Social Determinants of Health and Mental Health (II): Evaluation, Political Perspectives and Global Implications

This is the second part of the interview that Dilip Jeste, MD, director of the Global Research Network on Social Determinants of Mental Health and Exposomics, granted to Renato D. Alarcón, MD, MPH, Editorial Board member of Psychiatric Times.

RDA: You address really very important aspects of any didactic teaching or training program, namely thoroughness, a comprehensive, total focus on all the aspects of the complaints that the patient brings in. What we call clinician’s competence, be that professional, cultural, social or what otherscall ecological competence, and the way to explore those aspects of the clinical interview and any other transactions with patients, are extremely relevant.

DJ: At the same time, we realize that a clinician cannot ask 1000 different questions and, in fact, does not need to. What our current health care system lacks is sufficient involvement of, for instance, social workers in the patients’ thorough assessment. In the UK, for instance, there is something called social prescribing. What is social prescribing? The patient is seen by a link worker, a person who knows the local resources, the local community agencies. For example, if the patient is homeless, it is the social worker who finds that they can assist facing the problem with the local government housing agencies, some private foundations, etc. In the case of somebody who does not have enough food access, links with Meals on Wheels or nonprofit agencies like that, can assist in finding a solution. So, the main point here is that some social determinants can be initially detected by the clinician, but much more thoroughly handled by the social worker. This means that the latter must be a well-trained and paid member of the healthcare system, every patient must be seen and followed up by a social worker knowledgeable about the local community and prepared to assist the patient and his or her family in the search of effective solutions. It is clear that I see the psychiatrist as the leader of the team, but that does not mean that they should do everything¾that is neither feasible nor appropriate. They must get the information about, say, homelessness, because, by identifying the problem, its emotional or behavioral consequences become a part of a therapeutic line of action based on resiliency enforcement. We need to know the traumatic situations that the patient is facing, information provided by the patient, family members, coworkers, friends and, ultimately, by the multidisciplinary team members, in order to delineate and conduct a truly comprehensive treatment.

RDA: In that context, Dilip, the social determinants of health and mental health require also a sort of a political vision, right? There must be policy measures needed for the implementation of good, well focused care programs. What would be some of those policy needs? How should their diffusion, their being well known by the public, professionals, authorities, researchers, clinicians and administrators should be, in order to work together towards a better management of the social determinants?

DJ: That is another great point. When we discuss what to do about social differences, we must cover, at least, 2 different levels. One is the individual patient level that includes, as I said, issues like transportation, internet access, social habits, etc, to be documented by team members such as the social worker. The other is the public level that includes policies regarding discrimination, diversity, income, and so on. I insist that besides racism, sexism, and ageism, many other forms of discrimination exist. What needs to happen is the change of some policies, which is not easy because it depends on so many other factors. We need to work as a group, and to work together with other groups. For example, representatives of large organizations like the APA can go to the Congress and present our views about what can be done. But APA by itself cannot do much and, rather, will have to collaborate with the American Medical Association and similar institutions, for example. Such was the case when the Mental Health Care parity law got passed 30 years ago, as the result of the collaborative work of medical and nonmedical institutions and professionals. What is needed is the joint work of major organizations from various health care fields providing well-thought and practical suggestions. Politics and other areas may often be beyond our control, but if we persist, things will happen. I also think that what we have to do is to educate the public. We need to let people know why this is right and why this is wrong. And, ultimately, we have to work with the politicians. Changes like these in the social justice system may take time, but I really think we can work it out. It is undoubtedly hard to change national policies, whereas it is easier to change local ones. That is something we should consider doing¾exploring mutual access. Why don't we try to change policies first in the county where we live, then neighboring counties, then we go to the state and the national level, to finally reach the international level? Let us start small, let us start where we can actually have an impact; it is much easier to have a right impact on a local, small community where we can work with business leaders, nonprofit organizations, and many good people, even those who may disagree with us politically. That is my point: we need to see how we can get help from others, start small and then make it bigger.

RDA: Excellent!We have mentioned and implied several times, in the course of this conversation, the term globalization, or, more specifically, global mental health, a contemporary phenomenon of very distinctive characteristics. It is clear that social determinants of mental health play a role in the overall process of globalization. There are also a number of triggering factors of globalization, let me mention just 2, and ask you to elaborate on the implications of those 2 components vis-a-vis the social determinants of mental health. Those components would be, 1) migrations (internal and external), and 2) technology that, of course, implies the use of terms and instruments by millions of people on a daily basis. In short, globalization as a result of processes such as migration and technology. Can you elaborate on the relevance and implications of those 2 areas in the field of social determinants of mental health?

