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ABSTRACT

Introduction

The number of homeless people in England is increasing. In 2018, there is estimated to be approximately 4700 rough sleepers in England; 3000 more than in 2010. Similarly, the number of families living in temporary accommodation has grown by 68% between 2010 and 2017. However, because of the nature of homelessness and the way in which it is monitored, much of homelessness remains hidden; the true extent of the issue is believed to be far reaching and growing. Homelessness in the developed world is a particular issue because it is considered largely preventable and due to underperforming or under-funded support systems rather than a lack of resources.

Homeless people live substantially shorter lives, spend a much greater proportion of their life in poorer health, and have higher health and social care needs than the general population. In the UK, the life expectancy of a homeless person is 47 years, compared to 77 years for the general population. This difference in outcomes is related to higher rates of exposure to risk factors including alcohol, smoking, substance misuse and poor mental health. While some health issues are a reflection of a homeless person's living conditions, they can also be a factor in becoming and remaining homeless. Understanding the health issues and experiences of homeless people is critical to help deal with these issues in the short and longer terms, and to ultimately support them into a stable housing situation.

The relationship between homelessness and health is under-researched, particularly in terms of qualitative research, with the majority of studies originating in the USA or Canada. Understanding the experiences, practices and perceptions of homeless people in managing their health is essential to inform effective interventions to improve health outcomes. This study aims to explore homeless people's experiences and perceptions of health and health services to inform policy, commissioning and service provision to deliver better health outcomes for this group. The study was carried out in Gloucestershire (County in South West England). The county has two large urban centres (Gloucester and Cheltenham) with a large rural geography. This was chosen as the study sight due to the access of the researchers to the homeless population. It was also felt homeless issues in Gloucestershire will offer insights for other counties with a similar geography and population.

Methods

Participant recruitment

A convenience sampling approach was applied in recruitment of homeless participants present in Gloucestershire between January and March 2018. Homelessness was defined as any person who stays at or engages in rough sleeping, staying at hostels, bed and breakfast and other temporary accommodation, squats, derelict buildings, barns and other buildings not used for accommodation, 'doubling up' or 'sofa surfing', and 'survival sex' as a means of securing accommodation. Participants were recruited through non-health organisations providing services to homeless people in two urban locations within Gloucestershire. Participants provided written or recorded verbal consent.

Data collection

Twenty six semi-structured interviews were completed in private offices by interviewers. Twenty four interviews were with an individual and two with homeless couples. The interviews were digitally recorded where consent was given. Where consent to record was not given (one interview), detailed notes were taken.

The interviews were directed by a topic guide, which was structured around research objectives. The format of the interviews ensured key areas was examined, whilst allowing the flexibility to explore relevant themes arising through dialogue. Subject areas covered during the interviews included reasons for homelessness, understanding of 'being healthy', experiences and practices managing health, relationship between living environment and health and experiences and perceptions of healthcare services.

Data analysis

An interpretivist approach guided the study design and data analysis. Digital recordings were transcribed, and thematically analysed. The thematic analysis applied the Braun and Clarke approach to thematic analysis: familiarisation with data, generation of codes, searching for themes, reviewing themes and defining and naming themes. All transcripts and subsequent data analysis was anonymized, and participant names replaced with pseudonyms.

Ethics

The research proposal for this study was presented to the Gloucestershire County Council Research Governance Committee. The committee is supported by the Gloucestershire NHS Research Support Unit. The Committee reviewed the proposal and concluded that the primary purpose of the research was to inform service and system development in Gloucestershire to support homeless people. The committee also judged that participation would not induce undue psychological stress or anxiety. On this basis, the committee concluded that the research did not require formal ethics approval.

Results

Twenty eight homeless people were interviewed. The majority of participants were living in supported housing (54%) or rough sleeping (39%). The remainder defined themselves as sofa surfers or living in bed and breakfast accommodation. Twenty nine percentages of the participants were female. However, only 18% of those identifying themselves as rough sleepers were female. Seventy one percentages were of White British ethnicity. Interviews ranged between 20 and 50 minutes.

Becoming homeless

Participants described longer term causes of homelessness as stemming from the breakdown of a family unit when they were young, or where the family situation was chaotic. The instability normally involved one or both parents leaving the family home or bereavement of a significant family member or carer. Participants often described physical and emotional abuse within the family when describing their family situation. Participants related these traumas during their childhood to their subsequent misuse of drugs and/or alcohol. They recognized the relationship between the trauma, use of substances to manage the psychological impact and their subsequent loss of accommodation. Moreover, they appreciated their inability to deal with the early childhood trauma and drug/alcohol abuse affected their ability to manage their life and come out of homelessness.

Following release from prison, participants often attributed the most recent cause of homeless to a lack of support (resources or support networks), which left them without the ability to secure accommodation. Others described the breakdown of a relationship resulting in the loss of accommodation, and financial management issues which led to eviction from their accommodation. These issues whilst attributed by homeless people as the contributing factor to their most recent episode of homelessness are exacerbated low social capital and few alterative resources to call on. Additionally, having to manage substance misuse and/or mental health issues often left the individual unable to cope with the administration side of finding and sustaining accommodation.

Perceptions and understanding of health

Many participants descriptions of health including having control over their life and being able to determine their future. Being healthy was also described as not using drugs or alcohol, being able to manage mental health conditions, having social networks, having access to showering facilities and clean clothes and being able to sleep without disturbance. Participants understanding of health and 'being healthy' was complex and diverse, and extended well beyond a disease based paradigm. Commonly, their descriptions focused on control over their environment or future.

Although participants felt health was important, there were other issues which they prioritized above this; mainly achieving stable housing. Participants living in supported housing were keen to move into private rental accommodation, where they perceived they would have greater control over their lives and be able to gain more stability. Other priorities for homeless people focused on managing mental health issues and achieving control over addiction to drugs and/or alcohol. Participants felt that gaining control over these issues would then permit them to concentrate on achieving a healthier lifestyle.

Health issues for homeless people

Most participants reported a mental health or a physical health issue, often both. Mental health issues were most commonly reported: depression, anxiety, personality disorders and post-traumatic stress disorder. Participants understood the role substance misuse played in their mental health; however, they also described the role of drugs and alcohol in providing immediate short-term relief. Drugs and alcohol were used to block out memories or to help deal with traumatic experiences from their childhood, normally involving abuse or bereavement. Participants described episodes of self-harm and suicidal thoughts, which they related to their mental health issues and traumatic childhood events; some described attempting suicide on one or more occasions. Dividing issues between social and health categories was not useful or possible for many of the participants. Childhood trauma, mental health, substance misuse and homeless were not separate issues; they formed part of the complexity of their life and needed to be dealt with together.

