1. Social Determinants
of
Mental Health
LCDR Brian Lees, Psy.D.
Clinical Psychologist
USPHS

2. 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/

3. First, what defines our social experience?

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

5. Can you provide examples of how our social
environment in which we live affects our mental
and/or physical health?

6. 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/

7. 15 yo, found living in squalor,
abandoned by illegal immigrant
parents.

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

9. 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

11. 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

12. Contrast with “disease model”
Mental illness may NOT be a “brain disease” as
sometimes defined by mainstream Western
medicine
This 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

13. When do social influences start?

14. 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”

17. • “…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/

18. 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

19. Tobacco and substance abuse

20. “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

21. “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

22. “…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/

23. www.beginbeforebirth.org

24. 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/

25. The child is born!
Let’s discuss Adverse Childhood Experiences
(“ACEs”)

27. • “…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

28. 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.

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

30. Childhood Adversity Narrative
http://www.canarratives.org/
Also see Center for Disease Control website
http://www.cdc.gov/violenceprevention/acestu
dy/index.html

31. 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

32. 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

33. How does poverty affect mental
health?

34. 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

35. Poverty

36. 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

37. Discrimination

38. 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

39. 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.

40. 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.”

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

43. • “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”

45. Race

46. • 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.”

47. 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?)

48. Work/employment

49. “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

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

51. “…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

53. 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”

54. 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!

55. 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

56. 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)

57. 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!

58. 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!

59. Questions

60. • 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