What is modern psychiatry like? Why are people suffering from mental diseases often treated as lepers? And what should you do if you or any of your relatives become mentally ill? Vasily Glebovich Kaleda, Doctor of Medicine, Professor of Orthodox St. Tikhon’s University of Humanities, Deputy-Director of the Mental Health Research Center, answers all these and other questions in his interview with Pravoslavie.ru.
—We want our talk to be useful for people who are going to seek medical advice but for some reason hesitate, or for their relatives. We are aware that there are certain negative stereotypes of psychiatry in our society, so let us try to discuss, if not dispel them.
People are convinced that a mental disorder is a very rare phenomenon and that individuals with mental imbalances are automatically excluded from society. So, here is the first question: how many people are affected by mental diseases?
—Psychiatric disorders are quite a common phenomenon. About fourteen percent of the Russian Federation’s population is reportedly affected by mental illness and about 5.7 percent are in need of psychiatric support. In the USA and European countries the figures are similar. I mean the whole spectrum of psychiatric disturbances.
First of all, we should mention depression which affects around 350 million people worldwide and about nine million residents of Russia. According to estimates of the World Health Organization’s experts, by 2020, depression is likely to become the most common disease. Almost forty to forty-five percent of all serious somatic diseases, including cancer, cardiovascular diseases, post-apoplectic period, are accompanied by depression. Almost twenty per cent of all women in their postpartum period feel depressed instead of feeling the joy of motherhood. And it should be stressed that in some cases, when medical aid is not provided, severe depression may lead to fatal end—a person with depression commits suicide.
Over the past decades, due to the increase in life expectancy and general ageing of the population, various types of old age dementia, Alzheimer’s disease, and associated disorders have increased.
In recent years the problems related to infantile autism have become especially urgent as well (the current prevalence estimates one case per eighty-eight children). In many cases, when parents notice that their child is developing very differently from his or her peers, they will be willing to turn to anybody for help, but not to psychiatrists.
Unfortunately, in the Russian Federation there is still a very high percentage of people suffering from alcoholism and drug addiction.
At the present time, in connection with many people’s change of lifestyle of and the stressful environment, the rates of borderline personality disorders have increased. The prevalence of so-called endogenous mental diseases with genetic predisposition (as opposed to impact of external factors), such as bipolar affective disorder, recurrent depressive disorder, different types of schizophrenia, remains roughly the same—about two per cent. Schizophrenia affects approximately one per cent of the population.
—It looks like schizophrenia affects one in every 100 people. And how many of them remain socially active? I ask it because there is a stereotype in the public conscience that a person with a diagnosis like this is a social outcast—it shameful to be insane.
—It is quite inappropriate to assert that an illness is “shameful”. It is intolerable both from the religious and human points of view. Any illness is a cross which is sent by God, and each of these crosses has its own specific purpose. Let us recall the words of St. Ignatius (Brianchaninov) that we must treat everyone with proper respect and honor, regardless of his position in the society and state of health, because everyone is made in the image of God: “I will show honor to a blind man, a leper, a madman, a nursling, a criminal, and a pagan as to the image of God. You shouldn’t care about their weaknesses and faults! Keep watch on yourself lest you should have lack of love.” This is how any Christian should treat other people regardless of their diseases. Let us remember how Christ the Savior treated lepers.
But, unfortunately, sometimes mentally ill persons are viewed as society’s lepers.
Today the ways of overcoming stigma on mental illness are seriously discussed in the psychiatric literature: A change in society’s attitude towards the mentally ill, the organization of a system of mental health services that would make psychiatric support accessible to all groups of the population, so that seeing and consulting a psychiatrist might be regarded as seeing any other doctor. The diagnosis “schizophrenia” is not the end of life—different forms of this disorder vary in course, outcome and so on. Modern drugs can radically change the course and outcome of this disorder.
According to epidemiological evidence, from fifteen to twenty percent of patients have only one episode of schizophrenia symptoms and can achieve recovery, if adequate therapy is provided.
At our Mental Health Research Center we know many examples when a person became mentally ill in his adolescence, and twenty to twenty-five years later he had a high social status, was married, had children, made a successful career, succeeded in academia, defended a thesis, was conferred an academic rank, was recognized. Some even built big businesses. But it should be realized that in every case a prognosis is highly individual.
