Human rights and the social determinants of mental health: fostering interdisciplinary research collaboration

Abstract

There is a developing body of research indicating that individual and population-based mental health is affected by a range of ‘social determinants’. Discrimination, poverty, inadequate access to housing and education as well as exposure to violence, conflict and disaster have all been associated with poor mental health and mental illness. International human rights treaties identify many of the social determinants of mental health as matters of human rights. However, limited attention has been paid to the connection between social determinants and the right to enjoyment of the highest attainable standard of mental health. This paper explores the potential for incorporating elements of both social determinants and human rights approaches to provide a new framework for mental health research, policy and practice. While acknowledging potential challenges, it identifies advantages to collaborating across disciplinary boundaries. The social determinants approach provides a foundation for understanding the interconnectedness of rights and draws attention to individual and collective needs, while a human rights approach can help identify the measures that are required to secure the social determinants of good mental health and wellbeing.

Key words:

• health equity
• human rights
• interdisciplinary research
• mental health
• public health
• social determinants
• social rights

1. Introduction

The World Health Organization (WHO) has defined public health as ‘the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society’.¹ An essential component of public health programs is a focus on non-medical factors associated with health outcomes such as where people live and whether they have secure housing and employment as well as access to education. These non-medical factors are generally referred to as the ‘social determinants’ of health, and there is a comprehensive body of literature in the fields of social medicine, social epidemiology and public health that analyses the association between a range of social factors and health outcomes.² This literature suggests that social determinants of health ‘are responsible for a major part of health inequities between and within countries’;³ in consequence, identifying and addressing social determinants of health has been characterised as a necessary complement to the ‘development of health systems and relief of poverty’⁴ in global efforts to reduce ‘the unfair and avoidable differences in health status’ that constitute health inequities.⁵

The role of social determinants in the mental health of individuals and communities has received growing attention in recent decades.⁶ This entails a recognition that ‘[a] person’s mental health and many common mental disorders are shaped by various social, economic, and physical environments operating at different stages of life’.⁷ For example, discrimination and social exclusion, income inequality and poverty and lack of access to education, housing, secure employment and social safety nets, have all been identified as social determinants of poorer mental health and mental health inequity.⁸

Human rights organisations and academics have long recognised the connection between underlying social determinants of health and the realisation of the human right to the enjoyment of the highest attainable standard of health. For example, in the most comprehensive explanation of the right published in 2000, the United Nations Committee on Economic, Social and Cultural Rights (CESCR) clarified that the enjoyment of the right to health requires governments to take action on a range of ‘underlying determinants’ of health.⁹ Other United Nations bodies and mandates have elaborated further on the relationship between social determinants and the right to health, arguing both that progress on the social determinants of health requires attention to human rights, and that the human right to health will only be enjoyed where the social determinants of health are addressed.¹⁰

Until relatively recently, these discussions have given limited attention to the ‘mental health’ element of the right to health. The United Nations Convention on the Rights of Persons with Disabilities (CRPD), which came into force in 2008, affirmed that persons with disabilities enjoy the right to the highest attainable standard of physical and mental health without discrimination on the basis of disability.¹¹ Article 1 of the CRPD adopts a broad understanding of disability which includes people who have ‘long-term mental impairments’, thereby encouraging a focus on human rights relating to mental health. In this regard, however, most activity in the international human rights sphere, and in nations’ laws and policies, has been focused on protection of the rights of people with mental health conditions from arbitrary interference through the abolition or reform of problematic practices. This includes, for example, research and advocacy critiquing the imposition of coercive or involuntary mental health treatment on some people with mental health conditions or diagnoses and, associated with this, the denial of their legal capacity to consent to or refuse such treatment.¹²

There are now calls for action on mental health-related human rights to extend beyond protecting against interference with rights and encompass the promotion of the highest attainable standard of mental health. The significance to this mission of understanding and addressing social determinants of mental health has been noted at the United Nations level, in particular by Dainius Pūras, the most recent-past Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health (Special Rapporteur on Health).¹³ According to Pūras, the continued convergence of the two discourses of human rights and social determinants, ‘not only in theory, but also in policies and practice’, is crucial to the realisation of both human rights and health equity.¹⁴ He has asserted that, on the one hand, ‘research and action on the structural, political and social determinants of distress’ is fundamental to the realisation of the right to mental health¹⁵ and, on the other hand, that ‘intersecting political discussions, economic and social rights imperatives, and the struggle to overcome structural obstacles, can be fortified by the right to the enjoyment of the highest attainable standard of health’.¹⁶

The World Health Organization has similarly advocated for an approach to addressing social determinants of health and pursuing health equity, including in relation to mental health, that is informed by human rights principles and utilises human rights mechanisms.¹⁷ However, these calls still arguably constitute exceptions to a general failure of ‘rights-based approaches to health … [to engage] in a meaningful way’ with research that establishes the importance of social determinants on individuals’ and populations’ health, suggesting that there remain barriers to interdisciplinary knowledge-sharing and collaboration.¹⁸

In this article, we explore the overlap between human rights and social determinants approaches to mental health.¹⁹ We build on existing literature on the relationship between human rights and social determinants of health more generally to argue that there is potential to develop new knowledge and action on promoting the highest attainable standard of mental health – as a matter of both rights and equity – through interdisciplinary collaboration. We also discuss some potential challenges to bringing the perspectives together and identify potential ways forward.

