According to World Health Organization (WHO)[1], childhood and adolescence are considered to be critical stages for the development of skills in self-control, social interaction and learning. This can affect the mental health and well-being of children and adolescents, whereas exposure to risk factors (e.g. bullying at school) can negatively affect them in the long-term. As the rates of mental health and behavioural problems at the population level are high and continue to increase, healthcare systems could benefit from employing additional tools and methodologies.
Two of the objectives identified in the WHO’s comprehensive mental health plan (1) refer to (a) the provision of comprehensive and integrated mental health and social care services and (b) the strengthening of evidence-based information systems. In order to analyse and assess the functionality and operational capability of mental healthcare services, identification of correlations and relationships within such systems would provide a better insight related to the services provided. Such an approach would then easily provide an evidence-base for the consequences of a high socioeconomic burden of mental diseases, apart from the medical and emotional one, not only on the micro- (e.g. individuals and their families) level, but on the meso- (e.g. school population) and macro- (e.g. nation) level as well.
It is the aim of the current paper to suggest an integrated system’s approach based on General Systems Theory to show that the application and exploitation of such frameworks in a very specialized and focused attempt can help to define the individual and population relationships, characteristics and interactions inside and outside a system. Moreover, the assessment of the efficiency and operational capability within an existing mental healthcare provision center allows the observation and identification of a correspondence between social, economic and operational indicators. A description of these parameters are provided hereinafter, based on semi-structured interviews with the staff of the Hellenic Center of Mental Health and Research and online material provided by their website (http://www.ekepsye.gr/).
1.1 Description of the operational framework within the Hellenic Center of Mental Health and Research (HCMHR)
The Hellenic Center of Mental Health and Research (HCMHR) is a Mental Health Unit of the broader Public Sector and it is under the jurisdiction and financial support of the Greek Ministry of Health, which has eight Mental Health Units in total nationwide. The specific unit is located in the center of Athens and serves three of the seven municipal communities of the Municipality of Athens (Figure 1). More specifically it serves the fourth, fifth and sixth municipal districts, with the following characteristics:
- 4th Municipal Community (D4): It includes the western districts (Kolonos, Platonos Academy, Kolokynthos, Prophet Daniel, Sepolia, Nirvana). Its population according to the 2011 census is 85,629 (compared to 2001: 92,310).
- 5th Municipal Community (D5): It includes the northwestern districts from Kato Patisia to Probona (Agios Eleftherios, Patisia, Rizoupoli, Probona). Its population according to 2011 census is 98,665 (compared to 2001: 105,539).
- 6th Municipal Community (D6): It includes the central districts (America Square, Attica Square, Kipseli, Nea Kipseli, Ano Kipseli). Its population according to 2011 census list is 130,582 (compared to 2001: 162,366)
In addition, HCMHR serves the Municipality of Galatsi, but the same geographical area is also served by the Community Center for Mental Health of Children and Adolescents of the General Hospital Sotiria (located in Attica Square). This means that according to the 2011 census, a total of 314,876 residents are served by just one center in population level. In 2019, the HCMHR staff consists of 13 persons in total (two administrative clerks, three pediatric psychiatrists, five psychologists, two social workers and one speech therapist), which is considered adequate in accordance with the current operating framework.
The services provided by the HCMHR are particularly important as they are offered to children and adolescents with mental and developmental disorders and psychosocial functioning difficulties (such as dyslexia, autism spectrum disorders, anxiety or behavioral problems). These services include (a) diagnostic evaluation (and possibly evaluation related to cognitive and developmental skills) that could be communicated to school or other relevant stakeholders (e.g. cases of learning disabilities or when there are families applying for an insurance fund, when there are indications of special treatment plans) and (b) treatment.
According to the latest statistics, and specifically for the period from October 10, 2018 to October 10, 2019, the center had 445 new incidents covering all ages (0-18 years). Particular issues related to the whole process may arise from subgroups of populations due to different ethnicity and cultural identity (for example working with interpreters in case of referrals concerning refugee children), but in general there is representation from all social groups, so the HCMHR can be seen as a general system at the patient level that interacts with other systems at a population level (e.g. schools).
The usual procedure followed by HCMHR with the introduction of a new case (along with the relevant timeplans) is as follows:
- Introduction (of a new case) stage: families (in some cases even children or adolescents on their own) contact and arrange the booking of an appointment to meet with a specialist at HCMHR (usually there is a duration of one to three weeks until the meeting).
- Assessment stage: At this stage, learning and developmental difficulties, anxiety and behavioral problems among others are assessed. It is also decided whether the child or adolescent will proceed with a treatment plan. There is a two to five percent (2-5%) dropout rate, where the child may not continue or is referred to an external service. At this stage, other specialists may be included for additional sessions.
