Social determinants of mental health

Purpose

This position statement outlines the Royal Australian and New Zealand College of Psychiatrists’ (RANZCP) position on the social determinants of mental health (hereafter referred to as ‘social determinants’). It recognises that social conditions play a key role in shaping mental health and wellbeing of individuals, families, whānau, and communities in Australia and Aotearoa New Zealand. It also advocates for sustained inter-agency investment and leadership by psychiatrists in addressing the structural and systemic barriers that drive social inequities.

Key messages

Background

The social determinants are the non-medical factors that influence mental health outcomes. According to the World Health Organisation they are “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life”[1]. These include economic systems, social policies, political structures, and cultural norms.

Social determinants account for 30–55% of health outcomes and can outweigh genetic influences[1]. The negative impact of exposure to adverse determinants occurs through impaired childhood brain development, chronic stress responses, development of physical illness, hazardous substance use, and inequitable access to care[5].

Mental health follows a clear social gradient: the lower the socioeconomic position, the worse the outcomes. Social inequities are reproduced through systems and institutions of power, creating intergenerational disadvantage[3]. At the same time, social determinants can also be protective, with stable employment, good quality housing and education, as well as strong cultural connection shown to promote wellbeing[3].

Exposure is rarely singular as individuals often experience multiple adverse determinants whose cumulative effects are synergistic[6]. The relationship is bidirectional: poor social conditions increase mental illness, which in turn leads to further social disadvantage (for example, through job loss, housing insecurity, or imprisonment)[7]. These effects are further shaped by intersectionality, where overlapping identities (such as socioeconomic status, race, gender, and disability) interact to compound disadvantage and influence both exposure to risk and access to support.[8]

Conceptual frameworks for social determinants distinguish between upstream (macro-level policy), midstream (community-level), and downstream (individual or family-level) determinants. Families, carers and kin can additionally be affected by social determinants that in turn impact upon individuals’ development. Life-course approaches highlight the disproportionate impact of exposures in childhood on long-term outcomes[9].

Relevant determinants to Australia and Aotearoa New Zealand

Australia and Aotearoa New Zealand have unique demographics and histories that have created similarly unique determinants that may include but are not limited to:

• the historical and ongoing impact of colonisation[10–14]
• racial and/or religious discrimination[15]
• rural and remote living[16]
• insecure or unsuitable housing[10]
• unemployment and socioeconomic disadvantage[5,16]
• education access and quality[17]
• adverse childhood experiences pertaining to families, carers and kin affected by social determinants[18,19]
• family violence[20]
• migration-related trauma including forced displacement, indefinite detention and uncertain visa status[21]
• justice system involvement and incarceration[10]
• gender and sexuality-based inequities[16,22]
• social isolation and loneliness[23]
• impact of digital technologies whether through access (social media, online bullying, artificial intelligence) or lack of access (isolation, barriers to care/educational resource etc.)[24]
• climate change and environmental degradation[9]
• human rights infringements and international conflicts.[5]

Population approaches to addressing social determinants

Action on social determinants cannot rest with health professionals alone. It requires all parts of the government’s commitment, inter-agency cooperation, and partnership with civil society and the private sector[2].

Structural determinants should be framed as systemic inequalities rather individual vulnerabilities, thereby shifting responsibility from the person to the structures shaping their opportunities[3].

The overarching aim is to reduce the social gradient through proportionate universalism[9]: delivering universal services at a scale and intensity proportionate to the level of disadvantage.

Key principles include:

• prioritising primary prevention
• adopting a strength-based approach
• targeting multiple determinants simultaneously
• focusing on determinants with modifiable impact (e.g. education, housing)
• concentrating on critical life stages, particularly childhood
• ensuring interventions are evidence-based and rigorously evaluated
• balancing upstream (policy) and downstream (clinical/community) interventions.

Expanding the evidence base through prospective, longitudinal studies, and advancing methodological techniques such as data linkage and simulation models will be essential to identify and evaluate effective interventions[2].

The role of psychiatrists

Psychiatrists have an important role individually and collectively in addressing social determinants[25].

Individually, psychiatrists:

• Apply principles of prevention, promotion and early intervention in care.
• Explore social and cultural determinants during assessment and integrate them into management plans.
• Use structural competency to understand how social context shapes mental health, defined as the ability to recognise how social, economic and political structures influence health.[26]
• Advocate for patients, families and carers and include their perspectives in assessment and management.
• Collaborate with other sectors on social prescribing, vocational training and peer-led interventions in practice.

Collectively, RANZCP has a constitutional mandate to advance education, provide advice to governments, and promote public awareness of mental health. Advocacy on Social Determinants is therefore a matter of professional responsibility as well as social justice.

Recommendations

• Addressing social determinants should be a national priority to promote health and wellbeing as well as reducing rates of mental illness and suicide.
• Social determinants should be addressed through a whole-of-government approach enabling inter-agency cooperation, prioritising prevention, and targeting determinants with proven interventions.
• Childhood and adolescence should be priority stages for intervention, given their lifelong impact.
• Equity of access and quality of care must be embedded in health policy, with a strong emphasis on actively addressing stigma within healthcare systems.
• Health systems must reduce fragmentation, siloing, poor continuity, unsafe discharge, and the burden-shifting to families that can contribute to iatrogenic harm.
• RANZCP and psychiatrists should contribute expertise to research, training, and policy development on Social Determinants, particularly in relation to inequities in access to care and outcomes.
• In clinical practice, psychiatrists should routinely assess social determinants, recognising that these rarely occur in isolation, and incorporate them into holistic treatment and management plans.

