Mobile Mental Health Units in Heraklion Crete 2013–2022: Progress, Difficulties and Future Challenges

Abstract

Mobile mental health units (MMHUs) have been proposed as an effective model to serve the mental health needs of remote underserved areas. In 2013, the Department of Psychiatry, University of Crete, started a pilot MMHU to cover the needs of remote rural areas of the Heraklion Prefecture. The main objectives were early detection, prevention and therapy of patients with severe psychiatric disorders, without access to regular psychiatric care. In addition to regular visits to primary care health centers, a community support network was established. During this 10-year period, the MMHU has evaluated 3343 patients and performed 19,935 visits. The most frequent diagnoses are depression and anxiety (52.7%) whereas psychosis and bipolar disorders are the third (12.7%) and fifth most frequent diagnoses (4.7%). Half of the patients with depression/anxiety were older than 65 years and one third were living alone. Furthermore, the first visit with the MMHU of severely mentally ill was about 15 years later from the self-reported onset of psychotic symptoms. We discuss how to improve our ability to detect and intervene earlier in patients with severe mental illness, and how to address effectively, both pharmacologically and psychosocially, the depression and loneliness of older individuals living in small remote communities.

1. Introduction

1.1. Historical Background

In 1963, in the USA, it was President Kennedy who signed the legislation about community psychiatry (Community Mental Health Act), promoting the development of community mental health centers all over the country, in order to support the deinstitutionalization of mental patients living in state hospitals [1]. Indeed, based on the progress of psychiatry in the biological and psychosocial sciences, scientists, politicians and workers in mental health thought it was a mature goal to decrease drastically the number of beds in state psychiatric hospitals and to shift the care of severely psychiatric patients from the asylum type of mental facilities to the community. They concluded that it was preferable and necessary for patients with mental disorders to live, work and receive their therapy in the community, rather than in huge impersonal state psychiatric hospitals [2]. In Greece, this shift of focus of care for the mentally ill was introduced by the legislative body for the first time in 1983 under the name of “Psychiatric Reform”, which was funded from a European program [3,4].

In Crete, in 2006, the State Psychiatric Hospital of Chania in Souda closed and the care of psychiatric patients was transferred to in-patient units in general hospitals, community mental health centers, post-hospital hostels, boarding houses and other community-based mental health units. However, this change was not well prepared since the number of community mental health resources were limited. Specifically, the University Hospital in-patient Psychiatric Unit in Heraklion, with only 32 beds, was forced to take responsibility for a region of about 400,000 citizens living in the prefectures of Heraklion and Lasithi [5]. The latter is missing an in-patient general hospital psychiatric unit even today. This lack of community mental health facilities resulted in increased number of relapses, involuntary admissions and admitted patients having to sleep in the hall instead of in a regular bedroom. The situation is even worse if one considers that Crete’s statistical indices indicate higher frequency of mental health problems e.g., suicidal rates per 100,000 residents is twice as high as the rest of Greece and mental health facilities are scarce particularly in Eastern Crete [6]. The problem was even worse in rural and semi-rural areas of Heraklion, with about 140,000 residents [5]. There was not a mental health unit or even a private psychiatrist. The patients were left without any mental healthcare, except for those families that could afford a visit to a private practitioner in the city of Heraklion or Athens!

It was the late Professor P. Sakellaropoulos, who organized the very first mobile mental health unit (MMHU) in order to address the mental health needs in Fokida, a region primarily rural and semi-rural, where there was neither a psychiatric facility nor a psychiatrist [7]. This model appeared to be successful in serving the mental health needs of remote underserved areas and soon spread throughout provincial Greece [8].

In January 2013, the Department of Psychiatry of the University Hospital Heraklion, Crete, under the leadership of Professor Vgontzas, initiated the pilot function of a mobile mental health unit (MMHU) of the University General Hospital of Heraklion (PAGNI) that was supported and staffed by the department, without any external funding from national or EU programs. The initiative was well received by the physicians and staff of the primary care health centers (PCHC) and municipal social services and was supported by the local health administration (Head Antonis Gregorakis). In 2017, the existence and function of MMHU became official by a legislative act without, however, any further funding (EEC Regulation 754/Β΄/9-3-2017) [9].

