Human rights and Mental health: critical challenges for health professionals, users, and citizens’

Reports from United Nations Institutions have denounced respect for human rights and the discrimination of people with mental health conditions as a critical issue (United Nations, 2017, 2020, and 2022).

People with psychosocial disabilities are often denied basic civil rights in many countries, they cannot marry, have children, vote, or access to decent work, and they are exposed to inhuman treatments without any right to decide on treatment choices (Carta et al., 2020; Moro et al., 2022; Zgueb et al., 2020).

Although psychosocial disability accounts for one-third of the total disability worldwide, most people suffering from mental health conditions do not have access to mental health care of a sufficient level of quality (Moro et al., 2021; Vigo et al., 2016).

Around 80% of people with mental health conditions reside in low and middle-income countries where the expenditure for mental health care was less than 25 cents per capita per year in the pre-Covid era (Rathod et al., 2017). However, even in some rich countries with a great tradition of implementing community mental health care, such as Italy (in which the so-called “Basaglia low” closed psychiatric asylums), there has been a progressive impoverishment of the resources dedicated to mental health; this is partly due to low public spending on health but also reflects increased disinterest of rights of people with psychosocial disabilities (Carta et al., 2020).

Although the World Health Organisation guidelines promote community care [WHO., 2021], mental health care is mainly provided by psychiatric hospitals in most countries [Moro et al., 2022]. In several lower-income countries, many people with mental health conditions receive care from faith-based and traditional healers, but human rights violations were also denounced mainly in such a setting, for example, in prayer camps in West Africa (Human Rights Watch visits to Mount Horeb Prayer Camp, Mamfi, Eastern Region, 2012). There is no doubt that part of the reason for this is to do with explanatory models of illnesses but also due to lack of professional services.

The Covid emergency has dramatically highlighted, also in Europe and in other wealthy countries, the need to improve the support for people with psychosocial disabilities. An excess of Covid mortality for people with mental health conditions has been reported (Nemani et al., 2021). Indeed, during the pandemic, dramatic situations and even specific high mortality were described in the so-called “residential facilities” and “nursing homes” for older adults with cognitive impairment and people with mental health conditions (Carta and Bhugra, 2022), with the absurd situations of people with disabilities being abandoned and left to starve, as denounced in a European Country (The Guardian, 2021).

The organisations of people with psychosocial disabilities and the civil society organisations promoting the rights of these persons are either non-existent in many countries. If they do exist, they often lack the power to make a difference in several countries (Moro et al., 2022).

The objective of this special issue is to take stock of the situation and to collect suggestions and proposals to improve the horizon.

The review of the literature conducted by Mandiarian et al. (16) provides an overview of the current global situation of human rights in mental health services. This contribution shows that “despite significant improvements …in the past decade, there is still ….prominence of stigmatizing attitudes, and human rights violations and abuses in mental health settings”. The authors suggest “developing a more comprehensive model in mental health that integrates human rights into existing services and approaches”.

The prestigious contribution of Saraceno (17), an author famous for having always been at the forefront of the promotion of human rights in mental health, as well as having directed the Mental Health section of the World Health Organisation for a considerable period, indicates a “disturbing rift between the rhetoric of speech and complicity in practice” as studies and initiatives often have difficulty linking human rights violations to the places where such violations are practised. According to Saraceno, a possible explanation for the resistance to any substantial change often lies in a dominant culture that emphasises the dangerousness of persons with severe mental disorders and feeds a therapeutic pessimism even in psychiatrists.

Considering Saraceno’s indications, the contribution of Schomerus et al. (18), who investigated public attitudes towards protecting human rights, assumes additional importance. Authors found in recent data of studies carried out on people living in the community, scarce improvement in attitudes towards protecting human rights over the last decade, and in contrast, support for several restrictions in several countries, particularly support for restricting job opportunities for people with mental illness.

Nosè and Coll (19). addressed the issue of the impact of the pandemic on the well-being of individuals with pre-existing severe mental health conditions. Results of their systematic review indicate that “people with pre-existing mental health conditions were more likely to report greater self-isolation distress, anxiety, depression, COVID-19-related perceived stress, and were more likely to self-isolate voluntarily”. So, the pandemic determined a reduction in the well-being of people with mental health conditions, with increased inequalities and disrespect of the rights of these people.

Although mental health resources in the only country in the world that has closed psychiatric hospitals seem to be drastically decreasing, the work of Cossu et al (20) has found in Italy that, during the pandemic, “mental health services users show a higher level of satisfaction for care and higher perception of users’ human rights respect compared to non-mental health facilities users”. Thus, it is most likely that community-focused support and assistance, therefore closer to other networks (such as the social services of the municipalities and voluntary networks) and/or informal (family and friends) has withstood the impact of the pandemic much better than in other realities or in other sectors of healthcare where treatments more centred in the hospital.

The paper by Wincker (21) based on field experience, offers some ideas on how to deal with coercion in mental health care settings. These authors underline how non-coercive treatment can be delivered by adapted treatment, open-door policies, advanced care decisions, and overcoming the biomedical model of mental illness. They recommend introducing WHO’s QualityRights Training to improve knowledge of human rights standards and promote a non-coercive and respect of human rights approach.

A systematic review of the literature on the consequences of compulsory treatments on subsequent treatment adherence in mental health care is presented (22). Although the studies carried out so far are often poor and weak, the data do not show a trend of improvements in adherence. They do not exclude (indeed, they suggest) the possibility of worse compliance after compulsory hospitalisation. The authors conclude that such an important topic must be addressed in future explorations and research.

Managing patients with serious disabilities can also lead to personal job satisfaction if carried out properly. Through the analysis of the main components of a specially administered tool, Aviles-Gonzales (23) found that in the health professionals of three Latin American countries, the greater respect for the rights of patients produced higher levels of job satisfaction as well as organisational well-being. The researchers, therefore, conclude that the perception of respect for users’ rights is an essential component of organisational well-being in mental health services.

At the end of the special issue, we recognise that these contributions are selective and although authoritative, often do not provide a total picture which is an authoritative and comprehensive picture of the situation around the world. This issue illustrates that much more work needs to be done to manage a challenge that requires a heavy commitment from professionals, families, social partners, policymakers and citizens. This special issue, rather than a summary of everything that could have been written, therefore, is intended to bring together significant contributions to stimulate operators and researchers to continue their commitment.