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Interview with Vladimir Nakov on Bulgarian psychiatry

What ails Bulgarian psychiatry?

The oldest practising psychiatrist in the country is 89 years old and since the time he was born almost nothing has changed in this totally neglected by the state and society field. “I’m pulling articles from 1905 and they just need to change the year and they’ll sound relevant again,” Dr. Vladimir Nakov, a psychiatrist and head of the Mental Health Department at the National Center for Public Health and Analysis (NCPHA), told Mediapool. He and his colleagues recently published an article , addressing the severe staffing crisis in psychiatry, but it turns out this is far from its most serious problem. The system is largely stuck in communism in terms of facilities, treatment of patients, training of young doctors, and the reproduction of feudal clans, an extension of the totalitarian regime. Although reform of psychiatric care is enshrined in the National Strategy for Mental Health with a horizon to 2030 and in the Recovery and Development Plan, the mental health of Bulgarians is deteriorating, and reforms are being delayed

Psychiatry beyond the brink of crisis

“Psychiatry in Bulgaria is not on the brink of crisis. On the contrary, the crisis is here,” says the article by Dr. Nakov and his colleagues in the Bulgarian Journal of Public Health, the official publication of the National Center for Psychiatric Health. Although the staffing crisis is a universal problem for many medical specialities, psychiatry is one of the most affected areas.

According to the NSI, in 2022 there will be 675 psychiatrists or 2.28% of all doctors. This data contradicts the information from the register of the professional organization – the Bulgarian Medical Association, according to which there are 569 psychiatrists. A possible explanation for the discrepancy in the data is that sometimes the work of one doctor in two jobs is reported as two people or even more. Bulgaria ranks last in the EU in the number of psychiatrists per 100,000 population-just 8, or more than 3 times fewer than Germany (the country in the EU with the largest number of psychiatrists) and 6.5 times fewer than Switzerland (the country in Europe with the largest number of psychiatrists). The youngest psychiatrist in the country is 31 years old and the oldest is 89 years old. Nearly 40% of psychiatrists are currently of retirement age, and in 2026 this proportion will reach 60%. The projection shows that over the next ten years, the ageing process of the profession will continue at a high rate.

These statistics portend the closure of psychiatric facilities, the population’s difficulty in accessing psychiatric care and a deterioration in its overall health status.

But the crisis in psychiatry is not of now. In a 1969 article, T. Stankushev and L. Timchev describe that “dispensaries are housed in old and inadequate buildings, the number of psychiatric personnel is insufficient, there are no “trained specialists in the field of child and forensic psychiatry, there are no profiled narcologists, speech therapists and other specialists for the full care of the mentally ill. One district psychiatrist serves a population of over 120,000”.

And right now psychiatrists are overworked. “A psychiatrist has multiple roles: as well as working in and out of hospitals, there are academics, experts in the courts, employed in clinical trials, etc. And these roles can all be juggled by one person who is overworked,” explains Dr. Nakov.

“At some point, for purely biological reasons, hospital structures will start to disappear. To maintain a hospital structure, a minimum of 7 people are needed to cover the on-call schedule. That is, there must be: 7 doctors, 7 nurses and at least 7 orderlies,” he points out.

Both before and now psychiatry is a “last care”

At the same time, the work is unattractive, demotivating and poorly paid. Unlike other specialities in hospitals, which are funded on clinical pathways by the NHIF, psychiatry is funded by the state, supposedly as a state priority. But this is done under complex and opaque rules that only perpetuate the agony and ‘dark’ working in the system. And the measure of work done is the number of days spent. Staff salaries absorb 75% of the subsidy of medical institutions and there are no real resources for change. “And simply raising salaries will not solve the problem,” Dr. Nakov said.

In outpatient care, the NHIF covers only one primary examination lasting 15-20 minutes and covers one secondary examination per two patients within one month, which is woefully inadequate.

