Community-Based Psychiatric Treatment in Romania: Past, Present, Future

Community psychiatry has its origins in the West, in the 1950s, when many institutions for the mentally ill were closed down in an effort to shift the focus from hospital-based care to community-based. The aim of the current paper is to review the available literature on the community-based psychiatric treatment in Romania.

The Romanian Ministry of Health is dedicated to promoting mental health education and to creating a mental health system that ensures that every patient has access to care and treatments designed for their own particular needs. Today, in Romania, as across the entirety of Central and Eastern Europe, mental health systems are transitioning from hospital-based care to community-based services. The RECOVER-E project, the SEE Mental Health Project, the “Horizons” project, among others, showcase Romania’s mental healthcare system in terms of improving the chances of mental health patients’ recovery.

Community Psychiatry in Romania is a budding field that can greatly aid in the management and treatment of patients with mental disorders from both urban and rural areas. By applying the principles of deinstitutionalization and community health care at a systemic level, resources may be invested in the creation of a strong network of specialists that treat patients in their own living spaces.

INTRODUCTION

Community psychiatry has its origins in the West in the 1950s, when many institutions for the mentally ill were closed down in an effort to shift the focus from hospital-based care to community-based. The idea behind this worldwide trend was that a community-based care system enables patients to be as independent as possible within their own living environments, and this, in turn, would help them to fulfill their potentials [1]. The process of deinstitutionalization is based on three concepts: depopulation (releasing patients from state-run psychiatric hospitals), diversion (returning psychiatric patients to their communities), and decentralization (fragmentation of the responsibility for the patient across multiple entities) [2].

Today, the trend is towards implementing a Balanced Care Model [3, 4] that acknowledges the need for hospital care but strives to provide as much community care as possible [5]. To this end, the goal of the review is to gain a comprehensive view of the principles of community psychiatry in Romania, as well as the manner in which these principles are applied to the social rehabilitation and integration of psychiatric patients.

PRINCIPLES OF COMMUNITY PSYCHIATRY

As deinstitutionalization greatly changed the way in which the needs of psychiatric patients were met by the healthcare system, a conceptual framework was put in place to guide future interventions [6]. Ideally, community psychiatrists take responsibility for lowering the rates of mental disorders within the community and aim to reveal the needs of psychiatric patients so as to elaborate effective intervention plans and gather feedback in order to better understand how those needs were improved or changed within the community [7]. In other words, they adopt a Pro-Active Policy. In addition to the active role the psychiatrist and other community mental health teams (CMHT) members play in the community they serve, they must operate within a set of principles that guide the interventions they implement. The ten principles of community psychiatry state that care offered to mental patients must be: (1) recovery-oriented; (2) strengths-based; (3) community-focused; (4) person-centered; (5) allows for reciprocity in relations; (6) culturally-responsive; (7) grounded in the person’s life-context; (8) relationally-mediated; (9) optimizes natural support; and (10) recognized as a responsibility by the people involved in delivering care services [8].

With all this in mind, since the beginning of the shift of focus from the hospital to the community, in May 2013, the World Health Organization elaborated upon and promoted a Mental Health Action Plan that supports deinstitutionalization and the development of community-based services for mental patients that aim to improve clinical outcomes, as well as combating discrimination [9].

WORLDWIDE HISTORY OF COMMUNITY PSYCHIATRY

Hospital closures, focusing on reducing the number of patients that can be admitted into institutions, shed light to the numerous difficulties that people with severe mental disorders experience in various life domains, such as persistent symptoms that require long or frequent admissions, and deterioration of interpersonal relationships and social functions [10–12]. At the same time, lengthy admissions to hospital affect the patient’s professional and social activities and negatively impact their integration into the community [13–15]. This fact can lead to a diminished sense of purpose with bleak repercussions for recovery [16]. Furthermore, due to the nature of their illness, psychiatric patients are not always able to advocate their rights or seek medical treatment [17, 18].

In Romania, during the state socialist period psychiatry and psychology were used to discipline and police the Romanian people, as psychiatric hospitals were used to repress political dissidents that were deemed too problematic for the Ceausescu regime. The view of mental illness mainly followed a biological model, with little to no talk therapies and that relied mainly on some form of medication as treatment, leading to the over-medication of patients who would otherwise have benefited from a combination of medication, psychotherapy, and social interventions [19].

In 2004, at the summit of the European Council of Heads of State, Romania’s prospects of admission into the European Union were discussed. At the end of the summit, a 47-point list of accession was submitted, with two of the 47 points concerning the treatment of people with mental illness, as well as the need for reform in the Romanian mental health care system [20].

The Ministry of Health in Romania is dedicated to promoting mental health education and to creating a mental health system that ensures that every patient has access to care and treatments designed for their own particular needs [21]. The Mental Health Law, active since 2002, describes the statute of the psychiatric patient in Romania [22]. According to legislation, the patient can be treated and cared for in their own living environment through community psychiatry services. As these services are located within the patient’s living environment they are easily accessible, and range from general practitioner offices to treatment centers, day care centers, home care services, and occupational therapy workshops. The purpose of community psychiatry does not necessarily constitute complete remission of psychiatric symptoms but rather to cultivate and amplify remaining abilities that can best integrate the psychiatric patient into society [23].

