561713 research-article2014
RSH0010.1177/1757913914561713Current Topics & OpinionsCurrent Topics & Opinions
Current Topic & Opinion
What can be done about the social determinants of mental health? As the social determinants of health become increasingly recognised as an area of public health concern, Dr Patrick Larsson, Chartered Counselling Psychologist, Homerton University Hospital NHS Foundation Trust looks specifically at the social determinants of mental health and the policy changes needed to address these. There is increasing agreement that social Why look at the social determinants play a significant role in the determinants? development and maintenance of Besides conceptual problems related to common mental health problems such as the social determinants of mental health, anxiety and depression.1 Although still one of the main difficulties is that mental health theory, practice and research are lacking a precise definition, social predominantly ‘downstream’ in nature, determinants are generally understood to rather than ‘upstream’. This means that exist within the environment where the current focus is on the end result of individuals are born, grow, live, work and the social determinants, namely, on the age,2 which are shaped by the distribution of wealth and power at global, individual, rather than on the conditions which create that individual. This is national and local levels.3 Within this reflected in the dominant environment are a research agenda taken to number of individual, a number of matters of mental health, psychosocial and individual, such as the use of socioeconomic factors psychosocial and randomised controlled which interact to develop socioeconomic trials and the mental health difficulties, factors which conceptualisation of mental such as biological (i.e. interact to health difficulties as either genetic), structural (i.e. develop mental biomedical or cognitive. It level of income and health can be argued that the education), intermediate difficulties dominance of these (i.e. living conditions, perspectives has evolved population behaviour, from the mental health access to food) and disciplines adapting the ontological, sociopolitical (i.e. the overarching social epistemological and methodological system which affects individuals).4 It has perspectives of the ‘natural’ sciences therefore been found that the distribution rather than developing their own ‘human’ of mental health problems follows a science position which would potentially gradient, much like physical health, and be better suited to psychiatry and bodies such as the World Health psychology. The primary interventions Organization are generating data and offered by the mental health disciplines recommendations arguing that are subsequently individual in nature, interventions which tackle social such as through the use of medication in determinants of mental health need to the case of psychiatry, and use of move higher up the agenda. However, therapies such as cognitive behavioural what are the challenges inherent to this? therapy generally provided by It is one thing to say that these issues need to be addressed in order to improve psychologists. Working as a practitioner psychologist the psychological wellbeing of the in an inner-city London psychology population; it is another matter actually service, I am frequently faced with the finding a way of achieving this.
16 Perspectives in Public Health l January 2015 Vol 135 No 1
clash that emerges when individual models of mental health sanctioned and promoted by the health services are confronted by the socioeconomic challenges faced by service users. Unfortunately, there is nothing much to offer except medication or individual psychological interventions such as ‘stress management’, and there is often a danger of pathologising the individual with labels such as ‘anxiety’ and ‘depression’ when in truth these are understandable reactions to their situations. Although it must be acknowledged that individualised interventions can be helpful to the people accessing them, their dominance has resulted in the context relevant to the social determinants of mental health being missed out and the focus becoming too narrow. Due to their allegiance with the ‘natural’ sciences, there is apprehension within the mental health disciplines in approaching the political element of their field, which is necessary if the social determinants are to be included in a mental health agenda. Suggestions have been made of how to break this deadlock, particularly by changing the way we research the individual and questioning what we determine to be ‘good’ science. This might mean a more flexible use of methodologies and inviting the ‘participants’ as stakeholders involved in the research rather than objectified subjects. There is also a need for political will5 on the level of government to take
Copyright © Royal Society for Public Health 2014 SAGE Publications ISSN 1757-9139 DOI: 10.1177/1757913914561713
Current Topic & Opinion this agenda forward, which is currently lacking except if one’s individual wellbeing can be argued through an economic case (see, for example, Layard6).
Recommended Policy Changes There have been efforts to understand what policy changes are needed in order to begin addressing the social determinants of mental health; however, these have not been taken up on a large scale and remain absent from the mainstream mental health agenda and are generally confined to individual voices rather than a coherent movement. Recommendations put forward include: •• Increasing the presence of mental health interventions in the social development sector;7
•• Promoting the involvement of civil society in mental health-based research;8 •• Conducting more social determinants-based research in order to gain a better understanding of the policy changes needed to begin addressing them;9 •• Developing a multi-faceted approach to policy and the encouragement of a more multidisciplinary or inter-connected perspective.10 The social determinants of mental health are a diffuse and multi-factorial area of study, and there are significant challenges facing the development of mental health promotion and interventions where the concern is both on the individual as well as on
society; however, this does not mean that we should shy away from creating a climate where complex and ‘messy’ policy implementation research can be funded and conducted. 11 Another important, and more challenging, step would be to move away from a focus on technology-based interventions to an understanding of mental health as a social phenomenon, which in turn would require a distancing from constructions of mental health as disease or disease burdens and focus more on political or policy processes. 12 The question is whether the mental health disciplines and the health services are able to accommodate this shift, as this would require a re-thinking of the modern mental health agenda on a fundamental level.
