Living in the Conditions that Break Us: How Structural Conditions Produce Mental Health Inequities

Human Rights Research Center

5 hours ago

14 min read

September 30, 2026

Introduction

As humans, we all struggle with our mental health at some point in our lives whether we reach the clinical threshold for a diagnosis or not. Experiencing a mental health challenge is increasingly common. 1 in 7 individuals globally live with a mental health disorder (WHO, 2023). Mental health disorders have a significant impact on an individual’s daily functioning and overall well-being (Magomedova & Fatima, 2025). Moreover, there are substantial societal and economic costs as the global burden of mental health disorders continues to rise. For instance, depression is the leading cause of non-fatal disability worldwide (Reddy, 2010).

Many individuals with depression experience prolonged negative effects (Kessler, 2012). However, only 30% of individuals with depression globally receive some form of treatment (Mekonen et al., 2021). Notably, treatment rates are similar for other mental health disorders. Estimates suggest, on average, only 7% of individuals worldwide receive effective mental health treatment, resulting in a major treatment gap (Vigo et al., 2025).

Treatment rates are largely influenced by the barriers an individual faces when seeking care. Individuals with mental health disorders face numerous individual, societal, and structural barriers to receiving effective treatment (Mongelli et al., 2020). Common individual barriers include a lack of awareness of the presence of a mental health disorder as well as an individual’s personal attitudes and beliefs about having and receiving treatment for a mental health disorder. Societal stigma as well as cultural norms and beliefs about mental health care are frequent societal barriers for individuals. Lastly, financial costs, a lack of available providers, and difficulties accessing care, including transportation challenges, are notable structural barriers individuals face. While treatment rates are influenced by barriers, treatment rates vary based on an individual’s disorder, country, and context (Vigo et al., 2025).

The prevalence of individuals seeking and completing treatment in low- and middle-income countries (LMICs) is disproportionately lower than individuals in high-income countries (HICs) (Mekonen et al., 2021; Vigo et al., 2025). Greater barriers in accessing treatment likely contribute to lower treatment rates (Vigo et al., 2025) and greater global mental health burden (Liu et al., 2025) for individuals in LMICs. Furthermore, LMICs have lower mental health care budgets due to limited economic resources; limited economic resources contribute to consequential provider shortages and large treatment gaps (Patel et al., 2025). Yet, over 80% of individuals with a mental health disorder live in LMICs (WHO, 2022).

Mental Health Care as a Human Rights Issue

According to the World Health Organization, mental health is a basic human right that should be available to all people (WHO, 2023). In 1948, the United Nations General Assembly developed the Universal Declaration of Human Rights (UDHR) which has become a foundation for human rights law (United Nations General Assembly, 1948). The UDHR outlines 30 fundamental rights and freedoms that belong to everyone without discrimination. Article 25 states “everyone has a right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services…”. The two key points highlighted here are that everyone, without discrimination, has the right to adequate health and well-being, and that everyone has the right to a standard of living to achieve adequate health and well-being. Furthermore, Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR) states that everyone has the right to “the highest attainable standard of physical and mental health”, and that it is the country’s responsibility to ensure this occurs (ICESCR, 1966). The UDHR was unanimously adopted by the United Nations (UN) in 1948 with 48 countries voting in favor, 0 voting against, 8 abstaining from voting, and 2 not present. Similarly, the ICESCR was also unanimously adopted by the UN in 1966 with 104 countries voting in favor, 0 against, 0 abstaining, and 18 not present. Thus, almost all countries in the UN at the time the UDHR and ICESCR were adopted agreed to abide by them, with no countries voting against them. They agreed to ensure every individual, without discrimination, is able to attain adequate health and well-being and live in conditions that promote adequate well-being. Nonetheless, over 75 years since the UDHR and the ICESCR were adopted, this is still not the case.

