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English Language Page Prior to the beginning of the survey a seminar was conducted within the framework of which the researchers underwent special training on observation of rights of patients of psychiatric clinics. The all-Russian survey was conducted on the basis of a uniform scheme that employed research instruments specifically designed for that purpose. Among the basic instruments used there were interview questionnaires and observation charts. It was planned to conduct three types of interviews: one with the head of the institution (head physician or their deputy), one with the head of department, and one — with a nurse. The interview with the head of the institution contained the greatest number of questions since it was only the head of the institution who could provide general data on the clinic (such as, for instance, the data on funding, staffing, general technical and material base, various subdivisions, provision with pharmaceuticals, food stuffs, etc.) which had to be taken into account in the analysis of the survey results. Departmental head was selected as the most informed representative of the team of physicians who could provide information about the therapy process as such and observation of rights of patients in particular, while the medical nurse — as a representative of the medical personnel responsible for the treatment and care of patients and possessing the data on the variety of details about the life of the department (workload of the medical personnel, security measures, relationships with the patients, etc.) and patients (meetings with relatives, walks, smoking, possibility of independent actions, etc.). Many questions were deliberately included in the interviews with different representatives of the clinic which allowed for additional verification of the reliability of the data received. We had to refrain from interviewing patients. In order for the results of a survey among patients to be reliable it has to be conducted outside of the confines of the psychiatric institution. It was necessary to identify such former patients who on the one hand would consent to an interview and on the other hand — could provide reliable data. But those who undergo psychiatric therapy voluntarily are usually not anxious to inform the others about it, let alone participate in a survey even though anonymously. And those who have found themselves in an institution against their will are often so emotionally charged that they simply cannot be objective. Additionally, in order to interview patients with mental conditions one must have at least a minimal experience in implementing such tasks. In view of the aforementioned it was decided to use in the analysis the data of surveys conducted among mental patients by the Independent Psychiatric Association of Russia (IPA) in 2000-2003, as well as the data of Kazan psychiatrists who conducted in 2002 an anonymous survey among former mental patients in order to solicit their recommendations on how to improve operations of psychiatric clinics. Given that the IPA of Russia predominantly receives petitions from patients who have been institutionalized involuntarily and are therefore not content with the therapy process, while the survey conducted by Kazan psychiatrists focused primarily on patients who had submitted themselves to therapy of their own accord, the final results of both surveys complimented each other. In addition to interviewing the head of the institution, the head of the department, and a medical nurse, the researchers were to use standardized observation charts to assess: • The overall condition of the territory of the clinic and structures located on it; • General psychiatry departments (men’s and women’s) in which patients with all sorts of mental conditions undergo therapy; • Children’s department where children under 14 years of age undergo therapy; • Geriatric department in which senior individuals undergo therapy. General psychiatry departments as the most typical ones reflected the situation with the observation of rights of patients in each institution to the greatest degree. Children’s and geriatric departments were selected as specialized units the residence in which is associated not only with therapy, but also with the obligatory receipt of supplementary services reflecting the observation of patients’ rights. Children must be provided with the possibility to develop and study which is associated with the availability of play and study rooms, additional equipment and study materials, as well as appropriate specialists and personnel. Senior individuals require supplementary medical care in view of their somatic conditions, as well as a variety of orthopedic equipment and additional means of hygiene. The field phase of the survey took place in April-May of 2003. The conduct of the survey would have been extremely complicated or in fact impossible were it not for the letter of support provided by the head of the special care department of the RF Ministry of Health Care, A. Karpov, and addressed to heads of local health care authorities and head physicians of psychiatric institutions. In addition, survey participants who attended the training seminar received a document authorizing them to act on behalf of the IPA of Russia — a nongovernmental professional organization whose charter provides for visitation of psychiatric institutions. Nevertheless, the conduct of the survey in the regions was practically impossible without a lengthy coordination with local health care authorities. Psychiatry remains a closeted sphere of the Russian society. Unjustified circumspection, distrust of head physicians and local bureaucrats with respect to the purposes of the survey created additional obstacles to its effective implementation. This proves beyond doubt the factual unfeasibility of requirements with respect to the exercise of public control over the operations of psychiatric institutions (Article 43, “Control Over the Operations of the Psychiatric Care Exercised by Public Associations,” of Federal Law “On Psychiatric Care and Guarantees of the Rights of Citizens in Therapy” (further on — Federal Law “On Psychiatric Care” ). Head physicians viewed the survey differently. Some of them were circumspective and not very friendly towards the effort having confined themselves to brief and hardly informative answers to questions and having not provided any concrete information even when asked additional questions by interviewers (Kursk regional psychiatric clinic, Troitsk psychiatric clinic of the Republic of Buryatia, the Republican psychiatric clinic of Mordovia, the Kazan city neuro-psychiatric clinic named after Bekhterev of the Republic of Tatarstan, the Republican psychiatric clinic of Udmurtia). Others, on the contrary, were excessively talkative but often spoke about extraneous things