Geriatric Psychiatry in Romania
Senior Consultant Psychiatrist, Oradea, Romania, President of Romanian Association of Geriatric Psychiatry, Member in the Honorary Board of Romanian Association of Psychiatry, member in the Board of International Psychogeriatic Association and Chair of Geriatric Psychiatry Section of Association of European Psychiatrists.
Email: nicoleta_tataru@hotmail.com
Romania is a developing former communist country in Eastern Europe with a population of 21.794.793 (2002) and covers 237.500 square km with 42 districts. National statistics for 2002 showed infant death rate 17,3/1000 and life expectancy at birth 67,6 years for males and 71,1 years for female. The proportion of the national budget spent of the health system is 4 %, probable 2% of total health budget is for mental health (source: Statistic Department of Minister of Health). There are 188,87 physicians per 100.000 population. Romania is now in a period of transition from communism to democracy. Geographically Romania like other Eastern Europe countries is at the border between the Western world and Middle East and Asia and like other former communist countries was by December 1989, behind the Iron Curtain.
1. Mental health policy and development
Nationally, there are 908 psychiatrists for 21,8 million people (4,16 per 100.000 populations), of whom 260 are child psychiatrists (1,19 per 100.000 populations). They all work in public health sector, although some also work in private ambulatory clinics. There are also psychologists and social workers working in mental health care system.
2. Geriatric Psychiatry.
In Romania , around 14 per cent of the general populations are over the age of 65 years. Aging of the world population risks to be accompanied by an increase of chronic health problems, and most particularly of mental health problems. To face to these problems the organization of care and education in old age psychiatry is still quite insufficient worldwide. The increased prevalence of mental health problems in the elderly requires different approaches to the development of the old age psychiatry. Old Age Psychiatry becomes a basic discipline for all the socio-medical providers and a specialty for physicians and health workers who devote themselves to the care of the elderly . (WHO 1996)
If at international level the body of knowledge and skills of the psychiatry of the elderly is today enough recognized it is still very difficult to convince authorities at national and local levels to recognize this discipline as a sub-specialty of psychiatry.
Like in all countries in this part of the world, the geriatric psychiatry is still not enough represented. Only in some countries old age psychiatry is a recognized specialty In Romania, Old Age Psychiatry has been a recognized sub-specialty of Psychiatry since 2001. The number of professionals working in the field is still very low to satisfy the needs of care of elderly with mental disorders. Mental disorders in old age are common and are a source of massive burden and represent important costs for societies.
The scientific organizations like Romanian Alzheimer Society (1996), Romanian Association of Geriatric Psychiatry (1999), Romanian Medical Society of Research of Cognitive Disorders and AD (2001), try to improve this situation organizing the training post-graduate courses for young doctors psychiatrists and general practitioners, to be able to provide much better care of the elderly. There is a training post-graduate one-year course organized in Bucharest for a diploma in psychogeriatrics for psychiatrists, geriatricians and medical residents. Part of the educational programme is the summer courses on geriatric psychiatry organized in Romania ( Oradea ), for psychiatrists in all Eastern European countries. These courses are organized as Eastern European Initiative by International Psychogeriatric Association with Romanian Association of Geriatric Psychiatry. The Romanian Association of Geriatric Psychiatry and Romanian Alzheimer Society also participate in the pilot studies organized by WHO on Alzheimer Disease.
General practitioners and community nurses are also involved in the care of the elderly and it would be opportune for them to participate in the domiciliary visit by psychiatrists (Jolley and Arie, 1992; Wattis, 1994). To this end we have initiated an educational programme that includes courses for family doctors who are involved in the primary care. The objectives of the training are to promote development at every level for all those concerned and indicate the groups to whom education should be offered, what to teach them and which teaching methods to use. (World Health Organization, 1998; Camus et al., 2003 )
Despite worldwide demographic changes, with consequent increases in the numbers of elderly mentally ill, the teaching of old age psychiatry is widely neglected in all parts of the world. However in recent years a number of initiatives have helped reveal the current training situation in this specialty and have prepared the way for future positive developments. It has been one of the main goals of the WPA section on old age psychiatry, IPA and EAGP to promote the discipline.
2. 1. Mental health services for the elderly in Romania
Most psychiatric services are provided by hospitals and out-patient services attached to the Ministry of Health. There are no private psychiatric hospitals. The elderly with acute and chronic mental disorders, as well as those with dementia, are taken care of both in psychiatric short and long-stay hospitals and in social services. The last ones are inadequately trained to care for these patients, being without professional staff qualified in social work or in geriatric psychiatry.
