Comprehensive Clinical and Social Research at the Moscow Research Institute of Psychiatry: Translation into Clinical Practice

The article is devoted to the work of the Moscow Research Institute of Psychiatry to improve psychiatric care for patients with psychotic disorders. An important feature of this work was an integrated approach, in which the clinical picture of the disease was assessed in close connection with the patient's personal and psychological characteristics, social conditions of his life, therapeutic opportunities, rehabilitation potential and organizational structure of care.

The article reflects the results of many years of work of the department of outpatient psychiatry and the organization of psychiatric care under the guidance of Professor I.Ya. Gurovich. The results of scientific research carried out by the staff of the institute in a traditional humanistic manner are presented. The translational nature of the research is emphasized by its inextricable link with clinical and social approaches.

As a result of many years of work, a concept was developed to provide assistance to various groups of patients, starting with the first manifestations of the disease and ending with cases of long-term chronic disorders with a pronounced level of social maladaptation. As a result, a whole spectrum of new organizational forms of psychiatric care was proposed, such as departments (clinics) of the first psychotic episode, medical rehabilitation departments, assertive community treatment departments, designed for the most difficult patients. These organizational forms were fixed in the regulatory documents of the Ministry of Health and Social Development of the Russian Federation. To date, the above departments have been established in psychiatric institutions in many regions of the Russian Federation. Further development of this area is associated with neurobiological research to identify complex biomarkers of psychotic spectrum disorders.

Thus, the research carried out at the present time preserves the tradition of an integrated clinical and social approach to the study of mental disorders. It is shown that an important advantage of this approach is their translational nature.

INTRODUCTION

Russian psychiatry from the beginning of its establishment as a scientific discipline was characterized by a holistic approach to the mental healthcare provision. An important characteristic of this approach was comprehensive consideration of clinical, psychological and social aspects, personality of the patient, along with the organization of treatment and rehabilitation issues. The clinical manifestation of the disease was assessed together with the patient's personality, psychological traits and social conditions, therapeutic opportunities, rehabilitation potential and organizational structure of care. Typical of Russian psychiatry as a whole, this approach has formed the basis of the scientific and practical activities of the Moscow Research Institute of Psychiatry (MRIP) since it came into being. The clinical approach has definitely been the "carte-de-visite" of the MRIP across the entire period of its existence and remains such at the present time.

Professor Lev Markovich Rozenstein, one of the first directors of the MRIP, is known as a major theorist of psychiatric care organization and an active adept of the rehabilitation approach in psychiatry. He was a brilliant clinician and a sophisticated diagnostician, developing concepts for the prevention of mental disorders, based on a deep understanding and the practical application of K. Jaspers’ phenomenological method.1 His statements that hospitalizations alone cannot solve the problems of mental patients sound surprisingly modern. In his view, it is necessary to go beyond hospital psychiatry, especially since the majority of psychiatric patients will always remain in the community. The preventive approach in psychiatry, inextricably associated with outpatient psychiatric care, according to L.M. Rozenstein, was based on a comprehensive assessment of the patients’ condition (and not only the sum of certain symptoms of the disease) and a subtle analysis of the actual disease manifestations together with dynamics of the patient's personality in a social environment.

L.M. Rozenstein's ideas were reflected in the concept of social and vocational rehabilitation of patients with schizophrenia, which was actively developed in Russian psychiatry between the 1950s and the 1970s. Here we can highlight the studies of Professor Dmitry Evgenievich Melekhov,2 in which special attention was paid to the concept of “defect”, understood as persistent, post-psychotic manifestations not limited by negative symptoms, but rather possessing a certain structure, clinical features and dynamics.

D.E. Melekhov was the head of the MRIP in the 1950s and is one of the founders of the vocational rehabilitation system in the Soviet Union. Understanding the working capacity prognosis in his studies is inextricably associated with clinical indicators, using both static and dynamic characteristics (systematics of schizophrenia forms according to the "cross section" and "longitudinal section"), as well as post-psychotic states.2

In this regard, D.E. Melekhov singled out the period of defect development at the active disease stage, the period of formation and stabilization of the defect, as well as the period of the formed and compensated defect. At the same time, even in the latter case, the defect was not considered as being stiff condition, on the contrary, the dynamics of the formed, defective conditions in the guise of episodic, short-term inadequate mood and activity fluctuations, reactive states and the pathological development of the post-psychotic personality were indicated. Moreover, possibility of the compensation, subcompensation (labile and incomplete compensation) and defect decompensation were discussed. The need to distinguish between reactions developing during the active course of the disease and the reactions that generate new symptoms of the disease from truly compensatory reactions, were emphasized.

Based on the peculiarities of the clinical picture and the dynamics of the defect (which is much broader than negative disorders sometimes synonymously used in these cases), the tactics of social and labour recovery of patients were established. Indeed, it is important to distinguish between the restoration of social functioning, due to the symptoms regression in the active stage of the disease and the patient’s adjustment due to the defect compensation in the post-psychotic period. At the same time, the importance of purposeful activity of the individual and the significance of the environment in the compensation of defect were emphasized.2

The purpose of this article is to review the clinical and social research conducted at the Moscow Research Institute of Psychiatry, and implementation of their results in clinical practice.

