Global mental health and psychiatric institutions in the 21st century

Abstract

In the 19th century, psychiatric institutions were the focus of thousands of articles in the leading English-language medical and psychiatric journals. This area of concern remained important through the first half of the 20th century, with some decline in the number of published articles in the second half of the 20th century as de-institutionalisation gathered pace. The number of articles about this topic has declined sharply in the past 25 years, and psychiatric institutions are not the focus of any of the Grand Challenges in Global Mental Health even though psychiatric institutions of all kinds are widely acknowledged to be the among the main sites of human rights abuses. In this commentary we present examples of impressive transformations of institutions in Sri Lanka and Vietnam, and suggest that the field of global mental health should devote more of its efforts to improving the lives of persons with mental disorders who have been incarcerated in a variety of settings, often under the care of mental health specialists.

The rise and fall of interest in mental hospitals

In the 19th century, asylums for persons with mental disorders were an important topic in the precursors to five of the leading English-language medical and psychiatric journals: The New England Journal of Medicine (NEJM), The Lancet, The British Journal of Psychiatry (BJP), The British Medical Journal (BMJ) and The American Journal of Psychiatry (AJP). Between 1812 and 1899, these journals published 1354 articles with titles that contained the word ‘asylum’ and many more that contained ‘asylum’ somewhere in the text (see Table 1). The earliest article appeared in 1818 and offered a lengthy discussion of the causes of and treatments for ‘diseases of the mind,’ with specific reference to the work of Dr Benjamin Rush, the so-called ‘Father of American Psychiatry’ (Hayward, 1818). Nine years later, a letter to the Editor of The Lancet expressed dismay at conditions in private asylums, urged the English parliament to establish ‘public hospitals for insane paupers,’ and stressed the need for medical education to include placements in public hospitals in order to improve care (Humanitas, 1827).

Table 1. Number of publications with the terms asylum, mental hospital or psychiatric hospital in (a) the title and (b) in the full text in five key medical journals

* ‘Asylum’ was only search term used.

^† In text searches only searched for mental hospital or psychiatric hospital.

^‡ In text searches only searched for mental hospital or psychiatric hospital.

^§ Journal search engine does not allow exact phrases in title.

^‖ Nine are historical and one about asylum seekers.

^¶ An additional 957 are ‘Reports on Hospital and Surgical Practice in the Hospitals and Asylums of…’ (the British Empire or Great Britain and Ireland or Great Britain, Ireland and the Colonies).

** An additional 957 are ‘Reports on Hospital and Surgical Practice in the Hospitals and Asylums of…’ (the British Empire or Great Britain and Ireland or Great Britain, Ireland and the Colonies).

^†† Most are about asylum seekers.

^‡‡ 74 are about asylum seekers.

^§§ Official name changed to ‘mental hospital’ 30 May 1923 (Mental Treatment Bill in the House of Lords).

^‖‖ 182 titled, ‘Asylum Report’.

^¶¶ 27 are about asylum seekers.

*** from volume 2, issue 15.

^††† Five are historical and four are about asylum seekers.

The majority of articles about asylums concerned the management of (e.g., Hawkes, 1857) mortality and disease in (Francis, 1840; Crookshank, 1899) and statistics about (e.g. Earle, 1877) institutions in Great Britain, Ireland and the USA. Indeed, asylums were of such concern that The Lancet established a Commission on Lunatic Asylums for the purpose of determining ‘the general character’ of the asylums in and around London, documenting the systems of treatment, and to collect statistics ‘with a view to estimate the results’ of treatment (The Lancet, 1875, 1877).

There was also interest in institutions in Europe and beyond. For example, in 1830, The Boston Medical and Surgical Journal (precursor to NEJM) published a paper that described conditions in the asylum of Cairo, Egypt (Madden, 1830). Later in the century, eight more articles about this asylum were published in The Journal of Mental Science (the precursor to The British Journal of Psychiatry) (e.g. Tuke, 1879) and The Lancet (e.g. Greene, 1895). Accounts of the asylum in Palermo, Italy were published in 1835 (Tullidge, 1835) and 1846 (Wilson, 1846). The American Journal of Insanity (the precursor to The American Journal of Psychiatry) published accounts of visits to European (Earle, 1841) and Cuban (Earle, 1852) asylums. Throughout the second half of the 19th century, The Journal of Mental Science published accounts of visits to asylums in a wide variety of countries (e.g. Anonymous, 1860; Davidson, 1875; Fraser, 1879; Urquhart, 1880; British Journal of Psychiatry, 1899). And all of these journals published one or more accounts of the Colony of Gheel, the village in Flanders that was the site of an ancient system of foster care for persons with mental illness, and which represented, at least for some patients, an alternative to asylum care (e.g. Earle, 1851; Parigot, 1857). The articles about Gheel were part of a larger mid-century debate about the best method of providing care for individuals with severe mental disorders (e.g. Bucknill, 1861; Loiseau, 1862).

