Addressing the Social Determinants of Mental Health—or Perhaps Not

On June 22, 2021, Vivian Pender, MD, then the newly elected President of the APA, published an article on Psychiatric News titled Addressing Social Determinants of Mental Health.  Psychiatric News is the APA’s own online journal.

Here are the first two paragraphs:

“According to the World Health Organization, ‘A person’s mental health and many common mental disorders are shaped by various social, economic, and physical environments operating at different stages of life. Risk factors for many common mental disorders are heavily associated with social inequalities, whereby the greater the inequality, the higher the inequality in risk.’ In other words, people don’t necessarily start with the same opportunities or resources (inequity), and social factors further divide us. This suggests that our psychiatric patients suffer from biopsychosocial determinants that could have been prevented in the first place.”

and

“As psychiatrists, we know how to treat mental illness as it presents in an individual. But in addition to treating the illness, we need to be more aware of the broader context in which that illness occurred and how that context has shaped the health outcome. This awareness is broadly referred to as the social determinants of health, and for us, the social determinants of mental health.”

All of which sounds very advanced and promising, but let’s take a closer look.

First and foremost, notice the medical terminology:  “mental disorders”; “mental illness”; “treating the illness”; etc.  But if in fact, as Dr. Pender asserts, “psychiatric patients suffer from biopsychosocial determinants”, such as social inequalities, it makes a great deal more sense to conceptualize these so-called illnesses as understandable reactions to adverse events, and to stop “treating” them with dangerous drugs and shocks.  Dr. Pender affords no consideration to this aspect of the matter.  In fact, the spurious med-speak continues throughout the article.

RISK FACTORS

As can be seen above, Dr. Pender opens with a quote from WHO, but it is clear from subsequent text that she herself endorses the content and sentiments expressed. The essential content of the quote is that people’s mental health and their mental “illnesses” are shaped by various social, economic, and physical environments.

But in the platitudinous verbiage, the crucial point is lost.  The crucial point of this entire matter is that most of psychiatry’s so-called mental disorders are caused by social, economic, and physical environments, the exceptions being those conditions which are caused directly by damage or incorrect development of the individual’s thinking or feeling apparatus (e.g., dementia due to brain damage, etc.)

But Dr. Pender uses the word shaped instead of caused.  My New World dictionary defines the transitive verb shape as:  “to give definite shape to; make, as by cutting or molding material;” etc.  The same dictionary defines the transitive verb cause as: “to be the cause of; bring about; make happen; effect; induce; produce; compel;” etc.

In other words, to cause something is to make it happen, to bring it about.  To shape something is to fine tune its presentation, outer features, etc.  Obviously cause is the more fundamental concept, while shape refers to the outer appearance.

So although it seems that Dr. Pender has written something very fundamental about the genesis of what psychiatrists call mental illnesses, this is actually not the case.  What she has actually done in these opening remarks is evade the issue.

Then she appears to vacillate:

“This suggests that our psychiatric patients suffer from biopsychosocial determinants that could have been prevented in the first place.”

Firstly, notice that the prefix “bio” has been introduced.  Secondly, the notion that psychiatric “patients” suffer from biopsychosocial determinants implies that these biopsychosocial determinants are the true causes of the “mental illnesses”; they are what psychiatric “patients” suffer from.

But almost immediately Dr. Pender retreats from this position:

“As psychiatrists, we know how to treat mental illness as it presents in an individual. But in addition to treating the illness, we need to be more aware of the broader context in which that illness occurred and how that context has shaped the health outcome. This awareness is broadly referred to as the social determinants of health, and for us, the social determinants of mental health.”

So the biopsychosocial determinants, which she had earlier conceded were the cause of her “patients'” suffering, have now been relegated to the “broader context” in which the “mental illness” occurred.  Dr. Pender encourages her colleagues to become “more aware” of these broader contexts, and then seems to assert that such awareness actually constitutes the social determinants of mental health.  In other words, if the psychiatrist isn’t aware of these social determinants, then they don’t exist.

I think we can attribute this latter assertion to careless drafting, but the vacillations inherent in Dr. Pender’s opening paragraphs make it difficult to follow her line of reasoning.

