The State of Psychiatry in Russia
The State of Psychiatry in Russia
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.
The current state of the union
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.