Social Determinants of Mental Health

International Review of Psychiatry, August 2014; 26(4): 392407
Social determinants of mental health
JESSICA ALLEN, REUBEN BALFOUR, RUTH BELL & MICHAEL MARMOT
Int Rev Psychiatry Downloaded from informahealthcare.com by 188.25.40.203 on 05/26/15

For personal use only.
UCL Institute of Health Equity, University College London, UK
Abstract
A persons mental health and many common mental disorders are shaped by various social, economic, and physical
environments operating at different stages of life. Risk factors for many common mental disorders are heavily associated
with social inequalities, whereby the greater the inequality the higher the inequality in risk. The poor and disadvantaged
suffer disproportionately, but those in the middle of the social gradient are also affected. It is of major importance that
action is taken to improve the conditions of everyday life, beginning before birth and progressing into early childhood,
older childhood and adolescence, during family building and working ages, and through to older age. Action throughout
these life stages would provide opportunities for both improving population mental health, and for reducing risk of those
mental disorders that are associated with social inequalities. As mental disorders are fundamentally linked to a number
of other physical health conditions, these actions would also reduce inequalities in physical health and improve health
overall. Action needs to be universal: across the whole of society and proportionate to need. Policy-making at all levels of
governance and across sectors can make a positive difference.
Introduction
It is increasingly known that peoples social and economic circumstances affect their health. These social
determinants include the conditions in which people
are born, live, work, and age, and the health systems
they can access, which are in turn shaped by a wider
set of forces: economics, social, environmental policies, and politics. The landmark report of the Commission on Social Determinants of Health (2008)
as well as a number of other seminal reports and
reviews (Marmot Review Team, 2010; WHO, 2013d)
have described the evidence base linking social
determinants to a range of health outcomes.
Differences in social, economic, and environmental circumstances lead to health inequities, which
are defined as health inequalities that are systematic,
socially produced (and therefore modifiable), and
unfair (Whitehead & Dahlgren, 2006). There are
clear variations in longevity not only across countries
but also within the same nation. Thus, a child who
lives in a slum in Nairobi, Kenya is far more likely
to die before the age of five than a child from another
part of the city (WHO, 2008b). In Glasgow,
Scotland, male life expectancy varies from 54 to
82 years, depending on the part of the city in which
the person lives (Hanlon et al., 2006). These variations are a result of many factors including, in
particular, socio-economic status, living conditions,

and other social and environmental determinants.
Health inequities exist both between and within
countries and often follow a social gradient, thus
occurring both along a continuum and affecting
everyone in the population, not only the poorest or
most disadvantaged. Those in the middle typically
defined as those of average socio-economic status
generally experience worse outcomes than the
best-off in society, but better outcomes than the
worst-off.
The World Health Organization (WHO) defines
mental health as a state of well-being in which every
individual realizes his or her own potential, can cope
with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community (WHO, 2013e).
Importantly, the absence of mental disorder does not
necessarily mean the presence of good mental health
(Barry, 2009; Keyes, 2005) which raises significant
and important issues in managing mental illness as
well as mental well-being.
The Global Burden of Disease 2010 study estimates that 400 million people across the globe suffer
from depression (including dysthymia), and a further
272 million from anxiety disorders; 59 million
suffer from bipolar disorder and 24 million from
Correspondence: Ruth Bell, UCL Institute of Health Equity, University College London, 1-19 Torrington Place, London, UK. Tel: 0207 1684. Fax: 0203
108 3354. E-mail: r.bell@ucl.ac.uk
(Received 14 May 2014 ; accepted 22 May 2014 )
ISSN 09540261 print/ISSN 13691627 online 2014 Institute of Psychiatry
DOI: 10.3109/09540261.2014.928270


schizophrenia; 140 million people are affected by
alcohol and drug use disorders; and 80 million children have behavioural disorders (conduct disorder or
attention deficit hyperactivity disorder (Whiteford
et al., 2013). These estimates do not include those
who may have sub-threshold mental disorders. Some
psychiatric and psychological illnesses are precipitated by stressful experiences and life events, though
not always (Patten, 1991).
In this paper we make the case that mental health
and many common mental disorders are shaped
to a great extent by social determinants. We provide
evidence that strategic action on peoples social,
economic, and environmental circumstances and
effective interventions at different stages of the lifecourse have considerable potential for improving
mental health and in preventing and alleviating
mental disorders in countries irrespective of their
stages of economic development.
Methods
Following the method of analysis completed by the
WHO Commission of Social Determinants of Health
(Commission on Social Determinants of Health,
2008), the Marmot Review in England (Marmot
Review Team, 2010), the WHO Review of Social
Determinants of Health and the Health Divide
(WHO, 2013d), as well as pioneering WHO reports
on mental health promotion and prevention of mental health (WHO, 2004a; WHO, 2004b) and a number of recent, well-researched resources, two key
issues were identified and explored: (1) the social
determinants of common mental disorders; and
(2) action on social determinants that can prevent
mental health disorders and/or improve population
mental health. The work was undertaken in collaboration with staff members of the WHOs Department
of Mental Health and Substance Abuse and with
advice from an international panel of experts (WHO
& Gulbenkian Mental Health Platform (2014)). A
draft of the original paper was presented at the
Gulbenkian Global Mental Health Platforms International Forum on Innovation in Mental Health, and
modified taking into account comments received
from mental health experts
A multilevel framework was applied to organize
the evidence:
The life-course approach across various life stages
including pre- and perinatal periods, early childhood, later childhood, working and family-building
years, and older age
Community-level contexts, including the natural
and built environment, primary healthcare, and
humanitarian settings
393
Country-level contexts, including political, social,

economic, and environmental factors, cultural
and social norms operating within a specific society, and whether specific policies and strategies to
reduce social inequalities and to promote access
to education, employment, healthcare, housing
and services exist
Main findings
The poor and disadvantaged suffer disproportionately
from common mental disorders and their adverse
consequences (Campion et al., 2013; Melzer et al.,
2004; Patel & Kleinman, 2003; Patel et al., 2010a),
but middle classes are also affected. Gender also plays
a major role and women tend to have higher levels of
common mental disorders compared to men at every
level of household income (Fig. 1).
Household income is only one of the factors leading to common mental disorders; low educational
attainment, material disadvantage, unemployment
(Fryers et al., 2005), and for older people social isolation, are other factors, along with gender as noted
above.
Prevalence of depressed mood or anxiety has been
shown to be 2.5 times higher among young people
aged 10 to 15 years with low socio-economic status
than among youths with high socio-economic status
(Lemstra et al., 2008). Household wealth affects childrens emotional and behavioural difficulties even at
ages 35 years (Kelly et al., 2011).
Similar observations have been reported from low
and middle income countries. Of 115 studies
reviewed, more than 70% reported clear and positive
associations between poverty and common mental
disorders (Lund et al., 2010).
Inevitably those who are lower in the social hierarchy are more likely to experience less favourable
economic, social, and environmental conditions
throughout life and may have access to fewer buffers
and may experience accumulative stress as a result,
leading on to mental disorders. Financial debt is
also associated with psychiatric disorders and has a
gradient effect (Jenkins et al., 2008).
A life-course perspective
It is crucial to follow a life-course approach as individuals will have on-going and continuing stressors
affecting their health at various stages of life such as
pregnancy and perinatal periods, early childhood,
adolescence, working and family building years, and
older ages (Kieling et al., 2011; Marmot Review
Team, 2010). Fig. 2 illustrates this approach.
As mentioned above, exposure to stressors can be
accumulative and will affect epigenetic, psychosocial, physiological, and behavioural attributes of
394
J. Allen et al.
kindergartens, preschools, schools, universities and
colleges, employers all need to be involved for
building healthier and happier societies. This needs
national policies but local actions.
Prenatal and perinatal experiences

Fig. 1. Prevalence of any common mental disorder by household

income, England 2007 (McManus et al., 2007). Pale bars, women;
dark bars, men.
individuals, as well as social conditions in which

families, communities, and social groups live and
work. It is possible that such an accumulation of
advantage and disadvantage may well contribute to
social and economic inequities and consequently to
inequitable mental health outcomes. These processes are not static, and keep changing in response
to a whole host of factors. It is well known that a
greater number of adverse events in childhood is
associated with increased likelihood of developing
mental illness in adulthood (Kessler et al., 2010;
Oladeji et al., 2010).
At every stage in the life course, vulnerability and
exposure to harmful processes or stressors can be
disruptive, which is why any public mental health
intervention needs to take a life course approach. A
life course approach implies that institutions such as
Fig. 2. A life-course approach to tackling inequalities in health

(WHO, 2013d).
The prenatal period often gets ignored, but is a

critical period. The perinatal period has a significant
impact on a newborns physical, mental, and cognitive health. Maternal health is particularly important
and poor environmental conditions, poor health and
nutrition, tobacco use, alcohol and drug misuse,
stress, and highly demanding physical labour can all
negatively affect the development of the foetus and
later life outcomes (Joint Commissioning Panel for
Mental Health, 2013; WHO, 2013d). Children of
depressed mothers are at a greater risk of being
underweight and stunted. Pre-term and low birth
weight babies may well themselves develop depression in later life (Surkan et al., 2011). It has been
suggested that reducing maternal depression in
Pakistan by 25%, 50%, or 75% would result in
reductions in children born underweight by 7%,
26%, and 36% respectively (Rahman et al., 2008).
Education, particularly targeting women and new
mothers, can help manage problems such as infant
mortality, stunting and malnutrition, conduct problems, and emotional and mental health problems
(Bicego & Boerma, 1993; Case et al., 2005; Gleason
et al., 2011; Schady, 2011).
Early childhood
Not surprisingly, adverse conditions in early life are
associated with higher risk of mental disorders
(Jensen et al., 2013; WHO, 2013d). Again, it is well
known that quality of parenting and family conditions affect childrens physical and emotional growth.
Poor secure attachment, neglect, lack of quality stimulation and conflict all negatively affect future social
behaviour, educational outcomes, employment status and mental and physical health (Bell et al., 2013).
Physical and emotional neglect, abuse, and growing
up in the presence of domestic violence can all damage children (Fryers & Brugha, 2013). It has been
noted that children of mothers with mental ill-health
are five times more likely to have mental disorders
themselves (Melzer et al., 2003). As noted above,
social gradients in social and emotional difficulties
have been shown among children as young as three
years which can be offset by protective parenting
activities (Kelly et al., 2011).
Inequities in early years development are potentially remediable through family and parenting support, maternal care, childcare, and education. Wider
family and strong communities can act as buffers and
395
Box 1. Examples of interventions supporting mental health in the early years.

