Contents

Acknowledgements......................................................................................3
Background ................................................................................................4
Introduction ................................................................................................5
Economic, Social and Political Situation.....................................................6
Mental Health Problems in the Armenian Population...............................10
Organisation of Services...........................................................................12
Into Bedlam ..............................................................................................15
The Legislative Context.............................................................................18
Non Governmental Mental Health Organisations in Armenia...................19
The Future of InterMind’s Work in Armenia..............................................21
Appendix 1 - Russian Law No 225 & Vardenis Bylaw...............................23
Appendix 2 - People and Organisations....................................................36
Appendix 3 - Organisations Visited...........................................................37
Appendix 4 - Out of Country Contacts.......................................................38
Appendix 5 - References...........................................................................39
Appendix 6 - Romanian League for Mental Health...................................40
Strategic Plan (Extract)
 Acknowledgments
In producing this report I gathered information from a wide range of sources. (These
sources are listed in appendix 2 (people and organisations), appendix 3 (institutions
visited), appendix 4 (out of country contacts) and appendix 5 (references). I wish to
thank each and every person who so generously gave of their time and shared their
views with me and to acknowledge my debt to the wisdom and effort of others in
exploring this little known country.
I wish to particularly thank Dr. Arman Vardanyan and his colleagues from the Mental
Health Foundation and Miguel de Clerck and his colleagues from Medecins sans
Frontieres (Belge) for their kindness and support. Without them the task of producing
this document would have been significantly more difficult. In common with many post
totalitarian countries information and knowledge seems to be closely guarded.
I also wish to thank my family for supporting my absences from home and Liz
Kampman for her help in pulling together this report.
I thank the Charity Know How Fund in the UK for financing the visit that made this
report possible.
This document has been circulated to key contributers and I hope that it will in a small
way add to the widening of contacts and networks in, and for, Armenia.
Finally, I acknowledge that this is the work of someone who lives and works in Western
Europe and has seen Armenia through those eyes. They do not always see things as
they are!
 Background
Armenia is one of three internationally recognised states (Armenia, Georgia and
Azerbaijan in the central Caucasus region of South-western Asia; north of Iran, south of
Georgia and the Ukraine, east of Turkey and west of Azerbaijan. It is a small Christian
country surrounded by Muslim neighbours; a landlocked country cut off from the wider
world, whose people have been scattered to the Four Corners of the globe. The
country has a proud and important place in the history of civilisation. It has existed as a
nation state for over 2750 years and was the first (301A.D.) nation on earth to embrace
Christianity as the national religion. It is now only one tenth of it’s former size and the
population of 3,557,284 (July 1995 est.) lives on the high Armenian plateau surrounded
by mountains. The Armenian Diaspora, by contrast, numbers some seven million
(including one million in the US alone) and can be found from Argentina to Scotland,
from Detroit to Bangkok.
The Diaspora tells a tragic story. Philip Marsden, in his fine book, “The Crossing
Place; a journey among the Armenians”, writes, ”No other people has been quite so
haunted by the demons of disorder as the Armenians, with their centuries of
invasions, exile, massacres, earthquakes.”
 Introduction
I visited Armenia in October 1997, as part of my research and development work on
behalf of InterMinds, a Scottish Mental Health organisation. Mental Health issues in
Armenia were a mystery to everyone I asked about the country. From what I could
determine mental health services had not been visited or assisted by any of the wide
range of aid agencies I have come across in other countries of Eastern Europe. The
notable exceptions to this are the Red Cross, Oxfam and Medecins sans Frontieres,
who have provided material and food aid particularly from the time of the earthquake in
1988 onwards.
When discussing my proposed trip to Armenia with people who know something about
the country, I was given the strong impression that mental health services were
collapsing, even though the Armenian diaspora and American government had pumped
in millions of dollors in aid and humanitarian assistance. This gave me a confused
picture as to what I would find. In addition, given that Armenia is an ex-member of the
former Soviet Bloc, I anticipated finding a country struggling with economic and political
dislocation and a mental health infrastructure in decay and disintegration, much as I
had seen in Romania and Bulgaria.
In Armenia I visited psychiatric services, I talked and talked, laughed and drank, made
friends, and perhaps one or two enemies. I had difficulty putting together in my mind an
understanding of what I saw on my visit. The knowledge that significant humanitarian
and other aid had been given to Armenia contrasted starkly with the grim realities that
faced me as I travelled about the country and spoke to people. In particular, I witnessed
a Mental Health service of the most rudimentary kind having its meagre funding
withdrawn wholesale from under it and being forced to become increasingly
economically self-supporting. The impact of this on the users of the service was at its
best to enhance a corrupt system of access to services and an absence of food,
medicines and care. At its worst, something is happening which sounded ominously like
the early stages of a ‘slave’ regime in at least one hospital I visited.
So I could better understand why and what is happening to mental health services, it
seemed important to obtain a rudimentary understanding of some of the economic,
social and political realities facing the country. My reading and experiences have
convinced me that Armenia today is in crisis, as it has not been for many years. I
believe that, despite the help afforded by the Diaspora and international aid, the human
rights and basic human needs of its most vulnerable inhabitants are sorely threatened
by the impact of global economic policies and local politics, war, blockade and natural
disaster. So in this report I make no apology for describing the current economic and
political situation in Armenia as I perceive them and the background to this situation,
before describing the current realities in mental health services. I will then describe the
activities of NGO’s in this field and offer suggestions as to possible future work for
InterMinds.
 Economic, Social and Political Situation
Armenia’s relations with her neighbours are a key factor in her current economic crisis
and the siege state in which she finds herself has deep roots. When one also reminds
oneself of the political and cultural impact of her recent history as a Soviet satellite, the
repercussions of the 1988 earthquake and the pressures engendered by the new
‘economic realities’ for former members of the Soviet empire, one begins to get a
flavour of things.
Armenia was divided between the Romans and the Iranians in 387 AD but regained
independence in 885 AD. The Byzantine Empire overran Armenia in 1064. A new
Armenian state was established in Cilicia that survived till 1375. The Ottoman Turks
subsequently dominated Armenia. The Russians loosened the Turkish stranglehold in
the 19th century through a series of wars. Between 1915 and 1918 Turkish genocide
was responsible for the death of over 1,500,000 Armenians and the loss of great parts
of its territory as Kemal Attaturk, the Turkish leader established the secular Turkey that
exists today. (In 1923, the last 164,000 Pontic Greeks from Trebizond on the Black
Sea, were “returned home” to Greece from Turkey after a stay of 3000 years!) The
Turks have never acknowledged their guilt for these atrocities. Large parts of what was
previously Armenia became Turkish soil. This included Mount Ararat, of religious and
territorial, and profound symbolic significance to the Christian Armenians. Armenians
have a deep-seated resentment, if not hatred of their Turkic neighbours, Turkey and
Azerbaijan.
The further carving up of Armenia and its absorption into the Soviet Union followed a
brief period of independence from 1918 to 1921. During the seventy-year period of the
Soviet “deep freeze”, the country had the classic features of a satellite Soviet State.
The centrally planned economy was heavily dependent on the Russian market. A
barren, mountainous country, Armenia was a net importer of grain and other basic
foodstuffs and her exports to her Soviet neighbours were mainly chemical and
electronic products made from imported raw materials. Her citizens had no
constitutional rights and human rights were abused. Albeit that there was an oversupply
of hospital beds, no mental health legislation existed and care was often repressive.
On 7th December 1988 a devastating earthquake in which 25,000 people died hit
Armenia and 500,000 were made homeless and destitute and whole towns were
destroyed. Outside help was immediately required and was forthcoming, but the
intrinsic weaknesses of the economy were sharpened by this disaster.
Also in 1988, three years before Armenia finally regained independence, 130,000
ethnic Armenians in the Karabagh enclave, deep in neighbouring Azerbaijan, claimed
the right to self-determination, as they constituted some 85% of this small mountainous
area. The ensuing war raged in the Karabagh until May 1994 and embroiled
Azerbaijan, Armenia, Iran, Turkey, Russia, the OSCE, other governments and the US,
Both sides carried out forcible deportations (ethnic cleansing). 35,000 Armenians were
killed. 400,000 refugees have flooded into Armenia from Azerbaijan and the Karabagh,
increasing the problems of homelessness and destitution.
Ever the ‘Crossing Place’ (as Philip Marsden puts it), Armenia has traditionally allied
itself with Orthodox Christian Russia in its conflict with its Turkic neighbours.
Nevertheless, in 1991, with President Gorbachov’s perestroika and the disintegration of
the Soviet Union, Armenians seized the opportunity to re-establish their independent
nation on the national boundaries drawn by Stalin. (The western powers seem content
to seek resolution to the area conflicts on the basis of these arbitrary boundaries).
With independence, Armenia’s traditional ability to import and export into the Soviet
block collapsed leaving her with a looming crisis as to how to feed her people.
Armenia’s internal political climate continues to reflect its traditional dependency on
Russia, although there have been many moves to legislate for change. Armenia has a
constitutional government in which the President has extensive powers and the role of
the legislature relative to the executive branch is severely circumscribed. Democracy
exists, but the Government’s human rights record is uneven. Election laws have been
breached and freedom of speech is limited. Although the Soviet legal system is being
reformed, courts still operate largely as a rubber stamp for the prosecution. People are
arbitrarily arrested and detained. There is evidence of the torture and ill treatment of
political detainees. Although the 1993 Law on Invalids provides for the social, political
and individual rights of the disabled, the government does not have the resources to
make good its commitments in this area. The family is valued in Armenian society and
there have been attempts to shelter large families from the impact of the economic
situation, but disabled people are discriminated against by the wider population.
Political power is increasingly concentrated in the hands of local appointees of the
Government, for whom humanitarian issues may or may not be a priority.
There is currently a cease-fire in the Karabagh with Armenian and Karabagh troops
occupying significant (10%) Azeri territory. (It is said that 60% of GDP is spent on the
armed forces.) For their part, Azerbaijan and her ally Turkey are still blockading
Armenia, from either side, although Turkey has recently allowed an air route to open up
to Istanbul. All goods must go in and out of the country through Iran or by air, because
of the continuing tense situation in Georgia, where, just as in the Karabagh, the
Abkhazians have waged war to establish an, unrecognised, independent Republic,
which also enjoys a fragile cease-fire. Latterly the Georgian port of Batumi has begun
to be used for trade purposes, particularly for the import of wheat for Armenia.
Armenia’s ability to secure any future benefit from the anticipated economic boom
engendered by the discovery of abundant supplies of gas and oil in the Caspian Sea is
severely compromised, not to say hijacked, by the war and by its siege status in
relation to its Turkic neighbours. Oil rich Azerbaijan is the region’s centre of economic
attention and activity. A search for the war’s solution is tied to the struggle to control oil
exploration and transhipment. Russia will exploit gas supplies in the area and plans to
build a pipeline as joint venture with Armenia, to carry this gas via Armenia to Turkey
and Middle Eastern markets. Armenia wishes to continue its ties with Moscow and to
collaborate with the Russians on this venture, which would also enable Russia to
transport Azeri gas and thereby to tap into Azeri oil and gas revenues. The stalemate
with the Azeris threatens these plans. It also means that Armenia has virtually no
chance of hosting the new pipeline planned by the Azeris to carry their oil to the world
markets via the Black Sea and so charging a levy on the passage of Azeri oil.
Armenia’s economic future would appear to depend on a speedy resolution to the
Nagoro-Karabagh issue. But, if resumption in fighting seems unlikely, a resolution to
the issues appears even less so. Internal Armenian politics are profoundly confusing
for the outsider, but in essence hard-line intransigence over the Karabagh issue, borne
out of old wounds, battles with pragmatism over oil issues. Time is running out
because the route of the oil pipeline will have been decided before the next
parliamentary elections in 1999.
Armenia’s relations with its neighbours have other economic implications. The
countries export profile is a disaster with jewellery accounting for 33% and 25% of her
trade going to Turkmenistan, mainly in the form of barter. Most foreign investors are
wary of setting up in Armenia if it means jeopardising business opportunities in
Azerbaijan.
There There have been some recent improvements on the economic front. Compared

