RIGA STRADIŅŠ UNIVERSITY
MĀRIS TAUBE
Latvian psychiatry and perspectives of
its development
Speciality - psychiatry
Summary of promotional work
Scientific research reviewer
Dr. habil. med., Professor Mintauts Caune
Scientific consultant
Dr. med., Professor Raisa Andrēziņa
The work was done at
Riga Stradiņš University, Department of Psychiatry
and Narcology and Mental Health State agency
Topicality of the paper
Nowadays 450 million of people in the world have mental and neurological
diseases and behavioural disorders. A quarter of all people who are connected with
the health car services require assistance in the area of mental health. Four out of
six most frequent reasons of disablement are connected with neuropsychic
diseases (depression, alcoholism, schizophrenia, bipolar disorders). In a quarter of
families some family member has a mental disease. About 873 000 people each
year commit a suicide. These data proves the topicality of the problem of mental
disorders worldwide, and each country tries to search for their solutions. One of the
recommendations of the World Health Organization for improvement of the
situation in the area of mental health is to develop mental health enforcement
policy in each country. Such a plan is only for 59.5 % of the world and 67.3 % of
the European countries. Unfortunately Latvia is not among those countries, which
contrary to the recommendations of the World Health Organization have not
enforced a policy in the area of mental health, and this makes this scientific paper
topical.
After regaining of independence, Latvia during the last 15 years both politically
and economically was subject to material changes and over a short period of time
is trying to find the most correct way of development. These changes impact all
areas of economics, also medicine and psychiatry. Growth of other branches of
medicine is connected mainly with development of science and introduction of
new technologies in diagnostics and treatment, whereas in psychiatry larger
attention is paid to social and economic situation, approach of the state to certain
problems and opinion regarding the methods of its solution.
Different countries, which are in the transitional stage from the totalitarian regime
to a democratic society, are looking for their way of development in psychiatry,
and each of them is unique and specific.
The essence of the paper is to show scientific basis of the Latvian mental health
policy and raise issues significant for the operational program in order to create at
maximum realizable policy proper for the Latvian situation, which could be
enforced in life in the future.
Purpose and tasks of the scientific work
To develop scientifically justified improvement policy of Latvian psychiatry
service and public mental health, as well as recommendations and scenarios
for its practical realization in the country.
Research tasks necessary for reaching the purpose of scientific work:
1) to assess the living conditions, educational level and sources of basic living
income of people registered in Latvia with mental and behavioural disorders,
as well as estimate the interrelation of these data with mental diseases of
patients;
2) in connection with issues of medical care, to assess the income level of
patients being under in-patient treatment, whether they have a home of their
own and occupation/business;
3) to assess the social situation of Latvian psychiatry patients and their
possibilities to work;
4) to determine mutual interrelation of narcological and mental diseases
in
Latvian circumstances.
Scientific novelty of the paper
1) historical and social/psychiatric assessment of Latvian psychiatry;
2) improvement of Latvian population's mental health and development of
enforcement policy for psychiatric assistances.
Structure and scope of the paper
The paper consists of the introduction, literature survey, description of methods
used in the research, highlight of the results gained, discussion, conclusions,
practical recommendations and a list of literature used. The scope of the paper is
96 pages and 25 tables.
Research material
1) Information contained in the Mental disorders and mental diseases state
register on living conditions, education, sources of basic living income of 60
924 patients, as well as the fixed social diagnoses according to ICD-10 (the
data of April 2003).
2) Patients of 11 wards of the non-profit in-patient company VSIA ,,Psychiatry
Centre" from Riga and Riga district who were there due to aggravation and
acuity of mental diseases in 2003 and 2004.
3) Out-patient patients of a Riga micro district in 1995/1996 and 1999/2000 (the
researched environment comprised 60 000 inhabitants).
4) Information on 6385 treatment episodes in 2000 in the non-profit company
VSIA ,,Psychiatry Centre" (Riga Psycho-Neurological Hospital).
Research methods
1) Statistical analysis was made of the information on living conditions,
education, basic living income sources of 60 924 patients included in the
Mental disorders and mental diseases state register, as well as the fixed social
diagnoses according to ICD-10 (the data available in April 2003 were used).
2) One-time registration of 335 patients in 11 wards of the non-profit company
VSIA ,,Psychiatry Centre", which admitted patients with aggravations and
acuity of diseases from Riga city and Riga district. In this way the composition
of patients was fixed in hospitals, and afterwards psychiatric examination of
patients was made, as well as clarification of the most critical social data.
3) A pilot research was made in the form of a fixed interview or free discussion
by questioning out-patient patients of one Riga micro district (the environment
of research comprised 60 000 inhabitants). In 1995/1996, 640 patients were
interviewed and analyzed, but in 1999/2000 - 429 patients.
4) Statistical analysis was made of the data on 6385 treatments episodes in 2000
in the non-profit company BO VSIA ,,Psychiatry Centre" (Riga PsychoNeurological Hospital).
Statistical processing of research results
Break-down analysis was made of the ratios of the material in connection with
social and clinic characteristics. For checking the statistical significance of
differences in the gained results, the Student and McNemar test was used. Only
those differences where p<0.05 were considered as significant.
Results
1) The data obtained on living conditions of psychiatry patients in the Social
psychiatric statistical research show that 47 789 patients or 78.5% of all
registered patients live in a family, 6357 or 10.4% live alone, 4512 or 7.4% reside
in social care establishments.
