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Background and objectives Severe mental disorders require informal care, usually provided by family members of the affected. The aim of the study is to examine the burden of informal caregiving for individuals with schizophrenia and affective disorders prior to hospital admission in Bulgaria. Methods The study has an observational, cross-sectional, retrospective design. Individuals with schizophrenia and affective disorders and their caregivers are evaluated upon the patients’ admission for inpatient treatment. The objective and subjective consequences of providing informal care are evaluated with the Burden Assessment Scale (BAS) as a primary outcome measure. Its factor structure and determinants of high burden of care are examined. Results 117 individuals with mental disorder and 117 caregivers are evaluated, dichotomized in two groups according to the patient's diagnosis. The time spent in informal care is 5.7 hours per day (SD = 2.9) for schizophrenia and 3.9 hours per day (SD = 3.0) for affective disorders, p = .002. The mean score on the BAS is 44.7 (SD = 11.0) and 42.0 (SD = 12.8) respectively, p = .221. A common pattern of the burden with a 5-factor solution explaining 66% of the variance is presented, including the factors Limitations, Conflicts, Guilt, Trap, and Stigma. Contributors for the increase in the BAS are stigma (p Conclusions The caregivers of individuals with schizophrenia and affective disorders experience considerable objective and subjective burden.

Schizophrenia is a serious mental disorder which requires complex treatment and care. Although proof for effective, cost-effective and affordable treatment is available, health economic research is lacking in many low and middle-income countries. The aim of this study was to evaluate the costs and outcomes for individuals with acute exacerbations of schizophrenia before and after inpatient admission and to evaluate the cost-effectiveness of the current treatment in the clinical practice. We used an ambispective comparative observational health economic study design. The participants were individuals with schizophrenia and their primary caregivers. Costs at baseline and follow-up were evaluated from a healthcare perspective. The primary outcomes were psychopathology, social functioning and quality of life for the patients and burden of informal care for the caregivers. Cost-effectiveness planes and cost-effectiveness acceptability curves were generated to illustrate the cost-effectiveness of treating schizophrenia in the real clinical practice, compared to a do-nothing alternative. The main finding is that treatment of individuals with schizophrenia results in improved outcomes for both patients and caregivers, while it is associated with increased healthcare costs from 135.75 Euro (SD = 193.36) per patient before hospital treatment to 189.00 Euro (SD = 126.98) per patient in the follow-up (95% CI: −112.48; −2.31). After application of sensitivity analysis at a particular level of willingness to pay, the treatment remains cost-effective for all 4 outcomes. In conclusion, the treatment of patients with schizophrenia in Bulgaria is cost-effective at acceptable levels of willingness to pay for a unit of improvement on four different outcomes.

To examine the cost of psychotic disorders in Bulgaria prior to hospital admission and following discharge from two perspectives: healthcare and societal; and to evaluate the association between the costs and the patient’s characteristics. 96 individuals with psychosis experiencing psychotic exacerbation and their primary caregivers were evaluated upon the patients’ hospital admission. The participants were followed up after 12 months. The costs were evaluated from healthcare and societal perspective using the Client’s Sociodemographic and Service Receipt Inventory (CSSRI-EU). The psychopathology, functioning, quality of life and caregiver’s burden were measured using standardized instruments. The mean differences in the costs and the associations with the clinical and socio-demographic characteristics of the patients were evaluated. The healthcare costs increase from EUR 120.66 (SD = 163.85) at baseline to EUR 177.54 (SD = 136.98) at follow-up. The total cost from societal perspective are up to sixfold higher than the healthcare costs at both assessments [EUR 717.41 (SD = 402.33) and 880.40 (SD = 1592.00), respectively] and do not change significantly. A major shift in the subtypes of costs, and significant associations of the costs with the socio-demographic and clinical characteristics, were found. Psychotic disorders and psychotic exacerbations have high societal costs. The underfunding of mental healthcare in Bulgaria is at the expense of high caregivers’ and societal cost. The treatment of psychotic exacerbation is effective and investment in mental healthcare for the improvement of the psychopathology, social functioning, quality of life and the burden of informal care should be viewed as a sustainable investment.

