“Medicine is a social science, and politics is nothing else but medicine on a large scale.” – Dr Rudolph Virchow

At a time when our hospitals are bursting at the seams, it is worth looking at means of stemming the flow of patients upstream. This means paying attention to the neglected ‘social’ leg of our bio-psycho-social model of mental illness (Pilgrim, 2002). This neglect arises in part because social issues are perceived to be too large and structurally embedded to affect. We are more comfortable with the more human-sized biological and psychological interventions.

However, by focusing on modifiable root causes of mental health, we may be able to alter the trajectories of people away from our wards and therapy rooms. Perhaps it is time for clinicians and researchers to address the elephant in the prevalence rates of mental illness?

Various social, economic and physical environments affect a person’s mental health at different stages during their life. One major contributor is social inequality, which has a dose-dependent effect (McManus et al, 2007). Not only are the poor negatively affected by steep gradients, but so are people in the middle (Allen, 2014).

There are various key stages that offer targets for intervention in the body politic and a recent paper (Allen et al, 2014) and report (WHO, 2014) from the UCL institute of Health Equity, in collaboration with the WHO, offer some program and policy prescriptions.

Methods

The method used in this review was somewhat vague: it reports following the same methods as the famous Marmot review from 2010 and similar WHO reports of social determinants of health but did not offer further specifics. Going to those reports did not provide much clarification of precise resources used.

As best as can be discerned the researchers undertook a review of relevant literature to summarise what is known about the social determinants of mental health, and to identify successful examples of action affecting social determinants to improve population mental health.

They identified case examples of successful programs targeting key stages of the life course.

Results

The review found that the poor and disadvantaged suffer disproportionately from common mental disorders, including depression and anxiety, and their adverse consequences.

The following factors were found to associate with higher frequency of mental disorders:

• Low educational attainment
• Material disadvantage
• Unemployment
• Debt
• For older people, social isolation

The effect of social gradient was more marked in women than men. (Michael Marmot provides a neat definition of social gradient: “the more education, the lower the risk”).

The paper also emphasised how early these inequities emerge in the life-cycle. They have been detected as early as age 3, although evidence suggests that these trajectories are set even earlier, with prenatal and perinatal experiences affecting mental health outcomes later in life.

The mechanism linking social status and mental disorders is thought to be the accumulation of stressful experiences through successive stages of the life-cycle, mediated by individual resilience, and social support.

Solutions

The report identified programs and policies targeting different stages of the life-cycle in order to improve mental health outcomes. A selection, with potential relevance to the UK, is included below:

Interventions in the early years

In the USA, preschool interventions involving children from low income backgrounds have helped improve children’s educational achievement, economic success, and mental health outcomes in later life. These include:

• The HighScope Perry Preschool Project
• The Nurse Family Partnership (@NFP_nursefamily)
• The Incredible Years series (@IncredibleYrs)

School-based in later childhood

The Social and Emotional Learning programme in the USA has consistently improved children’s social-emotional skills, attitudes about self and others, school engagement, positive social behaviour, academic attainment, social conduct, and emotional distress by promoting supportive relationships which help develop children’s social and emotional skills.

Workplace-based intervention

In China, a workplace health promotion programme, incuding a focus on communication skills, stress management, problem solving, conflict management, and self-awareness, reduced depression and anxiety among the workforce, improved work performance, and reduced absenteeism.

Interventions during older ages

The Upstream Healthy Living Centre in the UK uses mentors to deliver tailored activities and improve social interaction, especially in rural settings, leading to improved psychological well-being and reduced depression by reducing social isolation.

Policies to reduce alcohol consumption

Minimum alcohol pricing can reduce levels of consumption: a 10% increase in minimum price, can reduce the overall consumption of alcohol by 3.4%.

Housing upgrades

Dealing with fuel poverty in the UK led to a reduction in depression, stress and anxiety among participants.

Active labour markets

A programme in Finland promotes and facilitates re-employment through training and support, and participants showed significantly lower levels of depression and increased levels of self-esteem, relative to controls at two years.

Discussion

This review advocates the benefits of addressing the social inequalities that contribute to the burden of mental disorders. In doing so, five principles should be adhered to:

1. Action should be taken in proportion to the level of disadvantage of a particular group
2. A life-course approach, addressing each stage with appropriate interventions
3. A focus particularly on early intervention
4. Taking into account the inter-relationship between physical and mental health
5. Taking mental health issues into account in a wide variety of sectors, including not just health, but also education, judicial, employment, welfare, transport and housing sectors

The authors also advocate avoiding short-termism and thinking about the long-term approaches to build communities that contribute to positive mental health, incorporating mental health equity into all policies, and that strategies are adopted both at a local level and at a country-wide level.

Limitations

This paper (Allen et al, 2014) and the accompanying report (WHO, 2014) represent a synthesis of relevant literature on the topic, with effective case studies highlighted.

Further work must be done to quantify the likely effects of the programs suggested, and their applicability to the UK context, as well as an attempt at quantification of the likely improvements in outcome to be gained from a focus on upstream determinants of mental health.

Conclusions

Overall, an increasing focus on the root causes of increased prevalence of mental disorders among certain groups may allow a reduction of the burden of disease.

Links

Allen J, Balfour R, Bell R, Marmot M. Social determinants of mental health. International Review of Psychiatry, August 2014, Vol. 26, No. 4 : Pages 392-407. [Abstract]

World Health Organization and Calouste Gulbenkian Foundation. Social determinants of mental health. Geneva, World Health Organization, 2014.

McManus  S , Meltzer  H , Brugha  T , Bebbington  P,  Jenkins , R . (2007) . Adult Psychiatric Morbidity in England, 2007. Leeds: NHS Information Centre for Health and Social Care . [PDF] (see p.32 for prevalence of common mental illnesses by income).

Pilgrim D. The biopsychosocial model in Anglo-American psychiatry: Past, present and future? Journal of Mental Health, 2002, Vol. 11, No. 6 , Pages 585-594 [PDF]

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