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 Table of Contents  
Year : 2019  |  Volume : 35  |  Issue : 3  |  Page : 155-157

Social determinants of mental health – Let's not lose the impetus this time!

1 Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication30-Sep-2019

Correspondence Address:
Dr. Debasish Basu
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijsp.ijsp_88_19

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How to cite this article:
Nebhinani N, Basu D. Social determinants of mental health – Let's not lose the impetus this time!. Indian J Soc Psychiatry 2019;35:155-7

How to cite this URL:
Nebhinani N, Basu D. Social determinants of mental health – Let's not lose the impetus this time!. Indian J Soc Psychiatry [serial online] 2019 [cited 2022 Aug 16];35:155-7. Available from: https://www.indjsp.org/text.asp?2019/35/3/155/268345

“Why treat people only to send them back to the conditions that made them sick in the first place” and “Reducing health inequities is an ethical imperative, while social injustice is killing people on a grand scale.” In 2008, the World Health Organization (WHO) Commission on the Social Determinants of Health made these statements in their final report.[1]

Ninety percent of health determinants derive from social and physical environments; therefore, we can achieve better physical and mental health by looking beyond the traditional medical model, thorough understanding of these factors, and appropriate social interventions.[2]

“Social determinants of health/mental health and access to care” is the theme of the 23rd World Congress of Social Psychiatry to be held in Bucharest, Romania, October 25–28, 2019. In this era of globalization and commercialization, social determinants of mental health are not addressed adequately, despite substantial developments in all other fields. Thus, it is a very timely and appropriate theme.

The WHO has defined social determinants of health as “the circumstances in which people are born, grow up, live, work, and age and the system put in place to deal with illness, which is shaped by with various social, economic and political factors and by access to resources like safe environment, education, and health.”[1]

Mental health is defined by the WHO as “a state of wellbeing in which individual realizes own abilities, can cope with the normal stressors of life, can work productively and fruitfully and is able to make positive contribution to the community.”

Inclusion of mental health care in universal health coverage is widely mentioned in the Sustainable Development Goal-3 (SDG-3), as endorsed by the United Nations member states in 2015. Demographic, economic, neighborhood, environmental, social, and cultural domains of the social determinants of mental disorders are included in SDGs.[3] The WHO employs the life course approach to depict how mental health problems cumulatively affect socioeconomic status and other social determinants.[4]

Social determinants of mental illness include poverty, poor education, poor housing, adverse experiences in early age, food insecurity, unemployment, discrimination, and limited access to health care.[2] Social determinants are key factors in the causation, severity, course, and outcome of mental health problems.[5] Therefore, emphasis on social determinants of mental health is vitally important to understand social perspective of mental health and illness and interaction of biology and psychology with external environment, to implement social interventions for mental health promotion and comprehensive management of mental illness, and also to design population-level interventions to tackle these social determinants of mental health.[6]

Social and environmental factors affect mental illness through their independent or combined effect on illness causation, poorer course and outcome as well as through gene–environment interaction (epigenetic modifications).[7]

Bidirectional association exists between social determinants and mental health, as social determinants affect mental health and on the other side mental illness also affects social determinants as poor mental health affects personal choices as well as living conditions that further limit opportunities.[4],[8] Similarly, the bidirectional association of poverty and psychiatric disorders is complex from childhood to older age and characterized by social causation and social drift.[9]

Children exposed to adverse experiences have a greater risk for various psychological (drug abuse, depression, and suicidal behavior) and physical disorders (e.g., cancer, ischemic heath disease, lung, liver, and sexually transmitted disease). Therefore, to obviate subsequent morbidity and social burden, we should focus on timely intervention at social and societal levels.[2]

Value of social relationships is termed as “social capital,” which explains the effects of social environment on health. In a population-based study in Chandigarh, Kaur et al. found socioeconomic status as a significant predictor of physical and mental health and social capital significantly mediated the effect of socioeconomic status on mental health.[10]

