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16 Dec 2008

By Emilia Chiscop

What lies behind a horrible murder, like that committed by Florin Astefanoaiei who beheaded his mother this summer in a flat in Iasi and then put her head on the window sill? Or like that committed by a woman from Iasi, Luminita Solcan, who, in the course of a religious service attended by thousands of believers stabbed to death the celebrated monk Roger, from France? Or like that by a teacher, Ramona Croitoru, from an elite high school in Iasi who, while on a visit to her parents three years ago, killed the village schoolteacher shocking her staff mates and everybody who knew her? All these had been long ago diagnosed with psychic problems, but after leaving Socola Hospital of Psychiatry, records of them were no longer kept by any institution responsible with monitoring their health condition. A part of the responsibility for these killings lies within the mental health system of Romania.

Almost everyone heard about the terrible murder that disrupted the peace of a summer evening in Iasi on July 3rd 2008. The news that a 39-year-old man beheaded his mother and put her head on the window sill and then tried to take his life by throwing himself out of the window circulated on all media channels. It was then made known that Florin Astefanoaiei had no discernment when committing the crime and that he was an old patient of Socola Hospital of Psychiatry of Iasi where he was hospitalized in 2002 and diagnosed with schizophrenia. However, six years have passed ever since, a period of time about which no medical or social institution can say anything concerning the health condition or treatment of a man who turned into a killer during a delirious fit. All this time, Florin Astefanoaiei had been living with his mother until voices from his mind 'commanded' him to kill her. If he had not committed the crime, this seriously sick man whom the block neighbors describe as having never been violent before would have continued to be left out of the institutional registers. This is perhaps the case of hundreds of persons with psychic problems in Romania, where the mental health system does not monitor its patients once they leave the hospital, if it is not they who take into account the seriousness of the problem. The horrible slaughter committed by Florin Astefanoaiei, labeled as 'the devil', is not only due to a mind disease. Maybe 'the devil' would have not existed if the patient had been taken care of in time. Or perhaps the devil is this very outdated system which calls for a reform that is being postponed year after year.

The same 'devil', another killing that shook the world three years ago. Luminita Solcan, aged 36, stabbed to death, in the neck, the famous monk Roger the confidant of Pope John Paul II from the Taize monastery in France, a pilgrimage site known in the entire world. Luminita Solcan was one of the pilgrims. She killed Brother Roger during the religious service, in front of thousands of people. In 2000, Luminita Solcan had been diagnosed with atypical depressive disorder, but the doctors couldn't say anything further about her. No specialist has consulted her ever since, until the tragedy happened.

'The woman was suffering from depression with atypical, i.e. delirious, hallucinatory elements. In most of the cases, the treatment leads to some normality, but when it is interrupted for a longer or shorter period of time, the disease may decompensate and evolve towards aggressiveness and socio-familial imbalances', stated in August 2005 Prof. Dr. Petru Boisteanu, director of Iasi Hospital of Psychiatry. 'I cannot believe at all it is about my daughter. She is a peaceful religious girl. She wouldn't hurt anybody. She went to France on her own and she paid the plane ticket with her money', recounted her horrified mother, a former teacher at a famous high school in Iasi.

Nobody's people

In the Romanian mental health system, persons with mental disorders have two possibilities in order to get consulted by doctors after leaving the hospital. One possibility is that their family keeps them permanently under attention, ensures that they take the medication and that they are regularly examined in ambulatory, and brings them to hospital in case of a new fit. This happens only in few cases.

'Due to the stigmatization of people with mental disorders considered shameful diseases, like syphilis and AIDS, the family of such a patient has an attitude that goes from one extreme to another', explains Dr. Serban Turluic, psychiatrist, Medical Director of the Socola Hospital of Psychiatry in Iasi: 'In the beginning the family swarms around doctors hoping they will make him well and deny that he is insane, but after several fits and internments the family tends to marginalize and exclude him he is not one of us. This turns into some kind of induced vegetation, the sick person is not involved in activities and the family is happy to see him quiet in front of the TV set', says Dr. Turliuc, raising one of the serious problems in Romania, where 'the mental disorder is something to be ashamed of, and that is the reason why the problems of the system are denied and hushed up'.

