The rights of people with psychosocial disabilities at times of global crisis in Italy

During global crises, such as the ongoing pandemic, wars, and climate disasters, the rights of people with psychosocial disabilities are often neglected, despite these individuals being disproportionately affected. Mortality rates for those with severe psychiatric conditions were twice as high during the pandemic compared to the general population, and those in conflict or disaster zones face greater challenges in accessing basic resources. The United Nations Convention on the Rights of Persons with Disabilities (CRPD) offers legal protection, yet violations and stigma remain widespread.

This paper discusses the WHO QualityRights initiative, which provides a framework for promoting the rights of people with psychosocial disabilities through community inclusion, autonomy, and the reform of mental health services. International projects in Lebanon, Armenia, Ghana, and Tunisia have employed the QualityRights Toolkit and e-learning course to enhance service quality and human rights. In Italy, the adoption of this approach has led to improved care and rights conditions in psychiatric services, despite ongoing challenges such as funding cuts.

The paper highlights the critical need for reforms to mental health policies and increased resources to maintain and strengthen community-based care models. It calls for a renewed commitment to the principles of the CRPD, emphasizing social inclusion, recovery, and user empowerment, as well as raising awareness among decision-makers to ensure lasting progress in protecting the rights of persons with psychosocial disabilities.

Article

In the current global crisis, after a pandemic that has claimed millions of lives, ongoing wars that divide nations and millions of refugees at borders, climate crises that cause deaths and disasters, addressing the rights of people with psychosocial disabilities may seem secondary. However, individuals with mental health problems are often those who suffer the most during crises. During the pandemic, mortality among people with serious psychiatric conditions was two times higher than the general population^1-2, and in war zones or under climates disasters, individuals with psychosocial disabilities face greater challenges in escaping danger, accessing food and water, and surviving³.

The rights of individuals with mental health conditions are protected by a United Nations convention signed by numerous countries, making it a shared ethical and cultural commitment globally⁴. In times of crisis, leaders in science, medicine, and human rights must recognize and uphold shared values, building bridges between cultures to support the paths of reconciliation. Thus, reviving the issue of human rights for people with psychosocial disabilities can promote unity amidst divisive global controversies.

In fact, human rights violations, stigma, and discrimination against people with psychosocial disabilities remain critical issues, as highlighted in several United Nations reports^5-6-7. While scientific societies, human rights groups and international organizations have promoted actions around the world to address these challenges, Saraceno suggested that rights advocates need to implement ethical practices in their own work environments before advocating general principles often in situations far from their own settings⁸. Our experience both in our own work context and in engaging in international projects is seeking to align with the promotion of human rights in mental health in accordance with the principles of the UN Convention on the Rights of Persons with Disabilities (CRPD) and the WHO QualityRights initiative, aiming at social inclusion through a human rights-based disability model^9-10. This dual approach involves a reciprocal relationship with international contexts to share principles and develop local solutions rather than importing or exporting models.

ADOPTING A HUMAN RIGHTS MODEL OF DISABILITY

A key reference point is the UN Convention on the Rights of Persons with Disabilities⁴. The CRPD proposes a new rights-based disability model that goes beyond the medical and social models, drawing the best from each and synergistically. The aspects of the social model that have been adopted focus on combating all types of barriers, stigma and discrimination. From the medical model, the CRPD focuses on measuring the effectiveness of interventions and emphasizing individual resources for personalized projects. Instead, we should stop considering disability simply as the consequence of an impairment or disorder but rather as the result of the interaction between the impairment or disorder and barriers, which in the case of mental health are largely psychosocial barriers and stigma.

The WHO QualityRights initiative offers a practical approach to psychosocial disability based on the principles of the CRPD^9-10. The main components of this initiative include opposing coercive interventions, respecting the right to legal capacity and promoting user autonomy, community inclusion and recovery. The stated objectives are: a) Strengthen capacity and expertise to combat stigma, promote human rights and support recovery; b) Improve quality of care and human rights conditions in mental health services; c) Establish community-based and recovery-oriented services; d) Engage civil society to carry out advocacy activities; and e) Reform national policies and laws in line with the CRPD. Those conducting assessments and improvement plans in mental health settings include service users, quality of care specialists, family members of users and health professionals. With the aim of objective assessments and measurable improvements, the project has created the “QualityRights Toolkit”¹¹, a set of tools to evaluate and implement improvement plans in mental health facilities. Training materials and an e-learning course have also been developed, covering topics such as mental health and human rights, evaluating and planning improvements in health services, alternatives to confinement and restraint, promoting a recovery approach, supporting civil society organisations, advocacy guidance and providing peer support¹².

