Voting and mental illness: the silent constituency

Mental illness has been long associated with denial of certain human rights, social exclusion and political disempowerment (Shorter, Reference Siddique and Lee1997; Scull, Reference Shorter2005). Too often, the cumulative effects of adverse social, economic and political circumstances, along with the stigma of mental illness, constitute a form of ‘structural violence’, which impairs access to psychiatric and social services among people with mental illness, and amplifies the effects of mental illness in the lives of sufferers and their families (Kelly, Reference Kelly2005, Reference Kennedy2006; Callard et al. Reference Callard, Sartorius, Arboleda-Flórez, Bartlett, Helmchen, Stuart, Taborda and Thornicroft2012). These over-arching social and economic factors contribute to the exclusion of certain people with enduring mental illness from full participation in civic, social and political life, constraining them to live lives shaped, at least in part, by stigma, isolation, homelessness and denial of rights.

In this issue of the Irish Journal of Psychological Medicine, Siddique & Lee (Reference Valentine and Turner2014) address one element of the political situation of the mentally ill by examining voting practices in an acute psychiatric unit in Ireland. They report that only 10% of psychiatry inpatients surveyed voted in the 2011 general election, in which national turnout was 70%. Many patients were unaware of their right to vote. These are interesting, disturbing and provocative findings, of considerable relevance to ongoing efforts to address and remedy the social and political exclusion of the mentally ill.

There is, in general, a paucity of data about voting rates and patterns among individuals with mental illness and individuals secondarily affected by mental illness (e.g. family, friends, carers). This paucity of data is explained, at least in part, by the fact that the lives of individuals with mental illness are not solely defined by illness, so there may not be a direct or readily-detectable link between mental illness and voting choices. Nonetheless, existing evidence suggests that, in the absence of dementia or cognitive impairment (Ott et al. Reference Raad, Karlawish and Appelbaum2003), the voting patterns of individuals with mental illness tend to differ somewhat, though not irrationally, from voting patterns of the overall population (Melamed et al. Reference Melamed, Solomon and Elizur1997a, Reference Melamed, Doron, Finkel, Kurs, Behrbalk, Noam, Gelkopf and Bleich1997b; Bullenkamp & Voges, Reference Callard, Sartorius, Arboleda-Flórez, Bartlett, Helmchen, Stuart, Taborda and Thornicroft2004), with a general tendency towards the liberal side of the political spectrum (Howard & Anthony, Reference Humphreys and Chiswick1977; Bullenkamp & Voges, Reference Callard, Sartorius, Arboleda-Flórez, Bartlett, Helmchen, Stuart, Taborda and Thornicroft2004).

One study, for example, found that outpatients with enduring mental illness in Germany were more likely to vote for left-wing parties compared with the general population (Bullenkamp & Voges, Reference Callard, Sartorius, Arboleda-Flórez, Bartlett, Helmchen, Stuart, Taborda and Thornicroft2004), suggesting that the political choices of the mentally ill reflect a set of priorities that is somewhat, although not dramatically, different to that of the overall population. Another study identified smaller differences in voting preferences among inpatients with mental illness in Israel (Melamed et al. Reference Melamed, Solomon and Elizur1997a), whereas in Canada the proportions of votes cast in psychiatric hospitals for various political parties were virtually the same as in the surrounding areas (Valentine & Turner, Reference Warner1989).

Interestingly, there is evidence that psychiatric inpatients are particularly well-informed voters (Bhopal et al. Reference Bhopal, Meagher and Soos1988; Jaychuk & Manchanda, Reference Kelly1991) and a majority report positive subjective feelings following voting, including a sense of responsibility, belonging to the general community and pride (Melamed et al. Reference Melamed, Donsky, Oyffe, Noam, Levy and Gelkopf2007). Nonetheless, voting rates among psychiatric inpatients can be as low as 3% (Humphreys & Chiswick, Reference Humphreys and Chiswick1993).

In a notably progressive recent initiative in Ireland, patients at the Central Mental Hospital (inpatient forensic psychiatry facility) were facilitated to vote for the first time in general elections in 2007, following a European Court of Human Rights ruling in 2005 (O’Brien, Reference Ott, Heindel and Papandonatos2007). Voting took place in the same way as voting at any other polling station and was overseen by the county sheriff. Voter turnout was high, at 75% (Kennedy, Reference Lawn, McMillan, Comley, Smith and Brayley2007). Two years later, voter turnout at the Central Mental Hospital remained high in European and local elections, and on the eve of the poll, three election candidates attended a question and answer session in the hospital (Houston, Reference Howard and Anthony2009).

Clearly, persons directly or indirectly affected by mental illness represent an extremely large political constituency – a constituency that political organisations rarely address during political campaigns. One reason for this may be a perception among politicians that individuals with enduring mental illness do not vote; failure to vote among the mentally ill, however, is likely attributable, in large part, to remediable secondary correlates of mental illness (e.g. homelessness), lack of knowledge (McIntyre et al. Reference Melamed, Shamir, Solomon and Elizur2012) or administrative problems (Humphreys & Chiswick, Reference Humphreys and Chiswick1993), rather than primary symptoms of mental illness itself. In Israel, for example, the most common reason for inpatients with mental disorder not voting is a lack of identity cards (Melamed et al. Reference Nash2013).

This relevance of contributory factors such as these demonstrates that the systematic disenfranchisement of the mentally ill represents a problem that is, in large part, remediable. This situation needs to be addressed not only by mental health service users, service providers, but also by advocacy services and other stakeholders through (a) improved staff awareness of patients’ voting rights (Rees, Reference Scull2010); (b) provision of relevant information to patients, especially inpatients (McIntyre et al. Reference Melamed, Shamir, Solomon and Elizur2012); (c) where indicated, assessments of voting capacity, using standardised, well-proven tools such as the Competency Assessment Tool for Voting (Appelbaum et al. Reference Appelbaum, Bonnie and Karlawish2005; Raad et al. Reference Rees2009); and (d) voter-registration programmes, all of which have important roles to play in the re-enfranchisement process (Nash, Reference O’Brien2002; Lawn et al. Reference Macleod and McCullough2014).

Another reason for the relatively low profile of mental health issues in political debate may relate to an apparent political consensus about mental health policy; for example, a consensus that traditional services need to be expanded, or that custodial approaches are needed for safety reasons (Warner, Reference Warner2004). The manufacture of such a faux consensus may simply represent a way to avoid debating the real, challenging social and political issues raised by mental illness. It is, in any case, highly unlikely that any apparent political consensus on an issue as complex as mental health is an accurate reflection of true social consensus, and it is only by repeatedly raising issues related to mental health that real political debate will evolve.

Overall, political participation is an important element of efforts to protect and promote the rights of the mentally ill, and voting is one important, empowering element of such political participation. The paper by Siddique & Lee (Reference Valentine and Turner2014) will hopefully help focus attention on this neglected issue in Ireland and expedite measures to optimise political participation among the mentally ill. In the words of Rudolf Virchow (1821–1902), the German pathologist and politician (Macleod & McCullough, Reference McIntyre, Yelamanchili, Naz, Khwaja and Clarke1994), ‘medicine is a social science, and politics nothing but medicine on a large scale’.