Scottish Government

Source: Melzer et al , 2004

Mental distress can be viewed as the psychological consequences of demoralisation, despair and discrimination experienced by individuals and communities (Rogers and Pilgrim, 2003). The way people feel and think is affected by the circumstances in which they live and work, which are in turn the product of economic and political conditions in society. Structural inequality can lead to people feeling distressed and hopeless and to unfairness being construed as in some way of their own making. Living in conditions which are themselves detrimental to health can lead to unhealthier life styles - smoking, unhealthy diet - further compounding inequalities in chances of reasonable mental health and well-being (Labonte, 1998). Financial pressures are the most frequently cited causes of depression ( IMS and Mental Health Survey, in Bundy, 2001).

People with mental health problems are more likely to be in debt and have difficulties managing money than other members of the general population ( SEU, 2004). Those who have a long term mental health problem are likely to be trapped in poverty for longer periods than other people and persistent low incomes make it more difficult for individuals to take part in social activities that would alleviate isolation. Lack of practical support and assistance with finance matters and benefit claims can reinforce the vicious cycle of poverty, exclusion and poor mental health (Cullen, 2004; SEU, 2004).

Employment status and mental health

Having a job is likely to be more beneficial for your health and your mental health than not having one, but this will depend on a range of factors. Unemployment tends to be detrimental to mental health, as a result of the interaction of objective (material) factors and subjective (psychosocial) factors. Financial difficulties, poor nutrition and physical health interact with and may be exacerbated by feelings of anxiety and depression engendered by hopelessness and powerlessness.

However, it should not be assumed that employment is good for mental health and unemployment detrimental. Unsatisfactory or insecure jobs can be as harmful to health as unemployment (Ferrie et al, 1999, in Wilkinson and Marmot, 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 (Marmot et al, 1991). For some people who are unemployed, social support, alternative opportunities to play a meaningful role or access to leisure activities can off-set the potentially detrimental effects of unemployment on mental health (Rogers and Pilgrim, 2003).

There is a strong case, in developing and implementing anti-poverty strategies, for making a clearer link between the experience of unemployment, poverty and mental ill health. The profile of people with a disability has been changing over the last decade. Now, mental health and stress related problems are among the main reasons why people move out of employment and on to incapacity benefit. You are far less likely to be working if you have a mental health problem than any other condition. This has prompted commentators to argue that anti-poverty strategies have to incorporate a response to this trend towards increasing experiences of mental ill health (Regan and Robertson, 2004).

People with an identified mental health problem are more likely to be excluded from work. Those with a common mental disorder are four to five times more likely to be unemployed, twice as likely to be on income support and four to five times more likely to be getting invalidity benefits, compared to the general population. People with a diagnosis of a psychotic illness have only a one in four chance of being in employment (Jenkins and Singh, 2001, in Rogers and Pilgrim, 2003). People with experience of mental health problems may also have lower levels of educational attainment and weaker social networks which amplify the negative consequences of unemployment or unsatisfactory employment.

Physical health and mental health

It is well known and widely recognised that social and economic conditions impact on health throughout life, with the result that if you are poorer you are more likely to experience worse health and to die younger. Both material and psychosocial causes contribute to these differences in health and mental health. Poverty and disadvantage may impact on physical health by affecting mental health, the experience of disadvantage and exclusion mediated through feelings of hopelessness, anxiety and powerlessness which lead to physical health consequences.

'It is not simply that poor material circumstances are harmful to health: the social meaning of being poor, unemployed, socially excluded or otherwise stigmatised also matters. As social beings we need not only good material conditions but, from early childhood onwards, we need to feel valued and appreciated. We need friends … more sociable societies … to feel useful … to exercise a significant degree of control over meaningful work. Without these we become more prone to depression, drug use, anxiety, hostility and feelings of hopelessness, [which all rebound on physical health]' (Wilkinson and Marmot, 2003, p. 9).

There is now a substantial and growing body of evidence that demonstrates the impact of mental health on physical health to the extent that it has been suggested that initiatives which aim to promote physical well being to the exclusion of mental and social well being may be 'doomed to failure' (Stewart-Brown, 1998).

At population level physical and mental health status are influenced by a range of socio-economic factors including: income, employment, poverty, education and access to community resources (Yen and Syme, 1999; Kawachi and Marmot, 1998; Baum, 1998) and demographic factors such as gender, age and ethnicity.

