Biomedical and psychosocial interventions in the mental health care system in Lithuania : “ Leaving the psychiatrist ’ s clinic – with at least a couple of prescriptions ”

Results: According to the patients, psychotherapeutic treatment requires a much higher degree of patients’ active involvement and input; medication-based treatment contributes to the patient’s passive position regarding their healing process. Experts’ opinions regarding the balance between psychotherapy and medication focused on the following topics: the availability of psychotherapy in bigger cities and its lack in rural settings; the supply of private providers and lack of public services; a progressive youth and a conservative older generation of psychiatrists; a paradoxical concentration of psychotherapy in inpatient facilities and its lack in the community.


INTRODUCTION
As Huhn at al. notes [1], there is much controversy surrounding the treatment of mental illness, including a debate about the effectiveness of various forms of treatments: pharmacotherapy as well as psychotherapy.Looking retrospec-tively at the history of the 20 th century, two main trends in the practice of science and psychiatry fought for dominance, the so-called pendulum tradition [2]: "during some time periods there was a trend of 'brainless mind', then the deviation to psychologization or sociologization of mental disorders might be noticed, and then returning to the 'mindless brain' side again and highlighting biological factors to the genesis of mental disorders and treatment.As it was decided that only biomedical interventions are effective to solve the problems induced by mental health disorders, but shortly after that it was stated that 'mindless brain' is more effective, and this deviation was corrected again, to the other extreme" [2: p. 129].
Though mental health care requires a clear and ethical balance of biomedical and psychotherapeutic interventions, a clear and public dialogue about the efficacy and advantages of different treatments is needed, but this consensus is still not achieved in many countries, including Lithuania.As Ghaemi states, the biological model "is criticized commonly but it is found to have important merits", when the biopsychosocial model "is praised commonly but it is found to have many limitations" [3].Inappropriate balance between these two approaches determines a lack of treatment innovations, mistrust in science and the practice of psychiatry, and as a result -poor mental health indicators [4].
Intensive comparative research analyzing the effects of psychotherapy and pharmaceutical treatment has been pursued since the 1960s, and the results of these studies were very different.Cole & Davis [5] stated, that according to the data they had at the time, a combination of medicine and social therapy is a considerably more effective form of treatment than applying only one of them.Hogarty et al. [6] analyzed the effects of psychosocial service and vocational rehabilitation, and concluded that medical treatment must be combined with psychosocial components.Lipton & Burnett [7], in their review of the literature on psychiatric treatment, noticed that the effect of antipsychotics is fast as compared with consistent psychological therapy.This determined the approach that dominated the end of the 1960s, namely that non-pharmaceutical treatment of schizophrenia is not effective and thus indefensible.In 1987, Kane [8] rejected psychotherapy completely, stating that this form of treatment is useless, unworthy of further research and could be used only as a trifling addition to pharmaceutical treatment.Though in the same year Goldstein [9] argued that psychosocial interventions in families are actually more effective than medicinal treatment only, he still did not suggest it as an alternative to medicinal treatment.
Latest studies in this field show a necessity to combine both of these forms of treatment to achieve the ultimate therapeutic effect.For instance, Cuijpers et al. [10] found that a combination of psychotherapy and antidepressants is effective in deep depression, panic attacks and obsessive-compulsive disorder.While in clinical practice, the combination of both methods is more usual for serious disorders, Cuijpers suggests using it in moderate severity disorders as well.Antonuccio et al. [11] looked at the prevalence of antidepressants in treating depression in the USA, and stated that there are safer alternatives with the same or even better effects, for example, psychological interventions, especially cognitive-behavioral therapy.Spielmans et al. [12] compared the effects of psychotherapy with pharmaceutical treatment of depression and found that in the short term the effects of these two methods almost do not differ, but in the long term psychotherapy may be more effective.Increasingly, research shows that a combination of psychotherapy and medicinal treatment is the most effective approach [13,14].Malmberg et al. [15] and Jauhar et al. [16] raise doubts about the overestimation of psychotherapeutic treatment in schizophrenia, however, they do not deny its usefulness and small-scale effects when combined with medication.Garakani et al. [17] and Mitte [18] show that psychotherapeutic treatment of panic disorder is, at the very least, no less effective than pharmaceutical treatment and in some parameters it is even more effective.Hay at al. [19], Barlow et al. [20] and Walsh et al. [21] reveal superiority of psychotherapy treatment for bulimia nervosa when comparing it with effects of medication and promote a combination of both treatment forms.Huhn et al. [1], having carried out a systematic review of the efficacy of pharmacotherapies and psychotherapies for major psychiatric disorders, state that "effec-tive medication and psychotherapy are available for most psychiatric disorders".It is important to note that "direct comparisons of drug therapy and psychotherapy did not show consistent differences, but their combination was often superior" [1].
