Recession and Mental Health

1.Purpose of Report

This paper sets out how the current economic circumstances are affecting people with mental health problems. Specifically - the reduced opportunity for them to find employment; changes in the benefit system and the impact on benefit claimants.

2. Two-way impact

2.1 The impact of the recession will be a two-way matter in fact – people with a mental health problem will find it harder to find or retain work and may be dealing with a very different benefit system than they are used to, one that puts a premium on finding work or at least undertaking work-related activity. In addition there may also be an upsurge in mental health problems (such as depression or substance misuse) from people who lose their jobs, or face homelessness or increased pressure from debts and low income. Appendix 1 sets out in more detail this two-way link and is taken from a website that is used by GP’s in assessing health care needs.

2.2. A Government backed report has already warned thatmental healthwill worsen in the general population as the economic downturn impacts on people’s lives. The report, “The Foresight Project on Mental Capital and Wellbeing” drew advice from over 400 international experts and examines the experiences and lifestyle factors that can either boost or diminish mental wellbeing throughout life.
2.3 The report states that “mental health already costs over £70bn in England alone, with almost another £50bn in direct costs to the economy. According to the report 16% of the population of Britain suffer from mental health illnesses, compared to 50% of all those in debt”.

According to the ‘trade’ magazine “Debt Management Today” , “various mental health organisations have expressed concern that the credit crunch is adversely affecting the psychological wellbeing of many Britons, and could even trigger a “mental health disaster”.

Health insurer Bupa has uncovered that a third of British workers are severely worried about the security of their jobs, and two out of five have said that levels of stress at work have risen since the onset of the financial crisis.

Mental health charity MIND has also stated that the volume of calls to its helpline has doubled year-on-year to October. The charity has put the increase down to the financial fallout.

Additionally, a study conducted by the Legal Services Research Centre revealed that roughly 130,000 people have visited their GP about debt-related stress recently, costing the NHS between £15 and £20 million.

Mental health ailments like stress, anxiety, depression and insomnia have largely been blamed on the rising cost of living, soaring debts and the threat of redundancy, repossession and recession.

In a 400 page report on Mental Capital and Wellbeing, the Government’s Foresight programme identified a strong link between mental health problems and debt.

The report found that debt-ridden individuals have two to three times the rate of depression, three times the rate of psychosis, double the rate of alcohol dependence, and four times the rate of drug dependence compared to the general population”.

3. The role of employment

3.1 The Government’s view is that employment can, in itself, be a ‘cure’ for mental health problems. A report produced by the Department of Health called “Is Work Good for your Health and Wellbeing? concludes that employment is good for both physical and mental health, boosting self-esteem and quality of life.

The adverse health effects of being out of work include higher rates of mental health problems than the general population, as well as an increased likelihood of suicide, disability and obesity.

However, the evidence reveals that this can be reversed - when people return to work, their health improves by as much as unemployment damages it.

3.2 The review highlights a lack of understanding among healthcare professionals of the benefits of work. A series of initiatives are under way to help them understand the links between work and health, the long-term consequences of signing patients off sick, and the role they can play in helping their patients remain in or return to work.

National director for health and work, Dame Carol Black, who is leading the government's Health Work and Wellbeing strategy, said: "I am determined to raise awareness among healthcare professionals that being out of work has a real and negative impact on people's mental and physical health. Very few doctors and nurses understand that work is health giving. Work is an intrinsic part of improving and maintaining health. It is crucial that GPs bear this in mind when offering advice and support to people with all types of health conditions."

3.3 Mental health problems account for 40% of sickness absence from work, and almost 60% of the 2.6m people getting incapacity benefit or income support because they are unfit for work have a mental health problem listed as the major or significant reason for their incapacity.

3.4 According to Work Solutions, HCC’s in-house service that helps people with a disability find employment, the numbers of referrals for people with mental health problems have been steadily increasing over the last few years and now account for 45% of the total clients referred (303 in 2007 and 309 up to November 1st in 2008). Work Solutions are still finding employment however and have placed 53 mental health service-users so far this year.

4. Benefit reform

4.1 It is with that background, and the Governments aim to reduce the claimant count to 1.6m within 10 years, that the benefit system has been recently amended to create a model where allegedly ‘no-one is written off’. The system becomes one where a claimant is no longer treated as ‘incapable of work’ but they are to be seen as having a ‘limited capacity for work’, which the benefit system will enhance until the claimant is fit and able to return to work.

