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MINISTRY OF HEALTH OF THE REPUBLIC OF MOLDOVA STATE MEDICAL AND PHARMACEUTICAL UNIVERSITY “NIVOLAE TESTEMITANU” FACULTY OF MEDICINE NR. II Department of Psychiatry Chief of the Department: Anatolie Nacu, MD, PhD, Professor License Thesis SOCIAL DETERMINANTS OF MENTAL HEALTH Scientific coordinator: Jana CHIHAI, MD, PhD, associate professor ABDEL-halim mohammad (Gr.1640) Chisinau 2014

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 Verified: Data 30.04.2015 Scientific Coordinator: dr. Chihai Jana, PhD, associate prof. Semnătura ____________ “Recommended for approval” At meeting od Psychiatry, Narcology, Medical Psychology Department Protocol nr.___19____from___13.05.2015____ Head of the Department prof. Anatol Nacu

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 ABSTRACT
 Mental health and mental disorders are not opposites, and mental health is “not just the absence of mental disorder”. The World Health Organization defines mental health as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”. In this, the absence of mental disorder does not necessarily mean the presence of good mental health. Mental disorders include anxiety, depression, schizophrenia, and alcohol and drug dependency. Common mental disorders can result from stressful experiences, but also occur in the absence of such experiences; stressful experiences do not always lead to mental disorders. Many people experience sub-threshold mental disorders, which means poor mental health that does not reach the threshold for diagnoses as mental disorders. Mental disorders and sub-threshold mental disorders affect a large proportion of populations. Despite their vulnerability, people with mental health have been largely overlooked as a target of development work. The prevalence and social distribution of mental disorders has been well documented in high-income countries, but the problem in low- and middle-income countries includes gap still exists in research to measure the problem, and in strategies, policies and programs, to prevent mental disorders. There is a considerable need to raise the priority given to the prevention of mental disorders and to the promotion of mental health through action on the social determinants of health. Keywords: mental health, vulnerable groups, mental disorders, sociodeterminants.

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 CONTENTS ABSTRACT
 ……………………………………………………………………………………………………………………………..
 3
 ABBREVIATIONS
 …………………………………………………………………………………………………………………..
 5
 INTRODUCTION
 …………………………………………………………………………………………………………………….
 6
 CHAPTER I. MENTAL HEALTH AND DEVELOPMENT: a literature review
 ……………
 11
 1.1 People with mental health conditions comprise a vulnerable group
 ……………………………………..
 11
 1.2. Prevention of mental disorders: a public health priority
 ………………………………………………………
 17
 1.3
 The
 concept
 of
 risk
 and
 protective
 factors
 ………………………………………………………………………..
 20
 1.4
 Social,
 environmental,
 economic
 and
 family-­‐related
 determinants
 ………………………………
 23
 CHAPTER
 II.
 
 STUDY
 DESIGN
 AND
 RESULTS
 ……………………………………………………………………
 27
 2.1.
 Methodology
 of
 the
 study
 ……………………………………………………………………………………………………
 27
 2.2. Procedure and instruments.
 ……………………………………………………………………………………………………
 29
 2.3. Results of the study
 …………………………………………………………………………………………………………………
 31
 2.4 Case studies – results:
 ………………………………………………………………………………………………………………
 37
 2.5. Conclusions for case studies:
 ………………………………………………………………………………………………….
 44
 2.6. Conclusions on opinion pull:
 ………………………………………………………………………………………………….
 45
 GENERAL
 CONCLUSION
 AND
 RECOMANDATION:
 …………………………………………………………..
 47
 REFERENCES
 ……………………………………………………………………………………………………………………….
 48
 V.
 Annexes
 …………………………………………………………………………………………………………………………..
 52

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 ABBREVIATIONS
 
 DSM-V – 5th edition of Diagnostic and Statistical Manual of Mental Disorders ICD -10 – 10th revision of the International Statistical Classification of Diseases and Related Health Problems. WHO – World Health Organization EBP – Evidence-based Practice GDP – Gross Domestic Product

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 INTRODUCTION
  Mental health and mental disorders are not opposites, and mental health is “not just the absence of mental disorder”. The World Health Organization defines mental health as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”. Globally, mental health conditions account for 13% of the total burden of disease, and 31% of all years lived with disability. By 2030, depression alone is likely to be the single highest contributor to burden of disease in the world – more so than heart disease, stroke, road traffic accidents, and HIV/AIDS. More than 80% of the global burden of disease due to mental health conditions can be found in low- and middle-income countries. In low-income countries, depression causes almost as much burden as malaria (3.2% versus 4.0% of the total disease burden); in middle-income countries, depression is the major contributor to disease burden, accounting for twice the burden of HIV/AIDS (5.1% versus 2.6% of total disease burden). Mental and behavioural disorders are not exclusive to any special group: they are found in people of all regions, all countries and all societies. About 450 million people suffer from mental dis- orders according to estimates given in WHO’s World Health Report 2001. One person in four will develop one or more mental or behavioural disorders during their lifetime (WHO, 2001b). Mental and behavioural disorders are present at any point in time in about 10% of the adult population worldwide. One fifth of teenagers under the age of 18 years suffer from developmental, emotional or behavioural problems, one in eight has a mental disorder; among disadvantaged children the rate is one in

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 five. Mental and neurological disorders account for 13% of the total Disability Adjusted Life Years (DALYs)2 lost due to all diseases and injuries in the world (WHO, 2004d). Five of the ten leading causes of disability worldwide are psychiatric conditions, including depression, alcohol use, schizophrenia and compulsive disorder (Murray & Lopez, 1996). Projections estimate that by the year 2020 neuropsychiatric conditions will account for 15% of disability worldwide, with unipolar depression alone accounting for 5.7% of DALYs. Considerable and growing evidence shows that mental health and many common mental disorders are shaped to a great extent by social, economic and environmental factors. A review of global evidence by Vikram Patel and colleagues for the WHO Commission on Social Determinants of Health reported convincing evidence that low socioeconomic position is systematically associated with increased rates of depression. Gender is also important, mental disorders are more common in women, they frequently experience social, economic and environmental factors in different ways to men. Mental disorder prevention targets those determinants that have a causal influence, predisposing to the onset of mental disorders. Risk factors are associated with an increased probability of onset, greater severity and longer duration of major health problems. Protective factors refer to conditions that improve people’s resistance to risk factors and disorders. Mostly, individual protective factors are identical to features of positive mental health, such as self-esteem, emotional resilience, positive thinking, problem-solving and social skills, stress management skills and feelings of mastery. For this reason, preventive interventions aiming to strengthen protective factors overlap largely with mental health promotion. Major socioeconomic and environmental determinants for mental health are

