A recent paper published in the Journal of Mental Health examines the frequency of clinical mental health data in the UK, including information related to social determinants of health, as well as phenomenological (symptom-focused) reports. This clinical data is based on codes from the International Statistical Classification of Diseases and Related Health Problems (ICD) and comes from the UK NHS Trust electronic database.
The authors, including British clinical psychologist Peter Kinderman, found that both social determinants of health and phenomenological codes were rarely used in clinical reporting, despite their known prevalence among service users.
“In 2012, a leading group of social psychiatrists argued that mental health care needed to reform, to take better account of social determinants. Similarly, the United Nations Special Rapporteur Dr. Dainius Puras argued that mental health problems are strongly linked to early childhood adversities, inequalities, and abuse, and argued for a ‘revolution’ in mental health care; a shift in focus from ‘treatment’ towards a more fundamental social basis for care. These kinds of visions for care take, as their first step, the recognition and recording of these social determinants,” write Kinderman and co-authors.
The United Nations and many others have called for the need to recognize the impact of social and economic factors on mental health instead of an individualizing approach based on the medical model. These social and economic factors include phenomena such as poverty, immigration, adverse childhood experiences, homelessness, and isolation.
Kinderman has also proposed reforming psychiatric diagnosis by placing a renewed emphasis on diagnosing social conditions instead of disorders within individuals (see MIA interview). Despite these calls, however, psychology and psychiatry continue to be ruled by a dominant paradigm based on individualism and narrow understandings of the brain.
The current paper examines how frequently social determinants of health codes were reported in UK mental health case records between January 1, 2015, and January 1, 2016. The authors, recognizing the “overwhelming evidence” for the impact of social determinants of health on mental health, sought to analyze how often ICD-10 and ICD-11 categories related to these phenomena are actually mentioned in clinical case records.
They also looked at the frequency of “phenomenological” ICD codes being reported, focusing on symptoms, such as auditory hallucinations and suicidal ideation, rather than diagnosable disorders.
The authors examined 21,701 case records from the UK NHS Trust, an electronic database based on “the ePEX system, an electronic healthcare records system designed both for internal Trust clinical activity and for mandatory reporting to commissioners and regulatory bodies.”
Out of the 21,701 case records, 4656 individuals were given a formal diagnosis.
10.2% of the entire sample of service users were diagnosed with a “mental, behavioral and neurodevelopmental disorder,” such as paranoid schizophrenia.
Use of “quasi-diagnostic” codes, consisting of “symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified,” was fairly rare. Nineteen people (0.1%) out of the 21,701 received a code related to, for example, auditory hallucinations or “‘other symptoms and signs involving emotional state’ (R45.8).”
The ICD system is complex and can include primary diagnoses and secondary diagnoses, however, which forced the authors to manually examine many cases. Codes related to “symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified” were mentioned a total of 66 times.
Only 43 references were made to ICD codes related to social determinants of health for 39 individuals (0.2%, or 0.8% of diagnosed individuals).
For example, two individuals were identified as “unemployed,” one individual was assigned the code for “other physical and mental strain related to work,” one was identified as “homeless,” and three were classified as “living alone.”
In addition, two were classified as having a “problem related to social environment,” seven were reported as having “problems related to alleged sexual abuse of child by person within primary support group,” and six were reported as dealing with the “disappearance and death of family member.” Others were given codes related to legal troubles, psychosocial circumstances, “stress, not elsewhere classified,” and other issues.
When individuals were given a mental diagnosis, such as PTSD, it was also rare to find an accompanying psychosocial code. For example, out of 64 people diagnosed with PTSD, only two cases mentioned vague “psychosocial circumstances.” In addition, no “specific traumatic events” were reported in any of these cases, despite PTSD being grounded in a personal history of trauma.
Similarly, out of 151 service users diagnosed with an “emotionally unstable personality disorder,” only one case mentioned anything related to social determinants of health—a single mention of alleged sexual abuse.