that did not have anything to do with the survey in question or provided internally contradictory information. Nevertheless, in many a hospital the researchers were met in a business-like manner (Kaliningrad city psychiatric clinic, Kostroma regional psychiatric clinic, Kostroma specialized psychiatric clinic with intensive observation, Nizhnii Novgorod city psychiatric clinic #1, Novgorod regional psychiatric clinic, Orenburg regional psychiatric clinic #1, the Republican psychiatric clinic of Karelia, and many others). The final analysis incorporated data collected in 93 psychiatric institutions from 61 subjects of the Russian Federation (see Appendix 1). Among the 93 surveyed health care institutions there was one specialized clinic with intensive observation for individuals who breeched the law and were concluded to be non compos mentis, one psychiatric center for children (for 70 beds), psychiatric departments in three multi-profile clinics, the rest of them being typical psychiatric clinics treating representatives of the population of adjacent territories. In some regions the outpatient and resident psychiatric care constitute a single structure and such a health care institution is known as a neuro-psychiatric dispensary with a resident unit. Large psychiatric clinics with the bed capacity of over 500 significantly prevailed (55 versus 33) among the surveyed psychiatric institutions which reflects very adequately the structure of the resident psychiatric care system of Russia. The preponderance of large institutions designed to provide therapy to a large number of patients simultaneously turns the work of physicians into a routine preventing them from individualizing the treatment and rehabilitation process in the required degree. Within the system of psychiatric care this is considered to be an obsolete approach which was given up by the majority of countries a long time ago. The first group consisted of nine clinics with the bed capacity of over 1500. The largest of them are located in Bashkortostan (the Republican psychiatric clinic) — designed for 2100 beds, in the Kursk region (Kursk regional psychiatric clinic) — designed for 1880 beds, in the Moscow region (Moscow regional psychiatric clinic #2) — designed for 1785 beds, and in Moscow (psychiatric clinic #13) — designed for 1600 beds. In the Republican psychiatric clinic of Tatarstan, St. Petersburg psychiatric clinic #1 named after Kaschenko, Kostroma regional psychiatric clinic and Moscow psychiatric clinic #4 the number of patients falls short of the designed capacity (2082 instead of 2300, 1450 instead of 1590, 1420 instead of 1550, and 1300 instead of 1510 respectively), while in the Samara regional psychiatric clinic at the moment of the survey there were only 1380 patients, the initial capacity being 2010 beds. Departments specializing in treatment of psychiatric patients suffering from tuberculosis have been created in all of these clinics except for the ones in Moscow and the Republican psychiatric clinic in Tatarstan. In addition, practically all the clinics provide court-psychiatric expertise and treat involuntarily institutionalized patients who breeched the law and were acknowledged to be non compos mentis. The next group consisted of 15 clinics with the bed capacity of 1000—1500. Among them there are also such whose patient body falls short of the initially designed bed capacity (for example, the Sverdlovsk regional psychiatric clinic #1 and the Republican psychiatric clinic of Karelia). In the majority of these clinics however all beds are taken. Almost all of these clinics treat mental patients suffering from tuberculosis, as well as patients who have been submitted to involuntary therapy by court decision. The majority of them also provide court-psychiatric expertise. The third and the most numerous group consists of psychiatric clinics which can admit from 500 to 1000 patients. The survey happened to cover 31 such institutions and they were regional and republican hospitals of subjects of the Russian Federation with large population. The majority of them also offer involuntary therapy and provide court-psychiatric expertise but only ten of them have departments that treat mental patients suffering from tuberculosis. Eight clinics had a bed capacity of 300—500, one of them being the specialized clinic with intensive observation in Kostroma; the other 25 could admit not more than 300 patients. The latter were mostly city and district clinics, a variety of specialized clinics (for example, the Republican psychiatric-tuberculosis clinic in Marii El, and the regional psychiatric center for children in the Bryansk region) or central psychiatric institutions (frequently — neuro-psychiatric dispensaries with resident units) in regions with an insignificant number of population. In the latter case the clinics provided court-psychiatric expertise and offered therapy to involuntarily admitted patients. In addition, psychiatric departments of three multi-profile hospitals were surveyed (Komi Permyatsky and Nenetsky autonomous districts and the Altai republic). Monitoring results required a detailed and meticulous analysis. Much of the obtained data was additionally verified against information provided in questionnaires and observation charts. For example, information on “respectful and humane treatment free from debasement of human dignity” was extracted from the entire body of data because disrespect for the personality of the patient manifests itself almost literally in everything — from the trashed territory and inadequate board to the paternalistic method of therapy and lack of confidentiality. Analogously, therapeutic factors include not only a set of pharmaceuticals, but also respectful attitude, voluntarism, awareness, and observation of other human rights and literally all factors of the environment because therapeutic, and more precisely, socio- and psycho-therapeutic aspects are to be found in everything. The order in which the chapters and sections of this report are organized corresponds with the degree of community of the rights of patients and at the same time to a large extent — with the hierarchy of their importance. They are the fundamental rights to life, freedom, and dignity. They are followed by chapters “The Right to Decent Environment” and “The Right to Adequate Therapy.” Such organization of the document is accounted for by the concrete goals of the survey: to evaluate observation of the rights of patients of psychiatric institutions provided for by Federal Law “On Psychiatric Care” and the “Foundations of the Legislation of the Russian Federation on the Health Care of Citizens” and the currently existing gaps in that field, as well as to improve the instruments used in the survey with the view of turning such surveys into a regular systematic practice. |
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