Another ratio, which gives a possibility to make certain conclusions on the ability
of patients to successfully function in the social environment, is education. It has
been clarified that most part of the patients have not studied, have attended school
for mentally retarded, studied, but not finished an educational course in primary
school or have finished primary school (See the table No. 1).
Most significant and informative data on the social status of patients are provided
by the information available in the Mental disorders and mental diseases state
register regarding living income of patients. 17 656 or 29% of the registered
patients live on their disablement pension, 15 997 or 26.3 % of patients are under
custody of other persons, 7953 or 13% of patients live on the old-age pension,
8907 or 14.6% of patients gain living income otherwise - mainly in non-regular
occasional works.
Another aspect, which was analyzed, was the interrelation of living conditions,
educational and living income with different diagnose groups. For assessment and
comparison, a group of organic, including symptomatic, mental disorders (F 0)
was chosen, where 14 340 or 23.5% of patients are registered, as well as a group
of schizophrenic disorders (F 2), where 17 373 or 28.5% of patients are registered.
These two groups are the largest in number and include patients with severe
mental and behavioural disorders. For comparison, also a group of affective
disorders was chosen (F 3), where 3678 or 6% of patients are registered. This
group is less in number, but there is a tendency of growth in patients observed in
this group. The patients of this group, compared to the patients of organic
disorders and schizophrenic disorders, more frequently are socially more adapted
and working, and it is seen in table No. 2.
2) Breakdown of patients involved in the Clinic social psychiatric research
in the non-profit in-patient company VSIA ,,Psychiatry Centre" according to the
age and sex is given in table No. 5, but breakdown in the main diagnostic groups in table No. 6.
As manifested by the table, most frequent patients involved in the research were
schizophrenic patients. The group ,,other" included cases of adaptation disorders,
personality disorders, reactions to stress and mental disorders for mentally
retarded. Only 54 (16.1 %) patients of all in-patients in the hospital were there for
the first time. Dependence phenomena as comorbide diagnose was observed in 46
cases (13.7%), mainly dependence on alcohol, but suicidal attempts and intentions
were observed in 28 cases (12.8%). 222 (66.3 %) patients had admitted disablement
(2nd disablement group) or they received old-age pension. 46 patients (13.7%) were
searching for work, but could not find it. Employed patients from all hospitalized patients
(including also part-time job) were 67 (20%). Personal income (disablement or oldage pension, social allowances, remuneration for work) gained on average per one of the
335 hospitalized patients amounted to Ls 56.48, but per one family member (or person
with whom co-habits) more - Ls 76,01. In 57.3% of cases the patients received the
necessary additional financing from other family members, relatives or people, which
whom they co-habited. A contrary tendency, i.e., that the patients shared their income with
family members (mainly children) could be detected in 15.8% of cases. When checking
with the so-called criterion of signs, in each of 11 wards the dominating tendency (with
p<0,05) was the one confirming that the patient received assistance from relatives.
As evidenced by table No. 7, the number of those patients, who had small personal income
- up to Ls 60 per month, prevail: 18.5% + 6.9% + 23.8% + 19.7 % = 68.9%.
Analogous calculation about small income per one family member reaches 49.6%.
Income, which is larger than 60 Ls per month per one family member, was for 50.4% of
patients (personal income > 60 Ls - 31.1%). This reflects the compensatory and
equalizing tendencies of the family and relatives. When calculating income per one
family member in the main, most represented
diagnostic basic categories, it appeared that this income on average was least for
the patients with organic mental disorders and schizophrenic patients respectively Ls 62.34 and Ls 73.25, but the highest - for affective disorders group
— Ls 97.40. This difference was mainly creating on the basis of those persons
whose income was above 80 Ls (See the table No. 8).
The following fact was discovered: if schizophrenia was continuous, chronic
progredients, the average monthly income per one family member was only Ls
59.12, but for the group of schizophrenia patients whose process of disease had a
tendency to remitting, the respective ratio reached Ls 95.76, thus being very close
to the income of patients with affective disorders (Ls 97.40). The breakdown of
schizophrenia patients depending on the specific characteristics of the process of
disease (See the table No. 9) shows that the main difference is manifested in that
group where the income exceeds Ls 100 per one family member.
patients, were noted in 51 cases. 14 patients out of all 335 were homeless (4.2%),
the cases when due to debts people faced with threat of being evicted from their
homes, which provoked and aggravated depressions, were 23 (6.9%), 14 (4.2%)
suffered from serious psychological incompatibility problems in their places of
habitation - those are persons who due to their material and psychological status
cannot change the situation.
103 patients in their process of disease had dominating depressive inflictions
(phases or components in the mental status, also in remissions) and their treatment
would require up-to-date antidepressants and neuroleptics, however only in 19
cases income per one family member exceeded Ls 100, which would give a
possibility to buy expensive medicaments (only nine out of 35 were affective
patients).
3) In the research regarding occupations/employment of mentally ill persons,
it was noted that 17 656 or 29% of the registered patients live on disablement
pension, 15 997 or 26.3% of patients are under custody of other persons, 8907 or
14.6% of patients gain sources of income in irregular occasional jobs. Only 22%
of the persons with mental and behavioural disorders as a result of different
successfully realized project had been employed in some work. 75-80% of women
and 25% of men want to engage in business therapy, 56-69% of patients want to
work.