References

1. Social determinants of mental health. Geneva: World Health Organisation and Calouste Gulbenkian Foundation; 2014.
2. Kirkbride JB, Anglin DM, Colman I, Dykxhoorn J, Jones PB, Patalay P, et al. The social determinants of mental health and disorder: evidence, prevention and recommendations. World psychiatry. 2024;23(1):58–90.
3. Donkin AJM. Social Gradient. Institute of Health Equity. 2014.
4. Alegría M, NeMoyer A, Falgàs Bagué I, Wang Y, Alvarez K. Social determinants of mental health: where we are and where we need to go. Current psychiatry reports. 2018;20(11):95.
5. Organization WH. Working together for equity and healthier populations: sustainable multisectoral collaboration based on health in all policies approaches. World Health Organization; 2023.
6. Solmi M, Veronese N, Galvano D, Favaro A, Ostinelli EG, Noventa V, et al. Factors associated with loneliness: an umbrella review of observational studies. Journal of affective disorders. 2020;271:131–8.
7. Park C, Majeed A, Gill H, Tamura J, Ho RC, Mansur RB, et al. The effect of loneliness on distinct health outcomes: a comprehensive review and meta-analysis. Psychiatry research. 2020;294:113514.
8. López N, Gadsden VL. Health inequities, social determinants, and intersectionality. In: Perspectives on health equity and social determinants of health. National Academies Press (US); 2017.
9. Marmot M. The health gap: the challenge of an unequal world. The Lancet. 2015;386(10011):2442–4.
10. Mental health [Inquiry Report] [Internet]. Canberra: Australian Government Productivity Commission; 2020. Available from: https://www.pc.gov.au/inquiries-and-research/mental-health/report/
11. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework: summary report June 2025. [Internet]. AIHW (Australian Government). Available from: https://www.indigenoushpf.gov.au/reports/summary-reports/summary-report
12. Australian Bureau of Statistics. National Aboriginal and Torres Strait Islander Health Survey [Web report] [Internet]. Canberra: ABS; 2026. Available from: https://www.abs.gov.au/statistics/people/aboriginal-and-torres-strait-islander-peoples/national-aboriginal-and-torres-strait-islander-health-survey/latest-release
13. Whanaketia – Through pain and trauma, from darkness to light [Internet]. Wellington: Abuse in Care Royal Commission of Inquiry; 2024. Available from: https://www.abuseincare.org.nz/reports
14. Williams AD, Clark TC, Lewycka S. The associations between cultural identity and mental health outcomes for indigenous Māori youth in New Zealand. Frontiers in public health. 2018;6:319.
15. Ferdinand AS, Paradies Y, Kelaher M. Mental health impacts of racial discrimination in Australian culturally and linguistically diverse communities: A cross-sectional survey. BMC public health. 2015;15(1):401.
16. Australian Bureau of Statistics. National Study of Mental Health and Wellbeing [Web report] [Internet]. Canberra: ABS; 2020 2022. Available from: https://www.abs.gov.au/statistics/health/mental-health/national-study-mental-health-and-wellbeing/2020-2022
17. Murray C, Gabriel F, Kennedy J. Factors that promote student well-being in schools: a scoping review of Australian and Aotearoa New Zealand literature. Humanities and Social Sciences Communications. 2024;11(1):1–11.
18. Hughes K, Bellis MA, Hardcastle KA, Sethi D, Butchart A, Mikton C, et al. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. The Lancet public health. 2017;2(8):e356–66.
19. Carr A, Duff H, Craddock F. A systematic review of reviews of the outcome of noninstitutional child maltreatment. Trauma, Violence, & Abuse. 2020;21(4):828–43.
20. Fanslow JL, Malihi Z, Hashemi L, Gulliver P, McIntosh T. Prevalence of interpersonal violence against women and men in New Zealand: results of a cross-sectional study. Australian and New Zealand Journal of Public Health. 2022;46(2):117–26.
21. Tomasi A marija, Slewa-Younan S, Narchal R, Rioseco P. Understanding the mental health and help-seeking behaviours of refugees. 2022.
22. Fergusson DM, Boden JM, Horwood LJ. Exposure to childhood sexual and physical abuse and adjustment in early adulthood. Child abuse & neglect. 2008;32(6):607–19.
23. Mann F, Wang J, Pearce E, Ma R, Schlief M, Lloyd-Evans B, et al. Loneliness and the onset of new mental health problems in the general population. Social psychiatry and psychiatric epidemiology. 2022;57(11):2161–78.
24. Baker DG, Wang M, Filia KM, Teo SM, Morgan R, Ziou M, et al. The changing impacts of social determinants on youth mental health in Australia. International Journal of Social Psychiatry. 2025;71(1):116–28.
25. Compton MT, Shim RS. The social determinants of mental health. Focus. 2015;13(4):419–25.
26. Metzl JM, Hansen H. Structural competency: theorizing a new medical engagement with stigma and inequality. Social science & medicine. 2014;103:126–33.

Disclaimer: This information is intended to provide general guidance to practitioners and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.