Psychiatry - O. K. Napryeyenko 2001

Propaedeutics of Psychiatry
Organization of Psychiatric Care

Among clinical disciplines, psychiatry holds a distinct position. Owing to its integrative nature and exceptional responsiveness to historical shifts, it simultaneously explores the body, the mind, and the social environment that invariably influences the psyche and frequently contributes to mental disorders.

However, before reaching its modern standing, psychiatry traversed a long and complex path. Historically, its evolution is commonly divided into theological, metaphysical, and materialistic periods, which largely reflect the socio-economic development, culture, and ideology of society at the time. Naturally, prevailing views on The Nature of mental illness dictated the choice of therapeutic Methods in each era.

Nevertheless, advanced therapeutic methods received scientific validation only over the past 30 years, following the widespread adoption of psychopharmacotherapy and social approaches in psychiatric practice.

Current trends in The Development of psychiatry in the civilized world are characterized by a humane and tolerant attitude toward psychiatric patients, alongside state protection of their legal rights. The Organization of psychiatric services aims to deliver care as close as possible to the patients' place of residence, minimize isolation from their families, and foster a partnership between patient and physician. It is also crucial to integrate the efforts of government agencies and public organizations in providing medical and social care.

Outpatient mental health services play a pivotal role in the Diagnosis and Treatment of patients. Typically, the majority of patients begin and complete their treatment on an outpatient basis, with only a small fraction—up to 10%—requiring inpatient care. Psychiatric hospitalization is primarily reserved for individuals with severe mental disorders.

The core principles of organizing modern psychiatric care include:

✵ developing a predominantly outpatient psychiatric network;

✵ integrating psychiatric and general somatic healthcare services;

✵ bringing care as close as possible to the patient;

✵ intensifying treatment using modern biomedical methods and psychotropic drugs;

✵ enhancing The Role of person-centered diagnostic and therapeutic approaches;

✵ minimizing the social isolation of psychiatric patients and mitigating the medical and social consequences of mental illness;

✵ ensuring continuity between general medical and psychiatric networks, as well as all other institutions and organizations involved in public mental health;

✵ widely introducing social forms and methods of treatment into psychiatric practice, and promoting the restoration of patients' social and personal status;

✵ safeguarding the rights and freedoms of individuals with mental disorders;

✵ implementing psychohygienic and preventive measures.

Adherence to these principles makes it possible to build a comprehensive system of measures addressing the primary requirements of psychiatric care.

Structure of Psychiatric Facilities

Psychiatric care is provided through inpatient, outpatient, and semi-inpatient (or intermediate) mental health facilities. Together, these form an integrated network of institutions varying in profile, purpose, and scope of work. They include: psychiatric hospitals, dispensaries (regional, municipal, and district), specialized centers (national, regional, municipal, and district), psychoneurological and psychosomatic departments and consulting rooms within general multidisciplinary hospitals and policlinics; day hospitals and therapeutic workshops attached to psychiatric hospitals, centers, and dispensaries, which serve as an intermediate link in the diagnostic, therapeutic, and rehabilitation process between inpatient and outpatient facilities. Furthermore, psychiatric services are the subject of research in research institutes and academic departments of psychiatry in higher medical educational institutions.

Psychiatric Inpatient Facilities

Inpatient psychiatric care is provided in psychiatric hospitals, centers, inpatient dispensary departments, psychoneurological and psychosomatic inpatient units within regional, municipal, and district hospitals, as well as in psychoneurological care homes under the Ministry of Social Protection and other agencies.

Each psychiatric hospital is assigned to a specific territory, has a defined service radius, and a designated capacity. The optimal size of a modern hospital ranges from 800±300 beds. Much like general hospitals, The structure of a psychiatric clinic comprises an admission unit, various diagnostic and therapeutic departments, and auxiliary units. Depending on the patients' AGE AND SEX, the course and stage of the mental illness, the nosological Specificity of the disorders, and specific objectives set by public health authorities, treatment wards are categorized into general and specialized units. In turn, these include units for adults and children, men and women, while subspecialized units encompass gerontopsychiatric, somatopsychiatric, epileptological, forensic-psychiatric, compulsory treatment, infectious, phthisiatric, hospital-based, rehabilitation, and psychosomatic wards, among others. Additionally, a ward's profile may be determined by its preferred therapeutic modality—biomedical or social. Wards typically accommodate patients of a single sex; however, in some clinics, men and women are housed within the same ward. Wards may also be specialized by function, such as diagnostic and therapeutic units (for first-time patients); active therapy units (for returning patients experiencing an exacerbation who require intensive, primarily biomedical treatment); and social therapy units (for patients with chronic relapsing psychoses who need supportive care and, above all, socio-psychological rehabilitation). Other specialized units exist as well. Psychiatric hospitals may also incorporate narcological dispensaries with inpatient units, narcological clinics, or corresponding departments. Alongside biomedical treatment, all inpatients are assigned a specific regimen based on their mental and somatic status, namely: restrictive, differential observation, open, semi-inpatient (day hospital), or partial hospitalization.

