# data[].attributes.attachment_link.description
IMPORTANT NOTICE: Updates to the ScotPHO website are currently paused while we undertake a review of the content, structure and hosting of the website. See our Website Notice for further details. Updates to the ScotPHO online profiles tool will continue as normal.

# data[].attributes.attachment_link.readable_text
Ailsa's husband, Richard, was diagnosed with Alzheimer's disease in 2019, aged 62. Life goes on for them, and they continue to make lasting memories together. This Autumn, they will embark on a European rail adventure to coincide with the Rugby World Cup

# data[].attributes.attachment_link.description
We are Alzheimer Scotland. We believe nobody should face dementia alone.

# data[].attributes.attachment_link.description
We bring people, services and organisations across sectors together to create a mental health system powered by lived experience. Together we can make Scotland a place where people expect mental health recovery and are supported at all stages of their recovery journey.

# data[].attributes.attachment_link.readable_text
Problems and stressors facing migrants and refugees

Migrants and refugees often face various problems and stressors which can take place at various stages of the migration process:

Pre-migration: lack of livelihoods and opportunities for education and development, exposure to armed conflict, violence, poverty and/or persecution.

Migration travel and transit: exposure to challenging and life-threatening conditions including violence and detention and lack of access to services to cover their basic needs.

Post-migration: barriers to accessing health care and other services to meet their basic needs as well as poor living conditions, separation from family members and support networks, possible uncertainty regarding work permits and legal status (asylum application), and in some cases immigration detention.

Integration and settlement: poor living or working conditions, unemployment, assimilation difficulties, challenges to cultural, religious, and gender identities, challenges with obtaining entitlements, changing policies in host countries, racism and exclusion, tension between host population and migrants and refugees, social isolation and possible deportation.

Risk and protective factors for mental health conditions

All of the above-mentioned stressors can increase the risk of developing mental health conditions.For example, unemployment, poor socioeconomic conditions, and lack of social integration among migrants and refugees are risk factors for mental health conditions such as depression. At the same time, these stressors can also exacerbate pre-existing social and mental health problems.

Factors that negatively impact the mental health and well-being of migrant and refugee children include socioeconomic deprivation, discrimination, racism, low family cohesion, and frequent school changes. Children who have been separated from migrating parents are at heightened risk of developing depression, anxiety, suicidal ideation, conduct disorder, and substance use problems.

On the other hand, the impact of stressors can be buffered by protective factors such as access to employment and services, social support, proficiency in the language of the host country, and family reunification. Among resettled refugee children, protective factors include better socioeconomic status, access to education, a perceived sense of safety, contacts with family, living and socialising alongside other people of the same ethnic origin, a stable and cohesive family structure and good parental mental health.

Prevalence of mental health conditions

Many migrants and refugees will experience distress (e.g. feelings of anxiety and sadness, hopelessness, difficulty sleeping, fatigue, irritability, anger and/or aches and pains).For most people, these reactions will improve over time.

Some studies show that the prevalence of common mental disorders (e.g. depression, anxiety and post-traumatic stress disorder (PTSD)) is higher among migrants and refugees than among host populations. Asylum seekers tend to be at elevated risk of suicide. There is also consistent evidence that the incidence of psychoses is higher among migrant populations in a number of countries, and this has been linked with the cumulative effect of social disadvantages before, during and after migration.

Responding to the mental health needs of migrants and refugees

A comprehensive, multi-disciplinary and inclusive approach is needed to address the mental health needs of migrants and refugees.
Overcoming barriers to receiving mental health care
Addressing barriers to receiving mental health care should include:

provision of clear information on mental health care entitlements and how to receive services (e.g. through reception centers, community outreach, schools, religious or cultural settings);

outreach to at-risk groups (e.g. unaccompanied minors, persons with disabilities, persons who identify as LGBTIQ+);

facilitation of affordable and non-discriminatory access to care regardless of legal status, ensuring financial coverage of mental health services and care provided;

facilitation of communication (e.g. through engaging interpreters and cultural mediators);

providing person-centred care that is respectful of cultural differences; and

facilitating the engagement of multiple sectors and systems (e.g. law enforcement, protection, social services and education) to integrate mental health considerations and support and ensure referral and access to mental health services.

Integrating mental health in primary health care
Making mental health care available through general health care can help identify migrants and refugees with mental health conditions and can make care more accessible and cost effective (e.g. see WHO mhGAP intervention guides mhGAP-HIG and mhGAP-IG). The delivery of interventions may require adaptation to migrant and refugee populations to take into account language and cultural considerations. Interventions provided should be consistent with the national guidelines and policies on mental health of the host country.
Ensuring continuity of care
When providing mental health care, an important consideration is related to the length of stay of the migrant or refugee in the host country. The continuity and quality of mental health care of migrants and refugees on the move can be improved by creating international protocols for assuring continuity of care, improving communication among different social and mental health service providers and providing key written information tailored to their needs that migrants and refugees can take with them and share with different providers.
Addressing social determinants and promoting social integration and inclusion
Migration management policies and provision that have proved to have a negative effect on the mental well-being of migrants (e.g. separation of families and children) should be avoided. The social integration of migrants and refugees can be facilitated by equal access to employment opportunities and decent work, vocational training, financial support, social protection services, and legal and law enforcement agencies, as well as mental health care and psychosocial support. The recognition of skills and qualifications acquired pre-migration can also help their integration into the employment sector. Activities and events that promote the social inclusion of migrants and refugees include community forums or peer-mentorship programmes organized by members of the same refugee or migrant group who are already well-integrated into the local community. Special attention is required to support asylum seekers.

WHO response

WHO is the lead International agency in providing technical advice on mental health.

WHO developed a Global Action Plan (2019-2023) to promote the health of migrants and refugees, approved by the World Health Assembly in May 2019. The Global Action Plan describes overarching priorities and guiding principles to promote the health of migrants and refugees and to contribute to achieving the aim of the 2030 Agenda for Sustainable Development - to leave no one behind. The Global Action Plan highlights how the many barriers that migrants and refugees experience in accessing health-care services can precipitate negative mental health outcomes.

The plan recommends priorities and options for action by the Secretariat in coordination and collaboration with the International Organization for Migration (IOM), the United Nations High Commissioner for Refugees (UNHCR) and other relevant partners.

In May 2021, the World Health Assembly endorsed an update of the Comprehensive Mental Health Action Plan (2013-2030), with the overall goal to promote mental well-being, prevent mental disorders, provide care, enhance recovery, promote human rights and reduce the mortality, morbidity and disability of persons with mental disorders.

WHO is committed to supporting Member States in promoting the physical and mental health of migrants and refugees by strengthening health care services, as appropriate and acceptable to country contexts and financial situations, and in line with their national priorities and legal frameworks and competence. WHO is also committed to ensuring that essential components are addressed, including the provision of treatment and care for mental and behavioural disorders.

In line with the Global Action Plan, WHO is operational on mental health in a range of countries and territories that host large numbers of migrants and refugees. These include Bangladesh, Colombia, Pakistan, Iraq, Jordan, Lebanon, Libya, Pakistan, South Sudan, Sudan, Turkey and Uganda.

WHO has close working relationship with other UN partners, including IOM and UNHCR to meet the mental health needs of migrants and refugees.

WHO co-chairs the Inter-Agency Standing Committee Reference Group on Mental Health and Psychosocial Support in Emergency Settings that provides advice and support to organizations working in emergencies and helps ensure that the mental health response is coordinated and effective. Emergency situations often cause displacement and may lead to people becoming refugees or internally displaced.

WHO's advice and tools are used by most large international humanitarian organizations active in mental health. WHO and partners have published a range of practical tools and guidelines to meet the mental health needs of people affected by emergencies, including migrants and refugees.

(1) World Migration Report 2020. International Organization for Migration, Geneva.

# data[].attributes.attachment_link.description
Migrants and refugees often face various problems and stressors which can take place at various stages of the migration process: Pre-migration: lack of livelihoods and opportunities for education and development, exposure to armed conflict, violence, poverty and/or persecution.

# data[].attributes.attachment_link.readable_text
At the end of 2015, there were 123,000 asylum seekers and refugees in the UK. ¹ Asylum seekers and refugees face unique and complex challenges related to their mental health and they are often at greater risk of developing a mental health problem.

Asylum seekers and refugees are more likely to experience poor mental health than the local population,² including higher rates of depression, PTSD and other anxiety disorders.3,4

The increased vulnerability to mental health problems that refugees and asylum seekers face is linked to pre-migration experiences (such as war trauma) and post-migration conditions (such as separation from family, difficulties with asylum procedures and poor housing).5,6

Research suggests that asylum seekers are five times more likely to have mental health needs than the general population and more than 61% will experience serious mental distress.⁷ However, data shows that they are less likely to receive support than the general population.⁸

Browse all the mental health statistics Download a PDF of all the stats
References

1. UNHCR. (2015). World at war Global Trends Report: Forced displacement in 2015. Geneva: UNHCR

2. Tribe, R. (2002). Mental health of refugees and asylumseekers. Advances in Psychiatric Treatment, 8, 240-247.

3. Fazel, M., Wheeler, J., & Danesh, J. (2005). Prevalence of serious mental disorder in 7,000 refugees resettled in Western countries: A systematic review. The Lancet, 365, 1309-1314.

4. Tempany, M. (2009). What research tells us about the mental health and psychosocial wellbeing of Sudanese refugees: A literature review. Transcultural Psychiatry, 46, 300-315.

5. Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R., & van Ommeren, M. (2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: A systematic review and meta-analysis. JAMA, 302, 537-549.

6. Porter, M., & Haslam, N. (2005). Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: A meta-analysis. JAMA, 294, 602-612.

7. Eaton, V., Ward, C., Womack, J., & Taylor, A. (2011). Mental Health and Wellbeing in Leeds: An Assessment of Need in the Adult Population. NHS Leeds.

8. Aspinall, P., & Watters, C. (2010). Refugees and asylum seekers: A review from an equality and human rights perspective. Equality and Human Rights Commission Research report 52, University of Kent.

# data[].attributes.attachment_link.title
Mental health statistics: refugees and asylum seekers

# data[].attributes.attachment_link.description
At the end of 2015, there were 123,000 asylum seekers and refugees in the UK. 1 Asylum seekers and refugees face unique and complex challenges related to their mental health and they are often at greater risk of developing a mental health problem.

