Spotlight
on Slovenia
Population: 2,1 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
Suicide is a major public health issue in Slovenia, and the country is one of the countries with the highest suicide rates. In 2019, the suicide quotient was 19.8%, which was higher than the European average (13 per 100,000 people). Suicide claims the lives of nearly four times as many men as it does women, and the elderly are particularly at risk. Suicide is the second leading cause of death among adolescents aged 15 to 19.9
Access to mental health services varies by geographical area in Slovenia, and it is also characterized by significant socioeconomic and demographic differences.
Slovenia is in the process of renewing its mental health system and developing new services in this area.
The Mental Health Act10 was adopted in 2008. The adoption of the Resolution on the National Mental Health Programme (2018–2028)5 marked a significant transition.
The National Mental Health Programme 2018–2028 (MIRA)11 is the Republic of Slovenia's first comprehensive mental health strategy document. The programme integrates existing structures and adds much-needed new ones to create an integrated, interdisciplinary, and cross-sectoral promotion, prevention, treatment, and rehabilitation organisation.
In 2021, the Association of Psychiatrists of the Slovenian Medical Association adopted Guidelines for the Treatment of Depression12 which mention psychotherapy, psychoeducation, and other psychosocial approaches, as well as biological approaches to treatment, in addition to pharmacological treatment of depression.
In Slovenia, compulsory health insurance covers the care and treatment of people with mental health issues (psychosis, bipolar disorder, and depression). The National Institute of Public Health (NIJZ)13 monitors, collects, and analyses data and activities in the field of mental health, but the main flaw in the mental health system's control and monitoring is the indicator of quality and outcome of care for the user.
In Slovenia, there are a number of non-governmental organisations (NGOs) that focus on mental health prevention and rehabilitation (education, accommodation, and employment) for people with mental issues, as well as support for their caregivers.
People suffering from depression can seek help in a variety of counselling centres throughout Slovenia, or they can call the confidential phone line at any time (24 hours a day, 7 days a week).
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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 minSince 2005, initiatives in Slovenia have been underway to identify depression in a timely manner and to include depression treatment at the primary level.14
Systematic depression screening15,16 is now included in the programme of reference clinics17,18 which have over 880 stations throughout Slovenia. If depression is suspected, the individual is referred to a general practitioner (family medicine specialist). The general practitioner diagnoses depression and initiates treatment with antidepressants. Any licenced physician, both at the primary and secondary levels, can prescribe antidepressant medication. As a result, there is no bottleneck in the introduction of treatment. Psychoeducational workshops are also available at the primary level to assist with coping with depression.19,20 These workshops are included in the Centres for Health Promotion (Center za krepitev zdravja-CKZ).21
Slovenia has psychiatric outpatient clinics within the framework of public health and the newly established Mental Health Centres (Center za duševno zdravje-CDZ)22 at the primary level. Access to a psychiatrist is possible without a referral (for consultation and basic treatment). If treatment at the primary level is unsuccessful or too complicated, the patient is referred to the secondary or tertiary level.
Slovenia is in the process of renewing its mental health system and is planning new services in this area.
Slovenia does not have a separate national programme for the treatment of depression, but it is included in the National Mental Health Programme4, along with other mental disorders.
In 2008, the Mental Health Act10 was passed, and in 2018, the Resolution on the National Mental Health Programme 2018–20285 (Resolucija nacionalnega programa za duševno zdravje-RNPDZ) was passed, which marked a significant shift. The National Mental Health Programme 2018–2028 (MIRA)4 is Slovenia's first strategic document that comprehensively addresses the field of mental health.
The Resolution establishes management structures for professional leadership, interdisciplinary and interinstitutional coordination, monitoring, and evaluation of the Resolution's implementation. The NIJZ is in charge of coordinating the MIRA Programme's implementation. The National Council of the Government of the Republic of Slovenia for Mental Health23 which is the government's consultative body in the supervision and management of the Resolution, was established in the middle of 2021. It brings together representatives of ministries, national professional bodies of the medical profession, social welfare, and education, providers, professional associations, and non-governmental organisations in the field of mental health with the status of a humanitarian organisation.
The programme integrates existing structures and adds much-needed new ones to create an integrated, interdisciplinary, and cross-sectoral promotion, prevention, treatment, and rehabilitation organisation.
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?
Is a range of therapeutic options reimbursed and available to people with depression, such as psychotherapy, counselling and cognitive behavioural therapy?
The national programme's three main challenges are: reducing mental health problems and burdens, as well as burdens due to poor mental health, increasing literacy and awareness in the field of mental health and destigmatization, and better organising mental health services.
