This Is the Water: The Social Determinants of Mental Health and the Future of Psychiatry

The social determinants of mental health surround us. You only need to take a look around to see them. For instance, consider the following scenarios.

The gunshot that changed him. “He shot my friend and his little boy as they were going into their house. I had just been walking with my friend when that guy walked right by me and shot them. I had just said goodbye on their front steps and was only about 20 feet away. My friend was a few years older, and I looked up to him. His son was 6. We both knew the guy who shot him, but I have no idea why it happened. I started feeling really depressed a few weeks later and made an appointment at the clinic.”

This is what the patient I (AT) was seeing, in consultation with his treating resident, told me when I asked him why he decided to come to our clinic. The resident said that the patient, who he had been seeing monthly for medical checks, met the DSM-5 criteria for major depression and did not meet the DSM-5 criteria for acute stress. Assuming the patient’s symptoms were due to grief, he had started the patient on antidepressants 3 months prior, but there was no improvement. As the patient was talking with me, I agreed that his symptoms met the criteria for major depression. But something in the way he was talking made me feel as if he was holding something back. I apologized for perhaps being presumptuous, as we had not met before, and asked if my feeling made sense to him. After a moment’s hesitation, he said, “Yes, there is something. I just keep thinking about what happened, and I feel guilty. I think about it all night and can’t sleep. I should have done something to keep him and his son from being killed.” He did have a stress disorder, and the mood changes were part of it.

Ready to move on. Not long ago, a patient who had been working hard on her recovery from trauma, depression, and opiate use came to see me (KST) and said, “I want to get a job. I want a real paycheck. But I’m afraid to apply. What will I do when they ask me about the big gaps in my résumé? I know they won’t hire me.”

What tools can I use during treatment to help her learn to confront the stigma and discrimination she faces? What resources might there be to help her find work?

Lack of support. I (KST) was part of a project that created a treatment and recovery program in a shelter. It was successful. People got better.

Unfortunately, the patients soon realized there was no housing available for them, and they felt overwhelming disappointment. They “got all dressed up and had nowhere to go.” My team and I were distraught that we could only find housing for 1 of 10 participants. There just was not enough affordable housing to go around.

Need for advocates on a larger, more political scale. I (KST) recently had a call from a friend of mine who has decided to run for Congress. He wants to help the people in Pittsburgh who have been left behind by the economy and further injured by the pandemic. He knows that 20% of the children in the district live in poverty. He knows about the deaths of despair due to opiates, suicide, and alcohol—the wages of deindustrialization. He wants to do the critical things necessary to improve our region’s health and well-being. What does he need to think about?

All of these scenarios present a number of questions. How did that resident—a very good one—miss a key emotional aspect of his patient’s world? How do we help people deal with the impact of stigma and other kinds of discrimination? How did we lose sight of the fact that people who are homeless need housing and that unemployed people want jobs? How often do we think about the importance of eliminating child poverty for the mental health of future generations? What in our psychiatric training and practice prepares us to really offer meaningful public policy advice that will equitably promote physical health, mental health, and well-being?

Where Has the Social in Biopsychosocial Been?

Should these questions come as a surprise to us? Of course not. Although science and experience have long made clear that social factors are a significant determinant of mental health and illness (as well as physical illness), we have often assumed there is little that we, as psychiatrists, can do about them. This has been particularly true for the last 40 years, with the rise of biological psychiatry and reaction against the social activism of the 1960s. It has resulted in omitting key aspects of the social in the biopsychosocial approach to psychiatric practice. This, in turn, has resulted in an inadvertent imprinting in our training programs and psychiatric practice with the belief that because there is little we can do about those factors at the societal level, there is little reason to address them with our patients, in our profession, or with society.

Rediscovery

But what if it’s not true that there is little we can do? What if we just haven’t found the most productive ways to act on behalf of our patients and the society in which we all live? Fortunately, in part due to the events of the past 2 years, the field has been thinking harder about this challenge. Our scientific evidence and our experience have made abundantly clear that psychiatric challenges are not randomly distributed among people. We now know that genetics plays a role. We also know that social identity and the experiences and exposures that constitute it plays a role—it is the water in which we swim.

Findings from innumerable studies in medical and psychiatric epidemiology have demonstrated a clear stepwise gradient at the population level between the burden of physical and psychiatric disorder and social class. Data from other studies have demonstrated how rates of disorders and treatments vary inequitably by age, geography, gender, sexual identity, disability, and race. These findings have brought a renewed focus on these experiences and exposures in a process we might compare to the efforts to map the genome.

