K. S. Jacob trained in medicine, psychiatry, epidemiology and anthropology and was part of the World Health Organisation’s Primary Care Consultation Group for the Revision of the International Classification of Diseases 10 Primary Health Care. He has worked in clinical and academic contexts in India, the United Kingdom and Australia. He has worked in primary care and has studied mental distress and illness presenting to general practice.
People who access primary care, physicians who deliver services and psychiatrists who attempt to influence mental health care delivery attempt to control the discourse related to mental health in general practice. Each perspective attempts to inform, negotiate, and create solutions; they are also dynamic and influenced by the other approaches. It results in a complex dance between stakeholders for improved understanding with shifting influence and power. Competing points of view complicate general practice.
People express their suffering in a variety of ways using diverse “idioms of distress” (IODs), that provide collective, shared ways of experiencing and talking about personal and social concerns.1 Psychiatric terminology (E.g. anxiety, depression), which started as Euro-American IODs, were exported around the globe and is now part of popular culture across countries and are used, along with local IODs, by people seeking mental health care and healing.2 However, these technical terms have evolved far beyond their original meaning. People who are unable to cope with problems of living flood health facilities, present with psychiatric IODs and are readily recognised by the system. These idioms are converted to disorder labels that provide new meaning, and reframe distress; they also offer personal, psychological, social and economic support, in addition, to medication. Idioms are also performative and effect social change, are prone to improvisation, co-exist with local idioms and serve as additional options for negotiating access to care and healing.2
People express their suffering in a variety of ways using diverse “idioms of distress”.
GPs attempt to support people through difficult circumstances, acknowledge psychosocial contexts, recognise multiple variants of distress, argue against using symptom checklists and oppose the medicalization of human suffering.3 They also recognise that psychiatric labels are rarely solutions to problems caused by psychosocial and economic adversity; antidepressants, counselling and meditation apps cannot change structural and social determinants of mental health. Consequently, they are reluctant to locate pathology in individuals when the causes for dysfunction are situated within environments.
Psychiatry, on the other hand, focuses on collections of symptoms (syndromes). These clusters, based on Euro-American idioms, were decontextualized and operationalized to achieve good diagnostic reliability.1 However, these labels lack external validity.4 The use of the term “disorder”, as suffix, transfers the disease halo to distress and illness labels. In addition, current psychiatric treatments are symptomatic, employed across diagnostic heads mandating the need to tailor care to the individual context.
Psychiatry, on the other hand, focuses on collections of symptoms [or] syndromes.
The blurred disease-illness divide, the inter-changeable use of these concepts and the illusion of specific brain pathology are supported by academia, health, insurance and pharmaceutical industries.5 Despite evidence that social determinants produce significant mental morbidity, most interventions favour post-hoc individual treatments to population-based public health approaches that are useful in reducing structural violence and in empowering large sections of society.
Psychiatric labels for distress have shifted the focus of responsibility of the state for poverty and structural violence and transferred pathology and burden to individuals. The disparate environments under which anxiety, depression and common mental disorders now exist are brought together as many strands, de-contextualized and unified into disease labels.5 Clinical presentations of individual distress are interpreted as abnormalities of structure or function. Retelling of the patient’s story, despite the use of the same anchor points, results in the construction of conflicting narratives.
The political economy of health, deeply rooted in capitalistic economic and social systems, undergirds these formulations. Psychiatric labels offer distinctive niches to diverse stakeholders: disease, reimbursement, profit, and deflection of responsibility. Depression, anxiety and common mental disorder labels and the culture of medicine fit in well with the neoliberal agenda, allowing the free market to expand its business interests. The technical approaches of evidence-based medicine are not necessarily value-neutral nor above specific interests.6
Psychiatry needs to theorize clinical practice relevant to primary care. There is a need to shift from “diagnosis-drug treatment” approach to a broader framework of “caring for illness” and understanding illness in context. It needs to acknowledge that clinical practice is far greater than making criterion-based diagnosis and prescribing evidence-based treatments.
Psychiatry needs to theorize clinical practice relevant to primary care.
The diverse discourses mandate that primary care consider its unique reality, and devise approaches to mental distress and illness, which are practical in routine practice. The process should be led and owned by primary care professionals and needs to engage with communities and stakeholders. The challenge is to theorise ideal practice rather than to practice inappropriate theory.
References
1. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth edition. . 2013, Arlington VA: American Psychiatric Association.
2. Jacob KS. Idioms of distress, mental symptoms, syndromes, disorders and transdiagnostic approaches. Asian J Psychiatry. 2019; 46:7-8.
3. Dowrick C, Francis A. Medicalising unhappiness: new classification of depression risks more patients being put on drug treatment from which they will not benefit. BMJ. 2013;347:f714.
4. Kendell R, Jablensky A. Distinguishing Between the Validity and Utility of Psychiatric Diagnoses. Am J Psychiatry. 2003;160: 4-12.
5. Jacob KS. Patient experience and psychiatric discourse. The Psychiatrist, 2012; 36: 414-17.
6. Greenhalgh T, Howick J, Maskrey N. Evidence-based medicine: a movement in crisis? BMJ. 2014; 348: g3725.
