Continuing a Croakey series on mental health reform, Dr Matt Fisher, from Flinders University, investigates how social and economic factors can influence mental health, for better and for worse.

It is an area deserving of wide-ranging policy attention, especially while overall socioeconomic inequality remains relatively high in Australia, he says.


Improving mental health requires action across multiple portfolios

Matt Fisher writes:

A recent national survey estimated 20% of Australians experience a diagnosable mental disorder within any 12-month period. Mental health policy in Australia has been the recent subject of much debate and reform; as discussed in Croakey and elsewhere.

There are certainly things to be applauded in recent changes, including measures to shift the balance of resources away from hospital services, toward a community-based model of coordinated care, and services for young people.

However, our overall policy orientation tends to evade some of the more difficult dimensions of the problem.

Abundant evidence on social determinants of health demonstrates that a range of social, economic and cultural factors can and do influence mental health, both for good and ill.

People on low incomes, in lower status jobs or unemployed, who have limited education, unaffordable housing, live in unsafe areas, have poor physical health, or who are exposed to family violence, abuse or neglect – especially children – all are at much higher risk of mental illness.

It is thought that chronic arousal of the body’s stress systems acts as a key pathway between exposure to such conditions and their effects on mental health.

Conversely, positive conditions such as a supportive family and social networks, and educational qualifications appear to promote positive well-being and capacities to cope better with occasional stresses.

At a population level, a consistent relationship prevails between the overall distribution of socioeconomic status (SES), and inequalities in the distribution of mental health outcomes.

Rates of common forms of mental illness are highest at the ‘low’ end of the SES scale and decrease progressively as you move ‘up’.

One main reason for this, I suggest, is simply that the likelihood of exposure to one or several social risk factors tends to decrease, and access to health promoting/protective factors tends to increase, as SES increases.

A fully-fledged population-based public health response (e.g. see chapter 3 here) taking account of the social determinants of health and health inequalities would act to preventively address various risk and protective factors as they affect communities, population sectors or the whole population, not just those who already have an illness or early symptoms.

And to do so, it must recognise and have mechanisms to address the potential health effects of policy decisions across a range of portfolios.

Based on current research, my assessment of current policy approaches on mental health is that, while they acknowledge some of the evidence on the social determinants of health and health inequalities and implement measures to address some key issues, they nevertheless stop short of such an approach.

For example, there is some recognition of social risk factors for mental illness, but little acknowledgement of health inequalities across the population. There are measures to address ‘social determinants’ such as affordable housing, secure employment or social support, but primarily for the 2% or so with an existing, more severe illness.

Policy does assert the need for a ‘whole-of-government’ approach, but in fact this is largely limited to better coordination between services and support for those with an existing illness.

There is a focus on prevention and promotion measures in early childhood, but more needs to be done.

We also know that indicators of positive early childhood development can in effect be largely trumped by on-going exposure to social disadvantage (e.g. see p. 9 here).

What is the problem here? It seems to me there is an underlying reticence in current policy to explicitly acknowledge that some dimensions of our everyday social and economic circumstances, and the distribution of these as assets or liabilities for mental health, are causally contributing to the nature and scale of the problem.

Thus it is very difficult to then advance a case for policy change in areas outside the health sector; even though that is where many of the possibilities for genuine primary prevention can be implemented.

Nothing about these observations is intended to glibly suggest that appropriate treatment services for mental illness are not important.

Also, it might be argued that social factors influencing health or health inequalities are already being addressed in other policy areas, which is true to an extent, especially in relation to some more severely disadvantaged groups.

However, overall socioeconomic inequality in Australia remains relatively high; coupled with significant SES differences in exposure to those risk factors noted above, and in access to factors that promote and protect good health.

Unfortunately, I suspect that without action to address social determinants of mental health in communities and the population at large (alongside health service responses), the prospects are limited for significant reductions in overall rates of illness, or in health inequalities.

• Matt Fisher is Research Officer at the Southgate Institute for Health, Society & Equity at Flinders University


Previous posts in this series

• Suggesting some long-term goals for mental health reform

• Important for mental health: a fair society and a good start to life

• Don’t rush the roadmap for national mental health reform: Alan Rosen

• What matters for people living with psychotic illness

• More effort needed to strengthen shared care arrangements for people with serious mental illness

• Some lessons from rural innovation in mental healthcare


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