Scholarly article on topic 'Impact of the UN convention on the rights of persons with disabilities (UN-CRPD) on mental health care research - a systematic review'

Impact of the UN convention on the rights of persons with disabilities (UN-CRPD) on mental health care research - a systematic review Academic research paper on "Clinical medicine"

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BMC Psychiatry
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Academic research paper on topic "Impact of the UN convention on the rights of persons with disabilities (UN-CRPD) on mental health care research - a systematic review"

Steinert et al. BMC Psychiatry (2016) 16:166 DOI 10.1186/s12888-016-0862-1

BMC Psychiatry


Impact of the UN convention on the rights of persons with disabilities (UN-CRPD) on mental health care research - a systematic review

Christoph Steinert1, Tilman Steinert2, Erich Flammer2* and Susanne Jaeger2


Background: The United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD) aims at stimulating profound changes and social development in many areas of the society. We wanted to examine the impact of the convention on mental health care research up to now by a systematic review.

Methods: We searched relevant electronic databases for empirical studies from the area of mental health which focused directly on the content of the UN-CRPD.

Results: One thousand six hundred ten articles were screened, 36 of which fulfilled the inclusion criteria and came from 22 different countries. 25 studies (69 %) are related to persons with intellectual disabilities, only 11 to other mental disorders. Study designs were quantitative and qualitative as well. Issues were realisation of the UN-CRPD, implementation and financing, development of instruments, and attitudes towards the UN-CRPD.

Conclusions: In contrast to possible wide-reaching consequences for the organisation of mental health care, theoretical debates prevail as of yet and empirical research is still scarce. Research on the UN-CRPD is more advanced for intellectual disabilities and provides good suggestions for relevant research aspects in major mental disorders.

Keywords: UN convention on the rights of persons with disabilities, Human rights, Inclusion, Mental health research


The United Nations (UN) Convention on the Rights of Persons with Disabilities (UN-CRPD) [1] was adopted by the United Nations General Assembly in 2006 and came into force in 2008. It was ratified by the European Union in 2010 and, in total, by 156 states in 2015. The UN-CRPD is the most recent in a row of UN human rights declarations, beginning from the Universal Declaration of Human Rights in 1948 [2]. The ratifying states acknowledge that the principles of the UN-CRPD should be transposed into their national legislations. Guiding principles are respect for inherent dignity, individual autonomy including the freedom to make one's own

* Correspondence: 2Department of Psychiatry and Psychotherapy I, Centres for Psychiatry Suedwuerttemberg, Ulm University, Versorgungsforschung Weissenau, Ravensburg, Germany

Fulllist of author information is available at the end of the article

(3 BioMed Central

choices, non-discrimination, full and effective participation and inclusion in society, equality of opportunity, and accessibility. The general idea of the UN-CRPD is inclusion of disabled people into the society and communities instead of establishing special rules and institutions [3]. Phrasing general principles of human rights, the UN-CRPD is completely applicable to the situation of people with mental illnesses as well as with other kinds of disabilities. Mental illness is not necessarily associated with disability; however, a clear distinction is not required since the UN-CRPD phrases principles which should be valid for all human beings, disabled or not. In the past two years, most interest has been attracted by article 12 (equal recognition before the law). This article does not contain any restrictions due to reduced mental capacity, which led to the idea that such a construct is generally not valid. Consequently in 2013, the special rapporteur on torture and other cruel, inhuman or degrading treatment or

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punishment of the UN Human Rights Council claimed to abolish all kind of coercive treatment as well as substituted decision-making legislations such as guardianship [4]. This has caused considerable concern among psychiatric organisations and stimulated ongoing controversies between psychiatrists and patients' organisations in some countries [5]. However, this current and mostly critical discussion thwarts the engagement with the other aspects of the UN-CRPD - setting goals for mental health care that are not less challenging. The UN-CRPD aims at stimulating profound changes and social development in many areas of the society such as schools, workplace environment and public transportation. On this behalf, the convention calls for data gathering and research in the signatory states. Taking into account this and the huge political relevance of the UN-CRPD, we wanted to examine the impact of the convention on mental health research up to now by a systematic review.


Our systematic review aims to identify studies that can be seen as a direct product of the impact of the UN-CRPD on mental health care research. For this purpose, a sequence of selection processes have been performed as described below.

