CLINICAL AND THERAPY

Psychiatry in Ukraine: general features

Prof. Alexander Filts*

Psychiatry in Ukraine: general features**

* Head of the Department of Psychiatry and Psychotherapy, Faculty of Post-Graduate Training, Lviv State Medical University

** Seminar held on 26 of September 2001 in the Institute of Clinical Psychiatry (Dir. Prof. Giuseppe Ferrari), University of Bologna

It is not that easy to describe the present situation in Ukrainian psychiatry. Psychiatry and psychotherapy encompass and focus all the contradictions, all the difficulties, and all the perspectives of development of humanistic relations. In 1996, I published an article in a philosophical magazine “Geneza”, which argues that Ukraine has quite real chances for elaborating the know-how of the social and humanistic approaches in the nearest future. Today, these chances seem even more real. They are associated with the absence of distinct bureaucratic structures (they are still being established), the actual neutrality in all political and cultural fields, and, the most important, in the vigorous search of an separate concept of nation. In the course of this search, ideas, little known in the world, but still interesting from the point of view of social know-how, keep emerging. Psychiatry, as it will be stated further, remains inert and resists these new ideas. More precisely, the ideas themselves exist, but they are presently impossible to realize. These ideas include, for instance, the argument on the necessity of a totally new systematic of mental disorders, based on the principles entirely different from the existing ones. The role and therapeutical problems of borderline condition are discussed, too. There are attempts to unite the psychodynamic and phenomenological psychopathology. But all these projects do not yet go beyond discussion. It seems like practical psychiatry should be reorganized at first, and only then more general theoretical issues should be regarded.

The history of psychiatry in the Soviet Union has its peculiarities, which are both positively and negatively reflected in Ukrainian psychiatry. The most important of them concern the following fields:
- academic psychiatry and psychiatry as a discipline;
- psychiatric education;
- applied psychiatry.

