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People with mental disorders run a high risk of losing their basic
personal and social rights. For that reason, users, their familes
and all those associated with that person or who participate, directly or
indirectly, in mental health promotion, need to be informed regarding
the current legal framework for mental healthcare.
From mandatory to voluntary internment
The first national legislation regulating psychiatric care," "Norms and regulations for asylums and the mentally alienated" was passed under the Giolitti government, in 1904, with the implementation act following in 1909. As public safety legislation, its main priority was protecting society from the mentally ill, with "custody" therefore taking precedence over "care". The criteria for internment in a mental asylum were set forth by the law as follows: "Persons affected with any form of mental alienation shall be interned and cared for in asylums if they constitute a danger to themselves or others or cause public scandal" (Italian Law n. 36/1904)
The internment procedure required certification by a physician and an order by the Questore; within 15 days (the observation period) the asylum director was then required to send a written report to the State Attorney and within 30 days the person would either be released or subjected to a "permanent internment". If interned, they suffered legal interdiction, with the loss of all civil rights and the appointment of a legal guardian. Permanent internment could only be ended by a certificate, issued at the asylum director's personal responsibility, that the patient was "cured", or if at the request of the inmate's family, a court authorised the "alienated person" to be released into their custody. Psychiatric care was administered by the provincial authorities and each province had to establish an asylum. Even if internment was voluntary, it was regulated by the same rigid rules.
This procedure remained in effect until 1968, when Italian Law n. 431 (known as the Mariotti Act) introduced voluntary internment and made it possible, at the patient's request, to convert a mandatory internment into a voluntary one. However, the real impact of the Law was to be found in the changes it enacted in asylum organisation and in the provisions it contained for prevention practices and follow-up care outside of the asylum itself.
From internment to the right to care: the Psychiatric Reform Act
The Psychiatric Reform Act, Regulations for voluntary and mandatory psychiatric evaluations and care (better known as Law 180), was approved on May 13, 1970 and subsequently incorporated into the National Healthcare Service Act (n.833, December 23, 1978). The Law established the principle that, as with general healthcare, psychiatric care would also be based on the individual's right to care and health, and not upon any presumed danger. Psychiatric care would now also voluntary, with mandatory treatment only for very exceptional and carefully regulated cases, and would be provided by services and facilities located in the community.
According to the Law, in the event of "altered mental states requiring
urgent therapeutic intervention" and if all attempts to obtain the person's
consent to such treatment have failed, then a Mandatory Healthcare Treatment
(MHT) can be requested by the physician and carried out in any community-based
psychiatric structure, or even in the patient's home. If hospitalisation is
also required for medical reasons, the MHT can be applied in the Psychiatric
Diagnosis and Care Unit (PDCU) within the general hospital.
Law 180 also sanctioned that no new patients could be interned in psychiatric
hospitals, (though permitting patients interned before May 1978 to continue
to remain for an indeterminate period) and that existing psychiatric hospitals
had to be closed (however, the definitive closure of all psychiatric hospitals
in Italy would only be decreed by the Health Ministry in 1999, more than 20
years after Law 180).
However, the Friuli Venezia Giulia Region had the distinction of fully incorporating all of the indications of the reform law into its own Regional Law n.72/23 (December 1980), thereby initiating a positive transformation process. This Regional Law became a model for the correct implementation of Law 180 and many of its elements were incorporated in the Mental Health Protection Goals Plan of November 1999 (Dpr 274/1999).
The National Healthcare Service
In Italy, the right to healthcare was sanctioned in 1978. Healthcare was completely free until 1990, when a system of partial reimbursement, or the payment of a so-called "ticket" was instituted; however, despite this innovation, public healthcare remains essentially free. The national healthcare budget was 88.2 billion Euro in 2005, and while 5% of the total healthcare budget (4.4 billion Euro) is considered the minimum for mental healthcare, in fact only 3% is actually allocated for that purpose. Italy thus ranks 20th in Europe, together with Portugal, Slovakia and the Czech Republic, while Sweden, Great Britain and Germany allocate about 10% of their total healthcare budget to mental health.
In Trieste, the percentage spent for mental healthcare has remained more
or less constant over the last decade, varying between 4.2-4.8% (in 2005,
Trieste spent 16,057,739 Euro or 4.3% of the local Healthcare Services Agency
– ASS1Triestina - budget).
