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Salud mental

versión impresa ISSN 0185-3325

Salud Ment vol.46 no.5 México sep./oct. 2023  Epub 16-Oct-2023 

Original articles

Mental health and psychiatry: Distinctions, links, and ethical/bioethical perspectives

Salud mental y psiquiatría: Deslindes, vínculos y perspectivas ético-bioéticas

Alberto Perales 1   2   * 

Renato D. Alarcón 3   4  

Patrick Wagner-Grau 5   6  

1Escuela de Medicina, Universidad Nacional Mayor de San Marcos, Lima, Perú.

2Instituto de Ética en Salud, Escuela de Medicina, Universidad Nacional Mayor de San Marcos, Lima, Perú.

3Honorio Delgado Chair, Universidad Peruana Cayetano Heredia, Lima, Perú.

4Department of Psychiatry and Psychology, School of Medicine, Mayo Clinic, Rochester, Minnesota, USA.

5Academia Nacional de Medicina, Perú.

6Red Peruana de Bioética Personalista, Lima, Perú.



Mental health and psychiatry have been terms of intense and complex use for almost a century, and they may have reached a critical level of ambiguous and imprecise synonymy that makes their definition and validation difficult.


To examine these concepts in depth, establishing precise distinctions, ontological connections, and instrumental scope reinforced by well-defined ideas in ethics and bioethics.


Narrative review of pertinent literature, consultation with diverse scientific, medical, historical, philosophical, and literary sources, with appropriate analysis of ethical and bioethical practices.


A broad, comprehensive definition is elaborated of mental health as a field with sociocultural, political, and demographic implications, and of psychiatry as a medical specialty. In addition to making clear distinctions and describing the specific impact of both fields on diverse populations, various levels of conceptual linkages, sociopolitical action, and ethical content are highlighted, as well as in processes of administration, education, and research.

Discussion and conclusion

There are factors that reinforce or weaken the scope of mental health and psychiatry, including their ethical and bioethical dimensions. Their effectiveness requires a reaffirmation of objectives and the reinforcement of individual and institutional initiatives, as well as the search for authentic connections and a social projection that is objective, comprehensive, and just.

Keywords: Health; mental health; ethics; bioethics; humanism



Salud Mental y Psiquiatría han sido términos de uso intenso y complejo por casi una centuria y, en el momento actual pueden haber llegado a un nivel crítico de sinonimia ambigua e imprecisa que dificulta su delineación y vigencia.


Estudiar en profundidad los conceptos mencionados, estableciendo distinciones precisas, vínculos ontológicos y alcances instrumentales reforzados por nociones éticas y bioéticas definidas.


Revisión narrativa de la literatura, consulta pertinente con fuentes de diversa índole médico-científica, histórica, filosófica y literaria y análisis de contenidos éticos y bioéticos pertinentes.


Se plantean concepciones amplias y comprensivas de Salud Mental como campo de implicaciones socioculturales, políticas y demográficas, y de Psiquiatría como especialidad médica. Aparte de claras distinciones y de su impacto específico en diversos sectores, se precisan varios niveles de vinculación conceptual, acción socio-política y contenido ético-bioético en ambos campos y en procesos de manejo administrativo, pedagógico y de investigación.

Discusión y Conclusión

Existen factores que apuntalan o debilitan los alcances de Salud Mental y Psiquiatría, así como sus características ético-bioéticas. Su vigencia requiere una reafirmación de objetivos y un reforzamiento de voluntades individuales e institucionales, así como la búsqueda de vinculaciones auténticas y una proyección social objetiva, íntegra y justiciera.

Palabras clave: Salud; salud mental; ética; bioética; humanismo


Health is a fundamental right, and also a duty of every human being. No country can cover all of the health needs of its population, so individuals must assume duties and responsibilities to contribute to the promotion of their own self-care and self-protection and that of the members of their community. As a bio-psycho-socio-cultural and spiritual phenomenon, health is conditioned by society’s historical and political evolvements (WHO, 2012; Perales, 2020).