In Jamaica a home-based intervention based on educating mothers about child-rearing including play activities and discussion
of parenting issues helped individuals cope better (Baker-Henningham et al., 2005).
The Triple P Positive Parenting Program has been implemented in numerous countries. It focuses on childrens behaviour
and development by altering the family environment to help reduce childrens risk of poor mental health (Sanders et al., 2008).
Originally from Australia, this programme has been used in China (Hong Kong), the Islamic Republic of Iran, Japan, and
Switzerland (Bodenmann et al., 2008; Leung et al., 2003; Matsumoto et al., 2007; Tehrani-Doost et al., 2009).
The Sure Start initiative in England is a good example of a scaled-up approach to early years intervention by engaging with
parents, pregnant mothers, infants and preschool age children to promote child development in an easily accessible manner
(Goff et al., 2013; Jane-Llopis & Anderson, 2006).
In the USA, studies have shown effectiveness of preschool interventions on young children living in low income and poverty
stricken settings. The High/Scope Perry Preschool Project, the NurseFamily Partnership and the Incredible Years series have
helped improve childrens educational achievement, economic success, and mental health outcomes in later life (Kitzman et al.,
2010; Schweinhart, 2006; Webster-Stratton et al., 2008). Incredible Years programmes have been implemented in 20 countries and
territories, including Denmark, Finland, the occupied Palestinian territory, and the Russian Federation (Incredible Years, 2013).
sources of support (WHO, 2013d). Additional

evidence-based actions are provided in Box 1.
Later childhood
Continued and appropriate forms of support are
needed throughout childhood and adolescence.
Depression in adolescence is linked with adverse
childhood experiences (Bell et al., 2013; Wickrama
et al., 2008) and risk taking in adolescence (including substance misuse) which affects development
(Campion, 2013; Casey et al., 2008). Emotional support from peers and families can help mitigate risk
behaviours. Poor environmental conditions such as
overcrowding and unhealthy living can add to stress
leading to poor educational achievements.
Implications for action
Schools are important in education but also for
providing a safe environment for personal development and growth, the effects of which can influence both short- and long-term mental health
(Barry, 2013). Schools allow access to a large number of children to teach about various matters
including managing stress (Jane-Llopis & Barry,
2005). Universal approaches include changes to

the school ethos, liaising with parents, special
teacher training, educating parents, community
involvement, and collaborating with external agencies (Weare & Nind, 2011). Country examples are
provided in Box 2.
Working age
Unemployment, irregular and poor-quality employment (such as employment with no or short-term
contracts), and jobs with low reward and low control
affect mental ill-health. A close association exists
between job loss and symptoms of common mental
disorders such as depression and anxiety (Catalano
et al., 2011; UCL IHE, 2012) especially in those
individuals who are long-term unemployed.
Job security and a sense of control at work are
protective factors (Anderson et al., 2011; Bambra,
2010). Employers who promote greater job control
and decreased demand can positively influence mental health by reducing stress, anxiety and depression,
and increasing self-esteem, job satisfaction and productivity (Bambra et al., 2007; Barry & Jenkins,
2007; Egan et al., 2007).
Box 2. Examples of school settings supporting mental health in later childhood.

School-based interventions can support mental health and address mental disorders in children and adolescents around the world
(Collins et al., 2014; Holen et al., 2012; Katz et al., 2013) especially in poor countries and war and disaster affected countries
The Social and Emotional Learning programme in the USA has consistently improved childrens social-emotional skills, attitudes
about self and others, school engagement, positive social behaviour, academic attainment, social conduct, and emotional distress
(Payton et al., 2008) by promoting supportive relationships which help develop childrens social and emotional skills (Mart et al.,
2011).
In Sri Lanka, post-civil conflict, a school-based intervention improved mental health and conduct behaviour, including
improvements in childrens ability to settle disputes in a non-violent way (Tol et al., 2012). This was based on models from other
war-afflicted countries, such as Indonesia (Tol et al., 2008).
396
J. Allen et al.
Box 3. A workplace intervention in China to promote mental health.

In China, a workplace health promotion programme reduced depression and anxiety among the workforce, improved work
performance, and reduced absenteeism.
It also provided employees with the ability to manage work demands more effectively (Sun et al., 2013).
Initiated by one of the largest retail companies in China, Credibility Retail Enterprise.
Interventions occurred at the organizational level (by teaching managers skills and training to promote mental health, create a
good working environment, and develop an organizational health policy) and at the employee level through better communication
skills, stress management, problem solving, conflict management, and self-awareness.


A reduction in long-term unemployment can reduce
risk of developing mental disorders, especially among
working age adults (Marmot Review Team, 2010)
but equally importantly minimum wage can enable
people to live better and thus reduce risk of mental
illness. Those who are employed require support
from their employers to promote and sustain mental
health.
Box 3 describes a programme in China that
reduced workers anxiety and depression, among
other positive outcomes.
It has been argued that every 1 spent on a
workplace mental health promotion programme
would generate 10 in economic returns (Knapp
et al., 2011).
Microfinance programmes are other potential
mechanisms to improve mental health by helping
people earn a living and enable communities
to work their way out of poverty (PATH, 2011).
These are underutilized resources with the potential to deliver health-related services to large and
hard-to-reach populations (Leatherman et al.,
2012). Nonetheless, only limited research (see
Box 4) has examined the effects of these programmes on mental health.
cognition as well as attachment patterns. Postnatal

depression can affect womens mental health, but also
family functioning.
In low and middle income countries, the prevalence of common mental disorders among women in
the perinatal period is estimated to be 16% before
birth and 20% postnatally (Fisher et al., 2012). In
England, postnatal depression shows a clear social
class gradient: from 2003 to 2004 just over 20% of
those in the lowest quintile for socio-economic status
had experienced postnatal depression, compared
with 7% in the highest socio-economic quintile
(Marmot Review Team, 2010). Similar gradients
may well exist in other countries. Additional risk
factors for common mental disorders in the perinatal
period included socio-economic disadvantages,
unintended pregnancy, being younger and unmarried, hostile in-laws and female child, while protective factors included education, being employed and
trustworthy partner.
Primary and community health workers can
intervene successfully to improve maternal mental
health, thereby buffering risk for children (Rahman
et al., 2013). Box 5 illustrates with an account from
South Africa.

Family-building
Families are often the basis of social support and provide safe environments in which people grow up and
develop. Families and cultures are crucial in developing
Interventions supporting maternal and postnatal

mental health benefit parents as well their children
and can disrupt the intergenerational transfer of
inequities (Marmot Review Team, 2010). Long-term
Box 4. Evidence of microfinance supporting mental health in working age.

In South Africa, Fernald et al. (2008) demonstrated that small individual loans reduced depressive symptoms among men, but not
among women (Fernald et al., 2008). However, other studies have shown that microfinance interventions can improve the lives of
women, including their mental health.
The Intervention with Microfinance for Aids and Gender Equity (IMAGE), which combined group-based microfinance with a
gender and HIV/AIDS training programme, significantly reduced levels of interpersonal violence in villages taking part in the
intervention with direct benefits to interpersonal, familial, and wider social relations along with a reduction in violence (Jan et al.,
2011).
Type of microfinance repayment scheme influenced levels of anxiety among clients in India, with 51% less experience of anxiety
about repayment than clients on a weekly repayment scheme (Field et al., 2012).
Box 5. Evidence from South Africa on maternal depression.

Effective interventions in South Africa have reduced
maternal depression and improved child attachment and
interaction (Cooper et al., 2007).
The Mother2Mothers programme helped communities
develop peer support through education on how to access
existing healthcare services. As a result, new mothers
experienced more positive changes (Baek et al., 2007).

