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In Greece, primary health care (PHC) was established by law in 1993 when the National Health System (NHS) was formed. Currently, primary care is predominantly provided by the general practitioners (GPs) and internists serving primary care health centres, all located in rural areas. Mental health care services in outpatient care are mainly provided by the psychiatrists and other mental health practitioners that predominantly serve the private sector. In Greece, the major attempt which has been taking place since 1984 to decentralise mental health care services and establish prevention oriented services, based on European Union recommendations, has been completed during recent years. 1 The Mental Health Act (Law 2716/1999) created a novel concept called ‘Psychargos’, which is a 10‐year action plan. 1 It was evident that Greece's mental health services are weak, and the Psychargos programme will provide, on a national level, dramatic reform and new visions and structure for mental health services. It focuses on restructuring the old mental health system, with a new emphasis on social inclusion and cohesion in the community; it will help to eliminate social stigma by creating new units (e.g. mental health centres and mobile units) to serve the citizens' needs. 1 Thus, over the past 25 years, a consistent shift from institutionalised settings to more community‐based environments for patients has been seen. Although through this modern Act and ten‐year plan much has been achieved, there is, as a recent review has reported, a large demand for integrated primary care, 2 making the integration of mental health into primary care an urgent issue in the current health policy agenda. 3
In the four‐year GP vocational training course, only 10 months is assigned to the community setting, while a three‐month period in psychiatric departments in the hospital setting is included. Given the lack of adequate programmes addressing GPs in residency, a focus on mental health education in general practice seems to be an urgent priority. For this purpose, the Greek College of GPs (ELEGEIA) has organised intensive courses on depression for small groups of GPs during the past eight consecutive years in different cities in Greece. 4 There is an impression that Greek GPs are capable in recognising common mental health morbidity, as is reflected in both intervention research programmes 5 and daily clinical practice. 6 Notably, it has been ascertained that GPs could play an important role in the management of mental disorders, and this seems to be accepted by other specialists, especially those practising in mental health. Towards this end, other research studies have confirmed that after intensive education programmes GPs become efficient in early diagnosis and effective management. 5 In addition, diagnostic instruments, as well as the diagnostic capabilities of the primary care physicians, have been explored and practical recommendations given with the aim of an enhanced quality of care in the primary care setting. 7
The University of Crete was the first in Greece to include a PHC course in its undergraduate training programme. It is also the university in which many of the PHC‐related PhDs have been undertaken and where research regarding mental health has been carried‐out and published. Research topics cover a wide spectrum, including morbidity, quality of life and determinants of health. Five papers are shortly to be presented as examples of the primary care research implemented in Greece and its impact on clinical practice.
One PhD research study attempted to report on an evaluation of the frequency of dementia and depression in people visiting primary care services in northern Greece. 6 This study involved a total of 536 participants aged 65 years and older. 6 The subjects were interviewed by a psychiatrist, the medical and family history data were recorded, and the Mini Mental State Examination (MMSE) and Geriatric Depression Screening Scale (GDSS) were used to assess cognitive and mood disorders. After close scrutiny of the data, it was found that 37.6% (men) and 41.6% (women) demonstrated symptoms of cognitive impairment, while 29.9% (women) and 19.6% (men) were found to have mild to moderate depression. 6 In the findings it was also noted that diabetes mellitus (DM) and hypertension frequently go hand in hand with depression and dementia. However, the message of this study is to illuminate and reaffirm that a high prevalence of these mental disorders exists in Greece.
In a recent study, the impact of diabetes on mental health and quality of life has been articulated in two different areas in Greece. 8 This study attempts to clarify the correlation between quality of life, health status and psychological distress in DM victims. Patients with DM from a rural primary healthcare centre were compared to patients attending a diabetes outpatient clinic at an urban hospital. The study population were individuals with a history of type 2 DM who attended the centre in their area. All the participants completed two questionnaires: the generic instrument Short Form‐36 version 2 (SF‐36 v2), and the disease‐specific Problem Areas in Diabetes (PAID) scale. It was determined that quality of life for DM patients was lower when compared to that of the general population and it was notable that patients from the urban diabetes outpatient clinic had significantly higher levels of distress and lower levels of quality of life in contrast to patients from the rural primary healthcare centre. These findings expose the necessity of paying attention to various domains, such as mental health and social functioning, that are not focused on at times.
In the article Sense of coherence in Crete and Sweden: key findings and messages from a comparative study 9 the concept of ‘sense of coherence’ (SOC), launched in 1987 by Aaron Antonovsky, is used to explain a different way of seeing the world, which is believed and seen to improve health. 9 To evaluate SOC a questionnaire was given to 200 subjects aged between 28 and 92 years; higher scores indicated reduced risks for cardiovascular disease and overall mortality. In this research, a rural area in Crete named Spili was studied. Comparing the SOC scores of the Spili group and the Swedish participants, a statistically significant difference was seen, with men reporting a higher SOC than women, while Cretan women scored significantly lower than their Swedish equivalents. 9 The reported low scores of the Cretan women helped raise awareness that there may have been a rise of morbidity due to psychiatric causes. Ample research is needed on the role of SOC in one's health, such as the impact of various environmental and cultural factors. A novel study like this was badly needed to open an ongoing dialogue and quest for reasons for the unfavorable contrast between the scores for the two genders.
A recent study 10 tackles the issue of musculoskeletal disorders (MSD), aiming to identify any connection between the state of mental health of an individual and their current quality of life. This study involved patients from one primary care centre (PCC) in rural Crete. Comprehensive validated questionnaires were given to the patients to help identify these connections. The results of this study found that quality of life was altered for patients suffering from MSD. The most common symptoms were pain in the lower back and knee (71.2%). 10 Along with the low quality of life identified through the questionnaires, these patients also suffered mental distress. 10 In this influential study, it is seen that mental ill health is evident in patients' living with musculoskeletal disorders.
In Crete, PhD students have invested time in the translation and validation of screening instruments. In one informative study recently completed in Heraklion, Crete, the Edinburgh Postnatal Depression Scale (EPDS), a key device and screening method used with mothers during the postpartum period for early detection of postnatal depression, was utilised. 11 A total of 130 women were recruited from four hospitals in Heraklion, two public and two private. 11 This study asserts that this is a problem faced by Greek women in today's society and that the involvement of primary care practitioners is needed for the early identification of postnatal depression. This article gives evidence that the Greek EPDS scale could be used as a useful mechanism not only in the clinical practice setting but also in research, as demonstrated by the close examination of the scale in this study.
In contemporary Greece, general practice seeks a pivotal and frontline role in managing mental health, while integrated primary care is still lacking in the current agenda. Although ELEGEIA and the University Department of Crete have made several efforts in the areas of education and research, there are actions that need to be taken in Greece.
Ample research is needed to develop quality education, launch collaborative studies, release guidelines and develop tools suitable for GPs. It is evident that a focus needs to be placed on mental health in Greece and unfortunately resources for producing independent research are limited. As seen in the studies stated above, mental health issues should be an increased priority in the vocational training programmes of GPs in Greece; credible instruments exist to measure one's mental health.
Stella Argyriadou, Vice‐President, Greek Association of General Practice.
Christos Lionis, Associate Professor of Social and Family Medicine, School of Medicine, University of Crete.