Dr Radu Teodorescu, a partner of ICAR Foundation, talks about mental health, stigma and public policies in the field.
Psychiatrist Radu Teodorescu, a physician in Obregia Hospital, talks about the politicians’ lack of interest in mental health and the authorities’ lack of interest in applying the mental health law, which provides a shift in emphasis from hospital to community psychiatry, which is more flexible given the beneficiaries’ needs and less expensive in the long run. The psychiatrist criticizes the absence of systematic and efficient information campaigns to encourage people to see a specialist, at a higher level lately, to prevent the suicide risk and deconstruct the stigma that makes less than 10% of the people having mental health issues be employed. Dr Teodorescu believes that the state should be 100% involved in mental health services under the circumstances of social precarisation.
An interview by Ioana Lupea
Ioana Lupea: There have been lots of talks on the topic of mental health reform in Romania. Myth or reality?
Radu Teodorescu: First of all, efforts were taken to promote a mental health law, in the early 2000, a law that is modern enough and respects human rights. It provided the development of community psychiatry and that emphasis must be shifted from hospital to community services. After Poiana Mare scandal, when Romania’s objective was to integrate into the European Community and had a mental health red flag, a committee was set up within the National School of Public Health, Management and Professional Development in the healthcare field, led by a professor from Vienna, whose mission was to assess the mental healthcare system in Romania. Further to this mission – several hospitals were visited – for chronic patients, safety hospitals, outpatient facilities – the committee issued a report including certain recommendations. Based on a report, a committee was set up and it was led by Mugur Ciumageanu. This committee was made up of around 10 very young and very enthusiastic psychiatrists and psychologists and had a European project for three years, during which they drew up a community psychiatry development plan which resulted in the drawing-up of a development strategy and five, six manuals for the family, patients, care staff, administration about what to do, how to make the assessment, how things should go. It was a full kit.
IL: What happened to this kit?
RT: They had a conflict with the minister at that time, Eugen Nicolaescu. They believed that, if all handed in their resignation, they would force the minister to accept the proposals. This didn’t happen and the resignation was for nothing. All documents exist, they were printed, published, they are somewhere in a warehouse. The idea was inspired by the French sectorisation – to create structures in the community so that you can ensure, through a network, full national coverage. If we considered such structure at 100,000-150,000 inhabitants, that would have meant over one hundred mental health centres in Romania. Only a few were created and that was it.
IL: Was it a money issue? Would the costs have been too high for the already small health budget?
RT: You can devise short-term and long-term plans. In the short run, you need to invest some money. In the long run, however, you obtain a financial advantage because nothing is more expensive than the hospital. The hospital has an accommodation component that is extremely expensive, which would have been gone because people would have stayed in their homes, would have paid for their food, electricity, heating, these costs would not have been borne by the state. And services would have been more suitable to the beneficiaries’ needs, to these populations’ needs, which also fluctuate even in a chronic disease like schizophrenia. There are times when such person needs perhaps daily accompaniment and for months, years, if they see their psychiatrist once a month, they are flexible enough. But, since we did not invent these things and they exist, even if, at first, it may seem difficult to apply them, they are, in fact, easy to apply because patients truly needing long-term support are relatively few: 0.5-1% of the population.
IL: So why the system’s attachment to the hospital?
RT: On the one hand, because we’ve never had a minister that understands psychiatry, which is particular. And I don’t think that there has been continuity, a national healthcare plan, plus that, irrespective of who is minister, that person can improve or change some things, but following a red line. My feeling is that there is no red line. I believe that there is no awareness at political level as far as mental health is concerned. In fact, I have never heard a politician talk about mental health, about this problem or about whether there is a problem.
IL: Is it a hidden issue, as it was before 1989?
RT: No, just ignored. It is simply a continent that is difficult to understand, which does not exist. Of course it is not ordinary medicine, of course it is medicine that comes into contact more with the social and political components than any other medical specialty. If there are cases where someone is brutally murdered and a mentally-ill person is involved, surely the first reflex is to ensure security. And that is precisely the attitude of the media: what is being done, how do we lock them up? They are concrete moments of awareness, in extreme situations, which are not representative for psychiatry and what happens with a mentally-ill person. But, after all this excitement, which lasts for two, three days, things remain without consequence.
“Less than 10% of people with mental illness are employed”
IL: But all this excitement creates stigma.
RT: Is does nothing else but maintain the pre-existing stigma. If I tell you that there is no destigmatisation campaign, I will surely be killed, because any NGO in the field has had at least once a grant or a sponsor that allowed it to make a one- or two-month campaign. But there is no constant campaign, not even a coordination of these NGOs that would ensure a continuation in time. So the fact that, at some point, somebody gave an interview, attended a television programme, wrote a material is too little. Because, to change mentalities, you must intervene on a permanent basis, reemphasize certain things and re-place them in the natural context. Let’s think about countries which traditionally had a higher suicide rate, for instance Hungary – the fact that it decreased is the result of long-term sustained campaigns and the efficiency of these campaigns and their absence in Romania. This is also one of the causes of the gap between Romania and other countries in terms of number of mentally-ill persons who are employed. In Romania, less than 10% of people with mental illness are employed.
IL: There is discrimination on the labour market, studies show it.
RT: Or lack of trust. We can use the word discrimination, which implies, however, a large amount of blaming. But I think that employers are simply uninformed. Of course there are also “bad” people, but I think that most of the potential employers know nothing and they share the current prejudice, that it is too difficult, why complicate things and that it is easier to hire someone else.
