Department of Public Health and Caring Sciences
Course Code: 3FV182
Authors: Hayrettin Yildirim, Karin Sillén, Ling Shen
Examiner: Pranee Lundberg
Challenges in Global Health, 7.5 ECTS
Mental health refers to a broad array of activities directly or indirectly related to the mental well-being component included in the World Health Organization (WHO)’s definition of health: “A state of complete physical, mental and social well-being, and not merely the absence of disease”. It is related to the promotion of well-being, the prevention of mental disorders, and the treatment and rehabilitation of people affected by mental disorders. Mental health is not just the absence of mental disorder. It is a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. Mental health challenges and disorders have many different signs and symptoms and can look different outcomes. The challenges can impact how a person thinks, feels and behaves. Some common symptoms of a mental health challenge or disorder are: changes in mood, and in the way you perceive things; obsessions; fears; feelings of anxiety. Mental health challenges and disorders can happen to anyone. They affect people of all ages, races and social classes. No one is immune.
In most countries, particularly low- and middle-income countries, mental health services are severely short of resources – both human and financial, which make it a socio-economical challenge. The best way to prevent mental health challenges from getting worse is to recognize symptoms early and get professional help. Many mental health challenges and disorders can be treated successfully. When the signs are recognized early, that person can get started on the path to a full recovery.
Aim and questions
To achieve better understanding of challenges in mental health prevention and the role of human rights in mental health promotion nationally and internationally.
- What are the challenges of human rights in mental health promotion?
- What is the content of human rights in mental health promotion internationally?
- How do patients experience compulsory psychiatric care in Sweden?
Literature search strategy
Database: Google Scholar, pubmed.com, World Health Organization, Statistics Sweden
The search terms used were mental health, mental illness, human rights, psykisk sjukdom tvångsvård,
World facts and statistics
Globally, (25%), suffer from mental disorders in both developed and developing countries. Four of the six leading causes of years lived with disability are depression, alcohol use disorders, schizophrenia, and bipolar disorder (WHO, 2013). Mental illness in the U.S., Canada, and Western Europe ranks first among illnesses that result in disability. In 2010, depression ranked the second for global disease burden. By 2020, depression is projected to be the leading cause of years lived with disability worldwide (WHO, 2013). The global cost of mental illness is estimated at nearly $2.5 trillion (T) (two thirds in indirect costs) in 2010, with a projected increase to over $6T by 2030. To put that in perspective, the entire global health spending in 2009 was $5.1T. The annual GDP for low-income countries is less than $1T. The entire overseas development aid over the past 20 years is less than $2.3T (Bloom et.al, 2011).
Worldwide, someone commits suicide every 40 seconds. About 1 million die by suicide every year, 86% of suicides occur in low- and middle-income countries (WHO, 2013). Mental illness accounts for more than 15% of the overall burden of disease from all causes in established market economies, such as the U.S. – slightly more than that of cancer. Mental illnesses do not discriminate, they can affect anyone: men, women and children, regardless of gender, race, ethnicity, and socio-economic status (WHO, 2013)
Stigma and Discrimination
The stigma attached to mental illness, and to the people who have it, is a major obstacle to better care and to the improvement of the quality of their lives. The public and health professionals often have negative attitudes to people with mental illness and will behave accordingly once they are told that a person has an illness about which they have prejudices. In addition to this, Psychiatrists and other mental health staff also stigmatize patients in other ways. Until recently psychiatrists in some European countries and elsewhere were requesting longer holidays and a higher salary than other doctors because they had to work with mentally ill patients who are dangerous, while arguing, at the same time, that mental illness is no different from other illnesses. Consequently, we can say that, psychiatrists and other medical professionals are not sufficiently engaged in fighting stigma and discrimination related to mental illness; what is worse, they may be contributing to it in various ways. (Norman Sartorious 2002)
People with mental health problems face poverty, homelessness and unemployment due to discrimination in the workplace and the benefits system. Those experiencing mental illness are often wrongly denied benefits, excluded from insurance cover and vulnerable to exploitation from credit card companies, often leading to them to rack up unmanageable debts. Therefore, this discrimination was undermining the ability of people with mental health problems to cope with everyday life and often exacerbated their illness. Private and voluntary sector staffs who deal with people with mental health problems should have awareness training to avoid them treating people unfairly (David Batty 2004). Not only doctors, but everyone must make his/her contribution to eliminate stigma/discrimination and fight it in every way possible.
In Turkey, we have mostly severe cases that are being treated. Because most of people think and are aware of the fact that once they talk about their problems, they will be treated differently and discriminated from the society. This is the case in almost all countries, the fear of stigmatization and discrimination lead people with mental disorders not to be cared until they have severe problems noticed by everyone.
