Health Policy And The Social Determinants

INEQUALITIES IN MENTAL HEALTH

Introduction and definitions:

Mental health is described by the World Health Organization (WHO) as:

“a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” (WHO 2001a, p.1).

According to NHS website every year in the UK, more than 250,000 people are admitted to psychiatric hospitals and over 4,000 people commit suicide

(http://www.nhs.uk/conditions/mental-health/Pages/Introduction.aspx , accessed 20-4-2010)

Mental health inequality is a long standing problem that has been tackled for decades by epidemiologists, sociologists and health professionals.

And because this problem has both strong social and health aspect there is no unified approach to identification and resolution.

From Sociologists viewpoint inequality with mental health is a problem that has two main explanations: people are poor because they have mentally illness that makes them unable to keep work probably (social selection), or they become mentally ill under the stress of being poor (social causation). However, in modern psychiatry other factors are believed to involve in the etiology such as genetic factors, diet, and hormonal disturbance which interact with personality disorders or emotional state to produce mental illness.

The problem of inequality is not only about serious mental illness but we can expand the definition of mental health inequality to include everyday feelings which is considered by United Kingdom Department of Health to be public health indicator:

“How people feel is not an elusive or abstract concept, but a significant public health indicator; as significant as rates of smoking, obesity and physical activity” (Mental Well-being Impact Assessment ,2009)

The table below gives examples of those factors that promote or reduce opportunities for good mental health (DOH 2001):

MENTAL HEALTH – PROTECTIVE FACTORS

INTERNAL PROTECTIVE FACTORS

EXTERNAL PROTECTIVE FACTORS

EMOTIONAL RESILIENCE

physical health

self esteem/positive sense of self

ability to manage conflict

ability to learn

CITIZENSHIP

a positive experience of early bonding

positive experience of attachment

ability to make, maintain and break relationships

communication skills

feeling of acceptance

EMOTIONAL RESILIENCE

basic needs met – food, warmth, shelter

CITIZENSHIP

societal or community validation

supportive social network

positive role models

employment

HEALTHY STRUCTURES

positive educational experiences

safe and secure environment in which to live

supportive political infrastructure

live within time of peace (absence of conflict)

MENTAL HEALTH – DEMOTING/VULNERABILITY FACTORS

INTERNAL VULNERABLE FACTORS

EXTERNAL VULNERABLE FACTORS

EMOTIONAL RESILIENCE

congenital illness, infirmity or disability

lack of self esteem and social status

feeling of helplessness

problems with sexuality or sexual orientation

CITIZENSHIP

poor quality of relationships

feeling of isolation

feeling of institutionalisation

experience of dissonance, conflict, or alienation

EMOTIONAL RESILIENCE

needs not being met – hunger, cold, homelessness/poor housing conditions etc.

experience separation and loss

experience of abuse or violence

substance misuse

family history of psychiatric disorder

CITIZENSHIP

cultural conflict – experience of alienation

discrimination – the negative experience of being stigmatised

lack of autonomy

the negative experience of peer pressure unemployment

HEALTHY STRUCTURES

value systems

effects of poverty

negative physical environment

Table 1: factors that promote or reduce opportunities for good mental health

What is the evidence on mental health inequalities?

Socio-economic status:

Community-based epidemiological studies across countries and over time have consistently identified an inverse relationship between Socio-economic status and prevalence rates of schizophrenia .The ratio between the current prevalence (defined as period prevalence up to one-year prevalence) of the disorder among low-SES and high-SES people was 3.4, whereas the ratio for lifetime prevalence was 2.4″ (Saraceno et al,2005), and in Britain, twice as many suicides occur among people from the most lower SES (Blamey A et al ,2002).

There are five hypotheses to explain this relation (Hudson 2005):

Hypothesis 1: Economic stress. The inverse SES-mental illness correlation is a speci¬c outcome of stressful economic conditions, such as poverty, unemployment, and housing unaffordability.

Hypothesis 2: Family fragmentation. The inverse SES-mental illness correlation is a function of the fragmentation of family structure and lack of family supports.

Hypothesis 3: Geographic drift. The inverse SES-mental illness correlation results from the movement of individuals from higher to lower SES communities subsequent to their initial hospitalization.

