IntroductionThere is growing consensus that consideration of the Social Determinants of Mental Health should be at the centre of mental health care provision. To facilitate this, a validated means to assess mental health service users' social contextual information is arguably needed. We therefore developed a questionnaire to assess the Social Determinants of Mental Health in clinical practice.MethodsOur guideline-informed development consisted of three steps; i) construct and purpose definition, ii) initial item generation based on the literature, similar questionnaires, and a selection of the ICD-10, iii) evaluation, revision, and content validation of the questionnaire. Initially we developed 249 items that were reduced, revised, and validated in several stages to 73 items. Content validation of the questionnaire was achieved through surveys and focus groups including mental health care service users and professionals.ResultsThe surveys and focus groups indicated the need for a standardised assessment of adverse social factors and highlighted that the benefits of such an assessment would be a more holistic approach to identifying and addressing fundamental factors involved in the development of mental health difficulties. Importantly, this study also revealed how any assessment of the Social Determinants of Mental Health must prioritise the assessed person having a central role in the process and control over their own data. The focus groups identified contradicting recommendations regarding the most suitable context to administer the questionnaire.DiscussionThe resulting questionnaire can be considered to be theoretically robust and partially validated. Future research is discussed.

We, a group of medical professionals, researchers, patient representatives, and politicians, call for the UK government to commit to a reversal

BackgroundThere has been a shift to implement human rights-based approaches in acute mental health care due to increasing concerns around quality of care. National Health Service (NHS) Trusts have a legal duty to uphold a person's human rights, therefore it is important to understand what any barriers might be. Using psychological theory may help to develop this understanding.AimTo test whether the theory of planned behaviour can be an effective model in understanding mental health professionals' intentions to work using a human rights-based approach.MethodParticipants were recruited from two NHS Trusts in the North West of England. A cross-sectional, survey design was used to examine mental health professionals' intentions to use human rights-based approaches.ResultsMultiple regression analyses were performed on the theory of planned behaviour constructs showing that attitude and subjective norm significantly predicted intention. Perceived behavioural control did not add any significant variance, nor any demographic variables.ConclusionThere could be factors outside of the individual clinician's control to fully work within a human rights-based framework on acute mental health wards. The theory of planned behaviour offers some understanding, however further development work into measuring human rights outcomes on acute mental health wards is needed.

Background:The diagnosis of obsessive compulsive disorder (OCD) is characterised by intrusive thoughts leading to compulsions to alleviate anxiety. However, research is lacking on impact post-diagnosis. Some research suggests diagnosis may benefit treatment access, but potentially leads to higher levels of stigma and altered self-identity. Aims:The present study assessed the utility (treatment access and problem identification) and impact (stigma, personal wellbeing or social identity) of receiving a diagnosis of OCD. Method:Semi-structured interviews with 12 individuals who had received a diagnosis of OCD were conducted between February and April 2020, then transcribed and analysed using theoretical thematic analysis. Results:Participants reported positive impacts of diagnosis on both 'utility' and 'impact'. Conclusions:The diagnosis of OCD was helpful for participants in making their symptoms tangible, providing relief and hope for recovery. Non-diagnostic or alternative frameworks should aim to meet this need. Future research may wish to identify how this understanding of disorders vary between different diagnoses, especially in terms of stigma and personal wellbeing.

In the nineteenth century, photography became common in psychiatric asylums. Although patient photographs were produced in large numbers, their original purpose and use are unclear. Journals, newspaper archives and Medical Superintendents' notes from the period 1845-1920 were analysed to understand the reasons behind the practice. This revealed: (1) empathic motivation: using photography to understand the mental condition and aid treatment; (2) therapeutic focus on biological processes: using photography to detect biological pathologies or phenotypes; and (3) eugenics: using photography to recognise hereditary insanity, aimed at preventing transmission to future generations. This reveals a conceptual move from empathic intentions and psychosocial understandings to largely biological and genetic explanations, providing context for contemporary psychiatry and the study of heredity.

