Amidst long arcs of the pendulum between attention to psychosocial and neurobiological factors in mental health, substantive progress now depends on these two approaches being seen as complementary and synergistic rather than contradictory. From this launchpad, Kirkbride et al's paper¹ is an impressive, high-level and up-to-date overview regarding the role of social determinants in mental health and disorders. Perhaps most helpfully, it highlights a series of complexities worth reflecting on as the field moves towards a more sophisticated understanding of the interpenetrating effects of social determinants, and to generating and actioning relevant interventions.

A first challenge is the false dichotomy between primary and secondary/tertiary prevention strategies. Primary prevention can be a powerful route to addressing social determinants, but is often not the only one. As a result, primary and secondary approaches ought to be seen as interdependent instead of oppositional². Delivery of effective primary prevention schemes should result in reduced need for secondary/tertiary prevention (albeit perhaps staggered or delayed), yet there will still be a need for clinical and service innovations to better address breakthrough cases and suffering. For example, a sizable proportion of young people presenting to community-based early intervention services appear to have more complex needs than might have initially been anticipated or planned for³. Despite the best of intentions, some youth may even be underserved in such settings, underscoring the urgency behind having a full suite of options across the entire continuum of care, and smooth pathways between the various layers of a mental health system⁴.

Second, psychiatry has historically become tangled – and at times knotted – around the question of whether poor mental health influences social circumstances or vice versa⁵. However, Kirkbride et al argue that, even without a granular accounting of each mechanistic link in complex causal chains, we now understand a fair bit regarding how to potentially break relevant feedback loops. Direct genetic and neurobiological factors, identified in impressive and rigorous studies, are at present mostly unmalleable and thus far account for only a small proportion of the population-attributable risk fraction across a range of mental health conditions. In contrast, putative social interventions or policy levers aimed at sensitive periods of development (to which biology undoubtedly contributes) certainly exist, and can at the very least be conceptualized and tested⁶, for a number of reasonably well-established social determinants – ranging from early years programs to neighborhood regeneration all the way through to indicated prevention strategies in clinical settings. And since so many of the social determinants are held in common across mental and even physical health conditions, interventions based on these variables are likely to have a slew of benefits. This is a critical corollary to Rose's prevention paradox: although the force required to shift the population curve may be intimidating compared to an approach that focuses on high-risk groups alone, the former may nonetheless have outsized and favourable ripple effects on both mental health as well as other aspects of health and well-being.

Kirkbride et al's paper compellingly suggests that this should be a central rationale for renewing the attention given to social determinants across primary and secondary prevention paradigms. Nowhere is this better illustrated than in their depiction of poverty, its cascading effects across the life course, and how intervention strategies that push poverty alleviation to the sidelines may therefore be destined for failure. There is little question, then, that those interested in addressing social determinants of mental health must appreciate not only individual risk factors, but the underlying causal structures through which risk manifests.

The wide-ranging ways in which inequality and poverty exert their direct and indirect effects also means that discrete interventions cannot be considered in isolation. Rather, they accentuate the need for social determinants of mental health to be addressed by coordinated interventions across layers of causal structure (including individual, interpersonal, institutional and structural) that are also purposefully designed to reach across policy domains. In the case of mental health, there is a porous boundary between preventive interventions and social/educational policy, such that the lens should be one of integrated public policy and not just health policy. Indeed, given the disability and indirect costs associated with mental health problems and disorders, their onset during youth and their persistence if untreated, a “whole of government” approach akin to that taken during other crises may be indicated and even necessary.

Finally, Kirkbride et al allude not just to the need for further investment in interventions and population health monitoring, but also to ongoing investigations regarding their effects. In part this is because interventions are not without risk and may have unintended consequences, including iatrogenic ones⁷. And, even when beneficial, potential interventions should be seen in their social context and recognized as having limits. For example, although specific migration exposures are widely acknowledged to be risk factors for psychosis, making reactive policy changes (such as eliminating immigration) based on this would be untenable as well as discriminatory. Instead, the key question is how public policy can benefit from dialogue between theorists, empiricists and policy practitioners to – among other things – appreciate that immigration may represent a proxy for underlying exposures and stressors; posit potential mechanisms across biological, psychological and social levels of causation; and then plan and test interventions that reduce risk, promote integration, and advance implementation. The optimal strategies will likely involve capturing diverse and patient-oriented outcomes, discerning the structures through which social conditions and outcomes emerge and are interwoven, and perceiving the widespread benefits of inclusive and equity-oriented policies.

More than anything, Kirkbride et al's depiction of the current state-of-the-art represents a call for creativity and investment to address the social determinants of mental health. If inequality harms⁸, then the current chasms between demonstrated need, the required multi-sectoral engagement, and concerted action on social factors affecting the mental health of individuals, communities and populations is deeply unsettling. It is also one of a range of contemporary dilemmas that – like climate change and diminishing economic opportunities – will particularly affect young people, the future of any society. Whether due to recent crises that have temporarily prevented new solutions from being born, or the longer-term hollowing out of government expertise and capacity⁹, the energy to catalyze integrative approaches to such a far-reaching challenge seems to have come to a lull. It now demands sustained renewal and revitalization.

