Natalya Lebedeva, a graduate of the Fundamental Sociology program of the MSSES, is conducting research on the medicalization of mental disorders. We talked with Natalya about how difficult it was to find informants for the study, why psychiatrists do not trust sociologists, whether it is possible to use the data obtained in an off-record interview, and how the new regulations of Moscow psychiatric services affect the specialists’ work.
Natalya Lebedeva, a graduate of the Fundamental Sociology program of the MSSES, is conducting research on the medicalization of mental disorders with the support of the OxfordRussiaFellowship program. She studies how mental health workers in Moscow and the Moscow region work in an environment of increased bureaucracy, when decisions from the top are made for the sake of the beauty of statistics and numbers, and what the consequences of reforms that do not take into account many professional factors can be. We talked with Natalya about how difficult it was to find informants for the study, why psychiatrists do not trust a sociologist, whether it is possible to use the data obtained in an off-record interview, and how the new regulations of Moscow psychiatric services affect the work of specialists.
What is medicalization?
The concept of medicalization originated in the 1970s with regard to the growth of the powers of medicine, which more and more often became the final authority in solving many public issues - from the regulation of births and deaths to the policy of insurance services. This rose to the uneasy feeling that medicine was becoming the hegemon in the modern world. In particular, the famous American psychiatrist Thomas Szasz, whose series of articles at that time was included in the classic collection devoted to this phenomenon, understood medicalization in this vein.
In the 1980s and the next decade, the medicalization debates shifted to a narrower channel of pharmacology. The growth of the market of the mental and neurotic treatment disorders drugs raised suspicions of collusion between pharmaceutical companies and medical services. Therefore, the term is usually used in a negative context. But the essence has not changed: medicalization is called the growth of the influence of medical institutions in a particular area of public life.
Psychiatry was initially subject to the concept of the organic nature of mental disorders. The human body and psyche as its derivative are usually presented as a kind of mechanism that from time to time fails at different levels of this system. The classification of psychopathologies, first proposed by Emil Kraepelin, was based on the physiological causes of mental disorders. This notion is still entrenched in the mass consciousness, despite the fact that the latest clinical guidelines ICD-11 and DSM-5 question Kraepelin's ideas about the nature of most mental disorders.
Deinstitutionalization of psychiatric help in Russia. A special way.
My research is not connected with the problems of diagnosis or the origin of mental disorders, but with the organization - or, more precisely, the reform - of the psychiatric service in Moscow and the Moscow region. In the Moscow region, the reform takes the form of a transition of mental health services to the system of compulsory medical insurance, and in the capital - the reorganization of neuropsychiatric dispensaries and strengthening the outpatient format of psychiatric support by reducing the number of inpatient psychiatric hospitals.
This process is called deinstitutionalization - the world has already had striking precedents, as, for example, in Italy, where, under the leadership of psychiatrist Franco Basagli, the famous "Law 180" was adopted in 1978, the law, abolishing all state mental hospitals in the country and replacing them with a number of public services. Such reforms cannot be assessed from the point of view of the effectiveness of managerial decisions - this is a change in the social paradigm, which can only be considered in the context of the joint efforts of medical workers, patients themselves and society as a whole.
I am afraid that in Russia the process of deinstitutionalization has taken a different path, despite the good goals of giving personal freedom to patients and ridding society of isolated psychiatric hospitals. Therefore, I am interested in how the service directives are refracted in the local orders of neuropsychiatric dispensaries.
This is an indicative case in the sense that, firstly, dispensaries are a link between different public authorities - not only psychiatric hospitals, but also courts, law enforcement agencies, and social protection. Many social routes pass through the neuropsychiatric dispensary in one way or another.
And secondly, after the reorganization of a number of psychiatric hospitals into neuropsychiatric dispensaries and boarding schools, the staff of these services has noticeably decreased, and now all attention is focused on how the NPD employees comply with process indicators, whether the reform of the psychiatric service was really effective in this regard.
In Italy, at one time, the abolition of hospitals was compensated by the creation of outpatient psychiatric centers. We were mainly engaged in the optimization of what we have. A large-scale reform began in 2015 - the first data on performance indicators will appear by 2020. But we can already say that expectations do not correlate well with reality.
The reform of the Moscow psychiatric service. Expectations and reality.
