By Máté Kapitány-Fövény
As part of an international online study of the Mental Health Sector of the Scientific Research Institute of the Pan-Hellenic Medical Association, the Hungarian research team assessed 738 adults (both healthy controls and respondents with mental disorders) during the pandemic (between 30.06.2020-12.09.2020), and reported especially severe anxiety and depression symptoms, increased smoking and increased use of sedatives among mental disorder patients as well as a significant reduction in physical activity within this time interval among the same subgroup as compared to healthy controls. In May 2020, a research group of the University of Szeged assessed a non-representative sample of Hungarian adults in the time of the national quarantine situation (n= 431). 34.1% of the respondents showed depression symptoms, while 36.2% were characterized by elevated levels of anxiety. Between 4th March and 25 May 2020 (during lockdown) Eötvös Loránd University launched a specialist online counselling program to provide crisis mental health support for all university members. The program consisted of one to three sessions (altogether 47 clients received this support). According to the observations of the counsellors involved in this program, the clients main psychological problems encompassed the fear from the virus, anxiety, fatigue, addictive behaviours and symptoms of depression or psychosis. Three key features of online counselling were identified: 1) the need of a problem-oriented approach; 2) the challenges of building rapport online; 3) the frames of online counselling and the difficulty of controlling them. Similar online programs were implemented in many other locations/institutes.
An online Pro Bono Counselling Project was provided by many Hungarian psychologist during the lockdown (Spring, 2020) to reach those clients in need who otherwise could not afford psychotherapy or counselling. As a response to the public health concern regarding post-Covid syndrome, a special outpatient clinic was opened (2th of April 2021) in the National Institute of Mental Health, Neurology and Neurosurgery (Budapest, Hungary) which is currently one of Hungary’s main psychiatric centres. The primary goal of this clinic is to provide help for those clients who struggle with the mental symptoms of post-Covid syndrome. The Hungarian Psychiatric Association has recently held its XXIV. itinery congress focusing on the major mental health correlates of peri and post Covid situation and condition, including both the individual (e.g. psychiatric symptoms of patients and health care workers, neuropsychiatric characteristics of post-covid syndrome, etc) and the organizational (e.g. cutting the availability of inpatient psychiatric beds, redeployment experiences) levels. The Hungarian Academy of Sciences – as requested by the Hungarian Government - has started to develop a post Covid strategy in the Spring of 2021, alongside with working on a medium-term national pandemic plan.
- Approximately 10 million inhabitants, which corresponds to a population density of 108 persons per square kilometer.
- Expenditure on health is 7.4 % of the total health budget.
Psychotherapy in the health care system
- The psychotherapic treatment is financed for the whole population by the health insurance in the framework of the healthcare system, including the treatment in hospitals, day treatment, and for out-patients.
- Financing of out-patient care does not cover its operational costs, making access to care difficult and limited.
- Private psychotherapeutic care is also available, completely financed by patients.
- Psychotherapy is defined in Act CLIV of 1997 on Health: “therapeutic method based on different scientifically established methods, applied in case of psychic and psychosomatic disorders, individually or in groups, in defined periodical sessions”.
- 16 accredited psychotherapeutic methods are available without restriction on the level of hospital, day treatment and out-patient care. Behavior-cognitive therapy and dynamic therapy, as well as family therapy, psychodrama and humanistic schools are also widely available. There are no prohibiting restrictions for the use of these methods. There are different financing categories in out-patient care depending on the qualification of the therapist (basic, intermediate and professional psychotherapy) and the length of the therapy session.
- Psychotherapy in hospitals: psychotherapy for individuals and groups, and applying a combination of different therapeutic methods is typical. There are only a few hospital departments specialized for psychotherapy in the country. Psychiatric wards usually apply group sessions.
- Sessions and methods in out-patient care can be chosen freely in accordance with the indications. Psychotherapy can be indicated in cases of affective disorders, anxiety disorders, compulsive disorders, conversional disorders, eating disorders, sexual dysfunctions, sleep disorders, somatization disorders, personality disorders, psychosomatic disorders and in given case of psychotic disorders and behavior disorders of children and teenagers.
