By now, anybody concerned with health matters will be aware that US President Trump has established a “Make America Healthy Again” Commission, chaired by his new Secretary for Health, Robert F Kennedy Jr. (see Substack Feb. 18th 2025). In addition to wrecking the Health Department, (e.g. cancelling Meals on Wheels at 1.20) the order requires Mr Kennedy to report within 100 days (from Feb. 13th) on a program to “Make Our Children Healthy Again.” The commission is heavy duty, with about 15 senior bureaucrats including the secretaries of a number of important domestic departments. They’ll have to be quick as the agenda is truly massive, but it’s not clear if they understand the really important question it raises.
The executive order starts by noting that by global standards, Americans have shorter lives with more chronic illness than any other developed country, yet their expenditure on health is two or even three times as high. Not only are their figures poor but they are deteriorating rapidly: “Overall, the global comparison data demonstrates that the health of Americans is on an alarming trajectory that requires immediate action.” In particular, comparative health standards for children and adolescents in the US are awful: “18% of late adolescents and young adults have fatty liver disease, close to 30% of adolescents are prediabetic, and more than 40% of adolescents are overweight or obese.” Alcohol and illegal drugs aren’t even mentioned.
While the situation is bad, and everybody in the world knows it’s bad, this is probably the first time there has been a major attempt to coordinate an investigation and plan a response. It is somewhat overdue. The global market in “ADHD treatment” (essentially stimulant drugs) is now worth US$38.5billion (B) per annum (over $100million a day), and is expected to double over the next eight years.
Coincidentally, the busy people at World Health Organisation (WHO) in Geneva (the same ones Trump has just defunded) have come down strongly on Kennedy’s side. In yet another door-stopper of a report (5 volumes), they have taken a firm stand against what they call the “biomedical model” of mental disorder:
The biomedical model views mental health conditions as primarily caused by neurobiological factors. With this approach the main focus of care is on diagnosis, medication, and symptom reduction, often overlooking the social and structural factors affecting mental health and individuals’ needs and rights for inclusion, social protection, among others [1, glossary, xi].
While they accept that worldwide, this is the dominant approach to mental disorder, they refer to another weighty publication from 18 months ago [2] which set out the legal obligations imposed by, among other international agreements, the Convention on the Rights of People with Disability (CRPD). That report argued the legal case for a complete change in mental health legislation around the world, due to the inherent failings of the standard coercive/custodial/medical model in force in practically every country in the world:
Poor quality services, dehumanizing treatment, and increasing rates of involuntary hospitalization and treatment are widespread issues. Seclusion and restraints are commonly used to enforce people’s compliance, and many individuals are institutionalized in psychiatric hospitals or social care facilities under appalling conditions, often for extended periods or even their entire lives. Others remain in the community, but confined at home, sometimes in shackles. These extensive violations and the resulting trauma have long-lasting effects on individuals, families, communities and future generations [1,p2].
As the WHO Commission on the Social Determinants of Health put it: “Why treat people only to send them back to the conditions that made them sick in the first place?” Also in practically every country in the world, there isn’t much argument over the fact that for psychiatric patients, conditions are substandard. Despite substantial increases in expenditure and drug prescription rates, their lives haven’t improved much over the past 60 years or so:
Coercive practices such as involuntary admission, involuntary treatment, seclusion, and the use of physical, mechanical, or chemical restraints are widespread in mental health services globally. However, there is no evidence that these practices offer any benefits, while significant evidence shows they cause physical and psychological harm, dehumanization, trauma, and worsening mental health, as well as eroding trust in services. These practices can also negatively impact family members as well as mental health practitioners, discouraging young professionals from entering the field and demotivating those already working in it [1,p4-5, emphasis added].
Faced with this dilemma, the standard response in most countries is “more of the same”: more money, more institutions, more staff in bigger bureaucracies. WHO is urging a major reorientation in the whole concept of mental health services, away from “disease- and institution-centred” services toward new approaches: “person-centred, recovery-oriented, and grounded in human rights”:
Rather than merely increasing funds, governments need to reallocate resources towards community-based, person-centred services providing both acute crisis and long-term support, alongside other initiatives and actions to protect and promote people’s mental health [1,p2].
