The written case presentation was used as an introduction to the discussion about the criteria for granting DP in the interviews. All participants evaluated the case as a typical DP issue and that the necessary criteria were presented. Almost all of the participants in both countries had evaluated similar patients and used their own professional experience in the evaluation of the case-vignette.
The diagnostic hierarchy and need for expertise in the diagnostic process
Even if the demand for a diagnostic evaluation was apparent in both the Norwegian and Russian interviews, it was more emphasized in the Russian ones. It was also apparent that the ability to undertake such an evaluation was to a larger extent among the Russians associated with the status as an expert in the field. The following quotation is an example:
Yes, a diagnosis is the most important factor. And the diagnosis should be made on a high professional level, the so-called expert level: it should include severity of the disease, whether the patient has some mental defects, how much his psychic functioning reduced and so on.
(Russian psychiatrist, out-patient department)
In contrast, a distinct aspect of the Norwegian interviews was the emphasis of the independent status of the GP as the responsible person for the medical evaluation. This was expressed in the following quotation:
But here in Tromsø, it is not usual for GP to get outside help in the evaluation of DP cases.
(Norwegian GP)
Both Russian and Norwegian specialists pointed out that it is easier to get DP for patients with psychotic diagnosis (schizophrenia) than those with a neurosis or personality disorder. However, the Russian psychiatrists had clearer hierarchical preference among diagnoses:
Yes, if the patient has schizophrenia, it is usual for this kind of patient to be granted a pension, as it is difficult for him to deal with others... So, in my certification, I will argue, on based on the nature of the nature of the disorder.... And with such a diagnosis he will get DP much more easily. (Russian psychiatrist, mental hospital)
The Russian respondents have argued for diagnostic preference and use both clinical and social-economic criteria, with the importance of the latter being the more critical:
It would be more difficult to apply for a patient with personality disorder and even more so for patients with a neurosis. In this case, you need to prove high level of social dysfunction: that he has frequently changed employment, many family issues, and many hospitalizations and so on.
(Russian psychiatrist, mental hospital)
Also in the Norwegian interviews, the different psychiatric diagnoses were considered in a similar hierarchy but not as a reason to delegate the process to a higher level of expertise. In the case of patients with non psychotic disorders, the diagnostic process may be especially difficult. The distinction between a mild psychiatric disorder and normal variation in behavior can be difficult, and in such cases the GP evaluated his/her own competence as insufficient, indicating that experts should be involved. However, the experts were regarded as complimentary, not as a reason for the GP to turn over the application process entirely to experts:
When it comes to neurotic and personality disturbances – this is another situation, and it could be suitable to insist upon the independent evaluations of two or three specialists – psychiatrists or psychologists.
(Norwegian GP)
Balancing the medical and functional/social criteria
The medical criteria were underlined by the Norwegian participants as important but other factors such as the outcome of the rehabilitation process and the social situation were evaluated on at least the same level.
The medical arguments are only arguments which should be taken in account. We need to focus on them... Sometimes, however, especially with regard to psychiatric patients, the social situation and the possibility to get a job can strongly influence the decision...
Even representatives of the medical profession, GPs and psychiatrists, underlined that the rehabilitation criterion was the most important. This is expressed below:
What exactly they have tried is difficult to know. You can read that they have tried all that is needed. First of all, I would like to know if they have tried vocational rehabilitation ... or if he has been evaluated at an employment office.
(Norwegian GP)
The SIO officer agreed about the importance of the medical criteria, but they showed broader interest into the background information about the patient. They wanted to have a total picture of the patient and an awareness of the entire situation before making a final decision. As is clear from the next quotation, the background information is rutinely collected not only from the patient, but also in other ways.
The medical certification is necessary in all cases. We have also to know about their background, working experience... The patient self report on these questions, as usual, and we have also information registered in our data system. So we have report about all of them where they have worked, income etc...
(Norwegian Country SIO officer)
The Russian participants evaluated the medical criterion as the most decisive one and pointed out that the other factors were usually consequences of the medical condition. They were also interested in patient's working experience and social situation, but this was evaluated as additional information that illustrated the severity of the disorder.
We would base our decision on clinical data here. It is quite clear that he has some paranoid symptoms which hinder him not only at work, but also socially. It is also very important that he doesn't have insight into his condition.
(Russian psychiatrist, mental hospital)
Not only medical doctors, but also social workers with not-medical professional background placed the criteria in the same order:
I think that first of all, his health condition is important. And other factors... If he can not make money, it is mostly consequence of his health condition which is reason for all the other factors... Delusions! He has never managed to get rid of them. He can not concentrate on a concrete task.
(Russian social worker, mental hospital)
Another tendency was that the psychiatrist working at the out-patient clinic was more prone to put weight on social factors and introduced the phrase "social maladjustment" as the most important aspect. Thus, it appears that the site of the evaluation (mental hospital versus out-patient clinic) may influence the weighting of the criteria more than the professional background of the persons involved.
The degree of social maladjustment is the most importent criterion. When the patient is in such a poor clinical state that he can not manage to be adapt to society. That is the reason he has not been able to work so long time.
(Russian psychiatrist, out-patient department)
The criteria for evaluation of a functional reduction are more detailed in Russia, where the criteria have been operationalised (see below). The Russian psychiatrists have the guidelines for the evaluation present on their desks, indicating that the criteria are well known by the professional community.
We have a table with detailed explanation of all criteria on our desk... Every medical doctor working here should have such table...
(Russian psychiatrist, mental out-patient department)