Busch & Sandberg [22] analyzed the main factors that determine the alliance of two treatment methods and the changing attitude of psychotherapy supporters towards medication use.These factors, as the authors have concluded, are the following: As a result of this consensus, the concept of the combined effects of psychotherapy and other psychosocial interventions is gaining ground in many Western countries.As Pūras et al. [2] observed in his study, in many countries, mental health treatment is funded from the national budget or health insurance, and the principle that psychosocial services should be funded as much as pharmaceutical treatment is starting to prevail.Placement of well-educated psychologists and clinical social workers in institutions, supporting mental health care services at the society level, and funding these services through the national budget or health care insurance resources have become a matter of course and have created a solid background for modern mental health care principles [2].On the other hand, Stirman at al. [23] states that while "many mental health systems have invested heavily in programs to implement [specific forms of psychotherapies], few eligible patients receive [them] in routine care settings, and clinicians do not appear to deliver the full treatment protocol to many of their patients".Authors reveal the need to develop strategies to promote the sustainability of a systematic use of psychotherapeutic services in mental health systems at the national level.

MENTAL HEALTH SERVICES IN LITHUANIA
In Lithuania, first mental health centers were established in 1996, and by 2016 there were 115 of them.Psychiatrists, child and adolescent psychiatrists, clinical psychologists, social workers, mental health nurses are working as a team in these centers.Providing mental health outpatient service at the primary level allows psychiatric help to become closer to people and improves service quality.All psychiatric inpatient care (especially outpatient day care) departments and the majority of mental health centers must provide combined mental health care service, including pharmacological treatment as well as psychological, psychotherapeutic and social treatment, and various types of art, music, occupation, movement and other therapies.However, due to insufficient human resources, not all of the mental health centers can provide the service of a full team of specialists; there is a particular shortage of child and adolescent psychiatrists and clinical psychologists [24].Data from the Institute of Hygiene [25] show that in 2016, there were 771 positions of psychiatrists (including child and adolescent psychiatrists and court psychiatrists; (26.69 per 100 000 population), 30 positions of psychiatrists-psychotherapists (1.03/100 000), 1032 positions of mental health nurses (35.72/100 000), and 578 positions of clinical psychologists (20/100 000).
While analyzing the situation in Lithuania, it is important to note that in 2001, the World Health Organization report named several obligatory components of mental health care (pharmacotherapy, psychotherapy, psychosocial rehabilitation, professional rehabilitation, work and accommodation), but in Lithuania only one of the components i s c o h e r e n t l y d e v e l o p e d , a n d i t i s pharmacotherapy.There is almost none of the development of other components [2].
Thus, this article is the first attempt to raise the question about the roles of psychotherapy, pharmacotherapy and their combination in Lithuanian mental health care system.The article present data from two studies conducted simultaneously and aimed at assessing research experts' attitudes towards mental health care system (expert research), and the subjective understanding of the effectiveness of various treatment forms (patient research).The aim of expert research was to evaluate the mental health care system from a broad perspective, representing both reformers and critics, as well as supporters and insiders of the system.The aim of patient research was to reveal subjective views of patients in mental health centers towards the treatment they are receiving.Both studies presented in this article are wide and cover various topics, but only the data related to the topic of biomedical and psychosocial approach towards the treatment of mental disorders is analyzed here.Both studies were undertaken between September 2015 and December 2016.

Expert research
Information about experts' attitudes towards the mental health care system was gathered using a semi-structured interview.Twenty respondents took part in the study, all representing non-governmental organizations (NGOs), academics, service workers, decision makers, and central government.The sample was composed to sustain a variety of opinions and institutions.It is noted that 7 experts work in more than one sector, and 3 experts are representing 3-4 sectors.Anonymity of the respondents was retained.Respondents were selected through their membership of professional, academic and NGO networks which the authors of this article are members of.
Expert interview is not a specific method to gather quantitative data, but it involves all types of qualitative data as respondents are experts in their field.Experts are described as persons positioning some knowledge of a specific social phenomenon [24].Expert interview is valuable because it lets us gather comprehensive information based on official data or dominating politics in a specific field [24].Therefore, a researcher who also is an expert in this field is able to obtain more information about the knowledge and position of other experts in the field using expert interviewing, as was the case in this research -in mental health care system and politics.