References 1.
2.
3.
4.
Patel V, Lund C, Hatherill S, Plagerson S, Corrigall J, Funk M et al. Mental disorders: Equity and social determinants. In E Blas, Kurup AS (eds) Equity, Social Determinants and Public Health Programmes. Geneva: World Health Organization, 2010, pp. 115–34. Rasanthan K, Krech R. Action on social determinants of health is essential to tackle noncommunicable diseases. Bulletin of the World Health Organization 2011; 89: 775–76. World Health Organization. Mental Health, Resilience and Inequalities. Copenhagen: World Health Organization, 2009. Kelly MP, Bonnefoy J, Morgan A, Florenzano F. The Development of the Evidence Base about the Social Determinants of Health. Chile: The National Institute for Health and Clinical Excellence (NICE) (UK) and the Universidad del Desarrollo (UDD) (Chile), 2006.
5.
Howden-Chapman P Evidence-based politics: How successful have government reviews been as policy instruments to reduce health inequalities in England? Social Science and Medicine 2010; 71: 1240–3. 6. Layard R. Mental Health: Britain’s Biggest Social Problem. London: Cabinet Office, 2004. 7. Jenkins R, Baingana F, Ahmad R, McDaid D, Atun R. International and national policy challenges in mental health. Mental Health in Family Medicine 2011; 8: 101–14. 8. Sanders D, Labonte R, Baum F, Chopra M. Making research matter: A civil society perspective on health research. Bulletin of the World Health Organization 2004; 82: 757–63. 9. Sinclair S, Meawasige A, Kinew KA. Youth for youth – A model for youth suicide
prevention: Case study of the Assembly of Manitoba Chiefs Youth Council and Secretariat. In E Blas, J Sommerfeld, AS Kuruo (eds) Social Determinants Approaches to Public Health: From Concept to Practice. Geneva: World Health Organization, 2011, pp. 25–39. 10. Exworthy M, Blane D, Marmot M. Tackling health inequalities in the United Kingdom: The progress and pitfalls of policy. Health Services Research 2003; 38: 1905–22. 1. Baum F. The Commission on the 1 Social Determinants of Health. reinventing health promotion for the twenty-first century? Critical Public Health 2008; 18: 457–66. 12. Das A, Rao M. Universal mental health: Re-evaluating the call for global mental health. Critical Public Health 2012; 22: 383–9.
January 2015 Vol 135 No 1 l Perspectives in Public Health 17
RSH0010.1177/1757913914561713Current Topics & OpinionsCurrent Topics & Opinions
Current Topic & Opinion
What can be done about the social determinants of mental health? As the social determinants of health become increasingly recognised as an area of public health concern, Dr Patrick Larsson, Chartered Counselling Psychologist, Homerton University Hospital NHS Foundation Trust looks specifically at the social determinants of mental health and the policy changes needed to address these. There is increasing agreement that social Why look at the social determinants play a significant role in the determinants? development and maintenance of Besides conceptual problems related to common mental health problems such as the social determinants of mental health, anxiety and depression.1 Although still one of the main difficulties is that mental health theory, practice and research are lacking a precise definition, social predominantly ‘downstream’ in nature, determinants are generally understood to rather than ‘upstream’. This means that exist within the environment where the current focus is on the end result of individuals are born, grow, live, work and the social determinants, namely, on the age,2 which are shaped by the distribution of wealth and power at global, individual, rather than on the conditions which create that individual. This is national and local levels.3 Within this reflected in the dominant environment are a research agenda taken to number of individual, a number of matters of mental health, psychosocial and individual, such as the use of socioeconomic factors psychosocial and randomised controlled which interact to develop socioeconomic trials and the mental health difficulties, factors which conceptualisation of mental such as biological (i.e. interact to health difficulties as either genetic), structural (i.e. develop mental biomedical or cognitive. It level of income and health can be argued that the education), intermediate difficulties dominance of these (i.e. living conditions, perspectives has evolved population behaviour, from the mental health access to food) and disciplines adapting the ontological, sociopolitical (i.e. the overarching social epistemological and methodological system which affects individuals).4 It has perspectives of the ‘natural’ sciences therefore been found that the distribution rather than developing their own ‘human’ of mental health problems follows a science position which would potentially gradient, much like physical health, and be better suited to psychiatry and bodies such as the World Health psychology. The primary interventions Organization are generating data and offered by the mental health disciplines recommendations arguing that are subsequently individual in nature, interventions which tackle social such as through the use of medication in determinants of mental health need to the case of psychiatry, and use of move higher up the agenda. However, therapies such as cognitive behavioural what are the challenges inherent to this? therapy generally provided by It is one thing to say that these issues need to be addressed in order to improve psychologists. Working as a practitioner psychologist the psychological wellbeing of the in an inner-city London psychology population; it is another matter actually service, I am frequently faced with the finding a way of achieving this.
