Spotlight
on Croatia
Population: 4 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
Mental health care is covered by three laws20,21,22, as well as by strategies, guidelines and public health programmes recognising mental disorders and depression as one of the most common medical conditions and causes of mortality.23 In addition to the existing National Health Care Development Plan 2021–2027 and the Healthcare Development Action Plan 2021–2025, the process of adoption of the Draft Strategic Framework for Mental Health Development 2022–2030 is in progress. All these documents underline that raising awareness of mental health issues, timely diagnosis of the conditions, and adequate treatment and rehabilitation are the bases for high-quality care. The Draft Strategic Framework identifies the key problems of a treatment system concentrated mainly on the tertiary level, underdeveloped cross-sectoral cooperation and specialist care, geographically uneven availability of services, and an insufficient number of sociotherapy services in the community.
Even though the delivery of mental health care is officially organised on all levels of publicly available mental health care services (primary, secondary and tertiary), in practice, the burden is the heaviest on the clinical and hospital levels. Special mental health support programmes have been developed for young people and employed persons24, and the Draft Strategic Framework for Mental Health Development 2022–2030 has recognised vulnerable groups as well. There is no programme targeting the older population in spite of the fact that almost 40% of all persons who committed suicide were over the age of 65.
Croatia has made headway in digitising medical records, but a database combining systematic records, tracking and mental disorder data shared on all levels of the health care system has not been implemented.
To be more successful in treating depression, Croatia needs to invest additional efforts in raising awareness of mental disorders among citizens and in destigmatising these disorders25, as the associated stigma is one of the biggest obstacles that prevent people with depression from taking the first steps toward seeking treatment.26
Depression is recognised as a fast-growing problem in the Draft Strategic Framework for Mental Health Development 2022–2030. In addition to identifying the deficiencies, the Framework lays out the measures required to improve the treatment and support system, such as implementing an early diagnosis programme for mental disorders, with a special emphasis on depression, developing programmes for employers and employees to reduce psychosocial stress, developing cross-sectoral and interdisciplinary cooperation, and ensuring treatment continuity by building connections between hospital and outpatient services, community care, and mobile teams. This broadest strategic framework is still in adoption phase. Specific action plans will be drafted, the measures implemented, and the results and enforcement measured only after its official adoption.
Budgetary contributions for mental disorders account for 4.3% of the health care budget in Croatia27, compared with the average of 5.75% in EU member states.28 Experts recommend that they should account for 10%29 in high-income countries like Croatia30.
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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 minThe depression treatment system in Croatia covers all three levels of the publicly available mental health care services system. People with depression have access to a variety of modern depression and depressive disorder treatment methods and techniques, along with combined pharmacological treatments and psychotherapy. Many private psychologists and psychiatrists are available outside of the system, but lower-income citizens cannot afford private services37, which are not co-funded by the Croatian Health Insurance Fund (HZZO).
Croatia has a health care spending of 7.4% GDP, much lower than the EU average of 9.9%, which places it among EU member states with the lowest health care spending38. According to the HZZO’s data, mental and behavioural disorder treatment costs amounted to HRK 1.018 billion39, only a small portion of the World Health Organization’s estimated total direct and indirect costs of mental health care in Croatia. A number of experts have called for increased investments in tackling mental disorders40,41,42,43 and for stronger involvement of public authorities.44
Croatia has developed depression treatment guidelines45,46, authored by a number of experts. Some of these documents have been prepared and published as the result of cooperation between primary care physicians and psychiatrists.
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?
Although well-organized in theory23, in practice the care system is concentrated on the secondary and tertiary levels14, and care options are not equally accessible across the country.
Zagreb-based psychiatric hospitals Vrapče and Sveti Ivan, as well as the psychiatric hospitals on the islands of Ugljan and Rab, and the neuropsychiatric hospital in Popovača, account for most of the hospital capacities for patients affected by mental disorders. Nevertheless, the five clinical hospital centres in Zagreb, Rijeka, Split and Osijek face a substantial number of patients on higher levels of health care, not only from their own respective areas, but also from the nearby counties, smaller towns, and islands. This undermines care accessibility and regularity, especially for patients in underprivileged and remote areas. While primary health care should perform regular triage, patient screening, and initial treatment, this is not the case in practice, even though it would disburden hospital capacities by a minimum of 10%, according to estimates.14 System stakeholders underline that this could be partially due to the lack of systematic training programmes that would encourage primary care physicians to take over triage and mental disorder treatment in the early stages to a greater extent.