to the cumulative decline in measured

output between 1990 and 1995 of 75%; growth is high and inflation is low. Foreign
capital is being encouraged and the sell off of state enterprises continues. Rotting
infrastructure is being replaced. (American Armenians have contributed to this to the
tune of tens of millions of dollars through the Armenia Fund). A Nuclear Power station
has re-opened and energy sources are being enhanced. The I.M.F. and the World
Bank disbursed funds recently and look favourably on Armenia’s programme for
withdrawing state subsidies and intervention in the economy and Public services.
However the problems are huge. There is 80% unemployment (Univ. of Michigan)
(90% according to BBC TV - 12/11/97) and a similar percentage living in absolute or
relative poverty or impoverishment.(UNDP) Armenian industry is working at 30% of
capacity. Growth in GDP is likely to slow to 3% this year because of the continuing
depression in the country’s industrial base. Inflation is on the rise as a result of the
loosening of monetary and fiscal policy. A consumer boom, supported in large part by
the Diaspora, is fuelling imports leading to a $500,000,000 current-account deficit, and
rising. But none of this changes a bleak long-term outlook according to the
commentators.
Once Armenia has sold its few prize assets it will be faced with the same tough
questions it needs to ask itself now... Why should investors be interested in Armenia
when neighbours are outperforming them economically? Why can an Armenian Banker
I met give no hint as to what an outsider might successfully invest in at the moment?
How can a landlocked country describe itself as an important regional crossroads when
most of its borders are closed? The graphs attached give some indications of the
problems being faced by Armenia.
Against this backdrop and in line with many other countries that are adjusting to the
new “economic realities” dictated by the IMF and the World Bank, major changes are
taking place in the Armenian Health service. 80% of the beds in medical institutions are
apparently empty because people have no money to pay for services that used to be
free. It is clear that change needed to happen. In all medical and psychiatric sectors
there was significant overprovision of beds. Experts suggest that Armenia could
manage with 10,000 beds as compared to the existing 28,000 if the smaller number
were efficiently and effectively utilised. The tragedy appears to be the impact of the
World Bank reforms on the way services are financed. State subsidies to Health are
said to create undesirable “market distortions, “which benefit the rich”! The World
Bank argue that user fees for primary health care to impoverished rural communities
should be exacted on the grounds of “greater equity” and “efficiency”. It is clear to
me that whilst such cost recovery schemes may ensure the limited and temporary
operational viability of a select number of health centres, the clear tendency is towards
increased social polarisation in the health care delivery system and a major reduction
in health coverage and an increase in the already large percentage of the population
which has no access to health services at all. In other words, the strict adherence to
macro economic policy is leading to a major disengagement of human and material
resources in the health sector. There is evidence of these facts wherever one goes in
the Mental Health services in Armenia.
 Mental Health Problems in the Armenian
Population
The effects of recent history on the nation’s outlook are fairly obvious. Problems with
mental health abound and are on the increase. The psychological trauma of war, death,
earthquake, homelessness, extreme poverty and totalitarianism are everywhere.
Depression is endemic, particularly among the refugee population and suicide rates are
rising. For example, studies have revealed that more than 90% of refugees are
suffering from depression. The picture bears some comparison with other former
Soviet Block countries. The following tables from a paper by Dr T Tomov, a Bulgarian
Psychiatrist, and based on a WHO-Europe database, sheds some (unreliable) light on
the situation. Armenia it is suggested, has the lowest number of psychiatric beds per
1,000 inhabitants. It also has the lowest number of psychiatrists and the lowest number
of admissions in the group of countries reported on, and the second highest number of
out-patient attendances. What is clearly missing from this picture in Armenia is any
service in the community to meet needs that might in other situations and countries be
met through the institutional route. This may provide Armenia with a unique
opportunity to consider adopting more “care in the community” orientated options and
solutions to the nation’s current mental health difficulties.

Psychiatric beds per 1000 inhabitants by country Admissions to psyshiatric wards and psychiatric wards
in general hospitals per 100,000 inhabitants by country

1982 1992 1982 1992

Albania 0.3 Albania 90.2

Armenia 1.0 0.7 Armenia 182.0 126.5

Belarus 1.2 1.0 Belarus 452.3 515.3

Bulgaria 0.9 1.0 Bulgaria 516.1 554.2

Croatia 1.3 1.0 Croatia 541.1 666.7

Georgia 1.0 0.9 Georgia 264.0 81.5

Kazakhstan 0.8 1.2 Kazakhstan 371.3 421.5

Latvia - 2.2 Latvia - 814.8

Lithuania 1.7 1.4 Lithuania 878.9 760.8

Moldova 1.0 1.0 Moldova - 468.8

Romania 2.4 2.8 Romania - -

Russia 1.5 1.3 Russia 458.8 428.1

Slovakia 0.9 0.9 Slovakia - -

Psychiatrists per 100,000 inhabitants by country Admissions per psychiatrist by country