IL: Coming back to politicians: shouldn’t they be worried about depression and suicide rate in Romania – 2 million people suffer from depression and a suicide rate that is higher than the European average? Shouldn’t these figures be a 0 moment?
RT: The zero moment was then, after Poiana Mare, under the pressure of the European Community, when it was important for us to accede to the European Union and mental health was one of the criteria of Romania’s assessment. Nothing has happened since then. Of course this is important, but a politician should answer this question. On the one hand, there is a patriotic discourse and everybody is crying, with Stefan cel Mare, with Mihai Viteazul. These people, politicians, seem to care a lot about their country. It is interesting to find out why they rather respect the dead and are not paying any attention to the living and suffering among us right now. What are they doing for them?
IL: From your clinical experience, are there many people who overcome the stigma and see a psychiatrist or psychologist?
RT: On the one hand, stigma is present and is a handicap for treatment and for having these problems addressed by a psychiatrist or psychologist. On the other hand, people have access to information about movie celebrities who have suffered from an illness, about writers, such as Andrew Solomon with the “The Noonday Demon”, which was also translated in Romanian, and this encourages them to see a psychiatrist. I think that there is higher addressability than before, perhaps because of the better training of physicians, including family physicians, in this area, who recognise easier psychiatric pathology even if it comes in the form of somatic pathology and send them to a psychiatrist.
IL: Are there specific, local causes for the increase of the incidence of mental illness?
RT: There is nothing different in Romania.
IL: Higher social precarity?
RT: Certainly crisis situations are associated with the increase of anxiety, depression disorders, consumption of alcohol and psychoactive substances. And the suicide rate increases significantly when there is an economic crisis. And probably there is also an impact on chronic disease to the extent to which, in a certain particular context related to economic factors, more frequent decompensations occur in certain pathologies. Certainly the social and economic background plays a part.
There is a tendency to psychiatrize the normal aspects of life
IL: You were speaking in an article for Dilema about the pathologization of loneliness and normal life circumstances. Would you like to develop this topic further?
RT: Somehow we live in a society in which being a victim seems to ensure something or people are under the impression that it ensures something. Disease may be a means of reasoning such statute. There are very many things that disturb us in our everyday life. I think that there is a certain air du temps that nobody should have the right to suffer. Suffering is excluded, everybody should be just fine and happy. If an event occurs in your life, like losing a loved one, it may be turned into pathology, that suffering is no longer seen as normal suffering. It so happens that I saw someone last week who had lost their mother, completely unexpectedly. Of course it is a traumatising event for someone who loves their mother very much. The request was that, three days after the funeral, I should prescribe an anti-depressive, so that the person in question would not suffer. The idea is that it’s not natural to suffer even when you lose your mother. But I believe that we can naturally metabolise suffering in particular situations and consider them as part of our natural existence. Of course that, if suffering is prolonged beyond a certain period of time, if it is so intense that it makes us completely dysfunctional, then the psychiatrist or psychotherapist serve their purpose and can help the person in question. The idea that the psychiatrist or psychotherapist makes you not suffer ever is a direction towards psychiatrizing and transforming the normal aspects of life into a disease. This is a problem of the Western world. Each discovers on their own as if they were the first person in the world that is encountering this situation. There is no tradition that transmits customs, people are not ready for family life, for what it means to have children and how to raise children, what they bring you or how they limit life. People seem to discover only when they are living an event. The fact that death may come one day is something nobody thinks about. In the religious discourse, death was very present and that perhaps made people accept the idea much easier than now, when this discourse is absent and important things in life, birth, marriage, death, are experienced without preparation.
IL: There is another modern trend, that of explaining any mental health problem biochemically, which maybe comes from a need of destigmatisation because biochemistry is beyond individual responsibility.
RT: I think that what we see most of all in Romania right now is this category of educated young people, with permanent access to information, who refuse to vaccinate their children. Instead of measuring more clearly what the dangers are, the more educated you are, the more one seems to find all sorts of counterarguments to go back of the 19th century. It is highly bizarre because they are presumably the promoters of new discoveries. It’s the same with psychiatry. If, in the past 60 years, 80% of the psychiatry beds have disappeared – this piece of information dates back to 2005, today the figure is higher -, this is due to medication, which manages to control at least the most disturbing part of certain pathologies. There are also very many people with a borderline pathology, such as the depressive disorder, where maybe medication is not necessary and, in such case, psycho-education and principles related to a healthy psychological life are things people should relatively easily accede to. In Romania, this is not the case because, unfortunately, psychotherapy is reserved to a category that affords paying for it.
The state’s involvement in mental health services should be 100%
IL: In Romania, there are also therapeutic services which are covered from the basic service package. In other states, I have seen talks about this state’s involvement, which has its adversaries too. How much should the state get involved?
RT: In my opinion, 100%: in Romania 30% of the population live below the poverty limit, and another 30% are very close to this limit. These people cannot afford accessible psychiatric services. We are talking about national solidarity, which should function. None of us has earned their health. It was a lottery and somebody lost and I find it absolutely normal to help them. There are serious psychiatric diseases that make 4-5% of the population unable to live in the absence of a state pension. The amount is ridiculous, it is a pension that maybe allows them to eat and pay maintenance. If you don’t ensure free-of-charge psychiatric care they need, these people will suffer tremendously and some of them will end up homeless. In fact, if we take a look at the street, compared to the homeless people of the 90s, whom we thought to have ended up there because of economic issues, currently, if you look around carefully at some of them, you’ll see that they are suffering from mental illness. It’s something you see in the west too, especially in the United States, where almost 70% of the homeless people are suffering from serious mental illnesses and are not homeless because they wouldn’t work or had problems.