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Are Social Determinants of Mental Health Being Sufficiently Considered?

A recent report jointly published by the WHO and Calouste Gulbenkian Foundation (2014) highlighted that risk factors for many common mental disorders are heavily associated with social inequalities, whereby ‘the greater the inequality the higher the inequality in risk’ (p. 9). The importance of addressing macro-level determinants of mental well-being is also highlighted in the WHO Mental Health Action Plan 2013-2020, which states that ‘[d] eterminants of mental health and mental disorders include not only individual attributes such as the ability to manage one’s thoughts, emotions, behaviours and interactions with others, but also social, cultural, economic, political and environmental factors such as national policies, social protection, living standards, working conditions, and community social supports’ (WHO 2013, p. 7). In particular, poverty, and its psychological and emotional consequences, is often highlighted as a potential determinant of mental health difficulties. For example, indebtedness to moneylenders is seen to play a key role in the high rates of farmer suicides in South Asia (Patel and Kleinman 2003). Laudable attempts to explore the social determinants of mental health tend to conceptualize social factors as a ‘trigger’ for underlying vulnerabilities, and furthermore, often take recourse to using psychiatric diagnostic categories to measure the mental health impact of social determinants (Mills 2015). Some argue that this leans towards an individual-oriented materialistic approach to social determinants of health that are consistent with neoliberal governance and a free market rationale, and that fail to acknowledge that social determinants are themselves determined by political and economic forces (Das 2011; Raphael 2006). For example, GMH advocates would do well to investigate the relationship between the aforementioned farmers’ distress and agricultural trade liberalization and global capitalist food production chains (Mills 2014a; Das 2011). Thus, it may be that the mention of social determinants by largely biomedical organizations such as the WHO, enables a discursive acknowledgement of mental health as affected by the social, while potentially diverting attention and resources from more widespread structural or systemic change (Mills 2014a). This points to a need to move away from the individualisation of distress by calling attention to the structural determinants of mental health and well-being more widely; the intergenerational trauma of social inequality, chronic poverty and colonialism, and the ways that intersecting forms of oppression (such as racism, ableism, sexism) may compound mental distress.

White et al. (2016) have recently called for GMH initiatives to utilize a welfare economics framework known as the Capabilities Approach (Sen 1992; Nussbaum 2006) to guide efforts to promote well-being. The Capabilities Approach places specific emphasis on tackling sources of social injustice and structural violence operating at a macro level that limit the extent to which individuals and communities can fulfil their potential (e.g. discrimination on the basis of gender, ethnicity, caste, physical/mental capacity, etc.). The application of this framework to GMH emphasizes the need to understand (1) what individuals in a particular setting regard as important to how they want to live their lives, and (2) the personal and structural factors that can either promote or hinder people’s opportunity to engage in behaviours that are in keeping with what they hold to be of value. Moving forward, there is certainly a need for GMH initiatives to demonstrate a purposeful shift in approach to systematically address the social determinants of mental health and wellbeing. This will require greater engagement with a wider range of stakeholders including service users, social scientists, non-governmental organizations, and government ministries.

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