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 related to macro- issues such as poverty, war and inequity. Populations living in poor socioeconomic circumstances are at increased risk of poor mental health, depression and lower subjective well-being (Patel & Jané-Llopis, 2005). Other macro-factors such as urbanisation, war and displacement, racial discrimination and economic instability have been linked to increased levels of psychiatric symptomatology and psychiatric morbidity. Social, biological and neurological sciences have provided substantial insight into the role of risk and protective factors in the developmental pathways to mental disorders and poor mental health. Biological, psychological, social and societal risk and protective factors and their interactions have been identified across the lifespan from as early as fetal life. Many of these factors are malleable and therefore potential targets for prevention and promotion measures. High comorbidity among mental disorders and their interrelatedness with physical illnesses and social problems stress the need for integrated public health policies, targeting clusters of related problems, common determinants, early stages of multiproblem trajectories and populations at multiple risks. A multilevel framework for understanding social determinants of mental disorders can be applied to strategies and interventions to reduce mental disorders and promote mental well being. Important areas are listed below. These areas are important for two reasons: – they influence the risk of mental disorders – they present opportunities for intervening to reduce risk. Life-course: Prenatal, Pregnancy and perinatal periods, early childhood, adolescence, working and family building years, older ages all related also to gender;

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 Parents, families, and households: parenting behaviours/attitudes; material conditions (income, access to resourses, food/nutrition, water sanitation housing, employment) employment conditions and unemployment, parental physical and mental health, pregnancy and maternal care, social support; Community: neighbourhood trust and safety, community based participation, violence/crime, attributes of the natural and built environment, neighbourhood deprivation; Local services: early years care and education provision, schools, youth/adolescent services, health care, social services, clean water and sanitation; Country level factors: poverty reduction, inequality, discrimination, governance, human rights, armed conflict, national policies to promote the access to education, employment, health care, houses and services proportionate to need, social protection policies that are universal and proportionate to need. The goal and objectives of the study This research will focus in socio-determinants in mental health field, especially in identification of the impact of environmental, social and economic factors of mental illnesses. Objectives: • Literature review about mental health, sociodeterminants, risk factors and burden of mental illnesses worldwide; • To identify the social opinion about mental illnesses, risk factors and sociodeterminants leading mental health problems;

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 • Development and evaluation of 4 case studies in order to establish causes of mental health problems and the factors that have intensified these problems.

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 CHAPTER I. MENTAL HEALTH AND DEVELOPMENT: a literature review 1.1 People with mental health conditions comprise a vulnerable group
 Mental health and mental disorders are not opposites, and mental health is “not just the absence of mental disorder”. The World Health Organization defines mental health as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”. In this, the absence of mental disorder does not necessarily mean the presence of good mental health. Looked at in another way, people living with mental disorder can also achieve good levels of well being – living a satisfying, meaningful, contributing life within the constraints of painful, distressing, or debilitating symptoms. Mental disorders include anxiety, depression, schizophrenia, and alcohol and drug dependency. Common mental disorders can result from stressful experiences, but also occur in the absence of such experiences; stressful experiences do not always lead to mental disorders. Many people experience sub-threshold mental disorders, which means poor mental health that does not reach the threshold for diagnoses as a mental disorders. Mental disorders and sub-threshold mental disorders affect a large proportion of populations. The less commonly-used term, mental illness, refers to depression and anxiety as well as schizophrenia and bipolar disorders. In country around the world, a shift of emphasis is needed towards preventing common mental disorders such as anxiety and depression by action on the social determinants of health, as well as improving treatment of

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 existing conditions. Action is needed as many of the causes and triggers of mental disorder lie in social, economic, and political spheres – in the conditions of daily life. Despite their vulnerability, people with mental health conditions – including schizophrenia, bipolar disorder, depression, epilepsy, alcohol and drug use disorders, child and adolescent mental health problems, and intellectual impairments – have been largely overlooked as a target of development work. This is despite the high prevalence of mental health conditions, their economic impact on families and communities, and the associated stigmatization, discrimination and exclusion. The need for development efforts to target people with mental health conditions is further reinforced by the United Nations Convention on the Rights of Persons with Disabilities, which requires the mainstreaming of disability issues into strategies for sustainable development. Certain groups are more vulnerable than others. This vulnerability is brought about by societal factors and the environments in which they live. Vulnerable groups share common challenges related to their social and economic status, social sup- ports, and living conditions, including: • Stigma and discrimination; • Violence and abuse; • Restrictions in exercising civil and political rights; • Exclusion from participating fully in society; • Reduced access to health and social services; • Reduced access to emergency relief services; • Lack of educational opportunities;

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 • Exclusion from income generation and employment opportunities; • Increased disability and premature death. Over time, these factors can interact, leading to further marginalization, diminished resources, and even greater vulnerability. Vulnerability should not be confused with incapacity, nor should vulnerable groups be regarded as passive victims. Ways must be found to empower vulnerable groups to participate fully in society. Studies from high-income countries have revealed that people with mental health conditions experience extremely high rates of physical and sexual victimization. One study from the United States of America found that, compared with the general population, people with mental health conditions were 11 times more likely to be targets of violent crime (completed or threatened violence), and 140 times more likely to be victims of personal theft. In Australia, 88% of those admitted to a psychiatric ward had experienced victimization at some point in their lives: 84% having experienced physical assault, and 57% having experienced sexual assault. People with mental health conditions often are abused in prisons; women with mental health conditions are at particularly heightened risk for sexual victimization in prisons. People living in mental health facilities also are exposed to violence and abuse by the very health professionals responsible for providing residents with treatment and care. Other forms of abuse also are common, including unhygienic and inhumane living conditions, and harmful and degrading treatment practices. People can be confined arbitrarily to institutions – against their will – for months or even years. Once committed, they often are restricted to cell-like seclusion rooms and/ or restraints.