The applied methods are in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [6].

Search strategy

Potentially relevant studies were identified by searching the electronic databases All EBM Reviews, Embase, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, PsycINFO and PSYNDEX plus Literature and Audiovisual Media. The searching process was performed in Ovid and conducted between the 3rd of July and the 17th of July 2015. We used the broadest possible search string consisting only of the nouns in the title of the UN-CRPD. Thus, we used the following search term in the multi-field search in Ovid: "convention" AND "rights" AND "persons" AND "disabilities". Taking into account the possible national or regional character of research in this field, no language restrictions were made. This yielded 1610 articles.

Inclusion criteria

Studies were selected in a two-stage process based on predefined inclusion and exclusion criteria.

In the first step, three criteria were applied. The first inclusion criterion was the requirement that a study was published in the context of the UN-CRPD. Consequently, we excluded articles which did not contain the term UN-CRPD (abbreviated or written-out) in its title, abstract or keywords.

The second inclusion criterion was the condition that the article could be classified as focused on the area of "mental health". For the purpose of our study we defined mental health as mentioning of the terms "mental health", "mental illness", "mental disorder" or explicit mentioning of a diagnosis out of the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10), chapter F (mental and behavioural disorders). Terms related to intellectual disability (ID, ICD-10 F 7x) such as "intellectual disability" and "mental retardation" also justified inclusion.

The third inclusion criterion required that a study could be classified as empirical. We defined empirical studies as all studies which are the product of research based on experimentation or observation. Thus, all studies were excluded which did not apply any form of qualitative or quantitative research. We assigned those excluded studies to three categories termed 'legal discussion', 'theoretical framework' and 'reviews or overviews'. The category 'legal discussion' refers to all studies which can be assigned to the juridical realm and which are based on norm-driven assumptions. 'Theoretical framework' delineates those articles which are based on theoretical concepts and their discussion. This category also includes case study-approaches without generalisations about a larger population. Finally, the category 'reviews or overviews' captures all non-systematic literature reviews, historical overviews, book reviews and general overviews about specific subject areas. All those excluded studies have in common that they did not produce or analyse real-world data.

We applied no a priori language restrictions to our search since we were confident to find competent translators in our multi-national hospital and research staff for all common languages. The Consort diagram of the selection process is displayed in Fig. 1. Deliberately, the first evaluation was rather lenient to avoid type II errors (false negative) at the expense of type I errors (false positive). The assessment of studies in the first-stage process was based on titles and abstracts.

Study selection

In the second-stage process we identified those of the studies kept after the first-stage process that focused directly on the content of the UN-CRPD. Three authors (CS, SJ, EF) evaluated their full text content independently. An article was qualified as focusing on the UN-CRPD based on its research question or aim. To be included, the research question or aim must have targeted directly on the UN-CPRD. This condition was fulfilled when the research question either explicitly addressed the UN-CRPD or when it dealt with one of its general principles codified in Article 3. For the latter case, the concepts of inclusion and participation were central keywords.

Fig. 1 Flow diagram

Ambiguous cases were only included after discussions between the researchers. This final screening phase resulted in studies which were judged as directly inspired by the UN-CRPD. Those studies can be seen as direct product of the convention and their research was carried out in the light of the UN-CRPD.


In the first-stage process, we identified 1,610 studies. 327 studies were excluded because they did not cover the UN-CRPD, 824 studies were excluded because they did not cover mental health, and 381 studies were excluded because they were non-empirical. So after the first screening process 78 studies remained. After 4 duplicates had been removed, 74 articles were assessed on basis of the full-text content. In this second-stage process, 38 studies turned out to be not directly focussing on the content of the UN-CRPD. Eventually 36 articles could be included.

Those 36 relevant studies were categorized into two groups. The first group incorporates all publications in the area of intellectual disabilities (ICD-10 F 7x) which are displayed in Table 1. In total, there are 25 publications in the realm of intellectual disabilities representing 69 % of all included studies. The second group contains all publications on other mental disorders which are displayed in Table 2. There are 11 publications on mental disorders representing 31 % of the included studies. The included studies were carried out in 22 countries illustrating the global dimension of the UN-CRPD. The country with the highest number of studies is Australia (8, 22 %). The included studies employed multi-method approaches ranging from randomised controlled trials (RCTs) to different quantitative and qualitative approaches. In total, there are 2 RCTs (6 %), 17 quantitative studies (47 %) and 17 qualitative articles (47 %).

