Social Determinants of Health: What’s in a Name?

I have a beef with the name “Social Determinants of Health”.

I absolutely agree with putting the word “social” right up front.  It’s a fact that zip code often has a greater effect on health than genetic code.  And the effects of social and environmental factors – such as trauma, loss, and deprivation – are especially relevant to mental health. 
It’s the specific word “determinants” that I’d want to change.  Social factors often have powerful negative or positive influences on physical and mental health.  And the effects of social and environmental factors can certainly overwhelm the treatments we provide.  But the impacts of social and environmental factors are almost always probabilistic rather than deterministic.  The term “social determinants” may sound more powerful than “social influences”, but it is also less accurate.  And the difference between “determinants” and “influences” is not just semantic hair-splitting. 

Adopting a deterministic – rather than probabilistic – view of social influences on health can distract us from places where our research can actually make a contribution.  When we study risk or causation, only a probabilistic view will allow us to understand individual variation in vulnerability and resilience.  In statistical terms, true understanding requires us to move beyond simple questions regarding main effects (Does a specific environmental insult matter on average?) to questions about interactions (For whom does that insult matter more or less?  Under what conditions is the health impact larger or smaller?).  When we examine those interactions, will likely find that the impact of social and environmental insults is even greater among the vulnerable or disadvantaged – those who have already experienced trauma, loss, and deprivation. 

When we develop or test interventions, a probabilistic view focuses us on disrupting specific linkages between social or environmental insults and subsequent mental health problems.  Here again, we can think of interventions as effect modifiers or interactions rather than simply main effects.  For example, we certainly hope that the association between childhood victimization and adult PTSD is not deterministic.  Instead, we hope it can be modified by timely and specific intervention.  Embracing probabilistic complexity should help us to identify interventions to support the most vulnerable by disrupting causal pathways with the biggest public health impact.  That probabilistic – rather than deterministic – view will usually direct resources to those with greatest need.  For example, interventions to address the long-term effects of early childhood trauma will likely have greatest benefit in those who were already disadvantaged.

A deterministic view can easily lead to what my colleague Evette Ludman and I have called sympathetic nihilism.  By that, we mean a well-intentioned but ultimately dispiriting focus on all the reasons for illness and disability – rather than a search for paths to recovery.  Mental health care too often falls into that trap of sympathetic nihilism.

Nevertheless, deterministic thinking can be appealing.  We would all hope to emulate John Snow, the London physician who interrupted an 1854 cholera epidemic with a single dramatic act, removing the handle from the contaminated Broad Street water pump.  In our modern times, social and environmental insults rarely have a single point source.  Instead, the sources of harm are more systemic.

Our closest modern analogue of John Snow is probably Mona Hanna-Attisha, the pediatrician who revealed the devastating effects of lead-contaminated water in Flint, Michigan.  She certainly did advocate for immediate action to interrupt ongoing lead exposure, but there was no single pump handle to remove.  She understood that toxic lead levels in children’s drinking water reflected a complex interaction of governmental decisions about water sources, decaying public infrastructure, and outdated plumbing in individual homes and schools.  The lead poisoning epidemic had no single point source.  So she advocated for governmental action to address systemic problems and educated individual families about reducing exposure.  She also realized that controlling every source of contamination would not reverse the chronic effects of childhood lead exposure.  Repairing those adverse developmental and mental health effects will require long-term therapeutic and rehabilitative interventions. Even if we could find and remove that magic pump handle, many children will be affected for decades to come.

None of us working in mental health will likely face that dramatic and deterministic John Snow scenario.  Instead, like Mona Hanna-Attisha, we regularly face complicated probabilistic scenarios.  To address that complexity, we are called to a range of responses.  Appropriate responses will often include both advocacy to address systemic social causes of poor mental health and a search for effective therapeutic and rehabilitative interventions.  While we will rarely discover that that point source of cholera to eradicate, we can aspire to discover and deliver the mental health equivalent of oral rehydration for cholera – an intervention that’s surprisingly effective, rapidly scalable, and easily affordable.  Developing an effective and scalable intervention certainly does not negate or undermine every person’s right to safe drinking water.  But it does help those who are already sick.

Greg Simon

Who decides what a word means?

“When I use a word,” Humpty Dumpty said, in rather a scornful tone, “it means just what I choose it to mean—neither more nor less.” 

Our collaboration with MHRN health systems to improve depression care has emphasized the systematic use of standard outcome measures –  like the PHQ9 depression scale.  More recently, we have encouraged use of the 9th item of the PHQ9 (regarding thoughts of death or self-harm) as a tool for identifying people at risk for suicidal behavior.  Front-line clinicians and health system managers often ask whether those standard questionnaires can accurately measure depression or predict suicidal behavior across diverse patient populations.

