The devil in Austerity: Inequality, discrimination beget mental illness

In an interview, UN Special rapporteur on health, Dr Dainius Puras, says addressing inequality and discrimination would be the best vaccine against mental illness instead of the emphasis on medication and therapy the past three decades; social justice is key to mental health.

Q Your interview with The Guardian highlights that austerity and inequality fuel mental illness and that governments should counteract them to tackle rising mental ailments. But has it not been a fact such social factors had always weighed down on people. Is it unprecedented?

My report reminds stakeholders, especially governments, that determinants of mental health such as inequalities, discrimination on all grounds and violence should be addressed in line with the human rights-based and modern public health approach.

I would like to remind the legacy of the Cold War. While the West criticised the East (Soviet Union) for violations of civil and political rights and freedoms, the East criticised violations of economic and social rights of people in the USA or Western European nations. Both sides were partly right. If you are selective and uphold one group of rights at the expense of other, you will have huge problems with mental health and well-being of individuals and societies in the long run.

In capitalism, the main detriment appeared to be social inequalities. Effects of poverty impacted mental health; many people with mental health conditions landed in prisons and on the streets. In the Soviet type of socialism that denied the people civil rights, freedoms and political rights, authorities claimed that mental health problems were non-existent. In many countries of Eastern Europe, after many decades of totalitarian rule, people lost skills to exercise freedoms. Since 1990s, there have been epidemics of destructive and self-destructive behaviour, including high rates of suicides and interpersonal violence.

We, independent experts, often observe that the unfortunate combination of violations of economic and social rights and infringements of civil freedoms go hand in hand, creating toxic psychosocial environments deleterious to mental health.

My report stresses the development of supportive environments in all settings — family, school, workplace, community, society at large. Also there is a need to have mutually respective relations between nations and also between man and nature.

Q: Is there a geographic divide between the Global North and the South in the way governments generally tackle mental ailments?   

More No, than Yes. Mental health was included in Millennium Development Goals but it is now present in Sustain-able Development Goals and Agenda 2030; in that context all countries are developing ones.

Developed countries (Global North) with highly developed mental health systems and much human resources invested in that system have not managed to reach good outcomes so far. My report of 2017 called for a paradigm shift. The Global North developed mental health systems that used biomedical intervention and coercion excessively. Ironically, the European region has highest number of people (children and adults) living in institutional care. Some countries of the region have very high suicide rates.

The status quo does not work. One of conclusions is that just bringing more money to the mental health sector will not necessarily be the solution. Change the system, we must.

We often discuss among experts, whether mental health reforms towards human rights- based non-coercive services could face less resistance in Global North or in Global South?

To some extent, countries which have services based on biomedical model have become its hostage, and systems are often self-feeding, so that system of psychiatric services with over-medicalisation (treat something as a medical problem, especially without justification) and coercion breeds helplessness and exclusion.

Now in Global North, there is an obvious lack of mental health services and mental healthcare workforce, and this can be seen as serious shortcoming. But on the other hand, there is an opportunity, as there is a space in developing countries to have innovative services that could avoid legacy of coercion and over-medicalization. For this, international assistance is needed and political will from national governments.

Q: Being a psychiatrist and now a UN Rapporteur, how do you propose to reconcile the divide between the two camps — those who “see mental illness as a predominantly biological, neurological malfunction, treatable by drugs and therapy, and those who believe it is much more psychosocial, the result of government policies, social atomisation, poverty, inequality and insecurity ?”

In history, we see this pendulum phenomenon of mental health policies moving from one extreme to another. There were paradigms, represented by theories of “mindless brain” and “brainless mind”. The bad news is that attempts to invest in mental health care usually undermined human rights because of the thinking of policy-makers, professionals and “normal society” that they knew what is better for people with mental health conditions. This thinking has lead to numerous examples of human rights abuses. One is reminded of lobotomy (a surgical operation involving incision into the prefrontal lobe of the brain, formerly used to treat mental illness), which was awarded the Nobel, and quite soon after that it was condemned by international community as a grave human rights violation. These cruel lessons are still not taken seriously and there are attempts to invest in the search for magical cure for different mental health conditions such as autism.

Psychiatry is a part of medicine, and if so, it should follow best traditions of modern medicine. Consult the patient and seek his or her informed consent. Second, explore social determinants of health and see the whole picture and not just some symptoms. Psychiatry took a too narrow approach and travelled long in the direction of neurosciences. The future of psychiatry is with modern social psychiatry, because all mental health conditions in the end depend on the interaction of brain with psychosocial environment. If modern psychiatry takes advantage of this, it can even become the leader for the rest of medicine - as a modern combination of social sciences and biomedicine.

Q: What about medication? UN report says, firstly, mental health drugs are big business — worth an estimated $80bn a year worldwide. Secondly, they are no panacea. Some people respond better to drugs than others. What’s your take on this?

I am not against medications and I am not against biomedical model and biomedical interventions. But in many parts of the world psychotropic medications are unnecessarily prescribed. Antidepressants may be needed for the treatment of severe depression but are prescribed even for mild depression in many countries by psychiatrists or general physicians. This has led to medicalisation of feelings, spreading from adult mental health to child and adolescent mental health.

Sadly this is happening in medical schools where future medical doctors are led to believe that depression is about “chemical imbalances”, which means that they are trained to medicalise social and psycho-social determinants of mental health. This is a sad example, when academic medicine is involved in advocating a reductionist approach, ignoring the huge importance of social determinants of mental health.

So this is about preventing the overuse of biomedicine and psychotropic medications.

Medicalising the phenomenon of suicide is fraught with serious negative effects. If we reckon suicide is caused by depression, a mere a mental disorder to be managed in a biomedical way, on outpatient basis or by hospitalisation, we will never succeed in preventing suicides. We may even raise the risk of suicidal behaviour.

Q: Would you recommend an acti-on plan to the UN?

I will continue working on this issue, and I plan to have my final version of recommendations for the UN and for governments who are willing to move ahead and to be champions in mental health and human rights, in the report which I will present to UN Human Rights Council in June 2020.