Expert interview in the study comprised 10 main questions (Box 1).The average duration of the interview was approx.70 min.
Archives of Psychiatry and Psychotherapy, 2018; 1: 67-75 health center provides mental health care on the primary level and the second -on the secondary level.Patients were interviewed within 2 months of their last episode of treatment.The average duration of interview was 26.33 min (it varied from 10.35 min to 49.56 min).The sample is taken from a non-homogeneous, varied group of respondents, according to their demographic characteristics and diagnoses.There were 18 women and 12 men, average age 38.8 years (from 20 to 69 years old).
Respondents had different diagnoses (schizophrenia spectrum disorders, affective disorders, anxiety disorders, alcohol abuse disorder, personality disorders); 5 persons were diagnosed with more than one disorder.All patients got treatment in one of three forms: 3 persons got ambulatory treatment only (average duration of treatment episode -7 weeks), 13 persons got outpatient treatment only (6.3 weeks on average), 6 persons got inpatient treatment only (4 weeks on average), and 8 persons got both inpatient and outpatient treatment (9 weeks on average).
Data were collected using a semi-structured interview.The interview questions were tested in a pilot study (2 respondents took part in it) and following the pilot they were reviewed and corrected.In the interview, a researcher asks one main question ("Could you please tell me about your treatment experience?") and some additional ones if needed ("What were the reasons and when did you come to this center for treatment?What was the treatment you received?What effects do you feel from this treatment?How has this treatment helped you or did not help to you?What were for you the most effective and the least effective methods, and what was the most important thing during this treatment episode?").Data were analyzed using thematic analysis based on the principles of Boyatzis [27] and Braun & Clarke [28], and were coded using ATLAS.ti, the Qualitative Data Analysis and Research Software.
Ethical considerations: all respondents who consented to participate received written information about the study.This information stated that the interviewer would contact the respondent in the near future.Oral and written information was given to respondents before the interview.They were informed that participation was voluntary, that they could leave the study at any time and without giving any reason, and that confidentiality was guaranteed.Each interview was recorded (with the oral agreement of respondent); later, the audio recordings were transcribed, changing personal details that could be used to identify individuals from the text (such as the names, places, titles, etc.).

Medication-based treatment: predominant, accessible and in certain cases effective
Both groups of respondents noted the dominance of medication-based treatments in Lithuanian mental health care system.Experts provided systemic and contextual understanding, while patients shared their personal experience.Some experts took a critical approach towards the existing system, others were in favor of it, however, all of them noted that the medicationbased treatment model is very well developed in Lithuania.Its main features are availability of psychiatric consultation and prompt prescription of compensated psychotropic medication: "If a patient approaches a psychiatrist, whatever his problems are, he will leave the doctor's office holding at least a couple of prescriptions" (expert).
Experts were asked to evaluate the proportion of medication-based and psychotherapeutic treatment on a 10-point rating scale, where 1 represented dominant medication treatment, and 10 represented dominant psychotherapy.The mean evaluation score was 3 points (evaluations ranged between 1 and 6).Representatives of the academic and NGO sector were most critical of the dominance of medicationbased treatment.
Patients' interview data show that psychotherapy is sometimes not being offered, although patients perceive it is an effective or even the most important part of their treatment.Speaking about the availability of psychotherapy, patients are guided by rumors or presumptions about when, why and for whom it is granted: "They cannot offer it to everyone, therefore they don't offer it if you don't ask for it, require it, fight for it, or request it" (patient).Those who nev-er "ask and require", those not informed about the availability of psychotherapy, perceive their treatment in the hospital as meaningless; lying in bed and regularly taking medications: "All you do, is go to one occupation session three times a week.You are free all day.You just take your meds" (patient).
More than a half of patients (N=18) confirmed that medication helps to diminish symptoms.It is necessary during severe episodes of illness, in acute conditions or relapses.According to them, medication is effective when treating certain symptoms, such as anxiety, insomnia, lack of appetite, chaos of thoughts, pain: "You take it -and at the same moment you get calm and you can sleep"; "Two pills help me to live without any pain and anxiety"; "Sleeping and anxiety, I'd say, are best affected by meds"; "Those pills help to get rid of [intrusive] thoughts" (patients).