4) In the psychiatry research of narcological comorbidity it was noted that in
808 episodes (12.7%) dual diagnoses were set (psychiatric and narcological). Out
of comorbid narcological pathologies, the first place is taken by mental and
behavioural disorders due to alcohol, 79.5% (n = 642), the second place - due to
opioid substances, 12.3% (n = 99), the third place - many narcotic and
psychoactive substances, 4.5% (n = 36).
Analysis of results
o
Latvian psychiatry before gaining of independence
In order to assess properly the situation of psychiatry nowadays, it is material to
make a minor highlight in the history of Latvian psychiatry.
A significant feature of psychiatry services in the times of Soviet Latvia was the
attitude towards patients. A patient was treated like a person who is unable to
solve his problem of life normally.
Taking into account the custody of the state, also the diagnostics and treatment
was frequently subjective, based on the intuition of doctor, his experience and
analogies, rather than strictly determined and discovered diagnostic criteria,
verified treatment methods. Given this subjective approach, sometimes a patient
received help by fixing the so-called easier rehabilitation diagnosis so that it is
easier for the patient to adapt, or a more severe diagnosis so that the patient would
have the reason for allowance, i.e., the pension.
Insufficient and formal was the respect of patients' human rights, overall
conditions in the hospitals and attitude of the staff towards the patients was
humiliating. Humane attitude towards patients was not a generally accepted norm,
but the issue of want, intelligence and humaneness of each individual. Psychiatry
service was established on centralized basis, of course, there was nothing like
competition among the providers of services, although it should be admitted that
for modern psychiatry it is more important to develop different types of services
and agree their enforcement rather than compete. During the time when Latvia was
a part of the USSR, a major component of the work of the service was recording
of patients and the system for the prevention and treatment of disease. The task of
the system was to ensure regular treatment of patients, in a way- forced attachment
to psychiatry.
During the Soviet times, in the same way as now, there were psycho-neurological
doctor's services operating. In this way it was an attempt to create a possibility for
the patient to receive treatment as far as close to his place of residence, as well as
ensure realization of the principles of prevention and treatment of disease. The
number of visits of patients to a psychiatrist over a year's time in the 80-ties of the
XXth century was close to the number of nowadays, and this evidences a similar
service to out-patients, similar composition of patients, with whom the
psychiatrists worked before regaining of Latvia's independence and now. During
the Soviet times, psychiatric care was based only on psychiatrists. Currently
there is tendency to base the care of persons with mental disorders on other
specialists, mainly - on psychiatry nurses.
An interest peculiarity was marked in the 80-ties of the XXth century when a
service telephone line started to operate, a social psychological assistance service
room, even a separate suicide service. In 1988 and 1989, there was a sufficient
number of psycho-therapeutic service rooms operated both in Riga's clinics, as
well as elsewhere in Latvia. In this way the state tried to solve the problems of
those patients who are ill with conditionally light disorders and who have
communication problems with people. It should be added that the quality of
provided services was low, the wish to integrate patients in society - formal, it was
more about statistical reports.
When analyzing the in-patient care, we see that this form of care was the
dominating one. In the 80-ties of the XXth century, the number of "beds" in
hospitals and clinics grew, also the number of "beds" for narcological profile. The
situation connected with consumption of alcohol remained unfavourable. The
number of psychiatric profile "beds" was large. Compared to 2004, in 1989 it was
larger by 30%. It should be added that the large number of patients were
practically in the same premises as now, therefore the living conditions of patients
were poor, even 20-30 patients were living in one room, co-habited areas were miserable.
In the 80-ties, there was a tendency observed to decrease the workload of doctors,
dynamically the number of "beds" for in-patients per one psychiatrist decreased.
The re-hospitalization ratio did not become much worse, which is usually taken
into account when analyzing the quality of the services. The re-hospitalization
ratio was similar to today's ratio of about 30%.
In the psychiatry system of Soviet Latvia a significant role was given to
specialized workshops, which acted at psychiatric hospitals. The workshops were
mainly used for the fact that the patients had to be busy, would be under
supervision of specialists. The purpose of workshops was to ensure that the
patients would not be disturbing to the society, and as a matter of fact this was a
way how to isolate the patients rather than prepare them for work in life and
include them in society.
After fall of the ,,iron curtain", there was a possibility to compare psychiatry in
Latvia and in Western Europe. A very material characteristic was the poverty of
our psychiatry, as well as our medicine. Western psychiatric establishments
worked in much better circumstances (spacious, sanitary norms compliant
premises), more staff employed, staff receiving better salaries, modern
medicaments available. Also different types of assistance possible to the patients,
especially in chronic cases, appeared to be vast and at higher level because work
with patients was more differentiated specialized and expansive. It especially
refers to overall rehabilitation, especially ergotherapy, work therapy, places of
residence of patients (disabled persons), social assistance, different type of
consultations and possibilities corrections (team work) by involving different
specialists. Compared to Western Europe, out-patient work was not developed,
non-differentiated.
The status in Riga in the area of forensic psychiatric expertise and forced treatment
could be evaluated as a catastrophe. In the expertise ward, it was tense, sanitary
conditions were poor and similar to imprisonment. Forced treatment was carried
out in common wards. The number of staff was not sufficient, the process of
forced treatment was not oriented to rehabilitation, ergotherapy.
In the area of education and raising of qualification there were some typical
drawbacks: 1) excessive ideology of psychiatry, 2) improper psychological
preparedness of doctors and other staff and insufficient use of knowledge in
diagnostics, treatment, rehabilitation, as well as in simple communication with the
patients, and 3) weakness and primitiveness of psychotherapy.
