Mental health in Russia

The Law contains 6 sections and 50 articles. Section I of the law describes general provisions of psychiatric care in Russia, covering items such as the right of persons with mental disorders, the voluntariness of seeking care/refusal of treatment, diagnostic and treatment procedures and ensuring that medical confidentiality is maintained in dealing with mentally ill patients. Section II covers the state provision of psychiatric care, including financial provision. Section III describes the rights and duties of mental health workers in Russia, as well as the authorised institutions that provide mental health services. Section IV details further into the types of psychiatric care and procedure of care, including the 'internment' process. Section V describes the role of law enforcement, while Section VI covers appeals against psychiatric care.[17]

Adoption of the Law On Psychiatric Care and Guarantees of Citizens' Rights during Its Provision is regarded as an epoch-making event in the history of domestic psychiatry, as establishing the legal basis for psychiatric care, and, first of all, mediating all involuntary measures through judicial procedure.[1] That is a major post-Soviet achievement of Russian psychiatry and the foundation for a basically new attitude to the mentally ill as persons reserving all their civil and political rights and freedoms.[1]

The main new democratic innovations for Russian psychiatry were the two ones of the Law:

1. The mandatory judicial procedure during all involuntary measures (examination, hospitalization, treatment).[18] However, during many involuntary hospitalizations in recent years, the staff of psychiatric hospitals did not follow the mandatory judicial procedure provided for by the Law.[19] Moreover, in 2012, the Independent Psychiatric Association published a paper by its former legal consultant, who in the paper proposed amendments to the Law on Fundamentals of Protection of Public Health in the Russian Federation to legalize involuntary dispensary supervision over persons with mental disorders without their informed consent and court judgment having been taken.[20] Establishing the dispensary supervision over persons specified in part 1 of Article 27 of the Law on Psychiatric Care always leads to legally meaningful consequences for them, such as restrictions on their right to performing specific types of professional occupation and that related to a source of an increased danger.[20]
2. The highly publicized claim of the full equality of rights and freedoms for the mentally disordered and those for all remaining citizens; the clear reference that it is impermissible to restrict the rights and freedoms on the basis alone of having a psychiatric diagnosis, being under dispensary supervision, in an inpatient psychiatric ward or in a psychoneurological institution.[18] The claim does not correspond to the law enforcement practice, under which the rights to be in correspondence without censorship, send and receive parcels, printed matters and remittances, use the telephone, receive visitors can be restricted by the attending doctor, the head of the unit or the head doctor in the interests of health or safety of the patients and others.[21] In addition, the IPA former legal consultant in his paper insisted that the right to daily walks should be added to the list of patients' rights that may be restricted on the recommendation of the attending doctor or the head doctor in the interests of health or safety of patients and others.[22]

According to the Russian psychiatrists Valery Krasnov and Isaac Gurovisch, the Law minimizes and prevents the institutionalization of the mentally ill if their behavior does not pose a danger to others.[23] However, article 38, which was once included in the Law as a guarantee of keeping the whole Law for patients of psychiatric hospitals, is still not working, and, as a result, the service independent of health authorities to defend rights of patients in psychiatric hospitals is still not created.[24]

In 1989, the World Psychiatric Association issued a statement that includes the following phrase: "Involuntary intervention is a great infringement of the human rights and the fundamental freedom of a patient. Therefore, specific and carefully defined criteria and safeguards are needed for such intervention."[25] The Law establishes substantive and procedural criteria for legitimacy of involuntary hospitalization.[26] Russia is among such countries and their parts as Austria, Belgium, Germany, Israel, the Netherlands, Northern Ireland, Taiwan, and the Canadian province of Ontario that emulated the United States in adopting hospitalization criteria based on the presumed danger of the mentally ill.[27] The same was true of the Soviet Union where the two guidelines of 1961 and 1971 read that the ground for urgent hospitalization was social danger of an ill person.[8] There is such a thing carefully cultivated by authorities as the prejudice that the mentally ill allegedly pose a danger to society, though it is not so: the percentage of criminals among the mentally ill is less than that among the so-called "healthy" population.[28] Statistics show those who are ill with schizophrenia commit fewer illegal acts (less than 1%) than those considered mentally healthy.[29] Involuntary hospitalization in a psychiatric hospital under article 29 of the Law is to meet the following three grounds:

