The Current Status of Psychiatric Services in Russia: Moving Towards Community-Based Psychiatry
I. Y. Gurovich
This purpose of this paper is to describe the reforms that have been initiated in Russia's psychiatric services system and the results to date. The paper begins with an analysis of factors that have challenged the services, and contributed to over use of hospitals and under use of 'outpatient' services. The significant effects of introducing psycho-social rehabilitation approaches in the late 1990s, followed by service innovations such as early episode clinics and other innovations that emerged during the Canada-Russia collaboration, are described and supported with evidence from evaluative research. The paper concludes by identifying a number of issues that will need to be considered as part of continuing evolution of mental health services.
With respect to the development of community psychiatry in our country, today we can speak not only about the beginning of the movement, but also about the significant steps undertaken in this direction, although many difficulties and problems still remain.
Psychiatric service reform has advanced significantly in the recent years, although this advance took place mostly on a methodological and functional, rather than structural, level. However, these changes are certainly very meaningful, have conceptual significance, and reflect the development of psychiatry as a science, as well as the achievements of service organization in psychiatry. In addition, the reform has changed the general outlook of the Russia's psychiatric services.
The development of psychiatric services in the recent decades can be divided into several important stages that reflect the directions and the intrinsic patterns of this development. In the early '80s mental health services were extended beyond the traditional structure that had been based on hospitals, dispensaries, and transitional institutions, and formed extra-dispensary services, with some areas of the system reaching out to various populations in the community. It is noteworthy that since that time, some substantial changes have been made in this area of services. Psychotherapy clinics ("cabinets") have acquires particular significance in regional policlinics (general community health centres), and separate psychotherapy centres have appeared. There is a tendency towards a broader integration of psychotherapy services into the general health care facilities. As well, the social significance of a service network for speech therapy and neurological rehabilitation has become more broadly recognized because of the increased occurrence of traumatic brain injury and post-stroke conditions. Suicide prevention services, which were initiated in many cities in the same time period, are also becoming more active. Similar changes can be observed in sexological services. As opposed to the traditional psychiatric service that is based on the geographic principle of catchment areas, and is designed to serve the entire general population, the out-of-dispensary service sector represents diverse components of mental health care, most often in the form of "cabinets" (specialized outpatient clinics) or other structures that reach out to populations in need for particular services. For example, 30% of clients served by psychotherapy cabinets in regional policlinics need help dealing with depression, psychosomatic and other [non-psychotic] disorders. Another example is suicide prevention and psychological-psychiatric services that, in addition to hot lines and crisis intervention clinics, are often created at large high education institutions or other community institutions where they can reach out to population groups with high risk of suicide.
The next stage of reform began in 1992 - 1993, when the Russian Federal Mental Health Act was first adopted (The Law on Psychiatric Care and the Guarantees of Citizens' Rights in its Provision). The Act not only defined the legal foundations of mental health care, but also served departing from the paternalistic principles of providing care and the transition to partnership relationships with our patients: It is particularly important to stress this essential aspect of the Act.
In 1995 a significant number of new positions were established in psychiatric institutions for psychologists, psychotherapists, social workers, and social work specialists. Initiation of these positions created conditions for the transition from predominantly medical to bio-psycho-social model of psychiatric care, and consequently, to the poly-professional services based on team approach.
Beginning in mid '90s the area of community crisis response started to take shape, while particular attention was paid to mental health care related to the consequences of such general factors as emergency situations, negative environmental impact, social stress, violence, and, accordingly, posttraumatic stress disorder and psychosomatic disorders. Crisis-related medical and psychological services, including mobile teams of psychologists and psychiatrists, were created through the Ministry of Emergency Situations, at research institutes, and through various functional groups of psychiatrists and psychologists based on local resources.
Current range of services
Today we can identify the following sectors of mental health services: in-patient hospital care, dispensary services, out-of-dispensary services, and community crisis response services (see Figure 1).
