A new concept of mental infantilism is introduced. It is proposed to differentiate between true infantilism and pseudoinfantilism. The former includes mostly various manifestations of emotional vivacity, and the latter is the consequence of mental pathology, cognitive and emotional deficiency in particular. It is stressed out that from biological point of view true infantilism belongs to a variety of mental normality. Characteristic traits of childhood and adolescence are summarized and their differences from pseudoinfantilism are analyzed.
"OBSERVATION OF RIGHTS OF PATIENTS OF IN-PATIENT MENTAL FACILITIES IN RUSSIA"[1]
Conducted in summer of 2003 by the Moscow Helsinki Group and the Independent Psychiatric Association of Russia monitoring conditions of patients in 93 mental facilities in 61 regions of Russia has demonstrated:
Even the right to security is not provided: there are many hospitals without disinfection chambers, only in 27% of mental hospitals there are all necessary means for disinfection, in 7% of mental hospitals it is not possible to do disinfection! The orders of sanitary epidemic stations are disregarded. There is no signalization and selector communication. It is not possible to hire junior personnel: only in 9% of hospitals situation with junior personnel is under control but it is due to unemployment in region. Only 17% of mental hospitals have journals for registering physical constraint, only 3% register aggressive actions. Censorship of correspondence takes place in 53% of mental hospitals.
21% of mental hospitals buildings has dilapidated to such a degree that it is evident by the naked eye. But the monitoring was conducted in region and territory and not in peripheral mental hospitals, where the situation is ten times worse. For instance, the Chief Physician of Stavropol Territory mental hospital I.A.Bylim said: "Our territory hospital is well financed[2], but seven peripheral ones drag out a miserable existence with 10 rubles (35 cents) per day for food and nothing by years for major repairs". That is why the official data is worse (B.A.Kazakovtsev and others, 1995, 1997), according to which a third of all mental in-patient establishments in the country since 2000 was declared unfit for use due to breakdown condition. So, the Altay republican hospital and the Tver regional mental hospital N 1 resemble "a city after bombing". Only half of all mental hospitals occupy suitable premises. Usually they are former barracks, prisons and detention camps. In 68% of mental hospitals there are still prison bars. Sometimes we used definition – a barrack type building in a veritable sense of this word. However, the pavilion type was not always praised, if it concerned former concentration camps, for instance, in vicinity of Moscow - the Dolgoprudny mental hospital. The Adygei regional mental out-patient center is situated in former stables. 21% of buildings have not seen major repairs sometimes since pre-revolutionary times. For instance, for a long time unsuitable catering facilities of the Udmurti republican mental hospital, calculated for 250 persons, now serves 800 persons.
In 34% of inspected hospitals one patient occupies less than 3 square meters and in 18% - less than 2.5 square meters, which is two times less than prison norms. The hospital norm was found only in 3% of hospitals! Instead of 25-30 beds abroad and 50 optimal for contemporary Russia prevail sections for 70-90 beds. The wards contain 10-15 or more beds, in 8% of hospitals beds stand in corridors and in two hospitals (in Bryansk and Krasnoyarsk) there are still double-tier beds. In 10% of hospitals foul smell was noticed, which was connected with decay of sewer pipes. In 3 inspected mental hospitals – the Krasnoyarsk Territory mental hospital N 3, the Rostov-on-Don city mental hospital (settlement Kovalevka) and the Yaroslavl regional mental hospital "Afonino" sewerage is non-existent at all. In 8 mental hospitals one lavatory pan is in use for 50 persons and in the Krasnodar Territory mental hospital N 1 – for 78 persons. Only in 7 hospitals the situation in this respect is satisfactory, and the best one in the Chukotka district mental hospital. Partitions in toilets exist only in 21% of hospitals, which puts the majority of the mentally ill in humiliating position. Purchase of pampers in many hospitals was called as needless "luxury". Patients have no place to keep their personal belongings because of cram and acute shortage of furniture.
19% of inspected hospitals have less than 20 rubles (70 cents) per day for their patients food and in the Prokhladnensk district mental hospital in Kabardino-Balkaria and in the Kostroma regional mental hospital lass than 10 rubles (35 cents), which is twice less the norm established in Russia for convicts. Relatives have to feed patients, bring them clothing, bedding, soap, electric bulbs and even salt...
Funding of such fundamental index as availability of medicines differs in various regions more than three times. 39% of mental hospitals don’t have even guaranteed minimum of psychotropic and anticonvulsive medicines of old generation. Patients are forced to buy the most part of medicines themselves. The laboratory and medical equipment in 38% of mental hospitals have been hopelessly out of date.
In this way the state actually delegates guaranteed to patients expenses to population and even patients themselves, who clean toilets and their meagre pensions are often used for hospitals needs.
