The State of Psychiatry in Russia

Table: Number of persons subjected to involuntary psychiatric examination and hospitalization per 100,000

It may be difficult for our American and European colleagues to imagine the constraints under which Russian psychiatrists practice. In Russia, treatment of the psychiatric population is at the mercy of government and society.

In this article, we provide a glimpse into Russian psychiatry from the point of view of the Independent Psychiatric Association of Russia (a professional human rights organization). Introducing readers to the various systems of mental health services in Russia will allow them to make a comparison with mental health services in their country.

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Always funded just to the verge of collapse, Russian psychiatry is going through a severe crisis. Constant attempts at cost saving affect the mentally ill, who are generally perceived as a burden on society or as a hidden danger, and their rights are openly ignored. Democratic gains that resulted from the law “On Psychiatric Assistance and Guarantees of Citizens’ Rights in Its Provision”-which guaranteed care of psychiatric inpatients-have gradually diminished. Since 1993, there has been no compliance with the article of this law, despite demands from the psychiatric community. In 2001, the state guarantee of “providing for high-quality mental health care” was abolished. Moreover, the Psychiatric Assistance Act does not provide any guarantees or sanctions for failure to comply. For example, up to 90% of inpatients do not receive accurate information about their diagnosis or treatment, nor do they have access to their own medical records.

During the early years that followed enactment of the Psychiatric Assistance Act, the number of persons subjected to involuntary examination increased in parallel with involuntary hospitalization. Since 1999, however, the opposite trend has been seen (Table). (Involuntary examination prevents unreasonable involuntary hospitalization, a more serious restriction of freedom.) The decrease is due to the fact that psychoneurological dispensaries (ie, outpatient clinics) prefer to avoid involuntary examinations that require court authorization and instead immediately send patients to the hospital citing imminent danger. Once in the hospital, patients with psychosis or dementia are coerced (by deception or threats) to sign a consent form for hospitalization and treatment. However, it is well known that about 20% of patients cannot give informed consent because of their mental condition, which testifies to falsification.

Patients are directed to dynamic clinical observation even less often (in 1999, 57% of all those seeking help; in 2011, 16.4%). The number of regular medical check-ups has also declined. Patients are to be examined at least once a year, yet up to 25% are overlooked.¹ New cases of psychosis identified in 2006 and 2011 per 100,000 people decreased from 67.1% to 62.0%, respectively; new cases of schizophrenia, from 15.9% to 12.2%; new cases of nonpsychotic disorders, from 27.4% to 25.0%; and new cases of mental retardation, from 45.8% to 23.8%. These rates reflect the changed guidelines and do not indicate a real reduction.

Guided by cost saving (even when the government had enough funds) and hiding behind the rhetoric of deinstitutionalization while erroneously assuming that institutional patient care is much more expensive, the Ministry of Health has drastically curtailed bed space by one quarter (more than 50,000 beds). Currently, there are 104.8 beds per 100,000 people, yet no measures have been taken to prepare new facilities for outpatient services.

Shortages are rampant

The number of outpatient clinics devoted to the primary care of people with mental disorders stopped increasing in 2005. By 2012, there were 277 such clinics instead of the 318 available in 2005. General employment of psychiatrists, including forensic psychiatric experts, sexologists, and psychotherapists, declined from 2006 through 2012 from 22,546 to 21,577, leading to a noticeable lack of personnel and lowered quality of mental health care. Concurrently, there was a dramatic decrease in the number of psychologists, welfare experts, and social workers, whose services are not available in 13 territories. The number of psychiatrists has decreased by more than 2000 in the last 2 years: in 2013, there were 12,117 practicing psychiatrists in all of Russia.

There have also been reductions in the number and quality of medications available to patients with psychiatric illnesses. In addition, the time available to assess patients has been reduced as has the duration of inpatient hospitalizations. Consequently, recidivism is high, and physicians are penalized. Recurrent admissions in 2012 exceeded 50% (eg, every third patient with schizophrenia is readmitted in the same year).

Although services are reduced, the physician’ workload and the need for documentation are increased. Reimbursed prescriptions are so hard to obtain that many people prefer to buy medicines on their own. Because health insurance is flawed, the financial burden is shifted largely onto the patient population. Physicians and staff must work at least 50% longer. On average, every specialist in the public sector of psychiatry manages 20 to 25 patients at the same time and receives a salary of US $200 to $500 per month. Salaries in Moscow and the private sector are 2 to 3 times higher, and psychiatrists see fewer patients-approximately 7 to 12 patients. The high patient load has adversely affected psychiatrists’ ability to provide quality care. The traditional clinical interview and communication with a patient that encompass clinical and psychopathological analysis have given way to simplified express procedures and questionnaires.

Since 2000, one-third of inpatient psychiatric facilities have been found to be unsuitable because of unsanitary conditions. During the Soviet era, psychiatric hospitals were often located in former barracks, monasteries, and even concentration camps. However, deinstitutionalization has not affected many of them, and people still perish in these buildings. In 2013, just outside Moscow and Novgorod, some 70 people died in a fire. Living conditions are frequently inadequate and at times gruesome: 12 to 15 patients in a big room, no bedside tables, bars on the windows, not enough toilets, and often no partitions. Despite difficult conditions and restrictions on their independence, some medical directors of these facilities manage to provide a decent psychological atmosphere and good psychiatric patient care in their institution.

The total state control and centralization of the mental health services reproduces the overall authoritarian management style and is ultimately most destructive to patient care-manageability is prioritized over efficiency. The advantages of decentralization are ignored as are desperate letters from the regional psychiatrists about the destruction of psychiatric service and the plight of the mentally ill-while the Ministry of Health flaunts health care reform and promises that those born in the 21st century will live at least 100 years.