Hypothesis 4: Socioeconomic drift. The inverse SES-mental illness correlation results from declining employment subsequent to initial hospitalization.

Hypothesis 5: Intergenerational drift. The inverse SES-mental illness correlation is a function of declines in community SES levels of hospitalized adolescents between their ¬rst hospitalization and their most recent hospitalization after turning 18

Age:

In elderly:

National Institute for Mental Health in England (NIMHE) has reported the following point regarding mental health problems in elderly :

3million older people in the UK experience symptoms of mental health problems

the annual economic burden of late onset dementia is £4.3 billion which is greater than that for stroke, cancer and heart disease combined

dementia affects 5% of those aged over 65 and 20% over 80

10-15% of all older people meet the clinical criteria for a diagnosis of depression

these numbers are set to increase by a third over the next 15 years

(NIMHE, 2009).

Mental health problems in elderly often go unrecognised. Even where they are acknowledged, they are often inadequately or inappropriately managed (DH 2005c).

The UK inquiry into mental health and well-being in later life (2006) identified five factors that influence the mental health of older people: discrimination (for example, by age or culture); participation in meaningful activity; relationships; physical health (including physical capability to undertake everyday tasks); and poverty.

in children :

WHO states, that the „development of a child and adolescent mental health policy requires an understanding of well-being and the prevalence of mental health problems among children and adolescents”(child and adolescent mental health policy, 2006)

However, there is an evidence that levels of distress and dysfunction during childhood are considerably high between 11 per cent and 26 per cent, while the severe cases that require interventions are around 3-6 per cent of people under 16 years of age (Bird et al.1988; Costello et al. 1988).

Emotionally disturbed children are exposed to abuse or neglect in their family of origin, with estimates up to 65 per cent (Zeigler-Dendy,1989).

Gender:

Women and Mental Health

Mental health problems are more common among women than men with higher incidence rates of depressive disorder than men (Palmer, 2003).

There are many factors to explain this, first: Socio-economic factors such as poverty and poor housing conditions cause greater stress and fear of future amongst women. lack of confidence and self-esteem may be the results of educational factors such negative school experiences , Living in unsafe neighbourhoods cause stress and anxiety amongst women , dependency on prescription drugs (for depressive and sleeping disorders) often leads to anxiety.

Men and Mental Health

Men tend to be more vulnerable to mental health problems and suicide than ever before due for a number of reasons including:

Men in general are less likely to talk about their problems or feelings or to admit that they have depression.

Men are less likely to seek help for mental and emotional health problems.

Unemployment has a greater impact on men in general.

Some mental disorders are more serious in men for example suicide is the leading cause of death among young men. The rate for young men aged 10-24 years is higher among those from deprived communities compared with those from affluent communities. Men also experience earlier onset of schizophrenia with poorer clinical outcomes (Piccinelli, 1997)

Risk groups for mental illness in men include (DHSSPS,2004):

Older men: they are less willing to use health services because of the perception that these services are for older women.

Divorced men – because they have less support available from family , and services designed to meet the needs of this group is particularly.

Male victims of domestic abuse -especially boys in rural areas.

Gay and bisexual men – few services are available to help men deal with problems such as homophobic bullying and harassment.

Male survivors of sexual abuse – lack of co-ordinated support for adult survivors of abuse

Fathers – despite examples of good practice, men have comparatively less access to support services than women, to enable them to cope with the stresses of parenthood.

Bereaved men – lack of appropriate services specifically targeted at men who have experienced bereavement.

Men in rural areas – particularly isolated in terms of service access.

Young offenders – inadequate psychological services in juvenile justice centres despite the high proportion of young people entering the juvenile system with a range of mental health problems.

Ethnic group:

A review by Commission for Healthcare Audit and Inspection,( Count me in, 2009) noted that “Rates of admission were lower than the national average among the White British, Indian and Chinese groups, and were average for the Pakistani and Bangladeshi groups. They were higher than average among other minority ethnic groups – particularly in the Black Caribbean, Black African, Other Black, White/Black Caribbean Mixed and White/Black African Mixed groups – with rates over three times higher than average, and nine times higher in the Other Black group.”

