THE MENTAL HEALTH OF THE PEOPLE AND DEVELOPMENT STRATEGIES OF PSYCHIATRY IN EAST AND WEST
P. I. Sidorov
The World Health Organization (WHO) proclaimed the year 2001 as the year of the mental health care. This decision has accumulated the understanding what for a heavy burden mental diseases are for the people suffering from them and their relatives. Mental disorders and need in hard times of an aid and a care do not befall a rare family. But the society does not notice or ignores this fact. We do not know how many people do not get a necessary care. A socium of mental patients is surrounded often by a vicious circle of the ignorance. It means sufferings, privations and even the death. Therefore the World Health Day was celebrated by nations and governments the world over at April 7-th 2001 just under the motto: “Give up the isolation - render an help”. The first part of the motto is the appeal to the population, the second - to the doctors and every body who is not indifferent to sufferings of mental patients. For just thus- with joint efforts - the disease can be won.
The mental health of the world population and patterns of the mental health care
To render an effective care one should clarify oneself scales of a occurrence. According to the estimation of experts 400 million people suffer from psychoneurological diseases and experience psychological troubles caused by alcohol and drugs.
Monopolar depression, alcohol dependence, manic-depressive psychosis, schizophrenia and obsessive-compulsive status have referred already in 1990 to 10 principal causes of the disability the world over .5 from 10 most serious diseases are mental by nature.
Around 45 million people at the age over 18 suffer from schizophrenia.
1 of 7 adults in USA, 7 per cent of the Brazilian population, nearly 10 per cent in Germany, 4,2 per cent in Turkey suffer from mood disorders. 5 per cent of American children at the age from 9 to 17 suffer from the depression - a disorder that as they considered before does not occur among the youth and adolescents. The depression is observed in 10 per cent of Alexandrian (Egypt) pupils, 17 per cent of school leavers have anxious statuses.
Depressive disorders and schizophrenia are the cause of 60 per cent of all the suicide cases. A death because of the suicide was registered every 40 seconds.
At present it is ascertained that around 11 million people the world over suffer from the Alzheimer’s disease. It is supposed that those figures double to 2025.
Investigations carried out by American Alzheimer Association in 1998 showed that this disease costs American economics 33 billion US$.
It is ascertained that 140 million persons the world over suffer from the alcohol dependence and 400 million abuse alcohol and can become a source of accidents and traumas, sufferings and a death. Alcohol abuse is the principal cause of a death that could be prevented, diseases and traumas. In 1992 economic losses because of alcohol made up in USA 148 billion US$. Research in other countries showed that losses because of problems bound up with alcohol abuses varies from 0,5 to 2,7 per cent of gross national product.
45 million people the world over suffer from the epilepsy. The number of patients in developing countries is five times as much compared with developed ones. In Africa 80 per cent of the people suffering from epilepsy do not get at all the treatment.
The prevalence of the mental deficiency varies according to national living standards. The percentage of young people the age of 18 and under mounts to 4,6 in developing countries and is fluctuating between 0,5-2,5 in countries with advanced economics. The difference between these figures shows that such the potential preventive measures like a better maternal and children health care and the special social invasion can lead to the total fall of the mental deficiency level the world over. All the spheres of our life become more intellectual. It requires a more intensive use of not only emotional but also cognitive human resources. Thus this aspect of the human activity turns out most vulnerable. It is not occasionally that 12 per cent of losses of the capacity for work are bound up with mental disorders. In advanced countries these figures mount to 23 per cent.
Considering up-to-date trends in the mental health care it is important, even if briefly, to analyse the experience of advanced countries (Dmitrieva T. B., 2001; Kazacovtsev B. A., 2001).
In USA where there are 120 thousand clinical psychologists and 40 thousand psychiatrists and 10 thousand of them are in the Civil Service the Congress now is considering the question of the regulative role of the government in the sphere of psychiatry. The suitable federal law is being prepared. More then an half of states have passed laws providing the equalization of amounts of means allotted for the development of mental and somatic medicine. For the first time the Federal Government sets an example allotting financial means for these objectives. In July 1999 it was officially declared that 23,4 per cent of the population should get the mental and narcological care. The psychiatry is more and more being integrated into the general medicine. It is planned to create in 10 years an integral system of the mental health care where the psychotherapy will act within limits of the psychiatry.
