Identifying the various social determinants of mental health

I recently received an email from Dr. Dilip Jeste stating that after serving 36 years at the University of California San Diego (UCSD), including nearly two decades as director of the Stein Institute for Research on Aging (SIRA), he was retiring from the university. In this new phase of his life, he intends to focus his research on the Social Determinants of Mental Health (SDoMH). As you might imagine, this was “bad” – or at least, bittersweet – news for the SIRA, but wonderful news for the world of SDoMH.

While at SIRA, Jeste was instrumental in promoting interdisciplinary programs focused on healthy and successful aging, as well as age-related illnesses. In addition to supporting research, the Stein Institute fosters training and education in geriatrics and gerontology. Beyond medical research, SIRA addresses the major challenges facing society as it prepares to accommodate a rapidly expanding demographic of older adults in terms of technology, housing, and age-friendly communities.

In the past year, Jeste became increasingly interested in research on how social connections, education, stigma, and climate, among other factors, impact mental health. He was appointed by Dr. Vivian Pender, the president of the American Psychiatric Association (APA), to be the chair of a new national task force on SDoMH. The task force prepared a paper on this topic with the goal to expand its scope nationally and beyond. The Royal College of Psychiatrists in the U.K. has also been interested in joining this effort.

My initial reaction was to think of Gestalt Therapy with its focus on the social and environmental aspects of a person’s life and the self-regulatory adjustments people make given their overall circumstances. Gestalt Therapy was developed by Fritz Perls in the 1940s and ’50s. One of Gestalt Therapy’s central ideas is that everyone is caught in webs of relationships; thus, it is only possible to know ourselves against the background of our relationships with others. Jeste is embarking on a very wide expansion of the concept of the various facets of the environments as they impact not only therapy but general mental health.

In a 2008 report, a World Health Organization (WHO) commission on the social determinants of health would achieve a major milestone in medicine by officially recognizing the impact of social factors on health and illness. The report included non-medical factors, such as nutrition, education, employment, and living environments as they impacted health inequalities; this list has since grown to include dozens of proposed social determinants.

Recently, the United States declared 2021–2030 as the Decade of Healthy Aging, encouraging a global collaboration to improve the lives of older people and their families and communities. This is indeed timely, as older adults remain the population most directly affected by the COVID-19 pandemic. Some of the age-related SDoMH concepts include ageism (defined as stereotypes), prejudice, and age-based discrimination. Ageism can be institutional, interpersonal, and even self-directed; its effects are detrimental to the individual, community, and society. Older adults with mental illnesses are even more impacted by several types of SDoMH, such as stigma against mental illness, healthcare disparities, a flawed criminal justice system, and homelessness.

Social isolation and loneliness are other significant problems for older adults. Exacerbated by the pandemic, the loss of family members and friends has subsequently increased overall rates of morbidity and mortality. Loneliness can lead to general anxiety disorders, major depression, dementia, and accelerated aging. Older adults are less able to use technology to interact with family, thus exacerbating feelings of distance. A recent study found that 76 percent of adult Californians are experiencing moderate to severe loneliness associated with worse mental and cognitive health.

Today in the U.S., we are also dealing with the geriatric workforce shortage. There is a growing gap between the need for and the availability of geriatric expertise. The number of doctors going into geriatric medicine and geriatric psychiatry has been dropping due to both poor reimbursements and an unmanageable volume of cases.

What is most important in any endeavor to improve mental health is to identify the issue(s). Recognition leads to awareness, which in turn leads to action. I am hopeful that roadmaps to both addressing the various problems as well as initiating innovative solutions will materialize. I wish Jeste success in this new adventure!

Addendum: This column is based on both excerpts and paraphrasing of three articles with Jeste as lead author: “Battling the Modem Behavioral Epidemic of Loneliness,” JAMA Psychiatry, 2020; “Social Determinants of Mental Health: Recommendations for Research, Training, Practice, and Policy,” JAMA Psychiatry, 2022”; and “Social Determinants of Mental Health for the New Decade of Healthy Aging,” American Journal of Geriatric Psychiatry, 2022.