Social inclusion in mental health: a Latin American perspective

Despite substantial efforts, many widely adopted frameworks on social inclusion of people with severe mental illness continue to operate within a narrow scope, insufficiently questioning and engaging with the structural forces that shape exclusion1. Here I argue that the advancement of social inclusion requires examining history, cultural contexts and other macro-social forces, especially in the Global South, and that Latin American frameworks, notably the Social Determination of Health Framework2, have been developed in response to these challenges. Latin America has a rich yet under-recognized tradition of linking health with social context. For many decades, movements in social medicine, collective health, and critical epidemiology across the region have highlighted gaps in conventional health paradigms, and proposed approaches to address the social drivers of illness and inclusion2. These traditions emerged from a recognition that health inequities cannot be fully addressed without confronting root causes2. Pioneering researchers such as J. Breilh and N. de Almeida-Filho have argued that health and disease are not merely influenced by social factors, but are fundamentally produced by them3. Accordingly, this perspective calls for a research agenda inseparable from social action and transformation. While these traditions originated in Latin America, key concepts and practices have been adopted by some scholars in the Global North, particularly in social and psychiatric epidemiology3. The Social Determination of Health Framework offers several unique contributions to the field of social inclusion in mental health4. First, it foregrounds history, recognizing that phenomena such as stigma, social isolation and exclusion are inseparable from the broader trajectories of political violence, neoliberal reforms and cultural domination. This approach challenges the tendency to decontextualize exclusion, exploring how historical processes have constructed the conditions for marginalization. Second, it compels us to ask not just what factors or determinants are associated with exclusion or inclusion, but why such factors are so prevalent among certain vulnerable groups, including people with severe mental illness. It shifts the focus from identifying and describing inequities to investigating their origins. Third, it invites researchers and policy makers to move from description to transformation – aligning scientific inquiry with emancipatory, community-led action. This involves not only producing high-quality evidence, but also co-producing solutions with affected groups and recognizing the legitimacy of experiential and collective knowledge4. A potential critique is that these Latin American approaches lack sufficient empirical validation. However, this imbalance itself is part of the problem – a reflection of what has been called the “centrality” of knowledge production in the Global North5. Hierarchies of evidence have been constructed to privilege randomized controlled trials and other standard methodologies, sometimes discounting the value of real-world innovations emerging from the Global South. There is an implicit assumption that the most reliable evidence and theories flow from wealthy countries outward, whereas ideas emerging from the Global South are less valid or remain untested5. Just as important is the notion of “linearity” in how we think about evidence and implementation. Mainstream health research often envisions a linear pipeline: discovery leads to trials, which lead to scaled implementation and policy5. Especially in the Global South, progress in mental health services and systems has often been anything but linear. Historical disruptions – i.e., revolutions, dictatorships, economic crises, and civil conflicts – have required creative, context-driven solutions that did not wait for formal evidence6. Mental health reforms are compelling examples of complex sociopolitical phenomena that provide context-sensitive and historically informed frameworks for understanding trends in social inclusion and exclusion. For instance, Brazil’s psychiatric reform was catalyzed in the late 20th century by a grassroots human rights movement in the wake of military rule. Brazilian reformers pushed to close asylums and build a network of community-based services7. The result was a nationwide shift toward community mental health care, with the establishment of hundreds of psychosocial care centers, and programs such as De Volta Para Casa (“Return Home”) to reintegrate long-stay patients into society. This reform, enacted via national policy and based on principles of justice and citizenship, moved forward through social mobilization, preceding formal validation by research. Over time, positive outcomes have been documented: improved access to care, reduced psychiatric hospitalizations, and an affirmation of consumers’ citizenship and rights in the community7. Similarly, Chile’s mental health reform was initiated in the 1950s, with very promising developments in community-based mental health services. This movement was then brutally dismantled under dictatorship after 1973 – community mental health was banned as “communist” and many progressive clinicians were persecuted8. Yet, these ideas survived underground. With the return to democracy in 1990, Chile began rebuilding mental health services oriented toward primary care and community support. By the 2010s, Chile had a national mental health plan emphasizing outpatient care, psychosocial rehabilitation, and increased inclusion of family and consumers in service design. The historical experience of repression and political transition directly informed Chile’s emphasis on rights, community solidarity, and participatory governance in mental health care8. The Latin American experiences thus suggest the need for a broader, more pluralistic view of what constitutes evidence and progress in the field. Adopting a social determination lens would push the social inclusion field to revisit some of its core assumptions. It would encourage new research questions, such as: How do colonial histories and ongoing extractive relationships continue to shape mental health outcomes? In what ways do policies designed to promote inclusion inadvertently reinforce structural exclusion? How can we build alliances with social movements and marginalized communities to co-produce more just and effective mental health services and systems? Such an approach would expand the boundaries of the field, foregrounding structural, historical and cultural forces that have too often been neglected. While social medicine, collective health and critical epidemiology have emerged from the specific contexts of Latin America, their insights are highly relevant beyond this region. Structural racism, economic inequality, and histories of dispossession are not confined to the Global South. By incorporating the Social Determination of Health Framework, the social inclusion field can develop more nuanced, historically informed, and politically engaged responses to exclusion also in Europe, North America, and elsewhere in the Global North. Learning from the Global South is not only a matter of justice or representation; it is also about expanding the analytical and practical toolkit available to those seeking to advance inclusion everywhere. This perspective invites the field to broaden its conceptual and practical horizons and to approach social inclusion and mental health with greater humility and openness9. In summary, promoting social inclusion in mental health requires more than technical refinement or evaluation of existing interventions or frameworks. It calls for a paradigm shift: a willingness to ground research, policy and practice in the analysis of power, history and collective action, as exemplified by Latin America’s rich academic and community-rooted traditions. Embracing these traditions offers a path forward – one that is more just, more democratic, and ultimately more capable of realizing the full promise of social inclusion for people with severe mental illness. To meet the needs of diverse communities and overcome persistent exclusion, the field must move beyond valuable but narrow approaches and engage with the complexity, creativity, and transformative spirit of social determination in mental health.