Outpatient Services for People with Mental Disorders in the Kyrgyz Republic: What Is Next?

The outpatient care service for patients with mental disorders in the Kyrgyz Republic is currently experiencing various difficulties. These are largely due to a number of organizational and socio-economic problems at the state level. Treatment of patients with mental disorders is still provided in state mental health centres, while psychosocial services at the community level are only now beginning to be developed. This article describes the directions of mental health care, as well as ongoing efforts to provide outpatient care for people with mental disorders. The actions of a few prolific nongovernmental organizations (NGOs) are proving insufficient to meet the needs of patients. There is currently a gradual and visible movement toward the development of the private sector in the field of mental healthcare. In order to overcome organizational difficulties, support from government structures and certain initiatives to create legislative grounds are needed.

BACKGROUND: PSYCHIATRIC CARE IN THE KYRGYZ REPUBLIC

The Kyrgyz Republic gained its independence from the Soviet Union in 1991, which on one hand led to a national identity crisis [1], and on the other ruined a large number of the establishments that had previously been built [2]. Although the reports by various international organizations described the Soviet healthcare system as “inefficient and over-centralized” [3], there was nevertheless a functioning network of outpatient services that provided regular medical examinations, well-functioning therapeutic workshops (occupational therapy), and home visits to patients with mental disorders.

During the Soviet period, outpatient services for patients with mental disorders operated according to the so-called territorial principle. A doctor and a nurse were assigned to each district of a town or village. The latter was obliged to visit patients discharged from hospital once a week, and, if necessary (for example, should their condition worsen), invite them to see a doctor who might, in turn, make changes to their therapy if needed. As a legacy of the Soviet system, the contemporary Kyrgyz Mental Health Service maintains a centralized treatment system for patients with mental disorders; this, however, results in the stigma of both psychiatric institutions and psychiatrists as professionals, but now without the territorial principle of service provision. A patient’s application for help is either initiated by relatives (the more frequently used option), or by the patient themselves.

According to official data from the statistical committee of the National Centre for Mental Health (NCMH), the incidence of mental disorders in Kyrgyz Republic is 48.1 of new registered cases per 100,000 of the population. By the end of 2021, the NCMH had treated 3,182 patients, 18% of whom presented with schizophrenia and schizoaffective disorders, 21% with mood disorders (including mild depressive disorders), and 17% with anxiety and traumatic stress disorders. Patients with dementia and delirium are more likely to remain at home, especially in rural areas, as cultural traditions discourage taking an elderly relative to a psychiatrist. The high proportion of patients with mental disabilities and mental retardation (33%) among those admitted to hospital for either diagnosis or forensic examination reflects the image of mental disorders in traditional society. To date, residents of rural areas do not consider a person to have a mental disorder if “he/she can speak normally”. Statistics on the prevalence of mental disorders remain unavailable, as patients who seek help at private psychological centres are not recorded in the national statistical system.

There are 153 psychiatrists working in the country that has a total population of 6,636,000 [4]. The availability of psychiatrists by region ranges from one to two per 100,000 inhabitants. The number of psychiatrists working solely in outpatient services in the Kyrgyz Republic decreased from 250 in 2001 to 80 in 2020 against the backdrop of the consequent reduction in psychiatric beds from 2,500 to 1,425 [5]. Day clinics are territorially attached to hospitals, and are typically used for subacute treatment and the selection of supportive treatment for patients who had previously been in acute psychosis wards. Along with the decrease in the number of highly professional specialists, the incidence of mental disorders remains essentially unchanged.

In many districts, there are no psychiatrists and the budgets for such specialists are typically allocated to other doctors available in the particular region in question. It should also be noted that the number of early career psychiatrists has been decreasing over the last 20 years, and the average age of psychiatrists is now 50–55, i.e., most psychiatrists are of preretirement age. The Kyrgyz Republic is still experiencing a lack of well-trained psychiatrists, despite the medical academy in the capital, Bishkek, and two state medical departments in both Bishkek and Osh, which in themselves should be sufficient for a small country. All primary care practitioners, whether trained or otherwise, are responsible for frontline diagnosis, treatment, and prevention of mental disorders, and are entirely funded by the mandatory health insurance fund. In 2020, this payment amounted to 3.2% of the total mental healthcare budget [6].

