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International Review of Psychiatry

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Social determinants of mental health

Jessica Allen, Reuben Balfour, Ruth Bell & Michael Marmot

To cite this article: Jessica Allen, Reuben Balfour, Ruth Bell & Michael Marmot (2014) Social
determinants of mental health, International Review of Psychiatry, 26:4, 392-407

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Published online: 19 Aug 2014.

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International Review of Psychiatry, August 2014; 26(4): 392–407

Social determinants of mental health


UCL Institute of Health Equity, University College London, UK

A person’s mental health and many common mental disorders are shaped by various social, economic, and physical
environments operating at different stages of life. Risk factors for many common mental disorders are heavily associated
with social inequalities, whereby the greater the inequality the higher the inequality in risk. The poor and disadvantaged
suffer disproportionately, but those in the middle of the social gradient are also affected. It is of major importance that
action is taken to improve the conditions of everyday life, beginning before birth and progressing into early childhood,
older childhood and adolescence, during family building and working ages, and through to older age. Action throughout
these life stages would provide opportunities for both improving population mental health, and for reducing risk of those
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mental disorders that are associated with social inequalities. As mental disorders are fundamentally linked to a number
of other physical health conditions, these actions would also reduce inequalities in physical health and improve health
overall. Action needs to be universal: across the whole of society and proportionate to need. Policy-making at all levels of
governance and across sectors can make a positive difference.

particular, socio-economic status, living conditions,
It is increasingly known that people’s social and eco- and other social and environmental determinants.
nomic circumstances affect their health. These social Health inequities exist both between and within
determinants include the conditions in which people countries and often follow a social gradient, thus
are born, live, work, and age, and the health systems occurring both along a continuum and affecting
they can access, which are in turn shaped by a wider everyone in the population, not only the poorest or
set of forces: economics, social, environmental poli- most disadvantaged. Those in the ‘middle’ – typically
cies, and politics. The landmark report of the Com- defined as those of average socio-economic status –
mission on Social Determinants of Health (2008) generally experience worse outcomes than the
– as well as a number of other seminal reports and best-off in society, but better outcomes than the
reviews (Marmot Review Team, 2010; WHO, 2013d) worst-off.
–have described the evidence base linking social The World Health Organization (WHO) defines
determinants to a range of health outcomes. mental health as ‘a state of well-being in which every
Differences in social, economic, and environmen- individual realizes his or her own potential, can cope
tal circumstances lead to health inequities, which with the normal stresses of life, can work produc-
are defined as health inequalities that are systematic, tively and fruitfully, and is able to make a contribu-
socially produced (and therefore modifiable), and tion to her or his community’ (WHO, 2013e).
unfair (Whitehead & Dahlgren, 2006). There are Importantly, the absence of mental disorder does not
clear variations in longevity not only across countries necessarily mean the presence of good mental health
but also within the same nation. Thus, a child who (Barry, 2009; Keyes, 2005) which raises significant
lives in a slum in Nairobi, Kenya is far more likely and important issues in managing mental illness as
to die before the age of five than a child from another well as mental well-being.
part of the city (WHO, 2008b). In Glasgow, The Global Burden of Disease 2010 study esti-
Scotland, male life expectancy varies from 54 to mates that 400 million people across the globe suffer
82 years, depending on the part of the city in which from depression (including dysthymia), and a further
the person lives (Hanlon et al., 2006). These varia- 272 million from anxiety disorders; 59 million
tions are a result of many factors including, in suffer from bipolar disorder and 24 million from

Correspondence: Ruth Bell, UCL Institute of Health Equity, University College London, 1-19 Torrington Place, London, UK. Tel: 0207 1684. Fax: 0203
108 3354. E-mail:

(Received 14 May 2014 ; accepted 22 May 2014 )

ISSN 0954–0261 print/ISSN 1369–1627 online © 2014 Institute of Psychiatry
DOI: 10.3109/09540261.2014.928270
Social determinants of mental health 393
schizophrenia; 140 million people are affected by • Country-level contexts, including political, social,
alcohol and drug use disorders; and 80 million chil- economic, and environmental factors, cultural
dren have behavioural disorders (conduct disorder or and social norms operating within a specific soci-
attention deficit hyperactivity disorder (Whiteford ety, and whether specific policies and strategies to
et al., 2013). These estimates do not include those reduce social inequalities and to promote access
who may have sub-threshold mental disorders. Some to education, employment, healthcare, housing
psychiatric and psychological illnesses are precipi- and services exist
tated by stressful experiences and life events, though
not always (Patten, 1991).
Main findings
In this paper we make the case that mental health
and many common mental disorders are shaped The poor and disadvantaged suffer disproportionately
to a great extent by social determinants. We provide from common mental disorders and their adverse
evidence that strategic action on people’s social, consequences (Campion et al., 2013; Melzer et al.,
economic, and environmental circumstances and 2004; Patel & Kleinman, 2003; Patel et al., 2010a),
effective interventions at different stages of the life- but middle classes are also affected. Gender also plays
course have considerable potential for improving a major role and women tend to have higher levels of
mental health and in preventing and alleviating common mental disorders compared to men at every
mental disorders in countries irrespective of their level of household income (Fig. 1).
stages of economic development. Household income is only one of the factors lead-
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ing to common mental disorders; low educational