The World Health Organization (WHO) defines mental health as “a state of well-being in which the individual is conscious of their own capabilities, can face the normal tensions of life, work in a productive and fruitful way, and contribute to their community” (OPS/OMS, 2004; Herman, Saxena, & Moodie, 2005). When mental health is compromised or impaired, a mental disorder may occur, and it enters the conceptual area of psychiatry. Mental health thus has two expressions: 1) positive mental health, in which the subject, without signs of alteration or abnormality, directs their personal potential into constructive behaviors and actions; and 2) negative mental health, where they show clear evidence of impairment or mental disorder, the essential focus of psychiatry. To consider mental health and psychiatry as synonyms is inappropriate, since conflating their study would make mental health a mere expression of the presence or absence of mental disorder, with a place in budgets for health care well below that of other, more dramatic medical pathologies with greater public demand. Mental health would then be a neglected component of comprehensive health care. It is therefore important to distinguish these concepts in order to adequately describe the broad field of mental health and the clinical nature of psychiatry, both directly linked to models of human behavior and ethics (Perales, 1993; Gracia, 2013).


This study explores the conceptual and pragmatic territories of mental health and psychiatry with a review of pertinent literature, delineating specific degrees of distance (distinctions) and closeness (links) to allow clear definitions, specific approaches, and norms of management. Ethical and bioethical concepts from well-defined perspectives of reflection, objectivity, fairness, and precision are used to reinforce substantive points in both fields.


Coverage and scope of mental health

The distinction between positive and negative mental health is inexact; it locks the concept into the medical field and confuses it with psychiatry. Mental health has an essential link with the process of human development, with both individual and collective well-being, and in connection with harmonious social development. The confusion is even greater when labels such as “mental health problem” are used inappropriately to avoid terms such as “psychiatric illness,” “problem,” and “disorder” (PAHO, 1995). These terms may be even more damaging when they are used in official documents of international institutions, such as the Strategic Plan of Pan American Health 2014-2019 (PAHO, 2013), or the demand from WHO (2009) regarding “parity and integration in the care of mental and physical health.” By emphasizing its concern for “the inadequate appropriation of expenditures for mental health” in the Americas, PAHO (2018) confirms that it is considering mental illness, that is, psychiatry, under the rubric of mental health. Kohn et al. (2018) demonstrate this conflation even more clearly in proposing that “the gap in the treatment of mental health in the region” must include an examination of “the prevalence of mental disorders, the use of mental health services, and the global disease burden.”

Such confusion leads to a false reductionism that minimizes and even denies the importance of authentic mental health and its impact in multiple areas. In Peru, for instance, there are no specific research plans or effective intervention programs for problems such as underdevelopment and poverty, generalized corruption, and violence in all its forms (Perales, 1993). It could be argued that the corruption prevailing at every level constitutes a critical problem of mental health: the attorney general’s office, after analyzing 4,225 cases of corruption involving 2,059 current and former authorities in regional and local agencies, reported that only 4.8% concluded in sentencing; this finding confirms the need for honest judges and prosecutors to guarantee objective investigation and fair sentences and reduce impunity (PPEDC, 2018). If the insufficient social scientific research on these problems is considered an expenditure rather than an investment to argue for the scarcity of resources, the result is not only the aggravation and perpetuation of the problem, but also its acceptance and normalization, creating a vicious circle that punishes the most disfavored populations and slows the comprehensive development of countries and communities.

What Is Mental Health?

In order to correct this conceptual confusion, more precise definitions of mental health have been offered, but they are still problematic. Definitions have been proposed based on the capacity to live and co-exist with oneself and others (Herman, 2001), adaptation to diverse social determinants of health and mental health (Rodríguez-Yunta, 2016), and the fostering of supportive communities free of racism and other social inequities (Primm et al., 2010). Severe climate change has also been postulated as a factor, as the erosion of physical surroundings damages social surroundings and affects community well-being (Berry et al., 2010; Satcher & Druss, 2010). Kjellstrom and Mercado (2008) warn that many negative social conditions are due to the failure of governments in cities and metropolitan areas, which generates the growth of informal settlements and marginal communities, creating unhealthy living and working environments for millions of people (Burris et al., 2007).

