Accounting for the Social Determinants in Psychiatric Care Delivery

Psychiatric illnesses—and any illness for that matter—do not exist in a psychological or physiological vacuum. They can result as a consequence of stressors: physiological, neurological, psychological, biological, sociological, environmental, etc. Termed “allostatic loads” (5–8)—the physiological cost of chronic social and environmental stressors—they can have enormous consequences on overall emotional health when they exist in excess (i.e., “allostatic overload” [5, 6, 8]). Not all patients carry identical allostatic loads; this difference in the allostatic load burden and its eventual consequence can lead to what Dr. Michael Marmot, former chair of the World Health Organization Commission on Social Determinants of Health, referred to as the health gradient: whereby those at the bottom of the socioeconomic ladder fare much worse in terms of health compared with those at the top (1, 2, 9, 10). In other words, social status and relative economic standing matter to overall health and persistence of illnesses in that they bear what Dr. Marmot later coined the status syndrome (10). Simply put, a patient from a limited socioeconomic background who is homeless and living on the street, with a history of multiple incarcerations, is not going to approach her treatment recommendations the same way as a patient from an affluent background presenting with the same chief complaint. Neither will she approach her treatment compliance the same way. Thus, the overall health of the two will differ.

Because these patients bring unique social determinant challenges from their environments to the psychiatric table of care, some of these challenges have to be tackled simultaneously with the psychiatric disorder if a productive therapeutic outcome is to be expected. Such dual approach is deemed necessary because the nature of these patients’ illnesses can be, at times, socioenvironmental in origin. As such, the “ecological context” (11) in which the psychiatric illness and recovery take place (i.e., the background story) can be as important a factor in the attainment of successful treatment outcomes as the psychotropic medications themselves.

Our approach to Ms. Z’s opioid use disorder treatment necessitated some maneuvering that went beyond the one-size-fits-all substance use disorder treatment protocol we are all too familiar with. Being overly focused on these treatment protocols and other classic treatment conventions, more often than not, leads physicians—psychiatrists included—to overlook the social environment (12) (the physical, social, and cultural milieus within which our patients function daily) contributing to the patient’s present state and health. Through years of studying, we have been trained to view patient care from a top-down disease-based model that has its limits. One such limit is that it fails to take into account the effects of social determinants on patients’ overall health, compliance to treatment, and functionality. This model neglects to make allowance for the social and economic stressors that have been reported to play both direct and indirect roles in disease development (5, 6, 8). In the case of Ms. Z, the social determinants were affecting her treatment participation and had to be accounted for in the treatment protocol to achieve better and longer-lasting therapeutic outcomes. Of course, this does not imply that her initial treatment failures were singularly the result of our not taking the social determinants into account in her treatment protocol. Nonetheless, not having seriously considered them was undoubtedly one factor in a multifactorial web of causation leading to the shortcoming of our initial therapeutic effort. Perhaps, this is not the end of Ms. Z’s substance abuse story. Perhaps, the final answers will come, in the next few months or years, as to the definite effect of our therapeutic approach on her long-term treatment outcome. Perhaps they will not. Nonetheless, we currently hail her abstinence from substances, even if briefly, as a great milestone on her road to recovery from opioid use disorder.

The learning point from Ms. Z’s case is that social and economic factors do matter when addressing recovery from substance abuse and other psychiatric illnesses (3, 11, 13). As existential burdens, social determinants, in and of themselves, can lead to psychiatric distress and dysfunction through their effects on the decisions they force patients to make and the life they force patients to live. Because social determinants mortgage the patients’ emotional well-being, they can lead to poor treatment compliance, worse therapeutic outcome, and significant psychoaffective end results. Addressing the social determinants in our patients’ lives forces us physicians to bear witness to the daily, chronic, negative consequences of health care disparity and socioeconomic inequality, which are issues physicians are not presently comfortable handling. While we are not trained to be social workers, being aware of social determinants and making appropriate referrals early in treatment can be significant to the therapeutic alliance and long-term therapeutic end results. Screening for these socioeconomic needs that are negatively affecting the health of our patients and guiding them to the correct path to local resources can help them overcome such disparities. Failure on this account can easily derail a well-thought-out therapeutic plan. In other words, social determinants should never be ignored in the development of the therapeutic plan for our patient’s optimal psychiatric care.

The author thanks Drs. Partam Manalai, Walter Bland, Tanya Alim, and Mansoor Malik for their mentorship and support.