Spotlight
on Hungary
Population: 9,75 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
In Hungary, the affected patient population can reach 600-700 000 patients per year, and there are nearly 200,000 major depression in any given month, less than half of whom are on medicinal treatment.2
The disease is generally under-diagnosed and under-treated, with diagnosis often delayed by years. In addition, the COVID-19 epidemic has led to a significant increase of depressive and anxiety symptoms and completed suicides in Hungary in 2020.16
Moreover, while the fight against mental disorders, including depression received increasing attention in outpatient and inpatient psychiatric care, education, and health programmes after the early 1990s, depression and psychiatric disorders seem to have lost their public health priority among health policy makers by now. It is scientifically demonstrated, that the most important factors behind the 65% decrease of suicide rates in Hungary between 1985-2020 were the improved access to psychiatry care and to effective treatments, therefore policy makers should keep mental health, patient care in the strategic focus.10
In general, the lay public and national policy makers are not or only partially informed about the socio-economic burden of major depression. The increasing prevalence and burden of mental disorders require a modern prevention and care system and integrated care organisation in Hungary.
A systemic approach to the treatment of patients with major depressive disorder should be emphasised: in addition to the traditional pharmacological and non-pharmacological therapies, integrated care should focus on disease awareness, prevention and education, thereby reducing stigma, further developing and expanding the capacity in both primary and specialist care, as well as facilitating interprofessional communication and patient follow-up.
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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 minIn Hungary, patients with depression have access to a range of publicly funded health services (such as general psychiatric examinations, drug therapy, psychotherapy, counselling or cognitive behavioural therapy), but many patients have limited access to publicly funded specialist care due to lack of specialist and institutional capacity and insufficient funding (such as capacity limits and long waiting lists).
Psychotherapy would be another pillar of integrated care, alongside pharmacotherapy with antidepressants: psychotherapy sessions are widely used and professionally acknowledged as a non-pharmacological treatment for major depression, and psychotherapy is often the best suited therapeutic alternative of non-pharmacological treatments.
The use of psychotherapeutic procedures/methods in Hungary is lower than the potential demand, based on professional experience and patient turnover data, as well as international comparison, largely due to underfunding. The total annual funding for psychotherapy in Hungary for major depression is less than HUF 150 million.2, 23
The underfunding of domestic psychiatric care (particularly psychotherapy sessions) greatly reduces access to appropriate and modern care for patients in need, and contributes to the migration of physicians from the public healthcare system to the private sector. There is a need for the maintenance and increase of outpatient DRG points/values (outpatient DRG values). Psychotherapy DRG points/values revision must recognize the real cost of interventions, and the increased DRG rates can impact the number of psychiatrists leaving the public healthcare system for private healthcare sector.
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?
Patient pathways in depression care is far from the optimal, as a result many patients are lost or drop out from the health care system.
It is also a problem that many patients with depression do not enter the health care system at all, due to the significant social stigma around the disease. Patients visiting the physician with their symptoms face a number of challenges at primary care already: GPs have limited prescription power therefore treatment options at primary care level are limited, patients referred by GPs to psychiatry care, specialist often drop out of the system due to long waiting times or due to stigma.
In specialist care - based on the experience of psychiatrists - the number of patient appointments are limited to 2-3 visits /year only, and as a consequence a significant proportion of patients drop out of care due to lack of continuous follow-up.
Non-optimal patient pathways also make it difficult the follow up of patients; many patients get lost in the health care system and as a result their major depressive disorder will not be treated.
There is a need to improve communication between levels of care and associate health care professionals (e.g.: requirement of regular consultation between regional Psychiatric Outpatient Units and primary care physicians), defining the actors and their competences, developing a more effective patient follow-up system than at present, , and patients with depression should be preferably treated by psychiatrists ( financial measures needed to support this preference), rather than neurologist and internists.
The clinical guidelines and recommendations related to major depression have been updated in 202124; the medical guideline on the early detection, care and prevention of suicidal behaviour in adults is also up to date.
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?
Research shows that nearly 50% of patients visiting their GP have a psychiatric symptom to treat, often associated with a somatic illness25. Major depression is recurrent in about 50% of cases and chronic in 20-30%, i.e., it persists for years or decades; early detection and treatment are also important to prevent complications.26 Due to their prevalence and recurrence depressive disorders represent a major challenge both for psychiatry and primary care: depression and its frequent complications (e.g. suicide, suicide attempts, secondary alcoholism/drug abuse, etc.) leads to a significant burden on patients, carers and on society level.27
Major depressive disordes can be treated effectively with medications and non- pharmacological treatments and suicidal thoughts can also be prevented.
