Academic psychiatry in Poland: adjustment to rapid changes

Poland has a long tradition of mental health care. The first institutions dedicated to the case of the mentally ill were setup in the XVI century (Krakow, 1534, Domicilium pro fovendis curandis mente captis; Gdansk, 1542, Pockenhaus). However, the first Polish university chairs of psychiatry were not founded until Poland regained independence after World War I. There were five university psychiatric departments in Poland in the period 1918–1939 and after the World War II 12 academic psychiatric centers came into being, the most recent chair in Bydgoszcz starting in 1985. In addition, the Institute of Psychiatry and Neurology was established in 1951, comprising several psychiatric departments.

Traditionally, academic psychiatry in Poland, along with education and scientific research, had been strongly connected with the supervision of general psychiatric care. Heads of departments have been to a great extent responsible for psychiatric care of specific regions. The major organizational event in Polish postwar psychiatry was subsectorization of mental hospitals in 1968, which divided the catchment area of the hospitals into smaller territories (subsectors) served by individual departments cooperating with the mental health outpatient clinics dedicated to those subsectors. The network of 600 public psychiatric outpatient clinic and over 400 dependence treatment clinics existed until late 1990s. Such subsectorization contributed to a decrease in the number of patients in hospitals, a substantial reduction in the number of hospital beds, and the elimination or reduction in size of wards for chronically ill and severely disturbed patients.

During the last 15 years, Polish psychiatry, including the academic sector, has been influenced by the profound changes in social, political, and economic structures initiated since the fall of communism, with both good and bad outcomes. The most strikingly negative social phenomenon with a direct impact on psychiatric morbidity has been the rise in unemployment, which had been virtually absent in the previous four decades in Poland. The current rate of 20% of unemployment, amounting to 3 million people, constitutes an important stressor not only for the affected person, but also for his/her family. Moreover, the number of people living under the constant stress of being released from their job is estimated to be at least 1–2 milion. On the other hand, the passing of the Mental Health Act by Parliament in 1994 was the most positive event in the recent history of Polish psychiatry. The Mental Health Act regulates numerous issues. They include promotion of mental health, prevention of mental disorders, shaping of appropriate social attitudes towards people with mental disorders, the provision of comprehensive and accessible care for people with mental disorders under the model of community mental health care and social welfare. Another key issue is the protection of the civil rights of people with mental disorders, in particular the assurance of the rights of people admitted to and treated in hospitals without their consent. Before this, Poland had no statutory regulation of involuntary admission to mental hospitals. The Act contains provisions regulating the use of physical restraint and envisages a clear system of judicial-procedural, judicial-supervisory and administrative-medical guarantees in order to protect the rights of people with mental disorders who are subject to compulsory proceedings. The monitoring of compulsory emergency admission to psychiatric hospitals in Poland in the last 10 years shows that the general percentage of involuntary inpatients has been stable (8–10% of all admissions), with some differences between individual hospitals.

Political transformation enabled Poland to become more integrated with Western Europe and to adopt the trends of Western psychiatry. Poland joined NATO in 1999, and the European Union in May 2004. During the last decade in Poland we are witnessing an unprecedented increase of the awareness of psychiatric disorders, including their high prevalence and need for treatment. At the medical educational level, since 1999, obligatory 4 weeks of psychiatry were included in the internship syllabus. In recent years the development of educational programmes in psychiatry, especially on depression for primary care physicians, has been implemented. It should be noted that in Poland, 80% of depressed patients are treated by psychiatrists and the rest by primary care physicians and other specialties while the opposite is true in most Western countries. The national campaign on recognizing and treating depression and abolishing the stigma of schizophrenia (Open the Door) with active participation of mass media has been annual events in recent years.

