Social determinants, mental health and development

Michael MarmotUCLSept 16th 2010New York

Health inequalities matter

Social Justice

Empowerment•Material•Psychosocial•political

Creating conditions forpeople to lead flourishinglives

Early child development and education

Healthy Places Fair Employment Social Protection

Universal Health Care

Health Equity in all Policies

Fair Financing Good Global Governance

Market Responsibility

Gender Equity

Political empowerment – inclusion and voice

CSDH – Areas for Action

Risk factors for depression

Level of evidence

Low socioeconomic position Very convincing

Low education Very convincing

Unemployment and under employment

Very convincing

Food insecurity and early nutrition deficiency

Strong

Gender inequity Strong

Low income Strong

WHO CSDH PPHC KN 2007

Odds ratio for depressive symptoms by presence of social deprivation at different phases of life course:

Eastern European countries

From Nicholson et al J Affective Disorders 2008

Early life

• Early child development and education

Socio-emotional difficulties at age 3 and 5:Millennium Cohort Study

Age 3 Age 5

Kelly et al, 2010 (in press)Fully adjusted = for parenting activities and psychosocial markers

Long term outcomes associated with childhood behavioural problems (New Zealand study)

1 1 1 1

1.95

1.51

1.24

1.69

4.13

2.39

1.57

3

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Crime Drugs Depression Suicide

Top 50% (no conduct problems) Middle 45% (some conduct problems)Bottom 5% (conduct disorder)

OR

Source: L. Friedli & M. Parsonage (2007) Mental health promotion: Building an economic case. Based on: Fergusson et al (2005) J. Child Psychl & Psych 46 (8): 837-849

Healthy Places

• Urban design– good urban design can encourage social cohesion– exercise - benefits for mental health– green spaces

Gender Equity

• Higher risk of depression in women – Multiple responsibilities with no financial gain– Caring responsibilities– Lack of support– Gender based violence– Access to health care– Poor physical health– Level of education– Autonomy in decision making– Migration

ODDS OF DEPRESSION BY CONTROL AT WORK & AT HOME WITHIN GRADE - WOMEN WHITEHALL II

1

2

3

4

Decision latitude Home control

odds

ra

tios

EMPLOYMENT GRADE

Griffin et al, Soc Sci Med, 2002

High Medium Low

Fair employment

• Employment conditions– Stress in the workplace increases the risk of disease.

DEPRESSION AND EFFORT-REWARD IMBALANCE:

RUSSIA, POLAND, CZECH

0

1

2

3

4

5

Low Imbalance Medium LowImbalance

Medium HighImbalance

High Imbalance

CE

S-D

epre

ssio

n Sc

ale*

*Adjusted for age, sex and centre(Pikhart et al. Soc Sci Med, 2004 58:1475-82)

Quartiles of effort-reward ratio

Older ages

Loneliness by wealth

% often/some of the time (except for “Feel in tune with people around” where % refers to hardly ever/never)

Social Protection

• Minimum income for healthy living – Morris et al. – Diet– Physical activity/body and mind– Psychosocial relations/social connections/active minds– Getting about– Medical care– Hygiene– Housing

Morris et al 2007

www.who.int/social_determinants/en