RE: Reconceptualising the treatment gap for common mental disorders: a fork in the road for global mental health?

Reconceptualising the treatment gap: a paradigm shift is urgently needed

I read with great interest the article by Roberts et al on reconceptualising the treatment gap, which highlights that the reason we have a gap in mental health treatment is not necessarily the shortage in effective treatments (pharmacological and psychological) – instead, it may be the fact that distressed individuals may not view their distress in medical or psychiatric terms but in terms of the causes of distress being related to socioeconomic circumstances that doctors and medical or psychological treatments cannot help with. The article also highlights the importance of addressing these socioeconomic determinants of health and well-being as a way of tackling the ‘prevention gap’.

I particularly enjoyed reading the brief description of four qualitative studies carried out with people in India, Mexico and Uganda and with young Black people in central London, which show, in the words of the participants, the limitations and the negative perceptions of the medical model that sees symptoms of illness and attempts to treat them instead of addressing the real causes of people's distress.

In this context, I believe that the paper did not address the part played by psychiatrists, representing mental health services, driven by a push to see quick results and under pressure from pharmaceutical companies, in medicalising and pathologising human distress. There seems be a tendency among psychiatrists to view people's distress as a manifestation of a mental illness or, worse still, as a sign of brain malfunction or chemical imbalance, as a way perhaps of justifying the use of medical or psychological treatments to the individual.

We find that psychiatrists translate the individual's expression of distress, often expressed in ‘down to earth’ ordinary language, into a medical or technical language (a diagnosis or a disease code), thereby turning the sufferer into a ‘patient’ who requires a medical treatment and therefore locating the fault or the dysfunction in the individual instead of the society, the system or the set of circumstances that may have led to the individual's distress.

In this way, the individual will be convinced, as told by the medical expert, that their suffering is a medical condition, called anxiety, post-traumatic stress disorder, etc., rather like diabetes or renal failure, and that their poor sleep, as they stay up all night worrying about the money running out before their pay day, is called ‘insomnia’, a sign of a medical condition called depression. The individual therefore believes that the ‘cure’ is in the hands of the doctor. It is clear that this approach leads to the ‘patient’ feeling less empowered to change or challenge their circumstances, whereas it grants the psychiatrist more power to continue to feel relevant and to practice so-called ‘evidence-based medicine’ derived from randomised controlled trials carried out in artificially sterile and pure laboratory conditions that have no resemblance to the complex realities that most distressed individuals live in.

This article is written from a global mental health perspective, focusing especially on low- and middle-income countries. However, the perspective proposed in the article has the potential of being greatly beneficial, albeit challenging, for psychiatrists operating in high-income countries such as the UK, if psychiatrists were to genuinely listen to people's suffering, as communicated by the people themselves, and to see this suffering through a truly biopsychosocial lens.