Brooke-Sumner, C

Burgess, R

Burns, J

Gurung, D

Kakuma, R

Kusi-Mensah, K

Ladrido-Ignacio, L

Lund, C

Maulik, PK

Roberts, T

Rose-Clarke, K

Thornicroft, G

Walker, IF

Williams, S

Yaro, P

English

UCL Discovery

Rethinking research on the social determinants of global mental health  Authors Kelly Rose-Clarke*1, Dristy Gurung*2, Carrie Brooke-Sumner3, Rochelle Burgess4, Jonathan Burns5, Ritsuko Kakuma6, Kwabena Kusi-Mensah7, Lourdes Ladrido-Ignacio8, Pallab Maulik9, Tessa Roberts10, Ian Walker11, Shehan Williams12, Peter Yaro13, Graham Thornicroft†14, Crick Lund†15  * Joint first authors † Joint senior authors  Corresponding author: Kelly Rose-Clarke, Department of Global Health and Social Medicine, King’s College London, Bush House North-East Wing, WC2B 4BG. Email address: kelly.rose-clarke@kcl.ac.uk  Affiliations 1 Department of Global Health and Social Medicine, King’s College London, London, UK.  2 Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK; Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal. 3 Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Alcohol, Tobacco and Other Drug Research Unit, Medical Research Council of South Africa, Cape Town, South Africa.  4 Institute for Global Health, University College London, London, UK. 5 University of Exeter Medical School, University of Exeter, Exeter, UK. 6 Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK. 7 Department of Psychiatry, University of Cambridge, Cambridge, UK; Department of Psychiatry, Komfo Anokye Teaching Hospital, Kumasi, Ghana. 8 College of Medicine, University of the Philippines, Manila, Philippines. 9 The George Institute for Global Health, New Delhi, India; Faculty of Medicine, University of New South Wales, Sydney, Australia; George Institute for Global Health, Oxford University, Oxford, UK. 10 Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK. 11 Global Public Health Division, Public Health England, UK. 12 Department of Psychiatry, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka. 13 BasicNeeds Ghana, Accra, Ghana. 14 Centre for Implementation Science, and Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK. 15 Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.   *Co-first authors     The Lancet Commission on Global Mental Health and Sustainable Development highlighted the need to make mental health an integral part of global development.1 Treatment interventions are not enough to reduce the population-level burden of mental disorders and a public health approach tackling the social determinants of mental health is indicated.1,2   In late 2019, the UK Academy of Medical Sciences and the InterAcademy Partnership for Health convened an international workshop to identify research gaps, intervention priorities and opportunities for collaboration on the social determinants of global mental health. Participants were over 60 researchers, clinicians, funders and representatives from non-governmental organisations, mainly from low- and middle-income countries. Participants contributed to one of five working groups on demographic, economic, neighbourhood, environmental or socio-cultural determinants (Panel 1).   In the demographic group, participants perceived a lack of research on how gender roles and experiences affect mental health and highlighted the need for more evidence-based early interventions. The economic group advocated for a deeper understanding of how social security and unemployment policies influence mental health, and for inclusion of mental health outcomes in evaluations of such policies. The environmental group outlined the need to better elucidate mechanisms linking climate change and mental health, including the role of epi/genetics, stigma and discrimination, and to explore the relevance of mental health guidelines in the context of both acute and chronic adversity.3 The neighbourhood group discussed the importance of community mobilisation in changing the social environment, and the need for research to understand how urban regeneration initiatives could benefit mental health. The socio-cultural group advocated for more research on the roles of faith, religion and spirituality in promoting mental health, and on how to integrate indigenous knowledge into interventions.    