Employment Status and Mental Health

Having a job helps to maintain better mental health than not having one, but this is not always true as many factors involve

For example, jobs which are unsatisfactory or insecure can be as harmful to health as unemployment (Wilkinson et al , 2003). Anxiety about job security, lack of job control, perceived effort-reward imbalance, negative relationships in the workplace, including bullying and harassment can have negative mental health consequences.

According to OSC Health Inequalities Review (2006) people with a common mental disorder are five times more likely to be unemployed, and if they have work they are more likely to be excluded, people with an identified mental health problem are twice as likely to be on income support and four to five times more likely to be getting invalidity benefits. A person with a diagnosis of a psychotic illness leaves him with only a one in four chance of being in employment.

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Geographic variation:

Studies result on geographic variation of mental illness are inconsistent , for example Hollie has concluded that “In mental health problems there is substantial variation at the household level but with no evidence of postcode unit variation and no association with residential environmental quality or geographical accessibility. It is believed that in common mental disorder the psychosocial environment is more important than the physical environment” (Hollie et al, 2007)

On the other hand, a recent Swedish study of 4.4 million adults found that the incidence rates of psychosis and depression rose with increasing levels of urbanisation (Sundquist K.et al.,2004).

Another study by Royal Commission on Environmental Pollution shows that people from densely populated areas had a 68-77% and 12-20% higher risk of developing any psychotic illness and depression respectively when compared to a control group in rural areas. Within urban areas the rates for psychoses map closely those for deprivation and the size of a city also matters; in London schizophrenia rates are about twice those in Bristol or Nottingham (Royal Commission on Environmental Pollution, 2007a, 2007b).

Disability and Mental Health:

Definition: According to Disability Discrimination Act (1995) (DDA)

‘A person has a disability if he has a physical or mental impairment which has substantial and long-term adverse affect on his ability to carry out normal day to day activities’

In the light of this definition we can focus on mental health inequality of three groups of people:

• People suffer socio-economic disadvantage caused by stigma and discrimination associated with their mental health problems.

• People with both mental health problems and physical disabilities.

• People with physical disabilities, whose experience discrimination and stigma because of their physical impairment and become mentally ill because of this experience.

Disabled people are more likely to experience stress and emotional instability than those who are not disabled.

a report by the Equality Commission for Northern Ireland (2003) has found that whilst 34% of those who were not disabled had experienced quite a lot or a great deal of stress in the last 12 months prior to the survey, the percentage rose to 52% for disabled people. Experiences of depression within the last 12 months were higher among women who were disabled (44%) than men (34%).

Conclusion:

Inequality in mental health is as important as any other form of health inequality, however the interaction between social and personal level in mental illness makes it more difficult to address different kinds of mental health Inequalities associated with it.

Question 2 : word count (2000)

Tackling inequalities in mental health

Introduction:

Mental illness, among other disorders, is widely considered as a significant determinant of both health and social outcomes and many studies have spotted mental health disorders as both consequence and cause of inequalities and social exclusion.

Mental health diseases have two distinct characteristics as a public health problem: first very high rates of prevalence; secondly : onset is usually at a much younger age than for other health problem , Mental health diseases effects all areas of people’s lives : personal relationships, employment, income and educational performance. (Friedli and Parsonage , 2007; McDaid , 2007)

Who is at risk for mental health problems?

Defining risk groups enables policies makers to determine how to manage available resources to achieve better health equality. Furthermore, these groups are the main targets for health equality promotional programs.

A review of recent evidences on mental health inequalities can help to define the large groups at risk:

• People living in institutional settings: such as care homes or those in secure care or subject to detention.

• People living in unhealthy settings and who may not be reached by traditional health care such as veterans or the homeless.

• People with physical and/or mental illness, people misusing drugs, people with alcohol problems, people who are victims of violence and abuse.

•children whose parents have problems with alcohol or with drugs, children whose parents have a mental illness and looked after and accommodated children,

• People from groups who experience discrimination.

Key policies:

These policies can be long term policies focusing on deep change over long period or short term seeking fast results such as health promotion.

Long term aims:

Inequalities in mental health are not only about equality of access, but also about quality of access.

In the year 2009 Mental Health Foundation has published a report on resilience and inequalities in mental health (Mental Health, Resilience and Inequalities ,2009)

This report mentioned four priorities for action:

1-Social, cultural and economic conditions that support family life:

This can be done by reduce child poverty , parenting skills training and high quality preschool education , increasing access to safe places for children to play, especially outdoors, inter-agency partnerships to reduce violence and sexual abuse.

