An overview of community based psychiatric treatment in Romania: A Narrative Review

  • Authors: Ciobanu A.M.1, Ciobanu A.C.2, Catrinescu L.M.3, Niculae C.P.3, Geza L.4, Ionita I.4
  • Affiliations:
    1. 1 "Carol Davila", University of Medicine and Pharmacy, Faculty of Medicine, Neurosciences Department, Discipline of Psychiatry 2 "Prof. Dr. Alexandru Obregia", Clinical Hospital of Psychiatry, Department of Psychiatry
    2. "Titu Maiorescu" University of Medicine and Pharmacy, Faculty of Medicine
    3. "Prof. Dr. Alexandru Obregia", Clinical Hospital of Psychiatry, Department of Psychiatry
    4. 1. "Prof. Dr Alexandru Obregia", Clinical Hospital of Psychiatry, Department of Psychiatry 2. "Carol Davila", University of Medicine and Pharmacy, Faculty of Medicine, Neurosciences Department, Discipline of Psychiatry.
  • Section: REVIEWS
  • URL: https://consortium-psy.com/jour/article/view/180
  • DOI: https://doi.org/10.17816/CP180


Cite item

Abstract

Community psychiatry has its origins in the West, in the 1950’s, when many institutions for the mentally ill have been closed down, in an effort to shift the focus from hospital-based care to a community based one. The current paper aims to review the available literature regarding the community based psychiatric treatment in Romania.

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. Today, in Romania, as in all 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 to improving the chances for recovery of mental health patients.

Community Psychiatry in Romania is a budding field that can greatly aid in the management and treatment of psychiatric patients of 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.

Full Text

Introduction

Community psychiatry has its origins in the West, in the 1950’s, when many institutions for the mentally ill have been closed down, in an effort to shift the focus from hospital-based care to a community based one. The idea behind this worldwide trend was that a community-based care system enabled patients to be as independent as possible within their own living environments, and this, in turn, would aid in them fulfilling their potential [1]. The process of deinstitutionalization is based on three concepts: depopulation (releasing patients from state run psychiatric hospitals), diversion (returning psychiatric patients within their communities) and decentralization (fragmentation of the responsibility for the patient to 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 study is to gain a comprehensive view of the principles of community psychiatry in Romania, as well as the manner in which those principles are applied to social rehabilitation and integration of the psychiatric patient.

Results

History of community psychiatry

Hospital closures, coupled with government policies that focused on reducing the number of patients that can be admitted in institutions, brought 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, deterioration of interpersonal relationships and social functions [6-8]. At the same time, lengthy admissions to the hospital affects the patient’s professional and social activities and negatively impact their integration in the community [9-11]. This fact can lead to a diminished sense of purpose with bleak repercussions for recovery [12]. Furthermore, due to the nature of their illness, psychiatric patients are not always able to advocate for their rights or seek out medical treatment [13, 14].

 

Key concepts in community psychiatry

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

Needs” are potentially remediable issues that affect a person’s clinical and social functioning below a specific level [15]. A study published in 2000 assessed the needs of psychiatric patients and what healthcare staff believed are the needs of psychiatric patients 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 [16].

“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, lack of employment or opportunities are issues that require addressing in order for a person with severe mental disorder to function at full capacity and participate in the community [17-18]. A strong relationship with mental health specialists, access to employment and financial support are characteristics that aid in the recovery process [19-21]. 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 [22]. The skills needed to reach these goals are major points of interest in the field of psychiatric rehabilitation and contribute greatly to a person’s quality of life [18, 23, 24]. 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 was reduced to baseline after five years [25].  Along with the recovery, other brain functions that have previously decreased, such as cognition may improve considerably [26].

 

The community mental health team

In response to the issues faced by psychiatric patients, community mental health teams (CMHT) were created within the domain of community psychiatry. They are multidisciplinary teams comprised of a psychiatrist, a psychologist, social workers, occupational therapists, nurses that are responsible for a section of the population, frequently defined by geographical vicinity. Additional members can intervene in special cases, such as crisis management, early interventions or assertive treatment [27]. 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 has been analyzed elsewhere [28].

 

Principles of community psychiatry

As deinstitutionalization greatly changed the way in which the needs of the psychiatric patient were met by the healthcare system, a conceptual framework was put in place to guide future interventions [17]. Ideally, community psychiatrists take responsibility for lowering the rates of mental disorders within the community and aim to reveal the needs of psychiatric patients in order to elaborate effective intervention plans and gather feedback in order to better understand how those needs within the community were improved or changed [29]. In other words, they adopt a Pro-Active Policy. In addition to the active role the psychiatrist and other 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 [30].

With all this in mind, since the beginning of the shift of focus from the hospital to the community, the World Health Organization has elaborated and promoted a Mental Health Action Plan that supports deinstitutionalization and the development of community-based services for mental patients, that aim improve clinical outcomes, as well as combating discrimination [31].

 

Historical background in Romania

In the past, during the state socialist period, psychiatry and psychology were used to discipline and police the Romanian peoples, as psychiatric hospitals were used to repress political dissidents that were deemed too problematic for the Ceausescu regime. The view on mental illness was mainly following a biological model, with little to no talk therapies and relying mainly on medications as treatment, leading to the over-medication of patients that would have benefited otherwise from a combination of medication, psychotherapy and social interventions [32].

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 mental health care system [33].