# data[].attributes.attachment_link.readable_text
1. Introduction

The purpose of the mental health and wellbeing JSNA toolkit is to support people developing the mental health and wellbeing content of their local joint strategic needs assessment. This chapter helps consider factors related to the promotion of mental wellbeing and the prevention of mental health problems. It provides easy access to nationally available topic focused information, guidance and knowledge. The chapter text aims to be plain English and ready to be cut and pasted. The numerous links to external sites should all be current, relevant, and provide access to material that contributes to the JSNA process.

One aim of a JSNA is to understand the determinants of health in an area and consider social and contextual factors that affect mental health, such as employment, crime, safety and housing. The mental health of each individual is influenced by their social setting, such as having the ability to earn enough money and feeling part of a community. This chapter considers these determinants which lead to unfair and avoidable differences in health within and between populations.

Understanding these social factors in a local area can help to quantify levels of risk, protection and resilience within a community. It can help to identify vulnerable groups and consider what interventions could help to reduce vulnerability and develop resilient communities. Greater community resilience has the potential to:

reduce the prevalence of mental health problems

increase the prevalence of good mental health

improve recovery and support for individuals who have become unwell

Understanding these 'place' effects on health, and particularly the effect of measures of deprivation, may have been considered elsewhere within the wider JSNA process. This should be drawn upon and used to consider which factors are important to mental health.

Interventions which affect the social determinants of mental health require joint working and collaboration across a range of partners, for example the education sector working with health and wellbeing boards.

Type of questions a JSNA could address include

what local social, economic and other factors encourage good mental health?

what local social, economic and other factors damage mental health?

how are these changing over time?

how do they affect different groups of people or cause inequalities?

what are the community's main assets and how strong are social networks?

what do local people feel about the area and what are they concerned about?

how do these wider factors affect the need for mental health services?

how can these wider influences on health be tackled by prevention initiatives?

2. Deprivation and inequality

It is well established that deprivation (a lack of money, resources and access to life opportunities) or being in a position of relative disadvantage (having significantly less resource than others) is associated with poorer health, including mental health.

2.1 Overview

Mental health is closely related to many forms of inequality, with a particularly pronounced gradient for severe mental illness. The prevalence of psychotic disorders among the lowest fifth of household income is 9 times higher than in the highest and double the level of common mental health problems between the same groups.

Deprivation is about more than lack of money. It can include lack of access to resources such as adequate housing and exposure to negative stressors such as violence, crime or lack of public green space. A growing body of evidence suggests the relationship between deprivation and mental health is not just about absolute lack of resource for individuals. Populations with large differences in wealth and resource between individuals are associated with higher levels of poor health and mental health problems for the population as a whole.

2.2 Data sources

Metrics in the profiling tool relating to deprivation and inequality are:

children in income deprivation (county and UA)

income deprivation affecting children index (UK) (ward)

deprivation score: IMD 2015 (county and UA, district and UA, CCG, GP, ward)

Other important data sources include:

Local data

Local analyses will be able to draw upon additional local data about deprivation and inequalities to further profile risk and map inequalities. For example, use of different services (primary care, accident and emergency ( A&E) and mental health services) by local deprivation measures.

2.3 Evidence and further information

The topic specific sections which follow will include additional relevant information on:

poverty and financial security

housing and homelessness

education and lifelong learning

employment and working conditions

crime and justice

community wellbeing

social capital

The following documents and supporting materials are useful sources of further information on this topic:

Health Matters: reducing health inequalities in mental illness is a publication by Public Health England describing the drivers of inequalities associated with mental health particularly in understanding the social inequalities and disadvantages in severe mental health illness.

LGA: Being mindful of mental health: The role of local government in mental health and wellbeing sets out the important role councils play in supporting the mental wellbeing of their communities, including the Local Government Association's ( LGA) vision of what a 'mentally healthy' place looks like.

The Royal Town Planning Institute's Poverty, place and inequality sets out a place-based approach to addressing poverty and inequality by understanding how local environments shape people's behavior and enhance wellbeing.

Marmot review report - Fair society, health lives 2010 proposes an evidence-based strategy to address the social determinants of health which can lead to health inequalities.

3. Poverty and financial insecurity

Low income and debt are risk factors for mental illness. Personal and family financial security is a protective factor. Improved understanding of financial circumstances can help identify and target vulnerable groups and support the recovery of people with mental health problems.

3.1 Overview

Poverty can be both a causal factor and a consequence of mental ill health. Across the UK, both men and women in the poorest fifth of the population are twice as likely to be at risk of developing mental health problems as those on an average income. The cumulative effects of poverty are present throughout the life course, starting before birth and continuing into older age.

Unmanageable financial debt is associated with poorer mental health,. A quarter of people experiencing common mental health conditions also have financial problems, 3 times more than the general population. Half of adults with a debt problem also have a common mental health condition. A survey of 5,500 people with mental health problems found that 86% of respondents said their financial situation had made their mental health problems worse.

Mind has a dedicated section on its website outlining the relationship between money and mental health problems. Mental health problems can effect an individual's motivation and ability to attend work or rehabilitation programmes which can affect income and recovery.

Additionally, a number of mental health conditions can lead to periods of impulsivity in spending, and anxiety is often exacerbated by money concerns. When people do not have enough money they may struggle to afford 'essentials' such as heating, housing, food and medication. Social activity is often an area where people look to save money, which can lead to increased social isolation and have a negative effect on people's relationships and mental health.

Since 2008, the UK has experienced the effects of a prolonged economic downturn. Policy decisions in response to the economic downturn have resulted in reductions in some public spending, and there is concern that this could negatively affect the mental health of the population[footnote 10].

3.2 Data sources

Metrics in the profiling tool relating to poverty and financial security include:

fuel poverty (county and UA, district and UA)

housing affordability (county and UA)

Other important data sources include:

3.3 Local data

Local analyses may be able to draw upon additional data about financial circumstances and associated supportive interventions. Local Citizens Advice Bureaus, Credit Unions, food banks and relevant local charities may hold data.

3.4 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic:

Citizens Advice: A debt effect? How is unmanageable debt related to other problems in people's lives? investigates the relationship between high levels of debt and a range of wider issues including unemployment, low pay, physical health problems and poor mental health.

Joseph Rowntree Foundation's We can solve poverty in the UK sets out recommendations on actions to solve poverty.

The Mental Health Foundation's Poverty and mental health review examines the relationship between poverty and mental health.

Money and mental health policy institute's ' The missing link - how tackling financial difficulty can boost recovery rates in IAPT' puts forward the case that the adult improving access to psychological therapies ( IAPT) programme should seek to recognise, and develop ways to mitigate, the effects of financial difficulty.

PHE's Commissioning cost-effective services for promotion of mental health and wellbeing and prevention of mental ill health includes a section on the effectiveness of providing debt advice to encourage mental health.

4. Housing and homelessness

Housing is critical to the prevention of mental health problems and the promotion of recovery[footnote 11]. Homelessness and poor quality housing are risk factors for mental health problems. Stable, good quality housing is a protective factor for mental health and can be a vital element of recovery.

Overview

Insecure, poor quality and overcrowded housing causes stress, anxiety, and depression, and exacerbates existing mental health conditions[footnote 12] . 19% of adults living in poor quality housing in England have poor mental health outcomes[footnote 13]. For example, adolescents living in cold housing are at a significantly greater risk of developing multiple mental health conditions[footnote 14]. A cold home also contributes to social isolation which may be a particular issue for older people[footnote 15].

Everybody who experiences homelessness will feel stress and anxiety, and many report depression[footnote 13]. Mental health problems among people experiencing homelessness are more prevalent than in the general population, particularly among people caught in the 'revolving door', between hostels, prison, hospitals and the streets[footnote 16]. Compared with the general population, homeless people are twice as likely to have a common mental health condition, and psychosis is up to 15 times more prevalent[footnote 11]. They are also over 9 times more likely to complete suicide[footnote 17] . People experiencing homelessness find it difficult to access health services, including mental health care[footnote 18] ,[footnote 19] .

4.1 Data sources

Metrics in the profiling tool relating to housing and homelessness include:

statutory homelessness (county and UA, district and UA, region)

fuel poverty (county and UA, district and UA)

housing affordability ratio (county and UA)

landlord home repossessions (district and UA)

stable and appropriate accommodation for adults in contact with mental health services (County and UA)

Other important data sources include:

4.2 Local data

Local analyses may be able to draw additional data about housing policy likely to have a beneficial effect on population mental wellbeing. This may include metrics on topics such as: numbers of supported accommodation places available, rental stability and security, affordable housing units planned/built in last year(s) and numbers of people with mental illness in receipt of direct payments or services to support them remaining in their own home. There may also be locally conducted surveys to assess housing needs and data from third sector organisations working with people who are homeless.

4.3 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic.

Centre for Mental Health's More than shelter presents a series of important themes for consideration in the future development of supported accommodation for adults with severe mental health problems, including those with multiple needs and substance misuse and those facing homelessness.

Homeless link website provides resources including audit tool for needs assessment and a prevention opportunities mapping and planning toolkit ( PrOMPT) which supports gathering information that can be used to redesign services and improve prevention.

The Mental Health Foundation's Mental health and housing report on types of supported accommodation that successfully meet the needs of people with mental health problems - to recommend effective housing solutions.

PHE's Homelessness: applying all our health provides an overview of the issues that are associated with homelessness and highlights interventions that can be implemented at population, community, family and individual levels.

PHE's Homes for health provides resources on housing conditions, suitability and homelessness, and building healthy communities to help local authorities, health and social care commissioners and decision makers make plans to improve health and wellbeing through the places people live.

PHE's Spatial planning for health: an evidence resource for planning and designing healthier places Community based provides public health planners and local communities with evidence informed principles for designing healthy places.

5. Education and lifelong learning

Education is an important determinant of later health and wellbeing. It improves peoples' life chances, increases their ability to access health services and enables people to live healthier lives.

Overview

Education develops skills that help people to function and make decisions in life. It increases peoples' ability to get a job and avoid living in poverty. It helps people to understand how social and health systems work allowing them to improve their health and wellbeing[footnote 20].

Pupils with emotional and conduct disorders are more likely to fall behind in their learning[footnote 23]. Those not in education, employment or training ( NEET) after the age of 16 are at increased risk of depression and suicide and the damaging effect of unemployment at this stage of life lasts into later life[footnote 24]. Successful interventions exist which reduce the proportion young people who are NEET. These are more likely to be effective if the intervention is early and if they tackle the barriers faced by children and young people in accessing education and training. They must also work across organisational and geographic boundaries[footnote 24].