Background Many health research policies invoke the construct of Social Determinants of Health, and more recently the construct of Social Determinants of Mental Health. While frequently referred to in the literature, it is unclear how these constructs relate to each other. Some commentators conceptualise the Determinants of Mental Health as a subgroup of the Determinants of general Health and others describe the Determinants of Mental Health as an autonomous construct. The current review investigates the relationship between both constructs. Methods Comprehensive literature searches were conducted for both constructs separately within seven electronic databases. A template analysis was conducted to compare the conceptualisations of the Social Determinants of Health and the Social Determinants of Mental Health. Results Of 4250 search results, 50 papers (25 for each construct) fulfilled our inclusion criteria and were incorporated into a narrative synthesis. Discussions of the Social Determinants of both general and Mental Health listed the same determinants. Both constructs were conceptualised on multiple levels and factors. Stress and health behaviour were also described as mediators for both constructs. The constructs differed, however, with respect to two components of their aetiologies and epistemologies. First, the causal mechanisms invoked for the Determinants of general Health followed predominantly direct pathways, in contrast to indirect pathways for the Social Determinants of Mental Health. Second, the Social Determinants of Mental Health were reported to influence mental health mediated through individuals’ perceptions and appraisal processes. Appraisal processes were considered of far less relevance in the construct of Social Determinants of Health. Conclusion The constructs of Social Determinants of Health and Social Determinants of Mental Health align in many respects but differ on important aetiological and epistemological grounds. Similar social factors are considered important, but whereas physical health conditions are primarily conceptualised to be driven by objective realities, mental health is explained mainly in terms of perception of these realities. This differentiation between physical and mental health is in line with a modern understanding of mind-body-dualism, the naturalistic dualism after Chalmers. Differentiating the Social Determinants of Mental Health from the Social Determinants of Health might bear relevance for policy making and research.

Background Efficacy trials of medications and/or psychological interventions for bipolar disorders (BD) aim to recruit homogenous samples of patients who are euthymic and such populations show high levels of adherence to the treatments offered. This study describes a secondary analysis of a large-scale multi-centre pragmatic effectiveness randomized controlled trial (RCT) of cognitive behaviour therapy plus treatment as usual (CBT) or treatment as usual alone (TAU) and explores outcomes in individuals who were: (i) recruited in depressive episodes, or (ii) receiving suboptimal doses of or no mood stabilizers (MS). Methods Data were extract on two separate subsamples (out of 253 RCT participants). Sample 1 comprised 67 individuals in a depressive episode (CBT: 34; TAU: 33); Sample 2 comprised 39 individuals receiving suboptimal MS treatment (CBT: 19; TAU: 20). Survival analyses (adjusted for confounding variables) were used to explore recovery in Sample 1 and relapse in Sample 2. Results In Sample 1 (individuals with depression), Cox proportional hazards regression model revealed that the median time to recovery was significantly shorter in the CBT group (10 weeks; 95% confidence intervals (CI) 8, 17) compared to the TAU group (17 weeks; 95% CI 9, 30) [Adjusted Hazard Ratio (HR) 1.89; 95% CI 1.04, 3.4; p < 0.035]. In Sample 2 (suboptimal MS), the median time to any relapse was significantly longer in the CBT group compared to the TAU group (~ 35 versus ~ 20 weeks; Adjusted HR 2.01; 95% CI 1.01, 3.96; p < 0.05) with the difference in survival time to first depressive relapse also reaching statistical significance (X 2 = 14.23, df 6, p 0.027). Conclusions Adjunctive use of CBT appears to have benefits for individuals diagnosed with BD who are highly representative of the patients seen in routine clinical practice, but often excluded from efficacy RCTs. However, as this is a secondary analysis of 42% of the original RCT sample, it is important to replicate these findings in independent larger scale studies specifically designed for purpose.

