Inequality makes a difference when it comes to mental health and illness. – Psychology Today

Report on the Socioeconomic Determinants of Mental Health and Their Implications for Sustainable Development Goals

1.0 Introduction: Historical Context and Alignment with SDG 3

A foundational 1958 study, “Social Class and Mental Illness,” by sociologist August Hollingshead and psychiatrist Fritz Redlich, provided seminal evidence on the social determinants of mental health. This report re-examines their findings through the lens of the United Nations Sustainable Development Goals (SDGs), primarily focusing on SDG 3 (Good Health and Well-being) and SDG 10 (Reduced Inequalities). The original study’s interdisciplinary social psychiatry approach, which aimed to identify social factors to prevent mental illness, aligns directly with the holistic and preventative principles embedded within the 2030 Agenda for Sustainable Development.

2.0 The New Haven Study: Methodology and Social Stratification

The research, conducted in New Haven, Connecticut, analyzed the relationship between social class and the prevalence and treatment of mental illness. This investigation is a critical historical precedent for understanding the challenges in achieving universal health coverage and well-being.

2.1 Social Class Framework

The study categorized the New Haven population into a five-tier class structure based on factors including ancestry, wealth, ethnicity, religion, race, and education. This stratification highlights the multifaceted nature of inequality, a central concern of SDG 10, which seeks to reduce inequality within and among countries.

1. Tier I: Wealthy families with lineage dating to pre-Revolutionary times.
2. Tier II-IV: Intermediate classes with varying levels of wealth and social standing.
3. Tier V: Low-income individuals, including immigrants and marginalized groups, reflecting challenges related to SDG 1 (No Poverty).

3.0 Key Findings: The Impact of Inequality on Mental Health Outcomes

The study’s findings revealed stark disparities in mental health outcomes across social strata, underscoring the profound impact of socioeconomic inequality on public health.

3.1 Prevalence of Mental Illness

A significant correlation was found between lower social class and a higher incidence of mental illness. Individuals in the lowest tier (Tier V) were three times more likely to be diagnosed with a mental illness than those in the top two tiers. This disparity represents a major barrier to achieving SDG 3.4, which aims to promote mental health and well-being for all.

3.2 Inequities in Diagnosis and Treatment Pathways

The research documented systemic inequities in how mental illness was diagnosed and treated, demonstrating a failure to provide equitable access to care, a core principle of the SDGs.

• Diagnostic Bias: Lower-class individuals were more likely to be diagnosed with psychoses, while upper-class individuals were more often diagnosed with neuroses.
• Referral Systems: Patients from lower socioeconomic backgrounds were frequently referred for mental health services through the justice system, rather than medical channels, highlighting institutional barriers relevant to SDG 16 (Peace, Justice and Strong Institutions).
• Treatment Disparities: A clear class divide existed in treatment modalities. Upper-class patients typically received psychotherapy from private psychiatrists, whereas lower-class patients in state hospitals were often prescribed drugs, electroconvulsive therapy, or lobotomies. This unequal access to quality care is a direct contradiction of the goals outlined in SDG 3.

4.0 Contemporary Relevance and Economic Implications

The core findings of the New Haven study have been consistently corroborated by modern research, such as the 2009 book The Spirit Level, which reaffirmed that inequality is detrimental to mental health. The introduction of factors like structural racism further exacerbates these health disparities, making the pursuit of SDG 10 even more critical.

4.1 The Economic Burden of Inaction

Recent estimates place the economic cost of mental illness in the United States at $282 billion annually, accounting for direct care costs and lost productivity. This significant economic impact undermines progress toward SDG 8 (Decent Work and Economic Growth) and reinforces the urgent need for proactive, preventative strategies that address the root social causes of mental illness.

5.0 Conclusion: A Call to Action for Integrated Policy

The enduring legacy of the Hollingshead and Redlich study is its clear demonstration that mental health cannot be separated from social and economic conditions. To make meaningful progress on SDG 3 (Good Health and Well-being), it is imperative to simultaneously address SDG 10 (Reduced Inequalities). A sustainable and effective public health strategy must focus on reducing socioeconomic disparities and ensuring equitable access to quality mental healthcare for all, thereby fulfilling the foundational SDG principle of “leaving no one behind.”

