A Visit into the Lithuanian Mental Health System

In November of 2011 I spent two weeks in Lithuania — a fascinating time. Some colleagues in Scandinavia connected me with a progressive psychiatrist of about my age who is the director of the biggest mental hospital in Kaunas, Lithuania’s second largest city. The psychiatrist, Ramune — who at first couldn’t understand why I wanted to visit Lithuania, because they don’t get a lot of visitors — wanted to screen one of my films, “Take These Broken Wings,” at a local conference for about a hundred Lithuanian psychiatrists. I agreed, figuring it would be curious, at the least.

But it turned out the conference was sponsored by Janssen, the makers of Risperdal, and I found myself in an odd position — to show the film or not. I talked about this with Ramune and with other Lithuanian psychiatrists, and what they said is that basically all Lithuanian conferences are similarly sponsored — and if you want to reach doctors in any number, this is the way to go. The country, although part of the European Union, is so cash-strapped that there isn’t extra money for conferences or meetings. Also, mental health professionals were surprisingly open with me about their earnings — which are shockingly low. According to them, the average Lithuanian psychiatrist earns about 2000 litas per month — which translates to a bit over $700 in U.S. currency. That’s more or less the American cost of one month of Risperdal…

When I spoke about my concerns the movie screening, Ramune told me she herself was taking a professional risk sharing the film, because many of the psychiatrists who would be coming wouldn’t be happy by the concept of recovery from “schizophrenia” without medication, having made their careers on prescribing drugs, often in high doses. She felt many would likely be offended, as my movie basically states (both by example and with documented research) that prescribing neuroleptics is a misguided course for working with people experiencing psychosis. But she wanted to take the risk anyway, as she felt that this offered the chance to open up a dialogue in a very new way — and in an extremely psychiatrically conservative country.

Lithuania is a former Soviet republic, and what I saw and heard when I visited a series of psychiatric wards in two different Lithuanian mental hospitals is that aside from the removal of paintings of Lenin from the walls, not a lot has changed in the twenty or so years since Lithuania became independent. Patients are still crammed into wards (though slightly less so now), there’s little or no psychotherapy for most (there are far more psychiatrists in the country than therapists), and pretty much everyone gets drugged. While visiting, I had the chance to see the medication rooms, and I saw that people were being prescribed the same brand name pills used in the USA and Western Europe — Seroquel, Zyprexa, and Risperdal, to name a few.

But how could such a poor country afford it?

This is where I found myself really surprised, for the answer was corruption — at many levels of society and many levels of the mental health field. First, from what a variety of people told me, politicians are corrupt. They get “paid” by the drug companies to use their influence to make sure that a goodly chunk of mental health-oriented state money goes to pay for the modern, expensive psychiatric drugs. People did tell me, though, that the brand-name drugs are less expensive in Lithuania than they are over here in the USA — perhaps half the price, more or less. Second, many doctors get “compensated” by the drug companies to prescribe their particular drugs. So doctors are much more likely to prescribe Zyprexa or Risperdal than haloperidol, which is an older and much cheaper, though not necessarily “less effective,” drug. And doctors get compensated best when they put their patients on two or three different expensive drugs at once — this is big money for the doctors. I heard that some doctors can make double or triple their salaries just through prescribing expensive drugs alone.

But who bears the financial cost of paying for the drugs? Not the patients — rather, all of society. Health care is free in Lithuania, so everyone pays for it, through their taxes. Though from what I heard from many people, it’s the poorer people who bear the heavier tax burden — they don’t have the resources to sneak through the tax loopholes.

Meanwhile, my movie screening proved interesting. I was asked to give a brief English introduction to myself and my film, and Ramune translated it into Lithuanian. I spoke about having worked as a therapist in New York and about having been committed to working with people without medication, if they so desired. I told about how I respected people’s choice about medication — and how I learned, over time, that those experiencing psychosis who chose not to take medication did better than those taking neuroleptics. And many got well. I explained how this went directly against my academic therapy training, and deeply motivated me to learn more — which is how I ended up on the path toward making my first film.

As I spoke, the psychiatrists were polite. But soon after I sat down and the film was rolling, many of the audience walked out: probably about half, in fact. Some said it was because of the language barrier (admittedly, Robert Whitaker, for example, does talk quickly), but I heard through the grapevine that others said the language barrier was only part of it. Quite frankly, they were bothered by the message. In short, who in the heck was this young-looking upstart of an American social worker to come in here and give us the ABC’s of (anti-)psychiatry?

