WMAContribution-SRMentalHealthReport-June2017

THE WORLD MEDICAL ASSOCIATION, INC.
L’ASSOCIATION MEDICALE MONDIALE, INC
ASOCIACION MEDICA MUNDIAL, INC
Centre International de Bureaux
Immeuble A “Keynes” Website : www.wma.net Postal Address :
13, chemin du Levant Telephone : (33) 4 50 40 75 75 Boîte Postale 63
01210 FERNEY-VOLTAIRE Fax : (33) 4 50 40 59 37 01210 FERNEY-VOLTAIRE Cedex
France E-mail address : wma@wma.net France
Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest
attainable standard of physical and mental health (A/HRC/35/21)
Thirty-fifth session of the Human Rights Council – 6-23 June 2017
Comments from the World Medical Association
1. Introduction
The World Medical Association (WMA) is the global federation of National Medical Associations
representing the millions of physicians worldwide. Acting on behalf of patients and physicians, the
WMA endeavours to achieve the highest possible standards of medical care, ethics, education and
health-related human rights for all people. As such, the WMA plays a key role in promoting good
practice, medical ethics and medical accountability internationally.
The WMA, being the reference body internationally for defining medical ethics values, believes
that our contribution to the discussion on mental health and human rights is essential.
The WMA welcomes the June 2017 Report on the Special Rapporteur on the right of everyone to
the enjoyment of the highest attainable standard of physical and mental health, denouncing the
widespread and continuous violations of the fundamental rights of persons with mental health
conditions. We have repeatedly advocated for the rights of persons with disabilities, including with
regard to their right to equal access to health services. We recently updated our Statement on
Ethical Issues Concerning Patients with Mental Illness, in which we outline physicians’
responsibilities to support the well-being and rights of patients with mental health issues. We also
state physicians’ ethical duties in treating and caring for those patients.
The general content of the Report adequately highlights aspects of the worldwide situation affecting
people with mental health problems. While it appropriately considers obstacles to care, the WMA
would like the Special Rapporteur to consider the following comments:
2. General comments
2.1 Biomedical vs Biological Treatment
Biological, biomedical, medical, and psychosocial models are not exclusive in clinical practice,
where it is may be possible to differentiate. For example, some psychiatrists, specialize in
neuroscientific research with a focus on biological aspects of the clinical profession. The same
diversity applies to physicians in general: some physicians may restrict treatment of physical
disorders to prescription drugs, but many of them adopt a holistic approach considering different
WMA page 2
needs of their patients. Thus, we suggest the change of the word “biomedical” by “biological”
within the report.
Additionally, considering physicians as solely advocates of a biological model and the other
relevant stakeholders as solely advocates of a psychosocial model has harmed those in need of
mental health care. This compartmentalizes mental health treatment rather than embracing a holistic
approach to care. Thus, the WMA advocates for placing all stakeholders together for a balanced
biopsychosocial model of care (such as in paragraph 10).
2.2 The Importance of Pharmacological Treatment
In light of paragraph 8 of the report, we emphasize the development of specific drugs to treat mental
illnesses. This advancement in psychiatry and medicine as a whole decreases the need to hospitalize
patients suffering from mental illnesses, and combats the issue of neglected mental health.
Additionally, we would like to point out that the main problem is not a “reductionist biomedical
paradigm” as suggested, but rather the frugal investment in good quality public mental health
services.
We fully share the concerns of the Special Rapporteur that “many of the concepts supporting the
biomedical model in mental health failed to be confirmed by further research”. Nonetheless, there is
lacking research and evidence-based data supporting psychosocial interventions and health care
providers, including psychiatrists and other mental health professionals, are waiting for proved
alternatives easily applicable and efficient. However, we would like to emphasize the important role
of pharmacological treatment, whose efficacy is widely proven by large evidence-based data.
Without sufficient research evidence to support the idea that psychosocial interventions are the first-
line treatment option for the majority of people who experience mental health issues, this claim
should not be advocated in this manner (as discussed in paragraph 80). Additionally, medication
cannot be proposed as a first-line “treatment” option considering that the majority of people who
experience mental health issues (and not diagnosed illnesses) do not need pharmacological
treatment, rather they need another kind of help. When considering mental illnesses, experience and
evidence up to this moment recommend a combination of medication and psychosocial
interventions for most of them.