SOME INTERNATIONAL EXPERIENCES WITH THE QUALITYRIGHTS NETWORK

Our group has leaded three projects funded by the European Union in Lebanon, Armenia, and Ghana, and another project supported by the Italian cooperation in Tunisia.

In Ghana, the cooperation project led to the assessment of the quality of services in 8 psychiatric hospitals and to the implementation of improvement plans in those hospitals¹³. The re-evaluations of the services after the improvement plans have been recently completed¹⁴. The project promoted the training of more than 30,000 stakeholders from which around 300 were traditional healers working in prayer camps facilitating the integration between conventional and traditional cares and promoting the human rights in the often-criticized prier camps¹⁵. A randomized controlled study on results in changing attitudes and practices is forthcoming). The projects in Armenia and Lebanon followed the same pattern and were closed in June 2024. According to an external audit “….despite the pandemic, wars, international crises, the projects have achieved their pre-established objectives”.

The results of the Tunisian pilot project have already been published in international journals¹⁶. The project took place at a time of a severe economic and political crisis. The evaluation revealed a dramatic decrease in mental health resources with a decline in the quality of care and respect for users’ rights. Factors linked to the political and economic crisis, such as the “flight” of health professionals abroad, the non-extension of the contracts of psychologists, and the difficulties in obtaining drugs, may have led to the demotivation of health workers and users. However, the study documented a positive change in the attitudes of those who attended the training program to become trainers.

THE INTRODUCTION OF QUALITYRIGHST PERSPECTIVE IN ITALY

In Italy, the QualityRights Toolkit and the e-learning course have been made available free of charge in Italian. People can access the e-learning course on the WHO website, and Italian health professionals can earn official formative credits (ECM) through accreditation with the ‘Azienda-Ospedaliera Universitaria di Cagliari’ provider.

One year after the course’s launch, 10,000 stakeholders have enrolled, with approximately 5,000 completing it. A QualityRights approach was used to assess the quality of care and the perceived respect for human rights among users and mental health professionals in four psychiatric health services, comparing these with non-psychiatric health services during the pandemic. Results published in several international journals revealed a surprisingly higher satisfaction among both health professionals and users in mental health services compared to other healthcare facilities^17-18. This difference may be attributed to Italy’s “community care” model, which, supported by local and family networks, may have allowed for a more effective pandemic response than the centralized care models common in other specialized medical fields in Italy. Despite these positive findings, both users and mental health professionals have expressed serious concerns about the reduction in funding for mental health services and deep apprehension about the future if new resources are not made available^17-18.

SOME CRITICAL POINTS IN THE CURRENT ITALIAN FRAMEWORK

The progressive decline in funding for mental health care in Italy becomes evident when compared to similar indicators from other European Union countries with homogeneous average incomes¹⁹. This reduction is not only seen as an absolute decrease in resources allocated to mental health but also as a significant reduction in the percentage of health expenditure dedicated to mental health. This trend is perceived to be the result of a little interest in the weakest than the consequence of the economic crisis¹⁹. In fact only in a cultural context of moral crisis can we explain why Italy spends less than 4% of its health budget on mental health care, compared to over 10-14% in countries like the United Kingdom, France, and Germany¹⁹.

This reduction in resources is eroding a mental health care network that was once seen as a mode worldwide^20-21. To preserve this model, it is essential to reorganize services with adequate resources and to realign with the principles of the CRPD, especially regarding social inclusion, recovery, and supporting users in making important life decisions.

Another point that needs attention in Italy is the importance of reliable measures on quality of care and respect users’ rights in mental health care services, as well as the rigorous verification of recovery outcomes. An approach dealing with a medical model verify effectiveness must be stronger than in the past¹⁹. The QualityRights perspective offers a new approach, providing support and tools for the continuous improvement of service quality through a reproducible method that includes user contributions. This approach should be accompanied by evaluations of the effectiveness of psychosocial interventions, adopting comprehensive measures aimed at recovery rather than being limited to symptomatic improvements.

However, these actions cannot occur solely through grassroots botton-up efforts. They require changes in policy and awareness-raising among decision-makers and, possibly, a shift in public opinion.

Conflict of interest statement

The authors declare no conflict of interest.

Funding

This research received no specific grant from any funding agency, commercial, or not-for-profit sectors.

Authors’ contributions

C.M.G. conceptualization; C.M.G. writing—original draft preparation; C.M.G., A.M.: writing—review and editing; C.M.G.: supervision.