In Mexico, the National Commission Against Addictions (Gobierno de México, 2022) notes that mental health “is more than the mere absence of mental disorders. It refers to the possibility of increasing the competence of individuals and communities, and allowing them to reach their own objectives. Mental health is a matter of general interest and not only for those affected by a mental disorder.” The WHO (OMS, 2009) laments the little interest shown in fostering mental health and the great risk that the situation may not change unless the conceptual confusion is overcome.

Concretely speaking, mental health cannot be examined or understood without a previous and clear definition of health; in fact, mental health constitutes the conceptual nucleus of the mental and social dimensions in the classic definition of health as “a state of complete physical, mental and social well-being, and not only the absence of afflictions or diseases” (WHO, 1948). Physical and mental health are closely linked with human development and productivity at individual and collective levels, seen from multisectoral and multidisciplinary perspectives. Both depend on levels of education and moral development, and as the concept of physical health involves medicine, mental health involves psychiatry.

This integration translates into physical, mental, social, and spiritual well-being, generating environmental, cultural, and economic well-being as well. An individual’s mental health generates their own full human maturity as well as that of their family and, stimulated by their own moral responsibility, also contributes to the progress of their community. Yet mental health problems are not necessarily psychiatric problems susceptible to specific clinical treatments; rather, they constitute situations in a complex causal network whose management requires interdisciplinary approaches. We will examine three such situations (Perales, 2016) that are now acutely present in Peru.

  1. Underdevelopment and poverty. These problems do not depend only on economic factors; their major variable may correspond to a deficit-created attitude of the individual in the face of reality, an inefficient repertoire of approaches to face them, and a “loss of freedoms” (Sen, 2000). The country has taken two approaches to the analysis and management of this situation. The first, violent and based on cruel, bloody methods, was represented by profoundly ideologized terrorist groups, for which the only way to overcome the problem was the extermination of a corrupt governing class. The second, rather silently, advocated a non-violent road, intense labor, and actions of solidarity. Its protagonists personified values and principles that showed moral fortitude and solid mental health: many inhabitants of the “inner country” (Andean communities) migrated to urban areas to escape the terrorist threat, and built “human settlements,” initially under very poor conditions. Stimulated, however, by their desire for a better future, they were able not only to develop what today are strong communities, but also to contribute to the country’s economic progress (de Soto, Ghersi, & Ghibellini, 1986).

  2. Generalized corruption. A human behavior that is not necessarily an expression of individual psychopathology, corruption is a type of social pathology in groups that take illegal advantage of economic, political, and other benefits. Corruption can be organized and grow around authorities and personnel of public and private institutions and be enhanced by cultural anti-values. Mass media report on corrupt activities, but they are covered with a mantle of impunity cultivated and supported by public institutions and even judicial authorities in the face of impotent confusion, incredulity, and even acceptance by the community.

  3. Violence. In addition to so-called narco-terrorist organizations and criminal groups linked to illegal businesses, two forms of violence are observed in Peru. One is delinquency-based, increasingly bold and protected by powerful, organized groups; another is of a social nature, and includes familial and street violence, with a gradual increase in feminicide. Some authors include violent automobile accidents on this list.

In short, the moral obligation of every state and government is to provide their citizens with the social environment and the means necessary for their development, so that their health, including mental health, can reach the maximum level allowed by their genetic potential. Interdependence, cooperation, and trust between the government and the population are essential components of this process (Perales, 2020).

The field of psychiatry

As a medical specialty, psychiatry fundamentally addresses mental disorders or illnesses, clinical entities recognized by diagnostic manuals, testing instruments, and professional, technical, and institutional pronouncements. In fact, the definitions of mental disorder in two universally accepted sources (DSM-5 TR, published by the American Psychiatric Association [APA], 2022; and CIE- 11, published by the WHO, 2022) include the abnormal behaviors characterized by identifiable symptoms and accompanied by distress and interference with habitual social, family, occupational, and intellectual activities, as well as “the ambiguity indispensable to incorporation of permanent advances in knowledge” (López-Ibor Aliño, 2002). In short, psychiatry is oriented, on the basis of scientific evidence, toward diagnosis, treatment, prevention, and research relative to abnormal behavior (Delgado, 1955). It is carried out by specialists, it adheres to the medical model, and it includes valid methodologies and codes of practice.