Physical health issues were relatively common including Hepatitis C, physical disabilities, diabetes, pancreatitis, ulcers, cirrhosis of the liver, asthma, deep vein thrombosis and migraines. These were rarely treated as priorities as more focus was placed on their mental health, housing and substance misuse.

Managing health

Participants had knowledge of proactive actions they could undertake to maintain their health. They understood what a balanced diet was and its benefit to their health. While rough sleepers had access to enough food, they had limited control over their diets and took what they were offered. This commonly meant they had limited access to fruit and vegetables unless they supplemented it with additional food purchases.

Conversely, those in supported housing have access to catering facilities, giving them more control over their diet. Although, some reported less access to the quantity of food previously available when rough sleeping. This appeared to be dependent on the proximity to services providing free meals. Participants in supported housing rarely reported a high level of fruit and vegetable intake. In both forms of homelessness, there appeared to be an issue over control and access.

When describing physical activity, participants normally talked about accessing a gym. Although none had access to a gym, many had aspirations to join one in the future. Most participants, particularly rough sleepers, described walking considerable distances during the day but very few viewed it as exercise. Again, exercise as an activity to manage health was seen as an aspirational activity, which would be addressed when more immediate base needs were fulfilled.

Many participants were regular tobacco smokers and recognized the impact on their health, but reducing or quitting smoking was a very low priority. Most were not interested in accessing support to stop or reduce tobacco use. If cessation attempts were important to the participant, they would be addressed after their other priorities were resolved.

Social networks and health

Many of the participants perceived dangers from socialising with their peers, usually where the participant was managing a substance misuse issue and did not want to interact with current users. The availability of substances and seeing others using could lead to them partaking. This often resulted in excluding themselves from socialising with other homeless people. Particularly among rough sleepers, there was a perception of having to manage relationships to avoid becoming a 'victim'. Trust levels appeared to be low with a perception that peers might take advantage for material gain. Participants did not tend to rely on their peers for social and emotional support; few described close relationships with other homeless people. This was a difficult situation for many, as they understood the importance of social networks for their wellbeing, but also realized the implications of integrating with their peers.

Some participants described a reluctance to engage with family members due to their current situation, normally described as not wishing to make the participant's issues a problem for their family. However, there were several instances where participants were maintaining family relationships, and finding these a source of support. For many, reconnecting with their family was a motivating factor to address their substance misuse issues and to find stable accommodation.

The relationship between health and living environment

Whilst rough sleepers acknowledged the discomfort associated with sleeping in wet, cold and windy conditions, they did not tend to relate this to their health. For many, the living environment was a housing issue, not a health one. They viewed their living environment as removing control over health attaining activities. They were precluded from accessing the resources they might have in a more stable situation.

In supported housing, there were positive experiences; with improvements in sleep and feelings of security, particularly for participants moving from rough sleeping or chaotic living situations. Negative impacts related to stressors in the living environment; usually noise and disturbances from other residents. This was felt to affect feelings of security, contributing to levels of anxiety and depression, as well as impacting on the sleep of some. Those within supported housing were focused on moving into private accommodation. This was felt by many as a key step out of homelessness, and away from the social networks and risk taking behaviours they perceived precipitated their homelessness.

Primary and secondary healthcare services

The dedicated NHS Homeless Healthcare Team, which provides primary care services to the homeless, was perceived very positively by participants. The key benefit was accessibility; it was based in a location that they frequented for other services, with relatively little waiting time. Participants reported being reminded about appointments and medication.

Rough sleepers felt it was difficult to access mainstream primary care services as they did not have a permanent address. Several described experiences where they were asked to provide proof of address before they could register at a GP Practice.

Whilst some participants expressed satisfaction with mainstream NHS services, several felt that they were being 'judged' or 'looked down on' by staff on account of their living circumstances or substance misuse problems. One participant acknowledged this perception may be a reflection of their own psychological state at the time of accessing the service.

Experiences of mental health (and substance misuse) services

Accessing mental health support was a priority for a large proportion of those interviewed. While participants understood mental health and substance misuse as part of the same problem, they felt that health services viewed them as independent issues. Participants felt they were required to be 'clean' before they could access mental health support which left them, at least temporarily, with potentially no resources to manage their condition. Some frustration was expressed regarding the waiting times to access mental health services, or where they believed there was no mental health support available or offered. Similarly, some referenced a wait time to access substance misuse support services, or that the treatment protocol did not match the treatment they had been on previously.

Discussion

Main finding of this study

This study provides a new insight into how homeless people understand, manage and prioritize health. Homeless people understand early trauma, family instability, mental health, substance misuse and homelessness as co-dependent variables, which have to be addressed together. They expressed frustration with supporting services, which compartmentalized these elements. Homeless people had an expansive positive understanding of health and the actions they could take to support their health, although rarely experienced control over these factors. Homeless people understand the importance of social networks, but also experience peer socialising as risky and often isolate as a protective measure. Homeless people report difficulties accessing mainstream primary care services. Some homeless people also perceive being 'looked down on' by healthcare staff.

What is already known on this topic

The relationship between homelessness and early trauma is examined in the wider literature, which highlights an association between homelessness and presence of abuse. The evidence regarding Adverse childhood Experiences also supports this association and further highlights the potential benefit of routine inquiry across the life course as a means of breaking the cycle of adversity. Moreover, the cumulative impact of adverse incidents on a person's personal resilience, coupled with a weak or absent social support network may result in higher propensity to become homeless., Research has also demonstrated a complex relationship between substance misuse and homelessness. This study describes a much more complex interaction of co-dependent variables, which should not be considered in isolation.

Other studies use the concept of intersectionality as a framework for understanding homelessness., This highlights the interconnectedness of social categories which define the issue of homelessness. Our study also highlighted specific traits which appear to be related to, or possibly a determinant of, homelessness. Looking at homelessness through the lens of intersectionality helps to expose homelessness as a complex set of determining factors, which is reflected in a diverse population who cannot easily be considered as a homogenous group. Our study did not explicitly consider the exploration of intersectionality in its design or analysis, but future studies would be greatly enhanced by doing so. Healthy behaviours were prioritized below issues such as housing by participants. This is supported in the wider literature which suggests that base level needs, such as housing and security must be addressed before the adoption of healthy behaviours.,, Rae and Rees also note that while health issues are recognized, they are often not prioritized. Our study additionally goes some way to describing why particularly physical health is not prioritized because of competing mental health and substance misuse issues.

