Abstract: The overall objective of this webinar is to harness the powerful data of populational studies to patients in clinical practice. This is effectively a plan for applying social psychiatry to the clinic –a call for “Clinical Social Psychiatry.” This objective will be addressed through three goals with seven steps: (A) Review social psychiatry’s powerful populational studies on psychiatric epidemiology and Social Determinants of Health & Mental Health (SDH/MH) 1. Adverse Childhood Experiences (ACE) Studies 2. Global Mental Health (GMH) – Treatment Gaps 3. Epidemiology to reflect the burden of disease (B) Promote translational research of social psychiatric studies – redefining health in social terms 4a. Translational research to redefine health 4b. Mental health in a social context (C) Provide ground-level prescriptions aimed at prevention, promotion, intervention, and adaptation 5. Mental health services to be delivered where people live 6. Shared care/integrated care/collaborative care 7. We can’t do everything – address common and pressing problems Keywords: Populational studies, social determinants of health & mental health (SDH/MH), translational research, ground-level prescriptions

1. From Populations to Patients
Social Determinants of Health &
Mental Health in Clinical Practice
Prof. Vincenzo Di Nicola
Global Research Network
on Social Determinants
of Mental Health and Exposomics
8 February 2024

2. Prof. Vincenzo Di Nicola
MPhil, MD, PhD, FRCPC, FCAHS, DLFAPA, DFCPA
Professor of Psychiatry
University of Montreal & The George Washington University
Honorary Chair & Professor of Social Psychiatry, Università Ambrosiana
President
World Association of Social Psychiatry
Canadian Association of Social Psychiatry
Fellow
Canadian Academy of Health Sciences
Distinguished Fellow, Canadian Psychiatric Association
Distinguished Life Fellow, American Psychiatric Association

3. Conflicts of Interest
The presenter has no financial conflicts of
interest to declare

5. Self-Portrait – From Science to Society
My career is bookended by training as a
researcher in psychology (McGill U,1976;
Institute of Psychiatry, UK, 1978) and
psychiatry (McGill, 1986) and my work as
a philosopher of psychiatry (EGS, 2012)
I’m a late-career psychiatrist and an
early-career philosopher

6. No disciple of the wise
may live in a city that
does not have a
physician, a surgeon,
a bathhouse, a
lavatory, a source of
water, a synagogue, a
school teacher, a
scribe, a treasurer of
charity funds for the
poor, a court that has
authority to punish.
– Maimonides

7. As a social psychiatrist I consider SDH/MH
our basic science (Di Nicola, 2019)
Reference: V Di Nicola.
“A person is a person through other persons”:
A social psychiatry manifesto for the 21st century.
World Social Psychiatry 2019; 1(1): 8-21.
Social Determinants of Health & Mental Health

8. Genetics & Epigenetics
Double-helix structure of DNA
Crick & Watson (1953)
Epigenetics
N Koltsov, CH Waddington “epigenetics” (1942)
Neuropsychology
“Synaptogenesis” – DO Hebb
Developmental psychology
“Epigenetic epistemology” – J Piaget
“Epigenetic principle” – E Erikson
“Probabilistic epigenesis” – G Gottlieb

10. Exposomics
A promising bridge between these domains is exposomics
and Hartung’s (2023) call for a Human Exposome Project
As a social philosopher, I am both curious and cautious
about the impact of this idea on the scientific community
and the general public (Rutherford, 2015)
Philosophy of mind & neurophilosophy have addressed
the implications (Pat & Paul Churchland – Tümkaya, 2021)
References: Hartung (2023), Rutherford (2015), Tümkaya (2021)

11. Introduction: Three Goals
I. Review social psychiatry’s powerful populational
studies on psychiatric epidemiology and Social
Determinants of Health & Mental Health (SDH/MH)
II. Promote translational research of social
psychiatric studies – redefining health in social terms
III. Provide ground-level prescriptions aimed at
prevention, promotion, intervention, and adaptation

12. Introduction: Seven Steps
I. Populational studies
1. Adverse Childhood Experiences (ACE) Studies
2. Global Mental Health (GMH) – Treatment Gaps
3. Epidemiology to reflect the burden of disease
II. Translational research
4a. Translational research to redefine health
4b. Mental health in a social context
III. Ground-level prescriptions
5. Mental health services to be delivered where people live
6. Shared care/integrated care/collaborative care
7. We can’t do everything – address common & pressing
problems

13. Populational Studies
Epidemiological studies
the shift is away from the
individual and the clinic, and
populations became the focus of
research

14. “Science and Society”