In France the ratio of civil psychiatrists to private practioners and the ratio of psychiatrists to the number of the population (one per 7 thousand) is approximately the same like in USA. Politics in the field of psychiatry has determined since the beginning of 1960th in legislative order. The division of the population into sectors, teams of the psychologists and other professionals, “intermediate houses” and differentiated regimens in mental hospitals are established. As a result in spite of the total increase of hospitalisations the number of beds for mental has fallen by 3Λ, the cost price of the services has decreased. At present reforms are directed to the integration of psychiatry into general medicine. The improvement of the quality of mental health care is caused by the growth of the budget quota for health care in the structure of the gross internal product.
In Britain where the national health care has taken leading positions since the beginning of 1990th here is an insufficient collaboration between health authorities and an insufficient financing
of national and municipal mental health institutions. In 1997 the Royal Charitable Fund proposed to establish a special structure within authorities of the executive power that would be occupied with aimed financing of mental institutions. The number of beds for acute patients and patients who is treated in mental departments of general hospitals has increased. Special means were allotted to render the mental health care, children and adolescents during 24 hours ,to elaborate standards of the psychiatric service, educative programs for the population devoted to questions of the psychiatric stigmatisation. In the country mental hospitals are breaking up into small units.
After the World War Second and particularly in 1970th the politics in the Federal Republic of Germany was directed to the support of most vulnerable social groups. In the German Democratic Republic such a position was rather declared than realized practically. Since the beginning of 1980ш when the economic crises began in socialistic states the development of the material and technical basis of mental hospitals in West and East Germany - countries with the identical cultures - has acquired essential distinctions. In West Germany the number of hospitals, was increasing, but the number of patients was decreasing. The growing level of public utilities and medical services rendered in institutions and patients being home was transferred to a municipality. In East Germany the material and technical basis of mental institutions being the State property was behind the material and technical basis of somatic institutions. A trend to a centralization of mental hospitals remained.
Since the beginning of 1990 standards of psychiatric, psychotherapeutical, psychological care and social work in the field of psychiatry in the Federal Republic of Germany have improved gradually. Public organizations rendering psychiatrists an assistance voluntarily developed in this period particularly actively. Increasing manifistations of partnership between a doctor and a patient promoted the decrease of paternalistic trends in psychiatry. The restructurization of big institutions, the inculcation of psychiatric departments into hospitals of general type promoted the more particular specialisation of the psychiatric care and its approximation to the population.
Above-named trends harmonised with changes of the legislation concerning psychiatry, its orientation to the social support of invalids. The same changes but at the low pace are occurring at present in the territory of former German Democratic Republic.
In countries of Latin America the task of the State regulating the mental health care is also brought to the foreground. The financing the mental health care at the place of a residence of a patient is maintained ,since the democracy has developed and the care of human rights has increased. But this innovation is inculcated with the difficulty because an half of the population lives in poverty and at present around 60 per cent of financial means belong to the private sector that does not provide poor people with an assistance.
The displacement of accents in favour of the national psychiatric care may be observed in many countries of the world including Europe, Asia, Australia, Africa.
As the case strands in former socialistic countries and former socialistic republics the establishment of the psychiatric care is notable for the essential ideological inactivity.
According to results of an investigation realized in Bulgaria, Hungary, Azerbaijan, Kirghizstan, Lithuania, Ukraine it was ascertained that in spite of the passing new legislation concerning services of the mental health regulating relations between patients and specialists doctors even at present are not quiet ready to involve patients into the process taking a decision. Authors of investigation come to the conclusion that an inherited socialistic culture is the culture of a dependence and a control. At the same time they consider that the culture of a partnership can be renewed if roles among professionals are divided.
In the opinion of Chief Psychiatrist of the Russian Health Ministry B. A. Kazakovtsev just the complex approach to the establishment of the psychiatric and the ability of managers to find operatively constant and provisional sources of the financing form the strategic basic of the solution of general tasks of the world psychiatry. National features of the development of the psychiatric care reflect rather traditions and an history of a country than some principal deviations from this general process.
