the frequency of depression and the importance of the consequences of depression in patients. It would be necessary to do a large epidemiological study of the incidence of depression. It was done in some cities and municipalities, but not at the level of the whole country. Prof. Dr. Latas points out that psychiatrists are not obliged to report all patients with depression to a central database, so no central records are kept. General data collection has not yet been funded by the state.
Prof. Dr. Ivana Stašević Karličić has announced that the Clinic for Psychiatric Diseases "Dr. Laza Lazarević" will conduct the first national study on mental health, and depression will be an important part of it. The funds for that were approved last year by the Government of the Republic of Serbia.19
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
The Mental Health Protection Program emphasizes the importance of involving patients, their families, and caregivers in the decision-making process on health care for patients with depression. However, it also cites their insufficient involvement in creating mental health care processes as one of the shortcomings of the existing mental health care system in Serbia.
In the Action Plan for the implementation of the Mental Health Protection Program in the Republic of Serbia for the period 2019-202615 there is mention of strengthening patients' associations, i.e., encouraging them to get involved in various media campaigns, as well as to receive adequate education. The Office for Cooperation with Civil Societies, civil society organizations (CSOs), the Chamber of Health Workers, the Center for Mental Health, the media, and the Serbian Ministry of the Internal Affairs are listed as the bodies implementing these projects or the partners available to them.
Caregivers of people suffering from depression, most often members of their families, are not covered by the Mental Health Program as part of their systemic treatment. They therefore do not have access to financial assistance to help support their loved ones living with depression. This could be changed by obtaining the possibility of paid leave for the care of a close family member, which is regulated by law, but it could also be improved by certain bylaws that would include access to certain funds that would provide more adequate care and nursing.18
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?
Social systems, patient advocacy associations and other civil society organizations are crucial to ensuring that mental health services reach all. However, the Mental Health Program does not provide for the existence of a national association to advocate for the rights of carers of persons suffering from a mental disorder or depression.
The Mental Health Program does not mention the mutual support of patients with depression as a form of providing health care to those individuals.
Experts point out that there is a part of the non-governmental sector that is making efforts in this area, but that discrimination, stigmatization and taboo remain a major obstacle.19 There is some progress in this area – there is cooperation with groups of citizens who have mental health problems, in terms of creating guidelines and certain legal solutions for mental health. 18
The first Network for the Promotion of Mental Health in Serbia, NAUM, consisting of 12 associations, had an impact when the National Mental Health Protection Program for the period 2019-2026 was created. In February 2021, NAUM launched the project "Everyone can break", with the support of partner organizations, and thanks to the donation which was awarded to the NAUM network by the ACT project - "Together for Active Civil Society" of the Government of Switzerland.
In this way, patients within these associations are in contact with decision makers and can have an insight into the implementation of this Program and the guidelines developed by a group of experts. The aim of the project is to focus on the implementation of the Program and establish a mechanism to advocate for the reform of the mental health care system, i.e., deinstitutionalization, the opening of mental health centers and the establishment of community-based services.
Also, its goal is to improve access to psychiatric services, to make this service available at the local level and to establish citizens' associations, which will bring together psychiatric service users. That way they also became more visible in order to reduce stigma.21
As for the relationship between patients and caregivers, people suffering from depression do not belong to severe psychiatric conditions and therefore do not receive financial help. However, they can go on sick leave, receive compensation, and are protected in that sense.17 People who take care of people with mental disorders are not financially supported, which could be changed by obtaining the possibility of paid leave for the care of a close family member.
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?
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.
Experts agree that the pandemic of COVID-19 in Serbia has accelerated the introduction of digital tools and telemedicine, which have become increasingly common in both public and private sectors. However, they point out that according to the current legal solutions, it is still necessary for the patient to be physically present to receive a written report. The experts also agree that there was not enough time to set legal frameworks and necessary standards in this area and they see this as a big task ahead of them.
The Clinic for Psychiatric Diseases "Dr Laza Lazarević" has some digital tools, which have proven to be a good direction. There are national SOS lines available 24 hours a day, and calls are anonymous and free. There are four national hotlines for citizens: suicide prevention, adolescents, psychological support for women before, during and after pregnancy, and psychosocial support for citizens in the context of the Covid-19 pandemic.
An application for mobile phones was created in cooperation with the WHO, with the goal to increase the prevention and promotion of mental health, as well as to provide more efficient guidance of people through the health system. Also, the application offers the possibility of calling the national SOS line.
