Post-traumatic stress device – Newspaper Kommersant No. 46 (7491) of 03/20/2023

The psychiatric professional community pioneered the development of clinical guidelines for the care of post-traumatic stress disorder (PTSD). They “clearly define” the mechanisms for working with combat veterans, describe educational programs for doctors on the specifics of managing this category of patients. There is also talk of the need for prevention, such as screening for stress disorders, either in the general population or in target groups such as SVR participants or their families. The document was approved by the scientific and practical council of the Ministry of Health at the end of February, meanwhile, a working group was created in the department to organize the provision of medical care for PTSD.

The working group of the Ministry of Health on organizing the provision of medical care for post-traumatic stress disorder was headed by the head of the department, Mikhail Murashko. As his deputy Oleg Salagai explained, the task of the group will be to coordinate the efforts of the authorities and specialized institutions that provide psychological assistance to citizens.

Meanwhile, the professional community has developed clinical guidelines for helping with PTSD: the document was approved by the scientific and practical council of the Ministry of Health on February 27.

So far, no such recommendations have been made. As the director of the National Research Center for Psychiatry and Neurology named after V.I. V. M. Bekhterev of the Ministry of Health of the Russian Federation Nikolai Neznanov, doctors in working with such patients relied on other regulatory documents – clinical guidelines for anxiety, panic disorders, standards for providing care to patients with a group of neurotic, stress-related and somatoform disorders. Answering the question why clinical recommendations for providing assistance in PTSD appeared right now, Mr. Neznanov points out that in addition to participants in hostilities, witnesses of such events may be at risk of developing this disease, including residents of the zone where hostilities are taking place or neighboring territories, refugees, doctors, volunteers. “The information space and the exchange of negative messages also have an influence,” says Nikolai Neznanov. “Communion, empathy carry a negative emotional burden. And the experience of a possible threat to life is a significant psycho-traumatic factor when a person is in conditions of uncertainty.”

According to the National Research Center for Psychiatry and Neurology named after V. M. Bekhtereva, the prevalence of PTSD ranges from 2.6% of the total number of the surveyed population to 73–92% in risk groups.

Psychic trauma leads to the development of PTSD in about 25-35% of cases. Up to 60% of trauma survivors continue to suffer from significant PTSD symptoms one year after the injury. It is estimated that approximately 7-10% of individuals in the general population have symptoms of PTSD. In military personnel who have taken part in hostilities, the prevalence of PTSD ranges from 3% to 11%. In wounded military personnel, borderline mental disorders develop in at least 30% of cases, and the proportion of PTSD among them reaches 14–17%.

The task of clinical guidelines, says Mr. Neznanov, is to provide best practices that doctors can apply in this case.

Fundamentally new, according to him, was the inclusion in the document of specific psychometric techniques, as well as desensitization and eye movement processing (a therapeutic approach based on the model of adaptive information processing). In addition, the recommendations reflect new results of randomized clinical trials regarding the effectiveness of certain pharmacological, as well as psycho- or sociotherapeutic interventions.

The document also talks about preventing the formation of PTSD, including providing timely assistance to the population (identifying cases requiring emergency care and referring patients to places of care) and interacting with other specialists (in particular, training to recognize and identify cases of acute reaction to stress, PTSD, adjustment disorder). Mr. Neznanov points out that the prevention of this condition in general can be implemented through screening for the detection of stress disorders either among the general population or among target groups, for example, among participants in SVR or their families. At the same time, he notes, it is important to ensure the formation of a “positive image” of psychiatrists and psychotherapists and a “calm attitude” towards them.

Svetlana Shport, chief freelance psychiatrist of the Ministry of Health of the Russian Federation, adds that the recommendations “clearly define” the organizational mechanisms for working with combat veterans, develop cycles for training doctors in the specifics of managing this category of patients, and provide for the right and freedom of a citizen at all stages of contacting the medical service.

According to her, the professional community is set to “maximum interaction with patients and the careful provision of medical services.”

“National centers in charge of psychiatric institutions monitor the treatment of combatants, study the validity of the diagnoses, analyze difficult cases and provide methodological support,” says Ms. Shport.

Vladimir Mendelevich, head of the Department of Psychiatry and Medical Psychology at Kazan State Medical University, notes that the Russian healthcare system has everything to help patients with PTSD: methods, drugs, specialists. However, the problem is that patients “are not very willing to be treated.” “A person comes embittered at everything that happened, he may have a physical concussion, and psychological, and severe stress, and he hates everyone around, including doctors and official organizations. Of course, he does not want to be treated. This is a very big problem, but not only ours – the world’s,” he says. Mr. Mendelevich’s fears are shared by Mikhail Yashin, Chairman of the Society of Invalid Wars in Afghanistan—Moscow House of Soldiers’ Heart. He notes that only ten hospitals for war veterans have survived in the country, but only one, in Krasnoyarka, has a center for medical and psychological rehabilitation. “There are only 32 beds in it, and here the guys are really rehabilitated there,” says Mr. Yashin. “If a veteran applied, he was rendered a service. If not, there is no mechanism to involve him in the rehabilitation mechanism. As soon as a person from the Ministry of Defense passes a military medical examination and takes off his shoulder straps, he becomes a civilian. For him, only a civilian structure remains, that is, in the case of PTSD, a neuropsychiatric dispensary. And a combat officer or soldier simply won’t go to the PND.”

The new social stratum of front-line soldiers, according to the founder of the Platform social design center, sociologist Alexei Firsov, is fundamentally different from the participants in the Afghan and Chechen wars.

The Afghans, according to him, consolidated against the backdrop of a weak state, the participants in the hostilities in Chechnya, on the contrary, disappeared – they were not abandoned, but they did not try to single them out either, since this was a situation of internal conflict. “Now, on the one hand, the state is strong and does not want an autonomous consolidation of groups of front-line soldiers. On the other hand, it will not dissolve this layer either,” suggests Mr. Firsov. The authorities, in his opinion, can try to “fix” this layer and glorify it rather than present this experience as a trauma. Aleksey Firsov considers the creation of a working group and the approval of clinical guidelines for PTSD to be a manifestation of concern not only for people who suffered as a result of hostilities, but also for the social environment to which they will return. Mr. Firsov gives examples of fears of an increase in the level of crime and aggression after the return of people from the front, but believes that such fears are exaggerated, and there are no comprehensive data on the scale of hostilities, the number of their participants and the proportion of those injured by combat experience and work in the rear.

Mikhail Yashin notes that so far the majority of SVO participants deny the problem of PTSD, but this does not mean that it does not exist. “Hands and legs in place means healthy. And the fact that he does not sleep at night, with cotton lies down to fight, that he has an upset stomach, irritability – he does not notice this. It is treated with folk remedies: beer and vodka products, or worse, psychotropics, ”he says. Mr. Yashin hopes that the Ministry of Health’s initiatives to treat PTSD will make help more accessible, but, in his opinion, it is worth starting with an accurate definition of the legal status of a combat veteran.

Natalia Kostarnova