In the previous parts of this piece, we considered the significant economic cost implications of mental health problems. In this, the third and final part, we will look at the importance of identifying and tackling those negative social determinants, which lead to a higher incidence of mental health problems amongst certain social categories. By adopting this approach it will be possible to reduce the overall level of mental health problems in Europe and consequently reduce their economic costs in the future.
Part 3. Social Determinants vs Genetic Factors
While genetic factors play a role in determining dissimilar health prospects at the level of the individual and in helping us understand and treat certain ailments, they are unable to adequately explain larger scale variations between social groups. Furthermore, they fail to account for the rapid changes in the health prospects and life expectancies of various social categories over relatively short timescales. As the WHO highlights in `The Solid Facts´:
The new discoveries on the human genome are exciting in the promise they hold for advances in the understanding and treatment of specific diseases. But however important individual genetic susceptibilities to disease may be, the common causes of the ill health that affects populations are environmental: they come and go far more quickly than the slow pace of genetic change because they reflect the changes in the way we live.1
This is not to ignore the role that biological or genetic predispositions can play in health related problems, including those concerning mental health. Rather it is to emphasise that they are generally not the determining factor. This is particularly true when examining the incidence of mental health problems across the general population.
Social Determinants and Health Inequity
This variance in health risks between various social groups is referred to as health inequity or health inequality. Health inequity measures the regular and consistent divergences in the health expectations of differing social groupings as opposed to the random and non-systematic disparities in health status between individuals.
Using 2004 data, Mackenback et al estimated that health inequalities were responsible for reducing the average life expectancy across the EU25 by 1.84 years or some 11.4 million years in total. Healthy life expectancy was reduced by, on average, 5.14 years or 33 million in total. In total, health inequities resulted in over 700,000 deaths per year and 33 million cases of ill health.
These social determinant derived health inequalities entail a significant economic cost equivalent to 20% of total health care costs and 15% of social security benefits.2
The most obvious general social determinant is poverty or economic insecurity. As the WHO Regional Committee for Europe noted:
Widening disparities in society or economic changes in individuals’ life courses seem to be of particular importance here. Whether defined by income, socioeconomic status, living conditions or educational level, poverty is an important determinant of mental disability and is associated with lower life expectancy and increased prevalence of alcohol and drug abuse, depression, suicide, antisocial behaviour and violence.3
Therefore, while an effective, well-resourced and responsive mental health service is crucial and indeed a key social determinant, it is inadequate in itself.
The systematic nature of social determinants and the consequent health inequities provide an opportunity to develop policies and programs to minimise their negative impact.
Indeed, it is arguably in the area of policy that the emphasis on social determinants will have the greatest impact in terms of mental health service delivery. Whereas mental health policy has generally been concerned with providing guidelines on how to best provide medical care at an optimal cost, it is now understood that mental health promotion involves a panoply of social and economic sectors.
As Keleher and Armstrong argue:
Mental health promotion requires action to influence determinants of mental health and address inequities through the implementation of effective multi-level interventions across a wide number of sectors, policies, programs, settings and environments. 4
Therefore, mental health not only involves the delivery of appropriate public mental health sector programmes but is also devised and implemented in cooperation with the relevant social and economic sectors.
In the same way as mental health ailments incur economic costs that extend beyond those involved in care provision, as discussed in Part 1 of this piece, the prevention of mental health problems requires the reduction of mental health inequities. Mental health should therefore not be regarded as solely the responsibility of the health care system.
Of course, the structure and operation of the mental health system is itself fundamental to achieving greater health equity. Indeed, good medical care is not only critical in ensuring that effective and quality treatment is received by those in need of assistance, it is itself one of the social determinants of health.
However, more is needed. To improve the mental health status of the population as a whole, it is essential that the social and economic status of the poorest sections of our population is improved.
Holistic Socio-Economic Approach
Taking a determinants approach to mental health promotion will require action across the width and breadth of our society and economy. It is crucial that the mental health policies that are developed in the future do not concentrate solely on the health sector itself. Instead there will be a need for “coherent action” across the range of identified social determinants of most importance. As Dr. Margaret Chan, the director-general of the WHO explains,
Health inequity really is a matter of life and death... health systems will not naturally gravitate towards equity. Unprecedented leadership is needed that compels all actors, including those beyond the health sector, to examine their impact on health.5
Furthermore, in addition to providing healthcare to service users, the mental health sector will need to extend its role to one where it both advocates and provides assistance to other key economic and social sectors so they can play their part in working towards better public mental health.
As Amnesty argue, from a human rights perspective:
As well as granting an entitlement to a system of mental health care, the State must protect other rights, such as housing, employment and education. These other rights are sometimes described as the underlying determinants of health because enjoying these rights can contribute to enjoying the right to health.6
Individual and un-coordinated actions that tackle one or other element of these social determinants will not be sufficient. Coherent and holistic policies and programmes of action will need to be developed to respond to the unequal distribution of negative social determinants amongst the various socio-economic categories. Of primary importance will be the drawing-up and implementation of inter-departmental policies and plans of action to eradicate structural inequality and endemic poverty.
Tackling the social determinants that contribute to mental health problems will also reap benefits in a wider range of areas. As the WHO emphasises in `The Solid Facts´:
... by tackling some of the material and social injustices, policy will not only improve health and well-being, but may also reduce a range of other social problems that flourish alongside ill health and are rooted in some of the same socioeconomic processes.1
Finally, addressing the crucial social determinants that impact upon mental health will require a long-term agenda and will potentially entail a radical overhaul of our current approach to social policies, economic structures and systems as well as political action. Failure to do so will not only lead to many European citizens suffering from potentially avoidable mental health problems but also result in a substantial drain on our economic resources.
Justin Frewen & Dr Anna Datta
1. WHO (2003) The Solid Facts: Social Determinants of Health 2nd ed. (Wilkinson, R. & Marmot, M. eds.). World Health Organization: Geneva
2. Mackenbach, J. P., Meerding, W. J. &, Kunst, A. E. (2007) Economic implications of socioeconomic inequalities in health in the European Union. European Commission: Luxembourg
3. WHO Europe (2003) Mental health in WHO’s European Region. World Health Organization: Geneva
4. Keleher, H. & Armstrong, R. (2006) Evidence based mental health promotion resource. Public Health Group Victorian Government Department of Human Services: Melbourne, Australia
5. WHO (2008a) Inequities are killing people on grand scale, reports WHO's Commission. Press Release.
6. Amnesty (2009) Mental Health and Your Human Rights: A Brief Guide. Amnesty International Ireland: Dublin
Back to Part 1. The Economic Costs (23/07/2010)
Back to Part 2. Human and Social Costs (30/07/2010)