From antiquity to modernity

Greek medicine was deeply influenced by philosophy, which flourished in the 5^th and 4^th centuries BCE. Philosophers were aware of the role of social factors in mental and medical health. They advocated for a balanced lifestyle, mental and physical fitness, which they considered vital components of a well-lived life. In the Republic, Plato (427-347 BCE) wrote that a just society creates conditions enabling its citizens to function according to their abilities and to contribute to the harmonious function of the community (Plato, 1989). He thought that society should cultivate the intellectual and moral faculties of its members, encourage a healthy lifestyle, and promote civic responsibility. Plato’s concern for psychological development as a powerful contributor to well-being is dramatized in the Chariot Allegory in Phaedrus, which is reminiscent of Freud’s ego, id, and superego psychological model (Plato, 1995). In this allegory, a charioteer, who represents the rational part of the “soul”, drives two horses. One horse is disciplined and dutiful, while the other horse is impulsive and represents primitive urges and appetites. The charioteer tries to control the horses and steers the chariot toward “wisdom”, the ultimate level of mental health and personal growth. Plato’s writings reflect an awareness that conditions surrounding the individuals’ development, lifestyle, work, and aging influence their mental well-being.

Aristotle’s (384-322 BCE) writings reveal an understanding of the impact of social factors on mental and physical well-being. In Politics, he argued that the city state (polis, πολιs) is the highest form of association, made possible by the human need to form cohesive social relationships (Aristotle, 1999). He thought that individuals are political animals (homo politicus) who can only realize their full potential by participating in society. Aristotle argued that education was important for the intellectual and moral growth of virtuous citizens. Throughout Politics, he emphasized the need for balance, justice, and avoidance of social inequality that promotes instability and threatens the well-being of citizens. In Nicomachean Ethics, Aristotle wrote that the ultimate good for an individual should be the pursuit of eudemonia (εὐδαιμονία) that is the flourishing and achieving one’s full potential (Aristotle, Reference Alexopoulos2004). Morality, according to Aristotle, is not inborn but developed with education and repeated virtuous acts. His concepts of eudemonia, his doctrine of means (balance between extremes in thought and action), and his urging to participate in social affairs reveal a holistic view of mental and medical health and underscore the importance of embeddedness of the individual in society.

Rationalism (ορθολογισμός) of the 5^th and 4^th centuries BCE enabled Greek medicine to break away from superstition and led to the recognition of biological dysfunction as the cause of disease. The two dominant medical schools in classic Greece, the school of Cnidus (Euryphon, Acesius) and the school of Kos (Hippocrates), relied on careful clinical observation, longitudinal review of symptoms and signs after a medical intervention, and critical thinking in interpreting clinical findings. Hippocrates had studied under the philosophers Democritus and Gorgias. Following the naturalistic philosophy of Democritus, Hippocrates rejected the divine causation of diseases and proposed a biological causation exemplified in his humoral hypothesis. On the causation of epilepsy, he wrote: “People think that epilepsy is divine simply because they do not know what causes epilepsy. But I believe that someday we will understand what causes epilepsy, and at that moment, we will cease to believe that it is divine. And so it is with everything in the universe”. Hippocrates’s focus on rational interpretation of clinical findings reflects Gorgias’s teaching on critical syllogism. In “Airs, Waters, and Places” Hippocrates discussed the impact of the environment on health (Hippocrates 1994). He recognized that geographical and climatic factors, as well as the quality of air and water, could influence the occurrence of diseases. Ancient Athens developed public health policies for disease prevention including the provision of clean water, sewage, and control of waste. A holistic philosophy of health encouraged mental and spiritual development, physical fitness, and proper diet, reflecting an understanding of the interconnectedness of the body with the physical, social, and cultural environment.

