Mobile Mental Health Units in Greece: Bridging Clinical Practice and Research in the Rural Context

The present Special Issue of Psych, which has been now fully released, aimed to highlight the importance of the Mobile Mental Health Units (MMHUs) in delivering services in rural and remote areas in Greece, and to stress their role as an easily accessible setting that provides a wide range of community-based psychosocial interventions, well beyond usual psychiatric care [1,2]. This Special Issue provided a forum for scholars in the field of community psychiatry in Greece to report on their work. Paschalidou and colleagues described the operation of the MMHU of the University General Hospital of Heraklion [3] in a large catchment area in the island of Crete, which is the largest Greek island. Through their detailed description, the authors presented the difficulties in delivering mental health services in rural and remote areas. They also stressed the issue of population aging in those areas, which would require respective adaptations of the caring team. Among the most noteworthy findings of this study was that patients with psychotic disorders are referred to the MMHU relatively late in the course of their illness, when their illness is rather chronic. This is an important finding that indicates the need for further study on early interventions in psychosis in rural Greece. The importance of early interventions in psychosis has been widely acknowledged [4,5], yet there are only scarce relative epidemiological data in Greece regarding the first episode in psychosis [6]. Accordingly, such a study in rural areas would be timely and relevant, and indeed, has been already undertaken by the MMHUs.

The article by Papachristou et al. provides a detailed account of the operation of two of the oldest MMHUs over the years [7]. The authors summarize the basic principles of service delivery by the MMHUs in rural areas in Greece and refer to the ongoing challenges that local services face. Both MMHUs have established a broad local network, comprising the community and several of the local authorities, as well as the church. This network enables supporting people with severe mental illness and their families. Moreover, it facilitates public education regarding mental illness and anti-stigma campaigns. Several differences among the two MMHUs are highlighted; they mostly reflect differences between the catchment areas, such as in population and geography, as well as in the availability of other mental healthcare services in those areas. Although the operation of the MMHUs is regulated by the principles of social and community psychiatry, several differences across MMHUs have been recorded previously [8]. Possible reasons for this phenomenon include differences across running institutions and local factors in different communities. This is not necessarily a problem and could rather reflect the flexibility of MMHUs, the challenges in delivering services in rural areas and the adjustments that have been made accordingly.

Additionally, the present Special Issue was a unique opportunity for the MMHUs across rural Greece to strengthen their collaboration and engage in research. This process enabled the recent re-establishment of their network, which was further expanded with the participation of the newly launched Assertive Community Treatment (ACT)-like teams [9]. The collaborative initiative may offer guidance and support to those teams that may have to deal with an unorganized local mental health network and may lack a strong pre-existing community background. Furthermore, over the procedure of the Special Issue’s preparation, the MMHUs had the opportunity to share information and co-operate for research projects. Several goals were set, such as the conduct of multi-center research and the regular participation in national congresses. Also, some points of concern, that will be briefly discussed below, have been recognized.

1. Challenges and Limitations in Research by the MMHUs

1.1. Missing Data

The collaboration of different MMHUs revealed some important limitations in research conduct. A major issue is missing data. In everyday clinical practice, patients’ charts are updated briefly and in a manner that data extraction for research purposes may be difficult. MMHUs do not regularly use rating scales for the monitoring of the clinical state of patients, or for the measuring of functioning and outcome. This is a major limitation for research and should be addressed by the MMHU network. The employment of technology could be helpful in this regard and to overcome time constraints.

1.2. Lack of Funding for Research

The present Special Issue was also a reminder that there are thousands of people that use the services of the MMHUs in rural Greece, and that the goal of the conduct of multi-center studies is feasible, yet overdue. Currently, research is scarce, mostly corresponding to specific institutional goals and personal incentives rather than an organized national effort. There is no additional funding available for research in the context of MMHUs, and that limits the motivation of the personnel to conduct research.

