The social determinants of mental health (SDOMH) are societal problems that disrupt mental health, increase risk of mental illness among certain groups, and worsen outcomes for individuals with mental illnesses. Much like the social determinants of health (SDOH), SDOMH include the non-medical factors that play a role in the likelihood and severity of health outcomes, such as income levels, education attainment, access to housing, and social inclusion. Disparities in mental health outcomes are a result of a multitude of factors and social determinants, including fixed characteristics on an individual level – such as age, gender, race/ethnicity, and sexual orientation – and environmental factors that stem from social and economic inequalities – such as inadequate access to proper food, housing, and transportation, and exposure to pollution. Interventions can be implemented to address the social determinants of mental health, environmentally, structurally, and locally to help improve mental health outcomes and reduce the rate of mental illnesses.
Definitions
Mental health, as defined by the CDC, encompasses individuals' emotional, psychological, and social well-being, while the most common mental disorders include anxiety-disorders such as generalized anxiety disorder, social anxiety, and panic disorder; depression; and post-traumatic stress disorder (PTSD).
The concept of social determinants stems from the life course approach. It draws from theories that explain the social, economic, environmental, and physical patterns that result in health disparities and vary across different stages of life (e.g. prenatal, early years, working age, and older ages). Identifying the social and structural determinants of mental health, in addition to individual determinants, enables policy makers to promote mental health and reduce risk of illness by designing appropriate interventions and taking action beyond the health sector.
Inequities in mental health Globally, in 2019, 1 in every 8 individuals (12.5% of the population) lived with a mental disorder; however, in 2020, due to the COVID-19 pandemic, that number grew dramatically by around 27%. While mental illnesses and disorders have become more prevalent, studies have shown that mental health outcomes are worse for some populations and communities than others. Socioeconomic, racial, and gender-based inequities impact the spread of which populations are inflicted with more mental illnesses and disorders.
Socioeconomic Inequities Several studies have shown that there is an association between the rate of mental illnesses within those who live in poverty and those who are in debt. Financial insecurity experienced by those with lower incomes tend to lead to higher rates of stress, anxiety, and depression due to a lack of job security, stable income, and strong social support systems. Furthermore, evidence compiled from several European population surveys shows that individuals facing educational and economic disadvantages are more likely to experience mental illnesses such as depression and anxiety. The opposite relationship also exists as stressors caused by mental illnesses contribute to long-term psychological distress and reduced access to resources such as education and stable employment.
Racial/Ethnic Inequities UK-based research has consistently reported that ethnic minority groups, particularly those of Black Caribbean and Black African descent, experience higher rates of severe psychotic illnesses such as schizophrenia at higher rates than those who are White. These disparities have persisted over decades and have been observed across multiple generations.
In the U.S., African Americans may have comparable rates of mental illnesses as White Americans; however, their mental health outcomes tend to be much worse due to racial inequities such as prejudice, discrimination, how mental health is perceived within their culture, and tendencies to have an overlap with other socioeconomic inequities.
Gender Inequities Studies have shown that women are almost twice as likely as men to have a mental illness. Women are more frequently diagnosed with depressive and anxiety disorders, while men have higher rates of substance use disorders and suicide in many regions. Some of the specific instances of gender inequities are biological differences due to different stress responses and brain structure, societal expectations regarding traditional gender roles, domestic and sexual abuse, lack of access to reproductive rights, lack of access to education, and different working conditions.
Social determinants of mental health impact men and women in different ways. Women often carry a larger share of unpaid domestic and caregiving responsibilities while being more likely to work in part-time or lower-paying occupations and face a gender-based wage gap, contributing to increased psychological stress. Women also face more internalized mental illnesses that are caused by feelings of hopelessness and despair as it manifests into anxiety and phobia-related mental illnesses. On the other hand, men are more frequently affected by externalizing mental illnesses, meaning that they are more likely to impact others, such as substance use and antisocial personality disorders. These are often associated with aggression, difficulties in interpersonal relationships, and negative impacts on physical health, employment, and family life.
Fixed characteristics Fixed characteristics refers to those that are genetic and biological and/or are not subjected to be influenced by the environment or social living conditions of an individual.
Gender The second leading cause of global disability burden in 2020 was unipolar depression, and research showed that depression was twice as likely to be prevalent in women than in men. Gender-based mental health disparities suggest that gender is a factor that could be leading to unequal health outcomes.