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 Despite the widespread prevalence of mental health conditions, a large proportion of affected people do not receive treatment and care. In low- and middle-income countries, 75% to 85% of people with severe mental health conditions do not have access to needed mental health treatment. In high-income countries, between 35% and 50% of people with severe mental health conditions do not receive needed treatment. People with severe mental health conditions also are less likely to receive treatment for physical health conditions. For example, people with schizophrenia are 40% less likely to be hospitalized for ischaemic heart disease, compared with people without mental health conditions who suffer from the same heart problem. Case reports indicate that in many low- and middle-income countries, people in psychiatric hospitals lack access to basic health care including general health examinations, dental care, vaccines, medications, and treatments for cuts and bed sores. Across a broad range of countries, treatment rates for mental health conditions are much lower compared to those for physical health problems. Large treatment gaps are not surprising given that almost one third of countries worldwide do not have a budget for mental health services, and a further one fifth of countries spend less than 1% of their total health budget on mental health services. Not only are services scarce, but many governments in low- and middle-income countries require individuals to pay for their mental health treatment, even when treatment for physical ailments is provided free of charge or covered by health insurance. This disparity disproportionately affects poorer people. Lack of access to housing and other social services also is a serious problem: numerous studies have documented a high prevalence of mental health conditions

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 in homeless people. Problems that exist at higher rates than the general population include schizophrenia, depression, anxiety, attempted suicide, emotional problems, hopelessness, and alcohol and drug use disorders. As a cumulative result of prolonged exposure to the preceding social and economic factors leading to vulnerability, people with mental health conditions are at heightened risk for premature death and disability. The substantial treatment gap – between the prevalence of mental health conditions, on one hand, and the number of people receiving treatment, and care, on the other hand – only com- pounds this burden. Globally, mental health conditions account for 13% of the total burden of disease, and 31% of all years lived with disability. By 2030, depression alone is likely to be the single highest contributor to burden of disease in the world – more so than heart disease, stroke, road traffic accidents, and HIV/AIDS. More than 80% of the global burden of disease due to mental health conditions can be found in low- and middle-income countries. In low-income countries, depression causes almost as much burden as malaria (3.2% versus 4.0% of the total disease burden); in middle-income countries, depression is the major contributor to disease burden, accounting for twice the burden of HIV/AIDS (5.1% versus 2.6% of total disease burden). The full health impact of mental health conditions extends well beyond that which is represented by their burden of disease calculations. People with mental health conditions are more likely than others to develop significant physical health conditions, including diabetes, heart disease, stroke and respiratory disease. Mental health conditions such as depression and schizophrenia also place people at higher risk for contracting infectious diseases such as HIV, due to a range of factors including misconceptions about

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 routes of transmission and high-risk sexual behavior. People with mental health conditions also are far more likely than the general population to die prematurely. Systematic reviews of studies conducted in many countries have shown that people with schizophrenia and depression have an overall increased risk of premature death that is 1.6 and 1.4 times greater, respectively, than that expected from the general population. Individuals with serious mental health conditions are more likely to suffer stroke and ischaemic heart disease before 55 years of age, and to survive for less than five years thereafter. Studies in low- and middle-income countries have shown that mental health conditions combined with AIDS lead to increased premature death rates, compared with AIDS alone. In the United States of America, a study found that women with depression and HIV were more than twice as likely to die, compared with women living with HIV without depression. People living with HIV also are at heightened risk for suicide. Two development paradigms, the need to improve aid effectiveness and the use of a human rights approach, should be taken into consideration when reviewing actions that can be taken to ensure people with mental health conditions are included in development programmes. The emphasis on improving aid effectiveness is changing the way development stakeholders are working: towards a greater focus on country-owned sectoral and broader national development planning, and increased harmonization and alignment among stakeholders on issues such as funding mechanisms. The increased emphasis on country-owned planning has highlighted the need for effective partnerships, for inclusive decision-making processes, and for a strong civil society to voice its issues and concerns. Never before has civil society had

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 such an opportunity to directly influence national planning processes; full advantage must be taken of this development. People with mental health conditions meet the major criteria for vulnerability as identified by an analysis of major development stakeholders’ projects and publications. They are subjected to stigma and discrimination on a daily basis, and they experience extremely high rates of physical and sexual victimization. Frequently, people with mental health conditions encounter restrictions in the exercise of their political and civil rights, and in their ability to participate in public affairs. They also are restricted in their ability to access essential health and social care, including emergency relief services. Most people with mental health conditions face disproportionate barriers in attending school and finding employment. As a result of all these factors, people with mental health conditions are much more likely to experience disability and die prematurely, compared with the general population.
 1.2. Prevention of mental disorders: a public health priority Mental and behavioural disorders are not exclusive to any special group: they are found in people of all regions, all countries and all societies. About 450 million people suffer from mental dis- orders according to estimates given in WHO’s World Health Report 2001. One person in four will develop one or more mental or behavioural disorders1 during their lifetime (WHO, 2001b). Mental and behavioural disorders are present at any point in time in about 10% of the adult population worldwide. One fifth of teenagers under the age of 18 years suffer from developmental, emotional or behavioural problems, one in eight has a mental disorder; among disadvantaged children

18
 the rate is one in five. Mental and neurological disorders account for 13% of the total Disability Adjusted Life Years (DALYs) lost due to all diseases and injuries in the world (WHO, 2004d). Five of the ten leading causes of disability worldwide are psychiatric conditions, including depression, alcohol use, schizophrenia and compulsive disorder (Murray & Lopez, 1996). Projections estimate that by the year 2020 neuropsychiatric conditions will account for 15% of disability worldwide, with unipolar depression alone accounting for 5.7% of DALYs. The economic impact of mental disorders is wide-ranging, long-lasting and enormous. These disorders impose a range of costs on individuals, families and communities. In the United States of America, the annual total costs related to mental disorders have been reported as reaching 147 billion US dollars, more than the costs attributed to cancer, respiratory disease or AIDS (Institute of Medicine, 1989). Although estimates of direct costs in low income countries do not reach these levels because of the low availability and coverage of mental health care services, indirect costs arising from productivity loss account for a larger proportion of overall costs (WHO, 2001b). Moreover, low treatment costs (because of lack of treatment) may actually increase the indirect costs by increasing the duration of untreated disorders and their associated disability. Overall, the economic costs of mental ill-health are enormous and not readily measurable. In addition to health and social service costs, lost employment, reduced productivity, the impact on families and caregivers, the levels of crime and public safety and the negative impact of premature mortality, there are other hard-to-measure costs, such as the negative impact of stigma and discrimination or lost opportunity costs to individuals and families that have not been taken into account (WHO, 2001b; Hosman & Jané-Llopis, 1999). To reduce the health, social and economic burdens of mental disorders it is

