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Introduction and definitions:
The World Health Organization (WHO) has defined the mental health as:
ï¿½A 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 communityï¿½ (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 (2).
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 medical 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 the present of a true mental illness but it is possible to expand the definition of mental health inequality to include everyday feelings which is considered by United Kingdom Department of Health to be a 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 (3)
The table below gives examples of those factors that promote or reduce opportunities for sound mental health (4):
ï¿½ Good physical health
ï¿½ High self esteem
ï¿½ Learning ability
ï¿½ Good conflict management
ï¿½ early and positive bonding and attachment experience
ï¿½ make relationships and ability to maintain or break them
ï¿½ acceptance feeling
ï¿½ good communication skills ï¿½ Availability of the basic needs such as shelter and food,
ï¿½ validation by the community
ï¿½ support from surrounding social network
ï¿½ present of role models
ï¿½ job security
ï¿½ good education level
ï¿½ feeling secure
ï¿½ political stability
ï¿½ congenital diseases or disability
ï¿½ low self-esteem or social status
ï¿½ sexuality problems
ï¿½ relationships problems
ï¿½ feeling of isolation
ï¿½ lack of essential needs food , heat , housing ..
ï¿½ loss and separation experience
ï¿½ violence or abuse experience
ï¿½ substance abuse
ï¿½ psychiatric disorder runs in family
ï¿½ unemployment peer pressure
ï¿½ pressure from value systems
Table 1: factors that affect good mental health
What is the evidence on mental health inequalities?
Many Community-based epidemiological studies showed an inverse relationship between Socio-economic status and rates of schizophrenia. Saraceno found that the current prevalence (calculated up to one-year prevalence) of the schizophrenia among low-SES is higher than people of high-SES with a ratio of 3.4, and when calculated to lifetime prevalence it is 2.4ï¿½ (5), and in Britain, suicides rates among people from lower SES nearly double that of high-SES (6).
There are five hypotheses to explain this relation (7)(8):
1: Economic stress. The mental illness is a speci?c outcome of the stress related to economic problems, such as unemployment, poverty, and housing unaffordability.
2: Family fragmentation. The inverse SESï¿½mental illness correlation is a function of the fragmentation of family structure and lack of family supports.
3: Geographic drift. Individuals movement from communities of subsequent to their initial hospitalization leads to inverse SESï¿½mental illness correlation (8).
4: Socioeconomic drift. Low employment rate related to initial hospitalization of lower SES communities.
5: Intergenerational drift. Can be explained as following ï¿½The inverse SESï¿½mental 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 18ï¿½ (8)
ï¿½ In elderly:
In a report for NIMHE (National Institute for Mental Health in England) (9 cited by 21) .the following point regarding mental health problems in elderly has been noticed:
ï¿½ The number of older people with symptoms of mental problems in the UK is about 3 millions.
ï¿½ 10-15% of older people could be diagnosed by depression when applying the approved clinical criteria.
ï¿½ About 5% of people aged over 65 and 20% over 80 are affected by dementia
ï¿½ The economic cost of dementia in elderly is about ï¿½4.3 billion per year , this is more than the cost for heart disease ,stroke, cancer combined
ï¿½ the above numbers are expected to rise by a third in the next 15 years
Mental health problems in elderly are more likely to go undiagnosed. Even where they are recognized, they are often poorly managed (10).
The UK inquiry into mental health in later life (11) listed five factors that affect the mental health of elderly: relationships; contribution in meaningful activity; physical health (capacity to do everyday tasks); discrimination (by age or culture); and poverty.
ï¿½ in children :
WHO states that the building an effective mental health policy for child and adolescent requires first deep understanding of mental health problems among children and adolescentsï¿½(12)
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 3ï¿½6 per cent of people under 16 years of age (13,14).
Emotionally disturbed children are exposed to abuse or neglect in their family of origin, with estimates up to 65 per cent (15).
ï¿½ Women and Mental Health
It is proved that mental health problems are more common among women than men with a higher incidence rates of depressive disorder than men (16).
There are many factors to explain this, first: Socio-economic problems such as poor housing conditions and poverty 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 neighborhoods cause stress and anxiety amongst women , another common problem is addiction on prescription medications (for depressive and sleeping disorders) leads to more stress and anxiety. (16).
ï¿½ Men and Mental Health
In today world Men tend to be more susceptible to mental health problems than ever before especially suicide, some possible reasons for this are (17):
ï¿½ Men in general are less likely to discuss their feelings or problems or even to admit that they may have depression.