In the 20th century, the term ‘asylum’ gradually lost its association with institutional care for individuals with severe mental disorders and other terms took its place. For example, in 1923 the House of Lords in Great Britain passed a bill stipulating that the term ‘mental hospital’ should replace ‘lunatic asylum’ (Pasmore, 1923) and the term ‘psychiatric hospital’ appears as early as 1919 in the American Journal of Insanity (Silk, 1919).

While the frequency of articles about hospitals for persons with severe mental illness declined during the 20th century, those institutions – whether they were termed asylums, mental hospitals or psychiatric hospitals – seemed to remain a topic of interest in these five English-language medical journals. However, it appears that this interest has fallen off sharply in the past 25 years (see Table 1). From one perspective, this is understandable given the ‘deinstitutionalisation’ that occurred during the second half of the 20th century in Western Europe, North America and Australia. This change in the loci of care did not necessarily always improve the lives of persons with severe mental illness, as evidenced by, for example, the horrendous conditions in so-called ‘adult homes’ in New York City (Levy, 2002) or prisons in France (Human Rights Watch, 2016). In regard to prisons in the USA, an editorial in Lancet Psychiatry began with the statement, ‘Have asylums disappeared, or have they simply changed their form? Over the past 50 years these notorious institutions have largely been closed down in the USA and Europe. But before modern society becomes too complacent about this apparent sign of progress, it should ask whether the asylum has been replaced with an environment that similarly constrains and damages vulnerable individuals – prison’ (Lancet Psychiatry, 2015).

Whatever its effects in high-income countries, large-scale deinstitutionalisation and closure of mental hospitals have not been the dominant narrative in many low- and middle-income countries (LMICs). Mental hospitals continue to be important and, sometimes, the only treatment facilities in many LMICs. In addition, mental hospitals consume a substantial proportion of the scant financial and human resources that do exist (Saxena et al. 2007). It is also true that these ‘asylums’ are widely acknowledged to be the sites of human rights abuses (Irmansyah et al. 2009; Drew et al. 2011; Bass et al. 2012; WHO, 2012, 2013), and that abuses also occur in less-obvious sites, e.g. those operated by alternative healers (Krishnakumar, 2001; Carey, 2015), social protection centres (Minas, 2009a ) and in communities (Minas & Diatri, 2008).

Mental hospital reforms are neglected in the current global mental health agenda

For reasons that are not clear, the obvious and persistent concerns about conditions in these institutions and the urgent and sustained attention needed to reform them are not the focus of any of the Grand Challenges in Global Mental Health (Collins et al. 2011, 2013; Kaaya et al. 2013; Ngo et al. 2013; Patel et al. 2013; Rahman et al. 2013). While it is true that the establishment in LMICs of high-quality community mental health and primary care mental health services, developed in conjunction with general hospital acute care, will make enormous contributions to improving the lives of persons with severe mental disorders, it is also true that the almost exclusive focus on developing community services neglects the deficiencies in treatment quality and human rights protection in these institutions.

This need not be so. We will give two brief examples of impressive transformations of institutions – Angoda Psychiatric Hospital in Sri Lanka and the system of social protection institutions in Vietnam.

Transformation of institutions and institutional systems is possible

The Lunatic Asylum, Angoda was opened by the British colonial administration in 1927, providing 1728 beds, which were fully occupied within the first year after opening, and had close to 2200 patients in 1929 (Carpenter & Mendis, 1988). Large numbers of patients died annually from diseases associated with overcrowding and poor sanitation, such as tuberculosis, beri-beri and dysentery. ‘Angoda, like its two predecessors, was understaffed, underfunded and once again showed the failure of attempts to institutionalise all of Ceylon's mentally ill within one centralised institution.’ When Professor Edward Mapother came to Ceylon in 1937 to carry out an assessment of Angoda for the British Colonial Government, he described an institution that gave the impression of ‘a neglected and dilapidated prison…densely packed with a turbulent mob of men’ where violence by patients and staff was common. The female wards by then contained nearly 1000 women, and the total number of patients was more than 3000.

In the period prior to December 2004, when the Indian Ocean tsunami devastated coastal regions of Sri Lanka, there were three psychiatric hospitals in Sri Lanka, Angoda, Mulleriyawa and Hendala, all in the Colombo area, with a total of 1700 long-stay patients. Conditions in these institutions would have been recognisable to Professor Mapother (Mills & Jain, 2009).

