So­cial de­ter­mi­nants of men­tal health

The im­por­tance of pub­lic pol­icy level in­ter­ven­tion on men­tal health

The McGill Daily - - Contents - Na­dia Boachie Neu­roethics

It may come as a sur­prise that your zip code might be a bet­ter in­di­ca­tor of your over­all phys­i­cal and men­tal health than your ge­netic code. An ad­vo­cate of this state­ment, No­bel Prize-win­ning econ­o­mist An­gus Deaton, once wrote in a pa­per that “poorer peo­ple die younger and are sicker than richer peo­ple, in­deed, mor­tal­ity mor­bid­ity rates are in­versely re­lated to many cor­re­lates of so­cioe­co­nomic sta­tus such as in­come, wealth, ed­u­ca­tion or so­cial class.”

It has been doc­u­mented that so­cial de­ter­mi­nants of health have a far greater im­pact on in­di­vid­u­als than the ac­tual pro­vi­sion of health care. So­cial de­ter­mi­nants in­clude the con­di­tions in which peo­ple are born, live, work, and age, and the health systems they can ac­cess. These de­ter­mi­nants of health are in turn shaped by a wider set of forces: eco­nom­ics, so­cial dy­nam­ics, en­vi­ron­men­tal poli­cies, and pol­i­tics.

There is ac­cu­mu­lated ev­i­dence that mea­sures of phys­i­cal health such as the preva­lence of in­fec­tious dis­eases, in­fant mor­tal­ity rate, and life ex­pectancy may be im­pacted by so­cial de­ter­mi­nants. Re­cently, sci­en­tists have found that men­tal health may also be im­pacted by such de­ter­mi­nants.

Pre­vi­ously, ge­netic un­der­pin­nings of men­tal ill­nesses have been heav­ily fo­cused on. In re­cent decades, how­ever, there has been a shift to a biopsy­choso­cial model, which takes so­cial fac­tors into con­sid­er­a­tion dur­ing di­ag­no­sis. This il­lus­trates that men­tal health pro­fes­sion­als are in­creas­ingly cog­nisant of the fact that men­tal ill­nesses are strongly driven by var­i­ous so­cial fac­tors.

Men­tal health in­equities may be un­der­stood as be­ing at least par­tially de­ter­mined by un­equal dis­tri­bu­tion of op­por­tu­nity and, more deeply, by so­cial norms and pub­lic poli­cies. So­cial norms are the cul­tural opin­ions and bi­ases that set the stage for poorer health among disadvantaged groups – for ex­am­ple, racial bi­ases against mi­nor­ity groups. Pub­lic poli­cies refers to leg­is­la­tion that may not par­tic­u­larly con­cern health but has far-reach­ing ef­fects on health. Ex­am­ples of pub­lic poli­cies that have di­verse down­stream ef­fects on health in­clude the tu­ition costs for higher ed­u­ca­tion within univer­sity systems, min­i­mum wage leg­is­la­tions, and a city’s zon­ing or­di­nances.two of the so­cial de­ter­mi­nants that may greatly im­pact men­tal health are in­come in­equal­ity and ed­u­ca­tion level.

In­come in­equal­ity as a so­cial de­ter­mi­nant of men­tal health

There is ev­i­dence that peo­ple in low so­cioe­co­nomic classes suf­fer from men­tal health is­sues and their ad­verse con­se­quences at a dis­pro­por­tion­ate rate com­pared to peo­ple in higher so­cioe­co­nomic classes. In­come in­equal­ity pro­duces psy­choso­cial stress, which leads to de­te­ri­o­rat­ing health and higher mor­tal­ity over time. There is good ev­i­dence that com­mon men­tal dis­or­ders, such as de­pres­sion and anx­i­ety, are dis­trib­uted ac­cord­ing to a gra­di­ent of eco­nomic dis­ad­van­tage across so­cial strata.

The Cana­dian In­sti­tute for Health In­for­ma­tion pub­lished re­sults from a na­tion­wide study that showed that be­tween 2003 and 2013, self-rat­ings of poor or fair men­tal health in­creased in the low­est in­come level but re­mained sta­ble in the high­est in­come level: the rate in the low­est in­come level is still more than five times higher than that in the high­est in­come level (ap­prox­i­mately 14.5 per cent ver­sus 2.8 per cent).

