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the conditions for involuntary placement and treatment do
not include a therapeutic purpose. The law does not provide
free legal representation for detained patients. The legal situ-
ation of people in social care homes remains largely unclear,
as they are de facto detained but without the requirement for
judicial reviews or other legal safeguards. A major concern
for non-governmental organisations is that the new law has
not been fully implemented.
References
Council of Europe (2004) Recommendation No. Rec(2004)10 of the
Committee of Ministers to member states concerning the protection
of the human rights and dignity of persons with mental disorder
and its explanatory memorandum. See https://wcd.coe.int/ViewDoc.
jsp?id=775685 (last accessed November 2008).
World Health Organization (2001) Atlas – Country Profiles on Mental
Health Resources 2001. WHO.
CouNtry Profile
The country profiles section of International Psychiatry aims to inform readers of mental health experiences and experiments from around
the world. We welcome potential contributions. Please email ip@rcpsych.ac.uk
The organisation of mental health services
in post-war Bosnia and Herzegovina
Osman Sinanovic,¹ Esmina Avdibegovic,² Mevludin Hasanovic,² Izet Pajevic,²
Alija Sutovic,² Slobodan Loga³ and Ismet Ceric³
¹Department of Neurology and 2Department of Psychiatry, University Clinical Centre Tuzla, Medical Faculty, University of Tuzla,
75000 Tuzla, Bosnia and Herzegovina; ³Department of Psychiatry, Clinical Hospital Centre Sarajevo, Medical Faculty, University of
Sarajevo, 71000 Sarajevo, Bosnia and Herzegovina
Bosnia and Herzegovina (BH) is located on the western
part of the Balkan Peninsula. It has an area of
51 210 km2 and a population of 3 972 000. According to
the Dayton Agreement of November 1995, which ended
the 1992–95 war, BH comprises two ‘entities’ – the Federa-
tion of Bosnia and Herzegovina (FBH) and the Republic of
Srpska (RS) – and the District of Brcko. The administra-
tive arrangements for the management and financing of
mental health services reflect this. The FBH, with 2 325 018
residents, is a federation of 10 cantons, which have equal
rights and responsibilities. The RS has 1 487 785 residents
and, in contrast, a centralised administra tion. Brcko District
has just under 80 000 residents.
Mental health policy
and legislation
Healthcare systems in BH are regulated basically by the
entities’ different laws on healthcare and on health insur-
ance. Each entity and Brcko District is responsible for the
financing, management, organisation and provision of
healthcare. The health administration is centralised in RS,
through the Ministry of Health and Social Welfare, but in
FBH is decentralised – each of the 10 cantonal adminis-
trations has responsibility for healthcare through its own
ministries. The central Ministry of Health of the FBH, located
in Sarajevo, coordinates cantonal health administrations at
a federal level. The District of Brcko provides primary and
secondary care to its citizens. The mental health policies and
national programmes for mental health were created in 1999
and adopted in 2005. A law on the protection of persons
with mental disorders was adopted in 2001 and 2002 in FBH
(Official Gazette of BH, Nos 37/01 and 40/02), and in 2004
in RS (Official Gazette of RS, No. 46/04). These laws define
the rights of people and regulates the procedure for volun-
tary or involuntary admission to a psychiatric hospital.
Mental health service delivery
There are no private mental health institutions. Psychiatric
services are available for all citizens, paid from a special
national fund for healthcare, financed by mandatory health
insurance. The reform of mental health services began in
1995. The focus has been on care in the community, limiting
the use of psychiatric hospital beds, establishing a network of
community mental health centres (CMHCs), and develop ing
other services in the community, a multidisciplinary approach
and teamwork, as well as cooperation between sectors.
Each CMHC is responsible for general mental health in a
catchment area of 50 000–80 000 inhabitants; each has 10
psychiatric beds, intended for the acute admission of patients
(these beds are in fact on neuropsychiatric wards of regional
general hospitals). The CMHCs have many different functions,
including the promotion of mental health, early detection of
mental disorders, and the provision of multidisciplinary care
(Ceric et al, 2001).
Psychiatric services are provided throughout BH through
the network of 55 CMHCs and family medicine services at
primary care level. Secondary and tertiary mental health
services are provided in three psychiatric clinics, one depart-
ment of a university clinical centre, two general psychiatry
hospitals, two institutions for the treatment, rehabilitation
and social care of patients who are chronically mentally ill,
and neuropsychiatric wards in general hospitals in major
cities. In the reform of the mental health services, mentioned
above, new out-patient services were established, the existing
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primary care services were adapted to mental healthcare and,
in addition to the CMHCs, sheltered housing services for
patients with a chronic mental illness were established.
The reform of mental health services had a direct impact
on the development of users’ initiatives in BH: there are now
several user associations, which are provided with pro fessional
support and education from CMHCs and psychiatry clinics.
