We feel it is important to respond to several points that Dr Cohen made in his letter. In our editorial, we did not propose that psychotropic medications should not be part of the treatment options for people with mental health difficulties living in LMIC. Instead, we questioned whether these medications should necessarily be the front-line treatment, and highlighted concerns about their long-term use. We cited the most comprehensive studies conducted to date to highlight that outcomes for serious mental health difficulties in high-income countries (HIC) are not superior to those in LMIC. The suggestion that outcomes were better in countries where populations may not have access to antipsychotic medications is supported by the WHO finding that ‘Patients in developing countries experienced significantly longer periods of unimpaired functioning in the community, although only 16% of them were on continuous anti-psychotic medication (compared with 61% in the developed countries)’. ^{Reference Jablensky and Sartorius1}

A recent meta-analysis of studies that have investigated antipsychotic medication for maintenance treatment of schizophrenia found that antipsychotic medications were superior to placebo in preventing relapse, and that the medication-placebo difference was smaller in longer, compared with shorter, trials. ^{Reference Leucht, Tardy, Komossa, Heres, Kissling and Salanti2} Various methodological issues were noted with the studies. ^{Reference Leucht, Tardy, Komossa, Heres, Kissling and Salanti2} More rigorously controlled long-term trials are required in both HIC and LMIC to investigate the impact of antipsychotic medications on recovery (incorporating a focus on social participation and citizenship) from serious mental health difficulties. Consistent with a previous British Journal of Psychiatry editorial ^{Reference Morrison, Hutton, Shiers and Turkington3} and the Kampala Declaration, ⁴ we believe that it is important for people to have the right to freely choose whether they take psychotropic medication on the basis of balanced information about the potential long-term benefits and costs of these treatments.

Dr Cohen casts doubt on the suggestion that the multiplicity of treatment/healing options for mental health difficulties available in LMIC may be associated with better mental health outcomes there. He points out that a range of potential treatment options is also available in HIC. Halliburton has spoken directly to this point, by commenting that in ‘developing country sites in the WHO studies, multiple medical systems exist within the mainstream and are often considered mutually compatible, whereas in most developed sites allopathic medicine is more hegemonic and “alternative” systems are more marginal’. ^{Reference Halliburton5} Indeed, it has been suggested that, over the past 200 years, complementary and alternative systems have contended with orchestrated resistance from biomedicine. ^{Reference Wahlberg6}

Whether non-biomedical interventions provided in HIC or LMIC are safe and efficacious is a matter for careful consideration and empirical investigation. Recent evidence from Ghana has indicated that human rights abuses can occur not only in non-biomedical settings (such as prayer camps), but in psychiatric hospitals as well. ^{Reference Méndez7} It is estimated that two-thirds of the global population rely on traditional forms of medicine used concurrently with, or as alternatives to, biomedicine. ⁸ We would suggest that dismissing out of hand the contribution of non-biomedical practitioners as the work of ‘charlatans’ potentially risks disenfranchising people from important sources of support.