The evidence suggests that the UK, among other high-income countries, is in the midst of a mental health crisis. A recent report by the Mental Health Network, found that 19% of adults had been diagnosed with depression at some point in their lives, while as many as one in four people experience a mental health problem in any given year. Even more worryingly, mental illness is high among the young, suggesting that the burden on the NHS and other social services will grow in the years to come.
It is commonly thought that depression and mental illness are “middle class problems”, yet this idea is not supported by evidence. Although mental health issues have risen among affluent social groups, studies have repeatedly shown that mental health remains inversely associated with social class. The risk of developing a mental disorder rises alongside socioeconomic disadvantage and the odds of reporting depression are almost twice as high among those in the lowest socioeconomic groups, compared with the highest.
Reviews also find that socioeconomically disadvantaged children are at greater risk of mental illness than those from more privileged backgrounds, suggesting that inequalities are intergenerational and start early in life.
Can policy make a difference?
The causes of these inequalities in mental health are thought to be the same as those which affect other aspects of the social distribution of health: poverty, unemployment, unhealthy lifestyles, poor working conditions, poor housing. Importantly, the negative impact of these “social determinants of health” can be reduced through well-designed social and labour market policies, as I discovered while researching my thesis on this topic.
The evidence to date reveals only broad links between social and labour market policies and inequalities in mental health. A number of studies have looked at variations and inequalities in mental health across “welfare regimes”. These are clusters of countries ranked according to their generosity of social protection, levels of social investment, and quality of working conditions. Those which are more generous and with better labour market conditions, are expected to have narrower inequalities in mental health as they will reduce the negative impact of poverty, unemployment and other “social determinants of health”.
One such study examined rates of depression across European welfare regimes. They found that on average depression was highest in liberal (UK) and southern (Italy, Spain, Greece) welfare states and lowest in Scandinavian (Sweden and Denmark) and conservative (Germany, Netherlands, Belgium, France, Switzerland and Austria) regimes. This they linked to the weaker social protection and poorer quality of work in the liberal and southern welfare states, compared with Scandinavian and conservative ones.
Another study which focused more directly on inequalities examined how links between depression and education varied across European welfare regimes. They also found that the southern (Italy, Spain, Greece) welfare state, with its poorly developed systems of social protection and high poverty rates, was less successful at reducing the link between education and depression, particularly when compared with the northern (Sweden and Denmark) welfare state. This, they suggested, may be partly explained by the generosity of the Nordic welfare regime.
Other studies reach similar conclusions and overall the evidence suggests that countries with generous social protection, low unemployment, high levels of social investment (education and training/support for the unemployed) and a well-regulated labour market, perform better in terms of inequalities in mental health.
Despite this, there is still a lack of convincing evidence about exactly how welfare states reduce (or widen) inequalities in mental health. In my thesis, I began to explore these questions and examine if and how policies to reduce unemployment (public employment services, training, employment incentives), might also reduce inequalities in mental health.
Building on the approach of Carter and Whitworth, I suggest this might happen through two mechanisms. First, participation in well-resourced training programs might reduce inequalities in mental health by improving the experience of unemployment. The negative effects on mental health linked to unemployment are believed to be partly related to the damage to self-esteem and sense of purpose, which training programs could reduce. And second, better employment outcomes might reduce inequalities in mental health, particularly among socially disadvantaged groups as good quality work is beneficial to mental health.
There would certainly be broader benefits to using policies to reduce inequalities in mental health. Most recipients of incapacity benefit, one of the most widely claimed benefits, are from lower socioeconomic groups and claim it for mental health reasons. Social inequalities in mental health may therefore contribute to incapacity benefit claims, suggesting that social and labour market policies that reduce inequalities in mental health will (paradoxically) reduce costs to the welfare system.
Similarly, inequalities in mental health increase demands on NHS services in disadvantaged areas, where budgets are often already overstretched. Reducing these inequalities through social policies which target the social determinants of mental health may relieve strains on health care services in deprived areas and also contribute to wider health equity.
There are also moral arguments for tackling the social determinants of mental health. It is unfair that those who experience a poor quality of life are also more likely to suffer from debilitating mental illness. Moreover, inequalities in mental health may matter for the social gap in life expectancy, too, as mental illness is a strong predictor of mortality. Therefore, if we are interested in reducing inequalities in mortality (as Theresa May recently pledged in her first statement as UK Prime Minister) then we must also consider reducing inequalities in mental illness. Well-funded and appropriately designed social and labour market policies may help to do just that.