Across groups, there were several common themes including a renewed focus on resilience, for example using theory and knowledge from fields such as ecology and disaster research to link individual resilience strategies to interventions at neighbourhood or larger-scale levels to inform more holistic interventions.4 Migration and displacement due to conflict, poverty and environmental events were also identified as of particular importance. More nuanced approaches that capture the diversity of migrant experiences are needed, along with interdisciplinary and international collaboration to track and support migrants and their families across borders.5 Participants also emphasised the need to design strategies to address the social factors that contribute to syndemics, i.e. the clustering of concurrent mental and physical health conditions, within the same individuals or population.6   The meeting identified opportunities for collaboration that extend beyond the disciplinary comfort zones of academics. At a global level, policy networks such as the Sustainable Development Solutions Network can be used to support global research collaborations, working with government, UN and other developmental agencies to integrate measures of mental health into national and international surveys. In addition they can support engagement with non-health funding partners such as those funding research on climate change and economic development. Local collaboration should involve cross-sectoral partnership with local authorities, civil society and advocacy groups, and service users, to prioritise conditions and strategies. Within academia, expertise in anthropology, economics, genetics, implementation science and neuroscience will be essential in designing innovative studies and coordinating multi-sectoral implementation.  The workshop concluded with several recommendations. First, we need to understand complexity by exploring the differential effects of social determinants across genders, generations and geographical borders. We need to stop thinking solely in terms of proximal individual determents and give serious attention to determinants at meso- and macro-levels of the socio-ecological model.7 Second, we must move beyond cross-sectional epidemiological approaches. Longitudinal qualitative and quantitative studies are essential to understand causality and the lived experience of exposure to multiple interacting determinants. New data collection technologies such as crowdsourcing, geospatial technology, and the Experience Sampling Method could provide valuable spatio-temporal information.8 Large-scale ethnographies and ethnographic process evaluations could be used to collect data on lived experiences and intervention processes in naturalistic settings.9  Third, social determinants are evolving. The growing reality of climate change is likely to have major mental health consequences, especially for vulnerable groups, and solastalgia – distress due to environmental change – is an important area for future research.10 The digital revolution has created new mental health risks such as cyber bullying and internet gaming disorders.11 Applying predictive analytics to the field of mental health could help to identify individuals at high risk.12 Partnerships with social media and networking services could inform ongoing digital development and forecast new and emerging risk factors. Finally, to address the many social determinants of mental health we need to fundamentally change national and global policies that perpetuate socio-economic and health inequity: we cannot shy away from this. As researchers we must play a more active and vocal role in advocacy and activism, working with international and local actors to realise the full potential of community mobilisation to address the social determinants of mental health.   Acknowledgements The workshop was funded by the Academy of Medical Sciences and the InterAcademy Partnership. GT is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration South London at King’s College London NHS Foundation Trust, and by the NIHR Asset Global Health Unit award. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. GT also receives support from the National Institute of Mental Health of the National Institutes of Health under award number R01MH100470 (Cobalt study). GT is supported by the UK Medical Research Council in relation to the Emilia (MR/S001255/1) and Indigo Partnership (MR/R023697/1) awards.  Declaration of interests We declare no competing interests.   References 1. Patel V, Saxena S, Lund C, et al. The Lancet Commission on global mental health and sustainable development,. The Lancet 2018; 392(10157): 1553-98. 2. Lund C, Brooke-Sumner C, Baingana F, et al. Social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews. Lancet Psychiatry 2018; 5(4): 357-69. 3. Thornicroft G, Mehta N, Clement S, et al. Evidence for effective interventions to reduce mental-health-related stigma and discrimination. The Lancet 2016; 387(10023): 1123-32. 4. Masten A, Obradović J. Disaster preparation and recovery: lessons from research on resilience in human development. Ecology and Society 2008; 13(1): 9. 5. Abubakar I, Aldridge RW, Devakumar D, et al. The UCL–Lancet Commission on Migration and Health: the health of a world on the move. The Lancet 2018; 392(10164): 2606-54. 6. Mendenhall E, Kohrt BA, Norris SA, Ndetei D, Prabhakaran D. Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations. Lancet (London, England) 2017; 389(10072): 951-63. 7. Burgess RA, Jain S, Peterson I, Lund C. Social interventions: a new era for global mental health? Lancet Psychiatry 2020; 7(2): 118-9. 