Routledge Handbook of Psychiatry in Asia

Dinesh Bhugra, Samson Tse, Roger Ng, Nori Takei, Dinesh Bhugra, Samson Tse, Roger Ng, Nori Takei

• Publisher: Taylor & Francis
• Year: 2015
• Print ISBN: 9780415711319
• eBook ISBN: 9781134651726
• Edition: 1
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

Geographically and demographically Asia is a huge region with a large number of societies and cultures, each affected by their own unique problems including over-population, major natural disasters, poverty and changing social and economic factors. Inevitably this means that different mental health needs have developed across the region. Colonialism, globalization, industrialization and urbanization have brought major demographic and cultural shifts in the region but clinical mental health practices and services and societal attitudes to mental health issues vary enormously.

This handbook surveys the state of the current psychiatric care field across the whole Asia-Pacific region. Focusing on individual countries, each chapter will include:

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• A summary of factors affecting the practice and provision of psychiatric care, including cultural attitudes to mental health issues

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• Coverage of the conceptualisation, causation and prevalence of mental health issues in society

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• An overview of mental health care services and systems available and workforce training

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• Coverage of country specific innovative practices and folk therapies

As the first major reference work on psychiatric care in Asia this book is an essential resource for scholars and students researching mental health in Asia as well as psychiatrists and other mental health professionals working in the region.

Section 1

Russia and Central Asia

Overview

Valery Krasnov

In the former USSR, the clinical approaches, research methodology in psychiatry and organization of mental health care were the same in the Russian Federation and the republics of Central Asia (Kazakhstan, Uzbekistan, Kyrgyzstan, Tajikistan and Turkmenistan). The scientific conceptualization of mental diseases and diagnostic criteria were based on the traditions of European and Russian psychiatry of the nineteenth to twentieth centuries.

In the middle of the twentieth century, clinical judgments and therapeutic approaches were in no way different from those in Europe and the USA.

Psychotropic medications had been used since 1957, i.e. at the same time as in Western European countries, and by the end of the 1960s psychopharmacology had become the main treatment for mental disorders. Lobotomy and other forms of psychosurgery were prohibited at the beginning of the 1950s. Psychotherapy was mostly represented by suggestive methods, including hypnosis; autogenic training and progressive muscular relaxation were also widely used, as well as the so-called rational psychotherapy.

The system of psychiatric care in Russia and the republics of Central Asia of the former USSR underwent substantial change during the twentieth century. Until the late 1920s, the whole of psychiatric care had been centered around psychiatric clinics, and in the 1920s and 1930s, the ideology of the so-called psychohygienic concept of psychiatric care was developed. The focus of psychiatric care shifted to outpatient units, e.g. psycho-neurological dispensaries, or special outpatient units quickly created throughout the country. The territorially focused network of such units was successful in covering most of the country. Psychiatric consulting offices were created at factories and universities, matched, in rural regions, with district outpatient units and psychiatric offices at district general hospitals.

However, psychiatric care units were generally undervalued, and to some extent, this sort of practice was similar to the concept of ‘community psychiatry’ developed in most countries in the late twentieth century, with some elements of sectoral psychiatric services.

However, by the mid twentieth century, the situation had started to change in some aspects, when huge hospitals (up to 2,000 beds) started to be constructed in large cities, and in general these dominated the structure of psychiatric care, although the network of district outpatient units still survived. The concentration of psychiatric care in large cities made providing aid to inhabitants of remote settlements in Siberia, the northern territories and the mountain regions of Central Asia more difficult. By the early 1990s, the number of beds per 1,000 population had approached 1.5. In addition, in the early 1980s, due to widespread alcoholism (especially in the Russian Federation), the special narcological (addictological) service was detached from the general psychiatric service, with its own network of local offices, outpatient units and several special narcological clinics. Most of the psychiatric beds were located in large cities, while many difficulties remained in rural regions in providing both consulting and care services, especially urgent care, due to the large distances between regional centers and remote settlements.