For adults, lifelong learning opportunities can increase the ability of those with low educational attainment to exert control of their lives[footnote 25]. Participation in adult learning can help encourage wellbeing and protect against age-related cognitive decline in older adults[footnote 26]. Community-based adult education programmes can be a form of social prescribing for mild to moderate anxiety and depression and have been found to reduce symptoms by offering access to social networks and activities[footnote 27].

5.1 Data sources

Metrics in the profiling tool relating to education and lifelong learning include:

school readiness (county and UA)

average attainment 8 scores (county and UA)

GCSEs achieved 5 grades A* to C (ward)

16 to 18 year olds not in education, employment or training (county and UA, region)

Other important data sources include:

5.2 Local data

Additional local data from education providers and local authorities will be available and should be used to gain insights on provision, access and needs in the local area. This could include data on availability of and access to life-long learning.

5.3 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic.

Department for Education's Mental health and behaviour in schools: departmental advice for school staff gives strategies to encourage resilience and support pupils at risk of developing mental health problems in schools.

Mental Health Foundation's Learning for life: adult learning, mental health and wellbeing outlines evidence for adult learning interventions for anxiety and depression.

Social and emotional wellbeing in primary and secondary education are NICE guidelines to promoting social and wellbeing in children in the educational setting.

PHE's Commissioning cost-effective services for promotion of mental health and wellbeing and prevention of mental ill health includes sections on the effectiveness of school-based social and emotional wellbeing programmes and programmes to address bullying of young people.

PHE and the Institute for Health Equity's Reducing the number of young people not in employment, education or training (NEET) outlines interventions to reduce the number of young people NEET and evidence for the cost-effectiveness of interventions.

PHE's Supporting mental health in schools and colleges provides a survey and case studies with schools on activities to support pupils' mental health and wellbeing.

6. Employment and working conditions

Stable and rewarding employment is a protective factor for mental health and can be a vital element of recovery from mental health problems. Unemployment and unstable employment are risk factors for mental health problems.

6.1 Overview

There are strong links between employment and mental health. The workplace provides an opportunity to encourage well-being and support people to 'build resilience, develop social networks and develop their own social capital'[footnote 30]. People who are unemployed are between 4 and 10 times more likely to report anxiety and depression and to complete suicide[footnote 31].

Challenges remain for people with mental health problems in gaining and maintaining employment, sometimes because of negative attitudes and stigma, and concerns from employers who know little about mental health. Between 30% and 50% of people with schizophrenia are thought to be capable of work given appropriate support and opportunity, yet only 9% of people with a probable psychotic disorder are working full-time and 19% part-time[footnote 35]. There is an emphasis on the doubling of access to individual placement and support ( IPS) interventions aimed at enabling people with severe mental illness to find and retain employment[footnote 36].

Mental health problems also have a significant effect on employers. Nearly one sixth of the workforce is affected by a mental health condition[footnote 37] and mental health related absences cost UK employers an estimated £26 billion per year[footnote 38] . Employers have a responsibility to provide a healthy workplace[footnote 39]. This can be achieved through providing a culture of participation, equality and fairness and developing the role of line managers[footnote 40],[footnote 41].

6.2 Data sources

Examples of metrics in the profiling tool relating to employment and working conditions include:

employment deprivation (county and UA, district and UA)

allowance and benefits (county and UA, district and UA)

employment of people with a mental illness or learning disability (county and UA)

gap in employment rate for those in contact with secondary mental health services and the overall employment rate (county and UA)

Other important data sources include:

NOMISWEB labour market statistics provided by the Office for National Statistics includes data on benefit claimants, including those recorded as being on benefits due to mental and behavioural disorders.

benefits statistics are also available on Stat-Explore

Public Health England provides assessment of the ROI of interventions to encourage health and wellbeing in the workplace and workplace interventions to prevent stress, depression and anxiety problems

Understanding local needs for wellbeing data from the What Works Centre for Wellbeing provides recommended relevant indicators

6.3 Local data

Additional local data may be available from local authorities, from relevant local agencies and from analysis of ad-hoc surveys which include questions about employment status and mental health state. There may also be local knowledge about changes in large employers and how these relate to employment at a sub-local authority level and data from programmes that support people into employment.

6.4 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic:

Business in the Community and PHE's Mental health toolkit for employers aimst to help organisations support mental health and wellbeing of employees.

The Centre for Mental Health's Individual placement and support (IPS) outlines the IPS approach, including links to the relevant evidence base and examples of successful implementation.

Department for Work and Pensions' Work, health and disability green paper is a government consultation paper highlighting the important relationship between work and health. Includes proposed improvement strategies.

The Cochrane review's Flexible working conditions and their effects on employee health and wellbeing evaluates the effects of flexible working interventions on the physical, mental and general health and wellbeing of employees and their families.

Mind's mental health at work web resources provide training information and webinars for individuals and employers. Includes resources about supporting staff who are experiencing a mental health problem.

Mental wellbeing at work and workplace health are NICE guidance publications developed to encourage mental wellbeing at work. Recommendations vary according to organisation type and size and links to relevant related guidance are made within the pathway. A comprehensive resource page is also available along with an accompanying guide.

PHE's Commissioning cost-effective services for promotion of mental health and wellbeing and prevention of mental ill health includes sections on the effectiveness of interventions to encourage health and wellbeing in the workplace and prevent stress, depression and anxiety problems.

PHE's Workplace health: applying 'All our health' provides evidence and guidance to help healthcare professionals encourage people to live healthy lifestyles at work. Also includes a wide range of references to relevant NICE publications and sources of employment indicators.

SCIE: Mental health, employment and the social care workforce summarises evidence on what prevents people with mental health problems from working or retaining work in social care and what can be done to enable them to work.

Workplace wellbeing charter is an online resource providing information for workplaces on how to assess and improve their workplace wellbeing.

7. Crime, safety and violence

The relationship between crime and mental health problems is complex. It can also be controversial, as public perception about the relationship can contribute to stigma, discrimination and social exclusion.

Overview

There is high prevalence of mental health needs among people in contact with the criminal justice system. 16% of prisoners report symptoms indicative of psychosis, a much higher proportion than in the general population[footnote 43]. These disorders are more severe and complex[footnote 44], and are often combined with poor physical health and substance misuse. There are high levels of mental health conditions amongst people on probation[footnote 45]. There are also high levels of mental health conditions (including psychosis, antisocial personality disorder and anxiety) among British male gang members[footnote 46].

People in contact with the criminal justice system have substantially more risk factors for suicide (increased prevalence of mental health conditions, substance misuse and socioeconomic deprivation) and are recognised as a priority group in the cross-government suicide prevention strategy[footnote 47]. The risk of suicide is highest in the 28 days following release from prison48. Suicide and self-harm is covered in more depth in Mental health: population factors.

Liaison and diversion services have received strong government backing in recent years[footnote 30]. The ambition is to divert people with mental health and/or substance problems away from custodial settings wherever possible, enable access to health and social care in the community and reduce likelihood of re-offending. Since 2017, parts of England have been testing a new Community Service Treatment Requirement ( CSTR) programme. In some instances where short-term custodial sentences have been ineffective, offenders with mental health, alcohol and substance abuse issues are diverted towards treatment that aims to tackle the root cause of their criminality. The NHS Long Term Plan reaffirms the commitment to expand provision of the scheme[footnote 49].

Many people in contact with justice services with mental health problems will additionally be experiencing other issues such as difficulty accessing good quality homes, employment and income. This may result in their mental health deteriorating. Many have been victims of abuse and crime themselves. Those in prison need to have their needs identified and addressed during their time in prison and support should continue when they return to their local community. The care after custody service, RECONNECT, starts working with people before they leave prison and helps them to make the transition to community-based services by providing the health and social care support they need[footnote 49].

The major determinants of violence are socio-economic factors and substance misuse, whether they occur concurrently with a mental health condition or not[footnote 50]. Violence prevention strategies should include early identification and treatment of substance abuse problems and greater attention to the diagnosis and management of concurrent substance abuse disorders among people with a severe mental illness ( see Mental health: population factors).

Being a victim of crime, or exposure to violent or unsafe environments can increase the risk of developing a mental health problem. The most serious example at a young age is child abuse, which can have a sustained detrimental effect on mental health through to adulthood[footnote 51].

Being a victim of intimate partner violence or domestic abuse increases the risk of mental health problems[footnote 52] and there are high rates of mental health conditions (particularly post traumatic stress disorder( PTSD)) among people who have been raped and among immigrant women who have undergone female genital mutilation[footnote 53].

7.1 Data sources

Examples of metrics in the profile relating to safety, violence and crime:

first time entrants to the Youth Justice System (county and UA)

re-offending levels (county and UA, district and UA)

violent crime (including sexual violence) - violence offences (county and UA, district and UA)

Other important data sources:

National Drug Treatment Monitoring Service (NDTMS) provides data on adult and children and young people's community substance misuse treatment services including referrals from criminal justice pathways. NDTMS also provides data across the adult prison and CYP secure estates in England. (NB: aggregate data prison-level data are not in public domain).

Ministry of Justice (MoJ) Prison Population Data: prison population demographics and population flows includes data provided directly from prisons and other datasets including ONS data.

Health and Justice Indicators of Performance (HJIPs - not in public domain) - this NHS data asset has been co-produced with PHE and NOMS and collects data on a broad range of health needs and health services including prisoner mental health.

Relevant indicators are recommended in the What Works Centre for Wellbeing's Understanding local needs for wellbeing data.

7.2 Local data

Local areas may be able to access relevant data which are not nationally available, eg for domestic abuse, additional local data may be obtainable from the police, Multiagency Risk Assessment Conferences ( MARAC) and from services that provide interventions. Local data may be available directly from the prisons, probation services, and from youth offending services, including statistics from initial assessments about mental health and drug and alcohol use.

Depending on the local population and data availability, areas may choose to focus their needs assessment work on specific topics, for example gang culture, cyber bullying, female genital mutilation, slavery, child exploitation and forced prostitution. Local areas may choose to include more detailed information on prison populations if they have a prison within their area.

7.3 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic.

Mental Health Crisis Care Concordat website aims to improve responses to people in mental health crisis, many of whom come into contact with the police. It brings major partners together to agree shared actions.

