Mental health issues closely linked to adversity and social and structural inequalities

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A recent study, published in Psychiatric Services, examines the prevalence and distribution of social determinants of health (SDoH) among adults receiving mental health services in New York State. The results of their large-scale cross-sectional survey reveal the disproportionate impact of unemployment, housing instability, low educational attainment, and criminal justice system involvement on consumers of public psychiatric services.

The researchers, led by Amy Ehntholt from Columbia University Irving Medical Center, draw attention to how the structural determinants of health are intertwined with structural racism and inequality. They write:

“The higher prevalence of each negative social determinant among people of color, particularly non-Hispanic black participants, was of particular concern. This inequity is consistent with the literature; systemic racism perpetuates the disproportionate frequency of social adversity faced by people of color.
“This study’s confirmation of the association between adverse social conditions and specific mental illnesses, the higher prevalence of these adversities among people of color, and the overrepresentation of people of color within the sample warrant further investigation. health equity.”

Social Determinants of Health Theory (SDoH) posits that human health is the product of the interaction between many structural conditions, including aspects of the physical environment, educational, social and health services, and broader sociopolitical forces such as structural racism and related inequalities. Ehntholt and the New York State Psychiatric Institute research team used SDoH theory to frame their research, asserting the “urgent need” to better understand the conditions of everyday life as ” powerful engines of health“. The authors advocate for the identification of social determinants in clinical settings as individual risk factors and for the development of federal policies and budget expenditures for programs that address these upstream determinants, consistent with recent directions from the Centers for Medicare and Medicaid Services (CMS).

This paper examines the distributions of four SDoHs—educational level, employment status, homelessness in the past six months, and current criminal involvement—among a population of people receiving public mental health services from New York State. The researchers aimed to determine whether SDoH was associated with specific psychiatric or substance abuse conditions and whether the distribution of SDoH varied by gender, race, ethnicity, or geographic region of residence of service users.

Data comes from the New York State Office of Mental Health (OMH) 2017 Patient Characteristics Survey, conducted every two years by mental health providers employed in more than 4 000 programs managed or approved by the OMH.

The authors examined the survey responses of 103,416 adults (ages 18-65) who received public OMH services for mental or emotional disorders between October 23rd and October 29e, 2017. Demographics collected included age, gender, race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, or other), and region of residence (New York vs rest of state). The four SDoH domains captured by the survey were education level ( Grade 12), employment status (unemployed, part-time, full-time), homelessness in the past six months (yes/no), and any current criminal court involvement (yes/no). The provider also reported any psychiatric and substance use diagnoses.

The survey results show that half of the service recipients were women (51.3%); 44.5% were non-Hispanic white, 26.9% were non-Hispanic black, 21.8% were Hispanic, and 6.7% were coded as “other race”. Half of the service users (50.4%) resided in New York. In particular, the researchers point to the possibility of discrepancies between provider reporting of demographic characteristics and self-identification of service users.

Nearly a third of service users reported having a primary diagnosis of psychotic disorder (29.9%) and a quarter of depressive disorder (25.9%). Prevalence rates for bipolar disorder (14.9%) and anxiety disorder (8.9%) were lower. Additionally, the proportion of adults with a co-occurring substance use disorder was 13.3% for alcohol-related disorders and 21.5% for drug-related disorders.

The SDoH results show that one-fifth of service users (20.9%) had less than 12 years of education. Additionally, the majority were unemployed (79.1%), 12.2% were currently under correctional supervision, and 8.2% had recently been homeless.

Among people with adverse social conditions (low education, unemployment, involvement with the justice and criminal systems, recent homelessness), a psychotic disorder was the most common primary diagnosis. Social determinants were also highly prevalent among adults with substance use disorders: 87.3% of those with drug use disorders were unemployed and 25.1% were currently involved in the justice system. penal.

Non-Hispanic black service users had the highest rates of unemployment (86.3%), recent homelessness (12.7%), and criminal involvement (17.2%) compared to white and Hispanic participants non-Hispanics. Rates of low education (

The authors then contextualized their findings by comparing SDoH prevalence rates in the sample to those in the general New York State population, revealing significant discrepancies. For example, recipients of mental health services had lower high school graduation rates than the general population (79.1% versus 86.5%, respectively) and significantly lower unemployment rates. higher (79.1% vs. 4.4%), housing instability (8.2% vs. 0.5%), and criminal and judicial involvement (12.2% vs. 1.0%) .

The striking overrepresentation of adverse social conditions among service users across the state is concerning, given the known associations between poor quality educationunderemploymentand criminal-legal involvement and an increased risk of physical health problems and poor mental health outcomes. The researchers’ findings that SDoH was most prevalent among people with psychotic spectrum disorders, in particular, are consistent with previous research that has linked structural inequalities to the risk of psychosis.

The authors also note that the high prevalence of all social determinants among service users of color, particularly non-Hispanic blacks, is consistent with research linking systemic racism to health disparitieswhich can be further compounded by discrimination based on mental health diagnosis status:

“Racism and discrimination at the individual level against people with substance use disorders and mental illnesses can further hinder employment and education opportunities while increasing the likelihood of being involved in the criminal justice system.

Given the cross-sectional nature of the data in this article, the direction of causation (e.g., SDoH causes mental illness) cannot be assumed. Additionally, the authors suggest the potential for reciprocal relationships between the variables:

“A two-way relationship may exist, compounding the likelihood of a poorer disease course and worse outcome. For example, unemployment may increase depressive symptoms; depression may also increase the risk of becoming unemployed.

Similarly, the disproportionately high rates of criminal and judicial involvement observed in the study sample may be emblematic of both overcriminalization of people with mental illness and the detrimental impact that the involvement of criminal justice systems (eg, victimization by the police) can have on mental health, especially for people of color.

A few key limitations of the current study are noteworthy. The combination of ‘race’ and ‘ethnicity’ into a single category and the inclusion of ‘other’ as a racial category are both problematic, as they impede understanding of the actual racial and ethnic composition of the sample. In addition, many relevant social determinants were not included in the analyzes (eg food insecurity). The authors point out that these limitations result from the use of administrative data from the state mental health system and indicate “a lack of standardized screening for social determinants during admission and routine assessment.”

By leveraging data from routine clinical services for their research, researchers highlight inequities in patients’ social conditions and the inadequacies of current approaches to identifying and addressing social determinants in mental health care settings.

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Ehntholt, A., Frimpong, EY, Compton, MT, Rowan, GA, Ferdousi, W., Swetnam, H., … & Rotter, M. (2022). Prevalence and correlates of four social determinants in a statewide survey of licensed mental health services. Psychiatric servicesappi-ps. (Link)

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