Social Determinants of

Mental Health

LCDR Brian Lees, Psy.D.Clinical Psychologist

USPHS

World Health Organization definition

“The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries.”WHO webpage on social determinants of health. http://www.who.int/social_determinants/sdh_definition/en/

First, what defines our social experience?

http://fosteringandadoption.rip.org.uk/topics/child-development/

Can you provide examples of how our social environment in which we live affects our mental

and/or physical health?

How old is this boy?

http://www.thestar.com.my/news/nation/2014/07/25/firdaus-goes-to-new-home-teen-to-celebrate-raya-with-79-other-special-needs-kids/

15 yo, found living in squalor, abandoned by illegal immigrant parents.

The hospital brought back his weight but he has physical and mental handicaps

Social determinant model posits• Environmental influences, likely not under our

direct control, plays a large role in health status

• Mental health problems, may be due to environmental stressors that, over time, create alterations in our cognitive and emotional functioning

WHO, 2014

• “Mental health and many common mental disorders are shaped to a great extent by the social, economic, and physical environments in which people live.”

• “Certain population subgroups are at higher risk of mental disorders because of greater exposure and vulnerability to unfavourable social, economic, and environmental circumstances, interrelated with gender. Disadvantage starts before birth and accumulates throughout life.”

World Health Organization and Calouste Gulbenkian Foundation. Social determinants of mental health. Geneva, World Health Organization, 2014. Retrieved from http://www.lisboninstitutegmh.org/assets/docs/publications/9789241506809_eng.pdf

Contrast with “disease model”

Mental illness may NOT be a “brain disease” as sometimes defined by mainstream Western medicineThis model posits that• something is “wrong” with your “chemical

imbalance”• the “blame” is on YOU This model is likely not accurate for the majority of people with mental health problems

When do social influences start?

Social influences start…

• Before you were even conceived!

• Our biological parents’ and their parents’ various exposures are scripted in their DNA, which was passed to us.

• Known as “epigenetics”

• “…results reveal that descendants of people who survived the Holocaust have different stress hormone profiles than their peers, perhaps predisposing them to anxiety disorders.”

• http://www.scientificamerican.com/article/descendants-of-holocaust-survivors-have-altered-stress-hormones/

While in the womb

Many studies have shown that stressors on the pre-natal/in-utero environment can lead to life-long mental health problems.

http://www.theayurveda.org/wp-content/uploads/2016/02/Baby-in-womb.jpg

Tobacco and substance abuse

“It provides the most definitive evidence to date that smoking during pregnancy is associated with schizophrenia [in offspring]. If replicated, these findings suggest that preventing smoking during pregnancy may decrease the incidence of schizophrenia.”

http://dx.doi.org/10.1176/appi.ajp.2016.15060800

“Maternal psychological health also exerts a powerful influence over the epigenetic outcome in offspring.…domestic violence triggers stress in pregnant women that results in epigenetic changes in the DNA of the cortisol receptor in offspring observed during adolescence.”

• http://journal.frontiersin.org/article/10.3389/fcell.2014.00049/full

“…studies are in line with the growing body of literature supporting the ‘fetal origins hypothesis’ that prenatal environmental exposures — including maternal psychological state–based alterations in in utero physiology — can have sustained effects across the lifespan.”• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3710585/

www.beginbeforebirth.org

Effect of prenatal stress

Animal experiments have shown that prenatal stress can cause all the following effects on the offspring:• More anxiety• Reduced attention• Learning deficits• Less difference in function between the left and right

sides of the brain• Altered sexual behaviour – males show homosexual

behaviour and females are less nurturing mothers.– http://www.beginbeforebirth.org/

The child is born!

Let’s discuss Adverse Childhood Experiences (“ACEs”)

• “…variations in the amount of licking and grooming received during infancy had a direct effect on how stress hormones…were expressed in adulthood. The more licking as babies, the lower the stress hormones as grown-ups.”

Hurley, D. (2015) Grandma’s experiences leave a mark on your genes. Discover. Retrieved from http://discovermagazine.com/2013/may/13-grandmas-experiences-leave-epigenetic-mark-on-your-genes

The original ACE study

• “…the most important public health study you never heard of.” http://www.huffingtonpost.com/jane-ellen-stevens/the-adverse-childhood-exp_1_b_1943647.html

• In the mid-1990’s, 17,337 participants (Kaiser-Permanente HMO recipients) were given questionnaires about childhood experiences and current health problems.

• Based on observations that many obese patients were reporting abuse histories.

http://www.npr.org/sections/health-shots/2015/03/02/387007941/take-the-ace-quiz-and-learn-what-it-does-and-doesnt-mean

Childhood Adversity Narrative

http://www.canarratives.org/

Also see Center for Disease Control website http://www.cdc.gov/violenceprevention/acestudy/index.html

ACES questionnaire

• The original ten ACE items that had the most significant impact on adult health

• Each ACE items (“score”) adds to risk of health or behavior problem in a “step-wise” manner

• More have been added from other studies – History of being bullied– Growing up in low socioeconomic status– Growing up with neighborhood violence

A PERSON WITH 4 OR MORE ACES IS:

• 12.2 times as likely to attempt suicide • 10.3 times as likely to use injection drugs • 7.4 times as likely to be an alcoholic

• 2.2 times as likely to have ischemic heart disease • 2.4 times as likely to have a stroke • 1.9 times as likely to have cancer • 1.6 times as likely to have diabetes

How does poverty affect mental health?