It is challenging to assess the number of psychologists in the country because there is no professional licensing system in place. A limited number of the private psychological centres function independently and without proper legislative grounding, often not following evidence-based service standards.

The NCMH is still the largest organization to provide mental health services. It has twelve wards, including a day hospital and two wards for psychosomatic disorders. The main wards are the acute psychosis wards that provide care for patients with moderate to severe mental disorders. Should a patient’s condition improve, they are transferred to a day hospital for further treatment or otherwise discharged. One of the wards is an outpatient clinic and, according to patient feedback, is the best in the country, being part of the NCMH. It is believed that the best specialists are concentrated in the Centre, where clinicians constantly undergo advanced training.

Two departments at the NCMH accept patients with common mental disorders. Patients with mood disorders, anxiety disorders, obsessive compulsive disorder and certain eating disorders are voluntarily hospitalized in an inpatient setting, while receiving mainly medication therapy. With a caseload of 15–30 people per clinician, there is essentially no time for psychotherapeutic work. Patients with suicidal tendencies are referred to acute psychosis wards, regardless the diagnosis they may have received. It is quite clear that a stay in hospital for a patient with a panic disorder is unlikely to help, just as it is unlikely to help a patient with a generalized anxiety disorder [7].

Reforms and programmes for supporting the mental health care system

None of the three public health reforms, “Manas”, “Manas Taalimi”, and “Den Sooluk”, addressed the needs of patients with mental disorders [8], and not only failed to reduce the cost of treatment for patients with somatic disorders as intended, but ultimately actually increased them.

In 2001, the National Programme “Mental Health of the Population of the Kyrgyz Republic for 2001–2010” was approved by the government [9]. One of the key directives of this programme was the “enhancement of the network of day-care clinics and involvement of primary care physicians in the activities of the mental health service” [9]. Although not all the goals of the Programme were achieved, substantial efforts were invested in the training of primary care physicians for the diagnostics of mental disorders.

Ideally, such specialists would screen patients for symptoms of mental disorders and, if necessary, refer them to a psychotherapist for further outpatient treatment. At the same time, primary care physicians were allowed to prescribe medication and treat anxiety and mood disorders. In practice, patients with mild symptoms continued to be observed by primary care physicians, while those with manifest mental disorders were referred to hospital by the community health centre psychiatrist (poliklinika). Thus, whilst out-of-hospital care for patients with mental disorders looked highly effective on paper, in practice the NCMH in most cases turned out to be the primary level care for patients with mental disorders, rather than the tertiary level, as it was originally designed to be [10].

The decentralization of psychiatric services and the transfer of certain diagnostic and therapeutic services to primary care physicians seemed to be beneficial, provided there was good associated funding and that the number of doctors in the field remained essentially stable. In reality, doctors acquired an increased workload without a concomitant increase in salary. The mass exodus of qualified specialists from the profession practically negated the World Health Organization’s (WHO) efforts to train therapists in the diagnostics and treatment of mild mental disorders, predominantly those of a depressive nature or on the anxiety spectrum. Medications were often prescribed in an uncontrolled manner by undertrained primary care practitioners, frequently violating treatment regimens and therapeutic doses.

This situation persisted until 2018 when the following national Programme, the “Mental Health of the Population of the Kyrgyz Republic for 2018–2030”, was accepted [11]. The Programme promised the provision of qualified, comprehensive, integrated, and responsive mental health and social care at the community level that followed evidence-based approaches.

The implementation of the Programme has already faced a number of significant challenges since 2018, such as a lack of financial support from the government, the persistent migration of well-trained specialists to other countries, and a lack of cooperation between ministries. Some mental health care branches have practically disappeared during this time; for example, there is currently only a limited number of specialists in child psychiatry in the country [12]. Moreover, primary care physicians must now deal not only with eligible patients but, additionally, with a range of other patients with more severe mental disorders. The increased workload has led to even more specialists leaving the profession, causing another wave of migration of qualified clinicians [13].

