Policy brief December 2018

Mental health and human rights Lessons from disability-inclusive development

Summary Thereisacloserelationshipbetweenmentalhealthandotherhealthanddevelopmentissues.Abroader,moreholisticapproachisrequiredtogobeyondtheidentificationandtreatmentofmentalconditions,byaddressingthesocialandstructuralriskfactorsthatdrivethem.Overlymedicalisedandinstitutionalisedmentalhealthsystemsrequirereform,andpeoplewithlivedexperienceofmentalillnessmusthaveastrongervoiceintheirpersonalrecoveryaswellasthepoliciesandpracticesthataffectthem.Buildingamoreinclusivesocietyforpeoplewithmentalconditionsandpsychosocialdisabilitiesmayseemlikeabigundertaking,buttherearemanypracticalstepsthatpolicy-makersandpractitionerscantaketobeginmakingchangeintherightdirection.

Key Recommendations •Recommendation1Supportthemeaningfulparticipationofpeoplewithlivedexperienceofmentalillnessintheactivitiesthataffectthemattheindividual,serviceandsystemslevels.Forexample,advanceddirectivesmayhelpindividualshavemoreofasayintheirtreatment,whiletheQualityRightsassessment,trainingandguidancetoolscanbeappliedbyadvocacyandothergroupstohelpdrivementalhealthsystemreformandultimatelychangehowpeoplearetreated.•Recommendation2Ensure“nooneisleftbehind”fromtheSustainableDevelopmentAgenda.Thismeansbeingexplicitaboutincludingmentalhealthinpolicyandprogrammingwithinandbeyondthehealthsector,forexamplebyadvocatingformentalhealthcareaspartofUniversalHealthCoverageandrequiringdevelopmentprogrammestocollectdataoninclusion.•Recommendation3Investincost-effectivesteppedcareandrecovery-orientedinterventionstoimprovethequalityandaccessibilityofmentalhealthcarewhilealsoimprovingcompliancewithhumanrightsinstruments.Thismayrequireclosercollaborationacrosshealthandsocialsectorsinordertobetteraddressthediverseneedsofpeoplewithmentalconditionsandpsychosocialdisabilities,whichgobeyondtreatment,andalsoaddresssocialbarrierstoinclusion.

Mental health and disability-inclusive development Consideringdisabilitygoesbeyondjustaddressingimpairmentsapersonmayhave,butaddressingthemanybarriersthatrestrictaperson’sfullandequalparticipationinsociety[Figure1].Hence,disability-inclusivedevelopmentisaboutmorethantreatingillnesstoreduceimpairment;it’saboutliftingbarriersandcreatingmoreequitableandjustsocieties.Takingadisability-inclusiveperspectivechallengesustothinkandtalkaboutmentalhealthinnewandimportantways,tackleinequitiesintheprovisionofhealthandsocialservices,andsupportpeopletoadvocatefortheirownrights.

Lesson 1: Simply identifying and treating people with mental conditions is not enough.First,mentalhealthandillnessexistonaspectrum.Whilediagnosiscanbeausefultooltohelpunderstandingandcommunication,categorisingpeopleaseithermentallyhealthyorillisofteninaccurate,canleadtolabellingandstigmatisationthatmayfeelworsethanthesymptomsthemselves,andisn’talwaysusefulinguidingdecisionsaboutcareandtreatment.Forexample,evidenceonnewapproachestomentalhealthcaresuggeststhatmanylow-cost,non-pharmaceuticalinterventionssuchastalkingtherapiescanbenefitpeoplewitharangeofdifferentdiagnosesandeventhosewithnodiagnosisatall.

Second,mentalhealthisnotjustahealthissue;itisanimportantsocialissue.Themutuallyreinforcingrelationshipbetweensocialinequalityandmentalconditionsiswell-documented.Forexample,researchershaveidentifiedinequalitiesineducationalattainment,income,housing,socialsupportandexposuretoviolenceasbothriskfactorsandoutcomesofmentalillness.Addressingtheseriskfactorsiscrucialtobreaktheviciouscyclebetweenillnessandinequality,andrequiresmoreholistic,multi-sectoralapproachestodevelopment.

Third,mentalillhealthwouldnotdisappearevenifthemosteffectiveserviceswereuniversallyavailable.Equitableaccesstohigh-qualitymentalhealthcareandsupportsisacruciallyimportanthumanrightsissue[Figure3].However,accesstoeventhemosteffectiveserviceswillnotworkforeveryoneorofferalifelong“cure”.Thisisanotherreasonwhyitissoimportanttotacklesocialriskfactors.