The clinical and heuristic activities of psychiatry also include etiopathogenic perspectives and diverse areas of study. This process configures the real or potential existence of subspecialties such as biological, social, cultural, forensic, pediatric, and geriatric psychiatry, among many others. All of these must be the object of duly conceived and applied ethical norms, supervised by well-trained personnel and competent agencies (Okasha, Arboleda-Flórez, & Sartorius, 2000).

Links between psychiatry and mental health

In spite of their differences, psychiatry and mental health must not be looked upon as antagonistic, subordinate, or autonomous fields, a perspective that would deny the integrity (and integration) of human beings and their experiences, a scenario initially conceived in lucid philosophical elaborations (Shorter, 1997; Kendler, 2014). In the Spanish language, this integration is eloquently described by Santiago Ramón y Cajal (1999); (2006), with the ontological and ethical quality of a universal and superior mind, and a “scientific morale” never far from the ideals or values of medicine, which condemns without reservation “the cruelties and insidiousness of an ancestral barbarism …[and]…of a coarse and anarchic individualism.”

The link between psychiatry and mental health is thus complementary, since the absence or exclusion of one or the other would leave an irreplaceable emptiness. At the same time, the management of every mental disorder or “problem” involves recurring to preventive and promotional measures that entail the clear perception of perturbations and anomalies (“symptoms”) as well as realities of harmony or equilibrium substantiated by the notion of comprehensive mental and physical health (Martínez-Pintor & Martínez Gamo, 2022). This exploration of clarity and complementarity profiles four components that provide the epistemological background that shares and nourishes this connection.

  1. Humanism. Every medical-psychiatric act entails the unique relationship of two individuals supposedly oriented toward the same objective, even if sometimes from diametrically opposed positions: the patient, under the overwhelming pressure of anomalous and damaging experiences, and the professional, in possession of objectivity and valid resources of clinical management (Mariátegui, 1987). Each protagonist carries powerful ethical and humanistic baggage: the patient, due to their expectations of help, support, and hope, and the physician, given their training and learning obtained through study and practice (López-Ibor, 1954). Surrounded by different human environments and coming perhaps from different sociodemographic and geographic backgrounds, patient and doctor generate not only a deliberative dialogue, but also a full and intense relationship of equals united by the common human and ethical objective of healing, improving, or fighting a common adversary with courage, resilience, and mutual loyalty. This dialectical encounter requires adaptability and comprehension, sincerity and trust, qualities that, from the psychiatrist’s perspective, demand a crowning ethical seal, clearly linked to the perspective and the action of “the most human medical specialties” (Laín-Entralgo, 1984). In the pragmatic phases of their work, the physician-psychiatrist must firmly adopt an ethical compass, and behave simultaneously as scientist, ethicist, and humanist. A bioethical humanism is sensible, alert, and consistently present in the classroom, the doctor’s office, the emergency room, or the laboratory (Kleinman, 1988). A humanistic bioethics in medicine is solid, strong, categorically established and rooted in the essence of the profession (Alarcón, 2021a).

  2. Eco-bio-genetic ethical determinism. To the extent that medicine as a scientific field not only promotes impressive advances toward the cure of diseases, but regrettably may also produce them, there is other evidence of the link between mental health and psychiatry. For instance, Gracia (2004, p. 69) points out that to the classic placebo effect of many pharmacological agents, the fact that “every agent is toxic” (i.e., it produces collateral effects) must be added. Its “indiscriminate and abusive consumption…fostered by the own inner structure of consumer society, produces an enormous amount of disease and even death.” Additional challenges that bypass the search for utopian objectives but also induce discomfort and frustration (Gracia, 2004) include: a) iatrogenic diseases; b) the biogenetic component that, in its extreme anti-Darwinian positions, generates distinctions in the consideration, accessibility, and management of vulnerable segments of the population; c) the deterioration of the environment and ecological crisis (Wallace-Wells, 2019); d) the scarcity of basic resources; and e) health, understood not only as a socially and economically productive life, but also as a fundamental state of well-being.