Social psychiatric problems were treated only as a problem of capitalism.
Educational programs were prepared centrally in Moscow and could not be
changed on spot in Latvia.
With the Western assistance, especially the German colleagues (president of
Oberfranken county Mr. E. Sitzmann and the head of Bayreuth clinic of psychiatry
and psychotherapy prof. M. Wolfersdorf) by organizing a lecture and a cycle of
consultations in Riga, exchange-of-experience trips of about 70 Latvian
psychiatrists to Bayreuth, as well as by receiving support and educational
possibilities (especially in rehabilitation, ergotherapy, patients' care) from
Sweden, Denmark and Norway, gradually promoted positive changes in education
and practical work - the psychological climate in Latvian psychiatry has changed,
professional knowledge of doctors and other staff has improved, establishment and
de-institutionalization of a clinic for forensic psychiatrics and forced treatment has
been much promoted, as well as differentiation and specialization of out-patient
treatment has been started.
o
Epidemiologic situation in mental and behavioural disorders in present
Latvia
Mental diseases and mental disorders in Latvia have been registered for 4.4% of
population (total number of disorders connected with use of psychoactive
substances - 5.6%), on active basis, i.e., at least once a year the psychiatry
services are used by 2.6% of population. These numbers are small and evidence
both about the insufficient availability of the services and their use, as well as
about shortcomings in records (there are no data from family doctors, etc.). When
analyzing the prevalence and incidence ratios of patients, it should be concluded
that a large share of these ratios is taken by schizophrenic and organic mental
disorders.
Latvia takes one of the first places in the world regarding the number of suicides.
The number of suicides is connected with psycho-social factors and this is
confirmed by observations in Eastern European countries. The number of suicides
decreased before regaining of independence when hopes and bright future plans
were in the air. The number of suicides rapidly grew in the first years of
independence when there was a social and economic crisis in the country. Over the
last years, when the economic situation in the country is improving and social
issues are started to be treated, the number of suicides is decreasing. The reasons
of all changes in the number of suicides have not been clarified, it is too early to
speak about a stable reduction in the number of suicides over a longer period of time,
o Organization of psychiatry service in present Latvia
a) Out-patient assistance
In Latvia, out-patient assistance is ensured by out-patient psychiatric departments
or ambulances at psychiatric hospitals in Rīga, Jelgava, Daugavpils, and Liepāja,
as well as regional psychiatrist doctor rooms in the whole Latvia. For children, outpatient psychiatric assistance is provided by children's psychiatrists in outpatient
departments in Daugavpils, Liepaja, Jelgava, as well as children's department
at wide profile children's hospital in Riga, as well as a minor number of
children's psychiatrist rooms in the regions.
In these establishments, the patients can receive a consultation of psychiatrist,
prescriptions for purchase of medicaments, if necessary - a confirmation on the
health condition, as well as the psychiatrist prepares the necessary documents for
work of expertise and other commissions.
In out-patient establishments, besides a psychiatrist there is also a psychiatry nurse
who mainly performs the documentation work, assists to the doctor, but is not
independently working with patients. Other specialists (psychologist, social
workers, ergotherapeutist) involve in the work in episodes, more frequently in out-
patient wards at psychiatric hospital because they have larger financial
possibilities to involve additional specialists, as well as a possibility to involve inpatient specialists.
When assessing diagnoses for patients who are under out-patient psychiatric
assistance care, it should be concluded that 83% of adult patients have
schizophrenic, organic mental disorders and diagnoses of mental retardness. For
children and teenagers, neurotic disorders prevail and it is connected with
diagnostic approach to children in psychiatry. It should be admitted that the
psychiatric out-patient service is engaged in treatment of a certain, severe, chronic
composition of patients.
When analyzing the number of patients who visit a psychiatrist in out-patient
treatment at least once a year, the regional psychiatrists care for 700 -1500
patients, whereas more patients are in the psychiatric care in out-patient wards of
psychiatric hospitals.
55 private doctor's companies were operating in Latvia in 2004, which have no
agreement with the State Compulsory Health Insurance Agency. It is not clear
what is the scope of work carried out by these doctors, but the author assumes that
they are engaged in those diagnostic categories, which are not comprised by the
state psychiatry.
Family doctors in Latvia are little involved in correction of serious mental diseases
and disorders, as they lack proper knowledge, conviction about their capabilities,
as well as time to be devoted to patients. If possible, in case of suspicion about a
mental disease, family doctors send their patients to a psychiatrist. Persons with
mental and behavioural disorders frequently arrive at the social services care in
connection with loss of apartment, insufficient living income.
Development possibilities of out-patient services
A variant. One of the variants of out-patient services development is to strengthen
the psychiatric out-patient services on the basis of municipal psychiatric rooms or
as separate structures. In this variant, it is necessary to offer the patients wider
services - social workers assistance, ergotherapy, psychologist's consultations or
at least conditions for spending time properly. The operation of such psychiatric
centres should be closer related to the specialists of primary care, thus attracting
other groups of patients, which would be sent to a psychiatrist by their family doctors.