Fourth,recoveryismuchmorethansymptomreduction.Intherightenvironment,peoplewhodohavementalhealthproblemsstillleadfullandmeaningfullivesevenwhileexperiencingsymptoms.Further,peoplewhohavementalconditionsoftenratesocialoutcomes,suchastheabilitytoworkandhaveafamily,asmoreimportantthanclinicaloutcomeslikesymptomreduction.Strictlymedicalapproachestomentalhealtharenotalwaysinlinewithwhatpeoplemostwantorneed.Peopleaffectedshouldhavetheopportunitytodefinewhatrecoverymeansforthem.

Figure1.

What are we talking about? Health, il lness,wellbeinganddisabil ity•Mentalhealthisapositiveconceptthatreferstoourcapacitiesforthought,emotion,andbehaviourthatenableustorelatetopeoplearoundus,copewithlife’snormalstresses,studyorworkproductively,contributetoourcommunity,andultimatelyrealiseourpotential.•Whentheyaresevereenoughtolimitourabilitytodothesethings,behaviouralandemotionalproblemsaredefinedbyanumberofmentalconditions.•Ouroverallwellbeing,orhowsatisfiedwearethatwehaveagoodandfulfilledlife,canbehinderedbymentalillness,buteveryonecanworktoimprovetheirmentalhealthandwellbeing.•Thetermpsychosocialdisabilitiesgoesbeyondsimplylabellingindividualsasill,recognisingthatitisoftenbarrierstoparticipationthatmostnegativesaffectpeople’slives.Reducingbarriersandpromotinginclusioninsocietyisequallyimportanttosimplyprovidingtreatment.

Lesson 2: People with mental illness are being left behind. The2030SustainableDevelopmentAgendamakesacommitmentto“leavenoonebehind”.Deliveringonthiscommitmentisapriorityofthedisability-inclusivedevelopmentagenda.However,evenamongpeoplewithdisabilities,peoplewithpsychosocialdisabilitiesareamongthemostlikelytobeexcludedfromdevelopment[Figure2].Thismustchange.Monitoringinclusion,forexamplebyusingtheWashingtonGroupquestionsondisability,isanimportantfirststeptoensurethatpeoplewithmentalconditionsandpsychosocialdisabilitieshaveequalaccesstohealthandsocialservices.

Despiteglobaleffortstotackleinstitutionalisationofpeoplewithdisabilities,institutionalisedmentalhealthcareremainsarealityformany.Worldwide,nearlyafifthofinpatientsstayatpsychiatricinstitutionsforayearormore.Over70%ofgovernmentmentalhealthexpenditureinlow-andmiddle-incomecountriesisspentrunningthesefacilities.Thereisanurgentneedtoinvestincost-effectivesteppedcaretobringmentalhealthservicesoutofinstitutionsandintocommunities,asdirectedinArticle19oftheUnitedNations(UN)ConventionontheRightsofPersonswithDisabilities(CRPD)[Figure3].

Notonlyarementalhealthservicesoftenconcentratedininstitutions,theyarealsooutofreachformany.OveraquarterofUNmemberstatesdonotincludementalillnessintheirnationalhealthinsuranceorreimbursementschemes.InAfricaandSoutheastAsia,morethan40%ofmemberstatesrequirepeopletopaymostlyorentirelyoutofpocketformentalhealthcare.EnsuringmentalhealthispartoftheessentialpackageofservicestowhichgovernmentsguaranteeaffordableaccessunderUniversalHealthCoverageiscrucialtoprotectingtherighttohealthoutlinedinArticle25oftheCRPD[Figure3].

Lesson 3: It is time to act on the voices of people affected Peoplewithmentalillnessexperiencestigma,discriminationandsometimesshockingabusesoftheirmostbasichumanrights.Aroundtheworld,peoplewithmentalillnesshaveanelevatedriskofexperiencingviolence,poverty,homelessness,incarcerationandunemployment.Inmanycountries,peoplewithmentalillnessexperienceforcedrestraint,prolongedseclusion,sexualassaultandotherphysical,sexualandpsychologicalabusesinfamilyhomes,healthfacilities,socialcareinstitutionsandformalandinformalhealingcentres.