The authors compared the infrequent use of these codes to estimated population prevalence. For example, only three people in the database were reported as living alone, while 11% of all mental health service users reported living alone in a representative survey.
Adverse childhood experiences related to trauma were reported only 11 times (0.05% of the total dataset), but in epidemiological studies, 31% of participants have reported trauma events in childhood.
“Overall, codes for possible social determinants were used in only 39 cases (0.2% of the whole dataset of 21,701 individuals, or 0.8% of the 4656 receiving a primary diagnosis). Comparison with relevant baseline frequencies revealed a highly significant under-reporting of key, known, social determinants.”
Meanwhile, phenomenological (symptom-focused) codes were used in only 19 cases. They note that these statistics are similar to findings from within the U.S. psychiatric system.
However, they do caution that this data does not provide insight into “individually held” psychiatric and nursing clinical notes.
The authors conclude:
“It is likely that diagnostic information might have guided clinical decisions on at least some occasions but was not recorded on the database. Nevertheless, the omission of records of the social determinants of mental health problems is important, because of the likely impact on our understanding of the problems, on care pathways, and on political agendas.
Describing the circumstances that may have contributed to distress promotes understanding and, thereby, compassion. Research has demonstrated that the inclusion of information about social determinants reduces the likelihood that a pattern of behavior is seen as pathological. Omitting information about psychosocial circumstances means that a biomedical, pathologizing explanation is more likely.”
Kinderman, P., Allsopp, K., Zero, R., Handerer, F., & Tai, S. (2021). Minimal use of ICD social determinant or phenomenological codes in mental health care records. Journal of Mental Health, 1-10. (Link)
“Adverse childhood experiences related to trauma were reported only 11 times (0.05% of the total dataset), but in epidemiological studies, 31% of participants have reported trauma events in childhood.”
ACEs have been reported at higher rates by others.
“the prevalence of childhood trauma exposure within borderline personality disorder patients has been evidenced to be as high as 92% (Yen et al., 2002). Within individuals diagnosed with psychotic or affective disorders, it reaches 82% (Larsson et al., 2012).”
The bottom line is huge percentages of those labeled with the DSM/ICD disorders are child abuse survivors. And covering up child abuse and rape has been the business of the psychological and psychiatric professions for a very long time.
And in the US, all this systemic child abuse covering up is by DSM design. It’s due to the lack of ability of the US “mental health” workers to bill for helping child abuse survivors.
It does appear that the ICD has allowed for billing to help child abuse survivors, seemingly since 2016? I’m not sure when this was added to the ICD.
“Research has demonstrated that the inclusion of information about social determinants reduces the likelihood that a pattern of behavior is seen as pathological.” So “inclusion of information about social determinants” should be made mandatory for all “mental health” workers.
To the logical mind, it’s absurd to think that entire industries – of self proclaimed “professionals” – could actually have gone off believing the bio-bio-bio theory that “all distress is caused by chemical imbalances in individuals’ brains,” for decades. How insane!
And I will say many (seemingly most) of the US psychologists and pastors don’t want to end this multibillion dollar, systemic child abuse and rape covering up, “dirty little secret of the two original educated professions.”
Someone Else, of course you are right. The problem is, speaking about my profession of psychology, we have no idea how to think about and how to help with “social conditions” like adverse childhood experiences. We know how to “diagnose” and “treat” “mental disorders.” We reframe adverse experiences in DSM terms (e.g., losing a loved one = major depressive disorder) and offer techniques to “reduce symptoms,” just as psychiatrists and GPs offer “medications” to “reduce symptoms.” The very defining feature of “clinical” psychology, as opposed to counselling or social work, is “diagnosing and treating mental disorders.” Returning to the title of Micah’s article, “Why not Diagnose Social Conditions Instead of Individual Symptoms?” – my answer is clear: because “mental health professionals” don’t think that way. Our entire system is organised, from the ground up, around a model that is designed (quite intentionally) to locate problems in the individual, ignore social conditions entirely, and provide pills and skills to control thoughts and feelings that are considered “bad.”
