Psychiatry in Ukraine.

Ukraine, at 603 700 km2, has the second largest landmass in Europe. It has a population of about 47.4 million. Ukraine is a lower-middle-income country with a gross national income per capita of US$1260 (World Bank, 2002).

The unmet mental health needs of the Afghan people are enormous. The challenge to increase the capacity of the mental health sector will remain huge over the coming years. U kraine, at 603 700 km 2 , has the second largest landmass in Europe. It has a population of about 47.4 million. Ukraine is a lower-middleincome country with a gross national income per capita of US$1260 (World Bank, 2002).

Healthcare
The health and well-being of the Ukrainian population, as in other former Soviet countries, are generally very poor. Life expectancy at birth is 69.7 years (64.4 years for men and 75.3 years for women). Overwhelmingly the most important reason for this is the combination of poverty, poor diet and living conditions, and lifestyle factors such as tobacco and alcohol use. Cardiovascular disease and trauma (accidents and poisonings) are the two most common causes of death, followed by cancer (UNDP & UNICEF, 2002).
Healthcare expenditure amounts to 3.5% of gross domestic product. In-patient care accounts for twothirds of total healthcare expenditure. The number of physicians per 100 000 is 229; hospital bed provision is 903.2 per 100 000 (1998 figure), much in line with the average of 812.0 per 100 000 across Europe.
During the past 10-15 years government programmes have sought to strengthen primary healthcare on the basis of family medical practice, to develop a system of health insurance, and to create the conditions for private medical practice. A key feature of the current situation in Ukraine is the low level of remuneration for doctors and other healthcare staff (International Labour Office, 2001).  1468 are in general hospitals. There are also 6535 beds in 40 in-patient drug misuse facilities. The main features of the network of mental health services are their centralised structure, their focus on patients with a psychosis and their relative separation from other medical services.

Mental health legislation
The Law on Mental Healthcare was adopted by the Ukrainian Parliament in February 2000. It defines the legal and organisational principles for the provision of psychiatric care to citizens. The Law also defines forms of mental healthcare and the legal basis for psychiatric assessment, as well as for out-patient and in-patient treatment. For the first time, the Law set up a system for the provision of involuntary psychiatric care. Also, the responsibilities of state authorities with respect to the protection of the rights and legitimate interests of persons with mental disorders are defined in the Law. Further, it sets out the rights and obligations of the persons responsible for the provision of psychiatric care.

Training
The graduate 6-year study programme in a medical university includes an obligatory 54 hours of training in medical psychology and 108 hours of training in psychiatry. Internship to become a specialist in psychiatry lasts 2 years. The programme includes some training in child psychiatry, the treatment of substance misuse, psychotherapy and neurology, but most of the training is in adult psychiatry.
After 3 years of work as a physician after graduation from medical university it is possible to receive training in the following specialties: psychiatry, child psychiatry, the treatment of substance misuse (in Ukraine and other post-Soviet countries this is a separate specialty named narcology), psychotherapy and sexology. This training takes 4-5 months.
Every psychiatrist should receive at least 1 month of professional training once every 5 years.

Resources
The state network of mental health services employs 3477 psychiatrists (7.33 per 100 000 population); of this total, 1783 work in out-patient facilities, 238 are psychotherapists, 94 are forensic psychiatrists and 1317 are narcologists (2.78 per 100 000). Other mental health professionals, such as nurses, psychologists, occupational specialists and social workers, are not included in the official statistics. Also, there are private mental health and substance misuse services, primarily in large cities, but again statistics are unavailable.

Research
There are wide networks of scientific institutions and departments of psychiatry at medical universities.
However, few papers reporting Ukrainian research in the field of mental health appear in the world literature.
In 2002 the Ukrainian Psychiatric Association, in collaboration with Division of Epidemiology of the Department of Psychiatry at the State University of New York at Stony Brook and Kiev's International Institute of Sociology, conducted the first epidemiological survey of mental health and substance use disorders. This found that close to one-third of the population experienced at least one psychiatric illness in their lifetime, 17.6% had experienced an episode in the past year and 10.6% had a current disorder. There was no gender difference in the overall prevalence rates. In men, the most common diagnoses were alcohol disorders (26.5% lifetime) and mood disorders (9.7% lifetime); in women, they were mood disorders (20.8% lifetime) and anxiety disorders (7.9% lifetime). The rates of treatment seeking were very low. The person to whom respondents talked most often about their symptoms was their general medical provider. For lifetime mood disorders, 16.6% talked to a professional; for anxiety disorders, the figure was 21.1%. The rates were higher in those with more severe forms of these disorders. Thus, for the subgroup of respondents with mood disorder who acknowledged suicidal thoughts, the percentage who talked to a professional was 25.1%.

