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CSME|CAPDA Medico-Legal Summit - Dr. Sherese Ali
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Causation in Mental Health
Dr. Sherese Ali, MD FRCPC

There is no single cause of a psychiatric disorder. Rather a complex interplay of acute triggers, risk, perpetuating and protective factors, culminate in the findings on the ‘present state examination’ from which the psychiatric diagnosis is made. This theory of George Engel, remains the standard approach to understanding etiology from a biopsychosocial perspective in psychiatric disorders. The approach, however, lends itself to variability in conclusions regarding causation in medico-legal settings. Subjective opinion and perspective may attribute different weight to the role of various factors, and debates may arise with respect to analysis of causation. While several theoretical causal relationships exist, the “but for” concept and material contribution test in the Law provide some clarity. The former utilizes the causal relationship of “sufficient, but not necessary” using the terminology “but for the event, [the mental disorder] would not have occurred.” The material contribution test states that if an event is a material contributing factor (even if there are other contributing factors) in a person’s injuries and subsequent disability, that person is still entitled to receive full compensation from the incident. Lastly, in medicine, the stress-diathesis model suggests that genetic contribution accounts for 25% of the chance of expressing illness. Stress and adversity contribute the remaining 75%. The dose of stress required for expression of pathology differs from individual to individual. Psychological factors (coping style, cognitive perceptions) play an instrumental role in the inter-individual variability of stress tolerance. Cognitive models in medicine, would therefore attribute causation to psychological factors rather that the event itself. In the Law, however, the “thin skull principle” sheds light on analysing causation, stating “If a person is fragile for whatever reason, such be it physical or psychological and that person is injured more easily or to a greater extent than someone who was not fragile, that person is entitled to receive full compensation for the full extent of the injuries suffered, notwithstanding that the person was more easily injured or injured to a greater extent than someone else may have been.” These concepts: “but for,” the material contribution test and the “thin skull principle” can help to increase inter-rater reliability in the analysis of causation in medicolegal mental health assessments.

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