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Above the town of Kuklen in the Rhodopes, not far from Plovdiv, is the monastery of St. St. Kozma and Damyan, also known as the first psychiatry in Europe in the Middle Ages. To this day, in the narthex of one of the two churches, shackles can be seen connected by a thick chain dug into the ground. At that time there were 12 of them, the mentally ill were in chains and spent the night in church. In the morning, the monks read prayers to them and then took them to the holy spring to pour healing water on them. On the first day, the pouring continued until the monk counted to two. The next day it lasted until three. So every day with a number on top. The end of “therapy” came when the monk reached the year 2000. According to legend, this type of psychiatric treatment worked in the 14th century.
Seven centuries later, in the field of treating the mentally ill, Bulgaria still counts. This is a finding from European reports that are not current today. You can see that. Most importantly, everyone who is affected in some way feels it.
Is Psychiatric Care Reform Science Fiction?
For years there has been talk of reforms in psychiatry. However, the talk is limited to repairs here and there, or terrifying reports. A few days ago, a new Strategy for psychiatric care with a horizon of ten years was uploaded to public discussion on the website of the Ministry of Health. As seven years ago, it also begins with the deinstitutionalization of the sick, but, unlike before, this time there are figures and concrete suggestions. Estimated at approximately BGN 600 million, the strategy aims to change the main problem in psychiatric care: fragmentation. Mental health centers are expected to open by 2024 in all seven regional centers, where there are currently none: Vidin, Montana, Gabrovo, Kyustendil, Silistra, Shumen and Pernik. In ten years there must be a network of daycare centers for psychosocial services, which must be in permanent contact with the psychiatric hospital services of each municipality. The strategy also foresees the opening of children’s psychiatric clinics in university hospitals, as well as increasing the salaries of medical personnel. A unified information system is also envisaged. Is all this possible?
“If I had not believed that the reform was feasible, we would not have uploaded the strategy to the ministry’s website,” Health Minister Dr. Kostadin Angelov told Deutsche Welle. “My first job in medicine was as a nurse at the Alexandrovska Hospital Psychiatric Clinic. I have been personally engaged since my first day as a minister,” he added.
Only 500 psychiatrists in Bulgaria
Common psychiatrists want to believe this too. In Bulgaria there are not so many, only 500 for the whole country. This field of medicine has stayed out of the clinical pathways, is funded in other ways and, in practice, lags behind in payment, sometimes many times compared to other specialties. Hence one of the first major problems to be solved by the reform: personnel. State psychiatric hospitals have a historical budget, which is justified insofar as traditional psychiatric illnesses tend to manifest themselves within the same framework, regardless of the generations. However, are new pathologies taken into account? The difference from the past is the increase in the number of dementias in elderly patients and the avalanche of disorders in children and young people: autism in its full spectrum, eating disorders, addictions. This is where things are really at stake, because there are a total of 22 child psychiatrists in our country and they are concentrated in Sofia and the big cities, and it is difficult to find candidates for specialization in this field. There is only one child psychiatric clinic. A year ago, a major Norwegian Financial Mechanism project helped train doctors and medical personnel to help with autism, Minister Angelov said, adding: “We have European projects in the future.”
Today the situation is critical
The new strategy comes at a time when things are really critical. The Addiction Department at the nation’s largest state psychiatric hospital “Dr. Georgi Kisov” in Radnevo has 60 beds, and patients rarely fall below 50. There are two doctors, nurses, a few more. The head of the department, Dr. Ivan Dobrinov, evaluates the strategy as “science fiction”, but adds that he will be very happy that it happens. However, previous strategies have set similar intentions, but nothing is happening except some other renovation of the building. “Deinstitutionalization is repeated like a mantra,” he says. The lack of a unified information system poses great difficulties for physicians. “The police or the ambulance take us to a patient who is in a stupor state. There is no information about whether he was treated, how he was treated, what his condition was. Every time you start over. Rather, things go wrong.” .
Abandoned construction of a new building within the Radnevo State Psychiatric Hospital for decades
Years ago, a detox room for drug addictions was established in Plovdiv, but after the introduction of methadone, it was closed. Literally the next day. In practice, a person who has stopped using drugs and is in abstinence cannot be helped anywhere else except state mental hospitals or for a hefty fee in some private practices. And over the years since the ward left, circumstances have changed: many more young people develop psychotic episodes after using a synthetic drug, many more need medical attention, and there is none.
“We work blindly”
If the reform is implemented in the proposed text, each regional city will have a Mental Health Center similar to that of Plovdiv. But what are the tricks there? “We monitor the condition of patients … whether they come alone or their relatives bring them. If there is a supportive environment, the patient is treated. However, we do not have the right to prescribe expensive medications, but to refer them to their personal physician for to issue them. address and must go to a private psychiatric clinic, where they will be discharged. And there, respectively, to pay for admission, “says Dr. Teodora Arabadjieva from the Central Penitentiary – Plovdiv.
She emphasizes that such a complicated path is difficult for a healthy person, much less for a mentally ill person. “The financing of our ambulatory unit comes from subsidizing the hospital beds. In practice, we do not accept dementias, addictions or serious pathologies. Milder diagnoses are preferred, funding is the same anyway. There is another – when issuing We have a case in which it was clear that we do not have one, but a complete monument of epicrisis with diagnoses of private practices left the National Institute of Social Security, because our report is important, On the other hand, the children with corrective defects treated, for example, for logoneurosis, who can no longer come to work as adults simply because they are in our records. “We work blind.”
Joro and Nikolay from Plovdiv
The supportive environment for the mentally ill turns out to be too important in this field of medicine. To better illustrate what it means, we will briefly describe two cases with a similar diagnosis. In both cases there are young men. Joro has a mother who also has mental disorders and can hardly take care of him. For years, Joro has roamed the streets like Forrest Gump, naked to the waist and barefoot in summer, whimpering in winter. He is not aggressive, from time to time he is hospitalized. When it comes out, it goes around again. His condition is only getting worse.
A supportive environment for the mentally ill is extremely important
Nikolai unlocked schizophrenia after taking drugs. There are concerned parents. After several years of treatment in the hospital and at home, after strict regular examinations and medication, he leads a normal life. Graduated from university, he works.
For Joro, someone must also control if he takes his medications, where he lives, if he eats, if he visits the doctor regularly. This is called “case tracking” and is done by social workers. But in our country this has been dead for decades. No this. Instead, the media periodically reports that neighbors are chasing a mentally ill woman from their block because they can’t stand her attacks. There are posts on Facebook that show a difficult case and good people rush to help, sometimes even succeeding. The end result generally depends on too many matches. That is why reports from abroad point us as a bad example.
We will see if the reform of psychiatric care takes place. The community itself is divided, so it won’t be easy. But it is indisputable that it is necessary. And not from now on. And hopefully it happens faster, not counting from 1 to 2000 as in the 14th century. Because Bulgaria is terribly late.
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