There are only two wards and two specialists for child
and adolescent psychiatry within the psychiatry clinics. There
are four institutions for the care of adults and children with
special needs and chronic mental disorders, mainly financed
from social welfare. Persons with drug addiction are treated
in a specialist institute and two other centres for addiction;
methadone is the predominant form of treatment.
There are no specific programmes for the mental
healthcare of minorities and the elderly in BH. There are
programmes for refugees and war victims of torture, through
a network of non-governmental organisations developed
during the war.
The provision of forensic psychiatry services is insuffi-
cient. Individuals with mental health problems who commit
criminal acts are treated in one forensic ward of a general
psychiatry department of a prison psychiatry hospital.
According to the Regional Office of the Mental Health
Project for South Eastern Europe (2004), in 2002 in FBH there
were 159 neuropsychiatrists, in RS 67 and in Brcko District 6.
The number of psychiatric beds in FBH was 632, in RS 640
and in Brcko District 30. These data differ from those in Table
1, from the World Health Organization (2005) and based on
data collected from 2001 to 2004.
Treatment of traumatised persons
At the beginning of the war (1992) knowledge about
the psycho logical consequences of war and therapeu-
tic approaches to post-traumatic stress disorder (PTSD) in
BH was rather poor. The therapeutic approach was based
on the experience of psychiatrists and their receptiveness
to the ideas suggested by the foreign literature and the
many foreign workers (Jensen & Ceric, 1994; Hasanovic
et al, 2006). At the end of the war, various psychosocial
programmes were organised by the government and inter-
national non- governmental organisations (de Jong & Stickers,
2003; Nelson, 2003). The psychosocial approach to trauma
aimed to reduce not only the risk of serious mental disorders
but also stigma, through mass education about the psycho-
logical consequences of trauma. Working with traumatised
people during the war, we perceived that religious people
coped more successfully with difficulties than those who
were not religious. In selected cases, spirituality and religion
are therefore used in the process of healing, and so they
found their place in educational programmes and psycho-
therapeutic treatment. In hospitals, adequate rooms for
the spiritual and religious needs of patients were allocated
(Pajevic et al, 2005).
Psychiatric training
There are five medical faculties, two in RS and three in FBH,
with different education programmes, all lasting 6 years. At
four medical faculties, the undergraduate courses include only
two semesters of psychiatry, while at one medical faculty the
undergraduate course has only a neuro psychiatry element.
Medical schools are associated with psychiatric clinics. After
graduation from the medical faculty and a 1-year internship,
specialisation in neuro psychiatry/psychiatry is available, author-
ised by the entity’s Ministry of Health.
Specialist training is different in the two entities. In FBH
there is specialisation in neuro psychiatry, which takes 4 years,
with 20 months of psychiatry, while in RS there is a pro-
gramme of education in psychiatry only, which also lasts 4
years. There is no unified national programme of psychiatric
education for residents.
Psychiatric sub-specialties and allied professions
The educational programme for the specialisation in neuro-
psychiatry/psychiatry does not include psychotherapy.
Residents from neuropsychiatry/psychiatry are familiar with
the theoretical basis of psychotherapy mainly from their
undergraduate education. There are no institutions for edu-
cation in psychotherapy in BH, and there is no regulation
of psychotherapy licences. Education in psychotherapy is
organised from psychiatry clinics and by psychologists’ asso-
ciations, in cooperation with psychotherapist educators from
other European countries.
The only recognised sub-specialisations are in social psy-
chiatry and alcoholism and drug addiction, each taking 1
year. There is undergraduate education in psychology, but no
specialisation in clinical psychology. Furthermore, there is no
specialist training for psychiatric nurses. Additional psychiatric
education for nurses is provided through special education
programmes organised at the psychiatric hospitals.
Main areas of research
Psychiatric research in BH is insufficiently developed. There
is no professional psychiatry journal, nor a particular insti-
tute for research in psychiatry. Existing research projects are
under taken at the psychiatric hospitals and medical facul-
ties. The main areas of research are currently related to the
psycho social consequences of war trauma. Lack of a uniform
Table 1 Numbers of psychiatric beds and staff
Federation of
Bosnia and
Herzegovina
Republic
of Srpska
Brcko
District
Total number of psychiatric beds
per 10 000 residents
3.6 3.93 3.5
in psychiatry hospitals 2.4 0.91
in general hospitals 1 0.68 3.5
in other institutions 0.2 2.33
Numbers of professionals per
100 000 residents
psychiatristsa– 2.3 –
neuropsychiatristsa1.8 1.2 7.0
nurses in psychiatry 10 19.4 21.8
psychologists 0.5 0.86 1.8
social workers 0.03 0.66 1.8
a In Bosnia and Herzegovina until 1992 there was education in ‘neuro psychiatry’
only; during the war (1992–95), medical doctors from the Republic of Srpska
were trained in Belgrade (Serbia), where they could gain a qualification in
‘psychiatry’.
Source: World Health Organization (2005).
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database and insufficient development of entity and cantonal
public health services represents big problem for research,
particularly epidemiological studies.
