Deconstructing the social determinants of mental health
Social factors have an important impact on the onset of and recovery from mental illness1. Where individuals live, how they live and what factors impinge on their living, including their access to nutrition, to housing, to recreation, as well as their pattern of interactions with other people around them, have consequences and relevance for their emotions and behaviours.
The fact that humans are social beings implies that, for most people, well-being depends on the totality of the social environment in which they live. It is useful and informative that research has sought to disaggregate the components of that environment and focus attention on specific aspects. But the reality is that not one social factor can exert its impact on health, including mental health, without the influence of several other factors. Indeed, in poor or low-resourced communities, where the living context is marked by multiple deprivations and interconnected social, physical and mental health problems, as well as by the intergenerational transmission of those syndemics2, the particular role of a given social factor in the onset or course of a mental health condition is difficult to isolate clearly. An acknowledgement of this conceptual complexity is therefore necessary, although the practical necessity of focusing on particular aspects as if they were operating in isolation is understandable.
As highlighted in the paper by Kirkbride et al1, the available body of knowledge suggests that the link between social factors and mental illness is rarely direct, even when factors as easily understood as poverty and economic disadvantage are those of interest. Furthermore, much of the evidence exploring the relationships of social factors with mental health has been provided by studies conducted in the Global North. Widening our exploration to diverse social, economic and cultural settings is likely to deepen our understating. Even though there is now a growing interest in the topic in the Global South3, studies with a focus on the social determinants of mental health from low- and middle-income countries need to be pursued more vigorously.
Social factors exist and manifest within cultural and traditional milieus. For example, while the relationship between gender equality and the gender-patterning of the distribution of some men-tal disorders is complex, culture may be an important driver of this complexity. Actually, the traditional and cultural position of women is relevant to whether gender inequality will be an important determinant of the distribution of some mental disorders. Cultural variations also exist in the way that families are composed, in the social position of the young and the elderly, and in the organization of and power distribution within households.
The fact that some of these social factors are also undergoing rapid changes in many countries, especially in low- and middle-income ones, introduces another layer of complexity to the relationship between social factors and health in general, and mental health in particular. In many countries, the traditional composition of families is changing from extended to nuclear, and so is the status of the elderly. Some of these changes are being driven by economic pressures as well as by unrelenting, and sometimes unplanned, urbanization. In these contexts, the urban drift of the young is leaving many elderly persons behind in towns and villages, increasing their risk of isolation and loneliness4. For such elderly persons, rural living is no longer a haven of serenity and peace, but rather a source of neglect and alienation.
The interpretation of the links between social factors and mental illness is further complicated by differences between objective and subjective assessments. In fact, the ambiguity of the findings concerning the link between low income and common mental disorders may be due to the fact that relative rather than absolute poverty is a predictor of mental illness when other factors are taken into account5. A similar caveat is required when interpreting the association between subjective or relative social status and mental health6. Indeed, one could argue that this is the basis of the paradoxical finding, in a number of population surveys, of a lower prev-alence of mental disorders in poorer than in richer countries. The meaning attached to a social factor or circumstance by an individual can be presumed to, at least in part, determine what coping and adaptation mechanisms will be available and deployed to meet adversities and other challenges to mental health.
Social factors are as important to the causation of mental disorders as they are to the recovery from them. The immediate source of support in times of ill health is often the family. The composition and size of a household are culturally determined, and are relevant to the immediacy of the availability of support to an individual when in need. In some communities, the relevant social network may also include non-family groups such as those available in places of worship and markets7. It is possible that these social groups pose challenges to an individual's mental health just as they may be available to provide various forms of instrumental and emotional support to help mitigate the effects of adversities. Whether the risks posed by a particular social network to the mental health of an individual outweigh the potential benefits may be related to the complex interplay of a variety of social and cultural factors.
What is the role of the understanding of social determinants of mental illness for planning of evidence-based interventions? Our understanding of the neurobiology of psychiatric conditions remains limited, in spite of the great strides in the study of the brain. Preventing or treating mental disorders continues to rely on blunt biopsychosocial tools that are limited in their capacity to deliver contextualized approaches. It is therefore evident that, as we seek to have a broader and deeper understanding of social determinants of mental health8, an important focus must be the need to design interventions that include context-informed social prescribing. That should also be a good fit for comprehensive mental health promotion and prevention strategies9.