The quality of the mental health and the establishment of the psychiatric care in Russia
Mental disorders in last decades acquire more and more a status of the most widespread forms of a pathology. According to generalized epidemiological data (Goldberg D., Haksli Р/. 1999) mental disorders are revealed in a third of the population in European cities with living standards (260-315 per 1000 persons). In Russia this level is essentially higher. The population of the Russian Federation makes up 145,6 million people and 4 million are officially registered as mental patients. By that real figures are much higher: according to estimations of experts only a quarter of them who have mental problems take an advice of a professional. But even the official figures are by 20 per cent higher then data of the prevalence of mental diseases registered in USA and most European countries.
In last 10 years the number of mental disorders of the limitary level (neurosis, disorders of a person, light depressions belong) has in creased. According to the statistics it has increased in adults 1.5 times as much, in children and adolescents - 2,5 times as much. It is bound up with the chronically stress that is unavoidable in every country experiencing a transitional period.
According to data of T. B. Dmitrieva only 10 per cent of the population may boast of the mental stability under conditions of a stress. Around 25 per cent stand a stress with losses of the health contracting depression, gastritis, stomach ulcer or arterial hypertension, i.e. these diseases are psychosomatic by nature. The rest of that (65 per cent) is between both the categories. A reaction of their body depends on low much objectively strong a stress is .
During all the period of the social and economic crisis in Russia a sharp increase of the number of revealed mental patients is registered: since 1989 practically two times as mach in comparison with the beginning of 1980th, later ,during all the decade, this index, was increasing constantly mainly because of persons having mental disorders of the non psychotic type (the revealing of those has increased practically three tines as much (Gurovich I.Ya., 2001).
Around 6 million patients in our country take advice of narcologists, around an half of those suffer from dependence diseases (2,6 million - alcoholism and 350 thousand - narcomania). It is data of the official statistics. As far as real figures are concerned the number of alcoholics should be multiplied by 2 and of narcomaniacs - by 5).
Every year 35 thousand people die from the alcoholic intoxication.
Although a level of suicides in Russia has slightly decreased (from 423 in 1994 to 35,4 in 1998 per 100 thousand of the population), it is 1,5times the level determined by WHO as critical. In up-to-date Russia 50-60 thousand suicides happen annually including 2-3 thousand committed by children and adolescents.
In 1990 251 per 100 thousand of Russian people were registered as mentally deficient, these official figures jumped in 1996 to 386. In 1980 from 8 to 10 per cent of Russian children suffered from mental disorders, in 2000 this index made up 18-20 per cent. According to data of the Director of Moscow Psychiatry Scientific Research Institute V. M. Krasnov a third of recruits called up for military service suffers from mental disorders. Among soldiers serving under conditions of the peace a third of those retires before the appointed time because of mental disorders. In 40 per cent of these soldiers light forms of the congenital mental deficiency are observed ,in 10-15 per cent - disorders of a person or temper (psychopathy), in the rest-various effects of traumas including berth traumas (Dmitrieva T.B., 2000).
The social and economic crisis has revealed a particular importance of the social aspect of the psychiatric care and exposed negative occurrences concerning the social status of patients. E.g. around a third of the dispensary group of patients was forced to change a place of a job, around 15 per cent of having schizophrenia are notable for the unstable adoption to a work.
The primary disability because of mental diseases has increased in the last decade approximately two times as much (1989-22,1; 1998-40,8 per 100 thousand of the population). Though the stabilization of this index was registered in last three years.
The total number of invalids because of mental disorders has increased since 1993 to 826 034 in 1995, i.e. by 15,7 per cent. Over 60 per cent of them are persons at the age of the ability to work. At the same time the number of employed patients since 1990 to 1999 was decreasing two times as much. The number of occupied in special medical industrial workshops has fallen three times as much. The unemployment among mental patients makes up 8 - 10 per cent.
Indices of the constant increase of taking care of human rights when rendering the psychiatric care are changes of the dynamics of forced psychiatric examination and forced hospitalisation.
The level of the forced psychiatric examination shows a slow but constant growth. This index has increased during the action of the law “Of the psychiatric care”(1993) approximately three times as much (1993 - 3,25; 1999 - 9,1 per 100 thousand of the population).
