Social Determinants of Mental Health

Being in the field of human services, we’re aware of the relationship between socioeconomic status and mental health. The National Institute of Health reports that more than 52 million adults in the United States live with mental illness, with correlations between their mental health and factors relating to how they live. These factors are known as Social Determinants of Mental Health, and they’re crucial for understanding the extent to which mental health is a social cause.

What Are Social Determinants of Mental Health?

Social Determinants of Mental Health are environmental, societal, and social factors that influence the way we live. Originally termed the Social Determinants of Health (SDOH), these factors make up a framework that health professionals use to understand mental health as a social issue. 

SDOH were originally intended to address physical health and answer the question, “How do social determinants contribute to the development of illness?” However, there’s a growing awareness of how they affect our behavioral health and ability to access mental health care. In either case, the determinants encompass a wide range of factors, environmental and societal, many of which are outside of your control. 

Why Are Social Determinants Important in Mental Health Care?

Addressing Social Determinants of Mental Health allows for mental health service delivery that recognizes the context in which a person lives. On a broader level, it helps deliver better care by breaking down societal barriers that create inequalities in our health care system, such as poverty, stigma, and lack of access to education or health care.

According to the World Health Organization (WHO), addressing social determinants is crucial to achieving “health equity” around the world. The WHO defines health equity as a condition in which “everyone has the opportunity to attain their full health potential and no one is disadvantaged from achieving this potential because of their social position or other socially determined circumstance.” 

Also, addressing the Social Determinants of Mental Health allows us to gain a fuller understanding of how mental health concerns develop. By identifying the variables, we can resolve issues at the root and generate better mental health outcomes. 

By working to improve on the determinants, we work toward a more equitable society. Given the correlation between mental health and poverty, resolutions often involve repairing unfavorable circumstances that leave certain populations more vulnerable to mental health risk factors. People are often born into a disadvantaged state. So repairing the social determinants that affect mental health in low-income neighborhoods can alleviate stressors that impact whole communities and generations.

Addressing the mental health of the individual is akin to treating symptoms. Addressing the systemic factors that have defined their mental health is to remove the disease process altogether. 

The Five Categories of Social Determinants of Mental Health

There are many factors that can influence our behavioral health. To break this down, The United States Department of Health and Human Services categorizes Social Determinants of Health, which also relates to mental health, into five domains:

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Economic Stability

To be economically stable means earning a steady income sufficient for satisfying our needs. Numerous influences can affect economic stability, including employment status, income level, expenses, debt, medical bills, and access to familial financial support. Also, economic determinants can change over time and are driven by personal choices, our communities, and the economy. So, for many, it can be quite challenging to avoid poverty.

In the field of behavioral health, we’re familiar with the relationship between poverty and mental health. Economically unstable individuals are susceptible to a wide range of mental health risks. On the individual level, it can lead to existential dread, with every instance of financial insufficiency — not enough money for food or the decision to go without a basic utility — generating another surge of crippling anxiety. 

The stress can metastasize socially, souring interactions with others and injecting tremendous strain into relationships. Survival consumes so much psychological real estate that an individual lacks the emotional capital to invest in others, and this may result in a lack of social support when a person needs it most. The effects of economic instability can outlast the individual and their community, too, as the next generation inherits the conditions that created the problems in the first place. The result is an “intergenerational cycle of poverty and poor health.”

Neighborhood and Built Environment

Our neighborhood and built environment encompasses everything in our physical surroundings that could influence our mental health. We’re not only talking about public spaces like parks, playgrounds, and the walkways we share with community members. We also mean private spaces and the points where they intersect with the public. 

To put it into perspective, imagine you’re sitting at your kitchen table, reading the news on your phone. Then a family member comes in and starts clattering pans and utensils to make breakfast. Another family member sits across from you with a handheld video game on full volume. A neighbor, outside, is revving the engine of their car. Now someone’s ringing the doorbell and knocking, too. All of these stimuli affect your state of mind. And if they were ongoing, integral parts of your environment, they could affect your mental predisposition to certain behavioral health concerns.

That’s what it’s like to live and work in some places. Crowding, clutter, noise, air pollution, and light pollution are a lot for the mind to process at any given moment.