1982 1992 1982 1992

Albania - 6.16 Albania - 38.3

Armenia 5.57 5.38 Armenia 32.8 23.5

Belarus 7.55 8.31 Belarus 59.9 62.0

Bulgaria 6.16 7.99 Bulgaria 83.8 69.4

Croatia 4.76 7.08 Croatia 113.6 94.1

Georgia 9.04 8.66 Georgia 29.2 9.4

Kazakhstan 4.61 5.75 Kazakhstan 80.5 73.3

Latvia - 8.10 Latvia - 49.5

Lithuania 13.45 15.03 Lithuania 65.4 100.6

Moldova 6.74 7.88 Moldova - 61.4

Romania 5.45 6.26 Romania - -

Russia 8.00 8.78 Russia 57.4 48.8

Slovakia 6.74 7.70 Slovakia - -

Outpatient attendences per 1000 inhabitants by country

1982 1992

Albania - -

Armenia 61.6 65.3

Belarus 14.9 17.2

Bulgaria - -

Croatia - -

Georgia 67.6 83.5

Kazakhstan 26.2 12.8

Latvia 71.6 52.4

Lithuania 11.1 52.8

Moldova - -

Romania - 7.3

Russia 52.0 -

Slovakia 148.8 -
 Organisation of Services
Lack of everyday resources is the first key issue for Mental Health services. In 1995
WHO European Regional office had as one of its priorities the "treatment and
improvement of care in psychiatric institutions.” “Of particular concern to WHO in the
Caucasus countries are the living conditions of mental health patients in
psychiatric institutions. Most institutions have only two wards one for men and
other for women, which are usually unheated. For many of the patients, the only
clothing they possess are their pyjamas. They receive only small rations of bread
and occasionally soup. Even in summer, patients are confined inside for 24 hours
a day.” Staff in the first Psychiatric Hospital I visited told me that food provided for the
patients came from the Red Cross, as the funds provided by the state were insufficient
to feed people. Medicines are in extremely short supply. When available, modecate
by depot injection is used in large amounts as a ‘chemical straitjacket’ because of lack
of staff.
The infrastructure of Mental Health services and the thinking behind them are very
poorly developed. There is absolutely no evidence of any form of community
orientation, or the recognition of the importance of the social dimension. The influence
of what is called the “Moscow School of Psychiatry” is everywhere. (Dr Salatian, an
Armenian psychiatrist working in Scotland was told on a recent visit that Insulin therapy
is still used in a hospital in Yerevan.) There is one small recent textbook on Psychiatry
available in Armenian. The Psychiatry textbooks translated into Russian by the Geneva
Initiative on Psychiatry have not appeared.
As a result of these two factors the Armenian Mental Health System is largely custodial
today. As an individual citizen experiencing Mental Health problems one’s first port of
call is the Polyclinic where one may occasionally find a Psychiatrist. This the Soviet
equivalent of the UK’s primary care services and the model provides for a wide range
of specialist services to be available at any clinic, which covers a much larger
population than a Health Centre in the UK. The model, though excellent, is severely
compromised when the specialist services aren’t available.
The next port of call is the nearest Regional Psychiatric Dispensary (hospital), of which
there are four. These vary considerably in standard. (I go on to describe two in the
next section). As in other ex-communist countries, there is an unlocked hospital called
“Neuroses Hospital” for people with neuroses and depression in Kasakh (near
Yerevan). The future of the “Stress Centre”, formerly the Institute for Mental Health in
Yerevan is also in doubt. Should you require any other more long-term services then
the options diminish to three institutions for chronic patients (two of which I describe
later.)
There are no community based mental health services of any sort. There is no evidence of
any team approach to mental health care. There is no special training of psychiatric nurses
and there are no social workers and few professionally trained psychologists. Psychiatrists
in training at the Medical University in Yerevan have only sporadic contact with the west.
The WHO Report on the Caucasus which I have quoted above, went on to suggest that “the
WHO is organising intensive courses on post-traumatic stress disorders and psychological
rehabilitation, and in some psychiatric hospitals, WHO is setting up demonstration projects
aimed at small groups of patients.” I did not see any evidence that this programme has
reached Armenia.
 FINANCING OF HEALTH CARE IN ARMENIA COMPARED TO SELECTED COUNTRIES

Armenia Rep- Costa- Argenti Paki-

ublic of Rica** na stan**
Korea**

1993 1994 1995 1996 1990 1990 1990 1990

Actual Actual Estim- Project-
ated ed

1. GDP per capita (PPP$) 510.0 365.0 616.0 791.0 6,733.0 4,542.0 4,295.0 1,862.0

2. Public expenditure on health 3.6 1.4 1.1 2.4 2.7 5.6 2.5 1.8
care (as % of GDP

3. Total expenditure on health - - - - 6.6 - 4.2 3.4

care (as % of GDP)

4. Public expenditure on health 18.4 5.1 6.8 19.0 182.0 254.0 107.0 33.5
care per capita in absolute
terms (PPP$)

5. Total expenditure on health - - - - 444.0 - 180.0 63.3

(PPP$)

* Calculations based on data provided by the ROA Directorate of Statistics

** Source HDR 94,94

Another key area of concern is the way in which services are now funded. As part of
the changes required to adapt to the new economic realities the budget, which is
annually voted on (the voted budget as it is known in Armenia) is now no longer
disbursed through the Ministry of Health. In line with the new policies of
decentralisation, the budget is passed to Governors of Regions. These are unelected
and personal appointments of the President. In their own areas they are establishing
little local “ministries of health” and the relationship between centre and periphery in
this area is unclear. It is interesting to note that although the state appears to be
heading for a 90% plus spend on the voted budget this year, local psychiatric
institutions will be doing well to receive 50%! In some months only 35% of that month’s
budget actually appears. Significant arrears of wages are therefore an ongoing part of
the pain. One may well wonder what is happening here.
One of the key changes to have been unleashed in Armenia is the transformation of
state services into “public enterprises”. This seems a crude attempt to privatise by
stealth, (appendix) and is full of dangers for the future. I will illustrate this point in more
detail because it is a central concern of mine in Armenia. Issue 40 (8 Oct.1997) of the
English language weekly, the “Noyan Tapan” contains an article entitled, ”Number of
Psychoes growing in Armenia”. It says that German POWs built Sevan Hospital
which I visited (in 1943). It now apparently “has all the basic necessary conveniences
following refurbishment” by IFRCRC and the Red Cross of Armenia with funding from
the EU ECHO programme. This view may not be shared by anyone who has actually
seen the place and I shall return to this institution later. Included in this programme it
would appear that funding was used to develop Greenhouses on the Hospital site,
ostensibly to provide activity for the patients. The reality may be a little more
problematic and potentially embarrassing for the European Union which funded these
activities trhough the ECHO prorgramme. The “bylaws” governing these Hospitals
describe them as a “Public Enterprise”, organised and conducted in compliance with
the Republic of Armenia’s laws on “Enterprise and Entrepreneureship”. These
enterprises have the following main objectives:
 • planning of internment activities
• providing chronic neuro-psychiatric patients older than the age of 18 and normal
old people with medical services and care;
• organising work therapy of the patients and the elderly;
• Undertaking production-economic, business and other activities not
prohibited by the Republic of Armenia’s Legislation.
Comments about this type of “production” were made to me by a number of people
throughout my visit. For example “The unfortunate trend of those occupational
activities is to switch over to cheap forced labour exploitation” or “this is a slave
regime.” This suggests that Directors of Institutions (earning $36 month) when faced
with the grim financial situation in which they find themselves are resorting to using
psychiatric patients as the means of production to generate income. This will and is
leading to exploitation and worse. I felt that a new form of slavery is in the process of
emerging in Armenia.
Another unintended consequence of the changes can be found at Vardenis Hospital
(one of the three institutions for the chronically ill). The free for all that currently
characterises the system has led to the existing 200 or so staff being turned into 400 or
so part timers! The reason for this has nothing to do with the needs of the patients but
reflects a means of extending a greater degree of political control and patronage by
providing employment. It is about buying votes!
The new system of paying for mental health services is an area that is still far from
clear though I did make strenuous efforts to understand what is going on! Pay for a
psychiatrist is about $20 per month at present, so the need to supplement one’s income
is great, given that a “basket” of basic necessities is calculated at $70 per month.
Under the heading of increasing the control of treatment costs the Ministry of Health
has deemed that treatment for acute psychiatric cases is free for a maximum stay of 80
days in patient care and the only outpatient treatment remaining free is that for
Schizophrenia and to a limited extent Epilepsy. After 80 days the patient is supposed to
leave hospital but I was told that in practise he/she is simply discharged and readmitted
the same day. On average the length of stay for acute patients is in fact much less,
some 20 to 30 days. It would appear that the hospitals for chronic patients are still
supposed to be free. Non acute care is available on payment. Because medication is in
such short supply, particularly in the chronic hospitals, grave problems exist when it
comes to the availability of medication and many mentally ill people are simply
incarcerated and not treated. This then leads to visits to these institutions having about
them the quality of bedlam. (Bedlam is a corruption of Bethlehem, a priory in
Bishopgate, London which was converted in the last century into a lunatic asylum and
the word now means: mad-house; a mental institution; a scene of uproar;
pandemonium.)
 Into Bedlam
Regional Dispensaries
These are found in Yerevan, Vanadzor, Gyumri, and Kapan. These cater for in and out
patients, both acute and chronic. I visited two.
The Psychiatric Hospital in Vanadzor by contrast to other institutions seems to reflect
some degree of humanity and care for people. Seriously damaged during the 1988
earthquake it has been restored and strengthened. As a building it therefore looks
more appealing and it’s location in the suburbs of Vanadzor means that it is accessible
for local people. The Hospital supports a vast number of out patients and Psychiatrists
regularly see 35 to 40 people per day. Having only 35 beds means that the staff are
able to more readily individualise their care. The Director of the hospital, Dr. Gayane
Kalantaryan, also a member of the Mental Health Foundation is trying very hard to
maintain reasonable standards in the face of overwhelming odds. This year has seen a
25% reduction in her budget for running the Hospital and significant pressure from the
Ministry of Health to move chronic patients to Sevan and/or Vardenis Hospitals, both
long distances away from Vanadzor. A basement area previously used as a workshop
for patients remains restored and unused due to lack of funds. The hospital used to
make pillows and sheets for other hospitals and there is desire to renew this activity as
a means of generating income and activity for the patients.
The Avan or “salt mine” Hospital was so named because of its proximity to a salt mine.
This hospital in Yerevan is also slowly being put to the torch. Bed numbers are
systematically being cut from 250 to 90 and staffing is down from 300 to 150. The Red
Cross of Armenia provides food. A Psychiatrist carries a caseload of 2400 patients!
There is no heating in winter though efforts are underway to rectify this. Chronic
patients are being moved to Sevan Hospital. In all respects the standards at this
Hospital show signs of age, decay and collapse.

