Political abuse in psychiatry

  Psychiatry has always had twin obligations – care for the individual patient and protection of society. This ‘social control’ aspect has to be weighed carefully against individual rights, especially in compulsory treatment. The balance remains a hotly debated issue in most countries. The vastly differing psychiatric care offered to blacks in South Africa under apartheid and in the US Southern States during segregation has often been characterized as political abuse. Similarly the high rate of compulsory detention of ethnic minority patients (particularly blacks of African and Caribbean origin) in England has been cited as an intolerance of different cultures that borders on the repressive. This is probably ‘politics with a small p’. Inequitable access to care is a characteristic of many health care systems. It may be inexcusable but it is hardly a deliberate policy aimed at persecuting a specific group.

  The use of psychiatry explicitly to repress or silence dissident political opinions in the former Soviet Union was, however, conscious persecution. The Soviets used a diagnosis of ‘sluggish schizophrenia’; meaning withdrawal and strangeness which developed slowly without positive symptoms (hallucinations, thought disorder, etc.). Sluggish schizophrenia was used to detain people with dissident political views who opposed the state but demonstrated no clear signs of mental illness. Of course some mentally ill individuals do oppose the state which they believe is persecuting them. The Soviets incarcerated vast numbers of clearly healthy individuals in their forensic psychiatric clinics. This was a scandal that has seriously damaged psychiatry’s credibility (particularly in Central and Eastern Europe).

  One positive outcome of the Soviet psychiatric abuses was the development of an international movement within psychiatry to challenge such practices. United Nations and Red Cross organizations regularly visit and monitor prisons and detention centres throughout the world and now routinely include mental hospitals in their work. China has recently had to submit to international scrutiny over its dealings with the Falun Gong sect. International awareness provides the strongest protection against political abuse.

Psychiatry unlimited: a diagnosis for everything

  Psychiatry has moved centre stage in public health. Four mental illnesses rank in the World Health Organization’s top ten global causes of lifelong disability. Depression is currently number two and predicted to be the number one by 2020. Forty-four million Americans have been treated for depression. Is this good news or bad news? It could be a long-overdue recognition of the burden of mental illness as reduced stigma improves detection and recording (and presumably treatment and recovery). Alternatively, it could be that modern living and an ageing population is associated with greater stresses and more mental illnesses. However, rates for established severe mental illnesses such as schizophrenia and bipolar disorder appear static.

  Could the rise in mental illness be illusory? Are there other factors at play and could psychiatry go astray if we don’t keep an eye on them? Psychiatry operates now in vastly different circumstances from those in which it originated. Medicine enters the 21st century well equipped to detect and control the failings of the early 20th century (professional arrogance and ignorance). Current risks may, however, stem more from psychiatrists unwittingly acting out the agendas of others (as Foucault has insisted they always have). Who else has an agenda?