A CASE STUDY

Dr. Pender then presents us with a brief vignette concerning a young woman who consulted Dr. Pender for problems with anxiety.

“A review of her symptoms did not reveal the cause of her anxiety. I prescribed anti-anxiety medication, and we agreed to schedule another appointment.”

This assertion from Dr. Pender needs to be compared with her earlier, somewhat fatuous statement that “As psychiatrists, we know how to treat mental illness as it presents in the individual.”  She now acknowledges that she prescribed an anti-anxiety drug before she had even ascertained the cause of the young woman’s anxiety.  This, of course, has been standard practice in psychiatry for decades.  It is the doctrine of cause neutrality, which states that it doesn’t matter why the individual might report distressing “symptoms”.  All that’s needed for a “diagnosis” is that he or she endorses the requisite (though arbitrary) number of “symptoms” from the DSM checklist.  And voila! just like that we have a “genuine” medical illness that psychiatrists know how to treat – eat these pills and come back next month, or in six months, or a year.

The case vignette ends with this:

“Her risk factors were clear, but year after year, they remained unidentified and/or unaddressed. It was striking to think that if any one of the social determinants in her history had been altered, her life trajectory might have followed another path.”

The young woman in the case study had been trafficked for sex in her teens, and although the case study is very truncated, Dr. Pender’s perspectives and biases are clearly evident in the above quote:

“Her risk factors were clear, but year after year, they remained unidentified and/or unaddressed.”

But the young woman must have identified at least some of these risk factors, because she managed to communicate them to Dr. Pender. When Dr. Pender asserts that the woman’s risk factors remained unidentified, she clearly means:  unidentified by a psychiatrist.  The client’s perspective clearly warrants no consideration.  It is the perceptions and biases of the psychiatrist that define reality for the hapless “patients”.

But more importantly:

“It was striking to think that if any one of the social determinants in her history had been altered, her life trajectory might have followed another path.”

How in the world can Dr. Pender describe such an obvious banality as “striking”?  If, as a newborn, I had been switched at the hospital, I might have become a renowned politician, a petty criminal, a rodeo clown, a pimp, or even – dare I say it – a psychiatrist!  The fact that Dr. Pender finds such considerations striking speaks volumes on the naïveté of psychiatrists in matters pertaining to human development.  And Dr. Pender is no ordinary psychiatrist.  She is the President of the APA, and her list of awards and achievements is, as they say, as long as one’s arm.  Her bio is posted on psychiatry.org.

THE TASK FORCE

Dr. Pender tells us that she has created an APA task force that will build on previous presidential initiatives that are “encompassed by the social determinants” of mental health.  This approach, she informs us, “says that differential health outcomes can be explained, in part, by reference to the places a person lives,…works, and plays.”

But, lest we get carried away with zeal and enthusiasm, Dr. Pender continues:

” It is not a replacement for medical care…”

What a relief!  So people who have been trafficked for sex in their teens can still count on psychiatry for a steady supply of anti-anxiety drugs and other pharma products, with all their potential adverse effects, including addiction, disempowerment, reduced impulse control, and suicide.

“…instead, we need to be aware of these other factors to inform the care we provide.”

Note the assumption:  that psychiatrists generally are unaware (or at least not sufficiently aware) of the effect that personal histories have on current performance, and a task force is needed to remedy this cognitive deficit.

And then, my dear and patient readers, we come to the core of destructiveness, disempowerment, and arrogance that has become a permanent fixture within the intellectually hollow halls of psychiatry.

“If we take this approach [becoming more aware of the social determinants of mental health] and apply it to mental health, it can lead to earlier intervention in communities, possibly before psychiatric symptoms begin.” [Emphasis added]

So, psychiatrists, their native arrogance and chronic group-think augmented by the wisdom imparted by Dr. Pender’s task force, will be able to intervene in communities even before any such need has been identified.  The justification for such interventions would be risk factors.  Dr. Pender provides a lengthy list of potential risk factors, which include:  racism; adverse childhood experiences; discrimination; social exclusion based on race, ethnicity, gender, age, mental illness; health care inequity; exposure to violence and exposure to the criminal justice system; economic factors related to resources, lack of education, employment insecurity, neighborhood poverty; poor housing; pollution of the air, water, and ground; and climate change.