Previously, the standard for repeated hospitalizations in a psychiatric hospital was 1 time in 3-4 months. Now it should be maintained at the level of once a year. Almost in every interview I hear that there should not be repeated hospitalizations. But at the same time, according to informants, doctors are forced to carry out the tricks and re-admit patients to the hospital under different names for fear of lowering formal process indicators and getting a reprimand from the management. This is considered a flaw in the outpatient department and directly contradicts the goals of the ongoing reform.
However, repeated hospitalizations are associated not with the negligence of doctors, who missed something, from which the patient's condition worsened, but with the specifics of certain disorders. Firstly, such conditions are, in principle, poorly controlled, and secondly, many drugs that treat mental disorders have a cumulative effect - it only begins to manifest itself in the 30 days allotted according to the new hospitalization standard. Doctors simply do not have time to adjust the treatment program in time if something goes wrong. Plus, the medical conditions of patients often prevent them from taking medications on time - someone must monitor this.
Short-term inpatient stays are also a well-known disadvantage, which has already taken place in developed countries that have de-institutionalized mental health care. Certain standards should be maintained: for example, for 100 discharged patients, 10 should be provided with inpatient beds in case of a relapse of the disease.
Now on the territory of Moscow there are only 3 psychiatric hospitals, each of which has a number of neuropsychiatric dispensaries. In my opinion, a complex and opaque network of hidden contracts is formed in this system. For example, if an incident occurs with a violent patient in one of the NPD, the administration of the dispensary knows how to carefully hush it up, how not to show that the patient has caused some kind of disturbance of public order.
In the Moscow region, where the reform is associated with the transition of psychiatric care to the compulsory medical insurance system, dispensaries are also part of polyclinics, but they have greater autonomy and report directly to the regional ministry and the Central Clinical Psychiatric Hospital. Here, NPD doctors are assessed by their throughput - how many patients they were able to receive. The issued admission coupons are accumulated in the Central Clinical Hospital, insurance companies regularly request lists of patients and their cards - thus the per capita financing of the dispensaries' work is calculated.
Now the approximate indicator of the throughput of a doctor in the NPD in the Moscow region is 25 people a day at full time. For comparison, the description of the desired organization of outpatient mental health care in the WHO guidelines indicates that there should be 100 patients for every 10 doctors. That is, our indicators differ from the optimal ones by 2.5 times.
But in Europe there is nowhere such a form of psychiatric care as a neuropsychiatric dispensary. In Germany, for example, there is a separate psychiatrist's office in general clinics. This is due to a decrease in the stigmatization of mental disorders: the patient does not come for help to a special isolated institution, but to where everyone else goes. This is also a WHO recommendation - to integrate the mental health care system into regular polyclinics, and not create a network of closed institutions.
In Moscow and the Moscow region, this is hampered by the problem of financing: optimizing the work of outpatient psychiatric care only by closing hospitals is apparently not the most effective solution. The entire burden with it falls on doctors, who complain about a sharp increase in paperwork: filling out various forms, maintaining double-entry bookkeeping. Even programs for electronic patient admission in hospitals often have incomplete functionality, and doctors are forced to duplicate all documents (patient cards, extracts) manually.
In addition, in the Moscow region, psychiatric service doctors work in an increased workload, because, in addition to receiving patients, they are engaged in issuing certificates - two queues go to one specialist at the same time, and he prescribes treatment with one hand, and conducts an examination and writes out conclusions with the other. Plus, there remains a huge scope of work, which turned out to be beyond the vision of the adopted standards: going to courts, going to polyclinics to participate in general medical commissions, interacting with social services, patients undergoing compulsory treatment by court order, etc. Moscow psychiatrists do not have much of this in their responsibilities, the scope of work is more clearly defined, and the standards for the state assignment for the capital and the region do not differ too much.
Exactly this aspect of the reform, the influence of formal and particular rules on the actual work of psychiatrists, is the object of my research. What system are these rules in? And what is the ratio of external requirements (government assignment, various medical reference books and regulatory documents) and the internal regulations that have developed in the team of a specific NPD? What are the doctors guided by when making this or that decision? How does the interaction of employees of psychiatric hospitals and NPD with patients work?
Research architecture. How to find and talk to informants.
Initially, it was planned to consider these interactions from the side of patients, so the focus of the study was directed mainly towards psychiatric hospitals. But the plan turned out to be too ambitious: it is quite difficult to get to a psychiatric hospital, and with such a research design, it would have to live there like an anthropologist. Therefore, in the process, I switched to motivating doctors in the context of the new rules of the NPD.
