by Steven D. Targum, Oleh Chaban, and Serhiy Mykhnyak
Steven D. Targum, MD, is the scientific director at Clintara LLC, the chief medical officer at Methylation Sciences Inc., BrainCells Inc., and Functional Neuromodulation Inc., the chief medical advisor at Prana Biotechnology Ltd., and a consultant in psychiatry at the Massachusetts General Hospital, Boston, Massachusetts. Prof. Oleh Chaban is the director of the Clinic for Borderline Conditions at the Scientific Research Institute of Social and Forensic Psychiatry and Narcology in Kiev, the vice president of the Ukrainian Association of Psychotherapists and Psychoanalytics, and an academician of the Ukrainian Academy of Sciences of High School in the Ukraine. Dr. Serhiy Mykhnyak is a psychiatrist and researcher at the Lviv District Clinical Psychiatric Hospital in the Ukraine.
Innov Clin Neurosci. 2013;10(4):41–46
Although psychiatry is practiced throughout the world, the unique customs of any specific cultural group and the available resources in their region may influence the nature of their clinical practices. These practices can change abruptly when the sociopolitical system influencing psychiatric practices change. For instance, psychiatric practice and research has experienced a marked evolution and transition in the Ukraine in the past 20 years following the establishment of independence in 1991. It is well documented that until the 1980s, psychiatry was often used for political purposes by the authorities in the former Soviet Union.[1–3] Political dissidents were often given a diagnosis of “sluggish” schizophrenia based upon a now discredited Soviet “idea” about psychiatric illness developed by Professor Snezhnevsky, the Director of Psychiatry at the Soviet Academy of Medical Sciences in those years. His theory conveniently described a schizophrenic disorder characterized by a ‘negative axis’ of symptoms that included conflict with authorities, poor social adaptation, and pessimism without the need for actual psychosis. In the Ukraine, the end of communism brought an end to these theories and allowed psychiatrists to learn from the rest of the world
I thought it would be of interest to the readers of Innovations in Clinical Neuroscience to explore the current state of psychiatry in the Ukraine and identify ongoing challenges for the future of practice and research in that country. For this article, I interviewed two Ukrainian psychiatrists: Professor Oleh Chaban, who is the director of the Clinic for Borderline Conditions at the Scientific Research Institute of Social and Forensic Psychiatry and Narcology in Kiev, vice president of Ukrainian Association of Psychotherapists and Psychoanalytics, and academician of the Ukrainian Academy of Sciences of High School; and Dr. Serhiy Mykhnyak, a psychiatrist and researcher at the Lviv District Clinical Psychiatric Hospital.
Both Drs. Chaban and Mykhnyak were originally trained during the Soviet era, which included the ideas and theories promoted by Soviet textbooks, but have subsequently witnessed the remarkable and dramatic opening up of psychiatry in the Ukraine.
Why did you become psychiatrists?
Dr. Chaban: My interest in psychiatry began during my school years, largely due to my curiosity about psychic phenomena and hypnosis, which then progressed into an interest in psychology during my university years. Later, I started to focus on brain physiology and joined a student’s circle of psychiatry. My first scientific work was on the use music therapy for mental disorders; this work received high commendations and encouraged me to continue my research in psychiatry.
Dr. Mykhnyak: I have lived through a period of tremendous social and political changes in the Soviet Union. Transforming events in all spheres of life have affected the lives and mentality of millions of people here. The dramatic sociopolitical switch that occurred in the 1990s gave psychiatry the push to get out of its stagnation and become a rapidly developing and highly promising branch of medicine. While I was at the university, my growing awareness of this emerging social and political transformation gave me the perspective and the inspiration to pursue my studies in psychiatry.
Describe your training to become a psychiatrist in the Ukraine?
Dr. Chaban: After six years at the university, I had a one-year internship in psychiatry. At first, I chose to train in the far east of Russia—Komsomolsk-on-Amur (a city close to the border of China)— instead of the Ukraine. I returned to the Ukraine in 1979 and began my clinical practice of psychiatry. Later I completed my PhD thesis and eventually became a lecturer and the Chair of Psychiatry in 1980.
We were taught the “acceptable” Soviet-era ideas about psychiatry during my training. At that time, the only available psychiatric textbooks were written by Soviet authors (Avrutsky, Snezhnevsky, Morozov). We had no original or translated foreign classical textbooks on psychiatry. Later in my career, I was able to get some books from my colleagues in Poland and the German Democratic Republic. I recollect that my first reading of the Russian edition of the classic textbook Kaplan and Sadock’s Comprehensive Textbook of Psychiatry did not occur until 1995.