2. The connections between human rights and the social determinants of health

The United Nations’ first formal articulation of a universal human right to health in 1948 was premised on the understanding that good health is influenced by a range of social factors and requires more than just access to medical services. The Universal Declaration of Human Rights (UDHR) pronounced that:

Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services.²⁰

The UDHR was not a binding document, and the subsequent expression of ‘the right of everyone to the enjoyment of the highest attainable standard of physical and mental health’ in the International Covenant on Economic, Social and Cultural Rights (ICESCR) in 1966 was less specific about the significance of social determinants of health and the obligations on states who were party to the Covenant to provide for them.²¹ The ICESCR did, however, articulate a range of other rights associated with the social determinants of health, including rights to social security, education, housing and safe and healthy working conditions.²² As noted above, the content of the right to health, and its relationship to other rights, was developed in detail in the General Comment on The Right to the Highest Attainable Standard of Health released by the CESCR in 2000. In that document, the CESCR – which is responsible for monitoring the implementation of ICESCR – expressed an interpretation of the right to health as:

an inclusive right extending not only to timely and appropriate health care but also to the underlying determinants of health, such as access to safe and potable water and adequate sanitation, an adequate supply of safe food, nutrition and housing, healthy occupational and environmental conditions, and access to health-related education and information, including on sexual and reproductive health.²³

It further explained that states were required to promote ‘the social determinants of good health, such as environmental safety, education, economic development and gender equity’.²⁴ Other human rights bodies and mandates have subsequently expanded on the relationship between the social determinants of health and the human right to health. Paul Hunt in particular elaborated on the link between the human right to health and the social determinants of health in reports and other commentary produced during his tenure as the United Nations Special Rapporteur on Health.²⁵ Hunt drew a distinction between what he termed underlying determinants of health such as safe water and adequate nutritious food and housing and social determinants such as gender, poverty and social exclusion.²⁶ This distinction may be a technical one, given that what was of most importance in Hunt’s view was that ‘the right to the highest attainable standard of health encompasses the traditional domains of both medical care and public health’.²⁷

Dainius Pūras, who was the Special Rapporteur on Health from 2014 to 2020, brought this concern with social determinants to bear on the right to mental health. Pūras argued in a series of reports that greater recognition of the links between social determinants of mental health and human rights is necessary to the realisation of health equity and the highest attainable standard of mental health.²⁸ He was particularly concerned that rights-based approaches to mental health tend to adopt ‘a narrow, individual focus on the prevention of mental health conditions’ through influencing individuals, meaning inadequate attention is given to wider social, economic, legal, political and other structural factors that affect mental health and well-being.²⁹ Pūras argued that a broader conceptualisation of the social determinants of mental health necessitates an interpretation of the right to mental health that extends to ‘no one be[ing] denied access to a healthy psychosocial environment to sustain their well-being, and that everyone be entitled to a life with respect, social connection, equal opportunities and dignity’.³⁰ This clarifies the breadth of obligations on states in relation to the right to mental health – it goes beyond the provision of mental health services to prevent or treat individuals’ mental health conditions and requires action to reduce inequality, discrimination and violence and ensure access to a range of supportive and protective services and resources, such as housing, food, social security and community integration.³¹ Pūras’ successor as the Special Rapporteur on Health, Tlaleng Mofokeng, published several reports in 2022 that further highlighted the need for states to take action on particular social determinants of physical and mental health, including violence and racism.³² Other United Nations bodies have suggested that the right to health should be interpreted in an expansive manner that obliges states to address a range of determinants of mental health affecting particular groups of rights-holders, including community inclusion for people with disability and freedom from violence for children.³³

Several WHO statements, reports and initiatives in recent decades have also discussed the value – if not necessity – of bringing together social determinants and human rights approaches in relation to health generally, and mental health specifically. For example, the WHO Commission on Social Determinants of Health (the CSDH) was established in 2005 to gather and synthesise evidence on social determinants of health and make recommendations to address health inequity. In its 2008 report, it made three main recommendations: that policies be introduced to improve daily living conditions; that governments tackle the inequitable distribution of power, money and resources; and that governments and international organisations acknowledge and measure health inequity, including via a research focus on social determinants.³⁴ The CSDH’s concern with social justice, its characterisation of health as a right and its emphasis on measurement, evaluation, research and raising public awareness were all characterised as being consistent with human rights realisation efforts.³⁵ Indeed, the CSDH report included a brief discussion of the connection between social determinants and human rights, noting ‘clear links’ between rights approaches and social determinants approaches in terms of both the similarities between social determinants and civil, cultural, economic, political and social rights, and the recognition in both perspectives that health is dependent on multiple interdependent factors that must be secured in order to promote positive health outcomes.³⁶ Paul Hunt nevertheless characterised the report as a missed opportunity to challenge misconceptions about human rights among the health professions and identify human rights as ‘a powerful ally in the struggle against harmful social determinants’.³⁷ Similarly, Audrey Chapman referred to the CSDH’s ‘reticence’ in recognising the potential contribution of human rights to the advancement of health equity as ‘particularly surprising’,³⁸ although Benjamin Mason Meier’s analysis indicates a long and regrettable history of reluctance within the WHO to advance a human rights-based approach to health.³⁹

More recent WHO publications have discussed the link between social determinants of health, including mental health, and human rights.⁴⁰ The WHO’s ‘Comprehensive Mental Health Action Plan 2013–2020’ listed the promotion of mental health through action on social determinants as one of its five key objectives, although critics argued that this objective was not translated into action during the life of the plan.⁴¹ In 2021, the authors of the WHO’s ‘Guidance on Community Mental Health Services’ observed that social determinants such as poverty, discrimination, violence and unemployment are often overlooked or ignored in relation to mental health, which they characterised as a hindrance to the realisation of a human rights approach to mental health for people living with mental health conditions and psychosocial disabilities.⁴²

