The Social Determinants of Health—Social Psychiatry’s Basic Science

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SECOND THOUGHTS

No disciple of the wise may live in a city that does not have a physician, a surgeon, a bathhouse, a lavatory, a source of water, a synagogue, a school teacher, a scribe, a treasurer of charity funds for the poor, a court that has authority to punish.

—Moses Maimonides¹

The medieval Jewish scholar Rabbi Moshe ben Maimon, known to us by his Greek name Maimonides (1135-1204), was considered the greatest authority of his time in medicine, philosophy, and Torah scholarship. Maimonides brought together a surprisingly contemporary worldview regarding what we call public health and social psychiatry. His list of essential ingredients for choosing a healthy city includes elements of basic public health needs to attend to the body, the mind and spirit, and to social justice and public order. In other texts, Maimonides also emphasized the need to locate a dwelling on an elevation where prevailing winds ensure fresh air and to locate lavatories and refuse dumps away from human habitation.

In the first column on social psychiatry in this series of Second Thoughts, I identified 3 related branches of social psychiatry from my Social Psychiatry Manifesto²:

1. Epidemiological studies represented by the WHO Commission on the Social Determinants of Health (CSDH)³ and the Adverse Childhood Experiences (ACE) study⁴ are what I call the “basic science” of social psychiatry.
2. Community psychiatry and the community mental health movement.⁵
3. The relational therapies, from relational psychoanalysis to the family therapy movement represented by Italian child psychiatrist and family therapist, Maurizio Andolfi, MD,⁶ and the community therapy of social psychiatrists like Brazil’s Adalberto Barreto, MD.⁷

In a later column, I discussed family therapy as the third branch of social psychiatry. In this column, I want to highlight our first, foundational branch of social psychiatry—psychiatric epidemiology and public mental health by focusing on the social determinants of health (SDoH). I consider SDoH the basic science of social psychiatry.

Psychiatric Epidemiology

Already in the Middle Ages, Maimonides was aware of the environmental and SDoH, not forgetting education, social justice, and spiritual factors. And yet, it took centuries before medicine integrated these social and environmental factors into medical research and practice.

As it happens, my graduate training in clinical psychology was at the Institute of Psychiatry (IoP, now the Institute of Psychiatry, Psychology and Neuroscience) and The Maudsley Hospital in London, England where Michael Shepherd, MD, became professor of Psychiatric Epidemiology, the first of its kind in the world. He was also a noted social psychiatrist, following in the footsteps of Sir Aubrey Lewis, MD, who led British psychiatry to pay attention to the social context of psychiatric illness. Another IoP pioneer was my mentor Sir Michael Rutter, MD, who conducted the first child psychiatric epidemiology with the Isle of Wight Study.^8,9

I chose to go into medicine at McMaster University Medical School where clinical biostatistics and epidemiology were basic sciences as much as pharmacology and genetics and where evidence-based medicine was invented. More significantly for my career in child psychiatry, Dan Offord, MD, conducted the first Canadian study on child psychiatric epidemiology at McMaster adapting Rutter’s methodology in the Ontario Child Health Study,¹⁰ later conducting my own child epidemiological study, The Children’s Food and Mood Study, for my doctorate at the University of London. Later still, after being recruited by the University of Montreal, I conducted a substudy of the Quebec Child Mental Health Study on single-parent families in an underprivileged neighborhood where I work in Montreal.¹¹

“Build Back Better”—Sir Michael Marmot, Epidemiology’s Working Man

Building on this foundation, rooted in Britain’s postwar Labour government’s commitment to social justice and the welfare state, Sir Michael Marmot, MD, conducted the authoritative WHO study on SDoH.³ Along with the complementary ACE studies,⁴ SDoH now form an empirical grounding for social psychiatry and have made Marmot the world’s most consequential epidemiologist, advocating for a “Fair society, healthy lives.”¹²

A major debate in policy making and public health has been the dichotomy between universalism (dealing with the whole population) and targeting (focusing on a particular segment) in the health field.¹² Marmot's solution is in Proportionate Universalism (PU). This notion evolved from the classical opposition of universalism to targeting in European socio-political history, to “targeting within universalism” or “progressive universalism” and, finally, to the PU approach which focuses on “upstream determinants” by advocating on social policies such as education or employment.¹³