attainment, material disadvantage, unemployment
(Fryers et al., 2005), and for older people social iso-
Methods lation, are other factors, along with gender as noted
Following the method of analysis completed by the above.
WHO Commission of Social Determinants of Health Prevalence of depressed mood or anxiety has been
(Commission on Social Determinants of Health, shown to be 2.5 times higher among young people
2008), the Marmot Review in England (Marmot aged 10 to 15 years with low socio-economic status
Review Team, 2010), the WHO Review of Social than among youths with high socio-economic status
Determinants of Health and the Health Divide (Lemstra et al., 2008). Household wealth affects chil-
(WHO, 2013d), as well as pioneering WHO reports dren’s emotional and behavioural difficulties even at
on mental health promotion and prevention of men- ages 3–5 years (Kelly et al., 2011).
tal health (WHO, 2004a; WHO, 2004b) and a num- Similar observations have been reported from low
ber of recent, well-researched resources, two key and middle income countries. Of 115 studies
issues were identified and explored: (1) the social reviewed, more than 70% reported clear and positive
determinants of common mental disorders; and associations between poverty and common mental
(2) action on social determinants that can prevent disorders (Lund et al., 2010).
mental health disorders and/or improve population Inevitably those who are lower in the social hier-
mental health. The work was undertaken in collabo- archy are more likely to experience less favourable
ration with staff members of the WHO’s Department economic, social, and environmental conditions
of Mental Health and Substance Abuse and with throughout life and may have access to fewer buffers
advice from an international panel of experts (WHO and may experience accumulative stress as a result,
& Gulbenkian Mental Health Platform (2014)). A leading on to mental disorders. Financial debt is
draft of the original paper was presented at the also associated with psychiatric disorders and has a
Gulbenkian Global Mental Health Platform’s Inter- gradient effect (Jenkins et al., 2008).
national Forum on Innovation in Mental Health, and
modified taking into account comments received A life-course perspective
from mental health experts
A multilevel framework was applied to organize It is crucial to follow a life-course approach as indi-
the evidence: viduals will have on-going and continuing stressors
affecting their health at various stages of life such as
• The life-course approach across various life stages pregnancy and perinatal periods, early childhood,
including pre- and perinatal periods, early child- adolescence, working and family building years, and
hood, later childhood, working and family-building older ages (Kieling et al., 2011; Marmot Review
years, and older age Team, 2010). Fig. 2 illustrates this approach.
• Community-level contexts, including the natural As mentioned above, exposure to stressors can be
and built environment, primary healthcare, and accumulative and will affect epigenetic, psychoso-
humanitarian settings cial, physiological, and behavioural attributes of
394 J. Allen et al.
kindergartens, preschools, schools, universities and
colleges, employers all need to be involved for
building healthier and happier societies. This needs
national policies but local actions.

Prenatal and perinatal experiences

The prenatal period often gets ignored, but is a
critical period. The perinatal period has a significant
impact on a newborn’s physical, mental, and cogni-
tive health. Maternal health is particularly important
and poor environmental conditions, poor health and
Fig. 1. Prevalence of any common mental disorder by household nutrition, tobacco use, alcohol and drug misuse,
income, England 2007 (McManus et al., 2007). Pale bars, women;
stress, and highly demanding physical labour can all
dark bars, men.
negatively affect the development of the foetus and
later life outcomes (Joint Commissioning Panel for
individuals, as well as social conditions in which Mental Health, 2013; WHO, 2013d). Children of
families, communities, and social groups live and depressed mothers are at a greater risk of being
work. It is possible that such an accumulation of underweight and stunted. Pre-term and low birth
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advantage and disadvantage may well contribute to weight babies may well themselves develop depres-
social and economic inequities and consequently to sion in later life (Surkan et al., 2011). It has been
inequitable mental health outcomes. These pro- suggested that reducing maternal depression in
cesses are not static, and keep changing in response Pakistan by 25%, 50%, or 75% would result in
to a whole host of factors. It is well known that a reductions in children born underweight by 7%,
greater number of adverse events in childhood is 26%, and 36% respectively (Rahman et al., 2008).
associated with increased likelihood of developing Education, particularly targeting women and new
mental illness in adulthood (Kessler et al., 2010; mothers, can help manage problems such as infant
Oladeji et al., 2010). mortality, stunting and malnutrition, conduct prob-
At every stage in the life course, vulnerability and lems, and emotional and mental health problems
exposure to harmful processes or stressors can be (Bicego & Boerma, 1993; Case et al., 2005; Gleason
disruptive, which is why any public mental health et al., 2011; Schady, 2011).
intervention needs to take a life course approach. A
life course approach implies that institutions such as
Early childhood
Not surprisingly, adverse conditions in early life are
associated with higher risk of mental disorders
(Jensen et al., 2013; WHO, 2013d). Again, it is well
known that quality of parenting and family condi-
tions affect children’s physical and emotional growth.
Poor secure attachment, neglect, lack of quality stim-
ulation and conflict all negatively affect future social
behaviour, educational outcomes, employment sta-
tus and mental and physical health (Bell et al., 2013).
Physical and emotional neglect, abuse, and growing
up in the presence of domestic violence can all dam-
age children (Fryers & Brugha, 2013). It has been
noted that children of mothers with mental ill-health
are five times more likely to have mental disorders
themselves (Melzer et al., 2003). As noted above,
social gradients in social and emotional difficulties
have been shown among children as young as three
years which can be offset by protective parenting
activities (Kelly et al., 2011).
Inequities in early years’ development are poten-
tially remediable through family and parenting sup-
Fig. 2. A life-course approach to tackling inequalities in health port, maternal care, childcare, and education. Wider
(WHO, 2013d). family and strong communities can act as buffers and
Social determinants of mental health 395

Box 1. Examples of interventions supporting mental health in the early years.