General practitioners, besides psychiatrists, play an important role in identifying the risk of suicide. Appropriate coordination and professional cooperation between levels of care should also be promoted at policy level.
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 minAs a single payer (sick fund) in Hungary, the National Health Insurance Fund Administration (NEAK) is the central organisation responsible for health insurance tasks defined by law: the management of the Health Insurance Fund, record-keeping, financial accounting and reporting.
Are data on people with depression systematically collected by the health system?
NEAK manages, operates and develops the IT systems necessary for the performance of health insurance tasks, and ensures the collection and transmission of statistical data. While the sick fund collects and publishes regional and national statistical data on both outpatient and inpatient care and on the use of medicines (mainly turnover/sales data) on a monthly basis:
It is of particular importance that the data currently available are collected and evaluated in a structured way, and that the content of the data is made available to both the treatment centres and decision-makers at regional and national level. Primary or secondary prevention programmes, targeted development projects should be based on real national patient turnover and epidemiological data and on data from the National eHealth Infrastructure (EESZT, i.e., national eHealth data space).
Are data on mental health services being used for planning?
Are patient-reported outcomes being measured systematically?
In Hungary, disease burden studies on diseases of major importance are rarely published to support policy and funding decisions by health policy makers. These studies could help shape sectoral strategies and public health programmes through a deeper understanding of the individual and societal burden of disease, taking into account the magnitude of the direct and indirect economic burden of disease.
Understanding the indirect burden of depression is of particular importance: depression accounts for the largest share of mental health-related burden in the WHO European Region, for 26% of all mental health-related harm in the European Union, and mental health conditions now account for 21.1% of work capacity losses, with depression being the second most important, after stress.13, 14 According to a study by the Hungarian Psychiatric Association, patients with major depression miss approximately 41 days of work due to their illness.2, 28
In 2021, the Hungarian Psychiatric Association published a report titled "Individual and socio-economic burden caused by major depressive disorder (MDD)". Based on this analysis, proposals for solutions have been formulated which could reduce not only the burden of disease of people with major depression, but also the burden on society.2
Data from patient registries play an important role in the development of health strategy, the planning of preventive action, the development of the care system, the improvement of patient care and in the conduct of clinical trials. Today, there are nearly 20 patient registries in Hungary (e.g. the National Cancer Registry, the National Stroke Registry, the National Heart Attack Registry or the National Affective Disorders Registry currently required in the field of psychiatry). 29
At both policy and institutional and patient care levels, it would be an important step forward to have a detailed understanding of quality and patient flow data on psychiatric diseases.
A suicide register could help to identify intervention needs more precisely – by area – to design targeted suicide prevention programmes, and to monitor more closely the results of these programmes.
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 minThere are several patient and non-governmental organisations in Hungary, including Magyar Lelki Elsősegély Telefonszolgálatok Szövetsége (Association of the Hungarian Phone Emergency Services), Búra (Dome), Lélekben Otthon (Home for the Soul Foundation), Betegszervezetek Magyarországi Szövetsége (Hungarian Alliance of Patient Organizations), Ébredések Alapítvány (Awakenings Foundation) and the Pszichiátriai Érdekvédelmi Fórum (Mental Health Interest Forum).
Patient organisations can help increase the social acceptance of depression, help patients cope with their illness by creating a supportive atmosphere, and play a significant role in reducing the number of both completed suicides and suicide attempts. An outstanding, positive example is the Deep Breath Project, which seeks to provide information on mood disorders in an easy-to-understand way in social media.
Unfortunately, a negative phenomenon in Hungary over the last 20 years has been the decrease in the number of patient organisations and foundations dealing with depression and suicide. Whereas in the early 2000s there were many patient organisations, today there are only a few.
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?
In Hungary, patients and patients' organisations are not, or only rarely, given the opportunity to participate in the preparation of health policy, development, public health or care financing decisions, despite the fact that the articulation and representation of life experiences, social and ethical values experienced with illness can be crucial in decision-making.
This is also true for health technology assessment (HTA, i.e., the evaluation and review of new procedures, interventions, drug therapies). Although the latest national health economic guideline mentions patient organisations as potential partners in the validation of the Hungarian standard of care/routine practice of therapies and procedures, patients and patient organisations do not currently play a real decision-preparatory or supporting role in health technology assessment.
