Mental health in context: structural vulnerability and support in primary care.

Abstract

In 2018, the British Medical Association drew attention to the increasing concern of GPs about the scale of mental health problems in the UK in light of insufficient resources.1 Due to the influence of social factors on mental health, the document highlights the importance of coordinating a public mental health response to address social determinants such as poverty, unemployment, housing, social environments, and relationships, and the symbiosis between physical and mental health.1 Three years on, the above issues have been compounded by the COVID-19 pandemic and its socioeconomic consequences, including poverty, isolation, and the political alienation of entire communities. These are known risk factors for the development of mental health problems.2 At present, structural factors rarely feature in assessment and treatment of mental health problems in the NHS. Instead, psychotropic prescriptions — and the risks associated with their use — increase year on year. Data from England indicate a 6.8% yearly increase in psychotropic prescriptions, with antidepressants increasing by 10% annually,3 and the number of antidepressant prescriptions has almost doubled over the past decade from 36 million in 2008 to 70.9 million in 2018.4 So why is this? The reasons are multifactorial but, we argue, chief among these is the ongoing conceptualisation of mental health within a biomedical model. New insights on the physiological basis of distress, and its impact on the brain and nervous system, are changing clinical practice. Brain structures such as the amygdala and the limbic system are key in our experience of emotion, memory, and autonomic function.5 The clinical application of this understanding is most apparent in the treatment of anxiety and selective memory resulting from traumatic experiences. Autonomic responses (for example, increased heart rate, dizziness, difficulty breathing), cognitive appraisal (for example, negative automatic thoughts, flashbacks), and ensuing emotions (for …