Social factors have an important impact on the onset of and recovery from mental illness¹. Where individuals live, how they live and what factors impinge on their living, including their access to nutrition, to housing, to recreation, as well as their pattern of interactions with other people around them, have consequences and relevance for their emotions and behaviours.

The fact that humans are social beings implies that, for most people, well-being depends on the totality of the social environment in which they live. It is useful and informative that research has sought to disaggregate the components of that environment and focus attention on specific aspects. But the reality is that not one social factor can exert its impact on health, including mental health, without the influence of several other factors. Indeed, in poor or low-resourced communities, where the living context is marked by multiple deprivations and interconnected social, physical and mental health problems, as well as by the intergenerational transmission of those syndemics², the particular role of a given social factor in the onset or course of a mental health condition is difficult to isolate clearly. An acknowledgement of this conceptual complexity is therefore necessary, although the practical necessity of focusing on particular aspects as if they were operating in isolation is understandable.

As highlighted in the paper by Kirkbride et al¹, the available body of knowledge suggests that the link between social factors and mental illness is rarely direct, even when factors as easily understood as poverty and economic disadvantage are those of interest. Furthermore, much of the evidence exploring the relationships of social factors with mental health has been provided by studies conducted in the Global North. Widening our exploration to diverse social, economic and cultural settings is likely to deepen our understating. Even though there is now a growing interest in the topic in the Global South³, studies with a focus on the social determinants of mental health from low- and middle-income countries need to be pursued more vigorously.

Social factors exist and manifest within cultural and traditional milieus. For example, while the relationship between gender equality and the gender-patterning of the distribution of some men-tal disorders is complex, culture may be an important driver of this complexity. Actually, the traditional and cultural position of women is relevant to whether gender inequality will be an important determinant of the distribution of some mental disorders. Cultural variations also exist in the way that families are composed, in the social position of the young and the elderly, and in the organization of and power distribution within households.

The fact that some of these social factors are also undergoing rapid changes in many countries, especially in low- and middle-income ones, introduces another layer of complexity to the relationship between social factors and health in general, and mental health in particular. In many countries, the traditional composition of families is changing from extended to nuclear, and so is the status of the elderly. Some of these changes are being driven by economic pressures as well as by unrelenting, and sometimes unplanned, urbanization. In these contexts, the urban drift of the young is leaving many elderly persons behind in towns and villages, increasing their risk of isolation and loneliness⁴. For such elderly persons, rural living is no longer a haven of serenity and peace, but rather a source of neglect and alienation.

The interpretation of the links between social factors and mental illness is further complicated by differences between objective and subjective assessments. In fact, the ambiguity of the findings concerning the link between low income and common mental disorders may be due to the fact that relative rather than absolute poverty is a predictor of mental illness when other factors are taken into account⁵. A similar caveat is required when interpreting the association between subjective or relative social status and mental health⁶. Indeed, one could argue that this is the basis of the paradoxical finding, in a number of population surveys, of a lower prev-alence of mental disorders in poorer than in richer countries. The meaning attached to a social factor or circumstance by an individual can be presumed to, at least in part, determine what coping and adaptation mechanisms will be available and deployed to meet adversities and other challenges to mental health.

Social factors are as important to the causation of mental disorders as they are to the recovery from them. The immediate source of support in times of ill health is often the family. The composition and size of a household are culturally determined, and are relevant to the immediacy of the availability of support to an individual when in need. In some communities, the relevant social network may also include non-family groups such as those available in places of worship and markets⁷. It is possible that these social groups pose challenges to an individual's mental health just as they may be available to provide various forms of instrumental and emotional support to help mitigate the effects of adversities. Whether the risks posed by a particular social network to the mental health of an individual outweigh the potential benefits may be related to the complex interplay of a variety of social and cultural factors.

What is the role of the understanding of social determinants of mental illness for planning of evidence-based interventions? Our understanding of the neurobiology of psychiatric conditions remains limited, in spite of the great strides in the study of the brain. Preventing or treating mental disorders continues to rely on blunt biopsychosocial tools that are limited in their capacity to deliver contextualized approaches. It is therefore evident that, as we seek to have a broader and deeper understanding of social determinants of mental health⁸, an important focus must be the need to design interventions that include context-informed social prescribing. That should also be a good fit for comprehensive mental health promotion and prevention strategies⁹.

