The social determinants of mental health and disorder: evidence, prevention and recommendations

Abstract

People exposed to more unfavourable social circumstances are more vulnerable to poor mental health over their life course, in ways that are often determined by structural factors which generate and perpetuate intergenerational cycles of disadvantage and poor health. Addressing these challenges is an imperative matter of social justice. In this paper we provide a roadmap to address the social determinants that cause mental ill health. Relying as far as possible on high‐quality evidence, we first map out the literature that supports a causal link between social determinants and later mental health outcomes. Given the breadth of this topic, we focus on the most pervasive social determinants across the life course, and those that are common across major mental disorders. We draw primarily on the available evidence from the Global North, acknowledging that other global contexts will face both similar and unique sets of social determinants that will require equitable attention. Much of our evidence focuses on mental health in groups who are marginalized, and thus often exposed to a multitude of intersecting social risk factors. These groups include refugees, asylum seekers and displaced persons, as well as ethnoracial minoritized groups; lesbian, gay, bisexual, transgender and queer (LGBTQ+) groups; and those living in poverty. We then introduce a preventive framework for conceptualizing the link between social determinants and mental health and disorder, which can guide much needed primary prevention strategies capable of reducing inequalities and improving population mental health. Following this, we provide a review of the evidence concerning candidate preventive strategies to intervene on social determinants of mental health. These interventions fall broadly within the scope of universal, selected and indicated primary prevention strategies, but we also briefly review important secondary and tertiary strategies to promote recovery in those with existing mental disorders. Finally, we provide seven key recommendations, framed around social justice, which constitute a roadmap for action in research, policy and public health. Adoption of these recommendations would provide an opportunity to advance efforts to intervene on modifiable social determinants that affect population mental health.

1 plus 1 is more than 2: mental health problems, financial difficulties, and social exclusion in a cross-sectional study of 28,047 general-population adults

“…By emphasizing this relationship, our findings underscore the importance of addressing these interconnected challenges to mitigate the risk of social exclusion. Kirkbride et al [ 16 ] have emphasized the importance of intervening on modifiable social determinants that have an impact on mental health problems and suggested that prevention of social exclusion should start with social determinants to secure adequate living conditions and the economic foundation for social participation. Priebe [ 37 ] goes even further and writes (p. 1): “What should be done?…”

“…The directionality of this concept has been challenged by a contradictory representation, known as social causation. In this framework, the process starts with the challenges associated with living in poverty, characterized by economic strain with poor housing, work, and educational conditions and violence and insecurity [ 16 ]. These factors in turn drive behaviors such as the tendency to withdraw from social interaction [ 17 ], including social interaction with family and friends and from other forms of community involvement and participation [ 18 ].…”

“…However, studies regarding the causal direction between mental health problems and poverty’s different aspects are not conclusive [ 19 ]. Kirkbride et al [ 16 ] argue for a “bi-directional” relationship, even if they argument for social preventive measures in their article. This withdrawal is often interpreted outside of the social context as a symptom of a mental illness.…”

Case fatality of repeated suicidal acts among suicide attempters in rural China: a retrospective cohort study

“…In addition, social determinants closely associated with mental health outcomes. 30 Disadvantaged individuals are more vulnerable to mental health conditions, and socio-environmental factors including subcultural contexts and urban-rural difference also correlate with suicide method selection. Strategy focusing on reducing socio-economic inequalities should be a key component of suicide prevention.…”

Assocations of Common Mental Disorder Severity With Treatment Contact and Treatment Intensity, and Its Changes Over Twelve Years

“…To address the low rates of service use by people with mental disorders, the 2001 World Mental Health Report made ten recommendations, including making mental health treatment more accessible in GMC, making psychotropic drugs more available, educating the public more about mental health, and increasing and improving the training of MHC professionals [9]. As this call for action has been widely adopted [10,11], it is unsurprising that increasing treatment rates for CMDs have been found since [12,13]. However, studies providing up-to-date and more in-depth information on the associations of CMD severity with treatment contact and treatment intensity are lacking, while this knowledge is essential to guide resource allocation.…”