Many psychiatrists are now seeing an increase in mental illness. Not only in isolated individuals, but in populations, rates are increasing. Brought about by longstanding disparities in income, employment, access to health care, education, nutrition and safe housing the destructive effects of discrimination on mental health may be permanent.
According to the World Health Organization, "depression is one of the leading causes of disability. Suicide is the second leading cause of death among 15-29-year-olds. People with severe mental health conditions die prematurely – as much as two decades early – due to preventable physical conditions." Effective treatment remains elusive.
The National Institute of Mental Health reported that an estimated one in four adults 18 years and older, or 26 percent of Americans, suffers from a diagnosable mental disorder each year.
The American Psychiatric Association is studying the constellation of factors that impact mental health. These are known as the social determinants of mental health that are focused on root causes with an eye to prevention. This framework strongly suggests a downstream link between a person's lived experience—determined by social, economic, environmental and structural factors—that contribute to mental health outcomes for communities. Authorities across the academic spectrum agree.
"Health is social," according to Zinobia Bennefield, a medical sociologist at the University of North Carolina, Charlotte. "It's about where you are, whether it's your physical, social, cultural, or economic environment."
Social factors include the effects of racism, adverse childhood experiences and lack of education. Macro and micro-aggressions toward people of color impose an undue burden of stress and trauma. Racism can increase a person's physical vulnerability to disease by increasing their "allostatic load," that is, the ability of the body to adjust to a challenge by producing stress hormones, even if the adjustment is ultimately harmful. A growing body of research has shown that childhood poverty is directly linked with adverse childhood experiences such as physical and sexual abuse, neglect and family dysfunction.
Economic factors include lack of access to health care and education, both of which are associated with poorer mental health among children and adults. Inadequate or unstable employment and housing can be constant sources of stress and worry. There is abundant research connecting childhood poverty to toxic stress, cumulative over a person's life that result in increased risk for mental health problems later in life. This can help explain some of the behavior in adults that police are called to address, and hospital emergency departments are called to treat.
Environmental factors include the built environment and substandard housing along with air and water pollution that can contribute to mental health problems. It matters where a person lives, and whether there is access to healthy food, green space, a safe school and community. Lead-poisoned water leads to brain damage. The July 2021 issue of the American Journal of Psychiatry highlighted how structural (baked in) racism is linked to neighborhood disadvantage ("red-lining"). This kind of environmental exposure to genetic vulnerability, perinatal complications and altered neurobiology may produce an adult who has phenotypic psychotic behavior.
Structural factors are policies, laws and regulations that institutionalize and normalize discrimination. There are more people with mental illnesses and substance use disorders in prisons and jails than in hospitals, reflecting the stigma against these individuals. No matter how hard I try, my patients are less likely to receive needed environmental change and more likely to die prematurely. The primary reasons for these are social—and not biological—factors.
Without the social determinants population framework, the standard medical analysis of, for example, aggressive behavior in inner city youth might focus on the diagnosis, and the medical treatment—sedatives and jail rather than intervention for possible substance use (perhaps through a community clinic). The framework expands the field of view and points out features of the environment that the individual lives in that are also contributing to this health outcome.
Mental health advocates need to go beyond traditional approaches and think more about how to prevent known causes of mental illness. Affordable safe housing, maternal health care, ensured education, relieving poverty, diversion to treatment facilities instead of jails and community outreach programs are needed to prevent mental illness from ever developing.
Dr. Vivian Pender is president of the American Psychiatric Association.
The views expressed in this article are the writer's own.
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