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Depression in post-communist Romania
World Report
Depression in post-communist Romania Depression and affective disorders have rocketed in Romania since the collapse of communism in 1989. Such illnesses are now a substantial health burden. But, reports Carmiola Ionescu, lowly government provisions for psychiatry mean that mental health care remains stuck in the past.
www.thelancet.com Vol 365 February 19, 2005
west where the emphasis is on a family environment. Romanian doctors say Ilin’s case is typical among middle-aged and elderly people in Romania who have not benefited from the country’s transition from Nicolae Ceausescu’s communist dictatorship to today’s free-market economy. Many have been left in poverty after being made redundant by companies looking to trim workforces as they adapt to the demands of competition on the free market and essentially have no chance of finding work. This, say the experts, has led to the doubling in numbers of cases of depression and the 7% rise in suicides. “The transition from communism has caused changes in the pathology of psychiatric illness in Romania”, says Florin Tudose, head of the psychiatric department at one of the largest hospitals in Romania, the University Hospital in Bucharest. “I conducted a study in 1995 to see if there was any change compared to the year 1990. The conclusion was very clear: affective disorders and depression were the top psychiatric diseases in 1995 while in 1990 they were only in fourth place. These diseases predominantly occurred between the ages of 40 and 55 years, representing exactly that segment of the population which was too old for adaptation [to the new capitalist system]. “These people had been dependent on someone else for their existence, namely the communist state, and when the source of their dependence disappeared, it was replaced by illness and depression. “There is a whole process of changing of values and social configuration going on and Romanians are still coping with this with difficulty”, he adds.
Mihai Gheorghe, a psychiatrist at the Military Hospital in Bucharest, said even more recent figures had confirmed that trend. He said that the number of cases of depression and affective psychosis have dramatically risen in Romania since the collapse of communism in 1989. By last year, the number of people suffering from these diseases had doubled while the number of suicides represents 31% of all deaths from non-natural causes—the same amount as deaths from road accidents and murders combined. And psychiatrists say that despite such figures all governments since 1989 have ignored
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Reuters
Last year, Milenco Ilin, 55, from Petrovaselo in western Romania tried to commit suicide. Living in poverty and with no job, he says he was so desperate he decided to take his own life. By fortunate accident, his suicide attempt failed and he says he no longer contemplates killing himself. But he is just one of hundreds of thousands of Romanians in the same position. And whereas he has found the strength to carry on with his life, many others will not. Ilin described what he went through: “I lost my job as an electrician after 30 years of work . . . my wife divorced me. I was too young to take my state pension and too old for anyone to think about employing me.” He says he got a rope, tied a noose in it and attached it to some wooden beams on the ceiling of his flat, put it around his neck and stood on a chair. However when he kicked the chair away the beams broke and he survived, scaring himself enough not to try a second attempt. Ilin’s experience is not unique. Psychiatrists in Romania warn that the government is underestimating the extent of psychiatric problems in the country after figures showed cases of depression have doubled and the suicide rate has risen 7% since the fall of communism 15 years ago. Experts say the state budget for psychiatric medicine is too low—3% of the annual health budget goes to psychiatry—and that there is only one psychiatrist for every 20 000 people in the country. They also claim psychiatric patients still face being stigmatised by society and point to the continued use of specialised wards and psychiatric hospitals which lag behind more modern treatment methods in the
Nicolae Ceausescu’s death marked the collapse of communism in Romania
645
World Report
the extent of psychiatric disorders in Romania. The plight of hundreds of thousands of mentally handicapped children abandoned in orphanages set up by Romania’s communist dictator Nicolae Ceausescu, who banned contraception and abortion under his regime, shocked the world when televised images of the children’s suffering were beamed around the globe in the early 1990s. Doctors say health authorities’ attitudes towards mental illness and disability are not much better today and add they still “behave as if this were the middle ages when mental illness was something shameful”. “The rest of the world is showing a great deal of interest in mental disorders and illnesses. But in Romania the interest is completely insignificant. Nobody has ever paid any attention to
Panos Pictures
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
The plight of thousands of mentally handicapped children imprisoned in Romanian orphanages gained worldwide attention during the 1990s
646
