While mental disorders may affect anyone in society, there is a social gradient in common mental disorders (depression and anxiety) with a higher prevalence found among those living in poorer households. What can be done? Early identification of people at risk and action on the social determinants is essential, writes Ruth Bell.
Thankfully, there is now increased attention on improving access to therapeutic treatments for the 1 in 6 people in the UK suffering from a mental health disorder. We need to go further, and also to nurture and protect mental health as a precious resource for individuals, families and society by tackling the wider social determinants.
Mental health is influenced by the conditions in which people are born, grow, live, work and age (the social determinants of health). These conditions are amenable to improvement, including by government policies, and by interventions put in place by governmental and non-governmental organisations, as well as by communities and individuals.
Evidence shows the association between social disadvantage and mental disorder. Factors such as poverty, debt, unemployment, low quality housing, low educational attainment and social isolation are all linked with mental disorder. We know that while mental health disorders may affect anyone in society, there is a social gradient in common mental disorders (depression and anxiety) with a higher prevalence found among those living in poorer households. Gender, and factors associated with gender, are linked to common mental disorders, with women having a higher prevalence than men at all levels of household income.
We know from researchstudies that around half of adult mental disorders have started by adolescence. Prevalence of anxiety and depression is between two and three times higher among young people ages 10 to 15 years with low socio-economic status than among their peers with high economic status.
Taking this knowledge on board, what can be done? Early identification of people at risk, with onward referral to appropriate community based services and primary preventive treatment is essential. This is particularly important for children and young people in schools and colleges. Action on the social determinants – to improve the conditions of daily life, during early childhood, at school age, during family building and working ages, and through to older age – provides opportunities to improve population mental health and to reduce the risk of those mental disorders that are associated with social inequalities. Such action is possible, and much can be done.
Locally based interventions can support mental health at different stages of life. Programmes and interventions to support parents can deliver benefits to the mental health of parents and support children’s social and emotional development and reduce behavioural problems. One example is the Incredible Years Preschool Basic Programme, a parenting group programme designed to help parents improve their child’s behaviour. Parents attend 18 to 20 weekly group sessions where they learn techniques to improve relationships with their children, communicate effectively, establish rules and routines and manage anger and conflict. The Early Intervention Foundation Guidebook describes further examples of effective programmes.
In school settings, Families and Schools Together (FAST) is an early intervention programme delivered in a number of areas of high deprivation. The programme consists of an initial phase of eight 2.5 hour weekly sessions, followed by on-going support for families from the FAST team for 2 years. The programme aims to improve family relationships and helps build a supportive network and home environment. Benefits include reduced child emotional problems and improved child social behaviour.
Unemployment, particularly long term unemployment, is associated with increased risk to mental health. Policies and local programmes that support unemployed people back to work can be beneficial. But employment is not always good for mental health; much depends on the terms and conditions of employment. Aspects of work that are important include job security, fair pay, organisational justice, and having control over how tasks are completed.
Social isolation and loneliness among older people has been identified as a risk for mental health. One example of a community based programme aimed at older people who may feel socially isolated in rural areas is the Upstream-UK which uses mentors to deliver tailored activities and improve social interaction, thereby improving psychological well-being and reducing depression.
Community based programmes and interventions are needed. So too is an integrated approach across the social determinants at local and national level to create an enabling context for effective and sustainable action. This involves aligning policy across child care and education, employment, welfare, housing, transport and environment. For children and families this includes ensuring family income that is sufficient for healthy living, parental leave arrangements and available and affordable, high quality childcare.
The recent update of the Marmot Indicators focuses attention on what needs to be done across the social determinants. The Marmot Indicators are a set of indicators of the social determinants of health, health outcomes and social inequality that broadly correspond to the policy recommendations proposed in Fair Society, Healthy Lives, which addressed six domains: ensure every child has the best start in life; enable all children, young people and adults to maximise their capabilities and have control over their lives; create fair employment and good work for all; ensure a healthy standard of living for all; create and develop healthy and sustainable places and communities; and strengthen the role and impact of ill-health prevention. Press coverage of the new Marmot Indicators dwelt mainly on data showing that nearly half of children did not achieve a good level of development at the end of reception class in 2012/13.
Further key findings give the bigger picture. Unemployment grew sharply after the financial crisis of 2008, and, while declining, has still not gone down to pre-crisis levels. The number of long term unemployed claiming Jobseeker’s Allowance for 12 months or more increased from 116,500 25-65 year olds in 2009 to 282,000 25-65 year olds in 2013. For the under 25 age group, the number claiming Job Seekers Allowance for 12 months or more rose from 7,500 in 2009 to almost 57,000 in 2013. For those in work, around 1,500 per 100,000 in 2011/12 reported that work has made them stressed, depressed or anxious, with no sign of a downward trend since 2005.
For an increasing number of families acceptable standards of living are out of reach. In 2011/12 23% of households studied (which covers 2/3rds of household types in England) did not receive enough income to reach an acceptable Minimum Income Standard (MIS) defined by Joseph Rowntree Foundation as not having enough income to afford a ‘minimum acceptable standard of living’. The proportion of people living in households below MIS increased by a fifth between 2008/9 and 2011/12, from 3.8 million to 4.7 million households.
Grappling with these social and economic issues is fundamental to reducing social inequalities and ultimately improving population mental health.
This article is based on an article co-authored by Ruth Bell, with Jessica Allen, Reuben Balfour and Michael Marmot, published in the International Review of Psychiatry, Volume 26(4), pages 392-407, 2014. It also refers to recent reports published by the UCL Institute of Health Equity
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Ruth Bell is a senior advisor at the UCL Institute of Health Equity and a senior research fellow in the Department of Epidemiology and Public Health, UCL . She is active in research and policy analysis for UK, European and other international projects in the area of social determinants of health.