THE CURRENT STATE OF OUTPATIENT CARE FOR PATIENTS WITH MENTAL DISORDERS IN THE KYRGYZ REPUBLIC

Outpatient care for people with mental disorders is essential to the prevention of relapse in the longer term [14]. The current issues with the outpatient services in the Kyrgyz Republic are the result of a long history of problems across the entire health care system during the post-Soviet period. At the same time, the current mental health care system is the direct descendent of the Soviet psychiatric system. After some years of relatively stable functioning, as fuelled by the remnants of Soviet resources and infrastructure, the mental health care system started to rapidly deteriorate, resulting in the outright neglect of outpatient care on the part of the state. Mental health services are currently funded based on the “residual budget”, which totals about 4% of overall expenditure on health care [15]. Hospitalization is considered the key means of the treatment of patients with mental disorders, even mild ones, and predictably such an illness is highly stigmatized.

There are almost no barriers to establishing a private practice or a mental health centre in the country, except for registering the business with the state fiscal authorities. At the state level, the concept of outpatient mental health services is practically lacking; there are no corresponding laws or regulations, no requirements regarding the professional qualifications of individual psychologists, thus no standards for university programmes based on licensure requirements, and, finally, no requirements for mental health clinics. This has led to poorly formulated requirements for educational organizations, such as degree and certification programmes in the universities. It has also resulted in the growth of educational centres that declare that they can prepare psychologists or counsellors for practice.

From 1996 to 2005, traditional healers and religious figures became extremely popular in the Kyrgyz Republic, essentially replacing psychiatrists and psychotherapists in the outlying regions of the country [16]. These practices were controlled during the Soviet period with some relative success, but which led to an exacerbated interest in these types of services after the collapse of the USSR. Private initiatives in the mental health sphere became essentially absent for several reasons: the sudden decrease of the population’s average income in the 1990s after the break-up of the USSR, the absence of a private insurance system, and the poor preparation of diverse mental health professionals (with the exception of psychiatrists). Similar issues were present in other areas of health care in the Kyrgyz Republic, which survived either at the expense of pharmaceutical companies or by attracting international donors [16].

Another reason for outpatient services being underdeveloped and of low quality in the country is the lack of appropriate legislative attention to the issues of mental health, private services, and the education of mental health professionals, amongst other things. To date, the 1999 “Law of the Kyrgyz Republic on psychiatric care and guaranteeing the rights of persons receiving such care”, signed by the first President of the Kyrgyz Republic and enacted by the Legislative assembly of the Kyrgyz Republic on 25 May 1999, remains the only document defining the key aspects of mental health care in the country [17]. Amendments to this law were introduced in 2017, but the key provisions of the law remain unchanged. According to the law, outpatient psychiatric care for a person suffering from a mental disorder, depending on medical indications, should be provided in the form of consultative care or dispensary observation. In the latest amendments to the law, dated 20 February 2017, this paragraph was left unchanged, and other forms of outpatient care were entirely ignored. When comparing the laws on psychiatric care in other Central Asian republics such as Kazakhstan, Uzbekistan, and Tajikistan, one can see that the associated legislations are largely identical. The differences concern “involuntary dispensary observation”, which is mandatory for the former patients of mental health centres, a clause that is absent in the law of the Kyrgyz Republic.