We worked exclusively with the International Statistical Classification of Diseases and Related Health Problems, Ninth Revision Edition(ICD-9) diagnostic classification system. We had heard about the existence of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in the United States but had never seen this classification.
When I began my practice of psychiatry, ordinary doctors like myself had to read the Soviet periodicals, and only the highly classified and “loyal to party” specialists were given access to alternative foreign sources of information. After our country gained independence, we started to meet colleagues from other countries and were able to read the professional literature from abroad for the first time.
Dr. Mykhnyak: After I attended the medical university, I had one-year internship in psychiatry in from 1990 to 1991 that concluded my professional education. At that time, official psychiatry used the ICD-9 classification and our teachers could only use the approved textbooks written by Soviet authors. The psychiatric literature was strictly controlled by the authorities that specifically disallowed all “ideologically peccant theories” of psychiatry. Of course, when the Ukraine became independent, all of the bans on reading the world’s psychiatric literature were removed; it is now possible to obtain printed materials from anywhere abroad. Our professional journals have become less conservative, and a whole number of translations of foreign texts have been done. For instance, translations of the first editions of Oxford Textbook of Psychiatry and Principles and Practice of Psychopharmacotherapy were printed and first made available in Russian in 1999.
Were you ever personally affected by the politics of psychiatry during the Soviet era?
Dr. Chaban: We all were affected by politics during the Soviet era. The political system meant that the soviet authorities had total control over the practice of psychiatry. Political solutions were created to keep psychiatry, and psychiatric patients, within the limits of the “soviet science,” which was considered, at that time, to be the only right science for all. Since the society was closed, we had no access to alternative sources of information. There was a sort of vacuum that was often filled with outdated (but artificially cultivated) clinical and scientific beliefs. Of course, this influence declined during the 1990s and completely vanished after the split-up of the Union of Soviet Socialist Republics (USSR).
Dr. Mykhnyak: Political influence was evident in all aspects of medical science during the Soviet era, and most especially in psychiatry. Soviet ideology was intended to be the cornerstone of our practice during the Soviet era, and psychiatrists were expected to preserve the moral, political, and ideological safety of Soviet citizens. Legislation on psychiatry was adopted in 2000 that made it possible to eliminate the misuse and/or manipulation of psychiatry for political purposes.
What happened to the people who were “political” patients rather than having genuine psychiatric disorders?
Dr. Chaban: Over time, I believe that history has made everything clear and ultimately has shown the truth about these unfortunate cases. In fact, many of the cases of “political” patients were traced by the foreign rights protection movements or organizations and made known to the public. We all know the history of Dr. Semen Gluzman, a psychiatrist who is today the president of the Ukrainian Association of Psychiatrists. Dr. Gluzman was one of the human rights activists during those times who was sentenced to seven years of prison for his activities.
The victims of the political abuse were rehabilitated, but many of them still suffer from health and social consequences caused by the years of imprisonment and even modern-day instability. Many former dissidents were pivotal in initiating major changes in the political and social life that led to the creation of a new democratic society in independent Ukraine.
Dr. Mykhnyak: According to the famous human rights movement activist and Sovietologist, Robert van Voren (Chief Executive of the Federation Global Initiative on Psychiatry), there were 16 special psychiatric hospitals in the former USSR (one of them was in the Ukraine). Many of those institutions are closed to the public. Some dissidents were sent to regular hospitals for brief periods of time (1–2 months) just to be frightened, while others, after already serving long periods of time at one of the special hospitals, were then tranferred to regular hospitals for a few months before being released to the society. According to van Voren, 99 percent of the psychiatrists either never knew about those “patients” or were sincerely convinced that the dissidents were insane.
Please describe your current hospitals.
Dr. Chaban: I work in a multidisciplinary, 400-bed hospital that was built in 1949. Thirty of the beds are in the Department of Psychiatry. We redesigned our psychiatric unit 12 years ago based on the psychosomatic ward at the University Clinic in Austria.
The newly reconstructed psychiatric unit provides contemporary diagnostic, treatment, and rehabilitation services. We serve many different types of patients in our clinic, including those with psychosomatic disorders, Alzheimer’s disease, affective disorders, and schizophrenia.
Dr. Mykhnyak: My hospital was originally founded over 135 years ago (in 1875) as a “house for the insane.” Of course, it has since been reorganized and not only houses but actively treats mental patients as well. The hospital survived hard times during the First and Second World Wars and during the Soviet era, but we now have 1,500 beds that offer specialized services, including an intensive care unit and separate wards for children, geriatric patients, and tuberculosis patients. Since it is a university clinic, we treat a wide range of mental disorders, including personality disorders, psychosis, and depression, including treatment-refractory depression.
