Psychiatry in Lithuania: the highest rate of suicide in the world

of about 3 724 000 (1994). It is a unitary, multi party republic which gained independence from the former USSR in 1990. The capital is Vilnius and its major cities are Kaunas, Klaipeda, Siauliai and Panevezys (Fig. 1). About 68% of the population live in urban areas. The majority of believers are Roman Catholics. Ethnic Lithua nians make up four-fifths of the population and there are smaller numbers of Russians, Poles. Byelorussians and Ukrainians. The literacy rate is 98.4%. The majority speak Lithuanian, an archaic language which is of all Indo-European languages closest to Sanskrit.


State of mental health in Lithuania
The gross national product (GNP) is US$310 per capita, almost 19 times less than the GNP of the US and 14 times less than that of the UK. Poor economic prospects, high rates of unemploy ment, corruption of some bankers, businessmen and government officials, and the disillusion ment of large numbers of the population who hoped for democracy without knowing precisely all the implications of an abrupt move from a communist system into a free economy have all produced general despair and public insecurity. In this context, according to the psychiatrists I met in Lithuania, there is an increase in the rate of delusions related to buying and selling and economic activities along with the development of the market economy in Lithuania. Even though official statistics are not yet available, the rate of depression is increasing in an unprecedented manner, along with an increasing rate of unemployment. At the same time, the number of socially neglected patients with Lithuania has the highest rate of suicide in the world and it is startling that 80% of the suicides are carried out by the violent method of hanging. The rate of suicide was about 35 per 100000 population per year between 1980and 1984. It declined sharply in 1985to 25 and fluctuated around 27 between 1986and 1990. Since independence the rate of suicide has increased precipitously to 46.4 and is still increasing (Dr Ona Davidoniene, Chief Psychiatrist of the Department of Health of Lithuania, personal communication). The rate in males is 3.8 times that in females, and in rural populations 2.1 times that in urban population. The highest rates of suicide are found among men in their 40s and 50s and among women in their 60s. This is seen in a country that already has a mortality rate (13.2 per 1000 population) which exceeds its birth rate (12.2 per 1000 population). The mortality rate started to exceed the birth rate for the first time in 1994. For the purpose of comparison it is useful to consider that the world average birth rate is about 26.0 per 1000 per year and the world average mortality rate 9.2 per 1000 per year (Encyclopaedia Britannica, 1995). 19861987198819891990199119921993199419951996 Year Fig. 2. Suicide in Lithuania 1986-1996 The high rate of suicide can be linked to the disillusionment of the nation, who remain pessimistic and fearful of the future following the independence. Under the Soviet regime everyone had a 'job'; those with little skill or ability were also asked to attend a workplace and were given an activity and a regular salary. With the arrival of a market economy, 35% of the population have become unemployed over five years. In the Lithuanian patriarchal society, where men are expected to be the main bread winners, the loss of status of unemployed men in families causes isolation, loss of self-esteem, depression and alcoholism. The dissolution of collective farms, the privatisation and redistribu tion of land in the absence of the previous central government support for equipment, fertilisers and seed, has caused great distress to people who were formerly dependent on a minimal, but guaranteed, standard of living during the soviet era. It is a huge stress for a nation in a collective economy to be suddenly expected to become selfreliant, in a market economy copied from individualistic Western societies.
The cheap production of alcoholic drinks in Lithuanian homes (which is illegal) helps the economy of some families and is at the same time a welcome stupÃ©fiant for the people who feel they have lost more than they have gained, or hoped for, after having so enthusiastically defended the independence of their homeland. The rate of alcohol-related psychiatric disorders has astro nomically increased (which has probably con tributed to the high rate of suicide). The rate of alcoholic psychosis was 55.3 per 100 000 in 1996, which corresponds to an increase of more than four times compared to the rate of 12 per 100 000 population in 1990. Indeed alcohol misuse is a matter of epidemic proportion in the republics of the former USSR.
Since the collapse of the Soviet Union, the Baltic states have been favourite transit points for smugglers running narcotics from the East to the West. The drugs are not just passing through, illicit drug use is on the increase all across the Baltics. The rise of a young moneyed class appears to have created an illicit drug market that did not exist during the Soviet era. Some bars and nightclubs have become distri bution points for everything from cocaine and amphetamines to opium and even narcotics made from poppies grown in the Baltic countryside. The rate of drug-related disorders has increased to 2.1 per 100 population in 1996 from 1.3 per 100 population in 1990.
While the average duration of stay in hospital for psychiatric patients is decreasing every year (from an average of 48.6 days per patient in 1993 to 38.6 days per patient in 1995), the rate of admission to psychiatric hospitals has increased from 700 in 1993 to 768 in 1994 and 790 per 100 000 population in 1995.