Only in 14% of hospitals duration of treatment doesn’t exceed 45 days. Only in 11% of hospitals there are free telephones and only in 2% they placed directly in sections. Mobile phones are forbidden in most of the hospitals.
In practice all doctors are forced to work extra time treating 50-60 patients, which substantially decreases quality of psychiatric care, but otherwise their salary would be lower than subsistence wage. The doctor earns 2.6 times less than the construction worker. In 14% of inspected hospitals psychiatrists occupy less than 50% of planned jobs, which deprives patient of skilled psychiatric care. Recently because of great expenses the process of post-graduate training has been greatly hampered. In 16% of mental hospitals a serious shortage of nurses was noted (more than 50%), in the Orel regional hospital – only 24% of required number! In 13% of hospitals there are no lawyers because of their scanty earnings.
Remuneration for hard and dangerous work of employees of psychiatric in-patient facilities is below subsistence level. Life and health of workers of the psychiatric service are not ensured in spite of especially dangerous conditions of their work, because the RF Government for more than 10 years has not worked out the relevant legislative act.
Only with the knowledge of real dimensions of the described picture one can estimate at true worth the courage of workers of the psychiatric care at all levels, which nowadays ensures vitality of psychiatric establishments.
The presented gloomy picture, according to most Chief physicians, in reality is far from being the worst one: in the last three years the situation has substantially improved.
The involuntary hospitalization in 55% of hospitals is less than 5% instead of natural 15-20% and voluntary treatment in 64% of mental hospitals is almost one hundred percent, which indicates falsification of voluntariness. It is absolutely natural that extremely overworked doctors in such a way met innovations of the Law, which require substantial expenditure of time and efforts for organization of court procedure. But it is necessary to make allowance for a period of acquiring new habit, which after transforming into a stereotype becomes 10 times easier. Those, rather numerous mental hospitals, which made the required initial effort, already don’t need it and necessary legal mechanism has been working in many regions ( Arkhangelsk, Vladimir, Kirov, Kurgan, Orenburg, Orel, Smolensk and Tver regions, Mordovia Republic, Moscow). And mental hospitals, which have been hampering and only imitating the legal mechanism, have created difficulties of the initial period themselves.
Only a few psychiatric in-patient establishments cooperate with non-governmental organizations.
So, monitoring 2003 has demonstrated rude nonfulfilment at all levels by the state of its obligations stipulated by the Law. In particular, nothing has changed in regard to major construction, while since the year of 2000 one third of all psychiatric in-patient facilities of Russia has crossed the border of depreciation which is dangerous for further keeping of hospitals. That circumstance namely was connected with so called "Program of urgent measures for development of psychiatric care for 1995-1997" prepared by the Ministry of Health and adopted by the Government. It was financed by 0.2%! After that severe failure there was not any program in subsequent 1998-2002. New program for 2003-2008 is devoted to pasportization of existing psychiatric establishments. The pasportization was already conducted in 1989. It is well known that the task of such a kind is put forward with the aim to get a record and what is worse with the aim to prolong period of exploitation of buildings like prolongation of expiry date of medicines.
No protest was followed, the authors of Commentaries to the Law "didn’t notice" such blunt demonstrative attitude of authorities to the psychiatric service and mental health of population. The Russian Society of Psychiatrists also "didn’t notice" it. Moreover, working since 1998 in the Ministry of Health the Commission for working out draft law "On supplements and changes in the Law on psychiatric care..." introduced for hearing in the Duma in September, 2003, changed by lobbying text, which contained an attempt to bring down level of guarantees of financing from legal to governmental one. Instead of financing psychiatric care "in volumes securing a guaranteed level and high quality of psychiatric care" the draft law proposes to be confined to "the program of state guarantees for providing citizens with free medical care approved by the RF Government in the established order" (Art.17). Actually it is a refusal of guarantees as the experience of the last six years has shown. Only the public protest, undesirable in the pre-election period, forced initiators of emasculation of the next democratic law to use the tactical trick: to put off discussion till the spring of 2004.
On the basis of the results of the present monitoring and direct experience of colleagues at the All-Russia conference of chief specialists and heads of psychiatric establishments on October 2, 2003 we prevented the leadership of the Ministry of Health from approval of amendments without wide open discussion.
The monitoring has demonstrated in all places blunt violation of not only the right to decent conditions of keeping and adequate treatment, but violation of even fundamental rights to security, voluntariness and human dignity. A person in psychiatric in-patient facility often finds himself cut from outside world and communication with it, actually totally depends on a treating doctor and heads of the section. Patients are forced to live in conditions, humiliating their human dignity and specialists and personnel are compelled to work in hard and dangerous conditions, receiving beggary remuneration for their labor. Life and health of doctors and personnel are not insured and patients actually are deprived of legal protection. Thus, the monitoring has confirmed the urgent need for establishing the Service for protection of rights of patients in psychiatric in-patient facilities, which would urgently and pliably correct at least the most serious violations. At the time being in many hospitals even complaints are subjected to censorship, which is a direct violation of the Law.
