While the role of social determinants in shaping mental health outcomes has long been recognized, a recent paper by Crick Rand of King’s College London and the University of Cape Town highlights the impact on global mental health outcomes. This highlights the urgent need to reconsider interventions.
Traditional approaches, primarily psychological and pharmacological in nature, are increasingly criticized for not adequately addressing the complex social determinants that influence mental health outcomes. These criticisms have been particularly vocal from those who are skeptical of the global mental health movement, with some arguing that it overemphasizes Western-style treatments for the world’s diverse populations.
“The overwhelming evidence regarding the negative and interactive effects of social determinants on mental health raises the question of how we can intervene to address social determinants of mental health.” “is important not only from a clinical perspective, but also as a means of preventing mental health conditions. It is also important for social justice reasons,” Lund wrote.
“The great inequality in the distribution of wealth (in the past two years, the richest 1% of the world’s population has earned twice as much as the rest of the world), the looming reality of climate change, and the war caused by Given the ongoing humanitarian crisis and the human suffering that conflict causes, conflict should not be allowed to continue. In short, there are essential reasons and means to address the social determinants of mental health. The essential reason is that addressing social determinants such as poverty, climate change, conflict, and child abuse is a concern for social justice. These social decisions Addressing the factors can be hugely beneficial, especially for vulnerable populations, as it can have massive mental health benefits.”
Social determinants include social and economic circumstances that significantly influence the occurrence and intensity of mental health conditions. These factors range from social structures that favor or disadvantage particular groups to personal experiences with trauma and resulting vulnerabilities and strengths.
Professor Lund’s research emphasizes the importance of five major areas of social determinants: demographics, economics, neighborhoods, environmental events, and society/culture. His findings suggest that truly addressing mental health challenges requires a holistic approach that goes beyond traditional psychological and pharmacological methods and integrates these areas. doing.
Recognizing these multifaceted challenges, academies of medicine and interacademy partnerships convened in 2019 to outline potential interventions. These proposals ranged from reducing gender-based violence to urban renewal initiatives, from improving disaster response to strategies to strengthen social capital and education.
However, while promising, these interventions face challenges, particularly in low- and middle-income countries. It requires interdisciplinary collaboration, an understanding of a wide range of socio-economic determinants, international collaboration, and a move away from traditional treatment-focused research.
Potential approaches to addressing social determinants of mental health
Building a theoretical model: Addressing the social determinants of mental health requires establishing theoretical models that outline the causal mechanisms. One approach is a “theory of change” model that involves diverse stakeholders. It not only determines the causal relationships of hypotheses leading to desired outcomes, but also incorporates various theories such as ‘program theory’, ‘middle range theory’, and even broader concepts such as Amartya Sen’s human performance theory. I’m here.
Test mechanism: Once theoretical models have been constructed, the next step is to validate the specified mechanisms within these models. Conducting a randomized controlled trial with mediation analysis allows us to pinpoint which variables act as mediators between an intervention and its outcome. This detailed analysis helps refine interventions. As an example, if cash transfers to refugee youth are found to prevent depression through mechanisms such as peer support, strengthening such mechanisms may increase the effectiveness of the intervention.
Pool of data: To ensure a comprehensive assessment, data must be aggregated across multiple sites. Realistic evaluations that seek to understand the context and mechanisms of a particular intervention are helpful. Instead of relying solely on traditional systematic reviews, ‘realist reviews’ can be used. These reviews identify different constructs that explain observed associations, such as between youth unemployment and anxiety, and ensure that interventions are tailored to specific contexts.
Building consensus and interdisciplinarity: Effective interventions require agreement on causal pathways, international data sharing, and collaboration across disciplines as diverse as economics, psychology, and anthropology. Unlike previous siled efforts, addressing the social determinants of mental health requires a multidisciplinary approach that combines insights from different disciplines.
Selection of social determinants of interest: Deciding which social determinants to focus on requires multiple considerations. The selected intervention must have a clear causal link to mental health outcomes, be culturally appropriate, feasible, generalizable to a larger scale, and sustainable. Sustainability requires channels for future funding, political support, and strong community engagement from the beginning.
Two ongoing studies are elucidating the relationship between socio-economic factors and mental health in low- to middle-income countries (LMIC). The CHANCES-6 study found that the design of cash transfer programs, including background and values, can have a significant impact on the mental well-being of young people in countries such as Brazil, Colombia and Mexico.
Similarly, the ALIVE study examines how poverty affects depression and anxiety among adolescents in countries such as Colombia, Nepal, and South Africa. This study highlights the importance of self-regulation and financial stability in reducing mental health problems.
Such findings highlight policy challenges in integrating mental health initiatives with broader socio-economic measures. Critics argue that policies can become less effective by attempting to address both mental health and its underlying socio-economic determinants. They argue that by stretching the focus too broadly, there is a risk of diluting the core message. However, proponents believe that addressing factors such as poverty and gender-based violence not only has intrinsic value, but also makes a significant contribution to improving overall mental health.
Research shows that interventions that focus on the social causes of mental health can have both behavioral and economic benefits. For example, a seven-year study conducted in Pakistan found that cognitive behavioral therapy not only improved depression in mothers, but also provided long-term financial benefits to the mothers who participated.
As the global mental health field continues to evolve, there is increasing emphasis on exploring the deeper social causes behind mental health conditions. This approach believes in combining cross-sectoral efforts by various sectors of government and civil society to address both the root causes and effects of mental health problems. The goal is to ensure comprehensive mental health care while recognizing and addressing its socio-economic determinants.
Lund calls for a fundamental rethinking of the world’s approach to mental health. Addressing broader socio-economic determinants from primarily psychological and pharmacological treatments is not only a clinical imperative but also a social justice issue.
Lund, C. (2023). Global mental health and its social determinants: How should we intervene? behavioral research and treatment, 169, 104402. https://doi.org/10.1016/j.brat.2023.104402 (link)