Since the turn of the twenty-first century there’s been spectacularly fast-growing and multi-pronged recognition of the worldwide costs of mental ill-health – costs magnified because they can be seen in several different lights. Most immediately, they must be reckoned with if we think ethically. They raise urgent concerns over injustice in the uneven distribution of care, for example, and of personal suffering that might be alleviated, as well as the baleful, unfair effects of mental illness stigma. They are equally pressing viewed not ethically but in terms of the economic burden of mental ill health. (By WHO (2017) estimates, mental, neurological and substance use disorders are responsible for over a third of all years lived with disability from non-fatal diseases.) And finally, mental health issues no less require attention from the most narrowly medical perspective, as an inescapable influence on physical health. Due to their unwarranted segregation, they’ve been unwarrantedly neglected, it is now increasingly acknowledged – an omission partly traceable to dualistic misapprehensions such as the idea that such conditions are imaginary complaints, or a reflection of personal, even moral, failure.

The confluence of these separate motivations, ethical, economic and narrowly medical, has led to an explosion of research during the last two decades, and to unprecedented practical and policy attention. Bold initiatives, often with world-wide scope, have been endorsed. In many cases, these propose extending to mental disorders the principles and methodology long employed by public health. For example, primary prevention has now been emphasized, its goal entirely averting or eliminating such disorders. Moreover, attention is increasingly towards whole populations rather than individuals; and governmental powers and resources are being enlisted, aided by newer methodologies permitting the collection and analysis of big data.

For me, these trends and their incumbent ethical complexities, have provided an enduring challenge for some years. (My first foray into the idea of public health models for psychiatry was at the INPP Conference in Gotenborg in 2011…) With my friend and one-time colleague Kelso Cratsley, they’ve been a point of common interest and focus, last year culminating in our jointly edited collection (Cratsley and Radden (eds)) Mental Health as Public Health: Interdisciplinary Perspectives on the Ethics of Prevention (Elsevier 2019). The book introduces some of these ethical issues, particularly as they arise from the new emphasis on preventive measures. Freshly-raised or augmented by trends such as those above, our authors, many of whom are active in AAPP, direct attention to public health approaches to disorders more traditionally treated through clinically-based medicine.

Some of these ethical issues apparently trace to obscurities in the etiology of such conditions. (At another remove, these issues can also be seen to flow from research neglect of etiological questions.) The will to take on improving mental health, even on a global scale, is there – but the knowledge base on which to proceed remains alarmingly incomplete. In one chapter of our collection, for example, authors Dany Lamothe and Mona Gupta illustrate that screening for depression to effect early diagnosis and treatment is limited by our inability to reliably identify cases of diagnostic error.

Other chapters indicate that the concept of the prodrome, so central to early intervention in many preventive initiatives, is elusive and unhelpful in determinations of when early intervention might be ethically or medically warranted. Too little is thus far known of the risk factors and causal antecedents involved (not to mention the relapse rates, functional outcomes, socio-economic costs and usefulness of interventions).

These uncertainties have heightened ethical import because they must guide decisions over the coercive practices that have been customarily seen as unavoidable in care and treatment settings where mental illness deprives people of agency. The stakes around these matters are also higher, our contributors show, once emphasis on primary prevention encourages the prospect of early intervention with non-adults, children and youth.

Some of these ethical issues, such as the use of machine learning for identifying suicide risks, discussed by Katie O’Leary and Phoebe Friesen, are a product of newer technologies and the advent of social media. Others reflect the influence of neurodiversity and Mad Pride activism, introduced by Ginger Hoffman, that are an unavoidable aspect of mental health politics in our era.

Looming over these particular issues are the stigmatizing societal attitudes about mental disorder that so add to the suffering these conditions already bring. By contrast with the unknowns described above, our understanding of the sources of such stigma is all too complete. Yet its effective elimination has proven obdurately resistant to policy efforts. (I recommend Peter Corrigan’s several important discussions of these hindrances to effective policy responses to stigma and discrimination.).

The rush towards a universal ‘global mental health’ that emerged out of efforts to think of mental health in public health terms introduces additional ethical complexities. While seemingly required by, and often justified in terms of, the demands of equality and fairness, such universal initiatives can be seen as encouraging a hubristic form of cultural imperialism that threatens to ride roughshod over local understandings, normative assumptions and models of disorder (explored in our volume by Mohammed Rashed and Rachel Bingham). Certainly as they apply universally, but even as they apply more locally, many of the matters raised by this recent focus on mental health as public health, with its drumbeat about primary prevention, call for closer examination employing philosophical and ethical approaches.