DJ: I mentioned earlier the loneliness pandemic, present mainly in the last 25-30 years, not really before then. Why is loneliness happening and changing everything in the midst of a globalization process? There is no question that transportation and many forms of communication have constantly increased. We get news every day from all parts of the world, people can go from anywhere to anywhere. Globalization is great, it has made the world smaller but also has a downside: it has induced a very severe competition; previously, we just used to compete with people in our neighborhood, now we are competing with people from all over the world. Also, the news we get are almost always bad news, and a sense of loneliness grows. So, globalization has positive and negative effects, and migration is a good example of such duplicity, creating problems that were not there previously. We must take that into account.

There is a second component that has grown enormously in recent decades: technology. It has evolved so much, so easily. Artificial intelligence, one of its main products, is going to markedly control our healthcare with its large language models. In fact, I really think it is going to change the world and change healthcare enormously. So, globalization, nourished by and generating bigger migrations, and by more sophisticated technologies leading to artificial intelligence and disseminated by impressively growing social media, has undoubtedly brought the whole world together. You know, at any moment, I can communicate with millions of people all over the world. Talking about social media, however, they have created a problem, especially for young people, because, in addition to superficiality, they get mainly adverse reactions from other people, and the resulting loneliness leads to a greater number of suicides. In turn, substance use has increased among older adults, and part of that is blamed on the excessive use of adverse social media and subsequent loneliness. So, coming to your question, migration and technology, evolving into a globalization process each time more difficult to handle, are part of today’s major world crisis. What to do? Almost everything in our era has a positive and a negative side. For example, despite their adversities, social media may be very useful for older individuals, allowing them to communicate with others, share pleasant experiences, learn from each other, etc. On the other hand, they may produce much stress, loneliness or isolation, particularly in younger individuals. A true paradox!

RDA: Absolutely, the impact of all those factors into human behavior at the global level is immeasurable, and the issue of artificial intelligence as a future component of the management of social determinants of mental health is really something that we should immediately pay attention to. Talking about migration, you and I share the experiences of this process, and I have always been impressed by the phenomenon of acculturation. Acculturation, that is, how does the migrant adapt to the social environment, the social behavior or behaviors that he or she finds out in the host city, the host country or the host continent. Acculturation, as a social determinant leading to what has been named acculturative tress, becomes a powerful aspect of the adaptation process of the incoming people, and should be in the minds of the interviewers, the clinicians, the professionals that deal with them. Is that a reasonable assumption?

DJ:Absolutely! As you said, migration rates are increasing phenomenally, and they will continue to do so due to a variety of reasons (social, economic, occupational, educational, political). Even language differences are no longer a question, because artificial intelligence machinery can now quickly translate anything into any language. Why is migration important, what are its most relevant features? Like you said, we both belong and have experienced the process. I was born in India, went to medical school and got married there, and then I moved to the United States because, among other things, I was interested in research, and here there are so many good things and resources to do it. I was delighted to come here for that reason and, certainly, went through the acculturative experience. There is no question about cultural differences. Briefly, the Indian culture is probably more interdependent, based on larger families, whereas the US and Western culture, in general, fosters a more individualized sense of independence. It focuses on what you do, how successful you are, whereas in India, it could be said that things are more based on sort of what a group does, what a family does. Both cultures have, of course, what could be called positive and negative features. Adapting to a new culture takes a variable time, but there is one thing for which there is no alternative: the establishment of social connections, their number, and quality. If I have good social connections reflected, for instance, in a solid friendship, it does not matter how long we do not see each other, the relationship and its implicit mutual support never change. In the migration process, some people have difficulties during phases of acculturation (a powerful social determinant of mental health) due to the differences between the original and the host culture. It is especially harder for people who migrate late in life, but what is needed is to accept the fact there is no such thing as a good or a bad culture. Each culture has its structural and functional processes, its mindset, to which the migrants must adapt. But it is also quite important to remark that the members of the host culture have new things to learn from the carriers of the incoming culture and, thus, enrich their perspectives of diversity, mutuality, and understanding. This is how positive and reciprocal social connections evolve.

RDA: Yes, of course. And these experiences teach us ways of distinguishing some concepts. For instance, you have mentioned loneliness, a concept very different from social isolation. Another term you have cited is social connections and my immediate association is with the concept of solidarity, a human resource that can help to modify or control the negative impacts of some social determinants. The precise knowledge about the meaning of those concepts, and the way professionals should handle the social determinants related to them are, I think, extremely important requirements, as you have pointed out. Could you round up some priority areas in the research field of social determinants of mental health? There are many, but which ones should be the main foci to implement research projects?

