Moldova: towards a new psychiatric care system

Moldova is undergoing a radical reform of the psychiatric care system. The country is transitioning from the old model of psychiatric assistance to a new system, based on the establishment of so-called "community medical centres". A reportage

F. seems to tell his past with ease. He remembers the phases of his life that he spent in the Codru psychiatric hospital almost as stages of a journey. He shows photos, which he has digitised and stored on his cellphone, and associates them with specific moments, memories. He then associates faces and names with these memories. "This one, with the guitar, is the doctor who took care of our ward", he says, sliding his finger on the screen, "here we were having a kind of party, in masks...".

From the capital Chișinău, you have to go down a long descent to get to Codru. A wooden religious icon marks the entrance to the town, which develops around a few streets lined with houses and apartment buildings. The Spitalul Clinic de Psihatrie, which is among the largest in the country, stands on a dirt road just after the houses. It is a large green area, where the wards of the psychiatric hospital alternate with nineteenth-century buildings often in ruins, gardens, and internal walkways.

The Soviet past

"I remember the times of the USSR: all medicines, healthcare, and hospital stays were covered by the state", says deputy director Iurie Pavlov. "There was simply more money and everything worked better. Now, instead, we have to deal with various problems, from lack of staff to scarcity of resources and supplies".

The hospital area was built in the Tsarist era, starting in 1895, and functioned in all respects as a psychiatric colony: people with mental disease were "interned" in the large reception facilities and assigned a plot of land to cultivate or a job in some factories specifically built inside the colony. The complex included a school, a church, and other facilities.

Then, in Soviet times, the psychiatric model called "Shemasko " was introduced, which provided for a total coverage of operating costs by the state and a strong centralisation of organisational procedures and treatment methods. "Even during that time, patients were given the opportunity to do some work", continues the deputy director. "Patients crafted, packaged for the postal system, worked in the on-site greenhouses and glassworks, and received a salary".

Today, the hospital offers assistance to 7,000-8,000 patients per year, against a staff of about 30 people including psychiatrists and psychologists. "It is a general problem, which has to do with the economic condition of Moldova. Many doctors emigrate in search of a better salary, to Western Europe or even to neighbouring Romania (where salaries can be up to four times higher than in Moldova and where for a couple of years the procedure for the recognition of qualifications in Medicine issued by foreign countries has been significantly facilitated , ed.) In addition, the system has changed a lot. Patients are no longer interned. They can still engage in small activities, from drawing to watching films or gardening within the area, but as a national hospital we only deal with the administration of drugs and emergency treatments. The actual rehabilitation process is now being taken over by the new community centres".

The Mensana project and community medical centres

F. – who is affected by a form of schizophrenia – knows that healing is a continuous and constant path, which does not happen overnight. "There are phases, the main thing is to learn to control the problem. In Codru, in addition to the more peaceful, sometimes even fun moments, the atmosphere was heavy and there was no possibility of doing much. Some of the drugs that they used to give us, I really hated them. You could be tied up in a straitjacket if you had a seizure or panic attack". The fact is that, for F. and his family, emergency treatment at a state hospital like Codru was virtually the only path available. "It was almost an automatic thought: if a person had a mental disorder, they were taken to Codru. Then, over time, I saw that alternative methodologies and centere were born, but they are still little-known practices and information is often missing. I don't know if I would have turned to them from the beginning, it's difficult to say in hindsight".

Moldova is transitioning from the old model of psychiatric assistance to a new system, based on the establishment of so-called "community medical centres", borrowed mainly from the Dutch context. In addition to the structural difficulties, state hospitals have been hit by some scandals and put under accusation by the press and public opinion for the harshness and the level of coercion used in treatments. In 2012, for example, a short documentary by journalist Natalia Ghilascu reported abuses and forced segregations by medical personnel operating in the state structure of Balti. Accusations of beatings and violence against a patient have recently arisen in Codru too. In general, however, it is the very concept of "systematic concentration" of psychiatric patients in few, large structures (in Moldova there are only three – Codru, Balti, and Tiraspol) that has proved inefficient and not very committed to seeking treatment practices respectful of the dignity of patients.

"As has happened in various parts of the world, also in Moldova psychiatric care practices have been a source of abuse and violations of human rights", says Mensana project spokeswoman Costanta Popa. "In 2010, the Moldovan Ministry of Health made the decision to reform the existing system. Therefore, thanks also to Swiss funds and with the collaboration of the Dutch Institute for Mental Health and Addictions Trimbos, the Mensana project was started, which seeks to overcome the current model in view of an organisation of psychiatric care that is more decentralised and more attentive to the needs of the patient. It was clear that there were difficulties and structural problems that had become unsolvable. In particular, in Soviet times, psychiatric treatment was also used for the purpose of punishing dissent and coercion of subjects deemed dangerous or “suspicious”. Later, from the 1990s until today, our system (as well as, in general, those of post-Soviet nations) has not been able to achieve the quality standards set by the United Nations Convention on Rights of people with disabilities or in any case to fully respect human rights. In addition, the structures built on the Moldovan territory responded to a logic of segregation of patients from the rest of the community: they were located outside inhabited centres, often near woods or isolated areas".

Starting in 2014, four pilot "community centres" (in the districts of Soroca, Orehi, Cimislia, and Cahul) were established through the Mensana project, covering a population of 412,000 people. Psychiatric assistance is offered thanks to the work of groups of professionals including psychiatrists, psychologists, nurses, and social workers, also with home visits. In the period 2014-2018, which constitutes the first phase of the project, there was a reduction by 23% of people hospitalised in psychiatric hospitals adjacent to the pilot centres, which therefore prompted the opening of other 40 centres throughout the territory of the Moldovan state and the start of a second phase of development of the new system, which will continue until 2022.

Stigma and change

Finally, the biggest obstacle to change in the Moldovan psychiatric care system seems to be the widespread stigma that leads to concentration and segregation of patients. "When we started to develop the psychiatric care model reform project, mental health was almost a taboo subject, an ultra-stigmatised area", concludes Costanta Popa. "Not only by ordinary people, for whom in many cases it is a problem even to live near someone suffering from a psychological disorder, but also by professionals themselves, so it is difficult for them to conceive changes to their way of operating. An example: often it was difficult to convince psychiatrists and psychologists to provide home care. They did not understand why they should go to the patient and not vice versa. But once this change was made, it was clear how much this measure benefited both parties and favoured the healing process in its entirety. Therefore, it is essential to increase awareness on the topic, starting first of all from those who work in the sector and, at times, are reluctant to change their perspective".

 

 

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