Community-based mental health services

Despite the many obvious difficulties, there have been several important positive developments regarding a better outpatient care system in the country. One such is the rapidly growing number of non-governmental organizations (NGOs), who are, in fact, the main motivators behind the reform. Multiple NGOs, funded by international donors, are working productively to organize multidisciplinary teams (MDTs) on a community-based level. Twelve MDTs have already been organized to provide community-based outpatient mental health services [18]. Such teams are currently working successfully in several of the country’s major cities. Each team includes a psychiatrist, a psychologist, a home care worker, and a nurse. Such teams provide care to patients through regular home visits. Having a psychiatrist, a psychologist, a home care worker, and a nurse on the team makes it possible to optimize the processes of diagnosis and treatment, to conduct highly accurate integrative assessments of patients’ conditions, and to offer a wide range of associated services. Such a multidisciplinary approach allows the interdepartmental barriers that arise to be successfully overcome. Community-based MDTs that provide assertive care directly contribute to a significant reduction in the number of cases and the duration of hospitalizations, resulting in longer at-home periods even among patients requiring multiple hospitalizations. Outpatient services, as provided by MDTs, improve patients’ quality of life, alleviate symptoms, and increase social functioning. The mobile team’s aim is to integrate patients into society, provide them with problem-solving skills, support them in taking responsibility, and train family members. The only downside of this system is that it is not state-funded, and the sustainability of this productive initiative may be somewhat questionable. Additionally, the manner in which a team is composed makes clients more vulnerable in terms of the ethics of care, such as the collection and storage of information within the team and between the specialists.

Outpatient rehabilitation programmes developed by the NGO “Family and society” aim to support patients in need of mental health care to live independently and with a minimum of medical intervention. Several projects for people with serious mental disorders are currently being carried out by international NGOs with the support of the Soros Foundation Kyrgyzstan, the Mental Health Initiative of the Open Society Institute, and the European Department of Caritas. Within the NMHC, a mobile team provides home care for mental health patients who are unable or unwilling to leave their homes. The recent increase in interest in the WHO’s Mental Health Gap Action Programme (mhGAP) and its implementation demonstrates the region’s willingness to reduce the treatment gap using evidence-based interventions, with workshops that were held across Kyrgyzstan in 2019.

Some of the types of sociopsychological services for outpatients that are more or less fulfilled by private initiatives and international organizations include services for the most vulnerable population groups: children with special needs, children in the foster care system, older adults (especially those who reside alone or have certain disabilities), female victims of violence, and members of the LGBTQ+ (lesbian, gay, bisexual, transgender, and queer) community. Many of these initiatives have been highly successful and sustainable, providing high-quality outpatient care and engaging qualified clinicians and experts.

Private psychological centres

In general, the situation with private psychological centres in the Kyrgyz Republic is rather ambiguous. Such centres can emerge and disappear rather randomly, as do privately practising psychologists. The private psychological counselling centres, on the one hand, are gradually replacing traditional inpatient care for patients with anxiety and stress-related disorders, but work in an unsupervised and unregulated manner on the other. The absence of a system of control, such as licensure requirements and a professional organization, has led to an increase in the number of self-defined psychologists or counsellors, who often practice without formal education in counselling or psychology, and who may harm patients in various ways. Some attempts to control this sector are being undertaken by individual activists from among the ranks of professional psychologists, who suggest that a professional association be established and suggest a move towards licensure for mental health care professionals. The proposal to adopt the Code of Ethics for Psychologists in Kyrgyz Republic was one such initiative which, whilst it has not been officially approved, is nevertheless widely used by professionals [19].

With only a few exceptions, the growth in the number of psychological centres and private practising psychologists should be viewed as a positive trend in the development of outpatient services.

Outpatient care for children in the Kyrgyz Republic

As for inpatient services for children, adolescents, and adults with autism and intellectual disabilities, which is defined as the medical and nursing care provided in hospital, these are in fact not available in the Kyrgyz Republic, and indeed see little demand from the general population. To undergo an assessment procedure and to receive a diagnosis, parents are often required to leave their children by themselves in the NCMH clinic for two weeks. The majority of parents naturally refuse to leave their children unattended in a psychiatric hospital, but the system is not very flexible with regard to this issue. Moreover, the assessment tools available at the NCMH are outdated and may not provide comprehensive developmental psychological and psychiatric assessments, even during two weeks of observation.

The situation with the public outpatient care for children is even poorer. In general, outpatient care should include a diagnostic, an assessment, and individualized treatment options matched to the intellectual and emotional developmental level of a child, as well as pharmacotherapy, family therapy, or parent training, and educational support for children with special needs. Parents can receive assistance from the state in the form of child psychiatrists and neurologists who provide a diagnosis and pharmacotherapy plan, and from the Psychological Medical Pedagogical Commission (PMPC) in terms of providing children with access to a special or inclusive education [20].