A randomised placebo-controlled "dose relation study" was conducted in 549 patients who met the criteria for major depressive disorder, to evaluate the efficacy and safety of three doses regimens of agomelatine during 6 weeks: low fixed dosage (10 mg/day, n=133), fixed dosage (25 mg/day, n=138) and a flexible dosage with up-titration in case of insufficient improvement at week 2 (25-50 mg/day, n=137). At last post-baseline assessment, there were significant and incremental placebo-agomelatine differences on mean HAM-D₁₇ total scores in favour of each agomelatine dose regimen (2.46 ± 0.76 points, p=0.001 at 10 mg; 4.71+0.75 points, p

BackgroundMental health policies emphasise that caregivers' views of involuntary psychiatric treatment should be taken into account. However, there is little evidence on how caregivers view such treatment.AimsTo explore caregivers' satisfaction with the involuntary hospital treatment of patients and what factors are associated with caregivers' appraisals of treatment.MethodA multicentre prospective study was carried out in eight European countries. Involuntarily admitted patients and their caregivers rated their appraisal of treatment using the Client Assessment of Treatment Scale 1 month after admission.ResultsA total of 336 patients and their caregivers participated. Caregivers' appraisals of treatment were positive (mean of 8.5 on a scale from 0 to 10) and moderately correlated with patients' views. More positive caregivers' views were associated with greater patients' symptom improvement.ConclusionsCaregivers' appraisals of involuntary in-patient treatment are rather favourable. Their correlation with patients' symptom improvement may underline their relevance in clinical practice.

Objective: Large numbers of psychiatric patients either are involuntarily admitted to hospital treatment or feel coerced despite a legally voluntary admission. For ethical and clinical reasons, the ...

This prospective analysis aimed to study the influence of psychopathological dimensions on the global functioning of persons suffering from psychotic disorders, taking into account the role of a broad range of potential confounders. A large international cohort (n = 1888) with ICD-10 non-affective psychosis was evaluated both at baseline during a hospital admission and three months after discharge. Trained interviewers administered a global functioning scale (GAF) and a psychopathological scale (BPRS) at baseline and follow-up). Baseline BPRS psychopathological dimensions were extracted using Principal Component Analysis. Results of multiple linear regression analyses demonstrated that affective symptoms (depressive or manic) prospectively predict a better global functioning, whilst agitation/cognitive symptoms determined poorer global functioning. Other predictors showing an independent effect on better global functioning were medication compliance, country of residence, female gender, married or coupled status, younger age and having a diagnosis of schizoaffective disorder rather than schizophrenia or other ICD-10 psychosis. A predicting model for global functioning in patients with psychosis is provided, showing that assessment of affective and agitation/cognitive symptoms should be emphasised during admission as they can be more informative than positive/negative symptoms in prospectively planning follow-up care that is geared towards a better functional recovery.

Objective: Service provision in psychiatric and social care is increasingly guided by recovery principles. However, little is known about the degree of consensus among stakeholders in diverse contexts on the components of care that most promote recovery. This study aimed to identify specific items of care that key stakeholders regard as most important in promoting recovery for people with longer-term mental health problems in institutional care, to measure consensus between and across stakeholder groups and countries, and to develop a conceptual framework of the most important domains of care. Methods: Ten European countries in various stages of deinstitutionalization participated in a series of conventional three-round iterative Delphi exercises. In each country individuals in four separate expert groups (service users, mental health professionals, caregivers, and advocates) identified components of care that they considered important to recovery and then rated their group’s suggestions in terms of importance. Median and consensus ratings were measured. High-ranking items were grouped into domains. Results: A total of 4,098 separate items of care were proposed by the 40 participating groups. Eleven broad domains of care important for recovery were identified: social policy and human rights, social inclusion, self-management and autonomy, therapeutic interventions, governance, staffing, staff attitudes, institutional environment, postdischarge care, caregivers, and physical health care. Consensus between groups and countries was generally high, but some modest differences in priorities were noted. Conclusions: The most consistently highly rated consensus domain was therapeutic interventions. Domains and components of care related to recovery principles were also viewed as important across stakeholder groups. (Psychiatric Services 61:293–299, 2010)

