Social Determinants of Health in People Living with Psychiatric Disorders: The Role of Pharmacists

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TL;DR

This narrative review examines how social determinants of health (SDOH) impact medication-related outcomes in people with psychiatric disorders and outlines the role pharmacists can play in addressing these barriers. The authors identify that SDOH such as economic instability, housing insecurity, and limited healthcare access contribute to medication therapy problems (MTPs) and poor adherence in psychiatric populations. Pharmacists—particularly clinical and psychiatric pharmacists—are well-positioned to mitigate these issues through comprehensive medication management (CMM), screening, advocacy, and interprofessional collaboration, though significant gaps remain in training, research, and policy recognition.

Full summary

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**Background:** Social determinants of health (SDOH) are nonmedical factors that influence health outcomes, accounting for an estimated 80–90% of a person's health. Psychiatric disorders are common and undertreated—21% of U.S. adults (52.9 million people in 2020) live with a mental illness, yet only 46.2% received mental health services in the past year. In 2020, 6.7% of adults (9.5 million) had both a mental illness and substance use disorder (SUD), but only 5.7% received treatment for both conditions. Medication therapy problems (MTPs) are common in psychiatric populations and include complex regimens, inadequate treatment of co-occurring conditions, and poor monitoring for metabolic adverse effects. Low medication adherence rates are also frequently linked to SDOH. Comprehensive medication management (CMM) is an individualized approach used by pharmacists to identify and resolve MTPs across four domains: indication, effectiveness, safety, and adherence.

**Methods:** The American Association of Psychiatric Pharmacists (AAPP) commissioned an expert panel to explore the intersection of SDOH, psychiatric disorders, and pharmacist roles. The panel met monthly for over one year to research and develop a framework, using Healthy People 2030 as the organizing structure. Two public health professionals provided feedback on drafts. This article is a narrative review and commentary, not a systematic review. The focus is on clinical pharmacists—defined as those who engage in direct patient observation, medication initiation/modification, and ongoing monitoring in collaboration with other health professionals—though community and psychiatric pharmacists are also discussed.

**Key Results:** The authors identified potential connections between SDOH and medication use across all five Healthy People 2030 domains: economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context. Specific SDOH affecting mental health include racial discrimination, adverse early life experiences, poor education, unemployment, poverty, neighborhood deprivation, poor housing, limited healthcare access, exposure to violence, mass incarceration, and poor environmental quality. Chronic stress from these determinants may increase risk of depressive and anxiety disorders or SUD through neural and somatic stress responses. Current barriers include: limited published research (only two articles identified on pharmacists and SDOH), underutilization of SDOH tools in electronic medical records (e.g., Epic's SDOH tool), lack of SDOH integration in pharmacy curricula until 2016 Accreditation Council for Pharmacy Education updates, and minimal awareness among healthcare professionals about appropriate follow-up after SDOH screening. Community pharmacists can address SDOH through services such as depression screening, long-acting injectable antipsychotic administration, and Medicare navigation. Clinical pharmacists use CMM to solve MTPs across SDOH domains—for example, reducing prescription costs by deprescribing, addressing food–drug interactions, and connecting patients with adherence packaging or medication delivery services. Psychiatric pharmacists (over 1,500 nationally) can help address the projected 27% psychiatrist shortfall by 2030 through collaborative practice agreements and CMM. Key strategies include improving access to long-acting injectable antipsychotics, supporting clozapine use for treatment-resistant schizophrenia, and facilitating medication-assisted treatment for opioid use disorder. More than two-thirds of individuals with schizophrenia are nonadherent with antipsychotics, and within 6 months of hospital discharge 50% discontinue their medications.

**Clinical Implications:** Pharmacists should be trained in SDOH screening, adverse childhood experiences (ACEs), trauma-informed care, and shared decision-making. Psychiatric pharmacy residency training now includes SDOH application experiences, and SDOH content has been added to the national certification exam for psychiatric pharmacists. Public health professionals should collaborate with pharmacists for community-level advocacy, including serving on boards, joining grassroots movements, and participating in community health needs assessments. At state and federal levels, pharmacists should be recognized as providers under the Social Security Act—a major current barrier to patient access. Future research should expand beyond medication adherence to include SDOH screening tool effectiveness, pharmacist roles in addressing health disparities, and the impact of pharmacy education on SDOH competency. The authors note that a limitation of this article is that it was authored solely by psychiatric pharmacists, though feedback from two public health professionals was incorporated.