A/HRC/44/48 35. It is now widely recognized that the mass incarceration of individuals from groups in marginalized situations is a pressing human rights issue. In order to prevent mass medicalization, it is essential to embed a human rights framework in the conceptualization of, and policies for, mental health. The importance of critical thinking (for example, learning about the strengths and weaknesses of a biomedical model) and knowledge of the importance of a human rights-based approach and the determinants of health must be a central part of medical education. B. World Health Organization essential medicines list and mental health 36. Essential medicines defined by WHO, “are those that satisfy the priority healthcare needs of the population … [they] are selected with due regard to disease prevalence and public health relevance, evidence of clinical efficacy and safety, and comparative costs and cost-effectiveness … For the past 30 years the Model List has led to a global acceptance of the concept of essential medicines as a powerful means to promote health equity.”26 37. In keeping with the position of WHO that the concept of the model list is a “forward-looking” mechanism to promote health equity and should be regularly reviewed and updated to “reflect new therapeutic options and … to ensure drug quality”, the Special Rapporteur stresses the following points. 38. Unlike other physical health conditions (for example, bacterial meningitis), for which there are essential medicines (for example, antibiotics), the pathophysiology of mental health conditions and the specific mechanisms by which psychotropic drugs may be effective are unknown. Although much progress has been made in terms of understanding the pharmacokinetics and pharmacodynamics of antidepressants and antipsychotic medications, their effectiveness is not comparable to amoxicillin for a bacterial infection. 39. WHO has identified a list of essential medicines for mental conditions but, however well-intentioned, it should reconsider the inclusion of 12 medications for the treatment of psychotic “disorders” (24.1 on the list), mood “disorders” (24.2), anxiety “disorders” (24.3) and obsessive-compulsive “disorders” (24.4). 40. A number of reanalyses of the randomized clinical trial data upon which the drugs were based and meta-analyses suggest that a re-evaluation of their risk-benefit ratios is needed. 27 It is now recognized that in general, response to initial treatment with antidepressant medication is in the range of 40–50 per cent and thus many individuals do not achieve a full response or remission from antidepressants. 28 There is growing concern about “treatment-resistant depression” and that anti-depressants on the list may actually be causing an iatrogenic effect. 29 There is a clear burden of side effects of antipsychotic medications. These facts in combination point to an important question: is having such medications listed as “essential” undermining a stepped, evidence-based approach to the care and support of people with mental health conditions, including persons with disabilities? The overemphasis on medication for addressing mental health issues has already been identified by the Special Rapporteur as no longer compliant with the right to health. 41. While debates continue over the evidence base for psychotropic medications, their inclusion on the essential medications list may raise other issues. For instance, their inclusion may reify contested disease categories and suggest that these mental conditions are primarily biomedical in nature, which further reinforces medicalization. Additionally, the list may inadvertently reinforce coercive practices because it is grounded in an 26 27 28 29 10 WHO, “Essential medicines and health products”, available from www.who.int/medicines/services/essmedicines_def/en/. See Joanna Le Noury and others, “Restoring Study 329: efficacy and harms of paroxetine and imipramine in treatment of major depression in adolescence”. See Claire D. Advokat, Joseph E. Comaty and Robert M. Julien, Julien’s Primer of Drug Action, 14th ed. (New York, Worth Publishers, 2019). See Ziad A. Ali, Sharon Nuss and Rif S. El-Mallakh, “Antidepressant discontinuation in treatment resistant depression”, Contemporary Clinical Trials Communications, vol. 15 (September 2019).