社会因素对精神疾病的发病和康复有重要影响¹。个人生活在哪里、如何生活以及影响他们生活的因素，包括他们获得营养、住房、娱乐的机会，以及他们与周围其他人的互动模式，都会对他们的情绪和行为产生影响和相关性。

人类是社会动物这一事实意味着，对于大多数人来说，幸福取决于他们所生活的社会环境的整体。研究试图分解该环境的组成部分并将注意力集中在特定方面，这是有用且信息丰富的。但现实情况是，没有任何一种社会因素能够在没有其他几个因素的影响的情况下对健康（包括心理健康）产生影响。事实上，在贫穷或资源匮乏的社区，其生活环境存在多重剥夺和相互关联的社会、身心健康问题，以及这些综合症的代际传播 2 ^，特定的社会因素在精神健康状况的发作或病程很难清楚地隔离。因此，承认这种概念上的复杂性是必要的，尽管关注特定方面的实际必要性是可以理解的，就好像它们是孤立运作的一样。

正如 Kirkbride 等人在论文中强调的那样¹，现有的知识体系表明，社会因素与精神疾病之间的联系很少是直接的，即使贫困和经济劣势等容易理解的因素是人们感兴趣的因素。此外，探索社会因素与心理健康关系的大部分证据都是由在北半球国家进行的研究提供的。将我们的探索扩大到不同的社会、经济和文化背景可能会加深我们的理解。尽管南半球国家现在对这一主题越来越感兴趣³，但仍需要更加积极地开展针对低收入和中等收入国家心理健康社会决定因素的研究。

社会因素存在于文化和传统环境中并表现出来。例如，虽然性别平等与某些精神障碍分布的性别模式之间的关系很复杂，但文化可能是这种复杂性的重要驱动因素。事实上，女性的传统和文化地位与性别不平等是否会成为某些精神障碍分布的重要决定因素有关。文化差异还存在于家庭的组成方式、年轻人和老年人的社会地位以及家庭内部的组织和权力分配方面。

事实上，其中一些社会因素在许多国家，特别是在低收入和中等收入国家也正在经历快速变化，这给社会因素与一般健康、特别是心理健康之间的关系带来了另一层复杂性。在许多国家，传统的家庭构成正在从大家庭转变为核心家庭，老年人的地位也是如此。其中一些变化是由经济压力以及无情的、有时是无计划的城市化推动的。在这种情况下，年轻人的城市流动将许多老年人留在城镇和村庄，增加了他们孤立和孤独的风险⁴。对于这些老年人来说，乡村生活不再是宁静祥和的避风港，而是被忽视和疏远的根源。

由于客观和主观评估之间的差异，对社会因素与精神疾病之间联系的解释变得更加复杂。事实上，有关低收入与常见精神疾病之间联系的研究结果的模糊性可能是由于在考虑其他因素时，相对贫困而非绝对贫困是精神疾病的预测因素⁵。在解释主观或相对社会地位与心理健康之间的关联时，也需要类似的警告⁶。事实上，有人可能会说，这是许多人口调查中得出的一项矛盾的发现的基础，即较贫穷国家的精神障碍患病率低于较富裕国家。可以推测，个人赋予社会因素或环境的意义至少部分地决定了可以使用和部署哪些应对和适应机制来应对逆境和其他心理健康挑战。

社会因素对于精神障碍的病因和从精神障碍的康复中同样重要。当健康不佳时，最直接的支持来源往往是家庭。家庭的组成和规模是由文化决定的，并且与个人在需要时能否立即获得支持有关。在一些社区中，相关社交网络还可能包括非家庭群体，例如礼拜场所和市场中的群体⁷。这些社会群体有可能对个人的心理健康构成挑战，就像他们可以提供各种形式的工具和情感支持以帮助减轻逆境的影响一样。特定社交网络对个人心理健康造成的风险是否超过潜在的好处可能与各种社会和文化因素的复杂相互作用有关。

了解精神疾病的社会决定因素对于规划循证干预措施有何作用？尽管大脑研究取得了巨大进步，但我们对精神疾病的神经生物学的理解仍然有限。预防或治疗精神障碍仍然依赖于生硬的生物心理社会工具，这些工具在提供情境化方法方面的能力有限。因此，很明显，当我们寻求对心理健康的社会决定因素有更广泛和更深入的了解时⁸，一个重要的重点必须是设计干预措施，包括基于背景的社会处方。这也应该非常适合全面的心理健康促进和预防战略⁹。