THE LANCET: EDITORIAL|VOLUME 398, ISSUE 10305, P1021, SEPTEMBER 18, 2021

Brain health and its social determinants

Brain health and its social determinants - The Lancet

Opinions about the relative importance of the biological and sociological causes of mental ill health have moved wildly from one extreme to another over the past 50 years. So, when Vivian Pender, the newly elected President of the American Psychiatric Association (APA), pronounced in July that “we need to be more aware of the broader context in which that illness occurred and how that context has shaped the health outcome”, cynics could be forgiven for thinking it just another swing of the pendulum. However, perhaps this time Pender—and many others, for she is not alone—has got it right.

Much evidence has been published supporting Pender's call for social determinants to be considered as key in understanding and treating mental illness. The Lancet Commission on global mental health and sustainable development stated that research consistently shows a strong association between social disadvantage and poor mental health. At the individual level, the Commission reported that poverty, childhood adversity, and violence are key risk factors for mental disorders. The COVID-19 pandemic has further focused attention on the importance of social determinants in causing both mental and physical illness.

That Pender has felt the need to create a taskforce to examine this issue, reporting to the APA's annual meeting in May, 2022, probably reflects the strength with which many US psychiatrists are wedded to the biomedical model of mental ill health and the utility of pharmacotherapy. Reaching for the prescription pad is certainly easier than fixing a patient's economic and social circumstances. But current treatments, including medication and talking therapy, have their limitations. Pender does not dismiss the importance of medication, but she encourages colleagues to rethink traditional approaches towards patients. Such ideals echo academics who, in an attempt to satisfy ardent protagonists from both camps, have proposed a convergent model of mental health that ties together findings from both psychiatry and neurology, as well as neuroscience, epidemiology, and sociology.

The emerging concept of good brain health—variously defined, but according to WHO, a state in which every individual can optimise their cognitive, emotional, psychological, and behavioural functioning; not merely the absence of disease—offers a way to bring disparate parties together. By demanding good brain health, reductionist, disease-focused clinicians (psychiatrists and neurologists), health professionals, and researchers might be encouraged to leave their silos and work together for a common good. A holistic suite of interventions are needed for good brain health, not just across the whole life course, but also in society at large.

Addressing the social determinants of mental health will require action on many fronts. At the population level, considerations must include economic and commercial disparities, conflicts and their consequences, cultural and societal differences, and the physical and natural environments. At the individual level, the focus should be on maternal and child health, education, employment and quality of work, and healthy ageing. Notably, interventions targeting common mental disorders and their risk factors have their largest effects during childhood and adolescence, emphasising the need to target developmentally sensitive periods in the life course.

Globally, definitive action to tackle the wider determinants of health inequalities and mental ill health—including poverty, racism, and discrimination—remains a low priority in too many countries. In England, for example, life expectancy has stalled since 2010, probably due to falling living standards and cuts to public services. The US Government's Healthy People 2030 initiative, which sets national goals for health promotion and disease prevention and includes numerous social determinants, indicates a change of direction in the USA. In May, the Biden administration also launched a unique initiative seeking information from both the public and private sectors for ideas about how historically underserved communities can be helped equitably.

Such plans are laudable. Services for and solutions to unemployment, housing problems, financial worries, excess drinking, use of cannabis and other illicit drugs, domestic violence, and concerns about child safety and education must be made universally available, along with provision of healthy diets and physical activity, in a holistic integrated care service. Governments must do better. And the clinician, facing patients repeatedly attending with poor brain health—manifesting most often as depression, anxiety, and sleep and memory difficulties—has a duty of care to demand such measures; without them, suffering will continue.