Social circumstances can cause long-term stress and continuing anxiety, low self-esteem, social isolation, lack of control over work and job prospects can have a major impact on health including mental health. Stress biology can help illuminate the mechanisms by which emotional distress exacerbates susceptibility to physical illness. How people feel (stressed, depressed, isolated, scared, excluded) has a direct effect on the immune system and the cardio-vascular system. Mental health status has been also shown to have an impact on recovery rates from myocardial infarction (Friedli, 2002).

From a different perspective it is also known that the physical health of those experiencing mental health problems, particularly those with long term and serious mental health problems, tends to be poor. People with severe and enduring mental illness (schizophrenia, psychosis, and bi-polar disorder) have a significantly increased risk of death due to infections and/or respiratory disease (Harris and Barraclough, 1998).

Explanations for this poor health record include the possible consequences of a psychiatric illness on lifestyle, which may make someone more likely to die from diseases, rather than trauma or by suicide (Kendler, 1986). This may be compounded by the paucity of health care provision to take preventive action to address known risk factors. Several primary care studies have found that despite physical health risk factors being recorded in GP records, very few attempts to intervene were apparent (Kendrick et al, 1995; Kendrick et al, 1994). In addition there is considerably less health promotion activity conducted within primary care targeted at those with severe and enduring mental health problems compared with what is available for the general population, despite known increased health risk factors and significantly higher than average GP consultation rates among this group (Brown et al, 2000).

Many people with long-term, serious mental health problems also face poverty and disadvantage and their poor physical health may therefore be mediated through feelings of demoralisation and hopelessness that arise from prolonged experiences of exclusion (Wilkinson and Marmot, 2003).

Social dimensions: poverty and social exclusion

Social support is an important protective factor for mental health and for physical health that can act as a buffer to protect against adverse life events.

It has long been recognised that poverty and surviving on a low income have social consequences which can lead to exclusion from social activities and opportunities and this effect still continues: the proportion of adults reporting a severe lack of social support and poorer GHQ scores increases as income decreases (Erens and Primatesta, 2000).

In local communities that enjoy a higher quality of life, residents are more likely to experience a greater sense of belonging, less isolation, greater access to leisure opportunities, more neighbourliness and security. Poorer mental health is associated with perceptions that the neighbourhood is in decline, less neighbourliness and fewer leisure opportunities (Huxley and Rogers, 2001).

Those living in deprived communities tend to have lower self esteem, are more likely to report feeling lonely and that life is not worth living and to have a lower sense of being in control over what happens in their life than those living in a more affluent area. In addition, residents in more deprived communities are more likely to report problems in the local environment (Ellaway, 2003).

People who are more socially connected and have more social support enjoy better general health and suffer less from mental health problems. People with lower social capital tend to be those who live in the most deprived areas, on lower incomes, and to have lower education levels (Palmer et al, 2003).

Reduced social and economic inequalities and social exclusion appear to be associated with greater social cohesion and better standards of health (Wilkinson and Marmot, 2003). An individuals health may have more to do with their relative position within society than with absolute standards of living (Kawachi et al, 1999). Communities rich in social capital have better mental and physical health ( HDA, 2002).

Cycles of Injustice

In considering the nature and distribution of mental health inequalities it is important to be aware of changes over time within and between generations. The effects of exclusion and disadvantage are deep seated and can be played out throughout the life cycle and indeed across generations. First, it is important to note that mental health is maintained or diminished by different influences at different points in the life cycle: for children, secure attachment and freedom from abuse and neglect are critical; in later life, physical health and social isolation assume greater relevance for mental health.

Secondly, there is evidence that experience of disadvantage can have cumulative effects over time. Emotionally disturbed children tend to accrue additional disadvantages of poor school performance or exclusion, low academic achievement, labour market disadvantage and poor mental health status in later life (Rogers and Pilgrim, 2003).

Social exclusion can pass from generation to generation and affect life chances. Children's futures are still greatly affected by the circumstances of their parents. This means that limited opportunities are not only experienced by those in the most extreme disadvantage; people within relatively strong communities not traditionally seen as excluded can experience disadvantage and poor opportunities that cascade down generations.
There is evidence of a clear association, for example, between: parental income, children's educational attainment and subsequent earnings; life expectancy and parental social class; and likelihood of teenage pregnancy and social class ( SEU, 2004).

Our experience of mental health and well-being is influenced by a wide variety of factors associated with our identity ( e.g. age, gender, sexual orientation, ethnicity), our make-up, current circumstances, past experiences and future prospects. This multiplicity of influences can lead to cumulative advantages and disadvantages in mental health outcomes. Figure 4.1 summarises these multiple and mutually reinforcing influences.