Priorities include: providing a community-based approach to mental health; promoting mental health; preventing and destigmatizing mental disorders; establishing a network of mental health services for various age groups; alcohol and mental health; suicide prevention; education; research; monitoring; and evaluation.
The National Mental Health Programme aims to move Slovenia's mental health care population in the direction of mental health strengthening, preventing the development of mental health problems in all environments and bringing accessible and connected mental health services for people with mental disorders to the primary level and the community.
To that end, it intends to establish 28 centres for the mental health of children and adolescents, as well as 25 centres for the mental health of adults. Slovenia currently has 16 children's and adolescent mental health centres (CDZM) and 14 adult mental health centres (CDZ). CDZ treatment (for children and adolescents, as well as adults) is interdisciplinary.
The main obstacle to implementing the planned network is the severe scarcity of experts in this field (pedopsychiatrists, clinical psychologists, and psychiatrists). Slovenia has fewer psychiatrists, pedopsychiatrists, and clinical psychologists than the EU average.
Three ministries are responsible for mental health management (Ministry of Health; Ministry of Labour, Family, Social Affairs, and Equal Opportunities; and the Ministry of Education, Science, and Sport). The mismatch between them prevents the National programme from being implemented successfully. The total cost of mental health is also difficult to assess because costs are shared among various ministries, which is why the Resolution calls for a shift of resources (financial and human) to community care. The majority of funds are now allocated to psychiatric hospitals and long-term care facilities. Regrettably, these funds are often insufficient. Read more here.
Are depression services available and tailored for at-risk groups?
Young people
Older people
People in the workplace
Homeless people
In 2021, the Slovenian Medical Association's Association of Psychiatrists adopted Guidelines for the Treatment of Depression, which include psychotherapy, psychoeducation, and other psychosocial approaches, as well as biological approaches to treatment, in addition to pharmacological treatment of depression. The guidelines also address the treatment of depressive disorders in specific populations, such as children, adolescents, and the elderly, as well as the treatment of postpartum depressive disorders.
In Slovenia, compulsory health insurance covers the care and treatment of people with mental health issues (psychosis, bipolar disorder, and depression). Individuals do not pay for services, either hospital or outpatient. Treatment is available to all, including those who do not have basic health insurance, in the event of a psychiatric emergency. Other services are also included, such as social services and the Ministry of Health, who coordinate all necessary follow-up care.
In Slovenia, according to the recommendations of the Guidelines for the Treatment of Depression, there are various options for the treatment of depression, in addition to pharmacological treatment also psychological support, psychotherapy, and cognitive behavioural therapy–CBT (vedenjska kognitivna terapija-VKT), but unfortunately to a limited extent in public services. When a patient is hospitalized, psychological support, CBT, and psychotherapy are provided in a hospital setting as well as in mental health centres. Patients are left to the market of service providers in outpatient treatment. Psychotherapy is a field that is not systematically regulated, it is understaffed, and self-funded.
In Slovenia, a Psychosomatic outpatient clinic is being established that will include the treatment of pain syndromes, pain conditions, and depression. A psychiatrist will be able to refer patients to this clinic.
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 absence of data on depression, such as demographic trends in prevalence and incidence, use and effectiveness of services and treatment, patient-reported indicators, and long-term outcomes, represents a missed opportunity to better understand depression trends in Slovenia.25
Regular health and other statistics, as well as regular and periodic surveys, are used to record indicators in the field of mental health, but they do not provide all the required data. In order to meet the needs of mental health monitoring, an internationally comparable data set that allows for comparable mental health monitoring must be defined.
All the experts interviewed agreed that there are no well-organized data on mental health in Slovenia.
Are data on people with depression systematically collected by the health system?
The National Institute of Public Health (Nacionalni inštitut za javno zdravje-NIJZ) is the collection manager in charge of monitoring all hospital treatments.13 It costs money to acquire this data. This data, however, is often useless. The data available is fragmented (at various levels of health care), unrelated (the same person may appear in multiple databases depending on visits to different services), and less accessible (data must be requested separately).
Every year, the NIJZ publishes the Health Statistical Yearbook of Slovenia, a comprehensive publication that presents data and information on various aspects of the population's health status, the health care system, health financing, and the role of the environment in influencing population health in a broad sense.
Each hospital has its own set of data that it needs to run and plan its operations. There is no established link between these hospital health statistics.
The Health Insurance Institute of Slovenia (Zavod za zdravstveno varstvo Slovenije-ZZZS) collects data on medicine consumption.