The main challenges to identifying developmental disorders correctly are associated with the lack of specialists trained in the diagnosis of autism or intelligence assessment and a lack of standardized up-to-date diagnostic instruments.

The quality of support in accessing educational goals provided by the PMPC is also questionable. In spite of the fact that many international organizations, in particular the European Union, supported the development of PMPCs by establishing commissions in seven regions and training 72 specialists in assessment [21], these institutions still lack the human, financial, and methodological resources to support children with autism, intellectual, or indeed other disabilities. Furthermore, apparently only two PMPCs in the country work throughout the year, while the remaining 16 do not practice on a regular basis but are rather organized once every six months, mainly to make the decision as to whether a child is eligible for special or regular education, meaning that there is basically no time to conduct an assessment and provide treatment [22]. Moreover, in outlying regions PMPC members are usually lacking in professional education and do not have the skills or qualifications to perform an assessment. Finally, most of the training funded by international organizations is focused on teaching what disability is, the principles and basics of inclusive education, and the United Nations convention of the rights of the child, but does not provide solid training on assessment and the contemporary instrument for assessment and programming early intervention.

At the same time, various new initiatives have been initiated to improve the wellbeing of children with special needs, organized mainly by NGOs, similar to the situation with other mental health patients. For the last decade we have observed a tendency for parent-led organizations to take over state responsibilities and attempt to shift the model of disability from a medical to a social one. Representatives of parent associations encourage parents to minimize medical treatment and instead turn to educational approaches and evidence-based interventions. In the majority of cases, these organizations are founded by prominent and devoted families that completely change their lives to serve children with special needs.

Besides providing outpatient services for children in terms of assessment, diagnosis, programming, and therapy, NGOs are instigating the development of policy documents related to the rights of children with special needs, training family doctors to screen for symptoms of autism, collaborating with child psychiatrists and neurologists, and attracting international donors in the attempt to develop a system of early interventions not only in Bishkek but also in other regions of Kyrgyzstan. Although such initiatives can have a tremendous effect on the lives of children with special needs, their services remain too expensive for many families, are not fully available in the regions, and may lack professionals trained in assessment and evidence-based treatment.

CONCLUSION: WHAT IS NEXT?

Outpatient care in the Kyrgyz Republic is still disconnected from in-hospital treatment and is insufficient both at the conceptual and the practical levels. There is a visible lack of legislature on community mental health care and psychosocial care, in contrast with psychiatric inpatient care, where clear legislation and national programmes exist and, indeed, are regularly updated. The outpatient care initiatives in the country, both public and private, are mostly disconnected from inpatient treatment and public psychiatric services, resulting in a fragmented system of care in the country. A similar situation exists in many post-Soviet Central Asian countries, where mental care is psychiatry-centred and considerably underdeveloped compared to Western countries with regard to other mental health specialities such as psychologists and social workers [6]. Currently, such professions as social workers and psychologists are undervalued and underfunded, resulting in poor-quality services and an imbalance in care in favour of inpatient services. Cases of continuous outpatient care for patients with mental disorders are still the exception rather than the rule. Community psychiatry and psychosocial care is just beginning to develop, and the creation of multidisciplinary teams providing patient care at home is certainly encouraging, but the sustainability of existing initiatives remains questionable.

Perspectives of the development of innovative methods of mental health care are associated with the educational, clinical, and research programmes of the NCMH, the largest professional institution in the Kyrgyz Republic.

The key actions that could currently be taken that should result in a better quality of outpatient care must include the following:

• development of the legislature that would provide the framework for the mental health services as well as defining the governmental position on the issues of public mental health;
• active steps by the professional community towards the creation and development of professional associations and other organizations that would take responsibility for the quality control processes;
• and the active position of universities that could prioritize the research and community service initiatives that influence long-term strategies in the development and popularization of mental health services.

Only the provision of the appropriate legislative grounds, developed in close collaboration with the professional community, would pave the way to better quality and more diverse services. Finally, a more articulated and proactive position on the part of the government regarding issues relating to the mental health care system, and the initiatives to provide better legislative grounds, will promote appropriate outpatient care in the near future.

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