Moscow, the capital of the former USSR, was the actual and absolute centre of academic and educational psychiatry in the Soviet Union. The two academic institutes in Moscow - the Institute of the Academy of Medical Sciences and the Russian Institute of Psychiatry were the ones to carry out the main clinical psychiatric research. Another institute - the Serbsky Institute of Forensic Psychiatry performed a function of a political instrument of the totalitarian regime. In this third institute, a lot of dissidents have undergone psychiatric expertise. Nevertheless, it must be mentioned that this odious role of Serbsky Institute is significantly exaggerated in the West. A lot of individuals who claimed to be dissidents and were recognized as having mental problems, later revealed signs of various mental disorders, and even benefited from psychiatrists' support in their further life. Today, the Serbsky Institute, along with the two others, deals merely with psychiatric problems, and is not involved in political collisions. Besides these three main schools, each one of the ex-republics of the USSR had its local research centres, but none of them had any significant scientific and methodological independence.
Paradoxical as it may seem, general bases of theoretical psychiatry, which one way or the other were imposed from Moscow, were associated with classical German psychopathology. There were specific historical grounds for this circumstance. First, many of the leading psychiatrists of the 20s and the 30s either learned from or co-operated with German psychiatrists, which at that time dominated in Europe and in the world. Second, part of Soviet psychiatrists of that time actively studied and practised psychoanalysis. Third, starting from the 30s, a part of the leading German psychiatrists immigrated to Russia, fleeing the Nazi regime. Among them were Kronfeld and Sternberg, who had built a foundation for the further academic clinically oriented psychiatry in Moscow. Through the Moscow institute, their concepts of psychiatry were spread over the rest of the Soviet Union.
One may say that even today, in all post-Soviet countries, including Ukraine, this German influence is very powerful. Perhaps, this is why the contemporary tendencies reaching us from the U.S. systematic of mental diseases, statistical research design, strong pragmatic approach, predomination of biological point of view, and diminishing of psychopathological understanding of mental disorder, etc. are still regarded reservedly in Ukraine.
Thus, a traditional clinical psychopathological orientation, rather inert to Anglo-Saxon innovations, still dominates the academic psychiatry in the entire post-Soviet region. Therefore, the studies using statistical test, scale and questionnaire methods are still not very popular in our country. Descriptive clinical studies are more valued.
Since the time of the USSR and to this day, psychiatric education in our country is scheduled the following way: after the six years of general medical education a young specialist studies psychiatry for a year of internship, after which he is licensed to practice. Besides, every practising psychiatrist is supposed to take a one-month of postgraduate training and to pass a qualification exam. There are three degrees of qualification. Physicians with the top level of qualification have a right to private practice, which is an innovation introduced 10 years ago.
Besides, there are three forms of scientific postgraduate education. They envisage writing a doctor`s thesis and habilitation. All the studies are carried out in medical universities at specialized departments. Our department is also engaged in postgraduate education. Medical university students are trained at separate departments.
In Ukraine of today, universities and their chairs, and the Ministry of Health are displeased with this present education state. In the nearest 3-5 years, a reform is planned, which will adapt education in Ukraine to European standards.
Applied psychiatry. Over the last decade, the system of mental healthcare has not changed. Large psychiatric hospitals with 1000 and more beds are the main basis; besides, cities and big towns have out-patient centres. These provide medical care for neurotic and borderline patients. Though, starting from 1998, the Ministry of Health introduced progressive reforms in decentralization of large hospitals and creation of psychiatric departments in regular hospitals, this reform still encounters inertia on part of psychiatrists. In large cities of Ukraine, small psychiatric clinics formally exist on bases of general hospitals, but they remain isolated from the general mental healthcare. Though the patients dislike large hospitals, but they still seek medical care in them.
One may make a conclusion that large hospitals remain a symbol of support and a large mother object model for patients.
Applied psychiatry in Ukraine is oriented at biological methods, among which such ancient ones as insulin coma therapy, administration of high doses of neuroleptics and antidepressants are used. Partially, it has objective grounds: large hospitals have no resources for new medications, as well as for new forms of social rehabilitation. Interestingly, psychiatrists themselves are willing to use new methods and are ready to changes, but the bureaucratic apparatus, on one part, and financial shortage and narrow-mindedness, on the other, do not allow for these changes.

Conclusions:
1. Ukrainian psychiatry has not changed significantly over the last decade;
2. Reforms of psychiatry in Ukraine still remain theoretical, and have little opportunity for practical realization;
3. The influence of the Western, especially American psychiatry, is limited, which leads to certain isolation of Ukrainian psychiatry;
4. The reform of psychiatric education has the highest chances for today.

Main drawbacks:
1. Strict traditionalism of scientific and practical psychiatry. Today, Ukraine is falling behind even Russia and other post-Soviet countries in terms of innovations, but the innovations in the field of applied psychiatry, as it was mentioned before.
2. The gap between the old rigid structure of psychiatry and innovative quests in the field of theory. Good ideas are hard to realize due to lack of appropriate structures and costs.
3. The rigidity of psychiatry makes a sad impression on the more progressive Western partners, which comlicates international collaboration. Soviet legacy still hinders the development of Ukrainian psychiatry.