And, of course, intervention in this context will almost always include pills and/or high-voltage electric shocks applied to the brain, because that’s pretty much all that psychiatry has to offer.

So there we have it:  psychiatric treatment for all.  For who is there among us who has never encountered at least one of these risk factors during childhood?  And are the rolls of history not replete with the names of men and women who achieved greatness precisely by rising above these risk factors through their own efforts?  But within Dr. Pender’s great vision, such considerations count for nothing.  What’s needed is more psychiatry, more disempowerment, more involuntary “treatment” (it’s for your own good), and more drugs and, of course, more shocks.  And all of these great psychiatric benefits will be showered down on all of us from the gracious, overflowing benevolence of psychiatrists – whether we need them or not.  How fortunate we are to live in such an enlightened age, when a “helping profession” such as psychiatry, steered and coached by one of the best PR institutions in the world, can co-opt the principles and aspirations of liberalism for the enlightened purpose of increasing their own business and prestige.  What a noble and selfless profession!

THE WORK OF THE TASK FORCE

Once the task force has identified the risk factors, psychiatrists “will focus on educational programs, training protocols, and policy guidance for academic institutions and [for] government agencies.”

So the task force will generate training programs, presumably for psychiatrists, and policy guidance for colleges and government agencies.  And to make sure that all psychiatrists realize the importance of these matters, the theme of the 2022 APA conference in May will be “Sociopolitical Determinants:  Practice, Policy and Implementation”, based on the social determinants of mental health.  And what kind of policy guidance, I find myself wondering, would an APA task force have for government agencies?

IF

Dr. Pender returns to her “severely anxious patient”:

“If she hadn’t been neglected and sexually abused in childhood, if her parents had been treated for substance use disorder, if her parents hadn’t been incarcerated for their substance use, if she hadn’t been arrested for prostitution, and if her community had offered more resources to her family and her school, such interventions surely would have made a difference and possibly reduced or prevented her psychiatric symptoms.” [Emphasis added]

And now, thanks to Dr. Pender’s timely psychiatric intervention, the client in question may well have another problem:  addiction to anti-anxiety drugs.

Dr. Pender continues:

“I encourage you to think big—to re-think traditional theories, diagnoses, and treatments and think more globally about each patient, not just in the present, but in their past by taking into account their community and social determinants of mental health so that as an organization, we can have an impact on improving the mental health of Americans who have too long been the victims of forces beyond their control.”

So Dr. Pender is encouraging psychiatrists to re-think “traditional theories, diagnoses, and treatments.”  This is interesting, because the most deeply-rooted traditional theory in modern psychiatry is that virtually all significant problems of thinking, feeling and/or behaving are the direct result of brain illnesses that need to be treated with psychotropic drugs and/or intra-cranial electric shocks.  Does Dr. Pender seriously imagine that she can overturn this Leviathan by convening a task force of the very individuals who have created and continue to maintain this travesty in their “diagnostic manual” and day-to-day work?  How often have non-psychiatrist mental health workers who have labored for years to promote a recognition of the bigger picture been arrogantly rebuffed by a psychiatrist’s pronouncement that “we have to treat the depression first”?  In other words – first we get the individual started on pills, which is, incidentally, exactly what Dr. Pender – by her own report – did in the case study that she outlined earlier.

Dr. Pender encourages her colleagues to “think more globally about each patient…so that as an organization, we can have an impact on improving the mental health of Americans…”

And how, I wonder, will psychiatrists fit all this global thinking into their busy 15-minute med check schedules?  Psychiatrists get paid for seeing people whom they fallaciously and condescendingly describe as “patients”.  And this is not a state of affairs that’s been foisted on psychiatrists.  Rather, it is the culmination of decades of sustained, calculated effort to establish themselves as real doctors, with prescription pads to prove it.  And from a pool of about 30,000 US psychiatrists, dissenting voices have seldom exceeded more than a few dozen.  If they start diverting significant numbers of these “patients” to “think tanks”, instead of just prescribing pills – they will quickly find themselves out of work, unless, of course, they can find gainful employment developing “educational programs, training protocols and policy guidance for academic institutions and [for] government agencies.”

