Poor mental health is not random: what can we do to achieve social justice?

Earlier this year a prospective PhD supervisor blogged for us about recruiting for a PhD scholarship focused on historically marginalised groups and mental health inequalities. That student is Alua Yeskendir, who provides this post on new research summarising the current state of the evidence around the social determinants of mental health.

We used to see mental health problems as primarily a biological phenomenon. But is it true? If we say that your mental health also depends on the distribution of social, economic and political wealth, power, and resources, does it make easier to solve the problem?

A major new state-of-the-science review led by Professor James Kirkbride (Division of Psychiatry, UCL) analyses the evidence around how social determinants affect mental health and disorder, and the effectiveness of prevention strategies which seek to improve the social conditions in which people live. The review published this month in World Psychiatry, as part of a wider forum on the social determinants of mental health, brings together international experts in the field to discuss this issue.

In the last few decades, researchers have established compelling new evidence that the risk of developing any mental health condition is strongly linked to social factors. Some of these factors are intuitively harmful, such as physical, sexual or emotional abuse, bullying or substance abuse.

Other social factors – or what are often termed the social determinants of health – may not be so obvious, and include things such as housing insecurity, poverty, job insecurity, maternal stress during pregnancy, forced migration and displacement, discrimination, lack of access to green spaces, or living in deprived, violent or unsafe neighbourhoods (Figure 1). It turns out that many of these social factors shape our mental health. Recent evidence that involved researchers from UCL, has found that around half of all mental disorders occur by 18 years old (Solmi et al., 2022), meaning they are likely to be shaped by both genetic factors, and social factors that occur early in life.

We also know that children who grow up in socioeconomic disadvantage are 2-3 times more prone to develop mental health problems (Reiss, 2013). Together, this knowledge means that good mental health – as well as the prevention of mental disorders – is likely to be at least partly social in origin, and therefore require societal or population-level solutions that promote social justice and equality in mental health and disorder.

It is well established that the higher burden of psychiatric morbidity is disproportionately experienced by those closer to the margins of society. In this regard, the research team including researchers from the UK, USA and Canada proposed a set of interventions prioritizing social determinants of mental health to lower the burden of psychiatric morbidity (Figure 2). The core of their vision of designing effective prevention strategies for mental health problems is social justice. Does this sound too utopian? Is it even possible to deliver social justice for all? Would this improve population mental health?

Most would agree that no society is perfectly just. But when we break down the social factors that influence our mental health, we see how most of them are strongly social patterned, along intersectional gradients and dimensions that include economic circumstances, exposure to adversity, minority position and minoritisation. The research team argues that because such factors are inherently modifiable, although complex and often intertwined, this leaves room for action, intervention and optimism that we can design public mental health strategies to improve population mental health.  

Currently, most available resources are devoted to secondary treatment of existing mental disorders, but we already know this is largely inadequate. In England, for example, a 54% increase in referrals to mental health services from 2016 to 2022 was accompanied by a mere 10.9% real-terms increase in funding (NHS, 2023a, 2023b), widening the severe gap between clinical need and mental health treatment provision. More worryingly, investment in secondary prevention strategies ignores primary preventive measures that aim to target and prevent the onset of mental health problems in the first place. These strategies may be more complex and more difficult to evaluate and implement successfully, but have the potential to improve the distribution of (good) mental health at the societal level, including targeting those largely affected by interpersonal, institutional, and systemic discrimination.

Considering the huge burden of mental disorders, researchers argue that priority must be given to primary preventive interventions that pay off in multiple domains (not solely mental health, but that address other health and societal problems) and that target critical windows of the life course to break often intergenerational cycles of disadvantage and poor mental health (Figure 2). Researchers recognise that this will require cross-sector collaboration recognizing mental health as a problem of multiple sectors including healthcare, education, social care, and criminal justice. Collaborative and innovative approaches in those sectors with inclusive outcome measures in the evaluation of any policy, programme or intervention targeting social determinants can facilitate real progress in improving the population’s mental health.

The cross-sectoral approach reveals another gap – a shortage of research on causal pathways between social determinants and mental health, demanding the proper evidence generation to understand the causal factors leading to psychiatric morbidity. The introduction of comprehensive and selective primary prevention strategies requires longitudinal monitoring of the population mental health at the country level. However, today, countries in both the Global North and Global South continue to struggle with monitoring the burden of psychiatric morbidities in their populations, which highlights the need for better mental health data management systems using the latest technological advances, data science and epidemiologic theory.

Social institutions such as governments, economies, educational establishments, and the healthcare sector often underpin the bedrock that allows societies, and individuals, to flourish, but too often systemic injustices prevent all groups from benefitting equitably from these shared resources. In turn, inequitable access to these resources creates inequalities in mental health and disorder, which become an imperative issue for social justice. Considering that social factors strongly contribute to the onset, severity and prognosis of mental disorders, healthcare and research strategies have to shift toward cross-sectoral approaches targeting the alleviation of social inequalities.

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Alua Yeskendir is a PhD student, Department of Epidemiology & Applied Clinical Research, Division of Psychiatry. She is supervised by Dr Jen Dykxhoorn and Professor James Kirkbride and was awarded a scholarship by Mental Health Research UK (MHRUK) to explore the causes of health and social inequalities in psychiatric disorders.

Research team: Professor James Kirkbride (Division of Psychiatry, UCL), Dr Jennifer Dykxhoorn (Division of Psychiatry, UCL), Dr Alexandra Pitman (Division of Psychiatry, UCL), and Dr Talen Wright (Division of Psychiatry, UCL), Thomas Steare (UCL), Professor Praveetha Patalay (UCL), Professor Peter B. Jones (University of Cambridge), Dr Emma Soneson (University of Oxford), Dr Sian Griffiths (University of Birmingham), Dr Deidre Anglin (City College University of New York), and Professor Ian Colman (University of Ottawa).