When we speak of schizophrenia and the so-called schizophrenia spectrum disorders, we shouldn’t forget that patients of this group need to take medications for many years or, in some cases, to stay on drugs for the rest of their lives, just as people with type one diabetes require frequent insulin injections.
So any patients’ attempts to discontinue the medication without their doctors’ knowledge are unacceptable—they lead to exacerbation of the illness and disability of the patient.
—Now let us talk about the onset of the disease. Very often an individual and his relatives cannot figure out what is happening to him for a long time. How can they understand that they cannot go without seeing a psychiatrist? I was told about one insane nun who was brought to a convent of one Local Orthodox Church. The first thing that they did at the convent was to allow her not to take drugs. Her condition got worse. Only then did the mother superior realize that it had been a mistake, so from that time on the sisters saw to it that she took her medicines on time. But even do churchmen not always understand what mental disorders are like.
—The problem of detecting mental diseases is a very serious and complex one. You have given us a very typical example: the convent sisters thought that they would be able to cope with the girl’s illness through their love and care of her. Unfortunately, in many cases people do not understand that it is a number of serious biological and genetic factors that contribute to the development of “our” disorders. Undoubtedly, attention and loving care are very important, yet professional medical aid is vital.
Regrettably, many are not aware of how serious this condition is. Here we can remember the tragic death of Fr. Pavel Adelgeim in the city of Pskov, killed in 2013 by a lunatic who instead of admission to hospital was sent to a priest for a conversation; or remember the three monks who were murdered at Optina Monastery by another lunatic in 1993.
People who suffer from endogenous psychoses often express doubtful and fanciful ideas (of being pursued, of being threatened, of their own greatness, or guilt); a common complaint is when they hear “voices” in their heads which usually command, comment or abuse. Not infrequently these people may suddenly freeze up in a strange posture or experience a psychomotor agitation. Their behavior towards their relatives and friends may change radically at times, unfounded hostile attitude and reticence may emerge along with fear for their own lives, accompanied by groundless protective actions (they tend to close the curtains on the windows, to lock the doors). At times by their words they want everyday things to appear “mysterious” and “significant”. It is also a common situation when these people refuse to eat, fearing that their food or drink is poisoned. They can also be preoccupied with taking legal actions (tend to file police reports, to write letters to various agencies with complaints about their neighbors).
It is not recommended to argue with a person with endogenous psychosis, to try to prove something to him, to ask him clarifying questions. Not only is it useless, it may aggravate the disorder. If he is relatively quiet and unworried, ready for communication and getting help, then we should hear him out attentively, try to calm him down and advise him to see a doctor. If his condition is accompanied by strong emotions (fear, anger, anxiety, grief), then it is advisable to admit of existence of his imaginary objects and to comfort the sick man.
—But people who are afraid of psychiatrists, say something like, “They will give him [their mentally ill relative] a million injections and leave him in a vegetative state!” and so on.
—Unfortunately, there are no (and cannot be any) drugs that treat a major illness without any side effects. This fact was confirmed even by Hippocrates (lived c. 460-c. 377 BC). Nowadays, pharmaceutical manufacturers aim to minimize or prevent adverse effects of modern medicines—that’s another thing. Let me remind you that the hair of patients with cancer comes out during their chemotherapy, but that therapy prolongs or even saves their lives. In the case of connective tissue diseases (for example, systemic lupus erythematosus), hormone therapy is used which causes pathological obesity, but patients’ lives are saved. In psychiatry we also have to deal with dangerous diseases, when people hear very loud internal voices which abuse them, give them commands, including orders to jump out of the window or to murder somebody else. Sick people experience fear of being influenced, persecuted, threatened. What should we do in these cases? Just watch them suffer?
At the first stage of treatment our primary task is to deliver our patients from this distress, and if they become sleepy and slow at this stage, that is not bad. Our medicines have a pathogenic effect, that is, they have an impact on the course of an illness, while drowsiness is just a side effect that they carry.
True, there are unfounded prejudices against psychiatrists, but that is not a unique peculiarity of Russia—that is a problem of the whole world. As a result the issue of “untreated psychosis” emerges—mentally afflicted persons express delusions of all kinds, but neither they nor their relatives consult a doctor.
