Scientific Grounds for the Organization of Ambulatory Care for Persons with Mental Disorders under Modern Socio-Legal Conditions

The dissertation is devoted to the scientific substantiation of the organization of ambulatory psychiatric care for persons with mental disorders under modern socio-legal conditions. The research was conducted on the material of a mixed agro-industrial region — Leningrad Oblast — and encompasses the analysis of the dynamics of morbidity and prevalence of mental disorders, performance indicators of the ambulatory psychiatric service, as well as a comparative characterization of care recipient contingents. The study identified differences in the coverage of urban and rural populations with ambulatory psychiatric care, investigated factors determining the choice of care type (dispensary supervision or consultative-therapeutic care), and developed recommendations for improving the organization of ambulatory care.

Research Relevance. The protection of mental health of Russian citizens and the provision of quality psychiatric care to the population constitute an urgent problem of healthcare and possess significant socio-economic importance.

During the period of socio-economic reform of Russian society, a sharp decline in the level of mental health of the population occurred (Churkin A.A., 1997; Shchepin I.O., 1998; Dmitrieva T.B., 2004). The unfavorable dynamics of mental health indicators, confirmed by statistical data, is associated with the impact of stress, social changes (Polozhii B.S., 1996), and numerous factors of social adversity (Dmitrieva T.B., 2004). All these factors have acquired the character of chronic stress, contributing to the further unfavorable dynamics of mental health both of individuals and of society as a whole.

By the present time, as noted by I.L. Leontiev (2004), medical-demographic, economic, legal, pharmacological, and information-technological prerequisites for changing the ideology of the psychiatric service in the country have matured. The increase in mental disorders, particularly at the non-psychotic level, necessitates the abandonment of the traditional policy of isolating mentally ill patients, the transition to a biopsychosocial model of psychiatric service, and the strengthening of preventive work among the general population. Under market conditions, maintaining large hospitals proves too costly, requiring new organizational approaches, in particular, priority attention to the development of outpatient forms of psychiatric care. As a result of the introduction of new medications, it has become possible to prolong the period of remission, which allows shifting the emphasis in psychiatric service activities from inpatient to ambulatory care and socio-medical forms of work. The Law on Psychiatric Care has been adopted; in accordance with international standards, departmental documents regulating the activities of psychiatric services have been amended, standards for the diagnosis and treatment of mental disorders have been developed and implemented, new forms of economic and other activities of psychiatric institutions have been introduced, and a system of public support and protection of mentally ill persons has been organized. However, as practice shows, the measures taken have proven insufficient for a substantial improvement in the quality of care provided and the situation of mentally ill patients (Yastrebov V.S., 2001).

In the ambulatory branch of the psychiatric service, the significance of social forms of care is increasing, and polyprofessional team forms of work are developing. Increasing attention is being devoted to the development of outpatient care, which is provided on a territorial and professional basis and is integrated into the system of general medical care, while preserving the continuity and organizational unity of the entire psychiatric care system.

Analysis and generalization of the experience of institutions providing ambulatory care to persons with mental disorders can be useful for improving the quality of work of the ambulatory branch of the psychiatric service, which will contribute to the rehabilitation of patients and their adaptation to complex living conditions.

The aim of the research is to develop scientifically grounded recommendations for the improvement of the organization of ambulatory psychiatric care in urban and rural settings.

The tasks of the research:

1. to conduct an analysis of the dynamics and structure of primary morbidity and prevalence of mental disorders among the population of a mixed agro-industrial region (on the example of Leningrad Oblast);

2. to conduct an analysis of the structure and performance indicators of the ambulatory psychiatric network of Leningrad Oblast;

3. to identify differences in the coverage of urban and rural residents with ambulatory psychiatric care;

4. to conduct a comparative analysis of contingents receiving ambulatory psychiatric care in the form of dispensary supervision and consultative-therapeutic care;

5. to study factors determining the choice of type of ambulatory psychiatric care (dispensary supervision or consultative-therapeutic care) under modern legal conditions;

6. to study factors influencing the volumes of consumption of psychiatric, including ambulatory, care;

7. to formulate priority directions for the improvement of the organization of ambulatory psychiatric care under modern socio-legal conditions.

