Psychiatry - H.T. Sonnyk 2003

Organization of Psychiatric Care in Ukraine

Principles of psychiatric care Organization.

The fundamental organizational principles of psychiatric care have undergone significant changes at various historical stages in accordance with the social development of contemporary society, its cultural level, and its degree of democracy. Based on these criteria, it is customary to distinguish the theological, metaphysical, and materialistic periods in the evolution of psychiatry.

The past forty years have marked a radical shift in Treatment Methods and attitudes toward patients, characterized by the widespread use of psychopharmacotherapy and social programs aimed at the rehabilitation of the mentally ill. The humanization of the treatment process, tolerance toward psychiatric patients, and state guarantees of their civil rights regardless of health status have become the core MODERN TRENDS IN The Development of psychiatry.

In Ukraine, the reform of psychiatric care is primarily aimed at bringing services as close as possible to the patient's place of residence, minimizing the patient's isolation from the family, and establishing a partnership in the patient-physician relationship. An important aspect is also recognized as the integration of medical and social care provided by governmental and public institutions.

In modern conditions, the fundamental principles of organizing psychiatric care are formulated as follows:

✵ development of a predominantly outpatient psychiatric network;

✵ maximizing the accessibility of care to the patient;

✵ close cooperation between psychiatric and general somatic healthcare services;

✵ continuity in the activities of general medical and psychiatric networks;

✵ intensification of treatment using modern techniques;

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

✵ mitigating the medical and social consequences of mental illnesses;

✵ widespread Structure/175.html">Implementation of social work practices with patients in psychiatric care;

✵ ensuring the rights and freedoms of individuals with mental disorders.

Adherence to these principles makes it possible to create a modern, highly effective, and human-oriented system of psychiatric care.

Structure of psychiatric care organization.

Psychiatric care is delivered through an integrated network of inpatient, outpatient, and partial hospitalization facilities. In addition, psychiatric service policies and practices are developed in research institutes and academic departments of psychiatry at higher medical educational institutions.

I. Outpatient psychiatric care facilities.

1. Psychoneurological dispensaries (PND):

- regional;

- municipal;

- district.

2. Psychoneurological dispensary departments (PNDD):

- as part of psychoneurological hospitals;

- as part of general somatic hospitals.

3. Psychoneurological offices (PNO) in general somatic polyclinics:

- general;

- specialized.

II. Inpatient psychiatric care facilities.

1. Psychiatric hospitals:

- regional and municipal;

- medical and labor dispensaries (MLD) for patients with alcoholism.

2. Psychoneurological departments:

- within psychoneurological dispensaries;

- within somatic hospitals and military-type hospitals;

- specialized units for drug addiction.

3. Day hospitals.

4. Psychoneurological sanatoriums.

5. Residential facilities for chronically mentally ill individuals.

III. Social and readjustment institutions.

1. Sheltered workshops and vocational rehabilitation units.

2. Specialized industrial workshops.

3. Boarding schools and institutions for children with intellectual disabilities.

4. Specialized schools for children with behavioral disorders.

5. Schools and groups for children with speech impairments.

6. Adolescent counseling offices.

Structure and tasks of psychiatric care facilities.

The core of the outpatient psychiatric care system is the psychoneurological dispensary, whereas inpatient care is centered around the psychiatric hospital. Psychiatric hospitals admit patients with acute psychotic disorders or chronic conditions in an exacerbation stage, whereas inpatient units of psychoneurological dispensaries and psychiatric wards in general hospitals primarily treat patients with non-psychotic disorders (largely resulting from somatic illnesses), as well as patients with psychoses who voluntarily seek help and do not require institutionalization in a psychiatric facility.

STRUCTURE OF THE PND.

Each dispensary is assigned to a specific service area, which is further divided into distinct medical districts to serve both adult and pediatric populations. Depending on the size of the served population, the PND structure comprises the following departments:

1. Outpatient Clinic:

- reception desk;

- district psychiatrists' offices;

- organizational and methodological office;

- narcology office;

- psychotherapy office;

- physiotherapy room;

- pediatric office;

- adolescent care office;

- neurologist's office;

- speech therapy office;

- legal aid office;

- sexology office.

