Mental health issues are of course challenging wherever you are, and Bulgaria is no exception. If you are an expat resident in the country, therefore, and concerned about your mental health, what levels of care might you expect, and how can you best safeguard your own mental state?Bulgaria has never had a separate law on mental health. Issues such as mandatory treatment, guardianship and legal capacity were regulated in the People’s Health Act, which was in force until 2005, when it was replaced by a new Health Act which has a section relating specifically to mental health issues. Around 15-17% of the local population are estimated to be suffering from depression and visiting psychiatrists is still stigmatized. Awareness of mental health is increasing, however, particularly in the private sector.
Mental health care in Bulgaria
If you suffer from a serious mental health issue, you are strongly advised to take out private health insurance rather than relying on the public healthcare system. Reports suggest that Bulgaria is still suffering from the legacy of Communism, in which mental health was stigmatized.
In 2018, out of the country’s 12 public psychiatric institutions, 11 were situated in remote areas of the country: an unfortunate policy of keeping the mentally ill out of the way. Still a very poor country, Bulgaria has limited provision for mental healthcare even now.
These psychiatric hospitals have 2,300 beds in total, while another 13 have beds for around 1,000 patients. There are estimated to be another 900 patients on the current waiting list. In 2018, France24 reported that conditions inside these institutions were very poor, with three patients to every room and only two toilets between 20 patients. In 2017, the UN’s Committee Against Torture reported concerns over “the high incidence of inappropriate or unnecessary non-consensual institutionalisation” and a lack of “independent inspection or monitoring mechanism for mental health institutions”.
Bulgaria’s mental health institutions are severely underfunded and understaffed: Professor Maya Stoimenova, director of the psychiatric clinic at the Medical University of Pleven in northern Bulgaria, described the budget as “ridiculous and absurd.”
The average wage of a specialist in rehabilitation is BGN 630 (around €320) a month, compared with €450 for a psychiatrist and €250 for a nurse. Since these wages fall far below comparable salaries in neighbouring European countries, Bulgarian medical staff often seek work abroad.
There are steps being taken by the government to address some of the problems with mental health provision: in 2018 it launched a three-year action plan, with the aim of closing 10 institutions and replacing them with day centres offering care within the community, in addition to several residential homes. It is thus shifting the burden of mental health provision from inpatient to outpatient care.
Mental health care under public health insurance
State health insurance is mandatory for employed expats and you will be able to pay into the national scheme (NOI), thus becoming eligible for medical reductions or free treatment. You will need a residence permit, but provided that you are paying into the system, you and your dependents will be covered by the national scheme for inpatient psychiatric care, GP visits and specialist appointments.
The WHO Mental Health Atlas states:
Prescription regulations authorize primary health care doctors to prescribe and/or to continue prescription of psychotherapeutic medicines but with restrictions. In contrast, the department of health does not authorize primary health care nurses to prescribe and/or to continue prescription of psychotherapeutic medicines. Similarly, official policy does not permit primary health care nurses to independently diagnose and treat mental disorders within the primary care system.
It goes on to tell us that the majority of primary health care doctors and nurses have received official in-service training on mental health within the last five years. Officially approved manuals on the management and treatment of mental disorders are not available in the majority of primary health care clinics. Official referral procedures for referring persons from primary care to secondary/tertiary care exist.
Mental health care under private health insurance
Given the above, you are advised to take out private health cover if you are intending to be resident in the country and have mental health issues. You can extend your existing private insurance to cover you internationally, but make sure you are aware of exactly what this covers: will it allow you to be flown home, for example, in the case of a medical emergency?
If you have a pre-existing condition, it is doubly important to check that you are covered. The big international providers, such as Cigna and BUPA, cover mental health provision in their policies (Cigna has a Behavioral Health network of licensed mental health providers).
Would you like to share your experience of life abroad with other readers? Answer the questions here to be featured in an interview!