2- Education that helps children both economically and emotionally by:

schools health promoting programs, involving teachers, pupils, parents and supporting parents to improve the home learning environment (HLE)

support social, sports and creative achievements, as well as academic performance

3- Reduce unemployment and poverty levels and promote and protect mental health by:

Supporting efforts to improve pay, work conditions and job security.

Facilitate early referral to workplace based support for employees with psychiatric symptoms or personal crises to prevent employment breakdown.

4- Tackle economic and social problems, which cause the psychological distress. Such as housing/transport problems, isolation, debt, beside that art and leisure centres can help to reduce stress too.

However, these strategies take long time to be effective, that means the need for more rapid actions or short term aims.

Short term aims: Mental health promotion:

To build an effective strategy to promotion for health equality the following points should be achieved:

• Comprehensive: Mental Health promotion is not only the responsibility of health services alone; other sectors of society should join that effort.

• Based on evidence

• Based on the needs of the local communities, and with the agreement of these communities.

• Subject to evaluation: The strategy should be subject to critical evaluation and can be changed when necessary.

A good example of such strategy is the Mental health national evidence based standards which have been issued by The National Service Framework for Mental Health (DOH 1999). The purpose of these standards is to deal with mental health discrimination and social exclusion associated with mental health problems. And that can be achieved by promotion:

promote mental health for the whole society, working with individuals and communities

Stop discrimination against individuals and groups with mental health problems, and take steps towards better promotion for their social inclusion.

Tackling inequalities for special risk groups:

The Suicide prevention strategy:

One of the best example is the strategy based on work by (DOH 2002) and The NSPSE (National Suicide Prevention Strategy for England), the report was the result of literature review of suicide prevention programs around the world and has reached the following goals:

1. To reduce the risk in key high-risk group.

2. To promote mental well-being in the wider population.

3. To reduce the availability and lethality of suicide methods.

4. To improve the reporting of suicide behavior in the media.

5. To promote research on suicide and suicide prevention.

6. To improve monitoring of progress towards the target for reducing suicide.

Women and Mental Health: Preventing:

The results of UK-based survey (Williams, 2002) shows that mental health services for women:

Do not meet women’s mental health needs.

Can replicate inequalities.

Can be unsafe for women.

Can be insensitive to the effects of gender and other social inequalities, such as race, class and age

However, in their response to a survey conducted in England and Wales, women said that they wanted services that:

• Keep them feel safe.

• Promote empowerment, choice and self-determination.

• Place importance on the underlying causes and context of their distress in addition to their symptoms.

• Addressee important issues relating to their roles as mothers, the need for safe accommodation and access to education, training and work opportunities.

• Value their strengths, abilities and potential for recovery.

(DH, 2002a)

These points are important to build a need-based action plan for better equality in health services.

Men and Mental Health: Preventing:

The Equal Minds conference workshop which had special focus on men and mental health listed five service design features targeted at men’s mental health and well-being (equal minds, 2005):

• Accessibility and flexibility of services regarding time, location. For example, Select places familiar for men, ‘Men Only’ sessions run by male staff, make use of some activities, such as sport and physical activity programmes.

• Holistic approach, works on the person as a whole, not just on mental health.

• Early intervention to prevent anxieties and concerns build up, especially in stress and anger management.

• Trust and confidence are important to solve problems of identity and role that can underlay men’s anxieties and self-perceptions or lack of self-esteem.

Ethnicity and Mental Health: Preventing:

The main problem in this field was the barriers to access services. Barriers include:

• Language.

• Stereotyping.

• Lack of awareness or understandings of mental illness.

The report Inside Outside (Sashidharan, 2003) which addresses mental health services for people from black and minority ethnic communities in England and Wales. Suggest that patients from all minority ethnic groups are more likely than white majority patients:

• To follow aversive pathways into specialist mental health care.

• To be admitted compulsorily (there are differences also between ethnic groups at all ages).

• To be misdiagnosed.

• To be prescribed drugs and Electroconvulsive therapy (ECT), more than talking therapies.

• To have higher readmission rates and stay for longer periods in hospital.

• To be admitted to secure care/forensic environments.