2. Inpatient Units.

3. Day Care Center.

4. Occupational Therapy Workshops.

Objectives of the Dispensary.

1. To provide all types of outpatient care.

2. To provide home-based medical care.

3. To conduct all types of medical examinations and expert evaluations.

4. Early Diagnosis of mental disorders.

5. Registration and tracking of primary and recurrent morbidity.

6. Dispensary follow-up and dynamic observation.

7. Registration of individuals with mental illnesses among the population.

8. Close cooperation with general somatic hospitals and polyclinics, children's hospitals, and adolescent health offices.

9. Psychohygiene and health education.

10. Social and legal assistance.

The district psychiatrist performs a full range of diagnostic, therapeutic, and preventive work in accordance with current regulations. They are responsible for the timely detection, initial examination or evaluation of patients, enrolling them in dispensary and consultative registers, and providing treatment, particularly maintenance therapy. In addition, the physician implements social, occupational, and legal measures to help restore the patient's social status. The district psychiatrist should also focus on managing home-care and outreach services (patronage) as a key form of rehabilitation and community-based care (collective patronage). Patronage refers to a time-limited agreement concluded between a psychiatric institution on the one hand, and an individual or legal entity (relatives, an enterprise, or a collective farm) on the other. This agreement must specify the obligations assumed by both parties regarding the care and Treatment of the patient, as well as the material support of the therapeutic process.

Structure of a Psychiatric Hospital.

Each psychiatric hospital serves a specific catchment area, has a designated service radius, and is designed for a defined number of beds. An optimal capacity for a modern hospital is considered to be 800±300 beds. Similar to general hospitals, The structure of a psychiatric clinic includes admission units, various diagnostic and treatment departments, and auxiliary units.

Depending on the AGE AND SEX of the patients, the course and stage of the illness, and the nosological Specificity of mental disorders, inpatient units are divided into general psychiatric and specialized wards. General psychiatric wards typically accommodate patients of the same sex (divided into male and female wards). The following departmental specialization is widely used:

- diagnostic and treatment units (for first-time patients);

- active therapy units (for returning patients experiencing acute exacerbations);

- social therapy units (for patients with chronic recurring psychoses who require social and psychological rehabilitation).

Narrowly specialized units include those for narcology, psychosomatic medicine, compulsory treatment, forensic psychiatric evaluation, gerontology, epileptology, infectious diseases (or an isolation ward), tuberculosis, neuroses, and a ward for disabled veterans.

Auxiliary services consist of occupational therapy workshops, an X-ray room, a pharmacy, a physiotherapy department, and physicians' offices (surgeon, ophthalmologist, otolaryngologist, general practitioner, dentist, psychotherapist, etc.).

Administrative and housekeeping services: the chief physician and their deputies, the medical department, the archives, the maintenance department, the accounting department, and the catering unit.

A modern psychiatric hospital must possess not only an effective diagnostic and therapeutic base, but also proper living conditions to ensure patient comfort. Traditional psychiatric attributes such as special devices, window bars, and locks should be avoided. The interior of the premises, including patient rooms, should not differ significantly from standard hospital facilities. Internal regulations for patients and visitors must be based on the principles of partnership, mutual assistance, and respect for human rights and freedoms.

Recently, there has been a trend toward the deinstitutionalization of hospitals (maximizing patient integration outside of institutional settings). The size of psychiatric hospitals is increasingly aimed at 300–500 beds, while eliminating artificial restrictions on patient freedom. In modern practice, clinics are viewed not as places for patient isolation, but as temporary residences during the therapeutic process. Wards are planned for no more than 1–3 occupants, with maximum comfort amenities, and inpatient units should comprise no more than 20–30 beds, complemented by day hospitals, lounges, and special facilities for recreation and leisure.

Objectives of a Psychiatric Hospital.