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 essential that countries and regions pay greater attention to prevention and promotion in mental health at the level of policy formulation, legislation, decision-making and resource allocation within the overall health care system. An initial difficulty faced by researchers and policy-makers in this field is related to the similarities and boundaries between the concepts of mental health and mental illness and between prevention and promotion. WHO defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity“ (WHO, 2001a, p.1). Hence, health includes mental, physical and social functioning, which are closely associated and interdepend- ent. There is evidence that mental and physical illnesses may accompany, follow, or precede one another as well as evidence indicating that mental disorders increase the risk of physical illness and vice versa. Mental health promotion often refers to positive mental health, considering mental health as a resource, as a value on its own and as a basic human right essential to social and economic development. Mental health promotion aims to impact on determinants of mental health so as to increase positive mental health, to reduce inequalities, to build social capital, to create health gain and to narrow the gap in health expectancy between countries and groups (Jakarta Declaration for Health Promotion, WHO, 1997). Mental health promotion interventions vary in scope and include strategies to promote the mental well-being of those who are not at risk, those who are at increased risk, and those who are suffering or recovering from mental health problems (box 1). Further information can be found in Promoting Mental Health: Concepts, Emerging Evidence, Practice (Herrman, Saxena & Moodie 2004; WHO 2004b). Considerable and growing evidence shows that mental health and many

20
 common mental disorders are shaped to a great extent by social, economic and environmental factors. A review of global evidence by Vikram Patel and colleagues for the WHO Commission on Social Determinants of Health reported convincing evidence that low socioeconomic position is systematically associated with increased rates of depression. Gender is also important, mental disorders are more common in women, they frequently experience social, economic and environmental factors in different ways to men. Taking action to improve the conditions of daily life from before birth, during early childhood, at school age, during family building and working ages, and at older ages provides opportunities both to improve population mental health and reduce the risk of those mental disorders that are associated with social inequalities. While comprehensive action the life course is needed, scientific consensus is considerable that giving every child the best possible start will generate the greatest societal and mental health benefits. The prevalence and social distribution of mental disorders has been well documented in high-income countries. While there is growing recognition of the problem in low- and middle-income countries, a significant gap still exists in research to measure the problem, and in strategies, policies and programs, to prevent mental disorders. There is a considerable need to raise the priority given to the prevention of mental disorders and to the promotion of mental health through action on the social determinants of health. 1.3
 The
 concept
 of
 risk
 and
 protective
 factors
 Mental disorder prevention targets those determinants that have a causal influence, predisposing to the onset of mental disorders. Risk factors are associated

21
 with an increased probability of onset, greater severity and longer duration of major health problems. Protective factors refer to conditions that improve people’s resistance to risk factors and disorders. They have been defined as those factors that modify, ameliorate or alter a person’s response to some environmental hazard that predisposes to a maladaptive outcome (Rutter, 1985). Mostly, individual protective factors are identical to features of positive mental health, such as self-esteem, emotional resilience, positive thinking, problem-solving and social skills, stress management skills and feelings of mastery. For this reason, preventive interventions aiming to strengthen protective factors overlap largely with mental health promotion. There is strong evidence on risk and protective factors and their links to the development of mental disorders (e.g. Coie et al., 1993; Ingram & Price, 2000). Both risk and protective factors can be individual, family-related, social, economic and environmental in nature. Mostly it is the cumulative effect of the presence of multiple risk factors, the lack of protective factors and the interplay of risk and protective situations that predisposes individuals to move from a mentally healthy condition to increased vulnerability, then to a mental problem and finally to a full-blown disorder. Interventions to prevent mental ill-health aim to counteract risk factors and reinforce protective factors along the lifespan in order to disrupt those processes that contribute to human mental dysfunction. The more influence individual factors have on the development of mental disorders and mental health the greater the preventive effect that can be expected when they are addressed successfully. It is imperative that determinants addressed in preventive interventions are malleable and encompass disease-specific as well as more generic risk and

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 protective factors. Generic risk and protective factors are those that are common to several mental health problems and disorders. Interventions that successfully address such generic factors may generate a broad spectrum of preventive effects. For example, poverty and child abuse are common to depression, anxiety and substance abuse. Interventions that successfully address poverty and child abuse can be expected to have an impact on all three of these disorders. Disease-specific risk and preventive factors are those that are mainly related to the development of a particular disorder. For example, negative thinking is specifically related to depression, and major depression is specifically related to suicide. There are also interrelationships between mental and physical health. For example, cardiovascular disease can lead to depression and vice versa. Mental and physical health can also be related through common risk factors, such as poor housing leading to both poor mental and poor physical health. Major understanding is needed of the relations between different mental disorders, between mental health and physical health, and on the developmental pathways of generic and disease-specific risk factors leading to mental ill-health. Sufficient evidence-based knowledge is already available on risk and protective factors to warrant governmental and nongovernmental investments in the development, dissemination and implementation of evidence-based programmes and policies. Those interventions that address risk and protective factors with a large impact or that are common to a range of related problems, including social and economic problems, will be most cost-effective and attractive to policy-makers and other stakeholders. Policy-makers and programme designers need to take into account that a specific mental disorder can be the outcome of quite different causal trajectories

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 operating for diverse populations at risk. Therefore, effective public health policies should encompass multiple preventive interventions addressing multiple causal trajectories for the relevant populations at risk. 1.4
 Social,
 environmental,
 economic
 and
 family-­‐related
 determinants
 Major socioeconomic and environmental determinants for mental health are related to macro- issues such as poverty, war and inequity. For example, poor people often live without the basic freedoms of security, action and choice that the better-off take for granted. They often lack adequate food, shelter, education and health, deprivations that keep them from leading the kind of life that everyone values (World Bank, 2000). Populations living in poor socioeconomic circumstances are at increased risk of poor mental health, depression and lower subjective well-being (Patel & Jané-Llopis, 2005). Other macro-factors such as urbanisation, war and displacement, racial discrimination and economic instability have been linked to increased levels of psychiatric symptomatology and psychiatric morbidity. For instance, war and war-related traumas cause post-traumatic stress disorders (PTSD), depression, anxiety and alcohol-related disorders (Musisi, Mollica & Weiss, 2005). In addition, such traumas can create psychiatric vulnerabilities in the offspring of traumatized and depressed parents. Box 4 depicts a range of evidence-based social, environmental and economic determinants of mental health that are discussed further in Prevention of Mental Disorders: Effective Interventions and Policy Options (Hosman, Jané-Llopis & Saxena, 2005).

