La psychiatrie en Moldavie, le parcours d’une psychiatrie totalitaire vers une psychiatrie communautaire

Abstract

ObjectivesThis article describes the development of psychiatric care in the present territory of the Republic of Moldova, which was formerly a part of the Moldavian Principality, and then a Russian province from 1812 to 1918. Afterwards, it belonged to Romania, before becoming a Soviet republic from 1940 to 1991 when it became an independent country. MethodsA longitudinal, retrospective analysis, using empirical methods and comparisons of bibliographic and statistical data, documents, activity reports, and evidence, enabled a synthesis and the description of the evolution of psychiatric care in Moldova. ResultsBy way of this analysis, we have delineated the different stages in the development of psychiatry in Moldova. In the Middle Ages, after the establishment of the Moldavian Principality, there was a humanist attitude towards mental patients. The Christian church, which often had the charge of these patients, was tolerant and protective towards them. The second stage started after the annexation of Moldova to the Russian Empire in 1812, the establishment of the first beds in general hospitals, and the opening of the first psychiatric hospital in 1895, which became at the time one of the most progressive and modern among the psychiatric hospitals of Russia, with the shortest duration of hospitalisation, and a large number of rehabilitation measures entailing work projects, patient colonies, and life in the community. This tendency persisted during the Romanian period, when the territory retrieved its cultural and linguistic links, making visible progress in the treatment of patients in the area of malnutrition (pellagra), and achieving a considerable reduction in the number of patients with pellagra. The Soviet period saw contradictory trends. On the one hand, the considerable development of hospital care, as a result of the establishment of new hospital centres, adequate drug supplies and the availability of rehabilitation care. At the same time, there was a considerable broadening of the criteria for schizophrenia diagnosis, which could serve as grounds for coercive hospitalisation. Individuals who displayed paranoid, borderline, schizoid manifestations were hospitalised with a diagnosis of mild schizophrenia, which meant compulsory treatment. In addition to this, far-reaching rehabilitation provisions were developed for the patients. The current period is characterised by a wide receptiveness in society towards psychiatric patients, a significant reduction in inpatients beds and the opening of centres in the community. At the same time, there is a considerable shortage of last-generation drugs which are not available for the majority of the population. A medical insurance system has been in place for several years and patients can receive basic care. DiscussionThe development of psychiatric care in the present territory of the Republic of Moldova over one century, from the tsarist regime to Romanian capitalism, then to the Soviet system and finally the independent State with European aspirations, has seen significant changes and enriching experiences at all stages and under all regimes. The foundations of the modern Moldavian psychiatry were laid by Russian psychiatry which followed on from the German psychiatric school. At present, the main concerns are related to future development and to the reorganisation of mental health, with particular emphasis on outpatient care and rehabilitation. The main problems to be overcome are the stigmatisation and discrimination of psychic patients, and the need for social structures in a very difficult economic and demographic context. Despite this situation, a mental health reform project is being implemented in the country over the period 2015-2018 by Trimbos Institute (the Netherlands Institute of Mental Health and Addiction), financed by the Swiss Government. The aim of the project is to develop a community mental health model so as to considerably reduce the number of beds in psychiatric hospitals. ConclusionThis work provides a retrospective account of psychiatric care in the present territory of the Republic of Moldova, and describes the current situation of the mental health system which is undergoing a process of fundamental change modelled on community psychiatry, despite the very difficult financial situation.