Hospitals for the Chronically Sick

The Psychiatric unit at the Vardenis complex, in a remote rural area about 170kms east
of Yerevan, is housed in a building on the outskirts of the village, that resembles a
typical communist “block” (of flats). This area has an “edge of the world” feel about it.
As one enters the building a noise begins to erupt. Not certain at first where it comes
from one’s eyes cast about in the gloom of the “lobby” and spot a hole that patients
have gouged out of the stone work. Roughly triangular in shape, some 15-20cms, it
forms the frame round a pleading mouth. The mouth speaks with urgency and growing
volume as the noise inside increases. As the door opens to let us in a seething mass of
humanity beseeches us. I finally realise what it is all about. Cigarettes! This is a locked
male ward and the desperation is about a smoke. This desperation even leads to
smoking the cotton inside mattresses.

Vardenis Hospital is a Hospital for chronic psychiatric patients recently the subject of a
report sponsored by the United Nations High Commissioner for Refugees and the
United Nations Department of Humanitarian Affairs. Medecins sans Frontieres
(Belge/Greece) and the Young Medics Association of Armenia carried out this
interesting report (Feb.1997). It reported that Vardenis has been assigned to
accommodate 150 beds for 1997. At present there are 140 beds occupied by 124
patients. There are 4 wards, 2 each for men and women. About 110 people are
admitted and discharged each year. In 1996 there were 18 deaths recorded or about
15% per annum. There is one nurse for each 30 patients and one auxiliary nurse for
each 18 patients. There is one Psychiatrist who is supported on demand by a General
Practitioner, dentist and Surgeon. Of the 124 patients a recent report suggested that
there are 39 people who should be discharged. (29 to the Internment and 10 out of the
hospital).
Vardenis Internment is a ”Hospital refuge” for mentally retarded or physically
handicapped people older than 18. It is assigned 120 patients and currently
accommodates 94 of whom Kharbert Orphanage recently transferred 7 to the
internment. Instead of the 33 auxiliary nurses that should be available there are at
present only 24 and instead of 9 general nurses there are only 5. At least one elderly
refugee from the Karabagh is housed in this institution even though she suffers no
psychiatric illness or mental retardation.
The smell of urine is everywhere. On entering the Internment I find myself in a small
room. There is a mattress in the corner on which are huddled a pathetic group of
physically and mentally handicapped youngsters. Several are rhythmically banging
their heads against the wall. There are four bare newly painted walls and no staff in
evidence. There is nothing to do and nowhere to go. The Ministry of Health has
decided that a further 15 kids should join this group from the Kharbert Orphanage.
The Hospital complex is currently undergoing renovation and repair thanks to Medecins
sans Frontieres. A new roof and windows means that patients may survive the winter in
a modicum of greater comfort. At present funding for heating fuel is not available and
appeal letters have been sent far and wide.
Conditions in both Institutions are much the same and fall well short of any reasonable
standards in all aspects.
A story is told of Hospital staff recently discovering that a female patient was seven
months pregnant with twins. The pregnancy went to term and she went to a medical
hospital for delivery. The babies were born alive but by the next morning they were
dead. Sexually active women in the Vardenis complex have since received IUDs.
Sevan Psychiatric Hospital and Alcoholics Dispensary is much larger and could be
home for up to 590 patients. At present it houses about 400 but numbers are growing
as the Ministry of Health forces transfers of chronic patients from Hospitals in Yerevan.
It consists of 2 departments each for men and women, a department for children, and 2
departments for drug addicts and alcoholics (1 for general treatment and one for
“obligatory” treatment, although there are no “obligatory” patients at present). Assigned
for 120 patients these 2 departments currently only have 15 patients. The children’s
unit is assigned 30 patients and currently has 9.

