The social determinants of mental health

Progressive change in mental health can be made by improving the social and economic status of the poorest. By Justin Frewen and Dr. Anna Datta.

There is a growing awareness among health professionals and policy makers of the role social and economic factors play in determining good mental health.

The WHO Regional Committee for Europe noted, “Widening disparities in society or economic changes in individuals’ life courses seem to be of particular importance here. Whether defined by income, socioeconomic status, living conditions or educational level, poverty is an important determinant of mental disability and is associated with lower life expectancy and increased prevalence of alcohol and drug abuse, depression, suicide, antisocial behaviour and violence”.

(Picture: Amnesty supporting the rights of mental health service users)

In Ireland, the highest rates of admission to psychiatric hospitals are from the unskilled occupational class. Common mental illnesses are twice as frequent among lowest income groups compared to the highest.

Balanda and White (2003) found the unemployed one-third more likely to obtain a poor general mental health score than the employed. Research in Northern Ireland revealed unemployed people ran twice the risk of a potential mental health problem than the employed.

These inequalities entail a significant economic cost. As Mackenbach et al showed, using 2004 data, over 700,000 deaths and 33 million cases of ill health in the EU were attributable to health inequities. Losses incurred were equivalent to 20% of healthcare costs and 15% of social security benefits.

The Northern Ireland Department of Health estimated up to 5,400 premature deaths annually in the North and South could be avoided by effectively tackling social deprivation and inequalities

These findings have serious policy implications. To successfully tackle mental health concerns, social determinants must be confronted.

Mental health is not solely the concern of the health sector but requires action across a range of social and economic domains.

This approach will entail progressing beyond diagnosing the immediate causes of particular diseases to placing greater emphasis on ‘upstream factors’ such as the socio-economic background and environment of health service users.

As Keleher and Armstrong argue, “Mental health promotion requires action to influence determinants of mental health and address inequities through the implementation of effective multi-level interventions across a wide number of sectors, policies, programs, settings and environments”.

In a recent Irish Medical Times article, Shane Leavy notes some economists argue the real correlation between higher levels of poverty and mental illness is a decrease in employment prospects due to their mental health status.

UK studies indicate some 76% of people with enduring schizophrenia are unemployed. While comparable statistics do not exist for Ireland, it appears reasonable to assume a similar situation here.

Research for the Irish Mental Health policy document A Vision for Change indicated 60% of those classified as 'mentally ill' relied on welfare payment or had no income.

There is therefore some truth that a certain degree of poverty comes from a deterioration in mental health. However, it is hard to see how studies, analysing the incidence of mental illness amongst large-scale social groups, can be adequately explained by this argument.

While it makes sense to claim enduring schizophrenia renders one more vulnerable, of greater relevance here would be a study identifying the 'original' social determinants of the population of schizophrenics. These might include their socio-economic background, educational levels, previous income levels, housing and so forth.

It is important to acknowledge a certain degree of variation in mental health is based on biological or genetic features. These factors can account for dissimilar health prospects at the individual level. However, the term health inequity refers to variances between social groups. In contradistinction to random and non-systematic mental health disparities between individuals, health inequalities lead to regular and consistent divergences.

Given the non-random nature of social determinants, the opportunity exists to mitigate their negative impact through coordinated and holistic action.

Although the critical role of social determinants in enabling good mental health has become more widely recognise

d, many areas require greater clarity. A national research programme is urgently required to examine the optimal means for tackling social determinants having a negative impact on mental health.

Resources could then be more effectively distributed to areas of need rather than depending on historical trends of expenditure. This would probably mean a weighting in favour of socio-economically deprived areas. However, a reduction of service provision in other areas should be avoided.

Arguably, the greatest impact this new emphasis on social determinants might have would be in health policy. Whereas previously health policy was regarded as almost solely concerned with providing effective medical care at an optimal cost, mental health must be seen as an issue involving a panoply of social and economic sectors.

A determinants approach to mental health requires action right across our society and economy. The health system will have an important role in advocating for other sectors to work towards better mental health.

The structure and operation of the mental health system is fundamental to achieving greater health equity. Good medical care is critical in ensuring effective and quality treatment is received by services users. Indeed, the availability of good quality medical care is itself a social determinant of health.

However, more is needed. To improve the mental health status of the population as a whole, the social and economic status of the poorest sections must be improved.


This article was originally published in the Irish Medical Times.

(This is Part 2 of a report by Justin Frewen and Dr. Anna Datta. Part 1, 'New mental health policies could benefit wider economy' is available here)