Project Directors:
Dr. Isaak Gurovich (left)
Dr. Aldred Neufeldt (right)
Since 1997, a series of projects were undertaken by Community Rehabilitation and Disability Studies and Moscow Research Institute of Psychiatry, in response to the Russian mental health system's need for development of community-based programs appropriate to Russia's diverse regional contexts. The first two were funded through the University of Calgary Gorbachev Foundation. The first, named "Community Mental Health Rehabilitation" started in October 1997 and was successfully completed by October 1999. The second, "Russia Mental Health System Reform", built on the first one, and ran from April 2000 to June 2002. The most recent initiative is funded by CIDA, as part of the Canada-Russia Disability Program. Projects are being undertaken in Central and South Russia and Siberia regions. The partnership introduced the concepts and best practices of community mental health rehabilitation through professional training and developing regional pilot projects, and facilitated development of parent and consumer support organizations.
Project Directors:
Dr. Isaak Gurovich (left)
Dr. Aldred Neufeldt (right)
Professional help for people with mental disorders in Russia traditionally has been provided by medical professionals (psychiatrists and psychiatric nurses) within the framework of the "medical model". What is needed in addition are professionals who might combine the duties of social work, community rehabilitation, vocational counselling and the like. While staff positions for such roles have been officially established in mental health facilities since 1995, they were not occupied because of a total absence of appropriately trained professionals.
The mental health system in Russia is at an early stage of reform from an institution-based to a community-based practice. The reform is being encouraged by two factors: a growing understanding that community treatment and support is much more desirable than long hospitalization; and, the economic necessity to increase the ratio of outpatients receiving psychiatric care, versus those who are hospitalized. With a rising number of persons with psychiatric disorders, the pressure upon the current system of institutionalized care is at an all time high. About one quarter of all inpatients in Russia have been hospitalized for more than 1 year, with this rate remaining quite stable. Amongst the patients who were hospitalized less than 1 year, the average duration of their hospital stay exceeds 70 days per admission, a very long time in comparison with Western countries, with annual readmission rates comparatively high at approximately 23% (Moscow Research Institute of Psychiatry statistics).
Given the absence of alternative community service models, there is no option but to transfer a sizable portion of long-term inpatients to specialized nursing homes for chronic mental patients, resulting in a process of ‘transinstitutionalization’ instead of the more desirable ‘deinstitutionalization’. A further problem is that current federal health policies prohibit transfer of funds from institutional services to community alternatives, and no money has been allocated to the development of new community services. Such policies limit the possibilities for reform in the mental health system, and will have to be changed.
The reform is progressing in the context of very limited knowledge of effective means whereby community-based services might be provided, and lack of professional personnel with appropriate training. There are very few models of community practice to help guide its development. Further, the parent and self-advocacy movement is very new, with little capacity to give guidance on appropriate interventions from a consumer perspective. So, while there has been a willingness to implement reform, its implementation has been severely constrained.
At the same time, the urgency for reform has increased in the context of Russia's economic and social crisis, with the numbers of people with mental disorders increasing dramatically. Between 1990 and 2000 the number of mental health outpatients has increased from 214.4 to 244.7 per 10,000 population, an increase of 14.1%, with the total in outpatient care reaching more than 3.5 million persons. Another statistic reflecting the impact of the economic and social crisis is the annual number newly recognized as unemployable due to mental disorder. This number was stable for many years at about 2.5 new persons per 10,000 population. From 1990 to 1998 the annual rate increased by 66.8% to 4.2 per 10,000 population, or 55,669 new persons for the year 2000. The total number of people recognized as unemployable due to mental disorder in 2000 was 851,651 (58.8 per 10,000 population), including 524,456 persons of working age (61.6%).
Impacts include the following. In Russia: 1) Learning through pilot programs has created models for future changes in the mental health system. 2) Professionals trained through these projects have trained other personnel in psychosocial support of people with chronic mental disorders. 3) People with mental disorders and their families benefited from newly created service models, and will continue to benefit directly in the longer term. Canada obtained a useful comparison with a mental health system in transition at the same time as Canada’s mental health services are being reformed.
…I have experienced a complete shift in my frame of thinking on this matter, my frame of reference regarding all the principles of our work, and not that much regarding the delivery of mental health services, but the principles of working with psychiatric patients…
These principles that I have heard and learnt here – as if I received answers to my own questions…
The new knowledge helped us …see the direction for action, and we can see the first results. We see faces of our patients, their response, and their smiles… it means we are moving in the right direction…
Quotes from interviews
with program graduates, reported in
“Russia Mental Health Reform Project:
Local Ownership of the Concepts of Community Mental Health Rehabilitation”
submitted to CRDS, U of C, by Nevena Kovatcheva, CIDA intern, May 2002