Contextual evaluation of social adversity in the management of depressive disorder

Abstract

Contextual rating of social adversity has its origins in the work of George Brown and colleagues (Brown & Harris, 1978). This review evaluates its strengths and weaknesses in rating the effects of social adversity on depressive disorder. We write from the perspective of its usefulness for clinical and training purposes both to the consultant psychiatrist and to the community mental health team working in general adult psychiatry. What is contextual rating of social adversity?Social adversity and social factors that mitigate it can be validly measured with or without considering their likely interpretation (context) by the individual. Contextual rating of social adversity is often clinically meaningful for both the health professional and the patient, enabling them to understand how, when and why social adversity may be connected with the patient's depressive disorder. In research, associations between social adversity and depression are also stronger using the contextual rating method than other methods (Kessler, 1997). The main alternative approach is to consider that each life event has a similar adverse effect on each individual. In this method, life events are sometimes ranked in terms of the likelihood of causing an adverse emotional effect in an individual. The nature of contextual rating is best illustrated by an example. A life event such as unemployment may be more of a blow to a 40-year-old man who is already in debt, has a large family and has worked all his life in one specialised field than to another 40-year-old man without such debt or commitments and who has a wide range of experience and skills. The former is likely to experience unemployment as a severe threat to his well-being, whereas the latter may even consider it as a fresh opportunity. A problem with contextual rating is that great care has to be taken to avoid making inaccurate assumptions about mitigating circumstances and causality. For example, it is possible that the reason our 40-yearold man is depressed, unemployed and in debt is because he is a heavy consumer of alcohol, which independently contributes to his depression, unemployment (e.g. through bad time-keeping) and indebtedness. Figure 1 illustrates the psychosocial formulation of a patient with a non-psychotic depressive episode. The model uses traditional categories of predisposing or vulnerability factors (Box 1), precipitating factors (Box 2) and maintaining factors (Box 3) likely to cause chronicity for 12 months or more. Vulnerability factors may increase the likelihood of both precipitating interpersonal life events and difficulties, and maintaining factors (Brown & Moran, 1994). Unlike traditional formulations, there is a Brown's model of social adversity

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