There was low trust in homeless social circles and peer groups were not experienced as a source of support. The absence of robust social networks is a key precipitating factor in becoming homeless and a strong determinant of health outcomes.,,, The lack of trust between homeless people suggests that building social capital may have to be facilitated by professionals, until they can form new networks outside of their homeless peer group. Other studies have also linked the promotion of positive social networks as being helpful to deliver 'recovery capital', which may ultimately help to address issues of addition, which have a close relationship with homelessness.

Mainstream primary care services were perceived to have substantial barriers to access, such as requiring a permanent address. This is a recurring theme in the wider literature, which may be a real barrier to access in some circumstances and a perceived barrier in others. While dedicated services are more effective in engaging homeless people, they may also be an important element in the 'citizenship' of homelessness. The perception of being stigmatized and judged by mainstream health services because of their personal situation is a common experience and barrier to access for homeless people.,,

The interdependence mental health and substance misuse issues was a strong theme throughout the study. There was frustration with the perceived independence of substance misuse and mental health services. This is an issue that has been recognized in research and policy., Dual diagnosis (co-occurring mental health and substance misuse) is prevalent and must be dealt with as part of a common integrated approach that does not attempt to silo these co-dependent variables.,

What this study adds

This study points to the requirement to deal with base level needs before healthy behaviours can be successfully adopted. This research also calls for an integrated approach to the understanding of and response to early trauma, family stability, mental health, substance misuse and homelessness. While the interventions to address the health issues for homeless people are important, the policy approach must be to work to eliminate the issue of homelessness and the stark health inequality that this represents. This can only be addressed by tackling the determinants of homelessness, which are often rooted in childhood experiences. This will mean early identification of risk factors related to adverse childhood experiences, and the timely deployment of support to manage this before the implications are realized.

Limitations of this study

Participants were recruited through non-healthcare services for homeless people. Only those who were accessing support services were 'heard' in the data. This may mean that the least engaged homeless people are omitted. Additionally, a self-selecting cohort of participants may not reflect the wider population of homeless people. All of the interviews were carried out in two urban centres. The experiences of homeless people living in these areas may differ to those who are homeless in more rural parts where services are limited.

Disclaimers

None.

Acknowledgements

With thanks to the Gloucestershire County Council team who supported interviews and transcriptions; B. Bhula, J. Cheminais, H. Ellis, N. Hargrave and D. Lane. A special thanks to the staff and volunteers at Gloucester City Mission, Elim Housing, P3 and Cheltenham Open Door who facilitated access to participants. We would also like to thank those who gave up their time to participate in the study.

Dave Mc Conalogue, Consultant in Public Health

Nicky Maunder, Commissioning Officer

Angelika Areington, Commissioning Officer

Katherine Martin, Data and Analysis Manager

Vikki Clarke, Commissioning Officer

Sarah Scott, Director of Public Health

Funding

This study was not funded.

Conflicts of interest

None declared.

References

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Homeless people and health: a qualitative enquiry into their practices and perceptions

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ABSTRACTBackground. Homeless people experience poorer health and shorter life expectancies than the UK average, but their health needs and expectations have rec

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Data availability statement

Data are available upon reasonable request. Should anyone wish to have access to the data, they can request as such.

https://creativecommons.org/licenses/by/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

Key messages

Thirty-eight per cent of veterans had a code on their medical record for a common mental health disorder.

The highest disorder prevalence was depression at 18%, followed by alcohol misuse at 17%, anxiety 15%, post-traumatic stress disorder was 3% and dementia 2%.

The SNOMED searches do not detail why certain groups had higher recordings of certain disorders.

Female veterans have a higher prevalence of common mental disorders than their male counterparts.

The National Health Service England and Royal College of General Practitioners need to identify if there is a mechanism for increasing primary healthcare veteran registration to provide a more reliable source of data.

Introduction

Serving military personnel have been identified as having a high prevalence of mental disorders with the likelihood of common mental disorders (CMDs) being approximately doubled. 1 In the British Armed Forces, depression is the most common mental health (MH) disorder, with the Ministry of Defence (MoD) reporting that 12.7% of the British Armed Forces were seen in military healthcare for an MH-related reason with 2.7% being seen by a specialist MH clinician. 2 There is estimated to be 2.4 million UK Armed Forces veterans, which make up an approximated 5% of the total population. 3 Within this veteran population, 89% are male, 60% are aged 65 years and over, and 62% are married. 3 Military veterans have a higher prevalence of CMD including anxiety, depression, 4 5 post-traumatic stress disorder (PTSD) and alcohol misuse than the general population, 6 and these rates are higher for those with combat experience. 7

To improve MH support for veterans, National Health Service England (NHSE) launched Op COURAGE: the Veterans Mental Health and Wellbeing Service, which aims to facilitate priority access to veteran-specific services for service-related problems. 8 The effectiveness of this initiative in part requires veterans to be correctly identified and registered with a primary healthcare (PHC) practice. Since 1985, UK patients' PHC medical records contain Read Codes (now being replaced by Systematized Nomenclature of Medicine - Clinical Terms SNOMED CT codes) that mark characteristics such as diagnosis, ethnicity and therapeutic interventions, and a code to annotate 'military veteran'. 9 One means to therefore estimate the level of MH disorders in the veteran population is through the PHC medical records. However, veterans typically have poor help-seeking behaviour for mental disorders; barriers include stigma, military culture of stoicism and concerns surrounding understanding by healthcare staff. 10 It may take reaching crisis point to seek help, leading to higher rates of PTSD. 11 Research indicates that only 8% of the veteran population are correctly registered; resulting in a potential lack of support for their specialised MH needs. 12 The Royal College of General Practitioners (RCGP) launched a 'veteran-friendly practice' accreditation in England to improve the recording and support of veterans within PHC; by October 2021, there were 1050 (from approximately 7000) practices accredited, 13 yet the number of correctly registered veterans remains low. This paper reports the levels of military veterans with CMDs using data drawn from PHC medical records. The authors are unaware of any similar English study with a cohort profile of English veterans.