This problem becomes much more acute when delusional disorders involve religious themes. People with this psychiatric condition tend to speak of their “special mission”, that they are “messiahs” sent by God in order “to save the mankind”, “to save Russia”, “to save the human race from spiritual death”, “from an economic crisis” and so forth. Not infrequently they are convinced that they are called to suffer for their cause—and, unfortunately, in some cases in their messianic delusion such people committ suicide, “sacrificing” themselves “for human kind’s sake”.
Among the religious psychoses there are many conditions with the dominant delusion of sinfulness. Clearly, consciousness of one’s sins is a stage of a Christian’s spiritual life when he realizes his unworthiness, his transgressions, seriously thinks of them, confesses his sins, takes Communion. But when we see delusional self-accusation, it appears that a person is obsessed with ideas of his sinfulness; besides, he loses the hope for God’s mercy, the hope that sins can be forgiven.
All of us know that the main thing required from a person who strives to live spiritual life is obedience. A believer cannot impose a penance on himself or keep a fast with a extra zeal without a priest’s blessing. This is a general, strict rule of spiritual life. A young monastery worker or a novice will never be allowed to observe the full monastic rule or schemamonk’s rule from the very beginning, in spite of his ardent desire. The novice will be given various obediences, and his prayer rule will also be strictly regulated. But an individual with a delusion of sinfulness will listen to nobody. He takes no heed of what is said by his confessor—he thinks that the priest does not understand the gravity of his sins and does not understand his situation. When the priest says to this person that he shouldn’t read ten Akathists per day, the latter concludes that this cleric is a shallow, superficial man and thus he goes to another priest. The other priest obviously says the same things, so he leaves him too, and so on. Quite often this person does not notice when the Lenten fast ends and Easter comes, and instead of rejoicing and breaking the fast, he continues his strict abstinence.
One should pay attention to this. Such “zeal without knowledge”, without obedience, is a key symptom of a serious mental disorder. Sadly, in many cases people with the delusion of sinfulness have ended up at resuscitation units due to extreme emaciation because their lives were under threat. At our Mental Health Research Center we know examples of individuals with depressive delusion of self-accusation and sinfulness who attempted to commit suicide or to kill their relatives (“an extended suicide”).
—Let us return to the theme of fear of psychiatry. Of course, there are hospitals in Russia, especially in the depths of the country, where hospitals have very terrible conditions. But, on the other hand, human life is more important. After all, sometimes it is better for your mentally ill relative to be admitted to a bad hospital than to die.
—Rendering timely medical aid is not only a psychiatric problem, but also a general medical problem. Unfortunately, we have quite a few examples of people with alarming symptoms who keep putting off their visit to the doctor, and when at last they resolve to see a doctor, it is already too late. It also concerns various oncological diseases, which are widespread nowadays. Nearly always a patient says that his first symptoms appeared a year, a year and a half, two years ago, but he did not pay much attention to them, ignored them. In psychiatry we see nearly the same picture.
However, one should remember and understand: there are certain conditions which are dangerous for one’s life. “Voices”—auditory or verbal hallucinations, as we call them—are often accompanied by commands. An individual hears a voice in his head which commands him to jump out of the window or do harm to somebody else—these are concrete examples.
There is also a major depressive disorder with suicidal thoughts, which is very hard to endure. People with this condition feel so bad that they cannot perceive what others say to them—because of their illness they are unable to perceive these words. Their psychological pain and mental anguish grow so strong that they find no meaning in their own lives any more. They may feel agonizing anxiety and distress, and probably already at this stage nobody and nothing will be able to keep them from an asocial action—neither relatives, nor a mother, nor a wife, nor children who will suffer greatly. This is why when a person expresses suicidal thoughts and intentions, we should encourage him to see a physician. The young require special attention because then the line between the expression of suicidal thoughts and their implementation is very fine. Moreover, a major depression may not manifest itself outwardly at this age—you cannot say that a teenager is melancholy or sad. Nevertheless, it is quite possible that the teenager will express the ideas that “life is meaningless” and that “it would be better to die”. Any expression of this kind is a reason for seeing a specialist—a psychiatrist or a psychotherapist.
