Mental health and inequalities

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Starting Today  Background Paper 3: Mental Health and Inequalities

Mental health and inequalities
Authors: Isabella Goldie, Julie Dowds, Chris O'Sullivan, Mental Health Foundation


Mental health determines and is determined by a wide range of social and health
outcomes at individual, community and societal levels and has an impact on all
aspects of our lives. Poor mental health contributes to socio-economic and health
problems such as higher levels of physical morbidity and mortality, lower levels of
educational attainment, poorer work performance/productivity, greater incidence of
addictions, higher crime rates and poor community and societal cohesion
(McCulloch & Goldie, 2010).

There is much confusion about what is meant by mental health, as a term it is often
misunderstood and is often accepted as a euphemism for mental illness, mental
disorder or mental health problems (Henderson, 2010). However the term mental
health relates to a positive state; often described as wellbeing or mental wellbeing.
Mental health is therefore something that we all share and the status of this resource
in individuals, communities and society as a whole should be a common concern.
However, mental health is not evenly distributed with those who experience the
highest levels of social disadvantage also experiencing poorer mental health than
that of the more advantaged members.

Inequality in mental health means the unequal distribution of factors that promote
and protect positive mental health and factors that are detrimental to mental health.
Despite investment to address social disadvantage deep inequalities remain in our
society with the gap between the rich and poorest increasing (Howell, 2013; Black
and O'Sullivan, 2012). Our unequal society and the costs of this to mental health
should be a central concern for us all; it leads to an unequal distribution across
population groups of mental health problems and illness and in people's ability to
recover and lead fulfilling lives.

If our aim is to create a fairer and more just society and then we need to address the
chronic stress and fractures that having less power, status and control brings; and
work with people to build strong communities and empowering services. To do this
we need to work across all areas of policy to influence the factors that serve as
determinants of mental health and enable inequalities and disadvantage to grow.

This paper provides an overview of the relationship between inequalities and mental
health and outlines our views on the future threats and opportunities within society to
tackle inequalities and improve the mental health of all.

Starting Today  Background Paper 3: Mental Health and Inequalities

Determinants of mental health

The concept of mental health cannot be separated from that of overall health with the
determinants of health closely aligned to the factors that create optimal or minimal
mental health and wellbeing. These factors operate at many levels and include;
personal (e.g. genetic factors, diet, exercise, relationships, how a person may
perceive events), social and community (e.g. family structure, friends, isolation, area
of deprivation) and larger societal and environmental conditions (e.g. education,
social connectedness, health care provision, unemployment levels, equality).

Demographics such as age, gender and ethnicity are also important determinants,
influencing explores to risk and protection factors across the life course. (Barry,

The combined influence of these factors determines an individual's health status. As
individuals, we have more control over some of these factors than others. In addition
our life circumstances significantly impacts upon our motivation and capacity to
make healthy choices and engage with health services and treatment. Any attempt
at understanding how these factors interact and impact upon the health of individuals
and communities needs to be understood in their sociocultural and environmental
setting. Examples of mental health determinants are shown in Table 1:

Table 1 Examples of determinants of mental health (McCulloch and Goldie, 2010)

There has been increased recognition on the broader determinants of mental health
with greater application of the social model of health to the mental health sphere.
This recognises that achieving positive mental health requires a focus on structural
and environmental factors that create conditions of poverty, discrimination and
inequity (Friedli, 2009; Marmot, 2010).
Starting Today  Background Paper 3: Mental Health and Inequalities

As we move forward, consideration should also be given to the physiological effects
of inequality, on both neurological systems and other processes. Traditionally there
has been a binary distinction between `biological and medical' models of mental
health and social models. Moving forward, it is clear that a greater understanding of
the physiological effects of exposure to social determinants of mental health may
provide another route to understanding complexity, multi-morbidity and the way in
which treatments can be more efficacious.

The link between mental health and inequalities

There is a strong body of evidence that living in poverty brings with it poorer mental
health, and that the stresses of living in poverty increases the risk of developing
mental health problems. In addition that living with a mental health problem brings
with it increased social disadvantage, such as higher levels of unemployment.
Across the UK, we experience mental health inequities, these are inequalities in
relation to mental health status that can be described as `morally or ethically' unfair
or unjust (Whitehead, 1990). These inequities are often experienced by the same
people and accumulate over a lifetime, placing older people who experience poverty
at increased risk of poor mental health and of developing mental health problems.

Adverse mental health outcomes are 2 to 2.5
                                                       The most common definition of
times higher among those experiencing               poverty is relative poverty, defined
greatest social disadvantage compared to           as those living below 60% of the UK's
those experiencing least disadvantage                   average household income
(Kessler et al., 1994; Macran et al., 1996;
Gilbert & Allan, 1998; Murali & Oyebode, 2004). In addition those living with
disability or a mental health problem remain at highest risk of poverty (Parckar,
2008). Socio-economic pressures such as poverty and low levels of education are
recognised risks to mental health for individuals and communities. The greater the
gap between the rich and the poor, the greater differences are observed in health.