The organizational structure of psychiatric services in Russia
The Russian psychiatric service system is experiencing transition from a predominantly medical to a poli-professional model of service delivery through the introduction of team approaches consistent with the poli-factorial origin of mental health disorders. The numbers of practicing mental health professionals has significantly increased (although they are still insufficient) through the addition of new specialists: psychologists, social work specialists, and social workers whose total number across the country more than doubled in the last five years. The ratio between psychiatrists and these new professionals is now 4 to 1, although newly established non-psychiatrist professional positions are still filled very unevenly in different regions. There are two main reasons for lack of specialists in regions: on the one hand, salaries are extremely low, which makes psychiatry unattractive for the specialists, and, on the other hand, the initiative of mental health system administrators is insufficient. The number of physician-psychotherapists has also increased dramatically. Unfortunately, the distribution of these professionals between hospitals and community organizations still reflects the predominance of inpatient services.
Factors affecting services
To analyze factors affecting our services, let us begin with reviewing the problems faced by hospitals. Since 1990, 40 thousand psychiatric beds have been cut across Russia, which is 1/5 of the total national bed capacity. That said, the number of beds per capita still remains high: 11.2 per 10 thousands of general population. We might be reminded that, according to one of the federal programs, it was planned to cut hospital bed capacity in Russia down to 7 - 8 per 10 thousands general population, and that in some countries psychiatric bed capacity is 2 to 3 per 10 thousands general population. In Russia, bed capacities are also highly centralized: more than 40% of beds belong to large hospitals of at least 1000 beds each. The question arises: With respect to reducing bed capacities, are we really achieving the goal of departing from the relying on the hospital component of our mental health service?
What are the functional indicators of inpatient hospital services? In 2006, the average duration of hospital stay still remained extremely high for all patients in general (77.4 days). Among these, for patients with schizophrenia duration of stay was 114.2 days. The occurrence of re-hospitalization in the same year was 20.3%, and this figure was particularly high for patients with schizophrenia: 29.1%, (almost 1/3) of these patients were discharged and returned to the hospital in the same year. The rate of patients who stay in hospitals longer than a year (i.e. people who practically "settle down" in hospitals, or are so called "hospital residents") has changed very little during the last few years. In 2006, the rate was 20.5%, which means that one in each five beds was occupied by a long-term patient. The number of patients hospitalized with non-psychotic disorders increased, while most of these people could be receiving outpatient treatment instead, or benefit from day programs. In 1990, there were 28% of such patients among all hospital admissions, in 1999 - 33%, and now this figure has reached 37.5%. The duration of hospital stay for people with non-psychotic conditions has been increasing, while the average duration of stay for patients with schizophrenia has become shorter. This phenomenon is similar to the "communicating vessels" effect, because the beds vacant after the discharge of patients with psychoses become occupied by people with non-psychotic disorders. It means that the cause lies within the existing budgeting system, in which resources are provided per hospital bed, which creates the necessity to fill up the bed capacity. That said, many hospitals work hard at improving their material resources and their patients' living conditions. To illustrate this, I will present the data on one of the indicators that is worth particular attention: the number of patients per room in hospitals (Table 1).
The distribution of wards in psychiatric hospitals, by the number of beds per room
Fewer than 5 beds per room - 11.2%
6 to 8 beds - 43.1%
11 to15 beds - 33.5%
16 to 20 beds - 8.5%
More than 20 beds per room - 3.7%
It is essential that this indicator be included as a required indicator for general evaluation, in order to motivate work towards the reduction of the number of patients per room in hospitals, and improving patients' conditions of stay.
A final illustrative indicator is hospitalization rate (the rate of hospital admissions per capita of general population per year). In the first five years of the 1990s, the admission rate was decreasing, dropping to as low as 42 per 10,000 general population, but by 1999 the hospitalization rate almost returned to the level of 1985 which was 46 per 10,000 population. In 2004 it became even higher (47), and in 2006 hospitalization practically returned to the level of 2000 (46.4). It is obvious that community services not only do not prevent the high level of hospital admission and readmission of people with psychoses, but also do not represent sufficiently strong competition with inpatient institutions with respect to services for people with non-psychotic mental health conditions.
