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Forensic psychiatry in Russia - the links with Britain evolve further

Bethlem Royal Hospital Denis Hill Unit, Monk's Orchard Road, Beckenham, Kent BR3 3BX
Institute of Psychiatry, London

Clive Meux, Consultant Forensic Psychiatrist

Oxford Clinic, Oxford

Declaration of interest

The links have been supported by Broadmoor Hospital and the British Council. Dr Clive Meux has worked as an Expert advisor to the CPT.

The perception of forensic psychiatry in Russia has been affected by the abuse of psychiatry for the detention of political dissidents during the later Soviet period (Smith & Oleszczuk, 1996). The Royal College of Psychiatrists played a key role in sanctioning the Soviet Society of Psychiatrists, but reintegration of Russian psychiatry into the international community of psychiatry now seems to be well underway.

During the 20th century, Russia, the country with the largest landmass in the world, notably underwent three different social systems. The initial czarism was followed in 1917 by Soviet communism and its geographic expansion, and since 1991, a post-soviet transition of the smaller Russian Federation into a capitalist economy (Mikheyev, 1996; Tolz, 2001). The past decade has also seen Russia become a member of the Council of Europe and a signatory to its convention concerning the prevention of torture and inhumane or degrading treatment or punishment (Gordon & Meux, 2000). Numerous centres throughout the Russian Federation have now been visited by the Council of Europe's European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) (Council of Europe, 2001). More recently, Russia has also reached agreement with the North Atlantic Treaty Organisation (NATO) to become an associate partner (Castle, 2002). Major international realignment of Russia has therefore occurred and the heritage of the abuse of psychiatry can now hopefully be seen as a tragic historic aberration.

During the 1990s, changes in mental health legislation and the production of a new ethical code for Russian psychiatrists set a new focus for psychiatric practice in Russia that is consistent with internationally-accepted perspectives (Polubinskaya & Bonnie, 1996). Changes in the criminal and civil law of the Russian Federation have also resulted in improved practices. However, social change in Russia has not been without its difficulties, including increases in economic hardship (Walberg et al, 1998), drug abuse (Green et al, 2000; Fleming et al, 2001), criminality (Mullerson, 1995) and mortality (Wise, 1997). Russia has been subject to international criticism regarding alleged human rights abuses in Chechnya, one of its autonomous republics in the northern caucasus (Mikheyev, 1996) and has also become the target of major terrorist acts, such as the siege of the Palace of Culture theatre in Moscow in October 2002.

The revitalisation of psychiatric services in Russia (and indeed in other post-communist East European societies) has been assisted by organisations such as the Geneva Initiative on Psychiatry (www.geneva-initiative.org), in which British and other European psychiatrists have continued to play an ongoing role. Specific British psychiatric links with Russia have also been established in the spheres of substance misuse (Green et al, 2000; Fleming et al, 2001) and general psychiatry (Collins, 1995). Furthermore, assistance has been offered as a result of concern regarding the psychiatric diagnosis and care of children in Russia who have been orphaned and admitted to institutions for abandoned children (Cox, 1997).

Contacts in forensic psychiatry involving psychiatrists and related health professionals between Russia and Britain began prior to the dissolution of the former Soviet Union and have now been maintained over the last 12 years (Gordon & Meux, 1994; Meux & Gordon, 1996; Bowden & Snowden, 1996; Gordon & Meux, 2000). Sponsorship for the links has come mostly from the British Council in Moscow, with assistance in earlier years also from Broadmoor Hospital. As part of this project, 10 senior psychiatric health professionals from Russia were funded to visit Britain for a one-week programme in April 2002. The Russian delegation was led by Professor Tatiana Dmitrieva who, in addition to being the Director of the Serbsky Institute for General and Forensic Psychiatry in Moscow and a Professor of Forensic Psychiatry at Moscow University, is also a past Minister of Health for Russia (during the Yeltsin Administration) and a member of the Russian Academy of Sciences. The Russian group came not only from Moscow but also included psychiatrists from cities in central Russia and the autonomous republic of Buratyia in Eastern Siberia near to Mongolia. The programme included a visit to a high-security prison (HMP Belmarsh, London), a medium secure psychiatric unit (Bracton Centre, Kent) and a high-security hospital (Broadmoor Hospital, Berkshire). Additionally, the delegation accepted an invitation to visit the Royal College of Psychiatrists, where they met with the then President, Professor John Cox, the Dean, Professor Cornelius Katona and other senior College personnel. That such a meeting could occur is a clear sign that events have moved on since the abuses of the communist period, which saw the withdrawal of the Soviet society of psychiatrists from the World Psychiatric Association in the 1980s.