And even as I write these words, I find myself wondering if Dr. Pender has indeed seen the writing on the wall: that psychiatric ‘pharmacotherapy”  has had its day and that psychiatry needs to re-invent itself as consultants to colleges and government agencies:  something similar to Dr. Lieberman’s 2013-2014 vision but a great deal more far-reaching.  Or maybe not.  I find it difficult to decipher Dr. Pender’s writing.

Dr. Pender ends her article with the notion that if psychiatrists embrace the framework that she has set out:

“…we can have an impact on improving the mental health of Americans who have too long been the victims of forces beyond their control.”

So psychiatrists are to create a task force which will ‘think big” about the psychosocial determinants of mental health and mental illness, and because of this “big thinking” on the part of psychiatrists, American psychiatric “patients” will be freed from the “forces” that for too long have been beyond their control.

And remember, because these individuals are “patients”, they can still depend on the numbing and addictive effects of psychiatric drugs to get them through in a pinch.  After all, psychiatrists know how to treat mental illness.

AND WHERE HAVE WE HEARD ALL THIS BEFORE?

Exhortations to psychiatrists to consider wider ramifications rather than focusing merely on the assigned “diagnosis” have been around since at least the publication of DSM-III (1980).  Axis IV in that manual provided “…a coding of the overall severity of a stressor judged to have been a significant contributor to the development or exacerbation of a current disorder”. (p 26).  Under the heading “Types of psychosocial stressors to be considered” the following passage can be found:

“To ascertain etiologically significant psychosocial stressors, the following areas may be considered: [Note the word “may”, implying clearly that consideration of these factors is not mandatory in the assigning of a “diagnosis”.]

Conjugal (marital and nonmarital): e.g., engagement, marriage, discord, separation, death of spouse.
Parenting: e.g., becoming a parent, friction with child, illness of child.
Other interpersonal: problems with one’s friends, neighbors, associates, or nonconjugal family members, e.g., illness of best friend, discordant relationship with boss.
Occupational: includes work, school, homemaker, e.g., unemployment, retirement, school problems.
Living circumstances: e.g., change in residence, threat to personal safety, immigration.
Financial: e.g., inadequate finances, change in financial status.
Legal: e.g., arrested, jailed, lawsuit or trial.
Developmental: phases of the life cycle, e.g., puberty, transition to adult status, menopause, ‘becoming 50.’
Physical illness or injury: e.g., illness, accident, surgery, abortion. (Note: A physical disorder is listed on Axis III whenever it is related to the development or management of an Axis I or II disorder. A physical disorder can also be a psychosocial stressor if its impact is due to its meaning to the individual, in which case it would be listed on both Axis III and Axis IV.)
Other psychosocial stressors: e.g., natural or manmade disaster, persecution, unwanted pregnancy, out-of-wedlock birth, rape.
Family factors (children and adolescents): In addition to the above, for children and adolescents the following stressors may be considered: cold or distant relationship between parents; overtly hostile relationship between parents; physical or mental disturbance in family members; cold or distant parental behavior toward child; overtly hostile parental behavior toward child; parental intrusiveness; inconsistent parental control; insufficient parental control; insufficient social or cognitive stimulation; anomalous family situation, e.g., single parent, foster family; institutional rearing; loss of nuclear family members.” (p 27-28)

Similar lists can be found in DSM-III-R (1987); DSM-IV (1994); and DSM-IV-TR (2000).

DSM-5 (2013) eliminated Axis IV from the “diagnostic” procedure and substituted a wide range of V and Z coded “conditions”.  The manual states that:

“The conditions and problems listed in this chapter are not mental disorders. Their inclusion in DSM-5 is meant to draw attention to the scope of additional issues that may be encountered in routine clinical practice and to provide a systematic listing that may be useful to clinicians in documenting these issues.” (p 715) [Note, again, the use of the word may – “may be useful”, implying clearly that consideration of these issues is not a necessary part of a “diagnosis”.]

So from at least DSM-III (1980) to DSM-5 (2013), and through to the present day, the APA has consistently suggested that its members not focus solely on assigning a “diagnosis”, but rather to incorporate a wide range of etiologically significant psychosocial information into their assessments, whilst at the same time, and in the self-same volumes, making it abundantly clear that the reasons for or causes of the “disorders” were of no great significance. All that mattered was the “symptom” checklist and endorsement of the requisite number of items to confirm the “diagnosis”.  Not surprisingly, the impact of the Axis IV and V and Z code suggestions has been approximately zero.