The Ukrainian Psychiatric Association
The Ukrainian Psychiatric Association (UPA) is a nongovernmental, non-profit organisation working in the field of psychiatry and professional training. It was founded in 1990. The UPA has become a leader among the similar organisations in Eastern Europe and Central Asia. It is an information centre for psychiatrists, psychiatric nurses, psychologists, lawyers and politicians working in the field of mental health and health system reform.
Since its inception, the UPA has considerably widened its network: there are now 31 UPA branches and more than 800 members. A priority for the UPA is to diminish the 'information isolation' of Ukrainian medical specialists.
In 1990 the UPA founded its special Experts' Commission for rendering social and legal assistance to mental health service users and their relatives. It provides assistance on a daily basis to all those who appeal to it. People appeal to the Commission with requests to protect their rights. The experts working on it represent the interests of people with psychiatric illnesses in the courts and provide juridical and social assistance to them. Their activities are wide in scope: specialist consulting; legal assistance (including representation in court); the assistance of forensic psychiatrists (including support in courts); the provision of consultations by forensic psychologists; psychological help; and the attendance of a social worker. The In men, the most common diagnoses were alcohol disorders (26.5% lifetime) and mood disorders (9.7% lifetime); in women, they were mood disorders (20.8% lifetime) and anxiety disorders (7.9% lifetime).
The UPA has become a leader among the similar organisations in Eastern Europe and Central Asia. It is an information centre for psychiatrists, psychiatric nurses, psychologists, lawyers and politicians working in the field of mental health and health system reform.

Board of International Affairs at the conference of the American Psychiatric Association
The Pan-American Division of the College has organised the symposium on 'Migration and Mental Illness Around the World'; College members and fellows from seven countries will be speaking. It forms part of the conference academic programme and will be held on 22 May at 2-5 p.m., at the Toronto Convention Center, North Level 100, room 104C. All College members attending the annual meeting of the American Psychiatric Association in Toronto are welcome to attend the reception organised by the Pan-American Division, which will be held on Monday, 22 May at 6.30-8.30 p.m., at the Sutton Place Hotel, at Wellesley and Bay Streets, in the Royal Sutton room A on the lobby level.
Commission has registered an increase in the number of cases pertaining to human rights and psychiatry abuses. This serves to confirm, unfortunately, the inadequacy of government assistance. The UPA's Expert Commission regularly informs the mass media, legal and law-enforcement authorities in relation to the human rights of people with a mental illness in Ukraine. The UPA more generally fulfils an important societal service, through its independent expert groups, in carrying out regular monitoring of human rights abuses in the field of psychiatry. The UPA provides assistance and consultations without charge. Since its establishment in 1990, the UPA has been actively engaged in overcoming the stigmatisation of psychiatric patients in Ukraine.
The UPA publishes two periodicals, in Ukrainian, the Review of Contemporary Psychiatry and the UPA Bulletin. These are distributed not only to psychiatrists in Ukraine and other ex-Soviet countries but also to psychiatric patients and their relatives. Moreover, the UPA has assisted in starting other journals, such as Social, Psychological and Medical Aspects of Cruelty and Social Policy and Social Work.
The research activities of the UPA have included the implementation of programmes in the following fields: m sociological -'monitoring of human rights observance', 'public opinion on mental health and psychiatric illness' m economic -'provision of a basic economic rationale of psychiatric system reorganisation' m epidemiological -'mental health of children', 'Chernobyl disaster victims', 'alcoholism and mental disorders in Ukraine' m historical -'history of psychiatry in prerevolutionary and Soviet periods'. In addition, a special project has been launched on the adaptation of ICD-10 in Ukraine, in cooperation with American psychiatrists.

Conclusion
The outline above reflects only one aspect of the situation, the formal one, as described by many international experts from the World Bank and other agencies.
The situation has another side, however, and it is a sad one. As in all post-Communist states, our psychiatric service is archaic (it does not correspond to the political, legal and economic realities of the country), ineffective and costly. The principles of evidence-based medicine are ignored within the system of psychiatric services. The collection of medical statistics, for example, is archaic and not of the best quality. Epidemiological studies (in the Western sense of the term) have not been carried out in this country. Financial institutions have never sought to examine the cost-effectiveness of the existing mental health system, responsibility for which is dispersed across at least seven government ministries and departments.
The Ministry of Healthcare of Ukraine formally admits the use of out-of-date, exotic and harmful methods of treatment (ranging from the well known sulfazine of Soviet punitive psychiatry to unmotivated psychosurgical intervention and inadequate application of electroconvulsive therapy).
Only recently has there emerged some hope that the system will be improved. For the first time in this country a competent and determined person has been appointed to the post of the Chief Psychiatrist. Hope is also inspired by the establishment of a national service users' association, the activism of the officers of the Department of Mental Health and Substance Dependence, and the World Health Organization's collaboration with various partners in this country.
The UPA publishes two periodicals, in Ukrainian, the Review of Contemporary Psychiatry and the uPA Bulletin. These are distributed not only to psychiatrists in Ukraine and other ex-Soviet countries, but also to psychiatric patients and their relatives.
For the first time in this country a competent and determined person has been appointed to the post of the Chief Psychiatrist.