Mentally ill patients in central Europe being kept in padlocked, caged beds
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7426.1249-c (Published 27 November 2003) Cite this as: BMJ 2003;327:1249
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Sir – Krosnar (BMJ 2003; 327 29th Nov; 1249) highlights an appalling
situation within psychiatric institutes in central Europe, which has
strong parallels with a psychiatric system that forms the core of our
emergency medical work in Tajikistan, Central Asia.
Following the collapse of the Soviet Union, a civil war broke out in
Tajikistan in 1992 that led to the virtual collapse of the Tajik health-
care system. Progress in rebuilding this sector has been painfully slow
and many of the consequences of this collapse are still visible today. The
psychiatric-care system appears to have been particularly affected.
Médecins Sans Frontières’ medical teams entered Tajikistan in 1997
and were overwhelmed by the magnitude of human suffering witnessed in the
17 psychiatric institutes visited throughout the country, and the problems
facing local doctors working there. Patients had, and continue to have,
almost no access to psychotropic drugs, basic medical care, or qualified
staff to treat simple daily health problems. No psychotropic drugs mean
that patients’ mental illness often gets worse, behaviour cannot be
controlled and consequently the patient becomes institutionalised for the
long-term. Patients are therefore more difficult to keep under control;
local doctors report their fear of the patients and a need to think of new
ways to calm patients down. In many cases, doctors and nurses say that
they have no choice but to tie patients to their beds. Violent or
disturbed patients, or those who tried to escape from the institutes, are
often bound to their beds or locked in containment rooms.
Staff discipline and management was understandably poor and staff
morale and commitment among the institute staff was low when MSF arrived
in 1997: staff had not received salaries and many scraped a living from
the institutes’ land.
Patients still live in overcrowded crumbling buildings that cannot be
heated and are not maintained. There are a lack of toilets, no regular
supply of water and patients rarely washed. Food supplies still remain
limited to donations from international non-governmental organisations
leaving many patients severely or moderately malnourished. Alcohol and
drug abuse are widespread.
Mortality rates inside the institutions were unacceptably high in
1996. In the two main hospitals of Lakkon and Leninsky, for example,
almost half of the inpatients who were admitted to or lived in these two
hospitals died (total patient population in each hospital in any one month
is around 400). This means that on average in Lakkon, one patient died
every three days, and in Leninsky, one patient died every two days -
figures far above international minimum crude mortality rates that
constitute a health emergency. Death was mainly a result of malnutrition
and the spread of infectious diseases.
Our primary aim on arrival in 1997 was therefore to prevent patients
from dying. We started by providing patients living in psychiatric
institutions throughout the country with emergency food and basic medical
aid, and started a programme of rehabilitation of buildings and
water/heating systems. By 1998/1999 the number of deaths per year in both
hospitals dropped significantly; however rates are still in excess of the
minimum crude mortality rate. There is still much work to be done to
reduce patient deaths that could be easily treated if resources were more
accessible and available. For despite the emergency intervention, the
institutes still suffer from chronic shortages of basic medical and
infrastructural support from the Tajik Ministry of Health (MoH).
As MSF makes its planned withdrawal from the programmes in December
2003, however, it is clear that the current situation is unsustainable and
inefficient. The time for emergency assistance is over and the onus is now
on the MoH to take over full responsibility for Tajikistan’s psychiatric
care system.
In addition to daily short-term needs, there are major longer-term
structural issues that need to be addressed. Of continuing concern at
present is the continued high readmission rates caused by a lack of
psychotropic drugs, community and primary health care support, and
occupational therapy for inpatients and outpatients; the institutions’
lack of ability to follow up patients after they have been discharged; and
the institutions’ lack of adequate medical screening and diagnosis, data
collection and analysis. Continued food and medical supplies must be
ensured as a crucial immediate need for these patients. In November, the
MoH’s first Consultative Working Group on Mental Health met to discuss
long-term reform of the psychiatric system in Tajikistan. This is clearly
a positive step forward, however increased commitment will be needed to
push this agenda forward with the speed and urgency such reforms require.
The World Health Organisation must take an active role in promoting and
supporting these developments, in accordance with pre-existing WHO
guidelines. Current Tajik health reform models do not recognise and
incorporate mental health as a priority, and subsequently many of these
issues remain absent from the health care agenda. Additionally,
initiatives such as that of organisations like the Geneva Initiative on
Psychiatry - a newly fledged 'consultative group on mental health' that
aims to support the MoH must be ensured political and financial support in
order to extend their extensive knowledge and experience of mental health
reform into the Tajikistan context.