• In Jamaica a home-based intervention based on educating mothers about child-rearing including play activities and discussion
of parenting issues helped individuals cope better (Baker-Henningham et al., 2005).
• The Triple P – Positive Parenting Program has been implemented in numerous countries. It focuses on children’s behaviour
and development by altering the family environment to help reduce children’s risk of poor mental health (Sanders et al., 2008).
Originally from Australia, this programme has been used in China (Hong Kong), the Islamic Republic of Iran, Japan, and
Switzerland (Bodenmann et al., 2008; Leung et al., 2003; Matsumoto et al., 2007; Tehrani-Doost et al., 2009).
• The Sure Start initiative in England is a good example of a scaled-up approach to early years intervention by engaging with
parents, pregnant mothers, infants and preschool age children to promote child development in an easily accessible manner
(Goff et al., 2013; Jane-Llopis & Anderson, 2006).
• In the USA, studies have shown effectiveness of preschool interventions on young children living in low income and poverty
stricken settings. The High/Scope Perry Preschool Project, the Nurse–Family Partnership and the Incredible Years series have
helped improve children’s educational achievement, economic success, and mental health outcomes in later life (Kitzman et al.,
2010; Schweinhart, 2006; Webster-Stratton et al., 2008). Incredible Years programmes have been implemented in 20 countries and
territories, including Denmark, Finland, the occupied Palestinian territory, and the Russian Federation (Incredible Years, 2013).

sources of support (WHO, 2013d). Additional 2005). Universal approaches include changes to
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evidence-based actions are provided in Box 1. the school ethos, liaising with parents, special
teacher training, educating parents, community
involvement, and collaborating with external agen-
Later childhood
cies (Weare & Nind, 2011). Country examples are
Continued and appropriate forms of support are provided in Box 2.
needed throughout childhood and adolescence.
Depression in adolescence is linked with adverse
childhood experiences (Bell et al., 2013; Wickrama
Working age
et al., 2008) and risk taking in adolescence (includ-
ing substance misuse) which affects development Unemployment, irregular and poor-quality employ-
(Campion, 2013; Casey et al., 2008). Emotional sup- ment (such as employment with no or short-term
port from peers and families can help mitigate risk contracts), and jobs with low reward and low control
behaviours. Poor environmental conditions such as affect mental ill-health. A close association exists
overcrowding and unhealthy living can add to stress between job loss and symptoms of common mental
leading to poor educational achievements. disorders such as depression and anxiety (Catalano
et al., 2011; UCL IHE, 2012) especially in those
individuals who are long-term unemployed.
Implications for action
Job security and a sense of control at work are
Schools are important in education but also for protective factors (Anderson et al., 2011; Bambra,
providing a safe environment for personal develop- 2010). Employers who promote greater job control
ment and growth, the effects of which can influ- and decreased demand can positively influence men-
ence both short- and long-term mental health tal health by reducing stress, anxiety and depression,
(Barry, 2013). Schools allow access to a large num- and increasing self-esteem, job satisfaction and pro-
ber of children to teach about various matters ductivity (Bambra et al., 2007; Barry & Jenkins,
including managing stress (Jane-Llopis & Barry, 2007; Egan et al., 2007).

Box 2. Examples of school settings supporting mental health in later childhood.

• School-based interventions can support mental health and address mental disorders in children and adolescents around the world
(Collins et al., 2014; Holen et al., 2012; Katz et al., 2013) especially in poor countries and war and disaster affected countries
• The Social and Emotional Learning programme in the USA has consistently improved children’s social-emotional skills, attitudes
about self and others, school engagement, positive social behaviour, academic attainment, social conduct, and emotional distress
(Payton et al., 2008) by promoting supportive relationships which help develop children’s social and emotional skills (Mart et al.,
• In Sri Lanka, post-civil conflict, a school-based intervention improved mental health and conduct behaviour, including
improvements in children’s ability to settle disputes in a non-violent way (Tol et al., 2012). This was based on models from other
war-afflicted countries, such as Indonesia (Tol et al., 2008).
396 J. Allen et al.

Box 3. A workplace intervention in China to promote mental health.

• In China, a workplace health promotion programme reduced depression and anxiety among the workforce, improved work
performance, and reduced absenteeism.
• It also provided employees with the ability to manage work demands more effectively (Sun et al., 2013).
• Initiated by one of the largest retail companies in China, Credibility Retail Enterprise.
• Interventions occurred at the organizational level (by teaching managers skills and training to promote mental health, create a
good working environment, and develop an organizational health policy) and at the employee level through better communication
skills, stress management, problem solving, conflict management, and self-awareness.

