As the notes on WHO's agenda for mental health point out, disability-adjusted life years are a useful way of measuring some aspects of mental health, but other ways are needed too (1). Socioeconomic indicators also directly affect epidemiology. The political, economic and social changes since 1989 in Hungary have had a major impact on health care (2). Suicides and disability contribute significantly to the burden of mental disorders. In this paper we would like to highlight recent changes in suicide rates and disability rates in Hungary, which is a good example of a country making the transition from communism to a market economy. We will look first at the correlation between decreasing suicide rates and improved treatment of depression, then at social and occupational dysfunctions in relation to changing market forces.
Depression and suicide rates in Hungary
Epidemiological data on depression and suicide before and after the major political changes in Hungary show an increase in depression (see Fig. 1), a decrease in suicide and an increase in the use of antidepressants (3-5).
[Figure 1 ILLUSTRATION OMITTED]
The improvement in the treatment of depression has been a result of changes in the Hungarian health care system. General practitioners have been motivated by privatization and capitation to provide better services. Several antidepressants were marketed in Hungary, and until July 1999 they enjoyed 100% reimbursement. A nationwide educational campaign for the general public, general practitioners and psychiatrists began in 1990, and contributed to better recognition and treatment of depression.
The continuing decrease in suicide rates and increase in the use of antidepressants (Fig. 2) supports the hypothesis of Rihmer, that recognition and treatment of depression strongly influence suicide rates (4).
[Figure 2 ILLUSTRATION OMITTED]
Employment and disability rates
Since the collapse of communism, the cost of making the transition to a market economy has been overwhelming: after 1989 the volume of gross domestic product decreased by one quarter and in 1998 still had not reached the level of 1989. Big state factories with accommodation for their workers were shut down, and this resulted in a wave of unemployed and homeless people. Psychiatric patients were among the first to be hit by unemployment and homelessness. There was increasing competition for employment, and government and health workers lost their control over employment and housing.
The communist governments left behind them a weak social support network and no self-help groups. Unemployment was zero from 1950 to the end of the 1980s, and stood at 8-12% in the 1990s. A 47-fold increase was registered in the unemployment rate in 1992 as compared to 1989, and there has been an 80-150% increase in the number of disability pension applications since 1989. The number of approved disability pension claims also had a transitory increase (Table 1). Of the newly disabled, 15-16% have mental disorders, which is the second largest group after patients suffering from cardiovascular disorders. Many data, such as those missing in Table 1 and approved disability claims in different diagnostic categories, could not be obtained, because the Hungarian insurance system was not computerized until recently.
Table 1. Selected data on unemployment and disability, Hungary
Year Population Number of Number of
(x [10.sup.6]) registered new
1989 10.5886 14 200 -
1990 10. …