Cohen, Öngür, and Harris call for schizophrenia, and personality disorder in particular, and psychiatric diagnoses more generally, to be renamed.1Cohen BM Öngür D Harris PQ Past due: improving the naming of psychiatric disorders.Lancet Psychiatry. 2022; 9: 264-266Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar New names are intended to communicate our experiences in a clearer and less stigmatising way. We argue that neither can be achieved simply by replacing one-word descriptions of very heterogenous experiences with other one-or-two-word labels. The term schizophrenia is not stigmatising, but the concept of schizophrenia is; the signifier is not the problem but rather the signified. Psychiatric disorders are built on the idea that distressing emotions, and behaviours perceived to be problematic, can be typified into a small number of categories, and that those categories are types of disorder or disease. These categories are widely criticised, including by Cohen and colleagues, for lacking reliability, validity, utility, and distinctiveness.1Cohen BM Öngür D Harris PQ Past due: improving the naming of psychiatric disorders.Lancet Psychiatry. 2022; 9: 264-266Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 2Kinderman P Read J Moncrieff J Bentall RP Drop the language of disorder.Evid Based Ment Health. 2013; 16: 2-3Crossref PubMed Scopus (68) Google Scholar Notwithstanding unclear boundaries, the conceptual models underlying psychiatric diagnoses generate stereotypes that will always create stigmas, especially when they encompass unusual and disturbing behaviours. Conversely, how such stereotypes could ever offer improved clarity about the treatment of individuals is unclear. Therefore, we argue that the problems identified by Cohen and colleagues are inherent to the construct of mental disorders, rather than attached to specific terms. Schizophrenia itself provides evidence for this construct-related stigmatisation, as the term schizophrenia replaced the more stigmatising dementia praecox and nevertheless has become conceptually vague and negatively perceived. Any replacement term proposed (now or in the future) for such diverse conditions will be inappropriate and will perpetuate stigmas. However, psychiatric nomenclature offers a solution to this issue of trying to find the right name for the wrong frame (which reminds us of Adorno's remark that "there is no right life in the wrong one"3Adorno T From Minima Moralia (1951).in: Damrosch D Melas N Buthelezi M The Princeton sourcebook in comparative literature: from the European Enlightenment to the Global Present. Princeton University Press, Princeton2021: 139-149Crossref Google Scholar). We have previously called for the use of phenomenological codes available in ICD-11 to record mental health difficulties.4Kinderman P Allsopp K Non-diagnostic recording of mental health difficulties in ICD-11.Lancet Psychiatry. 2018; 5: 966Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar It is possible, for example, to record aggressive behaviour (MB23.0), disorganised thinking (MB25.02), and auditory hallucinations (MB27.20), instead of schizophrenia (6A20). This classification would be clear, and it could reduce stigmatisation. Use of phenomenological codes would not try to signify a construct of stereotypical mental illness but would capture specific behaviours and experiences. Changing the designation of mental distress in this way would lastingly address the problems that Cohen, Öngür, and Harris discuss. We declare no competing interests. Past due: improving the naming of psychiatric disordersOne of the finest qualities of medicine is its drive to discover new information and communicate that information among experts and to the public, including patients. Despite those efforts, absent dramatic discoveries, some concepts and terms get frozen for generations. Full-Text PDF

Background We have previously argued that psychiatric diagnosis, by focusing on pathology, minimises the role of psychosocial factors. Despite suggestions that traditional diagnosis is the only way to access treatment services, we have recommended standardised use of existing codes for possible social determinants and precise description of psychological phenomena. Aims This study examines the current use of social determinant and phenomenological codes in mental health care records. Methods Data provided by a local NHS Trust included 21,701 cases with a first contact date between 01 January 2015 and 01 January 2016, 4656 of whom received a primary diagnosis. Results Overall, codes for possible social determinants were used on only 43 occasions, for 39 individuals (0.8% of the 4656 people receiving a primary diagnosis). Comparison with relevant baseline frequencies revealed a highly significant under-reporting of key social determinants. 19 cases (0.4% of 4.656) used codes for precise description of specific psychological phenomena. Conclusions Available ICD codes for social determinants and specific psychological phenomena are under-used in clinical practice.

