Credits: ShuttleMedia, Pixabay

By: Monique van Cauwenberghe

A human rights approach to mental health promotes and protects dignity, equality and non-discrimination particularly, in the provision of health care. As such, applying a right to mental health framework to premenstrual dysphoric disorder (PMDD), which has for too long gone under researched and poorly understood, provides the scaffolding to advocate for improved responses, including improved health services, research, policy and dedicated funding for PMDD. This blog post delves into this further.

What is PMDD?

Premenstrual Dysphoric Disorder (PMDD) is a cyclical hormone-based mood disorder that has been reported to affect between 1.6% - 8%^[1] of people who menstruate globally. While its classification and diagnoses have been and continue to be debated, it was included within the DSM-5 as an independent diagnosis and a depressive disorder in 2013. PMDD was eventually included in 2019 in the World Health Organisation’s (WHO) International Classification of Diseases (ICD-11), where it is listed under diseases of the genitourinary system. The WHO ICD-11 categorises its symptoms as a pattern of mood, somatic or cognitive symptoms. This includes depressed mood, irritability, anxiety, overeating, forgetfulness, and suicidal ideation, among others. Symptoms typically occur for 10-14 days within the luteal phase of the menstruation cycle. PMDD is severe and can be debilitating, and as classified within the ICD-11, enough to cause “significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning”. PMDD is not yet well understood, is under researched, misdiagnosed, and underdiagnosed.

The human right to mental health

Human rights law is a practical tool through which to address health concerns. It can empower individuals as rights holders to claim their rights and hold states as ‘duty-bearers’ accountable for violations. Importantly, it can also provide the tools (in the form of both legally binding and non-binding guidance) to advocate for change at a legislative, policy and services provision level. As such, these tools can advocate for improved consideration and attention to underrepresented health concerns such as PMDD.

The scope of human rights in which PMDD can be positioned is broad and extends to the right to physical and mental health, the right to life, right to sexual and reproductive health, and right to non-discrimination. The International Covenant on Economic, Social and Cultural Rights (ICESCR) Article 12 on the right to mental health is arguably the most logical starting point in addressing PMDD. ICESCR Article 12 recognises the right to physical and mental health. It can be read in light of the WHO definition of mental health - “...a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community.” As a mood disorder, one that is also recognised within the DSM-5 and by the WHO, PMDD certainly falls within this scope. State parties to the ICESCR have a positive obligation to fulfil particular rights outlined within the Covenant. This means, particularly concerning the right to mental health, that states must take sufficient measures to ensure that it is working towards the realisation of any particular right. States may realise the right to health progressively, meaning that measures can be taken over time, however, the implementation of minimum core obligations, such as non-discrimination require immediate implementation.

A core element of the right to mental health, as outlined by the Committee on Economic, Social and Cultural Rights (CESCR) General Comment No. 14, is consideration of the Available, Accessible, Acceptable and Quality (AAAQ) framework when addressing a health concern. One can apply the AAAQ framework to any health-related concern - ensuring that services are Available, Accessible (non-discrimination, physically accessible, information accessibility, economic accessibility), Acceptable and Quality. For example, when developing policies, health care services, and the allocation of resources such as funding, attention to the AAAQ framework can help to guide states to ensure that no considerations are overlooked. CESCR General Comment No. 14 outlines that “To eliminate discrimination against women, there is a need to develop and implement a comprehensive national strategy for promoting women’s right to health throughout their life span. Such a strategy should include interventions aimed at the prevention and treatment of diseases affecting women, as well as policies to provide access to a full range of high quality and affordable healthcare.” While there is somewhat limited attention afforded to mental health conditions in treaty guidance, the existing framework of the right to mental health still provides a strong foundation and starting point in which to address and improve conditions. However, expanded treaty body guidance in this regard would be apt, to direct state guidance on this topic.  

Within the context of PMDD, the AAAQ framework ensures that, diagnostic tests are available and accessible, scientifically accurate information on PMDD is widely accessible, sufficient funding and resources are allocated to conduct research on PMDD, and access to resources and essential medications are available to those living in rural areas. This framework also draws attention to the need for general practitioners, psychologists and mental health professionals to receive appropriate training on PMDD. Furthermore, specialist health providers, such as psychologists, and gynecologists that specialise in PMDD should also be economically accessible (affordable) for all. For a disorder that has been chronically misdiagnosed, dismissed and underdiagnosed, moving forward with a human rights approach provides those who require treatment with dignity and equitable access to healthcare.

A way forward?

This lack of attention and research to mental health necessitates immediate increased attention. Steps need to be taken to advocate for the increased awareness of PMDD, its incorporation into policy and research funding allocation, particularly through the use of the AAAQ framework. Similarly, interdisciplinary collaborations are needed, not only to research and understand PMDD, but to implement informed policy decisions. Applying this framework to PMDD requires collaborations between lawyers, policy makers and mental health experts that specialise in PMDD, among other relevant disorders. Finally, the CESCR is urged to incorporate considerations into their treaty guidance to facilitate state implementation of addressing such health concerns.

Bio:

Monique van Cauwenberghe is a PhD researcher at the University of Groningen. Her areas of research and interest include the right to mental health within the context of climate disasters, mental health and displacement in climate litigation, gender-based violence as a public health concern, and women’s health. She is coordinator of the Groningen Centre for Health Law (GCHL), Global Scientific Network on Law and Tobacco, and co-coordinator of the NNHRR Working Group on Human Rights and the Climate Crisis.