In the last few years, in most countries the psychiatric services have been more and more orientated towards the community. (Jolley and Arie, 1992; Arie, 1994; Philpot and Banerjee, 1996; Wattis, 1994; Wertheimer, 1997) The special needs of older people were not always recognized and respected by generic services. (Wattis, 1994) Any new mental health service strategy must take the following into consideration: integration of mental health care, creation of services adequate to specific needs of patients, continuity of care by cooperation among various services providers, multidisciplinary team work, community involvement and geographic catchment areas. (Cooper, 1997; Tătaru, 1997)
In most developing countries, including Romania , no national program for care of the elderly exists or has been financed. The Mental Health Law appeared in Romania in August 2002. In Chapter 4 of the law the forms of specific mental health services existing in Romania are listed, along with the care standards for people with mental disorders.(Mental Health Law, 2002) Only recently has Romania tried to add community mental health care services, to the traditional system of active psychiatric hospital care. This started by radically reducing the number of beds, but unfortunately without ensuring adequate community care programmes and services. Many long stay psychiatric wards were transferred to the social services. In district of Bihor alone 178 psychiatric beds out of 900 were transferred from Nucet Psychiatric Hospital (accountable to the Ministry of Health) to the social services (accountable to the Department of Labor and Social Protection).
2. 1. 1. In-patient services
The elderly with acute or chronic mental disorders are treated in psychiatric hospitals for acute mental disorders – in most districts, long-stay accommodation/ continuing hospital care, geropsychiatric wards in psychiatric hospitals (Nucet only; in Iasi – the department is only for dementia patients), psychiatric wards in general hospitals (in areas where psychiatric hospitals do not exist), liaison psychiatry department in University General Hospital Bucharest and in psychiatric departments in geriatric hospitals. These services are in most of districts, but are no in all districts.
2. 1. 2. Out-patient units
In Romania there are some out-patients services for elderly mentally ill, but only in few districts because there is still a severe lack of resources: out-patient or community assessment units – day care centres, primary care/ residential care, community mental health centres (which are a link between the patients and their families, GPs, hospitals for acutely or chronically mentally ill people) ( Tătaru, 1997; Tataru, 2003 ), memory clinic, community and social support services (organised by NGOs and churches in almost all districts).
Day programs contribute to the reducing stigma and discrimination against people with mental disorders by reducing isolation and increasing the abilities to face to daily life. ( Tătaru et al., 2002; De Mendonca Lima et al.,2002; Tătaru, 2003)
2.1.2.1. Community Care Centre for the Third Age , was organized in Oradea in 1996 by a NGO (Foundation “Worrying about grandparents”).
This centre comprises:
- Day Care Centre- able to accommodate 40 mobile patients
- Respite Hostel - with 28 beds providing temporary care for elderly with or without family, with or without mental disorders
- Residential medical and social care for old people who are unable to leave their homes.
Main objects
2.1.2.2. Memory Centre Bucharest – opened in 2000 inside ‘Prof. Dr. Alexandru Obregia’ University Hospital in Bucharest , is a modern facility for diagnostic and intervention.
An ambulatory facility having as main goals: early diagnostic of memory disorders with various etiologies in adults and elderly, early diagnostic of dementia and the differential diagnostic, diagnostic of affective disorders in elderly.
Other activities : E laboration of therapeutically strategies for cognitive and affective disorders in elderly, assistance of the families of the sufferers with dementia, promotion of clinical research, professional education for early detection of cognitive disorders, psycho-education, counseling, psychotherapy.
Responsibilities: discovering the nature of the problems of the patients and their families, preliminary evaluation of the seriousness of the medical problems of the patient who is asking, preliminary evaluation of the family resources for caring, presenting the services offered by the Memory Centre, referral to specialists and consultations schedule, counseling and education
2. 1. 3. Residence care
In 2003 started a program for residential care and follow up for patients of all ages. The elderly with mental disorders including dementia are also cared for by this programme. (Health Department, 2003) Medical treatment and also the domiciliary services, including meals-on-wheels, home helps, mobile laundry, help handicapped elderly to remain at home. The last ones are provided now, only by ONGs and churches. There is also some financial support from the Labor and Social Protection departments as compensation for families or caregivers of the chronically ill with handicap (including those with dementia), who are treated at home.
Older people with dementia and no behavioural disorders or significant physical disabilities are also admitted to nursing homes and other social services long-stay units organized by the state, non-governmental organizations (NGOs) or churches
In Romania there is no intermediate stage between home care support and the nursing home, which provides sheltered accommodation for elderly people, or those with less severe dementiaand behavioural disorders. (Lovestone and Gauthier, 2001)Most Romanians with dementia who have a family are treated at home. It is difficult for families to place them in a long-stay unit not only because of attitudes, shame and feelings of guilt, but also because patients who have families or relatives are not admitted to state nursing homes. Patients with dementia who have behavioural disturbances, psychotic symptoms or agitation require admission to a psychiatric hospital for acute or chronic illness, both those who live in nursing homes and the ones who live in their own homes.
Cooperation between social and medical services is difficult because of they are separately organized. The role of NGOs and of churches in the system of community care for the elderly is increasing in Romania , but it is still very limited.
2. 2. Mental Health programmes.
A national mental health programme developed in last years for treatment of schizophrenia and depression, to provide free medication for the patients at onset and for in-patients in forensic psychiatric units.
