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 Table of Contents  
Year : 2022  |  Volume : 38  |  Issue : 1  |  Page : 3-6

Mental health in an unequal world - The role of social determinants

1 Department of Psychiatry, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala, India
2 Camden and Islington NHS Foundation Trust, London, United Kingdom

Date of Submission06-Mar-2022
Date of Acceptance06-Mar-2022
Date of Web Publication30-Mar-2022

Correspondence Address:
Prof. Roy Abraham Kallivayalil
Department of Psychiatry, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla - 689 101, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijsp.ijsp_48_22

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The world, particularly in the past decade was shaped by events that exposed the drastic inequalities in modern-day societies. The social scientists and policy makers have looked at the interactions between these inequalities and health/illness. These interactions play a key role in the prevention, precipitation and treatment outcomes of mental health problems. The relevance of social determinants are often shaped by public policies that is a reflection of prevailing political ideologies. Adding to the problem is also a chronic underfunding in mental health creating a mental health treatment gap. Tackling these inequalities and understanding these social determinants, particularly in mental health and illness, will be key in the years ahead. The article will look to explore the social determinants, especially in the context of mental illness, in this unequal world.

Keywords: Mental health, social determinants, unequal world

How to cite this article:
Kallivayalil RA, Enara A. Mental health in an unequal world - The role of social determinants. Indian J Soc Psychiatry 2022;38:3-6

How to cite this URL:
Kallivayalil RA, Enara A. Mental health in an unequal world - The role of social determinants. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Jun 30];38:3-6. Available from: https://www.indjsp.org/text.asp?2022/38/1/3/341339

“In the middle of winter, I at last discovered that there was in me an invincible summer.”

– Albert Camus

  Introduction Top

Although the professed principle of any democracy is an egalitarian society, it is seldom achieved in actual practice. Inequalities – be it financial, ethnic, race, social class, gender, etc. – remain a fact of life in most parts of the world. This in turn affects the mental health of the people. The role of social determinants of health such as poverty, illiteracy, social exclusion, stigma, discrimination, housing, environment, employment, job security, early child development, and access to care needs renewed attention. Implementation of progressive strategies in these areas is vital to promote health and mental health.

Health inequalities and discussions around it have seeped into the mainstream, particularly in the context of COVID-19. Social determinants of health and illness have garnered a lot of attention. The time is right to further propel the evidence around social determinants and inequalities determining how societies function worldwide. There needs to be a clear call for action since the COVID-19 has further compounded these inequalities in our society. This article attempts to look into the role of health inequalities and social determinants of mental health and the current efforts to tackle them.

  Global Inequalities Top

The global landscape has always been deeply unequal; however, over the years, these inequalities have dominated the way societies function and organize. Inequalities based on income, gender, race, religion, place of residence, access to healthcare, opportunities, and ability to live a life people value have all become clearer in the past decade. The unnecessary disease and suffering of the disadvantaged, whether in poor countries or rich, result from the way we organize our affairs in society.[1] The World Social Report 2020[2] sheds light on these deep divides within and across countries despite an era of extraordinary economic growth and widespread improvements in living standards. The inequality challenge is global and is connected to many other issues such as rapid technological change, climate crisis, urbanization, and migration. The inequalities are added challenges that will definitely change the way societies organize and function in the years to come. It is often the role of public agencies, including governments across the world, to tackle these inequalities. That being said, the need for international cooperation has never been so important.

According to the World Social Report 2020, income inequality has increased in most developed countries and in some middle-income countries, including China and India, since 1990. Countries where inequality has grown are home to more than two-thirds (71%) of the world population. Despite progress in some countries, income and wealth are increasingly concentrated at the top. The richest 10% of the global population currently takes 52% of global income, whereas the poorest half of the population earns 8.5% of it. Global wealth inequalities have become even more pronounced than income inequalities. The poorest half of the global population barely owns any wealth at all, possessing just 2% of the total.[3] The World Inequality Report, 2022 confirms that inequality is not inevitable but a political choice.

There has been a major impact of policies on growing inequalities. Although seen as an inevitable cost of development process, governments across the globe should prioritize developing policies that do not further this divide. Inequalities of opportunities are particularly relevant since this impacts the young and their well-being. Inequality can also hurt social mobility when the advantages are passed from parents of high social class to their children. In highly unequal societies, elite groups are more effective at influencing policymakers, creating an environment that favors their interests, and shielding their children from downward mobility.[2] The effects of racial inequalities and structural racism have taken the world by storm over the past decade. It is important to understand that racism truncates or blocks access to avenues of success for societies across the world. At present, there is limited awareness of racial inequities in health and a definite lack of commitment to address them.

