Psychiatric leaders from war-torn Balkan nations met with colleagues in Illinois last month to collaborate on reforming their mental health systems from institutionally based services to community-based services.

"Although the wars have ended in Bosnia, Croatia, and Kosova, the brutality and ethnic cleansing have traumatized many people. There is a serious shortage of trained mental health professionals. Many hospitals that cared for the seriously mentally ill were destroyed or ruined in the wars," said Stevan Weine, M.D., cofounder and codirector of the University of Illinois at Chicago (UIC) Project on Genocide, Psychiatry, and Witnessing (PGPW).

Weine and PGPW codirector Ivan Pavkovic, M.D., organized a conference last month for psychiatric leaders from the three Balkan nations to discuss rebuilding their mental health systems. The Balkan psychiatrists also spent last month in Illinois learning how the state delivers comprehensive mental health services, said Weine in an interview with Psychiatric News.

Bosnia-Herzegovina has made great strides in reforming its mental health system since its three-year war with Serbia ended in 1995, according to the country’s mental health coordinator Ismet Ceric, M.D. He told Psychiatric News, "We have established 38 community mental health centers and closed all our psychiatric hospitals and institutions. Patients needing acute care are admitted to psychiatric wards in general hospitals."

The mental health clinics are staffed by interdisciplinary teams made up of a psychiatrist, a social worker, a psychologist, and four psychiatric nurses, said Ceric.

Because psychiatrists are scarce in their countries, Ceric and the other psychiatric leaders want to train general practitioners to diagnose and treat patients with less severe mental health problems. He expressed frustration that the Bosnian government has not made funding available for mental illness prevention and treatment. "We did, however, obtain a loan from the World Bank to fund our projects," said Ceric.

Kosova, which experienced a decade of Serbian oppression followed by "ethnic cleansing" last year, is just starting to rebuild its mental health system, noted Weine. The task is daunting because of an unstable political situation, no funding, and a shortage of electricity and heat, said Weine.

With its infrastructure destroyed, there are critical shortages of beds and psychiatrists, according to Ferid Agani, M.D., associate director of clinical services at the University Hospital in Pristina. Agani spoke at the UIC conference last month.

Agani estimated in his report that there is only one psychiatrist per 100,000 inhabitants in Kosova, which has a population of two million. This is 10 to 15 times below the ratio set by the World Health Organization (WHO).

"Every day more people experience the psychological consequences of war. But there is only one bed per 15,000 inhabitants available for chronic and acute cases," stated Agani.

Rather than attempt to rebuild the old system of psychiatric hospitals, psychiatrists in Kosova agreed to develop a community-based mental health system, said Agani in his report.

Croatia is now moving quickly to design a plan to deinstitutionalize patients and move them into community-based psychiatric care, according to Vlado Jukic, M.D., director of the psychiatric hospital in Vrapcee, Croatia.

Jukic estimated that 350 out of the 400 psychiatrists working in Croatia are employed by psychiatric institutions. "When Dr. Ivan Pavkovic visited my hospital four years ago and recommended that 70 percent of our patients be discharged, some psychiatrists became angry and feared losing their jobs," said Jukic.

He said that psychiatrists feared the unknown, meaning community mental health settings, after working in hospitals for so long.

Nonetheless, the idea for reform took hold and last year the Croatian Minister of Health decided to reorganize the country’s psychiatric services and appointed 13 experts including Pavkovic to develop a reform plan in six months, according to Jukic.

In 1998 Croatia became the first Balkan nation to enact a mental health reform law protecting the rights of the mentally ill, said Weine. Pavkovic is drafting a similar law to be presented to the Bosnian parliament this year and will initiate a similar effort in Kosova in the future, added Weine.