Properly adjusted medication helps people to normalize their emotional condition, feel more stable, and diminish suicidal risk: "My mood was such a mess… Of course, medication improves your mood, everything looks a lot more optimistic, not so horrifically terrible…"; "Having started new pills I feel I'm happier, I discover happiness, joy, I got rid of bad thoughts, [thoughts] that I want to leave this life" (patients).Medical treatment helps to think and to perceive the reality, to "leave that unconscious condition, totally inadequate condition" (patient).
Nevertheless, the biopsychosocial model sees medication-based treatment as just one element, and advocates a complex approach towards health, psychological and social problems.

Shortcomings of medication-based treatment
According to patients, the main difference between medication-based and psychotherapeutic treatment lies in the effect.Medication helps to reduce symptoms, but it never tackles the actual problems which caused the disease: "[Medications] somehow calm down the symptoms.However, the problems are solved by psychotherapy, I think" (patient).Seventeen patient participants mentioned that the effect of medication is limited, partial: "Those meds, they are just supportive treatment" (patient).
Experts criticize the over-availability of medication-based treatment, considering it "too available".In many cases, especially in outpatient mental health care facilities, it becomes the one and only manifestation of a psychiatrist's attention to the patient.Such a narrow and superficial approach is especially criticized by representatives of NGOs: "Sometimes a psychiatrist tells you that you are a patient, you will be sick all your life, you'll be taking meds your whole life.So you should be happy to have it prescribed, [it's] almost like this" (expert).
Psychotropic medication causes apathy, heaviness, problems with paying attention, and impedes concentration, learning and working.Multiple side-effects heavily hinder integration of persons with psychosocial disabilities.Moreover, they deprive them of the opportunity to adequately assess their own condition, and to contradict doctor's opinion regarding treatment: "Sometimes there comes our patient, he barely walks through the corridor, he is unable to do anything, he is completely subdued by medication.He never has courage to approach the doctor and ask [them] to change [their] meds" (expert).According to experts, this indicates more than failures of the mental health care system, this is clear evidence of inhumane treatment, even torture: "If a doctor prescribes, the system covers, and a patient takes [medication], which shouldn't be prescribed according to all algorithms and scientific evidence, I equate it to a major violation of human rights and even poisoning in some sense" (expert).

Psychotherapy: effective, yet unavailable
When discussing the benefits of psychotherapy, patients highlighted several points.Psychotherapy helps to perceive and control their illness better: "It's psychotherapy that helped me to differentiate and find that boundary, when I'm entering psychosis" (patient).Psychotherapy helps to realize one's experience: "And that willingness to die, the world appeared grey and empty.I thought, I'd kill myself.It was psychotherapy which helped me to overcome it.To differentiate, where I am, where the world is.And to manoeuver between both, somehow" (patient).Psychotherapy helps to acknowledge Archives of Psychiatry and Psychotherapy, 2018; 1: 67-75 the reality, not to dramatize the symptoms: "I thought I was dying, and the psychologist and group therapist managed to calm me down, to stop exaggerating all that business" (patient).Psychotherapy helped to improve relations with the outside world, to develop social skills: "These therapies help to integrate into the process of communication"; "It [therapy] helps [me] to socialize" (patients).In the personal area, psychotherapy helps with understanding, accepting and accepting oneself: "It granted me an understanding about what's going on within myself, better knowing myself, because I couldn't understand what a panic attack is"; "I gained back that joy about myself, that I'm valuable, I've lost nothing, there is no invalidity inside of me" (patients).
Although patients stressed the obvious and long-term effect of psychotherapy, the availability of these services is not secured.The phenomenon of inadequacy between the demand and supply has been widely analyzed by experts.They distinguished three opportunities of receiving psychotherapeutic services: first of all, the person in need should be able to cover private consultations out of their own pocket.Clients of private psychotherapists have certain advantages, such as avoiding stigmatizing visits to public mental health care centers.Moreover, they do not appear in patient registers, and thus are not at risk of losing their jobs, for example, in occupations such as a judge or attorney.And finally, they do not receive over-medication.Such opportunities are not offered to lowincome individuals who depend on the social security system: "Our [NGO] clients would never visit a private psychotherapist, none of them would do that" (expert).All they get are short consultations with a psychiatrist and usually medical treatment.Patients also mentioned financial obstacles: "Everywhere you have to pay [for psychotherapy], everywhere: at a psychiatrist's, at a psychologist's, when I was looking for help, anywhere I went they demanded incredible amounts of money" (patient).