Sadly, due to the common OIIIMOBY mindset (Only If It’s In My Own Back Yard), the prevailing collective attitude, however implicit or subconscious, basically follows: ‘Why should I care — I’m soundly raising my kid?’ or ‘What’s in it for me, the taxpayer, if I support child development programs for the sake of others’ bad parenting?’
Nonetheless, as likely countless other people also feel, I believe the wellbeing of all children — and not just what other parents’ children might/will cost us as future criminals or costly cases of government care, etcetera — should be of importance to us all, regardless of whether we’re doing a great job with our own developing children. A mentally sound and physically healthy future should be every child’s fundamental right (up there with food, water and shelter), especially considering the very troubled world into which they never asked to enter.
Perhaps not surprisingly, I’d like to see child-development science curriculum implemented for secondary high school students, though not overly complicated. If society is to avoid the most dreaded, invasive and reactive means of intervention — that of governmental forced removal of children from dysfunctional/abusive home environments — maybe we then should be willing to try an unconventional proactive means of preventing some future dysfunctional/abusive family situations. Education, perhaps through child development science high-school curriculum, might be one way.
Trauma from unchecked toxic abuse usually results in a helpless child’s brain improperly developing. If allowed to continue for a prolonged period, it can act as a starting point into a life in which the brain uncontrollably releases potentially damaging levels of inflammation-promoting stress hormones and chemicals, even in non-stressful daily routines. It has been described as a discomforting anticipation of ‘the other shoe dropping’ and simultaneously being scared of how badly you will deal with the upsetting event, which usually never transpires.
The pain — unlike an openly visible physical disability or condition, such as paralysis, a missing limb or eye — is very formidable yet invisibly confined to inside one’s head, solitarily suffered. It can make every day an emotional/psychological ordeal, unless the mental turmoil is treated with some form of medicating, either prescribed or illicit. Any resultant addiction is likely due to his/her attempt at silencing the anguish of PTSD symptoms through substance abuse.
“Why Not Diagnose Social Conditions Instead of Individual Symptoms?” Yes, Why not? Because, both are false. Both are deceptions and lies. And, that is because of the word, “diagnose” “Diagnose” imples the “medical model.” The “medical model” is nothing but a failed model. First, because it is a model. But, second because it’s basis is that everything and everybody is sick, needs that diagnosis and then some prescription to allegedly cure it, but more than likely the prescription is just a maintenance prescription. Maintenance prescriptions do not solve the problem; they only keep away or minimize the symptoms. None of this works. It also means that human beings in both social situations and individual situations are just experimental guinea pigs. And, therefore, the problems are never solved and still remain and risk the probabilty of spiraling out of control. What is the best answer? Treat people in all situations; social, individual, etc. not as symptoms to be diagnosed, etc. but, as whole human beings individually created in the image of God, not science and medicine. Thank you.
de-pressed by employment
relative poverty due to employment and political and economic policy/ideology
chronic ‘insert response here’ caused by political and economic policy/ideology
suffering due to class position
suffering due to school system
suffering from taking excessive responsibility for cultural disorders
suffering compacted and entrenched due to the medicalised mental health system
suffering caused by commuting, debt, awful housing
suffering due to no community
suffering due to consumerism and credit
suffering due to myriad cultural disorders turned into personal disorders
Actually, despite what some say; psychiatry already diagnoses “social conditions” which is why it fails time and time again. The DSM is not based on the individual person but an aggregrate of alleged symptoms by a group of mythical people. If psychiatry were truly concerned with individual, the “patient” would never be compared to “able-bodied people” or the alleged collective normal. Even in individual therapy, psychiatry is a Group activity. It is nothing but lies, deception and betrayal for those who profit from the mental illness industry to state anything else. Perhaps, we might ask for an apology and the truth. Thank you.