Author: Isabel Gerondelis

This brief was originally published on July 3, 2021 by Isabel Gerondelis. It was updated and republished by Josh Ludwig on June 30, 2022.

Social determinants are conditions in a person’s lived environment that impact their health and quality of life. There are five main groups of social determinants of health:

1. Economic stability
2. Education access and quality
3. Healthcare access and quality
4. Neighborhood and built environment
5. Social and community context

Social determinants of health contribute to health disparities and inequalities as factors like race, socioeconomic status, housing, educational attainment and more impact a person’s health.

Mental health is defined as our emotional, psychological, and social well-being that impacts our thoughts, actions, and feelings. Our mental health influences how we handle stress and make healthy choices. Conversations about mental health are becoming more widespread, partially in response to rising suicide rates. Suicide risk can be reduced with mental health screenings and treatment, but attention to mental health often goes overlooked. One consequence of this is that the U.S. suicide rate has increased 35% from 1999 to 2018. In 2018, suicide was the 10^th leading cause of death, claiming more lives than homicide deaths. Since the Covid-19 pandemic, suicides have also been increasing on college campuses. This has left college administrators struggling with how best to respond, as their resources are being overwhelmed with more students seeking mental healthcare from their colleges.

Furthermore, suicide was the 2^nd leading cause of death for youth in 2019. As a result, suicide is a major contributor to premature mortality and is considered an epidemic that greatly impacts societal health. The U.S. is a unique case with approximately ¼ of U.S. adults reporting a mental health diagnosis, which is a higher rate than other high-income countries. This fact suggests that the U.S. is lacking in mental health providers and creates conditions in which people feel significant stress, helplessness, and/or other emotions that can lead to mental health issues. It also suggests the U.S. needs to address mental health in more societal conversations, especially as the COVID-19 pandemic has increased feelings of anxiety, helplessness, and fear, leading to increased mental health impacts.

Since societal factors place certain groups at a higher risk of experiencing adverse mental health outcomes, it is important to understand what impacts specific social determinants can have on society.

Some examples include: 

College campuses (especially during the pandemic) – College campuses exemplify when these social determinants of health come together to create inequality. Due to the pandemic, inequalities between wealthy and low-income, and white versus minority students have made college a harder place to succeed, especially for certain groups. College is the age of onset for most mental health conditions, and it is important to have this conversation when talking about the social determinants of mental health for that reason.

Economic Stability – If a person is less economically stable due to the presence of debt, the inability to pay for essential needs like housing, food, and clothes, or having to work multiple jobs, we see an increased rate of stress and a higher risk of suicide. Financial strain may also deter people from seeking medical and mental health care, as they don’t have the financial means to pay for care and/or don’t have enough time to focus on self-care. COVID-19 has increased both economic and health disparities demonstrating how these disparities are linked to mental health. Conversely, stimulus checks during COVID-19 decreased economic instability, which also decreased stress and anxiety. Research has even shown that increasing the minimum wage by $1 may reduce the suicide rate. 

Education Access and Quality – People with higher levels of education tend to have higher incomes, which leads to less overall stress and anxiety. Having a higher income makes purchasing healthy food, accessing reliable transportation, and healthcare itself more affordable. Additionally, education can provide social networks that help with social support during difficult times and increase self-esteem. It can also help people combat adverse life events by providing knowledge about how to research and find available resources. Additionally, college students who are first generation face unique challenges that those whose parents went to college do not have to deal with. Some examples of this include feelings of family conflict and guilt, shame, imposter syndrome, confusion, and anxiety.

Healthcare Access and Quality – People who need or want to seek treatment often face barriers including difficulties finding a provider and navigating the fragmented healthcare system. If mental health professionals aren’t within a person’s insurance network, high out of pocket costs also deter people from seeking care. Furthermore, 1 in 6 U.S. adults is unable to afford professional help when they experience emotional distress. These barriers to care help explain why the U.S. has such a high suicide rate. For first generation college students, they face the challenges of not knowing how to access resources for counseling or healthcare options. This hidden curriculum is accessible to those whose parents or siblings went to college, as they have experience navigating these resources.

Neighborhood and Built Environment – 45% of US adults who reported experiencing emotional distress were also concerned about neighborhood safety. Living in an overcrowded apartment can also increase stress and anxiety, especially during COVID-19, as people in crowded living situations are more likely to contract the disease. Furthermore, the quality of housing affects the mental health of both children and adults. Poorer housing quality impacts motivation and leads to internalized symptoms, like depression and anxiety, and externalized symptoms, like aggression and learned helplessness.