Psychiatric training and the status of psychiatry in Lithuania
Since independence and along with the recogni tion of a greater need for psychiatric services, the status of psychiatry has increased in the country and psychiatrists report they have both more freedom and more power. The Soviet school was the only recognised one before 1990 in Lithua nian psychiatry. Since then links with the West, especially Western Europe, has affected the practice of psychiatry. ICD-9 and DSM-III-R are currently used as official classifications and the introduction of ICD-10 happened in Septem ber 1997. Participation in international confer ences is encouraged and longer study leave for psychiatrists allowed.
The duration of medical studies in Lithuania is six years followedby one year of internship when the newly qualified doctor gains further experi ence in surgery, medicine, gynaecology, obste trics and paediatrics. For those specialising in general adult psychiatry the duration of training is two years in Kaunas and three years in Vilnius, this is longer than the duration of psychiatric specialisation in the Soviet system which was only one year. The first year of these two or three years is spent only in general medicine, so in Kaunas the main psychiatric training still consists of one year in general medicine plus one year in general psychiatry. In Vilnius again the first year is spent in general medicine, the second year in general psychiatry and the third year in the psychiatry of substance misuse and child psychiatry.
The average salary of a psychiatrist is about Â£66per month, with a second job out of hours and during weekends the psychiatrist can usually gain a further Â£34per month (Â£100in total). A consultant only gets Â£74 per month and with another clinical job in the evenings can earn a further Â£36per month (Â£110in total). The figure only increases to Â£165per month for the Chief Psychiatrist of the Department of Health. This small difference in salaries between people of different levels of seniority is a remnant of the 'equalitarian practice' of the Soviet system. In larger towns and cities a small percentage (about 5%) of a psychiatrist's income is related to private practice.