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 [34]. The Mental Health Law active since 2002 describes the statute of the psychiatric patient in Romania [35]. According to legislation, the patient can be treated and cared for in his or her 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 [36].

 

Community psychiatry in Romania

Today, in Romania as in all Central and Eastern Europe, 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 are:

  • preventive care (e.g., general practitioners offices, specialist doctors, CMHTs and specialized mental health teams);
  • 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);
  • day care 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);
  • advocacy groups (people that speak and act on behalf of mental health patients and inform about mental health, collaborate with NGOs, organize events and meetings);
  • promotion of mental care and mental health (providing informational materials and resources to family or support networks of mental patients, creating campaigns on mental health issues, influencing policy makers)
  • 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].

 

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 Country, 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). Services were offered to patients, that shared in the 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 World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0), 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) [39]. The most stringent needs pf 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 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) [40]. Overall, the RECOVER-E project was a promising initiative that offered a varied and complex perspective on the therapeutic dynamic of health care personnel and patients outside the hospital setting.

The SEE Mental Health Project (‘‘Enhancing Social Cohesion through strengthening Community Mental Health Services in South Eastern Europe’’) was a project carried out by 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 [41].   There are two key requirements to consider when assessing a patient's response to therapy for psychiatric disorder: the need for community integration and the need for intimacy [42].

     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 an active and independent life. 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 in the community about mental health issues and to aid in the social and professional reinsertion of mental health patients. To reach these goals, the foundation has created workshops in domains such as health, education, pottery, weaving, iconography, gastronomy, tailoring and computer science. Furthermore, the foundation offers protected living spaces for patients and is involved in fighting stigma and advocate for changes within the community to benefit psychiatric patients [43].

     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 [43-44].

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 [45]. However, in the case of comorbid psychiatric disorders with a somatic pathology, the resolution of the latter can lead at the same time to the remission of psychiatric symptoms [46]. On the other hand, in severe cases, in terminally ill patients, the responsibility for care should not end with their death, but continue by supporting the family to get used to the idea [47].

 

Discussion

The main takeaway from our study is that the Romanian mental health system is a fertile field for implementing community psychiatry strategies and projects. Romanian mental health workers and specialists are educated and experienced in implementing community psychiatry methods in the complex treatment of the mental health patient. In addition to this, there are numerous and varied community-based treatment options, from day centers to advocacy groups, that are involved in the rehabilitation of patients.

          One of the strengths of our article is that it offers a global and historical view of community psychiatry, that can help the reader better understand the purpose and advantages of a community-based treatment strategy for the psychiatric patient. Another strength is that it explains key concepts of the field that broaden the understanding of what the goal of treatment should be. Lastly, probably the most valuable contribution of our article is that it familiarizes the reader with the many projects that were implemented in Romania regarding community psychiatry.

Among the limitations of our study, a main one is the broad strokes with which this complex field was painted, as many things could be further said about the legal implications or connected domains.

Our study is useful for everyone that wishes to gain a broad view of the subject and wants to familiarize themselves with the various community psychiatry projects that were conducted in Romania.

 

Conclusion

     Community Psychiatry in Romania is a budding field that can greatly aid in the management and treatment of psychiatric patients of 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 stigmatization of people with mental illnesses, in order to allow for a 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 so as to develop practical skills to deal with the requirements of such a community-based approach. Lastly, there is great need for complex systems analysis that use population statistics in order to gain a more comprehensive view of the situation of the mental health patient in Romania today.

 

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About the authors

Adela Magdalena Ciobanu

1 "Carol Davila", University of Medicine and Pharmacy, Faculty of Medicine, Neurosciences Department, Discipline of Psychiatry
2 "Prof. Dr. Alexandru Obregia", Clinical Hospital of Psychiatry, Department of Psychiatry

Email: adela.ciobanu@yahoo.com
ORCID iD: 0000-0003-2520-5486
ResearcherId: S-2435-2017
Romania, 1. Romania, Bucharest, 020021, Dionisie Lupu Street, 37 2. Romania, Bucharest, 041914, Berceni Street, 10-12

Alexandru Constantin Ciobanu

"Titu Maiorescu" University of Medicine and Pharmacy, Faculty of Medicine

Author for correspondence.
Email: alexc42ciobanu0@gmail.com
Romania, Bucharest, 040051, Calea Vacaresti Street, 187

Larisa Maria Catrinescu

"Prof. Dr. Alexandru Obregia", Clinical Hospital of Psychiatry, Department of Psychiatry

Email: larisa.afk1@gmail.com
Romania, Bucharest, 041914, Berceni Street, 10-12

Carmen Petrina Niculae

"Prof. Dr. Alexandru Obregia", Clinical Hospital of Psychiatry, Department of Psychiatry

Email: carmen_2992@yahoo.com
Romania, Bucharest, 041914, Berceni Street, 10-12

Luana Geza

1. "Prof. Dr Alexandru Obregia", Clinical Hospital of Psychiatry, Department of Psychiatry
2. "Carol Davila", University of Medicine and Pharmacy, Faculty of Medicine, Neurosciences Department, Discipline of Psychiatry.

Email: luana.geza@gmail.com
1. Romania, Bucharest, 041914, Berceni Street, 10-12 2. Romania, Bucharest, 020021, Dionisie Lupu Street, 37

Ioana Ionita

Email: ioana_ionita@ymail.com

"Prof. Dr Alexandru Obregia", Clinical Hospital of Psychiatry, Department of Psychiatry

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