KEY CONCEPTS IN ROMANIAN COMMUNITY PSYCHIATRY

In order to resolve these issues, light had to be shed on the needs of psychiatric patients, what constitutes a recovery from mental illness, and indeed how one gets from the former to the latter:

“Needs” are potentially remediable issues that affect a person’s clinical and social functioning below a specific level [24]. A study published in 2000 assessed the needs of psychiatric patients and what healthcare staff believed their need to be, and with surprising results: patients declared that they had a higher number of needs in the service domain, such as owning a telephone, being able to use transport, or having access to information, whereas healthcare staff identified a higher number of needs in domains such as psychiatric symptoms, physical health or drug and alcohol use [25].

“Recovery” or “rehabilitation” in the context of mental health is a complex and continuous process that exceeds the clinical remission of symptoms. Stigma attached to mental problems, and lack of employment or opportunities are issues that require addressing in order for a person with a severe mental disorder to function at full capacity and participate in their community [6, 26]. A strong relationship with mental health specialists, and access to employment and financial support are characteristics that aid in the recovery process [27–29]. During recovery, each patient must be encouraged to set their own goals and be given opportunities to act within the community through employment, involvement in social activities, responsibilities and independence in fulfilling their day-to-day activities [30]. The skills needed to reach these goals are major points of interest in the field of psychiatric rehabilitation and are known to contribute greatly to a person’s quality of life [26, 31, 32]. One important point to make is that involvement in the recovery of psychiatric patients has to be continuous, as one study found that positive assessments of life domains at one-year post-discharge were reduced to baseline after five years [33]. During recovery, other brain functions that have previously decreased, such as cognition, may improve considerably [34].

THE COMMUNITY MENTAL HEALTH TEAM

In response to the issues faced by psychiatric patients, the CMHT was created within the domain of community psychiatry. The CMHT is a multidisciplinary team comprised of a psychiatrist, a psychologist, social workers, occupational therapists, and nurses that are responsible for a section of the population, the latter being frequently defined by geographical vicinity. Additional members can intervene in special cases, such as crisis management, early interventions, or assertive treatment [35]. A special consideration must be given to the role of “case manager”, whose complex and multifaceted role lies beyond the scope of this article, but which has been analyzed elsewhere [36].

COMMUNITY PSYCHIATRY IN ROMANIA: STATE OF THE ART

Today in Romania, as in all Central and Eastern European countries, mental health systems are transitioning from hospital-based care to community-based services [37]. These services combine social and environmental elements with the biological and psychological aspects of mental health and psychiatric pathology [38].

Examples of community mental health services in Romania include:

1) preventive care (e.g., general practitioners offices — that aid patients with different disabilities; specialist doctors; CMHTs, comprised of specialists from varied disciplines like psychiatry, psychology, social work, that provide healthcare services in the community; specialized mental health teams, whose aim is to provide healthcare services in a particular field of medical problems, such as patients suffering from a particular type of psychiatric issue);

2) self-help groups (people with similar life experiences gather to empower each other and offer mutual support in order to avoid falling within the anomic minorities);

3) daycare centers (locations in the community designed to substitute psychiatric hospitals and aim to help patients reintegrate into society — one example of such service is the “Shield Centre” in Brasov, part of the “Estuar” Foundation center network, a non-profit organization whose aim is to offer prevention, recuperation, and psycho-socio-vocational rehabilitation for people with disabilities and disadvantaged young adults) [39];

4) advocacy groups (groups that speak and act on behalf of mental health patients and inform about mental health, collaborate with non-governmental organizations (NGOs), and organize events and meetings. Advocacy groups use various strategies to reach their goals, such as informational — using promotion and media actions to inform the general public about a particular condition; collaborative — that involve setting meetings between NGOs or the support of an expert that is involved in a certain social cause or press conferences; and confrontation — making use of demonstrations or boycotts to support a cause, in situations where dialogue and negotiation are not possible);

5) promotion of mental care and mental health (providing informational materials and resources to the families of, or support networks for mental patients, creating campaigns based on mental health issues, influencing policy makers)

6) offering support and care after hospitalization (community workers, social workers, volunteers who offer continuous support for patients with previous hospital admissions and CMHTs and specialized mental health teams that provide psychiatric support within the community) [2].

Community mental health services in Romania are organized by a case manager (routinely a psychiatrist), who is familiarized with the patient’s medical and social status. When a patient is discharged from hospital, they are directed toward a day center that schedules regular meetings with the patient and provides monitoring services in order to comprise a personalized healthcare plan. The aim of the plan is to identify the most suitable manner through which the needs of the patient can be met. The plan is comprised of objectives, problems specific to the patient, the services provided, and the people responsible for implementing the services. Consequently, community health specialists, such as general practitioners, community nurses, and social workers who work with the patient, are informed of the personalized healthcare plan through direct meetings. The following step concerns the direct implementation of appropriate healthcare services, whereby the patient receives medical care suitable to their particular needs (direct medical care, administration of injections, monitoring of physiological parameters, blood glucose monitoring, symptom management and pain management, to name but a few). In addition to medical services, the patient can be offered social assistance through counseling, case management, information, advocacy, psychotherapy, occupational therapy, and legal assistance [40].

