Despite growing knowledge about the biological underpinnings of many mental disorders, it remains all too apparent that social, economic and political factors have considerable relevance to clinical features, treatment and outcomes in many cases. Poor people have at earlier ages presentation and longer durations of untreated illness. The mentally ill are over-represented in homeless and prison populations, not least because they are more likely to be taken into custody following an offence, compared with those without mental disorder.
This is a vicious cycle: mental disorder increases likelihood of arrest; imprisonment increases disability and stigma, further impeding recovery. The adverse effects of these social, economic and societal factors, along with the stigma of mental disorder, impair access to social and psychiatric services, and amplify the effects of mental disorder in the lives of sufferers. As a result, the mentally ill are systematically excluded from full participation in civic and social life, often constrained to live lives often shaped by stigma, isolation, homelessness and denial of rights.
Against this background, this new edited collection, The Social Determinants of Mental Health, is very welcome indeed. This is a strongly US-oriented volume, albeit with a suitably stirring foreword by Sir Michael Marmot, Director of the Institute of Health Equity and Professor at the Department of Epidemiology and Public Health in University College London.
The individual chapters in the book, from a range of contributors, cover topics including discrimination, adverse early-life experiences, education, unemployment, job insecurity, poverty, inequality and housing instability. There is an especially disturbing chapter about food insecurity, which is a huge problem in the United States and elsewhere, and has substantial impact on both physical and mental health, as well as social well-being. There are also contributions dealing with the effects of the built environment and access to health care, among other matters.
The book concludes with a very clear ‘call to action’, written by David Satcher and Ruth S. Shim (one of the editors). Satcher and Shim start by quoting Leonardo da Vinci (1452–1519): ‘I have been impressed with the urgency of doing. Knowing is not enough; we must apply. Being willing is not enough; we must do’. But do what, exactly? How can we fix this?
Satcher and Shim are clear that public health approaches are critical if mental health outcomes are to be improved, as is considering the impact of other, ostensibly non-mental health policies on mental health (e.g. housing policy). More specifically, they recommend certain preschool interventions, ‘social prescribing’ or ‘community referral’ to non-medical interventions to address social determinants of mental health at individual level; ‘medico-legal partnerships’ in relation to, for example, housing, and various other measures, such as screening for food insecurity.
These are all important tasks, not just in the United States but around the globe. The WHO reports that most people affected by mental, neurological and substance-use disorders, including up to 75% of those in many low-income countries, do not have access to any treatment, let alone treatment that ensures their mental and social well-being. For the majority, then, the key human rights issue is not protection from violations of liberty, but access to care and social support.
The ultimate solutions lie in a range of measures, including (a) introduction of rational mental health policies, focusing on real needs and free from the rigid ideological crusades that have too often defined mental health policy in the past; (b) enhanced emphasis on human rights, balancing rights to both liberty and treatment, with the ‘dignity and worth of the human person’ as the over-arching right (as outlined in the United Nations’ ‘Universal Declaration of Human Rights’), mindful that untreated mental disorder is antithetical to both dignity and liberty; and (c) joined-up mental health and social services, recognising the intimate relationship between chronic mental disorder and social decline, and working to address the stigma that prevents the mentally ill and others from responding effectively to these challenges.
