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Social determinants of mental health

The importance of public policy level intervention on mental health

It may come as a surprise that your zip code might be a better indicator of your overall physical and mental health than your genetic code. An advocate of this statement, Nobel Prize-winning economist Angus Deaton, once wrote in a paper that “poorer people die younger and are sicker than richer people, indeed, mortality morbidity rates are inversely related to many correlates of socioeconomic status such as income, wealth, education or social class.”

It has been documented that social determinants of health have a far greater impact on individuals than the actual provision of health care. Social determinants include the conditions in which people are born, live, work, and age, and the health systems they can access. These determinants of health are in turn shaped by a wider set of forces: economics, social dynamics, environmental policies, and politics.

There is accumulated evidence that measures of physical health such as the prevalence of infectious diseases, infant mortality rate, and life expectancy may be impacted by social determinants. Recently, scientists have found that mental health may also be impacted by such determinants.

Previously, genetic underpinnings of mental illnesses have been heavily focused on. In recent decades, however,  there has been a shift to a biopsychosocial model, which takes social factors into consideration during diagnosis. This illustrates that mental health professionals are increasingly cognisant of the fact that mental illnesses are strongly driven by social factors.

Mental health inequities may be understood as being at least partially determined by unequal distribution of opportunity and, more deeply, by social norms and public policies. Social norms are the cultural opinions and biases that set the stage for poorer health among disadvantaged groups – for example, racial biases against minority groups. Public policies refers to legislation that may not particularly concern health but has far-reaching effects on health. Examples of public policies that have diverse downstream effects on health include the tuition costs for higher education within university systems, minimum wage legislations, and a city’s zoning ordinances.Two of the social determinants that may greatly impact mental health are income inequality and education level.

Income inequality as a social determinant of mental health

There is evidence that people in low socioeconomic classes suffer from mental health issues and their adverse consequences at a disproportionate rate compared to people in higher socioeconomic classes. Income inequality produces psychosocial stress, which leads to deteriorating health and higher mortality over time. There is good evidence that common mental disorders, such as depression and anxiety, are distributed according to a gradient of economic disadvantage across social strata.

The Canadian Institute for Health Information published results from a nationwide study that showed that between 2003 and 2013, self-ratings of poor or fair mental health increased in the lowest income level but remained stable in the highest income level: the rate in the lowest income level is still more than five times higher than that in the highest income level (14.5 per cent versus 2.8 per cent).

In 2010, Lund and colleagues, researchers from the Department of Psychiatry and Mental Health at  University of Cape Town, published a systematic review of the epidemiological literature on common mental illness and poverty in low and middle-income countries. It was shown that 70 per cent of the 115 studies reviewed reported positive associations between a variety of poverty measures and common mental illness. In another systematic review, it was reported that depressed mood or anxiety was 2.5 times higher among young people aged 10 to 15 years with low socioeconomic status than among youths with high socioeconomic status.

It is important to keep in mind that inequalities occur along a continuum and affect everyone in the population, not only the poorest or most disadvantaged. Researchers contend that inequality reduces social cohesion, a dynamic that leads to more stress, fear, and insecurity for everyone. Consequently, high levels of inequality can negatively affect the health of even the most affluent.  Money does not guarantee immunity from mental illness, nor does a lack of money lead to mental illness; however, it is generally conceded that poverty can be both a determinant and a consequence of poor mental health.

Education as a social determinant of mental health

Poor education is associated with decreased physical and mental health. Higher quality education and higher education attainment have been associated with better social outcomes, such as stable employment and higher income. Additionally, employment is a major determinant for mental health status. Unemployment significantly increases the odds of diagnosis with psychiatric disorders: in a study published in 2004, it was noted that unemployment almost quadrupled the odds of drug dependence after controlling for other socio-demographic variables.

Ethical implications of inequalities in mental health

The effect of inequality on mental health has profound ethical implications. Public health organizations are beginning to recognize the detrimental effects of social inequalities, and are making efforts to fulfill key bioethics principles of medicine and public health: respect for individuals, justice, beneficence, and non-malfeasance.

Importance of intervention at the policy-making level

Intervention at the policy-making level appears to be just as important as intervention at the individual and familial level. More attention should be paid to government funded programs that focus on reducing poverty. There is often political debate about the allocation of resources to programs that could narrow the inequality gaps. Politicians should be aware of the fact that funding these programs may, in the long term, better society by indirectly decreasing the burden on the health care system.

The changing roles of health care professionals

Absolute social equality is difficult to achieve. Therefore, varying prevalence rates of mental illness between unequal groups in society, will be difficult to completely eradicate. Researchers, psychiatrists, and other public health professionals must reduce the magnitude of this inequality.

There is a sense that the role of psychiatrists and other public health care professionals might evolve to include advocating for policy change. Psychiatrists may be forced to have a more active non-clinical role by advocating for policies that address these social determinants of mental health at varying levels in society.