It is also important to address inequalities within communities and families. Up to 30% of income inequality is due to inequality within households. The progress of women and girls has been unequal. Although there are trends across the world reducing the gender pay gap, the women and girls put in 12.5 billion hours of unpaid care work – a contribution to the global economy of at least $10.8 trillion a year, more than three times the size of the global tech industry.[4] There is also a need to address certain special groups such as indigenous people, migrants and refugees, persons with disabilities and ethnic and other minorities, owing to discrimination, marginalization, and lack of legal rights.

  Social Determinants of Mental Health Top

The landmark report of the Commission on Social Determinants of Health 2008,[5] as well the works of Marmont[1] have described the evidence-based linking social determinants to a range of health outcomes. The findings from a review by Allen et al.[6] throws light on the interaction between these social determinants and mental health. The poor and disadvantaged suffer disproportionately from common mental disorders and their adverse consequences. Gender also plays a major role, and women tend to have higher levels of common mental disorders compared to men at every level of household income. Household income is only one of the factors, leading to common mental disorders. Many other factors including low educational attainment, material disadvantage, and unemployment play a key role. In regard to older people, these factors are compounded by the social isolation that they have to endure.

There is a high prevalence of depressed mood or anxiety in young people aged 10–15 years with low socioeconomic status compared to high socioeconomic status. There is also an effect of the household wealth on the emotional and behavioral difficulties even at ages 3–5 years. Inevitably, those who are lower in the social hierarchy are more likely to experience less favorable economic, social, and environmental conditions throughout life and may have access to fewer buffers and may experience accumulative stress as a result, leading to mental disorders. Even in countries with universal healthcare, unemployment and employment conditions play a key role in developing and maintaining increased psychological distress.[7],[8],[9],[10] Employment status can also serve as an important moderator of other social determinants.[11] There is also evidence from longitudinal studies that exposure to poor-quality housing conditions can have negative effects on psychological health of youth and adults.[12]

There is growing evidence to suggest the impact of racism on mental health.[13],[14] Certain fixed characteristics including race/ethnicity, nationality, gender, and sexual orientation have significant interactions with mental health and illness. Despite this, the response to tackle discrimination of any kind across the world by the governments and public bodies can only be described as lukewarm. Familial relationships and social support are key social determinants that influence mental health of an individual.

Although the biopsychosocial model to explain mental health difficulties has gained prominence, there is a further need for person-centered approaches that will address the person in distress along with the social determinants at a societal and an individual level. It is also important to understand that mental illness can impact social determinants. Often, mental illness is interlinked with issues such as homelessness, educational attainment, marital instability, and economic insecurity.

  Addressing the Social Determinants of Mental Health – Current and Future Directions Top

Over the last several months, COVID-19 has resulted in unending grief and social isolation and also exposed structural and social inequalities in systems around the world. In the years ahead, there is a fundamental need for conversations and investment to shift toward person-centered care addressing the social inequalities and social determinants at an individual and societal level. This shift should be based on locally sourced and culturally accepted models of care and treatment which are often ignored.[15]

The Sustainable Development Goals (SDGs) is definitely an upgrade from its predecessor Millennium Development Goals and will seek to address many of the social determinants. Of particular interest is a study published in Nature[16] which looked at the empirical relationship between the SDGs and subjective well-being using SDG Index and the Gallup World Poll. The study found a strong correlation between achieving sustainable development and self-reported measures of well-being.

Organizations around the world, including governments and public bodies, will have to increase the investment in tackling inequalities in societies. Legislations and policies will have to take into account the growing divide between the rich and the poor and ensure that it does not further compound this divide. There are initiatives developed by many psychiatry organizations around the world to address social determinants of mental health.[17],[18],[19] There is definitely a need for further collaborations and partnerships among public and private sector organizations.

The research methodologies in understanding the social determinants of health need to go through advancements. This would include utilizing network-based models, simulation models, agent-based models, and machine learning algorithms to understand the complex interplay of multiple factors.[11] It is also quite important to understand the negative consequences of work on social determinants. For instance, the possibility of less responsibility for health-care systems, stigmatization, and disempowerment of patients. It is also important to carry out population based studies grounded on geography and culture. It is also important for the research to focus on structural factors hampering the social progress of certain groups.