A high level of social stigma is associated with mental illness in general, and for depression in particular: patients do not have supportive atmosphere they need at work, in their social life, and often not even from their relatives. The lay public often thinks that depression is a ’simple’ bad mood that the patient just needs to get over.
Due to social stigma, a significant proportion of patients do not consult physicians at all, fearing negative social consequences.
Many international and national projects have been developed over the last decade to reduce the stigma of the disease, such as depression awareness projects and community health promotion activities2. In general, any example of involving psychiatry in the work of any other co-discipline can be considered good practice. Examples include psychiatrists and clinical psychologists in general practice, who assist the general practitioner, raise awareness of the importance of mental illness and diagnose mental illnesses that are not detected by the general practitioner, thereby building trust in psychiatric practices, psychiatrists. This reduces social stigma and significantly improves the effectiveness of communication between psychiatric care and primary care.
Hungary does not currently have a national antistigma programme reflecting a coherent approach, so far mainly local antistigma programmes embedded in the rehabilitation process have been developed, while the transfer of relevant knowledge about mental disorders and the systemic sensitisation of the "general population" has been lagging behind. However, the establishment of the Hungarian Antistigma Working Group in 2020 is a positive example; their aim and task are to ensure that in the long run no one living with schizophrenia, bipolar disorder or depression should have to feel ashamed or stigmatised.
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 minIn connection with the COVID-19 epidemic, the health government recognised that in many cases institutional care might be associated with infection risks, thus the use of telemedicine services has come in focus in Hungary. According to a government decree issued in April 2020, the use of telemedicine platforms has become available and reimbursed for several medical specialities.
The regulation allowed specialists to diagnose, prescribe, advise, consult, refer or prescribe medicines online.
The use of telemedicine during the epidemic has supported patient care, physicians were able to reach patients who would otherwise not have seen a physician in person due to restrictions or fear of the epidemic.
It is worth noting that the reimbursement of publicly funded mental health telemedicine services is currently inadequate. According to the relevant regulation, only two procedures for the provision of psychiatry care can charged to social security budget:
The two procedures cannot be recorded and reported together in one session, and the funding value of both procedures is currently very low, with HUF 1,121 and HUF 224 respectively.30, i.e. telemedicine psychiatry care is not financially sustainable for the publicly funded treatment centres.
Hungary's e-health system is the National eHealth Infrastructure (EESZT), which was introduced in 2017 for GP services, outpatient and inpatient care institutions and all Hungarian pharmacies. The e-Prescription module offers centralised services that support all functions of prescribing and dispensing. The treating physician and pharmacist can access the data recorded in the system, in line with data privacy regulations, and the system provides the treating physician with options as one-off prescriptions, recurring prescriptions, revoked prescriptions and the possibility to query based on social security number. The treating physician can check and monitor whether the prescription has been dispensed, i.e., whether the patient has started or is continuing therapy.
The EESZT Sytem is a major step towards high quality patient care and also towards strengthening the follow up on treatment monitoring: further system developments will also improve the quality of care for patients with depression.
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?
The free S.O.S. Helpline is a substantial element of psychiatry system providing real support for patients with depression. The Association of the Hungarian Phone Emergency Services (LESZ) was established in 1991 and it has been uniting the emergency telephone services operating across the country since 1970. 31
The Association has 22 members in 2022, with around 500 operators on call 24 hours a day. In the LESZ, patients are assisted mainly by psychiatrists, psychologists, social workers, educators, mental health professionals and chaplains. The operators on duty are specially trained individuals who undergo several months of theoretical and practical training to acquire the knowledge that is essential for the helpline services.
The helpline service plays an important role in helping people in mental health crisis or suicidal crisis, referring them to the right healthcare professional or institution. The number of calls per year is between 100,000 and 120,000 and is increasing; 8-10% of them are due to plan for committing suicide or other serious crisis.2
The most important challenge to solve for the Phone Emergency Service is to gain adequate funding, as the current resources are covering the maintenance of services only, but are not sufficient for continued development of services.
The guidelines for helpline services are more than 6 years old. While the principles and procedures laid down in these have not changed in recent years, a formal update is required.
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 7minBased on statistics, major depression affects 7% of the adult population in Hungary every year.1 Despite the high number of patients, the depression patient care in Hungary does not receive adequate attention in health policy: limited attention is paid to this mental disorder outside of the scientific literature, having significant economic and societal consequences.