Advantages

1. The readiness for changes among the younger generations of physicians is very high. It is a favourable ground for the acceptance of the most advanced new trends: it is easier to build a new modern house than to reconstruct an old one with modern accessories.
2. Ukrainian psychiatry is especially sensitive to the most outstanding achievements of modern international psychiatry. This allows hoping that, sooner or later, these achievements will find their role in Ukraine.
3. Collaboration with Western partners, as soon as it becomes reliant and steady, is especially valued among Ukrainian psychiatrists. The example of collaboration with our Italian colleagues, initiated by Prof. Mario DiFiorino, speaks for itself. We have conducted three big international conferences, started a psychiatric rehabilitation project, introduced a joint website, and we plan on extending our cooperation.
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I would like to say a few words about the history of our hospital.
Before the 18th century, there was no psychiatric care for the population of Galychyna. Part of mental patients lived in monasteries, part of them was kept into the penitentiary institutions, but the major part remained in general population. First insane asylum in Galychyna was organized at the times of Austrian-Hungarian Empire in 1790 as the department for mental patients in Lviv Krayovy Hospital at Piyariv Street. At the beginning this department was mixed for both male and female patients, and only in 1870 it was divided into two parts: male patients were separated from females.
On May 15, 1875 these departments were transferred to the newly built houses, situated in Kulparkiv suburb of Lviv, and specially constructed for needs of mental patients. The status of Kulparkiv Institution for Mental Patients was adopted on May 25, 1875, and from January 1, 1876 this institution was reorganized into an independent structure. In 1876-80 it also had two branches: one for female patients in Peremyshl and another one - for male patients in Zhovkva. At the beginning hospital provided only board and general care for patients. Later, under the Polish rule (1918-1939), active treatment of patients began to play more important role. Number of beds in the hospital increased rapidly: from 345 to 1100 by 1907 and to 2300 in 1980.
Before World War I such people as Gustav Neiser (came to Lviv from Krakow), Vladyslav Colberger (originated from Peremyshlyany in Lviv region) and Vladyslav Sohatski (who elaborated instructions for personnel) made great contribution to setting up and growing of the hospital. The reunification of Ukrainian lands in 1939-40 marked a new stage in the development of the hospital, but the hard times of World War II slowed this progress. Many patients died of infectious diseases, cold, and starvation, part of the property was lost and the buildings were partially ruined. During World War II, many patients from Germany sought shelter in Lviv, which is recorded in the hospital’s archives.
After the end of the war, these buildings were reconstructed, and new changes took place: workshops complex was built, many problems concerning equipping mental departments of the hospital with necessary services and utilities were solved. Qualified specialists came to work in the hospital, in-patient system of psychiatric care was specialized and extended, and great efforts were made to improve the methods of diagnostics and treatment. In the post-war period hospital did a lot in organizing of the psychiatric service in cities and districts of Lviv region and in nearby regions.
Nowadays, the hospital contains 1735 beds in 20 departments. The major part of the departments is specialized: for children, adolescents, gerontological patients, for patients with tuberculosis, infectious diseases; there are also forensic and intensive care units. There are special wards for the patients with epilepsy (male and female).
Two departments of the hospital are diagnostic and, also there are two Departments of Lviv Medical University. The first one is the Department of Psychiatry and Psychotherapy for Advanced Postgraduate Training. The main directions of scientific activities are: psychotherapeutic work and psychological help, psychopharmacotherapy of major psychoses and affective disorders, clinical investigations in the field of psychopathology, rehabilitation and art therapy, alcohol and drug dependence, researches concerning new psychotropic drugs.

Over the last seven years, our Department is involved in the following activities:
1. In clinical psychiatry, the problems of prediction in schizophrenia, affective disorders, and suicides are studied.
2. In the field of addiction treatment, a specific medication with a know-how technology has been synthesized. It contains dysulfiram as an active ingredient, and has a prolonged effect. The studies of anti-abuse and anti-anxiety effects of the drug. Today, the results of the preliminary double-blind study of 15 patients are available. It has been discovered that the drug has a mild anti-anxiety effect and decreases the cognitive and affective tension to caused by abuse-topic in the period of abstinence. Besides, the medication significantly improves the possibilities of psychotherapeutical correction.
3. In the field of psychotherapy, our Department, in collaboration with Ukrainian Umbrella Association of Psychotherapists conducts a continuous international project, in which more than 170 participants from Ukraine, Russia, Belarus are educated in group psychoanalysis, client-centered psychotherapy, systemic family therapy, psychodrama, gestalt-therapy.
4. A pilote project on rehabilitation of the chronically mentally ill is launched jointly with our Italian colleagues.




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