We searched three databases (PubMed, PsycINFO, and Scopus) for systematic reviews, narrative reviews, meta-analyses, and meta-synthesis articles published in peer-reviewed academic journals, covering studies on all age groups, from all countries. To be included, studies had to be review articles that reported data on mental disorders and risk or protective factors in one or more of the five domains defined in the conceptual framework, namely demographic, economic, neighbourhood, environmental
ReviewSocial determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews
Introduction
The Sustainable Development Goals (SDGs), endorsed by all United Nations member states in 2015, represent an ambitious plan for sustainable human development by the year 2030.1 In a departure from the Millennium Development Goals, mental health and wellbeing are specifically addressed under SDG 3, which emphasises the inclusion of mental health care in universal health coverage. The acknowledgment of mental health in the SDGs is important, since the global human suffering and financial costs associated with mental disorders are substantial and growing.2, 3 Investments in mental health care have the potential to increase the capabilities and productivity of affected individuals and families, as shown in a recent return on investment analysis.4
However, there is growing global evidence that mental disorders in populations are strongly socially determined.5, 6 The social determinants of mental disorders are the social and economic conditions that have a direct influence on the prevalence and severity of mental disorders in men and women across the life course. For example, adverse social and economic circumstances, including poverty, income inequality, interpersonal and collective violence, and forced migration, are key determinants of mental disorders.5
Because mental disorders are so strongly socially determined, the global burden of these disorders is unlikely to be relieved by improved access to mental health treatments alone.5, 6 In the words of the final report of the WHO Commission on the social determinants of health in 2008: “Why treat people only to send them back to the conditions that made them sick in the first place?”7 In this context, the SDGs have the potential to reduce the burden of mental disorders at the population level by addressing their upstream social determinants. For this reduction to occur, greater clarity is needed on which social determinants to target and how they are aligned with the SDGs.
To date, there is very little consolidated evidence, particularly from low-income and middle-income countries, regarding the socioeconomic and violence-related factors that should be targeted for the prevention of mental disorders.8 Although the SDGs set out to address several pressing global challenges—such as violence, climate change, displacement, and income inequality—little is known about the extent to which addressing these challenges might prevent or reduce the burden of specific mental disorders.
This study had two purposes: first, to develop a preliminary conceptual framework for the social determinants of mental disorders that is aligned with the SDGs; and second, to use this framework to systematically review evidence regarding the social determinants of mental disorders, with a view to identifying potential mechanisms and targets for interventions that address these determinants. This task requires the collection of available research literature on social determinants of mental illness across the life course from low-income, middle-income, and high-income countries. Such an approach has the potential to increase alignment between the SDGs and reductions in the burden of mental disorders, and suggest possibilities for action across a range of sectors. It might also reveal potential mechanisms of interaction between socioeconomic factors and mental disorders. This, in turn, could provide an opportunity to shape the existing strategies for poverty alleviation and violence reduction set out in the SDGs to prevent the development of mental disorders in populations.
We developed a novel conceptual framework that summarised the major social determinants of mental health disorders and linked them with the SDGs. First, we identified the key domains of the social determinants of mental disorders, on the basis of available epidemiological data, namely: demographic, economic, neighbourhood, environmental events, and social and culture domains. The definitions of these domains are stated in the panel. These domains were based on previous conceptual work that we had done on the social determinants of mental health.9 The domains were chosen on the basis of their conceptual coherence and distinctness and the extent to which they could include both distal and proximal levels of effect on an individual's mental health outcomes. Second, we then examined these domains in relation to the WHO Commission on the Social Determinants of Health frameworks, to ensure that all key constructs were covered (for example, the use of a multilevel approach and the inclusion of a life-course dimension).6 Finally, we matched the SDGs with the specific domains for which they appeared to be most relevant. When an SDG appeared to be relevant for more than one domain, we selected the domain for which it seemed most relevant, by consensus among the group of authors.
The domains were organised into the conceptual framework. Both distal and proximal determinants in each domain act on mental disorders, mediated by family-level and biological variables. Following Bronfenbrenner's ecological approach,10 proximal factors refer to people, objects, or events in the immediate external environment with which the individual interacts that increase or reduce risk of mental disorders. Distal factors refer to the broader structural arrangements or trends in society which exert their influence on mental disorders in populations, frequently mediated by proximal factors. This framework seeks to capture the importance of an ecological approach10 and the complex multidimensional way in which social determinants interact with key genetic determinants to affect mental disorders. The domains also incorporate each of the SDGs, illustrated by mapping each SDG onto the domains of the social determinants framework in figure 1.
Section snippets
Methods
We searched three databases (PubMed, PsycINFO, and Scopus) for studies. The Scopus database enabled searching Embase for articles not indexed on PubMed or MEDLINE. Individual search strategies were developed for each domain, and searches were run in November, 2016, for each database (see appendix for full search terms). The search strategies were intentionally broad to capture the diversity of potential determinants of mental disorders, and were aligned with the conceptual framework for each of
Results
In total, 289 full-text articles were included in the final Review: 135 for the demographic domain, 63 for the economic domain, 31 for the neighbourhood domain, 26 for the environmental events domain, and 34 for the social and cultural domain (appendix).
From evidence to action: recommendations for policy and future research
The findings of this Review summarise a broad body of evidence that outlines the social determinants of mental disorders, and their relevance for the SDGs. Several key factors, hypothesised pathways, specific mental disorder outcomes, and potential interventions can be identified and linked to the SDGs (table). Importantly, social determinants do not act uniformly for all mental disorders in all circumstances, and there is considerable heterogeneity according to gender, developmental stage,
Conclusion
Addressing the SDGs that are relevant for the social determinants of mental disorders requires a coordinated, truly global effort by governments, civil societies, and the private sector. The interruption of negative cycles of poverty, violence, environmental degradation, and mental disorders is possible, as is establishing virtuous cycles of mental health, wellbeing, and sustainable development. Evidence presented in this study indicates opportunities for action in demographic, economic,
Search strategy and selection criteria
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