The social determinants of mental health
Over a billion people globally live with mental health difficulties, with depression and anxiety alone costing around US$1 trillion per year globally.[i] Social determinants are the contextual factors we experience throughout our lives which can increase the risk of developing mental health difficulties. These include: poverty, low income, limited education, poor housing, and adverse childhood experiences[ii]. These determinants often cause sustained stress and uncertainty, which is particularly detrimental to mental health. Current mental health interventions focus on managing symptoms, and cannot address the underlying determinants. Instead we need a “public health approach” which aims to tackle the underlying causes 1. This needs to be a multi-disciplinary approach targeting the different determinants to help reduce the likelihood of developing mental health difficulties for whole populations[iii].
Poverty
In 2023/4, 21% of individuals in the UK lived in poverty. Those at greater risk included large families, ethnic minorities, disabled people and home renters[iv]. Mental health difficulties are more prevalent among individuals from lower socio-economic backgrounds[v][vi]. Poverty and mental health difficulties are interrelated, forming a vicious cycle of lack of resources and distress[vii]. Poverty impacts your ability to obtain the essential resources for living - creating prolonged levels of stress and uncertainty, which are detrimental to mental health. Mental health symptoms may increase the risk of entering or remaining in poverty, with other factors involved, like loss of employment[viii]. Conversely, poverty may trigger psychological difficulties in vulnerable people, potentially exacerbated by factors such as housing insecurity or stress8[ix]. This suggests poverty is multi-faceted and intersectional, with many other factors involved in its precipitation and maintenance, not least the stress it causes. To begin tackling poverty directly, the government should consider social security. The UK’s spending on social protection is significantly below that of countries like Denmark[x]. Evidence suggests the government’s recent move to remove the two-child limit is the most efficient way to reduce poverty, potentially benefitting 1.7 million people[xi].
Economic Inequality
Rather than poverty specifically, might economic inequality be a determinant? Poverty is more an individual, household-level deprivation, whereas economic inequality occurs when income and wealth are distributed unequally across society[xii]. Studies have found that greater income inequality was associated with poorer mental health outcomes[xiii]. Inequality is believed to cause “status anxiety.” In societies with greater inequality, individuals compare themselves with those of higher social economic status, causing stress[xiv]. Exceptions to this association include being a member of a community with strong social cohesion, which can protect against the effects of inequality, particularly owing to the socioemotional support this can provide14. Encouraging more social capital, for example promoting volunteering and community participation opportunities, is therefore recommended14. Financially, recommendations include reforming the tax system to reduce tax avoidance14.
Adverse Childhood Experiences (ACEs)
ACEs are exposure to traumatic experiences and stressors early in life, including abuse, neglect, violence, parental separation, and parental mental illness[xv]. ACEs are lived experiences of stress and uncertainty, often leaving individuals with intolerance of uncertainty, a common presentation in anxiety disorders. Experiencing ACEs is associated with a higher risk of developing mental illnesses in adulthood, such as PTSD, depression, and anxiety[xvi]. The precise nature of the associations between ACEs and mental illness are unclear. Research suggests stress experienced from ACEs is associated with changes to the brain’s biological structure and connectivity, leading to developing mental illnesses[xvii]. We know that ACEs often co-occur, they can be “transmitted” across familial generations, and individuals from low socioeconomic status are more likely to experience ACEs than people from more advantaged backgrounds[xviii]. These facts reflect the cyclical, intersectional nature of ACEs and highlight quite how challenging it could be for families to improve their circumstances. To start addressing ACEs, investment in early intervention programmes and services is essential, many of which have suffered significant financial cuts. Examples include Sure Start which united different services for local families, including parenting classes aiming to improve child development and outcomes[xix]. To reduce or mitigate the impact of ACEs, the government should restore and ring-fence funding to provide equitable, well allocated early intervention services.
Housing
The impact of poor housing was estimated to cost the NHS around £1.4 billion per year in 2021[xx]. Inadequate housing impacts mental health, for example living in mould and damp conditions is associated with anxiety and depression[xxi]. Housing insecurity causes perpetual uncertainty and stress, with frequent relocations disrupting stability, impacting relationships, physical and mental health[xxii]. Specific groups are particularly at risk, including home renters, the elderly[xxiii], and individuals with long-term health conditions[xxiv]. Research refers to “ontological security”, whereby housing should act as a “secure base”,[xxv] helping individuals grow their self-confidence, enhancing their wellbeing[xxvi]. However, the UK has one of the oldest housing stocks compared to Europe, with 15% of homes in England unable to achieve the Decent Homes Standard in 2020[xxvii]. In contrast, in Denmark safe, secure housing is a political priority, with a stable, integrated housing market, which is tenant-led and not profit-focussed[xxviii]. Recommendations for the UK government include introducing a regulatory framework for the quality and accessibility of houses and to refurbish housing stock[xxix]. More support is required for those facing eviction and rent arrears, as well as supporting individuals out of homelessness[xxx].
