A long-standing notion in UK policy has been that increased public awareness can improve national mental health. Notable campaigns include the Mental Health Foundation Mental Health Awareness Week launched in 2001; England’s Time to Change campaign (2007-2021); and Heads Together launched in 2017 backed by the Prince and Princess of Wales. UK celebrities from the worlds of sport, music, and television have been encouraged to share their experiences of mental ill health to help challenge negative attitudes, raise awareness and empower people to seek help. On the one hand, these campaigns are criticised for marginalising people in distress by setting up mental illness as an individual medical problem rather than highlighting social conditions which trigger and maintain distress. On the other hand, we now have government ministers implying mental health awareness has “gone too far”.
Whilst awareness campaign evaluations make claims around improvements in public attitudes, the UK has seen an increase in the prevalence of mental health problems. A survey of over 29 million people between 2000–2019 revealed incidence of common mental disorders increased from 55.9 to 76.9 per 1,000 “person years”. The prevalence inflation hypothesis frames this as a partial success: campaigns have apparently increased prevalence through increased reporting of previously under-recognised symptoms. However, the concern is that people presenting with mild distress are now classified as having a mental disorder. It’s this concern which seems to feed the idea as voiced by the government’s Work and Pensions Secretary who claims that “mental health culture has gone too far”. We then heard the Prime Minister adapt this trope to include the lazy as well as the mad: “sick note culture” has apparently also gone too far.
As Heney commented in a recent blog, this idea distracts from a chronic failure of government to invest in mental health care. Both austerity prior to the pandemic, followed by increasing social and economic pressures created by COVID-19 are known to have exacerbated mental distress. Yet, in 2021–22, the NHS spent £12 billion on mental health services in England, which is only about 9% of the total NHS budget. So much for “no health without mental health”. This budget includes spending on the flagship psychological therapies programme launched in 2008 now called “NHS Talking Therapies”. The programme includes the training and deployment of thousands of psychological therapists and practitioners. The service increased accessibility of psychological services via a self-referral route. Yet, while 1 in 6 adults experience a common mental health problem, in 2021/22 the NHS reported 1.2 million people were able to access NHS Talking Therapy services (around 2% of the adult population). Between 2016–17 and 2021–22, the NHS mental health workforce increased by 22% rising to 133,000 full-time equivalent staff. However, during the same time, the NHS saw a 44% increase in mental health referrals “meaning that the increase in staff was outpaced by the rise in demand for services”. These shabby figures led the British Medical Association in April 2024 to call for the government to “urgently address that demand for mental health services is outpacing the resources afforded to them”.
Not only is mental health care provision highly inadequate across the board, there is also significant inequality in terms of who is able to access the limited support available. Our research (forthcoming) uses data from United Kingdom Household Longitudinal Study (UKHLS) to examine “undiagnosed distress” across protected characteristics. Undiagnosed distress can give us an indication of where there is a treatment gap, since diagnosis is a relatively standard practice in UK mental health care. Therefore, people experiencing clinical levels of distress without a diagnosis are likely not to have accessed mental health care. Our analysis found that people living with a disability have nearly three times the risk of undiagnosed mental distress compared with people without a disability. Since diagnosis is usually required for a “sick note” this suggests we have the opposite of a “sick note culture”. Women have 1.5 times the risk of undiagnosed distress compared with men. Lesbian, gay or bisexual people are 1.4 times more likely to have undiagnosed distress compared with heterosexual people. People aged 16-24 years have the highest risk compared with all other age groups.
If the treatment gap was only a symptom of under-funded mental health services then we might expect everyone to be equally affected, regardless of sexuality, age, sex or disability. Given the evident inequality in access to care, lack of funding is not the only long-term failure in UK mental health policy. Mental health support is not adapted to the needs of different groups (particularly young people, LGB groups, women and disabled people); these groups are struggling and not asking for help and quite possibly not going off sick when maybe they should. Services have particularly failed to respond to the growing crisis in our young people who have grown up during a long period of austerity which has damaged much of the social fabric of UK society necessary for good mental wellbeing.
Despite awareness campaigns, stigma remains a barrier to seeking support (particularly where a group already experiences discrimination such as homophobia or ableism). There is also evidence that many people are afraid that if they seek mental health support they will be treated with medication and that they may then become addicted. This belief may be a counter-productive aspect of awareness campaigns pitching mental distress as a medical problem but, equally, the fear is well founded. In spite of NICE guidelines recommending psychological treatments as first line interventions for depression, in 2023, politicians, experts, and patient representatives felt compelled to jointly call for the government to reverse the rate of antidepressant prescribing, which has risen nearly 30% over the last 7 years with over 85 millionitems being prescribed in 2022/23. This alongside an increase in long-term users with no improvement in mental health outcomes at population level.
In January 2021, the NHS launched the National Healthcare Inequalities Improvement Programme (HiQiP) which promised “equitable access, excellent experience and optimal outcomes.” Concerning mental health, this is an ambitious promise given where we are and will absolutely need both real terms increases in funding as well as a wider evidence-based lens on identifying and tackling inequalities. We therefore suggest that “mental health culture” has not gone far enough.
About the author: Claire Wicks completed her PhD in Health Studies at the University of Essex and currently holds research posts in the School of Health and Social Care and School of Sport, Rehabilitation and Exercise Sciences. Claire has worked alongside University colleagues to evaluate various nature-based initiatives at local and national level.