Research studies included in Lancet Psychiatry Women's Mental Health Series focuses on understanding why some of these gendered disparities might exist. Kuehner in her article Why is depression more common among women than among men? mentions several risk factors that contributes to these inequities, including the role of a women's sex hormones and "blunted hypothalamic-pituitary-adrenal axis response to stress". Other factors include a woman's increased likelihood to body shaming and rumination and stressors on an interpersonal level, as well as sexual abuse during childhood. Further, the prevalence of gender inequality and discrimination in society against women may also be a contributing factor. Li et al. finds that the monthly and lifespan fluctuations of sex hormones oestradiol and progesterone in women may also influence the gender gap, especially in the context of trauma-related, stress-related, and anxiety disorders, such as through increasing vulnerability to development of these disorders and permitting the continued persistence of symptoms for these disorders.
Increased likelihood of gender-based violence for women compared to men is also another risk factor that was studied by Oram et al. Researchers found that women have a higher risk of being subjected to domestic and sexual violence, thereby increasing their prevalence to post-traumatic stress, anxiety, and depression. Also notable to consider in the context of gender-based trauma are female genital mutilation, forced and early marriage, human trafficking, and honor crimes.
While women are reported to experience higher rates of depressive and anxiety related disorders, men are more likely to die by suicide than women: in the United Kingdom, suicide is the biggest cause of death for men 45 and younger, and in the likelihood of dying by suicide, men are four times more likely in Russia and Argentina, three and a half times more likely in the United States, and three times more likely in Australia, than women, to name a few countries. Gender differences in suicide are commonly explained by pressure for gender roles and higher risk-taking behavior among men.
Sexual orientation In studies comparing mental health outcomes between members of the lesbian, gay, bisexual, transgender, queer (questioning), intersex, asexual, aromantic and agender (LGBTQIA+) community with heterosexuals, the former showed increased risks of poor mental health. In fact, LGBTQIA+ individuals are twice as likely to have a mental disorder compared to their heterosexual counterparts, and two and a half times more likely to experience anxiety, depression, and substance misuse.
Based on the minority stress model, these mental health disparities among LGBTQIA+ people are due to discrimination and stigma. In fact, LGBTQIA+ individuals have expressed difficulty in accessing healthcare due to experienced discrimination and stigma, which as a result, causes them to not seek healthcare at all or rather delay it. Further societal isolation and feelings of rejection may also contribute to the prevalence of mental disorders among this community. In addition to the perceived and experienced stigma, LGBTQIA+ have an increased likelihood of being victims of violence. These factors, alongside others, contribute significantly to differences in mental health experiences for members of the LGBTQIA+ community in comparison to their heterosexual counterparts, thereby result in mental health inequities by sexual orientation.
Race/ethnicity Studies conducted in the United States have indicated that minorities have similar or smaller rates of prevalence for mental health disorders as their majority counterparts. Blacks (24.6%) and Hispanics (19.6%) have lower depression rates than their White counterparts (34.7%) in the United States. While racial/ethnic minority groups may have similar prevalence rates, the consequences because of mental illness are more prolonged – which may be partly explained due to the smaller access rates for mental health treatments. In 2018, while 56.7% of the general US population who had a mental illness didn't seek treatment, 69.4% and 67.1% Black and Hispanics didn't access care. Further, in the instances of some mental illnesses, such as schizophrenia, Blacks in the United States have been reported to have higher rates compared to their White counterparts, however, research suggests that this could be due to an overdiagnosis among clinicians and underdiagnosis for other illnesses, such as mood disorders, for which Blacks had lower reported prevalence rates for major depression. These instances of misdiagnosis may be due to "lack of cultural understanding by health care providers,...language differences between patient and provider, stigma of mental illness among minority groups, and cultural presentation of symptoms. Minority groups commonly report experiences with racism and discrimination, and they consider these experiences to be stressful. In a national probability sample of minority groups and whites. African Americans and Hispanic American reported experiencing higher overall levels of global stress than did whites.
Environmental factors
In addition to fixed characteristics, environmental factors, such as adequate access to food, housing, and health and exposure to pollution, impacts an individual's likelihood and severity of mental health outcomes. Although these factors can not directly change an individual's fixed characteristics of the social determinants of mental health, they can affect the degree to which an individual is influenced.
Inadequate access to proper food