Brinda et al. analyzed the data of the WHO study on global aging from six large low- and middle-income countries and reported a 4.7% prevalence of geriatric depression. Risk factors for depression were reported as female gender, illiteracy, poverty, indebtedness, and bereavement, while pension support and health insurance showed a protective role on geriatric depression.[11]

In a population-based survey in Vidarbha, Shidhaye et al. found female gender, higher age, lower education, indebtedness, and economic status below poverty line as the correlates of depression.[12] Panigrahi et al. reported the following social determinants of common mental disorders in married women residing in slum areas of Bhubaneswar: lack of time to attend social obligations and religious services, drug abuse in family members, and frequent quarrels and disharmony on domestic financial affairs.[13] Bala et al. reported a substantial impact of social determinants of health such as drug dependence and psychological distress on physical and mental health of urban construction workers in Hyderabad.[14]

To further emphasize on Indian scenario, the National Mental Health Policy of India (2014) highlighted on social determinants of mental health with following objectives: to provide universal access to mental health care; to increase access to and utilization of comprehensive mental health services by persons with mental illness and for vulnerable groups; to reduce prevalence and impact of risk factors associated with mental health problems; to ensure respect for rights and protection from harm of persons with mental illness; to reduce stigma associated with mental illness; and to identify and address the social, biological, and psychological determinants of mental illness and to provide appropriate interventions.[15]

On the same line, the recently enacted Mental Health Care Act of India also expanded the rights of persons with mental illness like to access mental health care; community living, protection from cruel, inhuman, and degrading treatment; equality and nondiscrimination; and right to information, confidentiality, legal aid, etc.[16]

To have a look at the morbidity data, the National Mental Health Survey of India (2015–2016) reported a 13.7% prevalence for lifetime mental morbidity and 10.6% for current mental morbidity with striking difference in prevalence rates across the centers possibly due to social determinants (the lowest lifetime prevalence of 8.1% in Assam and the highest 19.9% in Manipur). Unfortunately, the treatment gap of 85% for common mental disorder is very much concerning.[17]

There is a vital need to prioritize mental health promotion, prevention, and effective treatment of mental disorders through multipronged, life course approach to address social determinants of health in which people are born, grow, live, work, and age. To effectively address the needs of people, it is important to design promotive mental health interventions to be universal yet calibrated proportionately to the level of disadvantage.[4]

Interruption of negative cycles of social determinants (e.g., poverty, violence, poor housing, and education) and mental disorders is possible through coordinated global efforts by all stakeholders in economic, environmental, social, and cultural domains. Multisectoral interventions should be aimed at individual, family, system (e.g., education, health, and community living) and macro (e.g., economic, policy, and political) levels.[4],[18]

Mental health professionals should treat the whole person in a comprehensive manner, not just the illness.[8] To improve global mental health, we should look beyond the traditional medical model of care by advocating and adopting appropriate policies to address the social determinants of mental health.[5],[7]

Further multicentric, longitudinal studies should focus on understanding the pathways through which social determinants influence mental health and also to find effective strategies to address those factors and to reduce their negative effects.[19]

To conclude, several international organizations are drafting guidelines and policies on social determinants of mental health as there are encouraging indications for these determinants and growing evidence for social interventions that can improve global mental health in true sense. We have to buttress that this is nothing new – people have been talking about it for ages, but the theme gets repeatedly lost due to political, economic, biological, and other factors. It is a good time to recommit ourselves to research and advocacy in this area and the time is ripe – this time we must hold on to the focus and let not lose the impetus.