The medical and public health discoveries of the Greek classical era continued to be applied and expanded during the Hellenistic and the Roman periods and there have been additional accomplishments by Muslim (e.g., Avicenna) and Jewish (e.g., Maimonides) thinkers and physicians. Novel concepts on the SDoMMH emerged during the 17^th and 18^th centuries inspired by reason and by the emerging science. Hobbes’s Leviathan (1651) was one of the early writings on the social contract theory (Warrender, Reference Warrender2000). Hobbes viewed individuals as minding their interests without regard of the need of others. His “state of nature” was a hypothetical way of life prior to the formation of society in which every individual was in war of all against all, a “summum malum”. The need to avoid the dangers of the “state of nature” led to the formation of a commonwealth in which individuals surrender the right of governing themselves to a man or to an assembly who could create order and control aggression. Unlike Hobbes, the physician and philosopher Locke (1632-1707) believed that human nature is characterized by selfishness but also by reason and tolerance. A government established with consent of people should protect the people’s rights to life, liberty, and property and people should be able to withdraw their consent if the government fails to protect their rights (Locke, Reference Locke1998). Rousseau in The Social Contract (1762) wrote that the foundation of a just society must be based on a mutual agreement among individuals to form a community. Based on its voluntary nature, this community is best suited to mind for the rights and the well-being of its individual members (Rousseau, Reference Rousseau1987). The father of modern economics Adam Smith, in The Wealth of Nations (1776), argued that a well-functioning market economy, based on competition and specialization can create the economic prerequisites for social structures that contribute to a healthy lifestyle (Fleischacker, Reference Fleischacker2004). These philosophical views had a profound impact on the principles of the American Constitution and on the thinkers and leaders of the French Revolution.

Nineteenth century

The 19^th century was a time of revolutions throughout Europe, triggered by social inequities and inspired by liberal ideology originating in the 18^th century. The utopian socialist Saint-Simon believed that industrial development is the main engine of social growth and called for a cooperation of workers, industrialists, and scientists (the working class) to end the exploitation of aristocracy (idling class) and to develop a society that cares for the health, the well-being, and the growth of all its members (De Saint Simon, Reference De Saint Simon and Markham1964). He even proposed a secular religion of humanity to promote social harmony and the pursuit of common good. Auguste Comte, a contemporary and friend of Saint-Simon, was the founder of positivism, a philosophy that regards as legitimate knowledge only theories based on empirical observation (Comte, Reference Comte, Commins and Linscott1947). Comte believed that sociology must use an empirical method to understand the role of social structures and institutions (social statics) and of the processes of social change (social dynamics). Comte argued that as society progressed from the theological stage, to the metaphysical, and to the positive (scientific) stage, religious beliefs will be replaced by an ethical system focused on the well-being of people.

Karl Marx (1818-1883) argued that private ownership of the means of production during the industrial revolution concentrated the wealth and power in the hands of a few who resist redistribution and leads to an ever-increasing impoverished class. Marx introduced the concept of alienation of workers from the production process (Marx, Reference Marx and Tucker1844). Alienation creates a sense of estrangement from work, burnout, purposelessness, frustration, and chronic stress with adverse effects on mental and medical health. It also damages the workers’ self-esteem, strains their relationships with others, and promotes isolation, anxiety, depression, and alcohol and substance abuse. Unlike Saint-Simon and Comte who were proponents of social cooperation, Marx saw class struggle and revolution as inevitable. The increasing accumulation of capital and power in a few would predictably continue to impoverish the workers, engender their livelihood, and leave no recourse other than revolution.

Rudolf Virchow (1821-1902), the father of modern pathology, a dynamic public health advocate (and my hero), recognized the impact of social, economic, and environmental factors on mental and medical health and became a passionate reformer. He considered social inequality as the cause of diseases and advocated for an active political role of physicians to address it. He said that “medicine is a social science, and politics is nothing else but medicine on a large scale.” (Mackenbach, Reference Mackenbach2009) He suggested that medicine as the science of human beings, has the obligation to point out to problems and to work towards their solution. While working during the 1847-1848 typhus epidemic in Upper Silesia he developed the principles that guided the public health initiative of Germany. He also participated in the 1848 social revolution in Germany and as a consequence he lost his position in Charité university hospital. He started the newspaper Die Medizinische Reform in 1848, which advocated for the involvement of medicine in social reforms addressing inequality and social injustice. His newspaper was forced to close one year later.

