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Ethical issues in mental health services are present on various levels – from individual service access and provision to structural issues regarding the organization and management of health care systems and global health care priorities. During the twentieth century, the concepts of patient autonomy, privacy and conﬁdentiality became central for medical ethics. For mental health patients, these concepts are central also, but their application is often more complex than for patients with somatic diseases. First and foremost, mental disorders may affect a person’s sense of self, their experiences, thoughts, beliefs and capacities in ways that make it difﬁcult to ascertain a person’s will and autonomy.
Ethical aspects of the provision of mental health services globally concern issues like coercion, stigmatization and discrimination, access to services of particularly vulnerable populations as well as access during disasters. Like with other health care services also, with mental health there exists a wide global treatment gap between high and low-income countries. Additional ethical aspects concern underdiagnoses and overmedication issues and provision of evidence-based treatment.
Mental health services are health services pertaining to mental health and disorders.
The World Health Organization deﬁnes mental health as 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. This is a wide deﬁnition stressing the positive emotional and behavioural aspects of a well-functioning, mentally healthy person. Normal levels of anxiety, stress and occasionally more profound emotional responses (e.g., in mourning) are healthy and part of the life of every human being as long as one retains a long-term ability to function and ﬂourish individually and socially.
Mental health services can be either provided publicly or privately and comprise activities that are similar to other health care services – screening, prevention, intervention, treatment, rehabilitation, promotion of mental health, etc. In support of public health goals and for the promotion of evidence-based medicine, mental health services also gather information and data and undertake research as well as needs assessment and surveillance. Here, international cooperation is very important, be it the formulation of international legal baselines or scientiﬁc collaboration and mental health surveillance. In terms of prevention, some of the more successful universal prevention strategies and policy options are improved nutrition and housing, improved access to education, reduced economic insecurity, strengthened community networks, etc. (WHO 2004).
Background Of The Issue
All high-income as well as many middle and low-income countries have mental health services, but there is great variance as to the capacity and accessibility of those services. The services might be under-resourced, under-staffed or simply too expensive to make use of. Regardless of the nature of the services and infrastructure, it is a well-established fact that mental health services are universally under-utilized, that is, the actual needs for such services are considerably higher than the services provided. This is due to many factors, from individual choices and opportunities to wider social attitudes and stigmatization. The most well-known risk factors for mental illness are poverty, social exclusion, lack of education, unemployment and addictions but also stress, emergencies and disasters. The relationship between mental health and social cohesion is complex – people can be marginalized, unemployed or stigmatized as a result of a mental disorder, or vice versa, the difﬁculties in one’s life (especially the circumstances of the poor, the unemployed and the lower educated) might lead to mental disorder.
Mental health issues are cross cultural, that is, they are universal, and similar disorders are found across nations and cultures. Some of the leading disease burdens globally concern mental disorders – depression, substance use, self-inﬂicted injuries, schizophrenia and bipolar disorder being the most common (globally, four out of ten diseases with the highest disease burden are psychiatric). Mental disorders are a very signiﬁcant economic burden, the costs being mostly associated with lost or reduced productivity – for example, in Europe, psychiatric conditions constitute 25 % of the total burden of disease (Kastrup 2010).
Over the past 30–40 years, a global process of deinstitutionalization has taken place in the treatment of mental disorders. The large, prison-like asylums have largely been closed, and more care is being provided by local community services. This has been motivated by a patient’s rights movement that championed mental health patients as equal citizens, as people with full human rights whose long (and especially lifelong) institutionalization was seen as immoral. It was also hoped that community care would be economically more efﬁcient, but this has largely not been the case.
Although there remains a need for some patients for safe and secluded places, communities are often able to provide necessary services without hospitalization and empower and enable patients to become and remain full participants in community life. Comprehensive practices of community health care help manage recurrent illnesses, support recovery and socialization, provide family psychoeducation, support employment and provide many other services. Obviously, community psychiatry has also resulted in some additional problems compared to institutionalized psychiatry – increased homelessness, unemployment, substance addictions, disturbances of public order and loneliness being associated with it.