Table 3 depicts a typology of all included studies from Tables 1 and 2. To categorise the multitude of diverse studies, we identified four major themes of research in light of the UN-CRPD. The first major theme is the realisation of the UN-CRPD and comprises all studies which investigate the gap between the aspirations of the convention and reality. While realisation consequently describes the practical fulfilment of the UN-CRPD, the second major theme termed 'implementation and financing' describes the legal fulfilment of the UN-CRPD. Studies belonging to this major theme analyse the implementation of the UN-CRPD in national legislation and as one specific aspect the financial framework as an indispensable condition for an effective implementation. The third major theme of studies inspired by the UN-CRPD is the development of instruments to capture the realisation of the convention. While the aim of those instruments is eventually to quantify the realisation of the

UN-CRPD, articles belonging to this category focus rather on the construction of instruments than on the realisation as such. The last major theme we identified were attitudes towards the fulfilment of rights which are enshrined in the convention and the general awareness of the population of those rights. Studies belonging to this group analyse the realisation of the convention in people's minds as an essential precondition for a realisation in practical terms. Taken together, there are 27 studies (75 %) focusing on the realisation of the UN-CRPD, 3 studies (8 %) investigating the implementation and financing, 3 articles (8 %) concerned with the development of instruments and 3 studies (8 %) analysing attitudes towards the UN-CRPD. Table 3 shows that 16 studies (44 %) apply a broad perspective focusing on the UN-CRPD as a whole, while 20 studies (56 %) investigate individual articles of the convention.


The most important result of this review was what it did not find: an appropriate amount of research in mental health care reflecting the importance of the UN-CRPD. Empirical research on aspects of the UN-CRPD is still scarce. This is in sharp contrast with the huge impact it could and probably will have on the complete organisation and structure of mental health care in all ratifying countries. 25 out of 36 studies that could be included (69 %) were related to intellectual disabilities, which was an unexpected result. Intellectual disabilities fall into the definition of mental disorders as classified in the ICD-10, chapter F (F 7) and thus fulfilled our inclusion criteria, but in most countries service provision and care is separate from other mental disorders. In published articles, the term 'mental disorder' typically refers to psychotic and affective disorders, though intellectual disabilities and dementia are also classified as mental disorders. None of the included articles referred to dementia or acquired brain injury. Anyway, the detected body of research on intellectual disabilities provides valuable insight on important research topics which should be put on the agenda for other severe mental disorders.

The majority of studies inspired by the convention analyses to what extent the aspirations of the convention are realised in a real-world context. Drew et al. [7] find a wide range of violations of the convention's aims in low-income and middle-income countries. Kogstad [8] demonstrates that there is also a gap between human rights aims and patients' experiences in a high-income country. To bridge the gap between aspirations and reality, Vijayalakshmi et al. [9] assign the right to education a catalyst function. Successful examples of realisation of the UN-CRPD are represented by the studies by O'Brien et al. [10] and O'Connor et al. [11] who show the positive effects of inclusion in postsecondary education. In the

Relevant publications


Main results

Feldman et al. (2012) [31]

Brolan et al. (2012) [32]

Sermier Dessemontet & Bless (2013) [12]

Gray et al. (2014) [33]

McConkey & Leavey (2013) [22]

Badia et al. (2013) [16]

Gobrial (2012) [24]

Stancliffe et al. (2011) [18]

preliminary evaluation of health rights training

meaning, perceptions and experiences of advocacy by family members and paid support workers of adults with ID

the impact of including children with ID in general education classrooms with support on the academic achievement of their low-, average-, and high-achieving peers without disabilities

changes in living arrangements and participation in daytime activities over time in a community population of young )le with ID

changes from 2001 to 2011 in Irish attitudes towards the right to sexual fulfilment of persons with ID

leisure activities of persons with ID

awareness of human rights of children with ID in Egypt

benchmark on the degree of choice exercised by adult service users with ID in the USA

training group made significantly more correct responses on post training and follow-up tests

advocacy roles are vital to )le with ID

no significant difference in the progress of the low-, average-and high-achieving pupils from classrooms with or without inclusion

adequate provision of accommodation and employment services for young adults with ID is lacking

in 2011, half the people in the survey thought that people with ID had the right to sexual relationships

leisure activities and recreation activities were mostly solitary and passive in nature; age, type of schooling and severity of disability determine participation

widespread lack of awareness of the rights of children with ID; respondents believed that these children had limited access to mental health care, social care, education and rehabilitation

individuals living in their own home or an agency-operated apartment were more likely to choose where and with whom they live than individuals in nursing homes, institutions or group homes


