Reforming Undergraduate Psychiatry Training in Ukraine.

In Ukraine, mental health problems are common yet the mental health services available are still old fashioned and based on healthcare approaches used in the Soviet Union, providing mainly inpatient services and rudimentary community services. The World Health Organization (WHO) introduced the Mental Health Gap Action Programme (mhGAP) to reduce the mental health treatment gap all over the world and 2 years later introduced the WHO mhGAP-Intervention Guide (mhGAP-IG), version 2.0 (2016) as not only an educational tool, but also an evidence based guideline to scale up services for mental, neurological and substance use (MNS) conditions with an objective to reduce gap between available health systems capacity and resources for mental health. The main aim of this paper is to describe reforms of undergraduate psychiatry training in Ukraine using Kyiv Medical University as a case example. Kyiv Medical University (KMU) is the first university in Ukraine to introduce the mhGAP-IG in Ukraine. The revised psychiatry curricula in KMU aims to strengthens the evidence based teaching practices, to put emphasis on community orientated mental health care, and to use interactive teaching methods that the university hopes will attract more future doctors to psychiatry and ideally contribute towards the reduction of the mental health treatment-gap in Ukraine.

Ukraine is the largest European country, stretching across 603,628 square kilometres, from Russia in the east, to Poland in the west, and sandwiched between the Black Sea in the south and Belarus in the north. While the war in the East of Ukraine broke out in 2013, the Ukrainian government still does not have control over 13% of the Ukrainian territory today. The war and occupation of Crimea resulted in the displacement of 1.5 million of people, with more than one third of them suffering with post-traumatic stress disorder (PTSD).[1]

Even before the war in Ukraine, mental health problems were common and the mental health services available at this time were long outdated.[2] However, mental health services have changed very little since the Soviet times, with large psychiatric hospitals still providing inpatient services and rudimentary community services. Today, the provision of mental health services by family physicians is very limited and mental health care services in general lack continuity as a result of limited communication between providers. Stigma, out of pocket payments and an uneven geographical distribution of mental health providers all contribute to the widening gap between the need for mental services and the accessibility of such services within Ukraine.

In order to reduce the burden of mental health disorder globally, the World Health Organization (WHO)[3] developed WHO Mental Health Gap Action Programme Intervention Guide (mhGAP-IG). The mhGAP-IG contains only evidence-based recommendations that have been converted into explicit, step-by-step interventions. The mhGAP iniative calls for the integration of mental health care within non-specialized health settings (eg, primary care), with the provision of the necessary educational tools and resources.

A recent systematic review of the WHO’s[4] mhGAP-IG underscored that while the mhGAP-IG continues to be used within in-service training for the existing health care workforce, the implementation of the intervention guide in pre-service training remains very limited or not reported.

While mhGAP-IG in-service training is important in building capacity of health care professionals in non-specialist health settings, to assess and manage priority mental health disorders, there are long-term advantages in integrating WHO’s mhGAP-IG into pre-service training. These include (1) sustainability, as mhGAP-IG can be integrated into teaching curricula, does not require additional courses and mhGAP-IG is periodically updated by WHO based on current evidence; (2) cost effectiveness, as it reduces the need for more expensive in-service training; (3) the opportunity to develop a common understanding among different categories of health workers (psychologists, social workers, and other allied professionals) about the assessment and management of common mental health disorders; and (4) strengthening of health systems in the long term by building the health work force’s capacity to provide high-quality evidence-based care and providing a reference point for later in-service training. Integrating mhGAP-IG into pre-service training is therefore an important public health opportunity.[5]

Kyiv Medical University (KMU) has decided to incorporate Ukrainian version of mhGAP-IG[6] into the undergraduate Psychiatry curriculum after the WHO’s ‘mhGAP-IG in Pre-Service Education: Training of Trainers and Supervisors’ workshop that was held in Kiev, Ukraine, in December of 2018.

In early 2019, KMU revised the existing Psychiatry and Narcology training curriculum and in June 2019, received approval of the new curriculum from the Scientific Council. The old curriculum embraced didactic forms of teaching and learning. The introduction of the mhGAP-IG allowed for optimization of recourses, reduction of didactic sessions from 20 academic hours to 10 academic hours, and maintaining the same amount of hours spent on interactive practical sessions while putting more emphasis on self-studies using mhGAP-IG online materials. Student’s progress was assessed during clinical cases discussions in the classroom. KMU implemented the new mhGAP-IG enhanced curriculum in September of 2019. The lecture plans were adjusted, with modules of mhGAP-IG included on the following topics: dementia and epilepsy; disorders due to substance use; child and adolescent mental and behavioural disorders. The WHO’s mhGAP-IG as a clinical tool is also actively utilized in ‘small-group’ learning, covering the following topics: disorders due to substance use, epilepsy, child and adolescent mental and behavioural disorders.

The revised psychiatry curricula in KMU aims to strengthens the evidence based teaching practices, to put emphasis on community orientated mental health care, and to use interactive teaching methods that the university hopes will attract more future doctors to psychiatry and ideally contribute towards the reduction of the mental health treatment-gap in Ukraine.