Education

This category encompasses access to affordable early childhood education, vocational education, and higher education. Most people probably recognize that education plays a huge role in our lives, but they may not be aware of the connection it has to our mental health. 

Higher levels of education correlate with fewer instances of mental illness, and vice versa. Likely, the reason for this is complex. A college degree, for example, can lead to greater earning potential, increasing the potential for economic stability. So college graduates often have more means of building a foundation for mental health and more opportunities to develop their psychological well-being. Also, highly educated people tend to have a greater degree of control over the kinds of employment they take, which correlates with job satisfaction. This in turn correlates with positive mental health.

Community and Social Context

Community and social context relate to the characteristics of our physical environment, like:

  • Access to transportation.
  • Availability of housing. 
  • Availability of social support systems.
  • Safety.
  • Rates of civic participation.
  • Work conditions.
  • Systemic conditions.

We benefit from healthy social groups and social support systems, whereas factors like discrimination, racism, and systemic inequality have a huge impact on our mental health.

Health Care System

The nature and quality of our health care system influence our behavioral health. We’re referring to factors like provider availability, translation services, the affordability of health care, and disparities in access to health insurance, to name just a few.

When an individual is experiencing mental health issues, having access to high-quality mental care can be the key to restoring their psychological well-being. Unfortunately, health care access and quality aren’t consistent. Multiple factors determine the type of care services that are available to us, such as our socioeconomic status and geographical location. While telehealth services are becoming more common, particularly in our post-COVID world, economically unstable individuals may lack the finances and technical means required to use the technology. 

How Mental Health Agencies Are Addressing Social Determinants

There are a variety of ways that agencies are already working to address and track Social Determinants of Mental Health through their work. Namely:

Evaluating Resources Within the Community

Community resources — such as affordable education, free preschool, food banks, meal deliveries, job-search assistance, and public health centers — aim to close gaps in the Social Determinants of Mental Health. Educational, health care, and nutritional resources directly address their respective domains. Vocational resources help to attain economic stability. And together, all of these resources work to improve the physical and social environment, giving the most vulnerable populations a boost toward equity.

Creating and Implementing SDoH Assessment Tools

A variety of tools can help agencies assess Social Determinants of Mental Health in vulnerable populations. For example, these tools can help to measure social determinants on a broad, regional scale:

  • The Area Deprivation Index examines neighborhoods based on factors such as income, education, employment, and housing quality.
  • The National Equity Atlas looks at cities, states, and the country as a whole with respect to demographics, racial inclusion, and the economic benefits of equity.
  • County Health Rankings & Roadmaps evaluate communities on a wide range of key health factors, including education, income, employment, family and social support, community safety, housing, and transit.

Tracking Key Metrics Through EHR and Analytics Tools

Technologies such as electronic health records (EHRs) and analytics tools can help determine individual risk factors for social needs (food scurity, housing security, access to transportation, employment)  and predict health care utilization and health outcomes. With such insights at their disposal, we can make better decisions to guide vulnerable individuals via recommendations, referrals, and treatment plans. 

Developing Partnerships With Local Organizations

Partnerships can be critical to achieving health equity at the community level. Through the integration of organizations with shared values, the pursuit of equity becomes a larger vision, and the combination of resources enhances the feasibility of success.

“This is a once-in-a-lifetime opportunity to create bonds with these individuals that will outlast the pandemic; to create a new class of supporters and donors and political allies that can be with us after things return to normal”
Marlowe Greenberg
Founder & Chief Product Officer,
Foothold Technology
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Care Coordination

Since behavioral health is influenced by a wide variety of factors, it’s more important than ever for agencies to be able to send and receive data from other providers. Connections between human services agencies and other providers in their community can greatly enhance treatment and provide a holistic view of a client.

In this interview, Greenberg discusses with David Guth, Jr., Co-Founder and CEO of Centerstone:

  • The intersection of mental health and whole health.
  • Coordination among providers and payers.
  • Trends and predictions related to data.
  • Consumerism and technology.
  • Capacity-building and the search for systemic solutions through social determinants.

Mental health is about more than just diagnosis and treatment after the fact. It begins from the moment we enter the world and finds its influence in virtually every experience we have. So establishing physical, social, and emotional environments that promote healthy outlooks is more than just a corrective. It’s also a way to prevent mental health concerns from developing, realizing positive change as an ongoing process.