Materials and methods






RCT with 6 month follow-up (N = 31)

RCT (113 parents, 84 support workers of adults with ID)

quasi-experimental study (N = 404)

quantitative longitudinal study (N = 536)

quantitative study in 2001 (N = 1000), in 2006 (N = 1004), in 2011 (N = 1039)

cross-sectional quantitative study (.N = 237)

quantitative study, parents of children with ID (N = 72), professionals (n = 50), neither parents nor professionals (n = 78)

quantitative study (N = 6778)

Dusseljee et al. (2011) [34]

üa et al. (2011) [17]

Aznar et al. (2012) [26]

Martin & Cobigo (2011) [35]

variations in community participation in the domains work, social contacts and leisure activities among people with ID

influence of personal characteristics and environmenta factors on the participation in leisure activities of people with ID

testing the usefulness of the ITINERIS scale on the rights of persons with intellectual disabilities (ISRPID)

improving the understanding of the concept of social inclusion and its indicators

most people with ID in the Netherlands have work or other daytime activities, have soda contacts and have leisure activities; people with ID in general hardly participate in activities with people without ID

participation in leisure activities is determined more by persona factors and perceived barriers than by disability-related factors

the ISRPID can be an appropriate scale to monitor the UN-CRPD rights at an individual or group level

a clear definition of inclusion and its measurement is needed for decision-makers and service providers

Drew etal. (2011) [7]

Fasching (2012) [36]

Gomez etal. (2011) [37]

types of human rights violations experienced by people with mental and psychosocial disabilities in low-income and middle-income countries

access to labour market measures to enhance vocationa participation for people with ID

Exploratory investigation about implementation of human rights according to UN-CRPD

wide range of human rights violations including the inability to access adequate menta health services or being subjected to stigma and discrimination

vocational guidance predominates qualifying measures and measures directly aiming at integration on the regular labour market

many situations of abuse and negligence are still existing. Violation of privacy recognized as major problem by both groups

Garcia Iriarte et al. main issues for people with ID in core concerns: Living options,

(2014) [38] Ireland employment, relationships,

citizenship, leisure time, money management, self-advocacy and communication


quantitative study (N = 653)


Belize, Bosnia and Herzegovina (and others)



cross-sectional quantitative study (N = 237)

705 persons with ID, contra group of 524 college students

retrospective analyses with adults residing in institutions (N = 1014) and with adults receiving community-based residentia services (n = 327)

survey (N = 51 people with mental and psychosocial disabilities from 18 countries) and review of literature

nationwide survey (N = 625 persons with ID participating in vocational measures)

quantitative study (N = 586 persons with ID in defined services and N = 161 professionals in the same services)

national study involving 23 focus groups (N = 168)

McConkey et al. (2013) [14]

O'Connor et al. (2012) [11]

inclusion within the context of Youth Unified Sports (which combines of players with ID and those without ID in the same sport teams) as perceived by athletes, partners, coaches, family carers and community representatives

lecturer responses to the inclusion of students with ID auditing undergraduate classes

Saaltink et al. (2012) [39]

the right to participation for young people with ID in a family context

Hillman et al. (2012) [40]

issues related to human rights arising within the daily lives of people in personal support networks that included adults with ID

