a. National Plan for Mental Health
Law n.º 36/98 of the 24th of July established the bases for the national policy and organization of Mental Health for Portugal and was confirmed a few years later in the National Mental Health Plan.60
The National Mental Health Plan 2007-2016 (PNSM) was approved on January 24, 2008, by Resolution of the Council of Ministers (RCM) n.º 49/2008 in the scope of the High Commissioner for Health, with responsibility for coordinating its implementation. The PNSM was revised and updated in 2012.5
As a result of its application, it is considered:
a) The reduction in the number of institutionalized patients in psychiatric hospitals by 40%;
b) The closing of the oldest psychiatric hospital in the country and moves to deactivate others;
c) The creation of Mental Health services in general hospitals and the launch of some new services in the community, as well as the training of professionals in the context of developing integrated programs for the seriously mentally ill;
d) The launching of the foundations of continuous integrated mental health care and the creation of the first residential services and programs in this sector;
e) The creation of new units and a new referral network in the field of Mental Health for children and adolescents;
f) The start of several innovative programs that made it possible to integrate Mental Health in the fight against domestic violence, support for the homeless and young people with problems of adaptation and social inclusion in cooperation with the social, justice, education and of the job.
b. Access to Mental Health Care
According to the PNSM, «the issue of access to mental health care has been one of the most in-depth areas in recent years, with several of its determinants having already been identified:
Stigma and ignorance in the face of mental illness;
Shortage of human and structural resources;
Low priority in terms of policy option;
Disproportionately low budget for the disease burden involved;
Inadequate organization of psychiatry services, with concentration in large, centralized institutions and little articulated with primary health care.»62
Over the years, efforts have been made in Portugal to improve mental health care. Enacted in 1963, the Law of Bases for Mental Health (Law No. 2118, of 1963) allowed the decentralization of services through the creation of Mental Health centers in all districts of the country and the connection to primary health care.59The current Mental Health law (Law nº 36/98) and the subsidiary legislation enshrine the integration of Mental Health in the general health system and the transfer of specialized care to general and community hospitals. The development of psychosocial rehabilitation programs and structures, the legislation to support employment in the 1990s and the current National Program for Mental Health were also mentioned. Despite these advances, much remains to be done, not in terms of legislation, but in terms of implementing existing legislation on the ground.
The emergence of psychiatric care in Portugal and its evolution to the present day is described in an article published in the International Review of Psychiatry63, where a historical-descriptive and critical analysis of the situation of psychiatric care in Portugal is made.
c. National Network of Integrated Continuing Care for Mental Health
The rehabilitation programs developed since the late 1990s have played a fundamental role in the modernization of Mental Health in Portugal, especially with regard to the conceptual, legal and organizational bases of the Network of Continuing Care Integrated in Mental Health.60
The National Network for Continuing Integrated Care (RNCCI) was formally created in 2006, with Decree-Law No. 101/2006. Four years later, a specific guidance is established for people with severe mental illness –– Decree-Law n.º 22/2011, 10 February with the aim of contributing to «the development of rehabilitative responses that respond to situations of dependence and psychosocial incapacity caused» 61.
New legislative changes would introduce novelties in the RNCCI in 2015. With Decree-Law No. 136/2015, of 28 July, the first amendment was made to Decree-Law No. 101/2006, of 6 June, and the second amendment to Decree-Law no. 8/2010, of 28 January, leading to the integration into the RNCCI of the set of units and teams of continuous integrated mental health care created by Decree-Law no. 8/2010, of January 28th. The mental health units and teams that were authorized to be part of the RNCCI are listed in Annex III to Order No. 8320-B/2015, of 29 July, with a total of 312 places. Despite the publication of this information, they would not come into operation.
The process of deinstitutionalization of people with mental illness began in Portugal, in 2009, after the approval of the current Mental Health law (Law nº 36/98) and is part of a new model of psychiatric care. Since then, the number of institutionalized patients in public psychiatric hospitals has already reduced by 40%, having been transferred to other institutions in the community. As a result, three of the main psychiatric hospitals in the country were closed – Miguel Bombarda Hospital, Arnes Psychiatric Recovery Center and Lorvão Hospital.64
e. Integration of Mental Health care in the community
Thanks to the efforts made in recent decades, there have been some advances in the integration of mental health care services in the community. However, in some essential aspects, these advances are insufficient, leading to the realization that there is still a long way to go to ensure access for all to quality health care.
This path began in 2008, when the National Mental Health Plan was developed, prepared by the main stakeholders in the area in Portugal, leading to significant progress in the transition to the provision of health care in the community. 60
The negative and positive aspects of these advances, as well as the barriers to their implementation, were summarized by the report Portugal Situation Analysis – 2015 60 of the European Union program Joint Action on Mental Health And Well-Being, presented in 2015. This report highlighted the approval of the Mental Health Law, in 1998, which allowed important advances in the protection of the human rights of people with mental disorders and placed Portugal at the same level as other developed countries. With this Law came an increase in the number of partnerships with non-governmental organizations, an important contribution to the modernization of Mental Health care.60
f. Mental Health Challenges
According to the WHO Mental Health Action Plan 2013-202065, Portugal, like other countries, will face four important challenges in the area of Mental Health by 2020:
Strengthen leadership and promote effective management in the area of Mental Health;
Provide comprehensive, integrated and responsive mental health and social services within communities;
Implement strategies for promotion and prevention in the area of Mental Health;
Strengthen information systems, scientific evidence and research in the field of Mental Health.
The plan presents indicators and targets for Member States such as a 20% increase in service coverage for severe mental disorders and a 10% reduction in countries’ suicide rate by 202065.