interventions can help throughout the vulnerable

periods of childhood and adolescence.
Intergenerational transfer of disadvantage
As mentioned above, the family-building stage is
related closely to the perinatal and early years and
intergenerational transfer of disadvantage and inequity which can lead to further disadvantages through
the perpetuation of disadvantage. See Fig. 2.
397
differences in depression and well-being among the

elderly (Grundy et al., 2013). The Scandinavian
countries appear to be best for older individuals as
they have the lowest rates of depression, whereas
Mediterranean countries such as Italy, Greece and
Spain show the highest levels of late-life depression.
This variation is related to levels of state provision
managing mental health and pensions (Grundy et al.,
2013). Interestingly, rates of depression among older
adults in Japan are lower than those among younger
adults (Donovan & Halpern, 2002); whether this can
be explained by attitudes to ageing and filial piety
needs further exploration.
Social isolation reflecting lack of social contact
and support can be a key factor in developing depression, especially in women; 10% or more older adults
are noted to be socially isolated, and loneliness in
older people has been linked to depressive symptoms, poor mental health and cognition, alcohol
dependence, suicidal ideation, and death (Grundy
et al., 2013).
Older ages
Not surprisingly, older peoples mental health is

influenced by earlier life experiences and also related
to experiences, conditions, and contexts specific to
ageing and the post-retirement period which may be
strongly influenced by cultural and social factors.
With this group too, there will be a social gradient
in mental disorders among older people. Certainly
in high-income countries, inequalities in older peoples mental health have been shown to be related to
socio-economic status, educational status, gender,
ethnicity, age, level of physical health (itself related
to cultural, social, and economic factors) (Allen,
2008; McCrone et al., 2008). These experiences
also vary by country, related to social, political,
and economic arrangements, and to levels of social
protection (Grundy et al., 2013). Cultural factors
and attitudes to ageing will also affect social
support.
Depressive mood in older men is related to chronic
ill-health, whereas for older women social factors
such as levels of isolation, contact with family, and
belonging to faith or other community groups play a
role (Grundy et al., 2013). Once again, higher levels
of education appear to be a protective factor, particularly for women (Ploubidis & Grundy, 2009).
Older individuals have a higher risk of developing
depression (McCrone et al., 2008). Indeed, life
events related to ageing such as bereavement and
loss, loss of status, poor physical health and poor
social contacts can all contribute to depression. The
Survey of Health, Ageing and Retirement in Europe
(SHARE study) noted that there are cross-national
It is apparent that interventions which help prolong

levels of activity and reduce social isolation will
help reduce depressive symptoms (Forsman et al.,
2011). Reducing social isolation, increasing exercise
and physical activity and lifelong learning programmes all help (see Box 6 for examples), along
with a reduction in financial poverty (Campion
et al., 2011). In cold climates, improving heating
in the house (Critchley et al., 2007, Green &
Gilbertson, 2008), help older people (Mead et al.,
2010), and opportunities for older to people to volunteer (Lum & Lightfoot, 2005) are effective tools.
Further work is required as a matter of urgency in
low and middle income countries.
Box 6. Examples of interventions supporting mental health

during older ages.
In Auckland, New Zealand, the Meeting of the Minds
was formed to promote positive ageing through a
coordinated cognitive activity programme. Using
libraries as a resource enabled people to socialize, share
accounts, and be involved in other social activities to
meet new people and develop social relationships
(Saxena & Garrison, 2004).
The Upstream Healthy Living Centre in the UK uses
mentors to deliver tailored activities and improve
social interaction, especially in rural settings, leading
to improved psychological well-being and reduced
depression (Greaves & Farbus, 2006) by reducing
social isolation.
398
J. Allen et al.

Community-level contexts
There is little doubt that the environment or communities in which people grow, live, work, and age
have considerable influence upon mental health.
These include both tangible aspects such as the natural and built environment, and intangible aspects
such as neighbourhood trust and safety. In addition,
geographical accessibility to primary care and community are also important.
We now describe three aspects of the community
context in detail: the natural and built environment,
primary healthcare, and humanitarian settings.
General approaches to addressing the social determinants of mental health in communities also exist
(see Box 7).
good mental health. Almost half the worlds population now live in urban areas away from natural environments and connections with nature (Haines et al.,
2007). Living close to natural environments and
engaging in outdoor activities such as walking, running, cycling and gardening reduces stress, anxiety
and depression (Barton et al., 2009; Maller et al.,
2009; Pretty et al., 2007) in addition to conferring
the mental health benefits of physical activity
(whether indoors or outdoors) (Coon et al., 2011).
Connecting with the natural environment benefits
mental health. Taking walks in parks improved concentration among children with ADHD, employee
mood and performance improved after the introduction of plants into offices (Grinde & Patil, 2009; Kuo
& Taylor, 2004; Mind, 2007; Shibata & Suzuki, 2002;
Taylor & Kuo, 2009).
The natural and built environment

The natural and built environment includes both
natural and human-made aspects of communities
and includes geography and climate, housing quality,
water and sanitation systems, air quality, and transportation systems. These factors affect direct and
indirect aspects of mental disorders and poor mental
health (Turley et al., 2013; Wright & Moos, 2007).
Overcrowding, for example, can lead to stress
and family violence, including child maltreatment,
intimate partner violence and sexual violence, and
elder abuse (ODPM, 2004; UN Centre for Human
Settlements, 1998).
A number of specific interventions such as water,
sanitation and waste management improvements,
energy infrastructure upgrades, new transport infrastructure, mitigation of environmental hazards, and
improved housing (Turley et al., 2013) can improve
mental health and functioning. Box 8 provides some
illustrations of the impact of housing upgrades on
mental health. Ease of access to the natural environment and outdoor spaces is also vitally important for
Primary healthcare
Primary healthcare should be the bed-rock of healthcare delivery, but different healthcare systems around
the globe will provide different types of primary care.
Primary healthcare has a significant role to play in
promoting good mental health through direct provision and referrals to other more specialized services
(Barry & Jenkins, 2007). Primary healthcare may
be the only source of healthcare available in many
countries, especially for people on low incomes
(Rojas et al., 2007), and only physical health needs
may be met (Patel et al., 2010b). Resources for mental health are in short supply in many countries
(Kakuma et al., 2013).
If healthcare is organized around peoples needs
and expectations and around the tenets of primary
healthcare, it can produce a higher level of health
for the same investment (WHO, 2008c). Uganda is
one country that has done so (Box 9). The Mental
Health and Poverty Projects in Mayuge, Uganda,
and KwaZulu-Natal, South Africa, through multisectorial community collaborations, task shifting,
and the development and support of self-help groups
were particularly promising methods to address the
Box 7. Examples of community-level interventions in Ghana, Kenya and India.

Self-help groups in northern Ghana have helped facilitate access to the psychological services offered by the Ghanaian Health
Service. These groups in their monthly meetings support each other by sharing tasks such as collecting wood and water, even
visiting homes to cook for people and providing financial credit if needed (Cohen et al., 2012).
In rural Kenya the BasicNeeds programme has also led to significant improvements in mental health, quality of life, social relations,
and economic functioning (Lund et al., 2013).
In India the Comprehensive Rural Health Project is a community-based intervention that integrates mental health into the primary
healthcare setting with a strong focus on women, addressing the social and economic determinants of health and educating
individuals. Using trained volunteers the intervention works with groups of women from the community to build competence and
self-esteem, and to increase perceptions of personal control. These changes in lifestyle and circumstance improved their mental
health (Kermode et al., 2007, 2009).

399
Box 8. Examples of the positive mental health effects of

housing upgrades.
Box 10. A community-based intervention to support

mental health in post-conflict Rwanda.
Simple changes such as demonstrated in Mexico, where

replacing dirt floors with concrete significantly improved
the health of children by reducing incidence of disease
and infection, was associated with cognitive improvement
among children, and reduced depression and stress
among adults (Cattaneo et al., 2009).
Dealing with fuel poverty in the UK led to a reduction
in depression, stress and anxiety among participants
(Critchley et al., 2007; Green & Gilbertson, 2008).
Over 800,000 people were killed with over 2 million

refugees as a result of the Rwandan conflict in 1994.
A community-based programme launched in 2006 in the
Byumba district of Rwanda used interactions between
individuals and their social environment to facilitate the
re-establishment of values, norms, and relationships
using education, sharing of experiences and stories and
coping. Over 7,000 individuals have participated and
their mental health has improved (Richters et al., 2008;
Scholte et al., 2011).
treatment gap in low income settings (Petersen

et al., 2011).
Mental health integration into primary healthcare
is important (WHO, 2001, 2009; WHO & World
Organization of Family Doctors, 2008); and a companion thematic paper from the WHO/Gulbenkian
mental health series (WHO, 2014) addresses this
topic in detail. In addition, WHOs Mental Health
Gap Action Programme (WHO, 2008a) provides
policy-makers, health planners, and other stakeholders with clear guidance on how to scale up mental
healthcare. One key principle is that to be effective,
primary health workers must be supported by secondary-level mental health specialists for supervision
and referrals.
Humanitarian settings
Man-made or natural disasters can lead to mental
disorders (Meffert & Ekblad, 2013; Tol et al., 2011).
In addition, those with pre-existing mental health
problems might experience worse symptoms, while
at the same time structures delivering the services are
under increased pressure (WHO, 2013a), and inevitably poorer and more marginalized members of
communities tend to experience the most adverse
effects (WHO, 2010). A humanitarian crisis, whether
Box 9. Primary healthcare in Uganda.

In 1999, the Ugandan Ministry of Health introduced a
number of national health policy reforms that included,
as one of the guiding principles, the inclusion of primary
healthcare in its strategy for national health
development. This Uganda National Minimum Health
Care Package, includes mental health as a key
component alongside the decentralization of mental
health services, thus improving health (Kigozi, 2007).
Service is provided by general health workers
(Ssebunnya et al., 2010).
war, conflict, floods or other disasters, affects individuals as well as communities and social institutions, leading to the breakdown of families, social
networks, and community bonds. It is vital that
any interventions take into account the actual social
environment as well as health and nutritional needs
(see Box 10).