15. Populational Studies
Review social psychiatry’s powerful populational
studies on psychiatric epidemiology and the Social
Determinants of Health & Mental Health (SDH/MH)
1. Adverse Childhood Events (ACE) Studies
Linear gradient between childhood adversity and poor
health outcomes (Felitti & Anda, 2010)
Identify children at risk instead of treating everybody the
same – we don’t have the resources or the mandate –
“Don’t fix it if it ain’t broke”
References: CSDH (2008), Felitti & Anda (2010), Di Nicola (2012),
Jeste & Pender (2022)

16. Populational Studies
Review social psychiatry’s powerful populational
studies on psychiatric epidemiology and the Social
Determinants of Health & Mental Health (SDH/MH)
2. Global Mental Health (GMH) – Treatment Gaps
Gap between known burden of disease and access to
care (Marmot, 2015)
A key plank in the GMH Movement (Cohen, et al., 2013;
CSDH, 2008; Patel & Prince, 2010)
References: Cohen et al. (2013), CSDH (2008), Marmot (2015), Patel &
Prince (2010), Sorel (2012)

17. Populational Studies
Review social psychiatry’s powerful populational
studies on psychiatric epidemiology and the Social
Determinants of Health & Mental Health (SDH/MH)
3. Epidemiology to reflect the burden of disease
Service allocation should be based on reliable epidemiology – “the
science of denominators” – not the “numerators” that happen to catch
our attention
Overdiagnosis and overprescription are as dangerous as poor
access to care (Frances, 2021)
This is partly a side-effect of overspecialization
References: Frances A (2021),Aftab (2019)

18. Redefining Health
Promote translational research of social psychiatric
studies – redefining health in social terms
4a. Translational research to redefine health
As we totter from one psychiatric revolution to another,
we always leave part of the population behind
“A serial collapse into single-message mythologies”
– Paul Hoff, German psychiatrist and historian (Fulford, 2021)
Health is broadly social, not just biological or genetic (Prince,
et al., 2007; Di Nicola, 2019, 2021)
References: Fulford (2021), Prince et al. (2007)

19. Redefining Health
Promote translational research of social psychiatric
studies – redefining health in social terms
4b. Mental health in a social context
Just as there is no health without mental health, there is no
mental health without a healthy body in a healthy society
References: Di Nicola (2019, 2021), Prince et al. (2007)

20. Ground-level Prescriptions
Provide ground-level prescriptions aimed at
prevention, promotion, intervention, and adaptation
5. Mental health services should be delivered
where people live
Identifying access to care issues – the treatment gap – isn’t
enough
We need to build clinics and integrate services into real
communities –
Schools, workplaces, community centres, sports arenas, shoppingmalls

21. Ground-level Prescriptions
Provide ground-level prescriptions aimed at
prevention, promotion, intervention, and adaptation
6. Shared care/integrated care/collaborative
care
Primary care is overburdened
Specialty care is difficult to access
Communication between them is poor
References: Di Nicola (2022), Ivbijaro (ed., 2010), Kates et al. (2011)

22. Ground-level Prescriptions
Provide ground-level prescriptions aimed at
prevention, promotion, intervention, and adaptation
7. We can’t do everything – let’s address the
most common & pressing problems
Give them priority before they become urgent or chronic
and intractable
If primary prevention is a fantasy, secondary and tertiary
prevention are not

23. Social Psychiatry in the Clinic
We need to start thinking of clinical social
psychiatry where populational studies are
integrated and translated into practice in the four
domains of:
Teaching and research
Clinical interventions
Policy-making and service planning
Advocacy
Reference: Jeste & Pender (2022)

24. Social Psychiatry in the Clinic
Historical, theoretical & philosophical traps to avoid:
Binary thinking
Nature vs nurture, individual vs collective
Reductionism
Mind = brain (Insel)
Neurobiology of morals (Churchland, 2014)
“Single-message mythologies”
Paul Hoff (cited by Fulford, 2021)
Triumphalism (paradigms, revolutions)
References: Churchland (2014), Di Nicola (2019),
Di Nicola & Stoyanov (2021), Fulford 2021)

25. Trauma
Image courtesy of V Di Nicola

26. Social Psychiatry in the Clinic
Intergenerational trauma
Intergenerational transmission of trauma (Sigal et al.,
1988; cf. epigenetics; Malaspina’s seminar, 2024)
Historical traumas, slavery, genocide, minoritized groups
Trauma-informed care for individuals
(Mollica, 2006; Di Nicola, 2018)
Truth & reconciliation for community and society
Canadian example:
Pope’s visit to apologize to the Native Peoples of Canada for
abuses by Christians
References: Di Nicola (2018), Mollica (2006),
Sigal et al. (1988)

27. Pope Francis adjusts his headdress after it was given to him
by Chief Wilton “Willie” Littlechild on July 25, 2022– TODD KOROL/Reuters

