Week 2 RF-Recording the Social Determinants of Health

Question 1

What did Stuckler et al. (2009) find in their study of 26 European countries (1970-2007)?

Answer 1

+ 1% unemployment rate = + 0.8% in suicide rate

-Analysed suicide statistics from that date range

-Means these 2 rates seem closely linked

Question 2

What did McManus find when investigating the prevalence of any common mental disorder by household income in England 2007?

Answer 2

-lower the household income, the higher the likelihood of developing a CMD e.g., anxiety and depression

-Shows household income and CMDs are closely linked

Question 3

What did Pickett & Wilkinson (2010) find when investigating the income inequality in different countries with the % of any mental illness?

Answer 3

-When a country like Japan has low income inequality (i.e., more equal distribution), about 8% of the adult population are diagnosed with a mental illness

-When a country like the US has a high income inequality (i.e., lower equal distribition), about 25% of the adult population are diagnosed with a mental illness

Question 4

True of false: Mental health is determined by social factors such as income, race and wider political systems

Answer 4

TRUE!

Question 5

How could clinical psychologists address the inequalities faced?

Answer 5

Note the social factors in the medical record

Articles supporting this have suggested it would help as:
1. It would inform aetiological models (inform how we understand the cause of poor mental health)

2. Would inform the treatment an individual receives
3. Would inform healthcare planning and policy making (as more money would have to be spent on treatment if inequalities not addressed)

Question 6

What is the problem with the call to increase the recordings of social determinants in medical records?

Answer 6

It lacks empirical support

1. If medical records have such far reaching consequences; what are driving forces in their development?
2. What are current recording practises of the social determinants of mental health? (we don’t know)
3. Would recorded social contextual information affect clinical decision making?

Question 7

What are the driving forces in the development of medical records? (Handerer et al., 2021) Study 1 THEORY

Answer 7

-Basic theory was the ranking system and medical records are linked to medical knowledge

-Our current medical understanding shapes what we write down in clinical practise

-Record systems themselves would shape medical understanding through paper technology

Question 8

What are the driving forces in the development of medical records? (Handerer et al., 2021) Study 1 METHODS

Answer 8

-Analysed the development of standardised historical admission registers in English (Liverpool) asylums/psychiatries

-Found changing admission forms

-Collaborate with historian

-Retrieved the underlying laws

-Linked the form patterns with psychiatric discoveries of the time

Question 9

What are the driving forces in the development of medical records? (Handerer et al., 2021) Study 1 FINDINGS

Answer 9

-4 different standardised forms (basic form before being admitted) in England and Wales between 1845 and 1930

-The forms differ with respect to aetiological attributions of poor mental health (implied they already knew cause)

-These bureaucratic changes have shaped treatment (not necessarily driven by scientific discoveries)

Question 10

What are the driving forces in the development of medical records? (Handerer et al., 2021) Study 1 FINDINGS 1845

Answer 10

-First nationally standardised care for “lunatics, idiots and persons of unsound mind” (The Lunancy Act, 1845)

2 ways they were forced into care:
1. Private patients: 2 medical certificates & 1 family member to prove they were of unsound mind (paid for their own treatment)

2. Pauper patients: 1 medical certificate & 1 justice of the peace order (State paid for their treatment)
   “it having been once established that the insanity of a patient did not arise from the state of his bodily health, a man of common sense could give as good an opinion as any medical man I knew [respecting the treatment and the question of their sanity]”
   Earl of Shaftesbury, Chair of the Commissioners (1845-1885)
   -Mental health is something we all understand so no expert needed

-Developed a register admission form asking for name, age gender and the form of mental disorder and supposed cause of insanity

3 forms of mental disorder:
Mania, Melancholia and Dementia

-Clear focus on social factors e.g., Melancholia because their child drowned is understandable

Question 11

What are the driving forces in the development of medical records? (Handerer et al., 2021) Study 1 FINDINGS Lunancy act 1890

Answer 11

1. A royal scandal (wrongfully admitted royal family member because they didn’t like them)
2. Admission of private patients changed so that a justice of the Peace order was needed
3. “Professional crisis” as a psychiatrists became limited in control and earnings (fewer patients came into private care so less money)
4. 1902-1905: solved this with the generation of a new register by the Medico-Psychological Association (new admission form rate)

Question 12

What are the driving forces in the development of medical records? (Handerer et al., 2021) Study 1 FINDINGS 1906

Answer 12

-New admissions rate finally implemented

-No column for causes of insanity but aetiological factors for it instead

-Asked for principle and contradictory factors and column to ask extra comments

-53 codes of insanity (clear focus on biomedical understandings e.g., genetics)

Basis:
-“On the origin of species”
-“hereditary genius”
-“The Germ Plasm: A Theory of Inheritance”
-X-rays