“The problems are many, they are neglected, and this is not as of now. Going back historically, it has always been like this. In the first years after the coup of 1944, the state collected money for the Soviet Army Memorial, for the mausoleum, and at the same time nothing was given to psychiatrists. They always came last. And in 1900 they were still in last place, and now it is like that again,” says Dr. Nakov. The desperate state of the system is evidenced by reports from the Council of Europe’s Committee for the Prevention of Torture since 1997.

Lack of corrective and internal resistance

According to Dr. Nakov, the biggest problem is the lack of transparency in the work of psychiatric hospitals and the lack of a corrective. Because of this, there is no comparability of the results of the different hospitals and this maintains the status quo, which suits a large part of the psychiatrists’ guild. “The Bulgarian psychiatric community does not want to work on clinical pathways and does not want control,” he says.

There is also a problem with the training of young doctors and the population itself on human rights protection. “Very often the actions of the doctors themselves are outrageous,” he points out .

“It is a big omission that the court as an institution does not visit these facilities regularly. In countries where a patient is placed for involuntary treatment, the court goes on site to the hospital facility and assesses whether the conditions for treatment are there and whether this treatment will have a beneficial effect. This should be the guiding factor in the court’s decision. Imagine being sentenced to 1 month in a place with no private bathroom, no going out in the fresh air, having one TV that is in the attic and that is operated by an orderly and watched as the majority decides. How will you feel after 1 month? We’re not talking about luxuries like a library, basketball courts, etc. It’s a very sad picture, and the saddest thing is that there’s tremendous resistance from the guild itself to change anything. “Rejuvenation is also a problem,” says Dr. Nakov.

He has no hope that the system will change from within through the gradual rejuvenation of the guild. “If there is more than a 15-year gap between young doctors and those who train them, the young only learn bad practices: how to make samples of expertise, how to defend them in court, but they won’t get to the idea of patients’ rights, how to treat them. These are things that are not taught in universities”, Dr. Nakov points out.

One of the main reasons for all this is that there is no quality corrector in the psychiatry system. In principle, the role of the corrector should be played by patients and their relatives through patient organisations or other civil organisations that monitor the rights of the mentally ill. However, there is no patient organisation. “There is no patient organization in our speciality because if the leader gets sick, it fails. That’s why psychiatric patients organizations need to be funded by the state to have sustainability. They can’t win projects, enter into relationships with pharmaceutical or other industries that support them,” Nakov points out. Last but not least, the patients and their relatives, who should be the corrective of the system, are in the hands of the people who run the psychiatric system.

So the system continues to operate “in the dark”. “How many times have you visited a psychiatric hospital? Are there open days, is there control over the activities?” asks Dr. Nakov.

He recalls that since the time of Minister Petar Moskov there has been a ban on the Bulgarian Helsinki Committee (BHC) visiting psychiatric facilities and until recently this instrument of control was also absent. Thus, while other systems, a legacy of communism such as nursing homes, have nevertheless undergone change under civil control and pressure, psychiatric care remains intact.

What to change?

Dr. Nakov is adamant that it should be possible to compare the results and to see what the psychiatric institutions are actually doing in order to be clear about what the needs are and to cost of the services.

Telemedicine would reduce costs and increase the possibility of consulting people in remote locations. “There are such devices that allow laboratory tests to happen on-site without human presence. So for common mental disorders that can be treated outside hospitals, treatment can be done through some platform,” Dr. Nakov points out.

Another thing that is very important and is not promoted here in our country is the profession of a nurse, but performed by a man, which allows career development, he adds, giving the example of an acquaintance of his who is a professor of psychiatric nursing in Japan.

“The practice of the people being trained is also important. In Germany, the hospital where a colleague of mine trained is full of people who specialise. So there are young people among the patients all the time.

Staff and patients eat together in the same dining room and shop from the same place in Germany, Belgium, and Norway. And here, not only is that not the case, but patients often eat straight as horses in the corridor,” adds Dr. Nakov.

He also draws attention to the fact that here, tension de-escalation training is almost non-existent, so that there is no physical confrontation. And in the event that it does occur, to be done in the most humane and proper way.

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