Shaw et al. views of people with ID and

(2011) [19] their family members regarding

preferred models of housing and support for ageing people with ID

Kelly et al. views and experiences of Irish

(2009) [41] people with ID in the area of

sexuality and relationships

O'Brien et al. experiences of students with ID

(2009) [10] gaining access into a university


factors which facilitate soda inclusion of athletes: persona development of athletes and partners, creation of inclusive and equal bonds, promotion of positive perception of athletes, building alliances within loca communities

the initiative was strongly supported by all lecturers, providing opportunity to consider more inclusive instructional approaches for al learners

young people with ID follow an age-typical yet restricted pattern of participation in decisions about their lives; supported decision-making strategies are recommended

maintenance of rights within a supportive environment can be facilitated by deep knowledge, respect, promotion of active participation and provision of support

the main preference were models of housing that provide the opportunity to live in close proximity to their peers and in large groups in the community

people with ID are getting insufficient sex education

inclusion within the university setting led the students to see themselves more alike than different to their peers, they felt more accepted, more competent and more socially networked

Serbia, Poland, Ukraine, Germany, Hungary

qualitative study, 75 interviews in five different countries


qualitative study (N = 11)


qualitative study (N = 10)


qualitative study, ethnographic study of 9 personal support networks


qualitative study, focus group and individual interviews, adults with ID (N = 15) and family members (n = 10)


qualitative study, focus groups (N = 15)


qualitative study, focus groups (N = 19)

Frawley & Bigby political orientations of advisory the political perspective of

(2011) [13] body members with ID, their members with ID varied; work

participatory experiences and the was found hard but rewarding;

types of support they received both practical and intangible

obstacles to participation were


Cobigo ived experiences of persons with four components identified:

(2014) [42] intellectual and developmenta availability of choice

disabilities (IDD), identifying core opportunities, provision of choice

components of the fundamenta options, informed cognitive

right of choice process and act of choosing,

supportive environment.



qualitative study, members of disability advisory bodies with ID (N = 9) and without ID (n = 12)

scoping review

Relevant publications Vijayalakshmi et al. (2013) [9]

Angermeyer et al. (2014) [23]

Burns (2010) [43] Steinert et al. (2015) [44]

Kogstad (2009) [8] Nomidou (2013) [25] Nankivel et al. (2013) [15] Battams & Henderson (2012) [20]


the role of education in ascertaining human rights needs of people with mental illness

changes of public attitudes towards restrictions on mentally ill people

budget allocations over a 5-year period between psychiatric and general hospitals in KwaZulu-Nata

Patterns of individual mobility and active use of motorised vehicles

violations of dignity considered from a clients' point of view

human rights in in-patient care in Greek mental health facilities using the WHO QualityRights toolkit

orientation of nurses to human rights and access of consumers with severe mental illnesses to general practitioner services

current and potential impact of the UN-CRPD on Australian legislation and policy

Kleintjes et al. (2010) [21] current support for mental health

care user participation in policy development and implementation in South Africa

Main results


Materials and methods

education is a mechanism for the pursuit of other human rights; empowerment to pursue education will play an important role in fulfilling the obligations of the UN-CRPD

people's views on patient rights have become more liberal, but the public is more inclined to restrict patients' freedom in case of deviant behaviour

mean increase in budgets was considerably lower in psychiatric (3.8 %) than in general hospitals (10.2 %)

Participants drove considerably less in time and distances than genera population. Alcohol abuse and recurrent psychiatric hospitalisation were associated with exclusion

gap between human rights'aims and clients' experiences in severa settings; lack of safeguards against infringement

either improvement or initiation is necessary for the psychiatric clinic under research to fully comply with the requirements of the UN-CRPD

the studied nurses only rarely raised the topic of human rights


South Africa





quantitative study (N = 100)

quantitative study, two population surveys (N = 2094; n = 3642)

quantitative study based on budget allocations (5 psychiatric and 7 general hospitals)

quantitative study (N = 150) with participants with schizophrenia or schizoaffective disorder

qualitative content analysis of 335 client narratives

qualitative study, 21 in-depth interviews, documentation review and observation

qualitative study, 6 focus groups (N = 38)

there is a greater focus on concerns Australia

about 'negative rights' rather than

'positive rights'; high rates of

involuntary detention and a lack of

access to the law for people with

psychiatric disabilities continue to be

significant problems

mental health care user consultation South Africa

in policy development and

implementation has been limited;

however, most respondents felt that

inclusion of user perspectives in

policy processes would improve

policy development

qualitative study, ten interviews with professionals from law, psychiatry, policy and service user backgrounds

qualitative study, semi-structured interviews (N = 96) and policy document analysis