The dynamics of the level of the forced hospitalisation is notable also for the essential growth: the index per 100 thousand of the population has increased two times as much (1993 - 15,3; 1999 - 30,3),. the percentage of forced hospitalisations in comparison with the total number of all hospitalisations has increased also two times as much (1993 - 3,4 per cent; 1999 - 6,6 per cent). These figures reflect the increasing observance of standards of the law (Gurov- ich I.Ya, 2001).
Essential changes occur in mental hospitals. In last 10 years the number of mental hospitals has remained but the number of beds per an hospital has fallen since 1990 to 1999 by 13,1 per cent (26,5 thousand beds). Moreover 15 thousand beds are not used and remain unoccupied dunng a year (12,8 per cent). At the same time the number of psychosomatic beads has increased by 1,3 thousand. There is always a deficit of these beads. The decrease of number of beads in mental hospitals was caused partly by breaking up into small units and the differentiation of the bed fund.
Side by side with this high indices of the recurrence of hospitalisation of patients having a psychosis or schizophrenia remain around 28-30 per cent in 1999. It is as a matter of fact the recurrence of a problem of “turning doors” an index of the low capacity of polyclinics, dispensaries and ambulatories and first for all an effect of the deficit and the accessibility of medicines.
An other feature of the hospital patients group is the conservation of the big quota of patients being in an hospital over an year (22,5 per cent) (Gurovich I.Ya, 2000). It is an index of the absence of the psychosocial rehabilitation.
It the structure of the psychiatric service that is not an unit of hospitals a progress begins to show. The total number of dispensaries and dispensary departments has not increased but the number of psychiatric surgeries has grown - by 16,6 per cent (1993 — 1875,1999-2186). Particularly the subsequent growth of the psychotherapeutic surgeries in district polyclinics should be noted: since 1993 - by 30,6 per cent (1134 surgeries) that is a striking illustration of the progress towards the integration into general medicine.
A role of day hospitals in the structure of the psychiatric service is slightly grown: the number of them since 1993 to 1998 has increased by 10 per cent (from 12 493 to 13 905). At present the number of beds in day hospitals makes up 7,9 per cent of the total number of beds.
Essential changes occur concerning the personnel and the resources provision of Russian psychiatry.
In last 5 years (1995-1999) a constant average annual rate of growth of the number of psychiatrists is noted at the level 2-3 per cent. In preceding five years this index was notable by the negative value (-0,3 per cent during 1990 - 1994). The happened changes are indicative of that young specialists take interest in psychiatry again.
Now the psychiatric care rendered in Russia by 16596 psychiatrists. It is important to note that the number of doctors acting as private practitioners has grown from 40,4 to 45,0 per cent. It is an illustration of the increase of a role of polyclinics, ambulatories, dispensaries.
The named quantity of doctors includes 1862 psychotherapeutists. In last 10 years the number of them has increased three times as much. Moreover 1512 psychologists, 233 specialists in the field of social work and 605 social workers take part in the psychiatric care of the population. There is also a progress concerning the provision with a personnel of teams consisting from various professional but this process is not quiet intensive.
Russia disposes approximately 500 hospitals which are able to render a care of around 200 thousand people that makes up 5 per cent of them who are registered as mental patients. These clinics are overfull and financed irregularly. E.g. in Moscow region 20-25 per cent of necessary means are allotted for the nutrition and 7-8 per cent for the treatment of patients. Modern methods of the therapy are practically inaccessible for the majority of patients because an average pension in Russia is not big in particular in Arkhangelsk region it makes up 41,8 US$, but an average salary per a month in Russia -100 US$ (an average salary a month in Arkhangelsk region - 120 US$).
Thus the quality of the mental health of the population in Russia is determined by next characteristics:
- the number of psychogenic disorders cases has increased as matter of fact a new group of mental disorders has appeared caused by social stresses;
- the growth of the prevalence of alcoholism and alcoholic psychosis, narcomania and toxomania has happened;
- the number of mental deficiency cases has grown;
- the cases of disability because of mental diseases have become more frequent;
- the frequency and the heaviness of a type of socially dangerous actions of mental patients have increased;
- the prevalence of suicides has grown approximately two times as much that makes this tragic index in Russia one of the highest the world over.