Poverty

“According to data from the National Institute of Mental Health, low-income individuals are two to five times more likely to suffer from a diagnosable mental disorder than those of the highest socioeconomic group. …Poor children are at a greater risk for problems including lower IQ, poor academic achievement, poor socioemotional functioning, developmental delays and behavioral problems.”• http://www.apa.org/monitor/2016/04/living-wage.aspx

Poverty

Cyclical loop

Mental health problems impair work functioning

Thus have less income

Thus have less quality of life

resources (access to quality medical

care, nutrition, and exercise

opportunities),

which then leads to further mental

health problems

Discrimination

Various types of discrimination prohibited by the laws enforced by EEOC

• Age• Disability• Genetic information (e.g. family medical history)• National origin• Pregnancy• Race/color• Religion• Sex

Sex/Gender

World Health Organization: Gender Disparities in Mental Health http://www.who.int/mental_health/media/en/242.pdf

• “Rates of depression vary markedly between countries suggesting the importance of macrosocial factors. Nevertheless, depression is almost always reported to be twice as common in women compared with men across diverse societies and social contexts.

World Health Organization: Gender Disparities in Mental Health

• “Low rank is a powerful predictor of depression. Women's subordinate social status is reinforced in the workplace as they are more likely to occupy insecure, low status jobs with no decision making authority.”

• “Traditional gender roles further increase susceptibility by stressing passivity, submission and dependence”

• In regards to gender-based violence against women (e.g. honor killings): “Rates of depression in adult life are 3 to 4 fold higher in women exposed to violence…. Following rape, nearly 1 in 3 women will develop PTSD compared with 1 in 20 non victims.”

Conversely, gains in gender development that improve women's status are likely to bring with them improvements in women's mental health.”

Discrimination

http://www.apa.org/news/press/releases/2016/03/impact-of-discrimination.aspx

• “Regardless of the cause, average stress levels of those reporting discrimination are higher than for those who say they haven’t experienced discrimination. For many adults, dealing with discrimination results in a state of heightened vigilance and changes in behavior, which can trigger stress responses. Experiencing discrimination is also associated with poorer reported health.”

• “LGBT adults report higher stress levels than those who are not LGBT, especially if they say they have experienced discrimination because of their sexual orientation or gender identity.”

• “Adults with disabilities are more likely than those without a disability to say discrimination is a somewhat or significant source of stress”

Race

• The survey, of 3,361 adults in August 2015, found that nearly seven in 10 adults in the U.S. report having experienced discrimination, and 61 percent said they experience day-to-day discrimination, such as being treated with less courtesy or respect, receiving poorer service than others, or being threatened or harassed.

• Black adults are among the most likely to report experiencing some sort of discrimination. More than three in four black adults report experiencing day-to-day discrimination

• For many adults, even the anticipation of discrimination contributes to stress. Three in 10 Hispanic and black adults who report experiencing day-to-day discrimination at least once a week say that they feel they have to be very careful about their appearance to get good service or avoid harassment…also includes trying to prepare for insults from others before leaving home

• Stress also may be associated with other health disparities. …Adults who report that their health is only “fair” or “poor” have a higher reported stress level on average than those who rate their stress as “very good” or “excellent.”

How culture affects mental health

Our culture (macrosystem) dictates the way we:• experience life– Egocentric (“me”) vs. sociocentric (“we”)– Positives and negatives of each

• exhibit distress (idioms of distress)– (“shell shock” vs PTSD)

• request and receive help – (shame and stigma?)

Work/employment

“Unemployment and poor quality employment [closely related to social class and skill levels] are particularly strong risk factors for mental disorders… Conversely, job security and a sense of control at work are protective of good mental health” – WHO, Social Determinants of Mental Health, p.24

http://www.apaexcellence.org/assets/general/2016-work-and-wellbeing-survey-results.pdf?_ga=1.11213815.2139967331.1355864632

“…less than half of working Americans (44 percent) say the climate in their organization supports employee well-being, and 1 in 3 reports being chronically stressed on the job. The APA survey suggests a key part of the solution is senior leadership support.”

“And only 41 percent said their employer helps workers develop and maintain a healthy lifestyle.”

http://www.apa.org/news/press/releases/2016/06/workplace-well-being.aspx

A comment about resiliency

• While this presentations discusses the negative impact of social determinants, its important to note, even in the midst of such, many positive social events have happened in our lives– e.g, helped by the 1-2 people who really cared,– “Discrimination brought me closer with others like

me”

So what can we do?

• Are there evidenced based practices for reversing the mental health impact of social determinants?

• Can psychotherapy or medications change the emotional problems stemming from these social determinants?

I believe so!

So what can we do?

Timeline:• WRT epigenetics: Alter our own gene expression

through good health practices• WRT ACEs and discrimination, engage in therapy,

processing experiences of abuse, poverty, discrimination, etc.

• Does it help to “blame” our parents or society? It can, but shouldn’t be excessive

• Talk to siblings, and old friends. It doesn’t have to be a therapist

Improving our social systems

Microsystem• Who are you associating with?• Be more selective in peer and romantic

relationships (quality over quantity)• Learning conflict management when have to

deal with challenging relationships• Reciprocate (it feels good to help others)

Macrosystem:

• In regards to discrimination, be proud of who you are, band with others (strength in numbers), research your “kind”

• Pay attention to socio-political movements. Get involved, advocate for better health laws that address health disparity (for example extended maternity leave or rights for same-sex couples).

• Start a petition• Vote!

Summary

Our mental health issues, may not stem from “us,” but rather the interplay between us and the social environment in which we were born, raised, and continue to be a part of. Thus treatment involves learning about the effects of our social environment, processing how those events have affected us, and making an effort to change ourselves and the social world for the better!

Questions

• A two-way relationship exists between mental disorders and socioeconomic status: mental disorders lead to reduced income and employment, which entrenches poverty and in turn increases the risk of mental disorder

– WHO, 2014