The hospital is housed in a German POW camp dating from 1943. Patients are
accommodated in rooms of up to 30 each. Much basic work remains to be done to the
infrastructure of the Hospital to bring it up to acceptable standards. I was only allowed
to see the “best” parts of the hospital. In a small courtyard a large group of variously
dejected and angry women became silent as we approached. On my way out a women
with crystal clear eyes and an educated voice said to me in perfect English, ”please,
please help me leave this place………..” Typhus continues to be a serious problem.
I did not visit the third institution for chronic patients, Noubarashen in Yerevan.
 The Legislative Context
The simple answer is that there is no specific Armenian mental health legislation.
Russian Law No 225 of 21 March 1988 (see appendix) is the general guidance that
psychiatrists are supposed to adhere to. It is not enforceable as Armenian Law.
Culturally the family would still seem to hold significant sway and influence admission
and discharge. Psychiatrists are extremely reluctant to take the risk of discharging
someone if the family hasn’t taken back the “responsibility”. In Vardenis Hospital
because of “communication” difficulties nurses often admit patients. Some Psychiatrists
become very upset when one questions the current situation. Stories are certainly told
of Psychiatrists admitting people, particularly troublesome wives in this highly
patriarchal society, in return for payment. Gathering real evidence of such malpractice
would be extremely difficult. The climate certainly seems right for such type of activity.
As in Romania it seems reasonably clear that one way to avoid military service is to
pay a Psychiatrist to find you mentally ill. Because of visa problems with the US new
income can now be generated by disappearing the previous diagnosis and file! It is
also clear that individual Psychiatrists in Armenia collaborated with the KGB and
individuals were sent to Forensic units in Armenia or the Ukraine for “treatment” for
political and other reasons.
Typical of the communication problems in Armenia is the activity that is taking place in
an attempt to draft a law on Mental Illness/Health. Unbeknown to each other the Mental
Health Foundation of Armenia is busily trying to get the Geneva Initiative on Psychiatry
from Hilversum, Holland interested and involved whilst Medecins sans Frontieres has
established a working group with Toralf Hasvold, WHO Public Health Advisor in
Armenia.
It is a matter of great concern that no law exists. However in a situation where the
independence of the Judiciary from political pressure is so seriously in doubt, one
wonders how much difference the best law in the world would make. (US Department of
State report.) I have no evidence that there is any ongoing abuse of psychiatry for
political reasons now.
 Non Governmental Mental Health
Organisations in Armenia
The Mental Health Foundation. A recent entrant on the scene, exists more as a
dream of its members than a measurable reality. They have no staff and no Office. No
equipment and no money. But they do have experience and a passionate willingness to
do something; particularly to bring more modern thinking into play. They are particularly
concerned about the lack of mental health legislation. They are also keen to see the
development of the NGO sector in Mental Health, particularly the establishment of
organisations for Users/ Survivors and for Relatives. The organisation would appear to
have a significant range of highly useful connections. I had the pleasure of meeting
with a large group of members of this organisation and was impressed by the cross
section of interest it represented; psychologists & psychiatrists in the main with one or
two users and parents/relatives.
“Centre Datev 95” has been in existence for a number of years. Impressive
commitment and real involvement with groups of Refugees means that it is the only
mental health organisation that I met which was actually working as an NGO
exclusively in Mental Health. Of course they have no resources either but this hasn’t
stopped them from having a symbiotic relationship with a private organisation doing
reflexology training for Armenians. From this relationship they have obtained office
space and other practical support.
In the period May 1996 to May1997 they have offered psychological assistance to a
group of 18 refugee teachers, counselling to 165 war victims, assistance to 223
children in a range of institutions, psychotherapy for 56 people in Yerevan, training for
190 teachers and other professionals in a variety of courses.
“Datev 95” suggests, like others I spoke to, that foreign organisations left Armenia
within a couple of years of the earthquake. This meant the end of significant foreign
material, humanitarian and other assistance. The situation remains critical in their view.
There is a complete absence of decent psychological services. This means that the
growing number of people with “totalitarian trauma”, post-traumatic stress disorders,
phobias, neuroses, psychosomatic disorders, and suicidal behaviour amongst the
general population have no where to go for help. Also the obvious problems associated
with refugees, orphanages, street children, elderly, earthquake victims and the mentally
and physically ill/disabled and handicapped are overwhelming and with no hope of
resolution in the current climate.
Mission Armenia, created in 1993, is a well-established and highly regarded Armenian
NGO although only tenuously placed under the heading of mental health. It has been
actively supported by Oxfam and undertakes a range of community based work, mainly
for up to 3000 elderly people. It employs its own Doctors, Nurses and Social workers.
They suggest a growing problem of suicide amongst elderly people who wish to avoid
being a burden on their relatives in these hard times. They do not have experience of
working in the Mental Health field. Medecins sans Frontieres are in discussions with
them about taking over responsibility for running the “therapeutic workshop” at the
Vardenis Internment. Mission Armenia have worked with Medecins sans Frontieres on
the renovation of the hospital using money received from Save the Children Fund.
Mission Armenia expresses the hope of becoming more actively involved in the area of
mental health. Mission Armenia identifies training for their staff and public education
and attitude change as growing concerns.
Professor Hasmik Gevorkian established the NGO for Social Work and Sociological
Research in October 1997. I am not clear if it exists as a legal entity. It suggests it has
an interest in the growing numbers of people committing suicide in Armenia and work
with injured people, the handicapped, elderly houses, terminal illness, institutions for
young people and women’s centres, particularly for those suffering from marital
violence. I was unable to obtain any further written information about this organisation
or its activities.
Apart from these organisations I heard about the “Armenian Psychiatric Association”
from Prof. Melik-Pashayan at the Medical University of Yerevan. I take this to be a
professional association. I also heard about the “Society of Psychoanalytical Studies”
(Dr. Ara Chalikyan).
The concept of an NGO and the rules that should apply to its activities would appear to
be poorly understood and developed in Armenia. There is significant blurring of roles
and boundaries in organisational life. Members of the board of one organisation are
also the paid senior staff of the same organisation. A model that is familiar in the
private sector but less so in a not for profit NGO. This does not apply to the Mental
Health Foundation of Armenia. There is no evidence of networking or the exchange of
ideas amongst NGOs and during my visit I was at times facilitating the beginnings of
tentative contact between local and local as well as between local and international
NGOs. People seem quite ready to embark on major schemes without the benefit of
any organisational infrastructure. There is innocence about the understanding of the
NGO sector and its activities.
 The Future of InterMind’s work in Armenia
In our work in Eastern Europe we use our limited resources to work at a macro and
micro level in developing the NGO sector in mental health. At a macro level we
support the work of a national NGO (for example the Romanian League for Mental
Health). An extract of their current strategic plan is in the appendix. As a national
membership organisation it has important developmental, advocacy, educational and
campaigning roles in Mental Health. It develops its own policies and practices as well
as proposing legislation. It raises awareness and combats stigma, prejudice and human
rights abuses through Mental Health promotion and other work. Together with the
Romanian League for Mental Health, InterMinds (previously Penumbra International)
(at a micro level) entered a partnership to establish a Romanian community based and
service providing NGO that could innovate and develop pilot and demonstration
projects. In Romania this is the Estuar Foundation which is now a highly regarded and
successful organisation both in Romania and further afield. This model has clear
applicability in Armenia and in particular the development of the NGO sector in mental
health.
The need for clear local advocacy and champions for change is obvious. The
importance of the political agenda must not be under-estimated. A major political
struggle looms. To pressure both national, and of increasing importance, local
government in to adopting policies and practices that begin the long process of meeting
the needs of people with mental illness and mental health problems. This is an
enormous task and requires serious commitment from organisations from outside
Armenia. This is not a “hit and run” scenario. Political will is the engine of the
change process.
InterMinds, in its Board members, staff and UK and international partners, intend to
bring their significant project and organisational development experience into working
actively in partnership with the Mental Health Foundation. We would, through
working with it closely and advising it, assist it in becoming the leading national
umbrella NGO in the Mental Health sector in Armenia. As there are already
organisations on the ground which wish to develop their activities we will work with
them to achieve their aims. In particular this would be “Centre Tatev 95”.
We would assist in the establishment of a national user organisation as well as a
national organisation representing the interests of parents and relatives in order to
develop their capacity as stakeholders. As a priority in our view however, significant
energy should be expended on developing local stakeholder groups, bringing
concerned people together who are prepared to take on the political agenda in their
areas and campaign for appropriate policies, practices, resources and services.
We would assist with the working group established in Armenia to draft new mental
health legislation.
Appropriate training would be provided to Board and staff members of these emerging
organisations. This would include organisational development and management,
financial management, fundraising, quality and evaluation, campaigning and lobbying,
media relations, advocacy (safeguarding, empowerment) and human rights in mental
health. Care in the Community, alternatives to institutional care, assessment of need
including self-assessment and risk assessment would also be covered.
A programme of exchanges and study visits would be established and seconded staff
may be used for particular purposes such as the early stages of a project not previously
tested in Armenia.
Specific project proposals were received from organisations to do work with young
people, adults, war victims and refugees with Mental Health problems. (A synopsis of
these is found in the appendix)
InterMinds would actively assist these organisations in reviewing their plans and
priorities and would enage itself closely in their struggle to bring real hope and change
to mental health services in Armenia.
In his book, “Passage to Ararat”, Michael J. Arlen writes, “I realised at that moment to
be an Armenian, to have lived as an Armenian was to have become something
crazy. Not crazy in the colloquial sense of quirky or charmingly eccentric…., or
even of certifiably mad. But crazy: crazed, that deep thing-deep where the deep-
sea of souls of human beings twist and turn.”
 APPENDIX 1
The Legislation
1. General Considerations
1.1 “Vardenis Internment” Public Enterprise has been founded with the objective of
looking after neuro-psychiatric patients and the elderly.
1.2 “Vardenis Internment” public enterprise (hereinafter referred to as “Enterprise”,
is the legal heir of RA Social Welfare Ministry Vardenis No 7 budget based
boarding house for neuro-psychiatric patients.
1.3 Founder of Enterprise is Gegharkunic Marz of Republic of Armenia.
1.4 Enterprise activity shall be organised and conducted in compliance with RA law
on “Enterprise and Entrepreneurship”, other RA legislative acts, decrees, orders
directions of Geharkunic Marz and the Rules herein.
1.5 Enterprise is a juridical person, possesses a balance of its own, bank account,
round seal and with the National Emblem, other requisites.
1.6 Enterprise has Armenian as official language, English and Russian as
languages of international communications.
1.7 Enterprise official name is:
full name - RA Gegharkunic Marz “Vardenis Internment” Public Enterprise
Short name - RA Gegharkunic Marz “Vardenis Internment” PE
1.8 Enterprise Juridical Address:
Republic of Armenia, Gegharkunic Marz, town of Vardenis, Andranik str.1

2. Enterprise Main Objectives

2.1 planning internment activities;
2.2 providing chronic neuro-psychiatric patients older than the age of 18 and normal
old people with medical service and care;
2.3 organising work therapy of the patients and the elderly;
2.4 undertaking production - economic, business and other activities not prohibited
by RA legislation.

