Time for a global commission on mental health institutions
Authors: Alex Cohen, Sudipto Chatterjee, Harry Minas
Journal: World Psychiatry (2016)

Concerns about institutional care of people with mental disorders are no longer as prominent as they once were. This is understandable in light of deinstitutionalization and the closure of many psychiatric hospitals in much of the Western world. However, this neglect of old concerns is not excusable. Custodial mental hospitals which are, either directly or indirectly, the legacy of colonial psychiatry remain in many low- and middle-income countries the dominant, if not the only, component of national mental health systems. It is puzzling therefore that, despite the increasing attention to global mental health and the increasing familiarity with the unsatisfactory circumstances of people with mental disorders in such institutions, there is currently little interest in what is happening in those hospitals and other facilities in which people with severe and persistent mental disorders are treated and sometimes confined. To a great extent, the field of global mental health has relegated the exposure of abuses in mental hospitals and other institutions to news media1, non-governmental organizations2, and human rights commissions3. Hospitals and other institutions are not mentioned in any of the top 25 Grand Challenges in Global Mental Health4, although that paper includes a photo of women in a psychiatric hospital in Ukraine. Moreover, hospitals are not the only sites in which the human rights of people with mental disorders may be violated. For example, in Nigeria, prisons are often where families abandon members who are mentally ill6. In Indonesia, the conditions for long-term residents in some social shelters are horrendous and deadly for those mentally ill people who have no other place to live7. A report about mental health facilities in Ghana included scathing accounts of abuses in psychiatric hospitals and prayer camps run by spiritual healers8. To this list one can add the rapidly growing number of private nursing homes that warehouse patients who have been discharged from mental hospitals. Unfortunately, it does not seem that reform of these institutions is a priority for global mental health. Instead, development of community and primary care mental health services is overwhelmingly emphasized, with the implicit assumption that such services can meet all requirements of those who need care and treatment for a mental disorder. This is an ill-advised strategy that runs counter to the fact that long-term care options are necessary components of balanced and comprehensive mental health systems. Thus, it is imperative that attention is again directed to the task of transforming existing mental hospitals and other residential care institutions that are plagued by poor physical infrastructure, problematic staff attitudes and practices, the widely prevalent custodial ethos of care, and lack of appropriate discharge options and outreach services. These problems translate into formidable impediments to the creation of comprehensive mental health systems that have at their heart protection of the human rights of persons with mental disorder and disability. Despite this generally bleak picture, there are examples of mental hospitals that have been transformed into institutions of excellence and repute. Although there is little published evidence of how this is to be done, there is a wealth of accumulated experience of how major changes can be achieved. Just as there is a compelling case to be made for reducing the gap between the number of people in need of care and the number receiving effective treatments, a case must be made for closing the "knowledge and transformation gap" that exists in relation to those institutions that are responsible for the care of persons with mental disorders. Addressing this gap through a combination of internal changes along with the development of integrated community services, in collaboration with service users and local partners from multiple sectors, should become a priority of global mental health. We propose the establishment of a global commission on mental health institutions. This commission, which would be comprised of mental health professionals, social scientists, representatives of advocacy groups, and legal experts, would develop and carry out a programme of work that would include the following: a) establishing a working definition of "mental health institution"; b) comprehensively mapping mental health institutions in Europe, Asia, the Americas and Africa; c) documenting and understanding the determinants of poor conditions in mental institutions, using instruments such as the Quality Rights Toolkit of the World Health Organization; d) identifying the determinants of long-term stay in such institutions; and e) compiling a comprehensive report on successful strategies for bringing about institutional changes, such as those that have been applied at the National Institute of Mental Health and Neurosciences in Bengaluru, India; Angoda Hospital in Colombo, Sri Lanka; and Yuli Veterans Hospital in Taiwan9. The vision of the United Nations 2030 Agenda for Sustainable Development, adopted by the General Assembly in September 2015, includes "a world with equitable and universal access to quality education at all levels, to health care and social protection, where physical, mental and social well-being are assured" and where "all human beings can fulfill their potential in dignity and equality and in a healthy environment"10. The conditions in mental hospitals and other institutions for persons experiencing mental illness are an affront to such aspirations. This is the moment to embark on an ambitious program of work to address this problem. Alex Cohen1, Sudipto Chatterjee2, Harry Minas3 1London School of Hygiene and Tropical Medicine, London, UK; 2Parivartan Trust, Pune and Satara, India; 3Global and Cultural Mental Health Unit, School of Population and Global Health, University of Melbourne, Melbourne, Australia