Latest Frontier on Social Determinants: Mental Health

Mental health represents the latest dimension of the SDoH.

EDITOR’S NOTE: This topic was covered by Ms. Fink-Samnick during her featured appearance on the most recent edition of Monitor Mondays.

Mental health condition incidence has trended upward for years, especially for populations at risk of issues associated with the social determinants of health (SDoH). As such, recent funding has focused on a variety of behavioral health manifestations and conditions, including:

• Diagnoses often associated with social inequalities (e.g. unemployment, poverty, etc.), prompted by exacerbation from psychosocial stressors, treatment adherence challenges, or limited access to proper mental healthcare (to include conditions such as substance use, major depressive disorder, generalized anxiety disorder, and psychotic disorders as schizophrenia);
• Co-occuring health and behavioral chronic illnesses (e.g. diabetes, heart disease, asthma, chronic obstructive pulmonary disease, etc.) presenting along with anxiety, depression and substance use; and
• Trauma experienced by all ages in response to Adverse Childhood Experiences, or ACEs. These clients face psychosocial stressors and circumstances of family and domestic violence; child and adult abuse, neglect, and exploitation; abandonment, crime, incarceration etc., and more. The inclusion of a category of trauma-informed disorders in the Diagnostic Statistical Manual of Mental Disorders (5^th Edition) is no coincidence, encompassing illnesses including post-traumatic stress disorder (PTSD).

Industry experts are now calling for separate attention to be paid to the social determinants of mental health (SDoMH). As noted in assorted seminal reports on the topic, including one by the World Health Organization and the Calouste Gulbenkian Foundation, the greater the inequality, the higher the inequality in risk.

Co-occurance of Mental Health and the Social Determinants of Health
Mental health condition incidence and the SDoH are intertwined, with extensive evidence across the literature:

• Mental illness incidence is highest for adults below the poverty level.
• Substance abuse treatment admission rates in rural regions is higher than in inner cities: for alcohol, the rate is at almost 38 percent, compared to 34 percent for persons ages 12 and over.
• A total of 60-90 percent of individuals with a substance use disorder have experienced one or more traumatic events, from exposure to violence in the home to physical and/or sexual abuse.
• About a quarter of people experiencing homelessness have a serious mental illness, such as schizophrenia, bipolar disorder, post-traumatic stress disorder, or major depression. A majority of these individuals also have an addiction issue.
• In state prisons, 73 percent of women and 55 percent of men have at least one mental health problem.
• The largest inpatient provider of mental health treatment alternates between Illinois’s Cook County Jail and California’s L.A. County Jail.
• Medicaid is the top payor for mental health services nationally, approaching 30 percent of adults.

A Clear Answer to the SDoMH

The mandate for attention to the SDoMH is clear. Funding is one key strategy to address the issue. Over the past several weeks, a number of fiscal commitments have been implemented, with the states stepping up to take care of their own:

• CMS announced 1115 Demonstration waivers for Minnesota and Nebraska to expand care for Medicaid institutions for mental diseases (IMDs) over the next five years. The waivers provide Medicaid matching funds for treatment in IMDs to address the opioid epidemic, reduce overuse, and improve mortality.
  • Minnesota’s waiver extends funding for community behavioral health clinics.
  • Nebraska’s waiverpromotes Medicaid partners throughout the state’s managed care program, health systems, and the Department of Behavioral Health to provide public inpatient and outpatient facilities, emergency community health services, and substance use assistance. A goal is to reduce unnecessary emergent hospitalizations and readmissions for the population.
• In my old professional stomping grounds of Brooklyn, New York, a new neighborhood health hub addresses co-occuring mental and physical healthcare. While parts of the borough are seeing an economic upswing, pockets of extreme crime and poverty remain, with as much as 30 percent of the population living below the poverty level; this constitutes a clear mandate to address the area’s emergent health and mental health needs.
• San Diego county recently approved $23.8 million to expand mental health and substance abuse emergency response, as well as their crisis centers. The funding is targeted to expand the number of available patient beds, psychiatric emergency response teams, community-based mental health crisis stabilization centers, as well as additional resources for schools. There will also be an increased standing contract with Palomar Health, a prominent local health system.
• Pharmacists in impoverished communities around the country now provide education on health and behavioral health symptoms, along with medication management to reduce health disparities and common stigmas faced by minority populations, along with the prevalence of health literacy challenges and the inability to cover the costs of prescriptions. This model started outside of St. Louis, Mo. and is being expanded to other communities in need, including those in Charlotte, N.C., New York City, and Washington, D.C.
• A $100 million Federal Communications Commission (FCC) pilot proposal is scheduled for a vote on July 10, with the goal to enhance health and mental health access for low-income veterans across rural regions of the country. The funding will target both health and especially mental health deserts that present around rural communities, limiting needed access to care.

The Bottom Line

The SDoMH are not new, with mental health needs across all populations representing a clear and pressing challenge. As evidence and outcomes continue to emerge, we can expect to see expanded funding, creative programming, and groundbreaking initiatives introduced to address this latest dimension of the SDoH.