Mental Health and Wellbeing Strategy: Fairer Scotland Duty Impact Assessment

2 - Evidence

The link between poverty and poor mental health outcomes is well documented. Health outcomes, including mental health outcomes, are linked to a complex mix of social circumstances, ranging from individual experiences to fundamental causes which impact people across the globe. Public Health Scotland have carried out extensive work to understand what causes health inequalities and where action can be taken to decrease these^[1]. As poor health is linked to much wider influences like physical environment, access to learning, economic status, we developed the Strategy cross government, to cover:

• Fundamental causes
  • Global economic forces
  • Macro socio-political environment
  • Political priorities and decisions
  • Societal values to equity and fairness
• Wider environmental influences
  • Economic and work
  • Physical
  • Learning
  • Services
  • Social and cultural
• Individual experiences
  • Economic and work
  • Physical
  • Learning
  • Services
  • Social and interpersonal
• Inequalities in:
  • Wellbeing
  • Healthy life expectancy
  • Morbidity
  • Mortality

Poverty is the single biggest driver of poor mental health, and we know that people living in poverty carry a higher risk of suicide, as do those who are unemployed or socially isolated. Many people also face the additional barrier of digital exclusion, often felt more strongly in deprived areas, meaning it is harder to access advice, support and services.

We have produced a Mental Health Equality Evidence Report to accompany the Strategy. This report provides an overview of the current evidence relating to mental health inequality in Scotland. The report provides a summary of available evidence relating to each of the characteristics protected under the Equalities Act 2010, with the exclusion of marriage and civil partnership.

Recognising the clear link between poverty, deprivation and mental health outcomes, we made the decision to include of poverty and deprivation, geographical location and carers in the report in addition to the other protected characteristics. While reseraching and engaging on this equailties work, certain themes emerged consistently. Due to this, the report explores the following topics relating to each characteristic: existing inequalities and mental health disparities (including social determinants impacting mental health); inequity in accessing services and support; experiences of using mental health services and support; impacts of the COVID-19 pandemic; and data and evidence gaps. The report is based on a rapid review of evidence from population level survey data undertaken in Scotland and the wider UK, relevant academic and third sector literature and insights provided by organisations participating in the Mental Health Equalities and Human Rights Forum (MHEHRF).

Several cross-cutting themes were identified around mental health inequalities and social determinants of mental health, experiences of accessing and using services, and data and evidence, which relate to multiple different groups. While these impact different groups in a multitude of ways and are shaped by a variety of experiences and circumstances, they indicate key areas for future focus on equalities and mental health.

An extensive evidence narrative on mental health provides a review of currently available published data on what impacts positively and negatively on mental health and wellbeing across the population. The report looks at levels of population mental wellbeing, prevalence and burden of mental health conditions, trends within these and what influences mental health and wellbeing. It then reflects on some of the key challenges impacting upon population mental health and wellbeing that the strategy needs to tackle. It goes on to consider evidence-based approaches to addressing these challenges in both the immediate and longer term.

Key sources of quantitative data come from several population-level sources, including the Scottish Health Survey (SHeS) and Scottish Surveys Core Questions (SSCQ). Given the disruption to data collection during the COVID-19 pandemic, much of the evidence included from these surveys is taken from 2018 and 2019.

Additional quantitative and qualitative evidence targeting specific protected characteristic groups has been sourced from a range of relevant UK and Scotland-based government, third sector and academic publications through a process of rapid literature review. International academic evidence is used where relevant, primarily drawing on review-level evidence. Organisations participating in the Mental Health Equalities and Human Rights Forum (MHEHRF) contributed significantly to the evidence gathering via consultation throughout 2021, as well as highlighting evidence gaps and insights from the lived experiences of the people that they work with. This has been particularly valuable in providing insights across the period of the pandemic, in addition to the specific bodies of work which have taken place exploring the impact of the pandemic on mental health, wellbeing and influencing factors.

Estimates suggest that around one million people are living in poverty in Scotland. After housing costs, 21% of people in Scotland are living in relative poverty and 17% are living in absolute poverty. Evidence shows that people living in poverty are disproportionately affected by poor mental health^[2]. Living with mental health needs can increase the risk of poverty and living in poverty can have a negative impact on mental health outcomes.

The current cost of living has had an impact on the number of people experiencing various types of poverty, including fuel poverty and food poverty. There are indications that this has caused and exacerbate existing mental health needs by causing stress and anxiety^[3], particularly for people on low incomes. Based on a Royal College of Physicians survey in April/May of 2022, over half of the people surveyed in the UK said the crisis had a negative impact on their mental health^[4]. Furthermore, 16% said that they had been told by a doctor or health professional in the past year that stress caused by rising living costs had worsened their health^[4]. Data from ONS Opinions and Lifestyle Surveys in January 2023 in the UK indicated that around three-quarters (73%) of adults reported being very or somewhat worried about rising costs of living in the past two weeks^[5].

Estimates suggest that around one million people are living in poverty in Scotland. After housing costs, 21% of people in Scotland are living in relative poverty and 17% are living in absolute poverty^[6]. Evidence shows that people living in poverty are disproportionately affected by poor mental health. Living with mental health needs can increase the risk of poverty and living in poverty can have a negative impact on mental health outcomes. This cycle can worsen a persons mental health and personal circumstances.

In many cases, these same groups of people also often experience less access to effective and relevant support for their mental health. When they do get support, their experiences and outcomes can be poorer. These inequalities in mental healthcare can exacerbate mental health inequalities. The table below is taken from the Mental Health Equality Evidence Narrative and sets out specific data on the relationship between mental health and socioeconomic factors.

Evidence on the link between poverty, low income and material deprivation with mental health outcomes

Existing mental health inequalities

• Based on SHeS, there continues to be clear differences in WEMWBS wellbeing mean scores by areas of deprivation. There is a linear decrease from a mean of 51.5 among adults in the least deprived quintile to a significantly lower mean of 46.9 in the most deprived quintile^[7].
• Compared to adults living in the least deprived quintile, adults living in the most deprived quintiles are more likely to report two or more symptoms of depression (21% compared to 8%) and have higher rates of self-reported self-harm (13% compared to 5-7%)^[7].

Social determinants

• Social determinants which make people living in poverty more vulnerable to having mental health needs are: stress associated with living on low income and with debt, insecure and low quality employment^{[8], [9], [10]} increased likelihood of having experienced psychological trauma and adverse childhood experiences (ACEs)^[11], discrimination and stigma attached to being in poverty^{[12], [13]}, and low quality physical environments^[14]. People in receipt of housing benefits have been shown to be twice as likely to have a common mental health condition as those not in receipt^[15].

Substantial engagement was carried out in developing the Strategy and plans. This includes engaging with people with lived experience and the Mental Health Equalities and Human Rights Forum (MHEHRF). This was key to developing a Strategy which would try to deliver highly effective and well-functioning mental health system – with the right support available, in the right place, at the right time, whenever anyone asks for help. We made human rights explicit throughout the Strategy, Delivery Plan and Workforce Plan to demonstrate our intent to promote and help uphold rights across mental health services.