WHO provides guidance and examples of good practice (WHO, 2013c).
Country-level contexts
It is inevitable that the current political, social, economic, and environmental milieu, and cultural and
social norms, as well as the historical context of a
country, shape the conditions in which people live.
Countries with few political freedoms, unstable
policy environments, and poorly developed services
create vulnerabilities among their populations, causing deleterious effects on mental health (Marmot
Review Team, 2010). Poverty puts people at an
increased risk of mental health problems through a
number of intermediary factors.
The impact of political, social, and economic turbulence on mental and physical health was powerfully demonstrated by the decline and subsequent
fluctuations in life expectancy in the Russian
Federation after the collapse of the Soviet Union
(Marmot et al., 2012). Deaths increased sharply
among middle-aged adults in the Russian Federation
from 1991 to 2001 (Men et al., 2003) possibly attributable to harmful use of alcohol (Leon et al., 2007).
Alcohol plays a major role in contributing to mental ill-health, and various strategies can be used to
manage this (see Box 11).
Across the former Soviet Union, psychological
distress has varied between and within countries.
Women have shown higher rates of distress than

400
J. Allen et al.
Box 11. Policies to reduce alcohol consumption.
Box 12. Active labour markets.
Alcohol consumption affects population mental health,

increasing the likelihood of alcohol dependence,
depression, and suicide, along with contributing to poor
physical health, accidental injury, and domestic violence
(Wahlbeck & McDaid, 2012).
Political debate and policy changes have been growing in
countries such as Australia, Malawi, the UK (England
and Scotland) and Zambia (Collins & Lapsley, 2008;
Scottish Parliament, 2012; UN Development Programme,
2013; Woodhouse & Ward, 2013).
Minimum alcohol pricing has become a major issue in
many countries. Evidence from British Columbia,
Canada shows that as a result of minimum alcohol
pricing over the last 20 years the price of alcohol has
been adjusted incrementally over time.
It has been estimated that a 10% increase in the
minimum price of an alcoholic drink reduced
consumption relative to other drinks by 16.1%, and
overall consumption of alcohol by 3.4% (Stockwell
et al., 2012).
Active labour market programmes have been used in

countries such as Denmark (Jespersen et al., 2008),
Sweden (Sianesi 2002), and specific states within the
USA and they take an active approach to getting people
back to work (Stuckler & Basu, 2013).
The Finnish programme promotes and facilitates
re-employment through training and support, and
participants showed significantly lower levels of depression
and increased levels of self-esteem, relative to a control
group, at two years (Vuori & Silvonen, 2005; Vuori et al.,
2002).
men with risk factors including poverty, unemployment, low education, disability, lack of trust in people, and lack of personal support (Roberts et al.,
2010). Across the Czech Republic, Poland, and
the Russian Federation too, depression has been
associated with social deprivation for both men
and women. Socio-economic circumstances have
been shown to be more strongly associated with
depression than early life experience or level of education (Nicholson et al., 2008).
Following the 2008 banking crisis, rates of unemployment rose sharply in the European Union as did
rates of suicide (Stuckler et al., 2011). Between
19702007, in 26 European countries, every 1%
increase in unemployment was associated with a
0.79% rise in suicides at ages younger than 65 years
(Stuckler et al., 2009). As mentioned above, it is well
known that unemployment is associated with an
increased risk of depression (Kaplan et al., 1987,
Kasl & Jones, 2000) and job insecurity is associated
with sub-optimal mental health (UCL IHE, 2012,
Virtanen et al., 2011).
Strong social welfare systems seem to offer protection against unemployment risks for mental
disorders. Over a 25-year period it was noted that
in comparing Spain and Sweden, in the former
there was a direct correlation between unemployment and suicide rates, but not in the latter, indicating that higher level of social spending on active
labour markets in Sweden (average labour market
protection US$362 per head) than in Spain ($88
per head)may have had an impact (Kasl & Jones,
2000).
Additional information about active labour markets is provided in Box 12.

Policy measures
Several high-income countries, including Australia,
New Zealand, and England and Scotland in the UK,
have incorporated a social determinants of mental
health approach into national policy and strategy
using a multisectoral approach.
It is self-evident that peoples mental health is influenced by a number of social, economic and environmental factors, therefore governments need to work
across different departments, integrating mental
health into a broad range of related policy areas.
Discussion
There is considerable research evidence to show
that social inequalities affect the publics mental
health, and urgent action is needed to improve the
conditions of daily life throughout the life-course.
Broader economic and political interventions have
shown successful influences on the mental health of
populations.
It is important to understand that good mental
health is a core indicator of human development,
and it is necessary to integrate a mental health and
psychosocial perspective into development and
humanitarian policies, programmes and services,
particularly internationally agreed goals and commitments (WHO & UN, 2010). The WHOs
Mental Health Action Plan 20132020 (WHO,
2013b) calls for integration of mental health issues
into multisectoral policies and laws, including education, employment, disability, the judicial system,
human rights protection, social protection, poverty
reduction and development.

Principles and actions

Proportionate universalism
A key principle to be taken forward from this paper
is proportionate universalism, which is derived from
the observation that mental health inequities affect
everyone, not only the poorest or most disadvantaged
in society. Thus actions must be universal, yet calibrated in proportion to the level of disadvantage;
hence the term proportionate universalism.
Proportionate universalism needs to be differentiated from targeted programmes and services, whereby
the most vulnerable or disadvantaged are singled out
for specialized interventions. These services may exclude the neediest individuals who for whatever reason
may not fulfil their inclusion criteria. Services for the
poor often become poor services and are easily ghettoized, reduced or stopped altogether because they
may not have the support of the whole population.
401
depression and disrupting intergenerational transmission of inequity.

Healthy mind and healthy body
A social determinants of health approach should consider both mental and physical health implications
within all actions to tackle health inequalities. Mental
and physical health conditions are fundamentally
inter-related: sharing many underlying causes and
overarching consequences, highly interdependent
and tend to co-occur, and they are best managed
using integrated approaches. Programmes aimed at
improving water and sanitation, reducing unemployment, or mitigating the effects of climate change and
increasing sustainability are likely to have a positive
impact on both mental and physical health while
addressing health inequities.
Action across sectors
Prioritizing mental health
As explained above, successful interventions on the

social determinants of mental health result from action
across multiple sectors and levels, for instance health,
education, judicial, employment, welfare, transport,
and housing sectors. Effective leadership is essential
to inspire and make the case, and to drive through
the necessary negotiations. Multisectoral coordination
is also needed outside of government, with potential
participation and cooperation of international organizations, non-governmental organizations, social institutions and service providers, community and
voluntary groups, and the private sector.
Mental health needs to be given greater priority

across the world, but especially in low and middle
income countries, where the issue is often poorly
understood and/or not recognized as a major health
concern. Increased awareness and understanding of
mental health should be followed urgently by
increased allocations of appropriate and sufficient
financial, medical, and human resources towards
tackling mental disorders and reducing inequalities.
Life-course approach
The interplay of risk and protective factors changes
over the life cycle; interventions and strategies must
therefore be appropriate to different stages of life.
Therefore, taking a life-course perspective recognizes
that exposure to advantage and disadvantage at each
stage of life has the potential to influence mental
health in both the short term and long term. Hence,
in many cases, organizations in which people are
typically involved at different stages of life (e.g.
schools, employers) are the most appropriate settings
to deliver interventions.
Avoiding short-termism
Short-term thinking often obstructs progress. Thus
long-term interventions are needed which will include
community development, capacity-building, partnerships, and local institution-building across the
life-course.
Mental health equity in all policies
Reducing inequalities in mental health is a task that
must be taken on by the whole of government and
across all sectors. It is important that all policies
across all sectors do no harm to population mental
health, but rather, reduce mental health inequities.
Knowledge for action at the local level
Early intervention
Every child deserves to have the best possible
start in life. Interventions at the earliest stages of a
childs life can prevent both short- and long-term
mental disorders and enable them to maximize their
potential and a healthy adulthood. Early intervention strategies are also useful in reducing maternal
Information systems and processes are needed at

local levels to inform action. Different kinds of information are needed depending on the intended action,
but include:
Information on the distribution of mental disorders at the local level

402
J. Allen et al.
Information on how many of those with mental

disorders have access to effective therapeutic
treatment, and on the unmet need for therapy i.e.
what the mental health gap is
Information about social, economic, and environmental stressors explored and understood through
community engagement
Knowledge of local assets and resources, including how local social, economic, and environmental factors contribute to or reduce psychological
distress, understanding both precipitating and
protective factors
Triangulated knowledge about local assets and
resources, and interventions that have worked in
other settings and the lessons as well as strengths
and weaknesses of each approach
Assessments of all local development initiatives
with respect to their potential impact on mental
health equity (how different groups might be
impacted), especially those with mental disorders
Synergies between interventions: information
about how mental health and its social distribution are influenced by interventions to improve
aspects of the local educational services, healthcare services, built environment, natural environment, transport, income generating opportunities,
and community development
(UN, 2000), progress towards these goals contributes powerfully to mental health promotion. In preparation for the 2015 expiry date of the MDGs, the
United Nations (UN) is in the process of consultation and planning for the next phase of post-2015
sustainable human development (post-2015 agenda),
leading on from existing unfinished MDGs and the
Rio 20 environmental sustainability agenda (UN,
2012).
Embedding the social determinants of health
approach (UN Platform on Social Determinants of
Health, 2013) and universal health coverage (WHO,
2013f) in the post-2015 agenda would create a transformative development framework for health. Specific inclusion of mental health is also necessary
(Minas & Kwasik, 2013). The Movement for Global
Mental Health, a network of individuals and organizations aiming to improve services for people with
mental disorders, calls for three elements to be
included in the post-2015 agenda (Movement for
Global Mental Health, 2013): protecting human
rights and preventing discrimination against people
with mental disorders, bridging the massive mental
health treatment gap and improving access to health
and social care, and explicitly integrating mental
health into development initiatives.
Such information can lead to action at the local

level. Ideally, national-level strategies should provide
the framework and support for local-level action.
For local-level action to be effective and sustainable
over the longer term, country-wide strategies must
be implemented to tackle deep-rooted structural
issues arising from the unequal distribution of
power, money, and resources.
Conclusions
Country-wide strategies
Country-level strategies are likely to have a significant impact on reducing mental health inequalities
and have the greatest potential to reach large populations. These include the alleviation of poverty and
effective social protection across the life-course,
reduction of inequalities and discrimination, prevention of war and violent conflict, and promotion of
access to employment, healthcare, housing, and education. Particular emphasis should be given to policies relating to the treatment of maternal depression,
early childhood development, targeting families of
people with mental disorders in poverty alleviation
programmes, social welfare for the unemployed, and
alcohol policies. These are areas that have particularly strong associations with mental disorders and
have a clear social gradient.
Although mental health was not mentioned explicitly in the Millennium Development Goals (MDGs)
In this paper we have outlined how mental health