This paper explores the historical developments of admission registers of psychiatric asylums and hospitals in England and Wales between 1845 and 1950, with illustrative examples (principally from the archives of the Rainhill Asylum, UK). Standardized admission registers have been mandatory elements of the mental health legislative framework since 1845, and procedural changes illustrate the development from what, today, we would characterize as a predominantly psychosocial understanding of mental health problems towards primarily biomedical explanations. Over time, emphasis shifts from the social determinants of admission to an asylum to the diagnosis of an illness requiring treatment in hospital. We discuss the implications of this progressive historical diminution of the social determinants of mental health for current debates in mental health care.

There have been calls to standardise recording of social determinants of health to improve clinical practice, research, and policy.1Moscrop A Ziebland S Bloch G Iraola JR If social determinants of health are so important, shouldn't we ask patients about them?.BMJ. 2020; 371m4150Crossref PubMed Scopus (14) Google Scholar We explicitly support this demand,2Allsopp K Kinderman P A proposal to introduce formal recording of psychosocial adversities associated with mental health using ICD-10 codes.Lancet Psychiatry. 2017; 4: 664-665Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar but recognise that existing codes in the ICD system do not encompass all of the most important social determinants of health.3Jacobs ZG Codifying social determinants of health: a gap in the ICD-10-CM.J Gen Intern Med. 2021; (published online March 29.)https://doi.org/10.1007/s11606-021-06742-4Crossref Scopus (1) Google Scholar Therefore, it is not possible to consistently record social conditions even if practitioners assessed them in a standardised way. WHO guidance does not explain how the codes were developed. To investigate this, we contacted several employees in the classification unit, and a former WHO division director, yet no information was available about the process used for selecting and rejecting certain social factors for inclusion in the coding system. Codes for recording social determinants of health were introduced in ICD-9 and included in subsequent editions, with several scholars identifying the need for additional codes in ICD-10.4Robeznieks A New ICD-10 codes will help physicians tackle social barriers to care.https://www.ama-assn.org/practice-management/digital/new-icd-10-codes-will-help-physicians-tackle-social-barriers-careDate: April 2, 2019Date accessed: June 9, 2021Google Scholar Some of these demands have been considered in the development of ICD-11, in which social determinants of health are principally codified under the heading "factors influencing health status". For example, insufficient insurance coverage is now coded as QE30. Other calls for reform have not been met and it is difficult to justify why migration status, neighbourhood safety, or structural racism are not included as factors that influence health status. Some of the codes included in ICD-10 that have been omitted from ICD-11 are even more bewildering. Details on a personal history of abuse in childhood enlisted in ICD-10 have not been incorporated into ICD-11, without any apparent reason to assume that experiences such as a "personal history of forced labor or sexual exploitation in childhood" would no longer influence health. It is also hard to understand why the code "Z56.81 Sexual harassment on the job" has not been included in ICD-11. Medical records shape medical understanding.5Hess V Mendelsohn JA Case and series: medical knowledge and paper technology, 1600–1900.Hist Sci. 2010; 46: 287-315Crossref Scopus (95) Google Scholar Insufficient recording of social factors becomes problematic when it hinders a more complete understanding of health. Consequentially, we are calling for a more transparent selection of codes, and for mental health professionals of all disciplines worldwide to support the inclusion of a full range of social factors within ICD-11. ICD-11 was adopted in 2019, but might take a number of years to implement in many countries. In the meantime, practitioners can propose new codes for social living conditions on the ICD-11 maintenance platform. This period between ICD-11 publication and implementation should be used to better equip ourselves to assess and address the social determinants of health. We declare no competing interests. A proposal to introduce formal recording of psychosocial adversities associated with mental health using ICD-10 codesIt is well known that poverty and social inequity are major determinants of our mental health,1 and the United Nations Special Rapporteur2 characterises mental health care not as a crisis of individual conditions, but as a crisis of social obstacles, which hinders individual rights. Full-Text PDF