- Treatment stage: depending on each case, psychotherapy, counseling, or speech therapy sessions may be held. These sessions are held on a weekly basis (as far as the pediatric psychiatrists are concerned) and once every 15 days with a counseling expert, for a one year period. There is also the possibility of a supportive medication plan (if deemed necessary). These sessions last 45 minutes and take place on a weekly basis with an average of 40 sessions per week (this number refers to sessions held by all HCMHR specialists), without taking into account the time needed for the consultation.
- Re-evaluation stage: at the end of treatment, the condition is reviewed and the case is considered 'closed'. Usually 45-50% of cases have completed their cycle by the end of the year.
An indicative example of a new case at HCMHR could be described as such:
- Parents concerned about their children communicate by telephone with the HCMHR. An appointment meeting is scheduled where both parents and the child meet with a specialist within one week.
- During the meeting the specialist has a discussion with the parents and the child and concludes with a diagnosis of whether or not a therapeutic regimen may be available (depending on the conclusion reached by the specialist after the first meeting, the regimen could be applied with him/her or with more specialists). In some occasions, the case may also be referred to an external service.
- After their diagnosis, the child/adolescent and their parents are informed within one to two weeks of the findings in respective sessions. If there is a positive decision from both parties (parents and child), they proceed in a therapeutic plan, depending on the case. Psychotherapy, counseling and/or speech therapy sessions can be held. The sessions that take place, depending on the incident, last for one year and are held on a weekly basis (pediatric psychiatrist) and on a biweekly basis with counseling, possibly followed by a medication plan (if necessary). The sessions last for 45 minutes.
- At the end of treatment, the condition is reassessed (related certification is provided upon request from parents) and the case is considered 'closed'.
An event of particular interest is when there are too many new incoming cases preventing the HCMHR from being able to cope with their number. In this case, the HCMHR system "survives" through internal response mechanisms, limiting the therapeutic hours (therapeutic framework) it offers. The uncovered population is served by external services and private entities, however this is particularly important because, as already mentioned, HCMHR tries to serve mainly families based on low financial context, so there is a high likelihood that these families will not receive any treatment because of its accompanying cost. This adaptability feature shares common characteristics with living systems, which “adapt to a continually changing environment and to handle stress from both within and without” (2). This serves as an inspiration for the transformation of the HCMHR into a general system.
1.2 Existing status of Mental Health Services
Recent literature indicates a lack of quality, efficiency and effectiveness in mental health care services (3). While mental health is progressively acknowledged as a global health and socioeconomic development priority, several aspects including the social, cultural and medical criteria of the population have not been taken into consideration, as this was investigated in the case of the Japanese people (4) and the South African populations (5). As far as children are concerned, in order for mental healthcare services to be effective, they should be brought closer to the community with elements of care and efficient use of interprofessional teams (6,7). Moreover, previously unexplored evidence e.g. ambient temperature (8) and urban-related problems affecting families, such as housing affordability (9) should also be taken into consideration upon providing mental healthcare services.
This continuously changing field of mental health research demands a critical examination and investigation of different strategies and interventions. It is already known that a multidisciplinary approach (10–12) and an evidence-based modelling (13) of care are needed at the onset of mental health problems, in order to compare and understand the underlying mechanisms of the mental well-being. Therefore, in order to improve the quality and effectiveness of the provided mental health services, an assessment of the existing services’ quality is necessary, as well as “measuring and quantifying it in such a way so that comparisons can be made feasible over time at local, state, and transnational levels” (14) . General Systems Theory framework provides a strong ground for the decision makers to implement mechanisms of depicting and simulating characteristics of systems under investigation from different levels of approach.
1.3 General Systems Theory and Biopsychosocial Model in Mental Health
The foundation of General Systems Theory (GST) as this was introduced by Ludwig von Bertalanffy (15) have been recently brought into spotlight by Tramonti et al. (16) in an effort to re-examine the understanding of mental processes and psychological functioning along with the conceptual foundations for a variety of psychological constructs. The most commonly used derivative of GST is the Biopsychosocial (BPS) model, which is commonly mentioned in mental health care (17,18) along with its criticism (19). However an actual operating framework based on GST is not actually put into perspective to interested stakeholders, as it was pointed out by Sharma et al.(20), where they assessed the clinical implementation of BPS in temporomandibular and other orofacial pain conditions. Although evidence and information might be collected from across all of the three general BPS domains, these might not be comprehensive with regard to the individual BPS components, especially when cultural aspects and societal expectations are among the most influential factors in mental health. Evidence-based and multi-level assessment related to the criteria, indicators, and methodology for evaluating and improving the quality of mental health services and their related qualitative and quantitative indicators (14) are deemed more than necessary