Almost every mental health discussion currently revolves around individual experience. From symptoms to diagnosis, education, and medication, the primary focus has been on how to mitigate a mental health disorder once it has manifested. But what about the factors responsible for the rising number of mental health disorders? What if the social determinants of mental health—unaffordable housing, low financial compensation, job insecurity, a lack of benefits, social programs, and inequality—are also to blame? You might have heard that 'mental health does not discriminate', but that may not be entirely true.
Throughout history, there have been three prominent theories of the origin of mental illness: supernatural, somatogenic (arising from the body), and psychogenic (arising from the mind). This article will be talking about a fourth: the social determinants of mental health (arising from the environment).
How Far We Have Come
You don’t have to look far back in history to understand how rapidly public perceptions surrounding mental health have evolved. Just over 70 years ago, the pseudoscience of ‘hysteria’ was still prominent in the established medical community. (For anyone who doesn’t know, hysteria was a mental health disorder attributed to only women whose symptoms included nervousness, emotional outbursts and various sexual urges. The treatment? Pelvic massages, vibrators, and high-pressure hoses. Yup, nothing like a good ol’ hosing to treat your emotional distress). From burning witches at the stake to drilling into peoples skulls (lobotomies), a fear of the unknown has historically driven the societal response to mental health.
Mental health stigma is borne of a lack of education and understanding. However, the past decade’s focus on reducing mental health stigma, increasing education and access to individual care has transformed public perceptions surrounding mental health. The growing number of resources and discussions around mental health have almost normalized the subject, however, it is clear we still have a long way to go. According to the Centre for Addiction and Mental Health (CMHA), the total number of patients using their services has been steadily on the rise since 2007-08. Additionally, according to an online poll conducted by Angus Reid on behalf of the United Way, 76% of people who responded said that the pandemic has caused them increased stress, anxiety or depression. So, what are we missing? There is arguably less stigma surrounding mental health than ever before, with new organizations and resources popping up left and right—and yet, the number of people reaching out for help continues to rise.
Nature and Nurture
Mental health is an evolving and complex subject. However, two of the primary factors that impact mental health outcomes are genetic (biological psychiatry) and environmental (social determinants of mental health). As it turns out, the age old debate between nature versus nurture, looks a lot more like nature and nurture. Your mental health disorder likely falls somewhere between how you were born (nature), and the environment you were born into (nurture).
With the advent of biological psychiatry, there has been an increasing focus on the genetic and molecular risk factors, causes, and correlates of mental health disorders. Biological psychiatry is an approach to psychiatry that aims to understand a mental disorder in terms of the biological function of the nervous system. In the ‘nature and nurture’ scenario, biological psychiatry aims to explore nature, focusing on mental health disorders as biological phenomenon. Among most psychiatrists today, there is very little argument that biology underlies mental health disorders. This article, by no means, aims to undermine or belittle the advancements being made in biological psychiatry, nor the importance of their research in treating mental health disorders. However, your mental health does not occur in isolation. Where you live, how much money you make, how many positive social relationships you have, whether you have benefits, as well as a dozen other factors, heavily impact your mental health outcomes. These are called the social determinants of mental health.
As explained in 'The Social Determinants of Mental Health: An Overview and Call to Action', published in the Psychiatric Annals in 2014: “Major advances have been made in genetics, imaging, neurobiology, and psycho-pharmacology. However, just as biological reductionism replaced ideas about social causation of disease in the 19th century, there has been a gradual movement away from scientific evaluation of the social and environmental processes that contribute to the development and persistence of mental disorders.”
So, why should you care about the social determinants of mental health? Because tackling the mental health crisis requires a holistic approach. How can we begin to enact meaningful change if we remain blind to the environmental circumstances and conditions that worsen our collective mental health? How can we continue to treat the manifestation of symptoms without addressing one of their root causes? The social determinants of mental health point to actionable ways that we can actively improve the mental health of everyone before they are in crisis.
Social Determinants of Mental Health
A social determinant is defined as the social and economic conditions that shape your life. The World Health Organisation broadly defines ‘social determinants of health’ as circumstances in which people are born, grow, live, work, and age. These conditions are influenced by the distribution of money, power, and resources in a given state, province, or country. According to the Canadian government, social determinants of health include race, education, food security, sexual orientation, aboriginal status, disability, housing, income distribution, and many more.
Social determinants of health remind us that mental health, in many cases, is the direct result of an unbalanced social and economic environment. Understanding the social determinants of mental health provides us with a roadmap for improved policy, resources, benefits, services, and programs. Instead of waiting until mental health symptoms arise, or when people are in crisis, we should be actively trying to improve the conditions that negatively impact people’s emotional well-being in the first place.
