The discriminatory standards of constructing ‘patienthood’ of the ‘mentally ill’ within public health

The discriminatory standards of constructing ‘patienthood’ of the ‘mentally ill’ within public health

Bhargavi V Davar, Bapu Trust, Pune

Paper presented at the Medico Friends Circle Annual Meet, SM Joshi Foundation, Pune, 20th February 2015

 

This paper was presented before an audience of doctors and health activists who are closely associated with the People’s Health Movement (Jan Swasthya Abhiyan), India. The paper gives a critical psychiatry and human rights perspective, while not explicitly taking on the perspective of users and survivors of psychiatry. 

 

There has been a spate of literature in the last 2 decades, struggling to make a public health subject out of ‘mental disorder’. To become a public health subject, a variety of other scientific cognitions and proofs about constructing a ‘disorder’ have to be fulfilled: ‘Prevalence’, ‘evidence base’, ‘validity’, ‘effectiveness’, ‘universal coverage’, ‘life course approach’, etc. This construction of theory, proof and practice of ‘No health without mental health’ has filled several thousands of pages of publications since the 1990s. An alien reading the medical and medical social science journals today may be convinced that mental health is indeed a public health subject.

Going against the WHO findings of the late 1970s, which provided global evidence base for better outcomes for mental distress and disturbance in low income countries including India, the data of this century predicted, if not actually made manifest, an ‘epidemic’ of mental disorders in Low and Middle Income Countries (LMICs). This century has also witnessed the rise of the human rights movement for ‘persons with psychosocial disabilities’ and ‘users and survivors of psychiatry’ in the Asian region, including India: Their advocacy has been, in the main, for inclusive communities where people with psychosocial disabilities can fully and effectively participate and contribute to all aspects of life with autonomy and dignity on equal basis with others, in the face of severe social adversity and inequity. This advocacy has been inspired by the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) [1], [2].

Arguing that ‘Mental disorder’ scoped by psychiatry sits awkwardly within the frame of ‘public health’, causing various degrees of harm to its subjects, this paper draws from human rights movements and critical psychiatry. The paper throws light upon what constitutes the awkwardness, even ‘dis-ease’, having the effect of a disparity within medical disciplines. People diagnosed with ‘mental illness’ seem to be a different and lesser species of a ‘public health patient’, vulnerable to lowered standards of care; degrading, inhuman and torturous ‘treatments’; and a nonexistent medical ethics. We clarify that, we are not considering here the  ‘reform’ of ‘bad practice’, but rather the very geneology, design and practice of the discipline of psychiatry; Neither are we asking whether ‘psychiatrists are bad’, but rather, ‘Why and how did psychiatry and psychiatrists arise (the past); What spaces do they occupy (the present)? And, perhaps, being aspirational, what is their future role, in human development (the future)?’ This raises questions about the possibilities of responses of public health theorists and practitioners when it comes to the field of ‘mental disorder’, and also the psychiatrists, what is the history of their practices, the present nature of their relationship with human society and future engagements with health and disability.

Psychiatric diagnosis like no other medical diagnosis

Unlike other public health topics, there is a vast number and diversity of disciplines engaging critically on ‘mental illness’: Is it a social construct (medicalization of deviance); a legal construct (criminalization of difference); a historical construct (imperialistic approach to socially excluded constituencies); or a personal construct (experience of personal distress with associated embodied and mental phenomena)? Is it a construct upholding capital markets, if necessary by applying the rule of the gun, is also another question, that we raise, later in the paper. Such questions do not plague a disease, such as, say, ‘malaria’, ‘pneumonia’ or even to a certain extent, ‘leprosy’. We just find the bug and contain or kill it.

Is ‘mental illness’ an ‘illness’? As a stream of recent critiques of psychiatry, often by psychiatrists or ex-psychiatrists, has argued, unlike other medical conditions, there are no biological markers for a finding of an object like ‘depression’ or even a ‘schizophrenia’ [3], [4], [5], [6], [7].  ‘Mental disorder’ is not a natural kind in the same way as a physical disease. Finding the biological and cellular cause of ‘mental disease’ remains an Aspiration of a discipline desiring to be medical; somewhat akin to the Aspiration to Nirvana of practising Buddhists; but, alas, without the ‘Cause No Harm’ principle nor the necessary detachment required for the exercise of clarity and compassion, which are values central to any healing science, and particularly a mental healing science.

