Lifelong treatment. Why do psychiatric hospitals become prisons, and how is Georgia trying to change that?

Psychiatric institutions, where patients often spend a significant part of their lives, are still the most common form of treatment for people with mental disorders in many post-Soviet countries. Following the publication of shocking reports about living conditions in the largest psychiatric institutions in Georgia, human rights activists are calling on the authorities to speed up reform of a system that isolates vulnerable people from society.

In 2004, David Dgebuadze, a graduate of the History Faculty of Tbilisi University, found himself in a psychiatric clinic. “Some things seemed to me, and I agreed to voluntary treatment,” he says. He became a patient of the psychiatric hospital for 16 years. David doesn’t go into detail about his diagnosis, but proudly says he was born in Mtsatsminda, in the center of Tbilisi. After graduating from university, he lived in a church for three years – he says the priest offered to let him stay there. After a bout of illness, David ended up in the hospital – the first of many during his treatment. “The worst was in Bediani,” Dgebuadze says of the psychiatric clinic that long served as the de facto city government for the settlement in southern Georgia. “We had no rights there. They just gave us food and sometimes allowed us to walk in a small courtyard. Nothing more. Six to eight beds in a room and a common bedside table.”

The hospital in Bediani was known as a symbol of Soviet psychiatry. David lived at Bediani for about four years. He says patients there were treated rudely: tied up and sometimes physically abused. “They took my clothes and said, ‘We have these rules – everyone wears the same clothes,'” he says. In the fall of last year, the Office of the Public Defender of Georgia published a shocking report following a visit to Bediani Hospital. According to the report, rooms were overcrowded and many people had no place to store their personal belongings; bathroom doors did not close; patients had to use a shared sponge and sometimes showered together. The village could be reached only by a minibus that ran only once a day, and to catch the return trip, relatives could spend only a few minutes with the patients. Communication between men and women in the hospital was forbidden on the pretext of preventing sexual relations. They were not even allowed to talk during walks – the staff always watched the patients. Some described the Bedyani Psychiatric Hospital, located in a ravine behind a high concrete fence, as a symbol of Soviet psychiatry – a system designed to hide people with mental disorders from society.

Georgia has been trying to get rid of such a legacy for over ten years. At the end of 2018, 76.5 thousand people in Georgia were diagnosed with mental and behavioral disorders. In terms of providing assistance to these people, the authorities continue to rely on psychiatric hospitals: more than half of the budget for the mental health program is allocated to such institutions, where treatment is paid by the state. At the same time, those who need constant support and care, or who do not have a home of their own, are often condemned to lifelong isolation in hospitals, not so much because of their illness as out of desperation. According to the People’s Defender’s report, out of 158 patients at the Bediani clinic, 64 had been there for more than five years, and half of them had been there for more than 11 years.

Давид was a patient in psychiatric institutions for sixteen years. Only the hospitals to which he was transferred changed. We explain quickly, simply, and clearly what happened, why it matters, and what happens next. The number of offers should remain: episodes. The End of History. Advertising podcasts

“A psychiatric hospital should not be a refuge,” says Deputy Public Defender Ekaterina Skhiladze. “People should not live in medical institutions for years, especially against the background of the infrastructure problems that currently exist in psychiatric institutions,” she adds.

Year after year, the People’s Defender speaks about violations in psychiatric hospitals and calls for deinstitutionalization – the transfer of patients to another form of treatment that does not involve permanent hospitalization. This process began in Western countries in the middle of the last century, and the World Health Organization considers it one of the main stages in the reform of the psychiatric care system. Long stays in closed psychiatric institutions not only do not contribute to recovery, but also lead to the loss of independent living skills, specialists say. “The vast majority of people with mental disorders can lead a normal life in society, provided the necessary services are available. They should only be admitted to psychiatric hospitals for a short period of time in case of exacerbation until their condition stabilizes,” says Manana Sharashidze, Chairperson of the Board of the Georgian Mental Health Association, which has been advocating for the reform of psychiatric services in Georgia since the 1990s.

The government agrees: according to the Action Plan for 2015-2020, the decision to hospitalize a patient can only be made after all treatment and support alternatives have been exhausted. But despite the development of some forms of outpatient services, human rights activists say there are still few alternatives to large institutions for people in need of care and shelter.

Old buildings, rusty sinks and dark corridors of the Bedia Psychiatric Hospital were seen on many Georgian television channels last fall. Authorities acknowledged the violations and announced plans to close the hospital and turn it into a drug rehabilitation center. However, on October 18, employees, for whom the hospital is practically the only place of work in a small village, blocked the exit of the clinic with tree trunks in protest, preventing some patients from being transported from there. After plans to build a drug rehabilitation center in Bediani were abandoned by the authorities, the status of the psychiatric clinic was changed to a shelter, leaving about thirty patients in the women’s ward, which was in relatively good condition. Most of the patients from Bediani were transferred to the National Mental Health Center in the village of Kutiri in western Georgia. Among them was Davit.

