Diagnosing social ills: Theorising social determinants of health as a diagnostic category

Abstract

Medicine, as an institution and discipline, has embraced social determinants of health as a key influence on clinical practice and care. Beyond simply acknowledging their importance, most recent versions of the International Classification of Diseases explicitly codify social determinants as a viable diagnostic category. This diagnostic shift is noteworthy in the United States, where ‘Z‐codes’ were introduced to facilitate the documentation of illiteracy, unemployment, poverty and other social factors impacting health. Z‐codes hold promise in addressing patients’ social needs, but there are likely consequences to medicalising social determinants. In turn, this article provides a critical appraisal of Z‐codes, focussing on the role of diagnoses as both constructive and counterproductive sources of legitimacy, knowledge and responsibility in our collective understanding of health. Diagnosis codes for social determinants are powerful bureaucratic tools for framing and responding to psychosocial risks commensurate with biophysiological symptoms; however, they potentially reinforce beliefs about the centrality of individuals for addressing poor health at the population level. I contend that Z‐codes demonstrate the limited capacity of diagnoses to capture the complex individual and social aetiology of health, and that sociology benefits from looking further ‘upstream’ to identify the structural forces constraining the scope and utility of diagnoses.

Social determinants of health Z-code documentation practices in mental health settings: a scoping review

“…Social determinants of health Z codes can be used to document and track a range of social and environmental risk factors, with direct implications for treatment outcomes in psychiatric patient populations. Yet, despite expert consensus on the health relevance and importance of considering environmental variables on mental health outcomes that may or may not be genetically associated, 13-15 , 37-46 to date, our findings show that SDoH Z codes are documented at a very low rate in health care practice settings that provide mental health care. This finding is slightly consistent with prior work indicating a generally low rate of SDoH documentation using International Classification of Diseases, Ninth Revision (ICD-9), coding procedures to assess associations between adverse SDoH and mental health risk in the form of suicide.…”

Rebalancing commercial and public interests in prioritizing biomedical, social and environmental aspects of health through defining and managing conflicts of interest

“…Current inclusion of SDOH as a diagnostic category in the International Classification of Diseases can be seen as a victory but a very partial solution. It also legitimizes individual social needs only when they give rise to poor health and ignores acting on poor health at the population level ( 53 ).…”

“…More basically, the SDOH approach has failed to address the roots of social determinants -the political-economic arrangements that cause the maldistribution. For example, medical debt, driven by (53).…”