This study aims to identify whether selected patient and ward-related factors are associated with the use of coercive measures. Data were collected as part of the EUNOMIA international collaborative study on the use of coercive measures in ten European countries. Involuntarily admitted patients (N = 2,027) were divided into two groups. The first group (N = 770) included patients that had been subject to at least one of these coercive measures during hospitalization: restraint, and/or seclusion, and/or forced medication; the other group (N = 1,257) included patients who had not received any coercive measure during hospitalization. To identify predictors of use of coercive measures, both patients’ sociodemographic and clinical characteristics and centre-related characteristics were tested in a multivariate logistic regression model, controlled for countries’ effect. The frequency of the use of coercive measures varied significantly across countries, being higher in Poland, Italy and Greece. Patients who received coercive measures were more frequently male and with a diagnosis of psychotic disorder (F20–F29). According to the regression model, patients with higher levels of psychotic and hostility symptoms, and of perceived coercion had a higher risk to be coerced at admission. Controlling for countries’ effect, the risk of being coerced was higher in Poland. Patients’ sociodemographic characteristics and ward-related factors were not identifying as possible predictors because they did not enter the model. The use of coercive measures varied significantly in the participating countries. Clinical factors, such as high levels of psychotic symptoms and high levels of perceived coercion at admission were associated with the use of coercive measures, when controlling for countries’ effect. These factors should be taken into consideration by programs aimed at reducing the use of coercive measures in psychiatric wards.

e38070 BACKGROUND The Quality Indicator for Rehabilitative Care (QuIRC) is a staff rated, international toolkit that assesses care in longer term hospital and community based mental health facilities. The QuIRC was developed from review of the international literature, an international Delphi exercise with over 400 service users, practitioners, carers and advocates from ten European countries at different stages of deinstitutionalisation, and review of the care standards in these countries. It can be completed in under an hour by the facility manager and has robust content validity, acceptability and inter-rater reliability. In this study, we investigated the internal validity of the QuIRC. Our aim was to identify the QuIRC domains of care that independently predicted better service user experiences of care. METHOD At least 20 units providing longer term care for adults with severe mental illness were recruited in each of ten European countries. Service users completed standardised measures of their experiences of care, quality of life, autonomy and the unit's therapeutic milieu. Unit managers completed the QuIRC. Multilevel modelling allowed analysis of associations between service user ratings as dependent variables with unit QuIRC domain ratings as independent variables. RESULTS 1750/2495 (70%) users and the managers of 213 units from across ten European countries participated. QuIRC ratings were positively associated with service users' autonomy and experiences of care. Associations between QuIRC ratings and service users' ratings of their quality of life and the unit's therapeutic milieu were explained by service user characteristics (age, diagnosis and functioning). A hypothetical 10% increase in QuIRC rating resulted in a clinically meaningful improvement in autonomy. CONCLUSIONS Ratings of the quality of longer term mental health facilities made by service managers were positively associated with service users' autonomy and experiences of care. Interventions that improve quality of care in these settings may promote service users' autonomy. publishersversion published

