New thematic report on mental health from UN Special Rapporteur

World Mental Health Day, observed on the 10th October every year, presents an opportune moment to consider the United Nations’ current assessment of the core challenges and opportunities for advancing the realisation of the right to mental health for everyone across the globe.

In an extremely important and timely development, the UN Special Rapporteur on the Right of everyone to the enjoyment of the highest standard of physical and mental health Professor Daniel Puras, has produced a thematic report on mental health that deserves to be read from cover to cover by all concerned with improving mental health services in Northern Ireland and beyond. This report is the result of wide range of stakeholders, including users and former users of mental health services, mental health practitioners, academic experts and representatives of member states.

The colloquial expression ‘he doesn’t miss and hit the wall’ seems a fitting description of what is an exceptionally succinct report. At a time when rates of self-harm and deaths by suicide in Northern Ireland are worsening year on year, and when the funding allocation for mental health services is still a drop in the ocean of what’s needed, the report’s critical analysis coupled with clear recommendations as to way forward are exactly what is required.

Much of what Professor Puras highlights in this report is all too familiar to mental health rights activists here and elsewhere.  He makes explicit many of the detrimental and damaging ideologies, structures, processes and power relationships that campaigners are forced to confront on a day and daily basis in their fight for the rights of people with mental health problems.

Global and Local Context

In setting the context for the report, the Special Rapporteur points to one of the key indicators of the level of priority given to mental health across the globe:

despite clear evidence that there can be no health without mental health, nowhere in the world does mental health enjoy parity with physical health in national policies and budgets or in medical education and practice. Globally it is estimated that less than 7% of health budgets is allocated to mental health[1]

Shamefully the NI Executive’s most recent allocation for mental health, for 2016/17, at a risible 6%, was even lower again than the global average. Despite the ex Minister for Health, Ms. Michelle O’Neill’s pledge to achieve parity between mental and physical health, the funding situation is likely to have gotten worse if anything. There certainly hasn’t been any indication that mental health services will be protected in the planned cuts to health budgets across the Trusts.

The report briefly traces the history of mental health and psychiatry, a history marked by egregious rights violations, through to the point of a paradigm shift, driven as always by civil society and human rights activists, and articulated through the adoption of the UN Convention on the Rights of People with Disabilities (UNCPRD) That paradigm shift should have signalled the leaving behind of the legacy of human rights violations in mental health services. However, a decade on from the adoption of the UNCPRD the Special Rapporteur is forced to draw the following conclusion as to the underlying reasons for the marked slow rate of progress, public policies continue to neglect the importance of the preconditions of poor mental health, such as violence, disempowerment, social exclusion and isolation and the breakdown of communities, systemic socio economic disadvantage and harmful conditions at work and in schools[2]

Those charged with drafting Northern Ireland’s Protect Life 2 Suicide Prevention Strategy should take note of the above.  Quite unbelievably that consultation document failed to make a single reference to welfare reform and the planned introduction of Universal Credit in NI (roll out commenced on 27 September 2017 in Limavady). The introduction of Universal Credit across the water has been linked to a 50% in increase in mental health problems among the unemployed.

Obstacles that serve to maintain the status quo in mental health

A significant section of the report deals with the major obstacles that have served to maintain the status quo in mental health. Three obstacles are identified as follows:

a)      Dominance of the bio medical model[3] : the ‘myth’ that medications and other biomedical interventions are the best solutions for addressing mental health challenges is squarely named: “ the field of mental health continues to be over-medicalise and the reductionist biological model, with support from psychiatry and the pharmaceutical industry, dominates clinical practice, policy, research agendas, medical education and investment in health around the world[4]

b)      Power asymmetries: Professor Puras is unequivocal as to the gross power imbalances that exist and operate within the field of mental health “decision making power in mental health is concentrated in the hands of biomedical gatekeepers, in particular biological psychiatry backed by the pharmaceutical industry”.[5] He notes that for the promotion and protection of human rights in mental health to be realised there is a need for the “redistribution of power in the clinical, research and public policy settings”.

