The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction. Dr.

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1 The Social Determinants of Mental Health: An Overview and Call to Action Ruth Shim, MD, MPH; Carol Koplan, MD; Frederick J.P. Langheim, MD, PhD; Marc W. Manseau, MD, MPH; Rebecca A. Powers, MD, MPH; and Michael T. Compton, MD, MPH Ruth Shim, MD, MPH, is Associate Professor, Department of Psychiatry and Behavioral Sciences; Associate Director, National Center for Primary Care, Morehouse School of Medicine. Carol Koplan, MD, is Adjunct Assistant Professor, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University. Frederick J.P. Langheim, MD, PhD, is Joint Director, Consultation and Liaison Psychiatry, St. Mary s Hospital; Staff Psychiatrist, Dean Health System; Clinical Adjunct Assistant Professor, University of Wisconsin, Madison. Marc W. Manseau, MD, MPH, is Public Psychiatry Fellow, Department of Psychiatry, Columbia University Medical Center, New York State Psychiatric Institute. Rebecca A. Powers, MD, MPH, is Adjunct Clinical Associate Professor of Psychiatry, Stanford University School of Medicine. Michael T. Compton, MD, MPH, is Chairman, Department of Psychiatry, Lenox Hill Hospital; Professor, Department of Psychiatry, Hofstra North Shore LIJ School of Medicine at Hofstra University. Address correspondence to: Ruth Shim, MD, MPH, National Center for Primary Care, Morehouse School of Medicine, 720 Westview Drive, Atlanta, GA 30310; rshim@msm. edu. Disclosure: The authors have no relevant financial relationships to disclose. doi: / The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction. Dr. Rudolph Virchow Mental disorders are among the most prevalent, chronic, and disabling health conditions; they touch the lives of all Americans in some way. 1 Although these disorders clearly have biological correlates, they are also substantially influenced by modifiable social, economic, and environmental conditions that affect not only individuals, but whole communities, neighborhoods, and populations. Historically, many theories have been postulated to help explain the origins of disease. During the 19th century, miasma theory attributed the causes of disease epidemics to bad air and led to a focus on public health interventions to improve living conditions of populations as a means of effectively limiting the incidence and prevalence of disease. 2 This theory, although later supplanted by the germ theory of disease, was one of the earliest conceptualizations supporting the role of social factors in causing and sustaining illnesses. Furthermore, miasma theory led to important public health interventions, such as urban sanitation Shutterstock 22 Healio.com/Psychiatry PSYCHIATRIC ANNALS 44:1 JANUARY 2014

2 systems. Although germ theory was mechanistically correct, it arguably heralded a shift from social to biological factors in disease causation and prevention. After the rise and fall of miasma theory, during the early- to mid-20th century, social causes were again commonly considered major factors in disease origin with regard to both physical and mental illnesses. Research studies during that time described the various social factors that contribute to the development of diverse mental disorders and conditions, such as schizophrenia and suicide. 3-5 However, with the advent of biological psychiatry, fueled by the 1990 s decade of the brain, the social causes of mental illnesses were downplayed in favor of discussions about the molecular and genetic risk factors, causes, and correlates of mental disorders. The shift toward biological psychiatry has led to many positive outcomes, including a decrease in stigma associated with some mental disorders, such as depression (but not necessarily with others, like schizophrenia). 6,7 Major advances have been made in genetics, imaging, neurobiology, and psychopharmacology. However, just as biological reductionism replaced ideas about social causation of disease in the 19th century, there has been a gradual movement away from scientific evaluation of the social and environmental processes that contribute to the development and persistence of mental disorders. As a result, enormous investments are currently being made to understand the neurobiology of mental disorders. Conversely, the social underpinnings of mental disorders are increasingly recognized by society but grossly under-studied and inadequately addressed. In the past, nature and nurture were often presented as two competing realms at odds; however, medical science is increasingly aware of the importance of the interplay between biology and the environment. Psychiatry stands poised to recognize the mutual interaction of both; that one cannot understand biology without understanding the socio-environmental context, and that the mechanisms underpinning social factors cannot be understood without considering neurobiology. The social underpinnings of mental disorders are increasingly recognized by society but grossly understudied. DEFINING THE SOCIAL DETERMINANTS OF MENTAL HEALTH The social determinants of health defined as those conditions in which people are born, grow, live, work, and age that impact health and well-being are known to have major influences on diverse health outcomes. Recent years have witnessed a burgeoning focus on the social determinants of poor physical health. Special consideration should also be given to the social determinants of mental health, which are not necessarily distinct from the social determinants of physical health, but which have been largely neglected, especially within the United States. They therefore deserve focused attention and