  3. Behavior and Sociocultural Factors. Beyond purely medical territories, these mechanisms may push society to assume generally negative group behaviors, with an obviously unfavorable impact on the mental health of their protagonists and those around them. Paradoxically, the pathogenic impact of behaviors such as corruption and violence on collective mental health is often forgotten: it ranges from a bland indifference to a sterile fury or a paralyzing demoralization, through resigned acceptance or flagrant denial. The ethical perspective is then weakened and ineffective, and may result in attitudes and behaviors damaging to the emotional and physical health of the population (Kellar-Guenther, 2016).

    • The location and repository of traditions and beliefs, language and habits, and unique and non-transferable identities (Alarcón, 2013), culture also includes historical roots, human empowerment, dimensions of duty and processes of possibilities, and adjustment and agreement that may occasionally produce ambivalent results (Gracia, 1998). This foundation gives ethics and humanism distinctive characteristics of content and practice, contributing also to enriching comparisons and their subsequent universalization. It is only through an open, receptive, and flexible culture that the ecumenism of fundamental ethical principles and of genuinely human conceptions of compassion, solidarity, and identity have been achieved in some countries or regions of the world (Lolas & Rodríguez, 2020). Such culture is an effective antidote to dogmatic prescriptions, sectarian rules, and obsolete slogans.

    • The ontological and epistemological growth of psychiatry as a medical specialty has led to the definition of areas of study, reflection, and research with themes sufficiently broad to allow for semi-autonomous approaches (Leighton, 1981). Two of them, inappropriately called “subspecialties,” address individual and collective emotional suffering: cultural psychiatry and social psychiatry. Cultural psychiatry is defined as a discipline oriented to the description, evaluation, and management of psychiatric conditions insofar as they reflect the formative influence of cultural factors and variables (Alarcón et al., 1999; GAP, 2002). These variables include lifestyles, positions, and principles in individuals, families, communities, countries, regions, and continents. The exploration, recognition, and effective use of these characteristics, formalized, for instance, in the DSM-5 Cultural Formulation Interview (CFI; Lewis-Fernández et al., 2016), facilitate the psychiatrist-patient relationship on a solid foundation of competence, trust, respect, and ethics. The use of cultural elements and factors in psychotherapeutic relationships is considered an essential factor for favorable outcomes (Alarcón et al., 2020).

    • Social psychiatry includes collective and group-oriented projections, transferring cultural precepts and foundations to the life, functions, and attitudes of populations conceived as unities or organizations that are global in scope (Di Nicola, 2023). It encompasses well-defined multidisciplinary work and the conception, materialization, and promotion of community services, and, in its educational and scientific dimensions, epidemiological research and so-called preventive psychiatry, both substantive tasks of public health.

    • An essential element of social psychiatry are the so-called social determinants of health and mental health (Compton & Shim, 2015; Silva, Loureiro, & Cardoso, 2016; Alarcón, 2021b; Thompson & Tasman, 2022). These play a powerful role in the presence or absence of health, generate varied levels of symptomatic severity, and exercise a definitive causal process by triggering or perpetuating different kinds of psychopathologies (Kirkwood, 2020), including poverty and its sequelae of scarcity and need; violence and its impact of impotence and abandonment; lack of educational opportunities and its effects of disinformation and ignorance; corruption and its biased perception of power and manipulation; and sociopolitical instability, with its consequences of stress, uncertainty, negligence, and cynicism.

    • The close association between poverty and mental illness is an important consideration. Poverty is the cause, scenario, and consequence of a variety of social problems, such as homelessness, unemployment, deficient environmental and working conditions, and financial inequities (Laughland, 2020). Obviously, it is also related to lower educational levels, chaotic urbanization, and substantially reduced quality of life. Poverty generates emotional fragility and vulnerability in the face of a variety of stressors, including delinquency, violence, hostility, discrimination, segregation, negligence, and stigmatization, that increase the prevalence of physical and mental disorders and highlight the lack of access to health services.

    • The enormous number of physical and mental health problems caused by these social determinants, particularly in low and middle income countries (LMICs), such as those in Latin America (Alarcón, 2013; 2021b; Mari, 2021), also include inequities in areas such as sexual identity, ethnicity, and social class that accentuate the psychosocial disadvantages of those affected. Other features are apathy, lack of action, and even government or private measures that are directly harmful to large sectors of the population (Mitchell, 2009; Ekuma & Akobo, 2015).