Consequences:
-Hardly understandable for anyone without the code central (e.g., what does F.1 mean?)
-A.1 (insane hereditary) became the most often coded cause in 1913 (first example of paper technology)

Question 13

What are the driving forces in the development of medical records? (Handerer et al., 2021) Study 1 FINDINGS Mental Health treatment Act 1930

Answer 13

-Introduction of medical language “treatment” & “hospital” (instead of asylums)

-Voluntary admission

-Temporary admission (forced care up to 6 months)

-Solution to professional crisis: drew more patients into care due to free will plus forced 6 months

-2 columns asking aetiological factors and 1 of the 53 codes

Basis:
-Discovery of first neurotransmitter (Kraeplin) Understanding is GREATER

Consequences:Treat on a biomedical level
-Malarial therapy (induced high fever to reset working brain)
-Leucotomy therapy (went through nose to cut bit of brain to ‘fix them’
-Electroconvulsive therapy (electric shocks)

Question 14

What are the Laws in England and Wales today? (2022)

Answer 14

-2 registered medical practitioners can detain someone under guardianship or in hospital up to 6 months

Question 15

What are the driving forces in the development of medical records? (Handerer et al., 2021) Study 1 FINDINGS 1948

Answer 15

-NHS set up

-Local Health authorities led to local bookkeeping rules (not one standardised form anymore)

-Had one column asking patient if they are a twin or triplet and same sex, MZ, DZ etc., instead of aetiological factors

Basis:
-ICD 6th
-Non-use of the aetiological codes before

-Consequences are currently unforseable

Question 16

What are the driving forces in the development of medical records? (Handerer et al., 2021) Study 1 CONCLUSION

Answer 16

-Medical records provide the ground for treatment

-Medical records epitomise current medical understanding and shape medical understanding

-Medical records are also shaped by forces outside the medical remit i.e., monetary and power considerations (as lost patient numbers)

Question 17

What are current recording practises of social contextual information? (Kinderman et al., 2023) Study 2 METHODS

Answer 17

-Analysing all entries in one NHS mental health care trust over 1 year

-Requested all admission entries for 2015 in one trust

-Identified all phenomenological codes and codes for social contextual information

-Compared the coded information with known prevalences (e.g., homeless people struggling with mental health issues in the area)

Question 18

What are current recording practises of social contextual information? (Kinderman et al., 2023) Study 2 BACKGROUND What is the critique of the existing codes?

Answer 18

“Medical records shape medical understanding. 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.”

-Doesn’t cover all the important social determinants of health

Question 19

What are current recording practises of social contextual information? (Kinderman et al., 2023) Study 2 FINDINGS

Answer 19

-21,701 individuals in treatment

-4656 individuals received any primary diagnosis e.g., bipolar disorder

-Only 39 individuals had social information recorded

Question 20

What are current recording practises of social contextual information? (Kinderman et al., 2023) Study 2 CONCLUSIONS

Answer 20

-Existing codes for social contextual information is significantly underused i.e., barely used in practise

-But even the sporadic use, however demonstrates that the recording is implementable in clinical practise

Question 21

Would recorded social contextual information affect clinical decision making? Study 3 (not published yet) THEORY

Answer 21

-A RCT using video vignettes (method)

-Medical records divide individuals into manageable tasks e.g., heart rate, weight, height etc., so clinicans can then measure them

Medical records fastens individuals:
-Ties us down to a limited number of information e.g., height, weight
-Fasten up our treatment

Question 22

Would recorded social contextual information affect clinical decision making? Study 3 STUDY DESIGN

Answer 22

-Online study, participants were asked to imagine that they would be psychiatrists

-Presented with patients register (data on patient’s age, gender, mental disorder diagnosis) and 3 videos of fictitious (not real) patients describing their experiences and emotions

-Had to make clinical decisions

Question 23

Would recorded social contextual information affect clinical decision making? Study 3 MANIPULATION

Answer 23

-Manipulated random allocation of group

-Experimental group had Z codes in addition to age, height, weight

-Control group did NOT have Z codes (which was the manipulation

Question 24

Would recorded social contextual information affect clinical decision making? Study 3 HYPOTHESIS

Answer 24

Providing participants with additional social contextual information will lead to:
1. More social focused aetiological assumptions

2. More social oriented treatment recommendations
3. More optimistic prognosis
4. Less social distance to people with mental health problems

Question 25

Would recorded social contextual information affect clinical decision making? Study 3 MEASURES

Answer 25

1. Write down first question to patient
2. Note 3 aetiological assumptions (why’d they’d behave or feel a certain way)
3. Rate these assumptions on a biopsychosocial scale (1-10)
4. Treatment recommendation-psychiatrist, psychotherapist, confidant, religious leader, self-help group, family physician, non-medical practitioner, cure at a spa, community nurse/district or community public health department
5. Treatment rating psychotherapy, natural remedies, acupuncture, relaxation, psychotropic drugs, meditation/yoga, ECT (electroconvulsive therapy)