A mentally disturbed individual may be hospitalized in a psychiatric hospital against his will or the will of his legal representative and without a court decision having been taken, if the individual's examination or treatment can only be carried out by in-patient care, and the mental disorder is severe enough to give rise to:

a) a direct danger to the person or to others, or

b) the individual's helplessness, i.e. an inability to take care of himself, or

c) a significant impairment in health as a result of a deteriorating mental condition, if the affected person were to be left without psychiatric care.[30]

Neither direct danger[31] nor severe mental disorder is defined in the Law.[32] According to the IPA president Yuri Savenko, loud claims, importunate molestations, shocking texts in a personal computer, participation in protests, hunger strikes, protest reaction against sudden and rude involuntary measures started to be called a direct danger.[33] According to American psychiatrist Thomas Szasz, the psychiatric formula of "dangerousness to self and others" is very susceptible to changes of medical, political and social fashion.[34] Prior to 1973, homosexuality was such a dangerousness, and since then has no longer been.[34] Psychologist-criminalist Nataliya Varskaya says that neuroleptics that are applied to serious patients make them "vegetables", but the ill stop posing a danger to citizens; alas, but there are no other ways to secure surrounding people against them.[35] She adds, dangerous patients are not cured even in psychiatric hospitals, they were previously kept in the wards for life, doctors examined them every six months and prolonged, prolonged, prolonged their custody; the doctors were aware that these patients are very dangerous, it is inadmissible to let them go to the streets.[35]

The citizen may voluntarily come to a psychiatrist who would find a severe mental disorder that requires the mandatory admission to a psychiatric inpatient unit. If the patient refuses the hospitalization offered to him, the doctor gets the right to start the procedure of involuntary hospitalization.[36] As a psychiatrist says, it is only a psychiatrist who is able to inquire into a patient's condition and to decide whether his refusal to be treated is a free man's conscious choice or a symptom of a mental disorder.[37] In psychiatrist's opinion, the mentally ill often do not feel and do not deem they are ill.[38] They actively avoid therapy and resist all efforts to subject them to it.[38] The more the person resists the inpatient psychiatric ward's demands for his hospitalization, the greater are his chances to find himself indoors or, more precisely, to be left there, because his resistance can be presented by the ward representatives as the lack of his due insight into mental status, as an indication of the severity of his disease.[39] In the same vein, the practice was justified by American psychiatrist Benjamin Rush as early as the eighteenth century: "The more they resist our efforts to serve them, the more they have need of our services."[40] The reluctance of patients to undergo neuroleptic treatment, their "spontaneous irritation", protests, etc. are considered as either unremoved symptoms of mental illness (such as depressive neurosis) or, along with tremor, anxiety, dysphoric mood disorder, as "transitory complications".[3] It is profitable for doctors to hospitalize the person in any cases, then bedspace fills up.[41] Remuneration of the labour of physicians in psychiatric hospitals and funding of the entire industry in Russia are carried out on the basis of the number of beds run by the doctor.[41] Russian human rights activist Valery Abramkin says it should be clear for a Russian patient that each medic legally and illegally snatches his large sum from each bed.[42] However, psychiatrists in their usual way counter the remarks that their funding depends on the number of psychiatric beds by ascribing them to antipsychiatrists and stating that the main motto of antipsychiatrists is the idea that psychiatrists are villains who dream of placing as many people as possible to madhouses.[37]

Data obtained as results of analysing the work of the psychiatric inpatient facilities show that two thirds of patients placed in a hospital without their consent actively refuse hospitalization.[43] In the rest of cases, they are unable to express their attitude to the events because of their mental condition.[43]