Under these conditions, the only possibility for a patient with psychic problems to be seen by a doctor is that of the murder case happened in Iasi. 'An anti-social act must happen so that he should brought back to the hospital by the police or caregivers', explains Dr. Serban Turliuc.

A golden mean monitoring and prevention does not exist. 'In order not to come to an anti-social act, we should have enough social assistants integrated in the mental health system, specially trained for this kind of problems'. They would regularly keep in touch with the patients, on a weekly or on a monthly basis, would check out their state, whether or not they take their medication, would guide them into having timely health controls' further states Dr. Turliuc.

The interests of the hospital above those of the patient

At the present time, social assistants, occupational therapists, paramedic staff as members of therapeutic teams together with psychiatrists, psychologists and social assistants exist only theoretically. The law on mental health, adopted in 2002, but only operational after application rules were enforced in 2006, at the pressure of the European Union, creates the framework for the reformation of the system, which is currently excessively hospital-based, which turns every person with problems into the prisoner of an unilateral approach taken by the psychiatrist who holds the supremacy.

'In Romania it is the hospital that lies at the core of the healthcare system. It decides on the reception or release from the hospital and, if there is a community healthcare center nearby, this one must have the consent of the hospital as well. Even the terms pre-hospital, post-hospital, complementary health care services, show the existence of a mentality that places the hospital in the center of the system', says Mugur Cumageanu, clinician psychologist, expert of the Ministry of Health and one of the authors of the mental health strategy in Romania.

Although they are provided for by law, joint therapeutic teams are not actually functional. Apart from the insufficient number of the social assistants, they lack the required training necessary to fulfill their duty expressed by law. 'In Socola Hospital, the second largest in the country, there are only three social assistants', explains Mr. Turliuc, Medical Director.

The figures at national level confirm a critical situation. During 2006-2008, when appointed by the Ministry of Health as Director of the National Center for Mental Health, body created with the aim of coordinating reform in this field, Mugur Ciumageanu remarked that within the psychiatric healthcare (hospital and community) system in Romania there were 110 social assistants, that is 800 less than the minimum required. In an action plan proposed to the Ministry last year, he drew attention to the fact that their competence is not clearly defined, that they do not have adequate training, and he proposed massive staffing, investments in their training, and regulations aimed at eliminating confusions related to social assistants' work within the therapeutic teams as well as the introduction of salary premiums in order to stimulate professionals into the system so that these ones should no longer be tempted to work in other fields which are better paid and where they don't have a marginal role.

Social assistants represent the most deficient category of Romania mental health system, but not the only one. Psychologists total a number of 350 while the required minimum calculated last year was 800. The doctors, which are the major category for psychiatry healthcare, are far from sufficient. In the Hospital of Psychiatry of Iasi, the shortfall in psychiatrists, for instance, rises to 60%, almost 10% higher than the deficit at national level. Nurses and doctors share a similar deficit, somewhere around 50%.

16.000 potential people with mental disorders in Iasi

According to the information posted on the website of the Ministry of Health, all these specialists currently work in 37 psychiatry hospitals, 75 psychiatry departments of other hospital units and 66 mental health centers. These exclusively state-owned institutions administer, at least theoretically, nearly 300.000 persons with mental disorders, if we refer to the percentage indicated by the World Health Organization, that is 1-2% of patients with severe mental problems out of the entire population. This means that for a population of around 800.000 in Iasi county, 8000 to 16000 have mental health problems. 'Concerning the prevalence of mental problems, WHO statistics are even more alarming. One out of three people had or will develop a mental disorder in the future', says Dr. Serban Turliuc.

That is more than 260.000 people in Iasi region and 7 million Romanians in total. The real number of the Romanian citizens facing such illnesses remains unknown at governmental level.

