In May 2006, when President Vladimir Putin used his State of the Union speech to highlight the country’s demographic crisis – Russia is losing over 700,000 citizens a year – he mentioned road safety, bootleg alcohol and cardiovascular disease, but did not once mention the country’s number two killer after cardiovascular disease: suicide.
Every month, thousands of desperate Russians commit suicide to escape personal agony and harsh living conditions. In January, pop star Murat Nasyrov jumped from the fifth story balcony of his luxury Moscow apartment. In February, a university student shot himself in the head outside a local museum in Petrozavodsk. In March, a 41-year-old prisoner in Voronezh hung himself with bed sheets in his jail cell. In April, a middle-aged man jumped under the wheels of a subway entering Taganskaya metro station in Moscow. In May, a 13-year-old girl jumped out of a fourth story window at Middle School Number 26 in Rostov-on-Don.
These are, of course, isolated cases. In fact, some 60,000 Russians take their life each year – approximately one suicide every 10 minutes. This gives Russia the third highest suicide rate in the world, after Lithuania and Belarus – a rate that is approximately three and a half times higher than in the U.S., according to the World Health Organization. By any measure, this is a national catastrophe. Yet, there is little or no public discussion of the issue in Russia, because suicide is a mental health issue, and mental health issues are still largely taboo here.
The Scope of the Problem
Russian mental health experts estimate that some 30 percent of the population or 42 million people are in need of mental health care, and most are getting no care at all. The reasons for such high rates of untreated mental illness are complex: strong cultural shame about suffering from mental illness, lingering fear of Soviet-era psychiatric abuses, economic collapse and social dislocation during the 1980s and 1990s, as well as the federal government’s chronic under-funding and neglect of the mental heath care system.
As well, a variety of daily factors – conflict-ridden marriages, overcrowded housing, domestic violence, high divorce rates, low salaries, job insecurity, poverty, violent street crime, pollution, poor quality health care, inadequate social services, endemic government corruption – cause and intensify depression, alcoholism, anxiety, phobias and other kinds of emotional disorders, according to Aleksandra Lysova, professor of psychology at Far Eastern State University in Vladivostok.
The dissolution of the Soviet Union in 1991 left the state mental health care system in crisis and unable to assist the increased levels of stress people faced. “The 1990s were very difficult: there was practically no financing and salaries often went unpaid for months,” said Dr. Valery Krasnov, director of the state-run Moscow Institute of Psychiatry. “The transition period destroyed old traditions of collectivism... where people in society supported each other.”
The transition to a “lawless” market economy left people isolated and impoverished. “Factory workers used to have the support of their colleagues and the factory administration,” Krasnov said, “but now they are mostly working in more isolated places like in the street markets or in small stores. People migrate to different parts of the country looking for work, close family relationships are almost gone and work collectives are almost gone.”
The decline of Russia’s state mental health care system was part of the broader decline in the Soviet health care system. A November 2006 assessment by the OECD concluded that: “The deterioration in basic indicators of health and human welfare that began in the 1970s and accelerated in the 1990s has yet to be overcome… the overall picture remains extremely grim.”
Corruption in the health care system is also widespread, with many doctors demanding bribes for services which are supposed to be free, the Associated Press reported. Kirill Danishevsky, a health care analyst at the Russian Academy of Sciences, estimated that 35 percent of health care spending consists of such illegal under-the-table payments. This should not be surprising in a system where the starting salary for a psychiatrist at a regional state hospital is 7,500 rubles ($300) and about 12,500-17,500 rubles ($500-700) for a department head, Krasnov said.
Yet it is not as if any of this information is new: during both President Boris Yeltsin’s and President Putin’s tenures, the federal government has ignored periodic outcries by psychiatrists (M.D.s) and psychologists (Ph.D.s) about Russia’s growing crisis in mental health care.
The crisis persists despite massive federal budget surpluses (thanks to high international oil prices) and the funnelling of three trillion rubles ($117 billion) into a Stabilization Fund for future government spending.