In 2010, Lund and col­leagues, re­searchers from the Depart­ment of Psy­chi­a­try and Men­tal Health at Univer­sity of Cape Town, pub­lished a sys­tem­atic re­view of the epi­demi­o­log­i­cal lit­er­a­ture on com­mon men­tal ill­ness and poverty in low and mid­dle-in­come coun­tries. It was shown that 70 per cent of the 115 stud­ies re­viewed re­ported pos­i­tive as­so­ci­a­tions be­tween a va­ri­ety of poverty mea­sures and com­mon men­tal ill­ness. In an­other sys­tem­atic re­view, it was re­ported that de­pressed mood or anx­i­ety was 2.5 times higher among young peo­ple aged 10 to 15 years with low so­cioe­co­nomic sta­tus than among youths with high so­cioe­co­nomic sta­tus.

It is im­por­tant to keep in mind that in­equal­i­ties oc­cur along a con­tin­uum and af­fect ev­ery­one in the pop­u­la­tion, not only the poor­est or most disadvantaged. Re­searchers con­tend that in­equal­ity re­duces so­cial co­he­sion, a dy­namic that leads to more stress, fear, and in­se­cu­rity for ev­ery­one. Con­se­quently, high lev­els of in­equal­ity can neg­a­tively af­fect the health of even the most af­flu­ent. Money does not guar­an­tee im­mu­nity from men­tal ill­ness, nor does a lack of money lead to men­tal ill­ness; how­ever, it is gen­er­ally con­ceded that poverty can be both a de­ter­mi­nant and a con­se­quence of poor men­tal health.

Ed­u­ca­tion as a so­cial de­ter­mi­nant of men­tal health

Poor ed­u­ca­tion is as­so­ci­ated with de­creased phys­i­cal and men­tal health. Higher qual­ity ed­u­ca­tion and higher ed­u­ca­tion at­tain­ment have been as­so­ci­ated with bet­ter so­cial out­comes, such as sta­ble em­ploy­ment and higher in­come. Ad­di­tion­ally, em­ploy­ment is a ma­jor de­ter­mi­nant for men­tal health sta­tus. Un­em­ploy­ment sig­nif­i­cantly in­creases the odds of di­ag­no­sis with psy­chi­atric dis­or­ders: in a study pub­lished in 2004, it was noted that un­em­ploy­ment al­most quadru­pled the odds of drug de­pen­dence af­ter con­trol­ling for other so­cio- de­mo­graphic vari­ables.

Eth­i­cal im­pli­ca­tions of in­equal­i­ties in men­tal health

The ef­fect of in­equal­ity on men­tal health has pro­found eth­i­cal im­pli­ca­tions. Pub­lic health or­ga­ni­za­tions are be­gin­ning to rec­og­nize the detri­men­tal ef­fects of so­cial in­equal­i­ties, and are mak­ing ef­forts to ful­fill key bioethics prin­ci­ples of medicine and pub­lic health: re­spect for in­di­vid­u­als, jus­tice, benef­i­cence, and non-malfea­sance.

Im­por­tance of in­ter­ven­tion at the pol­icy-mak­ing level

In­ter­ven­tion at the pol­i­cy­mak­ing level ap­pears to be just as im­por­tant as in­ter­ven­tion at the in­di­vid­ual and fa­mil­ial level. More at­ten­tion should be paid to gov­ern­ment funded pro­grams that fo­cus on re­duc­ing poverty. There is of­ten po­lit­i­cal de­bate about the al­lo­ca­tion of re­sources to pro­grams that could nar­row the in­equal­ity gaps. Politi­cians should be aware of the fact that fund­ing these pro­grams may, in the long term, bet­ter so­ci­ety by in­di­rectly de­creas­ing the bur­den on the health care sys­tem.

The chang­ing roles of health care pro­fes­sion­als

Ab­so­lute so­cial equal­ity is dif­fi­cult to achieve. There­fore, vary­ing preva­lence rates of men­tal ill­ness be­tween un­equal groups in so­ci­ety, will be dif­fi­cult to com­pletely erad­i­cate. Re­searchers, psy­chi­a­trists, and other pub­lic health pro­fes­sion­als must re­duce the mag­ni­tude of this in­equal­ity.

There is a sense that the role of psy­chi­a­trists and other pub­lic health care pro­fes­sion­als might evolve to in­clude ad­vo­cat­ing for pol­icy change. Psy­chi­a­trists may be forced to have a more ac­tive non- clin­i­cal role by ad­vo­cat­ing for poli­cies that ad­dress these so­cial de­ter­mi­nants of men­tal health at vary­ing lev­els in so­ci­ety.

Your zip code might be a bet­ter in­di­ca­tor of your over­all phys­i­cal and men­tal health than your ge­netic code.

It has been doc­u­mented that so­cial de­ter­mi­nants of health have a far greater im­pact on in­di­vid­u­als than the ac­tual pro­vi­sion of health care.

Nelly Wat | The Mcgill Daily

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