Despite the 1992 Russian Mental Health Law, coercive psychiatry in Russia remains generally unregulated and fashioned by the same trends toward hyperdiagnosis and overreliance on institutional care characteristic of the Soviet period.[44] In Russia, mental health care is meant to be provided by inpatient psychiatric facilities rather than by outpatient services.[45] In the Soviet Union, there had been an increase of the bed numbers because psychiatric services had been used to treat dissidents.[46] In 2005, the Russian Federation had one of the highest levels of psychiatric beds per capita in Europe at 113.2 per 100,000 population, or more than 161,000 beds.[47] In 2014, Russia has 104.8 beds per 100,000 population and no actions have been taken to arrange new facilities for outpatient services.[48] The number of outpatient clinics designed for the primary care of the mentally disordered stopped increasing in 2005 and was reduced to 277 in 2012 as against 318 in 2005.[48] An average patient's stay in a day-and-night inpatient psychiatric facility is extremely long, 75.5 days.[45] Nevertheless, the average rehospitalization rate in the Russian Federation amounts to 21.5%, and the portion of people kept in inpatient facilities longer than one year was 21.7% in 2012[45] and 22.2% in 2013.[49] Psychiatrist Sofia Dorinskaya says she saw former convicts who have been living in a Russian mental hospital for ten years and will have been staying there until their dying day because of having no home.[50] The total number of the mentally ill registered disabled has increased by 20% over a few years, from 826,036 in 1999 to 1,020,002 in 2008 for the population of 141.9 million in the country (2010 figure).[51]

Persons who do not respond well to treatment at dispensaries can be sent to long-term social care institutions (internats) wherein they remain indefinitely.[47] The internats are managed by oblast Social Protection ministries.[47] Russia had 442 psychoneurologic internats by 1999, and their number amounted to 505 by 2013.[52] The internats provided places for approximately 125,000 people in 2007.[47] In 2013, Russian psychoneurologic internats accommodated 146,000 people, according to the consolidated data of the Department of Social Protection of Moscow and the Ministry of Labour and Social Protection of the Russian Federation.[52] It is supposed that the number of beds in internats is increasing at the same rate with which the number of beds is decreasing in psychiatric hospitals.[53]

Lyubov Vinogradova of the Independent Psychiatric Association of Russia provides the different figure of 122,091 or 85.5 places in psychoneurologic institutions of social protection (internats) per 100,000 population in 2013 and says that Russia is high on Europe's list of the number of places in the institutions.[54] Vinogradova states that many regions have the catastrophic shortage of places in psychoneurological internats, her words point out to the need to increase the number of places there and to the fact that the Independent Psychiatric Association of Russia is forcing transinstitutionalization—relocating the mentally ill from their homes and psychiatric hospitals to psychoneurological internats.[54] As Robert van Voren, the chief executive of the Federation Global Initiative on Psychiatry, supposes, the Russians want to have their compatriots with mental disorders locked up outside the city and do not want to have them in community.[55] Persons in internats are brought to sleepy condition by psychotropic drugs and have to pass through the very long and complex procedure to be discharged from an internat, as shown in the film See Me, Hear Me produced by Russia Today in 2014.[56] However, according to law, the staff does not have the right to treat inmates in psychoneurologic internats.[57]

Russia is decades behind the countries of the European Union in mental health reform, which has already been implemented or is being implemented in them.[28] Until Russian society, Russian psychiatrist Emmanuil Gushansky says, is aware of the need for mental health reform, we will live in the atmosphere of animosity, mistrust and violence.[28]

According to Yuri Savenko, the IPA president, law enforcement practice is very far from the letter of the Law. Forensic psychiatric expert examination has deteriorated because of the lack of competition, and courts implicitly fulfill wishes of the hierarchy of executive authority affected by corruption.[38]

Discrediting the citizens by instituting farfetched proceedings to obtain a ground for examination is a favorite tactic of officials whose interests are hurt by the active members of public.[58] The police deliver "the ill" to a psychiatric facility, and the doctor can be sure that his facility will not be reduced, and, in general, the more "patients", the more funding.[58] Even if the criminal case is closed due to its complete failure, it does not regard the dispensary, the person is all the same "ill".[58] There is nowhere to refute one's misdiagnosis in Russia.[58]

According to Yuliya Argunova, the IPA lawyer, police officers are obliged under part 3 of article 30 of the Law to assist medical workers in implementing involuntary hospitalization and to ensure safe conditions for the access to the hospitalized person and for his examination.[59] While assisting hospital attendants to enter into the homes of citizens whose names are written by psychoneurological dispensaries on their referrals to hospitalization, police officers have little care about the absence of a court order (which can't even be issued at such a stage), the security of the hospitalized persons, the protection of their personality and preservation of their property.[59]