B variant. In the second variant, it is possible to involve family doctors in
patients' care with mental and behavioural disorders by improving the knowledge
of family doctors and placing larger liability for treatment of mental patients. In
this variant, the role of psychiatrist would be mainly only consulting. This variant
would ensure patients' integration in society and overall health care system, would
possibly attract more persons with mental and behavioural disorders, which
especially refers to neurotic and depressive patients (those patients who are not
willing to attend a psychiatrist or a psychiatric establishment).
b) In-patient assistance
Currently patients in Latvia with acute and severe chronic mental disorders are
treated in psychiatric hospitals. In hospital conditions in Latvia, psychiatric
assistance is ensured by psychiatric hospitals in Riga, Jelgava, Liepaja,
Daugavpils, Streņči. These hospitals can be considered acute hospitals as here the
patients arrive not only with psychiatrist's prescription for planned treatment and
investigation, but also in acute, emergency cases with ambulance assistance
transport or police assistance. There are still the so-called chronic hospitals in
Latvia where the patients practically live, rarely leave the hospitals. Such hospitals
are in Vecpiebalga and Aknīste. Hospital assistance is provided also by a
psychiatric hospital in Jūrmala where specialists work with neurotic, depressive
group of patients by ensuring the care of health resort — rehabilitation. Hospital
psychiatric treatment for children is ensured by children's psychiatric ward in the
general type children's hospital in Riga, as well as children's wards in Jelgava,
Liepaja and Daugavpils psychiatric hospitals. Treatment and care of chronic
children is carried out in the children's hospital in Ainaži. Almost a quarter of all inpatient "beds" are permanent accommodation "beds". Latvia differently from other
countries is characteristic of weak specialization of in-patient "beds", which would
include specific mental disorders and diseases treatment of the ward - eating
disorders, depression, schizophrenia, etc. The data show that psychiatric hospitals
are sufficiently loaded. Similarly as when analyzing out-patient care, it should be
concluded that hospitals are mainly involving the treatment of schizophrenic and
organic mental disorders' patients. A third of the patients are treated longer than a
year, which means that a hospital has become a place of residence for a patient. It
should be concluded that there is a
certain part of the patients treated in hospitals who have problems to live in
society. This is evidenced also by the large number of patients (51.6%) who over a
year's time return to the hospital.
Forensic psychiatry and expertise departments in present Latvia comply with the
international standards. These departments are located in Riga. Patients' treatment
and expertise with court judgments are generally carried out in psychiatric hospitals.
Development possibilities of in-patient care
A variant. One of the in-patient service development variants is to improve inpatient establishments by ensuring acute psychiatry services in a certain statistical
region (Riga, Vidzeme, Latgale, Kurzeme, Zemgale). hi in-patient establishments,
the rehabilitations services should be developed at maximum, as well as the
employment possibilities improved, i.e., ergo therapy and specialized workshops.
B variant. In the second variant, it would be necessary to establish acute
psychiatric wards at general-type multi-profile in-patient establishments thus
ensuring the same treatment standards as for patients with other diseases and
decreasing prejudice against people with mental diseases. In these wards, highly
qualified diagnostics should be carried out using also all examination and
treatment possibilities, which are provided by the general profile in-patient
establishments. Establishment of such wards is considered as a progressive
development of these services.
c) Availability of medicaments
Medicaments are an essential part of psychiatric assistance, which frequently
determine the interest of patients to receive the services. There is a medicament
compensation system operating in Latvia. Up to the year 2005, only adult
schizophrenia (F 20) patients, but children - with wider range of diagnoses had a
possibility to receive medicaments with compensation. The list of diagnoses
includes both the medicaments of latest recipes, as well as older neuroleptics and
antidepressants, mood stabilizators. This in a way explains also the fact that
schizophrenic patients more often and more regularly attend a psychiatrist. Since
2005, medicaments with 75% compensation may also be received by the patients
who are ill with Alzheimer dementia, bipolar affective, recurrently depressive,
schizoaffective, schizotypical disorders and mentally retarded patients. Possibly
supplementing of the list with these diagnoses will be able to attract other groups
of patients for treatment and care. Maybe a part of patients come to the hospital
only because they want to receive medicaments, for whose purchase they lack proper financing.
Solutions of improvement in availability of medicaments
It is necessary to include additional diagnoses in the list of compensated
medicaments, to assess the current list and remove those medicaments, which are
not practically used and as far as possible include in the list non-original
preparations whose prices are lower. It is essential to assess the need to renew
social categories, which are due free of charge medicaments in order to ensure at
least minimum assistance for socially non-protected persons.
o
Significance of social issues in psychiatry
The situation of social patients and its interrelation with the process of mental and
behavioural disorders are very critical issues, which frequently are underestimated
when organizing psychiatry services and making reforms. Therefore one of the
most essential parts in this work, which was researched, was social issues. The data
acquired during the social psychiatry statistical research show that a large
number of patients live in families, and this is a positive fact, as the family creates
a basic support system for patients, although the statistical information gained
does not give a possibility to judge about the structure of this family and
relationship in it — whether the microclimate of family is favourable, whether the
patient receives the necessary support or is used as means for providing for the
family (disablement pension). Large number of patients live alone or in social care
establishments.
Insufficient education does not ensure the patients' ability to integrate flexibly in
the employment market, does not create a possibility for successful competition.
Here it is of major importance to correspond the patients' abilities with his
education, adapt to the status of illness, establishment of support system from
society (fixed work places, etc.).
Most troubling were the data acquired in the research regarding the number of
patients who are under custody of other persons, as such a status least promotes
the integration of patients in social environment, does not stimulate self-esteem of
patients. These results in the context with living conditions indicate that possible
the opinion about the large number of patients who successfully live in families is deceptive.