BACKGROUND: Despite the progress over recent decades in developing community mental health services internationally, many people still receive treatment and care in institutional settings. Those most likely to reside longest in these facilities have the most complex mental health problems and are at most risk of potential abuses of care and exploitation. This study aimed to develop an international, standardised toolkit to assess the quality of care in longer term hospital and community based mental health units, including the degree to which human rights, social inclusion and autonomy are promoted. METHOD: The domains of care included in the toolkit were identified from a systematic literature review, international expert Delphi exercise, and review of care standards in ten European countries. The draft toolkit comprised 154 questions for unit managers. Inter-rater reliability was tested in 202 units across ten countries at different stages of deinstitutionalisation and development of community mental health services. Exploratory factor analysis was used to corroborate the allocation of items to domains. Feedback from those using the toolkit was collected about its usefulness and ease of completion. RESULTS: The toolkit had excellent inter-rater reliability and few items with narrow spread of response. Unit managers found the content highly relevant and were able to complete it in around 90 minutes. Minimal refinement was required and the final version comprised 145 questions assessing seven domains of care. CONCLUSIONS: Triangulation of qualitative and quantitative evidence directed the development of a robust and comprehensive international quality assessment toolkit for units in highly variable socioeconomic and political contexts Yes ANTECEDENTES: A pesar de los avances en las últimas décadas en el desarrollo de servicios comunitarios de salud mental a nivel internacional, muchas personas siguen recibiendo tratamiento y la atención en las instituciones. Los más propensos a más largo residen en estas instalaciones cuentan con los problemas mentales más complejos de salud y están en mayor riesgo de posibles abusos de la atención y la explotación. Este estudio tuvo como objetivo desarrollar un conjunto de herramientas internacionales estandarizados para evaluar la calidad de la atención en el hospital más largo plazo y basadas en la comunidad las unidades de salud mental, incluyendo el grado en que los derechos humanos, la inclusión social y la autonomía son promovidos. MÉTODO: Los dominios de atención incluido en el kit de herramientas fueron identificados a partir de una revisión sistemática de la literatura, el ejercicio internacional de expertos Delphi, y la revisión de normas de atención en diez países europeos. El proyecto de guía comprende 154 preguntas para los administradores de la unidad. Confiabilidad entre los evaluadores fue probado en 202 unidades en diez países en diferentes etapas de la desinstitucionalización y el desarrollo de servicios comunitarios de salud mental. El análisis factorial exploratorio se utilizó para corroborar la asignación de temas a los dominios. Los comentarios de los usuarios de la caja de herramientas se recogió sobre su utilidad y facilidad de terminación. Resultados: La caja de herramientas había una excelente fiabilidad entre evaluadores y algunos artículos con un margen estrecho de respuesta. Responsables de las unidades encontraron que el contenido de gran relevancia y fueron capaces de llevarlo a cabo en alrededor de 90 minutos. Refinamiento mínimo se requiere y la versión final incluyó 145 preguntas para evaluar siete áreas de atención. CONCLUSIONES: La triangulación de datos cualitativos y cuantitativos dirigidos al desarrollo de una sólida y completa caja de herramientas internacionales para las unidades de evaluación de la calidad en los contextos socioeconómicos y políticos muy variable.

Objective: Involuntary treatment in mental health care is a sensitive but rarely studied issue. This study was part of the European Evaluation of Coercion in Psychiatry and Harmonization of Best Clinical Practice (EUNOMIA) project. It assessed and compared the use of coercive measures in psychiatric inpatient facilities in ten European countries. Methods: The sample included 2,030 involuntarily admitted patients. Data were obtained on coercive measures (physical restraint, seclusion, and forced medication). Results: In total, 1,462 coercive measures were used with 770 patients (38%). The percentage of patients receiving coercive measures in each country varied between 21% and 59%. The most frequent reason for prescribing coercive measures was patient aggression against others. In eight of the countries, the most frequent measure used was forced medication, and in two of the countries mechanical restraint was the most frequent measure used. Seclusion was rarely administered and was reported in only six countries. A diagnosis of schizophrenia and more severe symptoms were associated with a higher probability of receiving coercive measures. Conclusions: Coercive measures were used in a substantial group of involuntarily admitted patients across Europe. Their use appeared to depend on diagnosis and the severity of illness, but use was also heavily influenced by the individual country. Variation across countries may reflect differences in societal attitudes and clinical traditions. (Psychiatric Services 61: 1012-1017, 2010)

