What is a mental health issue?

By Jodie Jasmin

Deciding what creates a “mental health condition” relies upon numerous factors underpinned by social, political and cultural influences; some of which are evident in the making of psychiatric classification. The two most widely established psychiatric diagnosis systems are the American Psychological Association which specifies its mental health disorders in line with the Diagnostic and Statistical Manual of Mental Disorders (DSM), whilst on a larger scale the International Classification of Diseases (ICD) provided by the World Health Organisation (WHO) has a broader range of uses globally and provides critical knowledge on the extent, causes and consequences of human disease and death worldwide (WHO, 2019).

What is meant by the term “mental health issue?” The term ‘mental health’ has been criticised for being, ‘vague, elusive and ambiguous’ (Jahoda, 1958) however we might argue that this view has some strength since it can be difficult to determine whether one is referring to the mental health of an individual in a positive or negative context.

Cromby (2013) suggests that using the term “distress” to account for those conditions which are usually referred to as psychopathology, mental illness, mental disorder or mental health problems – is a better way to conceptualise individual experiences as it allows various professionals and society on the whole to consider the heterogeneous forces behind mental health issues; it is for this reason throughout the blog that we will use the terminology “mental health distress”.

Social, cultural and political factors in the formation of mental health distress

Those from lower socioeconomic backgrounds are most at risk of ‘mental illness’ and substance use disorders (Compton & Shim, 2015). Social determinants that can either support or hinder ideal mental health include (but not limited to): income, education, employment status, quality of food, condition of housing, access to services, geographical location, neighbourhood deprivation, job security, experiences of discrimination social exclusion.

A specific social determinant contributing to mental health formation which has cultural and political underpinnings includes, access to services which has demonstrated problematic for some groups in society. In addition to social determinants influencing mental health formation, vulnerability factors such as race, gender and disability can be an added risk.

Though global health policies may not appear to specifically pertain to the formation of mental health distress on the exterior as we look deeper, it is evident that access to health and social care support such as mental health services presents as a core determinant to distress (Compton & Shim, 2015). For example, in the USA it is widely documented of the racial wealth gap of Hispanics and African-Americans compared to the non-Hispanic white population, this wealth gap indicates inequity of income, employment, education, job opportunities’ thus impacting on the ability to afford health insurance (Dickman, 2017). 

This documented racial wealth gap has produced significant trends in deteriorating racial-ethnic disparities’ in accessing mental health. Cook et al., (2017) research found that between 2004 and 2012 little progress in reducing the disparities in accessing mental health care for blacks, Hispanics and Asians compared with whites even after adjustments were made in terms of clinician assessment for those from black and ethnic minority groups. Cook (2017) proceeds to discuss that the continuation of racial disparity results in sustained and worsening mental health for the minority community.

Furthermore, the research found that disparities were higher for Asian Americans which from a cultural perspective the formation or exacerbation of mental health distress can be accredited to cultural value differences such as conflict between collectivist and individualistic ways of living, stigma related to diagnosis also shame at receipt of treatment outside of the family hierarchical model (Cook, 2017).

We can question why is it that black and ethnic minorities are more at risk of mental health distress or psychiatric diagnosis? Qassem et al., (2011) believed discrimination, harassment, economic disadvantage, social inequity and institutional discrimination each contributed to increased risk of negative treatment from service providers in the mental health system including that of distress formation across the life span.

Nevertheless, there is some evidence towards the changes ethnic minorities experience when accessing services which can reduce mental health distress and diagnosis. Trivedi et al., (2014) research highlights an improved performance on quality measures on acute hospital care for myocardial infarction, heart failure and pneumonia amongst ethnicity minority and the white population in American hospitals between 2005 and 2010 which lessened due to the equity of care in hospitals that disproportionately service minority patients.

From a holistic perspective should a patient be concerned about a physical ailment which has limited their daily habits, mobility and autonomy – this undoubtedly will cause mental health to deteriorate or improve depending on care and treatment provided.  Therefore, what Trivedi research gives us is an indication of improved health equity which can connect to better mental health.

In contemplating further, factors and forces beyond diagnosis, political involvement in the formation of mental health distress is evident which has caused debate amongst professionals. Stakeholder investment in pharmaceutical industries means there is a responsibility to create and promote drugs as a form of treatment which generates profit to appease shareholders.

With the continuation of mental health diagnosis, this might appear to provide justification for psychotropic medication. For example, the serotonin hypothesis has widely been considered to provide an explanation of depression.  Pharmaceutical companies since the 1990s have promoted anti-depressants on this basis (Bogowicz et al., 2021) though there is little empirical support on the serotonin hypothesis (Moncrieff, 2022) as a cause of depression. In knowing that pharmaceutical companies and its stakeholders might profit from psychiatric diagnosis leaves us to question whether some mental health formation is politically influenced.

How can health professionals address social justice issues associated with mental health distress?

Compton and Shim (2015) research outlines how unequal distribution of resources and opportunity is mostly a concern about society, alluding to it being a social justice issue, rather than a clinical issue. By this definition of social justice, it is referred to as meaning, fair distribution of advantages and equal sharing of burdens while focusing on those most disadvantaged. For example, if we take the vulnerability factor of race – the wide recollection of inequality that minority ethnic groups have experienced in the mental health and psychiatric world is something in which the clinician may have to address in their practice.