Those questions about questionnaires are typically prompted by concern about wording of specific questionnaire items.  For example:  Does a question about “feeling tired or having little energy” really assess depression in people with diabetes or heart disease?  Does a question about “thoughts you would be better off dead” really assess risk of suicidal behavior in older adults with chronic medical illness? 

A recent MHRN paper led by Rebecca Rossom directly addresses that second question – using a sample of almost 1 million PHQ9 questionnaires completed by almost 300,000 patients in four health systems.  Her team found that response to item 9 of the PHQ9 was a strong predictor of subsequent suicide attempt and suicide death across all age groups, including those aged 65 or older.  Among those reporting frequent “thoughts you would be better off dead or thoughts of hurting yourself in some way”, risk of suicide death over the following two years was actually highest in those aged 65 or older. 

Those data would seem to settle the question.  Reporting “thoughts you would be better off dead” should not be dismissed as a normal part of aging or a normal reaction to chronic illness.  The burdens of chronic illness might certainly contribute to depression and suicidal ideation.  Empathy regarding those burdens is certainly an appropriate response, but a false sense of security is not.

This analysis is also a nice example of using data to escape from semantic arguments that abound in Alice’s Wonderland.  As we move forward with systematic assessment of outcomes in mental health care, we will likely encounter more questions about what a particular word or questionnaire item means.  Rather than responding like Humpty Dumpty, we can ask in return “What data would we need to figure that out?”

Greg Simon

Coordinated Care for First-Episode Psychosis and the End of Gadgets

As MHRN investigators, we often hear from academic researchers hoping to study new psychotherapies or eHealth interventions in our healthcare systems.  Those new interventions typically focus on a specific diagnosis (like obsessive-compulsive disorder) or patient subgroup (like depression in people with arthritis).  But when we bring these ideas to leaders in our care delivery systems, their interest in these specific interventions is often low.  Our health system partners are typically more interested in broader care improvements – like measurement-based care for depression or addressing suicide risk across all diagnoses.

It’s not surprising that researchers based in academic health centers focus on more specific interventions.  Care in academic centers is more often organized around subspecialty areas like obsessive-compulsive disorder or depression in rheumatoid arthritis.  And the typical path of an intervention researcher (from dissertation topic to post-doctoral fellowship to career development award) emphasizes finding a specific clinical niche.  The research grant review process also demands specificity – even if our diagnostic categories are much fuzzier and overlapping than we like to admit.

Thinking about the value of more specific interventions reminded me of a recent New York Times column proclaiming that “The Gadget Apocalypse Is Upon Us”. The premise of the column was that previously separate electronic gadgets have been swallowed by mobile phones.  That premise does seem true for MP3 players, GPS devices, and point-and-shoot cameras.  iPods have certainly faded, and only the most serious photographers now carry around separate cameras.  The music-playing and direction-giving and picture-taking features built into our mobile phones are good enough for most of us.  But not all separate gadgets have disappeared.  Wrist activity monitors seem to be doing just fine.  And new families of gadgets (like the Google and Amazon voice-controlled speakers) are still emerging.  A separate gadget that meets the right need at the right time can still succeed.  Those successful gadgets beg the question:  When is a specialized or dedicated tool (like a narrowly targeted mental health intervention) worth the extra effort or expense?

Asking that question about a new electronic gadget begins with the assumption that nearly everyone is already carrying a mobile phone.  So we’d only carry around a separate gadget if it really improved quality or efficiency.  A dedicated camera can take nicer pictures than my phone.  And a wrist activity monitor might save me from carrying my phone on a run. 

In the same way, asking our MHRN care systems about testing or implementing a specific mental health intervention begins with the assumption that a “generic” mental health infrastructure is already in place.  Geographically organized clinics are staffed with psychiatrists, nurses, psychologists, and other psychotherapists.  Those clinicians serve people seeking care for the full range of problems or diagnoses.  We would want to implement more specific treatments or programs if those specific treatments had real advantages – in either quality or efficiency – over the general-purpose treatments we are already providing.  It would not be convincing to show that a specific treatment or program is superior to no treatment or some “placebo” condition.  Instead, it would be necessary to show advantages over existing general-purpose treatment.  And the benefit of that new clinical “gadget” would have to be large enough to justify the extra expense or effort.

I’m finally getting to the topic of coordinated specialty care for first-episode psychosis.  We have clear evidence that coordinated programs improve outcomes compared to general-purpose care in community mental health centers.  In this case, the coordinated specialty care “gadget” probably does have real added value.  But our behavioral health leaders have not shown much interest in implementing specialized programs.  Our MHRN research shows that first presentations with psychotic symptoms are not rare in our health systems.  While initial engagement in care is high, over half of young people with new-onset psychotic symptoms have dropped out of mental health care within a few months.  From where we (MHRN researchers) sit, it looks like our health systems need a dedicated gadget to improve care for first-episode psychosis.  Now we have some marketing to do – convincing our health system partners that a specialized program would be useful enough often enough to justify the extra effort.

Greg Simon