Psychiatric services in Lithuania
Lithuanians have been open and direct about the limited but significant abuses of the Soviet psychiatry in their country. In an investigation carried out by a panel from the American Psychiatric Association in 1991, it was ascer tained that in the case of 11 political activists who had been hospitalised under the Soviet regime in Lithuania there were inadequate grounds for any psychiatric diagnosis (Dr Ona Davidoniene, Chief Psychiatrist of the Depart ment of Health of Lithuania, personal commu nication). During the Soviet regime the word 'schizophrenic' was used as equivalent of psy chopath or dissident. By the time of indepen dence these dissidents had already been discharged from hospital.
There are 11 psychiatric hospitals in Lithuania and there are around 600 psychiatrists, with 385 working in hospitals and 215 working in out patient services in polyclinics. The majority of these psychiatrists trained in Lithuania during the Soviet regime.
There is a psychiatric association in Lithuania with a membership of slightly more than 50% of the Lithuanian psychiatrists (although there are smaller associations of psychotherapists, child psychiatrists, etc.). The Psychiatric Association has contributed to the drafting of a very democratic Mental Health Act.
Since September 1996 a psychiatrist can have a patient admitted or held in hospital for 72 hours if the patient is considered a danger to himself or others. The previous Soviet rule had allocated the power of the extension of the compulsory admission following the initial 72 hours to a committee of three psychiatrists of the same hospital or polyclinic, but now there is, in all municipalities, a special committee composed of a judge, a doctor (not a psychiatrist) and a lay person who can extend the duration of the compulsory admission for one month up to a total of six months following which only a court can extend the duration by monthly extensions.
Except for the capital, the country is divided into districts each with a 45 000-60 000 popu lation. Each district has a general polyclinic with at least a part-time psychiatrist who can refer patients to hospitals and accept referrals for out patient follow-up of patients who are discharged from psychiatric units. There is some lack of continuity of care in the sense that the psychia trist responsible for follow-up is not the same psychiatrist who treated the patient in hospital. There are no such community services as pro vided by community psychiatric nurses in Britain and few patients receive visits by nurses in the community. Electroconvulsive therapy is not common as its administration needs a patient's consent even under compulsory admission.
Specialist psychiatric services such as psy chotherapy are mainly located in Vilnius and Kaunas; specialist in-patient services for chil dren and adolescents in Vilnius and services for alcohol and drugs in Vilnius and Klaipeda.
There are 4495 psychiatric beds in Lithuania, 4305 beds for adults and 190 beds for children. This means one psychiatric bed for every 828 people. Medications are free for in-patients but expensive medications such as selective seroto nin reuptake inhibitors (SSRls) are generally not used in hospital practice. For out-patients there is a list of free medications but they have to pay for some other drugs. Almost all psychotropic medications are imported.
After independence, due to economic pres sures, about 1000 psychiatric beds were closed and a number of patients were lodged in hostels which are in a poor state with inadequate psychiatric input. The plan of the Department of Health is to staff each polyclinic with at least one adult general psychiatrist, one child and adolescent psychiatrist, a psychiatrist with special interest in substance misuse, two or three social workers and two or three nurses. It is hoped that by closing more psychiatric beds the community services could develop but due to economic difficulties and existing debts it is unlikely that adequate funding could be allo cated to these services.
In-patients (except psychiatric in-patients) have to contribute towards hospital expenses which means that few people can easily afford hospital costs. The closure of beds in other specialities as a result of their being too ex pensive for the general public has led to the allocation of empty beds to newly fledged psychiatric wards in the general hospitals. There are seven such wards with a total of 147 beds. These wards are mainly for patients with neurotic disorders although some accept pa tients suffering from psychosis. The ubiquitous phenomenon of stigma affects psychiatric pa tients as well as psychiatrists and some patients prefer to see neurologists.
As an example of a psychiatric ward in a general hospital, the ward in Panevezys General Hospital is staffed by three psychiatrists, two psychologists and nine nurses. The ward has 30 beds and admits patients with psychosomatic and other neurotic disorders. In addition to a few single and double rooms the majority of bays contain five beds. There is no curtain or other barrier separating the beds and as a conse quence there is a low level of privacy on the ward.
The forensic psychiatric hospital in Rokiskis has 500 beds with 10 locked wards. There are about 60 patients of one gender on each ward, most wearing hospital clothes. As in Panevezys, the psychiatrists and nurses wear white uni forms. The hospital in Rokiskis has its own Xray, electrocardiograms and basic laboratory facilities. In the Soviet era all patients irrespec tive of their condition were kept on the same ward, at present patients are treated on different wards depending on the severity of their illness. Each ward is divided into rooms and there are up to 10 beds in each room with no partition separating the beds. Patients have their meals sitting in rows behind wooden tables in the middle of the wards and television is not allowed during meal times. The hospital is covered by 50 nurses and 17 psychiatrists, among other work ers, during the day. and 20 nurses and one oncall psychiatrist during the night. Even though there are no statistics, the duration of stay varies between two weeks and 10 years. Patients are referred from courts, prisons, police stations and polyclinics throughout the country. Those with a forensic history are treated in special wards with barricaded windows with a staff to patient ratio of three to one. The hospital has a debt of about 1 000 000 Litas (equivalent of Â£160000. which is a huge sum in Lithuanian economic terms).

Practical help
I have already discussed and planned a pro gramme of aid with Dr Davidoniene, Head of Planning. Department of Health of the Republic of Lithuania. Lithuanians are in need of medica tions, journals, books and equipment.
There is an extensive movement towards teaching English as a foreign language in Lithuania. Many recently graduated and younger psychiatrists speak at least some English. There are a certain number, but by no means a sufficient number, of books and journals in English in the medical libraries in Lithuania. The Department of Health of Lithuania has employed an interpreter to translate English psychiatric papers and book chapters for the benefit of psychiatrists who do not speak English. This indicates interest but it is not an adequate solution. Psychiatric books and litera ture in English would be a source of reference and a rich data base for research and education, especially for the graduating generation of medical students and young doctors.
Information technology equipment, hardware, software and fax machines are in short supply and this affects rapid communication, so im portant in improving the quality of care.
The medications most needed at the moment are SSRIs, which are needed in an ageing population in view of their low cardiovascular side-effects in the elderly and which have a lower risk of causing death in overdose in a country which has such a high rate of suicide. Even though overdose is not top on the list of means of suicide in Lithuania, it does cause a relatively heavy toll considering the very high rate of suicide in the country.