Written evidence submitted by The Mental Health Foundation (CVD0020)

The Mental Health Foundation

Our vision is for a world with good mental health for all.

The Mental Health Foundation works to prevent mental health problems.

We drive change towards a mentally healthy society for all, and support communities, families and individuals to live mentally healthier lives, with a particular focus on those at greatest risk. The Foundation is the home of Mental Health Awareness Week.

Website:              www.mentalhealth.org.uk

Coronavirus, disability and access to services

The Mental Health Effects of the Coronavirus Pandemic on Disabled People

1. In this submission, drawing on the Foundation’s experience in prevention of mental health problems, we focus on the mental health effects of the pandemic on disabled people.

Pre-existing mental health risks among disabled people

2. People with long-term physical health conditions, long-term mental health problems, and/or physical, sensory or learning disabilities were already at a disadvantage in terms of realising good mental health when the pandemic began, and these mental health inequalities have been exacerbated during the crisis.

People with long-term physical health conditions

3. People with long-term physical health conditions are two to three times more likely to experience mental health problems, with anxiety problems or mood disorders being particularly common.[1] Despite this, in 2008 a systematic review showed that non-psychiatric health professionals’ detection of depression in patients with physical illness was low,[2] while a qualitative study published in 2011 suggested that wider discussion and treatment of emotional problems in the context of physical illness was also low.[3] In the UK, GPs were incentivised to screen for depression among people with coronary heart disease and diabetes between 2006-13. While one study showed an increase in diagnosis of depression during the incentivisation scheme, the scheme has since been stopped and the outcome of this stoppage is not yet known.[4]
4. Co-morbid mental health problems have a number of serious implications for people with long-term conditions, including poorer clinical outcomes and lower quality of life.[5] Perhaps most worryingly, people with co-morbid mental health problems are more likely to die, and die sooner, from physical health conditions such as cardiovascular disease, diabetes, chronic obstructive pulmonary disease (COPD) or asthma.[6]
5. Based on these inequalities in health outcomes, the King’s Fund has recommended as a priority that people with long-term physical health conditions should receive support for the psychological aspects of their condition as a standard part of their physical health care.[7]
6. Conversely, those experiencing severe mental health problems die, on average, 15-20 years earlier than the general population,[8] while those with common mental health problems such as mild depression die 7-10 years earlier.[9] Although lower life expectancy is partly associated with higher suicide rates amongst people with mental health problems, the bulk of excess mortality in people diagnosed with severe mental health problems is largely attributed to preventable physical health problems such as cardiovascular disease, obesity and diabetes.[10]
7. These striking and persistent inequalities related to long-term health conditions serve as a powerful reminder that the case for an integrated approach to mental and physical health is an ethical one as much as an economic one.

People with physical and/or sensory disabilities

8. While not inevitable, having a physical disability can increase the risk of experiencing mental health problems and low wellbeing. There is consistent evidence of an association between physical disability and depression,[11] although a significant factor in this may be the social and other barriers people with disabilities face in day-to-day life.[12]
9. Individuals experiencing sensory impairments have also been found to be at a much higher risk of having mental health problems across the life course; however, the needs of this group tend to be underrepresented in research. Deaf children are more likely to experience mental health problems: estimates suggest a 40% prevalence rate of mental health problems in deaf children, compared to a 25% prevalence in children without hearing loss.[13] For older adults who are visually impaired, the prevalence of major depressive disorder (5.4%) and anxiety disorders (7.5%) is significantly higher compared to their normally-sighted peers. The most prevalent anxiety disorders are agoraphobia and social phobia.[14] Overall,
10. Both access to, and outcomes from, mental health services appear to be unequal. Evidence suggests that some groups of people continue to experience inequalities when it comes to access, experience and outcomes.[15] A recent analysis of IAPT (Improving Access to Psychological Therapies programme) outcome data found a range of differences in recovery rates for different groups based on, among other factors, levels of deprivation and disability. For example, non-disabled people have a recovery rate of 53.6%; but those reporting speech and sight difficulties, physical health conditions and learning disabilities have recovery rates ranging from 42 to 48%, while those with other forms of disability, including mobility and behavioural and emotional issues, have recovery rates under 40%.[16]