The modem status of the psychiatric care in Russia is determined by next trends:
- the low financing of the psychiatric service as an effect of the social and economic crisis;
- a deviation from hospitalisation trends and the development of units which do not form the structure of hospitals;
- the beginning transition from a mainly medical to a psyhobiosocial pattern of the rendering an assistance;
- the increase of the law security in the psychiatric service;
- the increase of the attention to a phenomenological direction of psychiatry, overcoming trends of the exaggerated diagnosis of slow progredient schizophrenia;
- the development of new directions of psychiatry: psychiatry of natural and technogenic, catastrophes, ethnopsychiatry and ecological psychiatry; the service of psychotherapeutic care of refugees and migrants and others;
- the active development of psychiatry as a reaction to “the hysteric and demonic renaissance” - the boom of the mystification in the public consciousness and the massive outflow of patients to magicians, extrasensories, healers and astrologers;
- the increase of the role of public organizations, communities of patients and their relatives;
• the active training in institutes of higher, education of specialists for the establishment of a therapeutic team consisting from various professionals: psychiatrists and psychotherapeutists, clinical psychologists and social workers.
In 1932 the famous psychologist, the winner of Nobel prize Ivan Petrovich Pavlov spoke once about his compatriots: “I should express my pessimistic opinion about Russian people - they have a so weak mental system that they are not able to perceive the reality adequately”. Nevertheless if we take into the consideration that Russian people undergo so many trials in the last decade the opinion of Pavlov may be considered as the excessively severe.
Principal trends of the integration of Russian psychiatry into the world psychiatric community
The development of Russian psychiatry and its integration into the world psychiatric community are directly by bound up with multilevel effects of the democratisation of the society and State institutes.
The next principal trends may be noted in this connection (Sartorius N., 1998; Poloshiy B. S., 2000; Dmitrieva Т. В., 2001;Kazakovtsev B. A., 2001).
- The decentralization of the psychiatric care and the professional psychiatric community.
The positive aspect of this process results in many variants of the development of the service in various regions of the country, the overcoming post Soviet provincial complices, the active regional scientific politics, the realization of the partnership relations and giving up Soviet traditions of the strong vertical administrating.
The collaboration of psychiatrists within the Barents-region uniting Northern parts of Russia, Sweden, Norway and Finland may set a good example. Today a big list of joint programs is realized (transcultural features of alcocholism and narcomania, mental health and juvenile delinquency, medial and social rehabilitation of mentally deficient children and others), international conferences and seminars probations of doctors, young scientists and students, summer university schools are organized, first defences of theses of Russian post-graduates have taken place in Norway and Swedish universities, manuals of prominent psychiatrists of the Barents-region are translated and published in Russian. This book is also an example of the fruitful collaboration in the North European professional field.
- The humanization of the regard to patients and the accessibility of the psychiatric care for all the strata of the population.
The increasing stratification of the Russian population according to economic standards dooms as a matter of fact the poorest strata of the mental patients to the “passive euthanasia” and the starvation. Just because of that State guarantees concerning free of charge volumes of the psychiatric care are necessary. These are approved within regional budgets of the health care system.
The founder of Russian clinical psychiatry S. S. Korsakov spoke: “According to the regard of the society to mental patients a grade of the civilization development may be considered”. The humanization must resist trends of the decivilization - the decrease of volumes of the care of the weakest and the poorest: children, invalids and mental patients, refugees and migrants.
- The legal security of mental patients in Russia is provided in Russia with the Federal Law “Of the psychiatric care and guarantees of rights of patients “ (1993). In the passed by UN 15 years ago Declaration of Human Rights a category of mental patients is particularly stressed whom the treatment and the prevention of abuses should be guaranteed. UN did not pass the same resolution for an other disease.
The rights of mental patients are regulated certainly by laws but these are predetermined unavoidably by the right culture and the quality of the right space of the modern crisis situation in Russia. To our regret there are many cases of various abuses (expulsion of mental patients from their apartments, no provision with medicines and others). Thus the publicity and the public discussion of all the problems appearing in the field of psychiatry are important.
