Health inequalities: briefing 10 Mental health

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Mental health
NHS Health Scotland is a national Health Board working with and through public, private and third sector organisations to reduce health inequalities and improve health. We are committed to working with others and provide a range of services to support our stakeholders take the action required to reduce health inequalities and improve health.
Key messages
• Poor mental health is a significant public health challenge. Promoting good mental wellbeing as part of prevention and early intervention will support complementary treatment and recovery from mental health problems.
• Mental health problems are strongly linked to health and social inequalities.
• A person’s position in society plays an important part in their mental health, with less advantaged people having greater experience of poor mental health.
Key actions
• Integrate mental health into all policies at a national and local level. • Use approaches that avoid relying on opting in, maximise income and
provide for those with the greatest need within universal services. These actions are likely to be the most effective in reducing mental health inequalities. • Tackle the social and health inequalities experienced by those with mental health problems, including those with long-term physical health conditions.
[email protected] A series of briefings to promote action to reduce health inequalities.1

What is this briefing about?
This is the 10th in a series of inequality briefings. It outlines two specific strands relating to social inequalities and mental health: (1) mental health inequalities as an (often neglected) component of health inequalities; and (2) the social and health inequalities experienced by people with mental health problems. This briefing sets out actions to address these issues based on evidence of what works and, as such, does not address the detail of inequalities in accessing mental health services. For further details on social inequalities and mental health and wellbeing, see NHS Health Scotland’s position paper Good Mental Health for All.1
What are health inequalities?
Health inequalities are the unfair and avoidable differences in people’s health across social groups and between different population groups. They represent thousands of unnecessary premature deaths every year in Scotland, and for men in the most deprived areas nearly 25 fewer years spent in ‘good health’ and 22 years for women. Please see the first briefing2 in this series for more information on health inequalities and the broad range of actions that can be taken to reduce them.
Why is mental health and wellbeing important?
At any given time, approximately one in six adults in Scotland experience a common mental health problem.3 Mental health problems are one of the major contributors to disability in the UK4,5,6 and are a major risk factor for suicidal behaviour.*,7
Recent data suggest that the economic costs of mental health to Scotland are substantial.
In 2009/10 this was approximately

a 25% increase from 2004/5 (£8.6 billion)
• It is estimated that almost £2 billion was spent on health and social care for those with mental health problems.8 However, in the latest Adult Psychiatric Morbidity Survey, only about one in three adults (37%) with common mental health problems± in England were accessing treatment at the time of the survey.9
* Suicidal behaviour includes both suicide and non-fatal self-harm. ± The term common mental health problems is used to refer to depression and anxiety disorders.


Inequality Briefing 10

• The Scottish economy lost an estimated £3.2 billion as a result of poor mental health experienced by the workforce during 2009/10.8 This is the result of worklessness,‡ losses of unpaid work, sickness absence and premature mortality.
• The human cost of mental health is even greater at £5.6 billion.8 This is a monetized estimate of the adverse effects of mental health problems at a population level, in terms of morbidity, quality of life and premature mortality resulting from suicides due to mental health problems.
Mental health inequalities
Mental health problems are not equally distributed across the population. Those who are socially disadvantaged are at increased risk.10 In 2010/2011, there were twice as many GP consultations for anxiety in areas of deprivation than in more affluent areas in Scotland (62 consultations vs. 28 per 1,000 patients).11 The prevalence and type of mental health problems also vary by sex and age. For example, recent surveys have identified that young women (16–24 years) are at increased risk of common mental health problems and self-harm.9,12
Adults living in the most deprived areas in Scotland are approximately twice
as likely to have common mental health
problems as those in the least deprived areas (22% vs. 11%)10
What drives inequalities in mental health?
The primary causes of health inequalities are rooted in the political and social decisions and priorities that result in an unequal distribution of income, power and wealth. This can lead to poverty and marginalisation of individuals and groups. These fundamental causes also influence the distribution of wider environmental influences on health, such as the availability of good-quality housing, green space, work, education and learning opportunities. They can also influence access to services and social and cultural opportunities in an area and in society.
The wider environment in which people live and work then shapes their individual experiences of low income, poor housing, discrimination and access to health services, for example. This all results in the unequal and unfair distribution of health, ill health (morbidity) and death (mortality).2