DJ: What is needed for research is, first, a real collaboration between different groups of experts in different research areas. That is absolutely critical, I feel strongly about that. Such collaboration should be at an international level to be thorough and truly representative of global realities. We know that 85% of the publications are based on only 15% of the world population as most of the studies come from the US and Europe, and very few from low-income countries, including those from Asia, Africa, etc. That is not beneficial. We need to have and count on a critical intercultural collaboration. Secondly, the work must be inter- and multidisciplinary, we cannot only have physicians, only psychiatrists doing it.That is not going to work. We must join efforts with social workers, nurses, pharmacists, psychologists, as their contributions will be truly valuable. Thirdly, we know about the biopsychosocial approach, but we break it up when we talk about social determinants. Some people ask themselves: what does biology have to do in the field of social determinants?We do not think about biology when we are talking about exposomics. Yet, exposomics is all genomics, and genomics is all about biology. No social factors affect genomics but, then, genomics affects social factors. I really think that something is missing there, and that psychiatry must do something about it. When I talk about social determinants, I must say something about microbiome and epigenetics. What does microbiome have to do with mental illness? Well, a lot, because microbiome includes bacteria, viruses, fungi and so on, right? Healthy people have a more diverse microbiome. If we interact with lots of people, we shake hands and eat with them, our microbiome will become more diverse. Furthermore, there are microbes that can increase our ability to socialize, whereas some chemicals will make us avoid other people. And how can microbes affect our socialization and sense of loneliness? So, once again, what is needed is collaboration between different countries, between different disciplines and, most important, collaboration between psychological, biological and social scientists—that is critical.

RDA: A very solid reasoning behind your response. Let me ask you at this point, to make a sort of final reflections on the topic of social determinants of mental health, their impact, their influence in the knowledge of all mental health disciplines, and the future of this field in the academic and social world order, please.

SJ: Thank you. Let me examine loneliness once again. What is the solution to this significant problem? There is no known effective intervention right now, both at an individual and at a social level. What should then be the intervention? Our studies have shown that there is a strong universal relationship between loneliness and wisdom. As an integral personality feature, wisdom has specific components like self-reflection, acceptance of diverse perspectives, compassion, emotional regulation, spirituality, etc.And wisdom has been known since biblical times. The Bible has 12 books of wisdom, has been source of deep philosophical analysis, but empirical research about it has intensified only during the last 30 to 40 years. Cross-sectional studies between loneliness and wisdom have reported negative relationships that have been extended also to clinical inquiries. We published a microbiome-based study and found that in lonely people with lower scores in the wisdom scale, the microbiome was not diverse at all, whereas in people with higher scores in the wisdom scale and lower levels of loneliness, it was significantly more diverse. In a longitudinal study of over 1200 persons, those with higher levels of wisdom at baseline were much less likely to be lonely, 5 to 7 years later. My point here is that we should think about how we can increase wisdom, especially its compassion component, to reduce loneliness. And this approach must go beyond just loneliness and consider overall wellbeing. Gallup polls have shown increasing levels of crime, anger, disparity and depression all over the world. Why are these things getting worse? We must do something. We need to improve our wellbeing, our sense of happiness, our social connections. I really think the solution lies, fundamentally, in reaching increased wisdom and, especially, compassion. What some are actually thinking about right now, is to convert artificial intelligence into “artificial wisdom.” People may say that such is a joke, but the large language models can make robots wise and compassionate, capable of helping other people become more compassionate, more self-reflective, to have more control over their emotions. There is already a Japanese robot that seeks to teach spirituality. So, my point here is that we need to find solutions to the problems of loneliness. In fact, it is not just loneliness. There is so much unhappiness and anger right now in the world, anger against migrants, against minorities leading to distress, depression and so on. As humans, we need to not only survive, but also to flourish. We need to be happy, right? How can we do that? We need to have more compassion, to be helpful. And the good news is that we can use AI for that. I've been working with some AI people, including those who make robots, and thinking about how this would be feasible. I am not a technology expert at all, but I think that this idea is no longer unimaginable. Of course, it is unquestionable that AI also has downsides, risks, and threats but, in the hands of good people, it can assist in improving compassion, social connections and happiness in individuals and communities.

RDA: Thank you very much, Dilip, for these remarkable reflections on topics about which you, your teams and institutions are cultivating wisdom, solidarity, research routes, and genuinely academic and human values.

Dr Alarcón is Distinguished Emeritus Professor of Psychiatry, Mayo Clinic School of Medicine, Rochester, MN; Honorio Delgado Chair, Universidad Peruana Cayetano Heredia, Lima, Perú; and Editorial Board Member of Psychiatric Times.

Dr Jeste is a former professor of psychiatry and distinguished researcher at the University of California in San Diego, former president of the American Psychiatric Association and, currently, director of the Global Research Network on Social Determinants of Mental Health and Exposomics, president elect of the World Federation for Psychotherapy, and editor-in-chief of the International Psychogeriatrics journal.