According to the central registry for public health, there has been an increase in psychiatric morbidity in Poland in the decade 1991–2001. This increase amounted to 30% in in-patient and to 60% in outpatient psychiatric care. In total, 3% of the Polish population has been treated in the public psychiatric sector—this does not include people treated in psychiatric private practice and in primary care and other specialties. No changes in suicide rate in Poland were observed during this period, the rate being stable at 12–14/100 000 per year. The question arises whether this rate would be higher had an increase in the use of antidepressant drugs not taken place.

The introduction of the new generation of antipsychotic and antidepressant medications has greatly modified the method of treatment of schizophrenia and mood and anxiety disorders. This caused a significant increase in the importance of the role of pharmaceutical companies, especially with regard to their financial support for scientific research and the implementation of modern psychiatric science. Polish psychiatrists, representing both clinical centres as well as hospitals, have increasingly participated in multicenter trials of the majority of new psychotropic drugs. Thanks to the support of pharmaceutical companies to many Polish psychiatrists, they have a much greater opportunity than before to participate in international scientific conferences. Additionally, more foreign lecturers can now be invited to take part in conferences in Poland. Within the last few years, the number of conferences on psychiatric topics organized in Poland with the participation of distinguished foreign lecturers has increased significantly. The topics included schizophrenia, mood disorders, anxiety disorders and dementia. Recent years have witnessed the first conferences regarding specific scientific issues, such as psychoimmunology, psychoendocrinology or molecular genetics of mental disorders. Thanks to the sponsoring of pharmaceutical companies, recent congress of Polish Psychiatric Association held in June 2004 included many prominent international guests such as Hagop Akiskal, Timothy Crow, Jim van Os, Joseph Peuskens, Zoltan Rihmer, Norman Sartorius, Tonmoy Sharma, Sam Tyano, to mention but a few in alphabetical order.

In 1999, a major reform of health system came into effect in Poland, introducing universal health insurance. Membership of a health insurance fund is compulsory, with a tax-deductible premium of 7.75% of personal income. Psychiatric services for in-patients are calculated by the cost of a patient-day and in specialized nonhospital care, the basis for the contract is the average cost of the procedure (visit). Initially, regional health insurance funds administered the money, but for the last 2 years the National Health Fund with local branches has been created. Theoretical premises for the health reform in Poland were improvement of availability of services, and their improved utilization and management.

The main problem with psychiatric services is that of limited funds. Psychiatric health care depends on public finances more than other branches of health care. There are examples in recent years of limiting or closing down psychiatric services in the public sector, especially those connected with psychosocial and community treatment. Access to outpatient medical services has worsened. The continuity of care (treatment and rehabilitation), which is crucial in community psychiatry, has been endangered. The new funding methods put the integrated facilities at a special disadvantage and may halt the process of transformation of psychiatric health care in Poland towards community-based care.

Limited funds for the reimbursement of modern psychotropic drugs decrease the availability of them for patients with most serious psychiatric illnesses. In addition, according to insurance standards, the reimbursement of second generation antipsychotic drugs (only risperidone and olanzapine have been reimbursed) is possible only for treatment-resistant schizophrenia. This means that before using them, the patient should be treated with classic antipsychotic drugs. This can for many first-episode patients create a traumatic experience. Most psychiatrists bypass this regulation, some of them risking penalties.

Increased admission to psychiatric hospitals was noted in recent years. The failure of outpatient system and new psychosocial stressors may be contributing factors. The Health Insurance Act abolished the sectorization of mental hospitals and psychiatric wards in general hospitals, which had previously been relatively successful; however, the subsectorization system still exists. On the positive level, savings in health care and closing down of some medical wards may make it possible to create new psychiatric wards within general multispecialty hospitals.

Nevertheless, despite the difficulties discussed above, access to basic psychiatric services in Poland and the level of treatment is reasonable. Hospitalization for major mental illness is allowed up for up to 8 weeks. There are not homeless mentally ill people roaming the streets. The number of psychiatrists has been growing and educated with high standards. They are committed to providing superior psychiatric care within existing limits.