Randall et al. (2012) [27]

Henderson & Battams (2011) [45]

producing a toolkit to document violations and good practice with the aim of preventing human rights violations and improving genera health care practice in psychiatric and and social care institutions

access and barriers to physical and mental health care

the toolkit has demonstrated UK (and others)

applicability and is qualified as

acceptable and feasible for the

systematic monitoring of human

rights in psychiatric and social care


methodological and implementation study conducted across 15 European countries in monitoring visits to 87 mental health organizations

main barriers to the achievement to the right of health are structural (eg.


qualitative study, interviews with 10 key stakeholders

Table 3 Typology of publications in the context of the UN-CRPD

Major theme



References of relevant publications


Implementation, Financing

Development of instruments


Key concerns of people with ID

Types of human rights violations

Living arrangements and participation in daytime activities of people with ID

Impact of inclusion on peers without disabilities

The right of participation of people with ID

Protection of rights in support networks

Freedom of choice of persons with IDD

Choice of living arrangements

Socialinclusion of people with ID

Role of education in meeting human rights needs of people with mentalillness

Inclusion of people with ID in postsecondary education

Access to physicalhealth care for people with serious mental illness

Health advocacy

Inclusion in political and public life

Patterns of leisure participation of people with developmentaldisabilities

The right to sexualself-determination

Access to labour market for people with ID

Use of motorized vehicles

Budget allocations to psychiatric hospitals

Impact of UN-CRPD on national legislation and policy

Mentalhealth care user participation in policy development and implementation

Application of ISRPID to measure the extent to which people with ID exercise their rights

Development of ITHACA toolkit for systematic monitoring of human rights violations

Application of the WHO QualityRights toolkit which is based on the UN-CRPD

Public attitudes towards restrictions on mentally ill people

Awareness of human rights of children with ID

Public attitudes towards the right of sexualfulfilment of people with ID

UN-CRPD as a whole [37, 38]

UN-CRPD as a whole [7, 8]

UN-CRPD as a whole [33]

UN-CRPD as a whole [12]

UN-CRPD as a whole [34, 39]

UN-CRPD as a whole [40]

Article 3, 19 (Choice) [42]

Article 3, 19 (Choice) [18, 19]

Article 19 (Social inclusion) [14, 35]

Article 24 (Education) [9]

Article 24 (Education) [10,11]

Article 9, 25 (Health care services) [15, 45]

Article 25 (Health) [31,32]

Article 29 (Participation in [13] political and public life)

Article 30 (Leisure participation) [16, 17]

Article 23, 25 (Sexual self-determination) [41]

Article 27 (Work and employment) [36]

Article 20 (personal mobility) [44]

UN-CRPD as a whole [43]

UN-CRPD as a whole [20]

Article 29 (Participation in political [21]

and public life)

UN-CRPD as a whole [26]

UN-CRPD as a whole [27]

UN-CRPD as a whole [25]

UN-CRPD as a whole [23]

UN-CRPD as a whole [24]

Article 23, 25 (Sexual self-determination) [22]

same vein, Sermier Dessemontet and Bless [12] demonstrate that there is no negative impact of inclusion on the achievements of non-disabled peers. Furthermore, the studies of Frawley and Bigby [13] and McConkey et al. [14] represent best-practice examples for the fulfilment of the principles of the convention. Other studies focus on the realisation of individual aspects of the convention such as access to physical care [15], participation in leisure activities [16, 17] or the choice of living arrangements [18, 19]. While those studies offer valuable insights, there is still a lack of systematic studies investigating the realisation of the UN-CRPD as a whole.