BMC Psychiatry Taylor, Tatiana L. Killaspy, Helen Wright, Christine Turton, Penny White, Sarah Kallert, Thomas W. Schuster, Mirjam Cervilla, Jorge A. Brangier, Paulette Raboch, Jiri Kalisova, Lucie Onchev, Georgi Dimitrov, Hristo Mezzina, Roberto Wolf, Kinou Wiersma, Durk Visser, Ellen Kiejna, Andrzej Piotrowski, Patryk Ploumpidis, Dimitri Gonidakis, Fragiskos Caldas-de-Almeida, Jose Cardoso, Graca King, Michael B.European Commission The authors would like to acknowledge all members of the international DEMoBinc Research Group and the project's funder, the European Commission. 138 BIOMED CENTRAL LTD LONDON 505SH Background: A proportion of people with mental health problems require longer term care in a psychiatric or social care institution. However, there are no internationally agreed quality standards for institutional care and no method to assess common care standards across countries. We aimed to identify the key components of institutional care for people with longer term mental health problems and the effectiveness of these components. Methods: We undertook a systematic review of the literature using comprehensive search terms in 11 electronic databases and identified 12,182 titles. We viewed 550 abstracts, reviewed 223 papers and included 110 of these. A "critical interpretative synthesis" of the evidence was used to identify domains of institutional care that are key to service users' recovery. Results: We identified eight domains of institutional care that were key to service users' recovery: living conditions; interventions for schizophrenia; physical health; restraint and seclusion; staff training and support; therapeutic relationship; autonomy and service user involvement; and clinical governance. Evidence was strongest for specific interventions for the treatment of schizophrenia (family psychoeducation, cognitive behavioural therapy (CBT) and vocational rehabilitation). Conclusion: Institutions should, ideally, be community based, operate a flexible regime, maintain a low density of residents and maximise residents' privacy. For service users with a diagnosis of schizophrenia, specific interventions (CBT, family interventions involving psychoeducation, and supported employment) should be provided through integrated programmes. Restraint and seclusion should be avoided wherever possible and staff should have adequate training in de-escalation techniques. Regular staff supervision should be provided and this should support service user involvement in decision making and positive therapeutic relationships between staff and service users. There should be clear lines of clinical governance that ensure adherence to evidence-based guidelines and attention should be paid to service users' physical health through regular screening. publishersversion published

Background: The impact of totalitarian legacy on present changes in legal regulation of mental health care and the interplay between legal and cultural factors in involuntary psychiatric treatment in post-totalitarian states have not been systematically analyzed, neither worked through. Objectives: To assess the characteristics of the legal system and social practices con- cerning involuntary psychiatric treatment in Bulgaria from historical perspective, parallel with the legal developments in other European countries. Methods: Review of relevant research and historical sources, cultural reference frame- work, and legal norms. Results: Cultural and legal developments are far from being parallel. Totalitarian lega- cy in the area of patients' rights and coercion in psychiatric treatment is coped with in a milieu of transitional rules where the basic challenges concern more cultural aspects rather than legislative ones. While legal changes in non-Soviet post-totalitarian states nowadays could be best described as normalization (illustrated with Bulgarian legal tradi- tions as an example), the major cultural shift concerning health care impacts novel con- cepts, e.g. autonomy vs. paternalism, and high tolerance to insecurity vs. fatalism, which mobilize defences and provoke confusion. Conclusions: Culture, and de-culturation in times of transition for that matter, is the limiting factor for practical implementation of law, and contributes to the discrepancy between written law and applicable law. Problematic issues subject to current changing legislation, such as informed consent, legal competence, disability, guardianship, and compulsory placement and treatment, could be understood and resolved if viewed in the context of a changing culture.

