Lessons from history: the politics of psychiatry in the USSR

Proposed Declassification of Disease Categories Related to Sexual Orientation in the International Statistical Classification of Diseases and Related Health Problems (ICD-11)

(Reprinted with permission from the Bulletin of the World Health Organization).

Proposed declassification of disease categories related to sexual orientation in the International Statistical Classification of Diseases and Related Health Problems (ICD-11)

The World Health Organization is developing the 11th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11), planned for publication in 2017. The Working Group on the Classification of Sexual Disorders and Sexual Health was charged with reviewing and making recommendations on disease categories related to sexuality in the chapter on mental and behavioural disorders in the 10th revision (ICD-10), published in 1990. This chapter includes categories for diagnoses based primarily on sexual orientation even though ICD-10 states that sexual orientation alone is not a disorder. This article reviews the scientific evidence and clinical rationale for continuing to include these categories in the ICD. A review of the evidence published since 1990 found little scientific interest in these categories. In addition, the Working Group found no evidence that they are clinically useful: they neither contribute to health service delivery or treatment selection nor provide essential information for public health surveillance. Moreover, use of these categories may create unnecessary harm by delaying accurate diagnosis and treatment. The Working Group recommends that these categories be deleted entirely from ICD-11. Health concerns related to sexual orientation can be better addressed using other ICD categories.

Russian and Soviet forensic psychiatry: troubled and troubling

Russian forensic psychiatry is defined by its troubled and troubling relationship to an unstable state, a state that was not a continuous entity during the modern era. From the mid-nineteenth century, Russia as a nation-state struggled to reform, collapsed, re-constituted itself in a bloody civil war, metastasized into a violent "totalitarian" regime, reformed and stagnated under "mature socialism" and then embraced capitalism and "managed democracy" at the end of the twentieth century. These upheavals had indelible effects on policing and the administration of justice, and on psychiatry's relationship with them. In Russia, physicians specializing in medicine of the mind had to cope with rapid and radical changes of legal and institutional forms, and sometimes, of the state itself. Despite this challenging environment, psychiatrists showed themselves to be active professionals seeking to guide the transformations that inevitably touched their work. In the second half of the nineteenth century debates about the role of psychiatry in criminal justice took place against a backdrop of increasingly alarming terrorist activity, and call for revolution. While German influence, with its preference for hereditarianism, was strong, Russian psychiatry was inclined toward social and environmental explanations of crime. When revolution came in 1917, the new communist regime quickly institutionalized forensic psychiatry. In the aftermath of revolution, the institutionalization of forensic psychiatry "advanced" with each turn of the state's transformation, with profound consequences for practitioners' independence and ethical probity. The abuses of Soviet psychiatry under Stalin and more intensively after his death in the 1960s-80s remain under-researched and key archives are still classified. The return to democracy since the late 1980s has seen mixed results for fresh attempts to reform both the justice system and forensic psychiatric practice.

From social pathologies to individual psyches: psychiatry navigating socio-political currents in 20th-century Latvia

The paper explores psychiatry's responses to the twentieth-century socio-political currents in Latvia by focusing on social objectives, clinical ideologies, and institutional contexts of Soviet mental health care. The tradition of German biological psychiatry in which Baltic psychiatrists had been trained blended well with the materialistic monism of Soviet psychoneurology. Pavlov's teaching of the second signal system was well suited to Soviet ideological needs: speech stimuli were seen as a vehicle for moulding the individual's mind. The transformation in diagnostic practices during the 1970s and 1980s reflected the demise of optimism about the capacity of the self to model itself to the needs of the society. Latvian psychiatry was prepared to embrace more individualistic and pessimistic theories of the self.