The regimen is prescribed by the psychiatrist upon admission, and this instruction must be recorded in the medical documentation. Subsequent medical prescriptions depend on the regimen, which is periodically reviewed in light of the patient's condition. Within the ward, patients are accommodated in rooms on a differentiated basis. Their movement is not restricted unnecessarily, which helps prevent potential incidents during episodes of psychomotor agitation or attempts at self-harm or harm to others (suicide, aggression, homicide, etc.).

A modern psychiatric hospital must possess not only a robust diagnostic and therapeutic base, advanced medical equipment, and instrumentation, but also proper living conditions to ensure patient comfort. Traditionally prevalent psychiatric attributes, such as special fixtures, window bars, and locks, should be avoided. The interior layout of premises, including wards and consulting rooms, as well as their furnishings, should not differ from those of ordinary hospitals. Moreover, it is highly desirable for each psychiatric clinic to feature a club, sports halls, outdoor courts, a landscaped park, places of worship, a complex of shops and cafes, personal service facilities, etc. House rules for patients and visitors should be grounded in the principles of partnership, mutual assistance, and respect for human rights and freedoms.

Recent decades have witnessed a trend toward deinstitutionalization (maximizing the transition of patients out of the hospital environment) and reducing psychiatric hospital capacities to 300–500 beds. Artificial restrictions on patient freedom are being phased out. Clinics are viewed not as places of isolation, but as temporary accommodations for the duration of treatment. Wards are designed to house no more than 1–3 individuals, complete with all utilities, while inpatient units are planned for a maximum of 20–30 beds, featuring day hospitals, lounges, and dedicated recreational and leisure spaces.

An essential component of measures aimed at restoring the social status of patients in a psychiatric hospital should include psychotherapeutic interventions and legal services. Ideally, the duration of inpatient treatment should be limited to an average of two weeks. Afterward, patients are discharged home for outpatient maintenance therapy or semi-residential treatment at a community mental health center or day care facility near their place of residence. Only a few patients require special attention and behavioral monitoring to promptly arrest any exacerbation of their condition. Patients presenting with acute psychotic symptoms are primarily assigned a restrictive regimen and medical treatment, and are housed in separate rooms under the supervision of medical staff.

Organization of Emergency and Urgent Psychiatric Care

In psychiatry, The concepts of emergency and urgent care often overlap and exist largely on a theoretical level, as it can be difficult to predetermine the course of action for a mobile psychiatric emergency team upon arrival at a call. A psychiatrist's tactics on-site depend primarily on the situation, the specific psychosomatic state of the patient, and their behavior. Typically, immediate psychiatric intervention is required for: patients in a 3 — 1-2538 state of psychomotor agitation of various etiologies accompanied by impulsive and aggressive actions; states of clouded consciousness; acute hallucinations and paranoia; depression accompanied by fear and suicidal tendencies; and pronounced dysphoria. Such patients receive emergency first aid through the administration of medications (psychopharmacological drugs) to subdue the attack and are subsequently hospitalized in a psychiatric facility.

In large cities, hospitalization is provided by specialized psychiatric emergency teams consisting of a psychiatrist, a paramedic, an orderly (junior nurse), and a driver. In district centers, this is handled by general emergency response teams upon referral from psychiatrists or neurologists. In rural areas, this function is performed by local general practitioners, paramedics, or nurses from feldsher-midwifery or medical stations.

Involuntary or forced hospitalization is administered as an emergency psychiatric measure without the consent of the patient or their legal representatives, performed by medical personnel and, if necessary, with the assistance of law enforcement officers. This occurs when there are undeniable signs of a mental disorder that render the patient antisocial, meaning dangerous to themselves and others. However, the mental disturbance must be unambiguous and confirmed by the patient's actions and statements—specifically, concrete facts. Only this provides grounds for compulsory hospitalization.

Therefore, to carry out enforced actions, primarily in the best interests of the mentally ill person, the medical criterion for emergency hospitalization (manifest mental disorders) must align with the legal or psychological criterion (the patient poses a danger to themselves or others). It must be emphasized that when deciding on emergency hospitalization, a physician has no room for doubt when assessing clear signs of psychotic symptoms and the reality of a patient's potential danger. In doing so, it is crucial not to make a mistake. Only a real situation, facts, and objectively confirmed threats can serve as the basis for concrete actions by the medical staff. Neglecting these rules can lead to an unjustified violation of human rights and freedoms, with all the ensuing consequences both for the patient and for those who inadvertently cross the BOUNDARIES OF THE law.