  4. Science. An ethical and bioethical emphasis must underly all areas of basic science and clinical research related to mental health and psychiatry. Their methodologies must include ethical consideration of such issues as confidentiality, selection of study participants, ethical approval and informed consent, reasons for acceptance or exclusion, and placebo and secondary effects (Gracia, 2004, pp. 303-334), plus established norms for examinations and laboratory tests. These considerations are most frequently related to genetic, biophysiological, and psychopharmacological research (Romeo Casabona, 1997), with special consideration of age groups and the specific objectives of each study.

    • Research in social and cultural psychiatry raises unique ethical issues. In the context of cultural relativism, the interpretation of findings must cover both their cultural significance and their eventual neurobiological correlates (Adams & Quartiroli, 2010). Finally, research in psychotherapy is a relatively new and complex field, due to the enormous variety of theoretical foci or “schools,” which requires a greater attachment to established methodological and interpretative norms (President’s Council on Bioethics, 2003). Serious research has also demonstrated that complex and intuitive factors such as hope play an important role in the outcome of psychotherapeutic interventions (Frank, 1973; Alarcón & Frank, 2012). The participation of the patient, and of relatives, friends, and close acquaintances, is also a crucial component of every study


Ethical and bioethical perspectives

Bioethics is the ethics of life. The term life or vita comes from the Latin word vis, which means force, power, or energy (Gribbin, 2003). Ethics, in turn, is identified with ethos, which alludes to the good, to what has been achieved, and to progress, growth, improvement, the search for and the finding of excellence. Cosmic and non-cosmic global bioethics, the latter identified with ecology and implying a harmonic balance, a dynamic that favors progress and well-being (Gamow, 2007), are emerging fields.

The vital root is expressed and culminates, finally, in the human being, the person (Comte, 1985). Personalistic bioethics considers the person as an actor, central figure, or author of an ethical worldview. It focuses on the person, a subject endowed with reason and moral experience, with the ability to fully distinguish between good and bad, virtue and evil, a characteristic that defines its organization and ecological balance (Teilhard de Chardin, 1959; 1963).

Mental health is the progressively structured modeling of the person from earliest childhood. Thus, it is influenced by family, school, community, and other social environments. In this context, moral and spiritual training are essential. The U.S. philosopher and pedagogue John Dewey (1915); (1925), insisted on these principles, and created a wholly pragmatic pedagogy, still essential in modern education and in the formation of people with healthy and productive minds. Philosophy, for Dewey, is basically a moral engineering which makes life more useful, beautiful, and creative. In this context, he compares different pedagogical approaches, describing "cultured" and "uncultured" educational processes, continuous and harmonious versus disrupted “training for life,” and education “in and for values.” He postulates that axiological training is the secret to a healthy, productive, creative, and above all ethically balanced life.

Mental health is one of the highest expressions of personalistic bioethics, as it makes us face true homeostasis, a bioethical ecology. The recovery of altered, lost, or threatened homeostasis is thus a fundamentally topic in bioethics. Human ecology also implies another profound issue: the necessary relationship between the life of the human being and moral law, indispensable to a dignified, valuable, and efficient internal and external environment (Kragh, 2007). The bioethics of caring for mentally ill patients is also based on these considerations, since care represents the therapeutic effort deployed to return balance, order, and harmonious ecology to the mind, that is to say, to recover lost virtue and the displaced or diminished good.

The ambiguities of this present-in-transition are the future challenges we face today. Ethics and bioethics must look at this future in the context of changes that are already being perceived in essential aspects of the medical profession and its practice, as well as in the populations, communities, and societies they serves. Medical and psychiatric practice will be increasingly based on the composition and activities of multidisciplinary teams, conducted by a democratic and equalitarian medical leadership (Weisstub & Arboleda-Florez, 2000). The system of compensation for medical actions will require changes, not only with respect to the economic reimbursement for each profession on the team, but also in terms of insurance coverage, access for the neediest, and sanctions for rule-breakers. Together with technical competence, the ethical dimensions of these processes, going far beyond administrative dispositions of public and mental health, are undeniable (Lolas, 2001; 2010a).

