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“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 disor-ders clearly have biological correlates, they are also substantially influenced by modifiable social, economic, and envi-ronmental 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, mi-asma theory attributed the causes of dis-ease 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 in-cidence 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, mias-ma theory led to important public health interventions, such as urban sanitation

Ruth Shim, MD, MPH, is Associate Professor,

Department of Psychiatry and Behavioral Sci-

ences; Associate Director, National Center for

Primary Care, Morehouse School of Medicine.

Carol Koplan, MD, is Adjunct Assistant Profes-

sor, Department of Behavioral Sciences and

Health Education, Rollins School of Public

Health, Emory University. Frederick J.P. Lang-

heim, MD, PhD, is Joint Director, Consultation

and Liaison Psychiatry, St. Mary’s Hospital;

Staff Psychiatrist, Dean Health System; Clini-

cal 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 Clini-

cal Associate Professor of Psychiatry, Stan-

ford University School of Medicine. Michael

T. Compton, MD, MPH, is Chairman, Depart-

ment of Psychiatry, Lenox Hill Hospital; Pro-

fessor, Department of Psychiatry, Hofstra

North Shore – LIJ School of Medicine at Hof-

stra University.

Address correspondence to: Ruth Shim,

MD, MPH, National Center for Primary Care,

Morehouse School of Medicine, 720 Westview

Drive, Atlanta, GA 30310; email: rshim@msm.

edu.

Disclosure: The authors have no relevant

financial relationships to disclose.

doi: 10.3928/00485713-20140108-04

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

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PSYCHIATRIC ANNALS 44:1 | JANUARY 2014 Healio.com/Psychiatry | 23

systems. Although germ theory was mechanistically “correct,” it arguably heralded a shift from social to biological factors in disease causation and preven-tion. After the rise and fall of miasma theory, during the early- to mid-20th cen-tury, social causes were again common-ly considered major factors in disease origin with regard to both physical and mental illnesses. Research studies during that time described the various social fac-tors 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 men-tal illnesses were downplayed in favor of discussions about the molecular and ge-netic risk factors, causes, and correlates of mental disorders.

The shift toward biological psychia-try has led to many positive outcomes, including a decrease in stigma associ-ated 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 psycho-pharmacology. However, just as biologi-cal reductionism replaced ideas about social causation of disease in the 19th century, there has been a gradual move-ment away from scientific evaluation of the social and environmental processes that contribute to the development and persistence of mental disorders. As a re-sult, enormous investments are currently being made to understand the neurobi-ology of mental disorders. Conversely, the social underpinnings of mental dis-orders are increasingly recognized by society but grossly under-studied and inadequately addressed. In the past, na-ture 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 in-

teraction of both; that one cannot under-stand biology without understanding the socio-environmental context, and that the mechanisms underpinning social factors cannot be understood without considering neurobiology.

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 physi-cal health. Special consideration should also be given to the social determinants of mental health, which are not necessar-

ily 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 im-portance of a population-based, public health approach in identifying and treat-ing mental disorders. This approach, described in Mental Health: A Report of the Surgeon General,8 focuses on men-tal disorders from the perspective of the population rather than the individual pa-tient. 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 il-lustrated by Thomas Freiden’s9 Health

Impact Pyramid. The pyramid defines interventions with the greatest popula-tion health impact as those that change the context to make individuals’ default decisions healthier, as well as those that address socioeconomic factors. Inter-ventions such as counseling, education, and clinical treatments, although effec-tive, 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 out-come, and protective factors, which pre-cede 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 soci-etal factors that underpin and drive in-dividual-level risk and protective factors for disease.10,11

Previous research on the social de-terminants of physical health has ad-vanced thinking about the social de-terminants of mental health. Link and Phalen12 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 so-cietal interventions could have on im-proving population health. Wilkinson and Marmot11 assembled the clearest scientific evidence and outlined the spe-cific role of public policy in address-ing the social determinants of physical and mental health. Consistent with the tenets of Wilkinson’s and Marmot’s work, mental illnesses, like physical ill-nesses, 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 determi-nants are clearly more modifiable than

The social underpinnings of mental disorders are

increasingly recognized by society but grossly under-

studied.