According to psychiatrist Sofia Dorinskaya, the situation always develops in the same way: either in the evening or at night, or in the early morning, when a person sleeps, the police break the door down in his apartment or room, handcuff and escort them directly or through a police office to a mental hospital, where the door is closed behind the person.[60] The suspected person sits face to face with a psychiatrist, then everything written by the psychiatrist will be a proof of the person's mental illness for the judge in court.[60] However, there is no system that verifies the psychiatrist's statements, so the activities of the accused are often falsified, even when the patient says or performs nothing abnormal.[60] One case, described by lawyers Yuri Ershov and Nataliya Kozlova, depicts an ambulance arriving with a rescue service brigade, in order for the person's front door to be broken down after the person refused to open the door. The doctor involved considered that the indignant reaction of the person to such situation was abnormal and sufficient to justify his hospitalization.[61] In her book The Psychiatrist's Notes, Dorinskaya depicts how a person well oriented in place and time was hospitalized because of a 'fit of schizophrenia', as described in the referral to his hospitalization. In addition, the referral reported that "he beat his wife and used bad language".[62] Dorinskaya writes how she and her colleagues forged many signatures of their patients on the forms of consent to hospitalization in medical histories before a prosecutor's investigation.[63] She cites the dialog: "And what if a signature does not match?"—"And who will investigate?"[63]

Although Ershov and Kozlova describe that it is easy for the lawyer to come to places of confinement and meet with his client and the administration of the penal colony after going through the formalities stipulated in law, the lawyers have to litigate for the right to get into a psychiatric hospital.[61]

As St. Petersburg lawyer Fanis Khalikov notes, the information about the time and place of the court session may simply be hidden from the hospitalized person and his representative. The hospitalized person may learn that he is in court at the time when the court session is underway or ready to start presently, when nothing can be done to ensure self-defence. It also happens that the person is not given an opportunity to contact his representative (lawyer), who could defend his interests in court, or with relatives (confidential agents, acquaintances, human rights organizations) so that they find and get a defence attorney to court. Or the defence attorney is not given an opportunity to meet with the hospitalized person; all possible obstacles are placed to prevent it. The hospitalized person is subjected to psychiatric treatment without his consent (and without the consent of the court) as soon as he finds himself in a psychiatric inpatient ward. Psychotropic drugs with effects varying in intensity are compulsorily administered into his body. As a result of having been drugged, the patient sometimes appears before the court in such a state that his look and behavior, caused by the influence of these drugs, can convince the judge that he sees a really inadequate person who is in need of psychiatric care. The patient is often in such an intoxication-induced condition that he is unable to put two words together, not to mention any real defence of his rights.[39]

According to the statement made by the IPA executive director Lyubov Vinogradova in 2005, a court comes to a hospital where it must make a number of judgments as to whether rightly or wrongly the hospital applies for the involuntary treatment of a person. The court makes its judgments for 20 cases within 20 minutes. In practice it means that the judge automatically signs judgments offered to him ready-made by the staff to allow for the involuntary treatments to continue.[64]

According to Doctor of Legal Sciences Vladimir Ovchinsky, regional differences in forensic psychiatric expert reports are striking.[65] For example, in some regions of Russia, 8 or 9 percent of all examinees are pronounced sane; in other regions up to 75 percent of all examinees are pronounced sane.[65] In some regions less than 2 percent of examinees are declared schizophrenics; in other regions up to 80 percent of examinees are declared schizophrenics.[65]

The Russian legislation did not implement Principle 18 of the Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care, approved by the UN General Assembly in 1991, with respect to a patient's right to an independent psychiatric report.[66] According to a report by the European Committee Against Torture, the Law does not reflect a patient's right to obtain the judgment for involuntary hospitalization.[67] In a hospital courtroom, the judge announces the judgment, but the patient does not obtain any motivated judgment.[67] There are sometimes cases where the patient is not informed by the court at all and hears about the judgment from his or her treating doctor or head of the unit.[67] Since the judgment for involuntary hospitalization, as a rule, is not delivered to the hospitalized person, he cannot appeal against the judgment in appeal hearing.[39] In other cases, the documents sent by him are censored and left in his medical record if not erased.[39] The hospitalized person also does not have opportunities to attend the court to obtain a copy of the judgment or come to the post office to send a complaint against the judgment.[39]