In essence, this is what is called Business Process Reengineering (BPR). According to IBM (who should know), BPR is “…a strategic management approach that is focused on fundamentally rethinking and redesigning core business processes to achieve significant improvements in performance and efficiency. BPR focuses on optimizing end-to-end processes and eliminating redundancies.” More to the point, it asks: “If we arrived today with nothing in place and saw the problem, would we build the same system or would we try something completely different?” In any reorganisation, the goal is to avoid being tied down by inefficient processes and vested interests that will want to maintain their status (and budgets) regardless of their efficiency.
This is not the same as Mr Musk’s “smash first, ask questions later” approach. Initially, BPR may actually cost more but the goal is to get more cost-effective outcomes in satisfying the needs of the sufferers. For example, a woman in a mental hospital in Victoria was recently found to have spent nearly ten years in solitary confinement. That would have cost nearly $10million: looking at her needs and the community’s, was that money well spent or was it simply satisfying the ambitions (and fears) of the medical staff and the nursing unions? Since worldwide, mental health costs and outcomes are steadily-worsening, these are critically important questions. They are consistent with the targets set for Mr Kennedy’s MAHA Commission, the overt goals of which are mostly unexceptional (neither Kennedy nor Trump wrote the Commission’s charter). The Commission is to report on chronic childhood conditions such as obesity, poor nutrition, low levels of exercise and how these contribute to America's generally poor performance on all international health parameters but one: the cost of American health care. While it says nothing about the brutal US health insurance industry, nor about the long-running goal of the Republican Party to cancel the food benefits program (SNAP) for poor families, a couple of directives have provoked alarm among the many people who make comfortable livings from unhealthy life styles:
(ix) restore the integrity of science, including by eliminating undue industry influence, releasing findings and underlying data to the maximum extent permitted under applicable law, and increasing methodological rigor; and
(x) establish a framework for transparency and ethics review in industry-funded projects.
“… eliminating undue industry influence”? How did that get there? Don’t they realise that the huge donations to Trump’s campaign from a dozen industries were intended to make sure nobody looked closely at their “science”? Based on past experience, these objectives will have a fairly short life span so we can only wait and see what emerges from the scrum. However, they’re not the only cause for conniptions in the C-suites: Items (ii) and (iii) are already keeping a lot of people up at night, frantically calling each other for reassurance:
(ii) assess the threat that potential over-utilization of medication… using rigorous and transparent data, including international comparisons;
(iii) assess the prevalence of and threat posed by the prescription of selective serotonin reuptake inhibitors, antipsychotics, mood stabilizers, stimulants, and weight-loss drugs;
This is potentially huge. Even the very language has caused shock waves throughout academic psychiatry and their paymasters, Big Pharma: nobody is allowed to use the word “threat” in the same sentence as “psychiatric medicines.” As for “over-utilisation,” everybody knows the real problem is under-utilisation, that far too many people aren’t taking anywhere near enough drugs. Clearly, it’s time for the adults to be heard before the party gets out of control, and that’s what’s happened. On March 21st, a group of professional bodies issued a short statement saying Kennedy’s Kids have got it all wrong:
The safety and efficacy of traditional antidepressants, antipsychotics, and mood stabilizers (such as lithium and some anticonvulsants) and stimulant medications have been established through decades of rigorous research, randomized clinical trials, peer-reviewed studies, meta-analyses, national registry studies of thousands of people, post-marketing pharmacovigilance monitoring, and FDA oversight ... When used appropriately, these medications can stabilize serious mental illness, reduce suffering, shorten periods of disability, and save lives. Physicians work closely with patients and families to assess the risks and benefits of psychopharmacology and monitor for potential side effects, ensuring each patient receives individualized care.
It was signed by half a dozen of the more heavily-committed groups working in the area: American Society of Clinical Psychopharmacology, American College of Neuropsychopharmacology. American Association of Chairs of Departments of Psychiatry, American Psychiatric Association, National Network of Depression Centers, and Society of Biological Psychiatry.