emphasis. Underlying the concept of the social determinants of mental health is the importance of a population-based, public health approach in identifying and treating mental disorders. This approach, described in Mental Health: A Report of the Surgeon General, 8 focuses on mental disorders from the perspective of the population rather than the individual patient. This public health approach also emphasizes the prevention of mental illnesses and the promotion of mental health. The importance of the population health approach has been effectively illustrated by Thomas Freiden s 9 Health Impact Pyramid. The pyramid defines interventions with the greatest population health impact as those that change the context to make individuals default decisions healthier, as well as those that address socioeconomic factors. Interventions such as counseling, education, and clinical treatments, although effective, require increasing effort and yield less overall population impact. Those interventions that effectively address the social determinants of health have the greatest impact on entire populations. Such interventions focus on prevention rather than treatment by addressing risk factors, which precede and increase the likelihood of an illness or adverse outcome, and protective factors, which precede and buffer against the development of an illness or adverse outcome. The social determinants of mental health can be conceptualized as the root causes, or causes of the causes; that is, those societal factors that underpin and drive individual-level risk and protective factors for disease. 10,11 Previous research on the social determinants of physical health has advanced thinking about the social determinants of mental health. Link and Phalen 12 eloquently described social factors as the fundamental causes of disease and discussed their impact on overall health. Their pioneering work delineated the major influence that societal interventions could have on improving population health. Wilkinson and Marmot 11 assembled the clearest scientific evidence and outlined the specific role of public policy in addressing the social determinants of physical and mental health. Consistent with the tenets of Wilkinson s and Marmot s work, mental illnesses, like physical illnesses, have genetic underpinnings, but social determinants clearly have a role in both causation and course of mental disorders. Moreover, through social and policy interventions, the social determinants are clearly more modifiable than PSYCHIATRIC ANNALS 44:1 JANUARY 2014 Healio.com/Psychiatry 23

3 Figure 1. The social determinants of mental health. Figure courtesy of Michael T. Compton, MD, PhD; and Ruth Shim, MD, MPH. genetic determinants. The Commission on the Social Determinants of Health 13 described the importance of addressing the social determinants of health in order to achieve global health equity. With the firm foundation of Link and Phalen, Wilkinson and Marmot, the Commission, and others works, the field of psychiatry is poised to make great strides in re-examining and taking action on the social and environmental factors that contribute to the development and persistence of mental disorders. Our nation s mental health and burden of mental disorders are partly driven by policies pertaining to our basic rights and opportunities (eg, food, education, employment, and energy), our surroundings (eg, neighborhood characteristics and housing), and the nature of our social fabric (eg, social connectedness, access to health care, and equal opportunity for political voice). In examining the social determinants of mental health (Figure 1), it is important to consider those determinants experienced at the individual level (eg, adverse early life experiences; poor social support and lack of connectedness; and social exclusion based on race, ethnicity, sexual orientation, or disability) as well as social determinants deriving from the societal/political milieu (eg, poverty and income inequality, low education, unemployment, housing instability, food insecurity, and adverse features of the built environment). Health equity, or the absence of health disparities, is of central importance when considering the social determinants of health. 14 Social determinants are the main drivers of health disparities, which are defined by the World Health Organization as differences in health which are not only unnecessary and avoidable, but, in addition, are considered unfair and unjust. 13 In addition, racial, ethnic, socioeconomic, and geographic disparities in health care are responsible for poor health outcomes across a number of illnesses, including cardiovascular disease, diabetes, and asthma In terms of mental and substance use disorders, disparities in prevalence persist across a wide range of conditions, as do disparities in access to care, quality of care, and overall burden of disease. 18 The elimination of disparities in health care has been a high priority in the U.S., as emphasized in Healthy People 2020, the Health and Human Services Action Plan to Reduce Racial and Ethnic Disparities, and the Patient Protection and Affordable Care Act. 19 Addressing the social determinants of physical and mental health can also mitigate disparities suffered by those with serious mental illnesses and holds potential for ameliorating poor outcomes in this population. This includes major problems in social functioning, unparalleled and unjust societal stigma, poor access to care, diverse comorbidities, and, shockingly, a reduced lifespan of up to 25 years on average. 8,18,20 It is important to note that the social determinants of mental health are shaped by the distribution of money, power, and resources, both worldwide and in the U.S. 13 Therefore, when considering social determinants, we cannot ignore major dilemmas that we face as a society in terms of how we choose to distribute power and formulate economic policies. Society has a role in determining how we address mental health inequities, including lack of insurance coverage parity, limited financial investments in mental health care, and failure to provide adequate care for individuals 24 Healio.com/Psychiatry PSYCHIATRIC ANNALS 44:1 JANUARY 2014

