How Social Determinants of Mental Health Increase Depression Risk

As we navigate a period of rapid social and economic change amplified by COVID-19, the social contributors to depression are of particular interest. Individuals who experience more unfavourable social circumstances are at higher risk for depression throughout their life course (Kirkbride et al., 2024). These social circumstances are often imposed by structural and systemic factors; an example being the links between low income and maternal depression (as discussed in “Playing on uneven playing fields”), which can perpetuate intergenerational cycles of poor mental health.

Prevalence rates of depression are rising, with rates of adult depression in the UK increasing from 10% pre-pandemic to 17% in 2022 (Office for National Statistics, 2022). The burden of disease is also very high, with depression costing £300 billion in the UK alone (Centre for Mental Health, 2022). There is an urgent need to investigate the social factors contributing to this trend.

While certain social determinants of mental health (SDoMHs) such as poverty have long been associated with risk for depression, recent efforts have tried to identify other individual- and public health-level SDoMHs that are associated with depression (Alegría et al., 2023). However, it is not known whether certain SDoMHs have a larger impact on depression than others. Government and policymakers often face limited resources, so comparisons of impact could highlight the SDoMHs to be targeted first.

In this recent study by Alon and colleagues (2024), the authors reviewed meta-analyses and systematic reviews that investigated associations between different SDoMHs and depression.

Methods

The search and inclusion criteria combined depression and SDoMHs that were included in the “Report of Social Determinants of Mental Health” released by the American Psychological Association (APA, 2022). There were four main categories of SDoMHs that were searched for:

1. Highly detrimental U.S societal problems (e.g., social exclusion, adverse childhood experiences, racism, and criminal justice involvement)

2. Socioeconomic status (e.g., low educational attainment, unemployment, poverty, and income inequality).

3. Physical environment (e.g., neighbourhood disorder, adverse built environment).

4. Basic needs (e.g., housing instability, food insecurity, and poor access to health care)

The quality of each identified paper was assessed using a widely used critical appraisal tool (Joanna Briggs Institute checklist; Aromataris et al. 2015). The odds ratios, effect sizes, and pooled prevalence rates of depression in samples with and without the specified SDoMHs were analysed and reported.

Results

The final umbrella review included 26 meta-analyses and systematic reviews. The mean JBI score across papers was 9 out of a possible 11, reflecting a high level of quality.

Childhood adversities, including neglect, emotional, physical, and sexual abuse, were significantly associated with increased risk of depression with a medium-size adverse effect. Additionally, intimate partner violence in females was associated with depression with a medium effect size. In the one study included in the review which investigated racial disparities, no differences were reported between Black and White Americans.

Smaller adverse effects were reported for natural or human-made disasters, including war, military combat and terrorist attacks. Mean prevalence rates of depression were elevated in incarcerated adolescents and adults with pooled rates of 10% to 26%, although no effect sizes were reported and significance was not tested for. Similarly, the prevalence of depression in migrants was elevated, with pooled rates of 17% to 33%.

Food insecurity was significantly associated with risk of depression with a medium effect size. Individuals experiencing housing insecurity had elevated prevalence rates of depression, ranging from 13% to 26%

Higher levels of parental care were associated with a lower risk of depression with a medium-size protective effect.

Conclusions

This umbrella review indicates that those who experience social determinants of mental health are at higher risk of developing depression. Those who experience early life adversities, intimate partner violence, and food insecurity face higher risk of depression than those who don’t. Those who experience natural and human-made disasters are also at a higher risk of depression, though the effect sizes were small. Housing insecurity, incarceration, and migration were also associated with elevated prevalence of depression. The included study investigating racial disparities between White and Black Americans did not report differences in depression, but this is likely due to barriers to healthcare and differences in symptom presentation. Parental care was a protective factor against the risk of depression.

Strengths and limitations

Strengths

• This umbrella review adhered to standardised guidelines, using a quality appraisal tool to critically appraise the evidence to achieve a rigorous quality assessment. Four independent researchers reviewed the evidence and resolved discrepancies through discussion, adding to the review’s reliability.

• A consistent definition of depression was applied throughout the 26 studies, focusing specifically on cases diagnosed with Major Depressive Disorder (MDD). By narrowing the scope to MDD, rather than broadly addressing depressive symptoms, the authors facilitated clearer comparisons across the SDoMHs included in the review.

• The study is both timely and relevant, addressing SDoMHs identified in nationally recognised areas of focus, as highlighted by the American Psychiatric Association (APA). Using pre-published priorities may attract attention from policymakers to influence future policy and practice.

Limitations

• Many SDoMHs are often experienced simultaneously in an intersectional manner. A more nuanced review could have examined these combined effects, rather than treating each determinant in isolation. While a study might find an association between one SDoMH and risk of depression, this association is likely conflated, as it is likely that various other social and cultural determinants are co-occurring. Further, gender differences significantly influence depression, with certain SDoMHs disproportionately affecting specific gender groups. However, this important factor was not explored in the study.

• The study focused exclusively on US and European populations, limiting its applicability to non-WEIRD (Western, Educated, Industrialized, Rich, and Democratic) countries. This Eurocentric analysis of the impact of Social Determinants of Mental Health (SDoMHs) may not be useful outside this group, especially for US-specific determinants such as racial disparities.

• Many of the social determinants of mental health (SDoMH) outlined in the four groups proposed by the APA and discussed in the methods were not fully represented in the review, likely due to the lack of eligible studies. As a result, several SDoMHs were supported by only one or two studies, limiting the strength of the review’s conclusions. For instance, the SDoMH of racial disparities was reported on in only one study. While the review identified four key SDoMH categories, it did not report any findings on those related to socioeconomic status, despite framing it as a central category.

