Poverty and Marginalisation - Forgotten Risk Factors That Never Went Away
I’m going to let you into an open secret — social status determines the likelihood of having a mental illness, accessing mental healthcare, your experience of it and how well you recover (or not). Poverty makes you mentally ill and so does being from a minoritised group — there, the cat’s out of the bag.
I’m Clinical Director of the National Collaborating Centre for Mental Health (NCCMH) at the Royal College of Psychiatrists, Clinical Director for Forensic Services at the Maudsley and a Visiting Senior Lecturer at the Institute of Psychiatry, Psychology and Neuroscience.
In the 30 years I’ve worked as a psychiatrist, it has become inescapable that inequality and deprivation make people ill, prolongs their illness and causes them to relapse, again and again. And like Marmot says, we have been treating people only to return them to the very conditions that made them ill in the first place.
Some years ago, I realised that addressing mental health inequality was not only ethically, morally and clinically the right thing to do, but it was economically the best thing to do too. As RCPsych Presidential Candidate, addressing inequality is one of my main priorities and I’ve developed and started implementing systems to do this.
The nature of mental health inequality
We all know money doesn’t buy happiness, but it certainly helps…poorer people have more than twice the rate of mental health problems than richer people (Advancing Mental Health Equality, AHME, resource, 2018). If you are lower down the social hierarchy scale, you’re more likely to be discriminated against and the evidence indicates that experiences of discrimination are associated with developing mental illness — anxiety, depression are 2–4 times more common in those who report experiencing racial discrimination; suicidal behaviour is increased in those who have experienced homophobia and even psychotic symptoms are higher in those who report more discrimination.
Yet we rarely cite poverty or discrimination as risk factors for mental disorder, other than to say a particular condition is more prevalent amongst the poor, or amongst Black people or South Asian people — as though there is something inherently problematic with those who are poor or Black or South Asian, which means they are more likely to attract disease. Until recently, poverty or discrimination as risk factors, were missing from our medical curricula and even our research.
In Victorian Britain there was a notion, based on a distortion of the thinking of writers such as Samuel Smiles, that poverty was, for some, a “lifestyle choice,” and that there was a mass of “undeserving poor” who simply by exercising some willpower could pull themselves out of poverty, the corollary being that they therefore wilfully put themselves in that position. Flash forward 200 years and this attitude is echoed by our modern debate around “skivers and strivers”.
For psychiatrists the main issue is this, if you work in an area with high levels of deprivation, or higher numbers of minoritised people (minoritised ethnic groups; LGBTQ; women), then it is likely that there will be twice as much or more mental illness in that area compared with a more affluent or less diverse area. But unlike Victorian times, we now have the welfare state and the ability to understand how resources can be shared that mitigate against the ravages of being poor, and we have laws against discrimination.
So why are we seeing levels of mental illness that are higher than ever before? Why is it still the case that care varies inversely according to need and what can we do about it?
Understanding Structural Discrimination and Mental Health Inequality
Structural discrimination is seen when there is differential access to goods, services and opportunities by race/ethnicity, religion, sexuality, or gender. It manifests as “inherited disadvantage” and is “codified” into our customs and practices — “it’s just how it is”. We’re all so used to the status quo, that we don’t notice it. There’s often no active perpetrator, we just fail to notice when there is a need, and that need is not being addressed.
Galtung described “Social structures and institutions harming the health of populations by creating barriers to resources that enable individuals to meet their fundamental developmental needs”. Unlike individually-mediated discrimination (i.e. the name-calling and violence, perpetrated by racists, misogynists, homophobes, anti-semites and Islamophobes), structural discrimination is something we are all involved with and so, for the most part, don’t notice. The institutional and structural factors that discriminate against others are so ingrained into our way of living, that we tend not to recognise that these factors may well be disadvantaging other people (or even ourselves).
For example, how affronted might you have been in 1870 if the doctor you went to see was a woman, knowing that women should not be educated to degree level as it was really bad for their health, caused them to become infertile and would lead to the degradation of society? Women becoming doctors was unthinkable, laughable, so they didn’t try and certainly weren’t encouraged, because everyone knew it couldn’t and shouldn’t be attempted, yet there was a need for female doctors and women’s health suffered because they could not always access the healthcare they needed. Structural and institutional “norms” disadvantaged women, not always deliberately so, but they too often resulted in inaction in the face of very obvious need. Women’s health needs are still not recognised adequately and hence they have poorer outcomes.
To reduce the health burden, we must tackle the causes of the causes, which means influencing governments to fundamentally tackle inequality (Marmot 2017). Until then, we must work to better address the needs of the most marginalised.
Tackling Mental Health Inequality
Good news — there’s a system and guidance we can use to re-design the delivery of care so it better meets the needs of those who need it, the Advancing Mental Health Equality (AMHE) system. We developed this at the NCCMH, it has been adopted nationally and Trusts across the country have joined up to address inequality in their local area. The programme supports them through four stages;- (1) Identify the Inequality; (2) Design a different way of providing care with the people who need it; (3) Deliver the new idea; and (4) Evaluate and improve.
We must acknowledge that the services we offer don’t cater for the needs of some groups of patients we care for — particularly those from more marginalised and impoverished groups. We must recognise and accept that these groups may have greater need and then we must involve them in designing services — the AMHE approach.
We know what causes mental illness: genetics; familial inheritance; perinatal factors; early trauma (Adverse Childhood Experiences); late trauma (in adulthood); substance use; life events. We have assiduously searched for and researched genetic factors and underlying biological mechanisms, but they interact with and are often shaped by social determinants.
The magic bullet cure evades us because mental disorder arises from the complex interplay between our biology, sociology, psychology and the environment within which we were born, raised and live — how we see ourselves and how society sees us.
It takes a special kind of clinician to appreciate this complexity; and that’s what we do as psychiatrists. We all know that inequality causes mental illness. Now we have the tools to tackle it. Time to step up to the challenge of our profession and lead the way in delivering equitable mental healthcare.
As I have always said, there can be “No Quality without Equality”.