The Current Focus of Mental Health Care

For many years, psychology has focused primarily on the medical and biological aspects of mental health. Biological and medical pathways have been the primary focus of reducing an individual's risk of developing a mental health disorder and improving an individual’s overall outcome. The National Institute of Mental Health (NIMH) has spent billions of dollars on research to determine the physiological causes of mental health disorders (Galves, 2024). In 2020, 75% of the NIMH budget was spent on studying the physiology of mental illness, while only 4% focused on studying treatment outcomes with psychotherapy. Yet in 2017, Dr. Thomas Insel, Director of NIMH from 2002-2015, said:

“I spent 13 years at NIMH really pushing on the neuroscience and genetics of mental disorders, and when I look back on that I realize that while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs – I think $20 billion – I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness.”

Years later, not much has changed. Large amounts of funding continue to be devoted to developing innovative individualistic treatments (i.e., psychedelic-assisted therapies, advanced brain stimulation, rapid-acting medications, etc.) (Scangos et al., 2023; Schipper et al., 2024). While individualistic, biological treatments are important and have proved useful for numerous people, it remains limited in scope.

Social Determinants of Mental Health

Social determinants of mental health (SDoMH) are the “conditions in the environments where people are born, live, learn, work, play, worship, and age that affect health, functioning, and quality of life outcomes” (Jeste & Pender, 2022). These social, economic, and physical environments define the development, treatment, and outcome of a mental health disorder for an individual (Alegria et al., 2019). SDoMH have been linked to decreased well-being and an increased risk for numerous mental health disorders including depression, anxiety, attention deficit hyperactivity disorder (ADHD), sleep disturbances, psychosis, and trauma (Kirkbride et al., 2024). For instance, lower socioeconomic status (SES) is linked to an increased risk for mood disorders, while food and water insecurity is linked to an increased risk for depression, anxiety, schizophrenia, and sleep disorders (Alegria et al., 2019; Kirkbride et al., 2024). In addition, job insecurity and financial concerns are linked to depression and anxiety, while neighborhood violence and discrimination are linked to trauma and psychosis. These are just a few examples of the relationship between SDoMH and mental health disorders.

SDoMH are present both within countries and between countries (Vargas-Huicochea & Berenzon, 2023). Specifically, while SDoMH impact mental health and well-being in both LMICs and HICs, health inequities from SDoMH are greater in LMICs due to considerable pre-existing resource shortages compared to HICs (Liu et al., 2025). Furthermore, SDoMH impede an individual’s ability to access treatment due to increased barriers, thereby worsening mental health outcomes (Alegria et al., 2019).

SDoMH are also present at the individual-level, at the family-level, and in the wider social environment (Kirkbride et al., 2024). SDoMH are often categorized into (Alegria et al., 2023):

socioeconomic status and opportunities for accruing wealth
basic needs in terms of housing, food, transportation, and health care
immediate and global physical environment
societal problems

At the individual and family level, common SDoMH include socioeconomic disadvantages, early life adversity, childhood adversity, migration, ethnoracial discrimination, sex-based inequalities, and loneliness and social isolation (Kirkbride et al., 2024). In the wider social environment, SDoMH include neighborhood socioeconomic disadvantages and inequality, social capital, fragmentation and low ethnic density, and physical environment.

Notably, a social gradient of health exists that stems from an unequal distribution of power, money, and resources; socioeconomic status influences health outcomes. Individuals with a lower SES have markedly poorer health outcomes (Bonaccio et al., 2020) and are most affected by mental health disorders (Alegria et al., 2019).

While SDoMH significantly impact mental health outcomes, the relationship between SDoMH and mental health is a two-way relationship. Mental health disorders can also influence social determinants (Alegria et al., 2019). Namely, poor mental health results in behavioral and emotional distress which can impact an individual’s daily life and overall functioning. In turn, mental health disorders can reduce educational and occupational performance, strain familial and social networks, impact personal and professional choices, and lead to justice system involvement (Prati, 2024; Vargas-Huicochea & Berenzon, 2023). To illustrate, if an individual is experiencing distress and decreased functioning due to a mental health disorder, this will impair their ability to work. Without working, the individual might not receive an income. Without an income, the individual may struggle to afford mental health care as well as necessities such as food, water, and shelter. As illustrated, mental health disorders can make it harder to escape the impact of SDoMH, yet SDoMH can make it challenging to receive effective mental health treatment.