3. Enterprise Rights and Liabilities

With the consent of the Founder the Enterprise has the right to:
3.1 in compliance with provisions of legislation obtain, reconstruct and by other
means not prohibited by the RA legislation establish any kind of legal,
organisational enterprises and through them conduct business transactions;
3.2 by any means not prohibited by legislation acquire properties, including
certificates, possess and use them and the earnings received from them;
3.3 on contractual basis use the property and belongings of other organisations and
individuals;
3.4 establish own financial resources including loans, in RA and other countries
receive bank and trade loans, also in foreign currency;
3.5 with the consent of the Founder give on rent, exchange and by other means not
prohibited by RA legislation, transfer property rights, act as mortgagor and
mortgagee;
3.6 sign contracts and discharge duties pursuant to provisions of RA legislation;
3.7 with the consent of the Founder choose transaction rules of its foreign economic
activity, and exercise it directly without any mediators, or through a mediator
specialised in the foreign economic field, or another organisation establishing
contractual relations with it;
3.8 possess finances in foreign currency, obtain them in the result of external
economic activities, and by any means not prohibited by RA legislation possess
them having paid taxes and pursuant to provisions of RA legislation sell them to
Government, organisations or individuals;
3.9 plan activity in compliance with provisions of RA legislation with obligatory and
prior fulfilment of state order, determine volumes and prices of services beyond
the state order;
3.10 determine the in-structure, regulations, list of subdivisions and the internal
management system;
3.11 involve hire workers, sign labour contracts with them, fix their salaries pursuant
to provisions of RA legislation;
3.12 establish rewards and pay them to enterprise workers, provide them with
privileges of enterprise services;
3.13 in legal form or through arbitration dispute activities of individuals, enterprises,
banking corporations, financial institutions, other organisations and
governmental bodies having caused damage to its interests, act as a claimant,
respondent and mediator in court or arbitration tribunal.
4. Enterprise Liabilities
4.1 ensure high-grade diagnosis, preventive and rehabilitation assistance to
population and their compliance with the established requirements;
4.2 ensure priority and quality in according to pursuing the signed agreement for the
state order and the requirements hereunder and RA legislation;
4.3 ensure protection of enterprise property and its optimal use;
4.4 ensure optimal and rational expense of Enterprise transactions’ income;
4.5 conclude labour contracts with Enterprise hired workers or organisations
authorised by them and presenting their interests, that according to RA
legislation are entitled to conclude agreements.
4.6 fully pay wages of all workers as signed their in labour agreements
4.7 ensure estimation and registration of conducted activities and services and
submission of monthly, quarterly and yearly reports on financial-economic
activities.
4.8 take actions towards expanding medical and other services beyond state order.
4.9 according to RA legislation bear responsibility and compensate damages
caused by the enterprise: breach or insufficient compliance with the agreements,
including labour agreement, violating other persons’ propriety rights.
4.10 undertake the obligatory insurance of the hired workers in compliance with
provisions of RA legislation, ensure labour and leisure conditions for the hired
workers according to the work agreement.

5. Enterprise Property and Financial-Economic Activity

5.1 Enterprise property, basic and circulating funds, financial means, target use
funds, are given to Enterprise on full management, disposal and use basis
without right on property; sources of Enterprise property:
5.2 financial and material inputs of the Founder, transfer of rights of property
disposal, its use and other property rights;
5.3 income from the realisation of goods, services and other economic transactions;
5.4 credits from banking corporations and other creditors;
5.5 capital investments from state budget, grants, additional payments, other
investments;
5.6 charity investments, donations by individuals and organisations;
5.7 other sources not prohibited by RA legislation
5.8 the Enterprise fulfills the State order providing the population with medical-
preventive, rehabilitation assistance and service. Volumes of activity conducted
within the state order, implementation and payment rules and conditions are
defined in State Order Distribution Agreement signed between Enterprise and
the Founder;
5.9 Sources of Enterprise financial means are: Founder’s financial and property
investments, earnings from realisation of goods/work, service/depreciation
compensations, interests from banking corporations holding Enterprise means,
insurance payments, other enterprise investments, as well as other monetary
inputs not prohibited by RA legislation.
6. Management of Enterprise Activity
6.1 the Enterprise is in the custody of the Founder or his authorised body which is
entitled to final decision in any enterprise activity referring issue’
6.2 to Founder’s full authority refer:
• defining Enterprise activity objectives and tasks
• adopting and amending Enterprise Rules
• verifying Enterprise activity annual results;
• appointing and dismissing enterprise Manager;
• issuing decrees on Enterprise activity suspension, appointing Dissolution
Committee, verifying dissolution balance;
6.3 Enterprise authorities are: Council and Manager acting within their power
stipulated herein;
6.4 Enterprise activity is controlled by Control Committee;
6.5 Council and Manager shall report to Founder. In case of insufficient activity
result, the Founder is entitled to withdraw the authority of Council members and
Manager and initiate new appointments before expiration of their periods;
Council Liabilities:
6.6 With the consent of the Founder and according to provisions of RA legislation,
make resolutions on establishing, acquiring, reconstructing or, by any other
means not prohibited by RA legislation, setting daughter and joint companies or
any other legal-organisational enterprises; approve their institutional documents
and make changes or amending them;
6.7 Approval of organisational internal structure of the enterprise and making
changes/amending them;
6.8 At least once annually, audit daughter enterprise activity results and make
respective decisions;
6.9 Appointment of Enterprise Control Committee members (on two-year basis) and
their dismissal, auditing, at least once annually, the statement of control
Committee and making relevant decisions;
6.10 Submission of suggestions to the Founder on changes or amendments in
Enterprise institutional documents;
6.11 fulfilment of assignments and other authorities issued by the Founder;
6.12 Council sessions are called on necessity but not less than once quarterly. At
Council sessions Manager acts as chairman; in case of his absence - once of
the members by Council decision;
6.13 One third of Council members should be representatives not included in the
 administrative body;
6.14 Council sessions are valid if at least half of Council members are present;
Council decisions are made by simple majority of members present, if Council
has not set another rule for any particular issue. In case of equal votes Manager
or the chairman has the final vote.
6.15 Enterprise Manager is at the same time Council chairman;
6.16 Enterprise Manager:
6.17 within his authority without license acts in the name of the Enterprise, presents
its interests, maintains Enterprise property and financial resources;
6.18 concludes work contracts with enterprise employees and acts as employer;
6.19 issue licenses, opens accounts in banks;
6.20 approves/determines staff, issues decrees gives directions to Enterprise
employees’
6.21 directs Enterprise Counsel activities’
6.22 within the requirements of the Rules herein and RA legislation fulfills his duties
and tasks received from the Founder;
6.23 Enterprise manager and his deputies are appointed by Founder: Head
accountant is appointed by the Manager with the consent of the Founder;
6.24 On appointing the Manager a contract is signed between the Founder/his
authorised body and the Manager which defines Manager’s rights, duties,
responsibilities and his relationship to Founder, Manager’s payment terms,
contract dates, resignation terms, contract suspension grounds and other
provisions that parties may find necessary;
6.25 Control committee is established in the Enterprise and its members appointed by
the Council;
6.26 Enterprise Manager and Council members cannot be member of control
committee;
6.27 Control Committee elects a chairman amongst Committee members who
organises Committee activities and keeps under observation the implementation
of its decrees;
6.28 Control Committee authorised to: control over implementation of Founder’s
decrees, as well as the compliance of committee-made decisions with Enterprise
Rules.;
6.29 control over Enterprise property protection and financial economic activities;
6.30 control committee members are entitled to demand from Enterprise authorities
and officials any data or records concerning issues within their authority;
6.31 Control Committee is obliged to at least once a year submit to Enterprise
Council a brief account on enterprise activity results, property protection etc.
6.32 Control committee sessions are held on necessity but not less than once very six
months;
6.33 Control Committee sessions are valid if a least half of Committee Members are
present;
6.34 Resolutions are carried by simple majority vote. In case of equal votes
Committee chairman ha the right to the final vote;
6.35 on issues at discussion the Committee makes resolutions, of which the Council
and the Manager are notified. If an issues is brought forward by the Founder he
is notified as well.

7. Enterprise Activity Suspension

7.1 Enterprise discontinues its activity by the Founder’s decision or on any other
grounds anticipated in RA legislation;
7.2 Enterprise activity suspension is carried out through reformulation/division,
separation, reorganisation or dissolution according to RA legislation;
7.3 Dissolution is carried out by Dissolution Committee set by the Founder; in case
of dissolution through court - by Dissolution Committee set by judicial bodies;
7.4 Dissolution date, rules and terms, as well as dissolution Committee rights and
duties are set forward by RA legislation.
 The Law
Buildings, territory and structure of psychiatric hospital
19. The territory of psychiatric hospital, its buildings, premises, technical equipment
are arranged in compliance with the Rules on system and operation of
psychiatric hospitals in practice and are maintained according to the
requirements of sanitary laws.
20. To perform full inspection and social-labour rehabilitation of the patients, within
the psychiatric hospital medical, therapeutic-diagnostic, therapeutic-
rehabilitation and other compartments, subdivisions and services will be
organised, the list of which is contained in section “structure of hospital” of Rules
on system and operation of psychiatric hospitals in force.
21. The activity of some compartments of mental hospital (forensic-psychiatric
compartments, day time stationary, therapeutic-industrial (labour) workshops
etc) can be regulated by separate laws.
22. To realise compulsory treatment, under the decision of the court, of the mentally
ill, having made an offence of offering socially-dangerous behaviour, a
compartment with strengthened supervision can be set within the psychiatric
hospital.
The order of receipt, keeping and routine of the patient in the compartment with
strengthened supervision are regulated by special laws.