Implications for action cognition as well as attachment patterns. Postnatal

depression can affect women’s mental health, but also
A reduction in long-term unemployment can reduce
family functioning.
risk of developing mental disorders, especially among
In low and middle income countries, the preva-
working age adults (Marmot Review Team, 2010)
lence of common mental disorders among women in
but equally importantly minimum wage can enable
the perinatal period is estimated to be 16% before
people to live better and thus reduce risk of mental
birth and 20% postnatally (Fisher et al., 2012). In
illness. Those who are employed require support
England, postnatal depression shows a clear social
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from their employers to promote and sustain mental

class gradient: from 2003 to 2004 just over 20% of
those in the lowest quintile for socio-economic status
Box 3 describes a programme in China that
had experienced postnatal depression, compared
reduced workers’ anxiety and depression, among
with 7% in the highest socio-economic quintile
other positive outcomes.
(Marmot Review Team, 2010). Similar gradients
It has been argued that every £1 spent on a
may well exist in other countries. Additional risk
workplace mental health promotion programme
factors for common mental disorders in the perinatal
would generate £10 in economic returns (Knapp
period included socio-economic disadvantages,
et al., 2011).
unintended pregnancy, being younger and unmar-
Microfinance programmes are other potential
ried, hostile in-laws and female child, while protec-
mechanisms to improve mental health by helping
tive factors included education, being employed and
people earn a living and enable communities
trustworthy partner.
to work their way out of poverty (PATH, 2011).
Primary and community health workers can
These are underutilized resources with the poten-
intervene successfully to improve maternal mental
tial to deliver health-related services to large and
health, thereby buffering risk for children (Rahman
hard-to-reach populations (Leatherman et al.,
et al., 2013). Box 5 illustrates with an account from
2012). Nonetheless, only limited research (see
South Africa.
Box 4) has examined the effects of these pro-
grammes on mental health.
Implications for action
Interventions supporting maternal and postnatal
Families are often the basis of social support and pro- mental health benefit parents as well their children
vide safe environments in which people grow up and and can disrupt the intergenerational transfer of
develop. Families and cultures are crucial in developing inequities (Marmot Review Team, 2010). Long-term

Box 4. Evidence of microfinance supporting mental health in working age.

• In South Africa, Fernald et al. (2008) demonstrated that small individual loans reduced depressive symptoms among men, but not
among women (Fernald et al., 2008). However, other studies have shown that microfinance interventions can improve the lives of
women, including their mental health.
• The Intervention with Microfinance for Aids and Gender Equity (IMAGE), which combined group-based microfinance with a
gender and HIV/AIDS training programme, significantly reduced levels of interpersonal violence in villages taking part in the
intervention with direct benefits to interpersonal, familial, and wider social relations along with a reduction in violence (Jan et al.,
• Type of microfinance repayment scheme influenced levels of anxiety among clients in India, with 51% less experience of anxiety
about repayment than clients on a weekly repayment scheme (Field et al., 2012).
Social determinants of mental health 397
differences in depression and well-being among the
Box 5. Evidence from South Africa on maternal depression. elderly (Grundy et al., 2013). The Scandinavian
countries appear to be best for older individuals as
• Effective interventions in South Africa have reduced
they have the lowest rates of depression, whereas
maternal depression and improved child attachment and
interaction (Cooper et al., 2007). Mediterranean countries such as Italy, Greece and
• The Mother2Mothers programme helped communities Spain show the highest levels of late-life depression.
develop peer support through education on how to access This variation is related to levels of state provision
existing healthcare services. As a result, new mothers managing mental health and pensions (Grundy et al.,
experienced more positive changes (Baek et al., 2007).
2013). Interestingly, rates of depression among older
adults in Japan are lower than those among younger
adults (Donovan & Halpern, 2002); whether this can
interventions can help throughout the vulnerable be explained by attitudes to ageing and filial piety
periods of childhood and adolescence. needs further exploration.
Social isolation reflecting lack of social contact
and support can be a key factor in developing depres-
Intergenerational transfer of disadvantage sion, especially in women; 10% or more older adults
are noted to be socially isolated, and loneliness in
As mentioned above, the family-building stage is
older people has been linked to depressive symp-
related closely to the perinatal and early years and
toms, poor mental health and cognition, alcohol
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intergenerational transfer of disadvantage and ineq-

dependence, suicidal ideation, and death (Grundy
uity which can lead to further disadvantages through
et al., 2013).
the perpetuation of disadvantage. See Fig. 2.