A tireless worker on behalf of the working classes, following a moral compass with a commitment to human dignity, Marmot makes the case in a series of evidence-based studies, projects, and policy papers for improving health outcomes by reducing inequality—“build back better.” “Most of the things that doctors treat,” Marmot contends, “are failed prevention.”¹⁴ Highlights of his career include the landmark Marmot Review of health inequalities in England, leading the Institute of Health Inequality in London, and a network of local authorities in England, “Marmot Cities,” which is tackling health inequalities.¹⁴

Closer to home, Dilip Jeste, MD, APA Past President and Chair of the APA Task Force on the SDoH,¹⁵ founded and directs the Global Research Network on Social Determinants of Health and Exposomics (SDoMHE Network), “a multi-disciplinary worldwide research Network of scientists, clinicians, educators, public health advocates, professional societies, and institutions” in a promising new synthesis for academic psychiatry. (Full disclosure: I am on the Advisory Board of the SDoMHE Network.)

The Still Hidden Injuries of Class

As a social psychiatrist, I share Marmot’s vision for healthy lives in a fair society and see SDoH as the empirical grounding for all our work. Now, if I had to hone that down to a message that resonates, I would invoke American sociologist Richard Sennett’s work, The Hidden Injuries of Class,¹⁶ and talk about the still hidden injuries of class. (See what Michael Marmot says about the impact of poverty on nutrition in his interview.¹⁴)

Today’s cultural psychiatry talks about the hidden injuries of race and gender. I get that.

I am talking about something that cuts across all of that. To all those concerns, from racism to anti-Semitism to gender discrimination; with every kind of mental, relational, and social suffering, from anorexia nervosa to schizophrenia to social isolation; and to all the issues of colonialism, power, and privilege, I point to: class, class, class. That is, social class, not as status anxiety but the socio-economics of class with a cascade of consequences affecting housing, education, health, and social services.

From Populations to Patients: Social Determinants of Health in Clinical Practice

A. Population Studies. With epidemiological or population studies, the shift is away from the individual and the clinic, and populations become the focus of research. Two major studies are worth noting here:

• The Adverse Childhood Events (ACE) Studies demonstrated a linear gradient between childhood adversity and poor health outcomes.⁴ 
• Take away message: Identify children at risk instead of treating everybody the same. We have neither the resources nor the mandate to treat everybody. As the popular saying advises: “Don’t fix it if it ain’t broke.”

• Global Mental Health (GMH)—Treatment Gaps. GMH defines the treatment gap as the gap between the known burden of disease and access to care.¹⁷
• Take away message: A key plank in the GMH Movement¹⁸ and a guide for health care planning to improve access to care.^{3,12,17,19,20}

Epidemiology to reflect the burden of disease. Service allocation should be based on reliable epidemiology—“the science of denominators”—not the “numerators” that happen to catch our attention in the clinic. Overdiagnosis and overprescription are as dangerous as poor access to care.^21,22 This is partly a side effect of overspecialization.

B. Translational Research

• Translational research to redefine health. As we totter from one psychiatric revolution to another, we always leave part of the population behind. The history of psychiatry has been described by Paul Hoff, MD, a German psychiatrist and medical historian, as “A serial collapse into single-message mythologies.”²³
• Take away message: Health is broadly social, not just biological or genetic.^2,24,25

• Mental health in a social context.
• Take away message: Just as there is no health without mental health as the GMH Movement announced,²⁴ social psychiatry holds that there is no mental health without a healthy body in a fair society.^2,25

C. Ground-Level Prescriptions

• Mental health services should be delivered where people live. Identifying access to care issues—the treatment gap—is not enough. Health care planning should be responsive to population needs and not only the interests of providers. This is relevant in terms of financial interests for third-party payors as in the US and just as true for the career interests of providers, including psychiatrists.
• Take away message: We need to build clinics and integrate services into real communities—schools, workplaces, community centers, sports arenas, shopping malls.

• Shared care/integrated care/collaborative care. Primary care is overburdened and specialty care is difficult to access. Communication between them is often poor.²⁶
• Take away message: We need models of shared care, also known as integrated or collaborative care.^11,27

• We cannot do everything—let us address the most common and pressing problems. Give them priority before they become urgent or chronic and intractable.
• Take away message: If primary prevention is a fantasy, secondary and tertiary prevention are not.

