Addressing Social Determinants of Mental Health

According to the World Health Organization, “A person’s mental health and many common mental disorders are shaped by various social, economic, and physical environments operating at different stages of life. Risk factors for many common mental disorders are heavily associated with social inequalities, whereby the greater the inequality, the higher the inequality in risk.” In other words, people don’t necessarily start with the same opportunities or resources (inequity), and social factors further divide us. This suggests that our psychiatric patients suffer from biopsychosocial determinants that could have been prevented in the first place.

As psychiatrists, we know how to treat mental illness as it presents in an individual. But in addition to treating the illness, we need to be more aware of the broader context in which that illness occurred and how that context has shaped the health outcome. This awareness is broadly referred to as the social determinants of health, and for us, the social determinants of mental health.

A clinical example may help to illustrate:

A young woman of color made an appointment for treatment of her anxiety. After her boyfriend proposed marriage, she began having increasing anxiety symptoms. At her office visit, she appeared dissociated. A review of her symptoms did not reveal the cause of her anxiety. I prescribed anti-anxiety medication, and we agreed to schedule another appointment. Rather than ask her to describe herself, I asked how I could help her. She had been referred by a community agency that helped women who had a history of abuse and had subsequent complex trauma. As she slowly began to feel safe, she revealed that in her teenage years, she had been locally trafficked for commercial sex. She was now a survivor. Her risk factors were clear, but year after year, they remained unidentified and/or unaddressed. It was striking to think that if any one of the social determinants in her history had been altered, her life trajectory might have followed another path.

What additional tools do psychiatrists have at their disposal to more fully care for our patients impacted by such factors? To borrow an approach from population studies that focuses on the social determinants of mental health (SDoMH), I have created a 2021-2022 APA task force. It will build upon previous presidential initiatives, such as structural racism, stigma, diversity, equity, innovation, and criminal justice that are encompassed by the social determinants. This approach says that differential health outcomes can be explained, in part, by reference to the places a person lives (ZIP code), works, and plays. It is not a replacement for medical care; instead, we need to be aware of these other factors to inform the care we provide. If we take this approach and apply it to mental health, it can lead to earlier intervention in communities, possibly before psychiatric symptoms begin.

The SDoMH more generally encompass multiple factors, such as the following:

• Social factors, including racism, adverse childhood experiences, discrimination, and social exclusion based on race, ethnicity, gender, age, or mental illness; health care inequity due to lack of access to care; and exposure to violence and the criminal justice system.

• Economic factors related to resources, lack of education, employment insecurity, and neighborhood poverty that have cumulative effects on an individual.

• Built-environment factors, including housing; pollution of the air, water, and ground; and climate change.

• Structural factors, including cultural norms; systemic policies; and laws and regulations that institutionalize disparities for populations, such as Black, Indigenous, Hispanic, rural, and other minority communities.

Once these factors are identified, then the question is, What can psychiatrists do to improve mental health outcomes? The work of the APA Task Force on Social Determinants of Mental Health will focus on educational programs, training protocols, policy guidance for academic institutions, and government agencies.

To emphasize the importance of these efforts, the theme of the 2021 Mental Health Services Conference in October and the 2022 Annual Meeting in May is “Sociopolitical Determinants: Practice, Policy, and Implementation,” based on the social determinants of mental health.

To return to my severely anxious patient: If she hadn’t been neglected and sexually abused in childhood, if her parents had been treated for substance use disorder, if her parents hadn’t been incarcerated for their substance use, if she hadn’t been arrested for prostitution, and if her community had offered more resources to her family and her school, such interventions surely would have made a difference and possibly reduced or prevented her psychiatric symptoms.

I encourage you to think big—to re-think traditional theories, diagnoses, and treatments and think more globally about each patient, not just in the present, but in their past by taking into account their community and social determinants of mental health so that as an organization, we can have an impact on improving the mental health of Americans who have too long been the victims of forces beyond their control. ■