Older ages Implications for action

Not surprisingly, older people’s mental health is It is apparent that interventions which help prolong
influenced by earlier life experiences and also related levels of activity and reduce social isolation will
to experiences, conditions, and contexts specific to help reduce depressive symptoms (Forsman et al.,
ageing and the post-retirement period which may be 2011). Reducing social isolation, increasing exercise
strongly influenced by cultural and social factors. and physical activity and lifelong learning pro-
With this group too, there will be a social gradient grammes all help (see Box 6 for examples), along
in mental disorders among older people. Certainly with a reduction in financial poverty (Campion
in high-income countries, inequalities in older peo- et al., 2011). In cold climates, improving heating
ple’s mental health have been shown to be related to in the house (Critchley et al., 2007, Green &
socio-economic status, educational status, gender, Gilbertson, 2008), help older people (Mead et al.,
ethnicity, age, level of physical health (itself related 2010), and opportunities for older to people to vol-
to cultural, social, and economic factors) (Allen, unteer (Lum & Lightfoot, 2005) are effective tools.
2008; McCrone et al., 2008). These experiences Further work is required as a matter of urgency in
also vary by country, related to social, political, low and middle income countries.
and economic arrangements, and to levels of social
protection (Grundy et al., 2013). Cultural factors
and attitudes to ageing will also affect social
Box 6. Examples of interventions supporting mental health
Depressive mood in older men is related to chronic
during older ages.
ill-health, whereas for older women social factors
such as levels of isolation, contact with family, and • In Auckland, New Zealand, the Meeting of the Minds
was formed to promote positive ageing through a
belonging to faith or other community groups play a
coordinated cognitive activity programme. Using
role (Grundy et al., 2013). Once again, higher levels libraries as a resource enabled people to socialize, share
of education appear to be a protective factor, par- accounts, and be involved in other social activities to
ticularly for women (Ploubidis & Grundy, 2009). meet new people and develop social relationships
Older individuals have a higher risk of developing (Saxena & Garrison, 2004).
• The Upstream Healthy Living Centre in the UK uses
depression (McCrone et al., 2008). Indeed, life
mentors to deliver tailored activities and improve
events related to ageing such as bereavement and social interaction, especially in rural settings, leading
loss, loss of status, poor physical health and poor to improved psychological well-being and reduced
social contacts can all contribute to depression. The depression (Greaves & Farbus, 2006) by reducing
Survey of Health, Ageing and Retirement in Europe social isolation.
(SHARE study) noted that there are cross-national
398 J. Allen et al.
Community-level contexts good mental health. Almost half the world’s popula-
tion now live in urban areas away from natural envi-
There is little doubt that the environment or com-
ronments and connections with nature (Haines et al.,
munities in which people grow, live, work, and age
2007). Living close to natural environments and
have considerable influence upon mental health.
engaging in outdoor activities such as walking, run-
These include both tangible aspects such as the nat-
ning, cycling and gardening reduces stress, anxiety
ural and built environment, and intangible aspects
and depression (Barton et al., 2009; Maller et al.,
such as neighbourhood trust and safety. In addition,
2009; Pretty et al., 2007) in addition to conferring
geographical accessibility to primary care and com-
the mental health benefits of physical activity
munity are also important.
(whether indoors or outdoors) (Coon et al., 2011).
We now describe three aspects of the community
Connecting with the natural environment benefits
context in detail: the natural and built environment,
mental health. Taking walks in parks improved con-
primary healthcare, and humanitarian settings.
centration among children with ADHD, employee
General approaches to addressing the social deter-
mood and performance improved after the introduc-
minants of mental health in communities also exist
tion of plants into offices (Grinde & Patil, 2009; Kuo
(see Box 7).
& Taylor, 2004; Mind, 2007; Shibata & Suzuki, 2002;
Taylor & Kuo, 2009).
The natural and built environment
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The natural and built environment includes both Primary healthcare

natural and human-made aspects of communities Primary healthcare should be the bed-rock of health-
and includes geography and climate, housing quality, care delivery, but different healthcare systems around
water and sanitation systems, air quality, and trans- the globe will provide different types of primary care.
portation systems. These factors affect direct and Primary healthcare has a significant role to play in
indirect aspects of mental disorders and poor mental promoting good mental health through direct provi-
health (Turley et al., 2013; Wright & Moos, 2007). sion and referrals to other more specialized services
Overcrowding, for example, can lead to stress (Barry & Jenkins, 2007). Primary healthcare may
and family violence, including child maltreatment, be the only source of healthcare available in many
intimate partner violence and sexual violence, and countries, especially for people on low incomes
elder abuse (ODPM, 2004; UN Centre for Human (Rojas et al., 2007), and only physical health needs
Settlements, 1998). may be met (Patel et al., 2010b). Resources for men-
tal health are in short supply in many countries
(Kakuma et al., 2013).
Implications for action
If healthcare is organized around people’s needs
A number of specific interventions such as water, and expectations and around the tenets of primary
sanitation and waste management improvements, healthcare, it can produce a higher level of health
energy infrastructure upgrades, new transport infra- for the same investment (WHO, 2008c). Uganda is
structure, mitigation of environmental hazards, and one country that has done so (Box 9). The Mental
improved housing (Turley et al., 2013) can improve Health and Poverty Projects in Mayuge, Uganda,
mental health and functioning. Box 8 provides some and KwaZulu-Natal, South Africa, through multi-
illustrations of the impact of housing upgrades on sectorial community collaborations, task shifting,
mental health. Ease of access to the natural environ- and the development and support of self-help groups
ment and outdoor spaces is also vitally important for were particularly promising methods to address the

Box 7. Examples of community-level interventions in Ghana, Kenya and India.