24
 
 Individual and family-related risk and protective factors can be biological, emotional, cognitive, behavioural, interpersonal or related to the family context. They may have their strongest impact on mental health at sensitive periods along the lifespan, and even have impact across generations. For example, child abuse and parental mental illness during infancy and early childhood can lead to depression and anxiety later in life as well in next generations, while secure attachment and family social support can reduce such risks (Hoefnagels, 2005; Beardslee, Solantaus & van Doesum, 2005). Maternal risk behaviour during pregnancy and aversive events early in life can cause neuropsychological vulnerabilities (Brown & Sturgeon, 2005). Marital discord can precede conduct problems in children, depression among women and alcohol-related problems in both parents (e.g. Sandler, Ayers & Dawson-McClure, 2005; Dyer & Halford, 1998). Elderly people who are physically ill may suffer from a range of subsequent t
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 risk factors and problems, such as chronic insomnia, alcohol problems, elder abuse, personal loss and bereavement. Other risk factors are closely related to individual histories of problem behaviours and disorders, such as earlier depressive episodes. Anxiety disorders increase the risk of depression, while depression increases the risk of later cardiovascular disease. Sometimes such causal trajectories can include a succession of attention deficit and hyperactivity disorder (ADHD) in early childhood, problem behaviour in late childhood, conduct disorders during adolescence, and alcohol-related problems and depression during adulthood. These are just some examples of the risk and protective factors that play a role within individuals and families. Box 5 depicts the main evidence-based factors that have been found to be related to the onset of mental disorders. Policy-makers and practitioners should be provided with knowledge of evidence-based and malleable determinants of mental health and their links to mental ill-health. There is strong evidence that these individual, family, social, economic and environmental determinants of mental health have led not only to a range of mental health problems and disorders but also to associated physical health problems. These include, for example, skull fractures, head injuries, cardiovascular dis- ease, cancer and cirrhosis of the liver. The following sections of this publication present evidence of how mental health problems and psychiatric morbidity can be tackled by addressing generic risk and protective factors through preventive interventions and mental health promotion.

26
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 CHAPTER
 II.
 
 STUDY
 DESIGN
 AND
 RESULTS
  2.1.
 Methodology
 of
 the
 study
 A multilevel framework for understanding social determinants of mental disorders can be applied to strategies and interventions to reduce mental disorders and promote mental well being. Important areas are listed below. These areas are important for two reasons: – they influence the risk of mental disorders – they present opportunities for intervening to reduce risk. Life-course: Prenatal, Pregnancy and perinatal periods, early childhood, adolescence, working and family building years, older ages all related also to gender; Parents, families, and households: parenting behaviours/attitudes; material conditions (income, access to resourses, food/nutrition, water sanitation housing, employment) employment conditions and unemployment, parental physical and mental health, pregnancy and maternal care, social support; Community: neighbourhood trust and safety, community based participation, violence/crime, attributes of the natural and built environment, neighbourhood deprivation; Local services: early years care and education provision, schools, youth/adolescent services, health care, social services, clean water and sanitation; Country level factors: poverty reduction, inequality, discrimination, governance, human rights, armed conflict, national policies to promote the access to education,

28
 employment, health care, houses and services proportionate to need, social protection policies that are universal and proportionate to need. The goal and objectives of the study This research will focus in socio-determinants in mental health field, especially in identification of the impact of environmental, social and economic factors of mental illnesses. Objectives: • Literature review about mental health, sociodeterminants, risk factors and burden of mental illnesses worldwide; • To identify the social opinion about mental illnesses, risk factors and sociodeterminants leading mental health problems; • Development and evaluation of 4 case studies in order to establish causes of mental health problems and the factors that have intensified these problems. Hypothesis: Frequently, people are exposed to various social, personal, economic and cultural factors, which have a negative impact on the social functioning and all the life aspects. Very often, this factors can be found as trigger and ethiologic factors of several mental health problems. The knowledge of socio-determinant factors that cause the mental health problems and the preventing measures, can substantially reduce the risk of their acquisition. The study consists of the application of a survey, the persons were randomly selected in different locations of Chisinau – the University of Medicine and Pharmacy, the University Clinic, the Republican Clinical Hospital; and the comparison of socio-determinant factors from the surveys and the case studies.

29
 The target group: 50 persons, randomly selected, that were asked to answer the 10 questions of the survey, and 4 beneficiaries of the Clinical Hospital of Psychiatry. 2.2. Procedure and instruments. In order to accomplish the goals and the objectives of the study, the following research methods and types of analysis were used: – Historical – review of the literature and theoretical synthesis; – Observation; – Empirical – research based on experience; – Sociological – questionnaire, survey and observation; – Comparison – comparison of data received from the research with previous studies in our country and abroad. The stages of the study: I stage: 1. September – October 2013 – review of the literature on mental health, historical context, stress and epidemiological context; 2. October -November 2013 – elaboration of hypothesis of the study; 3. November – December 2013 – development of the study design. II stage:

