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 Table of Contents  
Year : 2016  |  Volume : 32  |  Issue : 3  |  Page : 243-248

Social context and mental health, distress and illness: critical yet disregarded by psychiatric diagnosis and classification

Christian Medical College, Vellore, India

Date of Web Publication3-Nov-2016

Correspondence Address:
Dr. K S Jacob
Christian Medical College, Vellore
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9962.193196

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Social change is ubiquitous and associated with mental distress and illness worldwide. To argue that social change has a differential impact in low and middle-income countries requires evidence, yet unavailable. Any effort at serious comparison to obtain such evidence is limited by current psychiatric approaches, which have decontextualized psychiatric diagnosis. Current psychiatric diagnosis and classification do not take into consideration personal and social stressors as causal, even when present and contributory to distress and illness.
Euro-American psychiatry has decontexualized psychiatric diagnosis, medicalized social and personal distress, focused on treating individuals and diminished the role public health approaches in keeping with capitalistic economic and political thought. The altered framework disregards social stressors and hence does not document the universality and impact of social and economic pressures on mental health. It paves the way for a shift of responsibility onto individuals and away from society and governments. International psychiatry has completely bought into their approach and to argue otherwise is considered “unscientific”.
Social changes affect humans and most differences documented across countries are due to skewed measurement, decontextualized diagnostic systems and the biomedical theoretical frameworks employed.

Keywords: Psychiatric diagnosis, public health approaches, social stress

How to cite this article:
Jacob K S. Social context and mental health, distress and illness: critical yet disregarded by psychiatric diagnosis and classification. Indian J Soc Psychiatry 2016;32:243-8

How to cite this URL:
Jacob K S. Social context and mental health, distress and illness: critical yet disregarded by psychiatric diagnosis and classification. Indian J Soc Psychiatry [serial online] 2016 [cited 2022 Dec 9];32:243-8. Available from: https://www.indjsp.org/text.asp?2016/32/3/243/193196

  Introduction Top

Professor Gambheera has argued, in this issue of the journal, that social changes have differentially affected people living in developing countries compared to those living in richer nations.[1] He suggests that changes in communication, education, urbanization, migration and terrorism, reduction in social capital, variations in family structure and stigma related to psychiatric disorders have differentially impacted mental health and illness in the developing world. This paper argues against such a contention. The arguments include: (i) social changes are diverse, common and ubiquitous, (ii) social contexts determine mental health, (iii) social determinants across countries, (iv) differential impact of social determinants within populations, and (v) prevalence of common mental disorders a cross countries.

  Social change: diverse, common, and ubiquitous Top

Social changes, over time, are seen in all regions of the world. These changes include a variety of factors including transformations in political structures, changes in economic systems and environments, revolutions in education and communication technologies, alterations in family, community and social organization, uncertainties in employment and income, variations in social security and health care, and fluctuations in standards of living. The adage “the only constant in life is change,” is true. Social changes affect humans and are a part of human existence. Living in richer or poorer countries does not protect all people from the impact of personal, familial, social, cultural, economic, and political stressors.

  Social determinants of mental health Top

There is hard evidence to suggest that mental distress and illness is linked to social determinants.[2] Social determinants of mental health are distinct and diverse. The failure to meet basic needs (e.g., clean water, sanitation, nutrition, housing, immunization) due to poverty impacts physical and mental health.[3],[4],[5],6] Patriarchy results in gross gender injustice and significantly affects the health of girls and women. Low education and unemployment are common causes of mental distress. Structural violence, social discrimination (e.g., based race, religion, ethnicity, sexuality, etc.), and social exclusion increase misery and are seen in many countries. Interpersonal problems and marital discord, social and occupational stress, domestic violence and sexual abuse, poverty and structural violence, ethnic cleansing and internal, external and forced migration, armed conflict and war, etc., affect mental health of people. These risk factors for poor mental health works through insecurity, hopelessness, rapid social change, risk of violence, and poor physical health.[7] Many studies have documented the association between such social determinants and anxiety, depression, and other common mental disorders.

  Social determinants across countries Top

Although many of these stressors have been documented in low- and middle-income countries, they have also been recorded in high-income nations.[2],[8],[9] Relative poverty and income inequality have increased in the west with the introduction of neoliberal policies. Increasing unemployment in richer nations, mainly due to outsourcing of manufacturing and services to emerging economies, has added to economic distress. Urbanization and internal migration have been documented in industrialized cultures. Material disadvantage and financial debt are also associated with common mental disorders in the west. Limited health insurance, health care, and social services have negatively affected the health of poorer sections of the population even in developed economies. The increasing cost of education has increased student debt and widened the rich–poor divide. Violent crime and gun violence seems is common in the countries with lax gun laws. Breakdown of families and single-parent households have also increased. Social change is common, ubiquitous, and global.

