Address Mental Health’s Social Determinants Through Policy Change

In addition to treating mental illness, psychiatrists have a role in improving mental health and reducing risk for mental illness. Individual, patient-level opportunities exist for pursuing these prevention goals, but promoting mental health and preventing mental illness are most effectively carried out at the population level, through policy changes that address the social determinants of mental health.

Defined as social and environmental factors pertaining to where and under what circumstances we grow up, go to school, work, and age that adversely impact mental well-being, the social determinants of mental health include such diverse factors as (1) adverse childhood experiences; (2) racism, social exclusion, and discrimination; (3) poor education; (4) poverty, neighborhood deprivation, and income inequality; (5) unemployment and underemployment; (6) food insecurity; (7) poor housing quality and housing instability; (8) adverse features of the built environment, for example, public-works infrastructure and housing/office/school buildings; (9) poor or unequal access to health care services; and (10) exposure to natural disasters, trauma, gun violence, and war. This list artificially separates the social determinants, though they clearly overlap and interact.

Although some countries have much greater burdens of many of these adverse social and environmental factors (such as the West African nations struggling to contain Ebola virus transmission), each of the social determinants of mental health also affects people living in the United States. Furthermore, the social determinants of mental health are intimately linked to health disparities and inequities, which are unfair differences in health risk and outcomes among specific population groups.

The social determinants of mental health affect communities and the population as a whole, but they also affect individuals. They create psychological stress and physiological stress responses. They also constrict one’s options, setting the stage for poor choices and risky health behaviors (for example, reliance on an unhealthy but inexpensive diet or substance abuse). Additionally, these social determinants increase risk of exposure to injury, pathogens, and toxins.

In these ways, the social determinants are “the causes of the causes” of both physical and mental illnesses.

Genetics undoubtedly plays a role in risk for most mental illnesses, but the social and environmental risk factors likely interact with genetic risk through gene-by-environment interactions and epigenetic mechanisms. Although the social determinants of mental health are largely the same as those underpinning chronic physical health conditions and physical health disparities, we frame them as social determinants of mental health in order to translate existing literature to the mental health arena and articulate specific actions that mental health professionals, policymakers, and society at large can take to improve mental health and reduce mental illness risk.

To most effectively address the social determinants of mental health, one must ask what lies beneath them at even deeper levels.

In our conceptualization, the social determinants are, for the most part, created by unequal distribution of opportunity in society—opportunity meaning safe, stable, and nurturing environments in childhood; social inclusion; political capital and the ability to participate fully in society; equal access to education, jobs, healthy food, safe housing and neighborhoods, and health care and other resources; and other dimensions of social justice.

Even deeper, the unequal distribution of opportunity is underpinned by both public policies (policies, codes, rules, and legislation pertaining to education, employment, wages, food, housing, neighborhoods, and other aspects of society) and social norms (values, attitudes, impressions, and biases that drive stigma, discrimination, and social exclusion). Thus, to act on the most fundamental causes of poor mental health and mental illnesses, we must address both public policies and social norms that create unequal distribution of opportunity.

Psychiatrists and other mental health professionals have a moral responsibility to shape public policies and affect social norms. To truly promote mental health, psychiatrists must consider population-level interventions on public policies and social norms with the same intensity that they carry out clinical interventions. This includes public policies that, at first glance, might not appear to be health policies at all, such as local zoning ordinances, a state college system’s tuition costs, and federal minimum-wage legislation. This “health in all policies” approach complements clinical approaches at the individual patient level.

As our field pursues promotion of mental health and prevention of mental illness, we must embrace both clinical and policy approaches to addressing the social determinants of mental health. In doing so, we will move toward a more just and healthy society and better physical health and mental health for all. ■