This inequality is illustrated by Nazroo et al., (2019) research which purports that,

Ethnic minority people in the UK are at much greater risk than White British people of being diagnosed with a severe – psychosis related – mental illness, and this is particularly the case for those with Black Caribbean or Black African origins.

One could ask how might clinicians’ address complex social justice issues such as race inequality when working with clients? Crethar and Winterowd (2012) describe four principles of social justice: equity; access to services, resources, power, knowledge, and information; principles which those from black and ethnic minority backgrounds are not always equipped with (Bignall et al.,2019).

Nevertheless, we could argue that it isn’t always feasible to meet the above principles in practice even though it is expected that a clinician has the competency to evaluate where intervention is most and least successful in addressing the above-mentioned social justice issue, and then alter clinical interventions where necessary. Clinicians may find themselves restricted in their quest to address issues such as race inequality in the psychiatric field if held back by fluctuating social norms and public health policies.

In addressing social justice issues associated with race and mental health Nazroo et al., (2019) systematic review and meta-analysis recommended that clinicians, those who work within the mental health system and policy makers’ have an awareness of their internalised biases towards ethnic minorities which the research indicates this internal bias can be due to the institutional racism engrained in the practice and principles of psychiatry including its regulations, protocols and cultures.

The ability for a clinician to demonstrate self-awareness of internalised biases can be achieved through suitable application of an ethical framework that encourages the clinician to treat all service users equally with particular consideration of those service users as risk of adverse pathways into the mental health system. Additionally, utilising the core ethical principles outlined by the BPS: Respect, Competency, Integrity and Responsibility can serve to address social justice issues at least within the remit of the clinician.

What’s more, earlier on we discussed the factors and forces beyond diagnosis with little mention of psychological formulation. For clients from BAME communities, mental health distress is largely due to prejudicial treatment (Nazroo, 2015) clinicians could seek to find research pertaining to the first encounter of discrimination minority ethnicities experienced. As our early experiences can have an influence on later mental health, applying a psychodynamic perspective when attempting to understand factors and forces beyond diagnosis could prove useful. For example, building a narrative of the experiences and exploring the key events that an individual from a BAME background may have endured i.e., discrimination – can enable clinicians to not only appropriately diagnose and intervene but also enable them to address wider social issues at play.

Adopting a formulation method as opposed to psychiatric diagnosis in particular for ethnic minorities, it could help to avoid self-prophesising behaviours and a sense of helplessness as it removes opportunity for labelling or drug intervention; instead making use of psychological therapies or at least GP consultation (Nazroo, 2019), thus addressing social justice inequity.  

On balance, social justice issues pertaining to that of mental health distress are intricate. Nevertheless, if clinicians’ and policy makers work concurrently we could see improvements in the mental health of our society in terms of prevention and recovery.

References

BACP. (2022, September 8). Cost of living crisis: Survey shows impact on mental health. Www.bacp.co.uk. https://www.bacp.co.uk/news/news-from-bacp/2022/8-september-cost-of-living-crisis-survey-shows-impact-on-mental-health/

Bignall, T., Jeraj, S., Helsby, E., & Butt, J. (2019). Racial disparities in mental health: Literature and evidence review. https://raceequalityfoundation.org.uk/wp-content/uploads/2022/10/mental-health-report-v5-2.pdf

‌ Bogowicz, P., Curtis, H. J., Walker, A. J., Cowen, P., Geddes, J., & Goldacre, B. (2021). Trends and variation in antidepressant prescribing in English primary care: a retrospective longitudinal study. BJGP Open, 5(4), BJGPO.2021.0020. https://doi.org/10.3399/bjgpo.2021.0020

‌ Cook, B. L., Trinh, N.-H., Li, Z., Hou, S. S.-Y., & Progovac, A. M. (2017). Trends in Racial-Ethnic Disparities in Access to Mental Health Care, 2004–2012. Psychiatric Services, 68(1), 9–16. https://doi.org/10.1176/appi.ps.201500453

 Compton, M. T., & Shim, R. S. (2015). The Social Determinants of Mental Health. FOCUS, 13(4), 419–425. https://doi.org/10.1176/appi.focus.20150017

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‌ Crethar, H. C., & Winterowd, C. L. (2012). Values and Social Justice in Counseling. Counseling and Values, 57(1), 3–9. https://doi.org/10.1002/j.2161-007x.2012.00001.x

Dickman, S., Himmelstein, D., & Woolhandler, S. (2017). Inequality and the health-care system in the USA. The Lancet, 389(10077), 1431–1441. https://doi.org/10.1016/s0140-6736(17)30398-7

Greene, B. (2005). Psychology, diversity and social justice: Beyond heterosexism and across the cultural divide. Counselling Psychology Quarterly, 18(4), 295–306. https://doi.org/10.1080/09515070500385770

Halvorsrud, K., Nazroo, J., Otis, M., Brown Hajdukova, E., & Bhui, K. (2019). Ethnic inequalities in the incidence of diagnosis of severe mental illness in England: a systematic review and new meta-analyses for non-affective and affective psychoses. Social Psychiatry and Psychiatric Epidemiology, 54(11), 1311–1323. https://doi.org/10.1007/s00127-019-01758-y