3. Bringing together human rights and social determinants approaches: benefits and challenges

Calls from international bodies for greater synthesis of human rights and social determinants perspectives have been accompanied by some discussion in the research literature about the potential advantages and challenges of achieving this. Proponents suggest there are a range of potential benefits to both sides of sharing knowledge and evidence, and some challenges in doing so – especially in terms of progressing from high-level pleas for better engagement across perspectives to the development and implementation of ‘actions and priorities’ on either human rights or health equity.⁴³

3.1. The potential benefits of bringing together human rights and social determinants perspectives

The pursuit of mental health-related human rights can be supported by research on the social determinants of mental health in several senses. First, in its focus on ‘consistent patterns of inequality and their impact on health’ as well as ‘the complex, bidirectional association’ between health and these inequalities in multiple⁴⁴ social determinants, research can provide evidence to challenge dominant, individualistic understandings of mental distress and responses to mental illness around the world. As Dainius Pūras has explained, this individualistic approach means ‘[p]olicy funding, research priorities and debate on how to strengthen the response to global mental health challenges are still dominated by targeting individuals and their mental health conditions’.⁴⁵ This is inconsistent with the requirements of the CRPD, which conceptualises disability (including mental health-related disability) as arising from ‘the interaction between persons with impairments and attitudinal and environmental barriers that hinders their full and effective participation in society on an equal basis with others’ and thereby obliges states to take action to change society rather than requiring individuals to fit into existing systems and structures.⁴⁶ The authors of the WHO’s ‘Guidance on Community Mental Health Services’ (described above) similarly suggested that inadequate attention to social determinants, alongside stigmatisation and discrimination, leads to the medicalisation of mental distress without adequate consideration of each person’s circumstances and experiences.⁴⁷ They argued that this has implications for the design of mental health services – which must ‘engage with these important life issues’ – and for wider social services sectors in terms of the need for collaboration across services and the provision of ‘holistic support’ that is grounded in human rights.⁴⁸

According to Kumanan Rasanathan and colleagues,⁴⁹ research on health inequities and social determinants of health can also provide ‘glaring evidence’ of human rights violations. Research on social determinants also offers evidence to support the contestation that the right to the enjoyment of the highest attainable standard of health, including mental health, goes beyond the right to access health services to encompass access to housing, education, physical healthcare, income and social services, among other things.⁵⁰ To give two examples, Edmond D Shenassa and colleagues analysed survey data from eight European cities which indicated a connection between poor housing quality (dampness and mould) and depression, while research by Yin-Ling Irene Wong and Irving Piliavin found a reduction in psychological distress when adults experiencing homelessness were placed in permanent housing in one United States county.⁵¹ Such evidence of the nature and impacts of social determinants of mental health may also assist with human rights monitoring and compliance efforts, the significance of which we discuss further below.

In addition to helping identify and measure human rights issues, research on the social determinants of mental health can provide useful evidence for human rights researchers and practitioners about what is required to address negative social determinants and facilitate the right to the enjoyment of the highest standard of mental health and other human rights.⁵² This can be useful in light of the ‘impasse’ that is often observed in conversations about involuntary treatment and coercive practices in mental health care.⁵³ The United Nations Committee on the Rights of Persons with Disabilities (CRPD Committee), which monitors the implementation of the CRPD, and human rights advocates, have argued that such practices constitute violations of human rights protected in the CRPD and earlier human rights instruments, and must therefore be abolished.⁵⁴ Other commentators, as well as states that are party to the CRPD, have argued for a different interpretation whereby compulsory assistance or treatment is permitted where it is necessary, as a last resort and subject to safeguards.⁵⁵ While we have argued elsewhere that these issues require ongoing attention,⁵⁶ corresponding action to ensure that health, education, housing, social security and other mental health-facilitating systems are available, adequately resourced and rights based can arguably play a complementary, indirect role in the avoidance of human rights violations. Promoting the right to mental health in the expansive sense of the highest attainable standard of mental health – rather than focusing solely on the avoidance of the worst human rights harms – is also necessary to ensure that people with mental health conditions or psychosocial disability enjoy the full suite of human rights guaranteed to all persons.

Human rights research and law may in turn contribute to social determinants research and associated efforts to improve health equity, including in relation to mental health. First, the human rights perspective offers a framework for measuring and guiding progress on addressing social determinants of health, including mental health.⁵⁷ That is, international human rights law identifies many social determinants as matters of right, including rights to education, social security and social protection and housing, and the right of persons with disabilities to enjoy rights on an equal basis with others without discrimination.⁵⁸ The ICESCR, CRPD and other international instruments establish a range of mechanisms to monitor human rights protections and violations and hold states to account for failures to meet their human rights obligations – that is, ‘to name and frame these issues and patterns as violations with clear legal obligations for state action’.⁵⁹ These mechanisms include establishing human rights indicators, benchmarks and impact assessments through which states’ compliance with human rights requirements is measured and reported⁶⁰ and the conduct of periodic reviews of human rights compliance by United Nations committees. In this way, human rights instruments oblige states to take action to address the social determinants of health – or at least to explain why they have not. To this end, Sheila Wildeman has described the WHO’s ‘adoption of the normative framework of human rights as a mechanism for calling down a political response’ to address the social determinants of health.⁶¹ Similarly, Paul Hunt has argued that human rights mean:

that the authorities must be held to account and required to explain, before an appropriate independent body (not necessarily a court of law) that they are doing all they reasonably can to ensure that the disadvantage experienced by individuals, communities and populations is being tackled as a matter of urgency.⁶²

Where states have agreed to be bound by optional protocols to certain United Nations conventions, individuals or groups can also bring complaints to a United Nations committee about the actions of the state.⁶³ For example, under the Optional Protocol to the CRPD, the CRPD Committee can receive and consider ‘communications’ from individuals or groups claiming violations of the CRPD, examine ‘reliable information indicating grave or systematic violations’ by a state, conduct an inquiry, make comments and recommendations and monitor the actions implemented by the state to respond to the recommendations.⁶⁴