ï¿½ Comparing to women, fewer men look for help when having mental problems.
ï¿½ The impact of unemployment on men is deeper in general.
Some mental disorders are more serious in men. For example suicide is considered to be a leading cause of mortality among young men age group(18). Suicide rate is especially high in poor communities for men from age group 10-24 comparing to the same age group in wealthy communities. It is known also that the onset of schizophrenia is earlier in men and the clinical outcomes are poorer (18).
Risk groups for mental illness in men include (19):
ï¿½ Older men: many of them are less willing to benefit of provided health services because of the perception that these services are for older women.
ï¿½ Divorced men ï¿½ because of the lack of support available from their families, and services directed to meet the needs of this group.
ï¿½ Male victims of domestic abuse ï¿½ especially boys in rural areas.
ï¿½ Gay and bisexual men ï¿½ few services are available to assist this group to deal with problems such as homophobic bullying and harassment.
ï¿½ Sexual abuse victims, again insufficient support is provided for males of this group.
ï¿½ Fathers ï¿½ this is mainly due to stresses of parenthood combined with less support services when comparing to those available to mothers.
ï¿½ Mourning men ï¿½ With no or very few appropriate services specifically designed to men who have undergone bereavement.
ï¿½ Men living in rural areas ï¿½ obviously due to difficulty in getting access to proper support services.
ï¿½ Offenders of young age group ï¿½ less psychological services are available in juvenile justice centres in spite of the fact that there are high numbers of young Offenders who actually have mental health problems needed to be taken care of.
The ï¿½Count me inï¿½ report by Commission for Healthcare Audit and Inspection ( 20) noted differences in admission rates among different ethnic groups for example that rates were lower in white British ,Chinese and Indian comparing to the national average , while in Bangladeshi and Pakistani group the rates were around the national average , the highest rates (more than three times higher than average) were found in minority black groups (African and Caribbean) and in Mixed groups (White/Black African or White/Black Caribbean).
Employment Status and Mental Health
It is well-known that getting a job is a protective factor regarding mental illness (21).
But this is not always true. As Wilkinson (22) noted that jobs which are insecure or do not achieve the required level of satisfaction could have negative effects equal to that of unemployment. The main factors that cause this are (21): stress associated with fear of job loss, feeling of imbalance between effort and reward and inability to control job circumstances, stressful relationship with colleagues and bosses, cases of harassment or bullying. All this factors can lead ultimately to serious mental health illness.
On the other hand, According to OSC Health Inequalities Review (23) people with a mental illness have five times lesser chance to get a job, and if they are already working they become more likely to be fired, financially this group has in general lesser income (twice times chance than the general population) and more likely to depend on invalidity benefits. It is noticed that among mental disorders psychotic illness has the worse impact on employment rates which decline in this group to only one in four.
Studies result on geographic variation of mental illness are inconsistent , for example Hollie (24) has concluded that regarding mental problems it is possible to see notable variation at the household level but this variations do not exist in postcode units , and there is no proven connection with geographical accessibility or quality of residential environment
Hollie noticed also that in common mental illnesses the psychosocial environment has greater importance than the physical environmentï¿½
Another example comes from a recent Swedish study of 4.4 million adults found that with increasing levels of urbanisation; there was a notable rise in the incidence rates of psychosis and depression (25).
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 (26,27).
Disability and Mental Health:
Definition: According to Disability Discrimination Act (1995) (DDA) (28)
ï¿½A 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 activitiesï¿½
In the light of this definition we can focus on mental health inequality of three groups of people (21):
ï¿½ People suffer socio-economic disadvantage caused by stigma and discrimination associated with their mental health problems.
ï¿½ People with both physical disabilities and mental health problems.
ï¿½ 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 (29) had found that when surveyed 52% of disabled people had experienced high levels of stress in the last 12 months comparing to 34% of people who are not disabled , and when it comes to depression disabled women have a higher rate of depression than disabled men with 44% comparing to 34%
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
Many researchers agree that mental illness could be considered one of the fundamental social and health determinants, and it is difficult to separate these both sides because in most cases social exclusion and social inequalities are both cause and consequence of mental disorders (30)
Some studies refer particularly to two characteristics that distinguish mental illnesses when it comes to public health problems (30): first they are the recent high rates of incident and second is the early onset which affect much younger age group comparing to other health problems
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 aspects of peopleï¿½s lives : personal relationships, employment, income and educational performance. (31,32)
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 (33):
ï¿½ People living in institutional settings: such as care homes or those in secure care or subject to detention.