Émile Durkheim (1858-1917) was one of the first to link directly positive mental health with social integration and the sense of belongingness in his suicide studies (Durkheim, Reference Durkheim and Simpson1997). He proposed four types of suicide based on the individual’s relationship to community. Egotistic suicide occurs in alienated individuals with weak social bonds. Altruistic suicide is the suicide of individuals excessively connected with their social group as are soldiers who expose themselves to enormous risks to save their comrades. Fatalistic suicide is the suicide of individuals sensitive to oppressive societies who experience a sense of despair. Finally, anomic suicide occurs during periods of social upheaval or disruption during economic crises (e.g., suicides during the crash of 1929) or social change (e.g., suicides after Nazis occupied Vienna). These and many other thinkers during the 19^th century paved the way of what was to come.

From the twentieth century on

After Virchow and Durkheim, there has been a rapid development of concepts related to SDoMMH. Structural inequality received early attention. Structural inequality occurs when an embedded bias in leading organizations and social networks within a culture marginalizes and disadvantages certain groups and create advantages for others. Bias may be related to gender, race, ethnicity, religion, subculture, physical and identity characteristics, and sexual preferences of certain groups within a society. Structural inequality can influence opportunities for financial resources, housing education, employment, family relationships, and personal agency, all strong determinants of mental health. Structural inequality existed in all cultures and was either subtle as in modern western societies or explicit as in ancient cultures. For example, in the 5^th century BCE, the society of enlightened Athens was divided into citizens, metics (μετοικοι) who were free people, mostly immigrants from other city states, and slaves who were captured battle combatants. Only male citizens had the right to vote or hold public office.

The “Critical Theory” advanced by the Frankfurt School (Horkheimer, Adorno, Marcuse) in the mid-1920s focused on structural inequality. A concept central to the Theory is that knowledge and culture have been shaped by the dominant social and political structures at each historical point (Adorno and Horkheimer, Reference Adorno and Horkheimer2016). Using a dialectical analysis of contradictions and tensions within social events, critical theorists explore factors of the prevailing ideology that legitimize power structures and promote alienation, exploitation, and consumerism in western societies. Their analysis seeks to advance the understanding of how one’s beliefs and actions are influenced by societal structures and to promote a public dialogue that encourages self-reflection. The goal of this dialogue is to emancipate individuals from oppressive social conventions and initiate social change. In mental health, critical theorists focus on the role of social and economic policies and social norms that perpetuate poverty, inequality, stigmatization and marginalization, and inhibit access to high quality mental healthcare. They invite attention to the lived experiences of mental health sufferers, advocate for patient-centered care, and for grassroot action to address mental and medical health disparities.

The theory of “communicative action”, advanced by the late member of the Frankfurt School Jurgen Habermas (1929-), regards rational discourse and communication as critical functions in a society aspiring to promote mental health (Habermas, Reference Habermas1984). Social integration can emancipate individuals from oppressive social structures, enable them to realize their potential, and contribute to the growth of healthy individual and collective identities. Access to the “public sphere” (public forum) permits people to participate in economic and social discourse and strengthens their sense of agency. Habermas distinguished the domain of everyday life and interpersonal communication (“lifeworld”) from the domain of instrumental and bureaucratic rationality (“the system”). He argued that everyday lives are penetrated by formal systems such as the development of the corporate capitalism, and mass consumption that tend to “rationalize” and constrict public life. Colonization of the “lifeworld” by the instrumental rationality and by the logic of financial and bureaucratic structures disrupts interpersonal relationships, and promotes alienation and a loss of autonomy for individuals, as they internalize the priorities of the “system”. An “ideal speech” forum is one in which participants have the same capacities of discourse and their views are not confused by ideology or other influences. In this ideal situation, truth is what is agreed upon (consensus theory of truth). However, in real life, public communication is influenced by inequalities in access to the public sphere, money, media, and the manipulation of language for political or economic reasons. These distortions in public communication increase the dominance of the “system” over the “lifeworld” and promote alienation and a sense of powerlessness. Habermas argues that prioritizing the “lifeworld” and increasing meaningful access to the “public sphere” can reduce the influence of power structures, promote new perspectives, foster social progress, and improve the mental well-being of individuals.