Mental disorder prevention and treatment system is composed of a range of specialists, including psychologists, psychotherapists, social workers, occupational therapists and educators, but there is room for improvement as regards their communication, closer cross-sectoral cooperation, and data sharing.
Public health documents and system stakeholders have recognised the importance of providing stronger support to carers and caretakers for successful treatment outcomes, but this support is available mostly from specialised psychiatric hospitals. Outside of the system, carers depend on volunteer activities organised by patient associations for support. Health experts have underlined the importance of involving peers with the experience of depression in the recovery and healing process. Psychiatrists endorse the organisation of such support groups outside of the system, provided that they are under specialist supervision.
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 behavioural therapy?
Most experts believe the offer of sociotherapy programmes and the diversity of community support services to be insufficient. Certain institutions and a handful of non-governmental associations have launched initiatives and made breakthroughs in this area, but incentives are lacking for such engagement and support on national level.
Mental health associations in Croatia have formed the Croatian Federation of Mental Health Associations47, a roof organisation whose member associations are mostly active locally. With more activity and stronger coordination of local initiatives, the Federation could be a valuable collaborator and partner to the legislator in shaping and implementing mental health policies.
Prevention and depression treatment support for young people and adolescents is underlined in legislative documents and implemented under separate programmes, available for the most part in the capital. The Children and Youth Psychiatric Hospital48, for instance, provides care to young people in Croatia, and the City of Zagreb set up the Youth Health Centre49, with special focus on mental health support for school-age children.50
The Mental Health portal was launched in the City of Zagreb to provide support and information to the public. In addition to young people, it is focused on persons over 65 years of age, a group that has been left behind in mental health care.51 Older people are also the target population of the national programme Živjeti zdravo (Healthy Living)52, but, in practice, there are no tailored depression treatment activities and programmes for this group, even though depression is common in this population.
There are no tailored depression care programmes for homeless people either. Even though homeless people are not expressly mentioned in national plans, homeless shelters offer psychosocial support53, and support is also available from a delegated psychotherapist from the clinical hospital centre system, such as in Rijeka. The City of Zagreb is working on improving the social inclusion of homeless people through the Integration Centre54 in cooperation with a number of associations and the Sveti Ivan Psychiatric Hospital.
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 minThe Croatian Institute of Public Health collects certain data on people with depression, including a breakdown of hospitalizations by mental disorder causes and frequency.56 However, there is no systematic collection of depression-specific data and no registry of people with depression. Croatia maintains a Psychosis Registry, a tool for long-term monitoring of persons affected by schizophrenia or schizoaffective disorders.57 The Croatian Institute of Public Health and the Ministry of the Interior maintain a suicide registry, which contains no data on mental disorders.13
A registry of people with depression would improve data processing in this field. The establishment of such a registry would require the aggregation of patient databases from primary, secondary and tertiary health care. Data on tertiary health care patients is shared horizontally between hospital institutions (with the exception of day care hospitals and outpatients facilities), but there is still no information sharing between primary health care and other health care levels, which would help gain a better understanding, given that a certain number of people with depression are treated at the primary health care level.
The Health Care Plan and Programme 2020–2022 lays down more detailed data collection measures, including epidemiological data regarding mental health in order to maintain national health care statistics and facilitate scientific research. However, the implementation of the programme has only just begun. A special focus is placed on mental health in the measures targeting children and youth. Systematic mental health monitoring is required in regular intervals, including student surveys and screenings, but the implementation of these measurements has only just begun.58
The collection and processing of data regarding the efficiency of services used in depression treatment would help us better understand the trends and improve the depression treatment system in Croatia. Specialists underline the importance of measuring patient outcomes and collecting feedback from patients. In addition to a centralised database covering all levels of the health care system, this would help provide patients with better support, and facilitate their recovery.