Civic Initiatives
The lack of central government attention to (and funding for) mental health care problems has led to increased regional autonomy and a growth in non-governmental services.
“In the past, everything was decided in Moscow... Soviet-era psychiatry was hyper-centralized with a paternalistic medical approach,” said Krasnov. “Now, a lot depends on circumstances in the regions, like how much initiative is taken by local doctors and how open minded the local officials are” about the importance of mental health care. “Compared to Moscow,” Krasnov continued, “psychiatrists working in oil rich regions in the Urals and Siberia are able to provide better and more different types of care because authorities in cities like Tomsk and Tyumen are more understanding and agree to provide additional financial support.”
A network of activists and small civic organizations has also arisen to help patients with serious psychiatric illnesses like schizophrenia. One such activist is Nelli Levina, director of New Possibilities (Noviye Vozmozhnosti, nvm.org.ru), a Moscow-based organization which provides psychiatric patients and their relatives with rehabilitation and quietly encourages local authorities to provide better mental health care.
“The laws are written very well, but they are not being implemented,” said Levina, whose organization has requested and been denied meetings with federal and Moscow city authorities to discuss the lack of assistance for psychiatric patients. “We need someone our patients can turn to,” Levina added. “They need medication and rehabilitation, not just to be discharged from the hospital without the hospital knowing who has somewhere to return to and who will end up homeless.”
The passive hospital life, lack of rehabilitation and lack of dormitory-style transitional housing makes it harder for patients to return to a normal, independent life and avoid becoming a burden for relatives.
“We have big problems with medication in Moscow and the regions, because now even big hospitals that always had important medications no longer have them in stock,” Levina said. “The list of free medicines has been cut and retirees – who often must care for their mentally ill children – are on a pension and can’t afford very important but expensive medications.” For example, schizophrenia patients are highly dependent on antipsychotic medication (which can cost up to several hundred dollars a month) to suppress auditory and visual hallucinations. But the average pensioner receives just 3,300 rubles ($131) a month and their mentally ill children often face discrimination and great difficulty themselves finding paying work. “Employers refuse to hire such people or fire them the first chance they get,” the Federal Human Rights Ombudsman reported in 2006. “Law enforcement, judicial and administrative institutions that learn that a person is seeing a psychiatrist sometimes refuse to accept their complaints or petitions.”
Reducing this cultural stigma is a major challenge. “Our anti-stigma work is difficult because people don’t understand that these are individuals who are fragile, not aggressive,” Levina said. Tabloid reporting on isolated cases of violent psychiatric patients reinforces negative stereotypes, so Levina’s organization publishes pamphlets and books and organizes seminars to educate people with mental illnesses, their families and even government social service organizations that are reluctant to assist mentally ill patients. “Social service centers around the city are required by law to provide assistance to our boys [i.e., patients],” Levina said. “They provide services to pensioners but many are afraid of our boys and send them home. The stigma is so strong that many people don’t seek out help and keep telling themselves they’re having a bad day or are in a bad mood.”
Neglect and Fear
Many people with emotional disorders avoid treatment because they are afraid of the under-funded and overwhelmed medical bureaucracy. In 2004, an independent assessment of the state psychiatric system conducted by two Moscow-based human rights organizations – the Moscow Helsinki Group and the Independent Psychiatric Association – confirmed such fears to be valid, concluding that “under-financing is becoming the fundamental reason for the degradation of human dignity in terms of the patient’s living conditions, inadequate treatment, and not securing the elementary rights of the patient as well as the hospital staff.”
The impact of inadequate funding for hospitals, the report said, is stark: 73 percent lack adequate cleaning supplies; 39 percent lack important psychiatric medications; 38 percent have “hopelessly” outdated equipment; 19 percent spend less than 20 rubles (80 cents) a day feeding each patient; 10 percent smell of feces. Most are overcrowded facilities housed in former military barracks, prisons or labor camps; the Adygeya Oblast Psychiatric Clinic is housed in a former horse stable. Some 21 percent of institutions are structurally unsound for housing patients and for providing medical care; the psychiatric wards in Altai Republic Hospital and Tver Oblast Hospital No. 1 were like “a city after it was bombed,” the report declared. Rural psychiatric clinics were even worse off than the poorly funded oblast and regional level psychiatric facilities.
