Tajikistan: Mental Health Crisis Claims Disputed

It is widely believed in Tajikistan that more and more people suffering from serious mental illnesses are walking the streets and present a danger to the rest of society. But the authorities argue that the figures for psychiatric problems do not show a rise, and insist they are doing their best to make provision for high-risk cases.



Many Dushanbe residents interviewed by IWPR suggested that the capital was full of mentally unstable and potentially dangerous characters.



“There’s so many of them wandering around the city that it’s getting scary. What are the doctors up to?” was a typical response, in this case from a pensioner who had recently had a confrontation with a homeless man he believed was mentally ill.



But are such views anything more than prejudice?



One doctor from the National Clinical Centre for Psychiatry told IWPR on condition of anonymity that schizophrenia and related conditions were definitely on the increase.



“A steady trend can be seen in the spread of this illness [schizophrenia]…. There are currently 11,000 patients registered with psychiatric institutions who are suffering from schizophrenia,” he said. “This category of patients represents a danger to society during acute attacks of the disease.”



IWPR heard several stories where people with mental health problems were alleged to have caused disturbances. No doubt these incidents enter the urban mythology surrounding the risk such individuals pose.



Few would contest the view that after the collapse of the Soviet Union in 1991, new contributory factors to mental health problems appeared, chief among them the profound economic slump, high unemployment rates, the disappearance of many social safety nets, and the stress caused by five years of civil war. Doctors see drug addiction and alcoholism as additional factors affecting those vulnerable to psychiatric problems.



One figure that does appear to be rising is that for suicides, especially among men aged between 20 and 40.



But government medics insist that there is no evidence of an overall rise in recorded figures for mental illness.



Health ministry figures suggest that the incidence of mental illness has actually plummeted in the last 15 years. In 2004, these statistics indicate that there were less than 750 cases per 100,000 of the population, compared with just over 4,000 per 100,000 in 1991.



"My data do not show a rise in [mental] illness,” said Uktam Bobojonov, chief of the medical services department at the health ministry. “I would say rather that the incidence of new cases is static. There has been no obvious upsurge in mental illness since 2001.”



Kadir Yusupov, the chief medical specialist in Bobojonov’s department, agrees that there is little change, saying that this year’s official total of recorded cases, which stands at 41,500, is just 300 more than in 2004.



Yusupov says one third of the recorded cases are people living in Dushanbe, a point which would explain the perceptions encountered among interviewees.



Many doctors concur, however, that chronic lack of funding means that patient care, treatment availability, and rehabilitation are woefully inadequate and that this in turn can exacerbate an individual’s condition.



Bobojonov accepts that government funding for the sector remains “miniscule”, and acknowledges the role of international aid agencies, particularly Medecins Sans Frontieres – Netherlands, which filled the gap with donations of medical supplies; and the World Food Programme which has provided food for the country’s mental healthcare units.



There are no private mental health clinics, and according to Bobojonov the government is considering charging for some services, as has been the case in other healthcare areas since August 2005. He says serious cases including schizophrenics would continue to receive free treatment while others would have to pay.



If these plans go ahead, the numbers of people seeking treatment is likely to fall.



Even now, patients are generally only referred for treatment if they or their relatives press to see a psychiatrist.



According to Dr Olga Sokova, the senior physician at the Clinical Centre for Psychiatry, in rural areas people are even more unwilling to own up to mental health problems. One reason for that is the residual fear of being locked up against one’s will, as was the practice in the Soviet Union. A law passed in 2002 banned psychiatrists from treating patients without their consent, except in cases where the person’s behaviour is deemed to pose a danger to others.



Sokova’s clinic is the first port of call in an emergency, but it too is short of resources. It has only three psychiatrists instead of the five it should have to look after the maximum of 80 in-patients whom it can care for at any one time, in part because few qualifying doctors choose this as their specialisation.



Dushanbe resident Said Rahmatullaev recalled what happened when his brother began to display signs of serious disturbance. “He attacked his relatives with a knife, including his pregnant wife. It took three grown men to tie him to a radiator using strong ropes,” said Rahmatullaev.



“But when we rang for an ambulance, we were told that they didn’t have a team of psychiatrists, and that we’d have to take him ourselves to the Clinical Centre for Psychiatry.”



At the health ministry, Yusupov promised that the lack of capacity was being addressed, “An emergency psychiatric ambulance service will soon be established in Dushanbe, as in Soviet times, because the increasing numbers of patients in this category who are walking the streets represent a certain danger to society.”



Longer-term care is given at psychiatric hospitals, the main one being located at Koktash in the Rudaki district. The hospital has 700 beds, about half of which are currently occupied.



Bobojonov accepts claims that the hospital has suffered dire shortages of medicines and other resources in the past, but insists things have been getting better since 2003.



He also rejects another common view - that patients including some high-risk cases were in the past allowed to leave when the hospital lacked the money to look after them. Instead, he argues that some may have escaped from the facility but that these were isolated cases.



Two male patients who did escape, as long ago as 1997, were recently hounded out of a Dushanbe suburb after one of them was accused of a sexual assault on a minor. Their case suggests that if people with mental health problems are living in the community with no family to care for them, they may simply fall through the net.



Instead of going to the police, the girl’s family beat up the alleged attacker and forced both young men to leave the area, where they had been living in an unused basement since their escape and doing odd jobs for local residents to support themselves.



“I understand that their illness is a misfortune and not their fault. But why did no one from the medical or social services give them any help for so many years?” said the mother of the girl concerned.



People looking after relatives with psychiatric complaints find it hard to cope given the lack of outreach programmes and aftercare.



Maya Hashimova’s brother, now 40, began suffering problems six years ago when his wife and son were murdered, apparently in retaliation for an unpaid business debt. Now Maya is his carer, and she is finding it difficult, “I don’t have the money to get him good treatment, and I don’t want to hand him over to a mental hospital – he’d get worse there. They say they treat them badly [in hospital], make them work in the fields and don’t feed them.



“I’m in constant danger myself. He’s gone for me with a knife a few times and nearly killed me. But I can’t keep him tied up all the time.”



Artem Fradchuk is an independent journalist in Dushanbe.