Social Determinants of Health (SDOH), the 4th Realm of Healthcare
November 11, 2020April 10, 2024
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Social Determinants of Health (SDOH), the 4th Realm of Healthcare

Communities across the United States are looking for better ways to manage mental and behavioral health disorders, with the recognition that social determinants of health (SDOH) are inextricably linked with an individual’s mental health status. This is particularly true among individuals with comorbid medical conditions. Broadly put, SDOH represent the complex political, socioeconomic, and cultural circumstances into which individuals are born and live their lives, that impact health and well-being. The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) stress that effective chronic disease management must address the physical or built environment; access to healthcare, education, transportation, and nutrition; and social support and safety in tandem with medical care to have a substantive and sustained impact on healthcare and health outcomes. SDOH not only contribute to the development of obesity, diabetes, hypertension, heart disease, and depression, among many other diseases, but also stratify our communities, further contributing to health inequities and emotional distress. These elements, in turn, become risk factors for chronic disease, feeding this vicious cycle.

Poverty, food insecurity, housing instability, social isolation, racial inequity, and low health literacy, among other factors, challenge an individual’s ability to achieve and maintain strong mental and behavioral health. Persons with untreated behavioral health conditions and chronic conditions often have much poorer prognoses than when behavioral health conditions are well managed.
The State of Mental Health in the US
Mental health disorders, including depression, substance use disorder, anxiety, etc., account for over 1/3 of all disease in the United States1. Approximately 50% of all US citizens will experience a mental health issue in their lifetime, and more than 1/5 of adults are currently being treated for a mental health condition. Compared with other developed countries, adults in the US are twice as likely to be diagnosed with a mental health disorder. There is no question that the state of mental health in the US is in crisis.
A common framework for understanding holistic health care is the “health triangle,” which presumes that balanced social, physical, and emotional/mental health are required to improve overall health. One of the first steps to achieve this is capturing SDOH data which not only underly and impact both the mental and physical health of an individual but must themselves be addressed in order to realize the impact of clinical interventions. It is difficult to maintain a healthy diet, exercise, or take daily medications when safe housing is a concern. It is difficult to address obesity, heart disease, or depression living in a food desert without public transportation.
Healthcare and public health communities are realizing that SDOH have profound and complex effects on an individual’s physical and mental health. People experience better outcomes when providers—and community leaders—ensure that SDOH interventions are part of a larger strategy. The ability to integrate SDOH data into case management at the population and patient level has been effective in improving healthcare quality, health outcomes and patient satisfaction, and reducing cost. SDOH data can be combined with risk algorithms such as the Johns Hopkins ACGs and other prospective risk scores as well as healthcare utilization data to identify the SDOH impact on a patient’s medical condition and risk of future use.
It is important to remember that mental health and SDOH must be considered essential components of complex care management to truly impact health. As we work to improve the care of the whole person, and ultimately our communities, adopting a holistic approach is essential. Healthcare, payer, and public health organizations which take a comprehensive, patient-centered approach to health IT, integrating behavioral/mental health, medical care, and SDOH data can best help our most vulnerable residents.