• Self-help groups in northern Ghana have helped facilitate access to the psychological services offered by the Ghanaian Health
Service. These groups in their monthly meetings support each other by sharing tasks such as collecting wood and water, even
visiting homes to cook for people and providing financial credit if needed (Cohen et al., 2012).
• In rural Kenya the BasicNeeds programme has also led to significant improvements in mental health, quality of life, social relations,
and economic functioning (Lund et al., 2013).
• In India the Comprehensive Rural Health Project is a community-based intervention that integrates mental health into the primary
healthcare setting with a strong focus on women, addressing the social and economic determinants of health and educating
individuals. Using trained volunteers the intervention works with groups of women from the community to build competence and
self-esteem, and to increase perceptions of personal control. These changes in lifestyle and circumstance improved their mental
health (Kermode et al., 2007, 2009).
Social determinants of mental health 399

Box 8. Examples of the positive mental health effects of Box 10. A community-based intervention to support
housing upgrades. mental health in post-conflict Rwanda.

• Simple changes such as demonstrated in Mexico, where • Over 800,000 people were killed with over 2 million
replacing dirt floors with concrete significantly improved refugees as a result of the Rwandan conflict in 1994.
the health of children by reducing incidence of disease A community-based programme launched in 2006 in the
and infection, was associated with cognitive improvement Byumba district of Rwanda used interactions between
among children, and reduced depression and stress individuals and their social environment to facilitate the
among adults (Cattaneo et al., 2009). re-establishment of values, norms, and relationships
• Dealing with fuel poverty in the UK led to a reduction using education, sharing of experiences and stories and
in depression, stress and anxiety among participants coping. Over 7,000 individuals have participated and
(Critchley et al., 2007; Green & Gilbertson, 2008). their mental health has improved (Richters et al., 2008;
Scholte et al., 2011).

treatment gap in low income settings (Petersen

et al., 2011).
war, conflict, floods or other disasters, affects indi-
viduals as well as communities and social institu-
Implications for action
tions, leading to the breakdown of families, social
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Mental health integration into primary healthcare networks, and community bonds. It is vital that
is important (WHO, 2001, 2009; WHO & World any interventions take into account the actual social
Organization of Family Doctors, 2008); and a com- environment as well as health and nutritional needs
panion thematic paper from the WHO/Gulbenkian (see Box 10).
mental health series (WHO, 2014) addresses this
topic in detail. In addition, WHO’s Mental Health
Gap Action Programme (WHO, 2008a) provides Implications for action
policy-makers, health planners, and other stakehold-
WHO provides guidance and examples of good prac-
ers with clear guidance on how to scale up mental
tice (WHO, 2013c).
healthcare. One key principle is that to be effective,
primary health workers must be supported by sec-
ondary-level mental health specialists for supervision Country-level contexts
and referrals.
It is inevitable that the current political, social, eco-
nomic, and environmental milieu, and cultural and
Humanitarian settings social norms, as well as the historical context of a
country, shape the conditions in which people live.
Man-made or natural disasters can lead to mental
Countries with few political freedoms, unstable
disorders (Meffert & Ekblad, 2013; Tol et al., 2011).
policy environments, and poorly developed services
In addition, those with pre-existing mental health
create vulnerabilities among their populations, caus-
problems might experience worse symptoms, while
ing deleterious effects on mental health (Marmot
at the same time structures delivering the services are
Review Team, 2010). Poverty puts people at an
under increased pressure (WHO, 2013a), and inevi-
increased risk of mental health problems through a
tably poorer and more marginalized members of
number of intermediary factors.
communities tend to experience the most adverse
The impact of political, social, and economic tur-
effects (WHO, 2010). A humanitarian crisis, whether
bulence on mental and physical health was power-
fully demonstrated by the decline and subsequent
fluctuations in life expectancy in the Russian
Box 9. Primary healthcare in Uganda. Federation after the collapse of the Soviet Union
• In 1999, the Ugandan Ministry of Health introduced a (Marmot et al., 2012). Deaths increased sharply
number of national health policy reforms that included, among middle-aged adults in the Russian Federation
as one of the guiding principles, the inclusion of primary from 1991 to 2001 (Men et al., 2003) possibly attrib-
healthcare in its strategy for national health
utable to harmful use of alcohol (Leon et al., 2007).
development. This Uganda National Minimum Health
Care Package, includes mental health as a key Alcohol plays a major role in contributing to men-
component alongside the decentralization of mental tal ill-health, and various strategies can be used to
health services, thus improving health (Kigozi, 2007). manage this (see Box 11).
Service is provided by general health workers Across the former Soviet Union, psychological
(Ssebunnya et al., 2010).
distress has varied between and within countries.
Women have shown higher rates of distress than
400 J. Allen et al.

Box 11. Policies to reduce alcohol consumption. Box 12. Active labour markets.