A total of 60 patients with functional non-affective psychoses were assessed 16 years after their inclusion in the WHO co-ordinated study on reduction and assessment of psychiatric disability. All patients at inclusion had a recent onset of a psychotic disorder. About one-third of the patients had a good outcome. The rest showed moderate to severe psychiatric symptoms and social disability. Comparison with other similar studies suggested that our results show a low mortality rate, high levels of clinical symptoms, high levels of social disability and a low percentage of institutionalized patients. These findings are discussed in the context of the high level of family involvement in patients' care, which could reflect a cultural factor.

Background Despite the recent increase of research interest in involuntary treatment and the use of coercive measures, gender differences among coerced schizophrenia patients still remain understudied. It is well recognized that there are gender differences both in biological correlates and clinical presentations in schizophrenia, which is one of the most common diagnoses among patients who are treated against their will. The extent to which these differences may result in a difference in the use of coercive measures for men and women during the acute phase of the disease has not been studied. Methods 291 male and 231 female coerced patients with schizophrenia were included in this study, which utilized data gathered by the EUNOMIA project (European Evaluation of Coercion in Psychiatry and Harmonization of Best Clinical Practice) and was carried out as a multi-centre prospective cohort study at 13 centers in 12 European countries. Sociodemographic and clinical characteristics, social functioning and aggressive behavior in patients who received any form of coercive measure (seclusion and/or forced medication and/or physical restraint) during their hospital stay were assessed. Results When compared to the non-coerced inpatient population, there was no difference in sociodemographic or clinical characteristics across either gender. However coerced female patients did show a worse social functioning than their coerced male counterparts, a finding which contrasts with the non-coerced inpatient population. Moreover, patterns of aggressive behavior were different between men and women, such that women exhibited aggressive behavior more frequently, but men committed severe aggressive acts more frequently. Staff used forced medication in women more frequently and physical restraint and seclusion more frequently with men. Conclusions Results of this study point towards a higher threshold of aggressive behavior the treatment of women with coercive measures. This may be because less serious aggressive actions trigger the application of coercive measures in men. Moreover coerced women showed diminished social functioning, and more importantly more severe symptoms from the “excitement/hostile” cluster in contrast to coerced men. National and international recommendation on coercive treatment practices should include appropriate consideration of the evidence of gender differences in clinical presentation and aggressive behaviors found in inpatient populations.

The authors would also like to acknowledge the contributions of the members of the International Expert Panel throughout the study and thank them for their valuable input: Mr Jerry Tew (social scientist, UK); social care – Mr Tony Ryan (independent consultant on out of area placements, UK), Mr Michael Clark (Care Services Improvement Partnership, UK); rehabilitation psychiatry and psychology – Professor Tom Craig (UK), Dr Frank Holloway (UK), Dr Jaap van Weeghel (Netherlands), Dr Joanna Meder (Poland), Professor Geoff Shepherd (UK); service user perspective – Mr Maurice Arbuthnott (UK), Ms Vanessa Pinfold (Rethink, UK); human rights law – Associate Professor Luis Fernando Barrios-Flores (University of Granada, Spain); mental health law – Professor Peter Bartlett (Nottingham University, UK); disability rights – Ms Liz Sayce (Royal Association for Disability and Rehabilitation, UK); care standards – Dr Geraldine Strathdee (Healthcare Commission, UK)., Background: This study aims to build a measure for assessing and reviewing the living conditions, care and human rights of people with longer term mental health problems in psychiatric and social care institutions. Protection of their human rights is imperative since impaired mental capacity secondary to mental illness can make them vulnerable to abuse and exploitation from others. They also constitute a major resource pressure for mental health services, social services, informal carers and society as a whole. Methods/Design: This study uses an iterative methodology to develop a toolkit to assess internationally agreed domains of care that are considered most important for recovery. These domains are identified by collating results from: i) a systematic review of the literature on institutional care for this service user group; ii) a review of the relevant care standards in each participating country; iii) Delphi exercises in partner countries with mental health professionals, service users, carers and advocates. Common domains and cross-cutting themes are agreed by the principal researchers and an international expert panel. Items are developed to assess these domains and incorporated into the toolkit which is designed to be administered through a face to face interview with the institution's manager. The toolkit is refined in response to inter-rater reliability testing, feedback from interviewers and interviewees regarding its utility, and feedback from key stakeholders in each country about its ability to deliver information that can be used within each country's established systems for quality assessment and review. Cross-validation of the toolkit ratings against service users' quality of life, autonomy and markers of recovery tests whether it can deliver a proxy-measure of the service users' experiences of care and the institution's promotion of their human rights and recovery. The ability of the toolkit to assess the "value for money" delivered by institutions is investigated by comparing toolkit ratings and service costs. Discussion: The study will deliver the first international tool for the assessment of the quality of institutional care for people with longer term mental health problems that is accurate, reliable, informative, useful and easy to use., The study is funded by the Sixth Framework of the European Commission and the authors gratefully acknowledge this support.