What is a typical psychiatric treatment strategy?
Dr. Chaban and Dr. Mykhnyak: In general, our treatment approach is multidimensional and includes psychopharmacology combined with psychotherapy. In many cases, we add rehabilitation programs and offer additional treatments (e.g., physiotherapy). Historically, psychiatrists also are also involved in assessing and dealing with the social problems of our patients and have long recognized a biological and social connection in the mental disorders.
What type of psychotherapy is offered?
Dr. Chaban: I am personally very interested in psychotherapy. Being part of the European Federation for Psychoanalytic Psychotherapy, I can say that everything is different from how it was during Soviet times. We have new ideological ground, new values, and a different and open theory and philosophy. The most valuable things are diversity and a multidimensional approach to the treatment of our patients. Our clinic uses different types of psychotherapy, including Gestalt, group therapy, cognitive behavioral therapy (CBT), psychoanalysis, art therapy, and movement therapy.
Dr. Mykhnyak: The director of our hospital, Prof. Oleksandr Filts, is a world reknown psychotherapist (President Elect of the European Association of Psychotherapy) who initiated the broad implementation of different methods of psychotherapy into the practice of psychiatry. Consequently, we use a wide spectrum of psychotherapies, including psychoanalytical therapy, CBT, family therapy, Gestalt therapy, and even psychodrama in our hospital clinics.
What psychotropic drugs do you have available for treatment?
Dr. Chaban and Dr. Mykhnyak: In general, the pharmaceutical market in the Ukraine is well saturated, and most of the psychotropic drugs used in the West are commercially available to us as well. In fact, there is essentially no real difference in the availability of psychotropic medications and brands between Western Europe and us. Sometimes we do see some delays for new compounds to get to our market, but usually it depends on the manufacturer’s policy. Our country also has a number of local drug manufacturers, and the market has a wide spectrum of generic drugs. For instance, we have approximately six generic forms of risperidone available while the branded drug is high-priced.
In the Ukraine, medical service is financed by the state and only receives 3.5 percent of the national income (WHO experts have estimated this need to be closer to 6–7%). Hospitals are able to use these funds according to their needs, and purchase medications based on the drugs offered in the market. For this reason, the hospitals usually buy the less expensive drugs, and the more expensive psychotropic medications are bought in limited amounts.
Do you use electroconvulsive treatment (ECT)?
Dr. Mykhnyak: We do have ECT available for some of our difficult-to-treat cases. ECT is not going out of use. For instance, in some cases of treatment-refractory depression or major depressive disorder with severe suicidal ideation, febrile catatonia, or neuroleptic malignant syndrome, we consider ECT as the treatment of choice.
What is the role of the patient’s family in the evaluation and treatment of psychiatric patients?
Dr. Chaban: I consider the role of family members for information and support to be extremely important, but their involvement is insufficient in the Ukraine. Within the last few years, we have started to see the growth of User associations and family support groups. I believe that psychoeducation for the general public is insufficient due to a general under-appreciation of the social side of mental disorders
Is there stigma attached to psychosis in the Ukraine?
Dr. Chaban and Dr. Mykhnyak: The word “insane” sounds like “free of God” in Ukranian and means that the person has lost God. This term “insane” describes the attitude of many people toward the mentally ill: those with mental illness might be considered as requiring more compassion and help to return to the faith.
Of course, stigma is a common problem not only in the Ukraine. There is a lot of literature on that matter. There is a big need to overcome prejudices and promote the integration of mental patients into the community.
The general attitude on mental disorders in teh Ukraine depends, in part, on the peculiarities of the region of the country. For instance, in the more industrial eastern regions, mental disorders are associated with more load or pressure on the personality and a lack of spirituality, which is believed to provoke anxiety or even aggression in some people. On the other hand, there is more tolerance of those with mental disorders in the western regions of the country due to more religiousness and a more sincere and merciful attitude among the people.
Today, the physicians in the Ukraine share the same point of view as European psychiatrists in their concept of the biological and social-psychological dichotomy that may be present in any mental disorder.
Can you describe some cases that may differ from what Psychiatrists may observe in the United States?
Dr. Chaban: In my opinion, the last few years have been clearly marked by the sign of patomorphosis, which means a permanent clinical change in the clinical manifestations or course of a mental disorder that could be due to diverse medical, social, psychological, and biological factors. We have also seen more drug nonresponsiveness to the therapy.
I have seen a definite growth of the diagnosis of schizoaffective disorder in the Ukraine. It has also been very interesting to observe some diagnostic differences between my colleagues here and psychiatrists in the United States. For example, some of our patients who were diagnosed with schizophrenia in the Ukraine were, after emigrating to the United States, rediagnosed with bipolar disorder by American psychiatrists.