MODERN COMMUNITY PSYCHIATRY PROJECTS IN ROMANIA

One community psychiatry project that took place in Romania with the contribution of the European Union was the RECOVER-E project (start date 01.01.2018 – end date 31.12.2021). The aim of the project, which was implemented in Siret, Romania, was to train CMHTs to provide evidence-based mental care services within the community [37]. The conceptual backbone of the training program was based in the principles of assertive community treatment (ACT). The ACT model was a program designed in the 1970s by Stein and Test as a specialized care package designed to meet the needs of severe psychiatric cases, characterized by either high service use or chronic or severe diagnosis. Health care is implemented by a multidisciplinary team comprised of psychiatrists, nurses, case managers, and employees of community-based services, and sharing of caseloads and 24-hour coverage among clinicians [36]. In this study, services were offered to patients, who shared any decision making, and included aid in domains such as psychiatric symptoms, personal or social functioning, and were recovery-oriented. Changes in functioning were measured using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0), where outcomes were assessed using the three-level EuroQoL five dimensions (EQ-5D-3L) and costs were also measured with the Trimbos/iMTA Questionnaire on Costs associated with Psychiatric illness (TiC-P) [41]. The most stringent needs of psychiatric patients were in the following domains: participation in society, life activities, managing the household, and going to school or pursuing a career [37]. Another study assessed the confidence of mental health staff in terms of providing various services to patients, with interesting results that highlighted differences in confidence between nurses and peer workers (low confidence) and psychiatrists or psychologists (high confidence) [42]. Overall, the RECOVER-E project was a promising initiative that offered a varied and complex perspective on the therapeutic dynamic of healthcare personnel and patients outside the hospital setting.

The SEE Mental Health Project (“Enhancing Social Cohesion through strengthening Community Mental Health Services in Southeastern Europe”) was a project carried out by the WHO between 2002 and 2008 and involved nine countries, among which Romania was a participant. The aims of the project were to ensure that mental health policies and legislations were in line with European Community standards and to implement programs concerning mental health that addressed the needs of patients within their community. Results of studies on the SEE Project showed that patients value the relationship with mental health staff. However, one important issue that negatively affects the quality of life and treatment satisfaction of patients is unemployment [43]. There are two key requirements to consider when assessing a patient’s response to therapy for a psychiatric disorder: the need for community integration, and the need for intimacy [44].

An important project with interesting and varied implications in the domain of Community Psychiatry in Romania is the “Horizons” project carried out by the “Orizont” Foundation. The organization functions as an NGO and aims to support mentally ill people in regaining self-confidence and acquiring skills that enable them to lead active and independent lives. The objectives of the project are to inform and educate mental health patients about the issues they are facing, to use occupational therapy to teach skills, to raise awareness within the community about mental health issues, and to aid in the social and professional reinsertion of mental health patients. To achieve these goals, the foundation has created workshops in domains such as health, education, pottery, weaving, iconography, gastronomy, tailoring, and computer science, among others. Furthermore, the foundation offers protected living spaces for patients and is involved in fighting stigma and advocates changes within the community to benefit psychiatric patients [40].

In 2007, the RO-UA Mente project took place in the Campulung Moldovenesc Psychiatric Hospital. Its aim was to facilitate information and experience exchange between mental health professionals from Romania and Ukraine [40, 45].

In Bucharest, the TREPTE Center operated within the “Alexandru Obregia” Psychiatric Hospital. It was a day care service founded by the Romanian Association of Community Psychiatry that offered services such as psychological evaluations, education groups for patients and their families, health education, individual and group psychotherapy sessions, as well as activities that trained social and practical abilities, self-help groups, and recreational activities [46]. However, in the case of comorbid psychiatric disorders with a somatic pathology, the resolution of the latter can, at the same time, lead to the remission of psychiatric symptoms [47]. On the other hand, in severe cases, in terminally ill patients, the responsibility for care should not end with their death but continue by offering appropriate support to the family [48].

CONCLUSION

Romanian mental health workers and specialists are educated and experienced in implementing community psychiatry methods in the complex treatment of the mental health patient. Additionally, there are numerous and varied community-based treatment options, from day centers to advocacy groups, which are involved in the rehabilitation of patients.

Community Psychiatry in Romania is a budding field that can greatly aid in the management and treatment of psychiatric patients in urban and rural areas. In order to create a strong and efficient network of specialists invested in this cause, efforts must be made to apply the principles of deinstitutionalization and community health care. In order to support this endeavor, policies must be put in place to combat the stigmatization of people with mental illnesses in order to allow for their better integration into society and easier access to employment. Furthermore, training medical staff such as nurses and primary care physicians to care for and manage mental health patients must be a priority in this regard in order to develop the practical skills required to deal with the requirements of such a community-based approach. Finally, there is a considerable need for complex systems analysis that use population statistics in order to gain a more comprehensive view of the situation of mental health patients in Romania today.

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