1. Provision of all types of inpatient hospital care.

2. Performance of all types of inpatient expert evaluations.

3. Development of treatment and rehabilitation recommendations for discharged patients.

4. Ensuring continuity of care with outpatient psychiatric facilities.

5. Conducting preventive and health education work among the population.

An essential component of the therapeutic process in a psychiatric hospital must include psychotherapeutic intervention and legal assistance aimed at restoring patients' social status after recovery.

Treatment Regimen and Medical Documentation in a Psychiatric Inpatient Facility.

The patient's regimen is prescribed by the psychiatrist upon admission, and these orders must be recorded in the relevant medical documentation.

Subsequently, these orders are periodically reviewed in accordance with the patient's condition and aligned with ongoing medical prescriptions. Patients are assigned to rooms within the ward differentially to prevent potential incidents resulting from psychomotor agitation or attempts at self-harm or harm to others (suicide, aggression, etc.). Only certain patients, primarily those with acute psychotic symptoms, require special attention and behavioral monitoring to promptly manage disease flare-ups. They are assigned a restricted regime involving stays in observation wards under medical supervision and intensive pharmacotherapy.

Inpatient documentation:

1. Medical case histories.

2. Patient admission and discharge log.

3. Treatment room log.

4. Medication distribution log.

5. Patient observation log.

Basic rules of conduct for medical staff working with psychiatric patients:

1. A sensitive and attentive approach to the patient, respecting their personal dignity. Patients must always be addressed formally (using "Mr./Ms." and their full name).

2. Avoid arguing with or deceiving patients. Conversations should be conducted in a respectful, friendly, and unhurried tone.

3. Maintain vigilance on duty, especially regarding patients requiring heightened supervision.

4. Prevent sharp or otherwise dangerous objects from entering the ward, and keep ward keys strictly secure.

5. Staff must share information with one another about any changes in patients' conditions.

6. Refrain from discussing medical topics in the presence of the patient, particularly those related to their specific illness.

7. Do not fulfill a patient's requests without a doctor's permission (e.g., passing on letters or belongings, or providing visitors with any information about the patient). Do not hand anything over to a patient without proper authorization.

8. Do not leave potentially dangerous items in the ward (razor blades, knives, forks, needles, glassware, etc.).

Rapid and emergency psychiatric care.

The aforementioned concepts are largely theoretical and often overlap in practice. It is difficult to predetermine The sequence of actions for an emergency psychiatric response team upon arrival, as the psychiatrist's strategy on-site depends primarily on the situation, the patient's behavior, and their psychosomatic state. Indications for immediate psychiatric intervention include:

1. States of psychomotor agitation of various etiologies accompanied by impulsive and aggressive behavior;

2. Clouding of consciousness;

3. Acute hallucinations and delusions;

4. Depression accompanied by fear and suicidal ideation;

5. States of marked dysphoria.

Such patients are provided with emergency first aid through the administration of psychopharmacological medications to subdue the attack. The patient should always be invited first to take the medication voluntarily and agree to be transported to the hospital. In case of refusal, holding the patient by the shoulders and elbows, they should be placed on a bed, and the necessary injections administered intramuscularly. During escort to the vehicle, they are held by the shoulders and arms from both sides, placed onto a stretcher while maintaining the hold, and transported to the admission ward of a psychiatric facility. In particularly hazardous cases, hospitalization is handled by the emergency response team jointly with law enforcement officers.

The question of hospitalization in a psychiatric inpatient facility is decided solely by a psychiatrist after a personal examination of the patient. Referral to the hospital is based on absolute and relative indications.

Absolute indications include cases where the patient requires urgent medical care and poses a social threat (to themselves and others).

Relative indications include the inability to provide proper care for the patient at home.

In large cities, hospitalization is provided by emergency medical teams consisting of a psychiatrist, a paramedic, an orderly (junior nurse), and a driver. In district centers, it is carried out by general emergency medical teams acting upon the referral of psychiatrists or neuropathologists (if psychiatrists are unavailable). In rural areas, this function is assigned to district general practitioners, paramedics, or nurses of feldsher-midwife stations.