The scientific novelty of the research lies in the fact that, for the first time in modern socio-legal conditions, a comprehensive analysis of the structure and performance indicators of the ambulatory psychiatric service of a mixed agro-industrial region (Leningrad Oblast) has been conducted; trends in the dynamics of consultative and dispensary contingents have been investigated; and, using modern methods of statistical analysis and statistical modeling, factors that most significantly determine the choice of type of ambulatory psychiatric care and the overall volume of psychiatric care consumption have been identified.

The practical significance of the work is determined by the fact that the obtained results have formed the basis for practical recommendations for improving ambulatory psychiatric care to the population, bringing it into compliance with the needs of society, and enhancing its accessibility, manageability, quality, and effectiveness. The recommendations also address practical questions of further integration of the psychiatric service into the general somatic network, prospects for the development of inpatient-replacing technologies in psychiatry, and issues of organization of psychoprophylaxis and psychohygiene among the population. Taking into account regional features, the proposed model of organization of ambulatory care for persons with mental disorders can be implemented in other regions of the Russian Federation.

The main provisions presented for defense:

1. The organization of consultative-therapeutic psychiatric care contributes to the improvement of detection of mental disorders, in particular those at the borderline level.

2. Elderly persons living in rural areas are the least covered by qualified psychiatric care, despite their high need for it.

3. The place of residence of a patient in urban or rural settings is one of the factors determining the type of ambulatory psychiatric care provided (dispensary supervision or consultative-therapeutic care), as well as influencing the volume of consumption of inpatient psychiatric care.

4. The development of the ambulatory branch of psychiatric care is a necessary condition for bringing psychiatric care closer to the population and enhancing its accessibility.

Implementation of the research results in practice. The materials of the present research are used in the work of the Leningrad Oblast Psychoneurological Dispensary, in the work of the organizational-methodical department at the Chief Psychiatrist of Saint Petersburg. The materials of the dissertation research have been implemented in the practice of the Committee on Healthcare of Saint Petersburg; the results of the conducted research were used in the development of the concept of modernization of the healthcare system for 2004–2010, in the curatorship and coordination of psychiatric services of the subjects of the Northwestern Federal District. In addition, some results of the scientific work are used in the educational process of the Department of Public Health and Healthcare of Saint Petersburg State Medical University named after acad. I.P. Pavlov, as well as in the Educational Center of the Saint Petersburg Research Institute of Psychiatry and Neurology named after V.M. Bekhterev.

Validation of the work.

The main results were presented and discussed at:

The Scientific-Practical Conference dedicated to the 100th anniversary of the birth of Prof. S.Ya. Freydlin (Saint Petersburg, December 2003)

The II Congress of Chief Physicians of the Northwest of Russia (Saint Petersburg, 2003)

The Joint Session of the Problem Commission "Hygiene and Organization of Healthcare" and the Department of Public Health and Healthcare of SPbGMU named after acad. I.P. Pavlov (Saint Petersburg, February 2005)

The Scientific-Practical Conference of Psychiatrist Physicians of the Northwest Region of the Russian Federation "Actual Questions of Pharmacotherapy of Mental Disorders" (Leningrad Oblast, Svirstroy Psychiatric Hospital, July 6–7, 2004)

The Regional Scientific-Practical Conference "Modern Pharmacoeconomic Approaches to the Therapy of Mental Disorders" (Saint Petersburg, Kashchenko Hospital, May 28, 2004)

Volume and structure of the dissertation. The dissertation is presented on 113 pages of typed text and consists of an introduction, 5 chapters, conclusions and practical recommendations, a list of references, appendices, and documents confirming the implementation of the research results in practice. The list of references includes 220 sources, including 92 in foreign languages.