Amendments and changes were included in the Law several times: on 21 July 1998, 25 July 2002, 10 January 2003, 29 June and 22 August 2004, 27 July 2010, 7 February, 6 April, 21 November 2011.[8]

Over five years, from 1998 to 2003, the Serbsky Center made three attempts to submit for the Duma readings of amendments and additions to the Law, but the IPA and general public managed to successfully challenge these amendments, and they were finally tabled.[71] According to the IPA, these amendments to the Law, if adopted, would have impaired patients' rights.[72] In 2004, for instance, proponents of mental health reform could hardly prevent the effort by the doctors of the Serbsky Center to roll back some reforms in the Law.[73]

In November 2012, Mikhail Vinogradov, an expert of the Serbsky Center, said: "We must restore the legal act that was in the Soviet Union;" he noted that the request by a large group of Petersburg and Moscow psychiatrists to restore the old mental health act was submitted to the State Duma.[74] At the same time, Vinogradov expressed the opinion that the Soviet mental health act "has never been used for political persecution." Human rights activists who claim it did, in Vinogradov's words, "are not very mentally healthy."[75] However, Valeriya Novodvorskaya is widely known to have been arrested "for insulting President" in September 1990 and kept in a psychiatric hospital until August 1991.[76] In December 2012, Mikhail Vinogradov repeated his point, "My opinion: we should completely cancel the current Mental Health Law. One cannot give patients the right to decide their fate."[77] He added, "Do you talk about human rights activists? Most of them are just unhealthy people, I talked with them. As for the dissident General Grigorenko, I too saw him, kept him under observation, and noted oddities of his thinking. But he was eventually allowed to go abroad, as you know… Who? Bukovsky? I talked with him, and he is a completely crazy character. But he too was allowed to go abroad! You see, human rights activists are people who, due to their mental pathology, are unable to restrain themselves within the standards of society, and the West encourages their inability to do so."[77]

On the other hand, Leonid Kitaev-Smyk, a doctor and psychologist who specialized in extreme conditions, believes that unscrupulous people may use certain provisions of the Soviet mental health act, if restored, as a tool to settle scores, as was in Soviet times.[78] He says, "In some particular cases, people will simply write complaints against a person, will subject him to involuntary psychiatric examination. And he can be declared crazy after some bribe money have been paid. Creative, nonordinary, talented people have labile (as scientists say) nervous system, movable psychics. And they can be declared not quite normal mentally and, perhaps, even dangerous."[78] Sergei Shishkov, the key lawyer of the Serbsky Center, also disagreed with Vinogradov, "We are unlikely to return to the Soviet mental health act. It would be contrary to the international norms, which Russia has joined, as well as to the Russian Constitution. Article 29 of the Mental Health Law allows placing dangerous patients in a hospital. But when following necessary judicial procedures. If a patient is too socially dangerous, he is placed in a hospital, and a judgment is made through the court post factum. If a patient cannot be left without treatment, but he does not give his consent to the examination, there is such a concept as "deferred examination", or examination postscriptum."[77]

In the countries of the former Soviet Union, there is very limited knowledge and understanding of declarations and international documents that guarantee the rights of the mentally ill and include the ethical codes, adopted by the World Psychiatric Association, and the Convention on the Rights of Persons with Disabilities with far-reaching implications for the mental health profession.[94] Individual cases can be solved by litigation at the European Court of Human Rights in Strasbourg, however it does not change the attitudes of both mental health professionals and government officials.[94]

In December 2013, the Independent Psychiatric Association of Russia wrote to the World Psychiatric Association the open letter "On the failure of the Mental Health Law and alarming trends in domestic forensic psychiatry."[95] The letter reports on the failure of article 38 of the Law and requests to dispatch the audit commission to investigate a number of cases published in the Nezavisimiy Psikhiatricheskiy Zhurnal—the herald of the IPA, and at first to express formal concern about the contents of its letter.[95]

• Political abuse of psychiatry in Russia