Plenary Spotlights Why Addressing Social Determinants of Health Is Critical

Making a dent in our societal mental health crisis will require psychiatrists to begin to tackle the demand side of mental illness.

According to Sarah Y. Vinson, M.D., founder of Lorio Psych Group and an associate professor of psychiatry and behavioral sciences and director of the Child and Adolescent Psychiatry Fellowship Program at Morehouse School of Medicine, the mental health care system is focused on the fact that there are many more people in need of mental health services than there are services available to help them.

“We can address this mismatch in one of two ways,” she told Psychiatric News. “We can provide more services or we can ask the question, ‘Why are there somany people in need of services in the first place?’ ”

Vinson will join economics scholar Peter Q. Blair Ph.D., an assistant professor of education at the Harvard Graduate School of Education and principal investigator of the Blair Economics Lab, in delving into the economics of mental health service delivery at the Annual Meeting plenary session on Monday, May 23. “In order to really move the needle on patients’ mental health in a significant way, I think that these interdisciplinary collaborations are absolutely critical,” Vinson said. “Our traditional medical training is focused on individuals, symptoms, diagnoses, billing, best-case scenario formulation. It hasn’t taught us to think about these broader social issues that have such a huge impact on who comes to us, with what symptoms, and how.”

Vinson, who is a co-author of Social (In)Justice and Mental Health from APA Publishing, maintains that one of the most important ways of decreasing demand for mental health services is by advancing improvements in the social determinants of health that begin well before birth and leave subgroups of the population particularly vulnerable to mental illness. This includes addressing racial discrimination and social exclusion; adverse early life experiences; poor education; unemployment, underemployment, and job insecurity; poverty, income inequality, and neighborhood deprivation; poor access to healthy food; and inadequate health care.

Some psychiatrists maintain that assessing patients’ social determinants of health is beyond their scope of practice or that they are powerless to address these concerns. “The problem is, if you don’t consider these issues and their impact, then you are giving people diagnoses, prescribing medications, and creating interventions that are not fully informed. That has implications for the accuracy of your treatment and its effectiveness,” Vinson said. “The goal is to help people, not just come up with a diagnosis for which you can bill. Considering patients’ social determinants of health is not optional.”

One example is understanding patients’ housing situation: As of January, home prices skyrocketed 20% on average, compared with the previous year, with experts predicting even higher price hikes in the coming months. Vinson said even though psychiatrists may not find patients a new house, it is important to understand whether housing problems may be contributing to patients’ anxiety or insomnia.

“We need to validate their responses and not pathologize these legitimately stressful situations,” Vinson added. “It may be that five years ago, housing difficulties or even homelessness wasn’t a major concern for your clinic population, but now it is,” Vinson said. “If you’re going to take care of these patients, maybe you need to familiarize yourself with available community resources and think more about offering access to social work services and housing assistance.”

Vinson teaches her residents and fellows that the best treatment plan is the one that is clinically indicated and that the patient is able and willing to follow. “You don’t know what they’re able to follow if you don’t have a sense of these broader social determinants and structural issues.” When physicians prescribe a medication that patients cannot afford, they may be labeled “noncompliant” or “nonadherent with treatment” when they fail to take it, she pointed out. “But it could be that you developed a treatment plan that didn’t take into account the realities of their lives. There’s nothing therapeutic about that.”

Psychiatrists have an important role to play, too, in helping public officials understand the mental health implications of proposed policy actions. Psychiatrists can share their expertise by engaging in interdisciplinary collaboration, scholarly writing, getting involved in state or local government, or testifying before Congress. “We need to see this as part of our role of being in a healing profession,” she said.

Rather than carving out specific sessions at the Annual Meeting that address issues of racial diversity, equity, and inclusion, Vinson believes it is crucial that these concerns be incorporated into every session. “This is everyone’s job. There’s harm in acting as if it’s not. Otherwise, for minority patients who overcome all the barriers to seeing a mental health clinician, when they finally see someone, they will have a terrible experience. They won’t come back. That is what happens when clinicians don’t think it is part of their job to ask how patients are coping with racial violence in the news or their experience as a Black person,” Vinson said. “There needs to be an acknowledgement that attaining structural and cultural competency is central to your role as a mental health clinician.”

Although the focus is often trained solely on stigma, Vinson said research shows that the number one reason that Black Americans do not seek mental health treatment is cost. “There’s little discussion of the practical barriers that cost presents when you have a group of people who are disproportionately uninsured, disproportionately living in poverty, and disproportionately fired in a pandemic.” She urges clinicians to work one day a week at a public clinic, write about these issues, and/or mentor and sponsor trainees from underserved communities.

“There is something that everyone can do where they are,” she said. “You don’t have to become a researcher or a political activist, but there is something you can do in whatever role you currently inhabit,” Vinson said. ■