Dr. Mykhnyak: In the past few years, I have seen a number of cases of Folie a deux, which was comparatively rare decade ago, and I know that such cases are rarely seen in the United States today.
What are the challenges for clinical research in the Ukraine?
Dr. Chaban: We are encouraged to do research by Western standards and conduct our clinical trials following review and approval of licensure by the Ministry of Health. However, I think that our society is still not prepared to accept the idea of clinical trials. There is some resistance, generated by manipulative media and legislative inconsistencies, to clinical research that are common in any developing society. Our laws regarding the conduct of clinical trials are very strict, and I wish that the investigators had the same level of protection as subjects who participate in these studies.
Dr. Mykhnyak: Clinical research in our hospital has been done for many years. The Department of Psychiatry developed its own lithium glutaminate in 1990s and has participated as a clinical trial site in multinational clinical trials for the last 12 years works. Among the many challenges to clinical research in the Ukraine, there is an insufficient psychoeducational level in society. Some people have the idea that they are being used as “laboratory rats” and lack the understanding of the importance of this work and their own freedom to consent to their role in the research and to create a new level of partnership with the investigator. Perhaps it is the same in the United States.
What do you think will be the future of psychiatry in your country?
Dr. Chaban and Dr. Mykhnyak: Despite many controversies and a long and difficult history, psychiatry in the Ukraine is now in a new stage of development. Maybe it will take 20 years to shift the old tendencies and change the people’s minds and bring us to new grounds. We are working to understand and adopt global trends and to utilize them in our own settings while adjusting to the specific cultural and economical situation we have in the Ukraine. More open and progressive psychiatric education is providing us with more advanced specialists who are now able to benefit from exchange programs with clinicians from all over the world. General psychiatrists in the Ukraine are becoming more proficient in their field, and this increased knowledge base is providing a firm groundwork for better scientific research and clinical practice. Although our doctors are as prepared as their Western colleagues, the conditions of work are more difficult. We hope that it is time to reform psychiatry in the Ukraine to a more progressive, community-based model with deinstitutionalization. It is also time to introduce nongovernmental facilities to our psychiatric patients
There is no doubt in our view that humanistic ideas in psychiatry must remain of paramount importance and that it is essential to closely monitor both internal and external conditions to avoid the mistakes of the past and guarantee the future well-being of our patients.
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Funding: There was no funding for the development and writing of this article.
Financial disclosures: Dr. Targum is Scientific Director, Clintara LLC; Consultant, Massachusetts General Hospital, Psychiatry (Boston, Massachusetts); Chief Medical Advisor, Prana Biotechnology Ltd (Melbourne, Aus); Chief Medical Officer, BrainCells Inc (San Diego, California); Chief Medical Officer, Methylation Sciences Inc. (Vancouver, BC, Canada); Chief Medical Officer, Functional Neuromodulation Inc (Toronto, Canada); Consultation/CDAs within the past two years include the following: Acadia, Acumen, Alkermes Inc., AstraZeneca, BioMarin, BrainCells Inc., CeNeRx, Cephalon, CTNI MGH, EnVivo Pharmaceuticals, Euthymics, Forest Research, Functional Neuromodulation inc, Eli Lilly and Company, Intra-cellular Therapies Inc., Johnson & Johnson PRD, INC Research, Methylation Sciences Inc., Naurex Inc, NeoSync, Neurophage, Novartis Pharmaceuticals, Novartis Bioventures, Nupathe, Parexel International, PPD, PRA International, Prana Biotechnology Ltd., Reviva, Roche Labs, Sophiris, Sunovion, and Targacept, Transcept.
Prof. Oleh Chaban has received honoraria or consulting fees from AstraZeneca, Forest Research, Eli Lilly and Company, GlaxoSmithKline, Johnson & Johnson PRD, INC Research, H. Lundbeck A/S, Novartis Pharmaceuticals, Otsuka Pharmaceutical Group, Parexel International, Pfizer Inc., PPD, PRA International, Quintiles, Servier, and Teva Pharmaceutical Industries LTD.
Dr. Serhiy Mykhnyak has received honoraria or consulting fees from Alkermes Inc., AstraZeneca, Bracket Clintara LLC, Dainippon Sumitomo Pharma, Forest Research, GlaxoSmithKline, ICON plc, Johnson & Johnson PRD, INC Research, H. Lundbeck A/S, Novartis Pharmaceuticals, Parexel International, ICON plc, Quintiles, Roche Labs, Servier, Sunovion, and Targacept.