The legacy of repressive Soviet psychiatry also keeps many people from seeking needed treatment. Following a period of openness and experimentation in mental health care during the 1920s, the NKVD detained alleged political enemies in psychiatric prisons during the Stalinist repressions of the 1930s and 1940s. This practice was briefly curtailed during Khrushchev’s “Thaw” but then revived and continued until the late 1980s because, according to the academic journal Problems of Communism, authorities wanted a non-lethal way to silence critics. Thousands of dissidents and non-conformists were declared insane and sent off to a network of psychiatric prisons – called psikhushki in colloquial Russian – run by the Interior Ministry.
Psychiatrists and KGB officers at these prisons diagnosed dissidents like Alexander Yesenin-Volpin and Vladimir Bukovsky with scientifically unsubstantiated illnesses, like “creeping schizophrenia,” symptoms of which included “obsessive reformist delusions” or “mania for truth-seeking,” according to Problems of Communism and international press reports. Isolated from their families and denied access to lawyers, psychiatric prisoners endured years of isolation and painful, medically-unnecessary treatment like sulfazine and atropine injections, The New York Times and RFE/RL reported. Many prominent dissidents were sent to the Serbsky Institute for Forensic Psychiatry, which was at the apex of a network of psychiatric prisons around the country, according to The Moscow Times and RFE/RL.
Founded in 1921 by the Soviet National Commissariat of Health, the Serbsky Institute was feared throughout the Soviet era, because its psychiatrists were loyal servants of the State who regularly ignored patients rights and who testified in court cases affirming state accusations of insanity against independent-minded Soviet citizens.
International public opinion turned strongly against Soviet psychiatry during the 1970s as information about the abuses emerged in the Western media. This forced the Soviet Psychiatrists Society to withdraw from the World Psychiatric Association in 1982, to avoid being expelled, according to international press reports. Gorbachev’s reforms in the late 1980s forced the conservative psychiatric elite to initiate some reforms, while new civil society organizations like the Independent Psychiatric Association of Russia (npar.ru), established in 1989, actively lobbied for more aggressive psychiatric reforms.
Backsliding
In 1989, the Soviet delegation was provisionally readmitted to the WPA after they made three requisite changes: admit they had committed psychiatric abuses; replace several senior leaders of the state psychiatric system; and transfer psychiatric prisons from the Interior Ministry to the Health Ministry. “At that time, the Serbsky Institute was still a very dark place, even though they were forced to confess and admit their faults,” said Yuri Savenko, President of the Independent Psychiatric Association (NPAR). “They just removed the top leadership, but no one was ever held accountable” for past abuses. Serbsky Institute Director Georgy Morozov – who personally worked on the cases of many dissidents – stepped down in 1990 and was succeeded by Tatiana Dmitriyeva, his close friend and a 14-year veteran of the Serbsky Institute, according to Peter Reddaway, a political scientist and expert on Soviet psychiatry.
In 1992, the Russian parliament approved a Law on Psychiatric Care which protected patients’ rights and required a competent court psychiatrist to approve all involuntary detentions and treatment. The new law led to a decline in involuntary psychiatric detentions during Yeltsin’s first term, but in the mid- and late-1990s there was a backlash. In the mid 1990s, according to the U.S. Department of State, NPAR and other Russian human rights groups, many non-Russian Orthodox religious activists were improperly detained in psychiatric hospitals and accused of being “totalitarian sects” that were “unlawfully hypnotizing people.” In 1997, the Serbsky Institute began reasserting its authority by removing a representative of the Independent Psychiatric Association from its commission of experts, Savenko said.