• Their social care and psychological needs are less likely to be addressee within the care planning process.

• To have worse outcomes.

A strategic approach in Ethnicity and Mental Health:

In England and Wales a framework have been developed for action for ‘delivering race equality’ in mental health (DH, 2003b)

The framework focuses on three ‘building blocks’ which are essential to improved outcomes and experiences of people from black and minority ethnic communities:

• Information of better quality and more intelligently used.

• Services which are more appropriate and responsive.

• Increased community engagement

In other words any approach should take in consider both quality of health services and the socio-economic disadvantages experienced by people from ethnic communities.

Some suggested steps for this approach may include:

Providing interpretation and translation services beside mental health service to insure highest possible quality.

Adopting equalities practice in mental health services, that mean better understanding for cultural identity, the impact of racism, and culture differences in expression of mental distress.

Developing assessment and diagnostic tools that can better assess patients from different backgrounds and ethnicities.

Ensuring that services understand and respect spiritual requirements for different cultures.

Ensuring access equality to culturally appropriate services including, counseling, psychotherapy and advocacy.

Addressing common problem for people from black and minority communities, such as housing, employment, welfare benefits, and child-care.

Disability and Mental Health:

people with disabilities may experience high levels of socio-economic disadvantage due to discrimination and stigma , this group need a special interest regarding mental health services , they are liable for what Rogers and Pilgrim (2003) described :’inequalities created by service provision’.

Mental health services for disable people should be customized to their needs, some recommendations for such services may include:

Promotion for mental health, well-being and living with disability.

Early intervention: for people who show symptoms for possible mental illness.

Personalised care based on individuals’ needs and wishes

Stigma: work for better social inclusion and tackling stigma and discrimination associated with some disabilities.

Elderly and mental health:

In order to achieve better equality for this group, policy makers should insure better access to mental health services on the first place.

In the year 2005 the Department of Health published a report titled “Securing Better Mental Health for Older Adults to launch a new programme to bring together mental health and older people’s policy in order to improve services for older people with mental health problems.

The National Directors for older people and mental health promoted the dual principles of:

• Delivering non-discriminatory mental health and care services available on the basis of need, not age and

• Holistic, person-centred older people’s health and care services which address mental as well as physical health needs

Here, it is essential to emphasis the importance of specialist mental health service for older adults.

Sexual Orientation and Mental Health:

In this group health promotion plays a great role to address the mental problems associated with sexual orientation.

PACE organization has drawn up a set of practice guidelines for working with lesbian, gay and bisexual people in mental health services (PACE guideline.2006).

The guidelines suggest promoting services and resources specifically for LGB people, including services such counselling and advocacy provided by LGB organisations.

In response to these guidelines and studies about LGB such as (McNair et al, 2001). Mental health services for LGB people should:

Reflect upon the homophobia and heterosexism that LGBT people may experience within mental health services.

Enhance awareness of LGBT people problems, and the forms of discrimination and social exclusion they may face.

Consider the nature of a ‘culturally competent’ for LGBT people

Preventing in Mental Health Problems:

people with mental health problem are in need for “resilience factors” that enable them to recover from mental distress and to fight the effects of discrimination and stigma, we can name some of these factors such as confiding relationships, social networks, self-determination, financial security, however, support health services are essential for individual recovery and to achieve socially inclusive ‘accepting communities’ (Dunn, 1999).

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Examples for these services can be found in “report on Mental Health and Social Exclusion” which has been published by Social Exclusion Unit. The report included a 27-point Action Plan aimed at tackling stigma and discrimination, focusing on the role of health and social care in addressing problems of social exclusion, unemployment, and supporting families and community participation through ensuring access to goods and services such as housing, financial advice and transport (SEU,2004).

Beyond this report, it is important that policy makers be aware of connection between inequalities and mental health as a result and a cause, this will encourage more holistic approach that aim prevention on the long run.

Conclusion:

It is essential to put the different recommendations on mental health inequalities into everyday practice , for example a recent study by Glasgow Centre for Population Health found that policies are not driving practice for reducing inequalities in mental health within primary care, and the primary care organization studied is not conducive to addressing inequalities in mental health. (Craig, 2009).

For that reason, it is the responsibility of government, health services and health professionals to put these strategies and plans into action to insure a better and healthier society.