Social and Community Context – This is a social determinant with multiple subcategories that impact mental health. Subcategories include:

• Racism – Black and Indigenous People of Color (BIPOC) experience higher rates of mental illness because racism causes trauma and stress that can lead to anxiety, depression, and suicide. People of color, especially Black people, experience habitual discrimination and microaggressions which cause increased amounts of stress. This racial trauma can increase the risk of BIPOC meeting the criteria for PTSD. Furthermore, due to fears concerning racism, discrimination, stress, and crowded housing, people of a racial minority experience less sleep. Less sleep can lead to insomnia, which can increase suicidal thoughts. Additionally, people of color often experience discrimination within the medical and mental health fields where their symptoms aren’t taken as seriously, which can decrease the likelihood of people of color seeking help. More than a third of first-generation college students are minorities, which means they have to overcome racial prejudice. This can have negative effects on these students, with feelings of marginalization and isolation leading to negatively impacted mental health and academic success.
• Sexual Orientation and Gender Identity – LGBTQ+ people experience discrimination, hate crimes, and threats for their sexual and gender identity. This causes extreme stress and internalized shame As a result, LGBTQ+ youth contemplate suicide at almost three times the rate of heterosexual youth. Furthermore, being unable to live one’s identity and express one’s orientation safely in an accepting community leads to despair and depression. Over 60% of transgender or nonbinary people reported they self-harmed in the past year, which results from feelings of isolation, gaslighting when people don’t use the correct pronouns, and fear of societal consequences because of their gender identity. Experiencing discrimination from both society and family members about how a person identifies has significant mental health repercussions, making transgender people one of the most at-risk populations. Many college students discover and/or disclose their sexual orientation and/or gender identity during college, making it a formative time in their development. According to college administrators, Covid-19 worsened the mental health of LGBTQ+ students, worsening symptoms of anxiety, depression, loneliness, and difficulty coping with stress, as well as concerns about sharing their identity with their family members.
• Mental Health Stigma – Defined as when society places shame on people with mental illnesses, it can prevent people from seeking aid and feeling like they belong in society. Mental health stigmas can also make people feel weak for needing mental health assistance. Mental health stigmas can come from stereotypes such as people with depression being lazy, those with anxiety being cowardly, or individuals with mental health illnesses being more violent. Stigmas regarding mental health can exacerbate symptoms and make it harder to seek help. On college campuses, the presence of an Active Minds chapter can reduce the stigma of talking about mental health and mental illness by helping to make the campus more accepting of these topics. On college campuses that are perceived to be supportive of mental health issues, students are 20 percent more likely to seek out and receive mental health treatment.

When thinking about mental health in the U.S. think about what social, economic, and political factors play a role in the declining mental health in the country. What stressors exist in people’s lives? Are they able to find and afford help? Is there a safe community for them to talk, destress, and share experiences with? Thinking about the social determinants of mental health provides a more holistic view on why mental health can disproportionately impact different people in society and where the root causes originate from. College campuses provide a case study for how these social determinants of health can come together to perpetuate inequality and be the place where college students are in the age range of the age of onset of mental illnesses.

Purdue Pharmaceuticals L.P is a private pharmaceutical company founded in 1892 that develops, manufactures, and markets medications and consumer health products. The company has been accused of contributing to the opioid epidemic by aggressively marketing its opioid medications, which are highly addictive. The opioid epidemic refers to the increasing number of deaths and hospitalizations from opioids. Opioids are a type of drug derived from opium, which is a substance from the opium poppy plant. The increased marketing and prescriptions of opioid medications contributed to an uptick of opioid addictions, thus fueling the epidemic. The multiple lawsuits against Purdue Pharma attempt to hold Purdue Pharma accountable for their contributions to the opioid epidemic.

A Brief History of Purdue Pharma

Purdue Pharma was founded in 1892 by John Purdue Gray M.D. and George Frederick Bingham M.D. as the Purdue Frederick Company and was later sold to members of the Sackler family. By 1995, the company was focusing on launching medications that reduced pain. The main product was OxyContin, an opioid meant to relieve chronic pain for those suffering from cancer and other chronic conditions. In efforts to successfully launch the drug, Richard Sackler, the head of the company, hosted dinner programs for physicians who were prescribing greater amounts of OxyContin. The goal became to market the drug to anyone with chronic pain, rather than just those with malignant pain. OxyContin sales reached $48 million. However, the danger of overprescribing powerful pain medications is they are highly addictive. Most who become addicted to opioids do so through prescriptions. Concern grew about the illegal use of OxyContin, as people began to seek out other means to get the drugs, and in the fall of 2000 the problem grew to epidemic proportions. Meanwhile, Purdue Pharma’s sales increased to just under $1.1 billion.