This trend continued after President Putin came to power in 2000. More assertive, conservative psychiatric policies began to take shape under Dmitriyeva, who remained at the helm of the Serbsky Institute. In 2001, parliament passed a law giving the Serbsky Institute a monopoly on approving forensic psychiatry expert witnesses allowed to testify in court cases. “People are sceptical of government experts, because they are both medical experts as well as government employees,” with dual loyalties, Savenko said. This is particularly germane because some 15-20 military recruits commit suicide every month to escape violent hazing by their superiors. The new law made it easier for government psychiatrists to defend sergeants and officers accused in these so-called dedovshchina cases, Savenko said, to explain away the suicides and disconnect them from hazing. That same year, Dmitriyeva published a book downplaying Soviet psychiatric abuses.
In 2003 and 2004, the Serbsky Institute lobbied the Duma – unsuccessfully – to curtail some of the legal protections granted by the 1992 Law on Psychiatric Care, arguing that state psychiatrists needed more authority to involuntarily detain patients without court approval and that new restrictions should be added to prevent patients’ rights groups and independent psychiatric experts from testifying in court, said NPAR’s Savenko.
While still head of the Serbsky Institute, Dmitriyeva became a senior official of the pro-Putin United Russia party and has used her post to discredit government critics. She accused NPAR of being “agents of the CIA” after NPAR contradicted a Serbsky Institute assessment of an accused war criminal, the Moscow Helsinki Group reported. In November 2006, Dmitriyeva made a public statement suggesting Aleksandr Litvinenko was insane, a day after the London-based former KGB agent accused Putin of sending agents to poison him. (Dmitriyeva did not respond to a request for an interview.)
Over the years, the conservative state psychiatric leadership has also ignored reports from human rights groups and journalists about growing abuses in the state psychiatric system. When the Moscow Helsinki Group and NPAR published a 296-page report on psychiatric abuses in 2004, there was no official reaction and officials from the Health Ministry refused to meet to discuss the findings, Savenko said.
The report’s findings were in fact very troubling. While it found that legal procedures required by the Law on Psychiatric Care were more or less operating in certain regions – Arkhangelsk, Kirov, Kurgan, Moscow, Mordovia, Orenburg, Orlov, Smolensk, Tver, Vladimir – substantial abuses were detected in other regions. “Instead of going through the judicial procedures, many hospitals receive authorization from the patient for treatment through the use of pressure or by using deception and basically falsifying the authorization,” the report concluded.
Psychiatrists and judges are often instructed by politicians or bribed by businessmen or others to improperly authorize detentions, the NPAR report stated, concurring with reporting by other human rights groups. In April 2007, a metals magnate bribed two staff members from Psycho-Neurological Clinic No. 14 in Moscow to abduct and forcefully hospitalize his estranged 37-year-old wife, Marianna Saveleva, so that he could take back her apartment and their three children, the newspaper Novaya Gazeta reported. In May, the editor of the independent weekly Chugunka, Vladimir Chugunov, was released after being held for four months incommunicado in psychiatric wards, hospital wards and prison cells in retaliation for publishing critical stories on local politicians in Solnechnogorsk, a town 60 kilometers northwest of Moscow, the New York-based Committee to Protect Journalists reported.
“That [Soviet-era] characteristic remains, that if someone from above says ‘we need to treat this person,’ it still happens,” said Lyubov Vinogradova, Executive Director of NPAR. But, unlike the Soviet era, when repressive psychiatry was a state policy, current detentions usually last several days or weeks and reflect a general atmosphere of lawlessness and corruption. “If [improperly detained] people really protest, by getting lawyers and human rights activists involved, they can fight back and get released, because the courts are afraid of being in the middle of a public scandal,” Vinogradova said.
Going Private
Early in the 20th century, a few Russian psychiatrists and students had travelled to Europe for psychiatric training, but such exchange was interrupted by the Stalinist purges of the 1930s, the Nazi invasion in 1941 and the descent of the Iron Curtain, according to Duke University historian Martin Miller, in his book Freud and the Bolsheviks: Psychoanalysis in Imperial Russia and the Soviet Union.