Postmodernism, a philosophical movement introduced in the mid-20th century by Lyotard, Foucault, Bartes, Baudrillard, Derrida, Rorty, and others challenged the certainty of the Enlightenment, and rejected “grand theories” (e.g., Hegel’s dialectic of the spirit, psychoanalysis, etc.) that explained the function of the entire world. Postmodernists view knowledge as fragmented by nature and, instead of creating unifying theories, they argue that reality is context-dependent, and its interpretation is influenced by cultural and personal views. Accordingly, postmodernism focuses on the local and the specific, and values individual experiences, and the uniqueness of different contexts. Consistent with this position, postmodernism questions the authority of professionals, experts, and institutions, and exposes their role in creating inequalities compromising the mental well-being of underprivileged groups. Postmoderninsts are concerned about the influence of consumerism and the impact of mass media in shaping individual and group identities. Influenced by structuralism, postmodernists analyze how language is used across cultural expressions and point out how texts are influenced by other texts so that each text has several layers of meaning. Jacques Derrida’s “deconstruction” of language and concepts uncovered binary oppositions, (e.g., light-dark, rational-emotional) in which one of the two terms is privileged over the other (traditionally light and rational are privileged over dark and emotional). The privilege of some ideologies and groups, and marginalization of others have a direct impact on mental growth and well-being of unprivileged individuals.

The Western Marxist Antonio Gramsci drew attention to the cultural hegemony that excludes and displaces specific people and social groups from socio-economic institutions and deny their agency. The postmodernist Michel Foucault (1926-1984) argued that society constructs and maintains social processes related to mental health, which influence how individuals perceive themselves and others (Gutting, Reference Gutting1994). Unlike classical Marxism, Foucault recognized that the force that dominates the prevailing culture at various historical periods is not only exercised by the privileged class but is also disseminated throughout society by a complex network of relationships. Foucault’s “epistemes” are the cultural processes that define what is regarded as valid knowledge during different historical periods. Written and oral dialogues are the vehicles that produce the unconscious subjectivity that shapes the way individuals think of themselves and their place in society in each period. Consequently, the “episteme” of a period defines the boundaries of acceptable knowledge and morality of that period. The sense of individuals that their behavior is public (“panopticon”) leads to self-regulation and constitutes an important vehicle of social control. The concept of “panopticon” is particularly relevant for those with mental disorders who absorb the social role attributed to them and behave accordingly. Epistemes are not static but are transformed over time, marking transitions across successive periods of knowledge. Study of the public dialogue of an era (“archeology”) and following the historical origins of thinking and of institutions (“genealogy”) of that era can reveal the underlying structures of knowledge and transformations of knowledge and its power relations (Gutting, Reference Gutting1989). While the collective culture of each episteme is imposing, disobedience and non-conformity by individuals collectively can challenge the prevailing norms and facilitate change and growth. Accordingly, the role of mental health professionals and activists is to draw attention to social norms that stigmatize and undermine the growth and mental well-being of underprivileged individuals.

A contemporary of the postmodernists, Hannah Arendt (1906-1975) focused on the classical ideals and argued that people can achieve their full potential when they actively participate in political discourse. Her concept is reminiscent of Aristotle’s vitta activa, defined as a life of engagement in the public sphere that encompasses labor, work, and participation in the community. Discrimination, authoritarianism, and lack of opportunities for meaningful social interactions lead to feelings of powerlessness and have an adverse impact on mental well-being. She expressed concern about the decline of the “public sphere”, as consumerism and possession of material goods rather than political and social engagement have eroded the public realm, making it difficult for individuals to engage in meaningful political discourse and action. Arendt’s well-known phrase “banality of evil” refers to the view that evil actions may result from dehumanizing conformity to social conventions and thoughtlessness rather than conscious malevolence (Arendt, Reference Arendt1963).

