Responding to the UN Special Rapporteur’s anti-psychiatry bias

The Report of the Special Rapporteur on the ‘right of everyone to the enjoyment of the highest attainable standard of physical and mental health’ (UN Human Rights Council, 2017) has been hailed as a landmark publication (British Psychological Society, 2017) and properly draws attention to the pernicious problem of human rights abuses of the mentally ill. On the other hand, the Report also makes a number of assertions that undermine its own stated aim of optimizing mental health outcomes around the world.

The Report repeatedly challenges the biomedical model and, remarkably, appears to regard it as a primary cause of human rights abuse faced by the mentally ill. In the same vein, the decision-making power of psychiatrists and the misuse of medical evidence are identified in the ‘global burden of obstacles’ preventing improvements in public mental health. These arguments align with those of the global anti-psychiatry movement, elements of which are well represented among those endorsing the Report (British Psychological Society, 2017). This movement, while diverse and evolving, questions the legitimacy of medical psychiatry and typically views it as coercive and causing more harm than good.

Optimal management of mental illness depends on skilled formulation of individual cases, critical appraisal of available treatments and shared decision making with patients. Uncritical emphasis of a single approach is often unhelpful, as it risks depriving patients of effective interventions and thus is clearly at odds with providing the best attainable outcomes. The Report focuses repeatedly on biological versus psychosocial models of care, when the fundamental issue for many is access to any sort of care. World Health Organization (WHO) surveys identify gaps in treatment of severe mental illness in less developed countries, with overwhelming majorities (76–85%) receiving no treatment within 12 months (Demyttenaere et al., 2004).

Although acknowledging resource limitations, the Report fails to link these to the basic right of access to health care. At the heart of the issue is the dearth of funding and services provided by governments in many low-income and middle-income countries (Demyttenaere et al., 2004; Dharmawardene and Menkes, 2014). Access to pharmaceuticals, fundamental to the biomedical model, is markedly restricted in these countries; when drugs are available, choice is often restricted, limiting options for the majority who do not respond to or tolerate initial treatments (Dharmawardene and Menkes, 2014). In a striking example of ideological bias, the Report views inpatient psychiatric care as ‘inconsistent with the principle of doing no harm’ (p. 13).

Whereas the Report’s concern regarding corporate misuse of biomedical evidence is warranted, the anti-psychiatry ethos of its selective literature citation is not. For example, a meta-analysis cited as evidence of the general inefficacy of psychotropics in fact applies only to antidepressants and mainly reflects the predominance of the placebo effect in mild-moderate cases in wealthy countries (Fountoulakis and Möller, 2011). The Report fails to mention that the same dataset indicates distinct benefits for those with the severe symptom burden characteristic of cases in developing countries.

The Report’s assertion that biological psychiatry violates human rights is an alarming distraction from enduring deficits in treatment availability in the developing world. Indeed, access to any evidence-based treatment, biomedical or otherwise, supports rather than further compromises the rights and dignity of those affected by mental illness. It is worth noting that compulsory, often biological, treatment of severe mental illness has been recognized as necessary and humane in a geographically and culturally diverse range of settings. Similarly, while properly advocating the integration of mental health into general hospitals and primary care, the Report fails to acknowledge their fundamentally biomedical approach, and indeed their further value in the management of common medical comorbidities and emergency presentations.

The creeping devaluation of medicine in UK psychiatry has been likened to ‘throwing the baby out with the bathwater’. The current Report appears to advocate for the de-medicalization of psychiatry more generally and thus has the potential to undermine effective patient care on a global scale. Although the Report’s psychosocial emphasis provides a useful counterpoint to biomedical reductionism, it ignores evidence that many psychiatric presentations are effectively and quickly treated with purely biological treatments, while others appear to respond best to combined approaches. The Report’s claim that psychosocial formulations are more acceptable and less stigmatizing is similarly simplistic; available evidence indicates variation across conditions and individuals, and regarding mental health problems as illnesses like any other is for many a powerful tool to reduce stigma and discrimination.

In conclusion, patients are primarily concerned not with a treatment’s ideological baggage, but with what helps and what harms. Because of its manifest bias against the conceptual and therapeutic role of biomedicine, the Special Rapporteur’s Report fails to provide the balance and leadership required to address the vast global burden of untreated mental illness.