The association of schizophrenia with split personality is not an ubiquitous phenomenon: results from population studies in Russia and Germany

A widely prevalent stereotype connected with schizophrenia is its misperception as split personality. We examine whether the popular meaning of the term schizophrenia differs in countries of different cultural imprint by conducting an international cross-cultural comparison of public associations with the word schizophrenia in a Western and a Non-Western industrialized country. We analyze data from two representative population surveys in Novosibirsk, Russia (n = 745), and large German cities (n = 952) that used identical questions and sampling procedures. Unprompted associations with schizophrenia are compared by assigning them to a differentiated categorical system. 31.6% of respondents in Germany associated split personality with schizophrenia, compared to 2.0% in Novosibirsk. Logistic regression analysis controlling for age, gender and educational achievement demonstrated that country differences were independent of socio-demographic variables. Mention of split personality increased significantly with higher education. In Novosibirsk, associations with abnormality and unpredictability prevailed. We hypothesize on those cultural particularities in both countries that have shaped the different public understanding of the term and discuss implications for anti-stigma interventions.

Psychiatry and political-institutional abuse from the historical perspective: the ethical lessons of the Nuremberg Trial on their 60th anniversary

Sixty years ago at the Nuremberg Trials, 23 Nazi leaders were tried as war criminals, in what was known as "The Doctors' Trial". This trial exposed a perverse system of the criminal use of medicine in the fields of public health and human research. These practices, in which racial hygiene constituted one of the fundamental principles and euthanasia programmes were the most obvious consequence, violated the majority of known bioethical principles. Psychiatry played a central role in these programmes, and the mentally ill were the principal victims. The aim of the present work is to review, from the historical perspective, the antecedents of the shameful euthanasia programmes for the mentally ill, the procedures involved in their implementation and the use of mentally ill people as research material. The Nuremberg Code, a direct consequence of the Doctors' Trial, is considered to be the first international code of ethics for research with human beings, and represented an attempt to prevent any repeat of the tragedy that occurred under Nazism. Nevertheless, the last 60 years have seen continued government-endorsed psychiatric abuse and illegitimate use of psychoactive drugs in countries such as the Soviet Union or China, and even in some with a long democratic tradition, such as the United States. Even today, the improper use of psychiatry on behalf of governments is seen to be occurring in numerous parts of the globe: religious repression in China, enforced hospitalization in Russia, administration of psychoactive drugs in immigrant detention centres in Australia, and the application of the death penalty by lethal injection and psychiatric participation in coercive interrogation at military prisons, in relation to the USA. The Declaration of Madrid in 1996 constituted the most recent attempt to eradicate, from the ethical point of view, these horrendous practices. Various strategies can be used to combat such abuses, though it is uncertain how effective they are in preventing them.

Public attitudes toward psychiatric treatment. An international comparison

AIM

In order to examine whether there is a relationship between the state of mental health care and the acceptance of psychiatry, public attitudes toward psychiatric treatment in three countries where the reform of mental health care has progressed to a different degree will be compared.

METHODS

Population surveys on public beliefs about mental illness and attitudes toward psychiatric treatment were conducted in Bratislava, Slovak Republic, and Novosibirsk, Russia. The data were compared with those from a population survey that had recently been carried out in Germany. In all three surveys, the same sampling procedure and fully structured interview were applied.

RESULTS

Although respondents from all three countries were equally inclined to seek help from mental health professionals, those from Bratislava and Novosibirsk tended to recommend more frequently to address other medical or nonmedical professionals or members of the lay support system. In all three countries, psychotherapy was the most favored treatment modality, followed by psychotropic medication. Although natural remedies were more frequently recommended in Bratislava and Novosibirsk, meditation/yoga was more popular among the German public. Across all three countries, the endorsement of a brain disease as cause was associated with a greater willingness to seek help from medical professionals (psychiatrist, GP). Respondents who adopted biological causes tended to recommend psychotropic medication more frequently.

CONCLUSION

In countries with less developed mental health care systems, there appears to be a tendency of the public toward more frequently relying on helping sources outside the mental health sector and on traditional "alternative" treatment methods. However, it is our prognosis that with the progress of reforms observed, differences may further decrease.