ï¿½ People living in unhealthy settings and who may not be reached by traditional health care such as veterans or the homeless.
ï¿½ People with physical and/or mental illness, people misusing drugs, people with alcohol problems, people who are victims of violence and abuse.
ï¿½children whose parents have problems with alcohol or with drugs, children whose parents have a mental illness and looked after and accommodated children,
ï¿½ People from groups who experience discrimination.
These policies can be long term policies focusing on deep change over a 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 the 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) (30, 34)
This report mentioned four points that should be consider as priorities:
1- Factors that support the life of the families mainly the Social, cultural and economic conditions:
This can be done by reduce child poverty , parenting skills training and high quality preschool education , providing secure places for the children to play in particularly outdoors, and cooperation between the different governmental agencies to compact violence and sexual abuse.
2- Establishing an educational system that can effectively support children on both emotional and economical scale by:
ï¿½ Schools health promoting programs, involving teachers, pupils, parents and working with families to enhance the home learning environment (HLE).
ï¿½ Taking steps to encourage sport activities and social events beside academic performance.
3- Reduce unemployment and poverty levels to reduce their negative effect on mental health, and while this is not an easy goal but the steps that could be taken my include:
ï¿½ Supporting efforts to improve pay, work conditions and job security.
ï¿½ Taking advantages of workplace based support by early detecting and caring of personal problems or psychiatric symptoms before developing into serious stages.
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 a 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 (30,35).
ï¿½ Comprehensive: promotion of mental Health is not only the responsibility of health services alone; other sectors of society should join that effort.
ï¿½ Based on evidence
ï¿½ Responding to the needs of the local communities, and with the agreement of these communities.
ï¿½ Under continuous assessment: The strategy should undergo critical evaluation and can be changes should be made 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 (36). The idea of these standards is to deal with mental health discrimination and compact social exclusion in patients with mental illness. And that can be achieved by promotion:
ï¿½ Increase the awareness about the importance of mental health in the society
ï¿½ Take strong position against discrimination affecting individuals with mental illness, and promote the steps that make the social inclusion possible for them.
Tackling inequalities for special risk groups:
The Suicide prevention strategy:
One of the best example is the strategy based on work by 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 (38):
1. To identify and work on people with the highest suicidal risk.
2. To raise the awareness about mental well-being in the society .
3. To target common suicide methods and limits the possibility to get access to such methods if possible.
4. Work with the media for better coverage of suicidal behaviour and its dangers.
5. Support the research for better understanding of suicide and the possible way to reduce it.
6. To evaluate the steps taken to achieve lower rates of suicide.
Women and Mental Health: Preventing:
The results of UK-based survey (38 cited by 21) shows that mental health services for women:
ï¿½ Do not respond to special need of mental health in women.
ï¿½ Can be unequal.
ï¿½ Sometimes prove to be unsafe for women.
ï¿½ May not reflect to the gender effects on social inequalities, which present in deferent levels such as class and race.
However, in their response to a survey conducted in England and Wales (38), women said that they services should:
ï¿½ Provide Sense of Security for them.
ï¿½ Encourage the feelings of independence and ability to make choices and control their life again.
ï¿½ Try to identify and deal with the real causes beyond the stress and the problems they face not only the symptoms of these problems.
ï¿½ support motherhood by directly address this group problems, such as suitable accommodation, jobs opportunities, education.
ï¿½ Embrace their inner strength and potentials of recovery.
These points are crucial 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 some changes to the support services that make these services more related and directed to solve men mental health issues: (21):
ï¿½ the services should be designed especially for men and with easy access in mind , this include both the place and timing of the selected service , for example choosing places that men usually meet in , or including sport activities or introducing programs that run only by men
ï¿½ Holistic approach, works on the person as a whole, not just on mental health.
ï¿½ Early intervention to prevent anxieties and concerns build up, especially in stress and anger management.
ï¿½ Trust and confidence are vital to solve problems of identity and role which can cause a lot of stress and self-image problems in men.
Ethnicity and Mental Health: Preventing:
One of the main problems in this group is the accessibility to the mental health services due to many factors such as:
ï¿½ Linguistic communication.
ï¿½ Stereotypic approach to their problems.
ï¿½ Ignorance about the importance of mental health.