Researchers from low and middle income countries in the late 1990s and this century have published comprehensive data bases on the rising tsunami of mental disorders in low and middle income countries [8]. Data on ‘psychiatric morbidity’ had existed since the 1960s, generated using Diagnostic and Statistical Manual, III [9]. While socio economic features of those studies included basic socio demographics, the literature of the 1990s and later, presented the mental health sequelae of ushering in of the new economic order in emergent capitalist countries, including India. Poverty, gender, migration, displacement, disaster, HIV, conflict, violence and trafficking were linked to the meteoric rise of ‘mental disorders’ and the advocacy for ‘treatments’, rather than advocacy for a profound reform of how we live as a human society.

By 2000, the WHO set the policy ball rolling with comprehensive reports, talking about epidemiological explosion of mental disorders, and advocating governments to develop policies on ‘daring to care’ [10], [11], [12], [13], [14], [15][16] The ‘social determinants and risk’ approach (in the case of women, for example), led, not so much to integration of psychosocial health and wellbeing in empowerment processes; But rather to alarming findings of ‘Common Mental Disorders’ [17]. 11% of DALYs and 27% of YLDs were attributed to ‘neuropsychiatric’ disorders. Risk was magnified in primary health care, and  26% – 46% of primary health care patients were said to suffer from CMDs, with predictions and findings of ‘chronicity’ within a 12 month period. Several women’s ailments considered hitherto as public health failures by women’s health activists, now became elevated to primary health care topics, redefined as ‘mental disorder’ requiring psychiatric treatment. For example, ‘chronic fatigue’, ‘vaginal discharge’, ‘genital complaints’ and ‘medically unexplained’ pain were analyzed as masked depression in large sample point prevalence studies conducted in India on women. Such findings led to the development and validation of psychiatric diagnostic tools that can be easily administered at the PHC level, and to advocacy for anti-depressant medications being made available in primary health care [18].

Such findings led to moral indignation of neglect of an emerging public health topic, by researchers and policy makers, and then to a call for globalizing psychiatry:

“Borrowing from the lessons of our colleagues in other areas of public health, such an initiative could take the form of a Global Alliance for Mental Health, under the umbrella of the World Health Organization, in which mental health professionals work alongside patients, families, and public health groups. The practical design of policies, programs, and interventions is most likely to be effective when articulated with a moral orientation toward sufferers of mental illnesses. The Alliance’s primary goal would be to spearhead a movement to increase access to evidence-based care, perhaps a 5×10 program to get 5 million untreated patients into treatment and rehabilitation programs by 2010.[19]

By the year 2000, in India and in the wake of the Erwadi tragedy (2001), several researchers, policy makers and global bodies advocated ‘filling the treatment gap’ and scaling up ‘mental health treatment’ [20] in LMICs.

Global Mental Health Movement writings were based on a moral revulsion concerning those many millions of untreated public health patients in the low and middle income countries and outrage concerning those projected in the media and in field experience of people chained in communities or at traditional healing centers. In a recent significant intervention to the United Nations[21], the GMHM leaders recommend a target of “service coverage for severe mental disorders will have increased by 20% by 2020 and the rate of suicide will be reduced by 10% by 2020”.

This moral outrage masked some important political economic factors: The social determinants studies which indicated psychosocial stress, distress and disturbance required psychosocial, social economic and justice interventions. As the world changed very fast, especially in low and middle income countries, social systems crumbled, equality and justice safeguards disappeared and more war zones appeared on the map. Public health systems failed, a generalization which is a truism in this group. Yet, in the new psychiatric parlance, social, economic, justice and public health failures got algorithmically converted into psychiatric disorder. It is a brand new challenge and a finding  that people who are without money, homes, food, education, steady employment, belonging or social status will feel sad;  and GMHM is heralding the  ‘good news’ that ‘evidence based treatment is available’.  For an informed and intensely argued critique of ‘Evidence base in psychiatry’, see David Ingleby (2014) [22].

Noting that mental health law in the US (and also elsewhere in the world) uses circular or tautological definitions [23], Summerfield has been a very strong western psychiatric voice against psychiatric diagnoses [24], [25] arguing that it is a renewed western cultural oppression. For him, the question, whether we see a social disadvantage as new psychiatric business or  as requiring humane social policies and interventions has receded, in the alarmist way in which disadvantaged communities are being psychiatrized. Further, Derek Summerfield (2012) challenges the (RCP, UK) based claim for the World, that 1 out of 4 people in the general population will suffer a mental disorder:

