SOCIAL DETERMINANTS OF MENTAL HEALTH
According to the World Health Organization (WHO) and Calouste Gulbenkian Foundation, the social determinants of mental health (SDMH) involve the economic, social, and political conditions into which one is born that dictate the likelihood a person raised in poverty will develop persistent mental health challenges throughout his or her life (WHO and Calouste Gulbenkian Foundation, 2014). While the term is somewhat new, the concept of linking poverty to mental health disorders dates back at least to 2003, when Patel and Kleinman linked mental disorders with education and poor housing (Patel and Kleinman, 2003). Despite knowing the associations, and despite the recent focus many health professional schools are placing on educating students about the physical health effects of the social determinants, addressing the underlying causes of mental health disorders remains a gap in the education of most health professionals outside of the mental health and social service professions. Given the growing divide between rich and poor, as cited by the Organisation for Economic Cooperation and Development (OECD, 2015), the existence of well-trained health professionals who can advocate for their patients with mental health challenges is becoming increasingly essential.
A review of the literature uncovered articles describing the SDMH, but none of them offered guidance to faculty on how to incorporate key
issues into their curriculum (Allen et al., 2014; Ssebunnya et al., 2009; WHO and Calouste Gulbenkian Foundation, 2014). The National Academies of Sciences, Engineering, and Medicine (NASEM, 2016) published a framework for educating health professional students to address the social determinants. Similarly, Doran and colleagues (2008) detailed their curriculum on social determinants—known as the Poverty in Healthcare Curriculum—which was designed for medical students at the University of Michigan. While neither set of authors mentioned the mental health aspects of the social determinants, they did lay out a structure that could guide educators on how to set up a social determinants curriculum. Both examples drew inspiration from Kolb’s experiential learning theory as described by Rooks and Rael (2013). Such education would use experiential learning opportunities combined with observation and reflection to encourage learners to become actively involved in the SDMH. While that describes how educators could guide learners, a more pressing question is how—if at all—educators are currently educating students on the SDMH. For those who report educating their students on aspects of poverty and mental health, the next question is whether any evaluation of their classes or assessments of their learners was conducted to determine the impact of their education on individuals and/or communities.
Poverty is a key driver of those social determinants that are strongly associated with experiencing traumatic life events (Luby et al., 2013). These events range across the lifespan from unsupportive parenting and inadequate nutrition to being victims of physical and psychological abuse. Such events can have permanent detrimental impacts on the victims. Bak and Hvidhjelm (2017) explained trauma-informed care as an approach to setting up mental and physical safety nets for survivors who have experienced trauma. Similarly, trauma-informed practice supports providers who have experienced secondary trauma. Emergency medical teams and social and mental health workers recognize the importance of preventing and managing primary and secondary trauma across the education-to-practice continuum. Other health professions appear to acknowledge that secondary trauma is an issue but do not purposefully educate their students, faculty, or health professionals on how to address their own mental health challenges. In addition, many care organizations are not equipped with appropriate services and policies that would encourage healing for those exposed to trauma.
Allen, J., R. Balfour, R. Bell, and M. Marmot. 2014. Social determinants of mental health. International Review of Psychiatry 26(4):392–407.
Bak, J., and J. Hvidhjelm. 2017. The pros and cons of implementing trauma informed care in Danish psychiatry. Violence in Clinical Psychiatry, edited by P. Callaghan, N. Oud, H. Nijman, T. Palmstierna, and J. Duxbury. Amsterdam, The Netherlands: Oud Consultancy. Pp. 125–129.
Doran, K. M., K. Kirley, A. R. Barnosky, J. C. Williams, and J. E. Cheng. 2008. Developing a novel Poverty in Healthcare curriculum for medical students at the University of Michigan Medical School. Academic Medicine 83(1):5–13.
Luby, J., A. Belden, K. Botteron, N. Marrus, M. P. Harms, C. Babb, T. Nishino, and D. Barch. 2013. The effects of poverty on childhood brain development: The mediating effect of caregiving and stressful life events. JAMA Pediatrics 167(12):1135–1142.
NASEM (National Academies of Sciences, Engineering, and Medicine). 2016. A framework for educating health professionals to address the social determinants of health. Washington, DC: The National Academies Press.
OECD (Organisation for Economic Co-operation and Development). 2015. Income inequality: The gap between rich and poor. OECD Insights. https://doi.org/10.1787/9789264246010-en (accessed January 28, 2020).
Patel, V., and A. Kleinman. 2003. Poverty and common mental disorders in developing countries. Bulletin of the World Health Organization 81(8):609–615.
Rooks, R. N., and C. T. Rael. 2013. Enhancing curriculum through service learning in the social determinants of health course. Journal of the Scholarship of Teaching and Learning 13(2):84–100.
Ssebunnya, J., F. Kigozi, C. Lund, D, Kizza, and E, Okello. 2009. Stakeholder perceptions of mental health stigma and poverty in Uganda. BMC International Health and Human Rights 31(9):5.
WHO (World Health Organization) and Calouste Gulbenkian Foundation. 2014. Social determinants of mental health. World Health Organization. https://apps.who.int/iris/bitstream/handle/10665/112828/9789241506809_eng.pdf;jsessionid=0038B0C30674BF3E2FB51AA66F11B74F?sequence=1 (accessed January 28, 2020).
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