Goals Project for Safeguarding Mental Health
The first National Mental Health Goals Project in 1994 represents a milestone in psychiatric care in Italy, with the second Goals Project (1999-2000) going even further and effectively modifying and emending the Psychiatric Reform Law of 1978 (Law 180) by specifying MHD structures and services in Italy and defining their functions. This Project ended a 20 year cycle of start-up and experimentation of the 1978 Reform, which had been characterised by strong and often bitter opposition and conflict involving operators, families, local administrators, politicians and public opinion.
The Goals Project was, and remains an extremely useful tool for the quantitative
and qualitative development of psychiatric care because it:
Mental Healthcare Policies and the Rights of Citizenship
Much of the world's population still lives in oppressive conditions due to various factors: extreme cultural and economic misery; lack of resources in the local territory or the social class to which one belongs; inequality between North and South and authoritarian and repressive political regimes which violate fundamental human rights. In a context already characterised by profound inequalities, persons who suffer from a mental disorder constitute one of the most oppressed minorities, and not only because they are denied basic rights more frequently, but because this denial of rights is legitimised by a scientific statute of "illness".
Because the majority of funds intended for psychiatry are still invested for the hospitalisation and segregation in closed institutions of persons who suffer from mental disorders, governments must give priority to promoting policies which provide for the immediate closure of all places of internment and reclusion and the development of community-based services. Of particular urgency during this transitional phase is the creation of mental healthcare services for defined areas, with the mandate of identifying operational choices, and strategies for the promotion of health and the real access to rights.
For methods of care to change, the places where care is provided must also be changed; changing one and leaving the other intact is a dead end. The focus must be shifted from the illness to the whole person: their needs and rights, but also their abilities and resources. Programmes must provided a wide range of interconnected services directed not only at the individual but also at their context, and the network and social groups to which they belong.
Thus, the political task (of both central governments as well as local administrators)
must be that of promoting citizenship for the most disadvantaged and vulnerable
sectors of the population, improving the quality of life and encouraging autonomy
and emancipation (including from a dependency on the services) so that the
real tangible exercise of rights leads to a greater ability to choose and
National governments and local administrations should also offer healthcare education programmes for the general public in order to promote a more positive image of the mentally ill which is free of labelling and prejudices.
The Helsinki Declaration
In January, 2005, the WHO organised a 3-day European conference
on mental health in Helsinki. At the end of the conference, the health
ministers of 52 countries in the European geographic area, including Turkey
and Uzbekistan, unanimously approved a significant document in which the signers
declared their adherence to a shared analysis and evaluation regarding mentally
ill persons living in their countries. According to the WHO Director for Europe,
this agreement is the result of years of experience and work in defense of
human rights and the right to care, treatment and prevention in mental health,
and represents a historic achievement and point of departure.
The Helsinki conference also approved a Plan of Action which is binding for European governments. The principles expressed in these documents are the same ones which have sustained and driven the transformation process in Italy, with the "Trieste system" representing a real concrete experience of renewal.
But what does the Helsinki Declaration say? It begins by stressing that there is no health without mental health, that a person's mental health and mental wellbeing are fundamental to their quality of life, impacting on their productivity, the family, the community and the nation as a whole. Mental health enables a person to experience the true meaning of life, permits them to express their own creativity and be active and participatory citizens.
The Plan of Action provides for increasing investments for mental healthcare and establishing healthcare policies and laws based on current knowledge and human rights. The document further states that mental healthcare policies and practices should focus on promoting mental wellbeing, fighting discrimination and social exclusion, providing effective and adequate services and promoting prevention and the social reintegration of persons with severe mental disorders.
The WHO Declaration places mental health at the centre of the human, economic and social potential of the participating countries and exhorts all countries to consider it an integral part of their social policies, together with the defense of human rights, education and development.
The Declaration also establishes the following priorities for the coming decade:
The Green Paper
In May 2006, based upon the Helsinki Declaration the European Community prepared a "green paper" entitled: "Improving the public's mental health. Towards a mental healthcare strategy for the EU."
The mental health of European citizens is a resource for achieving a number
of the EU's declared strategic goals, such as long term prosperity, a greater
commitment to solidarity and social justice and a real improvement in the
quality of life of European citizens.
Improvement is possible in all of these areas and numerous initiatives have been launched. Further development is necessary, together with a consolidation of existing projects.
Appeal of Pope Benedict XVI
On February 11, 2006, on the occasion of the 14th World Day for the Sick,
Pope Benedict XVI made an appeal to persons around the world in order to stimulate
and promote attention, solidarity and effective action in favour of persons
suffering from mental disorders.
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