  Differential impact of social determinants Top

Although the quality of social issues may vary across countries, all populations face social change. The impact of such social change across populations is variable and is determined by different histories, politics, genetic vulnerability, socioeconomic circumstances, family environments, childhood adversities, and social supports.[10] Issues related to identity, power, and culture situate different people in different contexts making them differentially vulnerable to social stress. The universality of social change and the differential vulnerability of individuals result in a proportion of the population suffering under the impact of changed personal circumstances and social environments.

  Prevalence of common mental disorders Top

Patients with anxiety, depression, and common mental disorders commonly present to primary care, family, and general physicians across the globe. Their prevalence varies from 10% to 50% with a mean of about 24%.[11] Differences in settings, recruitment procedures, assessment instruments, explanatory models of illness, help seeking, and recognition rates make comparisons difficult. Yet, most primary care physicians recognize that these clinical presentations are often associated with psychosocial stress and/or poor social supports.

Depression is one of the leading causes of disability and contributes significantly to the global burden of disease.[12] Most studies document about a third/fourth of patients attending general practice across countries present with such distress. The ubiquitous nature of such presentations suggests that much of the impact of social stress is relative. Relative poverty, even in high-income countries, female gender, single parent status, unemployment, financial stress, domestic violence, sexual abuse, interpersonal conflict, and poor social supports are commonly associated with such clinical presentations.[2],[11]

  Social stress underappreciated, social distress unrecognized Top

Nevertheless, psychiatrists do not often appreciate the significant prevalence of social distress and its adversarial impact on mental health and illness across countries. Many reasons contribute to such lack of awareness and include: (i) Psychiatric diagnosis based on symptom counts sans context medicalizes social distress, (ii) Medicalization of social distress shifts responsibility and treatment to individuals, (iii) Medicalization of social distress has been rejected by primary care physicians, and (iv) Medicalization of personal and social distress is part of the neoliberal agenda.

  Medicalization of social distress Top

Frequent diagnostic disagreements, significant discrepancies in diagnostic practice among psychiatrists,[13] and major scandals[14] forced the discipline to look at the process of psychiatric diagnosis and its reliability. Feighner’s criteria[15] and Research Diagnostic Criteria[16] used symptoms counts sans context to improve reliability of diagnosis. DSM III introduced operational diagnostic criteria for all disorders, examined their reliability, and used rigorously tested checklists for diagnosis.[17] It introduced many radical changes including its so-called “atheoretical” approach, which essentially emphasized the medical model of mental disorders. It abandoned the concept of endogenous (melancholic/without stressor) and reactive (exogenous/with stress) depression by it use of a unified category of major depression, which did not consider context.[18] DSM III also subdivided the traditional category of anxiety into numerous diagnostic heads.

  Medicalization, pathology, and responsibility Top

The absence of gold standards and laboratory tests, lack of pathognomonic symptoms, use of individuals’ perception of unpleasant feelings and phenomena within the normal range of emotions, and the discounting of stress and context makes it difficult to separate normal human distress from mental disorders.[18],[19] Psychiatric labels medicalize mental distress.

Social determinants of health and mental health are ignored. Stress and trauma can be acute (e.g., bereavement), recurrent (e.g., domestic violence), or chronic (e.g., poverty); physical disease and disability, interpersonal difficulties, and other social determinants are associated with symptoms of depression and anxiety.[18],[19] Clinically and statistically significant relationship between psychosocial adversity and mental ill-health (i.e., distress, illness, and disease) complicates the simplistic “atheoretical” approach to psychiatric diagnosis. The current classifications provide labels by arbitrarily dividing the many complex dimensions of mental health, distress, illness, and disease into dichotomous normal/abnormal (disorder) categories.[19] The discipline with its biomedical framework transfers the disease halo reserved for severe mental illness, to all psychiatric diagnoses. It locates primary pathology in the individual when causal mechanism can lie in the environment. Medication-based solutions for problems of living are justified.