  Conclusions Top

Countries across the world have taken rapid strides in health, although it has been less remarkable in the area of mental health. Low- and middle-income countries like India have various health programs including a National Mental Health Programme in its revised form as District Mental Health Programme. However, they have not fully succeeded in empowering communities in health and mental health matters. Huge disparities continue to exist between different sections of the population. Unfortunately, the inequalities between various states or regions are even wider.[20] The major social and political events over the past decade and the COVID-19 pandemic have exposed the growing inequalities in society on a global scale. The impact of these inequalities is multifold, and if not tackled, the world would have to brace itself for a pandemic in mental illness. There is growing need for governments and policymakers to understand the evidence underlying the social determinants of health and incorporate them to realign the way societies organize. At the heart of all, these would be individuals and organizations, both public and private, that would believe in basic principles of human rights, justice, equity, and kindness.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Marmot M. Health in an unequal world: Social circumstances, biology and disease. Clin Med (Lond) 2006;6:559-72.  Back to cited text no. 1
United Nations. World Social Report 2020: Inequality in a Rapidly Changing World. United Nation publication ISBN 978-92-1-130392-6, UN; 2020. Available from: https://www.un-ilibrary.org/economic-and-social-development/world-social-report-2020_7f5d0efc-en. [Last accessed on 2021 Dec 26].  Back to cited text no. 2
The World #Inequality Report 2022 Presents the most Up-To-Date & Complete Data on Inequality Worldwide. World Inequality Report 2022; 2021. Available from: https://wir2022.wid.world/executive-summary/. [Last accessed on 2021 Dec 26].  Back to cited text no. 3
Nations U. Inequality – Bridging the Divide. United Nations. Available from: https://www.un.org/en/un75/inequality-bridging-divide. [Last accessed on 2021 Dec 26].  Back to cited text no. 4
World Health Organization. Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Geneva: World Health Organization; 2008.  Back to cited text no. 5
Allen J, Balfour R, Bell R, Marmot M. Social determinants of mental health. Int Rev Psychiatry 2014;26:392-407.  Back to cited text no. 6
Brydsten A, Hammarström A, San Sebastian M. Health inequalities between employed and unemployed in northern Sweden: A decomposition analysis of social determinants for mental health. Int J Equity Health 2018;17:59.  Back to cited text no. 7
Han S, Lee HS. Social capital and depression: Does household context matter? Asia Pac J Public Health 2015;27:P2008-18.  Back to cited text no. 8
Reibling N, Beckfield J, Huijts T, Schmidt-Catran A, Thomson KH, Wendt C. Depressed during the depression: Has the economic crisis affected mental health inequalities in Europe? Findings from the European Social Survey (2014) special module on the determinants of health. Eur J Public Health 2017;27:47-54.  Back to cited text no. 9
Salami B, Yaskina M, Hegadoren K, Diaz E, Meherali S, Rammohan A, et al. Migration and social determinants of mental health: Results from the Canadian health measures survey. Can J Public Health 2017;108:e362-7.  Back to cited text no. 10
Alegría M, NeMoyer A, Falgàs Bagué I, Wang Y, Alvarez K. Social determinants of mental health: Where we are and where we need to go. Curr Psychiatry Rep 2018;20:95.  Back to cited text no. 11
Pevalin DJ, Reeves A, Baker E, Bentley R. The impact of persistent poor housing conditions on mental health: A longitudinal population-based study. Prev Med 2017;105:304-10.  Back to cited text no. 12
Kairuz CA, Casanelia LM, Bennett-Brook K, Coombes J, Yadav UN. Impact of racism and discrimination on physical and mental health among Aboriginal and Torres Strait islander peoples living in Australia: A systematic scoping review. BMC Public Health 2021;21:1302.  Back to cited text no. 13
Kwate NO, Goodman MS. Cross-sectional and longitudinal effects of racism on mental health among residents of Black neighborhoods in New York City. Am J Public Health 2015;105:711-8.  Back to cited text no. 14
Kallivayalil RA, Enara A. The need for a paradigm shift to person-centered medicine during pandemic times. World Soc Psychiatry 2021;3:137.  Back to cited text no. 15
De Neve JE, Sachs JD. The SDGs and human well-being: A global analysis of synergies, trade-offs, and regional differences. Sci Rep 2020;10:15113.  Back to cited text no. 16
Pender VB. Addressing Social Determinants of Mental Health. Psychiatric News; June 22, 2021. Available from: https://psychnews.psychiatryonline.org/doi/abs/10.1176/appi.pn. 2021.7.42. [Last accessed on 2021 Dec 26].  Back to cited text no. 17
Ways We Can Address the Social Determinants of Mental Health | NAMI: National Alliance on Mental Illness. Available from: https://www.nami.org/Blogs/NAMI-Blog/August-2020/Ways-We-Can-Address-the-Social-Determinants-of-Mental-Health. [Last accessed on 2021 Dec 26].  Back to cited text no. 18
Social Determinants of Mental Health Ta sk Force. Available from: https://www.psychiatry.org/psychiatrists/social-determinants-of-mental-health-task-force. [Last accessed on 2021 Dec 26].  Back to cited text no. 19
Sarkar S. Research on social determinants of health necessary for health equity in India. Int J Med Public Health 2016;6:1-3.  Back to cited text no. 20
  [Full text]  

This paper was presented as the NN De Oration Award at the XXVIII National Conference of Indian Association for Social Psychiatry, Imphal, 26-28 November 2021.


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