mental health here. And depression, which is on the rise, is one of the most expensive diseases to treat and has many victims. Mental disorders do not kill generally, but depression does”, says Tudose. He recalls an example of the poor attitude of the health authorities to mental illness when the former health minister Daniela Bartos took antidepressives out of the category of subsidised or free medicine. “These subsidised and free medicines are a way of helping sick and poor Romanians get treatment”, explains Tudose. “This type of measure shows the complete ignorance of the Romanian health authorities. I publicly asked the health minister at the time to take responsibility for all suicides in that period. A lack of anti-depressives is always correlated with the number of suicides. “Romania has a bad tradition of not caring about psychiatry, created by the communists who behaved as if it were still the Middle Ages when mental illness was something shameful. This medieval way of thinking has been cultivated ever since and psychiatric diseases are stigmatised.” Other doctors point to the situation in hospitals for treatment of psychiatric illnesses. The Romanian Academy Hospital in Bucharest—the capital’s largest—has no resident psychiatrist. But at the other extreme, they say, “large scale” psychiatry hospitals still exist in Romania—a practice abandoned by many countries in the west. Psychiatrist Gheorghe says: “We are still working under the system of psychiatric hospitals with 900 beds. Take a look abroad and you will see that these kind of specialised hospitals barely exist. Psychiatric patients do not have to be marginalised. They are people like all of us. But unfortunately, stigmatisation is our problem. “Civil society usually gets involved in helping the sick and in defending their rights. But in Romania it is not the case. If in western countries there are
thousands of NGOs fighting for the rights of the mentally ill, in Romania you will barely find one. We do not have associations run by families of the sick. Who can deal with this kind of sickness if not the person’s family? We treat them in hospitals but a family environment remains the most important thing.” Others also point to the “insignificant” sums of money devoted to psychiatry in Romania. “The authorities are investing little money and are completely ignoring alternative therapies,” says Professor Tudor Udristoiu, head of the Romanian Psychiatric Association. “Only 3% of the total health budget goes to psychiatry. A minimum would be 10% although financing should equal the burden of psychiatric diseases, meaning 25% of direct and indirect expenses in the medical system.” He points out that more is spent in other central and eastern European states, for example in the Czech Republic where 15% of the country’s health-care budget goes to psychiatry. Tudose argues that there is also a shortage of psychiatrists. “In Switzerland, which has one of the highest suicide rates in Europe, there are 3000 psychiatrists for 8 million people. In Romania there are only 1300 for 22 million.” Doctors believe their only hope of changing how psychiatric patients are treated lies in the recent appointment of Mircea Cinteza as health minister. “We are not so naive as to hope for too much”, Tudose says. “But at the very least mental health should be made a top health-care priority. This would bring a big change and while there are so many things that need dealing with a clear signal is important. “I only hope that Romanian medicine will soon start to deal with the brain in a serious way. Because of communism we practically ignored the brain. And when we didn’t, we had only neurological psychiatry.”
Carmiola Ionescu www.thelancet.com Vol 365 February 19, 2005
Depression in post-communist Romania Depression and affective disorders have rocketed in Romania since the collapse of communism in 1989. Such illnesses are now a substantial health burden. But, reports Carmiola Ionescu, lowly government provisions for psychiatry mean that mental health care remains stuck in the past.
www.thelancet.com Vol 365 February 19, 2005
west where the emphasis is on a family environment. Romanian doctors say Ilin’s case is typical among middle-aged and elderly people in Romania who have not benefited from the country’s transition from Nicolae Ceausescu’s communist dictatorship to today’s free-market economy. Many have been left in poverty after being made redundant by companies looking to trim workforces as they adapt to the demands of competition on the free market and essentially have no chance of finding work. This, say the experts, has led to the doubling in numbers of cases of depression and the 7% rise in suicides. “The transition from communism has caused changes in the pathology of psychiatric illness in Romania”, says Florin Tudose, head of the psychiatric department at one of the largest hospitals in Romania, the University Hospital in Bucharest. “I conducted a study in 1995 to see if there was any change compared to the year 1990. The conclusion was very clear: affective disorders and depression were the top psychiatric diseases in 1995 while in 1990 they were only in fourth place. These diseases predominantly occurred between the ages of 40 and 55 years, representing exactly that segment of the population which was too old for adaptation [to the new capitalist system]. “These people had been dependent on someone else for their existence, namely the communist state, and when the source of their dependence disappeared, it was replaced by illness and depression. “There is a whole process of changing of values and social configuration going on and Romanians are still coping with this with difficulty”, he adds.