Police and Crime Bill contains provisions that prohibit people aged under 18 being held in police custody under the Mental Health Act, ensures adults are only detained in exceptional circumstances and also reduces the maximum permitted detention time to 24 hours.

NHS England's Liaison and diversion resources: offers a wide range of information on the liaison and diversion approach, including resources for services to use.

NICE guideline on Mental health of adults in contact with the criminal justice system covers assessing, diagnosing and managing mental health problems in adults (aged 18 and over) who are in contact with the criminal justice system.

Victims strategy offers a cross-governmental strategic framework to improving support for victims or witnesses to crime during their journey through the justice system. Often traumatic experiences can leave physical and mental scars that can endure many years after the events.

Understanding victims of crime by Victim Support offers quantitative and qualitative look at the effect of crime and the victims' needs, identifying the effects of victimisation and recognise victims' expressed needs.

PHE's annual health and justice report focuses on health in prisons and other places of detention.

Rebalancing act produced by Revolving Doors Agency and PHE, working with the Home Office and NHS England, supports collaborative work to improve health, reduce offending and health inequalities among people in contact with the criminal justice system.

Standards for Prison Mental Health Services is a framework by which to assess the quality of prison mental health services through a process of self and peer review.

8. Community wellbeing and social capital

Good mental health and wellbeing is an important health outcome in its own right and can improve resilience to mental and physical illness. Measures of good social capital are associated with better population-level health and wellbeing.

8.1 Overview

Mental wellbeing is more than the absence of mental illness. It is linked with an individual's emotional, physical and social wellbeing and the wider social, economic, cultural and environmental conditions in which they live. Mental wellbeing is a combination of an individual's experience (such as happiness and satisfaction) and their ability to function as both an individual and as a member of society[footnote 56]. It includes sense of control, resilience, self-efficacy and social connectedness.

Mental wellbeing is of particular importance to children and young people, influencing the way in which they cope with important life events. Children and adults with better mental wellbeing are likely to deal better with stressful events, recover more quickly from illness, and be less likely to put their health at risk[footnote 57].

The mental wellbeing of individuals is influenced by factors at a community level such as social networks, sense of local identify, levels of trust and reciprocity and civic engagement. The benefit of this "social capital" can be felt at an individual level (for example, through family support) or at a wider collective level (for example, through volunteering). Social capital is associated with values such as tolerance, solidarity or trust. These are said to be beneficial to society and are important for people to be able to cooperate[footnote 58].

Whilst disadvantaged communities have higher health need, they may also have assets within the community that can improve health and build resilience[footnote 59]. Community assets improve the health and the quality of the community. They include physical assets such as public green space, play areas and community buildings and social assets such as volunteer and charity groups, social networks and the knowledge and experiences of local residents. These assets have potential to protect and increase community wellbeing and thus strengthen resilience.

The wellbeing of young people is increasingly influenced by modern day technology. The significance of technology in peoples' lives have led to debate on the effects of social media on young people's mental and physical wellbeing[footnote 60]. The effects of substituting social media activity for other forms of social interaction is not fully understood. Cyberbullying is increasingly an issue in young people (see Children and young people).Understanding the use of this sometimes 'problematic' technology may help to manage the risks and instead be used to help improve wellbeing and health[footnote 61].

8.2 Data sources

Examples of metrics in the profiling tool relating to individual and community wellbeing include:

wellbeing in 15 year olds (county and UA)

enough physical activity (county and UA, district and UA)

self-reported wellbeing (county and UA)

Other important data sources include:

Local data

Local areas may focus on collection of metrics around wellbeing and community assets to help understand local resilience. This may include local surveys to measure social capital including aspects of trust, group membership, social connections and participation in decision making processes. Inclusion of locally collected metrics could form an important element of a JSNA.

Guidance documents on potential metrics include:

8.3 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic:

9. References

# data[].attributes.attachment_link.description
The purpose of the mental health and wellbeing JSNA toolkit is to support people developing the mental health and wellbeing content of their local joint strategic needs assessment. This chapter helps consider factors related to the promotion of mental wellbeing and the prevention of mental health problems. It provides easy access to nationally available topic focused information, guidance and knowledge.

# data[].attributes.attachment_link.readable_text
1. Introduction

The purpose of the mental health and wellbeing JSNA toolkit is to support people developing the mental health and wellbeing content of their local joint strategic needs assessment. This chapter helps consider factors related to the promotion of mental wellbeing and the prevention of mental health problems. It provides easy access to nationally available topic focused information, guidance and knowledge. The chapter text aims to be plain English and ready to be cut and pasted. The numerous links to external sites should all be current, relevant, and provide access to material that contributes to the JSNA process.

Understanding the local population is vital for good needs assessment and service planning. The characteristics of the local relevant population (for example, size, age and gender) should be known, including how this drives demand for mental health services now and in the future. Specific groups of people should be identified who are at risk of developing, or likely to have, mental health problems and who may benefit from targeted action for prevention and to ensure their needs are met.

To identify inequalities in prevalence of mental health problems, access to services and outcomes it can be helpful to look at population sub-groups. This segmentation looks at difference by gender, ethnicity and other ‘protected characteristics’ as defined by the Equality Act[footnote 1]. Understanding how people with such characteristics experience different levels of mental health problems to the general population will add context to any variation identified. Segmentation can also consider differences by geography and variation in exposure to social ‘place’ effects covered in Mental health: environmental factors.

Alongside mental health across the life-course (documents 4 to 7), there are important causes and consequences of mental health problems worth considering for the local population in terms of health improvement and prevention. These include health behaviours such as smoking, physical activity and misuse of alcohol and drugs. The inter-relationship between mental and physical health is important. Poor physical health increases the risk of developing mental health problems, and vice versa. Mental health problems are common in people with longer-term conditions such as cardiovascular, respiratory and liver diseases, cancer and chronic pain.

People with mental health problems, particularly those who do not access treatment early and with more severe conditions, experience poorer physical health and reduced life expectancy. One measure of local population vulnerability is the level of self-harm across the life-course. While not mental health outcomes in themselves, suicide and self-harm are closely related to factors associated with mental health.

Questions that a JSNA might address, based on the JSNA data inventory:

what different populations should be considered when commissioning mental health services?

how is the population changing? What will it look like in 5 and 10 years?

what is the level of life satisfaction and happiness scores in the different local populations?

what is the level of understanding about how to develop positive mental health and wellbeing in this population?

how many people have complex or additional mental health needs?

what are the main social, and physical and mental health inequalities in the area?

what are the local rates of safeguarding and crime prevention?

how do health behaviours affect mental health and wellbeing in this population?

what are the physical health needs of people with mental illness?

what are the mental health needs of people with physical health conditions - are they being recognised and met?

are preventive measures being provided to those who need them most?

what are the rates of suicide and self-harm and are interventions in place?

2. Population demographics and vulnerable groups

Avoidable, systematic inequalities between groups are unfair. Action can be taken to reduce these[footnote 3]. Some people experience several complex interrelated issues, and many will fall into more than one subgroup. Local areas should have their own knowledge of vulnerable or marginalized groups and perspectives on local equality issues.

2.1 Overview

The age and gender structure of the local population is a important driver of health need and demand for health services. Allocation of NHS resources for mental health (including dementia) is based on modelling mental health condition prevalence against known factors, such as acute mental health need being greatest among working age adults and dementia being more prevalent among older age groups[footnote 4]. Some further weighting is included for ethnicity and socio-demographic factors.

Some subgroups are more exposed and vulnerable to unfavourable social, economic, and environmental circumstances. These subgroups, interrelated with ethnicity, gender and age, are at higher risk of mental health problems. The following groups are identified as being of high risk of mental health problems:[footnote 5], [footnote 6]

black and minority ethnic groups (BAME) (see ‘equity of access’ chapter)

people living with physical disabilities

people living with learning disabilities

people with alcohol and/or drug dependence

prison population, offenders and victims of crime (see ‘crime, safety and violence’ in Mental health: environmental factors)

LGBT (lesbian, gay, bisexual and transgender) people

carers

people with sensory impairment

homeless people (see ‘housing and homelessness’ in ‘Mental health: environmental factors’)

refugees, asylum seekers and stateless person

High rates of people moving home within and between areas can disrupt social ties and community networks and is related to higher levels of stress and mental health problems[footnote 7]. This can include people in life transitions such as students. People who have recently arrived from abroad to live in an area may face barriers to accessing mental health services.

People who do not speak English well might need specific help to enable them to access the mental health services. Refugees are more likely to have experienced trauma and have higher prevalence of mental health conditions such as post-traumatic stress disorder (PTSD), depression and anxiety[footnote 8].

Other examples of high risk groups are highlighted in Mental health: environmental factors. In particular, higher rates of mental health problems are associated with poverty and socio-economic disadvantage. Across the life-course (documents 4 to 7), examples of groups identified as high priority are:

women who are pregnant or have a child aged under 12 months

children living at a socio-economic disadvantage

children with parents who have mental health or substance misuse problems

looked-after children

adults with a history of violence of abuse

people with poor physical health

older people living in care homes

isolated older people

2.2 Data sources

It is expected that demographic profiling of local populations has been undertaken elsewhere in the wider JSNA process. Important sources of demographic data include:

Census 2011: data on age, sex, ethnicity and prevalence of long term health conditions and disability presented at ward level. Includes data on carers.

School census: ethnic makeup of primary, secondary and special schools

ONS population and migration data

Common Mental Health Disorders Profile: includes data about demographics (limited English language skills, population turnover) and vulnerable groups (homeless, unpaid carers, asylum seekers)

Co-occurring Mental Health and Substance Misuse Profile

Learning Disabilities Profile: provides a range of data about people with learning disabilities at local authority level

Productive Healthy Ageing Profile

RNIB Sight Loss Data Tool: includes data and estimates at local authority level

annual survey of adult carers published by NHS Digital includes relevant questions about quality of life and services received

PANSI provides local area estimates and projections of numbers of people with a range of long term conditions, including mental health conditions

POPPI provides local area estimates and projections of numbers of older people and indicators of need, including those living alone and those living with long term conditions

ONS experimental statistics on sexual identity are available for 2016 by region

2.3 Local data

Local authorities will hold population and demographic data and may have additional local information on specific at-risk groups based on local data collection and surveys. There is likely to be a lack of data about some groups, due to it not being collated nationally.

