2.3. Treatment

Several international organizations have shown special concern that the treatment of mental patients be of the highest quality, the least intrusive, voluntary as far as possible, in accordance with ethical norms, dispensed in the least restrictive environment as close as possible to that of normal life and, when applicable, in the community. Some recommendations are particularly difficult to assure for patients with mental retardation such as that treatment should be "based on a plan discussed with the patient".

On the other hand, dual diagnosis is a risk factor for re-institutionalization, for treatment in institutional settings, for restrictions on care in the community and for a less frequent use (or lack) of psychotherapies.

Finally, it must be taken into account that women with mental retardation, especially if they have a psychiatric diagnosis or are in psychiatric treatment, are particularly prone to be subject to abusive "eugenic" practices (20).

All the safeguards against abusive research practices are similar to those applicable to other patients, but in the case of patients with mental retardation and psychiatric problems, some are more difficult to monitor : such as the need for informed consent and the right of the patient to freely withdraw consent at any time. If the patient does not have the capacity to give consent, the intervention may only be carried out with the authorization of his/her representative or an authority provided for by law. Informed consent must be obtained before presenting a patient to a class and, if possible, also when a case-history is released for scientific publication.

2.4. Rights and Conditions in Mental Health Facilities for Persons with Mental Retardation

Different international documents provide guidelines on the conditions which should be present in mental health centers : the center should dispose of qualified staff whose work is inspected on a regular basis; there must exist a socio-professional rehabilitation program enabling the patient's occupation and ensuring that their labor is not being exploited. The patient may request and produce at any hearing an independent mental health report; copies of the records shall be given to the patient; the right of the patient to make a complaint and request a hearing should be assured. These recommendations are frequently more difficult to monitor for persons with mental retardation.

In fact, psychiatric services for persons with mental retardation have been frequently accused of having an inadequate range of services, a lack of coordination and a questionable quality of care.
While one rationale for institutionalization is that such settings are safer than community living arrangements, many institutional settings have placed disabled people at greater risk of abuse. Jacobson and Richardson (21) report that 81 out of 100 women admitted to psychiatric care had a history of major physical or sexual abuse prior to admission. The majority of victims (about half) had been assaulted on " many " (more than 10) occasions. Only one-fifth of assaults were reported as single offenses. There is evidence that the risk of sexual abuse for institutionalized women with disabilities is from two to four times greater than if living in the community and that the risk of abuse increases with the level of disability. Most of the risk of abuse comes not from within the family, but from outside the home. In point of fact, revelations about the prevalence of physical and sexual abuse in institutionalized settings constituted a determining factor contributing to the closure of such institutions. Part of this problem is associated with the number of different caregivers who pass through institutions, and who therefore feel little personal accountability to the people for whom they work. A study in the United States, for example, found that the average annual staff turnover was about one-third in public residential facilities and over 50% in private residential facilities. Similarly, a report from the Mental Health Act Commission in Britain highlighted issues on overcrowded wards, bed shortages, lack of trained staff and inadequate management.

3. PARITY, MADNESS AND MENTAL RETARDATION

3.1. General Causes of Inequity in Health Care

Articles 1 and 2 of the UDHR state that " all people are born equal in dignity and rights " and that these rights are guaranteed for everyone. However, it is well known that apartheid, genocide, deprivation of freedom (in prisoners, immigrants) but also some other more subtle forms of discrimination (religious, racial, sexual, political, socio-economic) (22), hamper access to care. Stigmatization of mental patients has this same discriminatory effect. That is the reason why several international documents underline that mental patients have the rights to have access to a mental health facility in the same way as they would to any other facility ; to protection against discrimination on the grounds of mental illness ; to receive the same standards of treatment as any other sick person ; to be treated if possible on a voluntary basis in outpatient facilities without hospitalization ; to be treated in the community in an atmosphere suited to his or her cultural background ; not to be discriminated against. However, the fact is that dignity and equal rights are unevenly protected (23) insofar as questions of mental health are concerned. Historically stigmatization of the mentally ill resulted in a risk of denial of access to appropriate treatment or subjection to inappropriate clinical intervention or unwarranted long-term institutionalization. On the other hand, persons with mental retardation suffer from the double discrimination attached to each of the two diagnoses.

But discrimination frequently seeks justification in biological determinism that contends that gender, racial labels or diagnoses such as mental retardation, explain all disparities in health, income, employment, educational achievement or family structure. This bias can only be overcome if equity is considered to be a search for fairness, for social justice, taking into account an attempt to 'level the playing field', in the same sense that legislation has been enacted in the United States to promote measures of 'Affirmative Action' (24).

3.2. Inequity in Relation to Psychiatric Care

3.2.1. Discrimination

The World Health Organization's International Classification of Impairments, Disabilities and Handicaps (ICIDH) (1980) distinguishes among the terms " impairment " (any loss or abnormality of psychological, physiological, or anatomical structure or function), " disability " (any restriction or lack, resulting from an impairment, of the ability to perform an activity in the manner or in the range considered within human norms) and " handicap " (a disadvantage for a given individual, resulting from an impairment or disability that limits or prevents the fulfillment of a role that is normal, depending on age, gender, social and cultural factors, for that individual). There is at present some debate within the disability movement on the use of these terms (25. 26). One point of contention is that these definitions still place the burden of responsibility on the individual, when in fact much of the problem is societal and environmental. A second is that the terms " impairment " and " disability " often are used interchangeably, and therefore one should be dropped.

A distinction has also been made between "direct discrimination", which means treating people less favorably than others because of their disability; "indirect discrimination" which means imposing a requirement or condition for a job, facility or service which makes it harder for disabled people to gain access to it and "unequal burdens" which means failing to take reasonable steps to remove barriers in the social environment that prevent disabled people from participating equally.

The first concern of psychiatry in public health is of course the assurance of the best quality in psychiatric care. In this sense, during recent years, confronted with a policy of cost containment, most advocacy groups focused mainly on demanding "parity" for psychiatric patients, i.e. calling for the rights of mental patients to receive treatment equal to that granted to persons suffering from physical illness. In effect, currently, discrimination against the mentally ill persists worldwide both in the public health-care system and in the private sector insofar as reimbursement of hospitalization and outpatient treatment are concerned, either in relation to the length of stay or the number of interventions permitted. Health insurance associations criticize the legislation proposed in this respect in various countries fearing spiraling costs, despite the existence of studies showing that an increase in mental health coverage would be counterbalanced by a decrease in expenditure for other medical treatments and for incapacity derived from certain psychiatric illnesses.