The experience of members of the Belfast Mental Health Rights Group in attempting to hold the Health and Social Care Board to account for ensuring proper implementation by Trusts of the Card Before You Leave scheme provides a salutary lesson in this regard as to where decision making power really lies.

c)      Biased use of evidence in mental health: the mounting questions in respect of the evidence base for the efficacy of certain psychotropic medications, from both the scientific and experiential perspectives, are highlighted. The Special Rapporteur recognises that these interventions can be effective in managing certain conditions. However, in a comment certain to resonate with mental health service users, carers and families in NI, he notes that “there are increasing concerns about their over prescription and over use in cases where they may not be needed”. [6]

These concerns have been highlighted by the Beyond a Spin of the Wheel campaign, a new campaign to ensure timely and appropriate mental health care from GPs. Solutions proposed include longer appointments, increased mental health expertise among GPs and the provision of counselling on site.

A Right to mental health framework

The report then goes on to consider those elements involved in a right to mental health framework. The obligations on state parties in this regard, detailed in a number of human rights instruments including UNCPRD, UNESCR, UNCRC and CEDAW amongst others are summarised. These include participation[7], non-discrimination, accountability and international cooperation. The requirements that state parties must fulfil in order to ensure rights based care and support for mental health include the three ‘As’ of availability, accessibility, acceptability, as well as quality.

Call for a radical and meaningful paradigm shift

The Special Rapporteur calls for a radical and meaningful paradigm shift, one which responds to a) the human rights imperative to address promotion and prevention in mental health and b) the necessity of moving from an isolated focus on the individual to a rights based, inclusive model that priorities psycho-social interventions at both primary and specialised care levels. The report is highly critical of the failure to provide mental health service users with psycho-social and public health alternatives to medication, solely on the basis that they are not available, and labels it as being ‘incompatible with the right to health’.[8]

Action needed on recommendations

Central to the conclusions reached by the Special Rapporteur is the unacceptable failure of the status quo to address human rights violations in mental health care systems.  He urges governments to “target social determinants and abandon the predominant medical model that seeks to cure individuals by targeting ‘disorders’”.[9]

The report contains 18 recommendations, grouped under the following four themes:

  • Addressing the imbalance of the biomedical model
  • Ensuring that social and underlying determinants for the promotion of mental health are addressed
  • Ensuring international cooperation to secure the right to mental health
  • Ensuring that users are involved in the design, implementation, delivery and evaluation of mental health services, systems and policies

Collectively these recommendations constitute a clear agenda for change, a paradigm shift. They chime with many of the fundamental changes mental health service users and families bereaved by suicide have been campaigning and lobbying for many years. While it is certainly heartening to see the many of these reflected in the Special Rapporteur’s report, what is now needed is decisive action by the Department of Health, the Health and Social Care Board, the Health Trusts and all of those other agencies charged with improving mental health services.  World Mental Health Day 2018 will come around very quickly.  We need to see action now.




[1] United Nations General Assembly HRC 35th session 6-23 June 2017 A/HRC/35/21 paragraph  6

[2] Ibid paragraph 13

[3] The biomedical model regards neurobiological aspects and processes as the explanation for mental conditions and the basis for interventions.

[4] Op cited at note 1, paragraph 19

[5] Ibid, paragraph 21

[6] Ibid paragraph 27

[7] The report notes that participation in mental health services is a relatively recent phenomenon and is complicated by deeply entrenched power asymmetries within mental health systems (paragraph 44).  Regrettably, there is ample evidence from mental health service users as to the failure to date of the Personal and Public Involvement (PPI) duty imposed on health bodies and agencies under the Health and Social Care Reform Act 2008 to ensure their meaningful participation in decision making.

[8] Op cited at note 1, paragraph 79

[9] Ibid paragraph 87