The 30-minute assessment followed by regular 15 minute med checks still constitute the primary, and in most cases, only, components of psychiatric “treatment”.  And within this framework, there simply isn’t time to even scratch the surface of the older Axis IV items or the newer V and Z codes.

In March 2017, William Torrey, MD, a professor of psychiatry at Dartmouth, et al., published a piece on Psychiatry Online.  The article was titled Beyond “Med Management”  Here is a quote:

“Today, many outpatient psychiatric care providers are employed to provide ‘medication management’ in brief 15- to 20-minute visits. In qualitative interviews, patients and psychiatric care providers alike expressed that psychiatric care has been narrowed to the act of prescribing medications. Indeed, this is reflected in the terminology respondents used for standard psychiatric care: ‘med management,’ ‘med clinics,’ and ‘psychopharmacology clinics.’ During typical visits, many psychiatric care providers reported that they focus their efforts on assessing symptoms, the impact of medications on symptoms, and side effects of medications: ‘My goal is to make them symptom free.’  Some psychiatric care providers clearly distinguished their medication-focused work from psychotherapeutic work, which was viewed as the province of other clinicians. A psychiatrist described challenges that ensue when patients are not oriented to this difference:

Oftentimes, patients don’t understand what the difference is between a medication check and a therapy visit. . . . Sometimes it’s very hard for them to distinguish, ‘Are we talking about what’s going on with my life, or are we only talking about medication?’ Sometimes I feel like they leave with a sense that they have not been heard because I’ve had to refocus them back to, ‘We need to talk about medications.'”

Actually they haven’t been heard.  The purpose of a med check is to train the “patient” to comply with the prescription, and not think too hard about the issues.  Listening to the primary concerns of the “patient” has no importance for the med check psychiatrist, and can simply be dispensed with.

“Although many psychiatric care providers recognized the limitations of not engaging more fully with contextual aspects of patients’ lives, serious time constraints coupled with productivity pressures have made well-intentioned psychiatric care providers reluctant to ask more in-depth questions.”

. . . . . . . . . . . . . . . .

Here’s another quote, this one from Dave Davies’ NPR interview with Daniel Carlat, MD, July 2010.  Dr. Carlat is a psychiatrist on the faculty at Tufts Medical School.

“And then once we have a diagnosis, I match those symptoms up with a medication. So modern psychiatry is really a conversation, a series of symptoms and then a matching process of medication to these symptoms.”

. . . . . . . . . . . . . . . .

And here’s a quote from Successfully navigating the 15-minute ‘med check’ by Douglas Mossman, MD, which appeared in Current Psychiatry in June 2010.

“Even psychiatrists who deplore 15-minute med checks recognize that they have become standard care in psychiatry.” (p 40)

Dr. Mossman is deceased (2018), but at the time of this article, he was professor of psychiatry, and Program Director, Forensic Psychiatry at University of Cincinnati College of Medicine.

. . . . . . . . . . . . . . . .

So how in the world can Dr. Pender imagine that her Task Force will succeed, where successive revisions of the APA’s own “diagnostic” manual have failed so dismally over a period of more than three decades?

WHAT’S DRIVING PSYCHIATRY’S INFATUATION WITH 15-MINUTE MED CHECKS?  FOLLOW THE MONEY

In March 2011, the renowned journalist Gardiner Harris published a piece in the NY Times.  The title was “Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy”.  The article consisted of a fairly in-depth interview with psychiatrist Donald Levin, MD, who had stopped seeing clients for therapy, and was confining his practice to brief med checks.  Here are some interesting quotes:

“…Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy…”

“Instead, he prescribes medication, usually after a brief consultation with each patient.”

“Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.”

“‘I’m good at it,’ Dr. Levin went on, ‘but there’s not a lot to master in medications.'”

There it is.  Dr. Levin has stated psychiatry’s dirty little secret out loud.  “There’s not a lot to master in medication.” [Emphasis added]

“Insurance company reimbursement rates and policies that discourage talk therapy are part of the reason. A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.”