When it comes to their rights, in Turkey, the state has separate hospitals and care centers for people with mental illness. In addition to this, regarding the rules or laws that promote the rights of these people, the state introduces new laws in order to meet the need for these people’s rights which are determined or set by UN and EU. According to Aşkın Asan, the assistant of the minister for the Family and Social Policies, “the current aim of the state is not to introduce new rules that can give more rights to disabled citizens (-mentally or physically-There is no specific policy for those who mentally disabled, the policies include all disabled citizens), but to change minds towards them, to provide them an environment that they feel equal, and to get rid of the prejudices about them, this is what they need and want.” he said. (Engelli ve Yaşlı Hizmetleri 2013)
As we see, stigma and discrimination seems to be the basic problems in Turkey, as in all other countries. Therefore, the best way to help people with mental illness is to get rid of prejudices that causes to stigma and discrimination.
Ten Basic Principles for Mental Health Care Law
Here is an edited version of a WHO document which lists and describes ten basic principles of mental health care law. It also provides annotations (in the original form of document) for their implementation in practice. Ten basic principles in this document also mean the rights for people with mental illness all over the world.
The first principle is “Promotion of Mental Health and Prevention of Mental Disorders.” According to this principle, everyone should benefit from the best possible measures to promote their mental well-being and to prevent mental disorders. The second is “Access to Basic Mental Health Care”, which can be defined as; everyone in need should have access to basic mental health care. The third principle is “Mental Health Assessments in Accordance with Internationally Accepted Principles.” Regarding this principle, mental health assessments should be made in accordance with internationally accepted medical principles and instruments (e.g: WHO’s ICD-10 Classification of Mental and Behavioural Disorders – Clinical Descriptions and Diagnostic Guidelines, Tenth Revision, 1992). “Provision of the Least Restrictive Type of Mental Health Care” is another principle which means that persons with mental health disorders should be provided with health care which is the least
restrictive. The fifth one, “Self-Determination” principle, says that consent is required before any type of interference with a person can occur. Another principle is “Right to be Assisted in the Exercise of Self-Determination.” In case a patient merely experiences difficulties in appreciating the implications of a decision, although not unable to decide, he/she shall benefit from the assistance of a knowledgeable third party of his or her choice. Principle seven regards “Availability of Review Procedure.” According to this principle, there should be a review procedure available for any decision made by official (judge) or
surrogate (representative, e.g. guardian) decision-makers and by health care providers. The eighth principle is “Automatic Periodical Review Mechanism.” Regarding this principle, in the case of a decision affecting integrity (treatment) and/or liberty (hospitalization) with a long-lasting impact, there should be an automatic periodical review mechanism. “Qualified Decision-Maker” is the another principle, which can be explained as; decision-makers acting in official capacity (e.g. judge) or surrogate (consent-giving) capacity (e.g. relative, friend, guardian) shall be qualified to do so. The last principle is “Respect of the Rule of Law.” This principle means that decisions should be made in keeping with the body of law in force in the jurisdiction involved and not on another basis nor on an arbitrary basis. (WHO 1996)
During the recent years there has been an increase in depression and anxiety in the Swedish population. The numbers of sick leave because of burnout syndromes and stress related depressive disorders have increased dramatically. In 2004 approximately every fourth of the women (24%) and every sixth (16%) of the men reported psychological distress. In older people, especially in women, the prevalence of depression is high. In 2004, 42% of women and 19% of men aged 75 or older reported being depressed. In 2000 about one fifth (20%) of the 13 year-old boys and girls reported being bullied at least once during the previous months (Danielsson et al. 2012)
Sweden has a long tradition in preventive work. The most comprehensive prevention project in the field of mental health has been the developing of alcohol policy at the beginning of the 20th century. Mental ill health prevention is one priority area in the Swedish health care act. Prevention of mental disorders and promotion of mental health is mentioned in most key policy documents in the field of health. The idea is that prevention and promotion should be an integrated part of the work that is undertaken in the health care sector, in the schools and at the work places. At the county level almost all county councils have adopted health plans in which mental ill health is noted as one of the largest public health problems.
Compulsory psychiatric care in Sweden
According to the National Board of Health and Welfare (Socialstyrelsen) in Sweden, 3000 people are being treated under compulsory psychiatric care everyday in Sweden. These people are treated according to the Swedish law. It´s fundamental with good collaboration between everyone who´s involved in compulsory psychiatric care, but unfortunately this is not always the case. The United Nations states that a patient’s treatment must be based on an individual plan, which includes the patient’s involvement (United Nations, A7/RES746/119: Principle 9:2). The treatment is highly affected by the surrounding environment, care system, and patient safety (the National Board of Health and Welfare).
There are important factors that need to be incorporated when treating a person under compulsory psychiatric care. The patient must get information about his/her rights, be given the opportunity to express his/her views on the treatment, and the patient has to feel like he/she can trust the psychiatric care staff. Unless it´s not against the law of confidentiality, the patients family member or closest related should also attain information about the treatment. Compulsory psychiatric care is different kinds of treatments; amongst many things the patient must not leave the clinic, take compulsory medication, and clamping. The patient is thus allowed to communicate with the surrounding world, either by telephone or Internet (the Swedish Association of Health Professionals, (Vårdförbundet), 2003:42; United Nations, A/RES/46/119 Principle 13:1c).
