Mental Healthcare in Need of Treatment

An investigation into how widescale mental health reform in Romania has been ignored by the authorities. This feature required undercover reporting as many healthcare institutions do not allow journalists into their buildings. This was published in April 2010 for ‘The Diplomat – Bucharest’ magazine – http://www.thediplomat.ro/print2.php?id=1022

Mental healthcare in need of treatment

Underfunded, overcrowded, ignored, suffering from chronic prejudice: Romania’s treatment of the mentally ill is in a shocking state – but prescriptions for change are on the table, if the political will is ready to pick them up

As we pass the security gates, park the taxi, leave and approach the building, a crowd shuffles around us – men of different ages in mud-stained jumpers, tracksuit trousers and plastic sandals, many of whom wear red woolly hats printed with the words – ‘Mircea Geoana – Presidente’ – the name of the failed Social Democratic candidate in Romania’s 2009 election for head of state.
“Do you have cigarettes?” one asks. Another requests cash: “Cincizeci de bani? Cincizeci de bani?” repeated automatically. When it receives no response, it changes to broken English, “Ten-thousand, one-hundred thousand,” – a reference to the abandoned, inflation-heavy Romanian currency – then the same amounts in Italian “Diecimila, centomila”.
I open a packet of cigarettes. Further men peer out of the windows from the building, move into the lobby and run outside. The first asks for a smoke. By pressing his hands together in prayer. The second asks for two. The figure continues to rise. Hands grapple with cigarettes falling from an open packet of Camels. The skin at the base of the index finger and on the upper part of the middle-finger is stained black, with a yellow rim. The sign appears on most of the men. From inhaling unfiltered cigarettes. One man is smoking tobacco from the broken body of a ballpoint pen.
The cigarettes are exhausted. The demands return. ‘Cincizeci de bani’, ‘cincizeci de bani’, ‘10,000’, ‘100,000’. I refuse to give any money. A young man in his late twenties darts me a bitter look.
“Yeah, right – you’re from Bucharest and you do not have money,” he says.
This is the greeting a visitor receives outside Balanceanca – a three-floored guarded asylum in Ilfov county, five minutes from Bucharest’s giant Glina rubbish dump. The green and white block resembles cheap apartments built for the edge of the city during the last bankrupt days of Communism. Pregnant dogs move around the ground, while inside a small team of nurses and one doctor care for a 210-strong mix of schizophrenics, bipolar cases, the violently insane and the mentally disabled.
The patients are dressed in the off-loaded material from Presidential campaigns – Geoana’s and President Traian Basescu’s woolly headgear and sweat-shirts – and short-sleeve jumpers and trousers too high and too tight on the women. I later find out these are children’s clothes, donated from international charities to the Romanian state to give to Ceausescu’s orphans – now recycled as winter wear for institutionalised adults.
In each room, ten thin iron single beds are lined up next to one another, leaving no space to stretch. A naked man walks through the public spaces to the shower. Naked women run in and out of the bathroom to the corridor.
Now under the authority of Ilfov county, the nurses are paid minimum wage and the head doctor no more than 450 Euro a month – much less than those working in conventional hospitals. There was also no psychiatrist on call inside the building when we visited.
A few options are available for activities. There is a football field. Patients can draw pictures or play backgammon. The doctors used to grant the patients an allowance of ten cigarettes a day. But this has now stopped. A few televisions are on each floor. I ask a 50 year-old patient what he likes to watch. “Reality,” he says. “What happens in Bucharest.”
The corridors of one floor are clean, with new ceramic tiles and fresh-painted walls. This open space smells less of urine than the other floors. But the majority of the building is in crumbling concrete with broken windows. Reconstruction stopped in 2008 when the builders, unpaid, suddenly left.
There is one padded cell. When the “difficult” cases from juvenile wards reach eighteen years of age, they come here. A white-faced young man, stoned, eyes hooded, stares through the peep-hole. Another is in a makeshift cell – a separate room with an iron door and padlock. He is on a mattress lying underneath a blanket.
Some families visit once or twice a year. It is a location too remote, almost cut off when it snows. Many do not visit at all.