Breaking Down Barriers to Using Social Determinants of Health Data

If one were to think about individual health, you might think of the incredible advances in medicine that we have seen in the past 30 years. You could think about the use of new technologies that were only a dream 30 year years ago. You might also think that an annual physical is the key to a person’s health. Although all of these are important advances in medical care, they are only a very small part of the story. Medical care accounts for only 10%-20% of modifiable contributors to health outcomes for populations in the US. You may wonder, how is this possible? The answer comes in the correlation between patient outcomes and social determinants of health.  

For those in the behavioral health world, social determinants of health have always been at the center of the work that these providers do. They have developed community-based programs that address inequities and help people work, learn, and thrive in the community. For most behavioral health programs, social determinants have been at the core of recovery and rehabilitation for many years. 

In recent years, there has been a growing recognition of the importance of social determinants. There have been some focused, while limited, efforts to address this critical component of the healthcare system. Through COVID-19, we have gained knowledge about social determinants that has helped to highlight the disparities in our healthcare system, which come as a result of racial, gender, and economic inequalities. However, for the most part, social determinants have not been as deeply integrated into medical care, when compared to the behavioral health sector. 

Integrating Social Determinants Data into Healthcare 

As an industry, how can we be even more successful in identifying and incorporating these factors into healthcare treatment? I believe there are three factors that will help us integrate social determinants into healthcare: identification, access, and action. 

It starts with identification. Identifying social determinants is not as simple as “just ask the person.” Often, this information is not disclosed by an individual during a healthcare visit or during urgent care treatment. Even as social determinants have become more widely recognized as critical to an individual’s health, the healthcare system as it’s currently configured is not set up to fully identify an individual’s comprehensive array of social determinants. What’s more, clinical settings and reimbursement systems are not designed to identify and account for these factors. While there are pockets of successful efforts to integrate social determinants into the healthcare system, the system as a whole is still struggling to address social determinants. 

Access to social determinant information has been an ongoing issue. When thinking about the value of information, it is important to look at standardization, accessibility, and usability.  Projects such as the Gravity Project have made great progress in creating standardized nomenclature and coding for many of the social determinants. Including social determinants as part of the latest USCDI dataset provides an avenue for interoperability and sharing of this information. Beyond having this information standardized, we need to ensure that this information is readily available in a provider’s workflow. Since providers at all levels of care are struggling to keep up with their workloads, systems must be designed to make social determinants data easy to access and utilize in clinical decision making. 

Last, but not least, action must be taken to successfully infuse SDoH information into healthcare. Most clinical settings and reimbursement systems are not designed to address these issues. The simple answer is to refer individuals to a program that can address social determinants. However, in practice, this is not as simple as it sounds. Again, being able to create a replicable workflow and reimbursement structure that allows for care coordination and follow-up is crucial. Being able to easily communicate between a referring practice and the service delivery agency is critical to minimize workflow disruption and improve referral success.  

It’s time for action. This is the time to use technology to overcome the barriers in integrating SDoH information into healthcare, in the same way that electronic lab or testing information is readily shared and utilized. It is also a time for creativity and community support in improving access to behavioral health resources and building up those resources.

Ensuring that infrastructure and standardization is in place for providers to efficiently collect, share, and analyze social determinants of health data will be a joint effort between government, industry organizations, and the private sector. But the benefits of making this data accessible are real and the opportunity is endless. This information placed in the hands of those who truly can make a difference would drastically improve individual and population health. It can help shed light on inequities in healthcare, enable better clinical decisions, and support predictive analysis. This is an opportunity for technology to make a difference and to help create a healthier world. 

Article

How access to affordable housing impacts public health

Written by: Emma Rubin

In 2023, more than 650,000 people in the United States experienced homelessness. The number is a record since data collection began in 2007, and means more people than ever are confronted with the unique health risks that come from living without stable housing.

Homelessness can take many forms, from couch surfing to living in a shelter to sleeping on public streets. In a country like the U.S., where access to health care is determined by someone’s ability to pay, the economic instability that puts someone at risk of homelessness is also bound to have a direct impact on their health.

