In this season of New Year’s resolutions, perhaps we should resolve to improve things for the nearly 20% of Americans who experience mental illnesses and the more than 8% with substance use disorders. Mental illnesses are as disabling as cardiovascular diseases and cancers, and may be just as fatal. People with mental illnesses are more likely to die younger from commonly occurring physical health problems. Mental health inequities are rampant. Not only is the mortality risk higher, but among certain population groups, illnesses are more prevalent and more severe, and access to mental health services is still quite limited.
I suppose we can celebrate some small victories. There have been pharmaceutical and technological improvements in treating mental illnesses and substances use disorders. Lethal overdoses of heroin and prescription pain medications can be reversed with the administration of naloxone, which is becoming more available to first responders and other high-risk groups. Newer antidepressant medications are safe and effective, with fewer side effects than past iterations. Recovery is indeed possible, and there is renewed hope and understanding that people with mental illnesses and substance use disorders can lead meaningful lives. To an individual with a mental illness or substance use disorder, these and other advances mean a great deal.
But how much progress are we making on a societal level? Consider some of the big issues our country faces: violence, homelessness, unemployment, mass incarceration, food insecurity, poverty, income inequality. Each is a major contributor to the physical and mental health problems that are experienced by large segments of the population as a whole. We have yet to successfully address any of them. Multiple research studies have supported the idea that mental illnesses, and mental health inequities, are driven by the social determinants of health– how we live, grow, work, and age impact our health and well-being.
Take, for example, adverse childhood experiences, which has been extensively studied and discussed in detail in a series of posts on this blog. Children who experienced abuse, neglect, and a host of other negative events grow into adults with higher rates of a number of physical and mental health problems, including chronic obstructive pulmonary disease (COPD), heart disease, liver disease, depression, and substance use disorders. Adverse childhood experiences also increase the odds of engaging in high-risk behaviors, such as early initiation of smoking, early initiation of sexual activity, and teen pregnancy. These high-risk behaviors increase the chances of someone developing serious physical and mental disorders as they age. In fact, the risk of attempting suicide in adulthood increases exponentially with the increasing number of adverse childhood experiences.
These determinants are what doctors Bruce Link and Jo Phelan have termed “the fundamental causes of disease,” or what doctors Geoffrey Rose and Michael Marmot have deemed “the causes of the causes.” They are problems that are created by public policies and social norms.
We also know what works; creating healthy neighborhoods, subsidizing and increasing access to healthy foods, providing a living wage and viable employment opportunities, decreasing income inequality, and protecting and nurturing our nation’s children. Programs and interventions that cultivate these values prevent mental illnesses and substance use disorders before they ever begin. Highly successful examples include nurse home visits to pregnant mothers, early childhood education, and programs like Health Leads and Medical-Legal Partnerships. There is no shortage of efforts that prove that targeted investments really work. Some state and local governments have made great strides in this area through the work of committed leaders who understand the importance of social determinants of mental health (and Philadelphia is leading the charge).
But more needs to be done. These successful policies have not been universally or even widely adopted. We don’t have a comprehensive national strategy in place to promote these successful programs and interventions. As a society, we must determine that this is important enough for us to pursue, and develop the political will to change the system. It won’t be easy, but can we at least agree that it deserves our attention, our energy, and our efforts? Shouldn’t we resolve to promote and prioritize our society’s mental health?
Ruth Shim is vice chair of education and faculty development in the Department of Psychiatry at Lenox Hill Hospital in New York. She is co-editor of an upcoming book on the social determinants of mental health.
Dr. Shim will be delivering a lecture in the Population Health Spotlight series – “Health Inequities and the Social Determinants of Mental Health” – at 12:15 p.m. Wednesday, Jan. 13, at Drexel University's Dornsife School of Public Health. It is free and open to the public.
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