NEW APPROACHES TO THE MENTAL HEALTHCARE IN THE COMMUNITY

Professor Isaac Yakovlevich Gurovich also used an integrated approach to the rehabilitation of patients with mental illnesses. In 1978 as the head of the Outpatient Psychiatry and Organization of Mental Healthcare Department, he placed this clinical approach at the forefront of organizational healthcare in psychiatry. New organizational forms of mental care were filled in with clinical content; they were based on the understanding of the dynamic nature of psychiatric diseases, that determines the patients` social functioning.3

The system of treatment in day hospitals using step-wise approach and continuity of care was developed in the department. The development of the treatment approaches for subacute, subpsychotic conditions, the so-called "outpatient exacerbations" appeared to be a significant achievement.4 The dissertation researches performed in the department formed the basis for the Regulation on day hospitals, which laid the foundation for the further development of the psychiatric service, with a shift to outpatient care, and for the organization of new forms of care provision within the service. A detailed development of clinical and social indications and contraindications for the admission, significantly increased the scope of conditions that can be treated in day hospitals and enabled patients with psychotic disorders, who maintain socially acceptable behavior and have the support of their family,5 to receive treatment there. Other substitute forms of hospital care have been developed, such as home inpatient care.6

The essential role of psychosocial therapy and psychosocial rehabilitation as an obligatory component of psychiatric care at any stage of its provision including a day hospital,7 was emphasized together with the importance of adequate and intensive psychopharmacotherapy. An important administrative decision — the introduction of social workers into the staff of psychiatric institutions and their subdivisions (psychiatric hospitals, day hospitals, neuropsychiatric dispensaries), enshrined in the corresponding order of the Ministry of Health, was the logical result of this work and significant achievement of the department. This laid the foundation for comprehensive, polyprofessional healthcare for mentally ill. An important aspect of this approach was the consideration of psychosocial interventions not only as a tool to facilitate social adjustment, but also as an effective method of treatment.

The work of outpatient psychiatric facilities has significantly changed and their services have been tailored to the needs of the patients. The modern management of psychiatric patients in the dispensary was laid, the criteria for dispensary observation and the indications for withdrawal from it were developed and implemented.8

One of the research directions of the department were the issues of social adjustment and the rehabilitation of patients with chronic schizophrenia, which made up a significant part of the dispensary contingent. The features of clinical manifestations and social adjustment of patients with schizophrenia were studied at the stage of disorder stabilization, in an outpatient setting. As a result, a close relationship was highlighted between the clinical manifestations of the disease, forms of social adjustment and the conditions conducive to successful rehabilitation.9,10

It should be emphasized that all studies put the clinical approach at the forefront, based on a subtle diagnostic assessment of the patient, including both psychopathological analysis and the dynamics of the disease, as well as personality, psychological and social characteristics. For the first time in Russian psychiatry, the concept of quality of life was introduced into the analysis of the patients’ condition; its features were described in various groups of patients, as well as its importance for social adjustment and psychosocial treatment and rehabilitation.11

The pharmacoepidemiological and pharmacoeconomic aspects of the psychiatric care for patients with schizophrenia were studied for the first time.12

The Russian-Canadian disability program (1997–2007), which was organized by the staff of the Department of Outpatient Psychiatry and Organization of Mental Healthcare of the MRIP and the Department of Community Rehabilitation and Disability Studies at the University of Calgary (Canada) was the next step in the development of the clinical and social directions in psychiatry. The principles of psychosocial therapy and rehabilitation, the interprofessional team management of patients, as well as individual case management were developed within the framework of the Russian-Canadian program. The staff of the Department scientifically substantiated the efficiency of methods, widely known abroad such as psychoeducation, compliance therapy and the training of social and cognitive skills.

The long-term cooperation of the Department with the University of Calgary facilitated the development of joint educational programs, a large number of specialists from the regions of Russia were trained in psychosocial therapy and the rehabilitation of patients, including internships in Canada. Together with the Moscow State Social University (MSSU), the course for social workers, “Social work in psychiatry”, was developed.