The perfection of the legal care of mental patients includes questions of their social security, an employment, the pension provision, the tax politics and others.
- The replacement of the nosocen- tric paradigm by the healthcentric.
Methodologically it is the replacement of priorities concerning the rendering of the psychiatric care mot according to the quantity of mental patients but according to the total number of the population for that the service of the mental health is responsible. In the ideological aspect it is an orientation to the preservation and the consolidation of the national public health. The mental health is an essential part of it. It is an orientation to the preventive psychiatry and the training of the rising generation in the healthy mode of life. An individual today should feel more and more his responsibility for the own health. It is important to get rid of the inert thinking and the conviction of a consumer to that many Russian people have come considering that polyclinics should take care of their health.
- Integral trends of the development of the psychiatric care result in the creation of various professionals psychiatrists and psychotherapeutists, clinical psychologists and social workers work under the conditions of the partnership.
A new qualitative stage of the development of the complex approach is an open dialogue creating more productive therapeutic surroundings where a patient and his relatives take part actively in the solution of problems and the elaboration of an adaptive life style. A broad integration of a patient into the work and the society is noted. The mental and psychological training of a patient and his family is growing. An obligatory condition of the effective work in the regimen of an open dialogue is the achievement of the consensus between members of a therapeutic team, a patient and his family predeterming the partnership relations within the therapeutic surroundings.
A striking illustration of the abilities of a family to the rehabilitation of a mental patients is the experience of India where there are under three thousand psychiatrists to one billion of the population. But they manage their job well because families of patients render them a support.
Integral strategies of the psychiatric care give new opportunities for the use of the cognitive behavioral therapy, family therapy, therapy by surroundings and also the individual oriented therapy.
The world experience shows that a psychiatrist can not more manage without the collaboration a clinical psychologist and a specialist in the field of the social work. The individual program of the social and work rehabilitation including medicamental forms of the therapy, work therapy and an employment of persons suffering from mental disorders must provide the use of the person-oriented individual family and group psychotherapy, sociotherapy, therapy by surroundings. The necessity of the use of the so called team method of the treatment and the social support of a patient is caused by the complex character of clinical, psychological and social problems concerning him and his surroundings including members of a patient group, receiving together the group therapy. A psychiatrist and psychotherapeutist working in an hospital, a semihospital and dispensary form a group of patients of various nosological forms. They should begin with an informal communication between members of the group and a doctor, a joint participation in the work therapy and finish with a regular pharmacotherapy.
A clinical psychologist belonging to the team of various professionals renders the psychiatric and the psychological care, realizes a work concerning the correction of deviations from the development of a patient person, renders the psychological care of not only a patient but also his relatives, the medical personnel concerning the solution of personal, professional problems and problems bound up with conditions of life, is occupied together with a doctor with the vocational guidance of a patient according to his material and spiritual values, abilities, opportunities and actual plans.
A specialist in the field of the social work and social worker organize an individual and group collaboration with patients aimed to the improvement of their social adoption, the training of communicative abilities, carry out measures concerning the social and legal security of patients collaborating with organisations rendering a social care. They create together with a doctor and a clinical psychologist therapeutic surroundings, therapeutic communities of patients, groups of common hobbies, realizes the club work, promotes the formation of a patient sense of the responsibility for his social behaviour promotes the improvement of the social functioning in a family, at a school, in informal groups, in a work body and others. The formation in the country of the modern rehabilitation system in institutions rendering a psychiatric care is continuing using of the over one hundred years experience of the world psychotherapy but to our regret under the conditions of the underdeveloped material and technical basis and the deficit of the personnel — psychiatrists, psychotherapeutists, psychologists, social workers.
In the beginning of 1990th faculties of the social work and the clinical psychology were established at the Northern State Medical University together with universities of Umeo(Sweden) and Tromsoe(Norway). The function of the faculties on one hand is to increase the quality of the training of medical students in general, social and clinical psychology and on other hand to raise the number of clinical psychologists and specialists in the field of social work as the partners of a psychiatrist in the therapeutic team of various professionals.