References
Ceric, I., Loga, S., Sinanovic, O., et al (2001) Reconstruction of mental
health services in Bosnia and Herzegovina. Medicinski Arhive, 55
(suppl. 1), 5–23.
de Jong, K. & Stickers, R. (2003) Early psychosocial interventions for
war-affected populations. In Early Interventions in Emergencies (eds R.
Orner & U. Schnyder), pp. 184–192. Oxford University Press.
Hasanovic, M., Sinanovic, O., Pajevic, I., et al (2006) Post-war mental health
promotion in Bosnia and Herezgovina. Psychiatria Danubina, 8, 74–78.
CouNtry Profile
Peru: mental health in a complex country
Marta B. Rondon
Assistant Professor, Department of Psychiatry and Mental Health, Universidad Peruana Cayetano Heredia and Attending Psychiatrist,
Hospital E Rebagliati, Essalud, Lima, Peru
Peru is a land of mixed cultures, multiple ethnic herit-
ages and severe economic inequities. Its history goes
back thousands of years, from accounts of the first inhab-
itants of the continent to the impressive Inca Empire, the
rich Viceroyalty of Peru and the modern republic, which
boasts one of the highest economic growth rates in South
America. Yet, in spite of such complex cultural develop-
ment, or perhaps because of it, 21st-century Peruvians
have substantial difficulties establishing a national identity
and recognising each other as members of the same com-
munity.
Persons with mental illness represent with poignant clarity
‘the other’ which we seem to have so much trouble accept-
ing as equals in terms of dignity and rights. When we look
at mental health in terms of legislation, services and human
rights, therefore, we are faced with exclusion and discrimina-
tion, unequal and inefficient use of resources, and lack of
public interest.
Mental health as a component
of public health
Peruvian psychiatrists have traditionally had a bio-psycho-
social approach to mental health and illness. Social psychiatry
studies, under the leadership of Rotondo and Mariategui in
the 1950s and early ’60s, were fundamental in the concep-
tualisation of mental health as a cultural construct (Perales,
1989). Another interesting development is that of psycho-
somatic medicine, under the leadership of Seguin, which
originated in the establishment of a psychiatric ward in a
general hospital, long before the Declaration of Caracas so
suggested, and which also is the precursor of the current
interest in women’s mental health and in the consequences
of violence in the country.
As far back as the 1960s, pioneers such as Baltazar
Caravedo and Javier Mariátegui saw mental illness as a major
obstacle to the development of the country, and they pointed
to the need to devote public effort and money to the promo-
tion of mental health and the prevention and treatment of
mental illness. Others have followed this path, especially after
the results of a large epidemiological study by the National
Institute of Mental Health were made public (Rondon, 2006).
Mental health and disorders
Anxiety, depression and schizophrenia are considered to be
the most relevant psychiatric disorders in Peru. The use of
alcohol, the prevalence of interpersonal violence and the high
tolerance of psychopathic attitudes have also been identified
as important (Instituto Especializado de Salud Mental, 2002).
Perhaps more striking than the prevalence of disorders is
the large number of people (14.5–41.0% of those surveyed),
mostly women, who report feelings of unhappiness, pre-
occupation and pessimism (Instituto Especializado de Salud
Mental, 2004).
Interpersonal violence, in all its modalities, plays a significant
role in the production of psychiatric morbidity. Gender-based
violence is widely tolerated, with roots in the complex culture
of the country (Rondon, 2003). According to a World Health
Organization multi-country study on violence against women,
adult women in the Andean region of Cusco are the most
physically abused females in the world, with those in Lima
faring just slightly better (García-Moreno et al, 2005).
In the 1980s, the country suffered much political violence,
largely targeted against the civilian population. This led even-
tually to the establishment of the Truth and Reconciliation
Commission at the turn of the century. It has recognised
that exposure to political violence during the internal armed
conflict in the 1980s has inflicted severe psychological
Jensen, B. S. & Ceric, I. (1994) Community-Oriented Mental Health Care
in Bosnia and Herzegovina: Strategy and Model Project. WHO Office
for Bosnia and Herzegovina.
Nelson, B. S. (2003) Post-war trauma and reconciliation in Bosnia and
Herzegovina: observations, experiences, and implications for marriage
and family therapy. American Journal of Family Therapy, 31, 305–316.
Pajevic, I., Sinanovic, O. & Hasanovic, M. (2005) Religiosity and mental
health. Psychiatria Danubina, 17, 84–89.
Regional Office of the Mental Health Project for South-Eastern Europe
(2004) Mental Health Policies and Legislation in South-Eastern Europe.
Available at http://www.euro.who.int/document/E88509.pdf (last
accessed November 2008).
World Health Organization (2005) Mental Health Atlas, Bosnia and Herze-
govina. Available at http://www.who.int/globalatlas/predefinedReports/
MentalHealth/Files/BA_Mental_Health_Profile.pdf (last accessed November
2008).