2.4 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic:

the Mental Health Foundation’s Fundamental facts about mental health 2016 gives a summary of mental health research including needs of particular groups

Joint Commissioning Panel for Mental Health’s guidance for commissioners of mental health services for people with learning disabilities for commissioners and providers includes specific guidance on providing mental health services for BAME communities and people with learning disabilities

Good Things Foundation’s Health and wellbeing of unpaid carers 2015 report looking at how caring roles affect health and wellbeing, and how digital skills and community support could provide value to carers’ lives

3. Equity of access (with particular focus on ethnicity)

Social characteristics, such as gender, disability, age, race and ethnicity, sexual orientation and cultural attitudes influence access to support and services.

3.1 Overview

It is a legal requirement that access to mental health services should not be discriminatory on the basis of protected characteristics as defined by the Equality Act 2010. Protected characteristics are:

age

disability

gender reassignment

marriage/civil partnership

pregnancy

race

religion or belief

sex

sexual orientation

For instance, the needs of older people not being adequately considered when planning mental health services would potentially be considered discrimination.

It is also illegal to discriminate directly or indirectly against people with mental illness in public services and functions. Mental illness is defined as a disability characteristic if the ‘mental impairment has a substantial and long-term adverse effect on a person’s ability to carry out normal day to day activities. [footnote 1]

Research and equalities policy has given significant attention to the disparities in access to, and experience of, mental health services according to ethnicity. People from black and minority ethnic (BAME) groups living in the UK are more likely to[footnote 9]:

be diagnosed with a mental health problem

seek help in a crisis situation and in A&E

be admitted to hospital with a mental health problem

experience a poor outcome from treatment

disengage from mainstream mental health services

People from black African and Caribbean backgrounds are disproportionately seen in the ‘hard end’ of services (for example, at the point of arrest) and are more likely to receive harsher or more coercive treatments[footnote 10]. Due to the ‘eurocentricity’ of service design, people from some BAME communities struggle to access services in ways meaningful to them[footnote 11].

Following the referendum vote to leave the European Union, some experts have suggested that a culture of extremism and intolerance has become more visible in political debate. Stigma, prejudice and discrimination appear to be on the rise, with examples of racism and assault against migrants and religious and ethnic minorities[footnote 11]. A study based in south east London found that discrimination was associated with higher rates of common mental health conditions, and this effect was strongest for individuals who had recently migrated to the UK[footnote 12].

Detailed consideration of mental illness among BAME groups will require local action. This is likely to include local community engagement work and assessing the use of local support services by ethnic group through direct contact with providers (social care, CQC, advocacy services, specialist mental health, IAPT).

3.2 Data sources

Metrics in the profiling tool relating to ethnicity and equity of access include:

In services:

IAPT referrals for BME patients (CCG, STP)

The Severe Mental Illness tool includes proportions by broad ethnic group.

The Adult Psychiatric Morbidity Survey 2014 provides national data on the prevalence of mental health conditions by broad ethnic group. This information can be drawn upon to help understand likely need of particular groups for support in relation to mental health problems and used in conjunction with demographic data to assess equity in uptake and outcome of available care services.

A range of equality indicators are recommended in Understanding local needs for wellbeing data. Data on quality or outcome of services for BAME users is not yet available but may be available locally direct from services.

3.3 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic:

Public Health Matters: local action on health inequalities amongst ethnic minorities discusses understanding how ethnicity relates to inequality and health inequality and taking action to reduce ethnicity based inequality.

Race equality foundation and mental health providers forum: better practice in mental health for black and minority ethnic communities gives examples of best practice from organisations and projects promoting and addressing issues around mental health in BAME communities.

Ethnic inequalities in mental health: promoting lasting positive change is a summary of research and analysis in relation to people with a BAME background and mental health. Includes an overview of recent policy developments, headline statistics, and recommendations for action and investment.

Chief Medical Officer annual report: public mental health includes chapters on parity of esteem and on ethnic inequalities and social inclusion.

IAPT positive practice guides aim to increase access across the age spectrum and to meet the needs of diverse and underrepresented groups.

4. Smoking and health behaviours

Positive health behaviours, such as not smoking, eating healthy food, and engaging in physical activity, can encourage psychological wellbeing, improve physical health, prevent mental health problems, and support recovery among people who are unwell. In addition to supporting individuals to make healthy choices, interventions should focus on providing environments which support adopting healthy behaviours.

4.1 Overview

Smoking remains the single biggest cause of preventable death and illness in England. Smoking prevalence is higher among people with mental health problems[footnote 14] than the general population (40.5% of people with a serious mental illness compared to 14.9% of the adult population). A third of all tobacco is smoked by people with a mental health condition.[footnote 15] Smoking among those with a mental health condition has changed little over the past 20 years, in contrast to the marked decline in smoking prevalence in the general population.[footnote 16]

Alongside smoking, there are a number of other links between health behaviours and mental health problems:[footnote 17]

mental health problems in childhood predict unhealthy choices in adolescence

eating healthy food, particularly fruit and vegetables, can positively affect mental as well as physical health

physical activity can positively affect stress, self-esteem, anxiety, dementia and depression and is recommended in the treatment of depression[footnote 18]

rates of obesity are higher among people with a mental health condition

Health behaviour, physical health and mental health are closely related. Each is a determinant and consequence of the other and all are underpinned by wider social factors. Mental health affects risk behaviours, including smoking, alcohol and drug misuse, higher-risk sexual behaviour, lack of exercise, unhealthy eating and obesity.[footnote 19]

Risk behaviours cluster in particular groups. For example, low income and economic deprivation is associated with the 20 to 25% of people in the UK who are obese or smoke. This same population has the highest prevalence of anxiety and depression. Such clustering can lead to greater lifetime risk of mental health problems, as well as social, behavioural, financial, and general health problems.[footnote 19]

Negative health behaviours are contributing causes of poorer physical health among those with mental health problems. It is likely that the high prevalence of smoking accounts for much of the reduction in life expectancy among people with serious mental illness.[footnote 20]

People with mental health problems must have access to ‘stop smoking’ interventions where needed, as well as interventions for physical activity and obesity.[footnote 21]

Evidence has shown smokers are increasingly turning to the use of e-cigarettes to help quit smoking with health experts endorsing e-cigarettes to the more harmful substances produced by smoking tobacco.[footnote 22] As part of the NHS long-term plan, a new universal smoking cessation offer will be offered to long-term users of specialist mental health and learning disability services, with options for smokers to switch to e-cigarettes while in inpatient settings.[footnote 23]

Public health action to support healthy behaviour needs to recognise the wider role of social determinants. People’s behaviour choices are highly influenced by the opportunities and influences within their living environment and social setting. Access to public parks and green space can support people to be physically active.[footnote 24] Ensuring there is access to a diverse range of food in the local area and avoiding high density of hot food takeaway outlets can encourage healthy eating.[footnote 25]

4.2 Data Sources

Metrics in the profiling tool that relate to smoking and health behaviours are listed below.

In risk factors:

3 or more risky behaviours in 15 year olds (county and UA)

smoking prevalence in adults (county and UA, district and UA, CCG, region)

smoking prevalence in adults with depression and anxiety (county and UA, district and UA, region)

smoking prevalence in adults with long term mental health conditions (county and UA, district and UA, region)

excess weight in adults (county and UA, district and UA, region)

In protective factors:

enough physical activity (county and UA, district and UA)

use of outdoor space for exercise/health (county and UA)

Other important data sources include:

co-occurring substance misuse and mental health issues data tool - includes indicators about smoking

local tobacco control profiles for England - provides a snapshot of the extent of tobacco use, tobacco related harm and measures being taken to reduce this harm

physical activity tool

health profiles - includes various health behaviour indicators

National Drug Treatment Monitoring System (NDTMS) indicators - provides national statistics about drug and alcohol misuse treatment

Understanding local needs for wellbeing data from the What Works Centre for Wellbeing provides recommended relevant indicators

Local data

Local areas may focus on access to, uptake and outcomes of health behaviour interventions for people with a mental illness and who smoke, and data on these local services will be an important element of the JSNA.

4.3 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic.

ASH’s The stolen years sets out recommendations for how smoking rates for people with a mental health condition could be dramatically reduced.

Mental Health Foundation’s Physical health and mental health includes a summary of the relationship between health behaviours and mental health.

The National Institute for Health and Care Excellence (NICE) guidance Smoking: acute, maternity and mental health services aims to support smoking cessation, temporary abstinence from smoking and smoke free policies in all secondary care settings, including mental health services. Includes interactive pathway, baseline assessment, implementation advice and self-assessment tool.

PHE’s Smoking cessation in secondary care: mental health settings provides guidance and self-assessment framework for NHS mental health trusts to develop local action to reduce smoking prevalence and the use of tobacco.

National Centre for Smoking Cessation and Training (NCSCT)’s Smoking cessation and smokefree advice including mental health provides support, guidance and advice on smoking cessation and smokefree policies, including a number of briefings specific to mental health.

PHE’s Vaping in England: an evidence update provides the latest evidence on the prevalence of vaping in adults and young people and the use of e-cigarettes in stop-smoking services.

UK Faculty of Public Health’s Better mental health for all – relationship with physical health and healthy lifestyles provides evidence and information about the links between physical health, mental health and healthy lifestyles.

5. Alcohol misuse and drugs

Harmful use of alcohol or drugs often contributes to or co-exists with mental health problems and leads to poorer outcomes. When people have co-existing conditions it is important that they access relevant treatment in line with NICE and other national guidance. They should not be excluded based on mental health or alcohol/drug use conditions that they may have (‘no wrong door’ principle). It is important that people experiencing mental health crisis are not turned away from services due to intoxication.

5.1 Overview

People with co-occurring mental health and alcohol/drug use conditions often have multiple needs, with poor physical health alongside social issues such as debt, unemployment or housing problems. They are also more likely to be admitted to hospital, to self-harm, or die by suicide[footnote 26].

Alcohol is the third leading preventable cause of ill health after tobacco and hypertension[footnote 6], and in England, among people aged 15 to 49 years, it is the leading cause of ill-health, and disability [footnote 27].

Drinking more than the low risk guidelines can harm mental and physical health. It can also lead to social problems, such as unemployment, divorce, domestic abuse, and homelessness[footnote 28].