Longer-term reform of Tajikistan’s psychiatric care system is key to
alleviating the terrible suffering that these patients are currently
facing, and to ensure the basic human rights of these neglected patients
are respected. This is clearly the responsibility of the Tajik Ministry of
Health, although it will require the continued help and commitment of the
international community to fulfil that responsibility.
Competing interests:
None declared
Competing interests: No competing interests
The article “Mentally ill patients in central Europe being kept in
padlocked, caged beds” published in BMJ 327, is part of a campaign of
several patient’s organisations (e.g. Mental Health Advocacy Centre,
MDAC). These organisations have been heard in the Parliament of Czech
Republic and many Czech newspapers have published their complaints last
week. This indicates more than the bad situation in psychiatric hospitals
the openness for criticism and the freedom of speech in Czech Republic.
The authors of those anti-psychiatric articles are people without a
glimpse what acute psychosis means, and some discontent psychiatric
patients, of course. The use of compulsory measures (belts, seclusion,
restraint, net bed, caged bed) in psychiatric institutions currently still
is judged to be inevitable all over the world for some agitated,
disoriented, restless, self-mutilating or violent patients. Until now,
there is no evidence for any alternatives which could allow to give up
such compulsive measures completely without risking severe harm for the
respective patients or others (1). According to the recent government
expertise, there are about 240 net beds in the whole Czech Republic (10
million inhabitants) and the use of caged beds (= net bed with fencing
instead of net) is being cancelled. The use of these methods is regulated
by the decree of the director of each hospital – always only for doctor‘s
prescription in acute situations for limited time.
And what should Western psychiatrists recommend the future EU member
countries to do? To use “modern West European” practice? The practice of
such compulsory measures is very different in Europe and until now follows
tradition, not evidence. In many countries (e.g. Germany, Norway,
Switzerland) tissue or leather belts are widely used. In Germany, about 9
% of 14000 inpatients were exposed to seclusion or restraint in 2001 (2).
In the UK, mechanical restraint is prohibited because it is inhuman.
Instead; physical restraint and seclusion are used. In Denmark, however,
seclusion is prohibited – because it is inhuman. “Caged beds” are used in
psychiatric hospitals in Austria, too, which are part of a very modern and
well-conducted community-based mental health service. We doubt whether
there are reasonable arguments that the use of tissue belts, seclusion
rooms, or physical restraint should be generally less inhuman than caged
beds. The advantage of net beds is the possibility of movement in
comparison to restraint and the possibility of communication in comparison
to seclusion. Interestingly, a few days before the BMJ article had been
published, there was an article in a weekly German newspaper where a
doctor reported that he had “invented” caged beds for demented patients,
assuming this to be more human and less dangerous than tissue belts (3).
Actually, there is no evidence concerning medical indications or
different effects of all these interventions (1). In the USA a legislation
has been introduced that the “least restrictive measure” has to be
applied. But we know very little what is least restrictive for which
patient in which situation (4). Evidence from well-designed studies will
be necessary to discuss reasonable alternatives. Czech Republic is
involved in several international research projects on compulsory
measures, e.g. EUNOMIA project (5). Compulsory measures of which kind ever
may be indicated in some situations. Whether they can be characterized as
“inhuman”, depends on other factors like insufficient staffing levels,
poor or missing staff training, inadequate staff philosophy, and
insufficient funding of psychiatric institutions in relation to general
society.
1) Sailas E, Fenton M. Seclusion and restraint for people with
serious mental illnesses. The Cochrane database of systematic reviews
2000; p.CD 001163
2) German Psychiatric Congress (DGPPN),Berlin 2001
3) Medical Tribune 26, 25.11.2003: 2
4) Sheline Y, Nelson C. Patient choice: deciding between psychotropic
medication and physical restraints in an emergency. Bull Am Acad
Psychiatry Law 1993; 21: 321-329
Prof. Dr. Tilman Steinert, University of Ulm, Weissenau (Germany)
Member of the European Violence in Psychiatry Research Group
Dr. Jiri Svarc,
Director of forensic treatments
Psychiatric Hospital Prague
Competing interests:
None declared
Competing interests: No competing interests
It was shocking to read about the present practice of treating
mentally ill in certain countries. Developing countries with the limited
infrastructure are doing much better.Awareness of people should increase
and legal system in these countries should put an end to such inhumane
practices.There is no use of sophisticated neuroimaging techniques and
newer therapies if we cannot treat persons with mental illness in a humane
way.
Competing interests:
None declared
Competing interests: No competing interests
I am going to CZ Republic in 04. I now have a different view point of
the Republic after reading this article. I am going to voice my
objections to this type of treatment to the European Common Market and the
World Court at the Hague.