• Alcohol consumption affects population mental health, • Active labour market programmes have been used in
increasing the likelihood of alcohol dependence, countries such as Denmark (Jespersen et al., 2008),
depression, and suicide, along with contributing to poor Sweden (Sianesi 2002), and specific states within the
physical health, accidental injury, and domestic violence USA and they take an active approach to getting people
(Wahlbeck & McDaid, 2012). back to work (Stuckler & Basu, 2013).
• Political debate and policy changes have been growing in • The Finnish programme promotes and facilitates
countries such as Australia, Malawi, the UK (England re-employment through training and support, and
and Scotland) and Zambia (Collins & Lapsley, 2008; participants showed significantly lower levels of depression
Scottish Parliament, 2012; UN Development Programme, and increased levels of self-esteem, relative to a control
2013; Woodhouse & Ward, 2013). group, at two years (Vuori & Silvonen, 2005; Vuori et al.,
• Minimum alcohol pricing has become a major issue in 2002).
many countries. Evidence from British Columbia,
Canada shows that as a result of minimum alcohol
pricing over the last 20 years the price of alcohol has
been adjusted incrementally over time.
• It has been estimated that a 10% increase in the Additional information about active labour mar-
minimum price of an alcoholic drink reduced kets is provided in Box 12.
consumption relative to other drinks by 16.1%, and
overall consumption of alcohol by 3.4% (Stockwell
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et al., 2012). Policy measures

Several high-income countries, including Australia,
New Zealand, and England and Scotland in the UK,
have incorporated a social determinants of mental
health approach into national policy and strategy
men with risk factors including poverty, unemploy-
using a multisectoral approach.
ment, low education, disability, lack of trust in peo-
ple, and lack of personal support (Roberts et al.,
2010). Across the Czech Republic, Poland, and Implications for action
the Russian Federation too, depression has been
It is self-evident that people’s mental health is influ-
associated with social deprivation for both men
enced by a number of social, economic and environ-
and women. Socio-economic circumstances have
mental factors, therefore governments need to work
been shown to be more strongly associated with
across different departments, integrating mental
depression than early life experience or level of edu-
health into a broad range of related policy areas.
cation (Nicholson et al., 2008).
Following the 2008 banking crisis, rates of unem-
ployment rose sharply in the European Union as did
rates of suicide (Stuckler et al., 2011). Between
1970–2007, in 26 European countries, every 1% There is considerable research evidence to show
increase in unemployment was associated with a that social inequalities affect the public’s mental
0.79% rise in suicides at ages younger than 65 years health, and urgent action is needed to improve the
(Stuckler et al., 2009). As mentioned above, it is well conditions of daily life throughout the life-course.
known that unemployment is associated with an Broader economic and political interventions have
increased risk of depression (Kaplan et al., 1987, shown successful influences on the mental health of
Kasl & Jones, 2000) and job insecurity is associated populations.
with sub-optimal mental health (UCL IHE, 2012, It is important to understand that good mental
Virtanen et al., 2011). health is a core indicator of human development,
Strong social welfare systems seem to offer pro- and it is necessary to integrate a mental health and
tection against unemployment risks for mental psychosocial perspective into development and
disorders. Over a 25-year period it was noted that humanitarian policies, programmes and services,
in comparing Spain and Sweden, in the former particularly internationally agreed goals and com-
there was a direct correlation between unemploy- mitments (WHO & UN, 2010). The WHO’s
ment and suicide rates, but not in the latter, indicat- Mental Health Action Plan 2013–2020 (WHO,
ing that higher level of social spending on active 2013b) calls for integration of mental health issues
labour markets in Sweden (average labour market into multisectoral policies and laws, including edu-
protection US$362 per head) than in Spain ($88 cation, employment, disability, the judicial system,
per head)may have had an impact (Kasl & Jones, human rights protection, social protection, poverty
2000). reduction and development.
Social determinants of mental health 401
Principles and actions depression and disrupting intergenerational trans-
mission of inequity.
Proportionate universalism
A key principle to be taken forward from this paper
Healthy mind and healthy body
is ‘proportionate universalism’, which is derived from
the observation that mental health inequities affect A social determinants of health approach should con-
everyone, not only the poorest or most disadvantaged sider both mental and physical health implications
in society. Thus actions must be universal, yet cali- within all actions to tackle health inequalities. Mental
brated in proportion to the level of disadvantage; and physical health conditions are fundamentally
hence the term proportionate universalism. inter-related: sharing many underlying causes and
Proportionate universalism needs to be differenti- overarching consequences, highly interdependent
ated from targeted programmes and services, whereby and tend to co-occur, and they are best managed
the most vulnerable or disadvantaged are singled out using integrated approaches. Programmes aimed at
for specialized interventions. These services may excl- improving water and sanitation, reducing unemploy-
ude the neediest individuals who for whatever reason ment, or mitigating the effects of climate change and
may not fulfil their inclusion criteria. Services for the increasing sustainability are likely to have a positive
poor often become ‘poor services’ and are easily ghet- impact on both mental and physical health while
toized, reduced or stopped altogether because they addressing health inequities.
may not have the support of the whole population.
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Action across sectors Prioritizing mental health

