Social psychiatry, the unpopular (and forgotten) approach
In the mid-twentieth century, psychiatrists were, with much zeal, striving to combat the social and environmental contributors to mental distress by focusing on strengthening families, encouraging healthy lifestyles, and advocating relevant legal and health policy issues. Unfortunately, in subsequent decades, a lack of political will (admitting to the social antecedents of mental health issues would require elected officials to work to change laws) and withering public funding meant the social psychiatry approach became not only forgotten but also unpopular.
The era of psychiatry I trained in, in the early 2000s, for the most part, had embraced (and continues to embrace) a biological approach. This means that today, a conversation with a psychiatrist about mental health symptoms will mostly be focused on neurobiology, genetics, misfiring brain structures, and neurotransmitters gone awry. And yes, well-trained psychiatric practitioners who approach their practice from a bio-psych-social approach will take into consideration social factors but too often this is cursory. Why? Twenty-first-century psychiatric practice is simply not enabled or encouraged to support an in-depth assessment of or response to the social determinants that are causing mental distress to our patients. Too often frontline clinicians feel their hands are tied.
The consequences of abandoning social psychiatry
I’ve witnessed how the abandonment of social psychiatry leads to highly unsatisfactory outcomes such as the over-pathologizing of mental distress in individuals with diagnoses such as depressive and anxiety disorders when, in fact, the real culprits are social factors. Also overmedicating with anti-depressant, anti-anxiety, and insomnia medications— all inadequate band aids that don’t address the root cause of the symptoms and come with side effects.
The distinct trend in recent decades has been to ignore social psychiatry approaches that call out the mental health effects of broken systems and an unjust world. And this has come at a big cost with an over-reliance on individual responsibility and “fixing” brains or “altering” mindsets when changes to societal policies may have elevated the mental wellness of large swathes of the general population.
Will the management of social determinants finally become a reality in health care?
Imagine then, how delighted I was to come across this recent article about Past APA President Dilip Jeste, M.D., who wants to make the assessment and management of social determinants of health (SDoH) a reality in psychiatry and general medicine, not just an aspiration. He founded the Social Determinants of Health Network, a dedicated 501(c)(3) nonprofit foundation, to promote research and foster the education of healthcare professionals and the public about SDoH.
What is the meaning of SDoH?
SDoH are “non-medical social factors that affect health outcomes.” They are societal problems that affect both individuals and the larger population and have a well-established influence on mental health, risk for mental illnesses, and overall quality of life. SDoHs speak to the social fabric of our lives, the conditions in which we are born, raised, work, live, and age, and also the systemic and institutional forces that shape our everyday life circumstances.
SDoH include:
- Exposure to childhood trauma including ACEs
- The presence or absence of supportive social connections
- Exposure to stigma and discrimination
- Your financial status (including issues related to access to education)
- Your employment
- Access to transportation
- Access to food and shelter
To date, the problem has been less about the psychiatric profession resisting social determinants and more about practicality. What tools can practitioners use to formally assess and address the social determinants that affect our patients’ health in our clinics? What are the associated diagnostic terms? Are there expert consensus guidelines or algorithms that show us what actions we need to take when we identify SDoH that are affecting our patient’s health? How will health systems reimburse the time practitioners spend focusing on social determinants?
I’m looking forward to embracing a new era that will provide solutions to these practicalities and normalize the management of social determinants as a routine part of health care because social psychiatry is long overdue for a comeback.
