What are the most pressing issues that affect men and boys’ mental health, and how are these different to the wider population?

1.

One pressing issue facing men and boys’ mental health is the mis-diagnosis or under-recognition of depression in men. Differing patterns in the presentation and help-seeking behaviours of men can combine to leave men particularly vulnerable and less likely to receive necessary help. 

Men tend to seek help less than women do, and even when they do seek help, the lower level of recognition of depression amongst men means that their distress may not be taken seriously and support may not be provided. These two factors reduce the chances of men getting appropriate support and will increase the risk of suicide attempts (Fronimos and Brown, 2010). Men may present their mental and emotional distress differently to women e.g. through aggression or substance abuse. This means that when they do present to services, diagnosis can be missed, which places these individuals at higher risk of deterioration (White et al., 2011). 

The Society, alongside mental health charities, professional organisations and service providers as part of the ‘We Need to Talk’ coalition, has noted previously (2013) that the nationwide programme Improving Access to Psychological Therapies (IAPT) can potentially benefit men. Research has shown that men may be more receptive to treatments that emphasise outcomes and goals such as Cognitive Based Therapy (CBT) (Mind, 2009). However, the government’s own data (NHS Digital) on the outcome measures of IAPT show that so far men are showing less improvement than women: “Women’s IAPT referrals were more likely to have shown improvement than men’s, with the exception of women of mixed White and Asian background and Bangladeshi women (for the latter, the rates of improvement were very similar to those of men)” (Gov.UK, 2017, updated 2018) 

What are the social and economic costs of poor mental health in men and boys?

2.

No comment.

What is the effect of the following on men and boys’ mental health: 

         Gender stereotyping in childhood

         Gendered expectations around work

         Fatherhood

         Media portrayals of masculinity

         Household finances

         Relationship and family breakdown?

3.

Gendered expectations around work 

For many men, having a job and being able to provide for their family or at least to be seen as being a breadwinner themselves is central to the conception of ‘being a man’ (Braun et al., 2011). Although men’s wellbeing can benefit from job satisfaction (Barry & Daubney 2017; Barry 2018), unemployment can hit men harder than women psychologically (Platt S & Hawton, 2000). 

Fatherhood 

Understandably there are many provisions to help and support new mothers through the transition to parenthood. However, the experience of fatherhood also brings emotional and social challenges that can lead to poor mental health among new fathers. A meta-analysis of 74 studies found that of 41,480 male participants, 8.4% experienced postnatal depression (Cameron et al., 2016). It is likely this figure is under-reported as evidence suggests the screening tool used for detecting postnatal depression is less reliable for men, and the overall figure may be closer to a fifth (22%) of new fathers (Psouni et al., 2017). Despite this, under new proposals in the NHS Long-Term Plan only the partners of mothers accessing specialist perinatal mental health services will be assessed for their mental health and signposted to support as required (NHS, 2019). 

Effect on mental health of household finances 

Men may feel an even greater sense of shame and pressure if they cannot provide for their families or live up to societal ideals or expectations as a ‘breadwinner’. As a result, experience of financial difficulty can have particularly adverse effects on men’s mental health. Across the population those in problem debt are three times more likely to report suicidal ideation in the past year, with this rate being slightly higher for men than women (Money and Mental Health, 2018). One study of a hundred inquest reports found debt was mentioned as a relevant factor in 11% of male and 5% of female suicides (Scourfield et al., 2012). 

Effect on mental health of relationship and family breakdown? 

An assessment of data on 2209 suicides from the United States found that the main risk for men aged under 30 was intimate partner issues (Ream, 2019). Not only can divorced or separated men lose their home and much of their income, but they may lose some or all access to their children (see Wylie et al, 2012). After taking other risk factors into account, divorced men are 9.7 times more likely to kill themselves than divorced women, partly because divorced men have fewer rights to child access than divorced women (Kposowa, 2003). 

What issues other than access to healthcare affect the mental health of men and boys?

4.

Which groups of men and boys are particularly at risk of poor mental health and what is leading to this?

5.

In the most extreme cases figures indicate that men aged 20-29 and 40-49 are most at risk of suicide (ONS, 2018), while when looking at socio-economic circumstances unemployed men and men on benefits are more likely to take their own lives than other men (McManus et al., 2014). For example, we can see that white men appear to display higher incidences of depression than black men, but black men have significantly higher reported incidence of ‘psychological distress’ (Asari, 2017; Barnes & Bates, 2017), while suicide attempts amongst men (and women) show a clear negative correlation with income (Coope et al., 2014). 

What measures are needed to most effectively tackle poor mental health in men and boys and what are the barriers that prevent these being implemented?

6.

A more holistic approach to tackling poor mental health in men and boys is needed, that takes into consideration the circumstantial, social and psychological elements that may be contributory factors to poor mental health.  

A positive step towards these aims would be to develop new ways of delivering services and approaches that could appeal more to men and meet their needs within what may be differing social circumstances and psychological approaches to dealing with poor mental health. For example, men typically have lower levels of social support that women, which can contribute to poor mental health in middle age and later life (Fiori and Denckla, 2012). Additionally men may favour treatments that advocate problem-solving or goal-based approaches to addressing poor mental health (Mind, 2009).

Guidelines are becoming available for making mental health services more male-friendly, for example Liddon et al (2019). Evidence shows that men have different needs in therapy compared to women (e.g. Holloway et al, 2018; Liddon et al, 2017) that may lead to worse outcomes in therapy for men (Wright & McLeod, 2016). 

