Accounting for the Social Determinants in Psychiatric Care Delivery

Patients with psychiatric illnesses have unique existential challenges that affect their health and lives tremendously. Notorious among these challenges are those emanating from the social environments in which they are born, work, learn, live, worship, age, and play. Termed “social determinants” in modern literature (1–3), these challenges are remnants of human-, society-, and organization-made disparities transmitted from past unequal structural arrangements of resource distribution and socioeconomic inequalities. Examples of social determinants include adverse early-life events, poor education, poor access to health care, chronic unemployment, poverty, discrimination, and food and material insecurity, among others. Defined as “the cause of the causes” of poor health and unfavorable health outcomes (3, 4)—mental health included—social determinants can present serious impediments to patients’ therapeutic end-result and also can lead to poor compliance to treatment for major psychiatric illnesses. By virtue of the limitations they place on patients’ lives, the circumstances they force patients to live under, and the decisions they force patients to make daily, social determinants can hence be a serious handicap to psychiatric care and recovery from psychiatric illness, including substance abuse.

Case Vignette: Part I

“Ms. Z” is a 45-year-old woman who is HIV positive, homeless, never-married, childless, unemployed, and illiterate living in a shelter, with no formally diagnosed psychiatric disorder. She walked into the outpatient mental health clinic requesting help with chronic heroin use. She has been “an addict,” she said, since the age of 17, having been exposed to heroin while living on the streets after running away from a sexually abusive stepfather at home. With no education and no skills, as a way of supporting her habit, Ms. Z started prostituting herself shortly after leaving home. In the city jail, she became a familiar figure for various charges, including prostitution, shoplifting, possession with intent to sell, assault, etc., for which she served a combined 15 years. While under our care, she was treated for opioid use disorder with buprenorphine/naloxone maintenance therapy in addition to weekly group cognitive-behavioral therapy. She did well initially on this treatment regimen for the first 6 weeks. However, around the end of that period, she started testing positive for opiates again.

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.

Case Vignette: Part II

Ms. Z was recently kicked out of the shelter, unable to find meaningful work given her criminal record and poor education, and, cornered by the effects of her adverse early-life events, she resorted to old habits to maintain a “stable” existence.

The cumulative effect of the social determinants can limit the social and economic options of those affected by them. Ms. Z’s initial treatment failure, when seen in this light, was no more than a manifestation of the end result of the effects of her disadvantageous, deeply layered, and limited socioeconomic circumstances. In other words, her state of poverty and environment were contributing to her relapse and could not be ignored. We had to start looking at the ecological context in which her treatment was taking place and begin to examine our therapeutic shortcomings in terms of the effects of these social determinants on her daily life and therapeutic progress.

We first had to integrate and coordinate her care back to HIV treatment. We also referred her to a long-term inpatient detoxification program, while simultaneously helping her secure stable housing and employment with the help of our social worker. Ms. Z is still aiming to get back on her feet as we attempt to help her lift the layers of limitations these social determinants have imposed on her life. Nonetheless, we note improvements over the subsequent months following her inpatient detoxification treatment program: she has started to regularly attend her weekly group therapy, remains compliant to her treatment regimen, and has thus far been testing negative for substances of abuse.

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.

Conclusions

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.

Key Points/Clinical Pearls