People with learning disabilities

11. People with learning disabilities have an increased risk of developing a mental health problem (between 25 and 40% of those with learning disabilities experience mental health problems)[17] due to social, economic, psychological and emotional factors as well as some biomedical factors.
12. In 2007, the prevalence of diagnosed mental health conditions was estimated to be 36% among children with learning disabilities compared to 8% among children without a learning disability, although this study included autism spectrum disorder as a mental health condition. Increased prevalence was particularly marked for autism spectrum, attention deficit and conduct disorders.[18] The same study found that children with learning disabilities were at higher risk of exposure to social disadvantage, while lower exposure to social disadvantage reduced the risk of mental disorders between 33% and 51%, depending on the disorder. This suggests that measures to reduce social disadvantage among children with learning disabilities could significantly reduce the prevalence of mental disorders in this group.
13. Overall, and as evidenced by a 2015 report by Public Health England, children with learning disabilities, when compared with their non-disabled peers, are more likely to be exposed to a number of inequalities that are risk factors for mental health problems, including: living in overcrowded housing, living in housing in a poor state of repair and housing that was too cold in winter; being at increased risk of exposure to violence, including bullying, physical, sexual, emotional abuse or neglect; being less likely to have a close relationship with their mother; being more likely to be exposed to inconsistent and harsh parenting and more chaotic family environments; and being more likely to be exposed to a greater number and wider range of potentially adverse life events.[19]

The mental health effects of the pandemic on disabled people

14. In this section, we highlight findings from the Coronavirus: Mental Health in the Pandemic study as of the fifth wave of data collection carried out between 18th and 22nd June. The study is led by the Mental Health Foundation, in collaboration with the University of Cambridge, Swansea University, the University of Strathclyde and Queen’s University Belfast. Since mid-March 2020, the project has undertaken regular, repeated surveys of more than 4,000 adults who are representative of people aged 18+ and living in the UK. The surveys are conducted online by YouGov. More detailed information on the study is available at https://www.mentalhealth.org.uk/our-work/research/coronavirus-mental-health-pandemic.
15. Our study provides insights on people with self-reported long-term, limiting health conditions and disabilities and on people with pre-existing mental health problems. Due to the limitations of the study, we are not able to provide findings for specific types of disabilities.
16. Research by the Office for National Statistics (ONS) has shown that some older people people with long-term, disabling physical health conditions have been more likely to experience poor mental health and/or wellbeing during the pandemic. [20]While the Office for National Statistics (ONS) has found that, as of 9th-18th June, a majority (60%) of people in the official category of ‘shielding’ had not experienced a worsening in their mental health since being given shielding guidance, 29% of people said that their mental health had become slightly worse, and 7% said it had become much worse.[21]
17. The UN Office of the Commissioner for Human Rights has also drawn attention to the exacerbation of disability inequality during the pandemic due to attitudinal, environmental and institutional barriers.[22] People with disabling long-term health conditions may find themselves even more isolated and cut off from essential support. If living in residential care settings, they may find themselves at high risk of contracting the virus while at the same time having less access to information and health services. Ironically, the normal barriers people with disabilities face in trying to gain access to health services will have increased at a time when they are at even greater risk of disease. Similarly, their unequal position in the labour market is likely to be exacerbated at a time when employment becomes more uncertain in general.
18. The Coronavirus: Mental Health in the Pandemic study, being led by the Foundation, supports this view that the pandemic has hit the mental health and wellbeing of people with long-term, disabling health conditions particularly hard. We found in our most recent wave of research that a higher proportion of people with long term-disabling health conditions reported having difficulty coping (26%) compared to the overall population (14%). They were also more likely to have been worried that the pandemic may make their existing mental health condition worse (46%). Furthermore, this group was more likely to be more anxious, panicked, afraid and lonely:

