In medicine generally and psychiatry particularly, there has been increased attention in recent years to the social determinants of health (SDoH) and mental health, respectively.
From a diagnostic standpoint, these SDoH have been included in the Z Codes of ICD-10, and some of them in the corresponding V Codes of DSM-5. They are considered to be “Other Conditions That May Be a Focus of Clinical Attention,” but are not considered actual mental disorders, even if sometimes “these codes are more important than any psychiatric diagnosis.”
There are Z Codes for Education, Employment, Adverse Childhood Events, Upbringing, Housing, Economics, and Family. In terms of the social environment, Code Z60.5 is particularly notable for what I have come to call social psychopathologies. This code is titled “Target of perceived adverse discrimination and persecution,” with this description:
“Persecution or discrimination, perceived or real, on the basis of membership of some group (as defined by skin color, religion, ethnic origin, etc.).”
It is important to note that in ICD-11, used in Europe but not yet in the United States, the Z Codes seem to have been replaced with Q Codes. In particular, there is QE04, “Target of perceived adverse discrimination or persecution.”
Listed synonyms include all kinds of usually listed discrimination – ethnic, racial, religious, sexual – but also adds political discrimination. Personally, I would also add burnout, cultish thinking, and undue violence, among others.
In Europe, you can bill and be reimbursed for these codes.
So, what’s not to like? Plenty!
The use of the Z codes has not been reimbursable in the United States. Moreover, they are barely used at all. A recent study of a United Kingdom National Health Service (NHS) Trust dataset indicated that the codes for the SDoH were used in less than 1 percent of mental healthcare records.
Similar results have been reported in earlier studies in the United States. What is particularly striking is the omission of the SDoH in diagnoses for which an event seems to be a required causative factor, as in post-traumatic stress disorder (PTSD) and adjustment disorder.
Why is this diagnostic neglect so important? Among the many reasons are the following:
- Inadequate relevant social data for the policy world;
- Appreciating social circumstances promotes understanding and compassion for the patient;
- Recognizing the SDoH reduces the assumption that a pattern of behavior is individually pathological;
- Social context can help drive clinical decisions;
- Possible prevention of distress; and
- Recognition of the social determinants of mental health and that other strategies are needed.
Moreover, politics and legal precedents have not done enough to reduce these social psychopathologies that seem connected to social divisiveness, war, and psychological suffering of both victims and perpetrators.
There has been one success story, at least in some countries. That is as it relates to homophobia.
Homophobia has lessened so much due to the work of gay activists and gay psychiatrists that even the dystonic classification of it was taken out of the DSM and gay marriage approved in the United States. So, it can be done!
Why not develop something separate of the sort for social disorders that have not been dissipating fast enough, using experts in psychiatry, general medicine, psychology, social work, nursing, sociology, anthropology, and any other relevant expertise?
Such a separate classification of social disorders would likely spur new research and interventions, which could occur both on the individual and group levels. An intervention could be developed like that for anger management or even the cosmic connections that can occur with carefully used psychedelics. Such a development would eliminate the need for a Z or Q code for the social environment.
The goal is assessing populations with collective harmful attitudes toward others, instead of just individuals with a mental disorder.
Individuals with personality disorders by definition tend to hurt others with their ego-syntonic behavior; this would be groups that do so with their social-syntonic attitudes. This won’t be easy, since these social disorders are so embedded in societies. However, the thriving and surviving of our world may even be at stake.