A second contribution of the human rights approach to efforts to identify and address the social determinants of mental health is that it establishes a requirement to involve rights-holders – including mental health consumers and services users, and people experiencing mental distress – in all matters concerning them.⁶⁵ Meaningful ‘community involvement in the development and implementation of effective health systems and health protections’ has itself been characterised as a social determinant of health.⁶⁶ In the mental health context, the obligation on governments to consult with and involve the community has perhaps its clearest articulation in Article 4(3) of the CRPD, which states that:

In the development and implementation of legislation and policies to implement the present Convention, and in other decision-making processes concerning issues relating to persons with disabilities, States Parties shall closely consult with and actively involve persons with disabilities, including children with disabilities, through their representative organisations.⁶⁷

This means that rights-holders must be involved in monitoring and accountability processes, and in designing systems, legislation, policies and other mechanisms for the realisation of positive social determinants and human rights.⁶⁸

3.2. Challenges to bringing the perspectives together

Despite recognition of the potential of a more coordinated approach, a lack of progress on bringing human rights and social determinants perspectives together has led researchers to explore the challenges of doing so. One significant barrier to translating interest in the reciprocal contributions of human rights and social determinants approaches to health, including mental health, appears to be a lack of analysis of common ground across the perspectives, leading to a failure to go beyond theoretical discussions of the connections between them to identify how they should be implemented in policy and practice.⁶⁹ As Audrey Chapman has observed, there are ‘significant differences between the way the two communities have conceptualized and approached this subject as well as the relative emphasis they accord’.⁷⁰ Research on social determinants has focused on identifying and quantifying different outcomes for different populations and developing interventions to address them.⁷¹ In human rights research and policy, legal principles have dominated, resulting in a focus on identifying and addressing interference with civil and political rights, and on whether states are complying with their human rights obligations to individuals, without giving much guidance about what level of ‘health’ can and should be enjoyed.⁷² This is related to both a persistence of disciplinary silos and ‘the relative rarity of expertise that spans law and public/global health’.⁷³ There has also been criticism of a lack of engagement with collaborative approaches and a tendency to treat each right – such as the right to health, the right to social security and the right to life – as a separate matter, rather than recognising the ‘foundational principle’ that human rights are interdependent.⁷⁴

A further challenge to progress is that both social determinants and human rights approaches to mental health continue to be marginal or non-dominant perspectives in research and practice because they are premised to some extent on a ‘psychosocial’ or ‘biopsychosocial’ model of mental health. This model was first proposed in 1977 by the psychiatrist George Engel as a way of seeing individuals within a ‘whole system’ of their relationships, family, community and society,⁷⁵ in contrast to the prevailing individual or biomedical model touched on above, which has a ‘focus on locating problems and solutions within individuals [which] obscures the need to address the structural factors that make lives unliveable’.⁷⁶

Related to this, there may also be a tendency to see the role of mental health clinicians as circumscribed because clinical care relates to individual patients rather than communities. For example, the Lancet Psychiatry Commission in 2017 posed the question: Should psychiatrists ‘be involved in changing social determinants or should they limit themselves to remain doctors who treat mental disorders of individual patients?’⁷⁷ The Commission concluded that while psychiatrists’ main role will continue to be the treatment of individuals, there is room for them to advocate and lobby for beneficial social actions and work with local communities, services and authorities in this regard. Further, various mental health professional organisations have explicitly referred to human rights as a basis of their work. The American Psychological Association, for example, aspires to ‘[f]oster the advancement of human rights, fairness, diversity, and inclusion through the application of psychological science’,⁷⁸ thereby contemplating a role for psychologists beyond that of individual therapeutic relationships.

Forging links, developing a common vocabulary and an understanding of similarities and differences between perspectives and working towards common outcomes are all necessary – but not easy – elements of interdisciplinary work.⁷⁹ In the final part of this paper, we identify some avenues for potential progress on this for researchers and practitioners.

4. A way forward

Exploring new ways of approaching problems through interdisciplinary collaborations between human rights researchers and researchers in social medicine, social epidemiology and population health could support not only conceptual, but also practical, ways of improving mental health and inform the efforts of mental health practitioners, lawyers, mental health consumers and others to this end.⁸⁰ Interdisciplinary research has been defined as a ‘collaboration of [researchers] with largely non overlapping training and core expertise to solve a problem that lies outside the grasp of the individual [researcher]’.⁸¹ This type of research is sometimes described as integrating knowledge and methods from different disciplines. It differs from ‘multidisciplinary’ research where researchers work together but keep within the boundaries of their own disciplinary knowledge. The goal of interdisciplinary research – sometimes also known as ‘transdisciplinary’, ‘transversal’, ‘post-disciplinary’ and even ‘super-disciplinary’ research – is to move beyond discipline-specific approaches to address a common problem. There is a developing literature about ‘lived experience’ practice being seen as a discipline in its own right,⁸² and the importance of the full and effective participation of mental health service users in interdisciplinary research is now being recognised.⁸³ The key component of any such research is collaboration, and that requires good communication, trust and time.⁸⁴ Along these lines, the Lancet Commission on the Legal Determinants of Health – which was concerned with enhancing the role of law in promoting health and well-being and reducing health inequities – argued that ‘building disciplinary bridges’ between researchers and practitioners in health and law was essential to improving research, teaching, practice and problem-solving. Recent work by Fiona Haigh and colleagues on developing an explanatory theory about the relationship between human rights and the social determinants of health offers an example of the kind of preliminary work that is now underway to support better understanding, sharing of knowledge and collaboration across fields and between researchers and communities.⁸⁵