1.2. Description of the MMHU Program

1.2.1. Aims of MMHU

In January 2013, MMHUs started visiting the Primary Care Health Center (PCHC) of Moires (a town of about 60 km south from the city of Heraklion) and then gradually expanded to the PCHCs of Charakas (2013), Arkalochori (2014), Kastelli (2016), Hersonisos (2017), Archanes (2018) and Viannos (2018). The main broad objectives of the MMHU initially was prevention, early intervention, diagnosis and treatment of patients with the more severe mental illnesses i.e., schizophrenia and bipolar illness, with the ultimate goal to keep these patients in their familial and social environment. Specifically, MMHU aims at the prevention of a relapse of patients with severe psychiatric disorders and re-hospitalization of these patients. Additionally, MMHU aims to provide regular treatment and care of these patients in their community free of charge without having to travel long distances or to rely on private sectors. Finally, MMHU’s goal is to early intervene and diagnose patients in order to have better treatment response and psychosocial adjustment in their hometowns.

1.2.2. Catchment Area

Today, the MMHU regularly visits seven primary care health centers covering an area of about 110,000 residents living in small towns and villages of the inland of Heraklion [5]. The main occupation is agriculture and tourism, whereas the literacy level is rather low with most people, particularly older, having completed a six-year elementary education. The catchment area of MMHU is shown in Figure 1.

1.2.3. Structure of the MMHU

The MMHU today consists of three part-time psychiatrists (one of them on a volunteer basis), one psychiatric resident, two psychologists and one child psychologist. Additionally, one junior assistant researcher is included on the team. No visiting nurses or social workers were included in the MMHU team. The latter needs are covered to some extent from the staff of the PCHC and the social services of municipalities. The MMHU visits weekly the PCHC of Moires, biweekly the PCHC of Arkalochori, and monthly the rest of the PCHCs. Only in the recent months, as a result of new hires secondary to the emergency funding provided to assist the victims of the earthquake in Arkalochori, have we been able to increase the frequency of our visits biweekly to most of the PCHCs.

1.2.4. Networking

One of the basic principles of the MMHU is networking with existing services, institutions and volunteers within the community. Prevention, treatment and psychosocial rehabilitation cannot be accomplished without collaboration with significant others in rural areas. As a result, the MMHU has developed a strong network of psychosocial support of psychiatric patients including primary care health centers, community programs such as “Help at Home”, the Center of Daily Care of Older People, social services of municipalities and institutions such as church, police and cultural associations. The structure of this network is presented in Figure 2.

1.2.5. Education and Sensitization of the Public and Health Workers

One of the main goals of the MMHU is to educate and sensitize on mental health the entire community and members of the network, through conferences and seminars. More specifically, three conferences open to mental health workers and the lay public took place in semi-rural areas, in 2015 at Voroi, in 2017 at Moires and in 2019 at Arkalochori, each attended by more than 200 participants. Moreover, in 2017, we organized a full day seminar for primary care physicians and in 2017, 2018 and 2022, the MMHU in collaboration with the local Bishop organized seminars for priests of the Holy Diocese of Gortyna/Arcadia in Moires. In 2021, the MMHU organized two teleconferences on physical disasters, i.e., earthquakes and intrafamilial violence. Recently, Professor of Psychiatry Vgontzas was invited by the municipal authorities of Arkalochori to talk about suicide and suicidality in Crete.

1.3. Aims of the Study

The overall goal of this study is to present the demographic and clinical characteristics of the MMHU-served population, including frequencies of different diagnostic categories, age and gender distribution and living-condition characteristics. Secondary aims of the study are to examine and compare our results with the existing literature: the age and gender of the first admission to the university hospital in-patient psychiatric unit; and the age and gender of the onset of symptomatology of patients with severe psychiatric disorders, such as psychosis or bipolar disorder, compared to the first contact with MMHU.

2. Materials and Methods

2.1. Sample

The sample of our study consists of 3343 patients, who sought the services of the MMHU from January 2013 to June 2022, and there were 19,935 visits overall (

Table 1. Number of patients and visits (01/2013–06/2022).

Variables	N	%	Mean Age ± S.D.
Number of patients evaluated	3.343		61.54 ± 18.46
Men	1409	42.1	60.84 ± 18.25
Women	1934	57.9	62.04 ± 18.60
Total visits	19.935

). There was a wide age spectrum from 18 years old up to 101 years, with a mean age of 61.54 years old (S.D. = 18.46). Specifically, men consisted 42.1% of the sample with the mean age of 60.84 years, while women consisted 57.9% of the sample with the mean age of 62.04 years. All of them were living in the MMHU catchment area.