‡ This includes those who are unemployed, defined as not currently having a job but actively seeking employment; and those who are economically inactive, defined as not having a job and not actively seeking employment or being available for work.7



Current thinking suggests that the link between social status and mental health problems is the level, frequency and duration of stressful experiences and the extent to which these are buffered by social and individual resources and sources of support.3 These stressful experiences (including poverty, family conflict, poor parenting, childhood adversity, unemployment, chronic health problems and poor housing) occur across the life course and contribute to a greater risk of mental health problems if they are multiple in nature and if there are no protective factors to mitigate against their negative impact.§,3
Key areas for action
There is a clear case to invest in the prevention of mental health problems and promote mental wellbeing. Comprehensive, evidence-informed strategies delivered at a population level to address the determinants of mental health problems are likely to prevent them and, in the long term, contribute to a reduction in mental health problems and inequalities in mental health. This is consistent with the recommendations of Scotland’s Christie Commission Report.13 Local strategic partnerships have an important role to play.2 Actions across the life course and in all policy areas can help prevent mental health problems and reduce mental health inequalities. These actions need to run alongside and complement early interventions, treatment and care of people with mental health problems as reflected through the priorities outlined in the Scottish Government’s Mental Health Strategy: 2017–2027.14
Key areas where there is strong evidence for action include:
Addressing adversity and disadvantage in early years
Low and insecure income and problem debt
Unemployment and access to good work
Poor housing and the physical environment.
Early years
Half of all lifetime mental conditions start by the mid-teens and three-quarters by the mid-20s.15 These are influenced from an early age by the social environment. Adversity and multiple disadvantages in childhood, as well as abuse and neglect, poor parenting and parental mental health problems, are some of the factors associated with an increased risk of mental health problems in both childhood and adulthood.16,17,18 Further information about adverse childhood experiences (ACEs) can be found on NHS Health Scotland’s website.

§The stress-vulnerability model suggests that stressful life circumstances and events trigger and exacerbate mental health problems among those who are vulnerable.


Inequality Briefing 10

Actions should:
Support good maternal mental health
Promote good parent–child relationships
Prevent mental health and behaviour problems
Promote readiness for school, particularly among vulnerable groups.
Low income and debt
Low and insecure income and problem debt are associated with an increase in the risk of mental health problems.19,20,21 In the latest Adult Psychiatric Morbidity Survey, people in receipt of housing benefit in England were more than twice as likely to have a common mental health problem as those not in receipt.9 Similarly, estimates suggest that adults in debt were three times more likely to have a common mental health problem than those not in debt.20 The relationship between problem debt and mental health problems is likely to be two way. Around one-quarter of people with mental health problems report being in serious debt.19 Having a mental health problem can affect the ability to manage financial commitments and trigger problem debt, as well as affect the ability to regain financial control, thus contributing to a cycle of deprivation.19
Unemployment/poor-quality employment
Unemployment has consistently been associated with an increased risk of common mental health problems.22,23 This is of particular concern for young people with few qualifications who find it difficult to enter the labour market and those with mental health problems who are often excluded from the workforce. It is important to support people to move into sustainable paid employment which lifts them out of poverty and protects their mental wellbeing.
Equally, poor-quality employment which doesn’t protect against poverty and offers limited control is associated with an increased risk to mental wellbeing. The Marmot Review argued that to reduce health inequalities ‘jobs need to be sustainable and offer a minimum level of quality … Getting people off benefits and into low-paid, insecure and health-damaging work is not a desirable action’.24
NHS Health Scotland’s briefing paper Good Work for All25 highlights actions that can be taken to ensure good work is for all.
Unequal access to work
Many people with long-term mental health problems actively want to and can engage with work, training or education. This is important for recovery. Lack of work has significant implications in terms of income, daily routines and choices as well as contributing to social isolation and exclusion.26
Rates of employment are much lower among people with mental health problems. While rates vary with diagnosis, an English survey found the employment rate for those with severe mental health problems was 40% compared with 64% for those with common mental health problems and 76% for those with no mental health problems.27



Narrative of someone with mental health problems:28
‘Everyone wants a job or to be valued in some way. To be part of society again because you were so excluded all the time I don’t care what anyone says … we’re still excluded, excluded from the job market you know.’