How has psychiatric research in Poland evolved in recent years? Research activity is conducted mainly in academic centres—psychiatric departments at the 12 Medical Academies (university medical schools) and in the Institute of Psychiatry and Neurology in Warsaw (four psychiatric departments). The range of the research topics currently addressed by Polish psychiatry is diverse and comprises a wide spectrum, reflecting current research issues in international psychiatry. Some topics are traditionally the speciality of particular centres in Poland but their specific characteristics may have changed as new branches of psychiatric research are represented, such as molecular genetics, the pharmacogenomics of psychotropic drugs and neuroimaging of the brain. Some research programmes are financed by grants provided by the National Committee of Scientific Research. Financial support for specific research areas, for example, alcohol dependence, comes from governmental agencies (National Agency for Solving Alcohol-related Problems). In general, funds for conducting research come from resources allocated centrally for a given institution and from those generated by that institution (eg by conducting trials on psychotropic drugs for the use of pharmaceutical companies).

The principal scientific journal for Polish psychiatrists is ‘Psychiatria Polska’ (‘Polish Psychiatry’). Another official journal of the Polish Psychiatric Association, PPA, is ‘Psychoterapia’ (‘Psychotherapy’). Additionally, there are many other periodicals covering psychiatric issues, some of which have been established within the last few years, such as ‘Postepy Psychiatrii i Neurologii’ (‘Advances in Psychiatry and Neurology’), ‘Farmakoterapia w Psychiatrii i Neurologii’ (‘Pharmacotherapy in Psychiatry and Neurology’), ‘Alkoholizm i Narkomania’ (‘Alcoholism and Drug Addictions’), ‘Wiadomosci Psychiatryczne’ (‘Psychiatric News’), ‘Lek i Depresja’ (‘Anxiety and Depression’) and ‘Psychogeriatria Polska’ (‘Polish Psychogeriatrics’). Since December 1999, the quarterly ‘Archives of Psychiatry and Psychotherapy’ has been published in English, with an international editorial committee. This is an export periodical presenting the achievements of Polish psychiatry and promoting integrative approaches in the field. Numerous other Polish periodicals connected with psychiatry may be regarded as either educational or, alternatively, as fruits of an unnecessary proliferation of psychiatric journals.

The scientific achievements of Polish psychiatrists should be reflected by their publications in renowned international periodicals. Increasingly, such publications begin to play an important role in the evaluation of scholars by medical schools and scientific institutes. The number of such publications is, however, not high. During 2000–2004 there were 139 publications of Polish psychiatrists, which appeared in journals indexed in Current Contents, Life Sciences and Clinical Medicine. Their breakdown into psychiatric centres is shown in Table 1.

Table 1 Number of publications indexed in current contents (life sciences, clinical medicine) coming from psychiatric centers in Poland

The first place of Poznan can be interpreted as a result of the long tradition of biological and psychopharmacological investigation carried out in this center, reinforced in recent years by molecular genetics studies, and in collaboration with Bydgoszcz of modern neuropsychological studies. Due to a close and continuous collaboration between Poznan and Bydgoszcz (the author had long been a Chairman at the Department of Psychiatry in Bydgoszcz)—in all papers from Bydgoszcz, there is at least one author from Poznan. There is only one Polish publication in Molecular Psychiatry coming from Poznan with Bydgoszcz participant: Rybakowski JK, Borkowska A, Czerski PM, Hauser J: Dopamine D3 (DRD3) receptor gene polymorphism is associated with the intensity of eye movement disturbances in schizophrenic patients and healthy subjects. Molecular Psychiatry 2001, 6, 718–724.

In conclusion, academic psychiatry in Poland is struggling with the consequences of rapid and profound social, political, and economic changes, and it is adapting to international trends and scientific standards. This challenge is met with varying degrees of success in different centers.

Further reading

Bilikiewicz A, Rybakowski J (eds). Images in Psychiatry: Poland. Via Medica, Gdañsk 2002.