Beyond research, there are indications that interdisciplinary collaboration in practice can increase shared and supported decision-making, hence avoiding rigid hierarchical divisions between disciplines. When mental health consumers are engaged as active participants in the delivery of mental health services, reported benefits include improvements in therapeutic relationships and the fostering of supportive organisational cultures; these consumer roles are also associated with significant reductions in hospital stays among individuals they support.⁸⁶ As noted above, the involvement of mental health consumers in the design, implementation and monitoring of measures relating to the realisation of other human rights (or social determinants) – such as housing, employment and social security – is also consistent with the requirement in Article 4(3) of the CRPD to ‘closely consult with and actively involve persons with disabilities’ in the implementation of the CRPD and other decision-making processes concerning them.⁸⁷

A focus on how social determinants, especially social and economic inequities, affect mental health and how this can be articulated into the right to the enjoyment of the highest attainable standard of mental health means getting past simply acknowledging the relevance of social determinants and explaining what they are and how they can be addressed within and outside mental health systems.⁸⁸ It also means focusing on the ‘collective dimensions’ of the right to mental health – rather than only individuals’ access to services and treatment – and on responses to both immediate and longer-term needs.⁸⁹ This implies a need to engage with policies across sectors and to avoid offering only narrow recommendations about mental health systems and individuals’ access to services.⁹⁰ This is challenging and is likely to require the kinds of interdisciplinary research and activity mentioned above. It also has major implications for how systems are designed, regulated and resourced. Pūras suggests there is also a need for research evidence on the benefits of taking a social determinants approach to the right to mental health.⁹¹

In terms of changes to mental health systems and practice, services must be connected so that mental health services collaborate with ‘other sectors such as housing, education and employment’ to address and/or respond individually and collectively to social determinants of mental health.⁹² Training and knowledge-building for mental health workforces – on the influence of social determinants and the limits and harms of individualistic approaches, among other things – are essential.⁹³ Data collection must include social determinants of mental health; here, the WHO has identified a range of indicators including mortality, suicide/attempt rates, poverty, income level, employment, education, housing, social protection and disability support rates, homelessness, prescription rates and costs of psychotropic drugs.⁹⁴

5. Conclusion

The arguments in favour of cross-pollination and collaboration across social determinants and human rights approaches to the pursuit of better mental health outcomes around the world are compelling. Research on the social determinants of mental health can provide evidence of the link between rights enjoyment (or rights violations) and mental health and highlight the collective needs of communities and societies, while human rights law and scholarship can offer indicators, benchmarks and legal frameworks to guide action to address social determinants.

Any attempt towards greater cross-pollination between the social determinants and human rights perspectives relating to mental health issues will involve wrestling with ‘competing cultures, values, and priorities’.⁹⁵ The present lack of common language and understanding of the unique contributions of each side is arguably surmountable, although action on both sides will be necessary to foster interdisciplinary work. Fruitful avenues may include developing a common research agenda, working to articulate concrete measures that can be taken at local, national and global levels to advance health equity and the right to health in relation to mental health, and research to develop models for the implementation of such measures in mental health systems and beyond. Such collaborations are likely to produce new insights that can inform the work of psychiatrists, psychologists, other mental health practitioners, mental health consumers and human rights lawyers as well as highlighting how they can work together.

Ethical standards

Declaration of conflicts of interest

Yvette Maker has declared no conflicts of interest.

Bernadette McSherry has declared no conflicts of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Acknowledgments

The authors thank Jasmine Gan for her research assistance and the two anonymous reviewers for their comments.

Notes

1 Don Nutbeam, Health Promotion Glossary (World Health Organization 1998).

2 See eg Michael Marmot and Richard G Wilkinson (eds), Social Determinants of Health (OUP 1999); Pranee Liamputtong, Social Determinants of Health (OUP 2019).

3 CSDH, ‘Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health – Final Report of the Commission on Social Determinants of Health’ (2008) WHO/IER/CSDH/08.1, 1.

4 Michael Marmot, ‘Social Determinants of Health Inequalities’ (2005) 365(9464) The Lancet 1099.

5 World Health Organization, ‘Health Promotion Glossary of Terms’ (2021) <https://www.who.int/publications/i/item/9789240038349> accessed 4 July 2023.

6 See eg Jessica Allen, Reuben Balfour, Ruth Bell and Michael Marmot, ‘Social Determinants of Mental Health’ (2014) 26(4) Int Rev Psychiatry 392; Briana Woods-Jaeger, Bridget Cho and Ernestine C Briggs, ‘Training Psychologists to Address Social Determinants of Mental Health’ [2020] Train Educ Prof Psychol 1 <https://doi.org/10.1037/tep0000307>; accessed 4 July 2023.

7 World Health Organization and Calouste Gulbenkian Foundation, ‘Social Determinants of Mental Health’ (2014) <https://apps.who.int/iris/bitstream/handle/10665/112828/9789241506809_eng.pdf> 9, accessed 4 July 2023.

8 Sheila Wildeman, ‘Protecting Rights and Building Capacities: Challenges to Global Mental Health Policy in Light of the Convention on the Rights of Persons with Disabilities’ (2013) 41(1) J Law Med Ethics 48; World Health Organization, ‘Guidance on Community Mental Health Services: Promoting Person-centred and Rights-based Approaches’ (2021) <https://www.who.int/publications/i/item/9789240025707> accessed 4 July 2023; World Health Organization and Calouste Gulbenkian Foundation (n 7); Ruth S Shim, Michael T Compton, Marc W Manseau, Carol Koplan, Frederick J P Langheim and Rebecca A Powers, ‘Overview of the Social Determinants of Mental Health’ in Michael T Compton and Ruth S Shim (eds), The Social Determinants of Mental Health (Psychiatric Publishing 2014).