It was only in 1955 – two years after Stalin’s death – that the psychology department at Moscow State University (MGU) was reopened, focusing on theory and research but not on psychotherapy, said Yelena Spirkina, a MGU-educated psychologist. “During the Brezhnev era, all we knew was Freud and Jung… only a theoretical orientation was allowed,“ Spirkina said.
Public interest in Freud and psychotherapy grew rapidly during the 1990s, a time when a small group of Western psychotherapists began travelling regularly to Russia to conduct “shuttle analysis” – to train the first generation of Russian psychotherapists according to Western standards. Some Russian psychotherapists also travelled to Europe and the U.S. for training. Spirkina went to California and Massachusetts in 1990. “I decided that Russia needed this,” Spirkina said. She then returned to her job at the Russian Academy of Sciences and set about recruiting visiting Western psychotherapists to teach classes on the basics of psychotherapy.
In 1997, Spirkina formalized her work by establishing the Institute of Practical Psychology and Psychoanalysis (IPPP, psychol.ru), to provide university level training in individual and family psychotherapy according to the standards of the European Federation of Psychoanalytic Psychotherapy. “Most of our students are in their 30s and 40s,” Spirkina said, “and already have a university education and work experience, but have decided to change their profession. Our graduates only work in private practice, because their starting salaries are $1,000 a month, and with a couple of years of experience they can move up to $3,000-5,000 a month.”
Because government regulations remain chaotic and un-enforced, a major challenge IPPP graduates face is distinguishing themselves from the numerous untrained and unqualified people advertising themselves as psychotherapists. “There are so many dikiye [i.e., wild] psychotherapists working without any training who do a lot of damage to the profession... because they simply use their patients,” Spirkina said. “They pump them for money, ask for a ride home and I won’t even begin to talk about the amount of sexual relations with clients as well as business relations with them.”
The Moscow Times recently uncovered one such practitioner: Aleksei Lyubchenko, a 33-year-old Moscow businessman, who advertises his cell phone on the Internet as a crisis suicide hotline, yet has no psychological training and uses the same number to sell furniture, funeral services and organize religious activities. The tabloid-style showmanship of psychiatrist Anatoly Kashpirovsky and journalist Alan Chumak – who both became famous in the late 1980s for conducting séances and hypnotizing their patients on Soviet television – has also negatively affected public perception of the profession.
Nonetheless, despite all these obstacles, openness to psychotherapy is gaining ground in large cities, where Western values have reduced the stigma and high salaries mean private mental health care is affordable, Izvestia reported. Some individuals pay $20-100 per hour for professional help, but the large majority of the public is still sceptical. “A lot of people worry about being pressured or being too dependent on an unprofessional psychotherapist,” Spirkina said. “In this post-totalitarian environment, people are afraid of any dependency, they are afraid of falling into another system.”
“The attitude to psychotherapy is changing,” said NPAR’s Vinogradova, “but many people still remain afraid of psychiatrists, the poor quality of care and being labelled in their records as someone undergoing psychiatric care. There also isn’t yet a culture of psychotherapy… people think you say something to a psychotherapist and that you will be magically healed, they don’t understand that it’s a lot of work.”
State psychiatrist Krasnov echoed Vinogradova’s note of cautious optimism. “Now it’s a bit better [than it was in the 1990s],” he said, “but it’s hard to reform the system when most of the budget is spent on salaries and building maintenance. We’re still very much in a transition process.”
The bottom line is the bottom line. Experts agree that serious improvements in the state’s mental health system – and a consequent decline in suicide rates – can only occur when federal authorities provide more funding, develop a coherent plan and start fighting corruption and human rights abuses. “There is a lack of a national mental health care policy, it’s more like the imitation of a policy,” said NPAR’s Savenko. “What can you say about mental health care for citizens when torture is practiced in every police station… and the security services are recruiting informants everywhere these days, even in psychiatry?” RL
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