Thoseaffecteddonotalwayshavetheopportunitytoraisecomplaintsorseekjustice,partiallyasaresultofpoliticaldisenfranchisementandlackofappropriaterepresentation.OverathirdofUNmemberstatesdenyallpeoplewithmentalillnesstherighttovote,andrelativelyfeworganisationsactivelyrepresentpeoplewithmentalillnessinlow-andmiddle-incomecountries.LessthanathirdofcountriesintheAfricanregionhavemechanismsinplacetoconsultmentalhealthserviceusersandtheirfamiliesontheissuesthatimpactthem.

Figure2.

Discrimination against people with mental illness in development TwoexamplesfromtheWorldHealthOrganisation(2010)MentalHealthandDevelopmentreport

•HealthinsuranceinKenya:Thenationalhospitalinsurancefundexcludesmentalhealthcare;costsareoftenbornebypatientsandtheirfamilies.•SocialprotectioninUganda:Peoplewithmentalillnesshavebeendeniedaccesstomicrocreditbecausetheywerebelievedtobeunabletorepayloans.

Themostimportantstepwecantaketochallengethestatusquoistosupporttheempowermentofpeoplewithlivedexperiencetotakeastand,atapersonallevelaswellasapolicylevel.Recovery-orientedapproachestomentalhealthacknowledgethatpeoplewithlivedexperiencearebestplacedtodeterminewhichoutcomesaremostimportanttothemandhowtheirneedscanbestbemet—sometimeswiththesupportofatrustedfriend,familymemberorcaremanagertohelpnavigatethecomplexitiesofthehealthandsocialsectors.Peerinterventionssuchasself-helpgroupscansupportpersonalrecoverywhilealsocreatingaplatformforfurtheradvocacy,forexampleusingtheWorldHealthOrganisation’sQualityRightsassessment,trainingandguidancetoolstomonitorCRPDcomplianceandpushformentalhealthsystemreform.Unfortunately,todate,evenwherethereispolicyinplace,itoftendoesnotalignwelltoglobalhumanrightsinstruments,andtherearenotgoodmonitoringmechanismsinplace.

More information 1. BhugraD,PathareS,GosaviC,etal.Mentalillnessandtherighttovote:areviewoflegislationacross

theworld.InternationalReviewofPsychiatry,2016;28:395-9.2. DrewN,FunkM,TangS,etal.Humanrightsviolationsofpeoplewithmentalandpsychosocial

disabilities:anunresolvedglobalcrisis.TheLancet,2011;378(9803):1664-75.3. WHOQualityRightsinitiative–improvingquality,promotinghumanrights[internet]WorldHealth

Organization2017,[cited2017Jun8]Availablefrom:http://www.who.int/mental_health/policy/quality_rights/en/

4. WorldHealthOrganization.WHOQualityRightsguidanceandtrainingtools.[internet]WorldHealthOrganization2017,Availablefrom:http://www.who.int/mental_health/policy/quality_rights/guidance_training_tools/en/LancetCommissiononGlobalMentalHealthandSustainableDevelopment.TheLancet,2018.

5. UNConventionontheRightsofPersonswithDisabilities.NewYork:UnitedNations,2006.6. WHO.MentalHealthAtlas2017.Geneva:WorldHealthOrganisation,2018.

Acknowledgements ThispolicybriefwasproducedbytheMentalHealthInnovationNetworkforUnitedforGlobalMentalHealthwithfundingfromtheWellcomeTrust.

Publicationdetails:©LondonSchoolofHygiene&TropicalMedicine,December2018

Coverimage:Womencarryingnetstogether,Lomé,Togo©CBMInternational,2016

Suggestedcitation:JulianEaton,GraceRyan,OnaizaQureshi,NatashaSalaria.Mentalhealthandhumanrighs:Lessonsfromdisability-inclusivedevelopment.MentalHealthInnovationNetwork,CentreforGlobalMentalHealth,London,UK:LondonSchoolofHygiene&TropicalMedicine,2018.

Disclaimer:TheviewsexpressedinthispublicationarethoseoftheauthorsandshouldnotbeattributedtotheMentalHealthInnovationNetwork,UnitedforGlobalMentalHealth,theirfundersoraffiliates.

Figure3.

Convention on the Rights of Persons with Disabilities Whatdoes it meanforpeoplewithpsychosociald isabilities?Thereshouldbenodiscriminationagainstpeoplewithpsychosocialdisabilities.Thismeansbeingabletoliveincommunities(Article19),accesscivilandpoliticalrights(29),betreatedwithdignityinservices(24,25),earnaliving(27),andbeabletomakedecisionsabouttheirownlives(12,14).PeoplewithpsychosocialdisabilitiesshouldalsoparticipateinreportingoncompliancewiththearticlesoftheConvention,butareoftenexcluded.