Aim and objectives

The aim was to identify the prevalence of CMD within the English veteran population. The objectives are to: (a) identify trends regarding veterans' age, gender and marital status; (b) identify the prevalence of dementia, PTSD, depression, anxiety, alcohol misuse and substance misuse.

Methodology

PHC staff provided the data from PHC patient medical records. Read/SNOMED codes were used. These codes provide a consistent vocabulary for PHC staff to record factors such as characteristics, diagnosis and pharmacological treatments onto a patient's medical record. For example, if a patient is diagnosed with depression, a code will appear on their record for 'depression'. There are many different codes available, and it is to the discretion of the staff member who is recording the information to choose the appropriate code. The dependent variable was the SNOMED (code 753651000000107) or Read Code (code 13Ji) for 'military veteran' which was then correlated with the common military MH 8 recording of the codes for depression, anxiety, PTSD, alcohol misuse, substance abuse and the physical disorder of dementia. Practices were asked to include codes related specifically to these disorders. There was direction to try and ensure consistency as there were numerous codes that were used. For example, 'depression' included depressive episodes and depressive disorder, and anxiety often being coded along with depression as 'anxiety with depression' or 'mixed anxiety and depression' as well as its own code of 'anxiety disorder'. PTSD was only coded as 'post-traumatic stress disorder'. Substance abuse was often coded more specifically such as 'heroin addiction' or 'opioid dependence', all substance dependencies and addictions were asked to be included within the search. In addition, for alcohol this was coded as 'alcohol abuse' or 'chronic alcoholism' or simply 'alcohol'. Dementia was coded as 'dementia in Alzheimer's' or 'Alzheimer's disease' or simply 'dementia'. Significant MH disorders such as bipolar and schizophrenia should have restricted people with these problems from enlisting and were therefore excluded. Data were received in an anonymised and amalgamated form. Being aware of the considerable pressures on PHC, the search strategy was designed to maximise the data that could be collected while being cognisant of other demands and priorities on PHC staff. Therefore, the searches were restricted to common military MH disorders and basic demographical data (age, gender and marital status). The PHCs were financially remunerated for their time. Data were inputted into an SPSS database (Version 27) for analysis where descriptive statistics were identified, followed by inferential analyses of the relationships between MH disorders and demographical data.

Method

The authors worked with 16 PHCs across Cheshire and Lancashire with a total patient population of 178,568 to improve their veteran patient registration. Drawing on an estimated veteran population of 5% per PHC practice in Northwest England meant that at the commencement of these projects, 9.1% (N=781) of veterans were correctly coded; increasing to 28.7% (N=2449) by the time the project ended. This final figure provided the data for this paper, and the information was collected in March 2021. The research was funded by NHSE and Forces in Mind Trust (FiMT).

Results

From 2449 veteran PHC records, 88% (N=2147) were male and 12% (N=302) female. The average age was 62 years with a SD of 18. The youngest veteran was 16 years old and the oldest 99 years. The mode of the veterans was the age group 58-67 years, with 20% (N=490) belonging to this age group. For 68.4% (N=1675) of veterans, marital status was unknown. Of the remaining 774 veterans, 67% (N=518) were married, 20% (N=154) single, 5% (N=38) widowed, 4% (N=33) divorced, 2% (N=19) cohabiting, 1% (N=7) separated and 1% (N=5) were in a common law partnership. Thirty-eight per cent (N=938) of the veterans had a code on their medical record for PTSD, depression, anxiety, alcohol abuse, substance misuse or dementia. Furthermore, there was some comorbidity with veterans with more than one disorder. The highest disorder prevalence was depression (17.8%, N=437), followed by alcohol misuse (17.3%, N=423) and anxiety (15.0%, N=367); while PTSD was (3.4%, N=83), dementia (1.8%, N=45) and substance misuse (0.8%, N=19) (see Figure 1).

A total of 37.5% men (N=805) and 44.0% women (N=133) had a code on their record for a mental disorder. The relationship between gender and presence of a mental disorder was found to be significant (X ² (1, N=2449)=4.5, p<0.05) suggesting that female veterans have a higher prevalence of mental disorders than their male counterparts as is consistent with the general population. 14 Figure 2 shows the prevalence of each disorder by gender. Women had a higher prevalence than men for both anxiety (25.5%, N=77) and depression (25.8%, N=78), which may be due to poorer help-seeking behaviour from the male veteran population. 10 The relationship between anxiety and gender was also found to be significant (X ² (1, N=2449)=29, p<0.01), as was the relationship between depression and gender (X ² (1, N=2449)=14.4, p<0.01). Women also had a higher prevalence of substance misuse (1.0%, N=3), however this difference was not significant (X ² (1, N=2449)=0.01, p>0.05). In contrast, men had a higher prevalence of PTSD (3.7%, N=79), however the difference was not significant (X ² (1, N=2449)=3.8, p>0.05). Men also had a higher prevalence of dementia (1.9%, N=40), but again the difference was not significant (X ² (1, N=2449)=0.001, p>0.05) (see Figure 2).

The individual age with the highest percentage of mental disorders was 41 years, meaning 66.7% (N=10) of those aged 41 years had a mental disorder coded on their record. However, the age group with the highest number of veterans with mental disorders, and therefore the mode, was 48 years (N=29). Of those with mental disorders, the average age was 61 years, and the median age 60 years. The age group with the highest percentage of mental disorders was the group 38-47 years (44.4%, N=112), followed closely by the group 58-67 years (43.9%, N=215) and the group 48-57 years (43.8%, N=212). This percentage then decreased for the group 68-77 years (30.5%, N=99), climbing gradually thereafter, likely due to the presence of dementia. The difference between the age groups on having a mental disorder present was found to be significant (X ² (9, N=2449)=40, p<0.01) (see Figure 3).

The results indicated the presence of each disorder within the different age groups. Anxiety was the most prevalent among the age group 38-47 years (21.0%, N=53) closely followed by the 18-27 years (20.8%, N=11) suggesting anxiety has a higher prevalence among younger age groups in the veteran population. The difference between these groups in regard to anxiety prevalence was found to be significant (X ² (9, N=2449)=32.7, p<0.01). Depression was also highest among the age group 38-47 years (28.6%, N=72), likely due to the high comorbidity of these disorders; but the second highest prevalence was found in the group 28-37 years (22.6%, N=44). These differences were also found to be significant (X ² (9, N=2449)=73.9, p<0.01).