Background: The hypothesis that mental distress is caused by chemical imbalances in the brain is widespread in public and professional discourse, and has fuelled research into and prescription of antidepressant medication. Nevertheless, this hypothesis has very little supporting evidence, and has been branded as oversimplistic and reductionist, with some even claiming it is nothing but a myth. The continued discussion of this controversial explanatory model by various professions raises the question of how the chemical imbalance or monoamine hypothesis is used by expert witnesses in legal proceedings.Aims: The study examined how expert witnesses have used the chemical imbalance hypothesis as explanations in Court cases involving mental health.Method: The study was a qualitative investigation of secondary data. Two databases of Court transcripts were systematically searched, resulting in 19 transcripts where expert witnesses used/referred to the hypothesis. These transcripts were analysed using a hybrid method of thematic analysis and discourse analysis.Results: The chemical imbalance model was invoked in Court proceedings as an unquestioned scientific “fact” rather than a hypothesis with conflicting evidence, and to support divergent, even contradictory, conclusions.Conclusions: In the context of expert evidence to Courts, this appeared to serve the function of reinforcing the scientific basis of psychology or psychiatry – supporting and rendering unquestionable the subjective opinions of the expert (“trust me, I’m a scientist”).Funding: None to declare. Declaration of Interest: Author A reports no conflicts of interest. Author B is employed by the University of Liverpool and is a clinical psychologist in independent practice. Over the course of his career, Author B has received research grants from the National Institute of Health Research, the Medical Research Council, the Economic and Social Research Council, the Wellcome Trust, the Youth Justice Board for England, various NHS Trusts, the Department of Health, the European Commission, the British Psychological Society, and the Reader, and personal fees from the Department for Constitutional Affairs, legal counsel, the BBC, Smoking Gun Media, GLG Group, True North Productions, and Compass Pathways Ltd. He has also received royalties on published work in the field of mental health from Palgrave Macmillan, and Little, Brown Book Company, and travel and hospitality from a variety of organisations in relation to speaking and other professional activity. Author B has a remunerative secondment contract through his employers to act as a Clinical Advisor for Public Health England. Author B sits on the NICE (National Institute for Health and Care Excellence) Guidelines panel for Adult Depression 2015-2021, is a Member of the Council for Evidence Based Psychiatry, a director of Kyrie Therapeutic Farm Ltd, and a former President of the British Psychological Society. Author B is a member of the British Beekeepers’ Association, and a member of the Giordano Bruno Foundation (Giordano- Bruno-Stiftung). Author B owns shares in Alphabet (the parent company of Google), Twitter, and the Kindling Trust, and is Director and owner of Kinderman Consulting Ltd.

This paper examines the association between financial hardship in childhood and adulthood, and depression and anxiety in adulthood with reference to the accumulation, critical period and social mobility hypotheses in lifecourse epidemiology. Using the BBC Stress test, linear regression models were used to investigate the associations for the whole population and stratifying by sex and adjusting for age and highest education attainment. The critical period hypothesis was not confirmed. The accumulation hypothesis was confirmed and stratifying by sex women had a higher estimated mean GAD score if they were poor in both childhood and adulthood compared to men. Our findings do not support the social mobility hypothesis. However, stratifying by sex, a clear difference emerged with upward mobility having a favourable impact (lower) on women's mean GAD scores, while upward social mobility in adulthood did not attenuate the impact of financial hardship in childhood or men. The impact of financial hardship in childhood on later mental health outcomes is particularly concerning for future health outcomes as current levels of child poverty increases in the UK.

BACKGROUND:Diagnoses are controversial but ubiquitous in mental health; however, whether they are essential features of service entry has not been analysed.AIM:To investigate the use of diagnosis in the service entry criteria of UK NHS adult mental health services.METHODS:Freedom of Information requests were made to 17 NHS adult mental health Trusts; responses were analysed thematically.RESULTS:Four service types were identified: broadly diagnostic, problem-specific, supporting specific life circumstances and needs-led. Diagnoses were used frequently but not universally. Non-diagnostic factors were central to service entry criteria.CONCLUSIONS:Diagnoses were neither necessary nor sufficient in-service entry criteria. Broad clusters of difficulties were used rather than specific diagnoses. Extensive exceptions revealed diagnoses as inefficient proxies for risk, severity and need. Differences across criteria appeared largely driven by professional competencies. Implications for innovative care pathways include preventative services and working with psychosocial factors.