Many problems associated with relative deprivation are more prevalent in more
unequal societies. A review of the evidence suggested that this may be true of
morbidity and mortality, obesity, teenage birth rates, mental illness, homicide, low
trust, low social capital, hostility, racism, poor educational performance among
school children, the proportion of the population imprisoned, drug overdose mortality
and low social mobility (Wilkinson & Pickett, 2007). Arguably these are all part of the
same pattern of social problems in which mental illness is a (large) player.

The surveys by the World Health Organisation show that different societies have
different levels of mental illness. In some countries, 510% of the adult population
has suffered from any mental illness in the past year, but for example in the USA it is
more than 25%. The Equality Trust demonstrated a relationship between mental
illness and income inequality in developed countries with mental illness being more
common in more unequal countries (Figure 1; Picket et al, 2006).

Starting Today  Background Paper 3: Mental Health and Inequalities

Figure 1: Relationship between income inequality and prevalence of mental illness in
developed countries (The Equality Trust)

One reason for this phenomenon may be that relative deprivation is a catalyst for a
range of negative emotional and cognitive responses to inequality. That is, levels of
inequality have a strong impact on how people feel and how people feel (emotional
wellbeing) is a powerful indicator of their mental health. Socioeconomic position
shapes access to resources, aspects of experience in the home, neighbourhood and
workplace (Krieger, 2001; Graham, 2004; Regidor, 2006). In addition, aspects of
socioeconomic position such as education, income and occupation prestige may
influence health.

When discussing inequality it is important to reflect on groups of people who
experience discrimination, and although are also highly represented within lower
socio-economic groups, also encounter additional social injuries. Clear examples of
this are people from minority ethnic communities, refugees and asylum seekers,
older people and people with disabilities, including mental health problems and
learning disabilities.

Not everyone that experiences discrimination encounters socio-economic
inequalities although very many do, with large numbers of people with mental health
problems unemployed and poverty a very real experience for many older people
(Age Concern and Mental Health Foundation, 2006). People with disabilities and
long term health conditions have the additional disadvantage associated with their
health conditions, such as pain, unpredictability and the impact of long term use of
medications. All of this can serve to limit their lives and therefore their ability to
access opportunities that can work to protect mental health, such as employment
and social support.

Starting Today  Background Paper 3: Mental Health and Inequalities

In 2007, NHS Health Scotland and the National Resource Centre for Ethnic Minority
Health (NRCEMH) produced a report focused on the 6 equality and diversity strands
of: Gender; Age; Disability; Sexual Orientation  LGBT; Race and Ethnicity;
Spirituality. The report took as its starting point the argument that the factors that can
undermine mental health or promote well-being are not randomly distributed but
reflect social divisions of class and socio-economic status, aspects of social identity
such as age, gender race or ethnicity, sexual orientation, disability (including the
experience of mental health problems), religion and belief. The report made the point
that it is not being a woman, or being black or gay, per se that cause mental distress,
but the fact that some aspects of social identity can expose people to discrimination,
stigma and prejudice. The experience of discrimination and prejudice can undermine
mental health and well-being directly through exposure to, for example, harassment,
and indirectly through the experience of poverty, deprivation, exclusion and
inequality with which they are associated (NHS Health Scotland, 2007).

Approaches to mental health improvement and tackling inequalities

As outlined activities which are beneficial to health overall also have a positive
impact on mental health. In recent years UK and devolved government policy on
health improvement have focused on traditional approaches to promoting health.
This includes the promotion of healthy lifestyles  e.g. higher levels of physical
activity, eating fruit and vegetables, not smoking and drinking moderately - through
investment in population wide social marketing campaigns and policy initiatives that
encourage individual health behaviour change e.g. Keep Well Initiative in Scotland
and Every Contact Counts in England. Some of these have been supported by
wider policies - such as the no smoking ban - and some also recognise inequalities
by targeting campaigns at those living in the most deprived areas.

However, a review in Scotland into the future of Public Services (Christie
Commission, 2011) discusses the current failure within public services to prioritise a
preventative approach in order to break the cycle of deprivation and low aspiration.
It talks of `Failure demand'  demand on public services which could have been
avoided by earlier preventative measures  and of a system which is reactive and
targets the consequences not causes of inequalities. A key recommendation within
the report is the prioritisation of preventative services with a specific focus on
addressing generational inequalities (Christie Commission, 2011).

Furthermore, a recent report by the Kings Fund (Buck & Frosini, 2012) - which
analyzed data from the Health Survey in England in 2003 and 2008 to explore how
lifestyle risk behaviours cluster in the population and are distributed over time -
outlined that although the proportion of people engaging in multiple risky behaviours
(smoking, excessive drinking, physical activity and eating 5 fruit and veg) had fallen
overall in the general population the greatest reductions were among those in higher
socio-economic groups thus exacerbating health inequalities. This led the authors to

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