  Context, medicalization, and primary care Top

Despite psychiatry’s attempts at decontextualization of mental disorders, primary care physicians, general and family practitioners who manage most mental health problems in the community encounter difficulties in following the approach. Significant differences in primary and tertiary care settings, patient profiles, and physician perspectives influence their clinical practice.[22] Nonspecific symptoms, milder, mixed, and subsyndromal presentations, associated with psychosocial stress and physical adversity make the use of classical tertiary care concepts and categories (e.g., major depression and generalized anxiety) difficult to use in primary care. Yet, common clinical presentations in primary care (e.g., mixed anxiety depression) are not recognized or accepted as psychiatric labels even in psychiatric classifications for use in primary care.[22]

Physicians recognize the importance of psychosocial context (e.g., stress, personal resources, coping, social supports, and culture) and their effect on mental health. They prefer not to use mental disorder labels because of the high rates of spontaneous remission and placebo response and the absence of improvement with antidepressant medication in those with mild disorders.[23] General practitioners are seriously concerned about the medicalization of all personal and social distress.[24] They argue that the use of symptoms to diagnose mental disorders, without consideration of context, in particular psychosocial hardship, essentially flags nonclinically significant distress, especially at lower degrees of severity.

Many physicians and general practitioners are uncomfortable with the use of the concept of mental disorder, with its disease halo, which sidesteps the disease–illness dichotomy while attempting to encompass both disease and distress.[15] Consequently, they often do not use psychiatric categories at all, preferring to avoid potentially stigmatizing and meaningless labels. Consequently, the International Classification of Primary Care-2,[25] focuses on reasons for clinical encounters, patient data, and clinical activity. “Mixed anxiety depression” and “adjustment disorders” are preferred to the traditional psychiatric categories major depression and generalized anxiety. The diluted tertiary care concepts, classifications and management strategies, enforced top down are seldom practiced. Consequently, educational efforts by psychiatry in low- and middle-income countries to educate physicians are more in the realm of advocacy than technical input.

  Impact of political and economic systems Top

Although illness represents individual suffering, the term disease is used to document structural and functional abnormalities. The blurred disease–illness divide, the inter-changeable use of these concepts and the illusion of specific brain pathology are supported by academia, health, insurance, and pharmaceutical industries.[3],[19] Despite evidence that social determinants produce significant mental morbidity, most intervention strategies favor post hoc individual treatments to population-based public health approaches that are useful in reducing structural violence and in empowering large sections of society.[4],[19] Social security, access to health care, employment guarantee, and the provision of basic needs are considered old-fashioned socialistic goals.

Psychiatric labels for distress have shifted the focus from the responsibility of the state for poverty and structural violence and transferred pathology and burden to individuals. The disparate environments under which anxiety, depression, and common mental disorders now exist are brought together as many strands, de-contextualized ,and unified into disease labels.[19]

The progressive medicalization of distress is compound by increasing individualism in society, reduction in social and community supports, lowered thresholds for tolerance of suffering and for seeking medical attention.[18] Consequently, in such situations, psychiatric labels are used to justify medical input and treatment. The use of symptom counts sans context to diagnose mental disorders results in people with normal reactions to stress and those who cannot cope with the complex demands of life receiving psychiatric labels. Clinical presentations of individual suffering are interpreted by the new psychiatric diagnostic system as abnormalities of structure or function and labeled as mental disorder.[19] A diagnosis of depression, when viewed through the biomedical lens, tends to suggest disease, supposes a central nervous system etiology and pathogenesis, documents signs and symptoms, offers differential diagnoses, recommends pharmacological therapies, and prognosticates about the course and outcome.[18] In addition, recent psychiatric classifications have increased, manifold, the number of diagnostic labels. Such diversity also means that those seeking help for any form of distress are often given a label and treated for that condition.

The political economy of health, deeply rooted in capitalistic economic and social systems, undergirds these formulations. It reiterates the historical relationship between medicine and governments; with governmental administration serviced by experts responsible for managing social security, stability, and economic growth.[26],[27] It is an example of the broader role of medicine, of social control.

Psychiatric disease labels and individual treatments offer distinctive niches to diverse stakeholders: disease, reimbursement, profit, and deflection of responsibility.[19] Depression, anxiety, common mental disorder labels, and the culture of medicine fit in well with the neoliberal agenda, allowing the free market to expand its business interests. It demonstrates the nested position of the discipline of medicine, within the agendas of governing, which determine perspectives, formation of knowledge, institutional control, and policy.[26],[27] The technical approaches of evidence-based medicine are not necessarily value-neutral nor above specific interests.[28] Medicine is politics writ large and the health sector is a powerful player in national economies.