The Draft Strategic Framework for Mental Health Development 2022–2030 recognises the deficiencies in systematic collection of mental health data, as well as the lack of collection of positive mental health indicators. This data is only collected through infrequent studies, and very few research projects are aimed at improving and evaluating the mental health care system. A lack of experience is a problem in some areas too, which can only be addressed through cooperation with relevant foreign specialists and international organisations.14
Are data on people with depression systematically collected by the health system?
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 minHigh-quality care for people with depression requires engaging them in the care and decision-making processes, and empowering them both as patients and as functional members of the society. Guidelines prepared by specialist associations and organisations underline the importance of psychological education and participation in sociotherapy communities.45
There are approximately thirty non-governmental associations in Croatia focusing on a broad range of mental health related issues. However, only about ten are registered as providers of support to people with depression and suicidal people, supporting their reintegration and rehabilitation. The associations, and the patients and carers who are their members, have so far not had a very active role in the preparation of documents relating to the mental disorder treatment system and suicide prevention. However, civil society associations have participated in the preparation of the Draft Strategic Framework for Mental Health Development 2022–2030.14
Patient associations are not active in all counties, but they use social networks for communication, and the information on the activities they organize, and any other news, are available to their members across the country. The associations organise a wide range of activities, from therapy, creative and music workshops, to group physical exercise. Some of these associations also provide support to carers and caretakers, especially in exercising their rights and some also provide therapy assistant trainings, designed to train people with an experience of depression to provide support and assistance to people who just developed depression before they can get professional help. People with experience of depression are a valuable source of information about this disorder and its treatment. The Draft Strategic Framework for Mental Health Development 2022–2030 underlines the need to include them in the care process, and use the advantages of the so-called peer-to-peer approach.
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?
Clinical guidelines for depressive disorder treatment recognise the importance of family in rehabilitation, but do not recognise its role in making decisions regarding the planning and implementation of treatment.35 The involvement of the carer in the treatment process is recognised by law only when the person affected by the mental disorder is unable to protect their own rights and interests, or is deprived of legal capacity. Caretakers are then appointed and supervised by the Social Welfare Centre. Carers can get mental health support by participating in group therapies at the Clinical Hospital Centres and specialised psychiatric institutions.60 However, such forms of support are not widely available across Croatia, and are only offered through local patient association initiatives.
Legislators and specialists agree that sociotherapy communities, group therapies, individual counselling, psychodramas, autogenic trainings, art therapies, legal counselling offices and similar services should be made more widely available across Croatia, because such support programmes for persons with depression are a complementary component of treatment, which helps with better and quicker integration of the affected person into society. Sociotherapy communities and activities need to be separated from institutional care so as to disburden tertiary capacities, and their development needs to be promoted in all counties, especially those where hospital care is not readily available.
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 COVID-19 pandemic has accelerated digitalisation and increased the availability of online services in health care, including telepsychiatry61 for diagnosis and treatment, online individual and group therapy sessions using a variety of technological platforms, consultations by phone and online consultations, follow-up examinations, and e-prescription renewal.62 By virtue of a decision of the Croatian Institute of Emergency Medicine, and at the proposal of the Ministry of Health, on 13 November 2020 the Vrapče Psychiatric Hospital became Croatia’s first central telepsychiatry centre, offering more than 20 separate digital day care treatment programmes.
The Emergency Centre with the Zagreb Clinical Hospital has a hotline for Croatian citizens, open 24/7 for all emergencies, and the Centre provides assistance even without referral from a primary care physician.
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?
Even though most specialists have supported digital communication as a necessary alternative to classic treatment during the pandemic, especially in remote areas and on islands, they have also underlined that there are still differences in technical capacities between segments of the health care system and different regions, and that an adequate level of security has still not been reached in digital communication. Priority is still given to in-person meetings with the patient, which provide a more complete picture and understanding of the patient’s psychological state, appearance and behaviour as important aspects of evaluating their condition.
Croatia played an active part in the preparation of digital e-counselling and e-psychiatry guidelines63,64 under EU projects, but the standards for platform work and the evaluation of the quality of digital treatment services are yet to be set.