In the strictly clinical field, these changes affect both patients and the society of which they are part. No longer characterized merely by passivity, dependence, suffering, or frustrations of different kinds, patients are gradually becoming activists in defense of inalienable rights (Lolas 2010b; de la Fuente Muñiz, 2021). It is in the face of this “patient emancipation” process (Montori, 2020) that ethics must confer balance and discretion on the organizations involved. It will not be able to deny, for instance, the appropriate participation of patients and members of organizations in critical phases of the clinical process, but there must simultaneously be clear guidelines about the nature and limits of such participation. In turn, the impact of phenomena as diverse as internal and external migrations or advances in technology constitute, today and in the future, a process of globalization that also entails major ethical changes (Adis Castro, 1991; Alarcón, 2016).

Mental health demands a normal brain and the social modeling of its functions (Álvaro-González, 2015). It is a human process that advances in parallel with moral development. It responds to the formative modeling of society, beginning with the newborn who, after a long process of informal learning in the family and formal learning in school, along with learning the social ethos—the management of customs, habits and values—will become an authentic human being: a person. During this process, children register information in their neocortex, incorporating culture in its broadest individual expression: the forging of personality (Ortiz, 1997; 2019).

Spirituality is another strand in the development of mental health, based on its adaptive connection with the processes of coping with stress (Koenig, 2009). The microsociety of the family milieu and the educational system are the most prominent modulators of the basic behavior of the future citizen. In short, mental health is a product of the interplay of many variables, with education, the process of cultural transfer, one of the most significant. When those who occupy levels of political decision making understand the enormous value that mental health research and education have for national development, they will have recaptured its true meaning as investment and potential of comprehensive human development (Perales, 2013).


This article reflects a renewed debate not just on the means but on the purposes of medicine, mental health, and psychiatry. In his profound analysis, Gracia (2004) criticizes “the predominant rationalism in our Western world,” a feature he qualifies as “purely strategic,” as it does not question the moral characteristics of its objectives, but searches only for efficient means of achieving them. According to Kant (1997), this approach becomes the characteristic sign of moral life and thus becomes absolutist. Weber (1967) advocates for a “responsible” attitude that does not deny emotions or values, or even the need for a good “instrumental rationality.” It therefore becomes indispensable “to ponder means, purposes and values…as…objectives of a true ethics of responsibility.”

Humanism cannot resolve its differences with positions devoted to demonstrating the purely neurobiological basis of every human action, motor or emotional, cognitive or affective (Le Mappian, 1970), or with dogmatic philosophies that render superficial eminently practical accomplishments of a constructive, applied humanism (Vovelle, 1985). The principles of goodness (“to do good”), appropriateness, and justice must always occupy a central position in medical acts, including research, given their genuinely human nature.

One of the most important topics in these processes of reform and renovation are the definitions of health and disease. These must be continually updated with new concepts such as well-being and quality of life (Edwards, 1982; Griffin, 1986), as they relate to important sociocultural realities such as employability, productivity, comfortability, and even happiness. It also remains clear that there are numerous conditions and behaviors that should not be considered symptoms or mental illness and that are thus the appropriate focus of non-clinical disciplines.

Diverse international organizations, including the World Health Organization, the World Psychiatric Association, and other national professional and academic entities, have issued pronouncements and declarations about the ethical conduct and responsibilities of specialists, with clear guidelines for specific situations and universally applicable paradigms, based on promoting good and reducing evil (Sartorius, 2000). Standardized ideals of professional behavior create norms of respect, autonomy, beneficence, equity, and avoidance or minimization of damage in individuals and societies. Consensus based on evidence, experience, and periodic reexamination of norms at local and global levels is also a moral obligation of individuals and professional organizations.

There are also positive and negative factors that strengthen or weaken the essence of ethics and its role in mental health and psychiatry. The positive factors include altruism, compassion, honesty, honor, equality, judgment, justice, optimism, order, wisdom, and truth (CIPD, 2020), and the negative factors include abuse, chaos, cynicism, cruelty, envy, indifference, manipulation, materialism, reductionism, and treating people as objects. Power also has negative moral dimensions, including maleficence, maliciousness, malignity, and evil. The latter, when structural and thus supra-individual, possesses a sociocultural and historical character (Gracia, 2004; 2013) that has been present in the three major “social revolutions”—the agricultural, industrial, and consumer revolutions—leading to important ethical contingencies. To complicate matters even more, there are factors that could be called neutral, yet are as complex and decisive as the others. These include subjectivism, relativism, curiosity, and skepticism (Cherniss & Adler, 2000; Goleman, 2005).