Access to mental health services. Mental health services are under-utilized globally at the same time as mental health disorders are globally under-diagnosed. What are the main barriers to access to mental health services? Firstly, there are barriers that make it very difﬁcult for people to reach even existing mental health service providers. WHO has outlined ﬁve key barriers that need to be overcome globally:
- The absence of mental health from the public health agenda and the implications for funding
- The current organization of mental health services
- Lack of integration within primary care
- Inadequate human resources for mental health
- Lack of public mental health leadership
In addition to those more widespread issues of insufﬁcient funding and lack of human resources (e.g., in low and poor-income countries, there is only one child psychiatrist per one to four million people), also difﬁcult access to services in rural areas (i.e., no transportation options) has been highlighted as mental health resources tend to be centralized in cities and within larger institutions.
Secondly, there are barriers that keep people from seeking help from mental health services even when such services are within reach. For people with mental health problems, it is sometimes especially difﬁcult to seek help. Besides needing to overcome their own depression, fatigue, anxiety, etc., a widespread stigmatization of mental health conditions is a global phenomenon that inhibits people from seeking appropriate services.
Stigma – a mark of shame or discredit – is a constellation of negative and mostly unfair beliefs that a society holds about something. Besides stigmatization often causing discrimination towards individuals, their families or even communities, there is also self-stigmatization. Mental health patients have historically and cross-culturally been associated with being weak, dangerous, problematic, deﬁcient, damaged and violent. Stigmatization and the unfounded beliefs that mental health disorders cannot be successfully cured mean that many don’t even seek help. Over time, stigmatization has likely also had an effect on the availability of resources for mental health care. Destigmatization of mental health disorders with the help of social campaigns is important, but there is also need for structural changes to mental health services for provision of easier and equal access.
Ethical Issues In Mental Health Services
Ethical issues in mental health services arise on various levels – from individual service access and provision to structural issues in health care system organization and management and global health care priorities.
The most important professional ethical duties of psychiatrists have been outlined by the World Psychiatric Association in the Madrid Declaration on Ethical Standards for Psychiatric Practice (from 1996, subsequently enhanced).
As practitioners of medicine, psychiatrists must be aware of the ethical implications of being a physician and of the speciﬁc ethical demands of the specialty of psychiatry. As members of society, psychiatrists must advocate for fair and equal treatment of the mentally ill and for social justice and equity for all. (WPA 2011)
During the twentieth century, the concepts of patient autonomy, privacy and conﬁdentiality became central for medical ethics. For mental health patients, these concepts are central also, but their application is more complex than for patients with somatic diseases. First and foremost, mental disorders may affect a person’s sense of self, their experiences, thoughts, beliefs and capacities in ways that make it difﬁcult to ascertain a person’s will and autonomy. Persons can pose serious risks to themselves and others, and psychiatrists, more than any other clinicians, might have to constrain persons, limit their liberty and prescribe drugs that can affect the way that person thinks and feels. This is an enormous responsibility.
In mental health care systems globally, involuntary commitment to treatment and coercion are an everyday regular occurrence. Coercion is usually considered to be justiﬁed when it is deemed that a person poses a highly probable risk to herself/himself or a third party. While it is clear that sometimes mental health patients do pose a serious risk to themselves or others, it is also manifest that they are vulnerable and there is evident danger of abuse of patients. Appropriate legal regulations regarding coercion need to be in place, but internationally, there is variation, for example, in whether physical restraints are allowed or not.