Impacts on the Opioid Epidemic

The opioid epidemic has three main waves – the first starting with drug companies, like Purdue Pharma, encouraging doctors to overprescribe opioids. Doctors told patients that opioids were the answer to chronic pain. However, opioids are one of the most addictive drugs on the market.  21-29% of people prescribed opioids misuse them and continue seeking them out when they are no longer needed. As a result, there were hundreds of thousands of new addictions during the 1990s and 2000s. When doctors give them to patients who don’t require them, it needlessly increases the risk of becoming addicted. The growing opioid addictions brought attention to the problem of overprescribing opioids. 

In 2011 there was a crackdown on pill mills, or pain clinics that gave away pills for money, in efforts to decrease prescriptions. As prescription pills became more limited, drug prices rose which led to people seeking street drugs like heroin. The third wave occurred when drug dealers began making synthetic drugs, like fentanyl, that are much smaller and easier to distribute, but are much more potent. 

The lawsuits argue that Purdue Pharma played a role in the opioid epidemic when they encouraged overprescribing opioids and engaged in aggressive campaigning that downplayed the risks of using and becoming addicted to opioids. Purdue cited a letter that stated only 2 of 11,000+ patients became addicted when given opioid medicines to validate the safety of OxyContin. In reality, as with most other opioids, it takes a while for the full pain relief effect of OxyContin to settle in. Individuals may look for ways to take the drug quicker to feel the full effects instantly. Additionally, tolerance to the drug builds over time, resulting in the person needing more and more of it to experience the same effects. This is how addictions begin and this is what Purdue Pharma downplayed when marketing the drug. In fact, Purdue Pharma spent more than $400 million in promotional spending. This aggressive campaigning helped spread the word, increase the sale of, and claim the false safety of OxyContin. 

The Lawsuits

• 2002 – Florida attorney general’s office was one of the first law agencies to investigate Purdue Pharma. It cited almost 400 pill deaths in three Florida counties in the past 2 years and claimed Purdue Pharma was the one responsible.
• 2007 – Purdue pleaded guilty to felony charges of misbranding OxyContin. The company confessed to telling doctors the drug was less addictive than other opioids and paid a series of fines.
• There were many other lawsuits in many other states over the years.
• 2018 – Lawsuit by the state of Massachusetts, accusing Purdue executives of aggressively marketing pills and misleading doctors and patients about the risks. It said Purdue contributed to overdose deaths of over 670 Massachusetts residents.
• The final claim: Purdue’s marketing of powerful prescription pain meds contributed to the opioid epidemic, which has killed almost 500,000 people in the US in the last two decades.
• 2019 – Purdue Pharma filed for bankruptcy to settle the 3,000 lawsuits from state, local governments, and other impacted parties.

What’s Next

The new settlement as of July 7, 2021 is called the reorganization plan. It has several requirements, including:

• Making public tens of millions of internal documents, connecting the company and family to the opioid crisis.
• Contributing a total of $4.5 billion to charities aimed at ending the opioid epidemic. These funds will come from both the Purdue Pharma company and the Sackler family’s individual funds.
• Produce overdose-reversal drugs and medicated-assisted therapy (MAT) for those in recovery. MAT can be used to alleviate withdrawal symptoms.
• The Sackler family will give up ownership of Purdue Pharma by 2024 or will close down the company.
• The Sackler Family is banned from the opioid business.
• The Sackler Family is banned from naming rights of the money donated to charitable foundations until all obligations are paid.

The over 600 companies, people, and governments with claims against Purdue will vote on the package. The confirmation hearing is scheduled for August 9, 2021. 9 states have yet to approve the deal.

Is this solution enough? 

This case is the highest profile case against drug makers, pharmacies, and distribution companies, which are the main producers of opioids. However, the Sackler Family didn’t actually admit to any wrongdoing. The settlement doesn’t hold the family accountable and they’ll continue to be one of the richest families in the US. Furthermore, some attorneys argue that the settlement gives the Sackler family immunity through Purdue’s bankruptcy. In addition, the harm caused by the opioid epidemic is vast and while holding a major pharmaceutical company accountable is a step in the right direction, it won’t reverse the costs of the epidemic.

There were more overdose deaths in 2020 during the pandemic than any other year, reaching nearly 100,000 deaths. Every day around 128 people die from an opioid-related overdose. One problem that has persisted when trying to address the opioid epidemic is cutting supply, rather than focusing on reducing the demand. As a result, people resort to other more dangerous means, making that solution inadvertently further the epidemic. Perhaps more focus should be on drugs like buprenorphine and methadone, which help reduce the overdose death rate by 50% or more. In addition, naloxone, the life-saving medication that can prevent deaths from overdoses, should be widely distributed. More recovery centers, mental health resources, and training to administer life-saving medications are also needed to help combat the opioid epidemic, along with holding large pharmaceutical companies accountable.