In October 2018, the British Medical Association published a report entitled: “Tackling the Causes: promoting public mental health and investing in prevention”, which is a response to the most pressing issue in mental health services, itself reflected into primary care. Mental disorders are increasing (NHS Digital, 2016), and this rising demand for interventions is happening with decreasing resources (within health services) to meet that demand.
The Marmot Report (2010) brought together evidence of the “causes of the causes” for mental disorders; inequalities (principally poverty) drive the antecedents of mental illness. It gave clear solutions, but the years that followed saw inequalities increase in the UK, alongside year-on-year cuts to both necessary supports for vulnerable families (benefits, housing, social care) and public health budgets (reduced by about one third on 2010 baseline). These forces inspired this new BMA report and have led to recognition on 5th November 2018 by the Secretary of State for Health and Social Care, Matt Hancock, to refocus nationally on Prevention.
This report is data-driven work that examines the benefits of (for example) employment, stable socioeconomic environments and sustaining relationships on good mental health. Poverty is clearly a major factor in the pathway to poor mental health; with rates up to 5 times higher than other groups. In this setting, a child who lives in poverty may become the carer (by default) for a parent with mental illness; to the detriment of that child’s mental health, unless we intervene (give information on the parent’s mental disorder, supply one trusted adult relationship). Even if we remove the negative psychological effects of poverty on someone who in unemployed, having no meaningful work is itself a driver of mental disorder; with rates of depression/anxiety between 4 and 10 times higher.
Rising rates of childhood mental disorders mean we need to look at school too. Some adverse experiences happen at home (domestic violence, substance misuse by parents), but academic pressures and bullying are also causative of problems. Nor do these problems resolve by the time some of these children reach University. One report shows that well-being is low in the majority of students, with depression and/or loneliness experienced by 1 in 3 (HEPI, 2016). We know the challenges in adulthood caused by obesity and smoking are both driven by inequalities. The overlap with long term (physical) conditions is also well known, and interventions to prevent and mitigate these three will save money. However, the report documents very low public mental health spending with public health (1.6% of the total spend), and how 1 in 3 Wales local authorities spend nothing on public mental health.
It is not all bad, and the report authors welcome activities such as Time to Change (England and Wales) to reduce stigma and discrimination against people with mental health problems. Awareness of mental health is growing among the public, as it is in the workplace. In England, local suicide prevention strategies have shown successes, and the report authors welcome Scotland’s new Suicide Prevention Plan. These are important gains and show the value of resourced public heath approaches to (seemingly impossible) problems.
The BMA calls for a public mental health approach to:
- Reducing poverty; especially its effects on parents and their children
- Reducing unemployment and supporting the mental health of unemployed people
- Providing parenting programmes to targeted families
- Putting mental health at the centre of the schools’ curriculum; providing early help to distressed pupils at school
- Mental health support forums and anti-bullying campaigns: putting social media to use for the greater good
- Maintaining a life course approach: from infancy and childhood, through the workplace and including older adults
- Examining the effects of public health cuts on social determinants
- Promoting exercise in its own right, to reduce depression by a third
- Social prescribing seems the obvious tool for clinicians and frontline staff
- Acting on emerging evidence of the effects of air pollution on children’s cognitive abilities and mental disorders.
The Report is a useful starting point. Like us (the Royal College of Psychiatrists) the BMA look at the “causes of the causes”. Ongoing austerity will place an extra million UK children into poverty by 2022, and this will have enormous social, physical health and psychiatric consequences. CAMHS services are already rationing care through higher thresholds and waiting times. Anyone who cares about mental disorders wants to see a fair, transparent and supportive benefits system, and that prospect recedes from us each week. Changing how we organise, spend public money and deliver care is a tall order. Stopping further cuts to public health is the first step.
Strengths and limitations
My own journey in trying to understand why 1 in 5 UK children have self harmed before 18 led me to Wilkinson and Picket (2015). I propose we should echo Marmot to give every child “the best start in life” and (where this starts to go wrong), the best focus is Adverse Childhood Experiences (ACEs).
This report would have been enhanced by an ACE-led approach. Nor should we separate the psychological from the physical. Adverse Childhood Experiences shorten lives and create poor well-being, misery and mental illness. We need to look at variations across the four nations in mortality, physical morbidity, and common mental disorders to see what local/regional interventions are working, and where some areas have the most to do to catch up. For the Report, it gets full marks on aspiration but needs to make the arguments with graphs and informatics to engage a wider coalition of the willing to achieve prevention.
Implications for practice
And so, like the BMA, we turn to the things we can try to reduce: smoking, alcohol, substance misuse and obesity. But please no talk of “lifestyle choices” or “personal responsibility” as this excludes people already marginalised by inequalities. We will talk about “self management” and engage people with collaborative work-streams such as www.equallywell.co.uk.
At a local level, in England at least, knowing our local population (think poverty, black and minority ethnicity as the two major causes of inequality), we need to engage with Integrated Care Systems to get the resources to the people who need it the most. Better data should lead us to the right decisions, especially if we achieve strong local partnerships that include coproduction with local people. Our fragmented health systems, particularly how they are funded and where they are located, are part of the problem. A good start is re-investment in public health.
Nationally, and again for England, we need to get around the table to shape the Green Paper on Prevention and other initiatives. This ground has already been prepared in Scotland; they have six clear, succinct public health priorities:
- Healthy places and communities
- Early years
- Mental well-being
- Harmful substances
- Poverty and inequality
- Healthy weight and activity
Conflicts of interest
Peter Byrne is the Public Mental Health lead at the Royal College of Psychiatrists and a Trustee of the Mental Health Foundation.
NHS Digital (2016) Adult Psychiatric Morbidity Survey: Mental Health and Wellbeing, England, 2014.
Higher Education Policy Institute (2016) The invisible problem? Improving students’ mental health. Higher Education Policy Institute
M Marmot (2010) Fair society, healthy lives. Marmot review team.
Wilkinson R, Pickett K. (2010) The Spirit Level: Why Equality is Better for Everyone. Penguin books: 2010.
Scottish Government (2018) Public health priorities.