- Private out-patient psychotherapy offers all methods and group sessions. In addition, educational counselors and the Family Help Services use child and youth psychotherapy and family psychotherapy. The costs of these services are covered by the educational and the social systems.
- Patients with mental disorders receive in-patient psychotherapeutic care at specialized psychiatric rehabilitation units and addictology wards. The number of beds available is limited.
- Psychotherapy is regulated by Act CLIV of 1997 on Health. Accordingly, psychotherapy can be practiced only with specialist physician or specialized clinical psychologist qualification and with a psychotherapist specialist examination. The course is post gradual level. Based on the previously mentioned examination, the psychotherapist specialist examination is the second level, available for doctors with specialist clinical examination and to specialized clinical psychologists. The requirements of the examination are the same for the doctors and for the clinical psychologists. The requirements for the examinations are notable clinical knowledge, method specific psychotherapeutic knowledge, personal experience and at least three years of training. In the framework of the course, child and youth psychiatrists and clinical psychologists can also gain a psychotherapeutic qualification. The number of training hours for specific psychotherapeutic methods corresponds to international standards. The psychotherapeutic course is completed by taking the public specialist exam. The training has three phases: the propaedeutic, the clinical and the method specific phase where participants can choose their preferred methods. The course also includes a significant amount of practical training in a clinical setting. For certain psychotherapeutic methods, instead of a specialist exam, a certificate can be acquired through practice in institutions in the social sector. The acknowledged psychotherapeutic methods, the schedule of the courses, the requirements of the specialist exam, the accredited educational facilities and the list of graduated psychotherapists are collected and published by the Council of Psychotherapy and the committee of universities’ experts.
- Among the psychotherapists with psychotherapeutic specialist examination 42% are psychiatrists, 50% are specialized clinical psychologists and the remaining 8% works in different fields. The estimated number of qualified psychotherapists is 550. Outside the healthcare system, there are about 1500 therapists employed in the social and educational sectors, whose intermediate level psychotherapist qualification is based on basic level courses such as social worker, mental hygienist, art therapy, occupational therapy and community care. A large number of physicians and psychiatrists working in public institutions also have private practices.
Psychotherapy for Depression
- The professional guideline on depression published by the Hungarian College of Psychiatry suggests the use of psychotherapy parallel to medication. Clinical examinations proved that medication and psychotherapy are easy to combine and their combination provides the best efficiency. Due to the high risk factor of depression induced suicide and the severe Hungarian suicide data, the operation of crisis interventions and telephone counseling services are of high importance.
Desirable Changes to Health Policy
- The Hungarian psychotherapeutic services, despite the high standard of qualification and international level of experts, are not satisfying. Psychotherapists tend to prefer cities, making accessibility of in-patient and out-patient care limited in the countryside. The National Health Insurance Fund does not finance private practices, which places a significant burden on patients, preventing this type of care from a certain number of patients. The number of psychotherapists is also unsatisfying, since the costs of the course and the second specialist exam are also significant and are borne by the psychiatrists in training. Migration also causes significant problems in human resources.
- The continuous demand for psychotherapeutic training courses shows that this most humane treatment plays an important role in the fight against depression and suicide and in the treatment of mental disorders.
- In the fight against depression and suicide, the accessibility of psychotherapy should be improved, thus providing access and treatment to patients who have not been detected and treated by physicians.
- There is no Chamber of Psychotherapy in Hungary. Every psychotherapeutic method has its own Professional Associations, providing their own method specific training courses. The Council of Psychotherapy is a collective body for the Professional Associations, bringing together the presidents of the Associations and the representatives of the university faculties providing psychotherapeutic courses. The Council of Psychotherapy represents the Hungarian psychotherapists in the European Association for Psychotherapy (EAP). The members of the method specific scientific associations are also members of their international counterpart associations.
Janos Harmatta, M.D. Ph.D. Psychiatrist, Psychotherapist, President of the Hungarian College of Psychiatry, President of the Council of Psychotherapy (Hungary) and Dr. Ildikó Kissné Horváth, Head of Department for Heath Policy, Ministry for National Resources, Republic of Hungary
The text above is an excerpt from the paper "Psychotherapy in Europe – Disease Management Strategies for Depression. National Concepts of Psychotherapeutic Care".
You can download the paper here.