Revitalizing the role of social determinants in mental health
Amidst long arcs of the pendulum between attention to psychosocial and neurobiological factors in mental health, substantive progress now depends on these two approaches being seen as complementary and synergistic rather than contradictory. From this launchpad, Kirkbride et al's paper1 is an impressive, high-level and up-to-date overview regarding the role of social determinants in mental health and disorders. Perhaps most helpfully, it highlights a series of complexities worth reflecting on as the field moves towards a more sophisticated understanding of the interpenetrating effects of social determinants, and to generating and actioning relevant interventions.
A first challenge is the false dichotomy between primary and secondary/tertiary prevention strategies. Primary prevention can be a powerful route to addressing social determinants, but is often not the only one. As a result, primary and secondary approaches ought to be seen as interdependent instead of oppositional2. Delivery of effective primary prevention schemes should result in reduced need for secondary/tertiary prevention (albeit perhaps staggered or delayed), yet there will still be a need for clinical and service innovations to better address breakthrough cases and suffering. For example, a sizable proportion of young people presenting to community-based early intervention services appear to have more complex needs than might have initially been anticipated or planned for3. Despite the best of intentions, some youth may even be underserved in such settings, underscoring the urgency behind having a full suite of options across the entire continuum of care, and smooth pathways between the various layers of a mental health system4.
Second, psychiatry has historically become tangled – and at times knotted – around the question of whether poor mental health influences social circumstances or vice versa5. However, Kirkbride et al argue that, even without a granular accounting of each mechanistic link in complex causal chains, we now understand a fair bit regarding how to potentially break relevant feedback loops. Direct genetic and neurobiological factors, identified in impressive and rigorous studies, are at present mostly unmalleable and thus far account for only a small proportion of the population-attributable risk fraction across a range of mental health conditions. In contrast, putative social interventions or policy levers aimed at sensitive periods of development (to which biology undoubtedly contributes) certainly exist, and can at the very least be conceptualized and tested6, for a number of reasonably well-established social determinants – ranging from early years programs to neighborhood regeneration all the way through to indicated prevention strategies in clinical settings. And since so many of the social determinants are held in common across mental and even physical health conditions, interventions based on these variables are likely to have a slew of benefits. This is a critical corollary to Rose's prevention paradox: although the force required to shift the population curve may be intimidating compared to an approach that focuses on high-risk groups alone, the former may nonetheless have outsized and favourable ripple effects on both mental health as well as other aspects of health and well-being.
Kirkbride et al's paper compellingly suggests that this should be a central rationale for renewing the attention given to social determinants across primary and secondary prevention paradigms. Nowhere is this better illustrated than in their depiction of poverty, its cascading effects across the life course, and how intervention strategies that push poverty alleviation to the sidelines may therefore be destined for failure. There is little question, then, that those interested in addressing social determinants of mental health must appreciate not only individual risk factors, but the underlying causal structures through which risk manifests.
The wide-ranging ways in which inequality and poverty exert their direct and indirect effects also means that discrete interventions cannot be considered in isolation. Rather, they accentuate the need for social determinants of mental health to be addressed by coordinated interventions across layers of causal structure (including individual, interpersonal, institutional and structural) that are also purposefully designed to reach across policy domains. In the case of mental health, there is a porous boundary between preventive interventions and social/educational policy, such that the lens should be one of integrated public policy and not just health policy. Indeed, given the disability and indirect costs associated with mental health problems and disorders, their onset during youth and their persistence if untreated, a “whole of government” approach akin to that taken during other crises may be indicated and even necessary.
Finally, Kirkbride et al allude not just to the need for further investment in interventions and population health monitoring, but also to ongoing investigations regarding their effects. In part this is because interventions are not without risk and may have unintended consequences, including iatrogenic ones7. And, even when beneficial, potential interventions should be seen in their social context and recognized as having limits. For example, although specific migration exposures are widely acknowledged to be risk factors for psychosis, making reactive policy changes (such as eliminating immigration) based on this would be untenable as well as discriminatory. Instead, the key question is how public policy can benefit from dialogue between theorists, empiricists and policy practitioners to – among other things – appreciate that immigration may represent a proxy for underlying exposures and stressors; posit potential mechanisms across biological, psychological and social levels of causation; and then plan and test interventions that reduce risk, promote integration, and advance implementation. The optimal strategies will likely involve capturing diverse and patient-oriented outcomes, discerning the structures through which social conditions and outcomes emerge and are interwoven, and perceiving the widespread benefits of inclusive and equity-oriented policies.
More than anything, Kirkbride et al's depiction of the current state-of-the-art represents a call for creativity and investment to address the social determinants of mental health. If inequality harms8, then the current chasms between demonstrated need, the required multi-sectoral engagement, and concerted action on social factors affecting the mental health of individuals, communities and populations is deeply unsettling. It is also one of a range of contemporary dilemmas that – like climate change and diminishing economic opportunities – will particularly affect young people, the future of any society. Whether due to recent crises that have temporarily prevented new solutions from being born, or the longer-term hollowing out of government expertise and capacity9, the energy to catalyze integrative approaches to such a far-reaching challenge seems to have come to a lull. It now demands sustained renewal and revitalization.
