By Dr. David Laing Dawson
Of course there are social determinants of mental health, just as there are social determinants for all health, happiness, longevity, and the outcome of all illnesses. This is not news. And those social determinants can be as individual and commonplace as loss of a parent or sib, some bullying, a bad marriage, divorce, assault, job loss, car accident with injury, failure at a task or ambition, and as broad and culturally and politically and economically determined as poverty, poor or absent housing, poor or absent medical care, poor or absent education, poor or absent employment, and, of course, war and discrimination.
The biopsychosocial model has been touted in Psychiatry for a century now, though I have often thought it should be the biosociopsycho model. For when it comes to the determinants of human behaviour, biology is primary, our social world and experiences come second, and actual cognitive processes such as thinking come in a distant third.
Through the sixties, seventies, eighties into the nineties much of psychiatric treatment was delivered within multidisciplinary teams. And as much as possible these teams would have connections with housing and other services. And I have often caricatured the team meeting about a given patient as:
Psychiatrist: He needs his depression treated with antidepressants.
Social Worker: He needs a job and better housing.
Nurse: He needs a relationship, someone who cares about him.
Psychologist: He needs to think differently about himself and the world.
Each could be right, but usually we would find that until the depression was adequately treated the possibility of successful job hunting or retraining, of engaging in the process of finding better housing, of establishing a relationship, and of viewing the world differently, was zero.
A few years ago at a conference someone was touting the benefits of exercise. I had to point out that I had been recommending exercise to all my depressed and anxious patients for precisely 47 years. My success rate at this was approximately 0.3 percent. At least 0.3 percent before their depression, schizophrenia or anxiety was adequately treated. Then it might improve somewhat.
As a psychiatrist and physician my prime directive is to relieve the suffering of my patient. That may mean treating an illness. It may mean calling in the social worker to ask if there is any chance of finding better housing. It may mean calling in the dietician to see if she can influence my patient’s eating habits, or referring to an exercise program, or talking with his teachers, or filling out forms to increase his disability pension, or encouraging him to see his family physician for better general medical care, or talking with the welfare officer, lawyer, probation officer……
And definitely, if one develops schizophrenia the outcome of this illness is likely to be better if that person lives within a good functioning family, has adequate housing, experiences no more “adverse events” than the average child, has opportunities for education and suitable employment, some kind of social support, at least one meaningful activity, good general medical care, and adequate finances.
But the suggestion that “we should diagnose and treat social adversity within our societies.” is paradoxical nonsense in that it actually suggests we take a biomedical approach to social ills (diagnose and treat), while at the same time being hollow virtue signalling.
We are citizens and voters in this democratic society and we can do what is possible to do to prevent war, reduce poverty, increase equity, eliminate racism, improve housing, banish guns from the streets, and improve the health care system. But as physicians it is still our primary duty to treat (reduce the suffering) of the ill and/or wounded.