'In 2004, the Ministry of Public Health approved a study on the incidence and prevalence of mental disorders, contracted with the National Institute for Research and Development on Health (at the present, the National School of Public Health and Sanitary Management). The study should have been carried out on a sample of 5100 households. In 2007, the financing was no longer ensured by the Ministry, therefore the study was never finalized', holds Mugur Ciumageanu.

Out of the alleged 300.000 Romanians with severe mental problems, only 90.000 are permanently monitored, being assessed twice a year, in compliance with the law. They are the patients registered by the National Authority for the Persons with Handicap (ANPH), of which 70.000 are diagnosed with severe psychiatric handicaps. 'Practically, the other more than 200.000 are not constantly kept a record of by anybody', concludes Mugur Ciumageanu.

The dramas behind the blank figures

Much more evidence lies behind these figures. For instance, if all those 90.000 patients in ANPH registers were classified as suffering from neuro-psychic deficit, it would be unfair and inaccurate. Some are formally assessed and reconfirmed in diagnosis on social grounds. Among them there are the victims of the tough transition that Romania underwent during the 90s, when a large number of huge industrial companies closed their gates and thousands of people were fired.

'We had cohorts of women who found themselves jobless, useless at the age of 35-40, because nobody would employ them any more. It was an afflux of depressions, with suicidal attempts and bad fits, and we had to pension many of them. The legislator compelled us to carry out two assessments each year. It is well known that mental disorders may have episodes that do not occur only annually, but also once in five years. Therefore, we could un-pension some of them. If nobody employed them when they were 35-40, who will accept them now after being repeatedly admitted in psychiatric units? Facing this problem, as a doctor, all you can do is to reconfirm the diagnosis in order not to leave them out in the streets', says Serban Turliuc, who also notes that, in many cases, the social criterion takes precedence over the medical one, as well as regarding the admittance in establishments for psychiatric patients with chronic evolution, 'our failures' he says.

'The two institutions for chronic patients from Iasi county, located in Sipote and Birnova, are dead units. Nobody leaves those places alive. This is not because it wouldn't exist any psychiatric pathology there that might at least be corrected through occupational therapy or psyco-therapy, but because those units are occupied, in general, by abandoned or homeless people. We had there retarded people without parents or people from orphanages, who were classified as sick out of pity because they had no place to go to, and molested women', explains Dr. Serban Turliuc, who believes that these extreme and highly costly solutions would disappear if mental health policies sought to raise awareness of the society, that is to stop discriminating and stigmatizing those with such problems, and if investments were channeled towards the reformation of the system, with an accent on social psychiatry, a new domain that has been implemented for two decades in some states of the world such as United Kingdom, the Netherlands and the United States of America.

Unjustly stigmatized

As regards the other alleged 200.000 Romanians with severe mental problems, nothing more could be said. It is presumed that some are or were admitted in psychiatric units, others receive healthcare in ambulatory within hospitals and mental health centers, while others are not being monitored by anybody, as it happened for six years with Florin Astefanoaiei, who killed his mother this year while in a delirious fit.

However, if we consider all those 200.000 citizens with mental problems as dangerous people, this would be a stigma as unfair as if we consider as social peril the patients with hepatitis or heart affections. This is proven by the statistics of the Institute of Legal Medicine that show that aggressors with reduced or no discernment are a minority of the totality of people committing different types of violence.
In Iasi, the second largest county, for instance, of all the 698 psychiatric valuations carried out

in 2007 in relation to certain aggressions regulated by criminal law, 98 (14%) showed lack of or poor discernment.

Therefore, if violent acts committed by those deprived of discernment draw more attention to the public opinion, as they are much more publicized through the media, it is by no means due to the fact that they are more numerous, but more spectacular and sometimes more cruel. News are daily broadcast about assassinations or murder attempts but unlike these, a killing such as that committed by the man who cut off the head of his mother won't be forgotten too soon.