and many common mental disorders are shaped by
the social, economic and physical environments and
social gradient in which people live and work. Risk
factors for many common mental disorders are heavily associated with social inequalities, whereby the
greater the social inequality the higher the risk. The
poor and disadvantaged suffer disproportionately,
but everyone in society is affected to an extent.
People are made vulnerable to mental ill-health by
deep-rooted poverty, social inequality, and discrimination. Social arrangements and institutions, such as
education, social care, healthcare and work, also
have a considerable impact on mental health, for
better or for worse. To reduce inequities and promote good mental health, it is vital that action is
taken to improve the conditions of everyday life,
beginning before birth and progressing into early
childhood, older childhood and adolescence, during
family-building and working ages, and through to
older age. Not only must such action be throughout
these life stages, but also across various sectors
within and outside the country, which will provide
opportunities for both improving population
mental health, and for reducing risk of those mental
disorders that are associated with social inequalities.
As mental disorders are fundamentally linked to a
number of other physical health conditions, these

actions would also reduce inequalities in physical
health and improve health overall.
The evidence is convincing that policy-making at
all levels of governance and across sectors can make
a positive difference to mental health outcomes.
Action needs to be universal, across the whole of
society and proportionate to need. Empowerment of
individuals and communities is at the heart of action
on social determinants.

Acknowledgements
This paper is an edited and abridged version of the
report: World Health Organization and Calouste Gulbenkian Foundation. Social determinants of mental
health. Geneva, World Health Organization, 2014.
http://www.who.int/mental_health/publications/
gulbenkian_paper_social_determinants_of_mental_
health/en/ accessed 8th July 2014. Material in this
article has been republished with permission from
WHO.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References
Allen, J. (2008). Older People and Wellbeing. London: Institute for
Public Policy Research.
Anderson, P., McDaid, D., Basu, S., & Stuckler, D. (2011). Impact
of Economic Crises on Mental Health. Copenhagen: WHO European Office.
Baek, C., Mathambo, V., Mkhize, S., Friedman, I., Apicella, L., &
Rutenberg, N. (2007). Key Findings from an Evaluation of
the Mothers2Mothers Program in Kwa-Zulu-Natal, South Africa:
Horizons Final Report. Washington, DC: Population Council.
Baker-Henningham, H., Powell, C., Walker, S., &
Grantham-McGregor, S. (2005). The effect of early stimulation
on maternal depression: A cluster randomised controlled trial.
Archives of Disease in Childhood, 90, 12301234.
Bambra, C. (2010). Yesterday once more? Unemployment
and health in the 21st century. Journal of Epidemiology and
Community Health, 64, 213215.
Bambra, C., Egan, M., Thomas, S., Petticrew, M., &
Whitehead, M. (2007). The psychosocial and health effects
of workplace reorganisation. 2. A systematic review of task
restructuring interventions. Journal of Epidemiology and Community Health, 61, 10281037.
Barry, M.M. (2009). Addressing the determinants of positive
mental health: Concepts, evidence and practice. International
Journal of Mental Health Promotion, 11, 417.
Barry, M.M. (2013). Promoting positive mental health and
well-being: Practice and policy. In C. L. Keyes (Ed.), Mental
Well-Being: International Contributions to the Study of Positive
Mental Health. London: Springer.
Barry, M.M., & Jenkins, R. (2007). Implementing Mental Health
Promotion. Oxford: Churchill Livingstone Elsevier.
Barton, J., Hine, R., & Pretty, J. (2009). The health benefits
of walking in greenspaces of high natural and heritage value.
Journal of Integrative Environmental Sciences, 6, 261278.
403
Belfield, C.R., Nores, M., Barnett, S., & Schweinhart, L. (2006).

The High/Scope Perry Preschool Program: Cost-benefit Analysis Using Data from the Age-40 Followup. The Journal of
Human Resources, 41(1), 162190.
Bell, R., Donkin, A., & Marmot, M. (2013). Tackling Structural
and Social Issues to Reduce Inequalities in Childrens Outcome in
Low and Middle Income Countries. Florence: Office of Research,
UNICEF.
Bicego, G.T., & Boerma, J.T. (1993). Maternal education and
child survival: A comparative study of survey data from 17
countries. Social Science and Medicine, 36, 12071227.
Bodenmann, G., Cina, A., Ledermann, T., & Sanders, M.R.
(2008). The efficacy of the Triple P Positive Parenting
Program in improving parenting and child behaviour: A
comparison with two other treatment conditions. Behaviour
Research and Therapy, 46, 411427.
Campion, J. (2013). Public mental health: The local tangibles.
Psychiatrist, 37, 238243.
Campion, J., Bhugra, D., Bailey, S., & Marmot, M. (2013).
Inequality and mental disorders: opportunities for action.
Lancet, 382(9888), 183184.
Campion, J., Bhui, K., & Bhugra, D. (2011). European
Psychiatric Association (EPA) guidance on prevention of
mental disorders. European Psychiatry, 27, 6880.
Case, A., Fertig, A., & Paxson, C. (2005). The lasting impact
of childhood health and circumstance. Journal of Health
Economics, 24, 365389.
Casey, B.J., Jones, R.M., & Hare, T.A. (2008). The adolescent brain.
Annals of the New York Academy of Sciences, 1124, 111126.
Catalano, R., Goldman-Mellor, S., Saxton, K., Margerison-Zilko,
C., Subbaraman, M., LeWinn, K., & Anderson, E. (2011). The
health effects of economic decline. Annual Review of Public
Health, 32, 431450.
Cattaneo, M.D., Galiani, S., Gertler, P.J., Martinez, S., &
Titiunik, R. (2009). Housing, health, and happiness. American
Economic Journal: Economic Policy, 1, 75105.
Cohen, A., Raja, S., Underhill, C., Yaro, B.P., Dokurugu, A.Y.,
De Silva, M., & Patel, V. (2012). Sitting with others: Mental
health self-help groups in northern Ghana. International Journal
of Mental Health Systems, 6, 18.
Collins, D.J., & Lapsley, H.M. (2008). The Avoidable Costs of
Alcohol Abuse in Australia and the Potential Benefits of Effective
Policies to Reduce the Social Costs of Alcohol. Barton, ACT: Commonwealth of Australia.
Collins, S., Woolfson, L.M., & Durkin, K. (2014). Effect on
coping skills and anxiety of a universal school-based mental
health intervention delivered in Scottish primary schools. School
Psychology International, 35, 116.
Commission on Social Determinants of Health. (2008). Closing the
Gap in a Generation Health Equity Through Action on the Social
Determinants of Health. Geneva: World Health Organization.
Coon, J.T., Boddy, K., Stein, K., Whear, R., Barton, J., & Depledge,
M.H. (2011). Does participating in physical activity in outdoor
natural environments have a greater effect on physical and mental wellbeing than physical activity indoors? A systematic review.
Environmental Science and Technology, 45, 17611772.
Cooper, P.J., Tomlinson, M., Swartz, L., Landman, M.,
Molteno, C., Stein, A. Murray, L. (2007). Improving quality
of motherinfant relationship and infant attachment in socioeconomically deprived community in South Africa: Randomised
controlled trial. BMJ, 338, 18.
Critchley, R., Gilbertson, J., Grimsley, M., & Green, G. (2007).
Living in cold homes after heating improvements: Evidence
from Warm-Front, Englands Home Energy Efficiency Scheme.
Applied Energy, 84, 147158.
Donovan, N., & Halpern, D. (2002). Life Satisfaction: The State
of Knowledge and Implications for Government. London: Cabinet
Office.

