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
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.
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.
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-problem... [in Russian]. Accessed January 24, 2014.