2.2. Procedure

All participants were evaluated at the CHC of the catchment area, with the exception of those who were evaluated at home. The evaluation included detailed clinical history and mental status examination conducted by board-certified psychiatrists using a semi-structured clinical interview. The final clinical diagnosis was based on ICD-10 criteria. Demographic and clinical data i.e., age, sex, education, diagnosis, onset of disorder, admissions, substance abuse, living conditions and other relevant information were retrieved from the database of the MMHU and the Department of Psychiatry of University Hospital.

2.3. Statistical Analysis

Descriptive statistics were obtained for the demographic variables. Means and standard deviations were calculated for all continuous variables and frequencies and proportions for all categorical variables. T-tests for independent samples were conducted to detect age differences between the onset of symptoms, the first psychiatric admission, the first visit with the MMHU and living conditions stratified by gender. In this analysis, data were available only in a subgroup of subjects due to missing values. However, there were no statistical differences between the subgroup and the entire group of subjects in terms of key variables such as age, gender, education and socioeconomic status. The statistical analysis was performed by statistical package IBM SPSS Statistics (version 26) and the significance level was set at p < 0.05.

3. Results

3.1. Demographic and Clinical Characteristics of MMHU-Served Population

The most common diagnoses in patients evaluated by MMHU are depression, anxiety disorders and psychosis/schizophrenia, which represented 37.8% (n = 1262), 14.9% (n = 499) and 12.7% (n = 426) of all diagnoses, respectively (

Table 2. The most common diagnoses in patients evaluated by MMHU (n = 3343).

Diagnoses	N	%
Depression	1262	37.8%
Anxiety Disorder	499	14.9%
Psychosis/Schizophrenia	426	12.7%
Dementia/Organic Syndrome	200	6.0%
Bipolar Disorder	157	4.7%
Mental Retardation	95	2.8%
Addictions	65	1.9%
Personality Disorders	39	1.2%
Insomnia/Hypersomnia	46	1.4%
License to practice profession/carry guns	479	14.3%

Note. Classification diagnoses are according to the ICD-10 Diagnostic System.

). Moreover, significant statistical differences were observed between the mean age of patients diagnosed with depressive disorder and those diagnosed with anxiety disorders (t (1636) = 7.99, p < 0.001) (

Table 3. Mean age of patients with depression/anxiety (n = 3343).

	N	Mean Age ± S.D.	t	p
Depression disorder	1262	66.4 ± 17.86	7.99	<0.001
Anxiety disorders	499	59.1 ± 17.86
Total	1761	64.4 ± 17.86

). Specifically, patients with depressive disorder were significantly older than patients with anxiety disorders.

3.2. Age and Gender Distribution of Patients with Depression/Anxiety

An unexpected finding of patients with depression/anxiety is that they were markedly older. In fact, about 49.6% (n = 874) of patients with depressive and anxiety diagnoses were older than 65 years (M = 78.2 years, S.D. ± 8.27). More specifically, 80% have been diagnosed with major depressive disorder, while about 20% have been diagnosed with anxiety disorder. There were no significant statistical differences between mean ages of the two genders for depressive (t (694) = 1.59, p = 0.112) or anxiety (t (176) = 1.79, p = 0.075) disorders (

Table 4. Mean age and gender distribution of patients with depression/anxiety >65 years old.

Diagnoses	N	%	Mean Age ± S.D.	t	p
Depressive disorder
Above 65 years	696	79.6	78.2 ± 8.27
Men	210	30.2	78.9 ± 8.27	1.59	0.112
Women	486	69.8	77.8 ± 8.28
Anxiety disorders
Above 65 years	178	20.4	78.1 ± 8.28
Men	51	28.7	79.6 ± 8.27	1.79	0.075
Women	127	71.3	77.2 ± 8.28
Total both diagnoses
Above 65 years	874	49.6	78.2 ± 8.27
Men	261	29.9	79.1 ± 8.27	2.14	0.033
Women	613	70.1	77.7 ± 8.28

). However, there were significant differences in the terms of age distribution between men and women diagnosed with depression or anxiety disorders (t (872) = 2.14, p = 0.033), with men being older than women.

As expected, the majority of patients with depression/anxiety were women. Specifically, 69.8% (n = 486) of those diagnosed with depressive disorder and 71.31% (n = 127) of those diagnosed with anxiety disorder were women. In contrast, men represented 30.2% (n = 210) and 28.7% (n = 51) of the depressive and anxiety diagnoses, respectively (Table 4).

Furthermore, it was observed that a significant proportion of people above 65 years old diagnosed with depression or anxiety were living alone. Specifically, in a total of 529 patients from the available data, about 32% of those diagnosed with depression were living alone, whereas 20.9% of patients diagnosed with anxiety were also living alone. Overall, about one third of patients >65 years old with depression/anxiety disorders were living alone (

Table 5. Living conditions of patients >65 years (n = 529).