Regular consumption of alcohol has been shown to cause mental ill health including depression, anxiety, and a connection to higher levels of self-harm and suicide in people with alcohol problems[footnote 29]. Regular heavy drinking can also lead to alcohol dependence. The relationship between mental health problems and alcohol is a vicious cycle. Mental health problems can cause people to drink more, particularly as people often drink alcohol as a form of ‘self-medication’.

Drug misuse includes taking illegal drugs and the consumption of controlled prescription drugs, such as benzodiazepines, without a prescription. Estimates suggest that 2.7 million adults took illicit drug in the last year[footnote 30].

Research shows that mental health problems are experienced by the majority of drug (70%) and alcohol (86%) users in community substance misuse treatment.[footnote 31] 41% of people entering community alcohol and drug treatment in 2017 to 2018 reported a co-occurring mental health treatment need.[footnote 32] There are many factors associated with harmful alcohol and drug use. Drug misuse can cause social disadvantage, and social disadvantage may lead to drug use and dependence. Many are social factors, such as deprivation. Drug use and misuse tend to be clustered. For example, areas of relatively high social deprivation have a higher prevalence of illicit opiate and crack cocaine use and larger numbers of people in treatment.[footnote 33] [footnote 34] These also relate to mental health as discussed in Mental health: environmental factors.

The risk of alcohol and/or drug misuse are highest amongst people experiencing severe or multiple disadvantages.[footnote 35] For example, over half of all deaths of homeless people in 2017 were due to alcohol, drugs, or suicide; with drug poisoning alone making up to 32% of the total deaths.[footnote 36] Prevention and treatment interventions aiming to influence and treat drug and alcohol misuse should therefore consider the root causes of health and social harms. They must aim for broader interventions on the social determinants.

Alcohol and drug misuse contributes to wider social harms such as:[footnote 6]

absenteeism

unemployment

domestic violence

family breakdown

child maltreatment

public disorder

There are many links between substance misuse and crime. This includes gang violence and crimes such as theft, burglary, fraud and shoplifting. Victims believed the perpetrator(s) to be under the influence of alcohol in 39% of violent incidents, while 21% of the perpetrator(s) were believed to be under the influence of drugs.[footnote 37] Drunkenness is associated with a majority of murders, manslaughters and stabbings and half of domestic assaults.[footnote 38]

While there may be public perception of a relationship between violent crime and serious mental illness[footnote 39], between 2006 and 2016 11% of homicide convictions in the UK were known to be committed by mental health patients[footnote 40]. Research suggests that substance misuse and socio-economic factors play a far more important role[footnote 41].

NICE recommends that staff in mental health settings should routinely carry out alcohol screening and ask service users about recent legal and illicit drug use, including type, method of administration, quantity and frequency. They should provide brief interventions, harm reduction information and signpost to specialist services. NICE guidance for people with coexisting severe mental illness[footnote 42] and substance misuse outlines best practice which includes adapting existing secondary care mental health services to meet both a person’s co-occurring severe mental illness and substance misuse needs and focusing on their wider health and social care needs. It is important to provide coordinated services that address their wider health and social care needs as well as other issues such as employment and housing. Empathy and respect are vital as people with co-occurring conditions are often stereotyped and stigmatized[footnote 30].

NHS England is leading work to redesign and reorganise core community mental health teams into a new community-based offer that will include access to psychological therapies, improved physical health care, employment support, personalised and trauma-informed care, medicines management and support for self-harm and coexisting substance use.

5.2 Data sources

Metrics in the profiling tool that relate to alcohol misuse and drugs

In risk factors:

admission episodes for alcohol-related conditions (county and UA, district and UA)

3 or more risky behaviours in 15 year olds (county and UA)

estimated prevalence of opiate and/or crack cocaine use (county and UA)

In services:

admission to hospital for mental and behavioural disorders due to alcohol (county and UA, district and UA )

concurrent contact with mental health services and substance misuse services for drug misuse (county and UA)

concurrent contact with mental health services and substance misuse services for alcohol misuse (county and UA)

Other important data sources include:

Co-occurring Substance Misuse and Mental Health Issues data tool includes indicators about alcohol and drug misuse

Local Alcohol Profiles monitors the impact of alcohol on local communities and the services and initiatives that have been put in place to prevent and reduce the harmful impact of alcohol

Liver Disease Profiles include indicators about alcohol-related liver disease and indicators about hepatitis b and c infections, both related to injecting drugs

Children’s and Young People’s Mental Health Wellbeing profiling tool includes indicators about parents in drug and alcohol treatment and drug and alcohol consumption among teenagers.

5.3 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic:

Alcohol Concern’s An audit of the focus on alcohol-related harm in joint strategic needs assessments, joint health and wellbeing strategies and CCG commissioning plans focuses on the priority given to addressing alcohol-related harm in JSNAs, JHWS and Clinical Commissioning Group (CCG) plans across England.

[ NICE’s Coexisting severe mental illness and substance misuse: community health and social care services covers how to improve services for people aged 14 and above who have been diagnosed as having coexisting severe mental illness and substance misuse. The aim is to provide a range of coordinated services that address people’s wider health and social care needs, as well as other issues such as employment and housing.

PHE’s Better care for people with co-occurring mental health, and alcohol and drug use conditions gives guidance on commissioning and providing better care for people with co-occurring mental health, and alcohol and drug use conditions.

PHE’s JSNA support packs for alcohol, drug and tobacco use will help local areas to develop JSNAs and local joint health and wellbeing strategies, which effectively address public health issues relating to tobacco, drug and alcohol use.

The Joint Commissioning Panel for Mental Health (JCPMH)’s Guidance for commissioners of drugs and alcohol services is based on evidence and developed jointly between professionals and people who use drug and alcohol services.

Turning Point’s Dual diagnosis toolkit is a mental health and substance misuse guide for professionals and practitioners, written to support the development of services for people with co-existing mental health and substance use problems. At the heart of the handbook is a series of case studies showing how particular services have implemented good practice.

6. Comorbidity in mental and physical illness

Mental and physical health is totally linked. Mental health and physical health are both determinants and consequences of each other.

Overview

There is a strong argument that support for physical and mental health should be integrated. There are 4 related challenges:[footnote 43]

high rates of mental health conditions among people with long-term physical health problems

poor management of ‘medically unexplained symptoms’ which lack an identifiable organic cause

reduced life expectancy among people with the most severe mental health conditions, largely attributable to poor physical health

limited support for the wider psychological aspects of physical health and illness

On average, men with severe mental health conditions die 20 years earlier, and women die 15 years earlier, than the general population[footnote 19]. Compared with the general population people in contact with specialist mental health services have:[footnote 19]

nearly 4 times the rate of deaths from diseases of the respiratory system

just over 4 times the rate of deaths from diseases of the digestive system

nearly 3 times the rate of deaths from diseases of the circulatory system

Much of the extra burden of poor physical health among those with mental health problems can be explained by health behaviors such as smoking and alcohol (see section 5). Other factors also play a part such as barriers to receiving adequate physical healthcare; less than a third of people with schizophrenia in hospital received the recommended assessment of cardiovascular risk in the previous 12 months[footnote 19].

NHS England is leading work to ensure that it meets the physical health needs of 280,000 more people living with severe mental illness by 2020 to 2021. This will be achieved by increasing early detection and expanding access to evidence based physical care assessment and intervention each year. Collaboration between public health, primary care and secondary care mental health services is crucial to realising this aim. This commitment was reaffirmed in the NHS Long Term Plan pledging £2.3 billion a year by 2023 to 2024 to invest with the ambition to increase the number of people receiving physical health checks.

It is important to also consider the mental health needs of people with long-term physical health problems. Integrated care for physical health should include provision of psychological support, as failure to do so is associated with poorer outcomes and faster disease progression[footnote 43]. People with long term chronic conditions should receive psychological therapy support to improve their recovery[footnote 19].

The close relationship between mental health and physical health is strongly underpinned by the underlying social determinants of health, such as social deprivation. This is an important way in which inequalities are perpetuated[footnote 43] and a broad public health strategy should consider the role of these social determinants for the whole population.

6.1 Data sources

Metrics in the profiling tool relating to comorbidity in mental and physical health

In risk factors:

smoking in adults with anxiety or depression (county and UA, district and UA, region)

smoking in adults with long term mental health condition (county and UA, district and UA, region)

In quality and outcomes:

people with severe mental illness (SMI) who have received the complete physical health checks (CCG, STP)

excess under 75 mortality rate in adults with serious mental illness (county and UA)

Other important data sources include:

Public Health England’s Return on investment (ROI) toolkit provides assessment of the ROI of interventions to protect the mental health of people with physical health problems

Understanding local needs for wellbeing data from the What Works Centre for Wellbeing provides recommended relevant indicators

Public Health England’s analysis of the physical health inequalities of people with SMI uses a sample of primary care data to examine differences in prevalence of 10 physical health conditions between the population with SMI aged 15 to 74 years and the general population; it also looks at multi-morbidities between the 2 population groups and analyses health inequalities by age, gender and deprivation

6.2 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic.

Improving the physical health of adults with severe mental illness: essential actions is a report from the Academy of Royal Medical Colleges and the Royal Colleges of General Practitioners, Nursing, Pathologists, Psychiatrists, Physicians, the Royal Pharmaceutical Society and Public Health England providing recommendations.

NHS Rightcare’s Physical ill health and CVD prevention in people with severe mental illness toolkit was developed in collaboration with Public Health England. This toolkit provides expert practical advice and guidance to support system wide improvement to help improve physical health for people with severe mental illness and reduce health inequalities.

NHS toolkit Improving the physical health of people with a serious mental illness: a practical toolkit includes detailed case studies at pilot sites, short examples and supporting documents.

King’s Fund’s report Bringing together physical and mental health calls for integrated physical and mental healthcare. Provides examples of innovative service models and identifies areas where there is scope for improvement.

NHS England’s report from the independent Mental Health Taskforce Five year forward view for mental health sets out recommendations for the NHS and its arms-length bodies to achieve the ambition of parity of esteem between physical and mental health.

NHS health check best practice guidance underlines the importance of physical health checks for people with severe mental illness.

PHE’s Commissioning cost-effective services for promotion of mental health and wellbeing and prevention of mental ill health includes information on interventions to protect the mental health of people with physical health problems.

PHE’s Wellbeing in mental health: applying all our health gives examples to help healthcare professionals make interventions to encouragephysical health and wellbeing in mental health.

