Poverty, pathology and pills: moral narratives and the medicalisation of distress

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The provision of effective treatment and support for mental distress is a stated aim of the Department of Health and civil society organisations e.g. Mind. Yet despite a stated need to tackle health inequalities, current strategies e.g. Closing the Gap: Priorities for Essential Change in Mental Health (DoH 2014), frame mental distress as a psychological problem that lies within the individual concerned. This not only suggests that distress can be 'corrected' through medical treatment, but also masks the factors that often underlie the root causes of suffering e.g. poor living conditions, unemployment. At the same time, policies in place to restrict welfare support, and popular media e.g. Benefits Street, draw on moralising narratives that promote the idea that people are responsible for their own actions and circumstances. This research aims to explore how these moralising narratives impact on the ways that people in low-income communities perceive and respond to mental distress caused by material deprivation and social disadvantage, and to examine the impacts of this on their wellbeing. This will be achieved through in-depth research in two low-income communities in the South West, which seeks to understand: i) the way that moral narratives are defined and used or resisted in people's everyday lives in relation to mental distress; ii) the influence of moral narratives on people's decisions to seek medical support for distress; iii) how moral narratives manifest within GP consultations and influence treatment decisions and patient wellbeing; and iv) which responses to mental distress have the potential to effectively support vulnerable populations, and to inform ethical debates on the medicalisation of distress in a way that benefits patients, and assists practitioners and policy makers seeking to support low-income communities. This 30 month programme of research consists of two linked stages:1) 96 people from 2 targeted low-income areas will participate in focus groups to explore how moral narratives are defined and used/resisted in people's daily lives. Groups will be divided by gender and age to identify any differences across groups. Information collected in Stage 1 will provide informed contextualisation for data collection and analysis in Stage 2. 2) Secondary analysis of 60 video-recorded consultations will enable insight into the contexts in which GPs and low-income patients discuss mental distress. In-depth analysis of 30 consultations will identify how GP-patient interaction influences decision-making to prescribe/accept or withhold/reject treatment. Further insights will be gained through interviews with 10 GPs in the study sites and repeat interviews with 40 people from low-income communities who have attended a GP consultation for mental distress. The first interview will focus on the person's experiences of distress and the role of moral narratives in i) their decision to seek medical consultation, and ii) their responses to the treatment or intervention prescribed/accepted or withheld/rejected. The second interview will enable participants to reflect on their experiences of mental distress within the wider context of daily pressures e.g. poor living conditions, their decision to seek medical support, and the outcome of the GP consultation. The research programme is intended to have strong and distinctive impacts for user groups by informing policy and practice regarding the development of effective, meaningful and non-stigmatising responses to mental distress in low-income communities. This will be achieved by advancing understanding of i) people's use/resistance of moral narratives of responsibility (why? when? how? where? with who?); ii) the relationship between moral narratives and the medicalisation of distress; iii) the ethical implications of prescribing antidepressants for distress induced by poverty/deprivation; iv) identification of GP-patient interactions that enable positive wellbeing.