Russian Health Ministry (Kazacovtsev B.A., 2001) has elaborated and recommended variants of the new planning structure in psychoneurological dispensaries and psychiatric hospitals, rehabilitation centres, psychotherapeutic centres, centres of the speech pathology and neurorehabilitation for the use in regions including psychotherapeytic surgeries, departments of the physical rehabilitation,day hospitals, medical industrial workshops, psychological surgeries, departments of the social rehabilitation as principal units. Projects of the network and types of psychiatric and psychotherapeutical hospitals, semihospitals and other units are elaborated taking into account that the psychotherapeutic care should be approximated to the population.
The integration means an approximation of psychiatry to other fields of clinical medicine that equalises really mental patients to somatic patients in rights, changes the public opinion in favour of mental patients, the regard of the society to our patients, increases their social security, explodes an ingrained myth and prejudices concerning psychiatry and mental patients.
It concerns directly the realization of the next tread.
- The decrease of the patient and his family, psychiatrist and psychotherapeutist stigmatization.
A most accessible variant of the solution of this task is the transfer of the treatment of mental patients to society oriented forms of the care not being units of hospitals. The achievements of the modern psychopharmocology make it quiet possible creating optimal conditions for a subsequent socio - and psychotherapeutic care. Even today it is possible to create a broad network of psychiatric departments as units of general therapeutic centres ,hospitals, aid stations. According to the prognosis of B. S. Poloshiy (2001) around 80 per cent of patients requiring the stationary psychiatric care can receive the treatment under the conditions of specialized departments of general hospitals. It will increase diagnostic and therapeutic capacities of the treatment and allow patients to feel themselves as equal among others ,take off “a label” of a man isolated not only from the society but also from other patients. This trend may be supplemented with the creation of somatopsychiatric departments in big specialized medical centres. E.g. around 50 per cent of having myocardial infarction and 70 per cent having apoplectic stroke suffer from depressions and require the psychiatric care.
From 60 to 80 per cent of patients taking advice of various specialists of polyclinics have mental problems. Therefore it is important to establish more psychotherapeutic surgeries within the polyclinics network.
- The industrialisation of private narcological ard psychotherapeutic paactice.
Its specific gravity grows very rapidly. It is important to maintain the State and medical association control of the licensing and the quality of offered services. The factor of money of patients has had since Freud a particular psychotherapeutic value concerning the therapeutic process. It is not occasionally that the President of European Psychotherapeutic Association Professor V. V. Makarov delivers in the department of psychotherapy at Moscow Academy of Post-Graduative Education series of lectures: “Money in psychotherapy”.
A fact shows the colossal national demands for the psychotherapeutic care that according to the data of Russian Justice Ministry around 500 000 healers, extrasensories, magicians and other specialist are registered and undertake psychotherapeutic functions. They would not appear if the population did not require this care.
On the whole She financial provision of the security of the mental health should be revised undoubtedly. The world psychiatric community should determine financial quotas for the provision of minimal amounts of the care with elaborated standards of the quality.
The President of the World Psychiatric Association Norman Sartorius (1998) marks out four groups of countries according to the level of the social and economic development and the qualitity of the rendering of the psychiatric care: developed, rapidly developing, slowly developing, underdeveloped.
In developed countries the quantity of psychiatric beds makes up - 15 - 40 per 1000 of the population (Denmark, Ireland, Finland and others). There is there a psychiatrist per approximately 100 patients having serious mental troubles - schizophrenia, manic depressive syndrome and others. 2000 US$ are allotted per a patient annually. In underdeveloped countries, the number of beds is 400 times as little, the number of patients per a psychiatrist is around 40 000 (e.g. in Ethiopia there are only 6 psychiatrists per 6 million), and only 0,5 US$ is spent per a patient annually.
Russia does not belong to the extreme groups taking intermediate position. In Arkhangelsk region there are in all 1780 beds or 1,27 per 1000 of the population; 230 psychiatrists and narcologosts (300 patients per a psychiatrist).
A question is raised: may the strategy of the establishment of the psychiatric care in various countries be universal. Certainly not Basical principles and trends should be universal but forms and methods of the work, programs and strategies are various and diverse. Above all these would be accessible and effective in the concrete socium.