A hat too large on the heads of CSMs (Mental Health Centers)

The solution is the development of community psychiatry - say specialists open to reform and at the basis of this idea lies a very simple finding: 'all statistics show that the majority of people with mental problems can be seen outside the hospitals', stated Prof. Dr. Michaela Amering, psychotherapist within the Department of Psychiatry of the Medical University of Vienna, who was in Romania not long ago, where she participated in an EU-financed governmental project on the development of mental health services. This would require utter reformation of the mental health system, which is not easy to accomplish, on the one hand due to insufficient financing, on the other hand due to the resistance to change. 'Money and will are lacking', summarizes Dr. Turliuc the two big problems of the Romanian system.

First of all, at the basis of healthcare it would no longer be the hospital, like now, but the mental health centers defined by law as main specialized structures responsible for ensuring assistance to all those having health problems without requiring hospitalization. 'For Iasi, instead of a hospital with 870 beds, it should remain 450 and the rest of the patients be taken by community healthcare institutions', exemplifies the Medical Director of the Socola Hospital of Psychiatry.

In fact, Mugur Ciumageanu underlines, the focus should not be on one structure or another, but on the duties that the mental health community team carries out. 'Unfortunately, we are not used to think about duties. For the moment, all we have is the description of the Center as a building filled with furniture and personnel, that waits quietly, from within the hospital, for something to happen' comments Ciumageanu.

On the other hand, mental health centers, in the present-day conditions, cannot perform their activity according to the western standards of social psychiatry. Their responsibilities as they derive from the mental health law and implementing rules are confusing. Thus, if the law describes them as the main specialized structures of mental health, in reality, these function only as sections of hospitals 'sometimes in competition with the ambulatories of the same hospitals'.

It is not known for sure either to whom these bodies currently address, which, according to regulations in force, should do both prevention and early detection of different problems, ensure medical assistance in order to prevent acute episodes of illness in case of the patients diagnosed, guide patients towards protected dwellings, help them into social integration, monitor on site the mental problems during childhood, keep families at risk under supervision, ensure psycho-pedagogic services, etc. 'The problem appears at the moment when we imagine these things should get going by means of a team of seven persons the minimum requirement for operation' - remarks Mugur Ciumageanu 'a handful of discouraged, marginalized professionals in the mental healthcare system as a whole'.

As a consequence, he adds, the establishment order for these mental health centers can only be, under these conditions, 'a cosmetic measure that does not change the substance of things but rather creates false expectations'. What can CSMs do under these circumstances regarding their officials? 'Prescribe recipes, as they used to do in the years of Communism, being considered second-level institutions' comes the answer from the above mentioned expert.

The number of the centers that should each cover an average of 100.000 inhabitants is also insufficient. In Iasi city, for example, for a population of more than 350.000 people, there are only two mental health centers, 'Dr. Ghelerter' Center and the Mental Health Center in Lascar Catargi Street. 'Three more centers would be necessary in Iasi, but there is no money' says Dr. Serban Turliuc.

Cinderella of the Ministry of Health

The fact that money is the major impediment against reformation of the mental health system is proved also by the budget allocations. According to official data of World Health Organization, the budget for the national mental health program rises to only 3% of the whole public budget for health.

At the pressure of the European Union, the Ministry of Health launched in 2006 the national strategy for mental health, declared a national priority, and created the National Center for Mental Health (CNSM) in order to coordinate the reform in this field, promising great infusions of funds to that purpose. What was to happen afterwards showed that 'the strategy for mental health, i.e. the framework document of the reform, was rather used as an argument of the authorities that political will exists', says Mugur Ciumageanu, one of the authors of the strategy that he describes as 'a document devised patchily by a handful of professionals who did not have the time to consult the scientific community'.

Even so, however, the money infusion promised by the Ministry would have stirred things ensuring a financing of more than 50% of the strategy implementation plan. 'While the public budget for health was double in 2008 compared to 2007, the budget for the mental health program was seven times smaller: only 3 million euros in 2008, compared to 23 million euros in the previous year', states Cimageanu, who, in March 2008, resigned the chair of CNSM for that reason.