For PTSD, the highest prevalence was among the age group 28-37 years (8.7%, N=17), closely followed by the age group 38-47 years (8.3%, N=21), with significant differences between the groups (X ² (9, N=2449)=66.6, p<0.01). Dementia, as expected, had a higher prevalence among the older age groups with prevalence highest in the group 88-97 years (8.8%, N=14)-the differences again being significant (X ² (9, N=2449)=101.2, p<0.01). Alcohol misuse had the highest prevalence among the age group 58-67 years (24.5%, N=120), followed by the age group 48-57 years (20.2%, N=98), these differences were also significant (X ² (9, N=2449)=45.9, p<0.01). Finally, for substance misuse, the highest prevalence was among the age group 18-27 years (1.9%, N=1), closely followed by the age group 48-57 years (1.7%, N=8). However, the differences between these groups, for substance misuse, were not significant (X ² (9, N=2449)=8.9, p>0.05) (see Figure 3).

Discussion

Using PHC medical records to identify the prevalence of common MH disorders within the veteran population is severely hindered by the low percentage of veterans with the correct Read/SNOMED code applied (currently estimated to be under 10% 12 15). The authors were part of NHSE and FiMT-funded programmes to improve veteran registration and PHC staff awareness; consequently, this study was based on an average of 26.7% per practice (range 5.0%-54.1%). Searches were limited to the known common military MH disorders of PTSD, depression, anxiety, alcohol misuse, substance abuse and the physical disorder of dementia. If all MH disorders had been included, the overall total would have been higher.

Within this study, demographics from a gender perspective aligned to this known non-parametric population with 88% being male. Forty-six per cent of the veterans were aged 65 years and over, significantly lower than the MoD estimate of 60% for this age group. 3 The data from this study indicated that approximately 70% of veterans were in a relationship (67% married) and only 4% divorced. These are significantly lower than the general population and may be due to factors such as medical records not being updated. Age does indicate that, in particular, the more elderly veterans are not correctly registered with their general practitioner (GP) practice. There are multiple reasons for this, such as veterans being unaware of the 1-day inclusion criteria and therefore being unaware of their veteran status and never declaring as such. This could extend to those more vulnerable members of the population in care and residential homes, or with dementia, who may be reliant on others for much of their communication with PHC.

The overall rate of MH in the UK Armed Forces was found to be broadly comparable with the UK general population. 16 For the veteran cohort within this research study, depression, anxiety and alcohol misuse were the leading MH disorders. However, the levels of depression were lower than identified within the Defence Medical Services and the national population. Within this study, level of depression was 17.8%, while in the general population this stands at 21%, and for serving personnel at 32%; though prior to the isolation of COVID-19, the level in the general population was lower at 19%. 2 17 Both within the MoD and the general population, mild to moderate depression is predominately due to situational stressors such as relationship problems, employment and financial problems. 18 19 The more elderly group may be retired, and for those veterans who served a full career, the military pension is highly competitive; this may in part explain why levels of anxiety and depression reduced notably as the veteran got older. Depression and anxiety are also often linked (comorbidity) and some research studies may place an emphasis on the depressed element. There is also the issue that GPs will often not identify depression or record depression on a patient's medical record due to the direction of their patients who are concerned about the impact of a MH diagnosis on their future career options, or other everyday issues such as higher travel insurance costs. 20

Depression and anxiety were both significantly higher in women, which warrants further investigation. Previous studies have indicated that GPs were more likely to see female patients on a regular basis, which may help indicate why such issues may be picked up more often in women. 21 Furthermore, the Armed Forces may be seen as having a more 'macho' culture than some other careers, which may lead to poor help-seeking behaviour and concerns of being labelled 'weak'-potentially another factor in a lower level of depression and anxiety being picked up in male veterans. 10 However, there is evidence that help-seeking behaviour is increasing among both serving and ex-serving personnel. 22 In terms of age difference, the study revealed that anxiety in those aged 18-27 years old accounted for 21% (N=11) of cases. By their very essence, this age group will include young early service leavers. As the peak of the last major deployments (and therefore associated operationally related MH problems) was over 10 years ago, their anxiety may be due to their current living situations and potentially not related to their military service. However, anxiety and depression were highest in the age group 38-47 years, a possible reason being that veterans served longer and had greater difficulties in transitioning from the Armed Forces in relation to accommodation, finance, housing and employment. There may also have been adjustment issues for their spouse and children including schooling. But the coding of the veterans' medical records does not capture this information.

PTSD in a combined sample of veterans and serving personnel was found to be 4% in 2004/2006 and 2007/2009 but had risen to 6% in 2014/2016. 23 This compares with a rate of 4.4% within the civilian population. 23 The prevalence of PTSD is not consistent across these groups, however, with serving personnel having a prevalence of 4.8% and veterans significantly higher at 7.4%. 23 The PTSD levels in this study were comparable at 3.4% (N=83). The results, however, may be inflated as PTSD may remain on a patient record even when the patient is deemed to have received successful treatment, and unless the date of the last positive assessment or treatment is recorded then diagnosis will remain in the patient's medical record. Ideally, an inclusion criterion such as a positive assessment and affirmation of the condition in the last 5 years would help rectify this concern. Many studies show male veterans have significantly higher levels of PTSD but that was not the case in this study. In the UK, frontline troops are identified as having 17% compared with 4% on non-frontline troops which can be attributed to their role in the military and the increased likelihood that they have been in contact (combat) situations. 23 However, the average age group of those recorded in GP practices in this study at 38-47 years is significantly different to the attributed average age of veterans. Furthermore, the highest prevalence was 28-37 years old, which would include those who had deployed to Afghanistan (2004-2014) and Iraq (2001-2012).

The levels of listed alcohol misuse are of concern but significantly less than that often associated with the military. A potential reason is that veterans may be consuming more than the recommend weekly average; but they are functioning very well, have no concerns about their behaviour and are therefore not raising it as an issue with their GP. Even when they have, as it is not causing any problems, then the GP has not recorded the detail. There are differences between genders with men more likely to be diagnosed with an alcohol-related problem. Potentially harmful alcohol misuse remains a common behavioural problem but has declined steadily from 16% in 2004/2006 to 10% in 2014/2016. 23 Within these studies on veteran population, the highest was in the age group 58-67 years. A combination of factors such as the progressive nature of alcohol misuse, potentially being retired and that the records may be related to a diagnosis some years before are all potential factors.

