Physical Health and Social Determinants Need to Be Addressed in Patients With Mental Illness

Laura Joszt

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Mental health disorders are both a cause and a consequence of social determinants of health, and providing integrated care that addresses issues outside of the health system will require work at multiple levels, including clinical, policy, and finance, explained Benjamin G. Druss, MD, of the Rollins School of Public Health at Emory University, during a session at the American Psychiatric Association's 2018 Annual Meeting.

There are 2 sides to the public mental health coin, Druss explained. First, there is the acknowledgement that mental health needs to be a part of public health initiatives. Second, there is the consideration of how public health approaches can be used to improve outcomes in mental health.

From a public health perspective, prevention is important, and there is primary, secondary, and tertiary prevention. Tertiary prevention is simply what is considered healthcare. “The idea [is] that what you’re preventing is disability or bad outcomes once someone has a condition,” Druss said. Tertiary prevention is where the United States health system spends most of its energy and where most healthcare dollars are spent. “But it’s not where the need is,” Druss added.

Secondary prevention is about diagnosing a condition early and getting someone into treatment quickly to minimize the downstream burdens.

The goal is to target primary prevention, which is usually work that applies to a whole population and is universal. “In mental health, it’s a little harder to find what that is,” Druss admitted.

Primary prevention in mental health addresses things like social factors and how social determinants of health lead to other problems. It requires going “way upstream” to look at issues like environment, poverty, adverse childhood events.

The Global Burden of Disease Study, which began in 1990, put mental health on the public health radar. More recently, a study in JAMA highlighted the leading causes of disability and injury in the United States with disorders like major depressive disorder, anxiety disorders, and schizophrenia ranking highly.1 The reason mental disorders ranked highly, according to Druss, is because of the impact they have on function. In fact, he thinks they should have ranked higher.

“By definition, [mental health disorders] are disabling,” he said. “They impair the higher order functions you need to hold a job and make relationships.”

Another piece of the mental health puzzle that healthcare has come to appreciate in the last 20 years is the impact mental health disorders have on early mortality. Having a mental health disorder is a risk factor for early death, although these patients usually die from the same reasons as other patients, like heart disease, Druss said.

While the health industry has recently rediscovered social determinants of health and the impact of poverty, those 2 factors were looked at long ago, too. Druss spent some time going over the history of mental health care, which previously believed mental illness meant something was out of balance, and was caused by the social determinants of health discussed now. That imbalance was dealt with by getting the patient away from society and the factors causing the imbalance.

Even in the 1800s people had identified the interaction between mental illness and poverty and the “vicious cycle” they create, he said.

The field of psychiatry has been a leader in the development of interventions to address social determinants of health, Druss said. There has been robust evidence of the impact of supported employment and housing first and the belief by some in the field that “social determinants of health are important in and of themselves and should be addressed first.”

However, Druss gets concerned when there is too much focus on social determinants of health, which could have downstream effects. For instance, he’s worried that the health plans might get too involved in trying to address social determinants of health.

“Should they be getting involved in that?” he asked.

Druss also voiced his concerns over recent policy moves, including the openness of the current administration to implement Medicaid work requirements, which could have a big impact on patients with mental illness who are often disabled and are on Medicaid because they can’t work.

He also mentioned the “blurring lines between the public and private sector” and cited concerns with integration that patients with mental illness will end up getting lost in the general health system.

“There is a real expertise and set of services that happen in the public mental health sector, community mental health centers, and state hospitals that are still there that really can’t be replicated, I don’t think, in the general medical sector,” Druss said.

1. US Burden of Disease Collaborators, Mokdad AH1, Ballestros K, et al. The state of US health, 1990-2016: burden of diseases, injuries, and risk factors among US states. JAMA. 2018:10;319(14):1444-1472. doi: 10.1001/jama.2018.0158.
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