30
 4. January – March 2014 – Analysis of mental health context on international and local level; 5. March – May 2014 – Selection of scientific methods of studying the socio-determinant factors in the development of mental health problems; 6. May – October 2014 – Identifying the role and impact of socio-determinants in the development of mental health problems (the study itself). 7. October-November 2014 – Processing of results obtained and drawing conclusions and recommendations. The experimental basis is to achieve a qualitative study by surveying the community members and the realization of the case study of four beneficiaries (2 adults and 2 children) of the Clinical Hospital of Psychiatry from Chisinau. The study consists of the application of a survey, the persons were randomly selected in different locations of Chisinau – the University of Medicine and Pharmacy, the University Clinic, the Republican Clinical Hospital; and the comparison of socio-determinant factors from the surveys and the case studies. The target group: 50 persons, randomly selected, that were asked to answer the 10 questions of the survey, and 4 beneficiaries of the Mental Health Community Center. Criteria for selection of respondents were: • Acceptance to participate in the research study. • Age, sex, religion etc. weren’t criteria of inclusion or exclusion from the study. The importance of the work is that causality of mental health problems, social, cultural and family risk factors and the importance of stress, poverty and

31
 urbanization was approached, as well as the social vices involved in the development of mental health problems. The practical value of the research is that the study enabled us to propose prevention methods and prophylaxis of the mental health problems by simple methods of informing the community, these methods can be successfully used in the practice of social assistance, performed in state institutions and non-governmental organizations. 2.3. Results of the study The first phase of the study consisted of a survey. It was promoted to see the society's perception of socio-determinant factors that cause mental health problems. As a result of promoting the survey, we obtained the following results: When asked if parent issues, such as: very young or immature mothers who do not possess well developed parenting skills, mothers with low intelligence and learning difficulties may contribute to mental health problems in the future, we received the following results Yes – 45% No – 20% Do not know – 35%
Figure 2.3.1 Mother issues 45%
 20%
 35%
 da
 nu
 nu
 sSu

32
  We observe that 45% of people surveyed considers parent issues as one of the factors contributing to the emergence of mental health problems. Less than a quarter of respondents do not consider this factor as one trigger. And a third of respondents do not know if parent issues could stimulate the mental health problems. The question which concerns child abuse or neglect in the family, we have received the following answers: Yes – 37% No – 43% Do not know – 20%
Figure 2.3.2 Child abuse or neglect in the family Based on figures obtained above, we can notice that most respondents do not consider this factor as one that could facilitate mental health problems. But about a third of respondents mentions this factor as a facilitator for the development of mental health problems. 37%
 43%
 20%
 da
 nu
 nu
 sSu

33
 In the section that refers to the lack of family or frequent changes of living place / caregiver, the results are: Yes – 60% No – 10% Do not know – 30%
Figure 2.3.3 Lack of a family or frequent changes of the living place/caregiver These results show that this traumatizing factor, according to public opinion, is one that may stimulate the emergence of mental health problems. The question which refers to the economic situation of the family, show the following results: Yes – 85% No – 10%, Do not know – 5%.
Figure 2.3.4 The economic situation of the family From the above results it appears that for most of the people the economic factor is a key factor in the development of mental health problems. 60%
 10%
 30%
 da
 nu
 nu
 sSu
 
85%
 10%
 5%
 
da
 nu
 nu
 sSu

34
 Respondents mentioned that financial instability can trigger various mental health problems. Referring to the traumatic events, such as domestic violence, aggressions / physical, psychological abuses, sexual (rapes), we received the following data: Yes – 76%, No – 2%, Do not know – 22%.
Figure 2.3.5 Traumatic events From the obtained results, we can deduce that the majority of respondents know and understand the negative consequences of violence and abuse, considering this factor as an incentive factor in the development of mental health problems. Only 2 of 100 people did not consider this factor as one of triggers. Referring to the presence of the factor that keeps intrafamilial relationships disrupted, respondents gave the following answers: Yes – 59%, No – 31%, Do not know – 10%. 76%
 2%
 22%
 da
 nu
 nu
 sSu

35
  Figure 2.3.6 The presence of the factor that keeps intrafamilial relationships disrupted. Based on the data collected, more than a half of the respondents consider this factor as one of which increases the risk of mental illness. Less than a third of respondents do not consider this as an important factor. At the question concerning the presence of mental illnesses or serious somatic illnesses in parents, the answers were: Yes – 95%, No – 4%, Do not know – 1%.
Figure 2.3.7 The presence of mental illnesses or serious somatic illnesses in parents. The population perception about direct connection between their parent’s pathologies and the emergence of mental health problems in the following 59%
 31%
 10%
 da
 nu
 nu
 sSu
 
95%
 4%
 1%
 
da
 nu
 nu
 sSu

36
 generations was almost unanimous. 95 of the people surveyed answered affirmatively for this factor. In the chapter referring to the perturbed or inadequate school environment for the needs of teenagers, the results are similar to the ones of the previous question: Yes – 95%, No – 4%, I do not know – 1%.
Figure 2.3.8 The school environment Most of the respondents consider that school is being one of the basic stressing factors, which facilitate the apparition of mental disorders. The inadequate group of friends wasn’t considered by most of respondents as being a factor which can lead to mental health problems: Yes – 2%, No – 97%, Do not know – 1%.
Figure 2.3.9 Inadequate group of friends 95%
 4%
 1%
 
da
 nu
 nu
 sSu
 
2%
 97%
 1%
 
da
 nu
 nu
 sSu

37
 97 surveyed respondants do no assign that belonging to an inadequate group of friends is one of the factors that could cause the emergence of mental health problems. Speaking about addictions, the opinions split: Yes – 53%, No – 46%, Do not know – 1%.
Figure 2.3.10 Addictions At this question, the respondents formed two majority groups: 53 individuals consider addictions as being an important factor that leads to mental health problems, whilst 46 think that this factor is not of significant importance. 2.4 Case studies – results: In the second phase of the study we tried to check if the factors mentioned by opinion poll as socio-determinants of mental health problems were found in the case studies. For this we evaluated 4 users and did 4 case studies from Clinical Psychiatric Hospital: 2 adults and 2 children. 53%
 46%
 1%
 
da
 nu
 nu
 sSu

38
 CASE STUDY nr.1 SOCIAL STATUS Databout user’s family: • Identification’s data about family members: First and family name/ type of family members Age Occupation Residence son 21 student Ukraina son 19 student Rusia brother 46 unemployed Ungheni brother 44 unemployed Rusia • Relevant dates about family: she is divorced, has 2 children, leaves with father in Ucraina. Data about user’s development: • Information about birth, growth and development: was born in time. • Medical information: Schizophrenia, catatonic form, psychomotor agitation, permanently treat with antipsychotic drugs, was hospitalized many time. • Education: was finished 9 classes, professional status – worker. • Social assistance: received many different kind of social support including services and money.