The process of post-tsunami reconstruction and recovery offered an opportunity to develop community-based mental health services and to reform the centralised psychiatric institutions in Colombo. The Director of Angoda, Dr Jayan Mendis, with enormous energy and courage, and with assistance from WHO and other sources, began a sustained and systematic transformation of Angoda hospital, which is now the National Institute for Mental Health (NIMH). The NIMH vision is to be ‘the centre of excellence for psychiatric care and mental well-being’ (National Institute of Mental Health) and aims to promote mental well-being, prevent mental disorders, and to provide high-quality treatment and rehabilitation’. In the past decade, the NIMH has gradually become a tertiary centre with a range of specialist services, established training programme for psychiatrists, general doctors and other mental health disciplines, and is steadily building its research capacity (National Institute of Mental Health, 2015).

To a significant extent these developments were facilitated by the development of community services and the gradual opening of small acute psychiatric units in general hospitals across the country, both of which reduced the demand for admissions in Colombo. The key point, however, is that Angoda was not allowed to languish, while attention was focused on developing the rest of the mental health service system. The multiple human rights abuses that were previously a common experience of patients have been eradicated. Such transformations can and should be made in psychiatric institutions everywhere.

In Vietnam, a network of social protection centres provides institutional care for persons with mental disorders who may have been treated in a psychiatric hospital but have not recovered sufficiently to live independently in the community, do not have family or other social support, or are homeless. In 2009, one of the authors (HM) was asked by WHO Vietnam to assess the social protection system for persons with mental disorders and to provide recommendations to the Ministry of Labor, Invalids and Social Affairs (MOLISA) on possible reform. The report of the assessment (Minas, 2009b ) concluded that, despite government's increasing attention to the needs of people with serious mental illness and the development of institution-based (mental hospitals and Social Protection Centres) and primary care community-based services, there were substantial weaknesses and deficiencies in basic physical infrastructure, mental health human resources, quality of care, treatment and rehabilitation services, medication supplies, financial support and human rights protection. The findings were presented to, and discussed in detail with, the Vice Minister responsible for social protection, who readily acknowledged the deficiencies and undertook to implement the eleven recommendations made in the report.

From 2010 to the present all of the recommendations have been implemented. Programmes of reform of the mental health and social protection systems, informed by large-scale research projects designed to inform mental health and social protection policies and practice, have been initiated by the Ministry of Health and MOLISA (Minas et al. In press). For example, the National Project 1215 (Community Based Social Support and Rehabilitation for People with Mental Disorders, 2011–2020) – initiated by the Prime Minister and funded by the national government – is a massive programme that includes reform and development of social protection centres and community-based services and training 60 000 social workers to staff the community programmes. Multiple pilot and demonstration projects are being carried out across the country to evaluate new service designs. In 2014, the government ratified the Convention on the Rights of Persons with Disabilities.

For the first time there is now active collaboration between the Ministry of Health and MOLISA in provision of mental health services, including a joint circular that sets out major new features of the mental health system and respective responsibilities of the two ministries. Furthermore, the National Mental Health Strategy 2016–2025 has been completed and awaits approval by the government, and work has commenced on drafting of a mental health law. These developments have been supported by the National Taskforce for Community Mental Health System Development in Vietnam, based in the Ministry of Health, and the Integrated Mental Health System Technical Assistance Project 2010–2015 to support implementation of the 1215 programme, both supported by Atlantic Philanthropies. The relative speed with which these major reforms have been undertaken is an indication of what can be achieved when there is real political commitment and investment by government.

Conclusion

In June 2016, the United Nations Human Rights Council adopted a resolution titled ‘Mental health and human rights’ (Human Rights Council, 2016). Key universal human rights were re-iterated and the specific human rights protections that need to be put in place for persons with mental disorders were highlighted. The Council acknowledged the leadership role of WHO in the field of health and the central place of human rights in the implementation of the Mental Health Action Plan 2013–2020 and reaffirmed the obligation of member states ’to promote and protect all human rights and fundamental freedoms and to ensure that policies and services related to mental health comply with international human rights norms.’ The Council also requested that the UN High Commissioner for Human Rights prepare a report ‘on the integration of a human rights perspective in mental health and the realisation of the human rights and fundamental freedoms of persons with mental health conditions or psychosocial disabilities, including persons using mental health and community services.’

As psychiatric institutions are the location of many of the human rights abuses experienced by people with mental disorders, they should be a particular focus for the examination of existing problems – and opportunities for good practice – to be carried out by the UN High Commissioner for Human Rights, in partnership with governments and all key stakeholders. The field of global mental health, which has so far largely neglected the many problems in psychiatric institutions, should be an active partner in this effort, contributing its knowledge, skills and commitment to improving the lives of persons with mental disorders who have been incarcerated in a variety of settings, often under the care of mental health specialists.