Conclusion: Towards a Clinical Social Psychiatry

We need to practice social psychiatry in the clinic where populational studies are integrated and translated into psychiatric and mental health practice¹¹ in the 4 domains of:

• Teaching and research
• Clinical interventions
• Policy-making and service planning
• Advocacy with government, industry, and community leaders

I am calling for clinical social psychiatry as a bridge between populations and patients, society and psychiatric/mental health practice.

To conclude, here are some practical steps:

1. Like people who work on family issues with individuals, a starting point in treating individual patients is be aware of and take SDoH and ACE into account when we formulate their predicaments and treatment plans.
2. The next step would be to work with their social networks as resources and partners in care, including family members, friends, schools and workplaces, community health and social services. What I call relational therapies and social psychiatry’s therapeutic branch are already part of this—from couple and family therapy to group therapy and community therapy.
3. Finally, we need to advocate and act on community and societal levels to address what I call social psychiatry’s “public works projects” – suicide prevention, the stigma of mental illness, and promoting a sense of belonging to counter concerns about loneliness and social isolation that occurred during the COVID-19 syndemic, for example. (In a future column I will address the lessons we learned from COVID-19 and the first will be to name it correctly: it is a syndemic or a synergistic series of pandemics—biological, social, economic and ecological).

Special Note: While this column covers “second thoughts” on a wide array of topics in psychiatry, psychology and psychotherapy, my focus for the next 18 months, the rest of my term as President of the World Association of Social Psychiatry (WASP), will be on social psychiatry and I will offer an updated lexicon for social psychiatry, interspersed with related reflections. I will call this sub-series, “Terms of the Social,” covering the words social and society; the complex history of social class and socialism; the terms sociopetal and sociofugal from socio-architecture, all three terms coined by British-Canadian psychiatrist Humphrey Osmond, MD, and the related social space from American anthropologist Edward Hall’s proxemics; how to understand the social sciences from sociology to social psychology to social work, and such philosophical-clinical notions as R.D. Laing, MD’s social phenomenology and social construction versus social constructivism in understanding social reality as part of social philosophy; and, finally, the place of social psychiatry in all of this.

Resources

• Vincenzo Di Nicola, Webinar: “From Populations to Patients: Social Determinants of Health and Mental Health in Clinical Practice,” Global Research Network on Social Determinants of Mental Health and Exposomics, February 8, 2024. https://www.academia.edu/114651101/From_Populations_to_Patients_Social_Determinants_of_Health_and_Mental_Health_in_Clinical_Practice
• See this interview with Sir Michael Marmot: Claire McKenna. Michael Marmot: The Health of Nations. BJPsych Bull. 2023;47(1):56-59.

Dr Di Nicola is a child psychiatrist, family psychotherapist, and philosopher in Montreal, Quebec, Canada, where he is professor of psychiatry & addiction medicine at the University of Montreal and President of the World Association of Social Psychiatry (WASP). He has been recognized with numerous national and international awards, honorary professorships, and fellowships, and was recently elected a Fellow of the Canadian Academy of Health Sciences and given the Distinguished Service Award of the American Psychiatric Association. Dr Di Nicola’s work straddles psychiatry and psychotherapy on one side and philosophy and poetry on the other. Dr Di Nicola’s writing includes: A Stranger in the Family: Culture, Families and Therapy (WW Norton, 1997), Letters to a Young Therapist (Atropos Press, 2011, winner of a prize from the Quebec Psychiatric Association), and Psychiatry in Crisis: At the Crossroads of Social Sciences, the Humanities, and Neuroscience (with D. Stoyanov; Springer Nature, 2021); and, in the arts, his “Slow Thought Manifesto” (Aeon Magazine, 2018) and Two Kinds of People: Poems from Mile End (Delere Press, 2023, nominated for The Pushcart Prize).