The national programme for elderly care has been only a project that for the time being is lacking financial support.
3. Conclusions and future needs
Today in Romania , in the care of mentally ill people we are trying to re-orientate the mental services from old-fashioned psychiatric hospitals towards community care services. We started by reducing the number of beds, but without ensuring care programmes and community services for these patients. A great number of long-stay psychiatric wards were transferred to the social services. The elderly with chronic mental disorders as well as those with dementia are looked after both in psychiatric long-stay hospitals and in social services facilities whose staff are inadequately trained to care for these patients. However, most dementia patients are still in the care of their families, if they have one. Unfortunately there is not a clear picture of all services for elderly care, nor are there epidemiological studies in this field. In spite of the professionals’ endeavors specializing in teaching and educational programmes, there are only a few psychogeriatric services and even fewer special care services for dementia patients. The national programme for elderly care is only a project that, for the time being, lacks financial support. Stigma remains, maybe more than in developed countries, a major obstacle in ensuring access to good care for the elderly mentally ill patients, the work against stigmatization should become one of our most important activities.
The extension of outreach services of nursing homes and residential homes in conjunction with day-care centres, day hospitals and residence care could be a valuable alternative to the high degree of institutionalization of Romanian elderly people with or without mental disorders. (Tudose, 2001; Tătaru et al, 2002; Tătaru, 2003)
The quality standards must be improved, especially those concerning elementary care needs and quality of life (accommodation, food, sheltered house, sheltered work places) and involving the community and the governmental and local authorities in mental health care.
In Romania like in all former communist countries there are economical problems and we need national fundraising to support national psychiatric organizations and services.
References
Arie T: The Development in Britain , Principles and Practice ofGeriatric Psychiatry, Ed. By J. R. M. Copeland, M. T. Abou-Saleh, D. G. Blazer, John Wiley, Chichester , 6-10, 1994
Camus V, Katona C, De Mendonca Lima CA, Hakam A M A, Graham N, Baldwin R, Tataru N, Chiu E: Teaching and training in old age psychiatry: a general survey of the World Psychiatric Association member societies, International Journal of Geriatric Psychiatry , 2003, 18, 8, 694-699
Cooper B.: Principles of service provision in old age psychiatry, in Psychiatry in the elderly, 2nd Ed, R. Jacoby & C. Oppenheimer, eds., OUP, Oxford , 1997, 357-75.
***Health Department /318 - Standards for residence care, Monitorul oficial al Joley D, Arie T: Developments in psychogeriatric services, Recent Advances in Psychogeriatrics , Ed. By Tom Arie, 2 nd Ed, Churchill Livingstone, London , 117-135, 1992 Lovestone S., Gauthier S.: Management of Dementia, Martin Dunitz, 2001, 109-119.
***Mental Health Law: Monitorul oficial al Romaniei , XIV, Nr. 589, 8 August, 2002 De Mendonca Lima CA , Kuhne N and Bertolote JM: Day Hospitals in Old Age
Psychiatry: Past goals and future challenges, IPA European and Mediterranean Regional Meeting Rome , 7- 20 April 2002 Romaniei, XV, Nr.255, April 2003
Philpot M, Banerjee S: Mental Health Services for older people in London , London ’s Mental Health, 1996, King’s Foundation, London , 46- 64.
Tataru N: Project for the Development of an Ambulatory and Semi-Ambulatory Centre for the Third Age, Dementia and Geriatric Cognitive Disorders, 1997, 8, 128-131.
Tătaru N, Dicker A, Tudose C: The Old Age Psychiatry in Eastern Europe Countries, The 30 th Symposium of EAGP, 14- 16 Nov 2002 , Padova , Italy
Tataru N: Mental Health Services for the Elderly in Central and Eastern European Countries, IPA Regional European Meeting, April 2003, Geneva , Switzerland .
Wattis JP: The Pattern of Psychogeriatric Services, Principles and Practice of Geriatric Psychiatry, Ed. by J. R. M. Copeland, M. T. Abou-Saleh, D. G. Blazer, JohnWiley, Chichester , 779-883, 1994
Wertheimer J: Psychogeriatric Organisation in the Medico-Social Network: The Experience of the Canton of Sand , Switzerland , Dementia and Cognitive Disorders, 1997, 8, 143-145.
World Health Organization-Division on Mental Health and Prevention of Substance Abuse: Psychiatry of the Elderly- A Consensus Statement, 1996, Geneva
World Health Organization- Division on Mental Health and Prevention of Substance Abuse, and World Psychiatric Association: Program on Mental Health, Organization of Care in Psychiatry of the Elderly- A Technical Consensus Statement , 1997, Geneva
World Health Organization-Department of Mental Health and World Psychiatric Association: Education in Psychiatry of the Elderly- A Technical Consensus Statement, 1998, Geneva .
© 2005- T.C. Başbakanlık Özürlüler İdaresi - Bilgi İşlem Dairesi Başkanlığı