Global Mental Health Leaders Shift Away from Biomedical Model Towards Rights-Based Approaches

In a significant departure from the traditional biomedical model, leaders of the Movement for Global Mental Health are now advocating for a rights-based, culturally inclusive approach to mental health care.

Highlighted in a recent Lancet article, this change in approach focuses on addressing social determinants, incorporating lived experiences, and embracing diverse cultural healing methods. The aim is to rectify the inadequacies of current systems by promoting community-centered strategies that respect and leverage local contexts.

The article, led by Vikram Patel, marks a notable shift from his previous work for the Lancet Commission on Global Mental Health. It reflects the advocacy of people with lived experience, Mad activists, and psychosocial disability advocates, as well as critical scholars, who have long argued for these inclusive approaches. This broader understanding of mental health moves away from a one-size-fits-all model, emphasizing the importance of local contexts and lived experiences.

“There is growing acknowledgment that a singular, structural challenge has been the narrow dichotomous framing of mental ill health through the prism of diagnosed mental disorders. This framework has dominated the field for around half a century, ever since psychiatry adopted a monocausal mental model, which shaped a reductionistic approach to nosology with substantial implications for prevention and care,” the authors write. 

“One example of the consequences of this narrowed perspective is that, even though a wide range of social and psychological interventions are known to work for the prevention and care of mental ill health, medication is the most widely accessible (and in many populations, only accessible) intervention, in part fuelled by the collusion of the health-care system with commercial interests.”

The article outlines five transformative principles to revamp global mental health systems: addressing harmful social environments, moving away from diagnosis-based care, empowering diverse frontline providers, adopting rights-based care approaches, and centering those with lived experiences in all aspects of mental health care. By embracing these principles, the authors advocate for a holistic, biopsychosocial framework that not only challenges the dominance of the biomedical model but also proposes actionable policy recommendations. This approach aims to foster mental health equity and improve outcomes across diverse global contexts.

The Movement for Global Mental Health (MGMH), initiated by the Lancet Group in 2007, has aimed to expand mental health services, particularly in low- and middle-income countries, by scaling up existing psychiatric treatments and closing the treatment gap. This movement has framed mental health as crucial for global development.

However, critics, including people with lived experience, Mad activists, psychosocial disability advocates, and critical scholars, argued that this approach overlooked cultural contexts, social determinants, and local healing practices, often imposing Western biomedical models that were inadequate and potentially harmful in non-Western settings.

The recent Lancet article by Vikram Patel marks a significant shift. It aligns more closely with these critics by advocating for a rights-based, culturally inclusive approach that prioritizes social determinants and lived experiences over traditional biomedical treatments.

In their new article, Patel and colleagues note that traditional approaches that rely heavily on specialist interventions and diagnostic categories have proven inadequate to the challenge of the global mental health crisis. Despite significant investments, mental health metrics have not improved, particularly in high-income countries. They write:

“From a population perspective, there seems to be almost no correlation between the density of mental health professionals, proxies for clinical interventions, and the prevalence or incidence of mental illnesses.”

They explain that the history of psychiatry has long been dominated by a reductionist biomedical model, which views mental disorders primarily through the lens of biological abnormalities. This approach gained prominence in the mid-20th century, driven by the adoption of diagnostic categories based on clusters of symptoms observed in specialized clinics in high-income countries.

“Disappointingly, 50 years on, we still do not have a single biological finding that can be applied to diagnose any mental illness, nor a single new therapeutic agent or target for prevention. Yet, this reductionist framework continues to prevail, privileging certain types of providers (eg, mental health specialists), interventions (eg, medications), delivery settings (eg, hospitals), particular perspectives of recovery (eg, focused on clinical symptoms), and particular perspectives on research priorities (eg, focused on biological mechanisms). As a result, this privileging narrows the approaches in which psychiatrists and other specialist mental health providers are typically trained and accultured.”

However, this narrow biomedical model has faced criticism for its reliance on symptom-based diagnoses rather than concrete biological tests, which limits its applicability across diverse global contexts. Despite extensive research and substantial financial investments, no definitive biological markers for diagnosing mental illnesses have been found, nor have new therapeutic agents been developed. This has led to an overreliance on medications and specialized interventions, often at the expense of more holistic and culturally relevant approaches.