Admission
23. Patients who can be admitted to psychiatric hospital:

• persons, whose mental condition requires therapeutic-rehabilitation measures

in a psychiatric hospital;
• persons, sent by judicial bodies for compulsory treatment;
• persons, sent by judicial-inquiry bodies for stationary psychiatric examination
(evaluation);
• persons, sent to stationary examination for precise diagnosis, examination of
capability for work, fitness for service in the army, etc.
24. Patients, requiring stationary treatment, are put in psychiatric hospitals when
sent by doctors-psychiatrists of psychiatric health centres (dispensaries,
cabinets), doctors of specialised emergency psychiatric brigades, public health
agencies, and also in case of existing urgent medical indications to
hospitalisation.
25. Persons, sent to stationary examination for specification of diagnosis, medical-
labour or miliary-medical examination, are accepted in psychiatric hospitals
when sent by public health agencies, regional doctors-psychiatrists, and also
medical-labour or military-medical commissions respectively.
26. The order of acceptance and discharge from psychiatric hospitals of persons,
sent for stationary judicial-psychiatric examination; and the ill sent for
compulsory treatment, is regulated by the current legislation and appropriate
department instructions.
27. An obligatory condition for placing a patient in mental hospitals for treatment or
examination, except for cases, stipulated by the current legislation, is his/her
consent to hospitalisation. Placing patients in psychiatric hospitals
(compartment) is performed exclusively by the doctor-psychiatrist. If the person,
being subject to hospitalisation, has not reached the age of sixteen or because
of his/her mental condition is not capable of telling his/her will, consent to
hospitalisation should be received from his/her relatives or lawful
representatives, in case of their absence - from the head psychiatrist of the
territorial public health agency.
28. Mentally disordered who offer direct danger to themselves or surrounding and
need compulsory treatment, can be put in psychiatric hospitals without their
consent and without prior notification and consent of their relatives or lawful
representatives, as stipulated in current legislation and directions on the order of
urgent hospitalisation of the mentally ill.
29. On putting a patient/hospitalising in mental hospitals, the treating doctor of the
patient during the first days of hospitalisation notifies the divisional psychiatrist,
as well as the psychiatric dispensary (dispensary compartment, cabinets)
according to the patient’s permanent place of residence, as well as to his/her
relatives or lawful representatives.
30. In case of absence of indications for hospitalisation in psychiatric hospitals, the
on duty doctor refuses reception. Each case of a refusal with its motivation is
registered in the book of reception and refusals of hospitalisation with the
subsequent notice within a day, to the medical institution that sent the patient.
31. On receiving a patient the on duty doctor checks the medical order and
identification cards, carries out a thorough physical examination, as well as an
inspection of the mental and somatic condition of the patient, collects necessary
anamnestic data both from the patient and accompanying him persons and
enters the information into the book of reception and refusals of hospitalisation
and the medical card of the stationary patient.
32. In case of detecting signs of poisoning, wound or violence the on duty doctor
immediately notifies the local body of internal affairs and the department of
public health services of the region where the mental hospital is located.
33. In case of absence of documents on the patient, and therefore impossibility of
identifying him/her, he/she is registered in the book of “unknowns” and the local
body of the police is informed about his/her admission in the psychiatric hospital
with the exact description of his/her signs or photo for subsequent identification.
34. The question on necessity of sanitary treatment of the hospitalised person is
decided by the on duty doctor.
35. Belongings, documents, money and valuable items of the patient are accepted,
kept and given out in the order, established by the appropriate instruction of
Ministry of Health of the USSR.
36. According tot he discretion of the on duty doctor, afterwards of the head of the
department, the patient is authorised to use his linen, clothes and footwear, toilet
and cosmetic articles.
37. Children aged 4-14 brought to psychiatric hospitals are put in departments of
children, teenagers (15-17 years) - in teenager departments and wards. Note -
in case of absence of teenager departments or wards, teenagers are placed in
departments for adults.
 Provisional Directions
on the order of urgent hospitalisation of psychiatric patient
The necessity of preventing socially dangerous behaviour of the mentally ill requires in
a number of cases their urgent placement in psychiatric hospitals (compartments) with
the purpose of taking special actions of Prophylactics and treatment, assigned on the
bodies of public health by article 36 of “Bases of Legislation of USSR and Soviet
Republics on Health Policy”. Pursuant to “Laws on conditions and order of rendering
psychiatric help”, the urgent hospitalisation of the mentally ill is applied in the following
order:

1. Mentally disordered who offer direct danger to themselves or surroundings, can,

exclusively under the decision of psychiatrists, be placed in psychiatric hospitals
(compartment) without their consent, and also without prior notification and
consent of their relatives of lawful representatives.
2. An indication for urgent hospitalisation is the patient’s socially dangerous behaviour
(aggressive actions, psychomotor excitation, suicidal behaviour etc and also
high probability of such actions) caused by the following peculiarities of his/her
abnormal condition.
a) Inadequate behaviour owing to his/her psychotic condition (psycho motor
excitation, hallucinations, delirium, syndrome of psychic automatism, syndromes
of disordered consciousness, pathological impulsiveness, heavy dysphoria;
b) Systematic delirious syndromes, provided that there is the probability of socially
dangerous behaviour;
c) Depression, if it is accompanied by suicidal tendencies;
d) Maniacal and hypo-maniacal condition, causing infringements of the public order
or aggressive behaviour towards his/her surroundings;
e) Psychopath-like psychiatric diseases with pathology of inclinations and
increased conduct activity;
f) Condition of deep psychic defect, presenting mental helplessness, hygienic and
social neglect, vagrancy.
The above listed abnormal conditions, fraught with obvious danger for the patient
himself and the society, may be accompanied by externally correct behaviour. it is
necessary to be very cautious, particularly when estimating the mental condition of
such persons to prevent, with due hospitalisation, the possibility of publicly-
dangerous actions by the insane.

3. Patients with simple alcoholic intoxication, except for sharp intoxication psychosis
and psychotic conditions are not subject to urgent placement in psychiatric
hospitals (departments). Emotional reactions, litigious activity and antisocial
 forms of behaviour of persons, showing only psychopathic and neurotic
disturbances cannot serve as indications to urgent hospitalisation.

4. Persons, having committed publicly-dangerous acts specified by the criminal law and
there are doubts as to their being mentally healthy, are sent to forensic-
psychiatric examination int he order, specified by the criminal-procedure
legislation.
5. Urgent hospitalisation (if directions by doctors-psychiatrists exist) is directly carried
out by medical workers, on whom the public health bodies assign these
functions. In regions, where there are not enough doctors-psychiatrists, the
order on urgent hospitalisation is issued by the doctors, which are entitled to
rendering psychiatric help to population. In these cases the final decision on
necessity of urgent hospitalisation is taken by the doctor-psychiatrists of the
hospital, where the patient is brought. The doctor, sending a patient to a
psychiatric hospital for urgent hospitalisation should, in legible handwriting,
specify in his notice, that the patient is directed on urgent hospitalisation basis,
give detailed reasons, in the conclusion specifying his position, place of work,
last name and date of issuance of the order.
6. Bodies of internal affairs are obliged to assist, whenever addressed, the medical
workers in realising urgent hospitalisation of the mentally ill in case of:
• Resistance, aggression or their possibility, other actions on part of the insane
fraught with danger to the life and safety of the medical workers, as well as
their attempt to escape.
• Resistance to urgent hospitalisation of the insane on part of his relatives,
lawful representatives or other persons;
• Necessity of search and detention of the insane.
In case of urgent hospitalisation of a mentally ill, presenting obvious danger for
him/herself and surroundings, from the place of his residence is necessary and it
is highly probable, that he or his relatives will offer resistance, workers of
psychiatric-neurological dispensaries (dispensary departments, wards) and
emergency groups, can address to agencies of internal affairs of the territory
where the mentally ill is likely to be, for assistance. The head of the agency of
internal affairs or the person, replacing him, provides the arrival of the police at a
fixed time and respective address for rendering assistance to medical workers.
On hospitalising a mentally ill, having no relatives and friends, or living
separately, the police workers together with the administration of the household
take measures to ensure hereunder safety of the property of the mentally ill.
7. On accepting a mentally ill in a psychiatric hospital (department), the on duty doctor-
psychiatrist is obliged to make certain personally of the necessary indications for
urgent hospitalisation and make a record on the title page of the in-patient’s
medical card (form N003/y) and in the book of admission and refusals of
hospitalisation (form N001/y), that the patient is admitted as an urgently
hospitalised.
In cases, when the on duty doctor-psychiatrist finds no grounds for urgent
 hospitalisation, and the patient or his relatives and lawful representatives do not
give consent to hospitalisation, the on duty doctor refuses to place such patient
in a psychiatric hospital (compartment) and makes a motivated record in the log-
book of admission of patient and refusals of hospitalisation.
8. The administration of the psychiatric hospital (department), (on days off and holidays
- the on duty doctor) is obliged to immediately notify in writing or by phone the
relatives of the patient or his lawful representatives, and also the higher
agencies of public health services about his/her hospitalisation and a record is
made in the patient’s medical card on who, when, to whom and in which way has
forwarded the notice.
9. The mentally ill, accepted in a psychiatric hospital (department) on urgent
hospitalisation basis, are subject, except for days off and holidays, to
examination by a commission of doctors-psychiatrists, consisting of the treating
physician, head of the department, head of the institution (his deputy on medical
practice or persons authorised by the head of the institution), which solves the
problem on validity of urgent hospitalisation and necessity of compulsory
treatment. The motivated conclusion of the commission, signed by all the
members of the commission, is entered into the medical card of the patient.
If the commission find necessary to leave the patient in the psychiatric hospital
(department) for compulsory treatment, the administration of the hospital
(department) forwards the motivated conclusion within a day to the main
psychiatrist of the public health agency of the region (under whose authority the
psychiatric hospital (department) is located) for consideration and control, and
also informs the relatives of the patients or his lawful representatives.
The conclusion of the commission about no substantial basis for urgent
hospitalisation and compulsory treatment will be followed by the patient’s
immediate release. Such persons can be left for treatment in the psychiatric
hospital (department) only with their consent, or with the consent of his/her
relatives or lawful representatives if the patient is unable to express his/her will.
10. The mentally ill admitted in a psychiatric hospital (department) on urgent
hospitalisation basis, are subject, not less than once a month, to examination by
a commission of doctors-psychiatrists, consisting of the treating doctor, head of
the department and head of the institution (his deputy on medical practice or
persons authorised by the head of the institution) to decide the question on
termination or prolongation of compulsory treatment. The motivated conclusion
of the commission is entered into the medical card of the mentally ill.
In the case these patients remain in the psychiatric hospital more than 6 months,
decision on prolongation of compulsory treatment is taken by the main
psychiatrist of the public health agency of the region, according to the location of
the psychiatric hospital (department) not less than once every six months, on
submitting to him the motivated conclusion of the commission of the given
hospital (department).