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It is clear that, in addition to suicidal behaviour, episodes of major depression have a significant impact on the quality of life of patients, their work, their family role and the lives of their relatives and social networks. Common consequences of untreated depression are long-term disability, secondary alcohol/drug abuse and dependence, increased somatic (cardiovascular and cerebrovascular) morbidity and mortality, and a markedly increased risk of suicide. 2
Considering the high number of patients impacted, the disease burden and the systemic problems of psychiatry patient care in Hungary, a comprehensive approach to the care of patients with major depressive disorder should be prioritised. In addition to the traditional non-pharmacological and pharmacological therapies, a systemic approach to care will focus on disease awareness, prevention and education, reducing stigma, and further developing both primary and specialist care, increasing capacity, ensuring adequate funding, and promoting interprofessional communication and patient follow-up.
Despite many positive interventions in the field of mental health, there has been no systemic change in the last decade:
In summary: While the long waited systemic changes have not been implemented yet, the structure of speciality care is basically appropriate. Numerous reimbursed services and medications are available in the country, several specialised care facilities have been developed over the last decade, a new primary care structure has been developed and the salaries of psychiatrists and psychologists in state-funded institutions have started to be adjusted (however, there is a shortage of professionals in adult, child and adolescent psychiatry), but the necessary systemic change has not yet taken place.
The increasing prevalence and burden of mental illness requires a modern prevention and care system in Hungary. There is a need for partnership between all actors who can contribute to the prevention and treatment of mental disorders, to improve the health and quality of life of people living with mental illness, and to reduce the burden of mental disease.
A comprehensive national programme to support psychiatric care, including depression care, should, in addition to developing institutional capacity and improving care financing, place particular emphasis on close cooperation with health, social and educational institutions, care providers and local government bodies, as well as NGOs. The focus of system development should be on strengthening primary care, community care and outpatient care, while maintaining inpatient care capacity. Online forums, digital applications and the media should play an increasingly prominent role in disseminating knowledge and best practice about depression and dispelling misconceptions about the illness, in addition to professional communication, in primary and specialist care.
In the development of care, focused attention must also be paid to the information of patients and their carers: it is important that they have access to real-time information on the details of access to care (availability of professionals and institutions, range of professional services, patient pathways), regional services, prevention and awareness-raising programmes, and an accurate status of the civil and public/governmental organisations representing their interests, the range of support services and financial resources available, and the possibilities of applying for them.
It is also important that data already available regarding depression should be collected and evaluated in a structured way, and made accessible to treatment centres and decision-makers at regional and national level, so that in the future patient care can be developed in a targeted way, in line with the needs of regional and/or high-risk groups.
There is a need to build awareness and sensitise primary care physicians to mental disorders and thus encourage more effective involvement of primary care in psychiatric care. More effective involvement of primary care would allow patients with mild symptoms in the early stages of depressive disorder to be treated successfully at the lowest level of the care system, allowing more time for moderate and severe patients in specialist care, where capacity is limited. Based on international practice and a national proposal published in 2016, it may be worth introducing rapid screening tests of 5-10 questions to screen for the most severe mental disorders in general practice.26, 33
The higher involvement of primary care can be promoted and encouraged in several ways: either by changing the power of GPs to issue a prescription (linked to a specialist examination/licence exam) or by the provision of reimbursed psychiatric consultations and by making them more widespread. This would require the definition of a new diagnostic and therapeutic ICPM (International Classification of Procedures in Medicine) code. The strengthening of general practitioners' services/practices with a clinical psychologist is also justified to meet the increased demand of patients.
The underfunding of psychiatric care (e.g., psychotherapy sessions) greatly reduces access to adequate and modern care for patients in need, and contributes to the migration of physicians working in the public health care system to the private sector. There is a need to maintain/significantly increase funding values (in outpatient care).
In Hungary, patient pathway management for major depression care is sub-optimal and communication between levels of care and between allied professions needs to be improved.
Available pharmacotherapy alternatives need to be expanded, and new, innovative medicines must be made available to Hungarian patients.
Among the non-pharmacological alternatives, the access to treatments (partial sleep deprivation, light therapy) that have been shown to be effective in certain forms of major depression and the provision of funding for the latter are also recommended.
There is a strong need for a centrally compiled depression patient registry. The process has already started, the registry could provide detailed information about depression patient care and quality of care thus accelerate informed planning. Continuous monitoring and control of regional (psychiatric) capacities and knowledge of turnover and outcome data on the treatment of patients with depression will help both the health government and regional and national treatment centres.