Violence and abuse
There is a strong link between experiencing violence or domestic abuse and mental health problems.29,30
Women and girls are often at increased risk of violence, and women living in poverty are disproportionately affected by violence and abuse. The impact of intimate partner violence and abuse can be far-reaching. It can affect the next generation and have a negative impact on a broad range of infant and child health and wellbeing outcomes.31

Poor physical and social environments
Where we live, work and play, including our homes, neighbourhoods and access to green space, can influence our mental health and contribute to inequalities. The implementation of Scotland’s Community Empowerment Act in giving communities more input and control over the assets and decisions that affect them will be key to supporting positive mental health and wellbeing and reducing the inequalities experienced by those with poor mental health.

Poor-quality housing is one example of the physical environment having a negative effect on mental health.32,33 Fuel poverty in particular is associated with poor mental health both in childhood and adulthood. Warmth and energy efficiency interventions have shown improvements in mental health, as well as other health outcomes.34,35 While the mechanism that links aspects of poor housing to mental health is unclear, it is possible that either poor-quality housing acts as a direct source of stress or that poor-quality housing is a risk factor that is related to poverty and is therefore associated with other physical and social risk factors.32

NHS Health Scotland’s briefing papers Housing and Health Inequalities and Health and Homelessness highlight the role that having a warm, dry and affordable home can play in improving health and wellbeing and reducing health inequalities.36,37
The availability of and access to green space is associated with low levels of mental distress.38,39 Current thinking suggests that green space might offer psychological benefits for those experiencing stress. However, green space is unevenly distributed in urban areas. Those living in areas of the greatest socioeconomic deprivation are less likely to live within walking distance of green space and are less likely to be satisfied with that green space.40 Improving access to and the quality of green space in proportion to need therefore has the potential to reduce health inequalities.

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Inequality Briefing 5

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Inequality Briefing 6 Nov 2016

A series of briefings to promote action to reduce health inequalities.


Inequality Briefing 10

NHS Health Scotland’s briefing paper Place and Communities41 highlights the role that good-quality places can play in improving health and wellbeing and reducing health inequalities. It also suggests actions that can contribute to reducing health (including mental health) inequalities.
Social isolation and loneliness
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Inequality Briefing 4 June 2016

A series of briefings to promote action to reduce health inequa 1 lities.

Unequal access to healthcare services
It is probable that not everyone with significant symptoms of a mental health problem is currently receiving treatment (either medication or psychological interventions). For example, in the latest Adult Psychiatric Morbidity Survey, about one in three people with common mental health problems in England were receiving treatment at the time of the survey. Respondents to the Scottish Government’s public engagement exercise about the 2017–2027 Mental Health Strategy highlighted the gap between people who consider they have a mental health problem and those seeking help.43
Rates of physical ill health among those with long-term mental health problems are much higher than the general population. Life expectancy for men with a diagnosis of schizophrenia is 20 years less than the general population and for women is 15 years less.45 Approximately one-fifth of premature deaths are due to suicide and accidental death; however, a large proportion is due to physical illness.26

Poor access to mental health services is associated with:43 Lower social class Geographic location Ethnicity The presence of sensory or other impairments The presence of learning difficulties Other demographic factors such as age and sex

The current healthcare system is not designed to support an integrated approach to meeting the mental and physical health needs of the population. In addition, the continued stigma associated with mental health and diagnostic overshadowing** means that those with mental health problems, particularly long-term mental health problems, do not always receive the same quality of care for physical health problems. For example, despite higher