We are facing a situation in which hospital admissions have regressed to the high levels of past years. The system of outpatient mental health services has suffered significant loss of resources during the social-economic crisis (as shown below) and cannot meet the need for reducing hospital admissions and readmissions. In this situation, the simple reduction of bed capacities, without creating alternatives to hospital organizational forms and service models will lead only to the further loss of already strained mental health system resources.
The mental health service system in Russia, as illustrated, is characterized by a widely developed, dense network of outpatient facilities, such as dispensaries in urban areas and psychiatric "cabinets" (outpatient clinics) in rural areas. However, during the period of perestroika, as well as during the years of social and economic crisis, these facilities suffered from a significant decrease of their level of functioning. Along with some positive changes, these negative sources of influence in recent years continue to strongly impact the quality and effectiveness of mental health services.
When we analyze the activities of outpatient institutions, it is important to note the continuing growth in number of newly diagnosed patients, although in the recent years the rate of increase has slowed somewhat. Between 1990 and 2006 the number increased by 40.7%, with only 4.7% of this increase occurring between 1999 and 2006. The growth in number of newly diagnosed patients mostly was represented by those individuals who have non-psychotic forms of mental disorders.
Overall, the outpatient group is becoming increasingly large (between 1999 and 2006, the number increased by over 13 %), though the rate of those receiving continuous dispensary care is decreasing. Of course, the active work of psychotherapy cabinets in regional policlinics impacts these numbers to a certain extent. There are 1,097 such cabinets across Russia now, which equals over 1/5 of the total number of the dispensary catchment areas, although policlinic psychotherapy cabinets and dispensaries target different categories of patients. As opposed to the dispensaries, policlinic cabinets target mostly those people who seek services from their local primary health care practitioners or regional policlinics; for example, people with depression or psychosomatic disorders.
What is the situation with service for psychiatric dispensary catchment areas? There is a striking gap between the number of positions budgeted for psychiatrists and the number of actual persons who work in these positions (the number of actual persons is 1,319 lower than the number of positions across Russia). The extent of this phenomenon does not fully reflect the deficit of psychiatrists because, in addition to covering greater areas, psychiatrists also receive benefits on top of payment for their official staff positions based on extra caseloads. In fact, a dispensary psychiatrist often occupies more than one full time position, and serves a doubled size of catchment area population. It is not unusual any more that a dispensary psychiatrist whose catchment area is supposed to be 25,000 of general population, serves 50,000 instead. However, the intensity of dispensary psychiatrists' work in these clinics has decreased significantly as reflected in number of patient visits per year (from 4,945.9 in 1985 to 3,317.5 in 2006). Moreover, one third of these visits pursue purposes not related directly to illness treatment; rather, they involve requests for certificates, evaluations, or copies of patients' records. The number of visits directly associated with treatment is much lower than needed for good quality care, especially for quality outpatient follow-up in dispensaries.
It is important to note that working conditions of dispensary psychiatrists are not unlike those of general physicians in the primary health care sector. Dispensary psychiatrists see patients who belong to their catchment areas, while other specialists (e.g., neurologists or ophthalmologists) do not follow the territorial principle. According to the Mental Health Act, only a psychiatrist can establish a diagnosis of mental health disorder, especially the diagnosis that can have social consequences (other physicians can only give a preliminary diagnosis or identify syndromes). Only a psychiatrist can make a decision about involuntary assessment or hospitalization, which is often an emergency decision. Therefore, access to psychiatric appointments cannot be limited by referrals from general physicians or mediated by other gatekeepers, but has to be open, immediate, and direct. The dispensary psychiatrist is also responsible for outpatient follow-up, which includes home visits and other services.
Accordingly, the situation in our psychiatric dispensaries is not better than in the primary health care sector. There is no doubt that this situation requires special attention, and it is important to raise awareness about it among administrators and policy makers to initiate a discussion and undertake specific steps towards strengthening and improving the quality of service in this sector.