Publicly available mental health care services are available to all citizens through mandatory health insurance, including digital services such as remote psychotherapy or online group therapy counselling as a part of the treatment process. The pandemic moved the patients’ communication with their physicians to digital platforms overnight, resulting in a substantial increase in the number of e-mail requests for support and assistance. Persons with depression in Croatia can also use psychotherapy services provided by private practitioners, who added online counselling to the services they offer as soon as the pandemic started.
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 Republic of Croatia has recognised the growing problem of depression and the importance of protecting mental health, communicating about these issues in a number of health care documents, educational programmes and campaigns, such as the Živjeti zdravo campaign by the Croatian Institute of Public Health. However, a systematic operationalisation of policies, the implementation of positive measures, action plans and programmes, as well as the monitoring thereof, is lacking in spite of the well-defined legislative framework and guidelines. Depression treatment requires better connections between cross-sectoral policies and all stakeholders (health care system, social welfare centres, associations, therapeutic communities) and specialists (physicians, therapists, carers and educators) who have an impact on a person’s health, private and professional rehabilitation in prevention and treatment.
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Croatia’s budgetary contributions for mental disorders from the health care budget are 1.45 percentage points lower than comparable EU member states’, and 5.7 percentage points lower than the recommendations by specialists worldwide.28,30
To disburden clinical and hospital capacities and free them up for more complex cases and more complex treatment, it is essential to get primary health care more involved in depression treatment through more active screening, early detection, and initial treatment. The lack of involvement of primary health care might be due to the fact that the number of primary care physicians in Croatia is currently below the EU average37, and the pandemic has put new burdens on existing physicians. The availability of professional trainings and educations that could encourage primary care physicians to take a more active role in tackling depression and other mental disorders has meanwhile been drastically reduced.
Patient associations provide support and take on some of the work on the reintegration and rehabilitation of persons with depression, while also providing support to their carers and caretakers. Their work, and the experience they have with mental disorders, can make the associations a valuable partner and useful collaborator for the legislator and for the health care sector in preparing mental health policies. Given the number of persons with depression, new associations need to be established, and the existing ones strengthened and developed, especially in areas where they are still not active. The presence of sociotherapy communities in the society is relatively small: they are only available at specialised clinics or initiatives launched by certain local institutions or patient associations, in spite of their important role in maintaining mental health and preventing relapses.
Prevention and education are the most important tool against stigmatization and in timely diagnosis. Such campaigns should be run nationally, and should have the support of the relevant institutions. Regular campaigns should be run at educational institutions from the youngest age.
The recommendations below provide a synthesis of this report, which is a result of detailed research and reflection by specialists with many years of experience dealing with depression-related issues.
Operationalize strategies and action plans, as Croatia has a number of prepared and updated documents and policies, which are lacking swift operationalization and consistent practical implementation.
Make a national suicide and depression prevention plan that will set the foundations for prevention, education, and stronger support for persons with depression and persons at risk of suicide, as well as their carers.
Increase spending for tackling mental disorders and increase investments in the education of primary care physicians to give them more autonomy in triage, screening, and initial treatment.
Increase the availability of mobile mental health teams in remote areas and make depression treatment, psychotherapy, and telepsychiatry methods and modalities available in all counties.
Set up a central database to systematically collect, process and analyse patients’ clinical and personal data, and to facilitate data sharing between primary, secondary and tertiary health care, in order to get a better understanding of the health of persons with depression.
Make and implement (digital) protocols to monitor patient outcomes.
Align key national mental health indicators with the EU’s data tracking system, and increase availability and transparency.
Involve persons with experience of depression and representatives of patient associations more strongly in the preparation of policies and strategies focusing on the treatment of mental disorders.
Encourage the formation and activities of sociotherapy communities and psychological counselling offices outside of the health care system to take on some of the work on the rehabilitation and integration of people with depression in the society.
Regularly implement nationwide campaigns and systematically work on the education and destigmatization of mental disorders in the education system and the media.
Expand the availability of telepsychiatry and online services within publicly available mental health care services.
Co-finance the acquisition of technical and digital telepsychiatry and telemedicine equipment for the most underprivileged local communities.
Educate older age groups about the use of digital solutions and telepsychiatry services.
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