在对心理健康中的心理社会因素和神经生物学因素的关注之间的长期摇​​摆中，实质性进展现在取决于这两种方法是否被视为互补和协同而不是矛盾。 Kirkbride 等人的论文¹以此为起点，对社会决定因素在心理健康和疾病中的作用进行了令人印象深刻的、高水平的最新概述。也许最有帮助的是，随着该领域朝着更深入地理解社会决定因素的相互渗透影响以及制定和采取相关干预措施的方向发展，它强调了一系列值得反思的复杂性。

第一个挑战是一级和二级/三级预防策略之间的错误二分法。一级预防可以是解决社会决定因素的有效途径，但往往不是唯一的途径。因此，主要方法和次要方法应该被视为相互依存而不是对立的² 。实施有效的一级预防计划应会减少对二级/三级预防的需求（尽管可能是交错或延迟的），但仍然需要临床和服务创新，以更好地解决突破性病例和痛苦。例如，相当大一部分接受社区早期干预服务的年轻人的需求似乎比最初预期或计划的更为复杂³ 。尽管初衷是好的，但一些青少年在这种情况下甚至可能得不到充分的服务，这凸显了在整个护理过程中提供全套选择以及在精神卫生系统各层之间建立顺畅通道的紧迫性⁴ 。

其次，精神病学历史上一直围绕着“不良心理健康是否会影响社会环境，反之亦然”的问题而纠结——有时甚至打结⁵ 。然而，Kirkbride 等人认为，即使没有对复杂因果链中的每个机械环节进行精细的解释，我们现在也对如何潜在地打破相关反馈循环有了一定的了解。在令人印象深刻和严格的研究中发现的直接遗传和神经生物学因素目前大多是不可塑性的，迄今为止仅占一系列心理健康状况中人群归因风险部分的一小部分。相比之下，针对发展敏感时期（生物学无疑对此做出了贡献）的推定社会干预或政策杠杆肯定存在，并且至少可以针对许多相当完善的社会决定因素进行概念化和测试⁶早年的社区再生计划一直到临床环境中指定的预防策略。由于许多社会决定因素在精神甚至身体健康状况方面都是共同的，因此基于这些变量的干预措施可能会带来很多好处。这是罗斯预防悖论的一个重要推论：尽管与仅关注高风险群体的方法相比，改变人口曲线所需的力量可能令人生畏，但前者可能对心理健康和心理健康产生巨大且有利的连锁反应。以及健康和福祉的其他方面。

Kirkbride 等人的论文令人信服地表明，这应该成为重新关注初级和二级预防范式中的社会决定因素的核心理由。他们对贫困、贫困对生命历程的连锁效应以及将扶贫推向边缘的干预战略注定会失败的描述最能说明这一点。因此，毫无疑问，那些对解决心理健康的社会决定因素感兴趣的人不仅必须认识到个人风险因素，而且还必须认识到风险表现出来的潜在因果结构。

不平等和贫困产生直接和间接影响的方式多种多样，这也意味着不能孤立地考虑单独的干预措施。相反，它们强调需要通过跨因果结构层（包括个人、人际、机构和结构）的协调干预措施来解决心理健康的社会决定因素，这些干预措施也有目的地设计为跨政策领域。就心理健康而言，预防性干预措施和社会/教育政策之间存在漏洞，因此应该关注综合公共政策，而不仅仅是卫生政策。事实上，考虑到与精神健康问题和紊乱相关的残疾和间接成本、这些问题在青年时期发病以及如果不治疗则持续存在，可能需要采取类似于其他危机期间采取的“政府整体”方法，甚至是必要的。

最后，柯克布赖德等人不仅暗示需要进一步投资干预措施和人口健康监测，而且还暗示需要对其影响进行持续调查。部分原因是干预措施并非没有风险，并且可能会产生意想不到的后果，包括医源性后果⁷ 。而且，即使潜在的干预措施是有益的，也应该在其社会背景下看待并认识到其存在局限性。例如，尽管特定的移民暴露被广泛认为是精神病的危险因素，但据此做出反应性政策改变（例如消除移民）将是站不住脚的，而且具有歧视性。相反，关键问题是公共政策如何从理论家、经验主义者和政策实践者之间的对话中受益，尤其是认识到移民可能代表潜在的风险和压力源；提出跨生物学、心理和社会因果关系层面的潜在机制；然后计划和测试降低风险、促进整合和推进实施的干预措施。最佳策略可能涉及捕捉多样化和以患者为导向的结果，辨别社会条件和结果出现和交织的结构，并认识到包容性和公平导向的政策的广泛好处。

最重要的是，柯克布赖德等人对当前最先进技术的描述代表了对创造力和投资的呼吁，以解决心理健康的社会决定因素。如果不平等会造成损害⁸ ，那么目前已表明的需求、所需的多部门参与以及对影响个人、社区和人口心理健康的社会因素采取协调一致的行动之间存在的鸿沟令人深感不安。这也是一系列当代困境之一——就像气候变化和经济机会减少一样——将特别影响年轻人，即任何社会的未来。无论是由于最近的危机暂时阻止了新解决方案的诞生，还是由于政府专业知识和能力的长期空洞⁹ ，促进采取综合方法应对这一影响深远的挑战的能量似乎已经减弱。现在它需要持续的更新和振兴。