Analysis of SDGs, Targets, and Indicators

1. Which SDGs are addressed or connected to the issues highlighted in the article?

• SDG 3: Good Health and Well-being: The article’s central theme is the prevalence of mental illness and the disparities in mental health care, directly aligning with the goal of ensuring healthy lives and promoting well-being.
• SDG 10: Reduced Inequalities: The article explicitly links social class, race, and ethnicity to mental health outcomes, arguing that inequality is a primary driver of the mental illness burden. The core conclusion is that reducing inequality is essential for improving mental health.
• SDG 1: No Poverty: The study described in the article identifies the lowest social class (the “fifth tier”) as consisting of “poor immigrants,” directly connecting poverty with a higher incidence of mental illness and lower-quality care.

2. What specific targets under those SDGs can be identified based on the article’s content?

• SDG 3: Good Health and Well-being

  • Target 3.4: By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being. The article’s focus on the “mental illness burden,” its social determinants, and the need for prevention aligns directly with this target’s aim to promote mental health.
  • Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services… The article highlights severe disparities in access to mental health care, noting that lower-class individuals were less likely to seek care and received vastly different, often more invasive, treatments (drugs, ECT, lobotomies) compared to the psychotherapy offered to the upper class. It also mentions “cuts to public health care, diminishing access to mental health care” as an exacerbating factor.

• SDG 10: Reduced Inequalities

  • Target 10.2: By 2030, empower and promote the social, economic and political inclusion of all, irrespective of… race, ethnicity… or economic or other status. The article describes a rigid class system in New Haven built on “ancestry, wealth, ethnicity, religion, race, and education,” where those in lower tiers faced significant disadvantages in mental health outcomes, demonstrating a lack of social inclusion in health.
  • Target 10.3: Ensure equal opportunity and reduce inequalities of outcome… The stark finding that “people in the fifth tier were three times more likely to be diagnosed with a mental illness” is a clear example of an inequality of outcome based on social class. The different treatment paths for rich and poor also represent a failure to ensure equal opportunity for quality care.

• SDG 1: No Poverty

  • Target 1.3: Implement nationally appropriate social protection systems and measures for all… and achieve substantial coverage of the poor and the vulnerable. The article identifies the poorest group (“fifth tier”) as the most vulnerable to mental illness and inadequate care. Addressing their situation would require social protection systems that integrate health and economic support, as implied by the article’s call to tackle inequality.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

• Indicators for SDG 3

  • Prevalence of mental illness by socioeconomic group: The article provides a direct metric: “People in the fifth tier were three times more likely to be diagnosed with a mental illness than those in tiers one or two.” This can be used as an indicator to track the mental health gap between different social classes.
  • Disparities in the type of mental health treatment received: The article contrasts the treatments given to different classes (“psychotherapy by private psychiatrists” for the upper class versus “drugs, electroconvulsive therapy, or even lobotomies” for the lower class). This qualitative data serves as an indicator of unequal access to quality care.
  • Economic cost of mental illness: The article quantifies the economic burden at “$282 billion per year (including both the direct cost of care and lost productivity).” This figure can be used as a high-level indicator of the overall societal impact of mental illness.

• Indicators for SDG 10

  • Ratio of mental illness diagnosis between the highest and lowest income/social groups: The “three times more likely” statistic is a direct indicator of health outcome inequality.
  • Differences in referral pathways for mental health services: The article notes that lower-class individuals “tended to be referred for mental health services via the courts, rather than other medical services,” which is an indicator of systemic inequality in how different social groups enter the healthcare system.

• Indicators for SDG 1

  • Proportion of the population diagnosed with mental illness living below the national poverty line: While not providing a specific number, the article’s strong link between the “fifth tier” (described as poor) and high rates of mental illness implies that this would be a relevant indicator to measure the intersection of poverty and health vulnerability.

4. SDGs, Targets, and Indicators Table

Source: psychologytoday.com