The Social Determinants of Mental Health

Ninety percent of the determinants of our health derive from our lifetime social and physical environment. By understanding and responding to these determinants of health, we can achieve better health and mental health. Professor Paula Lantz and her colleagues (1) put it well when they remarked that Americans are prone to “medicalize health and illness”—in fact, to confound health care with health. It is our behaviors and our habits (such as excessive and poor eating, excessive drinking and drug use, smoking, physical inactivity, and high intake of salt and processed food) that drive the lion's share (40%) of our ill health and early demise. In addition, we cannot dismiss the fact that an estimated 30% of our health is attributable to our genes, because we now understand (through the science of epigenetics) that genes are turned on or off by their exposure to our environment and what we do and do not do (2). In other words, behaviors and environment are the primary factors that we will need to change in order to avoid or delay disease and achieve better health.

As we become more aware of the factors contributing to health, including mental health, public health officials in both developing and developed countries are also increasingly aware that noncommunicable diseases (NCDs) have surpassed communicable diseases in global morbidity and mortality. Conditions such as cardiovascular disease, pulmonary disorders (including asthma and obstructive lung diseases), neurological conditions (such as Alzheimer’s, Parkinson’s, and stroke), and highly prevalent and disabling mental disorders (such as depression; anxiety disorders, including posttraumatic stress disorder; substance use disorders; and psychotic illnesses) affect more than 1 billion individuals worldwide. NCDs account for two-thirds of the deaths each year on this planet (3). No longer do infectious diseases, such as plague, cholera, tuberculosis, and more recently HIV/AIDS, occupy center stage in the world’s health. Moreover, mental and addictive disorders frequently co-occur with chronic general medical illnesses, substantially impairing prevention, worsening the course of these illnesses, and increasing suffering and social burden (4).

We need to look beyond traditional hospital and medical practice venues to improve health and longevity and to control the massive costs that accrue from the consequences of poor health, including disability, work absenteeism and reduced productivity, and often unnecessary and certainly expensive medical and pharmaceutical treatments (5).

Understanding Social Determinants

My points are simple, but they have eluded our understanding and action to date. By focusing on population health, especially the social determinants of health and mental health, we can influence the 90% of health determinants that are outside the traditional health care system. We ignore mental health at our peril because of its role in the prevention of all diseases and its huge direct and indirect impact on chronic illnesses. Health care reform, with its attention to population and community health outcomes and integration of heath, behavioral health, social services, and wellness (6), is moving us toward a “community-integrated health system.”

The social determinants of mental health, according to the World Health Organization, are the conditions in which we “are born, grow, live, work and age,” which themselves are fashioned by economic status, social power, and access to resources such as education, health, and safe environments. These determinants have been recently described by Compton and Shim (7). Social determinants are the “the causes of the causes” of ill health, including mental ill health (8,9). Only by understanding and intervening in the primary drivers of our malaise and illnesses can we hope to prevent or treat these illnesses effectively. Because social and economic disparities and injustices are instrumental to an “unfair and unwell” society (7), we will have to reshape social policy and norms (expected standards of acceptable behavior in a society) to make them as relevant as medical practices.

The social determinants of mental health do their damage principally through the body’s stress response system: over time, stress negatively alters our psychology and physiology and induces illness. Stress also leads to addictive behaviors and risky sexual behaviors. Examples of social determinants of mental disorders include adverse childhood experiences (10), poor and unequal education, food insecurity, poor housing quality and housing instability, unemployment and underemployment, limited access to health care, poverty, and discrimination. Therefore, policy and practice initiatives in clinical care and political advocacy are needed to improve the nation’s health and mental health.

Adverse Childhood Experiences

Maria, age 13, is pregnant and failing in school. She is obese, smokes, and is showing metabolic evidence of insulin insensitivity. She has been diagnosed as having depression and has already had an acetaminophen overdose after a disappointment with her boyfriend. She was raised in foster care from age five after she was abused by her stepfather, and her mother was unable to care for her because of a crack cocaine addiction. Children are at exponentially greater risk of general medical and mental illnesses by young adulthood if they are exposed to physical, emotional, and sexual abuse; neglect; parental separation or divorce; mental illness, substance use disorder, or incarceration of a household member; or domestic violence. Each adverse childhood experience compounds any others in terms of risk. A robust body of evidence—more than 50 published studies and countless conferences—demonstrates the grave blows that adverse childhood experiences deliver.

We know that children exposed to four or more categories of adverse childhood experiences are at a fourfold to 12-fold increased risk of substance use problems, depression, and suicidal behavior. They are at a two- to fourfold increased risk of smoking, poor self-rated health, having more than 50 sexual partners, and sexually transmitted diseases. Risk of general medical disorders, such as cancer, ischemic heart disease, lung and liver diseases, and skeletal fractures, is also highly correlated with the number of categories of adverse childhood experiences to which an individual is exposed.

The implication is clear: a more effective health care system would intervene early with affected children and households to alter their social milieu and thereby avert later chronic general medical and mental disorders and limit social burden.

Policy Changes and Social Interventions

More effective health care policies and practices would ensure that social agencies and communities intervene “upstream” by creating better and more equitable jobs; ensuring food security; providing safe and affordable housing; fostering education, including access to prekindergarten; developing alternatives to incarceration; and increasing the income of low-wage earners. Implementing such social interventions will help prevent disabling and costly general medical and mental disorders and improve public health.

Working on “the causes of the causes” does not mean that physicians and mental health clinicians need to become politicians. But we need to recognize the powerful role that social problems create in our patients’ lives and join with other advocates and social entrepreneurs to shape and implement policies that alter the social and environmental milieu of our patients.

The wisdom of Dr. David Satcher, former U.S. Surgeon General, reminds us that “There is no health without mental health.” And there is no health or mental health unless we also attend to their social determinants. That’s how we can make a dent in the 90% of the factors that determine our health, well-being, and life span.

We have entered a new era of public health, with its needed focus on social determinants, population health, and delivery system reconfiguration. Fossilized practice and policy habits and vested interests in the status quo can jeopardize our progress. But wise voices are emerging, if we take the time to read, listen, and respond to them and sustain the will needed to succeed.