The Center for Mental Health closed its premises during the pandemic, and work continued through telemedicine, SOS lines and online platforms. One of the impacts of the Covid-19 pandemic was enabling patients to contact their therapists via Skype, Viber, and other social media in addition to telephone options.19
All chronic patients who have regular therapy were also allowed to extend their prescriptions by calling their chosen doctor at the Health Center or by sending an e-mail. The chosen doctor, through the information system (ISIS), extends the validity of prescriptions for a maximum of nine months, and the exception to this rule are those who have an appointment with a specialist, due to a possible change in therapy.
Digital tool - an application that offers various information on the topic of depression and gives you the opportunity to ask an expert something that interests you, is also being developed within the project "Everyone can break". Also, a similar application is being developed, as a part the national campaign "Unbreakable", launched by the Hemofarm Foundation.
Approval or monitoring of the quality of digital services in the field of depression treatment does not currently exist, and it should, since the topic is sensitive and those who give advice and information must be professionals.
Telemedicine and e-counseling are available in the private sector. During the lockdown, conversations across various platforms became more frequent, especially in the private sector.21 When it comes to the public sector, according to current regulations, physical presence is still necessary in order to receive a written report.20
Prof. Dr. Latas summarizes that there are still no nationally approved digital tools, but only individual channels that patients can access, such as the "Unbreakable" campaign website, which has not been established at the level of the Ministry of Health.
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?
The advantage of the health care system in Serbia is that patients have access to psychiatric services from the departments of emergency care, primary care, secondary care, and the justice system, which works very well on the level of consultations. However, a very high degree of stigmatization, but also the lack of professional staff at the local level, complicates the treatment process. The set of therapeutic options available to people with depression within the system of funded health services (including combined health care, psychotherapy, counseling, cognitive-behavioral therapy and other therapeutic approaches) is available, but not in the right measure for the needs expressed. In most smaller centers, excluding clinical centers and large cities, this type of treatment is very scarce.
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In Serbia there are no systems for approving or monitoring the quality of digital services in the field of depression treatment. According to the current regulations, physical presence is still necessary in order to receive a written report. Therefore, parallelly with the development of digital tools, a legislation must be developed concerning their use in the protection of mental health, since the issue of personal data protection is primarily raised. In order for telemedicine and e-counseling to be available and provided by the state, and for patients to have this opportunity within the state health care system, it is necessary for the RHIF to support such a service. Two years ago, the Clinic of Psychiatry, UKCS, started negotiations with the Fund in order to provide telemedicine services for patients, but it has not been realized yet.
Therapeutic services are available and free of charge for people with depression in health centers and state institutions for psychiatric disorders in Serbia. It is, however, necessary to increase awareness of this disorder and the need to treat depression and work on removing the social stigma of patients.
Excessive reliance on mental health services in health care institutions at the secondary and tertiary levels of health care has been observed. Therefore, experts recommend that some depressed patients be treated by primary care physicians, after additional training.
Services are insufficiently developed and adapted for risk groups. Vulnerable groups whose mental health is at risk need to be identified. These groups include school children, the elderly, refugees, or members of minority groups. It is necessary to develop prevention programs and programs for the improvement of mental health for these groups, within the framework of cooperation between sectors.
Establishing a central registry in which data on depression will be collected on the national level, and later used for the purpose of improving the provision of health care services, but also the quality of life of people struggling with mental disorders.
Establishing a register in which the outcomes of treatment reported by the patient will be systematically collected.
Improving the health care system by including systematic and regular measurement of the outcomes reported by patients with depression in the formation of good treatment practices and the formation of new legal acts.
Creating informational and awareness-raising campaigns to reduce stigma and convey the message that depression is a condition like any other and should be treated as early as possible to improve quality of life.
Establishing organizations to represent patients and their carers, which would be engaged in providing services, and their expertise involved in creating public policy for depression management.
Emphasizing the importance of mutual support for people living with depression.
The legislative framework needs to regulate the use of digital tools in mental health care.
It is necessary to introduce approval and monitoring of the quality of digital services in the field of depression treatment.
Special attention should be paid to the topic of personal data protection when using digital tools.
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2. World Health Organization Europe. Depression. Available at: WHO/Europe | Mental health - Depression
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19. Prof. Dr. Ivana Stašević Karličić, Acting Director of the Clinic for Psychiatric Diseases "Dr. Laza Lazarević"
20. Prof. Dr. Vladimir Janjic, psychiatrist, Clinic of Psychiatry, University Clinical Center Kragujevac
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