Diagnoses	n	%
Depressive disorder
Alone	134	32.0
With others	285	68.0
Total	419
Anxiety disorder
Alone	23	20.9
With others	87	79.1
Total	110
Both diagnoses
Alone	157	29.7
With others	372	70.3

).

3.3. Severe Psychiatric Diagnoses: Age at Onset of Symptoms and First in-Patient Admission

Our in-patient database showed that the mean age of the first admission of patients with severe psychiatric disorders, such as psychosis, was M = 42.79, S.D. = 14.58 or bipolar disorder was M = 42.47, S.D. = 13.80, in the in-patient psychiatric unit in PAGNI during the period of 2012–20. Additionally, women tended to have their first admission a bit later compared to men (t (1213) = −2.38, p = 0.017). Moreover, women diagnosed with psychosis had their first admission 2.76 years later compared to men (t (805) = −2.59, p = 0.010), while there were no differences in terms of the first admission age distribution between the two genders diagnosed with bipolar disorder (t (406) = −0.61, p = 0.540) (

Table 6. Age of first admission of patients with severe psychiatric disorders (n = 1215).

Diagnoses	N	Mean Age ± S.D.	t	p
Psychosis
Men	514	41.78 ± 13.96	−2.59	0.010
Women	293	44.54 ± 15.47
Bipolar disorder
Men	189	42.02 ± 13.78	−0.61	0.540
Women	219	42.86 ± 13.84
Total
Men	703	41.85 ± 13.90	−2.38	0.017
Women	512	43.82 ± 14.81

p-values reflect strength of statistical differences of age between men vs. women.

).

Interestingly and based on the self-report of available data from 697 patients, the mean age of symptom onset was much younger than the mean age of first admission to the in-patient psychiatric unit. Specifically, mean age of the onset of symptoms was 29.07 years for men with either psychosis or bipolar disorder, while the mean age of onset of symptoms for women patients was 31.81 years (t (695) = −2.78, p = 0.006). There were no significant age differences at the onset of symptoms between men and women diagnosed with bipolar disorder, while women with psychosis reported onset of symptoms significantly later compared to men (t (468) = −2.40, p = 0.017) (

Table 7. Age of onset of symptoms of patients with severe psychiatric disorders (n = 697).

Diagnoses	N	Mean ± S.D.	t	p
Psychosis
Men	319	28.72 ± 10.84	−2.40	0.017
Women	151	31.80 ± 13.86
Bipolar disorder
Men	108	30.10 ± 11.86	−1.02	0.303
Women	119	31.82 ± 13.24
Total
Men	427	29.07 ± 11.11	−2.78	0.006
Women	270	31.81 ± 13.56

p-values reflect statistical strength of age differences between men vs. women.

).

Consistent with the above findings are the data on the mean age of the first visit with the MMHU of patients with severe psychiatric disorders. Specifically, the mean age of first visit with the MMHU for men with psychosis was 45.11 (n = 257) years old and 45.80 (n = 104) years old for women. The same pattern was observed for patients with bipolar disorder; men had their first visit with the MMHU at 45.37 (n = 63) years old and women at 45.61 (n = 74) years old. There were no statistically significant differences of mean age of the first visit with the MMHU between the two genders diagnosed with either psychosis or bipolar disorder (t (496) = −0.54, p = 0.588) (

Table 8. Age of first visit with MMHU of patients with severe psychiatric disorders (n = 498) *.

Diagnoses	N	Mean ± S.D.	t	p
Psychosis
Men	257	45.11 ± 11.01	−0.53	0.594
Women	104	45.80 ± 11.15
Bipolar disorder
Men	63	45.37 ± 12.24	−0.12	0.899
Women	74	45.61 ± 9.58
Total
Men	320	45.16 ± 11.24	−0.54	0.588
Women	178	45.72 ± 10.50

p-values reflect statistical strength of age differences between men vs. women. * Patients older than 65 years at first visit with MMHU were excluded.

).

3.4. Other Interventions by MMHU

House visits were requested frequently for older people suffering from dementia and delirium, whereas a smaller number involved visits for patients with severe mental illness or bedridden individuals with psychiatric problems, mainly depression. Similar interventions of home-based treatment have been applied successfully from the MMHUs in other areas of Greece [10]. Many times, these house visits, particularly for old-old patients, served the purpose of modeling for primary care physicians (PCP) who did not anticipate that house calls are part of a PCP’s duty.