Sashidharan in his report titled: ï¿½Inside Outsideï¿½ (39 cited by 21) discussed the mental health services provided for black and minority ethnic groups in England and Wales. And he noticed that these services are different when comparing to services provided to the majority white population in some aspects:
ï¿½ Patients are less likely to receive specialist mental care.
ï¿½ Patients are more likely to undergo obligatory admission (there are differences exist between different ethnic groups and different age groups).
ï¿½ Patients are more likely to be wrongly diagnosed.
ï¿½ Patients are more likely to be treated with psychiatric drugs and Electroconvulsive therapy (ECT), more than receiving talking therapies.
ï¿½ To have higher readmission rates and stay for longer in hospitals.
ï¿½ To be admitted to secure care/forensic environments.
ï¿½ Their social care and psychological needs are less likely to be addressee within the care planning process.
ï¿½ To have worse outcomes.
A strategic approach in Ethnicity and Mental Health:
In England and Wales a framework has been developed for action for ï¿½delivering race equalityï¿½ in mental health (40 cited by 21)
The framework introduces three points which are essential to reach the targets of better services and results in mental health problems in minority ethnic groups, these points are:
ï¿½ Providing high quality Information services.
ï¿½ To insure that the provided services are easy to access and can respond quickly to minority groupsï¿½ needs.
ï¿½ Involve the community in the efforts toward better mental health.
In other words any approach should take in consider both quality of health services and the already existing socio-economic inequalities that ethnic groups may face.
Some suggested steps for this approach may include (21):
ï¿½ Providing interpretation and translation services beside mental health service to insure highest possible quality.
ï¿½ Adopting equalities practice in mental health services, that mean better understanding for cultural identity, the impact of racism, and culture differences in the ways people express of mental stress.
ï¿½ Researching better tools and assessment measures that can better assess patients from different backgrounds and ethnicities.
ï¿½ Ensuring that services understand and respect spiritual requirements for different cultures.
ï¿½ Ensuring access equality to services that more culturally accepted including, counseling, psychotherapy and advocacy.
ï¿½ Addressing common problems of 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 (41) described :ï¿½inequalities created by service provisionï¿½.
Mental health services for disable people should be customized to their needs, some recommendations for such services may include:
ï¿½ Promotion for well-being, mental health, and living with disability.
ï¿½ Early intervention: for people who show symptoms for possible mental illness.
ï¿½ Personalised care based on individuals’ wishes and needs.
ï¿½ Stigma: work for better social inclusion and try to deal with problems associated with 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 in the first place.
In the year 2005 the Department of Health introduced a report titled ï¿½Securing Better Mental Health for Older Adultsï¿½ (42) to launch a new program to enhance the levels of services provided for elderly suffering mental illnesses or problems, this report promoted for a new policy that depends on two important steps:
ï¿½ Ensuring equality in the provided mental services; that means that the availability of these services should depend on the actual need for it not on selective age groups.
ï¿½ The approach of these services should be Holistic and personalized to meet both mental and physical needs for older age group.
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 prominent role to address the mental problems associated with sexual orientation.
PACE organization has published practice guidelines for mental health services working with lesbian, gay and bisexual people (43 cited by 21).
The guidelines suggest that these services should especially designed to meet the needs of LGB people, examples of such services include particularly counseling and advocacy.
In response to these guidelines and other studies about LGB such as (44 cited by 21). Mental health services for LGB people should:
ï¿½ Deal with the problems of heterosexism and homophobia that this group frequently faces.
ï¿½ Raise the community awareness about the problems that this group suffer especially social exclusion and discrimination.
ï¿½ The services directed to LGBT people should be able to interact effectively with this group ï¿½culturally competentï¿½.
Preventing in Mental Health Problems:
People with mental health problem are in need for ï¿½resilience factorsï¿½ which may be the only way to heal from mental distress and to fight the stigma and discrimination they frequently face (21), 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 ï¿½accepting communitiesï¿½ (45).
Examples for these services can be found in ï¿½report on Mental Health and Social Exclusionï¿½ which has been introduced by Social Exclusion Unit. The report included a 27-point Action Plan especially designed to deal with discrimination and stigma (21).
In this action plan the health and social care services play an decisive role to fight the problem of social exclusion and provide the proper support for community and families, this support may include help to find better accommodation, and provide financial (46).
Beyond this report, it is essential 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 at the long run.
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 effective reduction in inequalities levels in mental health within primary care, and the primary care organization studied is not Contributive to tackle inequalities in mental health. (47).
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.
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