The WHO QualityRights initiative: building partnerships among psychiatrists, people with lived experience and other key stakeholders to improve the quality of mental healthcare

Summary

Psychiatrists have an essential role to play in promoting human rights in mental healthcare. The World Health Organization's QualityRights initiative, in partnership with different stakeholders, is improving the quality of psychiatric care in different countries.

In 2019, the World Health Organization (WHO) published the QualityRights training and guidance tools to enhance knowledge, skills and understanding in promoting the rights of persons with mental health conditions and improve the quality of psychiatric services.¹ The QualityRights tools adopt the modern human rights framework of the United Nations Convention on the Rights of Persons with Disabilities (CRPD). People with mental health conditions and their organisations were actively involved in the development phases of the QualityRights materials, alongside mental health professionals (including many psychiatrists) and other relevant stakeholders. Currently, there is a growing interest in the QualityRights initiative, and the WHO is implementing it in different countries. Psychiatrists play an essential role in the QualityRights movement to help realise the CRPD and promote a human-rights-based approach in mental healthcare. In a recent editorial in BJPsych ² Hoare & Duffy expressed concerns that the QualityRights training and guidance tools may ‘marginalise’ psychiatry and compromise the rights of persons with mental health conditions. It is important to address these concerns and other misperceptions and to highlight how QualityRights is making a major impact improving the quality of psychiatric care in different countries, building partnerships and collaboration among psychiatrists, people with lived experience of mental illness and other key stakeholders.

The role of psychiatrists in the QualityRights initiative

The QualityRights training and guidance modules use distinct educational approaches to promote a human-rights-based approach in mental healthcare, including the teaching of skills, engagement in myth-busting, group work and presentation of case vignettes. A conspicuous part of these materials specifically targets psychiatrists and other mental healthcare providers. Psychiatrists were involved at every stage of the production of the QualityRights materials and their collaboration was fundamental for this initiative's success. In total, 8 of the 26 international experts who contributed to drafting the modules and 31 of the 151 reviewers were psychiatrists. Furthermore, when delivering the training to psychiatrists, at least one psychiatrist is involved as a trainer and helps lead the discussion on the most challenging topics. The recent editorial by Hoare and Duffy expressed concerns that QualityRights may ‘marginalize’ psychiatry by its portrayal of psychiatrists. This was never the intention.² The case vignettes are teaching materials illustrating negative situations in mental healthcare which should be avoided with better training and understanding. The vignettes can foster discussions about challenging situations and what we could do, as psychiatrists, to improve the quality of the care we provide.

Similarly, the QualityRights modules include case vignettes and references to psychotropic medications, designed to emphasise medical prescription aspects that are currently problematic: incomplete information on side-effects, polypharmacy, prescription without informed consent, use of chemical restraint and forced medication. QualityRights includes psychotropic drugs as an important component of recovery plans, where service user outline which treatments or support they want to receive and which they do not want, including ‘which medication works or does not and what medication(s) one will not accept to take’. Within the QualityRights materials there is also extensive coverage of treatment approaches that are not medical or pharmacological. We believe that this is a neglected area that deserves more space in psychiatric research and clinical practice. These treatment approaches are not idealised but presented as part of complex discussions on different options that may be alternatives to compulsory treatment.

QualityRights position on involuntary practices

The CRPD and the General Comment on its Article 12 demand an end to practices that restrict the right to legal capacity, such as involuntary admission and treatment, and replace these with practices that align with people's will and preferences. The QualityRights initiative endorses this position but acknowledges that, in many countries, the legislative or policy context may not align with the CRPD on the right to legal capacity. The QualityRights materials make it explicit that the modules ‘are not intended to encourage practices which conflict with the requirements of national law or policy’. However, QualityRights asks countries to set goals and timelines to implement alternatives to involuntary practices and stakeholders to advocate for policy and law change, although this will take time and a variety of actions at all levels of society. Psychiatrists are in an excellent position to advocate for these changes and can do a lot at the individual level to promote alternatives to the use of involuntary practices. A common misperception is that psychiatrists already use coercive practices only as a last resort. However, evidence shows that psychiatry seems to be becoming more coercive, even within well-resourced mental healthcare systems.³ These data indicate that we, as a profession, need to do more to implement alternatives to coercion and involuntary practices. QualityRights can provide us with more instruments to fill this gap.