Substance abuse was higher in women but listed in only 1% of cases and not statistically significant. The military's regular random drug tests are a deterrent and this may have transitioned into veteran behaviour. It could also be due to under-reporting and that this is a more elderly population. Substance misuse was most prevalent in the group 18-27 years old, so again the early service leavers. There may also be a sense of shame from those who were discharged due to substance abuse and therefore they may not want to declare their veteran status.

Dementia was notable in the 78 years old and above cluster and most prevalent in the age group 88-97 years. As 60% of the veteran population are over 65 years and 50% over 70 years old, the authors had expected to see higher levels of dementia. As the leading cause of death within the UK, with a population estimate of 7.1% then the 1.8% within this study appears low. 24 Recent studies have indicated that dementia rates in the veteran population are not higher than the general population. 25 The low rate in this study is likely to be under-recording due to PHC being unaware of the veteran status and therefore does not have the correct military veteran code attached to their records. The NHSE and RCGP would need to identify if there is a mechanism for increasing registration for this group which would provide a more reliable source of data. It would be reasonable to anticipate that large numbers of veterans are residing in care/residential homes and a means of connecting with them to get them registered is required. In addition to ensuring this can be used to provide the best clinical care, then it also has important ramifications for non-statutory and third-sector organisations that have considerable resources to assist all of the veteran population. There is also the issue of UK women living on average to an older age than men (83 compared with 79 years), and veterans' spouses being left socially isolated, with financial difficulties and increasing dementia issues without their needs to be correctly identified, assessed and supported.

Conclusion

The searches were limited to the MH disorders commonly associated with the Armed Forces and veterans with PTSD, depression, anxiety, alcohol misuse, substance abuse and the physical disorder of dementia. This was a deliberate strategy with a key determinant being not to overwhelm the PHC staff completing the searches. This requirement was discussed with each of the 16 participating practices before the programmes started and it was clear that the association between the rationale for these searches was embraced by the staff and therefore helped compliance with conducting the data collection.

The SNOMED searches do not detail why certain groups had higher recordings of a certain disorder and a future study that accesses the written medical notes would prove enlightening to specifically identify what situational factors were having the most impact on the veteran population. As far as the authors can determine, this is the first published article outlining the English veteran morbidity using PHC medical records. As such, the results from a sizeable English population provide information that should be considered in developing veteran-specific clinical provision, educational syllabus and policy.

Data availability statement

Data are available upon reasonable request. Should anyone wish to have access to the data, they can request as such.

Acknowledgments

Kirsteen Waller from Forces in Mind Trust for supporting the centre during the project and its subsequent publications.

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Prevalence of common mental health disorders in military veterans: using primary healthcare data

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Introduction Serving military personnel and military veterans have been identified as having a high prevalence of mental disorders. Since 1985, UK patients' primary healthcare (PHC) medical records contain Read Codes (now being replaced by Systematized Nomenclature of Medicine - Clinical Terms (SNOMED CT) codes) that mark characteristics such as diagnosis, ethnicity and therapeutic interventions.

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Objectives Undertake a scoping review to determine the effectiveness of community-centred interventions designed to improve the mental health and well-being of adults from ethnic minority groups in the UK.

Methods We searched six electronic academic databases for studies published between January 1990 and September 2019: Medline, Embase, PsychINFO, Scopus, CINAHL and Cochrane. For intervention description and data extraction we used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist and Template for Intervention Description and Replication guide. Quality was assessed using Cochrane risk of bias tools. Grey literature results were deemed beyond the scope of this review due to the large number of interventions and lack of available outcomes data.

Results Of 4501 studies, 7 met the eligibility criteria of UK-based community interventions targeting mental health in adults from ethnic minority populations: four randomised controlled trials, one pre/post-pilot study, one cross-sectional study and one ethnographic study. Interventions included therapy-style sessions, peer-support groups, educational materials, gym access and a family services programme. Common components included a focus on tackling social isolation, using lay health workers from within the community, signposting and overcoming structural barriers to access. Four studies reported a statistically significant positive effect on mental health outcomes and six were appraised as having a high risk of bias. Study populations were ethnically heterogeneous and targeted people mainly from South Asia. No studies examined interventions targeting men.

Conclusions There is a paucity of high-quality evidence regarding community-centred interventions focused on improving public mental health among ethnic minority groups. Decision makers need scientific evidence to inform effective approaches to mitigating health disparities. Our next steps are to map promising community activities and interventions that are currently being provided to help identify emerging evidence.

Study identification

A systematic search of six electronic databases between January 1990 and September 2019 was conducted: Medline, Embase, PsycINFO, Scopus, CINAHL and Cochrane. The search strategy ( online supplemental appendix 1) was created with the support of a medical librarian and was based on the population, intervention, comparison, outcomes, context (PICOC) framework. It included key terms for ethnicity, age range, geography and mental health outcomes. No intervention or comparison terms were included to optimise capture of all relevant studies.

We excluded evidence from the grey literature as an initial search of primary data from local government, relevant third sector and NHS websites identified numerous activities and possible interventions (over 50 in a small geographical area). Information was provided in formats such as a flyer or a website or Facebook page describing services and activities, but with limited descriptions of the community intervention and outcomes data. Consequently, data synthesis exceeded the methodological approach of a scoping review; a mapping methodology would be more appropriate. 36

Eligibility criteria

Table 1 outlines the inclusion and exclusion criteria used to determine the eligibility of a study. We included studies published from 1990 onwards so that our findings would inform contemporary policy and practice. Furthermore, systematic ethnicity data collection in the UK began with the 1991 Census. 37 We included only UK studies due to variation in how race, ethnicity and ancestry are represented in different countries. This is a consequence of each country's unique pattern of migration and its political and social context.

Only community-centred interventions were eligible for inclusion. We defined community-centred broadly to include all interventions that were not clinical in nature, that is, did not involve the treatment of patients by health professionals such as cognitive-behavioural therapy and drug therapy. Therapy-style sessions that were delivered by lay health workers were included. There is a wide range of overlapping concepts in community-based and community-centred terms, and these were captured by our broad search strategy.