19. Our study also includes a Citizens’ Jury, and from the discussion with our Jurors, clear implications also emerged regarding employment opportunities, for example for disabled people:
20. Disabled people who are trying to seek work, they are already disadvantaged in the labour market, they're going to be even more so, you know, when you’ve got increased competition for work. And you’ve got employers who think that disabled people are, you know, they're going to be a higher risk to take on in the workplace. (Citizens’ Jury member)
21. People who entered the pandemic with a prior experience of a mental health problem have also been more likely to experience anxiety, panic, and hopelessness:
     

22. During lockdown, many of the supports for people with mental health problems, such as one-to-one therapy, training courses, volunteering and supported employment opportunities, were curtailed or stopped. Particularly, peer support and community resources that relied on meeting in a physical space have had to adapt or pause their provision, resulting in the loss of or reduction in support for many people. The Mental Health in the Pandemic study shows that people with a pre-existing mental health problem have been the most likely to experience stress and inability to cope. Very worryingly, they have reported suicidal thoughts and feelings at a rate that is almost triple that in the general population.
23. These feelings were shared by our Jurors, as for example one member stated:
24. Quite clearly, people with pre-existing mental health conditions, there are fairly serious impacts in lots of ways in terms of lockdown, in terms of coming out of lockdown (Citizens’ Jury member).

Recommendations

25. The Foundation’s full policy recommendations for the Government’s response to the pandemic are contained in our briefing paper at this link: https://www.mentalhealth.org.uk/coronavirus/pandemic-recommendations-prevention

A whole-government Mental Health Response and Recovery Plan

26. Our overarching recommendation is that the government should ensure a cross-governmental approach to mental health during the COVID-19-crisis and in the recovery phase by drafting a whole-government COVID-19 Mental Health Response and Recovery Plan. Prevention of mental health problems is possible through effective societal, community and individual support, but it cannot happen within the health sector alone – action must be taken in the spaces where people are born, raised and live (in the home, in schools, their communities and workplaces).
27. As we have set out in our report Tackling inequalities to reduce mental health problems – how everyone can flourish equally, there is strong and accumulating evidence that social inequalities such as poverty and income inequality, gender, a variety of minority statuses, and adverse childhood experiences and trauma, increase the risk of mental health problems. It is therefore logical that reducing these inequalities could prevent mental health problems.[23]
28. These are important risks for the UK government to consider as the recovery from the pandemic begins. Measures to address social determinants at the structural level require action by government departments other than health, for example communities and local government, education, justice, transport and welfare. Actions taken across government departments can help people to protect and recover their mental wellbeing during and after the pandemic and can prevent more severe mental health problems from taking hold as a consequence of the crisis.

The principle of ‘proportionate universalism’

29. The Mental Health COVID-19 Response and Recovery Plan should be informed by the overarching principle of ‘proportionate universalism’. There is often a tendency to focus mostly either on universal campaigns and messages or on targeted interventions for specific at-risk groups. However, since anyone can be at risk of developing a mental health problem and everyone benefits from good mental health and wellbeing, we support ‘universally proportionate’ approaches to interventions and measures, as recommended in the Marmot Review.[24] Such approaches balance universal and targeted approaches, allocating resources according to levels of need and risk for particular social groups in order to obtain the greatest gains for the resources available. In simple terms, this is an approach to addressing inequalities that means ensuring support for everyone, because we all have mental health, but focusing targeted support to address the greater risks that some groups face. In this regard, while disabled people can benefit from universal approaches, additional targeted prevention measures should be put in place to support their mental health during and after the pandemic.

The principle of co-production

30. The Mental Health COVID-19 Response and Recovery Plan should be developed with the involvement of disabled people, to help COVID ensure that the plan reflects their needs and preferences to the fullest extent possible. Co-production with disabled people should also be the approach used to develop and design of any associated targeted initiatives.

July 2020