There are a large number of patients who live on disablement pension. These data
evidence that so far there are no preconditions appearing in society for successful
integration in social environment.
Comparing the living conditions for different groups of diseases, we can see that
these ratios are similar for organic mental disorders and schizophrenia disorders
groups. It is understandable because both of these disease groups are different,
however there are similar according to their severity and impact on the social
status. Differently from the mentioned groups the largest part of mood (affective)
disorders patients live in a family, and this evidences of better social adaptation of
the patients of these disease groups.
When analyzing the interrelation of the level of education with groups of mental
disorders diagnoses, a lower level of education for patients is marked in the
organic mental disorders group and it arises also from the essence of mental
disorders - morphological damage of brain.
Larger number of affective disorders' patients work in public offices and this
indicates to possible hardships to work more intensive work in private structures.
Organic disorders and schizophrenic disorders groups involve more patients who
receive disablement or old-age pension, and this evidences of problems to
integrate in the labour market.
When looking upon the results gained in the Clinic social psychiatric research
carried out in the non-profit in-patient company VSIA ,,Psychiatry Centre",
attention is first caught by the large number of patients with very low and low
income. The data show that patients' income depends on the type of process of the
diseases. Affective and schizophrenic patients, which in one or the other level are
able to remit, better adapt, are longer able to keep adequate interpersonal
relationship, establish occupations and they have higher income levels. 51 out of
surveyed patients due to insufficient income forced the problems with apartment,
and it promoted adverse process of diseases, their aggravation. Free of charge
antidepressants and stabilizing medicaments for affective patients (F 3) during the
process of disease were not planned, therefore a part of patients with low income
search for rescue in hospital, although on the basis of clinic assumptions the
treatment could be carried in out-patient manner. The low income, real threat
to lose the apartment, as well as threat of
unemployment negatively impact the mental status of patients and process of
disease as they cause additional mental traumatization, disadaptation and due to
lack of financing patients are unable to purchase more modern, more effective
(expensive) medicaments for coping of depressive disorders. Social problems are
connected not only with insufficient financing of psychiatric and social care, but
also with clinic factors - nosologic diagnosis and variant of the process of
disease. The worst social situation is for patients with continuous process of disease
(schizophrenia) and organic pathology of cerebrum for whom assistance is required
most.
In the current situation, the problem with dwelling is especially topical for patients
with low income: establishment of cohabited apartments or hostels or group
apartments with closer psychiatric care, which would help to survive with lower
expenses and would promote introduction of rehabilitation elements. The results
gained in the Mentally ill persons' employment research indicate that the
psychiatry reform in our country is generally carried according to the so-called
Canada model. According to this model, the out-patients care system should be
planned not only in medical care establishments by making them closer to the
place of residence of their patients, but also in Day Centres, in which the business
therapy is possible, specialized workshops are opened, in which patients learn and
perform simple work. The supported work should be planned and performed in
coordination with the Ministry of Welfare, the State Employment Agency and the
Associations and Unions of employers.
The quality of remissions of schizophrenic patients has improved, and the patients
more actively search for a possibility to find work. 15% are patients with neurotic
and depressive disorders, which after a respective therapy course retain their
professional working ability, but unfortunately during the treatment (4-8 weeks)
have lost their jobs.
o
Personnel resources, educational standards and interrelation between
psychiatry and other branches of medicine
The most significant progress after regaining of independence in Latvia has been
reached exactly in the improvement of personnel qualification and change of
attitude towards patients, strengthening of knowledge about psychology,
rehabilitation and ergotherapy, about which a special thanks should be said to the
Western - especially German colleagues. This knowledge and materially different
approach to patients' treatment have a possibility to realize minimum standards of
human resources, which are required by the status of a European Union member country.
One of the aspects, which the author of the paper wanted to look upon, is the
available personnel resources, educational standards and interrelation between
psychiatry with other branches of medicine. This issue is topical when planning
development of the area and making it closer to the Western standards. The
Latvian psychiatric assistance is based mainly on psychiatrists. Such an
approach is traditional, although during the last years there are attempts to involve
other specialists in the treatment and care, i.e., psychiatry nurses, social workers,
ergotherapists. The main focus currently in Latvian psychiatry is laid on the
treatment, such approach is clear both to the patients, as well as medical persons.
Also the patients of other medical areas want to receive assistance from a
specialist of the given area of medicine, receive medicaments or a fixed procedure
for health improvement.
The number of social workers and ergotherapists is not sufficient in the country.
The most material aspect, which ensures successful operation and development of
any area by special reorganization or start of new types of activities, is the
personnel motivation. Real motivation for the work of personnel is proper
remuneration and satisfactory work environment.
During the psychiatric research of narcological comorbidity it appeared that
overall comorbide pathologies in local (Riga) circumstances are diagnosed less
than they are observed in clinic practice (Riga Psychoneurological Hospital) and
are described in the literature.
From comorbide narcological pathologies, the most prevailing dependence in
Latvia is that of alcohol and opioids. When analyzing the literature data and the
common mechanisms of narcological and psychiatric disorders, larger share
should be taken by Indian hemp alkaloids, cocaine and amphetamines. Also
mental and behavioural disorders due to use of caffeine, tobacco, sedatives, sleep
tablets, tranquilizers and correctors (cyclodoli) have not been sufficiently studied.