9 Committee on Economic, Social and Cultural Rights, ‘General Comment No. 14: The Right to the Highest Attainable Standard of Health’ (2000) UN Doc E/C.12/2000/4.

10 See eg Paul Hunt, ‘Report of the UN Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health’ (31 January 2008) UN Doc A/HRC/7/11 [45] (‘Hunt Report 7/11’); Paul Hunt, ‘Missed Opportunities: Human Rights and the Commission on Social Determinants of Health’ (2009) 16(1-Supplementary) Global Health Promot 36 (‘Missed Opportunities’).

11 International Covenant on Economic, Social and Cultural Rights (opened for signature 16 December 1966, entered into force 3 January 1976) 993 UNTS 3 (‘ICESCR’) art 12(1); Convention on the Rights of Persons with Disabilities (opened for signature 30 March 2007, entered into force 3 May 2008) 2515 UNTS 3 (‘CRPD’) art 25.

12 Jill Stavert and Rebecca McGregor, ‘Domestic Legislation and International Human Rights Standards: The Case of Mental Health and Incapacity’ (2018) 22(1) Int J Human Rights 70; Bernadette McSherry, Piers Gooding and Yvette Maker, ‘Human Rights Promotion and the “Geneva Impasse” in Mental Healthcare: Scoping Review’ (2023) 9(3) BJPsych Open e58.

13 See eg Dainius Pūras, ‘Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health’ (12 April 2019) UN Doc A/HRC/41/34 (‘Pūras Report 41/34’); Dainius Pūras, ‘Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health’ (28 March 2017) UN Doc A/HRC/35/21 (‘Pūras Report 35/21’); Dainius Pūras, ‘Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health’ (15 April 2020) UN Doc A/75/163 (‘Pūras Report 75/163’); Dainius Pūras, ‘Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health’ (14 July 2017) UN Doc A/72/137 (‘Pūras Report 72/137’).

14 Pūras Report 41/34 (n 13) [3].

15 Dainius Pūras, ‘Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health’ (15 April 2020) UN Doc A/HRC/44/48 (‘Pūras Report 44/48’) [26].

16 Pūras Report 41/34 (n 13) [6].

17 See eg Natalie Drew, Michelle Funk, Soumitra Pathare and Leslie Swatz, ‘Mental Health and Human Rights’ in Helen Herrman, Shekhar Saxena and Rob Moodie (eds), Promoting Mental Health (World Health Organization 2005); Michelle Funk, Natalie Drew, Melvyn Freeman, Edwige Faydi, Mark Van Ommeren and Audrey Kettaneh, Mental Health and Development: Targeting People with Mental Health Conditions as a Vulnerable Group (World Health Organization 2010).

18 Audrey R Chapman, Global Health, Human Rights and the Challenge of Neoliberal Policies (CUP 2016) 250; Fiona Haigh, Lynn Kemp, Patricia Bazeley and Neil Haigh, ‘Developing a Critical Realist Informed Framework to Explain How the Human Rights and Social Determinants of Health Relationship Works’ (2019) 19(1) BMC Public Health 1571.

19 Bernadette McSherry, ‘Australian Mental Health Laws and Human Rights’ in Paula Gerber and Melissa Castan (eds), Critical Perspectives on Human Rights Law in Australia (vol 1, Thomson Reuters 2021); Bernadette McSherry and Kay Wilson, ‘The Concept of Capacity in Australian Mental Health Law Reform: Going in the Wrong Direction?’ (2015) 40 Int J Law Psychiatry 60.

20 Universal Declaration of Human Rights (adopted 10 December 1948) UNGA Res 217 A(III).

21 Benjamin Mason Meier, ‘Global Health Governance and the Contentious Politics of Human Rights: Mainstreaming the Right to Health for Public Health Advancement’ (2010) 46(1) Stanford J Int Law 1.

22 ICESCR (n 11) Arts 7(b), 9, 11, 13; Ted Schrecker, Audrey R Chapman, Ronald Labonté and Roberto De Vogli, ‘Advancing Health Equity in the Global Marketplace: How Human Rights Can Help’ (2010) 71(8) Soc Sci Med 1520, 1521.

23 Committee on Economic, Social and Cultural Rights (n 9) [11].

24 Ibid [16].

25 See eg Paul Hunt and Gunilla Backman, ‘Health Systems and the Right to the Highest Attainable Standard of Health’ (2008) 10(1) Health Hum Rights 81; Hunt, ‘Missed Opportunities’ (n 10).

26 Hunt Report 7/11 (n 10) [45].

27 Ibid.

28 Pūras Report 41/34 (n 13); Pūras Report 35/21 (n 13); Pūras Report 75/163 (n 13); Pūras Report 72/137 (n 13); Pūras Report 44/48 (n 15); Dainius Pūras, ‘Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health’ (30 July 2015) UN Doc A/70/213 (‘Pūras Report 70/213’); Dainius Pūras, ‘Interim Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health’ (27 July 2018) UN Doc A/73/216; Dainius Pūras, ‘Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health’ (16 July 2019) UN Doc A/74/174 (‘Pūras Report 74/174’); Dainius Pūras, ‘World Mental Health Day: Open Statement by the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health’ (10 October 2019) <https://www.ohchr.org/en/statements/2019/10/world-mental-health-day-10-october-2019?LangID=E&NewsID=25117> accessed 4 July 2023 (‘Pūras Open Statement’).

29 Pūras Report 41/34 (n 13) [1], [4].

30 Pūras Report 41/34 (n 13) [5].

31 Pūras Report 41/34 (n 13).

32 Tlaleng Mofokeng, ‘Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health’ (14 April 2022) UN Doc A/HRC/50/28; Tlaleng Mofokeng, ‘Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health’ (20 July 2022) UN Doc A/77/197.