Historically, psychiatric services and theory have been used in unethical coercion and discrimination, for example, in immigrant mental health. The Madrid declaration also states that
there are aspects in the history of psychiatry and in present working expectations in some totalitarian political regimes and proﬁt driven economical systems that increase psychiatrists’ vulnerabilities to be abused in the sense of having to acquiesce to inappropriate demands to provide inaccurate psychiatric reports that help the system, but damage the interests of the person being assessed. (WPA 2011)
In the Soviet Union, involuntary treatment and coercion was used to silence and control political dissidents and other “unruly” citizens. Also today, violations of human rights of mental health patients are widespread, and they are often restrained and sequestered and their needs disregarded (WHO 2013a).
Over one million people commit suicide annually, and suicide is the second leading cause of death for young people (15–29 years) (WHO 2013a). Suicide is more common for men and often associated with mental disorders and substance abuse. Traditionally, suicide has been viewed as a sin (prohibited by various religions); in secular liberal thought, suicide in principle can be considered an autonomous decision of exercising one’s free will, but what is universally recognized is that people attempting or committing suicide generally do suffer from mental health issues. Therefore, the autonomous choice interpretation is in most cases a ﬁction, and early identiﬁcation and guidance of those at risk is important.
Mental Health Services And Particular Populations.
Since mental health issues affect disproportionately particular population segments, mental health services should pay special attention to the needs of those most vulnerable.
Immigrants and ethnic minorities. Migrants and ethnic minorities tend to under-utilize mental health services. This is due to several reasons – migration itself is a stressful process that entails leaving behind one’s social networks and communities and encountering discrimination, unemployment and lack of social support in a new country. Some research shows that immigrant populations in fact do suffer from elevated levels of mental disorders (e.g., schizophrenia) (Whitley 2014). This can be due to various, both pre and post-migratory factors. Amongst immigrants, refugees have higher rates of mental disorders due to the difﬁcult circumstances they have usually encountered when leaving their homeland and spending time in refugee camps. Cultural sensitivity is exceptionally important, especially in psychiatric services that cater to multicultural populations. The causes, explanations, manifestations and potential treatments of mental illness are often dependent on wider cultural values and patterns (Pumariega et al. 2005). Emotional suffering, stress and depression might be seen as individual and insigniﬁcant problems requiring familial, social or religious attention and not consideration of mental health services.
Mental health services and children. Almost 50 % of mental disorders manifest before the age of 14, meaning that such disorders are signiﬁcant causes of disability for young people (WHO 2013a). Because of such an early start (relative to other serious diseases), mental health disorders signiﬁcantly impact the lives of people, and screening or checkups are especially relevant for adolescents. Young people with mental health problems are especially vulnerable to dropping out of school and engaging in antisocial behaviour – and these events are very likely to mark a person for life. Ideally, schools should be involved in providing screening services, and if there are no resources available for universal services, then targeted checkups for at-risk strata are also effective. At the same time, the stigmatization associated with mental disorders needs to be taken into account when targeting particular populations (e.g., the socioeconomically disadvantaged, etc.).
Mental health services and gender. Women suffer more from mental disorders, with the exception of substance abuse (where men suffer more) and psychotic disorders (gender neutral). Men, on the other hand, also commit more suicides (although females have more suicide attempts). Depression is the leading cause of disease burden for women globally (WHO 2008). Poverty and social stress make people more vulnerable to mental disorders, and women’s disadvantageous social positions are often determined by their gender.
Mental Health Global Treatment Gap.
The treatment gap exists on two levels. First, the extensive under-diagnosis of mental health conditions globally – in high as well as low-income nations – means that the vast majority of mental health disorders go undetected and untreated. For example, almost 80 % of alcohol abuse, 50 % of bipolar disorders and 56 % of major depressions in Europe are untreated (Kohn et al. 2004). Secondly, as is often the case with global health issues, there exists a signiﬁcant gap between the poor and more well-off countries in terms of access to treatment. The signiﬁcant underdiagnosis and under-treatment of the mentally ill stems from the fact that less than 1 % of the health care budget concerns mental health in low-income countries (World Mental Health Atlas 2011).
