Psych · foundations — social determinants of mental health
Social determinants of mental health
Also known as Social determinants of mental health · SDH mental health · Structural determinants psychiatry · Social gradient mental disorders · Poverty and mental illness · ACE social psychiatry · Housing homelessness mental health · Equity mental health · Social psychiatry determinants
Exam-exhaustive social determinants of mental health for FRANZCP and MRCPsych: Marmot/Allen/Lund frameworks; structural vs intermediate determinants; life-course and ACE pathways; poverty, inequality, housing, education, employment, racism, migration, urbanicity; Rose population strategy; stigma as structural force; clinical social needs screening; multi-level interventions and equity. FRANZCP-primary, globally tagged.
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Red flags
- Formulating only symptoms and biology while ignoring housing, poverty, violence, racism, and legal status
- Blaming 'non-adherence' when the barrier is cost, transport, literacy, or culturally unsafe care
- Discharging high-risk patients to homelessness without multi-agency plan
- Treating social adversity and mental disorder as mutually exclusive rather than interacting
- Using recovery language to justify under-resourcing of structural supports
- Racial stereotyping or cultural essentialism under the guise of 'equity talk'
Meet the patient
A 41-year-old woman is brought to the emergency department after taking an overdose. She lost her cleaning job eight weeks ago when the agency closed, she is two months behind on rent, and she has slept in three different places this week. She has a teenage son at home. She says she is "not depressed, just tired." Her notes from two years ago say "non-compliant with sertraline."[2][6]
Every registrar writes the overdose. Every examiner asks the harder question: "Why is she unwell now, and what made the sertraline fail last time?" The honest answer runs through housing, income, and a service she could not get to — and it is not an excuse, it is the formulation.[1][11]
References20ShowHide
- [1]Allen J, Balfour R, Bell R, Marmot M Social determinants of mental health Int Rev Psychiatry, 2014.PMID 25137105
- [2]Lund C, Brooke-Sumner C, Baingana F, et al. Social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews Lancet Psychiatry, 2018.PMID 29580610
- [3]Marmot M Social determinants of health inequalities Lancet, 2005.PMID 15781105
- [4]Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study Am J Prev Med, 1998.PMID 9635069
- [5]Lund C, Breen A, Flisher AJ, et al. Poverty and common mental disorders in low and middle income countries: A systematic review Soc Sci Med, 2010.PMID 20621748
- [6]Ridley M, Rao G, Schilbach F, Patel V Poverty, depression, and anxiety: Causal evidence and mechanisms Science, 2020.PMID 33303583
- [7]Rose G Sick individuals and sick populations Int J Epidemiol, 2001.PMID 11416056
- [8]Gordon RS Jr An operational classification of disease prevention Public Health Rep, 1983.PMID 6856733
- [9]Arango C, Díaz-Caneja CM, McGorry PD, et al. Preventive strategies for mental health Lancet Psychiatry, 2018.PMID 29773478
- [10]Patel V, Saxena S, Lund C, et al. The Lancet Commission on global mental health and sustainable development Lancet, 2018.PMID 30314863
- [11]Saxena S, Thornicroft G, Knapp M, Whiteford H Resources for mental health: scarcity, inequity, and inefficiency Lancet, 2007.PMID 17804062
- [12]Kohn R, Saxena S, Levav I, Saraceno B The treatment gap in mental health care Bull World Health Organ, 2004.PMID 15640922
- [13]Prince M, Patel V, Saxena S, et al. No health without mental health Lancet, 2007.PMID 17804063
- [14]Hatzenbuehler ML, Phelan JC, Link BG Stigma as a fundamental cause of population health inequalities Am J Public Health, 2013.PMID 23488505
- [15]Thornicroft G, Mehta N, Clement S, et al. Evidence for effective interventions to reduce mental-health-related stigma and discrimination Lancet, 2016.PMID 26410341
- [16]Clement S, Schauman O, Graham T, et al. What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies Psychol Med, 2015.PMID 24569086
- [17]Cantor-Graae E, Selten JP Schizophrenia and migration: a meta-analysis and review Am J Psychiatry, 2005.PMID 15625195
- [18]Wilkinson R, Pickett K Inequality and mental illness Lancet Psychiatry, 2017.PMID 28552499
- [19]Campion J, Javed A, Lund C, et al. Public mental health: required actions to address implementation failure in the context of COVID-19 Lancet Psychiatry, 2022.PMID 35065723
- [20]Whiteford HA, Degenhardt L, Rehm J, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010 Lancet, 2013.PMID 23993280