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The images are haunting: psychiatric patients locked in cages so small they cannot stand up, naked, lying in their own excrement; zombie-like patients drugged with a half-dozen different neuroleptics simultaneously; patients spending their entire lives in remote facilities with no outside contact and nothing to do but watch television; and rampant use of ECT as a form of punishment and social control.
These hellish images, reminiscent of some of the worst conditions described in some 19th century and pre-World War II mental asylums in the United States, describe current conditions in Eastern Europe and South America, according to panelists at an APA annual meeting workshop on human rights and mental health system reform held in Toronto in June.
Panelist Eric Rosenthal, J.D., is the executive director of Mental Disability Rights International (MDRI), an outgrowth of the Bazelon Center for Mental Health Law in Washington, D.C. He has visited 11 countries in Eastern Europe and South America along with a consulting team of psychiatrists. He and panelists Robert Okin, M.D., and Humberto Martinez, M.D., who sit on MDRI's advisory board, cowrote two extensive reports on the conditions in Hungary and Uruguay. MDRI is currently investigating conditions in another Latin American country and will be releasing a report on conditions in Armenia later this year.
In Hungary 7,000 patients (about half of the institutionalized patient population) live in "social care homes," which resemble U.S. nursing homes but with far worse facilities, according to Okin, who is chief of psychiatry at San Francisco General Hospital. These homes are for people deemed "beyond rehabilitation," he said, and hence there are no efforts at treatment. The physical conditions are "drab, sterile, and cold," and the rooms are ventilated by opening windows even during frigid winter weather, he noted.
"There is absolutely nothing to do," hence there is an enforced idleness in which patients "while away their time," he continued. Their only contact with the outside world is television, and many spend the entire day in front of a set.
Patients' "basic human and legal rights are virtually nonexistent," said Okin. They are "cut off from whatever family and friends they may have had." Most patients spend their entire lives at the homes. These patients have no control over their lives, no privacy, no say on when they get up in the morning or go to bed at night, no say on what they wear, and no say on when they are subjected to seclusion and restraint, he added.
Psychiatrists are present only occasionally and in some of the homes appear to be totally absent. Hungarian psychiatrists have done little to advocate for these abandoned patients, Okin said.
"As psychiatrists, we must ask how these conditions have been permitted to exist," he remarked.
In Hungary, as in other Eastern European countries, there is no effective judicial process to protect patients other than the appointment of a guardian, who, after a patient is committed, is likely to lose all contact with the patient. There is no judicial review at the front end of the commitment process, nor is there any periodic review by a psychiatrist to see whether continued commitment is justified, Okin explained.
Although there are standards for commitment in psychiatric hospitals, as opposed to the social care homes, there are virtually no procedural protections to enforce those standards. There are no resources for community services, as all psychiatric resources are channeled to institutional facilities. But a lack of resources is no excuse for human rights abuses, particularly when Hungary is now spending billions of dollars on weapons to enter NATO, Okin asserted.
Partially in response to the MDRI report, Hungarian mental health law was revised this March. The new law requires an ombudsman in every psychiatric hospital and general hospital psychiatric unit, but is unclear about whether an ombudsman is required in the social care homes. Cages remain legal, but a self-regulating psychiatric group called the Council of Psychiatry recently affirmed its opposition to cages based on United Nations' principles stating that physical restraints should be used only "when they are necessary to prevent imminent harm, and people should be kept in the least-restrictive environment," according to Rosenthal.
Ironically, Hungary is the most developed Eastern European country, well known for its culture and for the sophistication of the psychiatrists who practice in and around Budapest, observed Rosenthal. Most Hungarian psychiatrists have never visited the social care homes, all of which are located on the borders of Hungary, as far from major population centers as possible, according to Rosenthal.
"They literally ring the borders of Hungary," he noted. This pattern is seen throughout most Soviet Union nations and satellites, including Ukraine, Armenia, and Romania.
MDRI advisory board member Martinez, M.D., who is the executive director of the South Bronx Mental Health Council Inc. in New York, cowrote the report on Uruguay after visiting four psychiatric facilities there. He found what was described as "rampant use" of ECT on the mentally retarded and other patients who could not possibly benefit from it.
In three of the four facilities that Martinez and the MDRI team visited, they found "a general atmosphere of despair," but in the fourth the level of care was fairly good, according to Martinez. The long-term facilities in Uruguay were similar to the Hungarian social care homes, he noted.
In general, treatment is "almost entirely limited to psychotropic medication and ECT," Martinez said. Drugs and ECT are often used as "a form of social control" with no treatment justification.
Patients receiving psychotropic drugs, including powerful antipsychotic medications, are not monitored for side effects or for appropriate dosage. Diagnosis is very poor and records sparse.
No procedures are in place for informed consent regarding use of psychotropic drugs and ECT despite the frequency with which they are used. At any one time, about 60 percent of the hospital staff is absent.
Any "social misfit" is at risk of institutionalization and, once institutionalized, may never get out, Martinez said. Some people are born, grow up, and die in psychiatric facilities with no apparent signs of mental illness.
The inappropriately hospitalized include people who suffered an acute disorder but are now in remission, the mentally retarded, alcoholics, people held so long that they have lost all social contacts and forgotten how to live on their own, and homeless people with no place to go. In some cases, elderly patients are at the point where they should be cared for in a nursing home.
The only continuing medical education for staff comes from pharmaceutical company representatives who visit the facilities.
There are no formal procedures to protect patient rights, although there is one designated "inspector of psychopaths" for all of Uruguay. When Rosenthal, who visited the facilities with Martinez, asked this official how he reviewed continued appropriateness of commitment, he picked up the phone, called a facility, and asked whether the patient Rosenthal had inquired about was still at the facility. Told that he was, the official then asked whether the patient was "still sick." When the orderly on the other end of the line said "yes," the official told Rosenthal that the "review" was over.
Relevant Web sites include those of the Open Society Institute, which funded the reports, at www.soros.org; the United Nations, www.un.org; and Mental Disability Rights International, www.mdri.org.