39
 Finantial statut • Residence: apartment with one room, source of income – salary and pension. Social problems identified Low general income; domestic violence in the past, deviant behavior, addition: smoking and alcohol. CASE STUDY nr.2 SOCIAL STATUS Databout user’s family: • Identification’s data about family members: First and family name/ type of family members Age Occupation Residence dad – disabled – I 58 employed Bălți mom – disabled I 57 employed Bălți • Relevant dates about family: he is the third children in the complete family. • Data about user’s development: • Information about birth, growth and development: was born at time with mental and physical retardation.

40
 • Medical information: severe mental retardation, has the permanent treatment, was hospitalized many time. • Education: special boarding school for severe mental disabilities for boys – Orhei • Professional status: doesn’t have some profession; • Social assistance: received social support. Finantial statut • Residence: apartment with 2 rooms, source of income: parents’ salaries and pension. Social problems identified Low general income, father is addicted to alcohol, domestic violence. The person was hospitalized in residential institution for 10 years. CASE STUDY nr.3 SOCIAL STATUS Databout user’s family: • Identification’s data about family members: First and family name/ type of family members Age Occupation Residence mom 54 unemployed Balti

41
 dad 52 employed Balti • Relevant dates about family: The family leave in apartment with 2 rooms. Family relationship are mostly harmonized, friendly, excluding the period when father used alcohol. Mother is unemployed and has the possibility to be with her dother all the time.
 Data about user’s development: • Information about birth, growth and development: the pregnancy was normal, the birth was in time, were observed physical and mental retardation. • Medical information: the girls has Down syndrome with mental retardation and behavior disturbances, heart defect, in 2000 had a surgery on heart. During the first year after birth had a pneumonia. • Education: was including in special education, including kindergarten, at 9 years old she started the school education, know she is in 5th class. • Professional status: – unemployed • Social assistance: received many different kind of social support including services and money. • Finantial statut • Residence: campus with 2 rooms.

42
 • Source of income: pension, social allocation for leaving, transport and father’s salary. Social problems identified Family pathology: father is addicted to alcohol; social isolation, low income family situation; children neglect. CASE STUDY nr.4 SOCIAL STATUS Databout user’s family: • Identification’s data about family members: First and family name/ type of family members Age Occupation Residence mom 36 unemployed Balti brother 17 pupil Balti grandmother 71 retired Balti • Relevant dates about family: He leave in the same house with the mother, brother and grandmother. The family relationship is tense. The boy’s parents divorced immediately after his birth. At thee moment the boy’s father is leaving abroad and doesn’t participate in the children’s life. His mother has multiple relations with men, but all these are conflictual. Data about user’s development:

43
 • Information about birth, growth and development : – Born II in number, natal trauma. Delayed psychomotor development. • Medical information: he is in psychiatry dispensary evidence, has a infantile cerebral paralysis with middle motor disturbances, severe mental health with speech deficiency, had many hospitalization (6), have permanent treatment for behavior disturbances. • Education: was including in special education, including kindergarten, at 7 years old she started the specialized school education, know she is in 5th class, in 2009 he was expelled for antisocial and aggressive behaviour. • Professional status: unemployed • Social assistance: from 2009 started a rehabilitation program in CMHC in Chisinau. Finantial statut • Residence: house • Source of income: Personal pension of disabilities and the family members’ pension. Social problems identified Poverty, social isolation, begging, parent’s neglected responsibilities, alcohol addiction violence, mental health problems in family (mother), instable family atmosphere.

44
 2.5. Conclusions for case studies: The analysis on the basis of two case studies can call the following: • Even one of the four cases is unknowing the exact cause which triggered the mental illness, but we can assume that a combination of physical, psychological and environmental is generates the symptoms of mental disorders. • In two of the four cases, we can see that triggers came from family, namely genetic. • In all cases studied psychological risk factors are present which are vulnerable, these being: suffering, neglect, loss of a parent, various abuses. in four cases are found among the risk factors illness, divorce, death, job loss, alcohol abuse, social expectations and family life unsatisfactory. In this respect we identify the next group of factors: A. Individually risk factors: Genetically inherited diseases, prenatal brain injury caused at birth, low weight and birth complications, poor health in childhood, low intelligence, difficult temperament, chronic illness, low social skills, low self-regard, sense of alienation, physical abuse, sexual and emotional, physical illness / disability. B. Family risk factors: Problems in the relationship between parents, conflict between parents and children, poor supervision and monitoring of the child, poor parental involvement

45
 in children's activities, neglect in childhood, criticism from parents / partner violence and disharmony in the family, long-term unemployment of parents, parent delinquency, substance abuse by parents, parents' mental disorder, social isolation, lack of heat and disease, divorce and separations, caring for a person suffering / with a disability, loss of a family member. C. Cultural and community factors: • school violence and crime in group membership, accommodation, lack of services we support including transport, shopping, recreational facilities D. Institutional risk factors: unemployment, homelessness, poverty / economic insecurity, poor relationships at work, living in a residential institution, socio-economic disadvantage, social discrimination. From all the above, we can conclude that in all cases are present many socio – determinants which are the trigger to purchase mental health problems.
 2.6. Conclusions on opinion pull: 1. Most of people do not consider child abuse or neglect as a factor that can lead to mental health problems. 2. For most people, the economic factor is key in the development of mental health problems. Respondents mentioned that financial instability can trigger mental health problems. 3. Most respondents know and understand the negative consequences of violence and abuse, considering this factor as a stimulant for the development of mental health problems.

46
 4. The perception of people about the direct link between parents pathologies and health problems occurring in future generations Intal is almost unanimous. 95 of the people surveyed responded affirmatively to this item. 5. The School is considered one of the basic stress factors that facilitate the emergence of mental health problems. 6. Perception of the population with reference to the link between addiction and mental health problems is 50-50. Half of the population consider this factor as a stimulant in the development of mental health problems, and the other half did not consider this factor. 7. In all cases are present many socio – determinants which are the trigger to purchase mental health problems.