OK folks, they say, no cause for alarm, keep moving and don’t forget your safe and effective tablets. Normally, a slap on the wrist like this is enough to pull everybody back into line but something says it isn’t going to work this time. Mr Kennedy doesn’t have a strong record of listening to people who disapprove of him and the many powerful people seated on the Commission are Trump loyalists, appointed for their slavish devotion, not for any record of independent thinking. Indeed, it's even whispered abroad that Mr Trump doesn’t actually like independent thinking.
So the battle lines are drawn. On one side, we have the excitable and fissiparous newbies of the MAGA crew and on the other, half a dozen long-term, deeply-connected, deeply conservative professional bodies who have seen it all before and survived to tell the story. What’s likely to happen? Well, that depends on who you ask, and despite Mr Musk, this Commission appears to have lots of money. They can appoint any number of researchers and reviewers but they won’t be looking through the usual lists of the Great and the Good for staff. Normally, if there’s a question of mental health policy, the Commission will ring the local university and ask Prof. Tweedledum for his opinion, then they call the APA and speak to Dr Tweedledee for an alternative opinion. Unsurprisingly, they get anodyne opinions like “these medications can stabilize serious mental illness, reduce suffering, shorten periods of disability, and save lives” (here, the operative word is “can”; equally, they “may not”). Everybody is happy, especially the drug companies who have shovelled fortunes in the direction of the good doctors. That’s not going to happen this time. There will be swarms of applications from bright young things who have been squeezed out of the universities for being obstreperous and who will be looking for vengeance. In Mr Kennedy, they’ve met their man.
On the other side, we find the supremely smooth, articulate and reassuring partisans of biological psychiatry who can say things like “Physicians work closely with patients and families to assess the risks and benefits of psychopharmacology and monitor for potential side effects” without blushing or gagging and who have no doubt that, one way or another, they’re going to win this stoush as they’ve won all the others. I say “without blushing or gagging” because, as everybody knows, that is a lie. We had a similar incident with the president of the RANZP (college of psychiatrists) some years ago. She released a press statement which, among other gems, said:
The prescription of antidepressant or antipsychotic medications is something that a psychiatrist only ever does in partnership with the patient and after due consideration of the risks and benefits (RANZCP, March 9th 2018).
Anybody who has had any dealings with psychiatrists knows that is completely untrue. Psychiatrists routinely dish out huge quantities of unpleasant and/or dangerous drugs without a word of explanation or consideration and, if patients object, they get them as an injection. When challenged on this blatant falsehood, she didn’t blink but calmly reiterated it (the full story is here, along with figures from my little survey that showed it was a lie, which the local journal refused to publish). This sort of whitewash is normal. In an interview last year, Prof. Ian Hickie of Sydney University Institute of Brain and Mind said that people don’t get depressed because bad life events have upset them, they have bad events because they are depressed. Without blushing or gagging, he said the depression comes first (he has been asked for proof but hasn’t supplied any).
When we go through the joint statement word by word, we find all the deceptions, half-truths and prevarications such as “When used appropriately…” The crucial word here is “appropriately,” so answer this question: The rate of so-called ADHD in the US is commonly assessed at about 5%, yet 11% of children are taking stimulant drugs, and up to 16% of boys (far more in some wealthy schools). 16% of the adult population take antidepressants but the suicide rate is going up and up, as is the rate of people on pensions for mental disability. Women get the bulk of antidepressants and ECT but their suicide rate per case of depression is far lower than that of men: men are at greater risk but it’s women who get locked up [2]. How is any of that “appropriate”? These are the sorts of contradictions that mainstream psychiatry glosses over in its slick presentations of “We’re the experts, we’re right on the problem, you don’t need to worry about anything, just keep sending money.” We can hope the ferrets Kennedy looses in academia know where to look because most of the evidence is well and truly buried – by experts in obfuscation who have a great deal to lose if any nuisances start digging through their dirty undies.
