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.
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.
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.
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:
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.”
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.
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 relate to the characteristics of our physical environment, like:
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.
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.
There are a variety of ways that agencies are already working to address and track Social Determinants of Mental Health through their work. Namely:
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.
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:
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.
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.
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:
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.
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.
We have decades of expertise in understanding the impact of Social Determinants of Mental Health on communities and providers.
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