According to current legislation, an individual who is hospitalized involuntarily—without their own consent or that of their legal representatives (relatives, guardian)—must be examined within 24 hours by a commission of three psychiatrists. The issue of the appropriateness of the patient's continued stay in the psychiatric hospital is decided collectively. If necessary, treatment is continued until the mental state improves, of which the HEAD physician (head of the department) notifies the patient and their relatives. If a patient exhibits no noticeable mental disorders, but only minor deviations, and does not pose a danger—since individual symptoms of mental impairment do not affect their behavior—yet categorically refuses treatment, they must be discharged from the hospital under the care of a psychiatrist or other medical personnel at their place of residence. Individuals in a state of intoxication or Drug poisoning (unless presenting with a psychotic state) are not subject to emergency hospitalization in a psychiatric hospital.

Acute psychotic states can arise from endogenous disorders (Schizophrenia, manic-depressive psychosis), exogenous factors (due to infections, trauma, intoxication), psychogenic causes (reactive states), age-related, organic, and vascular psychoses, as well as Epilepsy. Additionally, acute psychotic states sometimes result from complications during difficult childbirths or the postoperative period, severe somatic diseases, and so forth. Psychomotor agitation is most effectively managed using psychotropic drugs, primarily neuroleptics combined with tranquilizers. However, depending on the Etiology and type of agitation, antidepressants, anticonvulsants, and other medications may also be employed.

Among psychomotor agitations, the most common include: hallucinatory-paranoid, delirious, amentive, catatonic, hebephrenic, epileptic, psychopathic, manic, depressive, agitated depression, and others.

During the emergency hospitalization of a patient, the compulsory administration of medication may become necessary. However, the patient should first be offered the opportunity to voluntarily take their medication and agree to be transported to the hospital. If the patient refuses, they should be gently yet firmly held by the shoulders and elbows, placed on a bed, and administered intramuscular injections. While escorting them to the vehicle, staff should hold the patient by the shoulders and arms from both sides. Continuing to secure them, they are placed on a stretcher and transported to the admissions ward. In particularly dangerous cases, hospitalization is carried out by the emergency team together with law enforcement personnel.

Patients with acute mental disorders or chronic conditions in an acute phase are hospitalized in psychiatric hospitals, whereas inpatient units of psychoneurographic dispensaries, centers, or psychiatric departments in general hospitals primarily treat patients with non-psychotic mental disorders. Such pathologies often stem from various somatic illnesses. These facilities also treat patients with psychoses who do not require confinement in a specialized psychiatric institution. As a rule, such individuals seek care voluntarily or at the insistence of their relatives.

The establishment of psychiatric units within district and municipal general hospitals has proven to be effective. This is a step toward bridging psychiatry with general somatic medicine. This circumstance is of great social and rehabilitation significance, as patients in a conventional hospital are virtually unisolated from society, enjoy standard rights, and maintain contact with family and friends, which enhances treatment efficacy. Organizing such units with 30–60 beds is a vital task for inpatient psychiatric care services.

Outpatient Psychiatric Care

Interest in expanding outpatient psychiatric care continues to grow worldwide, fully aligning with modern requirements for the Treatment of Mental Disorders. Beyond economic advantages, it is equally important to preserve social status and maintain ties with society—specifically family, neighbors, and colleagues.

The task of providing outpatient psychiatric care is assigned to psychoneurographic dispensaries, psychoneurographic departments of multidisciplinary hospitals, and outpatient clinics located within patients' residential areas.

Depending on the size of the served population, regional, district, municipal, or inter-district dispensaries comprise outpatient clinics, inpatient units, day care facilities, and sheltered workshops.

The primary Functions of the dispensary service include the detection and registration of mentally ill individuals, medical and consultative, organizational and methodological, social and rehabilitation, preventive, and certain Other types of activities. Each dispensary is assigned a specific territory, which is divided into distinct medical districts for serving the adult and pediatric populations. The district psychiatrist performs the full scope of diagnostic, therapeutic, and preventive work within their district in accordance with current regulations. They are responsible for the timely detection, initial examination, or assessment of patients, placing them under dispensary and consultative observation, and providing treatment, including maintenance therapy. Registered patients require continuous monitoring. Furthermore, the physician implements social, occupational, and legal measures to help restore the patient's social functioning.

In recent years, significant changes have been introduced into The system of psychiatric registration and dispensary monitoring of patients, with greater emphasis placed on democratization and the observance of human rights and freedoms. However, the core missions of dispensary work remain unchanged: everyday care for The Fate of patients with severe disease courses, especially those who committed offenses while in a pathological state, as well as those who, due to mental disorders, may commit antisocial acts.

District psychiatrists should focus a certain amount of attention on restoring patients' work capacity, as well as on patronage work as a form of rehabilitation and maintaining the patient within a home environment (collective patronage).