The Russian Society of Psychiatrists is forced to ignore these well-known and painful facts, and the plight of the mentally ill is rarely discussed at congresses and conferences. The Ministry of Health continues to act without input from the psychiatric community and breeds illiterate draft laws, standards, and regulations, which results in absolute state control of mental health services.

Stigma related to mental illness is at the level of xenophobia. The mentally ill are perceived by the Russian public as dangerous, incurable, useless, and harmful. Nevertheless, the Ministry of Education eliminated the highly effective tolerance program for schoolchildren. Much of the general public holds a negative view of psychiatry, and this view is perpetuated by the mass media. And this social stigma is held not only by the general public-psychiatrists themselves are often also guilty. Soviet mentality has survived into the present. For example, despite the exclusion of homosexuality from the list of mental disorders, 62.5% of 450 surveyed psychiatrists in the Rostov Region consider it a disease, and up to three-quarters consider it to be immoral behavior. These psychiatrists support banning gay parades and the use of covert tactics to lay off openly gay and lesbian individuals from child care centers, schools, and other public institutions.²

The dichotomy

Since 1995, there has been complete state control of forensic psychiatry. That is, independent psychiatric examination has been eradicated, and this purging has been legitimized. A medical specialist (ie, a psychiatrist invited to explain special issues to the court) is not allowed to evaluate and criticize the conclusion of state experts. And judges often and easily violate the Criminal Procedure Code, refusing even to hear a medical specialist. For example, when my colleagues and I protested the gross distortion of ICD wording of PTSD criteria, we received absolutely meaningless formal replies and were allowed a mere 2 to 3 minutes to speak at conferences on these matters.

Having achieved the status of a subspecialty, forensic psychiatry lost contact with general psychiatry. As a result, and especially because competitive examination has been eliminated, corruption prospers in property cases, and mechanisms have been developed that allow the use of psychiatry for political purposes once again. The driving factor for this state of affairs is the administrative hierarchy in the courts and the lack of separation of powers in the country-in landmark cases, forensic psychiatric examination is always a weathercock of power. The Federal Service for Drug Control grossly interferes in the work of psychiatric and drug abuse services, mainly prosecuting consumers rather than drug traffickers.

Underlying all of this is a lack not only of respect but also of the very need for independent professional examination of draft laws and projects of national importance. This is demonstrated by the recent deprivation of the autonomy of the Russian Academy of Sciences by the Ministry of Health’s sabotaging of the Pirogov Congress. The Minister of Health ignored an invitation to the Congress, leaving an empty chair in the presidium, and there were no attendees from the Russian Federation Ministry of Health. And yet, the peculiarity of post-Soviet psychiatry is the organization of the Independent Psychiatric Association of Russia, a member of the World Psychiatric Association (WPA) since 1989 and of the Advisory Council of the Russian Commissioner for Human Rights since 1996. The Independent Psychiatric Association of Russia is able to blaze new trails and voice the most critical issues that cannot be afforded by the Russian Society of Psychiatrists.

We, as psychiatrists, draw enthusiasm from the knowledge that such systems of government are noncompetitive and will become obsolete. After all, the conditions created here in Russia drive people to emigrate. (Russian psychiatrists are routinely invited to practice in Germany, Canada, and other countries). We are also able to achieve personal success in the most diverse professional areas, including clinical psychopathological and biological psychiatry, practical work with patients using various psychotherapeutic and sociotherapeutic methods, and conceptual criticism of ICD-10 and 11.

Russian psychiatry has integrated into practice the up-to-date international achievements in psychopharmacotherapy, biological therapy, psychotherapy and sociotherapy, and art therapy, among others. New organizational formats include day clinics, home care, and helplines, as well as the use of a team approach. Expert exchanges have been organized between Russian psychiatrists and their colleagues from other European, Asian, and African countries. A school for training young psychiatric scientists has been established, the WPA publication World Psychiatry has been translated into Russian, and a new Russian psychiatric journal is planned in English, to provide comprehensive information on research and insights about positions on topical issues from a global perspective.

All this is possible because of the fall of the Iron Curtain and because of the ever-expanding international contacts that were once forcefully denied us. Clearly though, challenges remain. The struggle continues for decentralization that will reduce government involvement in the mental health service and for professional autonomy. We want the return of the functions (eg, certifying, licensing, pricing) that have been usurped by the Ministry of Health. We want a voice in the development of laws concerning the mentally ill. Competitive forensic psychiatric examination needs to be restored, and article 38 of the law “On Psychiatric Assistance and Guarantees of Citizens’ Rights in Its Provision” on establishing the Psychiatric Inpatients Protection Service, which is independent of the public health authorities, needs to be reinstated.

Disclosures:

Dr Savenko is President of the Independent Psychiatric Association of Russia, a member of the Council of Experts of the Russian Commissioner for Human Rights, and Editor-in-Chief of the Independent Psychiatric Journal. Dr Perekhov is Vice-President of the Independent Psychiatric Association of Russia, and Associate Professor of Psychiatry of the Rostov State Medical University in Rostov, Russia. They report no conflicts of interest concerning the subject matter of this article.

References:

1. Gurovich IY. The current state of psychiatric services in Russia: moving towards community-based psychiatry. Int J Disabil Commun Rehab. 2007. http://www.ijdcr.ca/VOL06_02_RUS/articles/gurovich.shtml. Accessed January 24, 2014.

2. Perekhov AY. Ethical problems in psychiatry: narcology, psychotherapy and sexual pathology; 2006. http://centerphoenix.ru/biblioteka/nauchnye-stati/690-eticheskie-problemy-psikhiatrii-narkologii-psikhoterapii-i-seksopatologii [in Russian]. Accessed January 24, 2014.