We need improved recognition of the social determinants of mental health.
PSYCHIATRIC VIEWS ON THE DAILY NEWS
In medicine generally, and psychiatry particularly, there has been increased attention in recent years on the social determinants of health and mental health, respectively. From a diagnostic standpoint, these determinants have been included in the Z Codes of the International Classification of Disease and some of them in the corresponding V Codes of DSM-5. They are considered to be “Other Conditions That May Be a Focus of Clinical Attention,” but are not considered to be actual mental disorders, even if sometimes “these codes are more important than any psychiatric diagnosis.”
There are Z Codes for education, employment, adverse childhood events, upbringing, housing, economics, and family. In terms of the social environment, Z60.5 is particularly notable for what I have come to call social psychopathologies. This code is titled “Target of perceived adverse discrimination and persecution,” with this description:
“Persecution or discrimination, perceived or real, on the basis of membership of some group (as defined by skin color, religion, ethnic origin, etc).”
In my tentative listing of social psychopathologies, I would particularly include racism, sexism, ageism, anti-Semitism, Islamophobia, transphobia, cults, burnout, and violence, that is, the undue violence recently epitomized by the gruesome beheadings of a father in the United States and the October 7th invasion of Israel.
In Europe, you can bill and be reimbursed for the Z codes.
So, what’s not to like? Plenty!
The use of the Z codes has not been reimbursable in the United States. Moreover, they are barely used at all. A recent study of a United Kingdom NHS Trust dataset indicated that the codes for social determinants were used in less than 1% of the mental health care records.1 Similar results have been reported in earlier studies in the United States.2 What is particularly striking is the omission of social determinants in diagnoses where an event seems to be a required causative factor, as in posttraumatic stress disorder and adjustment disorder.
Why is this diagnostic neglect so important? Among the many reasons are:
What is the solution? It seems that enough years and studies have gone by without improved recognition of the social determinants of mental health that other strategies are needed. Moreover, politics and legal precedents have not done enough to reduce these social psychopathologies that seem connected to social divisiveness, war, and psychological suffering of both the victims and perpetrators.
There has been 1 success story, at least in some countries. That is homophobia.
Attempts to include other social psychopathologies like racism in our DSM classifications have failed. Why not develop something of the sort for social disorders, using experts in psychiatry, psychology, social work, nursing, sociology, anthropology, and any other relevant expertise? Such a classification would likely spur new research and interventions.
The goal is assessing populations with collective harmful attitudes toward others instead of individuals with a mental disorder. Individuals with personality disorders, by definition, tend to hurt others with their ego-syntonic behavior; this would be groups that do so with their social-syntonic attitudes. The thriving and surviving of our world may even be at stake.
Dr Moffic is an award-winning psychiatrist who specialized in the cultural and ethical aspects of psychiatry and is now in retirement and retirement as a private pro bono community psychiatrist. A prolific writer and speaker, he has done a weekday column titled “Psychiatric Views on the Daily News” and a weekly video, “Psychiatry & Society,” since the COVID-19 pandemic emerged. He was chosen to receive the 2024 Abraham Halpern Humanitarian Award from the American Association for Social Psychiatry. Previously, he received the Administrative Award in 2016 from the American Psychiatric Association, the one-time designation of being a Hero of Public Psychiatry from the Speaker of the Assembly of the APA in 2002, and the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill in 1991. He is an advocate and activist for mental health issues related to climate instability, physician burnout, and xenophobia. He is now editing the final book in a 4-volume series on religions and psychiatry for Springer: Islamophobia, anti-Semitism, Christianity, and now The Eastern Religions, and Spirituality. He serves on the Editorial Board of Psychiatric Times.
1. Kinderman P, Allsopp, Zero R, et al. Minimal use of ICD social determinant or phenomenological codes in mental health care records. J Ment Health. 2023;32(1):216-225.
2. Torres JM, Lawlor J, Colvin JD, et al. ICD social codes: an underutilized resource for tracking social needs. Med Care. 2017;59(9):810-816.