How effective has Government policy been in improving mental health outcomes for men and boys?

7.

The Society recognises the increasing recognition in government that men are at a significantly higher risk of suicide and that action is required to develop and deliver preventative strategies aimed at this group. The Society welcomes the recently published Cross-Government Suicide Prevention Workplan with its identification of men as a high-risk group alongside a commitment to address factors such as relationship problems, financial difficulties and alcohol/drug problems as factors contributing to suicide risk among this group. 

However, the Society notes with concern that homelessness and unemployment are not included among the risk factors detailed in the report despite the fact that men who are unemployed and/or on benefits are more likely to take their own life (McManus et al., 2014).

Every year 300,000 people leave work due to poor mental health (Farmer and Stevenson, 2017) and figures show that nearly half (47%) of working age adults receiving an out-of-work benefit have a common mental disorder (Mc Manus et al., 2016). In addition to this, men are consistently shown to be at higher risk of depression during periods of unemployment (Ford et al., 2010). 

The previous cross-Government National Suicide Prevention Strategy published in 2012 and updated in 2017, made note of the importance of tailored responses for people in receipt of unemployment benefits. Since its initial publication, figures have shown 43% of people claiming Employment Support Allowance (ESA) will have attempted suicide in their lifetime compared to 7% who are not claiming ESA (McManus et al., 2016). Recent research from the Money and Mental Health Policy Institute (2019) has also found 90% of people surveyed reported some anxiety when engaging with the benefits system. 

The Society recommends that Government prioritises unemployed men as a specific at-risk group due to the combination of these factors, in addition to recognising the impact benefits policy may have on unemployed men claiming benefits. 

How effective are the following at tackling poor mental health in men and boys:
- NHS England
- Public Health England
- Child and Adolescent Mental Health Services
- Local Authorities
- Schools
- Local support groups, faith groups, carers, friends and family

8.

NHS England 

The NHS England Long-Term Plan proposes to support partners of new mothers with mental health conditions to be assessed for their mental health and signposted as required. This recommendation is welcomed by the Society given perinatal mental health conditions affects one in four mothers and the economic cost of perinatal mental health problems in mothers is estimated to be £8.1 billion for each one-year cohort of births in the UK (Bauer et al., 2014). However, the Society also notes that it is important to support the mental health of all fathers, not just those whose partners may be experiencing poor mental health and in contact with perinatal mental health services. 

Depression has been reported in one in ten fathers one year postpartum, while anxiety has been reported in one in five fathers in the same time period (Baldwin and Bick, 2018). Support services could be provided for fathers more widely, not just those whose partners may currently be experiencing poor mental health. 

Despite financial difficulties being recognised as a key risk factor for suicide in men, data on the financial situation of service users and their debts is not routinely collected in primary or secondary mental health care. This makes it impossible for NHS staff to act or know when it may be appropriate to refer service users to third party advice services. O’Connor noted in a Samaritans report on suicide and men that “more attention should be paid to men’s personal and social circumstances when they contact psychiatric or support services, particularly to employment, financial or housing problems, which may aid suicide risk assessment” (Wyllie et al., 2012). By routinely collecting data such as these, at-risk men could receive the full support needed to prevent deterioration. 

Similarly, it is vitally important that data on men and women are presented separately, in order that we can see where there are important gender differences in outcomes of therapy and policy. Although the NHS does this routinely in medicine, this practice is typically missing in mental health. When data are not presented by gender, we do not know whether interventions work well for women but don’t work for men (Wright and McLeod, 2016). IAPT

is a welcome example of a programme that has recently adopted assessments by gender, showing that men’s IAPT referrals were less likely to show an improvement than women’s (Gov.uk, 2017, updated 2018). 

Public Health England 

See previous comment re the NHS assessing sex differences in outcomes. 

Child and Adolescent Mental Health Services (CAMHS) 

No comment 

Local Authorities 

The Society believes more could be done by local authorities both to improve access to mental health therapies for men who may require them and to ensure preventative strategies are in place to promote positive wellbeing and prevent the deterioration of men’s mental health. 

Local Authorities in their role alongside Clinical Commissioning Groups (CCGs) are well placed to assess the equity of provision of and access to the Improving Access to Psychological Therapies (IAPT) for men in the region when conducting their Joint Strategic Needs Assessments (JSNA). A health equity audit using available NHS data conducted by West Sussex Council (2017) found that men were referred 15% less compared to women according to estimated levels of need. 

NHS Digital statistics have shown that across all CCGs for all ages, women receive more referrals to IAPT than men (House of Commons Library, 2018). The analysis of these statistics when producing JSNAs could better identify engagement needs with population subgroups such as men, already known to be less likely to seek-help for mental health problems. Necessary action to address any existing inequity could take the form of assessing existing referral pathways or improving guidelines on how services could be more supportive for men presenting with mental health problems. There is also evidence that men’s mental health might benefit from interventions beyond talking therapies e.g. sport & exercise (Liddon et al, 2019), which could be explored as potential new referral destinations. 

Schools 

The Society believes there could be increased efforts by schools to ensure that boys are not disadvantaged by teaching methods, which may lead to poorer educational outcomes and impact on mental wellbeing. For example, colour-blindness affects significantly more boys than girls (NHS, 2016), yet schools do not routinely use materials that are colour-blind friendly, meaning that 8% of boys and 0.5% of girls may have difficulty with school work and sports activities. Also certain conditions (e.g. ADHD, dyslexia) affect boys and their schooling more than girls 

Local support groups, faith groups, carers, friends and family 

See previous comments. 

References

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