5. Employment and Support Allowance (ESA)

5.1 This was introduced on October 28th 2008 for any person who wishes to claim State benefits as a result of being unable to work due to ill-health. Before that date, claimants would get Incapacity Benefit (IB) if they had a National Insurance record or means-tested Income Support (IS) if they didn’t or their IB wasn’t enough to live on.

Existing claimants of those benefits will remain on them for the next 2-3 years before switching to ESA.

5.2 During an initial 13 week ‘assessment phase’, the Job Centre will firstly assess whether the person has a ‘limited capacity for work’ or not. See Appendix 2 for the process that is used to assess that capacity for mental health problems.

5.3 If the Job Centre, using reports from the person’s GP as well as medical questionnaires and reports from their contracted medical advisers, decides that the person has more than a limited capacity for work (i.e they are fit for work) then the claimant will be advised to switch to Job Seekers Allowance (JSA).

5.4 If it is accepted that the person has a limited capacity for work, they will then be further assessed to see if they should go into the Work Related Activity Group (WRAG) or the Support Group. The latter will be relatively small in number, around 10-15% of claimants, and will be those with the most severe disabilities (physical or mental). They will receive a slightly higher rate of benefit.

5.5. Those in the WRAG will ultimately be expected to undertake activities such as NHS-supplied ‘condition management’ (e.g. re-training to another occupation or learning how to cope with workplace stress, or adjusting to life with a bad back). These work-related activitiesare designed to move a person nearer to finding work. They will be supplemented by a series of work-focussed interviews and ultimately, a referral to a “Pathways to Work” programme. In Hertfordshire, this will be provided by the Shaw Trust, who will be paid according to how successful they are in helping people return to work and retain that work.

6. ESA and Mental Health

6.1 Although ESA will impact on all benefit claimants who have health difficulties, there will be a particular impact on those with mental health problems. It will only be possible for the Government to hit its ‘target’ of reducing IB and IS claimant numbers if significant numbers of people who have a mental health problem are either assisted into employment or assessed as fit for work and transferred onto JSA.

6.2 In the current economic climate, with employers having far greater choice if they are recruiting, and recruitment itself being less common, it is anticipated that people with a mental health history will find it increasingly difficult to find work.

6.3 In addition, it is possible that some claimants with a mental health problem will find enhanced scrutiny by the Job Centre and what they may perceive as pressure (even if well-intentioned) as being too difficult to cope with and will simply drop out of the benefit system altogether. This happens to some extent already, with some mentally ill claimants failing to attend medicals and interviews at the Job Centre (often because of fears about contacting officialdom or health professionals) and may increase when greater efforts are being made to move them into employment or work-related activity.

6.4 It is hard to give precise details of the income that ESA claimants may receive, especially in comparison to existing IB and IS claimants because there are so many variables involved (extent and length of disability, whether a person has a partner, savings, other benefit income or a works pension, which ‘group’ they are placed in for ESA purposes etc).

6.5 However, to give a very rough set of comparisons, I will use a 45 year old single man with a chronic long-term mental health problem.

Under the ‘old’ Incapacity Benefit system, his benefit income would eventually be £103.25 a week, but would start at £63.75 a week for the first 6 months. If he didn’t have an N.I. record and was on income support instead, this would mean an income of £86.35 a week, although this might be up to £62.95 a week higher if he is assessed as being severely disabled.

Under ESA, he would get £60.50 a week for the first 13 weeks and then would either be switched to JSA of the same amount or placed in the WRAG and receive £84.50 a week or be placed in the Support Group and receive £89.35 a week. Again, up to £62.95 may be added if severely disabled.

6.6. It is hard therefore to make direct comparisons and assess whether ESA is more or less generous than the benefits it will ultimately replace. Younger claimants and those who are likely to remain on benefit for extended periods have been identified as amongst those who are more likely to lose out. Of course, from the Governments viewpoint, ESA is meant to be a ‘temporary’ benefit, paid until a person moves into employment or at least becomes job-ready. The concern is that people with mental health problems will find it harder to establish that they are unfit for work but also find it harder to get work.