“These claims surely amount to disease-mongering, highlighting an urgent need to deconstruct a naive reliance on the capacity of screening instruments to generate hard data on population prevalences. Such instruments, with their demand characteristics and tendency to reify subjective consciousness through a mechanistic focus on ‘‘symptoms’’, produce estimates that insult our common sense and everyday social experience. Structurally unable to assess a whole person immersed in the dynamic complexity of a life and situation, they tend to recast the physiology of normal distress as pathology. We face an epidemic of false positive diagnoses of mental disorder promoted by a mental health industry in which pharmaceutical companies are significant actors”. (p. 520)

The heated critiques of (DSM-5) contest the ‘diagnosis inflation’ and ‘diagnostic exuberance’, leading to the ‘pathologisation of the normal’ [26], [27].  Unlike ‘treatment for malaria’, treatment for ‘mental illness’ touches something very personal in its entirety. If markets saw a huge potential in harvesting persons as a whole, then why would they not do so, especially against the context of ‘evidence base’ of an ‘epidemic’? Values of autonomy, identity, individuality, liberty and choice, or ‘selfhood’, are held as core within the ‘psy’ disciplines in ‘inventing our selves’ in new ways through modernity [28]. Achieving a ‘modern self’ is fuelled by modern political economies, which are acted upon not only by doctors and therapists, but also by scientists, politicians, managers, families, lawyers, media, and a plethora of other authorities.  In reference to the making of the DSM Hacking (1998) has also referred to the ‘invention’ of the individual self in categorical and pathological terms, as having ‘looping effects’, i.e. ‘providing actionable DSM self identifications for the people taking up such self descriptions’ (Strong 2012): Thus, according to some, we become that which is projected on us, through the DSM, and there is the incredible rise of ‘mental disorder’.

Is this alarmist prediction of mental disorder (and the tools used for those predictions) itself a result of the capitalist order? Many have argued so, in the context of the presently adopted Diagnostic and Statistical Manual, Version 5. Public health diseases, with support of diagnostic, lab, radio, pathology testing, etc., are not so easily subject to the vagaries of market forces as are the psychiatric diagnoses, and once a pathogen is identified, there is usually diagnostic clarity. Absent a pathogen, the process by which little over half a dozen categories of ‘mental illness’ found in early DSM precedents, has now burgeoned into well over 300 diagnoses will remain a ‘public health’ puzzle, only if you neglect the market factor. Well, if there is no biological marker for a particular nominated ‘disease’, it is logical that 2000 diagnoses is as acceptable as 1; Further, free market enterprise will focus on the 2000 rather than the 1! This kind of mindless medicalization of the human condition has brought dishonour to the American Psychiatric Association, the promoter of the business of the Emperor’s New Clothes for the Millenium.

While the British Society of Humanistic Psychology has issued an open letter to APA, condemning the DSM 5, the American Psychological Association has been more tempered in their critique, reserving its comment to better transparency and imploring APA for keeping ‘best treatment outcomes’ in mind [29].  See, also, NIMH dissociating itself from DSM and DSM based clinical research, but pursuing the super-dream of finding the Mental Disorder Bug [30], which seems supremely vain and recalcitrant, and indeed, omnipresent and indestructible to any and all psychotropic cure, thereby ensuring evergreen business profits.  Following humungous payouts to communities in successful class action suits, psycho-pharmaceuticals are in ‘crisis’ [31], and do not want to take a market risk, slowly withdrawing from drug research for ‘mental disorder’.  See also Das and Rao (2012) [32] and Mills (2013[33]), among others in the Indian context, for a critique of the creation of psychiatric diagnoses using the business opportunities of globalization. Also see the collection of articles in a recent volume of Transcultural Psychiatry [34] where writers have critiqued the psychiatrization of communities, ignoring culturally available supports and resources and creating cultures of sick people, against rising social and economic disadvantage and deprivation, especially for children and the young.

Why something that has never been supported by material evidence, was upgraded to ‘disease’ is a primordial puzzle since many decades. Several other puzzles plague the canvas of ‘mental health as public health’, and I enlist a few of them below. Robert Whitaker[35] has articulated what is by now a classic puzzle in critical psychiatry: If mental health is a disease, and there are good medicines for it, how is it that psychiatric disorder has escalated phenomenally in the last 20 years? In a recent Bapu Trust evaluation, the senior psychiatrist who led the team noted that we should be ‘smoking them out from their dens’ (referring to people with psychosocial disabilities); adding that mental illness can only increase and we are not expecting it to go down in communities. But with a public health topic, is this the expected trend, that a public health intervention will actually result in an escalation of the problem and not its containment? As Summerfield has written,  “As more resources are provided for mental health services, more are perceived to be needed – an apparently circular process. Has the mental health industry in the West become as much a part of the problem as of the solution?” Several critical drug reviews in recent times suggest that indeed, psychiatric internment and drug treatment add layers of dis-ease and disability to the original ‘finding’ of mental disorder [36]. Philip Thomas, a Canadian psychiatrist, reviews psycho-tropics and a variety of clinical studies on effectiveness, placebos, etc. concluding that, while some of the drugs may work in the short term, long term effects are seriously hazardous and life threatening[37].