Въведение: Шизофрения и афективни разстройства са тежки психични заболявания с редица неблагоприятни последици за засегнатите, техните семейства и обществото. Цел: Анализ на разходите, ефективността и стойностната ефективност при лечение на шизофрения и афективни разстройства в реалната клинична практика. Материали и методи: Изследвани са 117 пациенти с шизофрения и афективни разстройства, постъпващи за болнично лечение в УМБАЛ „Александровска“, и техни близки и са проследени 12 месеца по-късно. Използвани са въпросници за оценка на използваните ресурси (CSSRI-EU), психопатологията (PANSS), функционирането (PSP), качеството на живот (MANSA) и бремето на неформалните грижи (BAS). Изследвани са разходите (от две перспективи: на здравната система и на обществото) и ефективността (като промяна в клиничните показатели). Проведен е анализ разход-ефективност с помощта на диаграми разход-ефективност и криви на приемливата рентабилност. Резултати: Шизофрения и афективни разстройства имат висока социална цена, като разходите от перспективата на обществото достигат респективно до 1737 лв./м. и 1072 лв./м. Само 20% от разходите са медицински. Ефективността е между 70 и 90% в зависимост от избора на клиничен измерител. Лечението на шизофрения и афективни разстройства в реалната клинична практика е ефективно и стойностно-ефективно при ниски нива на готовност за заплащане. Заключение: Инвестиране в психично-здравни грижи трябва да се възприема като устойчива инвестиция., Background: Schizophrenia and affective disorders are disabling mental illnesses with a range of negative consequences for the individuals, their families, and the society. Purpose: To analyze the cost, effectiveness, and cost-effectiveness of treating individuals with schizophrenia and affective disorders in the real clinical practice Materials and methods: 117 individuals with schizophrenia and affective disorder admitted for inpatient treatment at Alexandrovska University Hospital in Sofia, Bulgaria and their primary caregivers were recruited for the study and followed up after 12 months. Instruments were used to evaluate resource utilization (CSSRI-EU), psychopathology (PANSS), functioning (PSP), quality of life (MANSA) and caregiver’s burden (BAS). Costs were evaluated from healthcare and societal perspectives. Effectiveness was measured as the change in the clinical outcomes. Cost-effectiveness analysis was performed using cost-effectiveness planes and cost-effectiveness acceptability curves. Results: Schizophrenia and affective disorders have high societal costs, reaching up to 1737 and 1032 BGN per month respectively. The medical costs are only 20% of the total costs. The effectiveness varies from 70 to 90% depending on the chosen outcome. The treatment is cost-effective at low levels of willingness to pay. Conclusion: Investment in mental healthcare for should be viewed as a sustainable investment.