Moreover, there is a paucity of research about the implementation of the convention into national legislation. Battams and Henderson [20] provide such a study for the context of Australia and Kleintjes et al. [21] analyse the specific aspect of mental health care user participation in policy development and implementation. While there is a multitude of articles in the judicial realm analysing and discussing the implementation of the UN-CRPD, there is a lack of empirical studies concerned with this question. Also studies investigating attitudes towards the rights in the UN-CRPD and capturing the awareness of those rights are still rare. McConkey and Leavey [22] provide such a study specifically for Irish attitudes towards the right to sexual fulfilment of persons with intellectual disability. Angermeyer et al. [23] have a broader scope investigating general changes in public attitudes towards restrictions on mentally ill people. Gobrial's [24] study analyses the public awareness of children's rights with intellectual disability in Egypt. While those studies are interesting on their own, they just offer insights on specific attitudes about particular rights. There is lack of studies capturing the general awareness of the convention and general attitudes towards its meaning in the population. Finally, there are some remarkable attempts to develop instruments to capture the realisation of the UN-CRPD. While Nomidou's [25] study is based on the World Health Organization (WHO) QualityRights toolkit, Aznar et al. [26] have developed a particular instrument called ISR-PID to capture the realisation of the rights of persons with intellectual disabilities. Similarly, Randall et al. [27] have developed the Institutional Treatment, Human Rights and Care Assessment (ITHACA) toolkit which allows a systematic monitoring of the rights enshrined in the UN-CRPD. Those instruments have a huge potential to serve as a base for further studies investigating the realisation of the convention's rights.

Our review has several limitations. First of all, we may have applied too narrow inclusion criteria that limited the scope of possibly relevant studies. For instance, no example of peer research, i.e. participatory research by mental health service users, could be included. The few

research papers we could find had a focus slightly different from issues in the UN-CRPD, e.g. they focused on everyday experiences and individual coping strategies [28, 29]. Although they are covering important topics that are related to rights of people with disabilities the research was not explicitly 'a direct product of the UN-CRPD' as was required in this review paper. This is indeed a shortcoming of our inclusion criteria. Similarly, we could not include some methodological articles on the improvement of methods for the research in people with particular disabilities (e.g. specific interview techniques, participatory research) although they addressed a necessary precondition of the research we were interested in [30]. Further, the reliability of the criteria could be questioned. To rate studies as empirical studies in the area of mental health and in the context of the UN-CRPD seems quite straightforward. But whether a study focused directly on the content of the UN-CRPD is to some degree vague. It is possible that other researchers would have come to a somewhat different set of included studies.


There is urgent need for further research in all areas covered by the UN-CRPD relating to mental disorders. Much more evidence is needed for answering the many questions that are posed by the UN-CRPD, such as how inclusion and equality can be realised for people disabled by mental disorders and what impact a change of policies, service provision, legislation, and attitudes would have on their mental health. Up to now, the different research projects have been rather isolated and often focused on specific subject areas. While the UN-CRPD has inspired several studies, those studies are rather disconnected projects than part of a coherent body of research. More research has been done in the field of intellectual disabilities as compared to the field of severe mental disorders. This offers interesting suggestions to learn from. We therefore recommend systematic and ideally transnational research projects investigating the realisation and implementation of the UN-CRPD. In particular, in the subfield of mental disorders there is still a paucity of research about the achievements of the UN-CRPD. Further research in this area would contribute to pave the way for an effective realisation of the basic principles enshrined in the UN-CRPD.


ICD-10: InternationalStatistical Classification of Diseases and Related Health Problems, 10th revision; ID: intellectual disabilities; IDD: intellectual and developmentaldisabilities; ISRPID: ITINERIS scale on the rights of persons with intellectualdisabilities; ITHACA: InstitutionalTreatment, Human Rights and Care Assessment; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RCT: randomised controlled trial; UK: United Kingdom; UN: United Nations; UN-CRPD: United Nations Convention on the Rights of Persons with Disabilities; USA: United States of America; WHO: World Health Organization.


The authors declare that there was no funding. Availability of data and materials

All data supporting our findings is contained within the manuscript. Authors' contributions

CS carried out the database search, participated in the evaluation of the identified records and drafted the manuscript. TS conceived of the study, participated in the evaluation of the identified records and helped to draft the manuscript. SJ participated in the evaluation of the identified records and helped to draft the manuscript. EF participated in the evaluation of the identified records, helped to draft the manuscript and drafted the flow diagram. All authors read and approved the manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent to publish

Not applicable.

Ethics and consent to participate

Not applicable.

Author details

1 University of Mannheim, Chair for Political Science IV, Mannheim, Germany. 2Department of Psychiatry and Psychotherapy I, Centres for Psychiatry Suedwuerttemberg, Ulm University, Versorgungsforschung Weissenau, Ravensburg, Germany.

Received: 3 November 2015 Accepted: 12 May 2016 Published online: 26 May 2016


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