Bioethics, Gracia (2004, p. 89) points out, must assist health professionals in reflecting on the essential purposes of their work: “The greatest task of the future is to leave the purely professional sphere and move to the social space, in order to interact Socratically and debate these types of questions. It is good to get away from the excessively professional and sanitized conceptions of bioethics, and practice instead a general reflection on the problems of life and death, the body’s carrying on: a comprehensive focus.”

The humanization of medical assistance may be complicated by theoretical and practical approaches that are exclusivist, absolutist, or rationalistic. The rescue of what is emotional in this process has been laborious, due to confrontations with followers of old positivist prejudices that never updated the approaches (which were lucid in their historical moment) of Comte and Bernard. Knowledge, abilities, and attitudes do not have to lack an emotional and ethical substrate that complements the historical, cultural, and scientific components of authentic humanism.

The theoretical and practical vicissitudes resulting from inevitable changes in medicine, mental health, and psychiatry must, however, avoid the “feeling of imposition, the usurpation of the role that only the most veracious person can legitimately interpret.” The value of words as vehicles of change implies “a radical ascesis, a fight to overcome indolence” (Gómez Pin, 2012).

It is also pertinent to examine the ethics of technology in projects of mass digital education that can generate a depersonalization of the didactic process (Williamson, 2016). Brockman (1995) argues about the emergence, since the closing decades of the twentieth century, of a “third culture” beyond the traditional dichotomy of science versus the humanities. This third culture is the result of a convergence of humanists that must think like scientists and vice versa, testing the logical coherence, explanatory power, and agreement of their ideas with facts and empirical findings. Scientists, says the author, “are not reducing the humanities to biological and physical principles, but believe that art, literature, history, politics—a total panoply of humanistic concerns—need to take the sciences into account.” “Intellectually eclectic” humanists are thus needed to postulate a “realistic biology of the mind.”

However, authors like Lanier (2010) question the reticence of the “cybernetic totalists” to educate themselves in the tradition of “scientific skepticism,” and they voice concern in the face of a possible process of “self-intoxication” that could lead them “to essentially build their ideas within the software that commands and manipulates our society and our lives. If that occurs…[this ideology]…will pass from being a novelty to constitute itself as a force that could cause suffering to millions of people.” It must be reiterated here that mental health, unlike psychiatry, orients itself to the integral development of the human person and society in general, through valuable processes of cultural, scientific, technological, and axiological education (Perales, 2023).

In conclusion, a reaffirmation of objectives and a reinforcement of individual and institutional willpower (Clark, 2015) are required in the search for a non-prejudicial connection between mental health and psychiatry. It is indispensable to differentiate the two concepts, distinguish their constitutive values, and identify principles and duties that by becoming behaviors, define the specific objectives of bioethics (Lolas, 2001; Perales, 2023). In other words, the ethical debate and the humanistic discourse on the essence of mental health and psychiatry must be reopened (Alarcón, 2021a), as well as the view of human beings, healthy or ill, as connected with their environment and world, in harmonious exchange and with precise vital objectives. It is necessary to reaffirm and reformulate the technical, clinical, practical, and instrumental truths of our task, together with the social and economic realities that demand change: to combat poverty, abolish the victimization and isolation of disadvantaged populations, ensure just and comprehensive access to services, condemn and expel corruption and violence as normative elements, and face every type of problem or event with valid information, solid knowledge, clarity of mind, integrity, and genuine sense of justice, in order to build a more dignified, more ethical, and thus a freer society.


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Funding None.

Citation Perales, A., Alarcón, R. D., & Wagner-Grau, P. (2023). Mental health and psychiatry: Distinctions, links, and ethical/bioethical perspectives. Salud Mental, 46(5), 231-240.

Received: April 03, 2023; Accepted: April 26, 2023

Correspondence: Alberto Perales Jr. Lopez de Ayala 929, San Borja, 15021 Lima, Perú. Email:

Conflict of interest The authors declare that they have no conflicts of interest.

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