2.3 The Role of Psychiatrists and Other Physicians
We want to highlight the changes in governmental policies taking place in several countries which
have been making consistent efforts to reform their psychiatry model. We therefore do not support
the generalization of psychiatry as related to the pharmaceutical company as stated in the following
sentence in paragraph 19: “the reductionist [biological] model, with support from psychiatry and the
pharmaceutical industry, dominates clinical practice, policy”.
Along the same lines, in paragraph 16, to oppose medical interests to a rights-based mental health
care does not accurately reflect reality. Instead, it contributes to further exclude psychiatrists and
other physicians as part of the desirable solutions of the problems identified.
We also suggest not considering mental health activists (with a political and ideological agenda) as
general users who “threaten[s] and undermine[s] the reputation of the psychiatric profession”
(paragraph 24). Again here, the Special Rapporteur does not sufficiently include psychiatrists in the
report. If he “welcomes and encourages discussion within the psychiatric profession and with other
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stakeholders”, the document needs to be inclusive to psychiatrists and not consider them one of the
biggest problem affecting people’s human rights.
2.4 Scaling Up and Scaling Across
As discussed in paragraph 55, the scarcity of mental health services as well as diverse and good
quality mental health care is a worldwide phenomenon. Thus, calling “scaling up” of a rhetoric does
not properly defend a broad package of integrated and coordinated services. Furthermore, replacing
“scaling up” with “scaling across” does not completely address the issue because “scaling up” and
“scaling across” are not mutually exclusive. Rather, they should both be enhanced. Thus, we
suggest both scaling up appropriate care and scaling across sectors to improve care provisions.
2.5 Lack of Investments in Mental Health
We do not agree with the statement that “mental health investment continues to be predominantly
focused on a biomedical model” (paragraph 12). The current problem for most countries continues
to be the low investment in mental health programs and the scarcity of services and adequately
educated people to provide mental health care.
We would also like to emphasize that the issues concerning first line treatments are not due to a
“biomedical model of psychiatry”, but rather to the burdens general physicians face in their daily
practice. These practitioners are the ones in charge of treating at first place the majority of the
population. Lack of adequate education and overwhelming working conditions may also contribute
to the misuse of first-line prescriptions. Moreover, the lack of primary health care specialized
mental health services exacerbates this problem. We therefore suggest to widen/deeper the study of
this problem in order to tackle this issue more efficiently.
Accordingly to WHO 2014 Mental Health Atlas1
, “levels of public expenditures on mental health
are very low in low and middle-income countries (less than US$ 2 per capita)”. There is worldwide
an important lack of psychiatric services available and in countries that have adopted reforms to
close psychiatric hospitals, policies were not followed by enough new community services for
severe mental disorders and specialized outpatients’ clinics to treat the most prevalent mental
disorders. In parallel, general practitioners and family doctors working in primary care services in
most countries do not have the necessary education to diagnose and treat the most common mental
disorders2
.
2.6 Geographical Terms
We suggest the use of general geographical distribution terms such as “many countries” (such as in
paragraph 56) or “in different regions of the world” when referring to particular situations instead of
specifying the specific location (such as “in Central and Eastern Europe” noted in paragraph 57).
2.7 Separation of Mental Illnesses
When referring to people with cognitive, intellectual and psychosocial disabilities, the WMA does
not see the need to separate specified groups of patients, such as person with autism (paragraph 4).
1
http://www.who.int/mental_health/evidence/atlas/executive_summary_en.pdf?ua=1
2
Jorm AF, Korten AE, JAcomb PA, Rodgers B, Pollitt P (1997). Beliefs about helpfulness of interventions for mental
disorders: a comparison of general practitioners, psychiatrists and clinical psychologists. Australian and New Zealand
Journal of Psychiatry, 31: 844-851
WMA page 4
3. Conclusion
The World Medical Association welcomes the discussion on mental health by the Special
Rapporteur. We agree that mental health is often an underfunded and neglected sector which
contributes to abuses in provision of mental health services. For this reason, we would like to
emphasize that physicians are not to blame for the current situation in mental health but rather low
investments in mental health care. Thus, we urge the Special Rapporteur to include psychiatrists and
other physicians in the discussion on human rights in mental health and in advocating for an
inclusive, biopsychosocial approach.
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June 2017