  Classification in context Top

Classifications are not absolutes; they are merely indicators of current understanding of concepts and theories.[19] They are meant to help mental health professionals communicate and are useful tools for statisticians and public health administrators. They aid in reimbursement for insurance companies. They provide pharmaceutical companies “homogeneous populations” on whom to carry out drug trials. They also help individuals find terms to communicate distress and seek support and treatment. However, the complexity and multiple dimensions of mental health, distress, and illness complicate issues. The current classifications provide labels by arbitrarily dividing the many complex dimensions of mental health, distress, and disease into dichotomous normal/abnormal categories. Although the introduction of objective operational criteria for diagnosis has reduced subjectivity, arbitrariness, and idiosyncrasy, the discounting of context in diagnosis has also medicalized normal human distress.[19]

Nevertheless, legitimate diagnoses seem to combine fact and value.[18],[29],[30] Dysfunction can be viewed both in terms of biology, science, and fact as well as in the sociocultural context. Although the DSM system clearly emphasis that societal norms should not be the sole criterion to assess mental disorders, it uses the definite requirement for the presence of “clinically significant” dysfunction, distress, or disability in the individual to diagnose mental disorders.[21] Although it suggests that a negative value judgment is per se insufficient to diagnose mental disorders, it does not clearly acknowledge that psychiatric diagnosis seems to involve complex value judgments.

Despite its scientific base, medicine is a system sanctioned by the society in which it practices.[19] Scientific knowledge is composed of beliefs shared by experts.[27] The social nature of science argues that scientific authority belongs to communities, both within and outside medicine. Michel Foucault recognized knowledge structures, which enhance and maintain the exercise of power.[26] He argued that the religious practice of confession, secularized in the 18th and 19th centuries, allowed people to confess to their innermost thoughts. These became data for the social sciences, which used the knowledge to construct mechanisms of social control. However, Medicine in the early 20th centuries, switched emphasis from sin and social deviance to individual pathology. Yet, despite psychiatry’s decontextualized approach to disease and distress, which fix responsibility on individuals, physicians on the frontline of care do not buy into its specialist approach.

  Social change and mental health Top

Social changes affect humans and are a part of human existence. Living in richer or poorer countries does not protect people from the impact of social, cultural, economic, and political stressors. The fact that depression, anxiety, and common mental disorders have been documented across the world are linked to psychosocial pressures and often seen among the poor is proof of their impact on a significant proportion of the population. Poverty, documented in low-, middle-, and high-income countries, is relative and impacts mental health of people.

Viewing mental health and illness in a vacuum, focusing on decontextualized mental disorder labels, which medicalize personal, social, and economic distress, and providing individual treatments does not do justice to the people and their context.[19] Theorizing mental disorders within the biomedical framework denies the significance of context and often makes psychosocial changes and pressures invisible. A variation to a popular medical maxim is that the eye does not see what the mind does not acknowledge.

Social change and stress are part of human existence, adversely affecting a section of the population. There is a need to examine mental health and illness from a sociological and social psychiatry perspective to study the impact of social change on mental health, distress, illness, and disease. To argue that social change affects people living in diverse parts of the world differently, without focusing on the social context is naïve at best and denies the humanity of the people at worst. Adverse life events and unfavorable and adversarial social context and environments have a significant impact on mental health and living in certain parts of the world offers no specific protection.

Nevertheless, psychiatry as a whole remains resolutely Eurocentric and capitalistic in its orientation. It, therefore, seems futile to rehearse arguments for greater diversity of approaches. Symptom counts and the biomedical model have wiped out every other school of psychiatric thought—psychoanalytic, dynamic, behavioral, cognitive, social. There is a need for a broad-based understanding of mental health, distress, illness, and disease, particularly from a social perspective.Psychiatry, at this moment in time, has been compared to biology before Darwin and astronomy before Copernicus. Thomas Kuhn in his work “The structure of scientific revolutions”[31] described three stages: (i) normal science (routine scientific work) with paradigms and a dedication to solving puzzles; (ii) serious anomalies produced by research, which lead to a crisis; and finally (iii) resolution of the crisis by the creation of a new paradigm. Psychiatry today, with its current concepts, theories, and its many anomalies, is awaiting a paradigm shift, which will not only clarify these complex issues but will also provide for a new framework and understanding.[32] Psychiatric research, despite its current attempts at testable conjectures and refutations, is still within a paradigm, which seems inadequate for the complexity of the task. It awaits its new dawn. Psychiatry needs to be circumspect when it reiterates current research findings and justifies its clinical practice based on the biomedical framework sans context and psychosocial, economic, and political stress.

To argue that social change is limited to low- and middle-income countries or that its impact is differential requires evidence, yet unavailable. Any effort at serious comparison to obtain such evidence is also restricted by current psychiatric approaches, which have decontextualized psychiatric diagnosis. Current psychiatric diagnosis and classification do not take into consideration personal and social stressors as causal, even when present and contributory to distress and illness.

  Acknowledgments Top


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Conflicts of interest

There are no conflicts of interest.

  References Top

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