33 Committee on the Rights of Persons with Disabilities, ‘General Comment No. 5 on Living Independently and Being Included in the Community’ (2017) UN Doc CRPD/C/GC/5; Committee on the Rights of the Child, ‘General Comment No. 13 on the Right of the Child to Freedom From All Forms of Violence’ (2011) UN Doc CRC/C/GC/13; for further examples, see Pūras Report 41/34 (n 13) [17].

34 CSDH (n 3) 2.

35 Kumanan Rasanathan, Johanna Norenhag and Nicole Valentine, ‘Realizing Human Rights-based Approaches for Action on the Social Determinants of Health’ (2010) 12(2) Health Hum Rights 49, 53–55; Chapman (n 50) 255–57.

36 CSDH (n 3) 173.

37 Hunt, ‘Missed Opportunities’ (n 10) 40.

38 Audrey Chapman, ‘The Social Determinants of Health, Health Equity, and Human Rights (2010) 12(2) Health Hum Rights 17, 18.

39 Meier (n 21) 41.

40 See eg Drew et al (n 17) 81.

41 Pūras Report 41/34 (n 13) [6]; World Health Organization and Calouste Gulbenkian Foundation, ‘Policy Options on Mental Health: A WHO-Gulbenkian Mental Health Platform Collaboration’ (2017) <https://www.who.int/publications/i/item/9789241513296> accessed 4 July 2023.

42 World Health Organization (n 8) 2.

43 Hunt, ‘Missed Opportunities’ (n 10); Kristian Wahlbeck, ‘Public Mental Health: The Time Is Ripe for Translation of Evidence into Practice’ (2015) 14(1) World Psychiatry 36; Kristi Heather Kenyon, Lisa Forman and Claire E Brolan, ‘Deepening the Relationship Between Human Rights and the Social Determinants of Health: A Focus on Indivisibility of Power’ (2018) 20(2) Health Hum Rights 1; Haigh et al (n 18).

44 Kenyon, Forman and Brolan (n 43) 8.

45 Pūras Report 41/34 (n 13) [6]; see also Pūras Report 72/137 (n 13); Carolynne Shinn, ‘The Right to the Highest Attainable Standard of Health: Public Health’s Opportunity to Reframe a Human Rights Debate in the United States’ (1999) 4(1) Health Hum Rights 114; Rita Giacaman, Yoke Rabaia, Viet Ngueyn-Gillham, Rajaie Batniji, Raija-Leena Punamäki and Derek Summerfield, ‘Mental Health, Social Distress and Political Oppression: The Case of the Occupied Palestinian Territory’ (2011) 6(5) Global Public Health 547; Lisa Cosgrove and Allen F Shaughnessy, ‘Mental Health as a Basic Human Right and the Interference of Commercialized Science’ (2020) 22(1) Health Hum Rights J 61.

46 Theresia Degener, ‘Disability in a Human Rights Context’ (2016) 5(3) Laws 3 <https://doi.org/10.3390/laws5030035> accessed 29 June 2022.

47 World Health Organization (n 8) 2–3.

48 Ibid 3.

49 Rasanathan, Norenhag and Valentine (n 35) 56.

50 Ibid; Shim et al (n 8); Chapman (n 18) 257.

51 Edmond D Shenassa et al, ‘Dampness and Mold in the Home and Depression: An Examination of Mold-related Illness and Perceived Control of One’s Home as Possible Depression Pathways’ (2007) 97(10) Am J Publ Health 1893; Yin-Ling Irene Wong and Irving Piliavin, ‘Stressors, Resources, and Distress among Homeless Persons: A Longitudinal Analysis’ (2001) 52(7) Soc Sci Med (1982) 1029.

52 Pūras Report 41/34 (n 13); Roberto Mezzina, Alan Rosen, Michaela Amering and Afzal Javed, ‘The Practice of Freedom: Human Rights and the Global Mental Health Agenda’ in Afzal Javed and Kostas N Fountoulakis (eds), Advances in Psychiatry (Springer 2019) 483.

53 Wayne Martin and Sándor Gurbai, ‘Surveying the Geneva Impasse: Coercive Care and Human Rights’ (2019) 64 Int J Law Psychiatry 117.

54 UN Committee on the Rights of Persons with Disabilities, ‘Report of the Committee on the Rights of Persons with Disabilities’ (2019) UN Doc A/74/55 [69]; UN Committee on the Rights of Persons with Disabilities, ‘Report of the Committee on the Rights of Persons with Disabilities’ (2017) UN Doc A/72/55, [10], [13]; Tina Minkowitz, ‘Abolishing Mental Health Laws to Comply with the Convention on the Rights of Persons with Disabilities’ in Bernadette McSherry and Penelope Weller (eds), Rethinking Rights-based Mental Health Laws (Hart 2010) 151; Gerard Quinn and Abigail Rekas-Rosalbo, ‘Civil Death: Rethinking the Foundation of Legal Personhood for Persons with Disability’ (2016) 56 Ir Jurist 286; Anna Arstein-Kerslake, ‘Challenging the Foundations of Mental Health Law’ (2015) 128 Precedent 32.

55 See McSherry (n 19) 409.

56 Bernadette McSherry and Yvette Maker, ‘Restrictive Practices: Options and Opportunities’ in Bernadette McSherry and Yvette Maker (eds), Restrictive Practices in Health Care and Disability Settings: Legal, Policy and Practical Responses (Routledge 2021) 3.

57 Karien Stronks, Brigit Toebes, Aart Hendriks, Umar Ikram and Sridhar Venkatapuram, ‘Social Justice and Human Rights as a Framework for Addressing Social Determinants of Health’ (World Health Organization 2016).

