Mental health reform in the Russian Federation: an integrated approach to achieve social inclusion and recovery Rachel Jenkins,a Stuart Lancashire,a David McDaid,b Yevgeniy Samyshkin,c Samantha Green,a Jonathan Watkins,a Angelina Potasheva,d Alexey Nikiforov,e Zinaida Bobylova,d Valery Gafurov,f David Goldberg,a Peter Huxley,g Jo Lucas,h Nick Purchase a & Rifat Atun i Objective To facilitate mental health reform in one Russian oblast (region) using systematic approaches to policy design and implementation. Methods The authors undertook a three-year action-research programme across three pilot sites, comprising a multifaceted set of interventions combining situation appraisal to inform planning, sustained policy dialogue at federal and regional levels to catalyse change, introduction of multidisciplinary and intersectoral-working at all levels, skills-based training for professionals, and support for nongovernmental organizations (NGOs) to develop new care models. Findings Training programmes developed in this process have been adopted into routine curricula with measurable changes in staff skills. Approaches to care improved through multidisciplinary and multisectoral service delivery, with an increase in NGO activities, user involvement in care planning and delivery in all pilot sites. Hospital admissions at start and end of the study fell in two pilot sites, while the rate of readmissions in all three pilot sites by 2006 was below that for the region as a whole. Lessons learned have informed the development of regional and federal mental health policies. Conclusion A multifaceted and comprehensive programme can be effective in overcoming organizational barriers to the introduction of evidence-based multisectoral interventions in one Russian region. This can help facilitate significant and sustainable changes in policy and reduce institutionalization. Bulletin of the World Health Organization 2007;85:858–866. الرتجمة العربية لهذه الخالصة يف نهاية النص الكامل لهذه املقالة. .Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español Introduction rates along with widened socioeconomic pean Region, with rates of 69.3 per inequalities, high mortality from alcohol 100 000 males and 97.2 per 100 000 Mental illness is a major global health and tobacco-related diseases, rapidly ris- in the 45–54 year old age group.13,14 burden1 with substantial societal and ing HIV incidence and declines in life Between 1990 and 2000, the number economic consequences.2 In developed expectancy.6–10 of individuals registered as disabled countries, around 66% of people with The WHO Global Burden of Dis- because of mental illness increased by mental disorders do not receive treat- ease study – which used limited data 17.4% to reach 861 650. This accounts ment, but in developing countries this from the Russian Federation11 – esti- for 20% of all people registered as dis- 3,4 figure reaches 90%. mated unipolar depression to account abled in the Russian Federation.15,16 In Europe, after cardiovascular ill- for 4% of the country’s total burden The isolation of Russian psychiatry ness, mental disorders account for the of disease in 2002.12 The suicide rate during Soviet times and limited fund- 5 second-highest burden of disease. This peaked in the mid-1990s, when for ing of mental health services severely is particularly the case in the Russian men aged 50–54 years this was over curtailed access to new evidence.17,18 Federation and the countries in eco- six times that seen in the United States Consequently, most practitioners lack nomic and social transition around of America: 139 and 22.5 deaths per the knowledge and skills required to them. Following the collapse of the 100 000 population, respectively.13 In deliver a range of effective medical and Soviet Union, this region experienced 2002, Russian men had the second- psychosocial treatments necessary for increased mental illness and high suicide highest rates of suicide in WHO Euro- community-based care. a Institute of Psychiatry, Kings College London, de Crespigny Park, London SE5 8AF, England. Correspondence to Rachel Jenkins (e-mail: [email protected]). b Health and Social Care, and European Observatory on Health Systems and Policies, London School of Economics and Political Science, London, England. c IMS Health, London, England. d Sverdlovsk Oblast Ministry of Health. Ekaterinburg, Russia. e Sverdlovsk Oblast Ministry of Social Protection, Ekaterinburg, Russia. f AMH Project, Ekaterinburg, Russia. g Department of Applied Social Studies, University of Swansea, Swansea, England. h Kastanja Consulting, London, England. i Imperial College, London, England. doi: 10.2471/BLT.06.039156 (Submitted: 11 December 2006 – Revised version received: 29 April 2007 – Accepted: 2 May 2007) 858 Bulletin of the World Health Organization | November 2007, 85 (11) Research Rachel Jenkins et al. Mental health reform in the Russian Federation Moreover, despite the high bur- the Russian Federation were analysed to http://www.iop.kcl.ac.uk/departments/ den of mental illness globally, the understand the local context. In stage ?locator=430&project=10256). We used Millennium Development Goals do not two, we undertook a rapid situational interviews, focus group discussions, directly include targets for mental disor- assessment, an approach tailored from direct observations of clinical practice, ders; thus these illnesses attract meagre previous similar work in mental health teamwork and intersectoral liaison to investment by international donors.19 (for example, see www.mental-neuro- understand how our interventions in- Consequently, donor investment to re- logical-health.net) and communicable fluenced policy and practice. form mental health services in eastern diseases,28–31 which included site visits, We assessed the effectiveness of Europe, when available, has been sparse, discussions with key stakeholders and training using validated questionnaires short-term and unisectoral.20 key informant interviews to explore comparing pre- and immediate post- Although a Declaration and Action contextual and health system barriers course assessment of knowledge, fol- Plan endorsed by all WHO European to change and care delivery, especially lowed by interviews and focus group Member States prioritized mental health those factors which hindered intersec- discussions to ascertain if knowledge in Helsinki in 2005,21,22 the Russian toral approaches and the engagement and skills gained were applied when Federation and post-communist coun- of users and nongovernmental organi- planning and delivering services. tries have yet to introduce reforms to zations (NGOs) in the planning and We used routinely collected data enable innovative treatments to be em- delivery of care. These were augmented from the regional Health and Social bedded in routine care.23,24 by focus groups, direct observation of Protection ministries to measure service We summarize the main interven- clinical practice, and further examina- utilization by mentally ill clients, the tions employed and outcomes achieved tion of documents and routine data. number of dedicated beds for treating by a research project funded by the The data emerging from the sec- patients with mental illness, and admis- United Kingdom (UK) Department for ond stage informed the third stage of sion/readmission rates. There were no International Development. This proj- the study, which lasted two years and routinely collected patient-level data on ect adopted an integrated and multifac- included the design and implementa- outcomes. eted approach to mental health reform tion of three major organizational and in the Russian Federation that aimed to operational interventions aimed at: Results promote social inclusion of people with developing new structures to enhance The health system context mental illness. intersectoral working, strengthening Mental health has traditionally been a interagency collaboration, developing low priority within the Russian health Methods community-based services as alterna- system. While landmark legislation in tives to institution-based treatment and 1992 guaranteed the rights of indi- The study was implemented be- care, increasing the availability of social viduals with mental health problems, tween 2002 and 2004 in Sverd- rehabilitation, and fostering meaning- resources to support the system’s mod- lovsk oblast (available at: http:// ful involvement of users and NGOs ernization have been insufficient. In the www.iop.kcl.ac.uk/departments/ in care processes. First, we developed mid-1990s, the federal Urgent Measures ?locator=430&project=10256) in three federal- and oblast-level policy dialogues for Improving Psychiatric Care pro- pilot areas: urban, semi-urban and rural. and created intersectoral steering com- gramme received only 0.2% of gross It was directed by a multidisciplinary mittees (ISCs) at oblast and municipal domestic product (GDP) in funding group of UK-based and Russian profes- levels to coordinate access to health, and could not be implemented, while sionals led by the Institute of Psychiatry social care, housing, employment and it has been contended that in some in- in London and the government of the other support services for clients with 1 stitutions in the late 1990s there were Sverdlovsk oblast, in collaboration mental illness. Second, we established insufficient funds to provide adequate with the Russian Federal Government, and trained multidisciplinary spe- nutrition for inpatients.35