The Social Determinants of Mental Ill-Health
The past few decades have seen a growing awareness among health professionals and policy makers of the role that social and economic factors play in determining good mental health. As 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.
A range of studies conducted in Ireland would appear to confirm the correlation between poverty and other negative social determinants and poor mental health.
In Ireland, the highest rates of admission to psychiatric hospitals are those from the unskilled occupational class, while common mental illnesses are twice as frequent among the lowest income groups as compared to the highest. Furthermore, most admissions to psychiatric hospitals come from the unskilled occupational class with general mental disorders being twice as high amongst the 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 those in employment. Similarly, research in Northern Ireland revealed that unemployed people ran twice the risk of exhibiting a potential mental health problem than those employed.
Moreover, these inequalities in the distribution of social determinants entail a significant economic cost. As Mackenbach et al revealed, using 2004 data, there were over 700,000 deaths per year and 33 million cases of ill health in the European Union attributable to health inequities. They calculated the losses incurred as being equivalent to 20% of health care costs and 15% of social security benefits.
The Department of Health in Northern Ireland estimated it would be possible to prevent up to 5,400 premature deaths annually in both the North and South by effectively tackling social deprivation and inequalities
These findings have serious policy implications. In order to successfully tackle mental health issues, their social determinants must also be confronted. Mental health is not solely the concern of the health sector but requires action across a range of other social and economic domains.
To address health inequalities, the uneven distribution of its social determinants needs to be taken into account. This approach will entail progressing beyond simply diagnosing the immediate causes of particular diseases and placing a 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 article in the Irish Medical Times, Shane Leavy notes that some economists argue the real correlation between higher levels of poverty and mental illness to be attributable to a decrease in their employment prospects and earning power as a result of their mental health status.
Studies in the UK indicate that some 76% of people with enduring schizophrenia are unemployed. While comparable statistics do not exist for Ireland, it would appear reasonable to assume a relatively similar situation here. Research for the Irish Mental Health policy document - A Vision for Change - indicated that 60% of those classified as mentally ill relied on welfare payment or had no income.
Therefore, there is doubtlessly some truth in the contestation that a certain degree of poverty can be attributed to a deterioration in one´s mental health. However, it is hard to see how studies, which analyse the incidence of mental illness amongst large-scale social groups, can be adequately explained by such an argument.
For instance, while it makes perfect sense to claim that enduring schizophrenia renders one more vulnerable in terms of the prevailing social determinants, of greater relevance here would be a study of the population of schizophrenics in order to identify their ´original´ social determinants. These might include, for example, their socio-economic background, educational levels, previous income levels, housing and so forth.
It is also important to acknowledge that a certain amount of variation in mental health, as well as health in general, is based on biological or genetic features. These factors account for a degree of the dissimilar health prospects at the level of the individual. However, the term health inequity, as it relates to social determinants, is a more general measure, referring to the variances between various social groups. In contradistinction to the random and non-systematic disparities in mental health status between individuals, health inequalities lead to regular and consistent divergences.
Given the non-random nature of these social determinants and the resulting health inequalities, the opportunity exists to mitigate their negative impact through coordinated and holistic action on the part of the health and other relevant social and economic sectors.
However, although the important role of social determinants in enabling good mental health is becoming ever more widely recognised, there are still many areas that could do with greater clarity. It is crucial that accurate data is obtained as to which social determinants might have the greatest impact on mental health and how they might best be tackled.
To obtain greater clarity with respect to the inter-relationship between social determinants and mental health, a national research programme in this field is urgently required. This research should also examine the optimal means for tackling those social determinants having a negative impact on mental health.
It would then be possible to more effectively distribute resources to areas of need rather than, for example, depending on historical trends of expenditure. In effect, this would probably mean a weighting in favour of areas that are deprived in socio-economic terms. At the same time, care must be taken to avoid a reduction of service provision in other areas.
Arguably the greatest impact this new emphasis on the role social determinants play in the quality of mental health - and indeed on health generally - would be in the area of health policy. Whereas previously health policy was regarded as being almost solely concerned with determining the best means of providing medical care at an optimal cost, it is now realised that good mental health is an issue that involves a panoply of social and economic sectors.
Taking a determinants approach to mental health promotion requires action across the width and breadth of our society and economy. Indeed, in this respect, the health system has an important role to play in advocating for other sectors to play their part in working towards better mental health.
Of course, the structure and operation of the mental health system is itself fundamental to achieving greater health equity. Furthermore good medical care is obviously critical in ensuring that effective and quality treatment is received by those in need of assistance. Indeed, the availability of good quality medical care for all citizens is itself one of the social determinants of health.
However, more is needed. To improve the health status of the population as a whole, it is essential that the social and economic status of the poorest sections of our population is improved.
This article was co-authored by Justin Frewen and Dr. Anna Datta and originally published in the Irish Medical Times. The first part of this examination of mental health in Ireland, which looked at the social and economic costs of mental health was published last week.
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