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genetic determinants. The Commission on the Social Determinants of Health13 described the importance of addressing the social determinants of health in or-der to achieve global health equity. With the firm foundation of Link and Phalen, Wilkinson and Marmot, the Commis-sion, and others’ works, the field of psy-chiatry is poised to make great strides in re-examining and taking action on the social and environmental factors that contribute to the development and per-sistence of mental disorders.

Our nation’s mental health and burden of mental disorders are partly driven by policies pertaining to our ba-sic rights and opportunities (eg, food, education, employment, and energy), our surroundings (eg, neighborhood characteristics and housing), and the na-

ture of our social fabric (eg, social con-nectedness, access to health care, and equal opportunity for political voice). In examining the social determinants of mental health (Figure 1), it is im-portant to consider those determinants experienced at the individual level (eg, adverse early life experiences; poor so-cial support and lack of connectedness; and social exclusion based on race, eth-nicity, sexual orientation, or disability) as well as social determinants deriving from the societal/political milieu (eg, poverty and income inequality, low education, unemployment, housing in-stability, food insecurity, and adverse features of the built environment).

Health equity, or the absence of health disparities, is of central impor-tance when considering the social deter-

minants 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 consid-ered unfair and unjust.”13 In addition, racial, ethnic, socioeconomic, and geo-graphic disparities in health care are responsible for poor health outcomes across a number of illnesses, includ-ing cardiovascular disease, diabetes, and asthma.15-17 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 dispari-ties in health care has been a high prior-ity 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 mit-igate disparities suffered by those with serious mental illnesses and holds po-tential for ameliorating poor outcomes in this population. This includes major problems in social functioning, unparal-leled and unjust societal stigma, poor ac-cess 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 so-cial determinants of mental health are shaped by the distribution of money, power, and resources, both worldwide and in the U.S.13 Therefore, when con-sidering social determinants, we cannot ignore major dilemmas that we face as a society in terms of how we choose to distribute power and formulate econom-ic policies. Society has a role in deter-mining how we address mental health inequities, including lack of insurance coverage parity, limited financial invest-ments in mental health care, and failure to provide adequate care for individuals

Figure 1. The Social Determinants of Mental Health

Figure 1. The social determinants of mental health.

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PSYCHIATRIC ANNALS 44:1 | JANUARY 2014 Healio.com/Psychiatry | 25

with serious mental illnesses. These is-sues 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 ap-proach 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 em-ployed, but doing so yields less overall population impact. On an individual pa-tient 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 hin-der positive patient outcomes. Educat-ing patients on how these factors can lead to poor mental health may lead to some gains through changes in individ-ual decision-making and health behav-iors. 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 re-sources such as healthy food, housing, and economic assistance to patients, can help providers begin to tackle the social determinants in a more direct way with-in their clinics and waiting rooms.21

Despite the possibility of progress being made through counseling, educa-tion, and clinical interventions, these ap-proaches have relatively small impact on overall population health. The best way to make an impact on the social deter-minants of mental health is through ac-

tion 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 dis-course in order to advocate for policies

that promote mental health and well-ness. 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, Aus-tralia, 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 employ-ment and can live in healthy and safe communities, and that all individuals have a healthy standard of living.23

Taken together, these principles en-courage mental health professionals to take an active role in advocating for policies that improve the living condi-tions 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 men-tal 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 com-prehensive, biopsychosocial approach to the evaluation and treatment of mental

disorders.25 They should provide train-ing in prevention.26 By educating future psychiatrists on the principles of mental illness prevention and mental health pro-motion, educators themselves can help to increase awareness and take action on the social determinants of mental health.

CONCLUSIONSIncreasing our knowledge and un-

derstanding of the social determinants of mental health could lead to signifi-cant 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 gen-eral policies in the U.S., to take action to address the social determinants of mental health. In doing so, we can im-prove mental health and overall health outcomes for all. We challenge mental health providers to increase their aware-ness of the social determinants of mental health, as a matter of mental health pro-motion and social justice.

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