BHC - Psychiatric care in Bulgaria needs to be treated

The Bulgarian Helsinki Committee (BHC) opposes the published and disseminated Declaration of the Executive Board of the Bulgarian Psychiatric Association on May 19, 2023, regarding the unethical public statement by Dr. Vladimir Nakov. Although the Declaration acknowledges some of Dr. Vladimir Nakov's statements as true, it condemns "defamatory claims and the unethical public position of Dr. Vladimir Nakov," expressed in an interview with Mediapool agency on May 16, 2023, entitled "What Ails Bulgarian Psychiatry?" - Mediapool.bg. BHC finds Dr. Nakov's expressed position to be accurate in the points where our organization has observed issues in the psychiatric care system in Bulgaria. This position deserves not condemnation but rather broad public attention and consideration due to the extreme neglect of the numerous problems in psychiatric care in Bulgaria.

The Bulgarian Helsinki Committee (BHC) has a longstanding commitment to the rights of people with psycho-social and intellectual disabilities in Bulgaria. BHC conducted specialized monitoring field studies of psychiatric hospitals, dispensaries, and social institutions during the period 1996-2015. The organization also participated in the legislative process to amend totalitarian legislation related to psychiatric treatment and provided legal assistance before national courts and the European Court of Human Rights for individuals with disabilities whose rights to treatment, care, support, personal freedom, and security were violated by state institutions.

From its position of experience and expertise spanning over 25 years, the Bulgarian Helsinki Committee (BHC) advocates for the rights of people with psycho-social and intellectual disabilities and makes efforts to bring about changes in the psychiatric care system in Bulgaria. Unfortunately, since 2015, the Ministry of Health has denied the organization access to psychiatric hospitals and dispensaries for conducting human rights monitoring. Meanwhile, the Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) of the Council of Europe, the European Psychiatric Association, and the National Preventive Mechanism at the Ombudsman's office have conducted visits to psychiatric hospitals and reflected their alarming observations in monitoring reports.

In its report published on October 18, 2022, the CPT emphasized that in Bulgaria, "urgent action is needed in all areas - legislation, infrastructure, human resources and training, as well as treatment methods in line with modern European practices." Following its latest visit in 2021, it urged the Bulgarian government to "fight stigma," put an end to the paternalistic attitude towards patients with mental illness, and make genuine efforts to integrate people with psycho-social and intellectual disabilities into the community. The CPT stated categorically, "The long-standing mistreatment and neglect of such vulnerable service users in Bulgaria cannot continue and must be stopped immediately." For over 25 years, the CPT has expressed deep concern about the treatment, conditions, and legal guarantees for patients with mental disorders and people with disabilities in social institutions. The Committee believes that actions have long been overdue and that a comprehensive approach to mental health care in Bulgaria needs to be fundamentally changed.

On May 31 and June 1, 2022, the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) held discussions with the Bulgarian government regarding the systemic non-compliance with its 25-year-old recommendations and its public statement from November 2021[1]. In October 2022, the CPT published its report[2] from its visit to Bulgaria in 2021, which includes over 30 pages of observations in the state psychiatric hospitals (SPH) in Lovech, Karlukovo, and Kardzhali. In these hospitals, the CPT once again recorded violence by the staff, highly inappropriate material conditions, staff shortages, inadequate treatment, and attitude towards patients. In the SPH in Karlyukovo, the CPT received complaints that the staff shouts at patients, orderlies push and hit them, slap them, or drag them, and some employees use alcohol during work. In the SPH in Lovech and Kardzhali, such incidents were reported less frequently, but the staff still shouted, pushed, or hit patients. The CPT notes that despite significant internal repairs, the furnishings are inadequate, patients do not have lockable lockers for personal belongings, nor opportunities for seclusion and personal space. None of the hospitals offer a suitable protected outdoor walking area. Most patients simply lie on their beds or wander aimlessly through the corridors.

Many patients were not fully informed about their diagnosis and treatment. The use of physical restraint is still not in line with international standards and often not properly documented. In the SPH in Kardzhali, the CPT found patients (including those on voluntary treatment) left alone in 4 or 5-point belt restraints to their beds, in seclusion, for more than 48 hours, with diapers changed every six hours. Some patients also reported that their hands were restrained above their heads, causing pain, swelling, and loss of sensation. The CPT also identified several patients who had signed consent forms for treatment and were considered voluntary patients, but they did not agree with their admission and treatment and expressed their wish to leave, yet they were not allowed to do so – de facto, they were being detained. The CPT also noted a significant number of patients who did not require inpatient treatment (so-called social cases), but due to the continuing lack of effective community-based mental health services and support, they remained in an inappropriate institutional setting indefinitely.

BHC did not find any public position from the Bulgarian Psychiatric Association (BPA) or the management of the visited hospitals regarding the identified issues in the reports of CPT and the National Preventive Mechanism. In this regard, it is puzzling that BPA expresses a position against the statements of Dr. Nakov, which have been confirmed by observations from authoritative international and national institutions. With its statement, BPA practically aims to silence the voice of a Bulgarian psychiatrist.

BHC insists on taking adequate actions to improve psychiatric care in Bulgaria, including the participation of key professional organizations such as the Bulgarian Psychiatric Association.