Question 26

Would recorded social contextual information affect clinical decision making? Study 3 MEASURES PART 2

Answer 26

6. Prognosis
7. Social distance scale (“It is best not to associate with people who have been in mental hospitals.”)
8. Willingness to restrict rights (“Someone who has a severe mental illness should be admitted to a psychiatric hospital even against their will and should be detained if needed”)

Question 27

Would recorded social contextual information affect clinical decision making? Study 3 RECRUITMENT AND STUDY SAMPLE

Answer 27

-Pilot study with 130 students

-Main study: Recruited from June 2021 to May 2022 mental health care providers (psychiatrists, clinical psychologists, mental health nurses, occupational therapists, social workers)

-N of 140 based on power calculation

-Recruited through social media, MAD in America/ the UK, and mostly through the NHS

Question 28

Would recorded social contextual information affect clinical decision making? Study 3 SAMPLE CHARACTERISTICS

Answer 28

-Both conditions were similar with respect to gender, age, ethnicity, and job-distribution

-Generally the majority of the sample was white, female, between 45 and 55 (unrepresentative)

-Most common jobs were mental health nurse > clinical psychologists > psychiatrist

Question 29

Would recorded social contextual information affect clinical decision making? Study 3 PILOT STUDY FINDINGS

Answer 29

-Providing p’s with additional contextual information with Z codes = more likely to recommend psychosocial treatments

-Withholding Z codes (contextual information) = more likely to recommend biomedical and treatment forms

Question 30

Would recorded social contextual information affect clinical decision making? Study 3 FINDINGS PRIMARY MEASURE: REFERRALS

Answer 30

-No effect found with mental health care providers

-Additional contextual information did not change treatment recommendations

Question 31

Would recorded social contextual information affect clinical decision making? Study 3 FINDINGS SECONDARY MEASURES: TREATMENT EVALUATION

Answer 31

No significant differences between conditions

Question 32

Would recorded social contextual information affect clinical decision making? Study 3 FINDINGS SECONDARY MEASURES: BIOPSYCHOSOCIAL ATTRIBUTION

Answer 32

No significant difference between conditions

Question 33

Would recorded social contextual information affect clinical decision making? Study 3 FINDINGS SECONDARY MEASURES: PROGNOSES

Answer 33

No significant difference between conditions

Question 34

Would recorded social contextual information affect clinical decision making? Study 3 FINDINGS SECONDARY MEASURES: GENERALISED ATTITUDES TOWARDS MENTAL HEALTH CARE USERS

Answer 34

No significant difference between conditions

Question 35

Would recorded social contextual information affect clinical decision making? Study 3 FINDINGS SECONDARY MEASURES: PROVIDER-USER INTERACTION

Answer 35

-Analysed the noted first questions with a thematic analyses

-Categorised data blind as to the condition of participant

-Some questions were phrases that could have been used by anyone addressed at anyone (e.g. “How are you?” “How have things been?” “How have you been since last appointment?”)

-Others were more person centred (“How are you accessing your medication every day if you are currently homeless? “or “Hello. Would you like me to address you as Frederick or Fred, or something else?”)

-Additional social contextual information leads to significantly more person centred interactions (chi square 4.7; p = 0.031)

Question 36

Would recorded social contextual information affect clinical decision making? Study 3 FINDINGS SECONDARY MEASURES: AETIOLOGICAL ASSUMPTIONS

Answer 36

-Thematic analysis as for the interaction

Revealed 3 categories:
1. “Diagnosis related” subsumed all aetiological assumptions that either just named a mental disorder diagnosis, or a specific symptom (e.g. “flashbacks”, “auditory hallucinations” etc.).

2. “Events and external conditions” covered factors like trauma, insufficient healthcare, and adverse living conditions
3. “Personality and behaviour related” subsumed psychological, genetical and behavioural explanations

-Significant differences between conditions (chi square 15.2; p= >0.01)

Question 37

Would recorded social contextual information affect clinical decision making? Study 3 FINDINGS EXPLORATORY ANALYSIS

Answer 37

-Very consistent differences between professions

-Psychiatrists were significantly more likely to refer to biomedical services than psychologists p > 0.01

Question 38

Would recorded social contextual information affect clinical decision making? Study 3 CONCLUSIONS

Answer 38

-No effect of additional social information on decision making/ attribution/ prognoses of care providers

-Diagnoses seem to overshadow evaluation (e.g. diagnosis of schizophrenia overshadows everything else, therefore, additional information of homelessness is not considered for explaining someone‘s experiences)

-Profession seems to enhance this effect of diagnostic overshadowing

-Additional information makes interaction more person centred…makes aetiological assumptions more often referring to external events and conditions