Kirkbride et al¹ provide convincing evidence of a causal relationship between social determinants and poorer mental health outcomes. The extent, complexity and prevalence of these determinants could lead to hopelessness at the prospect of addressing the inequalities and inequities involved. However, the authors instil hope and optimism by providing examples of interventions delivered at the family, school, neighbourhood or societal level that have been effective in primary prevention. They then offer seven key recommendations for action by mental health professionals, policy makers and researchers to prevent or reduce mental health problems that arise from social determinants. All these recommendations warrant further discussion. However, I will focus on two: the need to prioritize interventions providing positive outcomes across multiple domains, and the demand to utilize the causal architecture approach in psychiatric epidemiology.

Kirkbride et al propose that mental health outcomes should be evaluated in any policy, programme or intervention targeting social determinants. This would be a highly informative and beneficial endeavour. However, while achievable, it would require a significant shift in how research is conducted, and would involve establishing and maintaining relationships and collaborations across multiple disciplines, faculties and departments. The benefits would be reciprocal, as the functional outcomes of education, employment, housing and diversion from the criminal justice system are likely to be very meaningful from the viewpoint of several stakeholders. This action would also entail that mental health clinicians and researchers have a role in advocacy at a government level, as any policy that affects the key social determinants will have a knock-on effect on mental health at a population level.

However, clinicians are already overburdened with the high prevalence of mental disorders, and academics need to be continuously productive in a highly competitive environment for grants and fellowships. The benefits of this approach would take years to realize and can be challenging to evaluate directly. Therefore, those time-consuming endeavours of across-discipline collaborations and advocacy would need to be acknowledged by the authorities and institutions that award grants and promotions, as some are already doing.

Kirkbride et al call for the causal architecture approach to be used in psychiatric epidemiology, as this would lead to an understanding of the pathways between one or more exposures and the disease/disorder. This approach could result in the identification of modifiable risk factors and inform where interventions should be targeted. The mechanisms by which social determinants contribute to the aetiology of mental disorders are likely to be complex and could also differ amongst individuals. For example, in the case of childhood adversity and trauma, the experience itself of being the victim of abuse or adversity could lead to subsequent mental health problems, but, additionally, the manner by which individuals are supported (or not supported) by their family and loved ones, as well as by the legal or medical system, could also be involved in the pathway². Another example of a likely complex relationship is that between low income and poor mental health, since socioeconomic differentials as well as psychological perceptions and self-esteem, in addition to an absolute lack of material resources, may lead to a higher risk of experiencing a mental disorder³.

Another key aspect of the causal architecture approach is that the sampling should be from a representative population. As the authors rightly point out, there is a relative lack of research in lower- and middle-income countries, despite these countries representing over 80% of the world's population⁴. There have been recent endeavours to undertake methodologically robust epidemiological studies in the Global South. In one such study, the incidence of untreated psychotic disorders was found to be three times higher in Northern Trinidad compared to both the Kancheepuram district in India and Ibadan in Nigeria⁵. The incidence rate observed in Northern Trinidad (59.1 per 100,000) would have ranked as the third highest if considered in a previous meta-analysis including 44 estimates of the international incidence of psychotic disorders⁶. Both substance use and levels of community violence and crime have increased markedly in Trinidad in recent years. This suggests that there are settings in which the potential for primary prevention of psychotic disorders by targeting social determinants could be particularly high.

It is also worth considering the proportion of mental disorders that interventions targeting social determinants could prevent. Population attributable fractions have been estimated to be nearly 38% for childhood adversity and just under 10% for cannabis use in schizophrenia, and to be 13.4% for childhood sexual abuse in depression⁷. This is in keeping with the call by Kirkbride et al for social determinants to be fully integrated into the bio-psycho-social model of mental health and illness. It also highlights that primary prevention strategies aimed at social determinants could reduce the incidence of mental disorders but not eradicate them. Considering this, while Kirkbride et al focus on primary prevention, social determinants could also inform improvements and advancements in secondary prevention.

To ensure an equitable allocation of resources, a secondary prevention strategy could be the determination of resourcing and funding of services on the basis of the geographic prevalence of social determinants, such as social deprivation, fragmentation and rates of migrants and minority ethnic groups. Indeed, it has been demonstrated that the incidence of psychotic disorders can be reliably predicted based on the prevalence of social determinants in geographically defined areas resulting from census data⁸. Yet, the majority of mental health services continue to be funded on a per capita basis. There are also inequalities and inequities for certain groups in accessing treatments; for example, individuals from racial and minority ethnic groups are less likely to be referred to or receive psychological interventions in the UK⁹. This unequal distribution of resources and these barriers to accessing services need to be addressed alongside the efforts for primary prevention.

The call to action by Kirkbride et al is ambitious, but its goals are achievable. It can help to address the underlying inequalities and inequities within our societies that contribute to the development of mental health problems and may sustain them across further generations.