16 Perspectives in Public Health l January 2015 Vol 135 No 1
clash that emerges when individual models of mental health sanctioned and promoted by the health services are confronted by the socioeconomic challenges faced by service users. Unfortunately, there is nothing much to offer except medication or individual psychological interventions such as ‘stress management’, and there is often a danger of pathologising the individual with labels such as ‘anxiety’ and ‘depression’ when in truth these are understandable reactions to their situations. Although it must be acknowledged that individualised interventions can be helpful to the people accessing them, their dominance has resulted in the context relevant to the social determinants of mental health being missed out and the focus becoming too narrow. Due to their allegiance with the ‘natural’ sciences, there is apprehension within the mental health disciplines in approaching the political element of their field, which is necessary if the social determinants are to be included in a mental health agenda. Suggestions have been made of how to break this deadlock, particularly by changing the way we research the individual and questioning what we determine to be ‘good’ science. This might mean a more flexible use of methodologies and inviting the ‘participants’ as stakeholders involved in the research rather than objectified subjects. There is also a need for political will5 on the level of government to take
Copyright © Royal Society for Public Health 2014 SAGE Publications ISSN 1757-9139 DOI: 10.1177/1757913914561713
Current Topic & Opinion this agenda forward, which is currently lacking except if one’s individual wellbeing can be argued through an economic case (see, for example, Layard6).
Recommended Policy Changes There have been efforts to understand what policy changes are needed in order to begin addressing the social determinants of mental health; however, these have not been taken up on a large scale and remain absent from the mainstream mental health agenda and are generally confined to individual voices rather than a coherent movement. Recommendations put forward include: •• Increasing the presence of mental health interventions in the social development sector;7
•• Promoting the involvement of civil society in mental health-based research;8 •• Conducting more social determinants-based research in order to gain a better understanding of the policy changes needed to begin addressing them;9 •• Developing a multi-faceted approach to policy and the encouragement of a more multidisciplinary or inter-connected perspective.10 The social determinants of mental health are a diffuse and multi-factorial area of study, and there are significant challenges facing the development of mental health promotion and interventions where the concern is both on the individual as well as on
society; however, this does not mean that we should shy away from creating a climate where complex and ‘messy’ policy implementation research can be funded and conducted. 11 Another important, and more challenging, step would be to move away from a focus on technology-based interventions to an understanding of mental health as a social phenomenon, which in turn would require a distancing from constructions of mental health as disease or disease burdens and focus more on political or policy processes. 12 The question is whether the mental health disciplines and the health services are able to accommodate this shift, as this would require a re-thinking of the modern mental health agenda on a fundamental level.
References 1.
2.
3.
4.
Patel V, Lund C, Hatherill S, Plagerson S, Corrigall J, Funk M et al. Mental disorders: Equity and social determinants. In E Blas, Kurup AS (eds) Equity, Social Determinants and Public Health Programmes. Geneva: World Health Organization, 2010, pp. 115–34. Rasanthan K, Krech R. Action on social determinants of health is essential to tackle noncommunicable diseases. Bulletin of the World Health Organization 2011; 89: 775–76. World Health Organization. Mental Health, Resilience and Inequalities. Copenhagen: World Health Organization, 2009. Kelly MP, Bonnefoy J, Morgan A, Florenzano F. The Development of the Evidence Base about the Social Determinants of Health. Chile: The National Institute for Health and Clinical Excellence (NICE) (UK) and the Universidad del Desarrollo (UDD) (Chile), 2006.
5.
Howden-Chapman P Evidence-based politics: How successful have government reviews been as policy instruments to reduce health inequalities in England? Social Science and Medicine 2010; 71: 1240–3. 6. Layard R. Mental Health: Britain’s Biggest Social Problem. London: Cabinet Office, 2004. 7. Jenkins R, Baingana F, Ahmad R, McDaid D, Atun R. International and national policy challenges in mental health. Mental Health in Family Medicine 2011; 8: 101–14. 8. Sanders D, Labonte R, Baum F, Chopra M. Making research matter: A civil society perspective on health research. Bulletin of the World Health Organization 2004; 82: 757–63. 9. Sinclair S, Meawasige A, Kinew KA. Youth for youth – A model for youth suicide
prevention: Case study of the Assembly of Manitoba Chiefs Youth Council and Secretariat. In E Blas, J Sommerfeld, AS Kuruo (eds) Social Determinants Approaches to Public Health: From Concept to Practice. Geneva: World Health Organization, 2011, pp. 25–39. 10. Exworthy M, Blane D, Marmot M. Tackling health inequalities in the United Kingdom: The progress and pitfalls of policy. Health Services Research 2003; 38: 1905–22. 1. Baum F. The Commission on the 1 Social Determinants of Health. reinventing health promotion for the twenty-first century? Critical Public Health 2008; 18: 457–66. 12. Das A, Rao M. Universal mental health: Re-evaluating the call for global mental health. Critical Public Health 2012; 22: 383–9.
January 2015 Vol 135 No 1 l Perspectives in Public Health 17