A study on patient’s experiences from compulsory psychiatric care
Sahlgrenska University Hospital executed a study on former patients that have experienced compulsory psychiatric care under the years 2008-2009. The study consisted of 12 adult persons, both women and men, who answered questions about their experience and staff relations. The data was collected from former patients from two psychosis clinics in the south of Sweden. Patients treated under compulsory psychiatric care are mostly diagnosed with a psychosis mental illness. Compulsory psychiatric treatment can result in different experiences for patients. Some patients experience positive feeling about the treatment due to the feeling of a sanctuary. On the other hand there are patients who feel powerless and less worthy. Patients experience the need of the staff to treat them as individual adults (Andreasson, 3-4).
One of the most essential answers the patients gave was that they wanted to receive the support that they needed. With the right support from the staff, the patients felt safer during the treatment. Patients needed to get encouraging support and simple everyday conversations with the staff, because that could help the patients not to think about their mental state and compulsory treatment (Andreasson, 7-8).
Another important factor was that patients wanted the feeling of security, to be able to trust the staff was essential. Some patients can feel that they are going to get some sort of psychosis and seek treatment before the breakout. Unfortunately, the doctors may not give treatment in time and the police get involved after the psychosis outbreak instead. There are positive aspects of letting the patient discuss with the doctors about wished treatment, which in turn can lead to other treatments instead of compulsory psychiatric care (Andreasson, 8).
The feeling of understanding is another answer given by the former patients. When patients are given written and oral information about compulsory psychiatric treatment it helps lessen the anxiety. Information at an early stage helps patients to prepare themselves, which in turn leads to a better and healthier compulsory treatment. Patients need to be able to have alone time but still be close to the staff, and have everyday routines during the treatment (Andreasson, 8-9).
Another important answer given by the patients is that they wanted to be treated with respect; the staff should listen to their insecurities and help patients overcome them respectfully. Some patients said that the staff sometimes neglected them, not listening to their problems, and that the staff talked above their heads instead of with them (Andreasson, 10). In relation to this, the patient’s independence was important, even though they were under compulsory psychiatric care. The need for the staff not to overdo anything unnecessary was important. The patient’s didn´t want the staff to decide things as what clothes they were having, or not letting them out on walks etc (Andreasson, 11). In the report from the Swedish Association of Health Professionals (44; see also United Nations, A/RES/46/119, Principle 21), one can read that the patient must be entitled to fail complaints and to make suggestions about the treatment. Involving the patient may lead to less forcing in the compulsory psychiatric care.
A patient wants to feel like they are a part of evolving the compulsory treatment. The patient’s opinions matters and they feel the importance of expressing their views, thoughts, and what they are afraid of. One way of including the patients is to draw out the care plan together with the staff. To involve the patient in the care plan is a compulsory step of compulsory psychiatric care in Sweden. Unfortunately, as mentioned above, this is not always the case. The goal with this individual care plans is to make the ill person accept the care voluntary. While drawing the care plan it´s important that the patient are informed about his/her rights and what the Swedish law has stated about compulsory psychiatric care (Vårdförbundet, 2003:42-43). The rights of the patient are also stated from the UN. As soon as possible the patient must be informed about his/her rights in the patients language in accordance with the law, there should also be information about how to exercise the rights (United Nations, A/RES/46/119, Principle 12:1).
Discussion and conclusions
After recognizing mental illness in a person, he or she should have a right to proper medical treatment. The governmental support is fundamental for a proper treatment. International aid, funds etc, are encouraged for low-income countries to be able to manage and found psychiatric care clinics. As we have mentioned in the text above, there are no discrimination among mental illness, everyone can get mentally ill. That is why it´s important with collaboration and aid funds. The socio-economic status a country has can make a huge difference in regards of treatment to mental illness. For low-income countries, there need to be some aid.
Detailed and personal documentation on the patient history is crucial for a proper treatment. Health workers must act professional; they must be non-judgmental and objective. Patients have to be treated as individuals, so it´s important for health workers not to make general assumptions about treatment. As stated from the survey made by Sahlgrenska University Hospital, the crucial problems lie in whether or not the patient experiences trust, individuality, and respect during treatment. By having conversation before required treatment can lead to treatment without compulsory psychiatric care. But the problem former patients felt was that this wasn´t always the case. Sometimes doctor’s didn´t pay enough attention to patient´s before the breakout of mental illness.
Human Right´s perspective
To sum up, people with mental illness should receive fair treatment and should be accorded certain rights. These include the right: to be treated with respect and dignity, to have their privacy protected, to receive age and culturally appropriate services, to understand available treatment options and alternatives, to receive care that does not discriminate on the basis of age, race, or type of illness.(Joseph Goldberg 2014) The most important problem is stigma/discrimination, thus; steps should to be taken to prevent stigma and discrimination.
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