Affective symptoms have been little diagnosed, most probably, it is "hiding" in the
neurotic disorders group, as well as included in the diverse schizophrenia symptoms.
The share of organic disorders among comorbide organic mental disorders can be
explained by the comparatively rapid impact of opioids on the central nervous
system, subsequent changes in behavior and personality.
When analyzing local (Riga) circumstances, dependence on alcohol is dominantly
prevailing among schizophrenic comorbide pathologies. This dependence has been
clinically and theoretically proved. Other comorbide narcological dependences
have not been sufficiently diagnosed (hemp alkaloids, cocaine, sedative and sleep
tablets, tranquilizers, correctors).
Comorbidity of neurotic, stress-related and somatophorm disorders are related
with dependence on alcohol due to spread of the use of alcohol in the country.
This group of diagnoses comprises a wide range of mental disorders, including
also reactive, adaptation disorders, temporary depressive reactions.
o
Financing of psychiatry services
Issues regarding finances are always very complex. Money is always too little,
also in the countries, which have had sufficient financing, periodically the use and
effectiveness of money is discussed again and again. Financing of psychiatry
services differs from financing of other areas of medicine because differently from
other areas, there are no expensive technologies, high costs of equipment in
psychiatry, which are easy to calculate. It is neither clear what is the result of
treatment, which would be understandable to society, i.e., the patient does not
recover, no one can guarantee long-lasting stable improvement, safety for society
or the very patient, return to work, life, etc. The result can frequently be treated as
improvement of life quality, however it is not understandable for people especially for the poorest part of society.
In Latvia, 79.6% of financing for psychiatry is used for in-patient care.
One of the positive aspects declared by the psychiatry or mental health reform
when transiting from in-patient care to out-patient or community-based care, is
economy of finances. However, one should take into account that for qualitative
development of out-patient assistance we need financing not only for creation of
infrastructure, but also for remuneration of personnel.
Conclusions
1.
Living conditions for persons with mental and behavioural disorders are
not fairly favourable, because, irrespective of the large share of patients living in
families, the patients are under custody of other persons or survive on minimum
pensions. Insufficient educational level limits the ability of patients to integrate in
society. The large number of disabled people indicates to a situation that there are
no preconditions appearing for successful integration in society and employment
environment, but disablement is the only means for ensuring elementary survival.
There is interrelation between living conditions, education, basic living income
sources and the diagnoses of patients - better family integrated, more educated
and well-off people are the patients of depressions, it is less observed among
patients with organic mental disorders and schizophrenia.
2.
The in-patient patients of the non-profit company VSIA 'Psychiatry
Centre" have serious social problems (low income, threat to lose dwelling,
unemployment). The low availability of most modern, effective medicaments
obstructs deinstitutionalization process. Social problem psychiatry patients are
connected with nosologic form of mental diseases, worse social situation is a
continuous drawback for schizophrenic and organic mental disorders patients.
3.
The possibilities to work of Latvian psychiatry patients are very limited,
and it is connected with lack of motivation for employers, changes in behaviour
and thinking of patients after getting ill.
4.
Narcological comorbides pathologies for psychiatry patients have not been
sufficiently diagnosed, and it may adversely impact the treatment and patients'
care. Special attention in development of psychiatry should be paid to the problem
of use of alcohol by mental patients, and the work of narcological and psychiatry
services should be coordinated and combined.
Practical recommendations
Taking into account the research results and conclusions developed in the
promotional work, the author of the paper has developed the basic guidelines
,,Mental health improvement of population in 2006-2016", updated them given
the recommendations of the work group members set up by the Health Minister
(order No. 159 of the Health Minister of September 14, 2004 ,,On Setting up of a
Work Group") and the World Health Organization's experts. The basic guidelines
have been published on the home page of the Ministry of Health www.vm.gov.lv
for public discussion.
Approbation of research
1.
Scientific conference of medicine area of Riga Stradiņš University in Riga
(Latvia) - 2002.
2.
Ill Baltic Region Biological psychiatry symposium in Klaipeda (Lithuania)
- 2002.
3.
International scientific conference ..Statistical research - basis of social
sciences and education" Riga (Latvia) - 2003.
4.
Scientific conference of medicine area of Riga Stradiņš University in Riga
(Latvia) - 2004.
5.
International scientific conference ,,Equal possibilities to all" in Riga
(Latvia) - 2004.
6.
Congress of the World Psychiatrist Association in Florence (Italy) - 2004.
7.
Congress of the Baltic Psychiatrists in Riga (Latvia) - 2005.
Scientific publications
1.
Taube M. Narcological comorbidity in psychiatry. // Scientific articles. Riga: Riga Stradiņš University, 2003: 61-64.
2.
Andrezina R., Taube M. Psychological and Motivation Difficulties of
Fixing Up Mentally 111 People. // Collection of Articles. - Riga:
Information Systems management Institute, 2004: 87-90.
3.
Taube M., Lāce V. Social psychiatry and statistics. // Conference news. —
Riga: Latvia University, 2004: 89-92.
4.
Andrēziņa R., Taube M. Employment of mentally ill persons - a
significant community-based psychiatry development problem. // Scientific
articles. - Riga: Riga Stradiņš University, 2005: 218-221.
5.
Caune M., Taube M. Results of clinic social and psychiatric research in
BO VSIA ,,Psychiatry Centre". // Scientific articles. - Riga: Riga Stradiņš
University, 2005: 121-125.