System in confusion

The major problem for the mental health sector in Romania is a lack of professionals. “They are not paid enough and not trained enough,” says Bucharest-based psychiatrist Adela Salceanu. Many move to the UK, France or Italy for better salaries and working conditions. There is also a hire freeze in the state healthcare sector. New graduates do not have a place to work unless an existing position becomes vacant, prompting them to go abroad.
In some counties in Romania – with around 320,000 people – there is only one psychiatrist. According to the World Health Organisation, at some point in their lives around 33 per cent of people will display symptoms of mental disorders, mainly depression, bipolar or anxiety and a fewer number [one per cent] will suffer from schizophrenia. In some Romanian counties there is one person to diagnose, treat and give prescriptions for a potential clientele of 107,000 people. It is impossible for psychiatrists to care for patients consistently.
In places such as Balanceanca, councils throw together the mentally disabled and schizophrenic, while some institutions also bring in the homeless. The mentally ill can become ‘buried’, with little access to psychotherapy. Instead medical doctors and nurses have to care for them – a position for which they are not qualified.
Salceanu gives one example. “There is one woman with history of schizophrenia who has just had a baby in a Romanian county hospital – two days later she is in an intense state of anxiety and to calm her down, the nurse throws a bucket of water over her head,” she says. “Healthcare staff do not know what to do.”
Along with a lack of trained psychiatrists, another problem is massive overcrowding. One EU observer recently witnessed isolation wards in one of the largest mental healthcare institutions in Romania – with up to five people in them.

Bribery rife

Romania’s healthcare system is steeped in bribery – from patients giving cash to a hospital security guard to enter the building up to paying thousands of Euro under the table for an organ transplant. But in the mental care system, it is harder for medical staff to solicit bribes from users – especially if they are not aware of what they are doing.
But this does not stop them. In Bucharest’s massive Obregia Hospital one ex-user says if a patient wants to change the sheets, he or she has to pay the cleaning lady five or ten RON [1.2 to 2.4 Euro]. The security guards are cheaper – says another user – they only need need one or two RON [40 to 80 Eurocents] to let in visitors out-of-hours.
When a patient comes with money in his hand to Salceanu, she sits the patient down and asks in a considerate fashion: “Why are you giving me this money?”
The answers she receives include: to expect more attention and better treatment or because this is what is expected of the system. Salceanu says she has to reassure the user that the psychiatrist will provide no difference in care with or without the transaction, before giving the money back. To refuse outright the cash with no explanation could unnerve the patient even further.

Asylums to community care

From people suffering from depression or anxiety disorders, most do not need to be hospitalised – the exception is those who are suicidal, potentially harmful to others or incapable of operating in society.
Sheltering too many cases in institutions often does not help in the long-term, especially if users do not receive adequate psychotherapy. Mental health problems are not always chronic – one third of schizophrenia sufferers do not remit.
But hospitals are paid by the number of patients they admit and the frequency they admit them, so they need to fill up the beds to gain more money from the Government – this creates an institutional problem that may not have existed before.
The alternative is for Romania to build more day-care centres, where users come during the day, socialise and undertake activities, then leave to go home at night. This helps ex-patients reintegrate into society, but gives them the option of daily therapy.
“The idea is to change beds into chairs,” says psychiatrist and addiction specialist Eugen Hriscu.