Poor medication resources also complicate the working conditions of dispensary psychiatrists. Pharmaco-economical and pharmaco-epidemiological research conducted by our Institute (Gurovich & Lyubov, 2003) has indicated that providing patients with appropriate pharmacological therapy in the 1990s was progressively decreasing in most regions, especially in rural areas, and the options for selecting psychotropic medication was narrowing. A high rate of inappropriate pharmacological therapy was also identified, as well as medication prescription practices that deviated from internationally approved and evidence-based patterns of treatment of psychiatric disorders. This situation was further complicated by limited financial capacity to introduce second-generation neuroleptics. In addition to inappropriate routine practices, pharmacotherapy is now characterized by budget deficit and, as a consequence, unstable provision of medication. Under these conditions, the significance of numerous publications and clinical manuals is practically devalued (Gurovich & Shmukler, 2002; Krasnov & Gurovich, 2002, 2004; Krasnov et al, 2007). Another significant loss occurred during the social-economic crisis of the late 1990s when vocational-rehabilitation workshops were closed in most territories. Such workshops used to be part of the overwhelming majority of dispensaries and psychiatric hospitals, as well as located in specialized departments of many industrial enterprises. Therefore, it is essential that we now search for other, alternative models of psychosocial rehabilitation through supported and sheltered employment.
In the late 1990s the restructuring of psychiatric services and redistribution of responsibility between regional and municipal levels in Russia resulted in transferring all the costs of mental health services from municipal to regional budgets . What will follow next? Will a network of municipal level mental health services develop under these conditions? In the past, a number of research projects in several regions demonstrated high significance of developing a network of psychiatric units in regional general hospitals in rural areas. If we want to build community-based psychiatry, we will inevitably need not only to preserve these units that reach out to rural populations, but also create more of such units that are as essential as outpatient psychiatric cabinets. This is an extremely important issue, and we have to do our best to assert our argument.
The development and implementation of psychosocial rehabilitation and psychosocial treatment have become priority directions within the established ideology for further improvement of community-oriented mental health service and its development towards community-based psychiatry (Table 2). These directions have created content foundations for implementing multi-professional (team) approach to mental health service providing (Gurovich & Shmukler, 2002; Gurovich, Shmukler, & Storozhakova, 2004). Achieving this objective has been identified as a key factor in accomplishing service reform in a number of regions across the country, and the awareness of the significance of this task is increasing among psychiatric communities.
Principles of community-based services
1. Fullest possible transition of mental health services towards community sector
2. Departure from the isolated traditional specialized service matrix (model), and utilizing additional governmental and public structures
3. Changing the structure of psychiatric services towards reaching out to the community within micro-social environment
4. Poli-professional team service
5. Involving micro-social environment in service providing
6. Systematic psychosocial treatment (in addition to pharmacological treatment) and psychosocial rehabilitation
7. Accessibility of all organizations and institutions in the community whose activities can be used to improve social functioning and quality of life of people with psychiatric disorders
Towards that end our Institute has developed a staged model of introducing psychosocial rehabilitation, and a number of training modules for accomplishing this work (Table 3). In total, approximately 500 professionals have graduated from training seminars provided at our Institute, including psychiatrists, psychologists, and social work specialists from 53 regions across Russia. Today some psychiatric hospitals and [entire regional] mental health service systems have adopted group psychosocial treatment and rehabilitation models as their routine practices, and continue to provide these services along with pharmacological therapy in all their units or service areas. In a number of regions, the results of such approach can be already observed as positive changes within outcome indicators of a regional level. For example, positive changes have been identified in the average duration of hospital stay, re-hospitalization numbers, and the number of patients who are "hospital residents", not to mention the positive outcomes that reflect social recovery of the patients. We also focused on intense dissemination work to spread the information about these positive experiences and best practices.
