Should a psychiatrist face prison for obeying the law? This was the question raised by the case of an anonymous Georgian psychiatrist who, until this past week, was facing criminal proceedings for not having admitted a patient with co-occurring mental health and substance use disorders. This doctor’s case brings to the forefront a broader issue within Georgia’s healthcare system, where people with co-occurring disorders are not able to receive care.
Stuck between two systems
In 2019, a patient with co-occurring substance use and neurological disorders was admitted to an addiction treatment clinic for short-term detoxification. However, as withdrawal set in through the treatment and his mental state deteriorated, he was discharged by the clinic and was sent to another addiction treatment centre, which demanded an unreasonably high payment for treatment.
Unable to pay, the only alternative for the patient was to be referred to the psychiatric division of the same clinic, which offers free treatment and operates through a separate license. Despite still needing drug treatment, Georgian addiction facilities lack licensing, training, and clinical guidelines to treat psychiatric or neurological conditions.
For unknown reasons (most likely due to the fact that their preference was addiction treatment and not mental health care), the patient and his caregivers refused to be admitted to the mental health hospital. With no care pathway, the patient was sent home.
Soon after, while experiencing a psychotic state associated with consuming an illegally produced substance locally known as managua (a boiled cannabis plant), the patient killed his 13-year-old nephew.
In the aftermath, the family sued the psychiatrist, who shared with me that they had barely seen the patient and had not been able to properly evaluate him.
Many of the issues with this patient’s challenges are not clinical, but structural; the siloed Georgian healthcare system has some crucial barriers that prevent the appropriate treatment of drug issues with co-occurring disorders.
Luckily, this case was resolved in the doctor’s favour and the court found them innocent. This is a step forward in Georgian mental health and addiction policy and practice. However, it is just a drop in the ocean and the issue remains prevalent.
A Soviet legacy that needs to be changed
Due to the enduring legacy of the Soviet-era approach in Georgia, psychiatry and addiction treatment remain institutionally and legally separated. As a result, patients with co-occurring conditions are routinely denied care by both systems. This case is a prime example of the deadly consequences of unresolved systemic failures.
Georgia’s separation of psychiatry and addiction medicine is an outdated remnant of a treatment model rooted in moral judgment rather than clinical evidence. Across former Soviet countries, substance use has long been treated as deviance or criminality, while psychiatry developed as a siloed discipline focused narrowly on “mental illness.”
The segregation of addiction and mental health persists despite decades of global research and evidence showing that co-occurring disorders are highly prevalent: in the US, approximately 53% of people with substance use disorders experience mental health challenges.
Mental health and substance use are commonly co-occurring. According to extensive health research, these two healthcare conditions share common underlying causes. These include, but are not limited to, trauma, similar changes in brain chemistry, genetic vulnerabilities, and more.
Many countries have moved beyond this model. Integrated treatment for co-occurring disorders is now standard across Europe. Despite challenges, these systems recognise addiction as a chronic medical condition and treat substance use and mental health together, across inpatient and outpatient settings.
Georgia, however, maintains the Soviet approach, as do many Eastern European countries. According to researchers, other post-Soviet countries such as Ukraine, Belarus, Moldova and Estonia face similar issues.
Root causes: trauma, poverty, and a transformed drug market
Since gaining independence just over 30 years ago, Georgia has survived armed conflicts, mass internal displacement, and prolonged economic instability. After the demise of the Soviet Union, thousands of families fled violence in Abkhazia and South Ossetia. These internally displaced people experienced torture, violence, detention, and family separation. Research shows that conflict exposure and forced displacement increase the risk of both mental health conditions and substance use disorders.
Research and collective experience of professionals working in the field illustrate that many veterans and displaced persons developed untreated post-traumatic stress disorder (PTSD). Untreated PTSD is strongly associated with increased alcohol and drug use as a form of self-medication, of which the former already happens in concerning amounts.
At the same time, Georgia’s drug supply has dramatically changed in the past decade. While opioid use once dominated the drug market in the country, the mid-2010s saw a rapid influx of new psychoactive substances, including synthetic cannabinoids and stimulants. These substances are associated with a wide range of mental health issues that include depression, anxiety and psychosis. National surveys and European monitoring data show that Georgian adults use certain psychoactive substances at higher rates than their European peers. What Georgia lacks is data on the mental health consequences of this shift.
Poverty further deepens the crisis. More than one-fifth of Georgians lived below the poverty line in 2020, with unemployment hovering near 12%. Poverty is one of the biggest social determinants of mental illness and substance use, trapping people in cycles of instability. The COVID-19 pandemic worsened these conditions, straining public resources while accelerating changes in the illicit drug market.
A denial of care and of rights
Even though Georgia provides universal healthcare, access to mental health and substance use treatment funding remains severely limited. Many patients wait months for treatment, with many paying out of pocket to access it. Private insurance, often acquired by one’s employer, rarely covers addiction or mental health services.
Even if covered, unemployment rates for people with substance use disorders remain high. Additionally, many people would avoid care out of fear of stigma, discrimination, or losing employment. Even though mental health treatment is better regulated, funding streams are extremely siloed with no incentives for integrated care.
Substance use in Georgia remains highly criminalised, with the Soviet moralistic approach to addiction still firmly in place. People with co-occurring disorders face double-fold stigma and no options for help, excluded from both mental health and addiction systems due to the complexity of their needs. But it is precisely because of the complexity of their situation that the state must support them.
Failing to help people access appropriate treatment is not only a public health issue but also a human rights issue. Denying people access to essential healthcare is not only a violation of their right to health, but in some cases it impedes their right to life. In the tragic example of this patient, the lack of access can have fatal consequences.
With no formal national strategy to recognise co-occurring mental health and substance use disorder treatment in the healthcare system, healthcare providers are neither informed nor trained to support those with complex needs. Separate operating licenses for mental health and addiction treatment services even prevents professionals with psychiatric and addiction treatment licences from providing integrated care to patients.
Criminalising doctors will not fix broken systems
This doctor’s case should alarm policymakers far beyond Georgia.
Part of the problem is the stigma around addiction. Reform must begin with acknowledging addiction as a chronic yet treatable medical condition, as defined by the American Society of Addiction Medicine.
Several other steps are needed to address this crisis. Georgia must create unified clinic licenses for integrated services. The country must develop national clinical guidelines for the treatment of co-occurring disorders. Mandatory training and continuing education on co-occurring disorder treatment must be incorporated into educational curricula.
Simultaneously, investment in local research and data infrastructure is essential to guide policy. Without coordinated action across licensing, regulation, financing, and workforce development, even the most skilled clinicians remain legally barred from providing the care that Georgian people with co-occurring disorders desperately need.
The tragedy that unfolded in this case was produced by a system that excludes people in need of care and punishes doctors for the country’s antiquated healthcare system. If Georgia continues to criminalise doctors for structural failures, we will only deepen the crisis we refuse and are unable to confront.
