From July 1, polyclinics have new rules for the provision of psychiatric care under compulsory medical insurance

From July 1, medical and psychological support offices should open in polyclinics – it will be possible to contact a psychologist within the framework of compulsory medical insurance. Such rules introduce a new procedure for providing psychiatric care to the population – now it will become more accessible, patients will have the opportunity to contact a specialist without waiting for a critical deterioration. The document also regulates the activities of sexologists: such specialists will not appear “in every clinic”, as the media previously suggested, but will work in the PND. In this case, doctors are concerned about their functionality: according to the wording of the order, they will provide assistance, including for “disorders of sexual orientation and gender identity,” which are not always considered violations from the point of view of the World Health Organization. However, it will be possible to understand exactly how the work of sexologists in the PND will be built only after the publication of official explanations, the expert notes.

From July 1, medical care for mental and behavioral disorders will be provided according to a new procedure. It is approved by the order of the Ministry of Health №668n, which replaced the previous order of the Ministry of Health and Social Development of 2012. Now clinics will have rooms for medical and psychological support. Within the framework of compulsory medical insurance, it will be possible to apply there for psychological help; To this end, the Ministry has introduced a new position – a medical psychologist. The tasks of these specialists are to advise the patient, his family members or other legal representatives; motivate the patient to follow the recommendations of the doctor; refer persons with signs of illness for consultation with specialists, including institutions providing medical care for mental disorders. According to Minister Mikhail Murashko, “weekly the regions are heard in this area, staffing is underway.”

The chief freelance psychiatrist at the Ministry of Health, Svetlana Shport, says that the new procedure is aimed at integrating the psychiatric service into the general healthcare system. It allows you to organize work “according to a modular principle”: organize rooms or departments in the primary care, deploy somatopsychiatric departments in multidisciplinary hospitals, and, if necessary, open nosological rooms (suicidological, geriatric).

The document makes it possible to involve medical psychologists in the work of the psychiatric service at the primary level. It also defines the normative principles for the organization of medical measures for compulsory treatment.

Psychiatrist-narcologist, head of Dr. Isaev’s Clinic, Ruslan Isaev, says the medical community welcomes the changes, as they lower the threshold for access to psychotherapy for the general population. Due to this, patients with psychiatric diagnoses will not be stigmatized. “As it used to be: if a person began to suspect that he had a psychiatric illness, he had two options – to go to a paid medical center or to a psycho-neurological dispensary for compulsory medical insurance,” says Mr. Isaev. “In the second case, many were stopped by the fear that a psychiatric diagnosis can lead to a restriction in rights (ban on driving a car, work in the public service, obtaining a certificate for weapons) or even involuntary hospitalization in a psychiatric hospital. In such a situation, very, very many do not receive help, they are treated on their own, which can be dangerous for both patients and others.”

With the introduction of the new order, patients facing problems should be able to seek help without waiting for the deterioration.

Mr. Isaev emphasizes that a number of mental and neurotic conditions are most often manifested at first by somatic complaints – at the level of the work of other internal organs. Therefore, patients first of all turn to general practitioners in a polyclinic or narrow specialists. Now a doctor in a polyclinic, having discovered that the cause of the symptoms lies in the psychiatric plane, can quickly refer the patient to a psychotherapist, the expert says.

The need for a wide coverage of the population with psychotherapeutic and psychiatric care has especially increased in the last two or three years due to COVID-19 and post-COVID complications, adds Ruslan Isaev. Many of them directly affect the mental status and can cause the onset of neurotic conditions or mental illness.

Another important provision of the order: for the first time, the activity of a sexologist was regulated in it. Some media suggested that along with psychotherapists, these specialists will also appear in polyclinics, but the Ministry of Health says that this is a misunderstanding of the essence of the changes. “The procedure provides for the possibility of creating offices of a sexologist in the structure of specialized medical organizations – these are neuropsychiatric dispensaries and polyclinic departments of psychiatric hospitals,” they say in the department. “The opening of such offices is modular – optional – in nature for each such medical organization.”

However, the functions of the offices of sexologists in the PND, prescribed in the document, still raise questions. Among them are the provision of primary specialized health care to persons suffering from “mental disorders related to sexual development and orientation”; “disorders of gender identity and sexual preference”; family and sexual disharmony; sexual dysfunctions.

In particular, it is envisaged to apply, together with a psychiatrist, “coercive measures of a medical nature in relation to persons suffering from sexual disorders.”

It also says about the “organization and conduct of sanitary and educational work among the population for the prevention of sexual disorders.”

The document does not specify what kind of sexual disorders in question. Note that in the ICD-10 (WHO International Classification of Diseases) the following disorders of sexual preference are indicated:

• fetishism,
• fetish transvestism,
• exhibitionism,
• voyeurism,
• pedophilia,
• sadomasochism,
• sexual behavior disorders and others.

In the ICD-11, approved in 2019, transsexualism and hermaphroditism were moved to the subsection “gender inconsistencies” – they are no longer considered a violation or disorder. The wording regarding pedophilia is also changing: in ICD-9 it was defined as “sexual perversion”, in ICD-10 as “sexual craving for children”, and in ICD-11 it is referred to as “pedophilic disorder”. As reported by Kommersantit was these two changes related to approaches to transsexualism and pedophilia that caused Russian officials and deputies to criticize the ICD-11 and argue about whether it should be adopted.

Psychiatrist-sexologist Oleg Starostin considers additional regulation of the activities of sexologists unnecessary. He notes that sexology in Russia developed within the framework of psychiatry and, in fact, is its subdiscipline. Therefore, it is regulated by all laws and by-laws relating to mental health care, and sexologist is the second specialty of psychiatry. Now, according to him, the job description of a sexologist says that “the duty of a sexologist is to provide “qualified medical care in his specialty,” and he has the right to make diagnoses on his own.”

According to Mr. Starostin, the main problem is that the new order recognizes “sexual orientation and gender identity” as a mental disorder.

This, according to Oleg Starostin, is contrary not only to the ICD-11, but also to the ICD-10 adopted and applied in Russia. “Firstly, it is correct to say not “sexual”, but “sexual orientation”. And not “gender identification”, but “gender inconsistency,” the doctor points out. regarded as a mental disorder. Qualified sexologists understand that sexual orientation is not a diagnosis and it is unethical to change it.” Ruslan Isaev, in turn, is in no hurry to comment on the provisions of the order: “How the work of sexologists will be built, it will be possible to say only after the publication of official explanations.”

Natalia Kostarnova