Therefore, the reform rather marks time. 'Much more needs to be done. There is no continuous link between hospital care and ambulatory treatments, hospitalization is being overestimated, most psychiatric doctors work in hospitals, which is not normal, and we have to fight against unshakeable mentalities', summarizes Ileana Botezat-Antonescu, Ciumageanu's successor in the chair of CNSM.

Although the law provides for different programs for prevention of mental illnesses, doctors are not aware of a penny having ever been allocated in this field. Connection psychiatry, i.e. employing psychiatric doctors in non-psychiatric hospitals for helping patients with other affections who develop psychic problems, is only a dream. The consequence is that patients are taken from one hospital to another, endangering their lives on the way to another clinic.

'Such cases are resolved by common agreement between doctors, but it can sometimes lead to serious situations. A hemophiliac was sent to us after having hurt himself. We cannot keep him in the psychiatry unit since we don't have the necessary equipments, and hemophiliac may die anytime, so we sent him back, but he twitched and was sent to us again, with a notice pointing to his homicidal tendencies. This is a way to get rid of patients with psychic problems', mentions Dr. Serban Turliuc.

The other institutions provided for by law healthcare services at home, protected dwellings, consultancy centers for domestic violence, etc. are just starting out, as the outcome of some partnerships with NGOs. It is but a long way until the community psychiatry will become the focus of psychiatric healthcare in Romania. Till then, those 200.000 potential patients with mental disorders, who are not listed in any registers continue to be left under the care of their families which have to play the role of the state.

Psychiatric Revolution in Cimpulung Moldovenesc

In Cimpulung Moldovenesc, a small town of 20.000 inhabitants, psychiatrist Alexandru Paziuc managed to do, in a few years, more than all the ministries of health have done since 1990 in the field of community psychiatry. He came to Cimpulung, as a disciplinary detached worker from Suceava: 'I came to make lots of enemies in Suceava because I often indicated that patients with mental problems in hospitals were not treated appropriately, are tied up and beaten', says Dr. Paziuc.

In Cimpulung, he reorganized the Psychiatry Department, later on turned into a hospital, taking as a model what happened in Western Europe. 'We started collaboration with Hamlet Trust British foundation, which provided assistance and support'. He set up units for occupational therapy, art-therapy, and was one of the first psychiatrists to understand that doctors should work together with psychologists and social assistants in order to speed up rehabilitation of patients.

Maybe his most unusual measure was when he turned a nurse position into that of a priest. Father Gabriel Grosu is paid by the Ministry of Health, conducts the religious service in the chapel that was arranged and painted in the former surgery room of the old hospital, talks with patients, organizes video sessions, engage them in community-related actions, collaborates with them for the 'To Be' magazine, edited by the 'Orizonturi' Foundation, which he manages.

Dearly loved by local people, the priest attracts lots of believers of Cimpulung who participate, along with patients, to important religious holidays. 'It is an extraordinary thing, they no longer feel stigmatized, kept away', says Dr. Paziuc, further mentioning that the hospital, in fact, continues a tradition. 'The building belongs to the oldest hospital in Bukovina, founded in 1881, with the contribution of the community and the help of the parishioner', says Dr. Paziuc who, taking into account what he did at Cimpulung Hospital, is considered one of the most 'avant-gardist' psychiatrists in the country.

The Mental Health Center in the city is one of the four centers of excellence in Romania, together with those form the university cities of Bucharest, Cluj and Timisoara. Al. Paziuc was many years the manager of the hospital, then head of Suceava Public Health Authority, and now is a PD-L (Democrat-Liberal Party) councilor, the hospital being managed by his wife, Dr. Ela Paziuc. Last week, Michaela Amering, from the University of Vienna, Hans Kroon and Hary Gras, from the Dutch Institute for Mental Health and Addiction, provided the staff of Cimpulung Hospital lessons of community psychiatry in the framework of a Phare project. The project is based on mobile treatment teams made up of 10-12 specialists (including doctors, social assistants, lawyers, etc.) whose principles focus on treating the patient in his/her home environment, i.e. outside the hospital.

Used with permission from Emilia Chiscop and Ziarul de Iasi. Copyright 2008.