404
J. Allen et al.
Egan, M., Bambra, C., Thomas, S., Petticrew, M., Whitehead, M.,
& Thomson, H. (2007). The psychosocial and health effects of
workplace reorganisation. 1. A systematic review of organisationallevel interventions that aim to increase employee control. Journal
of Epidemiology and Community Health, 61, 945954.
Fernald, L.C.H., Hamad, R., Karlan, D., Ozer, E.J., & Ziman, J.
(2008). Small individual loans and mental health: A randomized controlled trial among South African adults. BMC Public Health, 8, 114.
Field, E., Pande, R., Papp, J., & Park, Y.J. (2012). Repayment
flexibility can reduce financial stress: A randomized control trial
with microfinance clients in India. PLoS ONE, 7, 17.
Fisher, J., de Cabral, M.M., Patel, V., Rahman, A., Tran, T.,
Holton, S., & Holmes, W. (2012). Prevalence and determinants
of common perinatal mental disorders in women in low- and
lower-middle-income countries: A systematic review. Bulletin of
the World Health Organization, 90, 139G149G.
Forsman, A.K., Nordmyr, J., & Wahlbeck, K. (2011). Psychosocial
interventions for the promotion of mental health and the
prevention of depression among older adults. Health Promotion
International, 26, S85107.
Fryers, T., & Brugha, T. (2013). Childhood determinants of
adult psychiatric disorder. Clinical Practice and Epidemiology in
Mental Health, 9, 150.
Fryers, T., Melzer, D., Jenkins, R., & Brugha, T. (2005). The distribution of the common mental disorders: Social inequalities
in Europe. Journal of Public Mental Health, 1, 14.
Gleason, M.M., Zamfirescu, A., Egger, H.L., Nelson, C.A.,
Fox, N.A., & Zeanah, C.H. (2011). Epidemiology of psychiatric
disorders in very young children in a Romanian pediatric setting. European Child and Adolescent Psychiatry, 20, 527535.
Goff , J., Hall, J., Sylva, K., Smith, T., Smith, G., Eisenstadt, N.,
Chu, K. (2013). Evaluation of Childrens Centres in England
(ECCE). Strand 3: Delivery of Family Services by Childrens
Centres. Oxford: The University of Oxford.
Greaves, C.J., & Farbus, L. (2006). Effects of creative and social
activity on the health and wellbeing of socially isolated older
people: Outcomes from a multi-method observational study.
Journal of the Royal Society for the Promotion of Health, 126,
134142.
Green, G., & Gilbertson, J. (2008). Warm Front Better Health.
Health Impact Evaluation of the Warm Front Scheme. Sheffield
Hallam University: Centre for Regional, Economic Research.
Grinde, B., & Patil, G.G. (2009). Biophilia: Does visual contact
with nature impact on health and well-being? International Journal of Environmental Research and Public Health, 6, 23322343.
Grundy, E., van Campen, C., Deeg, D., Dourgnon, P.,
Huisman, M., Ploubidis, G., Tsimbos, C. (2013). Task group
on older people. Health inequalities and the health divide
among older people in the WHO European Region. Copenhagen, WHO Regional Office for Europe.
Haines, A., Smith, K.R., Anderson, D., Epstein, P.R.,
McMichael, A.J., Roberts, I. Woods, J. (2007). Policies for
accelerating access to clean energy, improving health, advancing
development, and mitigating climate change. Lancet, 370(9594),
12641281.
Hanlon, P., Walsh, D., & White, B. (2006). Let Glasgow Flourish.
Glasgow: Centre for Population Health.
Holen, S., Waaktaar, T., Lervag, A., & Ystgaard, M. (2012). The
effectiveness of a universal school-based programme on coping
and mental health: A randomised controlled study of Zippys
Friends. Educational Psychology, 32, 657677.
Incredible Years. (2013). The Incredible Years website. Retrieved
from http://incredibleyears.com/about/
Jan, S., Ferrari, G., Watts, C.H., Hargreaves, J.R., Kim, J.C.,
Phetla, G., Pronyk, P.M. (2011). Economic evaluation of a
combined microfinance and gender training intervention for
prevention of intimate partner violence in rural South Africa.
Health Policy Plan, 26, 366372.
Jane-Llopis, E., & Anderson, P. (2006). Mental Health Promotion

and Mental Disorder Prevention Across European Member States.
Luxembourg: European Communities.
Jane-Llopis, E., & Barry, M.M. (2005). What makes mental health
promotion effective? Global Health Promotion, 12, S4754.
Jenkins, R., Bhugra, D., Bebbington, P., Brugha, T., Farrell, M.,
Coid, J., Meltzer, H. (2008). Debt, income and mental disorder
in the general population. Psychological Medicine, 38, 14851493.
Jensen, B.B., Currie, C., Dyson, A., Eisenstadt, N., &
Melhuish, E. (2013). Early Years, Family and Education Task
Group: Report. European Review of Social Determinants of
Health and the Health Divide in the WHO European Region.
Copenhagen: World Health Organization.
Jespersen, S., Munch, J.R., & Skipper, L. (2008). Costs and
benefits of Danish active labour market programmes. Labour
Economics, 15, 859884.
Joint Commissioning Panel for Mental Health. (2013). Guidance
for Commissioning Public Mental Health Services Practical
Mental Health Commissioning. London: Author.
Kakuma, R., Minas, H., van Ginneken, N., Dal Poz, M.R.,
Morris, J.E., Saxena, S., & Scheffler, R.M. (2013). Human
resources for mental health care: Current situation and strategies for action. Lancet, 378, 16541663.
Kaplan, G.A., Roberts, R.E., Camacho, T.C., & Coyne, J.C.
(1987). Psychosocial predictors of depression: Prospective
evidence from the human population laboratory studies.
American Journal of Epidemiology, 125, 206220.
Kasl, S.V., & Jones, B.A. (2000). The impact of job loss and retirement on health. In L.F. Berkman & I. Kawachi (Eds.) Social
Epidemiology, Oxford: Oxford University Press.
Katz, C., Bolton, S., Katz, L.Y., Isaak, C., Tilston-Jones, T., &
Sareem, J. (2013). A systematic review of school-based suicide
prevention programs. Depression and Anxiety, 30(10), 10301045.
Kelly, Y., Sacker, A., Del, B.E., Francesconi, M., & Marmot, M.
(2011). What role for the home learning environment and
parenting in reducing the socioeconomic gradient in child
development? Findings from the Millennium Cohort Study.
Archives of Disease in Childhood, 96(9), 832837.
Kermode, M., Bowen, K., Arole, R., Joag, K., & Jorm, A.F.
(2009). Community beliefs about treatments and outcomes
of mental disorders: A mental literacy survey in a rural area of
Maharashtra, India. Public Health, 123, 476483.
Kermode, M., Herrman, H., Arole, R., White, J., Premkumar, R.,
& Patel, V. (2007). Empowerment of women and mental health
promotion: Qualitative study in rural Maharashtra, India. BMC
Public Health, 7, 110.
Kessler, R.C., McLaughlin, K.A., Green, J.G., Gruber, M.J.,
Sampson, N.A., Zaslavsky, A.M., Williams, D.R. (2010).
Childhood adversities and adult psychopathology in the
WHO Mental Health Surveys. British Journal of Psychiatry, 197,
378385.
Keyes, C.L. (2005). Mental illness and/or mental health? Investigating axioms of the complete state model of health. Journal of
Consulting and Clinical Psychology, 7, 539548.
Kieling, C., Baker-Henningham, H., Belfer, M., Conti, G., Ertem,
I., Omigbodun, O., Rahman, A. (2011). Child and adolescent mental health worldwide: Evidence for action. Lancet, 378,
15151525.
Kigozi, F. (2007). Integrating mental health into primary health
care Ugandas experience. South African Psychiatry Review,
10, 1719.
Kitzman, H.J., Olds, D.L., Cole, R.E., Hanks, C.A., Anson, E.A.,
Arcoleo, K.J, Holmberg, J.R. (2010). Enduring effects of
prenatal and infancy home visiting by nurses on children.
Archives of Pediatrics and Adolescent Medicine, 164, 412418.
Knapp, M., McNaid, D., & Parsonage, M. (2011). Mental Health
Promotion and Prevention: The Economic Case. London: Personal
Social Services Research Unit, London School of Economics
and Political Science.


Kuo, F.E., & Taylor, A.F. (2004). A potential natural treatment for
attention-deficit/hyperactivity disorder: Evidence from a national
study. American Journal of Public Health, 94, 15801586.
Leatherman, S., Metcalfe, M., Geissler, K., & Dunford, C. (2012).
Intergrating microfinance and health strategies: Examining the
evidence to inform policy and practice. Health Policy and Planning,
27, 85101.
Lemstra, M., Neudorf , C., DArcy, C., Kunst, A., Warren, L.M.,
& Bennett, N.R. (2008). A systematic review of depressed mood
and anxiety by SES in youth aged 1015 years. Canadian Journal of Public Health, 9, 125129.
Leon, D.A., Saburova, L., Tomkins, S., Andreev, E., Kiryanov, N.,
McKee, M., & Shkolnikov, V.M. (2007). Hazardous alcohol
drinking and premature mortality in Russia: A population based
case-control study. Lancet, 369(9587), 20012009.
Leung, C., Sanders, M.R., Leung, S., Mak, R., & Lau, J. (2003).
An outcome evaluation of the implementation of the Triple P
Positive Parenting Program in Hong Kong. Family Process, 42,
531544.
Lum, T.Y., & Lightfoot, E. (2005). The effect of volunteering on
the physical and mental healh of older people. Research on
Aging, 27, 3155.
Lund, C., Breen, A., Flisher, A., Kakuma, R., Corrigall, J.,
Joska, J., ... Patel, V. (2010). Poverty and common mental disorders in low and middle income countries: A systematic review.
Social Science and Medicine, 71, 517528.
Lund, C., Waruguru, M., Kingori, J., Kippen-Wood, S.,
Breuer, E., Mannarath, S., & Raja, S. (2013). Outcomes of the
mental health and development model in rural Kenya: A 2-year
prospective cohort intervention study. International Health, 5,
4350.
Maller, C.J., Henderson-Wilson, C., & Townsend, M. (2009). Rediscovering nature in everyday settings: Or how to create healthy
environments and healthy people. EcoHealth, 6, 553556.
Marmot, M., Allen, J., Bell, R., Bloomer, E., & Goldblatt, P.
(2012). WHO European review of social determinants of health
and the health divide. Lancet, 380, 10111029.
Marmot Review Team. (2010). Fair Society, Healthy Lives: Strategic
Review of Health Inequalities in England Post-2010. Retrieved
from www.instituteofhealthequity.org
Mart, A., Dusenbury, L., & Weissberg, R.P. (2011). Social,
emotional, and academic learning: complementary goals for
schoolfamily partnerships. In M. Redding, M. Murphy &
P. Sheley (Eds), Handbook on Family and Community.
Lincoln, IL: Academic Development Institute.
Matsumoto, Y., Sofronoff , K., & Sanders, M.R. (2007). The
efficacy of the Triple P Positive Parenting Program with
Japanese parents. Behaviour Change, 24(4), 205218.
McCrone, P., Dhanasiri, S., Patel, A., Knapp, M., &
Lawton-Smith, S. (2008). Paying the Price: The Cost of Mental
Health Care in England to 2026. London: Kings Fund.
McManus, S., Meltzer, H., Brugha, T., Bebbington, P., &
Jenkins, R. (2007). Adult Psychiatric Morbidity in England,
2007. Leeds: NHS Information Centre for Health and Social
Care.
Mead, N., Lester, H., Chew-Graham, C., Gask, L., & Bower, P.
(2010). Effects of befriending on depressive symptoms and
distress: Systematic review and meta-analysis. British Journal
of Psychiatry, 196, 96101.
Meffert, S., & Ekblad, S. (2013). Global mental health intervention research and mass trauma. Open Access Journal of Clinical
Trials, 5, 6169.
Melzer, D., Fryers, T., & Jenkins, R. (2004). Social Inequalities
and the Distribution of Common Mental Disorders. Maudsley
Monographs. Hove: Psychology Express.
Melzer, D., Fryers, T., Jenkins, R., Brugha, T., & McWilliams, B.
(2003). Social position and the common mental disorders with
disability: Estimates from the National Psychiatric Survey of
405
Great Britain. Social Psychiatry and Psychiatric Epidemiology, 38,