11. The main psychiatrists of public health agencies are obliged to exercise
systematic control over strict observation of rules established hereunder,
 through inspection of therapeutic-preventive institutions, carrying out compulsory
treatment of the patients hospitalised on urgent hospitalisation basis, also
through study and analysis of the conclusions of medical commissions on urgent
hospitalisation.

12. The decision on implementing urgent hospitalisation or initiating compulsory

treatment can be appealed against by the patient or his relatives or lawful
representatives to the main psychiatrist of the Ministry of Health, in court or may
be protested by the public prosecutor.

Head of Central Administration of therapeutic=preventive help

V.I. KALININ
 APPENDIX 2
People and Organisations

Vladimir Karmirshalian, Director, Centre for Democracy and Human Rights

Anahid Tevossian, Chairperson, “Datev 95” Psychotherapy and Counselling
Oliver Lacey-Hall, United Nations Department for Humanitarian Affairs
Miguel de Clerck, Head of Mission, Medecins sans Frontieres
Dr John Mitchiner, British Ambassador to Armenia
Hripsimeh Kirakossian, President, Mission Armenia
Dr Hasmik Gevorkian, Professor, Department of Sociology, Yerevan State University
Professor Marietta A Melik-Pashaian, Psychiatrist, Chair of Psychiatric Department
Medical University, Nork Psychiatric Hospital
Levon Nersisian, President of Union to aid the invalid children
Svetlana G Topchyan, MD, United Nations Population Fund
Sergei Yeritsian, Journalist and Member of Parliament
Dr Sebouh V Monjian, President, Young Medics Association
Dr Norayr Darbinian, Director, Yerevan Psychiatric Dispensary, Avan Hospital
Dr Marouch Eghiar, Vice-Director, 6th Children’s Hospital
Dr Gayane Kalantaryan, Director, Vanadzor Psychiatric Dispensary, Lory Region
Dr Horhannes Dourgarian, MP Vice-Chairman of the Commission on Health, Social
Care and Employment, Parliament of Armenia
Dr Arman Vardanyan, President, Mental Health Foundation of Armenia
Dr Gagik Horhannissian, Director, Sevan Hospital
Dr Miral Salatian, Psychiatrist, Forth Valley Health Care Trust

APPENDIX 3
 Organisations Visited

Mental Health Foundation of Armenia (NGO) Yerevan

“Datev 95” (NGO) Yerevan
Mission Armenia (NGO) Yerevan
Medecins sans Frontieres (NGO) Yerevan
A refugee facility for elderly people and orphans in Vanadzor
Centre for Democracy and Human Rights, Yerevan.
United Nations Department for Humanitarian Affairs, Yerevan
Vardenis Psychiatric Hospital and Internment
Sevan Psychiatric Hospital, Sevan
Avan Psychiatric Hospital, Yerevan
Vanadzor Psychiatric Dispensary and Hospital, Vanadzor
British Embassy, Yerevan
Medical University, Yerevan
The Stress Centre, National Institute for Mental Health and Rehabilitation, Yerevan
Astghik Union, A Parents’ NGO
 APPENDIX 4
Out of Country Contacts
Armenian Ambassador, Brussels
European Regional Council of the World Federation for Mental Health, Mrs Josee van
Remoortel.
Geneva Initiative on Psychiatry, Mr Robert van Voren, Director
WHO Geneva, Dr Stanislas Flache
Amnesty International, UK
Oxfam UK
Department for International Development, Know How Fund, Foreign Office, London,
UK
Jane Gabriel, Gabriel Productions- Independent film producer, UK
Mrs Ter-Petrosian, wife of President of Armenia (World Federation for Mental Health,
First Ladies for Mental Health group, via Josee van Remoortel)
 APPENDIX 5
References
“The Crossing Place” Philip Marsden
Report on Vardenis Psychiatric Complex. 12-26 Feb.1997 MSF Belge/Greece and the
Young Medics Association
“The Globalisation of Poverty.” Michel Chossudovsky
Armenian Human Development Report 1996 UNDP 12 September 1996
Fact Sheet: Armenia The University of Michigan-Dearborn
“Black Sea.” Neal Ascherson
“The lost Heart of Asia.” Colin Thubron
“Sketches of a Karabakh soldier” 1918-1920. Zareh Melik-Shahnazarov
Report on the activities of the “Datev 95” Charitable Centre for Psychotherapy and
counselling assistance. May 1996 to May 1997
Mission Armenia Report
Centre for Democracy and Human Rights Report
The Law governing the Buildings, Territory and structure of Psychiatric Hospitals.
The Vardenis Internment By-laws
Minutes of a variety of meetings including meetings concerning Mental Health
Legislation with Toralf Hasvold MD, WHO Public Health Advisor for Armenia and
Georgia
US Department of State Country Report on Human Rights Practices for 1996
Amnesty International Report for 1996
Helsinki Monitor 3/1995 Russia, the OSCE, and Security in the Caucasus
Helsinki Monitor 7/1996 A marriage of convenience: The OSCE and Russia in
Nagorny-Karabakh and Chechnya
EURO WHO (European Region) Report
 APPENDIX 6
ROMANIAN LEAGUE FOR MENTAL HEALTH
STRATEGIC PLANNING

OUR VISION FOR THE FUTURE IS: “To become the leading membership based
organisation shaping Government policy and promoting alternative practices in mental
health in Romania”.
OBJECTIVES
1. Establish a critical mass of active individual members (powerful membership
base)
2. Attract critical mass of organisations (powerful membership base)
3. Create programme and present to Ministry and Parliament (shaping government
policy
4. Collect and distribute information on all alternatives (promoting alternative
practices)
5. Act as a catalyst for other people’s projects (promoting alternative practices)

STRATEGIES
Objective 1 Establish a critical mass of active individual members (powerful
membership base)
Strategy 1 Enlarge membership
Strategy 2 Convert enough members into activists
Objective 2 Attract critical mass of organisations (powerful membership base)
Strategy 1 Draft and consult with balanced/mixed experienced outsiders and
seek membership approval
Objective 3 Create programme and present to Ministry and Parliament (shaping
government policy)
Strategy 1 Share common government programme
Objective 4 Collect and distribute information on all alternatives (promoting
alternative practices)
Strategy 1 Create resource centre
Objective 5 Act as a catalyst for other people’s projects (promoting alternative
practices)
Strategy 1 Evaluate projects and find leader/team