However, the whole deal brings into the open the “really important question” mentioned above, the carefully-concealed fissure in psychiatry’s foundations: do psychiatrists actually know the nature of mental disorder? This is where the WHO report is important. They are saying: “We have to move away from the failed biological/custodial/coercive approach to mental disorder, and start to see it as something that happens to human beings (i.e. with mental capacities) exposed to adverse life events.” That is, and contradicting Hickie, the life events cause the mental disorder, the clear implication being “There but for the grace of God go I.” It’s worth noting that in his final report to the UN High Commissioner for Human Rights some years ago, UN Special Rapporteur Prof. Dainius Puras put the same argument:
The combination of a dominant biomedical model, power asymmetries and the wide use of coercive practices together keep not only people with mental health conditions, but also the entire field of mental health, hostage to outdated and ineffective systems [3, p17].
Hickie reacted angrily to this [4], with the usual argument: We’re the experts, critics are just anti-psychiatry and don’t know what they’re talking about. No doubt he will have something to say on the latest WHO report but we know in advance he won’t say anything constructive.
The central issue is the ancient question: What is the nature of mental disorder? Mainstream psychiatry says it’s all biological, which mandates biological treatment. Despite their rock-solid certainty, the facts are that there is no such thing as a “biomedical model” to justify this position, and that perhaps $100billion spent on biological research (current values) over the past 80 years has found nothing that would qualify even as a “biological marker” of mental disorder [5]. These and so many other facts are carefully ignored by the smooth talkers in mainstream psychiatry. The alternative approach, which the WHO report advocates, is that mental disorder is very largely a psychosocial phenomenon that needs psychosocial responses: “Some of the relevant social and structural determinants of mental health include (but are not limited to):
stigma, discrimination, and racism based on individuals’ status or identity; poverty; gender (for example inequality and harmful gender norms); lack of, lower levels of, or interrupted education; unemployment, job insecurity, or income inequality; houselessness or unstable housing; food insecurity (in terms of availability and type of food); public health emergencies (for example, COVID-19); climate change, natural hazards, pollution, and industrial disasters; humanitarian crises (such as war, armed conflict, forced displacement, natural disasters, human-caused disasters, and other complex emergencies), and forced displacement and migration; violence and abuse; and loneliness and social isolation” [1,p6].
That’s quite a list. However, since all the research money is spent in biological laboratories, and all the treatment budgets are eaten by big hospitals and other top-heavy institutions, and all the training is directed at the biomedical pseudo-model, and given all the academic egos involved, and the hundreds of very profitable psychiatric journals, and the private psychiatric hospitals and, above, below and behind it all, the limitless resources of the drug companies (in America, also the private insurance companies), it’s not an even battle. Can the Kennedy Krew do anything to right the imbalance? I’m pessimistic. I think they’ll be led up the garden path by experts and quietly lost in the undergrowth.
The only good news is that the old guarantee, “The Government always pays its bills,” is broken. Defunding is real and it’s happening to an institution near you, so be scared. Kennedy has the entire biological psychiatry industry in the squirrel grip. Let’s hope he has a large pair of surgical scissors within reach.
References:
1. WHO Guidance on mental health policy and strategic action plans (2025).. https://www.who.int/publications/i/item/9789240106819
2. McLaren N (2017). Electroconvulsive Therapy: A Critical Perspective. Ethical Human Psychology and Psychiatry 19: 91-104. DOI: 10.1891/1559-4343.19.2.91
3. Puras D (2020). UN Human Rights Council. Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. UNHRC Document A /HRC/44/48. Final report: July 16th 2020, UN Doc. A/75/163. At: https://undocs.org/A/75/163
4. Hickie, I, (2019). Building the social, economic, legal, and health-care foundations for “Contributing Lives and Thriving Communities”. The Lancet Psychiatry. https://doi.org/10.1016/S2215-0366(19)30378-5
5. McLaren N (2013). Psychiatry as Ideology. Ethical Human Psychology and Psychiatry 15: 7-18. 10.1891/1559-4343.15.1.7
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Can some good come from the New Order of Trump? Will their determination to smash institutions include the institution of biomedical psychiatry? Carolyn
The WHO report, despite supporting Kennedy, may be ignored in the United States.