Primary or secondary prevention programmes, targeted development projects should be based on real national turnover and epidemiological data. Although data are collected systematically in Hungary, the available patient and care system statistics are not yet used for decision making.
When updating and developing reimbursement protocols, policy programmes and strategies, it is necessary to use the available public turnover and epidemiological data (payer and institution databases) in a targeted manner in the future to better explore and understand the area.
The establishment of a national suicide registry is justified alongside the development of suicide prevention programmes.
The significant disparities in capacity and regional care obligations of psychiatric outpatient care must be reduced, however this requires the targeted assessment of the available capacities and patient care data. Proposals for capacity allocation must be developed based on the assessment.
The social stigma surrounding mental disorders, including major depression, needs to be reduced in order to provide more effective care. Using best practices of psychiatry to develop national public health programmes and comprehensive awareness campaigns could enhance the social acceptance of depression and other mental disorders.
National suicide prevention programmes should be launched. Both state prevention programmes and national NGOs and patient organisations have a significant role to play in suicide prevention and their involvement should be strengthened.
The role of patient organisations in the preparation of health policy and financing proposals should be strengthened, and the current low level of representation should be increased.
In addition to improving the care of patients by specialists, there is also a need for increased support for patients' carers. Although no financial resources are available at system level to support carers, patients and carers are not always aware of other support options (e.g., housing assistance, emergency financial aid from municipal or public funds, home assistance, tax relief). People in need should receive information, educational materials on the range of supports available and also on how to apply for them.
The infrastructural conditions for telemedicine must be provided in all regions of the country and at all levels of progressivity (i.e., already at the level of outpatient care) and of adequate quality.
Various forms of telemedicine are being used increasingly by many specialities. Based on the feedback from specialists, there is a need to define telemedicine codes that can be recorded/financed in the psychiatric profession, not only in emergency but also in general practice, in order to improve both adult and paediatric care; this requires the integration of new ICPM codes into the Outpatient Handbook. It is also appropriate to revise the financing of the current telemedicine codes that can be used in psychiatric care and to increase the financing point values.
There is a need to create digital platforms that are easily accessible to patients, both to reduce stigma and to advance the rate of properly diagnosed patients.
Patients must made aware of mental health helpline services and these services, as a preclinical level, should be integrated into the therapeutic system.
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16. Osváth P; Bálint L; Németh A; Kapitány B; Rihmer Z; Döme P., Changes in suicide mortality of Hungary during the first year of the COVID-19 pandemic. Orv Hetil. 2021, 162 (41), 1631-1636.
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18. European Patients Forum, EPF Background Brief: Patient Empowerment. Brussels: EPF 2015.
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21. Hallgren KA; Bauer AM; Atkins DC., Digital technology and clinical decision making in depression treatment, Current findings and future opportunities. depression and anxiety 2017, 34 (6), 494-501.
22. Prescott J; Hanley T; Ujhelyi K., Peer Communication in Online Mental Health Forums for Young People: Directional and Nondirectional Support. JMIR Mental Health 2017, 4 (3), e29-e29.
23. National Health Insurance Fund Administrator Basic fees and performance data for curative and preventive benefits. http://neak.gov.hu/felso_menu/szakmai_oldalak/publikus_forgalmi_adatok/gyogyito_megelozo_forgalmi_adat/aladijak_telj_adatok.html.
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28. Lerner, D.; Adler, D. A.; Chang, H.; Lapitsky, L.; Hood, M. Y.; Perissinotto, C.; Reed, J.; McLaughlin, T. J.; Berndt, E. R.; Rogers, W. H., Unemployment, Job Retention, and Productivity Loss Among Employees With Depression Psychiatric Services 2004, 55 (12), 1371-1378.
29. EMMI, EMMI Decree 49/2018 (XII. 28.) on the scope of diseases of major public health significance or otherwise involving a significant cost burden, the designation of the body managing the disease register, and detailed rules for the notification and registration of these diseases.
30. NEFMI, Decree 9/2012 (II. 28.) NEFMI on the definition of outpatient specialised care activities eligible for financing from the Health Insurance Fund, the eligibility criteria and rules applicable to the use of such activities and the accounting of the services.
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32. Government of Hungary, Government Decision 1722/2018 (XII. 18.) on the National Health Programmes and the related policy programmes for the years 2019-2022.
33. Rihmer Z.; Torzsa P., A brief method for screening depression and suicide risk in general practice. Family Medicine Continuing Medical Education Journal 2016, 21, 584-589.
