Social determinants in global mental health: Beyond pills and psychotherapy

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The role of social determinants in shaping mental health outcomes has long been recognized, but a recent article by Crick Lund from King’s College London and the University of Cape Town underscores the pressing need to revisit interventions in global mental health.

Traditional approaches, primarily psychological and pharmacological in nature, are increasingly being critiqued for not adequately addressing the intricate web of social determinants that influence mental health outcomes. These critiques have been notably vocal from those sceptical of the Movement for Global Mental Health, which some argue overly emphasizes Western-style treatments for diverse global populations.

“The overwhelming evidence of the negative and interacting effects of social determinants on mental health begs the question: how can we go about intervening to address the social determinants of mental health? This is important not only from a clinical point of view, as a means of preventing mental health conditions. It is also vital for reasons of social justice,” Lund writes.
“The massive inequalities in the distribution of wealth (with the richest 1% of the world’s population earning twice as much as the rest of the world during the last two years), the looming reality of climate change, and ongoing humanitarian crises precipitated by war and conflict should not be allowed to continue, given the toll of human suffering they exact. In short, there are both intrinsic and instrumental reasons for addressing the social determinants of mental health: intrinsic because addressing social determinants such as poverty, climate change, conflict, and child maltreatment are concerns of social justice; and instrumental because addressing these social determinants has the potential for large scale mental health benefits, particularly in vulnerable populations.”

 

Social determinants encompass the social and economic conditions that significantly impact the occurrence and intensity of mental health conditions. These factors range from societal structures that favour or disadvantage specific groups to personal experiences with trauma and the resulting vulnerabilities or strengths they foster.

Professor Lund’s research emphasizes the importance of the five primary domains of social determinants: demographic, economic, neighbourhood, environmental events, and social/cultural. His findings suggest that truly addressing mental health challenges necessitates a holistic approach that integrates these domains, moving beyond traditional psychological and pharmacological methods.

Recognizing these multifaceted challenges, the Academy of Medical Sciences and the InterAcademy partnership convened in 2019, outlining potential interventions. These suggestions ranged from reducing gender-based violence to urban renewal initiatives and from improved disaster responses to strategies bolstering social capital and education.

However, these interventions, while promising, are met with challenges, especially in low and middle-income countries. There’s a need for interdisciplinary collaboration, an understanding of broad socio-economic determinants, international cooperation, and a departure from traditional treatment-focused research.

Potential Approaches in Addressing Social Determinants of Mental Health

Building Theoretical Models: To address social determinants of mental health, theoretical models outlining causal mechanisms must be established. One method is the “Theory of Change” model, which engages a diverse set of stakeholders. This not only determines the hypothesized causal path to desired results but also incorporates various theories such as ‘program theory,’ ‘middle range theory,’ and even broader concepts like Amartya Sen’s human capabilities theory.

Testing Mechanisms: Once theoretical models are constructed, the next step is to validate the specified mechanisms within these models. Implementing randomized controlled trials with mediation analysis can pinpoint which variables act as intermediaries between the intervention and its outcomes. This in-depth analysis helps refine interventions. As an illustration, if cash transfers to refugee youth were found to prevent depression through mechanisms like peer support, then enhancing such mechanisms might boost the intervention’s effectiveness.

Pooling Data: To ensure comprehensive evaluation, data should be aggregated across multiple sites. Realist evaluation, which seeks to understand the context and mechanisms of specific interventions, can be instrumental. Instead of solely relying on traditional systematic reviews, “realist reviews” can be utilized. These reviews discern various configurations explaining observed associations, like that between youth unemployment and anxiety, ensuring interventions are tailored to specific contexts.

Building Consensus and Interdisciplinarity: Effective intervention requires consensus on causal pathways, international data sharing, and collaboration across diverse fields like economics, psychology, and anthropology. Unlike prior siloed efforts, addressing the social determinants of mental health necessitates an interdisciplinary approach, combining insights from various sectors.

Choosing Social Determinants to Target: Deciding which social determinants to focus on involves multiple considerations. The chosen interventions should have a clear causal link to mental health outcomes, be culturally appropriate, feasible, generalizable on a larger scale, and be sustainable. Sustainability entails channels for future financing, political support, and robust community engagement from the start.

Two ongoing studies are shedding light on the relationship between socio-economic factors and mental health in lower to middle-income countries (LMICs). The CHANCES-6 study has found that the design of cash transfer programs, such as context and value, can significantly impact the mental well-being of the youth in countries including Brazil, Colombia, and Mexico.

Similarly, the ALIVE study is investigating how poverty influences adolescent depression and anxiety in countries like Colombia, Nepal, and South Africa. This study emphasizes the significance of self-regulation and economic stability in mitigating mental health challenges.

Such findings highlight the policy challenges in integrating mental health initiatives with broader socio-economic measures. Critics argue that policies might lose their impact by trying to address both mental health and its underlying socio-economic determinants. They contend that there’s a risk of diluting the core message by expanding the scope too broadly. However, proponents believe that addressing factors like poverty and gender-based violence not only has intrinsic value but also contributes significantly to improving overall mental health.

Studies show that interventions focusing on the social causes of mental health can yield both behavioural and economic benefits. For instance, a seven-year study in Pakistan found that cognitive behaviour therapy not only improved maternal depression but also had long-term economic benefits for the mothers involved.

As the global mental health field continues to evolve, there’s a growing emphasis on exploring the deeper social causes behind mental health conditions. This approach believes in combining inter-sectoral efforts from various arms of government and civil society to address both the root causes and effects of mental health challenges. The goal is to ensure comprehensive mental health care while also acknowledging and addressing its socio-economic determinants.

Lund calls for a radical rethinking in the approach to global mental health. Shifting from primarily psychological and pharmacological treatments to address wider socio-economic determinants is not only a clinical imperative but also a matter of social justice.

 

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Lund, C. (2023). Global mental health and its social determinants: How should we intervene? Behaviour Research and Therapy, 169, 104402. https://doi.org/10.1016/j.brat.2023.104402 (Link)

 

Editor’s Note: Part of MITUK’s core mission is to present a scientific critique of the existing paradigm of care. Each week we will be republishing Mad in America’s latest blog on the evidence supporting the need for radical change.

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Justin M. Karter is the lead research news editor for Mad in America. He completed his doctorate in Counseling Psychology at the University of Massachusetts Boston. He also holds graduate degrees in both Journalism and Community Psychology from Point Park University. He brings a particular interest in examining and decoding cultural narratives of mental health and reimagining the institutions built on these assumptions.