Another puzzle, relevant to postcolonial situations (India and some other commonwealth nations), is, If health care and mental health care patients are all patients, why is it that the former have the right to legally consent to treatment, while the latter cannot? While earlier literature in public health had been silent on the role of mental asylums and forced treatment in mental health care, more recent policy papers advocated in low and middle income countries talked about the need to, if necessary, enforce treatment by using a penal law [38].  Within the public health system, people don’t charge or accuse each other of being ‘diabetic’ or ‘cancerous’; and surely there exists no ‘special protection’ health care law which specifically codifies the nullification of the patient’s right to consent or their right to live freely in the community. The court of justice issues comes much later in the health system, when maltreatment happens. In mental health, the very ‘finding’ of ‘mental illness’ sets up a close medico-legal environment for that person, where justice and care get mixed up [39]. The mental hospital system, which, in the 200 years of its existence, never ascended to the status of ‘public health hospital’, but have remained ‘asylums’ (National Human Rights Commission Report, 1999). As described in other papers [40], [41], this is a peculiar situation where in the case of some health care subjects, viz. the ‘mentally ill’, the authorities first have to arrest them, strip them of all subjecthood and citizenship, and then bring them into an asylum / custodial treatment setting. In the health system, nuanced debates on proof of disease and effectiveness of treatment are possible and do happen, and cases of human rights violations may reach the consumer courts usually with petitions against the doctor. In mental health, the judicial contest begins with the very assertion of a finding of ‘mental illness’, and it is the patient who goes before the court, not the doctor. This ‘Guns and Pills’ situation is a very peculiar public health anomaly, defying all medical ethics.

In conclusion, there are huge anomalies in the ‘patienthood’ of the ‘mentally ill’ patients which the advocates of the position that mental illness is an illness, like diabetes, must contend with. The larger medical fraternity have a hugely critical role in this debate, especially in codifying an ethics that will hopefully bridge the anomalies and restore the dignity of persons with psychosocial disabilities.

[1] NAAJMI and Bapu Trust (2010). Bill of Rights: Insights from a Mad Pride Campaign, 2005-2010.  Published by National Alliance on Access to Justice for persons living with a Mental Illness and Bapu Trust, Pune.

[2] Report on “Transforming Communities for Inclusion of People with Psychosocial Disabilities: A Trans-Asia initiative”, Holiday Inn, Pune, April 30th – 4th May 2013, Pune. Supported by Open Society Foundation, NY. Organized by the Bapu Trust for Research on Mind & Discourse, Pune.

[3] Summerfield, D. (2012). ‘Afterword: Against ‘global mental health’ ‘, Transcultural Psychiatry, Special Issue. 49(3-4), pp. 519-530.

[4] Whitaker, R. (2010). Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. New York: Broadway Paperbacks.

[5] Fernando, S. (2014). Culture, Globalization and mental health. London: Palgrave MacMillan.

[6] Thomas, P. (2014). Psychiatry in context.

[7] Mills, C. (2014). Decolonizing Global Mental Health: The Psychiatrization of the Majority World. London and New York: Routledge.

[8] Desjarlais, R., Eisenberg, L., Good, B., & Kleinman, A. (1995). World mental health: Problems and priorities in LAMICS. New York: Oxford University Press.

[9] DSM-I was first released by the American Psychiatric Association in 1952, in the aftermath of the II World War.

[10] Regional Health Forum, (2001). Mental Health. 5(1), WHO, Geneva.

[11] WHO (2001). World health report. New understanding. New Hope. Geneva.

[12] R. Thara and V. Patel (2001). ‘Women’s mental health: A public health concern’. In Regional Health Forum, (2001). Mental Health. 5(1), WHO, Geneva. Pp. 24-33.

[13] V. Patel and R. Thara (2001). ‘MH policies in developing countries: A radical rethink’. In Regional Health Forum, (2001). Mental Health. 5(1), WHO, Geneva. Pp. 3-5.

[14] WHO. (2003). Organization of Services for Mental Health. Mental Health Policy and Service Guidance Package. Geneva: WHO.

[15] WHO. mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: mental health Gap Action Programme (mhGAP). Geneva: World Health Organization, 2010.