And still, the main achievement of the monitoring is blazing trail of the first large scale experience of public control, which has allowed to bring dramatic information to consciousness of not only wide layers of public, but to psychiatrists too.
The results of the monitoring have made it possible in a new way and much more adequately than before in regard to main priorities to look at the main reason of insufficient effectiveness of the Law. While earlier we were making long lists of guarantees for observation of the Law from availability of information about it to absence of Service for protection of patients’ rights, we were putting emphasis on either the latter, i.e. control function or absence of sanctions for non-observation of the Law or relevant legal consciousness, but now absolutely evidently in all its magnitude stands the domineering factor – guilt of the Government, which is the first and main violator of the Law. But admitting its irresponsibility and incapacity it is not subjected to any sanctions and doesn’t resign.
That elementary logical consequence from every day situation was qualified up to now in every possible way by various evasions. However, ten years were enough to take us for a ride. During that time the Ministry of Finance repeatedly categorically was refusing to allocate funds for realization of Article 38 of the Law of Psychiatric Care for creation of the Service for protection of rights of patients of in-patient establishments, i.e. the Article serving as an internal guarantee of observation of all the Law. Moreover, by the hands of the obedient commission the attempt is being made to actually decline the guarantees, the level of which is being lowered from imposed upon the Government to be determined by the Government! Concrete definition of guarantees is a task for by-laws, normative acts and instructions. Wholesome observation of stipulated in the Law obligations of the Government would have allowed the Law to work at least in three years after its adoption, i.e. in 1996 and would have allowed the psychiatric service to acquire second wind. At present it is falling to pieces.
The data collected in the monitoring is inexhaustible for further analysis in various aspects.
This text represents the part of a new future book of Moscow clinical psychotherapist-psychiatrist on clinical theatre-asylum for depressive defensive patients. This Theatre is a part of Russian native psychotherapeutic method – therapy by means of creative self-expression (Burno).
The purpose of the persisting research was a study of the efficiency of using antidepressant - pirlindole in complex therapy of paranoid schizophrenia patients, with resistence to neuroleptics therapy. On the whole were examined 32 persons (21 patient of the basic group and 11 patients of the control group), suffering from paranoid schizophrenia. The examination was realized before prescription of the preparation, then after 6 and 10 weeks after the beginning of pirlindole therapy. Duration of the observation before beginning of treatments was from 1 month to 1 year. Instruments used: PANSS, scale for depression (Hamilton). The authors substantiate using the preparation pirlindole for in patients with paranoid schizophrenia, resistant to therapy neuroleptics. Noted was not only high antidepressive effect of the preparation, but also its effect on all symptoms of schizophrenia when used in complex with neuroleptics. Using pirlindole in combination with neuroleptics raises efficiency of the last.
The goal of this article is to furnish the colleagues here in Russian with some information how in America an offender’s mental disorder may influence his or her criminal responsibility. The author reviews the basic "psychiatric" defenses starting with the insanity defense and its main formulations: the M’Naghten test, the irresistible impulse test, theDurham test, the ALI test, Federal test 1984. He also describes the other "psychiatric" defenses: the automatism defense, the diminished capacity defense, the "guilty but mentally ill" plea and perspectives of abolition of the insanity defense in America. Russian and American legal systems and philosophy of psychiatry in our two countries differ markedly. Sometimes it can cause difficulties in comprehension of some American concepts by Russian reader. In his efforts to make the process easier the author compares quite often Russian and American attitude to the problem or even "implants" some Russian examples into actual American situation and vice versa.
Mikhail Vrubel – one of the famous Russian artists of the end 19th and beginning of the 20th century. He serves as example of a man of genius who combined remarkable artistic accomplishments with severe psychopathology. In this article, we have attempted to examine the influence of the changes in the artist’s emotional state on the creative process. Vrubel’s biographers have made a special effort to separate reality from myth in the memoirs of the artist left by his relatives, friends and critics, on which they had to rely for their findings. The resulting descriptions portray Vrubel as a person endowed with controversial, often complex and versatile traits. The contradictions that abound in the descriptions of Vrubel’s character and conduct should, in all likelihood, be attributed not only to the complexity of his personality, but also to the possible effect of psychopathology on his behavior. We suppose that Vrubel suffered from affective disorder, complicated by syphilis, which influenced his creativity.
[1] Ref. "Monitoring mental hospitals of Russia" in IPJ, 2003, 2, 81-83. This text is being published in the editorial board of the IPA of Russia
[2] Still, in the Territory hospital there is an announcement for relatives to bring soap, washing powders, electric bulbs, salt, shampoo and towels.