According to some, the data could be incorporated into the Central Register of Patient Data (CRPP), which allows for the electronic exchange of health data between healthcare providers so that all of them would have access to it. Due to the sensitive nature of mental health issues, it is especially important to ensure privacy protection and controlled access.
Data collection on suicidal behaviour has a long history in Slovenia, with the most progress being made in this area with the establishment of the Register of suicide26,27 and suicide attempts in 1970.
The Resolution specifies how outpatient care will be monitored. On a primary level, it is supposed to connect family medicine, CDZ, and psychiatrists.
The responsible expert group of the RNPDZ manager has been determined within the Action Plan of the National Mental Health Programme MIRA (2021–2023)28 to monitor the success of the implementation of individual goals and measures from the priority areas of the Resolution. The group's top priority is to develop a set of internationally comparable indicators for monitoring men and women's mental health across all age groups and in vulnerable populations, as well as the establishment and implementation of appropriate ongoing monitoring and research of men's and women's mental health, as well as the efficacy of interventions in all age groups and vulnerable groups.
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 minIn Slovenia, there are a number of non-governmental organizations (NGOs) and associations (Ozara, Šent, Altra, DAM) that focus on mental health prevention and rehabilitation (education, housing, and employment) for people with mental disorders, as well as support for their caregivers.
Association representatives play a part in the planning and implementation of mental health care. They are invited to various working groups at the Ministries of Health and Social Affairs, Labour, Family, and Equal Opportunities. A relative representative is also present in the Mental Health Council30 which was established in 2021.
Patients and caregivers do not have their own representatives at the Health Insurance Institute of Slovenia (ZZZS), which is the central institution for ensuring the availability or financing of individual methods of treatment and rehabilitation, and thus do not have the opportunity to participate in introducing new treatment approaches.
All of their suggestions were taken into consideration when the National Mental Health Programme was adopted. In management structures, interdisciplinary working groups, and the professional programme council for the National Programme's implementation, representatives from associations, relatives, and patients are involved. However, there is still much that can be done to improve cooperation in practice. The most important aspect in this area is to empower patient organisations so that they can function and look like organisations from other disease areas that are already more involved in policymaking.
Stigma exists in Slovenia, and it should be addressed at various levels with the cooperation of various ministries, such as empowering patient advocates, introducing social and emotional learning programmes in schools, and implementing effective prevention and support programmes for families, to name a few examples. Many famous Slovenes have joined the public awareness group in recent years, speaking openly about depression.
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?
Only one organisation in Slovenia focuses solely on depression and anxiety disorders: the DAM association, which provides peer-to-peer support and self-help groups to members and others in need. In Slovenia, such assistance is not funded. Experts agree that peer support is beneficial in the treatment of depression and that more should be done in this area.
Financial support is not provided to relatives or caregivers of people suffering from depression. Societies provide them with emotional support as well as educational opportunities.
People suffering from depression can seek help in mental distress at various counselling centres throughout Slovenia, or they can call the confidential phone line at any time (24 hours a day, seven days a week) and similar Slovene websites are www.nebojse.si, www.tosemjaz.net, www.zivziv.si, www.telefon-samarijan.si, and Posvet.org.
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 paved the way for the use of digital technology. Prior to that, the profession was hesitant to adopt these solutions because psychiatry is based on a personal approach.
Treatment and re-examination services for depression are now available online. The service is governed by ZZZS rules and is compensated as such. The doctor's choice of remote method is based on the individual patient. These are mostly phone conversations, with a few video reviews (Zoom, Skype). This brings up the issue of security. However, there are currently no national guidelines or financial support in place to implement additional security options.
Digital devices are extremely important because they allow for faster treatment. Most doctors use the Mediately application for doctors, which is a medicine register with various tools for disease monitoring. These tools can be used by both the patient and the doctor, and they can also be printed. For the time being, there are no such options for people suffering from depression. In an ideal world, such information would be entered into a patient's digital file in the hospital's computer system.
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?
Before the pandemic, there were no digital tools available for people suffering from depression. OMRA31, a programme that educates patients, relatives, and professionals in the field of depression and anxiety disorders, has been transformed into "online" workshops that took place during the epidemic. Previously, the workshop could only be held in person (example 1).
The Ozara Association created the "Overcome Depression" application,32,33 which is freely available to anyone suffering from depression (example 3). However, due to a lack of financial resources, the promotion was insufficient to adequately inform the public. The Association is considering upgrading the application.
The digital system solution for depression and other mental disorders could be found in the central register of patient data (CRPP, eZdravje)34 which is a comprehensive system for collecting and exchanging health data on patients who live in Slovenia permanently or temporarily, as well as other patients who receive medical care in Slovenia.