Forensic psychiatric clinics and wards used to exist independently of general psychiatry. One of the definite advantages of the Soviet psychiatric care structure was its chargeless character for the whole population (as for all other types of health care). There used to be no private or commercial clinics. However, in the 1970–1980s, the drawbacks of the existing system started to come to light; first of all was the hypercentralization of the service, with all professional and technical capacities concentrated in large hospitals. Another drawback was the closed character of psychiatric facilities and their separation from general medical ones with lack of regular professional contacts. Unlike most of countries, at this period, in the USSR, there was no public control over the conditions and the quality of psychiatric care provision. With the relatively high level of psychopathological and general clinical education of the practitioners in the country, the dominant paternalism of the psychiatrists’ and medical institutions’ practices prevented even the slightest autonomy for patients.

It should be also mentioned that there was no special law concerning the provision of psychiatric care in the USSR at all. The regulation thereof had been prescribed by instructions from the Health Ministry. This had formed the grounds for the intervention of political pretexts into the professional psychiatric sphere and particularly was the basis for cases of abuse of psychiatric care for political reasons. Of worldwide notoriety was the practice of prejudiced psychiatric assessment and forced hospitalization to forensic psychiatric wards of so-called ‘dissidents’, critics of the Soviet system. These episodes were the subject of acute and mainly well-grounded criticism by human rights organizations and the World Psychiatric Association. Without recognizing and accepting this concern of several international committees, the Soviet administration, however, agreed to stop interfering in the regular professional activities of psychiatric services, allowing the professional psychiatric community to exercise reforms and democratization therein. This process was mainly executed in the already autonomous post-USSR states and was characterized by more or less common principles and solutions, matched by some locally motivated special features and directions.

In 1991 the Soviet Union fell apart and several other countries were formed (the former Union republics). Russia was the first country where a law on psychiatric care was passed. In 1992 this law was confirmed by the Parliament and it took effect in January 1993. The Russian law on psychiatric care, and guarantees of citizens’ rights in its provisions, was accepted and commended by international experts. The law considerably widened patients’ rights and restricted the possibility of unlawful actions in the course of psychiatric treatment.

In the 1990s Russia and most of the new countries (former Soviet republics) suffered severe crises, not only economic but also social and psychological, because of the loss of social identity and stratification of society without cohesion and psychological support in any communities. The consequences were an increase in suicide rates, migration, family problems and addiction among adolescents (which was rare in Soviet times). Until now Russia and the countries of Central Asia have been more or less in a transitional period of development.

The situation was especially painful for persons with severe mental disorders. They suffered not only from mental illness, but also from misunderstanding of their problems by society. Apart from the negative consequences mentioned above, a common burden in each country that still remains is stigmatization of the mental health sphere as a whole.

Another consequence was a shortage of qualified specialists. As is written in Chapter 2 on Kyrgyzstan:

The emigration of high-level professionals is relevant for all ethnic groups in the country. There was an imbalance between emigration and immigration from 1990 to 2010. The majority of psychiatrists who left the country permanently were ethnic Jews, Russians, Germans and Ukrainians. Moreover, many Kyrgyz psychiatrists had already left the country to work in other countries of the region, mostly Russia, as primary care physicians. After the political instability in Kyrgyzstan in 2010, the migration flow to Russia increased.

At the same time the psychiatrists in all these countries did try to develop psychiatric care despite difficult conditions, limited budgets and other problems. New forms of mental health care are developing taking into account local conditions. Many projects have been implemented with the support of international agencies, especially in Kyrgyzstan and Uzbekistan, rather less so in Kazakhstan and Russia. Not only technical support should be mentioned, but also the provision of ethical and legislative norms in psychiatry.

Central Asia is a major part of the Asian continent. It includes five republics of the former Soviet Union: Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan. In this section we consider the situation only in the three Asian countries and the Asian part of Russia. It has not been possible to obtain information about mental health services in Tajikistan and Turkmenistan.