Daily stay

At Bucharest’s day-centre Trepte in Sector 4, users gather round the entrance, say hello, ask what I am doing there and do not demand cigarettes or money – instead they want to show me their poems.
Alexandru, 22 years old, talks about how he worked as a chef chopping vegetables in the Rin Grand Hotel – the largest hotel in Bucharest with 1,500 rooms, run by Robert Negoita, a multi-millionaire construction magnate and Social Democratic MP. Now Alexandru has cut his finger and cannot work there any longer. “I like Mr Negoita very much,” he says. “I wrote a poem to send him.”
I asked what the poem was about. “It is about a very beautiful Aston Martin, I am driving this and a girl is looking to hitch-hike,” he says, “and I stop and she is a pretty girl and she gets inside. We drive and then she turns around to kiss me and I crash the car. The car is destroyed completely. And I have broken my back. But the girl is fine. There is nothing wrong with her.”
Another attendee of the centre, after a group discussion, hands me a poem he has written in English, about what is important in his life – books and women – and what is difficult in life – dealing with men and dealing with smoking.
The Trepte centre is a pioneering outpatient service for mental healthcare in Romania, which serves those with a history of bipolar and schizophrenic disorders, who have previously been admitted to a mental hospital.
Six similar units are run by NGO the Estuar foundation and three others exist in Romania run by local councils. In Trepte, the patients, or users, have the doctor’s email addresses and no one wears white coats. There are around 50 regular users and 300 in total. They learn French, English and IT. Nearby is a wooden chalet called the Happy House, which sells beads, brooches, necklaces, candles and ‘Martisor’ spring charms– made by outpatients. This project was initially funded by the World Bank and continues with cash from the Ministry of Health.
Director of the centre Radu Teodorescu gives one example of a client – a bipolar patient since 14 years of age whose mother was also bipolar and committed suicide. He is intellectually gifted, with a university degree, but spent time in mental institutions once every two years. He suffered from moments of delusions and paranoia, including hearing voices, and was a danger to his own life and to others. But one problem was that because he was routinely coming into an asylum every 24 months, in a cycle, he was expecting to be hospitalised before the episodes began. It was necessary to break this pattern by treating him as an outpatient, so that he could live in the community, but have immediate consultation with a doctor. In this half-way house, he could feel secure, get treatment, as well as talk with other users and start new relationships.
But Trepte is located inside a monolithic mental asylum – the once notorious Hospital Number Nine, now renamed Obregia. This is a village fenced off from the main road near the bustling market of Piata Sudului – with 1,200 beds and 120 psychiatrists. Nearly all of Bucharest’s schizophrenics, depressives and bipolars have been locked up here at some point in the last 60 years.
“It is an unusual situation to have an outpatient service inside a mental hospital,” says Teodorescu. “It is discouraging for people who have a bad memory of the hospital.”
One 40 year-old user tells me that, after spending months incarcerated in the asylum, he could not enter through the front gates to the outpatient clinic for nearly ten years – and instead had to come through the back-door.
Funding is dependent on the hospital and although Teodorescu still wants a strong relationship with Obregia, he does not want to be physically inside it. “We need to bring the building out of the system,” he says. “We need to go into the community – then I would die happy.”
However some local councils in Bucharest refuse to allow public buildings to be made available for Trepte. Teodorescu believes it is important to multiply these centres nationwide. An EU plan to support this has not happened, due to lack of both funding and political will. But the cost savings for a network would be huge – there would no longer be the need for so much hospitalisation, nor 24 hour care – nor would it take up so much space.
In Bucharest’s Sector Six is a community centre run by the Estuar Foundation. Propped up with cash from Phare programmes, food subsidies from the Labour Ministry and local council cash, this is a small villa which caters for 160 users – 40 of whom turn up daily.
But this is a crowded place – twenty gather in one room to listen to music, five in a small corridor to play cards and four in a kitchen making candles. Two days a week the centre has started caring for people with mental disabilities – because at the moment there is no day-care centre for the mentally handicapped among the two million inhabitants of Bucharest.
There is a socially active atmosphere, with ping-pong, cards, music and art therapy, while the centre runs a monthly magazine, edited by short story writer Daniel Stetin, who has suffered from depression and bipolar disorders. The Estuar foundation has also exhibited photos and paintings in an underground rock club named ‘Varza’. This involvement with the local community – even on a tight budget and fiercely overcrowded – is effective. One 63 year-old woman with a history of mental incarceration says: “I come here during the day and in the evening I go home to my husband, it is the right balance for him and the right balance for me.”

Jobless trap

At the Trepte centre the users chat in a large school room with desks formed in a U-shape. One 35 year-old women states that in the asylum the doctors are “not open” and there is “indifference” from staff, who do not give individual attention. She says the Trepte centre is better because people communicate and users socialise. “We can have constructive conversations here,” says a 48 year old man. “It is better for our self-esteem.”
Although stigma does not exist in the centre, there is a different view outside. These users live from state benefits and none of the 16 ex-patients I spoke to could get a job. Theoretically, the law says that anyone with a history of mental incarceration must not be prejudiced against, but because this information has to be presented at an interview, it is often a reason why potential employers reject candidates. “No one wants to employ anyone with a history of mental incarceration,” says a 45 year-old user. “So if we want to work, we have to work on the black market.”
This tends to be an extra stress for a schizophrenic.

