The political mission of psychiatry

What contributes to poor mental health is well known (1): adverse childhood conditions; experience of war, persecution and torture (2); social isolation; unemployment and social exclusion; poverty, poor education and low socio-economic status; and social inequality. In this issue of the journal, K. Wahlbeck (1) calls for action and requests that the evidence is translated into practice. What should be done? Obviously, in order to achieve substantial improvements in public mental health, we require societies to change and implement all those factors that promote mental health: societies should provide safe and supportive upbringing conditions; secure peace within and between countries; eradicate poverty; guarantee good education; strive for full employment; promote social cohesion and functional communities; and have little social inequality. These requirements are clear and unequivocal, no more research needed. Accordingly, the Melbourne charter concluded that mental well-being is best achieved in equitable, just and non-violent societies (1). Yet, there is little evidence that we are currently making much progress towards such societies. In most industrialized countries the difference between rich and poor has been increasing, making societies more rather than less unequal, and war activities have been increasing worldwide since 2011 (3). How can this be changed and societies improved? Changing the rules and processes within societies is clearly a political task. Politicians get elected to take decisions about military activities, expenditure on education and social welfare, employment rules, taxation and other means of re-distribution. Politicians are democratically legitimized and authorized, mental health experts are not. Perhaps, we should therefore just provide our expert view and leave it there? This appears to have been the dominating attitude of mental health professional bodies during the last three decades. One may conclude that such abstaining from political involvement has been a major mistake, both for people with mental disorders and the profession itself. If there is a will to engage politically and call for societal change on the basis of the evidence for public mental health, there are likely to be various and potentially strong allies, calling for similar changes based on expertise from other fields of medicine and social sciences. For example, social inequality is bad not only for mental health, but also for physical health and other social phenomena such as crime rates (4). Consequently, a World Health Organization European review of social health determinants (5) calls for action in the wider social and economic spheres, with less deprivation and a more balanced social gradient. Linking with such calls from experts in other fields may strengthen the impact of a political voice from mental health. Political engagement of mental health professionals – even if aligned with experts from other fields as well as patient and carer groups – might still not be successful. Other societal forces and interests might drive societies in opposite directions, e.g., towards military engagements and even greater social inequality. Politicians are unlikely to change the welfare system or stop wars just because they are told by experts that this would be better for public mental health. Despite this, raising our professional voice in the political arena might still be important. How can we – as mental health academics or clinicians – know the central importance of societal factors for mental health and not call for the political action to improve them – loudly and clearly? Whether effective or not, political engagement appears a moral imperative for a credible profession with coherent values (6). As a minimum, it can underline the societal relevance of psychiatry and help to link psychiatry and other important societal groups. There are two further aspects to the political mission of psychiatry. First, historically, when psychiatry and the wider society opened up towards each other with a mutual interest, major mental health reforms became possible and found wide public support. For instance, psychiatric reform legislation in the 1970s was passed by Italian and German parliaments practically unanimously. The case of people with mental disorders was important to parties from across the whole political spectrum, linked to values of liberalism, social religious teaching, emancipation and social inclusion. Second, political engagement for inclusive societies is essential to improve the situation for a core group of psychiatric patients, i.e., those with severe and chronic conditions. Even in rich countries, large numbers of such patients end up in prisons, get little appropriate care, or receive limited support in long-term protected housing arrangements (7). Increasingly, patients can get lost in fragmented care systems, that are driven by economic interests of provider organizations; and patients who are unlikely to be economically productive are of diminishing interest to health care funders. In more unequal societies, these patients are at risk of even further exclusion and disadvantage. They need a professional group to support them in everyday life and stand up for them – and as far as possible with them – on a political level. Specific and individualized prevention programmes will have only limited effects, unless general societal factors are addressed. For example, providing people with job problems with cognitive behavior therapy (1) is less important than ensuring that people have jobs in the first place and that contracts guarantee sufficient income and acceptable working conditions. Political engagement on a local, national and international level is required for credibility and realistic chances to improve public mental health. What credibility and what societal relevance do we have as a profession, if we disseminate the evidence in scientific journals, but do not care about the political action required to implement it?