Charting of data

Data were extracted by two independent reviewers (GZ, CB). A data extraction framework was developed to capture key study characteristics: author, year of publication, setting, study design, population demographics, sample size, theory of change, and outcomes and results. Intervention details were extracted using the Template for Intervention Description and Replication guide: rationale, materials, procedures, provider, methods, location, timing, tailoring, modifications and assessment of intervention adherence. 44

Collation and summary of results

Patient and public involvement

The research question was informed by people's experiences and stakeholder workshops. This study did not involve the recruitment of patients, and no patients were involved in the design or conduct of the study.

Intervention type and focus

The interventions were highly heterogeneous in design and focus. They included therapy-style sessions delivered by lay health workers, 49 50 peer-support groups, 51 52 an educational leaflet, 53 free gym access 54 and a family services programme. 55 All interventions were conducted in England. Certain subgroups were targeted more than others with interventions specifically tailored to individuals of Indian, Pakistani and Bengali heritage (n=3), women (n=4), and people with anxiety or depression (n=5).

Interventions were either a single session (n=1) or took place over a minimum of 10 weeks to 8 months (n=6). The duration of the family services programme is unclear. Four studies aimed to improve mental health by expanding social networks and facilitating social support 49 51 52 55 and four aimed to increase access to services by facilitating linkages or signposting to complementary social care and mental health services. 49-51 55

Qualitative data commonly found a reduction in social isolation and stress, and improved mood and self-confidence. 50 52 54 55 One RCT reported significant improvement in social functioning 51 and two had a statistically significant positive impact on depression outcomes. 52 53 All but one study 51 were appraised as having a high risk of bias with limitations relating to small sample sizes (n=9-123, mean=43, median=30), short follow-up periods (ranging from 2 to 9 months) and participant recruitment.

Thematic Analysis

Following narrative synthesis, we identified three themes with the perspective of informing the delivery of public mental health interventions for ethnic minority communities: addressing social isolation and loneliness, promoting access and use of services, and being delivered by lay health workers.

Addressing social isolation and loneliness

Chaudhry et al 52 evaluated the efficacy and cultural acceptability of establishing a social group for British Pakistani women with depression. Women were diagnosed with depression using the Schedule for Clinical Assessment in Neuropsychiatry and were recruited from an ongoing population-based study. Participants attended at least 6 of 10 weekly meetings at a community centre for the Pakistani community. Meetings included one session of psychoeducation and self-selected activities including personal grooming, exercise, yoga, and visits to museums and local shopping malls.

The intervention was successful in improving mental health outcomes; a significant reduction in depressive symptoms was found at the end of the 10 sessions (pre-intervention: 15, SD=3.08; post-intervention: 11.7, SD=5.95, p=0.039) and three women reported a reduction in suicidal ideas. These outcomes, and participants' anecdotal feedback, suggest that a reduction in depressive symptoms is partly attributed to reducing social isolation by bringing the women together. Participants highly valued the provision of free transport by female Urdu speakers to avoid any objections from family and community members. Heterogeneity in the content and attendance of each session makes it difficult to assess the mechanism for improved outcomes. The small sample size and lack of control group further limit the generalisability of these findings.

Chaudhry's pilot study formed the basis of the RCT conducted by Gater et al. 51 British Pakistani women (n=123) with depression were recruited from general practice surgeries. The women were randomised into one of three intervention arms: a social group intervention, antidepressant medication, or both the social group intervention and antidepressant medication. The social group involved 10 women, who attended 10 weekly sessions of social activities at a community centre. Facilitators were Urdu-speaking women who had completed a 5-day training programme.

The intervention had no significant change in depression in all three arms. Social functioning significantly improved in both the social intervention and combined treatment groups at 3 months (6.1, 95% CI: 1.4 to 10.8 and 5.9, 95% CI: 1.5 to 10.2) but not at 9 months. Focus groups, held at the end of each session, found that the intervention was too short and that a major barrier to participating was resistance from family members. Participants found it helpful to confide in others and were intending to maintain new friendships. Overall, this study was appraised as low risk and provides evidence in favour of social group interventions for short-term improvements of positive mental health.

Main findings

We found seven studies of community-centred interventions that aimed to improve mental health and well-being among ethnic minority groups in the UK. Although studies varied in design, four key interventional characteristics emerged.

First, interventions aimed to address social isolation through building peer-to-peer support and social networks. 49 51 52 54 Evidence suggests ethnic minority populations find it easier to start conversations on mental health within their own cultural networks rather than with health professionals; formal mental health services perceived as a last resort. 56 57 We found that social support interventions mainly targeted women and it is unclear whether men would find these acceptable.

Second, interventions aimed to overcome structural barriers in accessing care. Addressing practical considerations, such as translating educational materials into different languages 53 and providing appropriate transport, 51 52 increased participation in the intervention/ activities.

Third, interventions were delivered by lay health workers. 49 50 55 Over recent years, task-shifting in healthcare from health professionals to lay health workers has been common due to the need to meet escalating demand for care. 60 Lay health workers from the same community as patients may be perceived as more accessible 56 and help reduce the associated stigma of accessing mental health services. 61 62 They may also overcome language and cultural barriers that ethnic minority groups face when trying to communicate mental health needs to their healthcare provider. 63 64 However, lay health workers, unless they have received anti-stigma training, may hold beliefs that are more stigmatising than those held by health professionals. 65

Of the community interventions we identified, we found more targeted South Asian ethnic groups, which may reflect these groups making up a greater proportion of the UK population. There were no interventions designed for and targeting men, despite men being less likely to seek help for common mental health problems. 67

Limitations

A limitation of this study was the omission of grey literature. Preliminary grey literature searching found over 50 community-centred services, which confirms that most relevant interventions reside outside publication in peer-reviewed journals and indicates significant publication bias. We were unable to include these interventions in this review due to a large number of individual activities/ interventions and the lack of available primary data. We consider a mapping methodology to be more appropriate to comprehensively summarise this evidence. 36 We also only included community-centred interventions that targeted ethnic minority communities. It is possible that ethnic minority groups access public mental health interventions through universal provision, however uptake of screening programmes and utilisation of mental healthcare services show ethnic minority populations have lower use. 68

A further limitation is the generalisability of our results that include all ethnic minority populations in the UK; homogeneous recommendations cannot be made to a culturally and ethnically heterogeneous population. Furthermore, we excluded all white ethnic minority groups apart from Irish Travellers and Gypsies. However, the UK has a white ethnic minority European population, such as people from Poland, who may be subject to similar systemic health inequalities and challenges to their mental health and well-being as other ethnic minority groups. 2

Implications for policymakers and future research

We recognise that the evidence for ethnic differences in some common mental disorders is complex, variable and indeed equivocal for specific ethnic groups. However, there is a disconnect between the scale of community-centred intervention provisions and published evidence. This may imply a bias in terms of scientific priorities and funding that needs urgent rectification, as current evidence is limited and weak.