238243.
Men, T., Brennan, P., Boffetta, P., & Zaridze, D. (2003). Russian
mortality trends for 19912001: Analysis by cause and region.
British Medical Journal, 327, 964.
Minas, H., & Kwasik, J. (2013). The Post-2015 Development Agenda.
Retrieved from http://www.globalmentalhealth.org/post-2015development-agenda
Mind. (2007). Ecotherapy The Green Agenda for Mental Health.
London: Mind.
Ministry of Health. (2005). Te Tahuhu Improving Mental Health
20052015:The Second New Zealand Mental Health and Addiction
Plan. Wellington: Ministry of Health.
Movement for Global Mental Health. (2013). Position Statement
on Mental Health in the Post-2015 Development Agenda,
Retrieved
from
http://www.globalmentalhealth.org/sites/
default/files/MGMH%20Position%20Statement_Post2015%20Development%20Agenda.pdf
Nicholson, A., Pikhart, H., Pajak, A., Malyutina, S., Kubinova, R.,
Peasey, A., Marmot, M. (2008). Socioeconomic status over
the life-course and depressive symptoms in men and women in
Eastern Europe. Journal of Affective Disorders, 105, 125136.
Nussbam, M.C. (2003). Capabilities as fundamental entitlements:
Sen and social justice. Feminist Economics, 9, 3359.
ODPM. (2004). The Impact of Overcrowding on Health and Education: A Review of Evidence and Literature. London: Office of the
Deputy Prime Minister.
Oladeji, B.D., Makanjuola, V.A., & Gureje, O. (2010). Family-related
adverse childhood experiences as risk factors for psychiatric disorders in Nigeria. British Journal of Psychiatry, 196, 189191.
Patel, V., & Kleinman, A. (2003). Poverty and common mental
disorders in developing countries. Bulletin of the World Health
Organization, 81, 609615.
Patel, V., Lund, C., Hatheril, S., Plagerson, S., Corrigall, J.,
Funk, M., & Flisher, A.J. (2010a). Mental disorders: Equity and
social determinants. In E. Blas & A.S. Kurup (Eds.) Equity,
Social Determinants and Public Health Programmes (pp. 115134).
Geneva: World Health Organization.
Patel, V., Weiss, H.A., Chowdhary, N., Naik, S., Pednekar, S.,
Chatterjee, S., Kirkwood, B. (2010b). Effectiveness of an intervention led by lay health counsellors for depressive and anxiety
disorders in primary care in Goa, India (MANAS): A cluster
randomised controlled trial. Lancet, 376(9758), 20862095.
PATH. (2011). Microfinance and womens health: What do we
know? Outlook, 28, 18.
Patten, S.B. (1991). Are the Brown and Harris vulnerability
factors risk factors for depression? Journal of Psychiatry and
Neuroscience, 16(5), 267271.
Payton, J., Weissberg, R.P., Durlak, J.A., Dymnicki, A.B.,
Taylor, R.D., Schellinger, K.B., & Pachan, M. (2008). Emotional
Learning for Kindergarten to Eighth-Grade Students: Findings
from Three Scientific Reviews. Chicago, IL: Collaborative for
Academic, Social, and Emotional Learning.
Petersen, I., Ssebunnya, J., Bhana, A., & Baillie, K. (2011).
Lessons from case studies of integrating mental health into
primary health care in South Africa and Uganda. International
Journal of Mental Health Systems, 5, 8.
Ploubidis, G., & Grundy, E. (2009). Later-life mental health in
Europe: A country-level comparison. Journals of Gerontology Series
B: Psychological Sciences and Social Sciences, 64B, 666676.
Pretty, J., Peacock, J., Hine, R., Sellens, M., South, N., &
Griffin, M. (2007). Green exercise in the UK countryside:
Effects on health and psychological well-being, and implications for policy and planning. Journal of Environmental Planning
and Management, 50, 211231.
Rahman, A., Fisher, J., Bower, P., Luchters, S., Tran, T.,
Yasamy, M.T., Saxena, S., & Waheed, W. (2013). Interventions
for common perinatal mental disorders in women in low- and

406
J. Allen et al.
middle-income countries: A systematic review and meta-analysis.

Bulletin of the World Health Organization, 91(8), 593601.
Rahman, A., Patel, V., Maselko, J., & Kirkwood, B. (2008). The
neglected m in MCH programmes Why mental health of
mothers is important for child nutrition. Tropical Medicine and
International Health, 13, 579583.
Richters, A., Dekker, C., & Scholte, W.F. (2008). Community based
sociotherapy in Byumba, Rwanda. Intervention, 6, 100116.
Roberts, B., Abbott, P., & McKee, M. (2010). Levels and determinants of psychological distress in eight countries of the former
Soviet Union. Journal of Public Mental Health, 9, 1726.
Rojas, G., Fristch, R., Solic, J., Jadresic, E., Castillo, C., Gonzalez,
M., Araya, R. (2007). Treatment of postnatal depression in
low-income mothers in primary-care clinics in Santiago, Chile: A
randomised controlled trial. Lancet, 370(9599), 1016.
Sanders, M.R., Ralph, A., Sofronoff , K., Gardiner, P.,
Thompson, R., Dwyer, S., & Bidwell, K. (2008). Every family:
A population approach to reducing behavioural and emotional
problems in children making the transition to school. Journal
of Primary Prevention, 29, 197222.
Saxena, S., & Garrison, P. (2004). Mental Health Promotion Case
Studies from Countries. Geneva: World Health Organization.
Schady, N. (2011). Parents education, mothers vocabulary, and cognitive development in early childhood: Longitudinal evidence from
Ecuador. American Journal of Public Health, 101, 22992307.
Scholte, W.F., Verdiun, F., Kamperman, A.M., Rutayisire, T.,
Zwinderman, A.H., & Stronks, K. (2011). The effect on mental
health of a large scale psychosocial intervention for survivors of
mass violence: A quasi-experimental study in Rwanda. PLoS
ONE, 6(8), 18.
Scottish Government. (2012). Mental Health Strategy for Scotland:
20122015. Edinburgh: Scottish Government.
Scottish Parliament. (2012). Alcohol (Minimum Pricing) (Scotland)
Act. Norwich: TSO. Retrieved from http://www.legislation.gov.
uk/asp/2012/4/pdfs/asp_20120004_en.pdf
Sen, A. (1992). Inequality Reexamined, Oxford: Oxford University
Press.
Sen, A. (1997). From income inequality to economic inequality.
Southern Economic Journal, 64(2), 384401.
Shibata, S., & Suzuki, N. (2002). Effects of the foliage plant on
task performance and mood. Journal of Environmental Psychology,
22, 265272.
Sianesi, B. (2002). Swedish Active Labour Market Programmes in the
1990s: Overall Effectiveness and Differential Performance. London:
Institute of Fiscal Studies.
Ssebunnya, J., Kigozi, F., Kizza, D., & Ndyanabangi, S. (2010).
Integration of mental health into primary health care in
a rural district in Uganda. African Journal of Psychiatry, 13,
128131.
Stockwell, T., Auld, M.C., Zhao, J., & Martin, G. (2012). Does
minimum pricing reduce alcohol consumption? The experience
of a Canadian province. Addiction, 107, 912920.
Stuckler, D., & Basu, S. (2013). The Body Economy:Why Austerity
Kills, New York: Allen Lane.
Stuckler, D., Basu, S., Suhrcke, M., Coutts, A., & McKee, M.
(2009). The public health effect of economic crises and alternative policy responses in Europe: An empirical analysis. Lancet,
374(9686), 315323.
Stuckler, D., Basu, S., Suhrcke, M., Coutts, A., & McKee, M.
(2011). Effects of the 2008 recession on health: A first look at
European data. Lancet, 378(9786), 124125.
Sun, J., Buys, N., & Wang, X. (2013). Effectiveness in privately
owned enterprises in China. Population Health Management, 16,
19.
Surkan, P.J., Kennedy, C.E., Hurley, K.M., & Black, M.M. (2011).
Maternal depression and early childhood growth in developing
countries: Systematic review and meta-analysis. Bulletin of the
World Health Organization, 89, 608615.
Taylor, A.F., & Kuo, F.E. (2009). Children with attention deficits
concentrate better after walk in the park. Journal of Attention
Disorders, 12(5), 402409.
Tehrani-Doost, M., Shahrivar, Z., Gharaie, J.M., &
Alghband-Rad, J. (2009). Efficacy of positive parenting on
improving childrens behavior problems and parenting styles.
Iranian Journal of Psychiatry and Clinical Psychology, 14(4),
371379.
Tol, W.A., Barbui, C., Galappatti, A., Silove, D., Betancourt, T.S.,
Souza, R., ... van Ommeren, M. (2011). Mental health and
psychological support in humanitarian settings: Linking practice and research. Lancet, 378(9802), 15811591.
Tol, W.A., Komproe, I.H., Jordans, M.J.D., Vallipuram, A.,
Spisma, H., Sivoyokan, S., De Jong, J.T.V.M. (2012). Outcomes and moderators of a preventive school-based mental
health intervention for children affected by war in Sri Lanka:
A cluster randomised trial. World Psychiatry, 11, 114122.
Tol, W.A., Komproe, I.H., Susanty, D., Jordans, M.J.D.,
Macy, R.D., & De Jong, J.T.V.M. (2008). School-based mental
health intervention for children affected by political violence in
Indonesia A cluster randomized trial. Journal of the American
Medical Association, 300, 655662.
Turley, R., Saith, R., Bhan, N., Rehfuess, E., & Carter, B. (2013).
Slum upgrading strategies involving physical environment
and infrastructure interventions and their effects on health and
socio-economic outcomes. Cochrane Database of Systematic
Reviews, 1, CD010067.
UCL IHE. (2012). The Impact of the Economic Downturn and Policy
Changes on Health Inequalities in London. London: UCL IHE.
UN. (2000). United Nations Millennium Declaration. Retrieved
from http://www.un.org/millennium/declaration/ares552e.htm
UN. (2012). Report of the United Nation Conference on Sustainable
Development. New York: United Nations.
UN Centre for Human Settlements. (1998). Crowding and Health in
Low-Income Settlements of Guinea Bissau. Nairobi: UN-Habitat.
UN Development Programme. (2013). Addressing the Social
Determinants of Noncommunicable Diseases. New York: United
Nations.
UN Platform on Social Determinants of Health. (2013). Health
in the post-2015 development agenda: Need for a social determinants
of health approach: Joint statement of the UN Platform on Social
Determinants of Health. Geneva: World Health Organization.
Virtanen, M., Kawachi, I., Oksanen, T., Salo, P., Tuisku, K.,
Pulkki-Raback, L., Kivimaki, M. (2011). Socio-economic
differences in long-term psychiatric work disability: Prospective
cohort study of onset, recovery and recurrence. Occupational
and Environmental Medicine, 68, 791798.
Vuori, J., & Silvonen, J. (2005). The benefits of a preventive job
search program on re-employment and mental health at 2-year
follow-up. Journal of Occupational and Organizational Psychology,
78, 4352.
Vuori, J., Silvonen, J., Vinokur, A.D., & Price, R.H. (2002). The
Tyhn job search program in Finland: Benefits for the unemployed with risk of depression or discouragement. Journal of
Occupational Health Psychology, 7, 519.
Wahlbeck, K., & McDaid, D. (2012). Actions to alleviate the mental health impact of the economic crisis. World Psychiatry, 11,
139145.
Weare, K., & Nind, M. (2011). Mental health promotion and
problem prevention in schools: What does the evidence say?
Health Promotion International, 26, 2969.
Webster-Stratton, C., Reid, M.J., & Stoolmiller, M. (2008).
Preventing conduct problems and improving school readiness:
Evaluation of the Incredible Years Teacher and Child Training
Programs in high-risk schools. Journal of Child Psychology and
Psychiatry, 49, 471488.
Whiteford, H.A., Degenhardt, L., Rehm, J., Baxter, A.,
Ferrari, A., Erskine, H., Vos, T. (2013). Global burden of