1.3. Public Sector’s Difficulties

Most of the MMHUs in Greece are being run by Non-Governmental Organizations (NGOs). The public sector that runs MMHUs faces several problems in recruiting and maintaining personnel. This, in turn, affects adversely the ability of those MMHUs to engage in research, as their personnel has to deal with a high workload, and may have limited time available for other activities.

1.4. Fragmentation in Research

In general, research in the context of MMHUs is scarce and has been mostly conducted on islands [10,11,12] and on one site on the mainland [13,14,15,16]. Notably, most studies are single-center, which may limit the generalizability of their findings [17]. Indeed, in only two previous occasions, research has been multi-center with the co-operation of different MMHUs [8,18]. These examples suggest that multi-center research, although a feasible goal, is still the exemption. Clearly, more MMHUs should engage in research in order to highlight the importance of their clinical work and to establish their effectiveness. Indeed, research plans have been already discussed regarding the fields of the first episode of psychosis and neurocognitive disorders in the elderly.

2. Suggestions to Address Limitations in Research

To overcome the barriers of public hospitals in running MMHUs effectively and in conducting research, the partnership with MMHUs that are been run by NGOs should be considered. This is a model that has been recently implemented in early intervention in psychosis services [19] in Greece, and has yet to be evaluated. However, it could facilitate staffing and administration in the otherwise bureaucratic public sector. Moreover, the link of MMHUs that are being run by NGOs with academic centers and university hospitals could probably motivate personnel to participate in research on a regular basis.

3. Points for Consideration and Challenges

Alongside research involvement, the stable major pursuit of the MMHUs is to keep delivering effective and quality services to rural residents. In this respect, they have to deal with several challenges, such as the aging of the rural population. Although aging and age-related disorders in rural areas may constitute a major challenge for the Greek mental health system [20,21,22,23], there is little relative research in the context of the MMHUs [24,25]. On the other hand, there is no study regarding children and adolescents, despite that several MMHUs deliver services for this population as well. This is a major limitation that should be addressed by the MMHUs.

Another challenge is physical morbidity and premature mortality in patients with severe mental illness. Those patients are prioritized by the MMHUs, yet the optimal care of their physical health requires a close cooperation of mental healthcare professionals with primary care physicians [26,27]. The care of other special populations, such as migrants/refugees by the MMHUs remains a challenge and requires additional resources [28]. Moreover, there is a group of patients with SMI and high needs of care that are difficult to engage in treatment, even with the existing low-fidelity (the adjustments and variations in the originally proposed strict model) ACT-like model. Those patients would probably benefit from the more traditional high-fidelity models of ACT, which are not currently available neither in rural nor in urban areas in Greece.

4. Future Goals and Pursuits

In order for the MMHUs in rural Greece to further establish their role within the existing mental healthcare system, they have set several goals and pursuits that have been described in the recently published position paper of the coordinating committee of the MMHUs [29]. The commitment of the MMHUs involves the participation in relative forums and bodies; participation in the annual panhellenic psychiatric congress and organization of their own congress; and continuation of research. To maintain the quality of delivered services, the issues of continuing the education of the workforce and the recruitment and maintenance of highly trained personnel should be addressed. These goals could be facilitated by the connection of the MMHUs with academic centers and the implementation of new and more specialized treatment programs.

Moreover, the establishment of a common framework for the evaluation of the MMHUs’ effectiveness could be a future goal. The evaluation of mental health services in Greece is long overdue; the evaluation has been proposed to be linked with funding [30]. Currently, there is preliminary, yet limited, evidence that the MMHUs are effective in the treatment of both severe mental illness and common mental disorders [17,31]. This evidence should be replicated and strengthened by continuous research.

In our opinion, research in the context of the MMHUs in rural Greece could be informative for national clinical practice and mental healthcare policy, but also could be of interest for an international readership, given the paucity of research on mental health in rural areas globally [32,33,34]. There is a growing interest worldwide in increasing patients’ access to high-quality, cost-efficient evidence-based care [35], and the Greek model of MMHUs is an informative paradigm in this regard, which most importantly involves remote and underserved areas.