A foundational philosophy of justice, advanced by John Rawls (1921-2002), addresses the distribution of resources and opportunities in a just society promoting mental health and wellness. Rawls’ “original position” consists of a hypothetical state in which individuals making decisions about justice are behind a veil of ignorance making them unaware of their gender, race, abilities, social and economic conditions, thus, ensuring their impartiality (Rawls, Reference Rawls1971). He, then, proposed two fundamental principles of distributive justice. The Principle of Equal Basic Liberties (The First Principle), which states that individuals should agree to ensure that everyone has equal basic liberties, such as freedom of speech, freedom of thought, and the right to vote. Any inequalities in basic liberties must favor the least advantaged members of society. The Difference Principle (The Second Principle) allows some inequalities in the distribution of resources and wealth but only if they function to the advantage of the least privileged members so that it contributes to a more just society. If a conflict emerges between the First and the Second Principle, the First Principle must prevail. The application of principles of distributive justice is not static but it is transformed by a dynamic process of reflective equilibrium in response to moral intuitions and judgments.

Rawls’s approach to distributive justice was influenced by Kant’s a priori morality and by Hume’s empirical understanding of moral judgment. Inspired by Kant, Rawls sought to establish rational principles dictating distribution of resources. However, he recognizes that the application of moral principles is not only based on reason but also on human emotions, sentiments, and moral intuitions much like Hume had advocated. Rawls introduced the concept of “overlapping consensus” according to which groups with different doctrines on morality, religion, politics, and justice can agree on basic conceptions on which to build basic social institutions while refraining from arguments on philosophical or religious beliefs. “Public reason”, according to Rawls, is a set of standards for engaging in political discourse based on principles that can be endorsed by others in the public sphere, regardless of their normative doctrines. He considers “overlapping consensus” among social groups with differing views as the essence of political liberalism (Rawls, Reference Rawls1993). Rawls’s “property-owning democracy” is a social system that promotes wide distribution of resources offering individuals similar opportunities for economic advancement and political power so that they may cooperate under equal and free relationships and achieve their potential.

The philosopher Martha Nussbaum (1947-) and the economist Amartya Sen (1933-) proposed a “capability approach” to growth and well-being (Nussbaum, Reference Nussbaum2011; Sen, Reference Sen1999). They argue that humans have a basic right to dignity, which enables individuals to make life choices, pursue activities and goals they value, and maximize their internal combined capabilities for development. Access to education, employment, social support, and a safe living environment are integral to personal development. Marginalized populations are traumatized, live under continuous stress, and have limited access to mental healthcare, all of which negatively impact their emotional and intellectual growth and mental health. Education is a key capability because it imparts knowledge, social skills, and strengthens one’s ability to cope with challenges. In addition, education promotes emotional development, social understanding, and empathy - abilities that benefit both the individual and the community. Freedom to make choices and autonomy in shaping one’s life is integral to mental well-being.

The work of the philosopher and political theorist Marion Young (1949-2006) provided a theoretical framework for understanding how social factors and systemic inequalities contribute to disparities in mental health outcomes. Young considered structural injustice the set of social processes that put large categories of persons under a systematic deprivation of the means to develop and exercise their capacities, a concept directly linked to mental health (Young, Reference Young2011). Awareness of justice differs across classes of people so that the evaluation of injustice must recognize the distinct circumstances of specific social groups. Exploitation, marginalization, powerlessness, cultural domination, and violence are five distinct types of oppression that cannot be merged into larger categories and must be separately addressed when considering distributive justice. Young’s “social connection model” of responsibility asserts that each individual contributes to some aspects of social justice (Young, Reference Young2006). Accordingly, everyone who influences the structural processes that promote injustice has a political responsibility to remedy that injustice. The social connection model does not seek to identify and isolate specific liable actors. Instead, it focuses on background conditions that other models may have found acceptable and emphasizes the shared responsibility for systemic inequalities that can be addressed through collective, rather than individual action.

The question of who is systematically deprived is addressed by the “intersectionality theory”, which suggests that individuals have several social identities, e.g., race, gender, class, professional, political identities, etc. that intersect to form a composite identity. This composite identity influences their experience of everyone’s relationship to society (Young, Reference Young1990). Several philosophers focused on the social circumstances in which individuals exist and which have a direct impact on the development of the stories they construct (narratives) to make sense and to create a coherent continuity of their lives. Jean-Paul Sartre said: “A man is always a teller of tales, he lives surrounded by his stories and the stories of others, he sees everything that happens to him through them, and he tries to live his own life as if he were telling a story.” Stigma of mental illness is an important social contributor to the promotion of mental illness. Individuals with propensity for mental disorders are particularly sensitive to stigmatization, which can disrupt one’s ability to create a consistent life story, leading to feelings of disconnection and confusion. Beyond influencing people’s personal narratives and distorting their concept of self, social stigma inhibits the development of a positive and empowering narrative that promotes a sense of agency and facilitates recovery from mental illness. It follows that focusing on the individual’s personal narrative, subjective experiences, and values is a central component of patient-centered approach to mental health care.