Stages of Psychosocial Rehabilitation
* Stage 1. Active psychosocial interventions (psychosocial treatment)
* Stage 2. Mastering practical functions and social roles that are close to pre-existing particular patient's levels, or new for the patient
* Stage 3. Stabilization and maintenance (support) of full or partial social recovery
A series of research projects have provided evidence of the effectiveness of including psychosocial interventions into comprehensive therapy at various stages of psychiatric service. Effectiveness indicators included reducing the duration of hospital stay, decreasing the levels of re-hospitalization, reducing the numbers of long and frequent hospital admissions, and improving various indicators of patients' social recovery, including the alleviating of family burden. As an example, let us review some research data. Table 4 describes the effectiveness of including psychosocial interventions in the comprehensive psychiatric treatment at the early stages of psychiatric treatment in patients with their first psychotic episode (Movina, 2005). Table 5 outlines the results of including psychosocial rehabilitation in treatment programs at the opposite end of mental health service continuum, that is in an out-of-town hospital for persons with chronic schizophrenia who have a history of frequent (every year) and long-tem (over 6 months) hospitalizations (Davydov, 2005). With respect to the latter data, it is appropriate to refer to an article by Chisholm (2005) who noted that the use of antipsychotic medication resulted in improving the patients' everyday functioning by 15%, whereas adding psychosocial treatment to pharmacological therapy improved everyday functioning by 45%, which was a threefold increase of the effectiveness.
Utilizing Psychosocial Interventions within Comprehensive Treatment of Patients in an Early Episode Treatment Clinic (2-year Follow Up) (Data provided by L. G. Movina)
* improved quality of remissions (p<0,001)
* improved compliance (p<0,0001)
* decreased the number of re-hospitalizations (p<0,01)
* improved levels of social functioning and quality of life (p<0,05)
* improved quality of trusting relationships with the others (p<0,001)
* strengthened the feeling of support from the referent group (p<0,05)
* decreased (alleviated) family burden (p<0,05)
The Effectiveness of Including Psychosocial Interventions into Comprehensive Treatment for Patients with Frequent (every year) and Long-term (more than 6 months) hospitalizations: 2.1% of all Patients with Schizophrenia (2-year Follow Up) (Data provided by K. V. Davydov)
* improved results of PANSS scale: lower scores (p<0,001)
* improved social functioning (p<0,05)
* remission achieved in more than 50% of the patients (7.42% of beds vacated)
* positive changes in patients' social networks (improved density of the networks, frequency of contacts, etc.) (p<0,001)
* decreased (alleviated) family burden (p²0,05)
Having said that, it is important to note the following: The data demonstrated by these research projects can demonstrate changes only at the functional and methodological levels. Other experience has shown that the implementation of innovative approaches in a number of regions also resulted in active changes within the structure of mental health services, with the orientation towards developing service models in the community (Table 6). Such changes included building the system of psychosocial rehabilitation, organizing various models of supported housing (including "hostels"), a variety of collaborative work models with social services, units (or teams) of assertive community treatment, the model of "hospital at home", vocational programs, psycho-education and psychosocial work with families. In other words, the shift of approaches has revealed a certain deficit of organizational [structural] forms, or service models that could directly reach out to the community. Evaluation research is now underway in a number of regions to examine the effectiveness of such innovative service models.
Outpatient and community-based service models currently being tested
* Assertive Community Treatment Teams
* Outreach Mental Health Service Units (Teams)
* Outpatient Rehabilitation Units
* Psycho-educational groups for families of people with psychiatric disorders
* Inter-sectoral models of collaboration between psychiatric and social sector services, for enhancing rehabilitation process in persons with psychiatric disorders
* Various kinds of supported housing: "hostels" (group homes) for persons with psychiatric illness who lost their social connections:
different level of support according to needs;
- in urban areas;
- in rural areas;
- in combination with employment programs;
- satellite models
* Independent living housing units
* Increasing the capacities of Day Hospitals (Day Programs)
* Vocational rehabilitation offices attached to dispensaries (in collaboration with unemployment centres)
* Early Psychotic Episode Treatment Clinics with the continuity of follow up and treatment programs
* Non-governmental public organizations of people with psychiatric disabilities and their families
When evaluation research is completed, and the innovative service models are officially recognized (i.e., the relevant best practice standards are adopted), it will become possible to expand the models to other regions across Russia.