References

1. Maimonides M. Mishneh Torah: Laws Relating to Moral Dispositions and Ethical Conduct. In: Twersky I, ed. A Maimonides Reader. Behrman House; 1972. The quote is a composite of several published translations.
2. Di Nicola V. “A person is a person through other persons”: a manifesto for 21st century social psychiatry. In: Gogineni RR, Pumariega AJ, Kallivayalil R, et al, eds. The WASP Textbook on Social Psychiatry: Historical, Developmental, Cultural, and Clinical Perspectives. Oxford University Press; 2023:44-67.
3. CSDH. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health Final Report of the Commission on Social Determinants of Health. World Health Organization; 2008.
4. Felitti VJ, Anda RF. The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and sexual behavior: implications for health care. In: Lanius RA, Vermette E, Pain C, eds. The Impact of Early Trauma on Health and Disease: The Hidden Epidemic. Cambridge University Press; 2010:77-87.
5. Smith M. The First Resort: The History of Social Psychiatry in the United States. Columbia University Press; 2023.
6. Di Nicola V. Luminaries in social psychiatry—a relational dialogue with Maurizio Andolfi: master family therapist and social psychiatrist. Special Issue on “Families, Family Interventions and Social Psychiatry.” World Soc Psychiatry. 2024;6(1):6-13.
7. Barreto AP, Filha MO, Silva MZ, Di Nicola V. Integrative community therapy in the time of the new coronavirus pandemic in Brazil and Latin America. World Soc Psychiatry. 2020;2(2):103-105.
8. Rutter M, Tizard J, Yule W, et al. Research report: Isle of Wight Studies, 1964-1974. Psychol Med. 1976;6(2):313-332.
9. Rutter M. Isle of Wight revisited: twenty-five years of child psychiatric epidemiology. J Am Acad Child Adolesc Psychiatry. 1989;28(5):633-653.
10. Offord DR. Child psychiatric epidemiology: current status and future prospects. Can J Psychiatry. 1995;40(6):284-288.
11. Di Nicola V. Beyond shared care in child and adolescent psychiatry: collaborative care and community consultations. World Soc Psychiatry. 2022;4(2):78-84.
12. Marmot M, Bell R. Fair society, healthy lives. Public Health. 2012;126 Suppl 1:S4-10.
13. Francis-Oliviero F, Cambon L, Wittwer J, et al. Theoretical and practical challenges of proportionate universalism: a review. Rev Panam Salud Publica. 2020;44:e110.
14. McKenna C. Michael Marmot: The Health of Nations. BJPsych Bull. 2023;47(1):56-59.
15. Jeste DV, Pender VB. Social determinants of mental health: recommendations for research, training, practice, and policy. JAMA Psychiatry. 2022;79(4):283-284.
16. Sennett R, Cobb J. The Hidden Injuries of Class. Reissued. W.W. Norton & Co; 1993.
17. Marmot M. The health gap: the challenge of an unequal world.Lancet. 2015;386(10011):2442-2444.
18. Patel V, Prince M. Global mental health: a new global health field comes of age. JAMA. 2010;303(19):1976-1977.
19. Marmot M, Friel S, Bell R, et al. Closing the gap in a generation: health equity through action on the social determinants of health.Lancet. 2008;372(9650):1661-1669.
20. Di Nicola V. Family, psychosocial, and cultural determinants of health. In: E Sorel (ed). 21st Century Global Mental Health. Jones & Bartlett Learning; 2012:119-150.
21. Aftab A. Allen Frances, MD: relentless warrior for mental health. Psychiatric Times. 2019;36(10):17, 22-23. https://www.psychiatrictimes.com/view/conversations-critical-psychiatry-allen-frances-md
22. Frances A. Afterword: Saving Psychiatry. In: V Di Nicola, D Stoyanov. Psychiatry in Crisis: At the Crossroads of Social Science, The Humanities, and Neuroscience. Springer Nature; 2021:167-168.
23. Fulford KWM. Foreword: Beyond single message mythologies. In: V Di Nicola, D Stoyanov. Psychiatry in Crisis: At the Crossroads of Social Science, The Humanities, and Neuroscience. Springer Nature; 2021:vii-xix.
24. Prince M, Patel V, Saxena S, et al. No health without mental health. Lancet. 2007;370(9590):859-877.
25. Di Nicola V. Perspective – “There is no such thing as society”: the pervasive myth of the atomistic individual in psychology and psychiatry. Follow-up and reply to commentaries on “A social psychiatry manifesto for the 21st century.” World Soc Psychiatry. 2021;3(2):60-64.
26. Kates N, McPherson-Doe C, George L. Integrating mental health care services within primary care settings: The Hamilton Family Health Team. J Ambul Care Manage. 2011;34(2):174-182.
27. Ivbijaro G, ed. Companion to Primary Care Mental Health. CRC Press; 2010.