47
 GENERAL
 CONCLUSION
 AND
 RECOMANDATION:
  • People with mental health conditions meet criteria for vulnerability. • Because they are vulnerable, people with mental health conditions merit targeting by development strategies and plans. • The recommended actions in this report provide a starting point to achieve these aims • Prevention of mental disorders is a public health priority • Mental disorders have multiple determinants; prevention needs to be a multipronged effort • Effective prevention can reduce the risk of mental disorders • Prevention needs to be sensitive to culture and to resources available across countries • Protecting human rights is a major strategy to prevent mental disorders

48
 REFERENCES
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 8. Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry- 10th Edition-Ch.13-P.467 9. Murray L, Cooper PJ. Intergenerational transmission of affective and cognitive processes associ- ated with depression: infancy and the pre-school years. In: Goodyer IM, ed. Unipolar depression: a lifespan perspective. Oxford, Oxford University Press, 2003:17–46. 10. Neurological disorders: public health challenges. Geneva, World Health Organization, 2006. 11. Pasmore, W. (1995) Social science transformed: the socio-technical perspective, Human Relations, 48(1): 1–21. 12. Regional health development center on mental health in South-eastern Europe. Newsletter. 2001;1:7. [cited 2012 Sep 23] Available from: http://euro.who.int_data/assets/pdffile/0008/164348/RHDC-SEE-Newsletter-Issue-1.pdf 13. Saraceno, B., van Ommeren M, Batniji R et al (2007) Barriers to improvement of mental health services in low-income and middle-income countries Global Mental Health 5 14. Stability Pact for South Eastern Europe (2004) SEE Mental Health Project: Overview of Country Assessment of Mental Health Policy and Legislation in SEE. Sarajevo: Regional Report, WHO Regional Office for Europe. 15. Secretary-General, in message for World Mental Health Day, cites pressing duty to scale up services for mental disorders, especially among disadvantaged. New York, United Nations, 2007 (SG/SM/11193 OBV/652). 16. The Human Rights Based Approach to Development Cooperation Towards a

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 Common Understanding Among UN Agencies. UNDP (http://www.undp.org/governance/docs/HR_Pub_ Missinglink.pdf, accessed 29 December 2009). 17. Thornicroft G et al. Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. The Lancet, 2009, 373:408–415. 18. Thornicroft, G. and Tansella, M. (1999) The Mental Health Matrix. Cambridge: Cambridge University Press. 19. World Health Report 2003. Shaping the future. Geneva, World Health Organization, 2003. 4 WHO World Mental Health Survey Consortium. Prevalence, severity and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. Journal of the American Medical Association, 2004, 291:2581–2590. 20. WHO Europe. Mental health. [cited 2012 Sep 23] Available from: http://www.euro.who.int/en/what-we-do/health-topics/noncommunicable-diseases/mental-health 21. WHO. Mental health. [cited 2012 Sep 23]. Available from: http://www.who.int/mental_health/management/depression/definition/en/ 22. World Health Organization (2003) Mental Health Policy and Service Guidance Package – The Mental Health Context. World Health Organization 23. World Health Organization (2003) Mental Health Policy and Service Guidance Package – Organization of services for Mental Health. World Health Organization

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 24. World Health Organization (2003) Mental Health Policy and Service Guidance Package – Quality Improvement for Mental Health. World Health Organization 25. World Health Organization (2005) Mental Health Policy and Service Guidance Package – Human Resources and Training in Mental Health. World Health Organization 26. World Health Organization Mental Health Survey Consortium (2008) Prevalence, Severity, and Unmet Need for Treatment of Mental Disorders in the World Health Organization World Mental Health Surveys 27. WHO-International Classification of Diseases (ICD-10) 28. World Bank. Data by country: http://data.worldbank.org/country/moldova 29. World Health Organization. Prevention of mental disorders : effective interventions and policy options : summary report / a report of the World Health Organization Dept. of Mental Health and Substance Abuse ; in collaboration with the Prevention Research Centre of the Universities of Nijmegen and Maastricht ., 2004. 30. UN Convention on the Rights of Persons with Disabilities – A major step forward in promoting and protecting rights. Geneva, World Health Organization, 2008 (http://www.who.int/mental_health/ policy/legislation/4_UNConventionRightsofPersonswithDisabilities_Infosheet.pdf, accessed 29 December 2009).

52
 V.
 Annexes
 
 Annex
 nr.
 1:
 OPINION POLL 1. Does the parents’ problems, such as very young or immature mothers who do not have well developed parenting skills, mothers with low intelligence and learning difficulties, contribute to the occurrence of mental health problems? • yes • no • I don’t know 2. Is child abuse or neglect in the family a factor that can facilitate the occurrence of mental health problems? • yes • no • I don’t know 3. Is the lack of family or frequent change of place / person of care a factor that determines the purchase of mental health problems? • yes • no • I don’t know

53
 4. Are the mental health problems provoked by financial situation of the family? • yes • no • I don’t know 5. Are the traumatic events, such as domestic violence, physical psychological, sexual (rape) assault / abuse, the factors that cause mental health problems? • yes • no • I don’t know 6. Does the disrupted or inadequate family atmosphere such as parental crime or verbal and physical domestic violence factors that contribute to the occurrence of mental health problems? • yes • no • I don’t know 7. Are the mental disorders or serious somatic illness of parents facilitate the occurraence of health problems? • yes • no • I don’t know

54
  8. Does the disrupted or inadequate school’s atmosphere for the needs of adolescent facilitate the emergency of mental health problems? • yes • no • I don’t know 9. Does the bad group of friends give rise mental health problems? • yes • no • I don’t know 10. Does the presence of addictions contribute to mental health problems? • yes • no • I don’t know

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Declaration I hereby declare that the diploma paper entitled ”SOCIAL DETERMINANTS OF MENTAL HEALTH” It is written by me and never ever submitted to another university or higher education institution in the country or abroad. Also that all sources used, including those on the Internet, they are stated in the paper with the rules to avoid plagiarism: • all text fragments reproduced exactly, even in his own translation of other languages are in quotation marks and have detailed reference source ; • reformulation of texts written in their own words by other authors hold detailed reference; • summarizing the ideas of other authors hold detailed reference to the original. Data Student: ABDEL-halim mohammad ________________ (signature)