Walking area near the renovated National Center for Mental Health building. In the courtyard of Kutiri Hospital, discarded old lattice beds have been replaced with new furniture, according to the staff. Behind the concrete fence with barbed wire is a separate building for convicts and those who are here for compulsory treatment under a court order. In other buildings – concrete filled and fenced areas for walking. “It was better there, but there was also a small courtyard. You could go for walks with the permission of the staff (BBC). There was an iron door that they locked several times a day,” David recalls of the place where he spent about half a year.

Some patients are still kept behind metal doors. The massive doors are still there. In one of the buildings, we walk down a long corridor with narrow door windows that allow us to see the thin faces of patients who are being involuntarily treated. Through the opening, someone asks the center’s staff for a cigarette. The same metal doors are in place where the people from Bedyani were transferred. The center’s staff says it’s temporary until repairs are completed. After that, they promise to move them to rooms with windows, without bars, and with regular doors. I am not allowed to talk to any of the patients – even those who have voluntarily come here – about pandemic safety measures. This is the largest psychiatric institution in Georgia, located a few kilometers from the town of Khoni, with a population of 9,000. Today there are about 650 patients and beneficiaries – those who live in the center’s shelter. In 2015, 95% of the center was privatized, while the remaining 5% is still owned by the state.

The facade of the building where the shelter is located has been partially renovated. The director and owner of the Gocha Bakuradze Center proudly states that he was one of the first to announce a quarantine and ban on visitors since the beginning of March. Patients can only communicate with their families by phone. “Everyone understands that,” Bakuradze believes. “Everyone knows that there are no alternatives to compulsory treatment units like ours in the country. God forbid, if an infection gets there, where will these people be transferred? To a hotel? That is out of the question. That is why I strictly follow all the rules. Living conditions in the shelter near Kutir Hospital were also described as inhumane and degrading in the People’s Defender’s report. The facade of the building where the shelter is located is half renovated. Laundry is drying in the untouched old part with peeling walls, but the center’s staff does not allow me to go inside. It was not the infrastructure of the center that the ombudsman criticized the most, but rather the established practice of treating patients at the center. According to the report, methods of “physical and chemical restraint” were applied to them, including fixation (tying up) of patients and neuroleptics – drugs that suppress nervous activity and emotional state. The report mentioned that this applied to both voluntary and involuntary patients, and that “physical restraint” was sometimes used in the presence of other patients.

The staff of the center promises to move the patients to rooms with windows without bars and regular wooden doors after the renovation. Such methods were not unique to Kutiri. Olga Kalina, a human rights defender and one of the founders of the Platform for New Opportunities, was first admitted to a psychiatric hospital at the age of 21. At the time, there were no alternatives to hospitalization, so when her illness began to manifest itself, her relatives took her to a hospital on the outskirts of Tbilisi. There, Olga was diagnosed with paranoid schizophrenia, a disorder characterized by distorted perceptions of reality and hallucinations. “I was just locked in there. When I tried to protest and ask why the door was locked, they tied me up and used neuroleptics,” Kalina recalls of her first hospital. “They didn’t explain anything to me: what was wrong with me, what the treatment options were, or how long I would be there. After that, Olga ended up in a psychiatric hospital twice more. She recalls that patients were restrained and sometimes violence was used. “The woman couldn’t move, more for mental reasons than physical ones. The orderlies would hit her to make her get up and move,” Olga explains. The last time Kalina went to the hospital was in 2011, by which time she had experience working with an NGO and knew her rights as a patient. But it didn’t always help.

Today, Olga Kalina works for three organizations dedicated to protecting the rights of people with disabilities and promoting psychiatric reform. “I remember saying that I refused to take any medication until I talked to my psychiatrist. They told me that the psychiatrist would be available on Monday and until then they would treat me as they wanted. At that time they injected me in the back in front of other patients. It was very humiliating, but the staff doesn’t understand,” she says. “If a person protests or expresses dissatisfaction, it is considered a worsening of the condition or psychosis.”

In their report on the situation in the Kutiri psychiatric center, human rights activists also drew attention to the quality of medical care: in the majority of medical records of the 25 patients who died in this hospital or shortly after being transferred from it from the end of January 2018 to the end of April 2019, sudden death due to acute cardiovascular insufficiency was indicated as the cause of death. The report notes that in some cases, the deterioration of patients’ condition may have been caused by the overdose of antipsychotic drugs and the risky combination of medications without taking into account the patient’s physical condition. In the city center, there is a therapist on staff who responds immediately to patients’ health problems and, if necessary, the emergency medical team transports them to other medical facilities.

In the renovated new building, there is a bright reception area for visitors. Photographs of the old building hang on the walls. According to the director of the Gocha Bakuradze Center, he does not understand the term “chemical restraint” at all, and physical restraint is a last resort that is rarely used in the facility. Bakuradze also complains that other psychiatric institutions often “transfer” patients and send the most problematic ones to them. “You know, all the numbers compared to other psychiatric institutions will be much higher because there are many more patients. And if there is such an approach, like some of my colleagues in other psychiatric institutions: ‘Oh, this is too acute a psychosis, he must be transferred to Hony, we cannot accept him’, then of course there will be more fixation and use of medication in Hony,” he says.

The People’s Defender’s reports also contain other shocking examples of the conditions of detention in psychiatric hospitals. For example, the staff of the hospital in Bediani only found out that a patient was pregnant when she gave birth in the toilet without any outside help.