**D iagnostic overshadowing is a process by which physical symptoms are misattributed to mental health problems.



rates of cardiovascular disease and related health issues among people with a diagnosis of schizophrenia, there is evidence of under-recognition and treatment of these conditions.2
The actions to achieve the priorities set out in the Scottish Government’s Mental Health Strategy: 2017–202714 will help to reduce the health inequalities experienced by those with severe and enduring mental health problems through improving service access and responses.
Stigma and discrimination
While mental health problems and the side effects of some medication can contribute to poor health and social outcomes, stigma, injustice and discrimination are significant barriers to achieving the same level of access, health and citizenship.
Good mental health for all means reducing stigma and discrimination. It means that every individual is respected and has equal access to all public services including mental and physical health services and good work. This is included in the 2017–2027 Mental Health Strategy’s14 vision of having a ‘Scotland where people can get the right help at the right time, expect recovery and fully enjoy their rights, free from discrimination and stigma’. This is supported by the SeeMe programme which specifically focuses on addressing mental health stigma and discrimination. It targets the general population as well as specific groups and locations such as young people and workplaces.
How do we achieve good mental health for all?
• Taking actions to improve life circumstance through addressing factors that increase the risk of mental health problems at each stage of life from pre-natal to later life. Actions should work to build opportunities and sources of support which we know can help buffer against difficult life circumstances.
• Achieving good mental health for all is the responsibility of all agencies and policy areas. Actions across health, social, economic and environmental policy areas can have an impact on mental health. Collaboration across all policy areas, as well as integrating mental health into health and health inequality outcomes, are also necessary. In parallel, any potential unintended negative consequences of policies on mental health and inequalities in mental health should be considered and addressed.
• Many of the principles and actions described in the first briefing in this series are likely to contribute to reducing mental health inequalities including focusing on reducing adversity and disadvantage in early years; addressing poverty and problem debt; improving access to good work; and improving housing and the physical environment.


Inequality Briefing 10

Recommended actions to reduce inequalities and improve mental health
Children and young people
Actions to reduce the impact of child poverty include: • working to maximise the household income and resources of pregnant women and families
with young children • identifying and removing the cost barriers that prevent children who live in low-income
households from participating fully in school • early years support and coaching for parents, particularly from disadvantaged groups • targeted early childhood education and childcare for vulnerable children.
Low income and debt
Actions to ensure everyone, including those who can’t earn, have sufficient income for healthy living, include: • maximising income through the delivery of financial inclusion services • providing accessible services and support for debt advice • ensuring that people on a low income do not pay premium rates for essential services • tighten regulation and enforcement of the Office of Fair Trading guidelines about
responsible lending.
Reduce violence and abuse
Actions to reduce violence and abuse include: • implementing strategies that have a broad impact on violence, rather than focusing on
individual behaviour, and aim to challenge the norms which give rise to and sustain abuse • providing a coordinated response, underpinned by interagency collaboration, with a focus
on increased identification through, for example, routine enquiry, and the provision of tailored advocacy, support and outreach to enhance protection and reduce revictimisation • implementing school-based programmes and early years interventions to support longer-term prevention of abuse including programmes that promote positive behaviour and relationships.
Physical and social environments
Actions to improve physical and social environments include: • ensuring that everyone has access to a quality home that is warm, dry and affordable • encouraging the use of the Place Standard tool, which provides a simple framework to
identify aspects of a place that need to be targeted to improve people’s health, wellbeing and quality of life • improving access to and the quality of green space, particularly in deprived areas, providing places for play, physical activity and social interaction.



Social isolation and loneliness
Actions to tackle social isolation and loneliness include:
• developing and evaluating system-wide approaches between local authorities, primary and community care and mental health services and the third sector
• raising awareness of the impact of social isolation, loneliness and their consequences on mental health and wellbeing at all ages
• creating more robust data on social isolation and loneliness.
Reduce unequal access to healthcare services
Actions to create more equal access to healthcare services include:
• developing services that are based on need rather than demand, and are equitable rather than equal to ensure fair access
• providing adequate training to ensure that the public sector workforce feels confident and competent to take an individualised approach that recognises all aspects of a person’s identity, such as race, religion and sexual identity
• targeting and tailoring activities that aim to promote health and prevent ill health, such as weight management services and chronic disease management programmes in primary care, while taking into account that some population groups may need additional support.
Reduce stigma and discrimination
Actions to reduce stigma and discrimination include:
• providing support to employers and public services to implement the Equality Act 2010 with respect to mental health problems in all areas of life
• taking a human rights-based approach to mental health in order to tackle stigma and discrimination
• developing and implementing evidence-informed programmes to reduce stigma and discrimination among target groups prioritised by mental health service users. Adults’ views of mental health problems have been shown to change after social contact with people living with mental health problems.


Inequality Briefing 10

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Health inequalities: briefing 10 Mental health