Sunday 10 October was World Mental Health Day. This year’s theme was ‘Mental Health in an Unequal World’, with the aim of emphasising the continuing gulf in investment in, and access to, mental health care between demographics and regions.
World Mental Health Day was first launched in 1992 by the World Federation for Mental Health, a global organisation working to promote mental health awareness, advocacy and care. The federation began to assign topical themes to each annual Mental Health Day in 1994, with previous themes including the impacts of trauma and violence, the relationship between mental and physical health, mental health issues in older adults, and mental health in the workplace.
Inequality and access in 2021
The COVID-19 pandemic has amplified and exacerbated existing inequalities of age, ethnicity, sex, income and disability.1 At the same time, the psychological stress incurred by the pandemic has led to a severe – and potentially long-term – rise in symptoms of mental ill-health globally,2 while the actual availability and accessibility of primary mental health care and treatment has decreased.3
People living in poverty are at heightened risk of mental illness, while simultaneously facing increased barriers to access to mental health care and support, particularly at the primary care level.4 The psychiatrists Vijaya Murali and Femi Oyebode note that: “Money is not a guarantor of mental health, nor does its absence necessarily lead to mental illness. However, it is generally conceded that poverty can be both a determinant and a consequence of poor mental health.”5
More than 80% of people with mental health disorders live in low- and middle-income countries (LMICs).6 Mental health services in these lower-income regions are commonly sparse, and where they are present, concentrated in urban hubs, making it effectively impossible for residents of rural areas to access effective care.7 In the majority of LMICs, the burden of caring for people who are mentally unwell falls primarily on women and children.4
Diagnosis and treatment
Social risk factors contribute to a higher risk of episodes of mental ill-health among marginalised demographics. Women, for example, are more likely than men to experience traumatic gender-based violence, which can be a key contributor to mental health issues.10 Similarly, institutional discrimination against ethnic minorities and immigrants has been highlighted as a contributor to heightened stress and trauma among these groups.11
Post-traumatic stress disorder (PTSD) affects around 5.1% of women and 3.7% of men in England.12 Women who have undergone mental health treatment in the UK report a significant lack of understanding of the need for trauma-informed care: patients reported being physically restrained by male staff, and care providers failing to ask the key questions needed to identify abuse.10
In areas where the availability of mental health support is limited, people suffering from mental distress face increased risk of incarceration, particularly if they are a member of an ethnic minority.4 In the UK, Black patients are more likely than White patients to be subject to compulsory admission to mental health treatment, are detained for longer periods of time and are disproportionately targeted for physical restraint.13 A 2019 review by the Care Quality Commission found that 48% of Black and minority ethnic people with experience of UK mental health services wanted to flag concerns about their treatment, in comparison with 13% of White service users.14
Stigma is still attached to mental illness, even within the healthcare sector, and patients experiencing mental distress have reported feeling “devalued, dismissed and dehumanised” by the medical professionals delivering their care.15 Discrimination against patients on the basis of mental illness, by the very practitioners whose job it is to treat them, acts as a further barrier to care, potentially delaying diagnoses and discouraging patients from seeking help in the future.16
Addressing inequality in care
Access to, and use of, adequate mental health treatment are rarely prioritised in the development and allocation of healthcare resources.4 The World Health Organization recommends integrating mental health care into primary care systems, in order to both minimise stigma and facilitate access to treatment.17 The collaborative care model, which brings patients together with primary care providers and mental health specialists under the oversight of case managers,18 is widely recommended as an integrative strategy.19
- Blundell R, Costa Dias M, Joyce R, Xu X. COVID-19 and inequalities. Available at: https://bit.ly/3AaB1zd [Accessed October 2021].
- Abbott A. COVID’s mental-health toll: how scientists are tracking a surge in depression. Nature 2021;590(7845):194–195. https://go.nature.com/3FhhQHt
- Williams R, Jenkins DA, Ashcroft DM, et al. Diagnosis of physical and mental health conditions in primary care during the COVID-19 pandemic: a retrospective cohort study. Lancet Public Health 2020;5:e543–e550. https://doi.org/10.1016/S2468-2667(20)30201-2
- Ngui EM, Khasakhala L, Ndetei D, Roberts LW. Mental disorders, health inequalities and ethics: a global perspective. Int Rev Psychiatry 2010;22(3):235–244. https://doi.org/10.3109/09540261.2010.485273
- Murali V, Oyebode F. Poverty, social inequality and mental health. Adv Psychiatr Treat 2004;10(3):216–224. https://doi.org/10.1192/apt.10.3.216
- Jacob KS, Sharan P, Mirza I, et al. Mental health systems in countries: where are we now? Lancet. 2007;370(9592):1061–1077. https://doi.org/10.1016/S0140-6736(07)61241-0
- Rathod S, Pinninti N, Irfan M, et al. Mental health service provision in low- and middle-income countries. Health Serv Insights 2017;10:1178632917694350. https://doi.org/10.1177/1178632917694350
- Mental Health Foundation. Black, Asian and minority ethnic (BAME) communities. Available at: https://bit.ly/2ZZmLgj [Accessed October 2021].
- Sambrook Smith M, Lawrence V, Sadler E, Easter A. Barriers to accessing mental health services for women with perinatal mental illness: systematic review and meta-synthesis of qualitative studies in the UK. BMJ Open 2019;9(1):e024803. http://doi.org/10.1136/bmjopen-2018-024803
- The Women’s Mental Health Taskforce. Final report. Available at: https://bit.ly/3a8STzS [Accessed October 2021].
- Williams DR. Stress and the mental health of populations of color: advancing our understanding of race-related stressors. J Health Soc Behav 2018;59(4):466–485. https://doi.org/10.1177/0022146518814251
- Post-traumatic stress disorder: how common is it? Available at: https://bit.ly/3At7Uaw [Accessed October 2021].
- Bignall T, Jeraj S, Helsby E, Butt J. Racial disparities in mental health: literature and evidence review. Available at: https://bit.ly/3Bi5IUo [Accessed October 2021].
- Care Quality Commission. Declare your care: people from black and ethnic minority communities. Available at: https://bit.ly/3mrXfYp [Accessed October 2021].
- Knaak S, Mantler E, Szeto A. Mental illness-related stigma in healthcare: barriers to access and care and evidence-based solutions. Healthc Manage Forum 2017;30(2):111–116. https://doi.org/10.1177/0840470416679413
- Nyblade L, Stockton MA, Giger K, et al. Stigma in health facilities: why it matters and how we can change it. BMC Med 2019;17(1):25. https://doi.org/10.1186/s12916-019-1256-2
- WHO Europe. Mental health in primary care. Available at: https://bit.ly/3A7RhRj [Accessed October 2021].
- Thota A, Sipe TA, Byard GJ, et al. Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis. Am J Prev Med 2012;42(5):525–538. https://doi.org/10.1016/j.amepre.2012.01.019
- Patel V, Belkin GS, Chockalingam A, Cooper J, Saxena S, Unützer J. Grand challenges: integrating mental health services into priority health care platforms. PLoS Med 2013;10(5):e1001448. https://doi.org/10.1371/journal.pmed.1001448