28. Science and Society
“Medicine is a social science, and politics is nothing
more than medicine on a large scale.”
“If medicine is to fulfill its mission, it must enter the
political and social life.... The physicians are the
natural attorneys of the poor, and the social problems
should largely be solved by them.” *
– Rudolf Virchow, “the father of modern pathology”
(* with thanks to George Alexopoulos)

29. Acknowledgements
Dilip V. Jeste, Director
SDoMHE Network
Richard F. Mollica, Director
Harvard Program in
Refugee Trauma
World Association
of Social Psychiatry (WASP)

30. References
Aftab A. Conversationsin Critical Psychiatry Series. Allen Frances, MD:
Relentless Warrior for Mental Health. Psychiatric Times, May 23, 2019; 36
(10): 17, 22-23. https://www.psychiatrictimes.com/view/conversations-
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Churchland PS. The neurobiologicalplatform for moral values. Behaviour,
151 (2014): 283–296
Cohen A, Patel V, Minas H. A very brief history of global mental health. In:
Patel V, Minas H, Cohen A, Prince MJ, editors. Global Mental Health:
Principles and Practice. Oxford,UK: Oxford University Press; 2013. p. 3-26.
CSDH. Closing the Gap in a Generation: Health Equity through Action on
the Social Determinants of Health. Final Report of the Commission on
Social Determinants of Health. Geneva,Switzerland: World Health
Organization; 2008.

31. References
Di Nicola V. Family, psychosocial,and cultural determinants of health. In:
Sorel, Eliot, ed., 21st Century Global Mental Health. Burlington, MA: Jones
& Bartlett Learning; 2012. p. 119-150.
Di Nicola V. Two trauma communities: A philosophical archaeology of
cultural and clinical trauma theories. In: PT Capretto & E Boynton (Eds),
Trauma and Transcendence: Limits in Theory and Prospects in Thinking.
New York: FordhamUniversity Press, 2018. p. 17-52.
Di Nicola V. Review Article – “A person is a person through other persons:”
A social psychiatry manifesto for the 21st century. World Social Psychiatry,
2019; 1(1): 8-21.
Di Nicola V. Review Article – The Global South: An emergent epistemology
for social psychiatry. World Social Psychiatry, 2020; 2(1): 20-26.

32. References
Di Nicola V. Perspective – “Thereis no such thing as society”: The
pervasive myth of the atomistic individual in psychology and psychiatry.
Follow-up and reply to commentaries on “A social psychiatry manifesto for
the 21st century.” World Social Psychiatry, 2021; 3(2): 60-64.
Di Nicola V. Beyond shared care in Child and Adolescent Psychiatry:
Collaborative care and community consultations. Special issue on Child &
Adolescent Psychiatry, World Social Psychiatry, 2022, in press.
Felitti VJ, Anda RF. The relationship of adverse childhood experiencesto
adult medical disease, psychiatric disordersand sexual behavior:
implications for health care. In: Lanius RA, Vermetten E, Pain C, editors.
The Impact of Early Trauma on Health and Disease: The Hidden Epidemic.
Cambridge, UK: Cambridge University Press; 2010. p. 77-87.
Frances A. Afterword: Saving Psychiatry. In: V Di Nicola, D Stoyanov.
Psychiatry in Crisis: At the Crossroads of Social Science, The Humanities,
and Neuroscience. Cham, Switzerland: Springer Nature; 2021. p. 167-168.

33. References
Fulford KWM.Foreword: Beyond single message mythologies. In: V Di
Nicola, D Stoyanov.Psychiatry in Crisis: At the Crossroads of Social Science,
The Humanities, and Neuroscience. Cham, Switzerland: Springer Nature;
2021. p. vii-xix.
Hartung T. A call for a Human Exposome Project. ALTEX. 2023;40(1):4-33.
doi: 10.14573/altex.2301061. PMID: 36648285.
Ivbijaro G (Ed.) Companion to Primary Care Mental Health. Boca Raton, FL:
CRC Press; 2010.
Jeste DV, Pender VB. Social Determinants of Mental Health:
Recommendationsfor research,training, practice, and policy. JAMA
Psychiatry, published online February 23, 2022.
doi:10.1001/jamapsychiatry.2021.4385
Kates N, McPherson-DoeC, GeorgeL. Integrating mental health care
services within primary care settings: The Hamilton Family Health Team. J
Ambulatory Care Manage 2011;34(2):174-182.

34. References
Malaspina D. Social epigenetics, racism, and perinatal trauma. Global
Research Network on Social Determinants of Mental Health and
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Mollica RF. Healing Invisible Wounds: Paths to Hope and Recovery in a
Violent World. New York, NY: Harcourt, International; 2006.
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35. References
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