Vikram Patel, an Indian psychiatrist and researcher, is potentially best known for his work on child development and mental disability in low income communities. One study undertaken by Vikram Patel set out to explore the relationship between income inequality in different societies globally and the prevalence of depression. The correlation was self evident. The study warned that, as income inequality widens worldwide, so “we should expect worse mental health globally in the years ahead” and that the burden will likely fall hardest on those who “already bear a disproportionate burden of mental health problems”.
Another study by Vikram Patel, Poverty, depression, and anxiety: Causal evidence and mechanisms, cites that"within a given location, those with the lowest incomes are typically 1.5 to 3 times more likely than the rich to experience depression or anxiety." While it is true that mental health problems can affect anyone at any time, it is clear that they are not equally distributed and prevalence varies across social groups. It is a vicious cycle. You experience from poor economic conditions, develop a mental health disorder, and are less able to pull yourself out of poor economic conditions.
According to Poverty and Mental Health, published by the Mental Health Foundation in the UK: "People with no previous history of mental health problems may develop them as a consequence of having to cope with the ongoing stress of job insecurity, sudden and unexpected redundancy, and the impacts of loss of employment (financial, social and psychological). Keeping people with mental health problems in work and getting people back to work are key policy and service responses to the economic downturn."
Countries that have placed increased importance on the social determinants of health, like the United Kingdom, Australia, and Scandinavian countries, have significantly improved mental health outcomes over time. These countries have policies in place to ensure that children have the best possible opportunities for physical and emotional health.
It is difficult to argue that equal access to education, affordable housing, meaningful employment opportunities, and living wages aren't going to improve our collective mental health. A lack of investment in people results in greater, and more significant, costs down the road.
What Can You Do?
I know that this article paints a pretty grim picture. Mental health is such a big, diverse, topic, that it can feel overwhelming trying to conquer it all, but I promise you that small changes make a big difference.
Shop Consciously
Purchase products and services that align with your own personal values. Instead of supporting major retailers like Amazon or Walmart, support businesses who pay their workers living wages, pay their taxes, provide flexibility to workers, advocate for healthy working conditions, are committed to sustainability, and provide benefits, hazard pay, and sick days for workers. If you don't know, ask. Whenever you can, try and support small and local and businesses.
*I recognize that this option is not available to everyone. Shopping consciously can require a substantial amount of time and can often be more costly. Do what you can.
Advocate
No matter who you are, how big or small your network is, or what you do, you can be an advocate for change. Focus on how you can advocate for policies, resources, and programs that benefit the most vulnerable people in your community. You can advocate for racial equality by introducing a diversity and inclusion policy at your company. You can advocate for affordable housing in your community by starting a petition. You can advocate for mandatory paid sick days by contacting your city councillor. You can advocate for your loved ones by helping them navigate the mental health system. You can advocate for change by simply posting online about issues that matter to you. When we act together, these seemingly small acts make a big difference.
Education
Whether you or someone you love has experienced mental health difficulties or not, it is always beneficial to educate yourself on various disorders, their symptoms, how they manifest, and how to be an ally. If you’re willing to go a step further, learn more about the social determinants of health, and how poverty and associative environmental factors impact mental health outcomes. The more you know, the more well equipped you will be to make decisions that benefit the mental health of everyone.
Vote When you vote, consider whether the person you’re voting for advocates for the protection of society’s most vulnerable. It is common (and perfectly okay!) to vote with your own interests in mind. But as a mental health advocate, ask yourself which party advocates for the betterment of everyone, not just a select few. Do they support affordable housing? Do they support paid sick days? Do they support better protections for workers? Do they support increased mental health access?
Conclusion
It is vital that we continue to place a focus on providing people with the services, programs, and resources they need to mitigate their symptoms--the focus should always be on keeping people alive and improving their quality of life. However, we need to consider the conditions and policies that turned this into a crisis in the first place. We can’t continue to ignore the primary drivers of poor mental health outcomes. Until we start addressing the uncomfortable truth that the distribution of wealth and resources in our society is partially responsible for the mental health crisis, then we are not invested in a real solution.
SOURCES
https://www.camh.ca/en/driving-change/the-crisis-is-real https://ontario.cmha.ca/provincial-policy/social-determinants/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5775138/ https://science.sciencemag.org/content/370/6522/eaay0214?rss%253D1=
https://www.mentalhealth.org.uk/sites/default/files/Poverty%20and%20Mental%20Health.pdf