Studies found that improvements to homes, like wall insulation, reduced hospital admissions for respiratory, cardiovascular r and circulatory conditions for up to 5 years[xxxi]. Home improvements also help to reduce stress, benefitting individual’s overall wellbeing[xxxii]. For businesses, the benefits would be to reduce the costs of items and services, but also to increase their competitiveness nationally and internationally long-term[xxxiii]. Employment and training opportunities and would also be created, for example, through the retrofitting of buildings[xxxiv]. However, to avoid further problems, retrofitting must be informed by professionals with design expertise, specific quality standards should be established, with only a skilled workforce carrying out the work[xxxv].
Fuel Poverty
In the UK, electricity costs have soared, triggered by Russia’s invasion of Ukraine and its suspension of European gas exports[xxxvi][xxxvii]. Around 6.1 million UK households are in “fuel poverty”, spending over 10% of their income on heating their homes to a satisfactory level[xxxviii]. Particularly impacted by energy costs are low-income households, the elderly, retired and vulnerable[xxxix][xl]. Fuel poverty significantly impacts public health, increasing hospital admissions and winter deaths; it causes significant stress, exacerbating vulnerability to mental health difficulties[xli].
Food Insecurity
In 2022, it was estimated that 18% of UK households struggled with food insecurity[xlii] - which is evidenced to cause significant psychological distress, causing or worsening mental health conditions[xliii]. There are associations between psychological difficulties and consuming food that is energy dense with poor nutritional value[xliv]. Prolonged uncertainty in obtaining enough food may trigger a stress response, exacerbating anxiety and depression[xlv]. Recommendations for the UK government to address food insecurity include social protection policy interventions. For example, the short-term £20 increase to Universal Credit during the covid-19 pandemic helped reduce poverty rates. The government could also consider food programmes similar to the USA’s Supplemental Nutrition Assistance Program (SNAP), where eligible households received a set amount to spend up on specific foods from particular retailers[xlvi]. Schemes like these are evidenced to reduce food insecurity, ameliorate meal quality and consumption[xlvii].
Education
There is a strong correlation between higher levels of academic achievement and better mental health[xlviii]. Similarly, lower educational achievement has been linked to many different psychological disorders, particularly schizophrenia[xlix]. However, cause and effect relationships between education and mental health are very difficult to establish[l]. Higher education achievement can lead to improved knowledge about health through health literacy and healthy behaviours[li], thus acting as a protective factor. Low education attainment often involves other factors, for example inadequate housing increases stress, affecting mental health[lii] and therefore the ability to engage with education. Education is an example of how different social determinants intersect to impact mental health. Measures to improve education attainment and mental health should unite different disciplines. For example, addressing poverty, food insecurity and poor housing would give children the best chance to access their education.
Financing the recommendations
A significant policy dilemma is that many of the suggested recommendations require additional funding. Examples include increased welfare expenditure, investment in early intervention programmes, refurbishing housing stock and funding food programmes. However, the government is struggling to meet existing financial commitments and the UK’s lacklustre economic performance suggests little hope of increased income for some time.
This suggests a need to:
- Consider policy options which don’t require significant expenditure, such as legislation and regulation. For example, there is growing pressure from parents, teachers and across the political spectrum for a ban on smartphones for under 16s, to protect young people’s mental health - with smartphones an example of a potential socio-technological determinant.
- Prioritise recommendations which provide clear potential returns on investment. Reducing energy costs is a good example. The UK has some of the highest energy costs in the developed world. This increases the risk of fuel poverty for low-income families already struggling with the cost of living. However, it also increases costs for businesses, the public sector (including schools and hospitals) and charities. For example, UK businesses and industrial users face electricity prices around 50% higher than those of France and Germany42 So, working to bring down energy costs would not only help those living in fuel poverty, it would also benefit the UK economy, public sector organisations and charities (including those working with the most deprived families). Where this can be achieved by a continued transition to renewable energy this would have environmental benefits and potentially also benefits for employment by creating skilled, green job and training opportunities50.
Emily Wyke
January 2026
References
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