MENTAL HEALTH AND INEQUALITY

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MENTAL HEALTH AND INEQUALITY

• THE TRIALECTIC OF ENVIRONMENT, SERVICES AND
  PROFESSIONAL KNOWLEDGE
• Anne Rogers

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Long standing evidence of inequalities

• Social class and mental health Study of
  admissions - Higher rates of illness in those
  groups from poor areas (Faris and Dunham 1939)
• The role of social isolation (social exclusion)
  -Dunham (1957)
• Labour market optimal mental health correlated
  with secure well-paid work with workers having
  control over tasks

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Mental health inequalities a dynamic field..

• Mental health is relatively ignored in health
  inequality research (Rogers and Pilgrim, 2004).
• Differences in morbidity (the poor recurrently
  dying younger), occupational disease, class
  differences in cancer, lung and heart disease,
  ethnic differences in diabetes
• Mediating processes leading to focus more on
  mental health depression and premature death
  from heart disease

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Relationship one of mental health increasing
inequality a vicious circle

• The consequences of depression
• Effects on family and relationships
• Physical impact (heart disease)
• Loss of income/poverty issues - 11 days lost in 6
  months cf. to 2-3 days for people without
  depression
• 109 million working days are lost each year in
  the UK through depression and anxiety (Thomas
  Morris, 2003)

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3 Basic Questions

• 1 How do socio-economic inequalities affect
  mental health status?
• 2 What is the range/type of knowledge we should
  use about mental health problems to understand
  inequalities?
• 3 In what way are services and service contact
  implicated in generating and sustaining
  inequalities?

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The trialectic of services, knowledge and
external influences
Social and environmental influences on mental
health
Knowledge
Mental Health services
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Background to a different approach based on

• Epidemiology is important but limited
• Psychiatric knowledge maybe problematic as well
  as useful in health inequalities
• The relationship with services is underplayed
• Recursive relationship between external drivers
  of inequality and service delivery

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Epidemiology is important Emergence of trends
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When things get better or worse
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Relationship between key variables important and
some are stronger than others

• Socio-economic position strong consistent
  relationship
• Childhood socio-economic position impacts on
  depression in mid-life (Stansfield et al, 2008
  British Journal of Psychiatry).

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Other Central Concepts Introduced

• Gender
• Age
• Social Class
• Place

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Increasingly Complex Epidemiology
Meltzer
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Knowledge about inequalities

• Epidemiologists collect evidence about
  inequalities mapping illness and health in
  large populations- objective variables
  (employment housing, living arrangements,
  diagnosis).

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But is there still a problem with psychiatric
knowledge?

• Contested conceptually (aetiological specificity,
  predictive validity)
• Are they sufficiently focussed on issues of
  social influence?
• Influences of culture
• Ignores service and other types of knowledge

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The bio-psychosocial model

• A conceptual model that assumes that
  psychological and social factors must also be
  included along with the biological in
  understanding a person's medical illness or
  disorder.
• (05 Mar 2000)

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The Biopredominates?

• The framework does not look at issues such as
  poverty, stigma and discrimination due to age,
  ethnicity and gender, in preference of
  individualised psychosocial experiences which may
  be the result of these issues. these specific
  factors are usually perceived as part of the
  experience of poverty (but) the concept of
  poverty is not focused upon in the writings of
  epidemiologists in mental health. (Ramon 2007)

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Stigma a social concept

• Labeled persons are set apart in a distinct
  category that separates us from them. The
  culmination of the stigma process occurs when
  designated differences lead to various forms of
  disapproval, rejection, exclusion and
  discrimination (Bruce Link 2000)

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Appropriating Social Knowledge from a medical
bases -Stigma?

• Stigma, is a social not clinical phenomenon and
  yet the campaign re-framed it to claim medical
  expertise. It deliberately yoked stigma to
  specific medical categories and understated
  relevant sociological knowledge ..College authors
  started with diagnoses and than mapped stigmas
  (plural) onto them, rather than examining stigma
  generically and the role psychiatric labelling
  may play in its reduction or aggravation.
  Psychiatrists as social engineers A study of an
  anti-stigma campaign, 61, 12, December 2005,
  2546-2556

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Other type of knowledge from a different source
Lay Knowledge

• A different perspective and set of variables
  about cause
• patients have extensive knowledge of their own
  lives and the conditions in which they live.
• they can turn themselves into experts in order
  to challenge medical hegemony.

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Lay vs Professional knowledge

• GPs encourage patients to view depression as
  separate from the self and normal sadness.
• Patients question these boundaries rejecting
  the notion of a medical cure and emphasise
  self-management.
• Depression-management strategies wanted to get
  out of their depression -focused on getting by
  from day to day,
• Clash with GP priorities and patient goals,
• Stress the value of listening to elicit . More
  options
• Johnson O, Kumar S, Kendall K, Peveler R, Gabbay
  J, Kendrick T, (2007) British Journal of General
  Practice. 57, 544, 872-879.

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Knowledge and Sexuality Problematised

• C19th biological determinism fatalism as
  treatment
• Psychoanalytical behaviour therapeutic measures
  psychiatrists interfered and aspired to cure
• Deviation from gender roles assumed to be abnormal

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Does service contact affect the risk of
inequality?

• A role in causing inequalities rather than
  separated out from them?
• Risk of stigma and social exclusion
• Distinguishing professional from social stigma
• Iatrogenic effects

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The paradox of the inverse care law?

• Access increases with increasing class status
  (Tudor Hart)
• Those with the least need of health care services
  use services more
• The same logic applied to mental health?

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Services Gradient of Coercion

• The Inverse Care Law
• Applicable to mental health dubious proposition
• Access does not always meet need in the same way
  as physical illness
• Gradient of coercion voluntary sector through
  to special hospitals

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Access and Services

• Prestige bear consequences for actual priority
  setting in healthcare systems
• Mental health has low prestige in general
  settings
• It was demonstrated that active, specialized,
  biomedical, and high-technological types of
  medicine practised on organs in the upper part of
  the bodies of young or middle-aged people were
  accorded high levels of prestige Norredam M,
  Album D. (2007) Scandinavian Journal of Public
  Health 35, 6, 655-661
• Primary care point of equity

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Conclusions

• Bodies of knowledge exist about
• the causal role of social inequalities in
  predicting mental health status
• the impact of service contact
• the role of clinical knowledge
• We still need to develop a transdisciplinary
  approach to the relationship between these bodies
  of knowledge.