Yes, there is still a strong bias against mental hospitals in our society. But when it comes to human life, the most important thing is helping a person. It is better to hospitalize him than to leave flowers at his grave. But even if there is no danger of death, the sooner we bring him to a psychiatrist the sooner he overcomes his psychosis. It applies to long-term prognosis of the course of a depression as well: according to a recent study, the sooner therapy starts, the more favorable the prognosis.
—In one of your interviews I read about your father, Archpriest Gleb Kaleda: “He used to tell me that it is so important that there should be believers among psychiatrists.” We can find similar words in the letters of Archimandrite John (Krestiankin) who blessed those suffering from mental diseases to confess and take Communion regularly and seek for an Orthodox psychiatrist. Why is it so important?
—Yes, Fr. Gleb stressed the importance of Orthodox psychiatrists. Such psychiatrists whom he knew personally were Professor Dmitry Evgenievich Melekhov (1899-1979) and Andrei Alexandrovich Sukhovsky (1941-2012), the latter even became a priest. But Father Gleb never said that one should go only to physicians who believe in God. So we had the following tradition in our family: Whenever any of us needed to receive medical aid, he first prayed to the Doctor with a capital D and then with humility went to a doctor that the Lord would send him. There are special prayers not only for the sick, but also for physicians, so that God would enlighten them and help them make a right decision. One should try to find good doctors, professionals, especially when it comes to mental diseases.
Moreover, when a person experiences a psychosis, any talks on religious themes may be of little avail, if not contra-indicated. In such a condition he will simply not be able to talk on such lofty subjects. True, at the next stage, when this patient’s condition is improving, it is desirable that he have an Orthodox psychiatrist, but, I will repeat myself, this is not a mandatory requirement. It is essential for him to have a spiritual father who would support him and realize the need for treatment. We have many professional, competent psychiatrists who respect their patients’ religious convictions and ensure a high standard of medical care.
—How can we assess the state of Russian psychiatry in the context of world psychiatry? Is it good or bad?
Currently, all the latest achievements of world psychiatry are available to any doctor in any point of the globe. If we speak of psychiatry as a science, then it can be said that our Russian psychiatry is on a world level.
Today our principal problems are the poor conditions of many mental hospitals, the shortage of some medications for patients who are observed by specialized clinics and should receive them free of charge, and in rendering social aid to these patients. Unfortunately, at a certain stage some of our patients become disabled—that is true for Russia as well as foreign countries. These people need not only drug therapy, but also social assistance, care, rehabilitation provided by relevant services. And the situation with these social services in our country leaves much to be desired.
It should be noted that at the present time our country is pursuing a specific approach towards the change of the organization of mental health services. Our outpatient clinical facilities are underdeveloped—so-called psycho-neurological dispensaries, psychiatrist’s and psychotherapist’s consulting rooms attached to some hospitals and outpatients’ clinics. So, now particular attention will be turned to this sphere which is, of course, very reasonable.
Vasily Glebovich, here is my final question. You teach a course in pastoral psychiatry at St. Tikhon’s Orthodox University of Humanities. What is this course like and why was it introduced?
As I have said, mental diseases are quite a common phenomenon, and a priest will inevitably meet people with mental disorders during his pastoral ministry. At the Church you will encounter people with mental illness more often than in any other institution, and that is understandable: When a misfortune overtakes someone, he comes to the Church and finds consolation there.
This course in pastoral psychiatry is extremely important. It is taught not only at St. Tikhon’s University, but also at the Moscow Theological Academy, and at the Sretensky and Belgorod Theological Seminaries. At one time Metropolitan Anthony (Bloom), Professor-Archimandrite Cyprian (Kern) and other outstanding Church figures stressed the need for the introduction of this course to theological schools which prepare pastors.
The purpose of this course is that future priests should know the main symptoms of psychiatric disturbances, their stages, and what drugs doctors prescribe to treat these maladies. Priests shouldn’t allow themselves to be led by their spiritual children (as often is the case) and shouldn’t bless them to discontinue the use of drugs or to reduce doses without their doctors’ knowledge.
A priest should know that, according to The Basis of the Social Concept of the Russian Orthodox Church (and it is an official conciliar document), there is a sharp distinction between the field of competence of a priest and that of a psychiatrist. He should know the specifics of pastoral care of people with mental health problems as well. It should be made clear that guidance of a person suffering from a mental illness is the most effective when he is observed by a psychiatrist and is guided by an experienced confessor simultaneously.