Mental health policy and practice across Europe: an overview

Policy in former eastern bloc countries 399
What they all share, despite economic and cultural differences, is the common
legacy of their mental health systems. Unlike Russia, after 1989 it has been
much easier for sizeable groups of the psychiatric profession in the other three
countries to draw a distinction between propaganda and reality. Much of this
debate, however, has not yet involved official decision-makers, including health
administrators in particular.
In a third group of eastern bloc countries, after 1989 the need for progress in
psychiatry was not contested but innovation was met with prejudice and
stigma. Discrimination against psychiatry was structural and manifested itself
not only as the prevailing layperson’s attitude to mental illness, but also as legal
restrictions in many domains of life. Although political abuse of psychiatry had
not occurred in these countries, respect for pluralism and human rights was
regarded as political clutter rather than as a realistic opportunity for new mental
health policy. For example, the authorities in these countries could afford to
tolerate the unduly dismal quality of life experienced in psychiatric institutions
without fear of public condemnation at home. Bulgaria and Lithuania are two
countries from this third group, which first saw reformist developments in the
non-governmental sector. Unlike Russia, which passed an impeccable mental
health law as early as 1992, even to this day Bulgaria has not reformed its mental
health legislation despite constant debate. The impression is, however, that in
reality the culture of psychiatric institutions in Russia has changed far less than
the culture of those in Bulgaria. Unfortunately, this finding can be substantiated
with ‘soft’ data only – a fact that pinpoints the limitations in shedding light on
social change exclusively with the help of quantitative analyses.
Sources of information
This chapter draws on a variety of different sources of information which are
often difficult to compare. Official country statistics were used for six countries:
Azerbaijan, Bulgaria, Georgia, Lithuania, Russia and Ukraine. Instrumental in
complementing this information with ‘insider’ interpretations were national
teams established for collaborative projects sponsored by international donors
and which constituted a regional network. Two projects in particular need to
be mentioned here. The first, ‘Attitudes and Needs Assessment in Psychiatry’
(Tomov 2001) examined the attitudes to mental illness and psychiatry, and the
expectations for reform, that prevailed in these six countries. This study was
conducted against a background of mounting criticism of health policy in eastern
Europe, which had seen a move away from universal access and tax-funded
health systems to more pluralist systems with a greater reliance on health insurance.
The principal criticism levelled against this move was that during times of
economic recession it would lead to a widening of inequity in access to health
care (Domenighetti 2003). This attitudinal study suggested that the introduction
of psychiatric reforms in such circumstances might not be wise if there was
little participation in the reform process by the community (as is the case in
all post-totalitarian countries), particularly if this fact is not acknowledged by
political and health governance institutions.
The second project, ‘Analytic Studies of Mental Health Policies and Services’