Inequalities between countries are also significant in terms of human resources – there are 170 psychiatrists in high-income countries per single psychiatrist in low and middle-income countries (WHO 2013a). Clearly, the ﬁnancial and social costs of untreated mental disorders are a signiﬁcant burden in these countries. It has been suggested that in such circumstances, the provision of mental health services should be rethought – for example, by employing less trained specialists, focusing more on refugees, asylum seekers and disaster victims and engaging psychiatrists on levels of public health management and design (Patel 2009). Highly educated specialists could supervise and train staff and not treat patients themselves. This might raise issues of relativism in providing care, but it might equally make sense to consider the situation in many low-income countries an emergency, thus requiring the ethical principles of public health ethics to overtake the more individual-based approaches of clinical ethics.
In terms of global justice, the price of drugs in low-income countries is also a grave concern – despite the manifold differences in GNP, the price of drugs is still only little less in low-income countries compared to high-income countries (Saxena et al. 2007).
Mental Health Services In Disaster Situations.
Disasters of various kinds – from earthquakes and storms to ethnic conﬂicts and hunger – cause displacement, injury and obviously high levels of stress. WHO has claimed that mental disorders tend to double after emergencies (WHO 2013b). The existing health care infrastructure is likely affected, and chronic conditions might be worsened due to lack of medication. Obviously, new conditions might emerge (e.g., post-traumatic stress disorder PTSD). In disaster situations or emergency, the highly important privacy requirements surrounding mental health diagnosis and treatment might be in jeopardy. The inﬂux of foreign humanitarian organizations after disaster might create chaos and mental health services could be affected by miscommunication, provision of unnecessary or inappropriate treatments, etc.
(Over)-Diagnosis And Over-Medication Issues.
Over the past decades, there has been a signiﬁcant increase in pharmacological treatments and psychiatric diagnoses, especially in high-income countries. Some have argued that this is the result of a for-proﬁt pharmaceutical industry’s successful marketing (Spiegelman and Parry 2010) or even cultural bias. Others are of the opinion that ﬁnally, those who need help are receiving necessary diagnosis and treatment. Clearly, as ever larger groups of children and adolescents are diagnosed (e.g., with ADHD), this raises important ethical issues. In developing countries, mental disorders are now the number one cause of medical disability for people aged 15–40. Fears of over-medication can be considered barriers to services as parents are unwilling to cooperate for fear of the negative effects of mental health medications (psychopharmacological drugs are often also perceived as addictive) and the general stigma of mental health disorders.
Evidence-based treatment in mental health services. Evidence-based medicine has been rather a latecomer in mental health, but the reliance on research ﬁndings, evidence and insights from neuroscience is very much on the increase (Insel 2009). In comparison to somatic diseases, in mental disorders there tends to be a stronger placebo effect in trials, and diagnosis is more difﬁcult. Selective publishing of trial data by pharmaceutical companies also skews the information that doctors and patients have about the likelihood of positive as well as negative effects. Due to unequal access to care, some of the best evidence-based treatments are not available in low and middle-income countries. More effective research is also needed for many mental health services and treatments. In the near future, mental health services will also need increasingly to grapple with the rise of personalized medicine (pharmacogenomics), and cooperation with neurosciences is likely to have an impact on how services are provided as well as what kind of treatment options are available.
From the perspective of global bioethics, mental health services, like other health services, are affected by the global treatment gap – the under diagnosis and under-treatment of mental health disorders, especially in low-income countries. Nevertheless, under-diagnosis is also an issue for high-income countries, having to do with associated social stigmatization of the conditions and with the priorities and funding within the health care infrastructure. At the same time and perhaps paradoxically, there are worries in higher-income countries regarding over-diagnosis and over-medication, especially of children with mental conditions.
Regardless of the geographical location or level of income, certain ethical issues are pertinent everywhere – the increased danger of coercion associated with mental health treatment, issues of suicide prevention and the fact that there are always particular populations that are more vulnerable to mental health issues.
Last but not least, mental health diseases are globally a very signiﬁcant economic burden.
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