Mental health disorders are among the leading worldwide causes of disease and long-term disability. Both in Western countries and in Russia, the development of effective mental care is a priority for public health systems. This issue has a long and painful history of gradual de-stigmatization of patients, coinciding with humanization of therapeutic approaches. What are the current trends in Russia regarding this issue and in what ways is it similar to and different from Western countries? Below, IQ.HSE provides an overview of this problem based on research carried out by Svetlana Kolpakova.
Before the advent of classical medicine, the behaviour of the mentally ill was generally explained according to religious and mystical reasons. Aggressive or dangerous people were believed to be ‘possessed by demons,’ while quiet sick people were considered ‘God’s chosen’. Moreover, consistent observation of such people was not practiced. So, our understanding of their existence only comes from myths and folklore.
In Ancient Greece, initial attempts to rationally explain behavioural deviations were made. The first psychiatric terms appeared in manuscripts, which described specific cases, such as melancholy, mania, paranoia, and epilepsy. Then, scholars in the 3rd and 2nd centuries BC studied human anatomy and theorized that the human brain was the central organ to the nervous system. Investigation of the nervous system is considered one of the main achievements of Alexandrian medical science.
The Middle Ages was generally a time of stagnation in scientific thought. Mentally ill people were again perceived as being ‘possessed’ and socially dangerous. They were either executed or isolated. This era also saw the first use of asylums – the prototypes for psychiatric hospitals. This was mostly in Western European cultures. In Russia at this time, mentally ill people were sent to monasteries, as they tended to be treated with more mercy.
Later, at the end of 17th and the start of the 19th centuries, thanks to accumulated scientific knowledge and changes in society and politics, psychiatry became a more independent field in medicine. As such, it went through qualitative changes. Philippe Pinel (1745—1826), chief doctor at a French hospital, drastically changed popular attitudes to the mentally ill. He freed patients from their chains and ordered the use of strait jackets only in extreme cases (for particularly violent patients). There is evidence that such an approach led to the complete recovery for some of his patients.
Despite the fact that a new system of mental health care (MHC) was not adopted by other countries at once, Pinel had his successors, who laid the foundation for scientific clinical psychiatry in the 19th century.
The next century saw the development of outpatient forms of psychiatric care. Research has proven that in-patient treatment has a smaller therapeutic effect, and in certain cases, may even worsen a person’s psychiatric condition. In addition, society and the medical community, in general, started paying more attention to patient rights at hospitals.
In 1950, the anti-psychiatric movement arose in the Western countries, which led to deinstitutionalization – a massive reduction in the populations of psychiatric hospitals in tandem with the development of outpatient services.
The Soviet Union started developing its mental health care system after 1922. Priority was given to developing a network of local outpatient care centres (i.e., psychiatric dispensaries). In the 1930s, daycare hospitals and occupational therapy centres started appearing in addition the dispensary system. In the 1960s, the psychiatric care system was a unified network, which included asylums, local clinics, kindergartens, active therapy seminars, psychiatrists at factories and production plants, homes for chronic patients, and special schools for children with mental issues.
In addition to drug therapy, art therapy and occupation therapy were used. The latter was used so widely, that some researchers during this period were inclined to define this approach as hidden labour exploitation of mental patients.
No public discussion about the violations of patient rights took place. It was believed that the relations between patients and doctors would be based on trust, and, taking into account the professional ethics and morality of the latter, there can’t be any violations on their part. However, in reality, there were many cases when patients were stigmatized both by medical staff and the society at large.
Mental health policies vary throughout European countries, but not critically, since all European countries are guided by the WHO’s (World Health Organization) recommendations. Therefore, key areas of care can be clearly identified, including:
The main legislation regarding MHC in Russia is the ‘Law on Psychiatric Care and Guarantees of Citizens’ Rights in its Provision,’ which was was adopted in 1992 and has been amended 18 times over nearly three decades. Under this law, three federal programmes aimed at improving the MHC system have been implemented.
state support for up-to-date and high quality psychiatric care;
improving the training of psychiatrists and other professionals;
developing a new concept for the designs of psychiatric institution buildings and equipment;
developing and reorganizing forensic psychiatry.
developing networks of psychiatric care network in Russia’s regions;
decentralization of psychiatric support;
improving conditions in psychiatric hospitals;
expanding outpatient services (e.g., daycare hospitals, housing, psychiatric dispensaries, and offices).
elaborating and realizing consultative help, educational programs for the population regarding mental health protection and preventing suicides;
engagement of polyprofessional teams in treatment and application of contemporary methods of psychosocial therapy and rehabilitation;
building and reconstructing psychiatric care facilities.
The researchers analyzed legal papers and reports on the psychiatric system and the changes made thereto. They reached the conclusion that, since 1991, Russia has generally aimed at following WHO recommendations and has also been moving towards contemporary Western models and principles. Decentralization is underway; outpatient care and psychosocial rehabilitation are becoming more common; multidisciplinary team approaches are being implemented. But, of course, there still are issues of underdevelopment that require additional attention and effort.
For example, the focus on community care, which has become widespread in the West, has still not taken root in Russia. In Russia, it is believed that local dispensaries, where all mentally ill people are obliged to register, play a similar role.
Meanwhile, approaches to treatment have changed considerably: patients are now taken care of not only by psychiatrists, but also by social workers, psychologists and psychotherapists. There is also an evolving trend of integrating psychiatry with primary care and somatic medicine.
However, stigma and social inclusion are still ignored issues. The law mostly cares about reducing the negative consequences for state and society from mental disorders, such as disability and incapacity for work, crime, unfitness for military service and so forth. Policy documents primarily focus on the issue of human rights mostly with regards to inpatient treatment regulations, while no particular attention is paid at patients’ rights beyond hospital walls.
The number of psychiatric institutions has generally decreased throughout the country. For instance, the number of dispensaries (leading in outpatient treatment) decreased from 173 in 2005 to 99 in 2013 and to 92 in 2015. Moreover, the number of psychotherapeutic offices was reduced from 1,095 in 2005 to 727 in 2013 and to 676 in 2015.
In 2012–2013, 150 rehabilitation services were established in 83 of Russia’s 85 constituent regions. This trend can be explained by poor funding due to the fact that MHC has been switched to local budgets rather than federal funding. The federal budget only finances forensic psychiatric hospitals and partially funds federal organizations.
Svetlana Kolpakova concludes that the lack of state funding and the very low level of resources within civil society hamper the implementation of all aims set by federal programmes and challenge the ideas of diversity, quality and accessibility of mental health care in today’s Russia.IQ