There were very big problems with access - not only to institutions, but also to information in general. I tried to contact psychiatrists through friends, but in the end I still had to go to the administration of the psychiatric hospital to explain what the study was. By law, psychiatrists generally have no right to disclose any information about their work without the permission of the Ministry of Health.
This is a problem familiar to sociologists - there are a number of techniques for getting such informants to talk and, in particular, making them switch from the language of standards and documentation to speech that is more understandable for a person. You can not ask sharp questions head-on - for example, do not sharpen attention when a doctor talks about postscripts. You just pretend to be a mathematician, you say, “Wait, something doesn’t agree with me - let's calculate how long the shift lasts. Yeah, it turns out 15 minutes per patient. But this is unrealistic, especially with the initial treatment!”
But most of the questions are pretty simple. Tell us about your daily routine. Here a patient comes to you with such and such a problem - how do you make a decision in this case? In what cases do you send to a boarding school, what is needed for this? Are appeals lost? How is the data transferred if the patient changes his place of residence? How is the process of issuing certificates arranged, how long does it take? How is cooperation with law enforcement agencies organized?
This is a semi-structured interview without a pre-thought system of questions. It is difficult to search for patterns in a large list of free questions. The informants could not often answer everything, since I could not keep the doctor busy for an hour. Plus there is a problem with recording a conversation, when data not recorded by the recorder cannot be used as valid.
We even had a discussion among the OxfordRussiaFellowship scholars about this. I used only one such conversation, but, of course, with the caveat that it was partially reproduced from memory. He was a very valuable informant with extensive experience in various psychiatric services - boarding schools, ambulances - since the 1990s.
Institutional reform that affects everyone
Hypotheses are also going through some changes now. It was assumed that the work of psychiatrists was influenced by the disposition of relationships that develops between wide ranges of psychiatric actors: from the Ministry of Health to the medical staff of a particular institution. But this hypothesis was not fully confirmed, as can be seen from the example of the so-called postscripts, when Moscow doctors, in order to comply with the formal rules of the state assignment, enter 2 - 3 unnecessary patient admissions, allegedly on the basis of adjusting the treatment. In this case, how physicians circumvent clinical guidelines and regulations depends on a more complex combination of factors than the formal structure of the relationship between the NPD and, let’s say, a hospital or ministry.
There is a formal circular of rules and a certain hierarchy. But there are also purely professional things. The relationship with the patient does not always fit into the existing regulations. When a situation requires personal intervention, the doctor does what is best for the patient. And the management is sympathetic to this kind of "violations" of the procedure. That is, the degree of loyalty of the management and the employee's willingness to take responsibility for actions outside the rules play an important role. This, of course, does not happen in all institutions: someone only needs beautiful statistics and no arbitrariness.
For Moscow and the Moscow region, the difference in such practices can also be explained by the fact that the NPD in the Moscow region reports to the insurance service, where the checks are arranged differently, and there is no stable scenario how you can hush up some inconvenient things.
But I am just beginning to analyze the collected material - individual plots are beginning to emerge, but it is too early to speak about definite conclusions.
When I applied for the OxfordRussiaFellowship, we were asked to justify why this particular study was important. Here I, probably, will not reveal any new truth: reforms in psychiatry continue to excite society in Russia, where until the 2010s there were also cases of punitive psychiatry in the traditions of the Soviet period. And people, of course, are interested in what direction this system is changing now.
Almost every one of us, in one way or another, is forced to interact with mental health services. This is necessary for concluding real estate transactions, for employment, certification for work in law enforcement agencies, paramilitary structures, some social services, admission to training, obtaining a driver's license, rights to bear arms. And the prevalence of mental disorders is quite high - if people do not seek help yet, this is mainly due to the stigmatization of these diseases.
First of all, this is a study of how people work in conditions of increased bureaucracy, when decisions are made from above, formally, for the sake of the beauty of statistics and numbers, and what the consequences of reforms that do not take into account many professional factors can be.
What to read about the research topic?
Szasz T. The Medicalization of Everyday Life: Selected Essays. Syracuse. NY: Syracuse University Press, 2007
The Sociology of Mental Illness: Basic studies / ed. O. Grusky, M. Pollner. NY: Holt, Rinehart and Winston, 1981
Conrad P., Schneider J.W. Deviance and medicalization: from badness to sickness. Philadelphia: TempleUniversityPress, 1992
Bardina S. This is nonsense! Is it possible to make sense of the madness? M.: AST Publishing House, 2018
Saltman R.B., Figueiras J. Reforms of the health care system in Europe. Analysis of modern strategies. M .: Geotar Medicine, 2000