[16] Patel, V., Araya, R., Chatterjee, S., Chisholm, D., Cohen, A., De Silva, M., et al (2007). ‘Treatment and prevention of mental disorders in low-income and middle-income countries’. The Lancet, 370(9591), 991–1005.

[17] V. Patel, et. al. (2006). ‘Risk factors for Common mental disorders in women: Population based longitudinal study’. British Journal of Psychiatry, 189, 547-555.

[18] V. Patel (2005). ‘Social origins, biological treatments: The public health implications of CMDs in India’. Indian Journal of Psychiatry, 47:15-20.

[19] V. Patel, B. Saraceno and A. Kleinman (2006). ‘Beyond Evidence: The moral case for International mental health’. Editorial. American Journal of Psychiatry, 163:8, 1312-1315.

[20] Prince, M., Patel, V., Saxena, S., Maj, Joanna Maselko, Michael R Phillips, Atif Rahman, (2007) No health without mental health’, Lancet, pp. 1-19 Lancet Online, Published September 4, 2007DOI:10.1016/S0140-6736(07)61238-0

[21] Thornicroft, G. and Patel, V. (2014) “Including mental health among the new sustainable development goals: The case is compelling”. British Medical Journal, 2014; 349:g5189

[22] Ingleby, D. (2014). How ‘evidence based’ is the movement for Global mental health? Disability and the Global South, Volume 1, No. 2, pp. 203-226.

[23] Such as ‘Mental illness’ is any mental disorder other than mental retardation‘ (Mental health Act, 1987).

[24] Summerfield, D. (1999). ‘A critique of seven assumptions behind psychological trauma programmes

in war-affected areas’. Social Science and Medicine, 48, 1449–1462.

[25] Summerfield, D. (2004). Cross-cultural perspectives on the medicalisation of human suffering.

In G. Rosen (Ed.), Posttraumatic stress disorder: Issues and controversies. (pp. 233–245). Chichester, UK: John Wiley.

[26] Frances, Allen. (2012). “Diagnosing the D.S.M.” Retrieved online from the New York Times from: http://www.nytimes.com/2012/05/12/opinion/break-up-the-psychiatric-monopoly.html

[27] Strong, T., Gaete Silva, J., Sametband, I., French, J., & Eeson, J. (2012). ‘Counsellors respond to the DSM-IV-TR.’. Canadian Journal of Counselling and Psychotherapy, 46(2): 85-106.

[28] Rose, Nikolas. 1996. Inventing our selves. London: Cambridge University Press.

[29] http://www.apa.org/news/press/releases/2011/12/development-process.aspx

[30] http://www.boston.com/lifestyle/health/childinmind/2013/05/dsm_and_nimh_on_mental_illness.html  accessed 10-02-2015.

[31] Greenslit, NP and Kaptchuk, TJ (2012). ‘Antidepressants and advertising: psychopharmaceuticals in crisis’. Yale Journal of Biology and Medicine, 85, 1, pp. 153-158. Accessed online on 13th February 2015

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3313530/

[32] Das, A. & Rao, M. (2012) ‘Universal mental health: re-evaluating the call for global mental health, Critical Public Health’, DOI:10.1080/09581596.2012.700393

[33] Mills, C. (2014). Decolonizing Global Mental Health: The Psychiatrization of the Majority World. London and New York: Routledge.

[34] Campbell, C. & Burgess, R. (2012). Special Section: Communities and Global mental health. Transcultural Psychiatry, 49(3-4), July-September.

[35] Whitaker, R. (2010). Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. New York: Broadway Paperbacks.

[36] Jani H. Jenkins (Edited). (2010). Pharmaceutical self. The global shaping of experience in an age of psycho-pharmacology. Santa Fe: School for Advanced Research Press.

[37] Thomas, P. (2014). Psychiatry in context: Experience, Meaning and Communities. Monmouth: PCCS Books.

[38] Patel, V. (2013). ‘Legislating the right to care for mental illness’, Economic and Political Weekly, XLVIII(09), March, p. 49.

[39] Davar, B.V. and Ravindran, S. (2015). Gendering mental health: Knowledges, Identities, Institutions. Oxford University Press.

[40] Davar, B. (2012). Legal Frameworks for and against people with psychosocial disabilities. Economic and Political weekly, XLV11(52), 123-131.

[41] Davar, BV (2013). ‘Globalizing psychiatry and the case of the vanishing alternatives’. In China Mills and Suman Fernando, (2014), Globalising mental health or pathologising the global south: Mapping the ethics, theory and practice of Global mental health. Disability and the global south, Volume 1, Issue No. 2. Special Issue

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