Tuesday, June 13, 2017

Rights-based reform of the Mental Health Act

At the recent General Election, the Conservative Party said that it would replace the 1983 Mental Health Act in England and Wales with new laws tackling "unnecessary detention" (see BBC News story). Their manifesto said:-
We will ... reform outdated laws to ensure that those with mental illness are treated fairly and employers fulfill their responsibilities effectively.
The current Mental Health Act does not operate as it should: if you are put on a community treatment order it is very difficult to be discharged; sectioning is too often used to detain rather than treat; families’ information about their loved ones is severely curtailed – parents can be the last to learn that their son or daughter has been sectioned. So we will introduce the first new Mental Health Bill for thirty-five years, putting parity of esteem at the heart of treatment.

Part of the motivation for this change was probably coming from the mental health charities, which formed a Mental Health Policy Group to produce A Manifesto for Better Mental Health. One of these charities, Mind, had a 2017 election manifesto, which had 6 points, of which one was:-
Change outdated and discriminatory legislation like the Mental Health Act and the definition of disability to ensure everyone with mental health problems gets support and respect.

Of course the 1983 Mental Health Act was amended in 2007 to introduce community treatment orders, amongst other changes. There was a several year debate/protest before this amendment and I had a Mental Health Policy website at the time (now essentially defunct). It was the reform of the Mental Health Act then that led to the formation of the Critical Psychiatry Network in 1999. I think changing the Mental Health Act again in the way suggested by the Conservative party is less likely to lead to as much controversy as previously.

If the Conservative Party has enough support to manage to get replacing the current Mental Health Act into a Queen's Speech, the Mental Health Bill needs to take account of the Convention on the Rights of Persons with Disabilities (CRPD). This is what the UN Special Rapporteur on the right to health has proposed (see previous post) and the rest of this blog uses quotes or amended quotes from his report.

The disability framework should radically reduce medical coercion. It starts from the principle that a disability shall in no case justify a deprivation of liberty. There is shared agreement about the unacceptably high prevalence of human rights violations within mental health settings and that change is necessary. Persons with psychosocial disabilities are generally falsely viewed as dangerous, despite commonly being victims rather than perpetrators of violence.

Change has taken place over recent years to challenge the disability stereotype, as many can live independently when empowered through appropriate legal protection and support. There are limitations to focusing on individual pathology.

Similarly, failure to secure the right to health and other freedoms is a primary driver of coercion and confinement in mental health. Mental health problems and disability are not exactly the same and this does need to be teased out in any new Mental Health Bill. In fact, it is still not clear how non-consensual treatment in mental health should be taken forward following the Convention on the Rights of Persons with Disabilities. This should be a government priority, even for a minority government. It needs to make use of appropriate indicators and benchmarks to monitor progress in respect of reducing medical coercion. The active involvement of mental health professionals in the shift towards rights-compliant mental health services is a crucial element for its success.

Mental health as a global health priority

I have mentioned previously (see post) the value of implicating mental health as one of the United Nations sustainable development goals. As pointed out by the UN Special Rapporteur (see previous post)The 2030 Agenda for Sustainable Development includes Goal 3, which "seeks to ensure healthy lives and promote well-being at all ages", and target 3.4, which "includes the promotion of mental health and well-being in reducing mortality from non-communicable diseases". As he also points out, this 2030 Agenda and other influences from WHO, the Movement for Global Mental Health and the World Bank mean that "mental health is emerging at the international level as a human development imperative".

I have tweeted relevant quotes or amended quotes for global mental health from the Special Rapporteur's report (see my responses to my tweet with the link to the report). I'll try and condense them in this blog.

The report emphasises the importance of parity with physical health in national policies and budgets or in medical education and practice, but suggests nowhere in the world has this been achieved. It does not want to forget that the political abuse of psychiatry remains an issue of serious concern in some countries (see previous post).

I have also previously mentioned the critique of The Movement for Global Mental Health by critical psychiatry (see post). The Special Rapporteur agrees with this critique. As he points out, it's all very well to note that millions of people round the world are grossly underserved by mental health services, but quoting alarming statistics about the scale and economic burden of "mental disorders" must not root the global mental health crisis within a biomedical model, as this approach is too narrow to be proactive and responsive. The scaling-up of mental health care must not involve the scaling-up of inappropriate care. He prefers to talk about actions to "scale across", by which he means embracing "a broad package of integrated and coordinated services for promotion, prevention, treatment, rehabilitation, care and recovery", including "mental health services integrated into primary and general health care, which support early identification and intervention, with services designed to support a diverse community". Furthermore:-
Evidence-based psychosocial interventions and trained community health workers to deliver them must be enhanced. Services must support the rights of people with intellectual, cognitive and psychosocial disabilities and with autism to live independently and be included in the community, rather than being segregated in inappropriate care facilities.

As he does in the rest of the report, the Special Rapporteur is encouraging all countries, including lower and middle-income countries, to develop rights-based mental health care.

Critical psychiatry position adopted by United Nations

The United Nations Special Rapporteur on the right to health, Dainius PÅ«ras, has produced a report which focuses on the right of everyone to mental health (see press release). It is the result of extensive consultations among a wide range of stakeholders, including representatives of the disability community and users and former users of mental health services.

It essentially argues for a rights-based mental health service, as has been recognised by the World Health Organisation, to promote and protect the mental health of entire populations. The Special Rapporteur believes that the crisis in mental health should not be managed as a crisis of individual conditions but as a crisis of social obstacles which hinders individual rights. He calls for mental health leadership to confront the global burden of obstacles and embed right-based mental health innovation in public policy.