Patronage is one of the oldest methods of helping patients adapt to life outside the hospital and continues to play a significant role today. Patronage is formalized as a fixed-term agreement between a psychiatric institution on one hand, and an individual or legal entity (relatives, an enterprise, a collective farm) on the other. The agreement outlines the responsibilities for providing care, medical treatment, and material support from both parties.

Sheltered workshops operate as facilities for the vocational readjustment (occupational therapy) of patients, vocational training, learning a new trade, or temporary employment. They operate on a self-financing basis or via special funds and provide a designated number of workstations. Occupational therapy is prescribed to patients based on medical indications by physicians and is overseen by specially trained occupational instructors and masters under the guidance of a physician, workshop nurses, and social workers, who monitor the work-therapy process.

An equally important role in outpatient treatment is played by day care facilities attached to psychiatric dispensaries or hospitals, including general somatic hospitals. This is a component of the system that ensures continuous and consistent treatment for patients with both mild psychotic disorders and non-psychotic conditions. While remaining within their familiar social environment, patients visit for treatment at scheduled times and then return home, continuing therapy until their condition improves or they recover.

Psychiatric offices also exist within district outpatient clinics or—in the absence of psychoneurographic dispensaries—within district hospitals. The district psychiatrist performs the duties of a dispensary district psychiatrist and reports directly to the chief physician of the hospital or clinic. Organizational and methodological guidance for municipal and regional psychoneurographic dispensaries, departments, and offices is provided through regional psychoneurographic dispensaries, dispensary departments of regional psychiatric hospitals, or central municipal psychoneurographic dispensaries in large cities.

In rural areas, psychiatric care has certain distinctive features due to the larger service radius and lower population density. The center of psychiatric care in a district is the psychoneurographic department or corresponding office of the district hospital. Local rural physicians take a direct part in identifying mentally ill patients, registering them, and providing medical care. They carry out the district psychiatrist's prescriptions and monitor the patients. Together with the district psychiatrist, they address issues of social rehabilitation and employment, and when necessary, facilitate disability status placement, organize maintenance treatment, and conduct relevant preventive and psychological measures.

Rehabilitation of Mentally Ill Patients

MODERN TRENDS IN psychiatric care focus on restoring patients' individual and social status through rehabilitation measures. Rehabilitation aims at early and effective treatment, the Prevention of disability, and the timely and successful reintegration of patients and individuals with disabilities into society and professional life. Restoring social connections lost during illness is of paramount importance. This is achieved by enforcing current legislation and implementing a comprehensive range of medical, socio-economic, psychological, pedagogical, and legal measures.

The forms and methods of rehabilitation are diverse. They include differentiated treatment regimens, occupational therapy, psychotherapy, remedial gymnastics, art therapy, Special Methods of social activation (such as self-organization and self-care), vocational guidance, as well as individual and group forms of patronage, among others.

International practice distinguishes three stages of rehabilitation: medical, vocational, and social. While there are no rigid boundaries between them, each stage addresses specific tasks with the ultimate goal of personal restoration and the elimination of social maladjustment. The medical stage seeks to eliminate productive psychopathological symptoms and prevent institutionalism (often referred to as hospitalism), disability, and social inadequacy. The vocational stage focuses on consolidating therapeutic gains and restoring working capacity and social connections. The social rehabilitation stage aims at maximally restoring the patient's social standing and ensuring social adaptation and employment.

Achieving these goals is impossible without a well-defined, comprehensive individual psychiatric rehabilitation program tailored to a specific psychiatric institution, city, district, or region. Such a program must take into account the patient demographic, socio-economic and demographic factors, the STRUCTURE AND FUNCTIONS of psychiatric facilities, local employment rates, relevant legislation, and the capacity of local authorities regarding employment opportunities.

To implement such programs, specialized units are established within psychiatric institutions and administrative bodies to ensure information analysis, coordination, and control over the program's execution.

The physician plays a central role in rehabilitation. Therefore, when developing a rehabilitation program, they must consider the patient's individuality, occupation, and interests, the specific clinical course of the disease, as well as clinical and socio-occupational prognosis.

The effectiveness of rehabilitation is evaluated using clinical-psychological, socio-occupational, and socio-economic criteria. Key indicators include recovery of work capacity, disability structure, indications for rehospitalization, bed occupancy efficiency, and patient employment rates.

Review Questions

1. Basic principles of the modern organization of psychiatric care.

2. Structure and Functional purpose of outpatient psychiatric services. Interaction and cooperation with inpatient psychiatric facilities.

3. Structure and purpose of inpatient psychiatric services.

4. Treatment regimens in psychiatric hospitals.

5. Methodology of emergency and urgent psychiatric care.

6. Functions of the district psychiatrist.

7. Facilities for the occupational readaptation of psychiatric patients.

8. Purpose, forms, and methods of rehabilitation for psychiatric patients.