Involuntary hospitalization is implemented as an emergency Procedure, without the consent of the patient or their legal representatives, by medical personnel and, when necessary, with the assistance of police officers. This requires the coordination of legal and strictly medical criteria for involuntary hospitalization. In other words, this mechanism is applied when there are undeniable signs of a mental disorder (medical criterion) that lead the patient to engage in antisocial behavior, making them a danger to themselves and others (legal criterion).

The grounds for involuntary hospitalization can only be indisputable mental disorders confirmed by specific facts, that is, the patient's words and actions. Only a real situation and objectively confirmed facts can serve as the basis for concrete actions by medical personnel. Disregard for these rules may lead to the violation of citizens' rights and freedoms, with all possible tragic consequences both for the patient and for those who inadvertently cross the BOUNDARIES OF THE law.

According to current legislation, an involuntarily hospitalized person must be examined within 24 hours by a board of three psychiatrists (the chief medical officer, the HEAD of the department, and the attending resident physician). Collegially, they decide on the advisability of the patient's further stay in a psychiatric inpatient facility. If necessary, a decision is made to extend treatment until the mental state improves, of which the chief medical officer (or head of the department) notifies the patient and their relatives. If a patient exhibits minor mental disorders, is not deemed dangerous, and categorically refuses treatment, they must be discharged under the care of a district psychiatrist or other medical personnel at their place of residence.

Mentally ill individuals who have committed offenses and been declared insane by a court are also sent for compulsory treatment by court order.

Individuals in a state of simple intoxication or drug-induced intoxication (without psychotic symptoms) are not subject to emergency hospitalization in a psychiatric hospital.

Rehabilitation of the mentally ill.

In accordance with modern trends in the development of psychiatric care, the treatment of mentally ill patients is focused on the fullest possible restoration of their individual and social status through rehabilitation measures. These measures are aimed at the early and effective treatment of patients, the Prevention of disability, and their timely and full reintegration into social activities. An important role in accomplishing these tasks is played by the restoration of social ties lost during the illness.

International practice identifies three MAIN STAGES OF rehabilitation:

1. Medical stage — main efforts are directed at eliminating productive psychopathological symptoms, preventing the development of institutionalism (so-called hospitalism), disability, and social inferiority.

2. Professional stage — involves consolidating the achieved therapeutic effect and restoring work capacity and social connections.

3. Social stage — aimed at the maximum restoration of the patient's social standing and ensuring social adaptation and employment.

There is no clear boundary between these stages, but specific tasks must be addressed at each of them to achieve a single ultimate goal: the restoration of personal harmony and the elimination of social maladjustment.

For the purpose of rehabilitating the mentally ill, differentiated treatment regimens, work therapy and psychotherapy, therapeutic physical training, art therapy, Special Methods of social activation of patients (self-organization, self-care), individual and collective forms of patronage, etc., are applied.

Achieving rehabilitation goals is impossible without developing a clear, comprehensive action program adopted by the psychiatric institution or the respective territorial unit. To implement such programs, special units are established within psychiatric facilities to monitor their execution.

The effectiveness of rehabilitation is evaluated according to clinical-psychological, social-occupational, and socio-economic criteria.

Review Questions.

1. Basic principles of organizing psychiatric care in Ukraine.

2. Structure of psychiatric care in Ukraine.

3. Structure of the psychoneurological dispensary.

4. Tasks of the psychoneurological dispensary.

5. Internal Structure of a psychiatric hospital.

6. Tasks of psychiatric inpatient facilities.

7. Basic rules of conduct for medical personnel in psychiatric institutions.

8. Operating routine and main documentation of a psychiatric inpatient facility.

9. Indications for emergency psychiatric hospitalization.

10. Procedure for emergency hospitalization.

11. LEGAL ASPECTS OF psychiatric care in Ukraine.

12. Rehabilitation of psychiatric patients.