disease attributable to mental and substance use disorders:
Findings from the Global Burden of Disease Study 2010.
Lancet, 382(9904), 15751586.
Whitehead, M., & Dahlgren, G. (2006). Concepts and Principles
for Tackling Social Inequities in Health: Levelling Up Part 1.
Copenhagen: World Health Organization.
WHO. (2001). The World Health Report 2001: Mental Health (New
Understanding, New Hope). Geneva: World Health Organization.
WHO. (2004a). Prevention of Mental Disorders: Effective Interventions and Policy Options, Summary Report. Geneva: World Health
Organization.
WHO. (2004b). Promoting Mental Health: Concepts, Emerging
Evidence, Practice: Summary Report. Geneva: World Health
Organization.
WHO. (2008a). Mental Health Gap Action Programme: Scaling Up
Care for Mental, Neurological and Susbstance Use Orders. World
Health Organization.
WHO. (2008b). Our Cities, Our Health, Our Future. Kobe, Japan:
World Health Organization.
WHO. (2008c). TheWorld Health Report 2008 Primary Health Care
(Now More Than Ever). Geneva: World Health Organization.
WHO. (2009). Improving Health Systems and Services for Mental
Health. Geneva: World Health Organization.
WHO. (2010). Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings. Kobe, Japan: World Health Organization.
WHO. (2013a). Building Back Better: Sustainable Mental Health
Care After Emergencies Geneva: World Health Organization.
WHO. (2013b). Comprehensive Mental Health Action Plan 2013
2020. Geneva: World Health Organization.
WHO. (2013c). Mental Health and Psychosocial Support in Emergencies. World Health Organization. Retrieved from http://www.
who.int/mental_health/emergencies/en/
407
WHO. (2013d). Review of Social Determinants and the Health

Divide in the WHO European Region: Final Report. Copenhagen:
World Health Organization.
WHO. (2013e). What is Mental Health? World Health Organization. Retrieved from http://www.who.int/features/qa/62/en/
WHO. (2013f). What is Universal Coverage? World Health Organization. Retrieved from http://www.who.int/health_financing/
universal_coverage_definition/en/
WHO & Calouste Gulbenkian Foundation. (2014). Integrating the
response to mental disorders and other chronic diseases in health care
systems. Geneva, World Health Organization.
WHO & Gulbenkian Global Mental Health Platform. (2014).
Social Determinants of Mental Health. Geneva: World Health
Organization.
WHO & UN. (2010). UN(DESA)WHO Policy Analysis. Mental
Health and Development: Integrating Mental Health Into All Development Efforts Including MDGs. Retrieved from http://
www.un.org/disabilities/documents/who_desa_mental_health_
policy_analysis.doc
WHO & World Organization of Family Doctors. (2008). Integrating Mental Health Into Primary Care: A Global Perspective.
Geneva: World Health Organization.
Wickrama, K.A., Conger, R.D., Lorenz, F.O., & Jung, T. (2008).
Family antecedents and consequences of trajectories of depressive symptoms from adolescence to young adulthood: A life
course investigation. Journal of Health and Social Behavior, 49,
468483.
Woodhouse, J., & Ward, P. (2013). A Minimum Price for Alcohol?
London: House of Commons.
Wright, P.A., & Moos, B. (2007). Housing environment and mental health outcomes: A levels of analysis perspective. Journal of
Environmental Psychology, 27, 7989.

Social Determinants of Mental Health

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Social Determinants of Mental Health

Uploaded by

Copyright:

Available Formats

International Review of Psychiatry, August 2014; 26(4): 392407

Social determinants of mental health

JESSICA ALLEN, REUBEN BALFOUR, RUTH BELL & MICHAEL MARMOT

Int Rev Psychiatry Downloaded from informahealthcare.com by 188.25.40.203 on 05/26/15

UCL Institute of Health Equity, University College London, UK

particular, socio-economic status, living conditions,

Int Rev Psychiatry Downloaded from informahealthcare.com by 188.25.40.203 on 05/26/15

Social determinants of mental health

Country-level contexts, including political, social,

Int Rev Psychiatry Downloaded from informahealthcare.com by 188.25.40.203 on 05/26/15

Fig. 1. Prevalence of any common mental disorder by household

individuals, as well as social conditions in which

Fig. 2. A life-course approach to tackling inequalities in health

The prenatal period often gets ignored, but is a

Social determinants of mental health

Box 1. Examples of interventions supporting mental health in the early years.

Int Rev Psychiatry Downloaded from informahealthcare.com by 188.25.40.203 on 05/26/15

sources of support (WHO, 2013d). Additional

2005). Universal approaches include changes to

Box 2. Examples of school settings supporting mental health in later childhood.

Box 3. A workplace intervention in China to promote mental health.

Int Rev Psychiatry Downloaded from informahealthcare.com by 188.25.40.203 on 05/26/15

Implications for action

cognition as well as attachment patterns. Postnatal

Implications for action

Interventions supporting maternal and postnatal

Box 4. Evidence of microfinance supporting mental health in working age.

Social determinants of mental health

Box 5. Evidence from South Africa on maternal depression.

Int Rev Psychiatry Downloaded from informahealthcare.com by 188.25.40.203 on 05/26/15

interventions can help throughout the vulnerable

differences in depression and well-being among the

Implications for action

Not surprisingly, older peoples mental health is

It is apparent that interventions which help prolong

Box 6. Examples of interventions supporting mental health

Int Rev Psychiatry Downloaded from informahealthcare.com by 188.25.40.203 on 05/26/15

The natural and built environment

Box 7. Examples of community-level interventions in Ghana, Kenya and India.

Int Rev Psychiatry Downloaded from informahealthcare.com by 188.25.40.203 on 05/26/15

Social determinants of mental health

Box 8. Examples of the positive mental health effects of

Box 10. A community-based intervention to support

Simple changes such as demonstrated in Mexico, where

Over 800,000 people were killed with over 2 million

treatment gap in low income settings (Petersen

Box 9. Primary healthcare in Uganda.

Implications for action

Int Rev Psychiatry Downloaded from informahealthcare.com by 188.25.40.203 on 05/26/15

Box 11. Policies to reduce alcohol consumption.

Box 12. Active labour markets.

Alcohol consumption affects population mental health,

Active labour market programmes have been used in

Additional information about active labour markets is provided in Box 12.

Social determinants of mental health

Int Rev Psychiatry Downloaded from informahealthcare.com by 188.25.40.203 on 05/26/15

depression and disrupting intergenerational transmission of inequity.

Action across sectors

Prioritizing mental health

As explained above, successful interventions on the

Mental health needs to be given greater priority

Information systems and processes are needed at

Int Rev Psychiatry Downloaded from informahealthcare.com by 188.25.40.203 on 05/26/15

Information on how many of those with mental