(My grandparents are from CZ Rep. I still have cousins in CZ.)
Competing interests:
I am against confinment of this nature.
Competing interests: No competing interests
Sir,
When Dr Al-Sheikhli says, “so we ought to remember Pinel (1745-1826)
who worked at Salpetriere Hospital in Paris for freeing the insane,” [1]
he is omitting an important part of medical history of which I assume he
is oblivious:
“May we not then justly claim for Hahnemann the honor of being the
first who advocated and practiced the moral treatment of the insane? At
all events he may divide the honor with Pinel, for we find that towards
the end of this same year, 1792, when Hahnemann was applying his principle
of moral treatment to practice, Pinel made his first experiment of
unchaining the maniacs of the Bicêtre." (At Paris.) Herr Klockenbring,
[Hahnemann’s patient] as the result of his treatment, returned to Hanover
cured in March, 1793. For this cure Hahnemann received a fee of 1,000
thalers, about $750, in addition to the expenses of the board of the
patient.” [2]
As I am sure he will appreciate, “in fact, it was on 2 September in
the year 1793, that "Pinel made his first experiment of unchaining maniacs
in the Bicêtre," which was some fifteen months after Hahnemann had
commenced treating Klockenbring.” [3]
Hahnemann's entry into the psychiatric field, "was four years before
William Tuke, the English Quaker had finally established the Retreat in
York…and a year before Pinel reformed the Bicêtre Asylum in Paris." [4]
Hahnemann can be regarded as the originator of "entirely new methods in
the treatment of mental patients, independently of his famous
contemporaries Pinel and Reil," [5]
Therefore, it is not Pinel to whom psychiatry should be grateful for
pioneering the humane treatment of the insane, it is Samuel Hahnemann, who
later in life was the founder of homeopathy.
Sources
[1] AK. Al-Sheikhli, To remember Pinel for freeing the Insane, BMJ e-
letter, 1 Dec 2003
http://bmj.bmjjournals.com/cgi/eletters/327/7426/1249-c#41975
[2] Thomas Lindsley Bradford, The Life and Letters of Dr Samuel
Hahnemann, Chapter 13.
http://homeoint.org/books4/bradford/chapter13.htm
[3] Peter Morrell, Hahnemann: the Real Pioneer of Psychiatry, American Journal
of Homeopathic Medicine [formerly JAIH], Vol. 96.2, summer 2003, p.164 et
seq
[4] Rosa W Hobhouse, Life of Hahnemann, India: Harjeet Co, 1933, 85
[5] Richard Haehl, Samuel Hahnemann his Life and Works, 1922, volume
1, 272
Competing interests:
None declared
Competing interests: No competing interests
EDITOR, It was interesting to read Krosnar paper, Mentally ill patients in
central Europe being kept in padlocked, caged beds(1). Howard, Psychiatry in
pictures shows photographs of psychiatric patients taken during May 1998
near Mozambique-Zimbabwe border, chained with irons to a block of
concrete!(2) We are in the new millennium, and still psychiatric patients
in some parts of the World are treated like those who were in the
concentration camps of the 2nd World war!. So we ought to remember Pinel
(1745-1826) who worked at Salpetriere Hospital in Paris for freeing the
insane (3).
References,
1.Krosnar K,Mentally ill patients in central Europe being kept in
padlocked,caged beds,British Medical Journal 2003;327:1249.
2.Howard R,Psychiatry in pictures,British Journal of Psychiatry
2003,;183:A18.
3.Harris JC,Arts and Images in psychiatry,The Salpetriere Hospital:From
confining the poor to freeing the insane,American Journal of Psychiatry
2003;160(9):1579.
Competing interests:
None declared
Competing interests: No competing interests
I have been really ashamed for the backwardness of my country since
it was reported a few years back that mentally ill patients were kept
chained, locked, and in cages in privately run psychiatric nursing homes
of South India but this report clearly uncovers the general insensitivity
towards mentally ill patients through out the world. Restraining is needed
in some mentally ill patients but a more humane method should be devised
and accepted internationally by the medical profession
Competing interests:
None declared
Competing interests: No competing interests
Sir,
This is to bring to your notice that in India,there are only about 3000
psychiatrists for about 100 billion individuals of this country.We do not
treat people that way.We have had bad experiences of mentally ill people
being chained to pillars and having perished in a fire in 2001.After
this,the Indian Government has passed stringent rules regarding
establishment and recognition of hospitals for the mentally ill.For a
population of this size,we Indian psychiatrists should be saying that we
are unsderstaffed.In reality,we have never made such statements.The
justification that Central European Countries,with 1/10th the population
of India are understaffed is itself unjustified.