In this regard, the work of Ruth S. Shim, MD, MPH, and Michael T. Compton, MD, MPH, and their colleagues stands out (Figure). Their 2015 book, The Social Determinants of Mental Health,¹ incorporates years of study that directs our attention to the social determinants of general health and well-being. In the book, Shim and Compton outline some of the critical elements we must consider to better understand the social determinants of mental health in a way that is thorough, if not exhaustive. They include issues such as discrimination and adverse life experiences including exposure to violence, poor education, neighborhood deprivation, housing, unemployment, and more. They describe the impact of each of these on mental health with critically important ideas about how to address them at the clinical, public health practice, and policy levels.

Just as crucial as this new understanding of the problem is the growing willingness to act on it, fueled by a desire for social justice and to ensure that all people can thrive. Although distress over inequitable treatment on account of race, class, and gender has been around for a long time, only recently has the focus shifted to the much more ambitious desire to minimize, or ideally eliminate, inequities in the health status of different populations. The goal of achieving health equity goes far beyond that of ensuring health care for all. It reflects the growing awareness that health care has only a limited role in the production of health. This new pursuit of health equity requires a keen focus and action on the social determinants of mental health and well-being.

How can we do this? Where do we begin to enhance psychiatric training and practice to incorporate these issues? How can we better address the basic needs patients bring to us in practice? How can we develop a public health approach to mental health and create and implement primary prevention interventions? How can we begin to understand how social policies affect mental health, and where can we learn about and practice public policy development and implementation? Answering these questions will involve a sustained major effort throughout our profession.

We know that our largest professional organizations have withdrawn from addressing these issues, perhaps responding to harsh criticism of our social activism in the 1960s and 1970s. This moment, however, is different. If the events of the last decade—especially in the past 2 years—have taught us anything, it is that, as practicing psychiatrists, we cannot stick to narrowly defined “medical necessity.” We cannot take care of people and expect the world in which they live to take care of itself.

We need to know enough about their world to understand the challenges they face and address those during treatment. We have to learn what we can do to make that world a better place for them to be. And it goes beyond this. It is not just about our patients. It also includes the people who are not our patients (yet). We need to do all we can to help prevent psychiatric disorders and to equitably promote mental health and well-being. Of course, we cannot do this alone. We will need help from each other and from our whole society.

Moving Forward

To accomplish this, our profession must lead the charge. Not only do we have the knowledge that requires action, we also have a social position that demands it. As a group of privileged professionals, psychiatrists live very well in our current social structure. We certainly earn it, but much of our income results in part from the suffering our society generates. To not recognize and respond to this fact risks making us complicit with the inequities we see every day.

Fortunately, our largest and most important professional organization has, although belatedly, started stepping up. Vivian B. Pender, MD, president of the American Psychiatric Association (APA), has initiated the special Task Force on the Social Determinants of Mental Health. This group’s charge is to help catalyze action on the goals addressed in a position paper regarding social determinants endorsed by the APA Board of Trustees and Assembly in 2018² (Table).

While, to date, there has been little action to implement the positions approved in 2018, task force work groups are currently considering how the APA can better promote and implement the positions approved by the board of trustees 3 years ago.

To ensure that the work of the task force does not become just another paper on a shelf, the task force submitted a proposal to the APA board to fund a fulltime staff director position so that our most important professional organization can more effectively focus on the social determinants of mental health. This proposal was rejected as premature by the APA budget committee in November 2021, and the future for APA action in this regard is not known as we write this column.

Author David Foster Wallace famously observed that just as fish do not recognize the water in which they swim, people often have little awareness of the world in which we all inhabit. It is too close—too overwhelming. It takes a great deal of effort and time to gain enough perspective to see the incredibly complex social aspects of our world and to learn how they can be shaped for ourselves and others.

It is our hope that, as you read this, you have already learned that the APA—the flagship organization of our profession—has better understood the water around us and has not missed the boat to begin a new journey toward more effective training, practice, and advocacy regarding the social determinants of mental health.

Dr Thompson is medical director and founder of the Pennsylvania Psychiatric Leadership Council and former medical director of the Center for Mental Health Services at the Substance Abuse and Mental Health Services Administration. Dr Tasman is emeritus John J. and Ruby B. Schwab Endowed Chair in Social, Community and Family Psychiatry and a professor at the University of Louisville School of Medicine, past president of the APA, and editor emeritus of Psychiatric Times^TM. Both authors are members of the APA Task Force on the Social Determinants of Mental Health, but the perspectives and opinions expressed in this article are their own and not necessarily those of the task force.

References

1. Compton MT, Shim RS, eds. The Social Determinants of Mental Health. 1st ed. American Psychiatric Publishing; 2015.

2. Castillo EG, Hansen H, Rocha E. Position statement on mental health equity and the social and structural determinants of mental health. American Psychiatric Association; 2018. ❒