Who gets to decide what counts as psychological distress, and whose diagnostic framework becomes the standard? These are the questions at the heart of a Perspectives piece in the July 11 issue of The Lancet by Abhijit Nadkarni, Professor of Global Mental Health at the London School of Hygiene and Tropical Medicine.
The piece, categorized as a “Perspectives Book” contribution, examines the power dynamics embedded in psychiatric diagnosis, a topic that Nadkarni is well-positioned to address. As co-director of the Centre for Global Mental Health at LSHTM and King’s College London, and as an addiction psychiatrist whose research focuses on increasing access to mental healthcare in low-resource settings, Nadkarni has spent his career confronting the tension between universal diagnostic frameworks and the local contexts in which distress is experienced.
The central question
The title “Whose distress, whose diagnosis?” captures the core concern: diagnostic categories in psychiatry are not neutral descriptions of natural kinds. They are products of specific cultural, institutional, and professional contexts, primarily Western biomedical frameworks, that are then exported globally through training, research funding, and treatment guidelines.
Nadkarni’s work in India, where he directs the Addictions Research Group at the mental health research NGO Sangath, has repeatedly demonstrated that effective mental healthcare requires adapting diagnostic and treatment frameworks to local understandings of distress, not simply transplanting Western categories and assuming they have universal validity.
The piece questions whether the growing global mental health movement, for all its laudable goals of closing the treatment gap, risks imposing one set of diagnostic assumptions on populations whose experiences of distress may be better captured by different frameworks.
Broader context
The question of who defines distress has practical consequences. Diagnostic frameworks determine who qualifies for treatment, what kind of treatment is offered, how research funding is allocated, and how prevalence data are interpreted. If a diagnostic system systematically misses or mislabels the ways that distress manifests in specific cultural contexts, the global burden of mental illness estimates derived from that system will be systematically wrong.
Nadkarni’s own research has focused on culturally adapting psychological treatments for depressive disorders and alcohol use disorders in low- and middle-income countries, work that has demonstrated that locally adapted interventions can be as effective as their Western counterparts while being more acceptable and scalable.
The Lancet piece, while part of the journal’s Perspectives book review section, situates this ongoing debate within the broader literature on global mental health, cultural psychiatry, and the politics of diagnosis. Nadkarni serves on the State Mental Health Authority for Goa and has advised the Ministry of Health and Family Welfare on India’s mental health operational guidelines, giving him a policy as well as academic perspective on whose frameworks ultimately shape care.