In May 2014, the MMHU along with mental health workers hired temporarily by municipal services started the pilot function of a day healthcare center located in Moires. The center served two types of patients: younger patients suffering from severe mental illness; older patients, primarily women, suffering from depression/loneliness. The number of patients attending the day center is small because of fear of being exposed to the “eyes” of the community i.e., stigma, lack of transportation, and mainly lack of permanent staff and infrastructure to support this venture. Nevertheless, the day center continues to function in a biweekly frequency and it is a place where patients and their families may share experiences, worries and difficulties in everyday life, and receive support from mental health workers.

Finally, in September 2021, our MMHU and volunteers familiar with the work of the unit were ready to provide immediate mental assistance to the victims of the severe earthquake that hit Arkalochori.

4. Discussion

Our data indicate that the MMHU has, for the last ten years, served successfully the mental health needs of a large group of patients living in rural and semi-rural areas of the Heraklion prefecture, with about 110,000 residents not having access to mental health care [5]. The unit has evaluated about 3,400 patients, and more than half of them suffer from depressive or anxiety disorder. Our data are consistent with data from the MMHUs in other areas in Greece, where patients with affective disorders represented the majority of those seeking the MMHU services [11,12]. About one fifth of the entire group of patients has a diagnosis of a severe psychiatric disorder, such as psychosis or bipolar disorder, which is somewhat lower than the number of patients with severe psychiatric disorders followed by a MMHU in northern Greece (Alexandroupolis) [12]. Based on preliminary data presented in national conferences but unpublished yet, there is a reduction in the relapses and readmissions in the in-patient psychiatric unit of the university hospital of patients with psychosis or bipolar disorder [13,14], which is in line with previous research in Greece and abroad [15,16]. This single index indicates that the impact of the MMHU on mental health needs of this population is successful. However, our impression is that the demands for mental health services are only partially met by the current structure and function of the unit.

Our data highlight some interesting issues that deserve to be discussed. The first is that only a relatively small portion of patients with severe psychiatric disorders is followed by the MMHU. If we assume, based on the published literature that a conservative prevalence of these disorders is 1% [17,18,19,20], then we should expect that in this catchment area there are about 1,100 patients with psychosis and another 1,100 with bipolar disorder. We follow only about 450 patients with psychosis and another 150 with bipolar disorder. This raises important questions: are these patients with severe psychiatric disorders followed by other mental health facilities or other practitioners, so that the illness remains “secret” from the rest of their small community? Are these patients living within the community supported/protected by their family, functioning at a low level both socially and personally and without any systematic follow-up of their mental health problem? Furthermore, our data indicate that the mean age of the first contact of patients with severe mental illness with the MMHU is relatively old, about 45 years old. This is consistent with findings from the university hospital that the mean age of the first admission for patients with severe mental illness is about 42 years old [21]. This is significantly older than the mean age of first admission (about 27 years) based on international bibliography [22,23,24,25] and unpublished data from the Department of Psychiatry of the University of Athens. Our data on the onset of psychotic symptoms between 28–31 years old are similar to the international literature. For example, the age of the first psychotic episode is reported to range between 22 and 28 years old [24,26]. Our findings are also consistent with results from other parts of Greece (Ioannina) that have shown similar age range of the first episode of psychosis [27]. Further, it has been reported that onset of psychotic symptomatology was three to four years earlier for men compared to women [24]. Similarly, the age of onset of bipolar disorder was found to be at the middle-to late twenties (23–28 years) [28,29]. Finally, a recent meta-analysis showed that there is a 5.9-year duration of untreated bipolar disorder and a 3.5-year delay in help-seeking [30].

These findings of our study support the hypothesis that the Cretan families try to take care of their ill patients within the family and outside of the public mental health system [31,32]. This can be related to an effort to avoid the stigma associated with severe mental illness [33] or mistrust of the public health system. Research data are needed to support these alternative hypotheses.