A Summary of Patient Information (Summary) and medical records are both included in the CRPP. The CRPP's aim is to allow the electronic exchange of health data between healthcare providers so that all of them have access to their patients' data. The patient becomes acquainted with the data collected about him through the zVEM portal.35 Registration on the zVEM portal necessitates the use of a digital certificate.
The e-Recept36 tool also allows for remote prescribing and renewal of prescriptions for depression treatment, so that a patient can order an extension of his prescription from home with his doctor and pick it up at a nearby pharmacy.
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 7minIndividuals in Slovenia have unlimited access to psychiatrists 24 hours a day, seven days a week, without the need for a referral.
Depression is covered by compulsory health insurance, and most antidepressants can be prescribed by a general practitioner or any doctor licenced at the primary and secondary levels.
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For several years, depression screening has been implemented in reference clinics.37,38 Reference clinics18 are located in all health centres and are part of public health.
Slovenia is updating its mental health system and developing new services in this area.
The National Mental Health Programme4 aims to shift the population of Slovenia's mental health care in the direction of strengthening mental health, preventing mental health problems from developing in all environments, and bringing accessible and connected services for people with mental health problems to the primary level and the community.
Slovenia also focuses on two public health problems – harmful alcohol use39 and suicide9 which should be specifically addressed – alcohol as self-medication of depression40 and suicide as a result of depression, in addition to transient mental distress plaguing the adult population, as well as stress, anxiety, and depressive disorders in adults and dementia in the elderly.
The Mira programme is establishing a network of mental health centres staffed by interdisciplinary teams of experts. The guiding principle of mental health centres is to ensure that all groups of people in a given area have equal access to services and programmes. Although access to psychiatric care in Slovenia is good, it varies by region. Equal access is not currently guaranteed for all regions, and some areas are underfunded, which must be addressed in the future.
There is a severe shortage of mental health professionals in Slovenia (psychiatrists, clinical psychologists, psychotherapists, and pedopsychiatrists). It is imperative that sectoral policies be linked and coordinated (education, health, social services). As a result of the foregoing, the field of resolving mental health issues in various vulnerable groups, such as children, adolescents, and the elderly, remains neglected, particularly at the primary level. Because this is an interdisciplinary approach (nurses, social workers), coherence between ministries and coordinated implementation are critical. It is critical to maintain the fluidity of these systems in order to provide the best possible assistance to the individual.
Work at the secondary and tertiary levels of depression management should be coordinated with mental health centres.
The Guidelines for the Treatment of Depression recognise psychotherapy as an appropriate treatment next to pharmacological treatment for depression. Since there is a shortage of psychotherapists in Slovenia, it is necessary to regulate this field on a systemic level (financially and in terms of human resources) and to pass a psychotherapy law.
Creating a comprehensive and integrated Mental health information system (Informacijski sistem duševnega zdravja - ISDZ) can help with monitoring service implementation and quality from both the population and individual perspectives.
The Resolution's Action Plan (RNPDZ) envisions the establishment and implementation of appropriate continuous monitoring and research on men's and women's mental health, as well as the efficacy of interventions in all age groups and vulnerable groups. It makes sense to connect all those who deal with the treatment of people with depression or mental health issues at the primary level-family physicians, paediatricians, outpatient psychiatrists, and CDZ.
Because of concerns about data security and confidentiality, most psychiatric institutions are hesitant to submit data to the CRPP. We could have allocated space within this interoperable backbone, in collaboration with the NIJZ, where data would be entered on a regular basis if there was a will and financial support.
The profession recognised well-being of self-help and peer support groups in Slovenia, both in adults with depression and in children and adolescents and their caregivers, needs to be strengthened (case study 2).
Patients and caregivers do not have their own representatives at the Health Insurance Institute (ZZZS), which is the central institution in charge of ensuring the availability or financing of individual treatment and treatment methods. As a result, they are unable to participate in the introduction of new treatment approaches. Involvement of patients and caregivers associations in policymaking is still insufficient. The most crucial aspect in this area is the empowerment of patient associations.
Adult mental health associations have been present in Slovenia for a long time. However, there are no associations dedicated to children's and adolescents' mental health.
A variety of digital tools should be used to raise public awareness of depression, educate the general public about it, and help depressed people cope with it.
During the COVID-19 pandemic, new approaches to dealing with people suffering from depression and other mental disorders (telephone, video chat) emerged, but the issue of security and confidentiality arises. Several systems that provide such treatment are already available due to the development of these services during the aforementioned time period. Financial investments in such digital technology should be considered in accordance with time and needs.
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