Psychosocial adversity and mental illness: Differentiating distress, contextualizing diagnosis

Byline: K. Jacob Psychiatry has made significant advances in the last century. The use of pharmacological medication to treat mental disorders, refinements in psychological therapies, insights into the genetic, and biological basis and advances in operational diagnosis and classification have changed practice. However, the role of psychosocial stress and the relationship between psychosocial adversity and psychiatric diagnosis remains controversial. This article highlights the challenges and suggests possible solutions. Complex Nature of Adversity Suicide is a classical outcome of both psychosocial adversity and of mental illness. The standard teaching was that the suicide rate in India was low (11/100,000) [sup][1] and that the majority were secondary to mental illness. [sup][2] However, recent data suggests much higher rates, [sup][3],[4],[5] much lower proportion of suicide attributed to severe mental disorders [sup][6] and evidence of psychosocial adversity (E.g., loneliness, break in relationship, chronic pain, on-going stress) as the risk factors for such deaths. [sup][6] It is widely recognized that, while people with mental disorders kill themselves, a much greater proportion of deaths in the country are impulsive and secondary to psychosocial adversity in people without serious mental illness. Psychosocial adversity causes mental distress and psychiatric disorders (disease). Such trauma can be acute (E.g., bereavement), recurrent (E.g., domestic violence) or chronic (E.g., poverty). Combinations of such patterns of adversity are also common (E.g., domestic violence in poor women with alcohol dependent partners). Relationship to Vulnerability The Stress-Vulnerability Model [sup][7] and its many variants [sup][8] have long-postulated a relationship between stress and vulnerability (i.e., genetic, biological, psychological and social). The response to adversity ranges from good coping to hopelessness and despair. Such responses can be self-preserving and adaptive and it can be a sign of normal reaction to stress (E.g., short-lived adjustment difficulties in people with good coping skills who are under severe stress) or it can result in mental disease at the extreme (E.g., acute psychosis precipitated by stress). The Stress-Vulnerability Model argues for the inverse relationship between stress and vulnerability. Lower degrees of stress can result in illness and disease in individuals with greater vulnerability and vice versa. While psychosocial adversity is necessary to cause mental distress, it is not sufficient to cause mental disease. The clinical significance of the stress is dependent on the context, the severity and nature of the stressor(s), the person's vulnerability, resilience, and response. The complex relationship between the psychosocial adversity, individual vulnerability, and the resultant coping/de-compensation mandates clinical assessment. It also requires a degree of interpretation, given the fact that our understanding of stress and vulnerability is conceptual and abstract rather than concrete and specific. Psychosocial Determinants of Mental Health The role of social determinants and their impact on physical health has been well documented. [sup][9] The result of inequitable distribution of resources, power and money perpetuate a vicious cycle of poverty and ill-health, often spanning generations. [sup][10] Public health reformers who advocated social reform on political, economic, humanitarian, and scientific grounds had long acknowledged, reciprocal relationship between poverty and disease. [sup][11] These social determinants of health significantly affect mental health. Poverty, gender violence, cultural tensions, social discrimination, political oppression, ethnic cleansing, armed conflicts, and forced migration are associated with depression, anxiety and common mental disorders. [sup][12],[13],[14],[15] Poverty works through the experience of insecurity, hopelessness, rapid social change, risk of violence and physical illness to produce poor mental-health. …