Health Matters: reducing health inequalities in mental illness is a professional resource focusing on some of the actions local areas can take to reduce physical health inequalities experienced by people living with mental health illness.

World Suicide Prevention Day 2019 is a study by the National Cancer Registration and Analysis Service exploring data in the risk of suicide after cancer diagnosis in patients, and the risk between the types of cancers which are considered preventable.

7. Suicide and self harm

Every suicide should be seen as preventable. Gaining an understanding of vulnerability in local populations can aid development of an effective suicide prevention plan. People with a history of self-harm are a high-risk group for suicide.

7.1 Overview

Suicide and self-harm are not mental health problems themselves, but they are linked with mental distress[footnote 5]. Suicide is preventable, yet suicide rates in England have generally increased since 2007. Suicide is the biggest killer of men under 50 as well as a leading cause of death in young people and new mothers. On average, 13 people kill themselves every day. The death of someone by suicide has a devastating effect on families, friends, workplaces, schools and communities, as well as an economic cost[footnote 44].

The cross-government prevention strategy identified 7 important areas for action:[footnote 44]

reduce the risk of suicide in high-risk groups

tailor approaches to improve mental health in specific groups

reduce access to the means of suicide

provide better information and support to those bereaved or affected by suicide

support the media in taking a sensitive approach to suicide and suicidal behaviour

support research, data collection and monitoring

reduce rates of self-harm as a major indicator of suicide risk

People with a history of self-harm are a high-risk group and a priority for prevention. Some groups have higher rates of self-harm, including young people, particularly looked after children and care leavers, and lesbian, gay and bisexual people. In a recent survey 22% of 15 year olds said that they had previously self-harmed, with almost 3 times as many girls reporting self-harm than boys[footnote 45].

People who self-harm are at increased risk of suicide; although for many people self-harm is a coping mechanism and not a suicide attempt. Risk of suicide is particularly increased in those repeating self-harm and in those who have used violent/dangerous methods of self-harm[footnote 44].

Other groups identified as high risk for suicide are:

young and middle-aged men

people in the care of mental health services, including inpatients

people in contact with the criminal justice system

specific occupational groups, such as doctors, nurses, veterinary workers, farmers and agricultural workers

Local areas should have multi-agency suicide prevention plans in place that contribute to a 10% reduction in suicide nationally by 2020 to 2021. By the beginning of 2019 every local area in England has a multi-agency suicide prevention plan in place or in development[footnote 46]. The NHS Long-Term Plan will continue to make reducing suicides over the next decade as a priority by building on the progress that is already made.

7.2 Data Sources

Metrics relating to suicide and self-harm in the profiling tool

In risk factors:

long-term unemployment (county and UA, district)

children in need due to family stress (county and UA)

children in need due to abuse or neglect (county and UA)

In services:

hospital admissions as a result of self-harm (all ages) (county and UA, district and UA, region)

hospital admissions as a result of self-harm (standardised admissions ratio) (ward)

emergency hospital admissions for intentional self-harm (county and UA, ward)

In quality and outcomes:

suicide: age standardised rate (males, all ages) (county and UA, CCG, STP)

suicide: age standardised rate (females, all ages) (county and UA, CCG, STP)

Other important data sources include:

Suicide Prevention Profile provides a range of metrics at local authority, unitary authority and CCG level to enable local areas to understand their need and benchmark against similar populations

7.3 Local data

Guidance on undertaking a needs assessment is in the local suicide prevention planning guidance, the ‘Making sense of national and local data’ section of the Local suicide prevention planning: a practice resource.

Local authorities may want to add to this information with local demographics such as migrant population figures and protected characteristics as defined in the Equality Act. Information collected for local suicide audits can help understand the demographics and circumstances of those in their area who have died by suicide. Some areas are setting up real time suspected suicide surveillance systems to reduce the time delay in obtaining information.

7.4 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic.

Local Government Association: Suicide prevention a guide for local authorities is a guide for local councils on their role in suicide prevention, including a range of approaches and case studies to inform decision making.

Multicentre study of self-harm in England is a collaborative research programme between the University of Oxford, University of Manchester and Derbyshire Healthcare NHS Foundation Trust.

National confidential inquiry into suicide and homicide by people with mental illness provides the latest data and makes recommendations for improving clinical practice and service delivery to prevent suicide and reduce risk.

NICE’s Preventing suicide in community and custodial settings is a quality statement around self-harm includes aspects of suicide prevention advice, particularly in the resource section (with particular reference to the use of risk assessments).

NICE’s Self-harm pathway is a useful way to navigate through the stages of life course.

PHE’s Suicide prevention – resources and guidance support local authorities and healthcare professionals to develop a suicide prevention strategy and implement action to reduce suicides and improve support for those bereaved or affected by suicide.

Samaritans’ suicide statistics report provides details of England suicide rates (along with Wales, Scotland and the Republic of Ireland) and helps to understand and interpret suicide statistics.

8. References

# data[].attributes.attachment_link.description
The purpose of the mental health and wellbeing JSNA toolkit is to support people developing the mental health and wellbeing content of their local joint strategic needs assessment. This chapter helps consider factors related to the promotion of mental wellbeing and the prevention of mental health pr…

# data[].attributes.attachment_link.readable_text
Scots are being encouraged to join forces and build on improved public perceptions of mental health as part of a new nationwide campaign.

A survey of over 2,000 Scots, including 1,000 who have experienced mental health problems, found that more than half (58%) say that their own perceptions of people with mental health problems have improved in the last 10 years.

The research, from See Me, Scotland's programme to end mental health stigma and discrimination, also found 63% think that perceptions of mental health had improved since the start of the pandemic.

The findings have been published today (20 October), at the launch of a new campaign - See Us - asking Scotland to keep the momentum going.

See Us encourages people from all walks of life - whether they have experience of a mental health problem or not - to join the movement to end stigma, by getting involved in events, activities and speaking up to challenge outdated stereotypes.

While attitudes have improved, See Me says big changes are still needed in people's behaviours. The same research, which was carried out by Censuswide, found that more than two-thirds of people (71%) with mental health problems surveyed have still experienced stigma or discrimination - most commonly from someone they know, including friends, people online, immediate family and work colleagues.

Stigma and discrimination often prevent people from asking for help when they need it most - and can be the difference between life and death.

See Me director Wendy Halliday said: "For too long tackling mental health stigma has been seen as the responsibility of those who have experienced it.

"It's time to move past Seeing Me, the person struggling, and for everyone to stand up and say, 'See Us, we're making a difference together.'

"Wherever you want to make a change, and however you want to do it, there is something for you in this movement."

See Me volunteer Osama Nadeem, from Paisley, has struggled with his mental health since primary school as a result of racist bullying.

The 22-year-old says that stigma was one of the biggest barriers he faced when it came to asking for help - but that acts of kindness, and showing support, can make a huge difference for those who are struggling.

He said: "When I was in primary seven, I remember standing in the corner of the playground, and I started to cry as it all just got to me. Two girls who were in my year came over to me, and asked what was wrong. I didn't want to say, but they wouldn't leave me until I told them. Them coming to me helped - and that memory sticks with me.

"No one needs to be an expert to talk about mental health. If you're struggling, just talking about it - talking about stigma, talking about how you're feeling - can help a lot. That's why this campaign is so important."

Fellow volunteer Jenn Barnes, 34, from Glasgow, joined the call for support. Jenn, who has struggled with her own mental health since her teenage years, lost her brother to suicide in 2017, and has spent the time since campaigning and raising awareness of the impact of mental health stigma and the power of speaking up.

Jenn said: "While there is more awareness of mental health now, stigma still exists - and I think a lot of people don't even realise it. It's really important that we get as many people as possible to back the campaign to end mental health stigma and discrimination.

"You can't do it on your own. It's like mental health in itself - you need someone there to help you. If everybody comes together, it will make things a lot easier."

# data[].attributes.attachment_link.title
Campaign to focus on improved perception of mental health in Scotland - TFN

# data[].attributes.attachment_link.description
Scots are being encouraged to join forces and build on improved public perceptions of mental health as part of a new nationwide campaign. A survey of over 2,000 Scots, including 1,000 who have experienced mental health problems, found that more than half (58%) say that their own perceptions of people with mental health problems have improved in the last 10 years.

# data[].attributes.attachment_link.readable_text
A national mental health campaign to help people cope during the coronavirus (COVID-19) pandemic has now launched.

The Scottish Government's 'Clear Your Head' campaign highlights the practical things people can do to help them feel better whilst continuing to stay at home, acknowledging these are worrying and uncertain times for many.

Simple steps to taking better care of our mental health and wellbeing over the coming weeks include:
· Keeping to a routine - trying to sleep and wake at the same time, and eating at regular times. · Moving more - staying active, within the current guidance, to boost your mood. · Taking a break - limiting exposure to the news on social media if you feel things are getting on top of you, instead using fun games, quizzes and apps online to pass the time. · Making time for yourself - simply taking a breather or doing something you enjoy. · Keeping in touch - phoning family and friends to ease worry and feel connected.
Along with a range of tips on how to stay positive, the campaign website www.clearyourhead.scot will signpost sources of help and advice including NHS Inform, and helplines including NHS24, Breathing Space, SAMH and the Samaritans.

The campaign, which will run across television, radio, and online, is part of a package of measures announced by the Scottish Government to help people look after their mental health during and after the coronavirus outbreak.

This includes £3.8 million of extra funding to begin to increase the capacity of NHS24's telephone and online services, and investment of more than £1 million towards the expansion of the Distress Brief Intervention (DBI) programme.

Minister for Mental Health Clare Haughey said:

"The restrictions on our lives, whilst vital, are undoubtedly tough, bringing feelings of anxiety, frustration and worry as we try to cope and adapt. It's never been more important to look after our mental health, and this campaign has been launched to highlight the things we can do every day to feel better and stay mentally healthy.

"These are unprecedented times and it's important that people know what support is there if they need to speak to someone. We appreciate everyone's efforts to prevent the spread of the virus, and hope this campaign helps people to take care of themselves as restrictions continue."

Consultant Psychiatrist Dr John Mitchell said:

"There's never been a better time to think and talk about how you're feeling. We're all experiencing the loss of things we may have taken for granted, such as loss of social interaction, loss of livelihoods, and for some the loss of health or bereavement.

"Creating new mental health habits, simple things that help structure our days, give us a boost or make us feel connected, is important in these times. These practical tips will help people do the right things to look after themselves in the coming weeks and months, making them better able to cope and meet the challenges they are facing."