The Need for a Change

SDoMH are not just risk factors that we can view from a public health perspective. SDoMH are human rights violations that are preventable, yet are maintained by structural and systemic inequities. SDoMH are shaped by policy, resource allocation, and governance. As such, SDoMH can be modified through population and community-wide interventions targeting social determinants Examples of these interventions include social and economic policies and programs targeting poverty, racism and discrimination, food insecurity, house instability, and unemployment (Alegria et al., 2023). Prevention and intervention occur at three different levels (Kirkbride et al., 2024):

Primary prevention: focuses on preventing the development of mental health disorders
Secondary prevention: focuses on lowering the prevalence of pre-existing mental health disorders
Tertiary prevention: focuses on reducing disability and distress from mental health disorders, and enhancing recovery.

While all three levels of prevention are important, primary prevention strategies are the core of addressing SDoMH. The three types of primary prevention strategies are:

Universal prevention: targets the general public, regardless of risk for a mental health disorder
Selective prevention: target individuals and groups at risk of developing a mental health disorder
Indicated prevention: targets high-risk individuals and groups who are already displaying symptoms of a mental health disorder but fall below the clinical threshold for a mental health diagnosis

There are numerous examples of prevention and intervention strategies that have shown promising results in improving mental health outcomes and reducing the impact of SDoMH. Namely, supported employment programs improve employment rates, increase individual functioning and well-being, and decrease depressive symptoms (Alegria et al., 2019; Alegria et al., 2023). Community-based programs focused on improving neighborhood trust and safety and decreasing crime have been linked to lower depressive symptoms, lower stress, improved physical activity, and greater social connectedness. Additionally, universal health care is linked with greater emotional well-being. Other prevention strategies that show favorable results include (Alegria et al., 2023; Kirkbride et al., 2024 Smith-Carrier & Power, 2025):

School-based interventions: (e.g., teaching children about emotions and mental health in school)
Parenting interventions (e.g., parenting groups)
Direct economic interventions (e.g., income support, welfare benefits, unemployment insurance)
Early life home visit programs
Peripartum maternal support
Community-based mental health programs (e.g., collaborative care, early identification and intervention programs, psychosocial interventions)
Services addressing homelessness

Primary prevention needs to be emphasized to remove social inequities and decrease the onset of mental health disorders. SDoMH are systemic inequities that have been built into local, national, and global systems and policies. As such, structural and policy-level changes are crucial to making substantial progress in reducing mental health inequities. Mental health care needs to recognize and effectively address SDoMH in treatment (Jeste & Pender, 2021). Local, national, and global funding needs to prioritize attributing funding towards primary prevention interventions and population-wide interventions that will improve the overall mental health and well-being of the entire population. Particularly, policies that reduce discrimination and decrease the social gradient need to be implemented to improve the social and environmental living conditions for all individuals (Kirkbride et al., 2024). Interventions that target poverty alleviation need to be a high priority; these interventions show significant promise as poverty is strongly linked to most SDoMH (Kirkbride et al., 2024). Additionally, conducting needs assessments in communities will help to identify specific needs and develop targeted selective prevention strategies (Alegria et al., 2023).

Conclusion

Mental health is socially determined. Structural inequities are human-rights failures that continue to harm those on the lower end of the social gradient. The location and environment into which an individual is born should not determine their risk of poor mental health and ability to receive adequate treatment for mental health disorders. Yet it does. That needs to change. For too long, interventions have focused on the individual person and placed the responsibility of healing on the individual. Structural and social determinants not only contribute to the development of mental health disorders but also impede access to effective mental health care. Making mental health the individual’s problem and responsibility maintains the structural inequities that created the problems in the first place. Failing to address the key sociopolitical factors that are at the core of these inequities exacerbates pre-existing mental health problems. Thus, primarily focusing on individual-level interventions will not make substantial progress towards mental health equity. Instead, primary prevention strategies, including structural and policy changes, are needed to reduce the social gradient, decrease the impact of SDoMH, and make mental health and well-being the human right it should be. Mental health equity is a collective responsibility, not an individual burden.