The life expectancy of people experiencing homelessness is between 42 and 52 years old, according to a study from the University of Pennsylvania published in 2022. Meanwhile, the overall life expectancy in the U.S. is 76 years old.

Foothold Technology used data from the Department of Housing and Urban Development to explore how access to housing impacts health, and vice versa.

Some of the health risks from cold winters, air pollution in dense cities, and extreme heat may seem obvious, but internal and chronic health conditions also fuel shorter life expectancies for unhoused people.

Monkey Business Images // Shutterstock

A study in the Journal of the American Medical Association published in 2023 examined deaths among unhoused people in San Francisco over eight years and found the sudden mortality rate was 16 times higher than the housed population. Sudden mortality events include heart attacks, drug overdoses, strokes, and more. Even when the researchers adjusted to remove drug overdoses and focus exclusively on cardiac events where a defibrillator could intervene, the sudden mortality rate remained seven times higher.

Another study by the National Bureau of Economic Research found that people experiencing homelessness were 3.2 times more likely to die within a six-month period than housed people. They remained 1.6 times more likely to die within a six-month period than low-income, housed individuals.

The connection between access to housing and health is also cyclic. Just as homelessness can worsen health outcomes, health problems can also lead to homelessness. Certain disabilities and health problems can limit available job opportunities, and the high cost of medical treatment can be burdensome—even for those with consistent income. About 8% of people hold medical debt in the U.S., but the share jumps to 14% for people in fair health, and 20% for people in poor health.

Health issues are harder to manage without stable housing

Seeking treatment for chronic health issues can be a challenge when 60% of unhoused people are without health insurance. Although HIV/AIDS can be managed and prevented with medications today, limited access to such care has resulted in higher diagnosis rates among the unhoused population.

Economic and housing instability can exacerbate mental health conditions, and severe conditions can make it more challenging to hold a job and interact with people.

When it comes to mental health and substance use disorders, the national program Projects for Assistance in Transition from Homelessness connected with more than 100,000 unhoused people also experiencing serious mental health conditions in 2021. Nearly 60,000 enrolled in a variety of their services including screening and treatment, rehabilitation, and housing services.

The wider availability of overdose-reversing drugs like naloxone has also been effective for intervening in emergency situations. The National Institutes of Health estimates that the distribution of naloxone kits has reduced overdose deaths by 6%.

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Other health care issues can be especially difficult to manage without having a consistent roof over one’s head. The FDA recommends diabetes patients keep insulin in the refrigerator. Diet-related conditions like hypertension are harder to manage without access to a kitchen to prepare unprocessed foods.

Estimates suggest that people experiencing homelessness also more often live with disabilities. Among the sheltered homeless population in 2021, 57.3% had disabilities compared to 13% of the American population overall.

A whole-person health approach

In 2016, California began rolling out programs to coordinate the health care needs of its population with the social service needs of its population. This includes helping connect patients with housing and food resources and allowing federal health funding to be used for certain housing services. This “whole person care” approach has shown success in the state, where 13 million people are enrolled in Medicaid.

The program showed success in its first five years. A 2021 report from the UCLA Center for Health Policy Research showed enrollees reported 45 fewer hospital stays and 130 fewer emergency room visits for every 1,000 beneficiaries compared to similar-profile Medicaid beneficiaries who did not participate in the program. This also reduced Medicaid payments by $383 per beneficiary per year.

Also in California, newly legalized mobile pharmacies will now be able to immediately dispense uncontrolled substances to patients without permanent addresses.

California isn’t the only state beginning to use Medicaid funds for food and housing needs. Several other states—including Arizona, Arkansas, Massachusetts, Nevada, New Jersey, New York, Oregon, and Washington—have launched pilot projects.

Nevada’s program will cover rent and food costs for eligible participants as well as housing transition services, case management, and deposits for housing. State Medicaid Administrator Stacie Weeks told the Nevada Current that the state’s program was a “small piece of the puzzle to improve health outcomes and lower the risk of high health care costs that can come from being unhoused.”

Story editing by Nicole Caldwell. Copy editing by Tim Bruns.

We have decades of expertise in understanding the impact of Social Determinants of Mental Health on communities and providers.