For information and advice visit www.clearyourhead.scot

# data[].attributes.attachment_link.description
A national mental health campaign to help people cope during the coronavirus (COVID-19) pandemic has now launched. The Scottish Government's 'Clear Your Head' campaign highlights the practical things people can do to help them feel better whilst continuing to stay at home, acknowledging these are worrying and uncertain times for many.

# data[].attributes.attachment_link.readable_text
In this section we have focussed on conditions that account for a major proportion of the burden of disease in Scotland, such as coronary heart disease, stroke and the major cancers.

We have also included conditions that have important impacts on population health, where it may be difficult to find information, or where there is a need to highlight significant information gaps. Examples include asthma, allergic conditions, epilepsy, chronic obstructive pulmonary disease (COPD), chronic liver disease, kidney disease and multiple sclerosis.

We have also included information on factors that influence our health, including immunisations, injuries, infections, diabetes, oral health and hepatitis C.

We include information on wellbeing in our mental health and suicide pages.

# data[].attributes.attachment_link.description
In this section we have focussed on conditions that account for a major proportion of the burden of disease in Scotland, such as coronary heart disease, stroke and the major cancers. We have also included conditions that have important impacts on population health, where it may be difficult to find information, or where there is a need to highlight significant information gaps.

# data[].attributes.attachment_link.readable_text
Poor mental health is an important public health challenge and significant mental health inequalities exist in Scotland. Improving the mental health and wellbeing of the population is a national priority because this is recognised as having a positive effect on many different aspects of society.

As our publication Good Mental Health for All alludes to, good mental health is essential in achieving and improving outcomes for individuals, families and communities. As such, it underpins successful delivery of a wide range of national priorities and strategy commitments.

Our Mental Health Inequalities Briefing set outs key messages and actions to address the issue of mental health inequalities.

You can find information below on

our work on mental health inequalities, including our inequality briefing

the Good Mental Health for All initiative

the Scottish Government's Mental Health Strategy.

Impact of COVID-19 on public mental health

The COVID-19 outbreak is likely to have an impact on everyone's daily lives, mental health and wellbeing.

Our rapid review of the impact of COVID-19 on public mental health includes studies from 4 March to 15 May 2020 during the COVID-19 outbreak and aims to answer three research questions

1. What impact is the COVID-19 pandemic having on mental health outcomes (using validated measures) at the population level?
2. What risk and protective factors are associated with mental health outcomes during the COVID-19 pandemic?
3. What are the key learnings and implications for Scotland?

Mental health inequalities

Mental health problems are not equally distributed across the population. Socially disadvantaged people have an increased risk of developing mental health issues to the extent that

adults living in the most deprived areas are approximately twice as likely to have common mental health problems as those in the least deprived areas (22% versus 11%)

there were twice as many GP consultations for anxiety in areas of deprivation than in more affluent areas in Scotland (62 versus 28 consultations per 1000 patients in 2010-2011).

The link between social status and mental health problems is thought to result from the level, frequency and duration of stressful experiences and the extent to which social and individual resources and sources of support reduce their impact.

Stressful experiences occur across the life course and include

poverty

poor housing

family conflict

unemployment

childhood adversity

chronic health problems.

These all contribute to a greater risk of mental health problems, particularly if several occur together and there are no protective factors to offset their negative impact.

Our mental health inequality briefing outlines two specific strands relating to social inequalities and mental health

mental health inequalities as an (often neglected) component of health inequalities

the social and health inequalities experienced by people with mental health problems.

This briefing sets out actions to address these issues based on evidence of what works and, as such, does not address the detail of inequalities in accessing mental health services.

Impacts of interventions for depression on population health and health inequalities

We know that mental health interventions can have benefits for individuals, but we don't know the scale of their impacts on population health and health inequalities. So we included three interventions for the treatment of depression in our 'Informing Interventions to reduce health Inequalities' (Triple I) project.

The interventions we included were computerised cognitive behavioural therapy, individual guided self-help, and group physical activity.

Using the interactive tool you can alter the number of individuals treated and the targeting strategy (e.g. to deprived areas), in order to estimate results for local areas as well as for Scotland.

We found that interventions for depression could help to reduce health inequalities if targeted where most needed.

National and local actions

Scotland's Mental Health Strategy

The Scottish Government's Mental Health Strategy takes a health promoting and preventative approach and sets out a range of commitments around

more accessible child and adolescent mental health

improved responses to common mental health problems

integrated community, inpatient and crisis mental health services.

The ambition is to create the best social circumstances possible and improve the conditions in which people are born, grow, live, work and age. This cannot be achieved solely by the NHS. Community Planning Partnerships, Integrated Joint Boards, third sector organisations, people with lived experience and their families and carers will also play a key role. Such partnerships can assist by working together to take action to reduce mental health inequalities, both as part of prevention and as part of service provision.

The Scottish Government has developed a framework with priorities to transform mental health in Scotland over the next 10 years.

You can read the current mental health strategy on the Scottish Government's website.

Good Mental Health for All

'Good Mental Health for All' is an initiative developed by us and endorsed by the Scottish Government and the Convention of Scottish Local Authorities which sets out a vision to improve mental health and wellbeing. It links to the Scottish Government's Mental Health Strategy and encourages action at national, local and community levels.

The document brings together a vision of a mentally flourishing Scotland and sets it in the context of the best evidence of what works and what we need to do to address health inequalities. This is essential if good mental health for all is to be achieved.

Distress Brief Intervention (DBI) programme

The Distress Brief Intervention (DBI) programme provides a framework for a compassionate and effective response to people in distress, making it more likely that they will engage with and stay connected to services or supports that may benefit them over time.

You can also read our initial evaluability assessment which aims to identify possible evaluation options.

Training and support

We provide

Information for the public

If you are looking for information on specific mental health conditions or have concerns about yourself or someone you know, please visit NHS Inform.

Find out more

You can contact us about our work on mental health.

# data[].attributes.attachment_link.description
Poor mental health is an important public health challenge and significant mental health inequalities exist in Scotland. Improving the mental health and wellbeing of the population is a national priority because this is recognised as having a positive effect on many different aspects of society.

# data[].attributes.attachment_link.readable_text
Groups & Communities most at risk of discrimination

This See Us movement has to be for everyone in Scotland, but there are some communities and groups who experience more stigma and discrimination than others.

Some groups and communities in Scotland, such as BAME, LGBT, those living in poverty experience high levels of mental health problems, and dual stigma and discrimination.. So it’s vital that people in the See Us movement are making changes in the targeted areas which need it most.

On going and sustained change is the most effective way to tackle mental health stigma and discrimination. But we know that taking action has to start somewhere. We have resources and tools here for you, whether you want to learn more, host a small starter activity, do something big to get everyone talking, or want to make on going and sustained change.

What sorts of resources are you looking for?

Here you can see what resources we have which suit you best. Select the types of resource you want, let us know the size of action you want to take, where you’re at in your journey and the reason you want to take action. We also have a few recommended resources for making a change in specific groups and communities. if you’re not sure where to start.

Recommendations

Filter by department:

Filter by:

You may also be interested in

While we have created tools and resources specifically for making changes for different groups and communities, there are hundreds of resources we have for other areas of the programme, which can also be used to make real, impactful change in this area. Here are a couple we think can help.

Sign up to See Us

Sign up to be part of the change, get our See Us Activity Pack to help you to take action at work, get updates on what is happening in the movement across Scotland and receive our See Change mail out.

# data[].attributes.attachment_link.title
See Me is Scotland’s Programme to tackle mental health stigma and discrimination.

# data[].attributes.attachment_link.description
See Me is led by a partnership of SAMH and MHF Scotland and is funded by the Scottish Government and Comic Relief.

# data[].attributes.attachment_link.readable_text
See Me is Scotland's national programme to end mental health stigma and discrimination. We are encouraging people to take action to make a difference. You can be part of that change by joining a movement of thousands of people across Scotland. Visit the See Us pages and get all the tools and resources you need to take action.

Sign up to be part of the See Us movement and you'll receive our action activity pack, get updates on what is happening and how you can get involved, and receive our monthly See Change mail out, which focuses on where stigma exists and what you can do to tackle it.

# data[].attributes.attachment_link.title
See Me is Scotland's Programme to tackle mental health stigma and discrimination.

# data[].attributes.attachment_link.description
See Me is Scotland's national programme to end mental health stigma and discrimination. We are encouraging people to take action to make a difference. You can be part of that change by joining a movement of thousands of people across Scotland. Visit the See Us pages and get all the tools and resources you need to take action.

# data[].attributes.attachment_link.description
The primary causes of health inequalities in Scotland.

# data[].attributes.attachment_link.readable_text
Cookie settings

When you visit any website, it may store or retrieve information on your browser, mostly in the form of cookies. This information might be about you, your preferences or your device and is mostly used to make the site work as you expect it to. The information does not usually directly identify you, but it can give you a more personalised web experience. Because we respect your right to privacy, you can choose not to allow some types of cookies. Click on the different category headings to find out more and change our default settings. However, blocking some types of cookies may impact your experience of the site and the services we are able to offer.
Cookie policy

Manage Consent Preferences

Strictly Necessary Cookies

Always active

These cookies are necessary for the website to function and cannot be switched off in our systems. They are usually only set in response to actions made by you which amount to a request for services, such as setting your privacy preferences, logging in or filling in forms. You can set your browser to block or alert you about these cookies, but some parts of the site will not then work. These cookies do not store any personally identifiable information.

Performance Cookies

Performance Cookies

These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. They help us to know which pages are the most and least popular and see how visitors move around the site. All information these cookies collect is aggregated and therefore anonymous. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance.

Functional Cookies

Functional Cookies

These cookies enable the website to provide enhanced functionality and personalisation. They may be set by us or by third party providers whose services we have added to our pages. If you do not allow these cookies then some or all of these services may not function properly.

Targeting Cookies

Targeting Cookies

These cookies may be set through our site by our advertising partners. They may be used by those companies to build a profile of your interests and show you relevant adverts on other sites. They do not store directly personal information, but are based on uniquely identifying your browser and internet device. If you do not allow these cookies, you will experience less targeted advertising.

# data[].attributes.attachment_link.title
Our programmes in Scotland | Mental Health Foundation

# data[].attributes.attachment_link.description
Good mental health for all. Dedicated to finding and addressing the sources of mental health problems.