“Of course, there are thousands of psychiatrists who still offer talk therapy to all their patients, but they care mostly for the worried wealthy who pay in cash. In New York City, for instance, a select group of psychiatrists charge $600 or more per hour to treat investment bankers, and top child psychiatrists charge $2,000 and more for initial evaluations.”

“He [Dr. Levin] could have accepted less money and could have provided time to patients even when insurers did not pay, but, he said, ‘I want to retire with the lifestyle that my wife and I have been living for the last 40 years.'”

“‘And people want to tell me about what’s going on in their lives as far as stress,’ Dr. Levin said, ‘and I’m forced to keep saying: ‘I’m not your therapist. I’m not here to help you figure out how to get along with your boss, what you do that’s self-defeating, and what alternative choices you have.'”

“And years ago, he often saw patients 10 or more times before arriving at a diagnosis. Now, he makes that decision in the first 45-minute visit. ‘You have to have a diagnosis to get paid,’ he said with a shrug. ‘I play the game.'”

“‘The sad thing is that I’m very important to them, but I barely know them,’ he said. ‘I feel shame about that, but that’s probably because I was trained in a different era.'”

Another one of psychiatry’s dirty little secrets?  “I’m very important to them.”  And by Dr. Levin’s own account, this is not because he takes an interest in their lives and problems.  The whole point of the interview is that he doesn’t.  He’s important to them because they have become psychologically or physically dependent on the drugs and he is their supplier.

Accounts similar to Dr. Levin’s, though not usually as candid, can be found on a wide range of psychiatric forums and websites.  For instance:

Why psychiatrists don’t take insurance

Psychiatry’s Med Check: Is 15 Minutes Enough?

The 16-Minute Med Check

Talk is cheap: How insurance changed the face of psychiatry

. . . . . . . . . . . . . . . .

The bottom line is that psychiatrists en masse switched from therapy to med checks because it pays better, and because they were willing to turn blind eyes to the obvious similarity between their work and more conventional forms of drug pushing.  They were also willing to ignore the long trail of casualties in their wake.

Dr. Levin admits to a measure of shame about how he runs his practice, and it needs to be acknowledged that his feelings are right on the mark. What psychiatrists are doing is shameful.  It’s a massive hoax, carefully sculpted and promoted.  It’s become an integral part of psychiatrists’ reimbursement system, which is why it’s so deeply rooted and resistant to change.

PSYCHIATRISTS’ SHAME

The history of the change from therapy to med checks is interesting.  Here’s a quote from The Carlat Psychiatry Blog, from March 2011.  The post is titled Dr. Levin, Modern Psychiatrist–Unfulfilled, Bored–But Wealthy

“To the modern eye it seems absurd that intelligent people could believe that you had to go to medical school to do psychotherapy, but the potential for loss of income often confuses the mind. From the 1950s until the 1980s, the APA continuously lobbied state legislatures to prevent independent credentialing for non-MD therapists, but they eventually lost in every state.

Ironically, many within the APA were eventually happy to off-load their therapy tasks to psychologists and social workers, because a plethora of psychotropic drugs were introduced in the 1980s and 1990s. Psychiatrists no longer needed to do therapy to make good money. But this forced a decision point for many psychiatrists, like Dr. Levin, who loved doing psychotherapy. Would they continue to do psychotherapy–thereby diminishing their incomes–or would they become psychopharmacologists, lucratively churning through patients in 15 minute increments?”

But Dr. Levin acknowledges a sense of shame about the way he makes his living.  The question comes to mind:  is this a common feeling among psychiatrists?  They certainly have a lot to feel ashamed of.

PREDICTION

I don’t think that Dr. Pender’s task force has a remote chance of making even a dent in this system.  The task force will produce a paper which will be nicely bound, with pictures of brain scans and other irrelevancies.  The paper will be widely circulated, and everyone will say how wonderful it is.

But when the dust settles, the status quo will still prevail, and the med check will continue to hold dominion over all.

Med checks are not only ineffective but an expression of psychiatric arrogance – we can change you with pills!  All you have to do is eat them, and everything will be all right.

Except, of course, for the things that won’t.