Two international collaborative programs have contributed to these changes: the Canada-Russia program that involved a number of territories and psychiatric facilities, and the British-Russian project that involved the Sverdlovsk region.
In addition to the above, early psychotic episode treatment clinics have been created or are underway in over 20 regions across Russia, and long-term plans have been developed for individual interventions for these patients. The development of such clinics promotes the prevention aspect, because they focus on avoiding the unfavorable course of schizophrenia. The creation of early episode clinics also has a broader general significance, because they promote the transformation of in-patient facilities into day hospital units, and practice the implementation of psychosocial treatment. The development of all these models, or at least some of their elements, is essential to offset the reduction of hospital bed capacities. Furthermore, there is a need to establish mechanisms for gradual, partial transformation of in-patient bed resources [into community service capacities] in such way that will be acceptable and even beneficial for professional groups working in hospitals.
And finally, there is a social theory of "empowerment", which is used to describe and explain social support interventions aimed at encouraging the individuals' own active position and efforts, as opposed to the traditional paternalistic forms of support. With respect to this attitude, we have supported the emergence of the All-Russia public organization of people with psychiatric disabilities and their families New Choices, which has established itself, become independent, and now includes branches in 53 regions across the country that maintain continuous, meaningful work. All these developments, practically, represent elements of the concrete plan for transition towards the implementation of community-oriented psychiatry.
The Government of the Russian Federation has recently adopted the Target Federal Program entitled The Prevention of and Fighting against Socially Significant Diseases (for 2007 - 2011). The Program includes a section on psychiatric disorders, with significant resources designated for implementing the relevant plans. In this section, significant attention is given to the following areas of improving mental health services:
- Transition towards poli-professional team services;
- Strengthening collaboration and establishing shared services with the primary health care sector, in particular for identifying depression, psychosomatic and other [non-psychotic] disorders in people who access primary care professionals;
- Implementing psychosocial treatment and psychosocial rehabilitation at all stages of mental health care;
- In all mental health services across the country, implementing the following innovative service models:
- in-patient rehabilitation units,
- assertive community treatment teams,
- poli-professional teams at dispensaries for working with families of persons with psychiatric illness,
- various models of supported housing such as hostel units attached to hospitals, group homes in the community for people experiencing various stages of rehabilitation, satellite housing units for persons with previous long-term hospital stay, and independent living apartments in the community;
- Models of collaboration between psychiatric and social services; and,
- Other innovative models.
Our immediate objectives at this time include spreading the information and best practice experience across the country, and maintaining the assertive and consistent work aimed at transition towards community based mental health services.
The experience of implementing new service models in different regional mental health care systems in Russia has provided foundations for comparative evaluation and analytical thought. The data available now has already revealed some disputable areas. In addition to questioning many particular issues, one can ask the following general, conceptual questions. In the context of the transition towards community psychiatry (or, using a more appropriate term, community-based psychiatry), should we define the limits of the service area related to the professional competence of psychiatrists, and what can be viewed as proper roles of the community and its institutions that are involved in resolving mental health issues? Should we rather speak of a continuum of tasks, the achievement of which requires the primary focus on either biological (involving professionals) or social approaches? In the latter case, where are the limits of competence of different professionals, and what can be delegated to the community? If there exists a wide variety of services available for meeting therapeutic and rehabilitation needs of different groups of persons with psychiatric disorders, should psychiatric services maintain its identity and specific structure, or should it merge with other medical facilities and become just an element of other governmental or community services and structures, to the extent of becoming "invisible" and thus, according to some authors, de-stigmatized? These and many other questions are becoming increasingly important as we approach our goal of implementing community-oriented psychiatry.
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Isaac Gurovich, MD, PhD, Professor
Deputy Director of Moscow Research Institute of Psychiatry
Head of the Department of Outpatient Psychiatry and Mental Health Services Organization
Translated from Russian by
Svetlana Shklarov, MD, PhD Candidate
Interdisciplinary Graduate Program
Community Rehabilitation and Disability Studies Program
University of Calgary
International Journal of Disability, Community &
Volume 6, No. 2