The late contact of patients with severe mental illness with our unit indicates that a large number of younger patients are outside of the radar of the MMHU or of Community Services, such as PCHC, Municipal Social Services, Program “Help at Home” etc. It is well established that early detection and intervention in patients with severe mental illness is associated with better outcome [34]. It is one of our biggest challenges to increase the number of young patients with severe mental illness that are followed by our unit. There is no ready recipe for how this can be achieved. It is our impression and our goal to educate in a more systematic way the health workers of the “first line” health services, such as primary care physicians, municipal social workers, visiting nurses, etc., to early detect and refer these patients to the MMHU. Additionally, we have to have an open sincere dialogue with our colleagues in private practice if a visit here and there by a person with severe mental illness with limited or no insight to their problem and a family that desperately tries to keep the problem “secret” from the community, serves the purpose of continuity of care, a primary goal in keeping these patients safe and healthy in their communities. Finally, we have to explore the potential helpful role of key individuals in these communities, such as priests, teachers, local community authorities, police, members of volunteer groups such as Red Cross, etc.

Another interesting finding of our data is the large number of patients with a diagnosis of depression or anxiety disorder, the relatively high proportion of women compared to men as well as the fact that they are predominantly older. These findings have several implications. First, depression and anxiety are very common in rural areas of Crete [35], similar to epidemiologic data from urban populations [36,37,38]. The large majority of these patients were referred by their primary care physicians and most ended up receiving medication. Although our initial goal was to focus on patients with severe psychiatric disorders, we could not deny our services to these patients with depression or anxiety disorder associated with significant subjective dysphoria and/or daily dysfunction and/or multiple physical complains, not explained by organic causes. It is our impression based on our current structure and capacity that we cannot follow up systematically with this large group of patients, including regular medication check-ups. In our view, there is a need to train primary care physicians to be able to handle this large group, including, but not only, medication management. Second, a large percentage of these patients are women who are old and living alone, which is in line with previous findings [11,12,39]. Existing literature supports that depression and anxiety are more prevalent in women with a ratio 2:1, whereas there are no significant differences in terms of age distribution [40]. The higher proportion of older women in our sample may be related to the fact that older women feel more comfortable visiting a health professional compared to older men. The low percentage of young individuals in our depressed/anxiety-diagnosed population may be related to the fact that most young people have left rural areas for better professional educational and life opportunities in urban areas. An alternative, not mutually exclusive, explanation is that young people facing emotional problems may seek help far from their small communities to secure “anonymity”. The finding that one third of depressed individuals live alone defeats the common assumption that in small communities in rural areas in Greece there is close connectivity between its members. Professor Lyberaki has demonstrated that older women living in rural areas in Greece are lonelier than their counterparts living in European countries, such as Sweden or Germany [41]. Since our data show that depression and anxiety in this group of patients are related to a significant degree to lack of family and social support and corresponding loneliness, there is a need of community structures to assist with the socialization and community involvement of these patients. Church, cultural organizations and volunteering groups have to fill in the gaps created by the socioeconomic and family structure changes that took place in our country over the last 4–5 decades. A positive finding of our data is that older people, although of less education compared to the younger ones, have overcome the stigma of the mental illness, and do not have a problem visiting a mental health care professional in their hometown. It appears that the stigma is stronger in younger individuals with severe mental illness and their families because of the fear that, if the community “knows”, this will have an adverse impact on their professional, personal and family lives.

Our descriptive study has several strengths, such as its large sample size, its wide age spectrum, the inclusion of both genders and its long-term existence under stable academic and medical leadership. However, several limitations should be noted. One limitation of our study is that the diagnoses were provided by multiple physicians. However, all these physicians were board-certified psychiatrists using a semi-structured interview and followed the criteria of a single diagnostic system, ICD-10. Another limitation is that, in some of our analyses, we have missing data for key variables such as age, gender, education and socioeconomic status. However, there were no statistical differences between the subgroup and the entire group of subjects in terms of key variables such as age, gender, education and socioeconomic status. Finally, our study is cross-sectional and does not allow for any etiologic associations.

5. Conclusions

In conclusion, our preliminary data indicate that the MMHU is a model that, if adequately supported, can serve the increasing mental health needs of people living in rural areas. The accomplishment of such a goal requires strong connection with health and social services and key institutions in these communities. Second, a large number of individuals with severe mental illnesses, such as psychosis or bipolar disorder, are not being followed by the MMHU. One of the future challenges is to explore and apply novel tactics in early detection and intervention for these individuals. Third, adequate care of older patients with anxiety and depression cannot be accomplished without the active involvement of the primary care physicians and other health professionals such as “Help at Home”. Lastly, the loneliness and the socialization of these patients, particularly of women, cannot be dealt with just by medication. The potential usefulness of mental health units, such as day care centers, has to be examined. However, that these people live in remote small communities without transportation raises a question of how realistic and effective such an approach can be, currently. In the meantime, the active role of institutions such as churches, cultural organizations, and volunteer groups may be particularly useful, albeit not taken for granted.