Abuse Said to Be Rampant In Turkey's Mental Hospitals

An APA committee wants the Turkish Psychiatric Association to clarify allegations of human rights abuses in Turkey's public psychiatric facilities that were raised in a recent report by a Washington-based advocacy group.

“We're approaching [Turkish psychiatrists] as colleagues concerned about the quality of care that they provide, the ethical and other protections they have for patients, and how can we help them do something about it,” said Alan Stone, M.D., a former APA president and the Touroff-Glueck Professor of Law and Psychiatry at Harvard, in an interview with Psychiatric News.

The report, issued in September by Mental Disability Rights International (MDRI), delineated the “pervasive” use of electroconvulsive therapy (ECT) as punishment, its use with children and adolescents, and“ unmodified” by muscle relaxants, anesthesia, or oxygenation. It pointed to the lack of mental health laws that protect patients from arbitrary detention. The MDRI team also visited rehabilitation centers and orphanages and observed improper use of restraints and seclusion, lack of rehabilitation and medical care, and disabled children “emaciated from starvation.”

“Inhuman and degrading conditions of confinement are widespread throughout the Turkish mental health system,” said the report.“ Locked away and out of public view, people with psychiatric disorders as well as people with intellectual disabilities, such as mental retardation, are subjected to treatment practices that are tantamount to torture.”

Psychiatric Association Responds

In a statement issued in response, the Turkish Psychiatric Association and the Turkish Medical Association said that some information in the MDRI report was anecdotal, but they largely agreed with its findings.

“We have to regretfully acknowledge that the deficiencies and shortcomings pointed out.. .are consistent with the facts,” said the two associations. “It is a well-known fact that psychiatric services in Turkey are well behind those in developed countries and even behind general health standards in our country.”

A Turkish government representative disputed MDRI's assessment of conditions in Turkey, however.

“The report has been taken seriously in Ankara but the government does not consider it accurate,” said Fatih Yildiz, first secretary of the Turkish Embassy in Washington, D.C. He said the report did not reflect the current situation and rejected claims of arbitrary detention. ECT was not performed on minors and was not used as punishment, he said, and according to the Ministry of Health, “it is not always medically possible to provide anesthesia for all patients receiving ECT.”

MDRI investigators said they visited sites in Turkey in April 2005 and July 2005, and stood by the statements in their report.

APA's Corresponding Committee on the Misuse and Abuse of Psychiatry is seeking more information about the practices reported by MDRI and to find ways to support the Turkish Psychiatric Association's desire for reform of standards and quality of care in Turkey, while acknowledging the inadequate resources available there.

“My understanding is that the Turks have been aware of these concerns since 1997, but they have not modified the conditions since then,” said Stone. “As colleagues, we're concerned about questions of care, what can be done, and how we can help them.”

The MDRI investigators included American and Turkish members. MDRI has produced similar reports on the status of persons with mental disabilities in Peru, Kosovo, Paraguay, and Mexico.

“The problem does not seem to be a lack of resources,” said investigator Robert Okin, M.D., a professor of clinical psychiatry at the University of California, San Francisco, chief of psychiatry at San Francisco General Hospital, and the only physician on the team. Okin cited the case of Mexico, which he has also visited on behalf of MDRI and where unmodified ECT is not used, despite modest available resources.

“The human rights violations we witnessed in Turkey are a result of government policies, not the personal or professional trespasses of Turkish psychiatrists,” said Okin. “It is important that psychiatrists in the U.S. join with them as allies and colleagues to focus on the source of the problem.”

Chance to Have Impact

“We chose Turkey because it was where we could be most effective,” said Laurie Ahern, associate director of MDRI and one of the report's co-authors, in an interview. Turkey is in the spotlight at the moment, pending its application to join the European Union (EU).

The Commission on Enlargement of the EU will release a report on the general progress made by Turkey on November 9, said Krisztina Nagy, an EU spokesperson in Brussels. “What we can say at this stage is that the commission follows very closely the situation of vulnerable groups in the candidate countries, including mentally disabled people. The commission's experts will study in detail the report of Mental Disability Rights International, but at this stage we have no particular comment to the content of this specific report.”

After a two-year investigation, MDRI described human rights abuses in several aspects of psychiatric care. While most Turkish persons with mental disabilities live with family members, existing social or mental health services are not enough to cover treatment or support in the community. Lack of community-based care has filled state psychiatric facilities with chronic patients while draining resources for persons needing acute care for psychiatric crises.

Care at state facilities was largely custodial. At the Bakirköy and Erenköy hospitals in Istanbul, said co-authors Ahern and Eric Rosenthal, J.D., “people sat in beds or chairs or wandered the grounds of the facility with little to occupy them.”

Legal protections for the mentally ill in Turkey are almost nonexistent, said the report. Persons facing confinement may be arbitrarily detained in psychiatric facilities, have no right to appeal of their commitment, and are denied the right to informed consent or to refuse treatment.

The country will need more than formal legal protections for the mentally ill, said Okin, in an interview. At present, Turkey lacks the judicial structures (such as hearing officers or special courts) to carry out laws and judges trained in human rights.

A total of 359 staff psychiatrists serve the 5,500 beds in five public psychiatric hospitals, said the report. Treatment is minimal and consists mainly of medications and ECT.

“The most widespread and serious human rights violation MDRI observed in Turkey's mental health system is the common practice of using electroconvulsive therapy (ECT) in `unmodified' forms without anesthesia, muscle relaxants, or oxygenation,” said the authors. ECT was used for children and the elderly and for a longer list of indications than the four that Turkish Ministry of Health agreed to with the European Committee for the Prevention of Torture in 1997.

“The misuses of ECT were already established as inhumane and degrading before we came along,” said Ahern. MDRI was told that high use of ECT allowed institution officials to release patients and free up beds for new ones. Often, ECT was the only treatment these patients received. Patients sent home after ECT frequently had little access to psychiatric medications, either because they could not afford them or because they lived in rural areas where such drugs were not available or where there were no psychiatrists to write frequent prescriptions, as required under current regulations.

“I don't link it to Turkish culture or Turkish psychiatrists because it's not happening in university hospitals,” said Okin. “There is some lack of recognition on the part of the Turkish government that this is a real human-rights violation.”

Besides its findings, the report also includes MDRI's recommendations to improve Turkey's mental health system, including “ending the abuse of ECT; protecting against inhuman and degrading conditions in institutions; [and ending] improper and arbitrary detention.”

MDRI also offered an assessment of a proposed mental health law drafted by the Turkish Psychiatric Association, lauding its goals but expressing concern for its perceived deficiencies and offering suggestions for improving it.

“We have reason to believe that Turkey has professionals who care about these issues and has the resources to make changes,” said Ahern.“ We had support from Turkish advocates, psychiatrists, and human-rights lawyers. Our goal is to support reform in Turkey.”

The APA committee is drafting a letter of inquiry, urging Turkey to put international norms for ECT into effect immediately, not to use ECT on children, and to publish standards of care and make them available to the public, patients, and physicians. Perhaps the scheduled presence of a World Psychiatric Association congress in Istanbul in July 2006, will spur Turkey to institute reforms, said Stone.

“What Turkey really needs to do is create community alternatives, a legal framework and a legal structure, and make changes in its institutions,” said Okin. “If the European Union is firm and vigorous in insisting that human-rights violations in parts of Turkey will be corrected, then Turkey will make the needed changes.”

The report “Behind Closed Doors: Human Rights Abuses in the Psychiatric Facilities, Orphanages, and Rehabilitation Centers of Turkey” is posted at<www.mdri.org/projects/turkey/turkey%20final%209-26-05.pdf>.▪