It is important that future research seeks to understand how successful interventions work to improve mental health and for whom, taking into account intersectionality such as between gender and ethnicity. This requires resources to be appropriately allocated to third sector organisations, which typically provide these interventions, as they are often bound to deliver short-term projects and lack resources for robust evaluations. Evaluations should also include economic analysis; community interventions are potentially an affordable means to improving public mental health. 73

These findings also suggest the need for more activity on preventing mental illness and promoting well-being; most of the studies focused on people with existing common mental conditions. Health promotion and primary prevention alongside universal approaches are critical components of strong public mental health and sustainable health systems. 68 Additionally, further research is needed to understand the societal, structural and institutional challenges affecting community-centred public mental health interventions for ethnic minority groups to help identify potential solutions.

Lastly, labels such as 'Asian' or 'Black African' present challenges to mental health research by viewing ethnic minority groups as homogeneous in their mental health needs, despite evidence indicating otherwise. 2 74 75 We recommend that national census categories are consistently used across all sectors, so that important variations and inequities can be identified and investigated further.

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Community-centred interventions for improving public mental health among adults from ethnic minority populations in the UK: a scoping review

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Objectives Undertake a scoping review to determine the effectiveness of community-centred interventions designed to improve the mental health and well-being of adults from ethnic minority groups in the UK. Methods We searched six electronic academic databases for studies published between January 1990 and September 2019: Medline, Embase, PsychINFO, Scopus, CINAHL and Cochrane.

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Abstract

Purpose

Pregnancy and the first postnatal year can be a difficult and distressing period for women with mental health problems, particularly if they are not able to access appropriate and timely assessment and treatment. The aim of this systematic review was to synthesise qualitative evidence on experiences of care for women with (or at risk of developing) antenatal or postnatal mental health problems across a range of disorders (including non-psychotic mental disorders).

Methods

Six electronic databases were searched for papers published from 2000 to April 2014. Thirty-nine studies were identified that met the inclusion criteria. Findings were synthesised using secondary framework and thematic analysis approaches.

Results

Seven key themes were identified across mental disorder groups: an unmet need for collaborative and integrated care; stigma and fears about loss of custody; healthcare professionals unable or unwilling to address psychological needs; focus on babies over mothers; importance of non-judgemental and compassionate support; an unmet need for information; importance of service user involvement in treatment decisions.

Conclusions

Women's experience of accessing and engaging with care for mental health problems could be improved if given the opportunity to develop trusting relationships with healthcare professionals who acknowledge and reinforce the woman's role in caring for her baby in a non-judgemental and compassionate manner, and foster hope and optimism about treatment. Information for women, their families and healthcare professionals, and the provision of individualised care and treatment, are also crucial to enable full implementation of a person-centred programme of care.

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Authors and Affiliations

1. National Collaborating Centre for Mental Health, Royal College of Psychiatrists, 21 Prescot Street, London, E1 8BB, UK

Odette Megnin-Viggars, Iona Symington & Stephen Pilling

2. Research Department of Clinical, Educational and Health Psychology, University College London, Gower Street, London, WC1E 7HB, UK

Iona Symington & Stephen Pilling

3. Section of Women's Mental Health, Health Service and Population Research Department, King's College London, De Crespigny Park, London, SE5 8AF, UK

Louise M. Howard

Corresponding author

Correspondence to Odette Megnin-Viggars.

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Megnin-Viggars, O., Symington, I., Howard, L.M. et al. Experience of care for mental health problems in the antenatal or postnatal period for women in the UK: a systematic review and meta-synthesis of qualitative research. Arch Womens Ment Health 18, 745-759 (2015). https://doi.org/10.1007/s00737-015-0548-6
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DOI: https://doi.org/10.1007/s00737-015-0548-6

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# data[].attributes.attachment_link.title
Experience of care for mental health problems in the antenatal or postnatal period for women in the UK: a systematic review and meta-synthesis of qualitative research - Archives of Women's Mental Health

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Purpose Pregnancy and the first postnatal year can be a difficult and distressing period for women with mental health problems, particularly if they are not able to access appropriate and timely assessment and treatment.

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Pattinson, E.M. , McDermott, E. , Eastham, R. , Hughes, E. , Johnson, K. , Davis, S. Pryjmachuk, S. , Jenzen, O. and Mateus, C. , 2021. Tackling LGBTQ+ youth mental health inequality: mapping mental health support across the UK. The British Student Doctor, 5 (3), pp. 20-29. ISSN 2514-3174 ORCID: 0000-0002-9296-8793 ,

Abstract

Young people who identify as lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ+) experience higher rates of mental health distress than reported in the general population, yet are far less likely to seek support services. Factors such as homophobia, biphiobia and transphobia, cis-heteronormativity, fear of judgement and lack of staff awareness of LGBTQ+ identities are barriers to help seeking. This paper reports on the first stage of a study that investigated and mapped current LGBTQ+ youth specific mental health service provision across the UK. An online and offline service mapping exercise was undertaken to identify services. 111 services were identified across the search strategies, the majority in urban settings in England. There were three significant characteristics of LGBTQ+ child and adolescent mental health UK provision. Firstly, there was an absence of mainstream NHS support that specifically addressed the needs of LGBTQ+ young people. Secondly, the majority of LGBTQ+ youth mental health support was provided by voluntary/community organisations. Thirdly, there was a new emerging model of service that is based on collaborative working between NHS trusts and community/voluntary organisations. The results of this mapping exercise suggest that there is a reliance on the voluntary/community sector to provide mental health provision for LGBTQ+ young people. Furthermore, there was a distinct divergence in the approaches of the support provided by the voluntary/community sector and those from within the NHS. The affirmation of LGBTQ+ identities that is pivotal to the support provided by voluntary/community services contrasted with the 'treating everyone the same' approach prevalent in mainstream service provision. NHS mental health services must recognise that to tackle LGBTQ+ youth mental health inequality, statutory mental health support must address specifically the mental health needs of LGBTQ+ young people.

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