In one sense, I can certainly understand: it’s not pleasant to have your life’s work labeled as incorrect and hurtful. And all the more so considering several of the psychiatrists I spoke with afterward (those polite enough to talk with me), told me that they were committed to prescribing neuroleptics — because they genuinely felt this was the most heathy and appropriate way to “treat psychotics,” and that I was suggesting dangerous, even unethical, methods. Yet when it came time for me to share my reply, I found most not particularly curious. They were more curious to talk with each other — and to the pharmaceutical drug reps.

I myself also met a few of the drug reps at the conference, and in some ways they surprised me most of all. I am used to drug reps being smart but not too broadly educated on the subject of psychiatric medications. These reps were different: not only did they have the slick social skills of other reps I’ve met, but they were seriously scientifically educated as well. I wondered if it was cheaper to educate drug reps in Lithuania, but this proved not to be the case. Instead, what I found is that it’s easier to buy doctors in Lithuania. In the United States, most of the drugs reps I’ve met have bachelors degrees — and that’s it. No so in Lithuania. Rather, for a fraction of the cost of paying a post-bachelors-level rep in the USA, the pharmaceutical companies can hire a full-fledged doctor in Lithuania. And for a doctor willing to leave the medical field and work for Big Pharma, it’s big bucks — you can double your salary immediately, buy a Volkswagen, put your kids in private school, and quit your second job.

This scared me. Although I could understand the reasoning behind wanting to be paid more — after all, life is not easy in Lithuania — I felt sickened in discussion with the drug reps. They blasted me with study after study after study about the safety and efficacy of their drugs, and before I even finished my rebuttal sentences they were bringing out more pro-drug data. And they were clever: they’d done their homework, they’d made up their minds, and they weren’t listening to me. Also, it scared me to think that because of their wits and decisions they were earning more than most of the psychiatrists in the audience!

But I don’t want to speak of my Lithuanian experience as too negative, because I did not leave without hope. What made my experience hopeful was twofold. First, the two main psychiatrists who were my contacts, one in Kaunas and one in the capital, Vilnius, were hungrily open-minded. They were hungry for research and data about alternatives and about non-drug recovery, and welcomed me into their homes and their hospitals to see how they lived, how they worked, and how things really were behind the scenes. It took courage for them to do this: after all, at my most polite I am openly critical of traditional psychiatry. Also, in all the hospital units I visited — many with paint-peeling walls and rusty-shut, barred windows — I was treated by staff with kindness and respect. They let me ask questions, they let me poke around (which is my way), they let me study the medications they prescribed, and they let me be alone with their patients — even in the riskiest place…the place where staff don’t go…the smoking room. This was wonderful (if smoky).

So the second thing that gave me hope, and gave me profound hope, was talking with the patients on the wards. They were wonderful! They had a million questions, they were open-minded, they were curious, they were excited, and they spoke their minds. Interestingly, almost none of them spoke anything but Lithuanian and Russian, neither of which I can speak, so I had to have psychiatrists translate for me. This was odd, at best. When I introduced myself to the patients as a former therapist who made movies about recovery from psychosis and schizophrenia without medication, I was met with endless questions about how to get off meds and how to recover without them, and endless stories of how rotten their meds were. What was odd was that the person translating their questions and statements to me and my replies and comments to them was the very person prescribing their medication. I’d never been in that position before!

Oddly, the patients did not mind. In fact, they thoughts it was pretty funny. At first I worried they might be afraid to talk openly in front of their psychiatrists, and later, in the smoking room (sharing their cigarettes), I found a French-speaking Lithuanian patient with whom I could converse directly, as I speak halfway decent French. He told me they weren’t afraid to talk to me, because their psychiatrist is a good person — and that if my information can help them, it’s for the good of all. And honestly, I didn’t feel any animosity from the ward psychiatrists, which was a relief. Perhaps they had a few choice words about me for their colleagues when I left, but at the time I felt welcomed, and they even encouraged me to talk with the patients. And the patients…well, they were just excited, and even thrilled. Many wanted to tell me their stories…their hardships, their histories, their points of view, their unusual experiences. Several insisted on giving me gifts — little spotty apples from their home gardens, Russian chocolates, and little knit decorations they’d made while confined.

So I left partially inspired. I am presently involved in pulling together a translation project to translate my three films into several languages, one of them being Lithuanian. Although Lithuanian, with its 3.2 million speakers, is not, like Arabic or Russian or French or Spanish, a world language by anyone’s definition, I was moved by my time in Lithuania, and want to provide my newfound friends and colleagues with some new tools in their arsenal — new tools for change, for recovery, for health, and for hope. My personal hope is that maybe, the next time there’s a Lithuanian film screening of “Take These Broken Wings,” the whole audience will sit and watch — and maybe some patients will be present too. And even if the professionals don’t or can’t accept the message, my hope is that if it’s presented in their native tongue it’s that much more likely to lodge somewhere inside of them…