Beatings, misdiagnosis, shock treatment when conscious:
30 years of mental healthcare in Romania

Bucharest-born
Stefan Bandol, 48 years old:
“At eighteen in 1979 I was signed up to the army. They gave us absurd instructions. All they needed to tell us was how to shoot and take apart a gun. But they keep us for nine months doing nothing. So I said ‘fuck you’ to a superior. The regiment chief asked me what was wrong. I said we were wasting our time.
In the last month I was sick in the infirmary, I went back to my barracks, but my colleagues had locked the door. I knocked, but they would not open. One soldier swore about my mother. I was angry. To release some stress, I put my leg through a window.
The military police took me to an ambulance. But this broke down. They tied my hands down on a stretcher and kept me overnight. Officers came in to check on me. For two days I was left in an ambulance. When it was repaired and they untied me, I smashed everything in the ambulance to pieces.
They took me to the Podari asylum near Craiova. I was still in pain. A shard of glass was in my leg from the window I broke. My hands and legs were tied so tightly I could hardly feel them. I started screaming that I needed to go to the bathroom – but no one gave a damn.
There was another patient – sitting on the bed and moving back and forth, humming. I asked him to release me because I could not feel my arms and legs. Half an hour later a male nurse saw me untied, moved over to the other guy, hit him in the face, picked him up and threw him on the bed like a sack of potatoes and tied him up.
At the institution they gave me shock treatment (ECT) without my consent three times. Then my mother persuaded the doctors to move me to a psychiatric hospital in Bucharest, where I was confined. One evening here I went to the sentry booth, where a guard kept people in and out. I was limping due to my leg. I told him I was in the orthopaedic ward and had a toothache – so could he give me a cigarette. As I smoked, I dropped on my hands and knees, so he could not see me, crawled around the booth and ran outside. In my pyjamas, I hailed down a taxi. I escaped from the military hospital in the style of Laurel and Hardy. The next day the ambulance pulled up at my house and took me to a locked cell in south Bucharest’s Obregia asylum.
I was in pain for 18 months – and only then did the doctors take out from my leg that five-centimetre piece of glass.
I studied geology – one of my teachers was later to become President Emil Constantinescu. I graduated, married and divorced and moved to Covasna, as a commercial director for a vodka producer. To everyone who came into the I would offer a glass of vodka.
In 1992 I was commercial director of a sugar import-export company. At that time sugar was rationed. It was before the general election and the Iliescu Government wanted to give a higher ration to the people as an electoral bribe. A policeman – ordered by a plain clothes officer – forced the general director to give them sugar for free or to delay payments. But she refused. So they came for me. The policeman said there had been complaints that I had disturbed public order. I sat in my office with my typewriter and my papers and said: ‘can you tell me how I disturb public order?’ They handcuffed me and pulled me outside. In the police car, the officer punched me in the stomach. They detained me for 24 hours. That was my next nervous breakdown. I went back to hospital.
In Obregia in the early 90s orderlies would attack patients. One orderly who had just washed a floor was angry because a patient wanted to walk over the floor to the toilet, so he beat him up. At that time I had ECT without my or my parents’ consent and without sedation. I was in a bed, tied down with a wooden spoon in my mouth when the electricity hit.
My diagnosis is schizophrenia or schizo-affected disorders. I cannot realise when a breakdown is happening. I am convinced what is happening is normal and I become paranoid. I need to be hospitalised.
By 2007 in Obregia, I was locked in an isolation room with a violent patient. He was a schizophrenic and was pissed off with me. I don’t know why, he beat me up. The nurse said I was okay. But I was still in pain and in isolation. After four weeks the doctor found some cracked ribs. I had a good doctor – who was patient with me. She made me realise I was not abandoned.
I now run NGO Aripi [Wings], with 67 users. We have meetings, exhibitions and theatre workshops, but no money – the NGO is running on empty. We have land near Sighisoara where we want to build houses for international users to stay for vacation and an ecumenical church – so far we have raised our first house with a Maramures-style wooden roof. It will be a sanctuary for users from Europe and could be a place for alternative therapies. But due to the financial crisis, all our sponsors pulled their funding.”

Report by Michael Bird

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