1

State of mental health care in the Republic of Kazakhstan

Saya Nurmagambetova and Marat Assimov

Geographical location of the Republic of Kazakhstan

The Republic of Kazakhstan is the ninth largest country in the world, at 2,774,000 square kilometres. It is located across the junction of two continents – Europe and Asia. To the east, north and northwest Kazakhstan has borders with Russia; in the south with the Central Asian states – Uzbekistan, Kyrgyzstan and Turkmenistan; in the southeast with China. The total length of the borders is over 12,200 km, including 600 km along the Caspian Sea (in the west). Over a quarter of the territory of Kazakhstan is covered by steppes, half by deserts and semi-deserts, and the remaining quarter by mountains, lakes and rivers, and coastal areas. The water resources of Kazakhstan depend to a large extent on the rivers and lakes. The rivers are largely fed by glaciers. Kazakhstan’s climate is strongly continental. Average temperatures in January range from –19°C to –4°C, in July from +19°C to +26°C. The lowest recorded temperature is –45°C, the highest +30°C.¹

The Republic of Kazakhstan consists of 14 provinces and two cities of republican status – Astana (the capital since 1997) and Almaty (the former capital). The country’s population at the beginning of 2013 was 16,967,500, of whom 9,314,100 (54.9 per cent) could be classified as urban and 7,653,400 (45.1 per cent) as rural. The population consists of 131 ethnic groups, including Kazakhs (63 per cent), Russians, Ukrainians, Germans, Uzbeks, Tatars and Uyghurs.² According to World Bank data, in 2012 the GNP per capita in Kazakhstan was US$12,007 and about 4.5 per cent of GDP was allocated to health care.³

Available data on psychiatric epidemiology

The number of registered patients with newly diagnosed mental and behavioural disorders decreased from 18,936 in 2011 to 17,079 in 2012; the incidence of such disorders per 100,000 population in those two years was, respectively, 114.4 and 101.7.

Mental and behavioural disorders in children have also slightly decreased, from 170.1 per 100,000 children in 2011 to 148.7 in 2012. Higher incidence rates are recorded in the Pavlodar (425.3) and Karaganda (339.1) regions. Mental and behavioural disorders in the adolescent population also decreased in incidence, from 166.9 per 100,000 in 2012 to 131.5 in 2011; the regions with a high incidence were Kostanai (497.0), North Kazakhstan (363.6) and Almaty (362.0).

The apparent decreases in both the incidence and the prevalence of mental and behavioural disorders may in fact result from a combination of an increase in the population of Kazakhstan and a shortage of specialists in mental health services.

At the beginning of 2013 the total number of patients with mental and behavioural disorders (excluding the use of psychoactive substances) had slightly decreased from 287,832 in 2011 to 277,133, and prevalence of mental disorders was 1,633.3 per 100,000 population (vs 1,726.1 in 2011). Notably, only 78,724 people had consulted the psychiatric services. Higher than average prevalence rates were seen in the Karaganda (1,801.2) and Kyzyl-Orda (1,801.3) regions.

In accordance with the Mental Health Ordinance Order Number 663 of the Ministry of Health of the Republic of Kazakhstan, dated September 28, 2012, since 2012 dispensary (outpatient clinic) patients with mental and behavioural disorders have been divided into two groups:

1. patients under medical supervision (dispensary);

2. patients under consultant observation (after 12 months of observation these patients can be ‘removed’ from this observation or transferred to dispensary supervision).

The number of children under observation decreased from 40,724 in 2011 to 37,836 in 2012 (among them, 22,853 were under dispensary supervision, and 14,983 were under consultant observation). In 2011, the prevalence of mental and behavioural disorders in children was 980 per 100,000. This indicator was high in the Karaganda (1,796.5) and East Kazakhstan (951.9) regions.

The total number of mental and behavioural disorders in adolescents in 2011 was 14,892 per 100,000. In 2012 this figure was 9,204, but counting only patients under dispensary observation.

The number of patients removed from dispensary observation due to recovery or health improvement was 1.8 per 100 patients in 2012 (3.3 in 2011).

The number of new cases with ...

Table of contents

• Cover Page
• Half-Title Page
• Title Page
• Copyright Page
• Table of Contents
• List of figures
• List of tables
• Notes on contributors
• Preface by Dinesh Bhugra, Samson Tse, Roger Ng and Nori Takei
• SECTION 1 Russia and Central Asia
• SECTION 2 Indian subcontinent
• SECTION 3 Greater China
• SECTION 4 Far East
• SECTION 5 South East Asia: Malaysia, the Philippines and Singapore
• SECTION 6 Thailand and nearby countries
• Index