Competing interests:
None declared
Competing interests: No competing interests
How quick, no doubt, we (and I mean the "civilised countries of the
European Union") will all judge these shocking practices and demand that
entry to the EU is witheld - since there are fundamental human rights that
must be protected in any civil society!
And yet, how slow we will be to consider practices in our own Mental
Health Service that are, perhaps, only judged not to transgress the
Convention on Human Rights because they pre-date that document. Can we
really claim that non-consensual ECT, were it to be have been proposed for
the first time today, would be deemed to be Human Rights compliant?
How about the "experimental" polypharmacy that is so rife in Mental
Health Facilities? The use of outdated medicines because they are cheaper
than the newer, more effective medicines, notwithstanding the reduced
complications of the newer drugs?
Or how about the proposals regarding non-consensual destructive
nerosurgery contained in the Mental Health Bill (albeit with the case for
such treatment having to be proved before the Court?
And let us not forget that use of solitary confinement and physical
restraint is still sanctioned - perhaps for very good reasons. Perhaps
not.
There is more than one way to cage a human being - all in the name of
medicine.
Competing interests:
None declared
Competing interests: No competing interests
Restraint and confinement in Canada
In 1949, Macdonald Bell abolished all restraints and opened all the
doors of Dingleton Hospital near Melrose, Scotland (1). The hospital
continued that policy until it was closed half a century later. After
Dingleton, many psychiatric hospitals followed, both in the United Kingdom
and elsewhere (2)(3). Regrettably, the closure of those hospitals and the
rise of "psychiatric intensive care units" has begun to reverse the tide.
In much of the industrialized west, coercion is making a comeback. With
the possible exception of the United States, nowhere is this trend more
evident than in Canada . . . particularly in the provinces of British
Columbia and Ontario.
Canadian governments are wealthy by comparison to most and this
increased use of coercion would seem unrelated to any fiscal constraints.
In British Columbia, for example, mental health expenditures have
increased by a quarter in the last four years (3). Yet these expenditure
increases have followed upon more coercive legislation (4).
Though in no way unique, the "psychiatric intensive care unit" of
Prince George Regional Hospital in British Columbia, is a smaller unit of
4 cells within a larger locked ward. (Both psychiatric wards are small
but locked). Each cell lies behind four locked doors. No cell has open
access to toilet facilities. Patients must often resort to urinating in
their styrofoam drinking cups or on the floor. Only two of the cells have
windows. Patients are permitted no access to fresh air. The cells are
furnished with only a mattress. Personal possessions of no kind are
permitted in the cells. Each cell is equipped with restraint points.
Restraints are used, but infrequently. Patients are observed by several
closed-circuit cameras. Communication is made by means of intercom
systems controlled from the nursing station. The intercoms are shut off
unless a nurse wishes to communicate with a patient. Patients may be
deprived of direct human contact for many hours at a time. The minimum
stay is 24 hours and there is no maximum. Patients may be held in the
cells for a month or more. At least one patient has died in these cells.
Although most patients are admitted on compulsory orders and although
most involuntary patients are admitted to the cells, the hospital does not
normally accept forensic psychiatric patients. They are admitted to a
specialist facility elsewhere.
Such conditions are specifically precluded under the United Nations
Standard Minimum Rules for the Treatment of Prisoners (specifically
sections 11(a); 12; and 21(1)). These rules have been adopted and
enforced in prisons by Canada and many other western nations. Yet
psychiatric patients, who may have committed no crime, are not accorded
these same minimum rights.
The institutionalized violation of human rights in psychiatry is
confined to neither eastern Europe nor the Third World. But it remains an
affront to us all.
Ted Hayes
[1] G.M. Bell A Mental Hospital with Open Doors International
Journal of Social Psychiatry Vol 1 pp 42-48 1955
[2] David H. Clark (1995) The Story of a Mental Hospital: Fulbourn,
1858-1983 London:Process Press
[3] McKerracher DG (1966) Trends in Psychiatric Care Royal
Commission on Health Services (1964) Queens Printer Ottawa
[4] Government of British Columbia (2003) Budget 2003
http://www.bcbudget.gov.bc.ca/sp2003/hs/hs_strategic_link4.htm
[5] Government of British Columbia Mental Health Act [RSBC 1996]
CHAPTER 288
Competing interests:
Registered Psychiatric Nurse registered and previously practising in British Columbia
Competing interests: No competing interests