4 with serious mental illnesses. These issues are a direct result of politics and the political agendas in our society, such as hot-button issues pertaining to access to and availability of firearms, drugs, cigarettes, and alcohol; access to healthy foods; and whether society chooses to provide services and support for its poorest and most vulnerable citizens. ADDRESSING THE SOCIAL DETERMINANTS OF MENTAL HEALTH Addressing the social determinants of mental health requires taking an approach distinct from the typical clinical interventions of psychiatrists and other mental health professionals in everyday practice. One-on-one interventions, such as counseling and education, can be employed, but doing so yields less overall population impact. On an individual patient basis, mental health clinicians can begin to address risk factors stemming from the social determinants of mental health by identifying the family/social network, economic, and environmental factors that influence illness and hinder positive patient outcomes. Educating patients on how these factors can lead to poor mental health may lead to some gains through changes in individual decision-making and health behaviors. Similarly, prescriptions that move beyond medications can be employed in the management of individual patients. Innovative programs like Health Leads, which allows physicians to prescribe resources such as healthy food, housing, and economic assistance to patients, can help providers begin to tackle the social determinants in a more direct way within their clinics and waiting rooms. 21 Despite the possibility of progress being made through counseling, education, and clinical interventions, these approaches have relatively small impact on overall population health. The best way to make an impact on the social determinants of mental health is through action at the policy level. Mental health providers can advocate within the health care system, but also at the community, state, and federal levels, for policies that lead to a healthier society. Psychiatrists and other mental health clinicians can provide their expertise and knowledge and actively participate in political discourse in order to advocate for policies Countries that have assigned high policy priority to the social determinants of health have significantly improved health outcomes over time. that promote mental health and wellness. Psychiatrists cannot be bystanders or remain neutral during these debates. 22 Countries that have assigned high policy priority to the social determinants of health (eg, the United Kingdom, Australia, and Scandinavian countries) have significantly improved health outcomes over time. These countries have specific policy plans to ensure that children have the best opportunities for physical and emotional health from the beginning of their lives, that adults have fair employment and can live in healthy and safe communities, and that all individuals have a healthy standard of living. 23 Taken together, these principles encourage mental health professionals to take an active role in advocating for policies that improve the living conditions in their own communities, as well as the communities of their patients. In addition, mental health care providers can work to enhance their understanding of mental illness prevention and mental health promotion, and to collaborate across sectors to address inequities on a population level. 24 Medical schools and psychiatry residency training programs also have a responsibility to take a comprehensive, biopsychosocial approach to the evaluation and treatment of mental disorders. 25 They should provide training in prevention. 26 By educating future psychiatrists on the principles of mental illness prevention and mental health promotion, educators themselves can help to increase awareness and take action on the social determinants of mental health. CONCLUSIONS Increasing our knowledge and understanding of the social determinants of mental health could lead to significant mental health gains by focusing on an area that has not received sufficient attention, but that could have a major public health impact. Now is the time for mental health professionals, who possess previously untapped influence on both health-related policies and general policies in the U.S., to take action to address the social determinants of mental health. In doing so, we can improve mental health and overall health outcomes for all. We challenge mental health providers to increase their awareness of the social determinants of mental health, as a matter of mental health promotion and social justice. REFERENCES 1. Kessler RC, Zhao S. The prevalence of mental illness. In: Horwitz AV, Scheid TL, eds. Handbook of the Sociology of Mental Health: Social Contexts, Theories, and Systems. 2nd ed. Cambridge, England: Cambridge University Press; 2010: Susser M. Does risk factor epidemiology put epidemiology at risk? Peering into the future. J Epidemiol Community Health. 1998;52(10): Durkheim E. Suicide: A Study in Sociology (JA Spaulding & G Simpson, Trans.). Glencoe, IL: Free Press. 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