8. Myin-Germeys I, Kasanova Z, Vaessen T, et al. Experience sampling methodology in mental health research: new insights and technical developments. World psychiatry : official journal of the World Psychiatric Association (WPA) 2018; 17(2): 123-32. 9. Morgan-Trimmer S, Wood F. Ethnographic methods for process evaluations of complex health behaviour interventions. Trials 2016; 17(1): 232. 10. Galway LP, Beery T, Jones-Casey K, Tasala K. Mapping the Solastalgia Literature: A Scoping Review Study. International journal of environmental research and public health 2019; 16(15): 2662. 11. Przybylski AK, Weinstein N, Murayama K. Internet Gaming Disorder: Investigating the Clinical Relevance of a New Phenomenon. American Journal of Psychiatry 2016; 174(3): 230-6. 12. Rocha TB-M, Fisher HL, Caye A, et al. Identifying adolescents at risk for depression: a prediction score performance in cohorts based in three different continents. Journal of the American Academy of Child & Adolescent Psychiatry 2020; In press.   Panel 1: Research gaps and intervention priorities Demographic  Research gaps  Lack of longitudinal data to assess causality  Lack of qualitative approaches to understanding determinants across the life course and at different levels of the socio-ecological model  Neglected topics: resilience and other positive predictors of mental health, ageing, LGBTQIA+, understanding how perceived gender norms influence mental health  Intervention priorities  Interventions for men’s mental health, gender-based violence, ageing populations and migrant families  Early interventions (school-, family-, community-based and community-led)  Economic Research gaps  Poor understanding of economic drivers of mental health  Inadequate advocacy and attention to macro-economic determinants of mental health  Inadequate understanding of how household economics affect mental health  Intervention priorities  Include mental health measures in economic surveys to understand the relationships between economic and psychological characteristics  Social protection systems/cash transfers  Evaluation of mental health outcomes of economic interventions  Environmental Research gaps  Role of resilience in adverse events and disaster risk reduction   Epigenetics and links to vulnerability   Understanding commonalities/differences between acute and chronic adverse events   Understanding the mechanisms linking environmental events and mental health   Impact of environmental disasters on people with severe mental illness  Stigma/discrimination related to the label of being a ‘victim’ or ‘survivor’ of environmental events Intervention priorities  Advocacy and collaboration with other sectors to reduce impact of environmental events on mental health  Evaluating the effectiveness and sustainability of existing tools on psychosocial response to environmental events   Focus on disaster preparedness by building resilience in individuals and communities through multi-disciplinary approaches (bio-psycho-socio-cultural and spiritual)   Focus on disaster response by supporting people with multiple vulnerabilities, and campaigning to raise awareness on links between environmental events and mental health  Neighbourhood Research gaps  Gaps in definition of neighbourhood and its characteristics and tools to measure them  Knowledge on mechanisms of action and linkages between neighbourhood characteristics and mental health outcomes  Gaps in innovative research methods such as Geographic Information Systems and other mixed methods studies, as well as longitudinal studies   Field of mental health working in isolation from other sectors such as urban planners and engineers  Studies on neighbourhood and community resilience and how they act as protective factors for mental health  Intervention priorities  Social interventions targeting violence in neighbourhoods, building social capital and trust to make communities healthier  Coordinated actions to improve infrastructure (water and sanitation, waste management and recycling, open spaces, social housing and schools) and assess its impact on mental health outcomes  Socio-cultural Research gaps  Lack of understanding of causal pathway between socio-cultural determinants and mental health  More understanding of the impact of population movement on social support and cohesion  Intervention priorities  Promoting community inclusive development (focus on indigenous knowledge and healing systems)  Prevention of early childhood adversities and maximising protective factors for children  School-based intervention around anti-bullying and social/emotional learning  Occupational interventions focusing on migrant labourers  Interventions focusing on social isolation, social support and social capital among older adults 

Rethinking research on the social determinants of global mental health

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Rethinking research on the social determinants of global mental health

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