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by Claire Wicks and Susan McPherson May 29, 2024A long-standing notion in UK policy has been that increased public awareness can improve national mental health. Notable campaigns include the Mental Health Foundation Mental Health Awareness Week launched in 2001; England’s Time to Change campaign (2007-2021); and Heads Together launched in 2017 backed by the Prince and Princess of Wales. UK celebrities from the worlds of sport, music, and television have been encouraged to share their experiences of mental ill health to help challenge negative attitudes, raise awareness and empower people to seek help. On the one hand, these campaigns are criticised for marginalising people in distress by setting up mental illness as an individual medical problem rather than highlighting social conditions which trigger and maintain distress. On the other hand, we now have government ministers implying mental health awareness has “gone too far”.
Whilst awareness campaign evaluations make claims around improvements in public attitudes, the UK has seen an increase in the prevalence of mental health problems. A survey of over 29 million people between 2000–2019 revealed incidence of common mental disorders increased from 55.9 to 76.9 per 1,000 “person years”. The prevalence inflation hypothesis frames this as a partial success: campaigns have apparently increased prevalence through increased reporting of previously under-recognised symptoms. However, the concern is that people presenting with mild distress are now classified as having a mental disorder. It’s this concern which seems to feed the idea as voiced by the government’s Work and Pensions Secretary who claims that “mental health culture has gone too far”. We then heard the Prime Minister adapt this trope to include the lazy as well as the mad: “sick note culture” has apparently also gone too far.
As Heney commented in a recent blog, this idea distracts from a chronic failure of government to invest in mental health care. Both austerity prior to the pandemic, followed by increasing social and economic pressures created by COVID-19 are known to have exacerbated mental distress. Yet, in 2021–22, the NHS spent £12 billion on mental health services in England, which is only about 9% of the total NHS budget. So much for “no health without mental health”. This budget includes spending on the flagship psychological therapies programme launched in 2008 now called “NHS Talking Therapies”. The programme includes the training and deployment of thousands of psychological therapists and practitioners. The service increased accessibility of psychological services via a self-referral route. Yet, while 1 in 6 adults experience a common mental health problem, in 2021/22 the NHS reported 1.2 million people were able to access NHS Talking Therapy services (around 2% of the adult population). Between 2016–17 and 2021–22, the NHS mental health workforce increased by 22% rising to 133,000 full-time equivalent staff. However, during the same time, the NHS saw a 44% increase in mental health referrals “meaning that the increase in staff was outpaced by the rise in demand for services”. These shabby figures led the British Medical Association in April 2024 to call for the government to “urgently address that demand for mental health services is outpacing the resources afforded to them”.
Not only is mental health care provision highly inadequate across the board, there is also significant inequality in terms of who is able to access the limited support available. Our research (forthcoming) uses data from United Kingdom Household Longitudinal Study (UKHLS) to examine “undiagnosed distress” across protected characteristics. Undiagnosed distress can give us an indication of where there is a treatment gap, since diagnosis is a relatively standard practice in UK mental health care. Therefore, people experiencing clinical levels of distress without a diagnosis are likely not to have accessed mental health care. Our analysis found that people living with a disability have nearly three times the risk of undiagnosed mental distress compared with people without a disability. Since diagnosis is usually required for a “sick note” this suggests we have the opposite of a “sick note culture”. Women have 1.5 times the risk of undiagnosed distress compared with men. Lesbian, gay or bisexual people are 1.4 times more likely to have undiagnosed distress compared with heterosexual people. People aged 16-24 years have the highest risk compared with all other age groups.
If the treatment gap was only a symptom of under-funded mental health services then we might expect everyone to be equally affected, regardless of sexuality, age, sex or disability. Given the evident inequality in access to care, lack of funding is not the only long-term failure in UK mental health policy. Mental health support is not adapted to the needs of different groups (particularly young people, LGB groups, women and disabled people); these groups are struggling and not asking for help and quite possibly not going off sick when maybe they should. Services have particularly failed to respond to the growing crisis in our young people who have grown up during a long period of austerity which has damaged much of the social fabric of UK society necessary for good mental wellbeing.
Despite awareness campaigns, stigma remains a barrier to seeking support (particularly where a group already experiences discrimination such as homophobia or ableism). There is also evidence that many people are afraid that if they seek mental health support they will be treated with medication and that they may then become addicted. This belief may be a counter-productive aspect of awareness campaigns pitching mental distress as a medical problem but, equally, the fear is well founded. In spite of NICE guidelines recommending psychological treatments as first line interventions for depression, in 2023, politicians, experts, and patient representatives felt compelled to jointly call for the government to reverse the rate of antidepressant prescribing, which has risen nearly 30% over the last 7 years with over 85 millionitems being prescribed in 2022/23. This alongside an increase in long-term users with no improvement in mental health outcomes at population level.
In January 2021, the NHS launched the National Healthcare Inequalities Improvement Programme (HiQiP) which promised “equitable access, excellent experience and optimal outcomes.” Concerning mental health, this is an ambitious promise given where we are and will absolutely need both real terms increases in funding as well as a wider evidence-based lens on identifying and tackling inequalities. We therefore suggest that “mental health culture” has not gone far enough.
About the author: Claire Wicks completed her PhD in Health Studies at the University of Essex and currently holds research posts in the School of Health and Social Care and School of Sport, Rehabilitation and Exercise Sciences. Claire has worked alongside University colleagues to evaluate various nature-based initiatives at local and national level.