Mihai Gheorghe, a psychiatrist at the Military Hospital in Bucharest, said even more recent figures had confirmed that trend. He said that the number of cases of depression and affective psychosis have dramatically risen in Romania since the collapse of communism in 1989. By last year, the number of people suffering from these diseases had doubled while the number of suicides represents 31% of all deaths from non-natural causes—the same amount as deaths from road accidents and murders combined. And psychiatrists say that despite such figures all governments since 1989 have ignored
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Reuters
Last year, Milenco Ilin, 55, from Petrovaselo in western Romania tried to commit suicide. Living in poverty and with no job, he says he was so desperate he decided to take his own life. By fortunate accident, his suicide attempt failed and he says he no longer contemplates killing himself. But he is just one of hundreds of thousands of Romanians in the same position. And whereas he has found the strength to carry on with his life, many others will not. Ilin described what he went through: “I lost my job as an electrician after 30 years of work . . . my wife divorced me. I was too young to take my state pension and too old for anyone to think about employing me.” He says he got a rope, tied a noose in it and attached it to some wooden beams on the ceiling of his flat, put it around his neck and stood on a chair. However when he kicked the chair away the beams broke and he survived, scaring himself enough not to try a second attempt. Ilin’s experience is not unique. Psychiatrists in Romania warn that the government is underestimating the extent of psychiatric problems in the country after figures showed cases of depression have doubled and the suicide rate has risen 7% since the fall of communism 15 years ago. Experts say the state budget for psychiatric medicine is too low—3% of the annual health budget goes to psychiatry—and that there is only one psychiatrist for every 20 000 people in the country. They also claim psychiatric patients still face being stigmatised by society and point to the continued use of specialised wards and psychiatric hospitals which lag behind more modern treatment methods in the
Nicolae Ceausescu’s death marked the collapse of communism in Romania
645
World Report
the extent of psychiatric disorders in Romania. The plight of hundreds of thousands of mentally handicapped children abandoned in orphanages set up by Romania’s communist dictator Nicolae Ceausescu, who banned contraception and abortion under his regime, shocked the world when televised images of the children’s suffering were beamed around the globe in the early 1990s. Doctors say health authorities’ attitudes towards mental illness and disability are not much better today and add they still “behave as if this were the middle ages when mental illness was something shameful”. “The rest of the world is showing a great deal of interest in mental disorders and illnesses. But in Romania the interest is completely insignificant. Nobody has ever paid any attention to
Panos Pictures
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
The plight of thousands of mentally handicapped children imprisoned in Romanian orphanages gained worldwide attention during the 1990s
646
mental health here. And depression, which is on the rise, is one of the most expensive diseases to treat and has many victims. Mental disorders do not kill generally, but depression does”, says Tudose. He recalls an example of the poor attitude of the health authorities to mental illness when the former health minister Daniela Bartos took antidepressives out of the category of subsidised or free medicine. “These subsidised and free medicines are a way of helping sick and poor Romanians get treatment”, explains Tudose. “This type of measure shows the complete ignorance of the Romanian health authorities. I publicly asked the health minister at the time to take responsibility for all suicides in that period. A lack of anti-depressives is always correlated with the number of suicides. “Romania has a bad tradition of not caring about psychiatry, created by the communists who behaved as if it were still the Middle Ages when mental illness was something shameful. This medieval way of thinking has been cultivated ever since and psychiatric diseases are stigmatised.” Other doctors point to the situation in hospitals for treatment of psychiatric illnesses. The Romanian Academy Hospital in Bucharest—the capital’s largest—has no resident psychiatrist. But at the other extreme, they say, “large scale” psychiatry hospitals still exist in Romania—a practice abandoned by many countries in the west. Psychiatrist Gheorghe says: “We are still working under the system of psychiatric hospitals with 900 beds. Take a look abroad and you will see that these kind of specialised hospitals barely exist. Psychiatric patients do not have to be marginalised. They are people like all of us. But unfortunately, stigmatisation is our problem. “Civil society usually gets involved in helping the sick and in defending their rights. But in Romania it is not the case. If in western countries there are
thousands of NGOs fighting for the rights of the mentally ill, in Romania you will barely find one. We do not have associations run by families of the sick. Who can deal with this kind of sickness if not the person’s family? We treat them in hospitals but a family environment remains the most important thing.” Others also point to the “insignificant” sums of money devoted to psychiatry in Romania. “The authorities are investing little money and are completely ignoring alternative therapies,” says Professor Tudor Udristoiu, head of the Romanian Psychiatric Association. “Only 3% of the total health budget goes to psychiatry. A minimum would be 10% although financing should equal the burden of psychiatric diseases, meaning 25% of direct and indirect expenses in the medical system.” He points out that more is spent in other central and eastern European states, for example in the Czech Republic where 15% of the country’s health-care budget goes to psychiatry. Tudose argues that there is also a shortage of psychiatrists. “In Switzerland, which has one of the highest suicide rates in Europe, there are 3000 psychiatrists for 8 million people. In Romania there are only 1300 for 22 million.” Doctors believe their only hope of changing how psychiatric patients are treated lies in the recent appointment of Mircea Cinteza as health minister. “We are not so naive as to hope for too much”, Tudose says. “But at the very least mental health should be made a top health-care priority. This would bring a big change and while there are so many things that need dealing with a clear signal is important. “I only hope that Romanian medicine will soon start to deal with the brain in a serious way. Because of communism we practically ignored the brain. And when we didn’t, we had only neurological psychiatry.”
Carmiola Ionescu www.thelancet.com Vol 365 February 19, 2005