Secondly, young psychiatrists are usually interested in practicing innovative methods of treatment: "There are young professionals in the hospital, they treat you differently, they dedicate you more time, they really care about you" (patient).A social worker from a psychiatric hospi-tal who participated in the experts' research noted that younger psychiatrists tend to qualify as psychotherapists, and then apply psychotherapy methods and prescribe fewer medications to their patients: "During their consultations you can feel that psychotherapy takes over, not medical treatment.Most often they choose only one medication instead of three popular ones.Very often they apply psychotherapy alongside medication" (expert).According to an expert who is very well aware of the mental health care system in Lithuania, older psychiatrists continue to apply methods learned during the soviet times: "A doctor [who] was trained in psychiatry some forty years ago, who was [taught] that medication is all a patient needs, believes that doctor and only doctor knows what is best for the patient and his family" (expert).
Nevertheless, young, open-minded psychiatrists either emigrate or choose to work in big psychiatric hospitals, while small mental health care centers are dominated by aging professionals.This fact enlightens a systematic paradox as well as the third way to receive psychotherapy: most often, high-quality psychotherapeutic services without any waiting lists are available in psychiatric hospitals: "If we speak of free psychotherapy, it is available in inpatient facilities.As long as a patient is in the hospital, he will receive it" (expert).Meanwhile, persons with moderate or light depression are treated with "antidepressants of antipsychotic formula, which is 'heavy artillery', although light depression shouldn't be treated with medication.It is best treated with short therapies, which are available only on a private basis" (expert).Patient participants who received psychotherapy during their hospitalization named it as the principal, most effective treatment, which brought a long-term improvement: "Psychotherapy is the main treatment"; "If you won't work with yourself, if you won't participate at the meetings, if you won't communicate with psychiatrists, you won't get any better after medical treatment only" (patient).
The imbalance between availability of medication-based treatment and psychotherapy was compared by experts to an entrapment of patients and psychiatrists.Patients become hostages of the system if they cannot receive other, more effective methods of treatment.They com-ply with their limited opportunities for help, although diagnosis requires a different strategy of treatment: "During the conversation with my colleagues, child or adult psychiatrists, I keep on repeating: 'Why would you prescribe medication, if a patient has just a light depression?' and they answer: 'I know I shouldn't, but there is no psychotherapy available… I had to prescribe something, so I prescribed'" (expert).Among other reasons, only big psychiatric hospitals can afford to provide psychotherapeutic services due to a faulty financing scheme that does not consider the specifics of this type of consultation.According to this scheme, psychotherapeutic counseling costs as much as any other doctor's consultation, although psychotherapy lasts much longer.One of the experts claims that during financial planning a question is asked: "Why do you [psychotherapists] want to be treated exceptionally?Each doctor's consultation should cost equally" (expert).Psychiatrists are a consolidated professional group, which has all the necessary evidence-based knowledge at their disposal and can provide arguments about efficacy of each type of treatment.It is another paradox that psychiatrists fail to formulate and communicate their concerns about the failures of the system: "If colleagues are able to mobilize themselves, to engage in a dialogue with the government, then they can formulate policies.If there is no joint opinion, or if these opinions differ, policy formulation is stuck" (expert).

CONCLUSIONS
Our research shows that both psychotherapy and medication-based treatment are regarded as useful elements of treatment.However, psychotherapy is the principal treatment, whereas medication is its additional element.
Psychotherapeutic aspect of treatment requires a much higher degree of patients' active involvement and input.Treatment based entirely on medication contributes to the passive position of the patient regarding his healing process, and does not allow him or her to have control over their own condition (both illness and healing/recovery).
The highly decentralized mental health care centers in Lithuania (there are currently 108 and the number tends to grow) represents a quantitative, not qualitative, development of mental health care services.A high number of mental health care centers gives the impression of a decentralized system and easy accessible community-based services.However, it only increases availability of medication and does not provide an alternative to inpatient treatment.
A principle of contrast has been identified in the experts' opinions regarding the balance between psychotherapy and medication: the availability of psychotherapy in bigger cities and its lack in provinces; the supply of private providers and lack of public services; a progressive youth and a conservative older generation; a paradoxical concentration of psychotherapy in inpatient facilities and their lack in the community.
Our study has revealed parallels between the individual and systemic levels of the mental health care system: being passive recipients (patients) or providers (psychiatrists) of medication-based treatment, representatives of both groups do not raise their concerns on the political level.Instead, both groups assume certain individual coping strategies: young psychiatrists emigrate, meanwhile patients with a high level of mental health literacy, and those who can afford it financially, approach private providers of psychotherapy.