The above account outlines some of the landmark philosophical thinking on social factors that influence the health, wellness, and growth of individuals and communities. Many more contemporary thinkers have contributed important concepts that this paper cannot cover.

Epilogue

Mental and physical fitness and a balanced lifestyle were identified as the vehicles for a “well-lived life” in the classical era and remain central concepts in understanding the SDoMMH. The role of government and of the community in enhancing or compromising the well-being of its members received attention during the Enlightenment and was articulated in Rousseau’s Social Contract. In the 19^th century, Marx wrote that the alienation of workers from their product creates a sense of estrangement, purposelessness, and chronic stress with deleterious effects on mental and medical health. At about the same time, Rudolf Virchow, a giant of medicine, drew awareness to the role of social inequality as the cause of mental and medical illnesses and argued that physicians are the natural advocates for the poor and the proponents of social change.

The above ideas have been the foundation of the many new concepts developed in the 20^th century and until present. Structural inequality marginalizing certain groups received early attention. Stigmatization was implicated in inhibiting the development of an empowering personal narrative that promotes a sense of agency and growth. The Frankfurt School analyzed contradictions and tensions within the culture and developed a Critical Theory explicating how power structures foster inequalities damaging personal growth and mental well-being. The theory of Communicative Action argued that the autonomy and personal growth are impeded when instrumental and bureaucratic rationality infiltrates interpersonal communication. Postmodernism’s attention to the “context dependence of reality” offered a novel optic focusing on the specific and the local in understanding marginalization and its impact on mental well-being. Consistent with postmodernism, the Intersectionality Theory points out that everyone has a composite identity consisting of the integration of several social identities, including race, gender, education, sexual orientation, etc. The Capability Approach to well-being focuses on a person’s potential for development, freedom to choose, and opportunity provided by socioeconomic conditions that influence individual growth. Rawls offers an optimistic view by arguing that groups with different cultures and philosophies can achieve an “overlapping consensus” on the basic concepts needed in building just social institutions. Finally, tools are being developed for measuring the exposome (Chung et al., Reference Chung2021; Wu et al., Reference Wu, Eckhardt and Baccarelli2023) so that scientists can study the mechanisms by which social factors influence mental health and reliably assess the health outcome of social interventions.

A number of studies of SDoMMH, especially in older adults, have been published during the last few years (Ayalon and Cohn-Schwartz, Reference Ayalon and Cohn-Schwartz2022; Cheung et al., Reference Cheung, Chai, Troya and Luo2022; Giebel et al., Reference Giebel, Ivan, Burger and Ddumba2022; Jeste and Pender, Reference Jeste and Pender2022; Jeste, Reference Jeste2022). Recently, a new Global Research Network on SDoMMH has been established by Dilip Jeste and colleagues (socialdeterminantsofhealthnetwork.org). It focuses on inter-disciplinary research on social and environmental factors which impact the health of people with mental illnesses. The goal is to develop validated and pragmatic assessments, understand underlying biological mechanisms, and test preventive and therapeutic strategies targeting SDoMMH.

Postscript

We have been endowed with a strong foundational knowledge for understanding the role of the SDoMMH, which can inform new science and on which to build advocacy and action. As Karl Marx wrote on the eleventh thesis on Feuerbach: “Philosophers have hitherto only interpreted the world in various ways; the point is to change it.” We, geriatric psychiatrists, are the physicians of the “whole” aging person who has been subjected to many negative and positive influences through many phases of development. Therefore, we are in a unique position to advocate for both the science and the social changes needed for improving our aging communities’ and our patients’ well-being. Let us be reminded of the words of the great professor Virchow: “If medicine is to fulfill its mission, it must enter the political and social life…The physicians are the natural attorneys of the poor, and the social problems should largely be solved by them.”