PERSPECTIVE: Social Determinants: New Possibilities for Intervention Research in Global Mental Health.

Background: Since its launch in 2007, the field of global mental health has generated substantial research on the social determinants of mental health. Yet relatively little is known about how to intervene to address these social determinants: are such interventions feasible and effective? If they are effective, what are the mechanisms of these effects?

Discussion: This article interrogates some of the important challenges and potential approaches to consider when intervening to address the social determinants of mental health. Challenges include distal intervention targets, opaque mechanisms, intractable political and structural challenges, the need for interdisciplinary approaches, limited currently available datasets, ethical challenges when conducting trials in this field and challenges to research funders, who may be required to fund beyond their disciplinary silos and to convene inter-disciplinary review panels. Nevertheless, several approaches hold promise. First, we need to build more robust and precise theoretical models of how specific social and economic adversities lead to mental health outcomes. This is vital to clearly identify causal mechanisms that may be targeted in interventions. Second, we must test the specific mechanisms in these hypothesized causal pathways for example through including adequately powered mediation analyses in the design of our trials. Third, data need to be shared and where appropriate, pooled across multiple sites, to provide more statistical power and to take context into consideration. Finally, clear criteria need to guide the choice of which social determinants to target.

Recommendations for future research: Regarding observational studies, more research is needed to measure the intergenerational transmission of poverty and mental illness and to explore the mechanisms of poverty and mental health over time. We need to understand more about the links between gender, poverty and mental health across the life course, including genetic, biological and socioeconomic risk and protective factors. In relation to intervention studies, research is needed on interventions that address proximal and more distal mechanisms, for example the impact of living environments, climate change and migration on mental health. We are on the threshold of a new era of heightened risk for a broad range of social and economic determinants triggered by climate change, conflict and migration. There is a great deal more that we could be doing to improve our resilience and responsiveness to these challenging circumstances.

Recommendations for policy: Adopting a social determinants approach requires a broadened policy agenda. Global mental health advocacy must now also campaign for improved living environments, human rights and reductions in conflict to improve the mental health of populations and reduce inequities in the distribution of mental health. The policy message is twofold: invest in mental healthcare and invest in interventions that address the social determinants of mental health. This requires broad based whole-of-society approaches with interventions that address both the causes and the consequences of mental illness.