To this end, the Lancet article outlines five transformative principles aimed at overhauling global mental health systems to make them more effective, inclusive, and equitable.

1. Target Harmful Social Environments Across the Life Course The first principle emphasizes the importance of preventing mental health issues and promoting mental well-being by addressing adverse social and economic conditions, such as poverty and inequality. These factors significantly impact mental health, and interventions like income support, food subsidies, and laws promoting gender equality can mitigate their effects. This approach prioritizes early intervention, particularly during childhood, to shape healthy development and mental health through supportive environments and reducing exposure to negative experiences like maltreatment and violence.
2. Care is Determined by a Person’s Needs, Not Their Diagnosis The second principle advocates for a shift from diagnosis-based care to needs-based care. Traditional diagnostic categories often fail to capture individual experiences and unique needs. Instead, the staging model of mental illness, which recognizes different stages of mental health conditions, should guide care. This model allows for tailored interventions at each stage, focusing on the specific needs of the individual rather than fitting them into predefined diagnostic boxes.
3. Empower Front-Line Workers to Deliver Evidence-Based Psychosocial Interventions The third principle calls for expanding the mental health care workforce to include non-specialist providers like community health workers, teachers, and peers. These front-line workers can effectively deliver brief psychosocial interventions within their communities, making mental health care more accessible and integrated with other services. Training and supporting these providers can improve early intervention, case management, and long-term support, addressing mental health needs more comprehensively and equitably.
4. Embrace a Rights-Based Perspective for Mental Health Care The fourth principle focuses on eliminating discrimination and protecting the human rights of people with mental health conditions. This includes ensuring dignity, reducing stigma, and providing alternatives to coercion in mental health care. Strategies such as the WHO QualityRights initiative can guide efforts to protect rights, involve people with lived experiences in decision-making, and ensure legal protections.
5. Place People with Lived Experience at the Centre of the Care System The final principle emphasizes the importance of involving people with lived experience in all aspects of mental health care. Their insights and experiences should shape the design, implementation, and evaluation of mental health services. This person-centered approach ensures that care is aligned with what matters most to those directly affected. It also involves supporting shared decision-making and promoting structural interventions like supportive housing and guaranteed income, which are crucial for holistic mental health care.

To implement this framework, four key policy actions are proposed: adopting a whole-of-society approach that involves various sectors beyond health to address social, economic, and ecological determinants of mental health; investing in nurturing environments and effective interventions from early childhood; ensuring the involvement of civil society organizations in promoting rights-based care; and fostering inter-ministerial collaboration and leadership at all government levels to prioritize mental health as central to human development and well-being.

The authors also advocate shifting from institutional care in mental hospitals to community-based services, integrating short-stay inpatient units within general hospitals for severe cases, and offering long-term support for those with enduring disabilities. Additionally, they argue that population mental health should be addressed through coordinated care models that include diverse providers like primary care physicians and community health workers.

They go on to suggest a shift in investment in mental health, with a recommended allocation of at least 5% of the health budget in low- and middle-income countries and 10% in high-income countries. This investment should support community and grassroots actions, build the front-line workforce, and train non-health professionals to promote mental health. Resources should be shifted away from cost-ineffective institutional care to evidence-based, community-centered interventions.

By advocating for a rights-based, culturally inclusive framework that addresses social determinants and empowers non-specialist care providers, the article reflects a departure from the narrow, reductionist biomedical model that has dominated psychiatry. It champions a holistic, community-centered approach, recognizing the profound importance of local contexts and lived experiences.

 

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Patel, V., Saxena, S., Lund, C., Kohrt, B., Kieling, C., Sunkel, C., Kola, L., Chang, O., Charlson, F., O’Neill, K., & Herrman, H. (2023). Transforming mental health systems globally: Principles and policy recommendations. The Lancet, 402(10402), 656-666. https://doi.org/10.1016/S0140-6736(23)00918-2 (Link)