Implications for practice

This research highlights significant opportunities for both individual-level and public health interventions aimed at addressing the SDoMHs in relation to depression and other mental health conditions.

At the individual level, childhood adversities can cause lasting epigenetic changes in the brain, endocrine, and immune systems (Chen et al., 2021). However, emerging evidence suggests that trauma-focused psychotherapeutic interventions may reverse these epigenetic changes, potentially benefiting future generations. For instance, a randomised controlled trial demonstrated that methylation in certain genomic regions is linked to both the development and treatment of PTSD, showing that psychotherapy can have a biological impact (Vinkers et al., 2021). Additionally, positive social determinants like parental care, social connections, religion, and compassionate communities are associated with reduced risk of depression (Kidd et al., 2022). This underscores the need for mental health interventions that foster such protective factors. Furthermore, while PTSD is prevalent after disasters, there is evidence of post-traumatic growth (Seo & Lee, 2020), indicating the potential for recovery at both individual and community levels. Pragmatic intervention models, such as stepped-care approaches, should be tested and implemented in mental health settings, with valid and practical assessments of these interventions.

At the public health level, various SDoMHs require attention through policy and systemic interventions. Food insecurity, housing instability, and incarceration are critical factors that exacerbate mental health issues. Effective strategies to address these include advocating for legislation that promotes food security, supporting food banks, and integrating nutrition-focused interventions into healthcare settings. However, interventions that target a singular SDoMH such as housing programs (e.g. Housing first; (Stergiopoulos et al., 2019) ) or cash transfer programs (CHANCES6; Ziebold et al., 2021) have shown mixed results in improving mental health outcomes. This may stem from the intersectional nature of SDoMH, where multiple factors are experienced simultaneously and cannot be addressed by focusing on a single issue. Ongoing exploration of these programs is essential, with a focus on addressing intersecting determinants rather than isolated factors.

So, while interventions targeting SDoMHs have shown potential, significant gaps remain, particularly in addressing diversity, equity, and inclusion. There is a clear need for frameworks that integrate these principles into mental health interventions and for evaluating their efficacy.

Statement of interests

No conflicts of interest to declare.

Links

Primary paper

Alon N, Macrynikola N, Jester D. et al (2024) Social determinants of mental health in major depressive disorder: Umbrella review of 26 meta-analyses and systematic reviews. Psychiatry Research, 335 115854. https://doi.org/10.1016/j.psychres.2024.115854

Other references

Alegría, M, Alvarez, K, Cheng, M et al. (2023). Recent Advances on Social Determinants of Mental Health: Looking Fast Forward. American Journal of Psychiatry, 180(7), 473–482. https://doi.org/10.1176/appi.ajp.20230371

Aromataris E, Fernandez R, Godfrey C et al. (2015). Summarizing systematic reviews: methodological development, conduct and reporting of an Umbrella review approach. Int J Evid Based Healthc., 13(3):132-40. https://jbi.global/sites/default/files/2019-05/JBI_Critical_Appraisal-Checklist_for_Systematic_Reviews2017_0.pdf

Cardoso, F & McHale, Z (2022) The Economic and Social Costs of Mental Ill Health: Review of the methodology and update of calculations. Centre for Mental Health.

Chen, M. A., LeRoy, A. S., Majd, M et al. (2021). Immune and Epigenetic Pathways Linking Childhood Adversity and Health Across the Lifespan. Frontiers in psychology, 12, 788351. https://doi.org/10.3389/fpsyg.2021.788351

Kidd K, Prasad D, Cunningham J et al. (2022). The relationship between parental bonding and mood, anxiety and related disorders in adulthood: A systematic review and meta-analysis. Journal of Affective Disorders 307 211-236. https://doi.org/10.1016/j.jad.2022.03.069

Kirkbride, J. B., Anglin, D. M., Colman, I et al. (2024). The social determinants of mental health and disorder: evidence, prevention and recommendations. World psychiatry: Official journal of the World Psychiatric Association, 23(1), 58–90. https://doi.org/10.1002/wps.21160

Office for National Statistics (ONS) released 6 December 2022, ONS website, article, Cost of living and depression in adults, Great Britain: 29 September to 23 October 2022.

Seo, H., & Lee, O. (2020). Mediating role of post-traumatic stress disorder in post-traumatic growth in adults who experienced the 2017 Pohang earthquake. Journal of affective disorders, 263, 246–251. https://doi.org/10.1016/j.jad.2019.11.162

Stergiopoulous V, Meija-Lancheros C, Nisenbaum R et al. (2019). Long-term effects of rent supplements and mental health support services on housing and health outcomes of homeless adults with mental illness: extension study of the At Home/Chez Soi randomised controlled trial. The Lancet Psychiatry, 6(11) 915-925. https://doi.org/10.1016/S2215-0366(19)30371-2

UCL Psychiatry MSc. Loneliness linked to mid-life depression: can tackling loneliness help prevent depression in older people? The Mental Elf, 5 May 2021. https://www.nationalelfservice.net/populations-and-settings/loneliness/loneliness-depression-adults/

Vinkers C, Geuze E, van Rooij S et al. (2021) Successful treatment of post-traumatic stress disorder reverses DNA methylation marks. Molecular Psychiatry, 26 1264-1271. https://doi.org/10.1038/s41380-019-0549-3

Ziebold, C, Paula, S., Santos, S et al. (2021). Conditional cash transfers and adolescent mental health in Brazil: Evidence from the 2004 Pelotas Birth Cohort. Journal of global health, 11 04066. https://doi.org/10.7189/jogh.11.04066

Photo credits