Social Determinants of Mental Health Problems, and Psychological Therapies

Our results demonstrate that psychological processes of response style (specifically a greater tendency to ruminate) and self-blame (or an internal attributional style for negative events) powerfully determine the impact of familial histories of mental health problems, life events and traumas, and social deprivation in the aetiology of depression and anxiety and in the maintenance of well-being. This study is the first multivariate empirical test of specific and previously published hypotheses [5] about the role of psychological processes as mediators in a revision of the ubiquitous bio-psycho-social model [4]. Our access to this unprecedented and large data set has allowed clear dissection of the inter-connections between factors, and in particular, has permitted analysis of the specific mediating effect of psychological factors. Our results clearly support the contention that biological, social, and circumstantial causal agents affect our mental health and well-being through their impact on how we process information and perceive the world. In this study, life events constituted the most significant direct causal factor, and two key processes – self-blame and response style – significantly mediated all causal pathways.

Our results did not support a fully mediated model (that is, with no residual direct effects), but this is entirely unsurprising. Mental health and well-being can be safely assumed to be the result of a huge number of causal factors with a large number of mediating psychological processes. In this study, we examined only two of the very many psychological processes hypothesised to be important in mental health. Nevertheless, we are confident both that these findings are themselves robust and that other psychological processes would also act as mediators in causal paths similar to those revealed here.

The present study was designed as an empirical test of a hypothesised set of relationships derived from previously published theoretical research [5]. Because of this, and for practical reasons, we reduced the huge complexity of mental health to a testable model of linear relationships between a limited number of variables. Mental health problems, like all other clinical conditions, can be understood on many simultaneous levels, incorporating genetic, metabolic, cellular, systemic bodily, personal, social anthropological and spiritual dimensions. We did not, for example, address issues concerning individuals’ understanding of their own mental health issues [33], nor did we dissect the complex relationships between genetics, heritability and family history [34]. Further research is clearly required to explore how the detailed pathway from genetics through neurocognitive processes on the one hand, and interpersonal and interpretative frameworks on the other, link to mental health outcomes. Anxiety and depression are recognised as two major dimensions underlying common mental health problems, but there are clearly very many more recognised psychological difficulties. Further research could also explore whether different psychological mechanisms mediate the pathways from either specific or generic causal and risk factors to different mental health problems.

There was also a potential element of self-selection in the present study, given the recruitment strategy and the on-line methodology. However, although more of our participants were white, had slightly higher earnings, and were better educated than the England and Wales average [14], there was broad comparability with other national demographic data, with a similar regional breakdown to other major health surveys [15].

These results support a significant revision of the biopsychosocial model. Instead of regarding these three causal agents as co-equal partners in the aetiology of mental health problems, these results demonstrate that the impact of physical and social causes on mental health and well-being outcomes is mediated by psychological processes. In other words, psychological processes determine the causal impact of biological, social, and circumstantial risk factors.

These findings and this interpretation have significant implications. Reductionist biological accounts of mental health have been robustly criticised on scientific, ethical, and practical grounds [3]. An alternative, scientifically valid, model may have implications for policy, education and clinical practice [5], [33]. Psychological processes such as rumination and self-blame are amenable to evidence-based psychological therapy [35]. Significant gains in mental health are achieved when people experiencing mental health problems are supported in achieving greater control over their own psychological processes [36]. A clear understanding of the role of psychological processes in the aetiology of mental health problems and the maintenance of well-being is an important step in that process. Further research in this area should include further validation of this model (particularly through prospective studies), careful consideration of the interactions between causal factors (particularly biological factors) and the mediating role of psychological mechanisms.