58 ICESCR (n 11) Arts 2, 9, 10, 11; CRPD (n 11) Arts 24, 28. See also Drew et al (n 17).

59 Kenyon, Forman and Brolan (n 43) 8.

60 Hunt, ‘Missed Opportunities’ (n 10) 39; Rasanathan, Norenhag and Valentine (n 35) 54.

61 Wildeman (n 8) 51; see also Meier (n 21) 37.

62 Hunt, ‘Missed Opportunities’ (n 10) 40.

63 See eg Optional Protocol to the Convention on the Elimination of All Forms of Discrimination against Women (opened for signature 10 December 1999, entered into force 22 December 2000) 2131 UNTS 83.

64 Optional Protocol to the Convention on the Rights of Persons with Disabilities (opened for signature 30 March 2007, entered into force 3 May 2008) 2518 UNTS 283 art 6.

65 Hunt, ‘Missed Opportunities’ (n 10); Lisa Cosgrove, Zenobia Morrill, Justin M Karter, Evan Valdes and Chia-Po Cheng, ‘The Cultural Politics of Mental Illness: Toward a Rights-based Approach to Global Mental Health’ (2021) 57(1) Commun Mental Health J 3.

66 Kenyon, Forman and Brolan (n 43) 3.

67 CRPD (n 11) art 4(3).

68 Rasanathan, Norenhag and Valentine (n 35) 55; Cosgrove et al (n 65).

69 S Gruskin, EJ Mills and D Tarantola, ‘History, Principles, and Practice of Health and Human Rights’ (2007) 370/9585 Lancet 453, cited by Rasanathan, Norenhag and Valentine (n 35); Pūras Report 41/34 (n 13); Haigh et al (n 18).

70 Chapman (n 18) 256.

71 Rasanathan, Norenhag and Valentine (n 35) 50–51.

72 Ibid 52.

73 John Coggon, ‘Legal, Moral and Political Determinants within the Social Determinants of Health: Approaching Transdisciplinary Challenges through Intradisciplinary Reflection’ (2020) 13(1) Publ Health Ethics 41, 42, citing Lawrence Gostin et al, ‘The Legal Determinants of Health: Harnessing the Power of Law for Global Health and Sustainable Development’ (2019) 393 The Lancet 1857–1910.

74 Chapman (n 18) 256; Rasanathan, Norenhag and Valentine (n 35) 51, 55.

75 George Engel, ‘The Need for a New Medical Model: A Challenge for Biomedicine’ (1977) 196(4286) Science 129; Linda Gask, ‘In Defence of the Biopsychosocial Model’ (2018) 5 The Lancet Psychiatry 548.

76 Pūras Open Statement (n 28). See also Chapman (n 50) 248–82.

77 Dinesh Bhugra, Allan Tasman, Soumitra Pathare, Stefan Priebe, Shubulade Smith et al, ‘The WPA-Lancet Psychiatry Commission on the Future of Psychiatry’ (2017) 4 Lancet Psychiatry 775, 789.

78 American Psychological Association, ‘Impact – APA and APA Services Inc Strategic Plan’ (2019) 7 <https://www.apa.org/about/apa/strategic-plan/impact-apa-strategic-plan.pdf> accessed 5 July 2023.

79 Rasanathan, Norenhag and Valentine (n 35) 56, noting the challenges of bringing together the different approaches.

80 Chapman (n 18) 248–82.

81 Thomas R Cech and Gerald M Rubin, ‘Nurturing Interdisciplinary Research’ (2004) 11(12) Nat Struct Mol Biol 1166, 1166.

82 Louise Byrne, Brenda Happell and Kerry Reid-Searl, ‘Risky Business: Lived Experience Mental Health Practice, Nurses as Potential Allies’ (2017) 26(3) Int J Mental Health Nurs 285.

83 Bernadette McSherry, ‘Inter-Disciplinary Collaboration in the Mental Health Sector: The Role of Law’ in Brendan Kelly and Mary Donnelly (eds), Routledge Handbook of Mental Health Law (Routledge Forthcoming). <https://www.routledge.com/Routledge-Handbook-of-Mental-Health-Law/Kelly-Donnelly/p/book/9781032128375>

84 Catherine Lyall, Being an Interdisciplinary Academic (Palgrave Macmillan 2017).

85 Ibid; See also Coggon (n 73).

86 Marija Trachtenberg, Michael Parsonage, Geoff Shepherd and Jed Boardman, ‘Peer Support in Mental Health Care: Is it Good Value for Money?’ (Centre for Mental Health 2013).

87 CRPD (n 11) art 4(3).

88 Chapman (n 18) 257.

89 Ibid 252, 257–59; World Health Organization (n 8) 12.

90 Pūras Special Report 44/48 (n 15).

91 See also Vikram Patel, Crick Lund, Sean Hatherill, Sophie Plagerson, Joanne Carrigall, Michelle Funk and Alan J Flisher, ‘Mental Disorders: Equity and Social Determinants’ in Erik Blas and Anand Sivasankara Kurup (eds), ‘Equity, Social Determinants and Public Health Programmes’ (World Health Organization 2010) 115–76; World Health Organization, ‘Investing in Mental Health: Evidence for Action’ (2013) <http://apps.who.int/iris/bitstream/handle/10665/87232/9789241564618_eng.pdf?sequence=1&isAllowed=y> accessed 5 July 2023.

92 World Health Organization (n 8) 152.

93 Ibid 200; Pūras Special Report 70/213 (n 28); Pūras Special Report 74/174 (n 28); Pūras Report 75/163 (n 13).

94 World Health Organization (n 8) 205–206.

95 Ian Freckelton, ‘Scholarship in Psychiatry, Psychology and Law 1985–2020’ (2020) 27(3) Psychiatry, Psychology and Law 333, 333.