  References Top

World Health Organization. Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Geneva: World Health Organization; 2008.  Back to cited text no. 1
United Nations. General Assembly. Resolution A/RES/70/1 – Transforming our World: the 2030 Agenda for Sustainable Development. New York, NY: United Nations; 2015.  Back to cited text no. 2
Lund C, Stansfeld S, De Silva M. Social determinants of mental health. In: Patel V, Minas H, Cohen A, Prince MJ, editors. Global Mental Health: Principles and Practice. 1st ed. New York: Oxford University Press; 2013. p. 16-136.  Back to cited text no. 3
Sederer LI. The social determinants of mental health. Psychiatr Serv 2016;67:234-5.  Back to cited text no. 4
Compton MT, Shim RS. The social determinants of mental health. Focus 2015;13:419-25.  Back to cited text no. 5
Shim RS, Compton MT. Addressing the social determinants of mental health: If not now, when? If not us, who? Psychiatr Serv 2018;69:844-6.  Back to cited text no. 6
Alegría M, NeMoyer A, FalgÁ s Bagué I, Wang Y, Alvarez K. Social determinants of mental health: Where we are and where we need to go. Curr Psychiatry Rep 2018;20:95.  Back to cited text no. 7
Lund C, Brooke-Sumner C, Baingana F, Baron EC, Breuer E, Chandra P, et al. Social determinants of mental disorders and the sustainable development goals: A systematic review of reviews. Lancet Psychiatry 2018;5:357-69.  Back to cited text no. 8
Silva M, Loureiro A, Cardoso G. Social determinants of mental health: A review of the evidence. Eur J Psychiatry 2016;30:259-92.  Back to cited text no. 9
Kaur M, Chakrapani V, Newtonraj A, Lakshmi PV, Vijin PP. Social capital as a mediator of the influence of socioeconomic position on health: Findings from a population-based cross-sectional study in Chandigarh, India. Indian J Public Health 2018;62:294-8.  Back to cited text no. 10
[PUBMED]  [Full text]  
Brinda EM, Rajkumar AP, Attermann J, Gerdtham UG, Enemark U, Jacob KS. Health, social, and economic variables associated with depression among older people in low and middle income countries: World Health Organization study on global AGEing and adult health. Am J Geriatr Psychiatry 2016;24:1196-208.  Back to cited text no. 11
Shidhaye R, Gangale S, Patel V. Prevalence and treatment coverage for depression: A population-based survey in Vidarbha, India. Soc Psychiatry Psychiatr Epidemiol 2016;51:993-1003.  Back to cited text no. 12
Panigrahi A, Panigrahi M, Padhy AP, Das SC. Common mental disorder and its socio-demographic correlates among married women residing in slum areas of Bhubaneswar, India. Women Health 2017;57:521-33.  Back to cited text no. 13
Bala S, Valsangkar S, Lakshman Rao RL, Surya Prabha ML. Impact of social determinants on well-being of urban construction workers of Hyderabad. Indian J Occup Environ Med 2016;20:10-3.  Back to cited text no. 14
[PUBMED]  [Full text]  
Ministry of Health & Family Welfare, Government of India. National Mental Health Policy of India: New Pathways, New Hope. Ministry of Health and Family Welfare, Government of India; 2014. Available from: https://www.nhp.gov.in/sites/default/files/pdf/national%20mental%20health%20policy%20of%20india%202014.pdf. [Last accessed on 2019 Aug 25].  Back to cited text no. 15
The Mental Health Care Act; 2017. Available from: https://www.prsindia.org/uploads/media/Mental%20Health/Mental%20Healthcare%20Act,%202017.pdf. [Last accessed on 2019 Aug 25].  Back to cited text no. 16
Murthy RS. National mental health survey of India 2015-2016. Indian J Psychiatry 2017;59:21-6.  Back to cited text no. 17
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World Health Organization and Calouste Gulbenkian Foundation. Social Determinants of Mental Health. Geneva: World Health Organization; 2014.  Back to cited text no. 18
Bell R, Donkin A, Marmot M. Tackling Structural and Social Issues to Reduce Inequities in Children's Outcomes in Low-To Middle Income Countries. Office of Research Discussion Paper No. 2013-02. Florence: UNICEF Office of Research; 2013.  Back to cited text no. 19

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