Kirkbride 等人¹提供了令人信服的证据，证明社会决定因素与较差的心理健康结果之间存在因果关系。这些决定因素的范围、复杂性和普遍性可能导致解决所涉及的不平等和不公平问题的前景无望。然而，作者通过提供在家庭、学校、社区或社会层面实施的、在初级预防中有效的干预措施的例子，给人们灌输了希望和乐观情绪。然后，他们提出了七项关键建议，供心理健康专业人员、政策制定者和研究人员采取行动，以预防或减少社会决定因素引起的心理健康问题。所有这些建议都值得进一步讨论。然而，我将重点关注两个：需要优先考虑在多个领域提供积极成果的干预措施，以及需要在精神病学流行病学中利用因果结构方法。

Kirkbride 等人提出，任何针对社会决定因素的政策、计划或干预措施都应评估心理健康结果。这将是一次信息丰富且有益的努力。然而，虽然可以实现，但它需要研究的进行方式发生重大转变，并且需要建立和维持跨学科、院系和部门的关系与合作。好处是互惠的，因为从多个利益相关者的角度来看，教育、就业、住房和从刑事司法系统转移的功能结果可能非常有意义。这一行动还要求心理健康临床医生和研究人员在政府层面的宣传中发挥作用，因为任何影响关键社会决定因素的政策都会对人口层面的心理健康产生连锁反应。

然而，精神障碍的高患病率已经让临床医生不堪重负，学术界也需要在资助和奖学金竞争激烈的环境中不断提高生产力。这种方法的好处需要数年时间才能实现，并且直接评估可能具有挑战性。因此，那些耗时的跨学科合作和宣传工作需要得到授予赠款和晋升的当局和机构的认可，正如一些机构和机构已经在做的那样。

Kirkbride 等人呼吁在精神病学流行病学中使用因果结构方法，因为这将有助于了解一种或多种暴露与疾病/紊乱之间的途径。这种方法可以识别可改变的风险因素，并告知干预措施的目标。社会决定因素导致精神障碍病因的机制可能很复杂，而且个体之间也可能有所不同。例如，在童年逆境和创伤的情况下，成为虐待或逆境受害者的经历本身可能会导致随后的心理健康问题，但此外，个人得到家庭支持（或不支持）的方式亲人以及法律或医疗系统也可能参与途径²。另一个可能复杂关系的例子是低收入和心理健康状况不佳之间的关系，因为社会经济差异以及心理认知和自尊，除了物质资源的绝对缺乏之外，可能会导致经历心理健康问题的更高风险。紊乱³．

因果架构方法的另一个关键方面是抽样应该来自代表性人群。正如作者正确指出的那样，中低收入国家的研究相对缺乏，尽管这些国家的人口占世界人口的 80% 以上⁴。最近，人们努力在南半球开展方法学上可靠的流行病学研究。在一项此类研究中，发现特立尼达北部未经治疗的精神障碍发病率是印度 Ka​​ncheepuram 地区和尼日利亚伊巴丹地区的三倍⁵。如果考虑之前的荟萃分析（包括对国际精神障碍发病率的 44 项估计），北特立尼达观察到的发病率（每 100,000 人 59.1 例）将排在第三位。⁶。近年来，特立尼达的药物使用以及社区暴力和犯罪水平均显着增加。这表明，在某些情况下，通过针对社会决定因素来一级预防精神障碍的潜力可能特别高。

还值得考虑针对社会决定因素的干预措施可以预防的精神障碍比例。据估计，儿童期逆境的人口归因分数接近 38%，精神分裂症的吸食大麻的人口归因分数略低于 10%，抑郁症的儿童性虐待的人口归因分数为 13.4% ⁷。这符合 Kirkbride 等人的呼吁，即将社会决定因素完全纳入心理健康和疾病的生物心理社会模型中。它还强调，针对社会决定因素的初级预防策略可以减少精神障碍的发生率，但不能根除它们。考虑到这一点，虽然 Kirkbride 等人关注一级预防，但社会决定因素也可以为二级预防的改进和进步提供信息。

为了确保资源的公平分配，二级预防战略可以根据社会决定因素的地理普遍性（例如社会剥夺、分裂以及移民和少数民族群体的比率）来确定服务的资源和资金。事实上，已经证明，根据人口普查数据得出的地理界定区域中社会决定因素的流行情况，可以可靠地预测精神障碍的发病率⁸。然而，大多数精神卫生服务仍然按人均提供资金。某些群体在获得治疗方面也存在不平等和不平等；例如，在英国，来自种族和少数族裔群体的个人不太可能被转介或接受心理干预⁹。这种资源分配不均和获取服务的障碍需要与初级预防一起解决。

柯克布赖德等人的行动呼吁雄心勃勃，但其目标是可以实现的。它可以帮助解决我们社会内部潜在的不平等和不平等问题，这些不平等和不平等现象会导致心理健康问题的发展，并可能在后代中持续存在。