Mental health in post-communist countries

Massive political, economic, and social changes in eastern and central Europe since the 1990s have created conditions of instability and stress, which are associated with troubling trends in health. Severe economic constraints after the collapse of the former Soviet Union followed by patchy economic growth have contributed to marked inequalities in income1 and social upheaval. These changes have been associated with increased physical morbidity, mortality, and mental illness in the population of such transitional countries,2 including high suicide rates, high mortality from alcohol and tobacco related diseases, and rapidly rising HIV rates.3 Compounding the recent changes are the political and social legacies of communism. These include the massive over-institutionalisation of people with mental disorders and intellectual disabilities4 that still occurs in the health and social protection sectors and leaves many in mental hospitals and internats (social asylums). These top heavy systems of mental health care are coupled with relatively underdeveloped systems of primary care. Primary care services are not generally expected to manage common mental disorders, and most simply refer patients to specialist services. While access to essential medicines is usually possible, access to evidence based psychological interventions is still limited. This arises from isolation from the west and poor awareness of the international evidence base on diagnosis, effective services, and interventions. Partly as a result of the hierarchical structures inherited from the communist era, intersectoral joint collaborative working between systems for health, social care, education, housing, employment, and criminal justice is still extremely difficult to achieve. There is little joint working between programmes for mental health and those for preventing HIV infection and substance misuse, for reducing harms, and for promoting health. There are, however, many levers for change. A situation appraisal (a detailed formal assessment) of social, political, and geographic context; of populations' needs; and of the structures, processes, and outcomes of services is crucial to inform subsequent policy and planning.5-9 The transitional countries of central and eastern Europe must develop and implement comprehensive policies for mental health and integrate these policies with wider reforms in health care and other sectors and with plans for economic recovery.10 Schools in the region should offer integrated education on physical and mental health, and societies should make comprehensive efforts to reduce social stigma and discrimination associated with mental illness.10 In addition, legislation on mental health is needed to protect the human rights of people subject to compulsory admission and treatment. Several countries in the region—for example Russia11—now have such progressive legislation, but this is not widely implemented because professionals working in courts, prisons, the police, and services for health and social protection have not been trained to use the new laws. Improvements in mental health will depend greatly on effective working between public sectors. Some countries, including Georgia, Bulgaria, Lithuania, and Slovenia, have developed comprehensive strategies for improving mental health and preventing suicide, but, again, implementation of these policies is limited. The development of local comprehensive services that are socially inclusive and based in the community is hindered by inherent financial disincentives. These include the way disability benefits are allocated (creating disincentives to return to work) and the funding of mental hospitals and internats by the number of inpatients. When attention and resources shift from such institutions to the community, conditions for patients in the institutions that are still open often worsen, paradoxically exacerbating inpatients' loss of human rights. Non-governmental organisations can play an important part in advocating better services, setting up pilot services to test new models of care, and conducting research and audits of provision, range, and quality of services. For example, the US Open Society Institute has supported non-governmental organisations providing community based services and advocacy to promote social inclusion and the human rights of people with mental disabilities. Such investment by donors has allowed a variety of demonstration projects in health, social, educational, and employment services in the region, but community based models of care have not yet been disseminated nationally in any systematic way.12 Fully integrated care has also been tested successfully—for example, in a project to reform services for adult mental health in Russia, funded by the UK Department for International Development (Jenkins et al, in preparation). Such combined approaches, developed through projects funded by donor organisations, can provide an effective model and can accelerate subsequent national dissemination.