As explained above, successful interventions on the Mental health needs to be given greater priority
social determinants of mental health result from action across the world, but especially in low and middle
across multiple sectors and levels, for instance health, income countries, where the issue is often poorly
education, judicial, employment, welfare, transport, understood and/or not recognized as a major health
and housing sectors. Effective leadership is essential concern. Increased awareness and understanding of
to inspire and make the case, and to drive through mental health should be followed urgently by
the necessary negotiations. Multisectoral coordination increased allocations of appropriate and sufficient
is also needed outside of government, with potential financial, medical, and human resources towards
participation and cooperation of international organi- tackling mental disorders and reducing inequalities.
zations, non-governmental organizations, social insti-
tutions and service providers, community and
voluntary groups, and the private sector. Avoiding short-termism
Short-term thinking often obstructs progress. Thus
Life-course approach long-term interventions are needed which will include
community development, capacity-building, part-
The interplay of risk and protective factors changes nerships, and local institution-building across the
over the life cycle; interventions and strategies must life-course.
therefore be appropriate to different stages of life.
Therefore, taking a life-course perspective recognizes
that exposure to advantage and disadvantage at each Mental health equity in all policies
stage of life has the potential to influence mental Reducing inequalities in mental health is a task that
health in both the short term and long term. Hence, must be taken on by the whole of government and
in many cases, organizations in which people are across all sectors. It is important that all policies
typically involved at different stages of life (e.g. across all sectors do no harm to population mental
schools, employers) are the most appropriate settings health, but rather, reduce mental health inequities.
to deliver interventions.
Knowledge for action at the local level
Early intervention
Information systems and processes are needed at
Every child deserves to have the best possible local levels to inform action. Different kinds of infor-
start in life. Interventions at the earliest stages of a mation are needed depending on the intended action,
child’s life can prevent both short- and long-term but include:
mental disorders and enable them to maximize their
potential and a healthy adulthood. Early interven- • Information on the distribution of mental disor-
tion strategies are also useful in reducing maternal ders at the local level
402 J. Allen et al.
• Information on how many of those with mental (UN, 2000), progress towards these goals contrib-
disorders have access to effective therapeutic utes powerfully to mental health promotion. In prep-
treatment, and on the unmet need for therapy i.e. aration for the 2015 expiry date of the MDGs, the
what the mental health gap is United Nations (UN) is in the process of consulta-
• Information about social, economic, and environ- tion and planning for the next phase of post-2015
mental stressors explored and understood through sustainable human development (post-2015 agenda),
community engagement leading on from existing unfinished MDGs and the
• Knowledge of local assets and resources, includ- Rio ⫹ 20 environmental sustainability agenda (UN,
ing how local social, economic, and environmen- 2012).
tal factors contribute to or reduce psychological Embedding the social determinants of health
distress, understanding both precipitating and approach (UN Platform on Social Determinants of
protective factors Health, 2013) and universal health coverage (WHO,
• Triangulated knowledge about local assets and 2013f) in the post-2015 agenda would create a trans-
resources, and interventions that have worked in formative development framework for health. Spe-
other settings and the lessons as well as strengths cific inclusion of mental health is also necessary
and weaknesses of each approach (Minas & Kwasik, 2013). The Movement for Global
• Assessments of all local development initiatives Mental Health, a network of individuals and organi-
with respect to their potential impact on mental zations aiming to improve services for people with
health equity (how different groups might be mental disorders, calls for three elements to be
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impacted), especially those with mental disorders included in the post-2015 agenda (Movement for
• Synergies between interventions: information Global Mental Health, 2013): protecting human
about how mental health and its social distribu- rights and preventing discrimination against people
tion are influenced by interventions to improve with mental disorders, bridging the massive mental
aspects of the local educational services, health- health treatment gap and improving access to health
care services, built environment, natural environ- and social care, and explicitly integrating mental
ment, transport, income generating opportunities, health into development initiatives.
and community development

Such information can lead to action at the local Conclusions

level. Ideally, national-level strategies should provide In this paper we have outlined how mental health
the framework and support for local-level action. and many common mental disorders are shaped by
For local-level action to be effective and sustainable the social, economic and physical environments and
over the longer term, country-wide strategies must social gradient in which people live and work. Risk
be implemented to tackle deep-rooted structural factors for many common mental disorders are heav-
issues arising from the unequal distribution of ily associated with social inequalities, whereby the
power, money, and resources. greater the social inequality the higher the risk. The
poor and disadvantaged suffer disproportionately,
but everyone in society is affected to an extent.
Country-wide strategies
People are made vulnerable to mental ill-health by
Country-level strategies are likely to have a signifi- deep-rooted poverty, social inequality, and discrimi-
cant impact on reducing mental health inequalities nation. Social arrangements and institutions, such as
and have the greatest potential to reach large popula- education, social care, healthcare and work, also
tions. These include the alleviation of poverty and have a considerable impact on mental health, for
effective social protection across the life-course, better or for worse. To reduce inequities and pro-
reduction of inequalities and discrimination, preven- mote good mental health, it is vital that action is
tion of war and violent conflict, and promotion of taken to improve the conditions of everyday life,
access to employment, healthcare, housing, and edu- beginning before birth and progressing into early
cation. Particular emphasis should be given to poli- childhood, older childhood and adolescence, during
cies relating to the treatment of maternal depression, family-building and working ages, and through to
early childhood development, targeting families of older age. Not only must such action be throughout
people with mental disorders in poverty alleviation these life stages, but also across various sectors
programmes, social welfare for the unemployed, and within and outside the country, which will provide
alcohol policies. These are areas that have particu- opportunities for both improving population
larly strong associations with mental disorders and mental health, and for reducing risk of those mental
have a clear social gradient. disorders that are associated with social inequalities.
Although mental health was not mentioned explic- As mental disorders are fundamentally linked to a
itly in the Millennium Development Goals (MDGs) number of other physical health conditions, these
Social determinants of mental health 403
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