Careful consideration must be given to the alternatives to involuntary practices and the danger of criminalising people with mental health conditions. QualityRights again uses case vignettes to foster discussions about challenging situations. These case vignettes are not meant to provide definitive solutions and they draw from practices implemented in some countries. For instance, there is an example that draws from contexts where law enforcement bodies are collaborating with psychiatrists without criminalising people with mental health conditions: in Italy, police officers can contact psychiatrists when they consider persons to be a danger to themselves or others and believe the persons are experiencing a mental health crisis. Similarly, psychiatrists can contact officers in situations where persons are violent to other service users or staff. In such situations, the psychiatrists reassure the persons and encourage admission to a psychiatric service to receive support, while the police officers maintain safety.

QualityRights recognises that, because of limitations in current mental health systems and difficult contexts, involuntary practices may still occur even in situations where staff have made great efforts to implement alternatives such as advance directives and supported decision-making. However, it is essential that the use of involuntary practices is seen as an opportunity for review and learning and that measures are put in place to avoid their use in the future. QualityRights also acknowledges that there are instances when not using involuntary practices could put individuals with mental health conditions at risk (several case vignettes present such scenarios). However, there is mounting evidence that involuntary practices are deleterious and undermine the dignity and well-being of people with mental health conditions. Involuntary practices often also have negative impacts on trust, including an unwillingness to seek help and engage with practitioners.⁴ A frank discussion on these issues and more efforts to move forward with a human-rights-based approach in mental healthcare are needed.

QualityRights is improving the quality of mental healthcare

In Gujarat, India, the first large-scale implementation and systematic evaluation of the QualityRights instruments to support a human-rights-based approach in mental healthcare showed that over 12 months, the quality of care in psychiatric services significantly improved.⁵ Mental health professionals had improved attitudes towards persons with mental health conditions and service users felt more empowered and had higher satisfaction with services, while caregivers reported reduced care burden.⁵ In 2019, Ghana launched a country-wide implementation of QualityRights with the wide-scale rollout of the e-training programme among national stakeholders (including mental health practitioners). In 2020, seven of the ten psychiatric facilities in Ghana were evaluated using the QualityRights toolkit. A total of 8745 Ghanaians have already completed the training, and preliminary data show that these stakeholders hold more positive attitudes towards persons with mental health conditions after the training. In the Czech Republic, 2433 of 3129 stakeholders registered have completed their training, and in Kenya and the Philippines, 4043 and 3572 stakeholders respectively have registered for the programme and are receiving QualityRights training. QualityRights activities are also being implemented on a wide scale in Turkey, Estonia, Lebanon, Armenia, Bosnia and Herzegovina, with actions starting in Croatia and Lithuania. Efforts to measure sustained improvements in clinical culture, practice and outcomes are underway in Ghana and Kenya. Additional data will be available over time as these initiatives are rolled out and maintained across countries’ mental health systems.

To date, the QualityRights initiative has been systematically implemented only in low- and middle-income countries, although human rights violations in psychiatric services are an equally pressing concern in high-income countries. However, this is changing gradually. Recently, the German Association for Psychiatry, Psychotherapy and Psychosomatic Medicine (DGPPN) voted in its General Assembly to translate QualityRights into German and recommend it to practitioners in psychiatric services. QualityRights implementation has also started in Italy, France and Spain.

In all these countries, psychiatrists have a fundamental role, in collaboration with people with lived experience of mental illness and other stakeholders, in delivering QualityRights and ensuring this initiative's success.

Conclusions

Psychiatrists have played an essential role in the success of the QualityRights movement to help realise the CRPD, promote alternatives to involuntary practices, and end violations in psychiatric services and the general community, but there is much work still to do. Frank discussions on the issues surrounding the implementation of a human-rights-based approach in mental healthcare are necessary for progress. QualityRights has a key role to play in reforming mental health services and promoting the full realisation of the rights of people with mental health conditions. Psychiatrists should welcome and support this change and collaborate with people with lived experience of mental illness and other stakeholders in promoting CRPD rights.