6.7 If they do move into work, there are a number of in-work benefits that may apply – working tax credit, housing benefit and a new 1-year Return to Work credit. The difficulty will be in finding the employment in the first place.

Appendix 1 ()

Poverty and Mental Health

Cause and Effect

People with schizophrenia tend to come from the lower social classes. This might be interpreted as suggesting that being of low social class predisposes to developing schizophrenia. However, if the social class of the father, rather than the individual is examined, there is a much more normal distribution. This suggests that schizophrenia does not have a predilection to strike at low social classes but that those with the disease tend to drift down the social scale.1 However, a more recent review of schizophrenia has concluded that poverty in itself may be a contributory factor.2

Employment

Having mental illness has a number of adverse effects on ability to earn. It is more difficult to study and to achieve qualifications. It is more difficult to hold down a responsible job. A person with mental illness may need to take time out occasionally, when the illness needs more intense treatment, whether this means time in hospital or not. Employers like reliability and do not take kindly to employees who frequently take time off. This applies whether the problem is mental or physical illness. The Disability Discrimination Act is supposed to offer protection but legislation can change laws much more easily than it changes attitudes. Mental illness carries a heavy social stigma and employers are also worried about what the sufferer may do when still working but unwell.
It is not only in highly responsible jobs that people with mental health problems face discrimination. Employers like reliability in the workforce at all levels and surveys have shown a reluctance to take on anyone with a disability at any level, especially a mental disability. They may suffer disparaging remarks at work. There is a lack of sympathy and understanding.
Not everyone with mental health problems is capable of working. Of people actively seeking employment, the rate of unemployment is much lower amongst those without any medical problems than it is amongst those with physical disability. Those with mental disability face even more difficulty in getting work.

Association and Causation

Just because two things are associated, does not mean that one causes the other. It is not fair to assume that because the mentally ill are more likely to face poverty that poverty causes mental illness. It is necessary to look at the evidence.
Mental illness is multifactorial and the tendency to descend the social scale complicates the proposition of post hoc ergo propter hoc (which came first, the chicken or the egg?). A paper from Bristol concluded that mental health differences in Wales are partly explained by the level of regional social deprivation.3
A group from Newcastle used the GHQ-28 to assess a cohort of people born in 1947. Poorer reported mental health in men was associated with downward socioeconomic trajectory over the whole lifecourse.4 This was not found for women. Again, it suggests social decline with poor mental health rather than poor mental health resulting from social disadvantage.
Both individual and neighbourhood deprivation increase the risk of poor general and mental health.5 The rate of compulsory admission under the Mental Health Act tends to be higher in deprived areas.6 This suggests more serious mental illness in such areas but it does not mean that poverty causes mental illness.
Poverty and unemployment increase the duration of episodes of common mental disorders but not the likelihood of their onset. Financial strain is a better predictor of future psychiatric morbidity than either of these more objective risk factors though the nature of this risk factor and its relation with poverty and unemployment remain unclear.7 Like mortality and physical morbidity, common mental disorders are associated with a poor material standard of living, independent of occupational social class. These findings support the view that recent widening of inequalities in material standards of living in the United Kingdom poses a substantial threat to health.8 There is limited evidence of an association between income inequality and worse self rated health in Britain. As regions with the highest income inequality are also the most urban, these findings may be attributable to characteristics of cities rather than income inequality.9

Young People

Because of the social decline with mental illness, it may be more useful to examine mental health in young people who are still dependent upon their parents for their economic position. A paper from the Institute of Psychiatry in London10 found that none of the variables they examined were associated with all types of disorder. Poor general health and life events were related to emotional disorders, while conduct disorders were most closely associated with family variables……….. They concluded that disadvantaged schools, deprived neighbourhoods, low socioeconomic status, parental unemployment, cohabiting, large family size, and poverty were not independently associated with disorder. Individually assessed child and family factors may be more influential than aggregate measures of school and neighbourhood factors.
Early adverse circumstances were strongly associated with lower cognitive ability in childhood and adolescence, and were detectable on measures of verbal ability, memory, and speed and concentration in midlife.11 However, these long term effects were mostly explained by the effects of adversity on childhood or adolescent cognitive ability or by differences in educational attainment and adult social class. This still does not properly test the proposition that a poor start to life leads to low intellect and educational achievement. ……………………………….
Financial difficulties as a student and incurring debt are associated with poor mental health.12