Gratitude
The author would like to express major gratitude for support, practical
assistance in performance of research and persistence to the Scientific
Research Reviewer professor Mintauts Caune and the Scientific Consultant
professor Raisa Andrēziņa, as well as the Director of the Mental Health
Agency Jānis Buģins and other employees for support in performance of
research.
„ Latvian psychiatry and perspectives of its development"
SUMMARY
Nowadays 450 million of people in the world have mental and neurological
diseases and behavioural disorders. A quarter of people who face health care
services, need assistance in the area of mental health. Four of six most frequent
disablement reasons are connected with neuropsychic diseases. In a quarter of
families some family member has a mental disease. About 873 000 people each
year commit a suicide.
Contrary to the recommendations of the World Health Organization, Latvia
currently has no mental health or psychiatry development policy and action plan.
Both the European and world countries develop their mental health policies and
realize them in practical work. Reforms in each country proceed differently,
individual experience of each country, social and economic he situation,
differences in the state health care-system and other aspects are respected. Overall
a generally accepted and acknowledged mental health care model is the so-called
community-based mental health care or balanced mental health care. Such a
mental health care system comprises persons with mental and behavioural
disorders in order to ensure maximum care in the place of their residence, shorter
time, which the patients spend in psychiatric hospitals, diversity of care forms
outside hospitals, as well as involvement of different specialists in medical
treatment and care (psychiatrists, family doctors, psychiatry nurses, social
workers, ergotherapists, etc.). After reforming the psychiatrics assistances system,
the social issues are very significant, as well as interdisciplinary cooperation and
overall issues of keeping the public mental health, which are currently very topical
also in the world.
The objective of the paper is to develop scientifically justified Latvian psychiatry
services and public mental health improvement policy, as well as
recommendations and scenarios for their practical realization in the country. The
paper consists of four researches: 1) Analysis of the data of Mental disorders and
mental diseases state register comprising living conditions, education, basic
living income of 60 924 patients, as well as interrelation of these data with the
fixed diagnoses, 2) assessment of social situation of 335 patients of the non-profit
in-patient company VSIA ,,Psychiatry Centre" in 11 wards, 3) survey of social
situation and employment possibilities of Riga out-patient patients in 1995/1996
and 1999/2000, 4) assessment of registered comorbide diagnoses of 6385
treatment episodes in the non-profit in-patient company VSIA ,,Psychiatry Centre"
in 2000 (psychiatric un narcological).
The results gained in the Social psychiatric statistical research give a possibility to
conclude that living conditions of persons with mental and behavioural disorders
might be adverse - although many patients live in families, patients are under
custody of other persons or survive on the minimum pensions. Insufficient
educational level limits the patients' ability to integrate in society. The large
number of disabled persons indicates to the situation that there are no
preconditions creating for successful integration in society and labor environment,
but disablement is the only means of ensuring elementary survival. There is an
interrelation between living conditions, education, basic living income sources and
the patients' diagnoses - better integrated in the family, educated and well-off
people are patients of depressions, it is less observed for patients with organic
mental disorders and schizophrenic patients.
The results of the Clinic social psychiatric research in the in-patient company BO
VSIA ..Psychiatry Centre" indicate to serious social problems for in-patient
patients (low income, threat to lose dwelling, unemployment). The low availability
of most modern and effective medicaments obstructs deinstitutionalization
process. Social problems for psychiatry patients are connected with the nosologic
form of mental diseases, worse social situation is a continuous drawback for
schizophrenic and organic mental disorders patients.
The research of employment possibilities for mentally ill people showed that work
feasibility of Latvian psychiatry patients is very limited and it is connected with
lack of motivation for employers, changes in behaviour and thinking of patients
after getting ill.
The results of the research of Narcological comorbidity in psychiatry evidenced
that comorbides pathologies for psychiatry patients have not been sufficiently
diagnosed, and it may adversely impact the treatment and patients' care. Special
attention in development of psychiatry should be paid to the problem of use of
alcohol by mental patients, and the work of narcological and psychiatry services
should be coordinated and combined.
In the framework of results gained, also the situation in Latvian psychiatry before
regaining of independence was assessed by marking the most essential problems of
those times — poverty of the service, focus on hospital assistance, nonobservance of human rights of patients, formal introduction of different
innovations in patients' care, miserable situation in forensic psychiatry. In order to
achieve the objective of the research in a more successful manner, major
significance is paid not only to proper evaluation of social issues, but also to
establishment of out-patient assistance service, supply of medicaments for as far as
possible larger number of patients, involvement of sufficient and qualified mental
health specialists, as well as ensuring of adequate financing and consolidation of
services.
Taking into account the results gained in the research, their assessment and
conclusions made, according to the order No. 159 of the Health Minister of
September 14, 2004 ,,On Setting up of a Work Group") and in cooperation with the
World Health Organization, a policy document was developed and submitted to the
Ministry of Health: ,,Mental health improvement of population in 2006— 2016".
The above mentioned document includes such mental health ensuring elements as
solution of mental health problems in the primary care level, ensuring of
psychotropic medicaments, development of community-based mental health service,
ensuring of personnel resources, ensuring of financing, involvement of the
community stakeholders, mental health service users and their family members in the
medical care, preparation of legislative support in the area of mental health, ensuring
of information system, enforcement of a special program for risk group patients children, teenagers and old people, prevention of mental health problems and
suicides, promotion of researches and enforcement of mental health campaigns.