CARE SYSTEM FOR SPECIAL PATIENT GROUPS

A further development of the concept of psychosocial therapy and rehabilitation led to the study of clinical and social characteristics and the identification of the special needs of various groups of patients with schizophrenia. One of the most important areas of research was the study of the initial stages of psychotic spectrum disorders and, on this basis, the development of scientifically-grounded practical approaches to organizing care for patients with newly emerging psychotic conditions. Along with detailed descriptions of the clinical picture and therapeutic approaches in care, considerable attention was paid to the clinical and organizational aspects. As a result, the principles underlying the work of first episode psychosis departments (clinics), were established. After a series of educational seminars, similar clinics were opened in more than 30 regions of the Russian Federation. In fact, a reference system of mental healthcare at the initial stages of psychotic spectrum disorders was developed, including not only inpatient and day hospital treatment, but also the long-term follow up of patients. Its efficiency was proved, both from a clinical point of view and the social recovery of patients.13–15

Along with the first psychotic episode, considerable attention was paid to the study of the clinical features and the social functioning of patients with a chronic course of the disease, frequent and prolonged hospitalizations, as well as those who had lost social ties.16,17 The efficiency of the complex community therapy of schizophrenic patients, discharged after long-term hospitalizations, has been demonstrated, which, along with active pharmacotherapy, should include the psychoeducation of patients and their relatives, as well as training in self-care and independent living skills.18,19 The efficiency of special rehabilitation programs was investigated using the example of the "Club House" model.20 Various groups of patients with schizophrenia and schizophrenia spectrum disorders, receiving care as outpatients, were studied. The principles of complex community-based psychosocial therapy and rehabilitation were developed and implemented for each of these groups.21–23

An important element of the department's scientific activity was the study of socially vulnerable groups of patients with schizophrenia, and the development of adequate organizational forms of mental healthcare, tailored to their needs. These groups included patients with unstable social and labour adaptation, with frequent and very frequent hospitalizations, as well as lonely patients.24–28

The work was carried out in two directions: on the one hand, the psychological components surrounding the issues of loneliness, the disability of patients with schizophrenia and the stigma of mental illness were investigated and the main "targets" of psychosocial interventions for these patients were identified;29,30 on the other hand, the efficiency of psychosocial work with this group of patients was demonstrated with the involvement of community resources, namely, the integrated social services centres.31 The study of the social environmental factors and the immediate surroundings of patients with schizophrenia made it possible to develop and put into practice the methods of work with the family of patients with mental illnesses, known as compliance therapy.32

An important milestone in the development of community-based psychiatry was the organization of Russia's first association of psychiatric care consumers and their relatives, called "New Choices", with branches in more than 50 regions of the country.33 This organization is now known as the All-Russian Public Organization of People with Mental Disabilities.

Such forms of transdisciplinary collaboration of psychiatric institutions, social protection services and public institutions, aimed at the re-integration of patients with mental illnesses into society, are now an essential part of community-oriented psychiatry.

CONCLUSION

Thus, as a result of longstanding work, the concept of care for various groups of patients was developed, starting with the first manifestations of the disease and ending with cases of long-term, chronic disorders with a pronounced level of social maladjustment. As a result, a broad spectrum of new organizational forms of mental healthcare was proposed. In addition to the aforementioned first episode psychosis clinics,34 medical rehabilitation departments (operating both within a hospital and in the community) were proposed and put into practice. Staffing, objectives, indications for referral and the methodology of work were developed. Furthermore, a completely new form of care for Russian psychiatry — intensive care departments for patients with the most severe symptoms, receiving care in a day hospital — was introduced.35–37 These organizational forms were statutory enshrined in the Order of the Ministry of Health and Social Development of the Russian Federation No. 566n, "On approval of the procedure of medical care provision for mental and behavioral disorders", dated May 17th, 2012. To date, the aforementioned departments have been established in psychiatric services in many regions of the Russian Federation.

All these new organizational forms of psychiatric care are characterized by a significant proportion of psychosocial therapy and rehabilitation within the treatment course. This approach is based on a thorough study of psychosocial intervention targets and their therapeutic mechanisms. In this regard, the study of cognitive impairments in psychotic spectrum disorders, which play a decisive role in the social functioning, is essential.

The features of neurocognitive deficit and its dynamics were described in detail among patients with schizophrenia and schizophrenia spectrum disorders at different stages of the disease, and depending on the course type.38–41 Much attention has been paid to the studies of social cognitive functions, resulted in development of the whole range of new pathogenetic-oriented approaches to psychosocial therapy.42,43 An investigation into the negative symptoms of schizophrenia and their relationship with cognitive functioning has been carried out; new tools are being validated to assess social cognitions and negative symptoms.44,45 The latest forms of cognitive remediation are tested in clinical units (first episode psychosis clinic, medical rehabilitation department). Methodological developments in this direction have contributed to the introduction of a number of modern training programs into the practice, such as training on cognitive and social skills,46 motivational training for patients with schizophrenia47 and metacognitive training for patients with psychosis.48,49

The further development is associated with neurobiological studies, aimed at the identification of complex biomarkers for diagnosistics and determination of biopsychosocial intervention tactics. This refers to the study of evoked potentials,50,51 in particular, the study of facial expressions,52–55 the study of oculomotor alterations in patients with schizophrenia spectrum disorders56 and autoimmune disorders in newly emerging psychotic states.56–59 In general, the task is to carry out a network analysis of the identified disorders.60–62

Thus, the research carried out at the present time preserves the tradition of an integrated clinical and social approach, on the basis of which organizational models of psychiatric services are proposed. An important advantage of this approach is the applicability of its results in healthcare practice, that is, the translational nature of scientific studies.

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