Community Psychiatry Pilot Projects in Ukraine
In May 1998 I traveled from Canada to Ukraine to spend a month as a volunteer psychiatrist for the American Jewish World Service—to consult with the director of the Zhitomir Psychiatric Hospital, assess mental health services in the region, and suggest improvements. I spent two weeks visiting all the psychiatric facilities in the area, was allowed to see whatever I wanted without restrictions, and had an outstanding translator.
The Zhitomir hospital, which is just outside the city, has several old buildings housing 700 patients in conditions reminiscent of past asylums. Facilities were quite primitive and crowded, and treatment was primarily custodial. Patients were treated kindly by staff, and I saw no evidence of abuse or of incarceration of political prisoners. However, activities for patients seemed minimal, and most sat looking bored.
Similar bleak conditions characterized the 400-bed Regional Psychiatric Hospital Number 2, near the Byelorussian border. The most upsetting place I visited was an internad, or boarding home, which was a farm two hours' drive from Zhitomir. One hundred and sixty women lived in this facility that had one physician and offered minimal "treatment." Patients rarely had visitors or a chance to integrate into society. The pervasive public attitude about psychiatric patients seemed to be "out of sight, out of mind." Patients were sent to hospitals or boarding homes and tended to remain there, as almost no community services existed. The best facilities were outpatient clinics in Zhitomir, which were well staffed and looked more user friendly.
Psychiatrists received only about a year's training. Many mentally ill patients who did not fulfill DSM-IV criteria for schizophrenia were diagnosed as having that disorder, and affective disorders were underdiagnosed. Psychiatrists were also required to treat patients with mental retardation or with epilepsy along with the mentally ill.
What I was shown as psychotherapy seemed more like activity therapy or psychoeducation. Psychotropic medication was inadequately used. Often neuroleptics were prescribed for nonpsychotic patients. Dosages were often on the low side due to lack of drugs, and medications were frequently discontinued due to lack of funds. Yet often several neuroleptics were given when one would suffice. The drug prescribed might depend greatly on what was available. Our newer antidepressants were seldom obtainable, and laboratory monitoring was rare. It was frustrating to see patients lack the benefits of simple, common remedies.
The psychiatrists were unfamiliar with the concept of multidisciplinary teams. Nurses were available, but were not highly trained in psychiatry and basically carried out orders. Psychologists provided some testing and specific therapies. There were no social workers. Self-help groups were almost nonexistent. I met with a group of patients' relatives who were organized to provide mutual support, but not to promote political action or public awareness of mental health concerns.
The common themes I heard were that there was not enough money, the government needed to provide more, and the government was not to be trusted. People did not have the concept of helping themselves. There was no association for physicians, although a psychiatric association had recently been formed.
Before leaving, I met several times with the director and staff of the Zhitomir hospital and described in detail the outstanding differences between Canadian and Ukrainian psychiatry, including the Canadian emphasis on multidisciplinary teams and community treatment rather than hospitalization. The hospital director and I met with the local director of social welfare, initiating possibile ongoing collaboration.
We also agreed on two pilot projects. The Zhitomir outpatient dispensary would select 20 difficult-to-treat patients with a chronic psychotic illness such as schizophrenia. They would receive the proper neuroleptics, including long-acting depot medications, and would attend the dispensary twice a week for drugs, monitoring, and activities with mental health personnel. The staff would assist patients with any current family, personal, or social problems. To assess the project, simple data would be collected after six months and one year. A similar project would be carried out in nearby Novograd.
Such endeavors are unique in Ukraine. They emphasize community care, mobilization of patients, and regular, uninterrupted pharmacological regimens. They involve a multidisciplinary team and, one hopes, relatives and community organizations.
I have maintained e-mail contact to keep the projects on track and have obtained donations of depot medication from a manufacturer. The problems facing Ukraine are enormous, but the people I met were hopeful and motivated to make improvements. They are accustomed to sacrifices. I hope I can return to witness their progress.
Dr. Uhlmann is clinical assistant professor of psychiatry at the University of British Columbia. For more information, contact him at Box 4, RR2, Malaspina Road, Powell River, British Columbia, Canada V8A 4Z3 (e-mail, [email protected]).