I have been merrily tweeting quotes or mostly amended quotes from the report, as it very much comes from a critical psychiatry perspective. For example:-

Mental health services governed by reductionist biomedical paradigm that has contributed to exclusion, neglect, coercion and abuse of people
10 Jun 2017, 10:59

Preoccupation with biomedical interventions, including psychotropic medications and non-consensual measures, is no longer defensible
10 Jun 2017, 11:06

Reductive biomedical approaches that do not adequately address context and relationships cannot be considered compliant with right to health
11 Jun 2017, 18:10

While biomedical component important, its dominance has become counter-productive, disempowering rights and reinforcing stigma and exclusion
11 Jun 2017, 18:11

Medicine, in particular mental health, is to a large extent a social science and this understanding should be used to guide its practice
11 Jun 2017, 18:03

Mental health policies should address the “power imbalance” rather than “chemical imbalance”
11 Jun 2017, 22:43

The Special Rapporteur proposes, as would critical psychiatry, that there are three major obstacles to a rights-based mental health for all: (1) dominance of the biomedical model (2) power asymmetries and (3) the biased use of evidence.

As far as the dominance of the biomedical model is concerned, he concludes that:-

We have been sold a myth that the best solutions for addressing mental health challenges are medications and other biomedical interventions
10 Jun 2017, 11:40

The balance between the psychosocial model and interventions and the biomedical model and interventions should be more appropriate
12 Jun 2017, 10:54

For the rest of this blog, I'll try and condense what Lucy Johnstone called my twitter-friendly summary of the report.
Thanks to @DBDouble for the Twitter-friendly summary. Special Rapporteur who authored the UN report is also a psychiatrist.
12 Jun 2017, 21:42
Anyone who does want to see the list of tweets, though, see my responses to:-
UN Report on right of everyone to enjoyment of highest attainable standard of physical and mental health documents-dds-ny.un.org/doc/UNDOC/GEN/…
10 Jun 2017, 10:44

As far as power asymmetries are concerned, the report goes on to note that biomedical gatekeepers, in particular biological psychiatry backed by the pharmaceutical industry, are the dominant influence. National mental health strategies tend to reflect biomedical agendas and obscure the views and meaningful participation of civil society. Such biomedical bias leads to the mistrust of many users and threatens and undermines the reputation of the psychiatric profession. It dominates services, even when not supported by the evidence. In summary, biomedical power undermines the principles of holistic care, governance for mental health, innovative and independent interdisciplinary research and the formulation of rights-based priorities in mental health policy.

The individual relationship between psychiatric professional and user can also be exploited. Power imbalance reinforces paternalism and even patriarchal approaches. The asymmetry between professionals and users disempowers users and undermines their right to make decisions about their health and creates an environment where human rights violations can and do occur. This misuse of power asymmetries thrives, in part, because legal statutes often compel the profession and obligates the State to take coercive action.

As far as biased use of evidence is concerned, the report notes that the evidence base for the efficacy of certain psychotropic medications is increasingly challenged from both a scientific and experiential perspective. Similarly, research is accumulating in support of psychosocial, recovery-oriented services and non-coercive alternatives. There are increasing concerns about overprescription and overuse of psychotropic medications in cases where they are not needed. Because of the biomedical bias in mental health, there exists a worrying lag between emerging evidence and how it is used to inform practice.

There are various reasons for this research bias, some of which are mentioned in the report. There is a long history of pharmaceutical companies not disclosing negative results of drug trials, which has obscured the evidence base. Scientific research in mental health continues to suffer from lack of diversified funding and remains focused on the neurobiological model. Academic psychiatry has outsize influence, informing policymakers on resource allocation and guiding principles for mental health services. It has mostly confined its research agenda to the biological determinants of mental health. There are also implications for teaching in that the biomedical bias in mental health dominates teaching in medical schools, restricting knowledge transfer to the next generation of professionals.

How can all this be changed? There needs to be a strong ethical focus. Mental health services must respect ethics and rights (including “first, do no harm”), choice, control, autonomy, will, preference and dignity. The overreliance on pharmacology, coercive approaches and in-patient treatment is inconsistent with doing no harm, as well as human rights. Abuse of biomedical interventions compromises the right to quality care in mental health services.

The report does make some specific comments about treatment. Psychosocial interventions and support, not medications, should be the first-line treatment option for the majority of people who experience mental health issues. Sadly, such interventions tend to be viewed as luxuries, rather than essential, and therefore lack sustainable investment. In most cases of mild and moderate depression “watchful waiting”, psychosocial support and psychotherapy should be the frontline treatments. It is not a right to health to prescribe psychotropic medication merely because effective psychosocial and public health interventions are unavailable. There are compelling arguments that forced treatment, including with psychotropic medications, is not effective, despite its widespread use. Peer support, when not compromised, is an integral part of recovery-based services. The right to health requires that mental health care comes closer to primary care and general medicine, integrating mental with physical health.

The report does emphasise that people can and do recover from even the most severe mental health conditions and go on to live full and rich lives. It considers that whether the global community has actually learned from the painful past of rights violations in mental health remains an open question.

I worry that this report will just "collect dust". As the Special Rapporteur himself says there is now unequivocal evidence of failures of a system that relies too heavily on the biomedical model of mental health, and yet this model persists despite the critique. I do think critical psychiatry does need to do more to expose the self-interest of modern psychiatry (see previous post). Still, it's very welcome to have United Nations support in this aim.