The largest event of the visit was a conference held at King's College Hospital and the Institute of Psychiatry, London, involving the Russian delegation and some 50 British invited participants, who included not only psychiatrists and related health professionals in general, adolescent and forensic psychiatry, but also representatives of the Department of Health and some senior British physicians specialising in the study of tuberculosis. The conference was facilitated by the employment of equipment for English/Russian simultaneous translation. Themes at the conference included issues pertaining to human rights, female offenders, adolescent offenders, forensic psychotherapy, risk assessment and sex offenders, all areas of particular interest to forensic psychiatrists from both countries. Strengths and weaknesses in both countries' forensic psychiatric systems were identified.

However, the issue of tuberculosis that arose during the conference reminded us all that forensic psychiatrists are primarily doctors, albeit specialists, working in a public health arena. Conditions in Russian prisons are known to be among the most overcrowded and unhealthy in the world (Amnesty International, 1997) and Russia now has the highest rate of imprisonment in the world (Walmsley, 1999). If prisoners in Russia are not ill when they enter prison, such imprisonment is likely to carry with it an additional extra-judicial sentence of ill-health. In particular, in Russian prisons the hugely problematic incidence of tuberculosis (Meux, 1995) has now reached epidemic proportions. With some of the prisoners suffering from the multi-drug resistant variety (resistant to isoniazid and rifampicin), the mortality rate of prisoners from tuberculosis has been recorded as some 18% higher than in the general Russian population (Stern, 1999). The epidemic is a result of a combination of factors including the problems of the Russian economy, a collapse in the public health infrastructure, inefficiencies in the criminal justice system and the inadequate financing of the Russian prison system, no longer centrally guaranteed by the State or supported by prison labour. Once tuberculosis is contracted within Russian prisons, some prisoners may well still be symptomatic at the time of release, increasing the risk of spread within the community from the prison ‘reservoirs’ and, indeed, beyond the borders of Russia. The prevalence of tuberculosis has resulted in dedicated tuberculosis wards within psychiatric and forensic psychiatric hospitals. It is difficult to reconcile that the nation that celebrated sending the first man into space is, almost 50 years later, often unable to provide conditions for its citizens in prisons that are humane, instead providing those that frequently induce physical illness and psychological morbidity.

It was agreed at the conference that making better use of telemedicine would facilitate the links as well as improving educational opportunities. Individual forensic psychiatric hospitals and mental health centres in Russia and Britain are also now considering the gains of ‘twinning’ with each other (Richards, 1992), which has already occurred between prisons in the two countries. A conference is being planned for this September, to be held in Moscow, on the subject of psychiatric and health care in prisons. Funding is being sought for further collaboration in forensic psychiatry between Britain and Russia, the link between professionals in the two nations in this field of practice now having matured into a stable working relationship.

In Russia, the improvement of forensic psychiatric care (and prison health care) will be affected by the level of economic development. The reintegration of Russian psychiatry into the international psychiatric community needs to be maintained, not only to allow Russian psychiatrists to learn from their colleagues abroad, but also so that psychiatrists across the world can benefit from the extensive experience available in Russia. The future of forensic psychiatry in Russia is no longer dependent on an ideology in which psychiatrists are essentially seen as agents of State control. While general and forensic psychiatry in both Russia and Britain needs to seek to balance the needs of patients with the safety of the public, it must retain its practice independently of the state in both countries.

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