Glossary

Abstaining: choosing not to vote
Adequate: sufficient for a specific need or requirement
Adversity: a very difficult or unfavorable situation
Allocation: the process of giving someone their part of a total amount of something to use in a particular way
Attainable: possible to achieve
Clinical threshold: the diagnostic criteria (often based on the DSM 5-TR) that need to be met to receive a mental health diagnosis
Collective: shared or assumed by all members of a group
Consequential: important, and having a strong influence on events, decisions, etc.
Deep brain stimulation: a type of therapy involving a neurosurgical procedure that uses implanted electrodes and electrical stimulation to treat movement disorders and mental health disorders
Determinant: an element that identifies or determines the nature of something or that fixes or conditions an outcome
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR): the handbook of mental health diagnoses/criteria used by mental health professionals to determine if someone meets criteria for a mental health disorder
Discrimination: the unjust and differential treatment of the members of different age, gender, racial, ethnic, religious, national, ability identity, sexual orientation, socioeconomic, and other group
Disproportionately: in a way that is too large or too small in relation to something else
Ethnic density: the proportion or concentration of residents belonging to a specific racial or ethnic minority group living within a defined local neighborhood or area
Ethnoracial: a combined term relating to ethnicity and race
Familial: affecting several members of the same family
Fundamental rights: rights that are inherent to all human beings, whatever their nationality, place of residence, sex, national or ethnic origin, color, religion, language, or any other status.
Indicated prevention: prevention strategies that target high-risk individuals who are already displaying symptoms of a mental health disorder but fall below the clinical threshold for a mental health diagnosis
Innovative: using new methods or ideas
Neuroscience: the study of the nervous system (brain, spinal cord, sensory and motor networks)
Non-fatal disability: a disability or disorder that does not result in death but compromises an individual’s quality of life
Peripartum: the period shortly before, during, and immediately after giving birth
Physiological: relating to the way in which the bodies of living things work
Prevalence: the proportion of a population who have a specific characteristic in a given time period
Primary prevention strategies: prevention strategies that focus on preventing the development of mental health disorders
Poverty alleviation: programs and strategies aimed at reducing poverty through initiatives to accumulate assets and enhance economic opportunities
Psychedelic-assisted therapies: involves the use of psychedelic drugs, such as LSD, psilocybin, and MDMA, in mental health treatment
Psychotherapy: any psychological service provided by a trained professional that primarily uses forms of communication and interaction to assess, diagnose, and treat dysfunctional emotional reactions, ways of thinking, and behavior patterns
Psychosis: the term for a collection of symptoms that happen when a person has trouble telling the difference between what’s real and what’s not
Schizophrenia: a mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior.
Secondary prevention strategies: prevention strategies that focus on lowering the prevalence of pre-existing mental health disorders
Selective prevention: prevention strategies that focus on those at risk of developing a mental health disorder
Stigma: a set of negative and unfair beliefs that a society or group of people have about something
Structural barriers: policies, practices, and norms that collectively and disproportionately disadvantage a marginalized group while perpetuating disparities in health, social, educational, and other outcomes
Social determinants of mental health: conditions in the environments where people are born, live, learn, work, play, worship, and age that affect health, functioning, and quality of life outcomes
Social gradient of health: people who have a lower socioeconomic position have worse health outcomes than those who have a higher socioeconomic position
Socioeconomic: related to the differences between groups of people caused mainly by their financial situation
Sociopolitical: of, relating to, or involving a combination of social and political factors
Tertiary prevention strategies: prevention strategies that focus on reducing disability and distress, and enhance recovery from mental health disorders
Unanimously: in a way that is agreed or supported by everyone in a group
Universal prevention: prevention strategies that target the general public, regardless of risk

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