Keir Starmer’s pledge in his Party conference speech that a Labour government would make sure that anyone needing mental health support from the NHS would get it within a month, is a reactive response to an increasingly evident mental health crisis that until recently hardly dared speak its name. However, it is also a fire fighting response to symptoms; implying no attempt to look at causes.
That requires a deeper look at what’s going on, what is the scale of the problem, why it is happening, what are the “solutions” that are currently being tried; and what are they trying to do and whether they work (and who for)?
What’s going on?
The MHFA in England reported the following before the pandemic.
- 1 in 4 people experience mental health issues each year.
- At any given time, 1 in 6 working-age adults have symptoms associated with mental ill health.
- Mental illness is the second-largest source of burden of disease in England. Mental illnesses are more common, long-lasting and impactful than other health conditions..
- People with a long-term mental health condition lose their jobs every year at around double the rate of those without a mental health condition. This equates to 300,000 people – the equivalent of the population of Newcastle or Belfast.
- 75% of mental illness (excluding dementia) starts before age 18.
- 70-75% of people with diagnosable mental illness receive no treatment at all.
When considering young people.
- 12.8% of young people aged 5-19 meet clinical criteria for a mental health disorder.
- Women between the ages of 16 and 24 are almost three times as likely (26%) to experience a common mental health issue as males of the same age (9%).
- The percentage of young people aged 5-15 with depression or anxiety increased from 3.9% in 2004 to 5.8% in 2017.
- About 20% of young people with mental ill health wait more than six months to receive care from a specialist.
- In a 2018 OECD survey of 15-year-olds, the UK ranked 29th for life satisfaction, out of a total of 30 OECD countries.
- About 10% of young people aged 8-15 experience a low sense of wellbeing.
Not surprisingly, research carried out in the UK by NHS Digital between February and March 2021 found a very high and incidence of sleep problems, eating disorders and loneliness among young people aged 6 to 23; and that these had risen very sharply since 2017.
Four things jump out from this.
- It is widespread.
- It is damaging.
- It is expensive.
- It is growing fast.
Why is it happening?
It is apparent that, as a general rule, people with less social standing, wealth and power get more depressed than people with more. The Joseph Rowntree Trust reports:
“Across the UK, both men and women in the poorest fifth of the population are twice as likely to be at risk
of developing mental health problems as those on average incomes.
Material disadvantage (with low educational attainment and unemployment) was associated with common mental health problems (depression and anxiety) in a review of population surveys in Europe… and is more marked in women than in men”.
So, the worse off you are, the more likely you are to suffer depression and anxiety.
So, though individual mental frailty or a chemical imbalance, or genetic predisposition can be factors, the main underlying factors are primarily social conditions that can be exacerbated or ameliorated by policy.
Its not hard to work out why. If you have resources, a comfortable place to live, assets in the bank, secure well paid employment, a role in society that confers respect, smart clothes, time and money to pursue culture and (sometimes) power over others; you live in a different world to someone who has no job, or a zero hours contract, or casual employment, scraping along on benefits, owing money to a loan shark, having to use a food bank, paying rent at an extortionate rate with no security of tenure for a gaff with mould that is ruinous or impossible to keep warm, wearing clothes until they wear out, and looked down on as a person worthy of no respect or value, no matter how much they graft. Being in the “Precariat” can be like standing on the edge of a precipice being relentlessly nudged towards it, while a rock capable of crushing you hovers over your head; and every system you try to use to navigate your way out presents itself as a labyrinth of tricks designed to frustrate you. Not this office mate, down there…Hopelessness, powerlessness, frustration.
And, women get more depressed than men. Which reflects the patterns of wealth and power, in society and the family.
And People on the receiving end of racism, are also hit harder than average.
- “Black men are more likely to have experienced a psychotic disorder in the last year than White men
- Black people are four times more likely to be detained under the Mental Health Act than White people
- older South Asian women are an at-risk group for suicide
- refugees and asylum seekers are more likely to experience mental health problems than the general population, including higher rates of depression, anxiety and PTSD.”
So far, so structural.
When we look at trends, its clear that increased impoverishment combined with disempowerment lead to an epidemic of mental ill health in the last decade; as any notion that the future offers hope to people at the bottom of the heap is closed off. Hopelessness tends to depression or rage, or sharp veers between the two.
Increases in child poverty since 2010 are continuing, and sometimes given a push by government legislation – like the restriction on benefits to larger families that came in in 2017. The Joseph Rowntree Trust has these figures for before the pandemic.
- Poverty rose from 13% in 1996/97 to 22% in 2018/19 in lone-parent families working full time.
- Between 1998/99 and 2010/11, the child poverty rate in lone-parent families working part-time more than halved from 52% to 22% but it has since risen back to 41%.
- Poverty among single earner couples where one parent works full-time rose from 29% in 1996/97 to 38% in 2014/15 and remains at this level in 2018/19.
This is what the UN Special Rapporteur concluded about the UK in 2018.
“14 million people, a fifth of the population, live in poverty. Four million of these are more than 50% below the poverty line, and 1.5 million are destitute, unable to afford basic essentials”.
The pandemic is reckoned to have put a further 200,000 children below the poverty line.
The impact of the pandemic has also generated greater inequality and mental illness, hitting the poorest, women and ethnic minorities hardest – in cases, deaths, long Covid, bereavements, job losses, increased debt, increased workloads. This study in the Lancet shows that the countries with the worst infection and death rates have had the greatest increase in depression and anxiety and spells out the reasons this has hit women harder than men. “Women are more likely to take on additional carer and household responsibilities due to school closures or family members becoming unwell. Women also tend to have lower salaries, less savings, and less secure employment than men”.
At the same time, the number of billionaires in the UK increased by a quarter; and people with secure settled jobs they could do at home on a laptop piled up additional spending power. The combination of being more vulnerable to illness and increased insecurity on the one hand, and declining social standing on the other is potentially devastating for those losing out and left below.
And hovering over everything, the impact of the climate crisis is now unmissable. Even the Murdoch press in Australia has began to wake up and move in. Turn on the news and there are pictures of cars being flooded down German streets like so many paper boats, Chinese tube trains filling with water, London streets flash flooding, towns in the North Western USA burned out in minutes, plagues of locusts in East Africa. As a consequence, recent survey of young people showed that 75% globally (and 72% in the UK) are frightened of the future, 54% think that humanity is doomed and 39%, as a consequence, are planning not to have children. “No Future. No Future. No Future for you” as the song went. Climate anxiety is a live discussion in schools. This is not a false anxiety, not a mental disorder, but a completely rational response to a real threat.
The consequence of a continued failure to develop a social mission to avert climate breakdown is likely to be an increasingly pathological society; as a fatalistic or defeatist acceptance of impending civilizational breakdown leads to a last days of Nazi Berlin hedonistic frenzy. The field full of discarded single use plastic tents at the end of the Reading Festival at the end of August could stand as an early sign of this.
None of this is down to chemical imbalances or personal frailty. All are consequences of political choices.
These are huge over arching issues. There are other, smaller but no less real factors gnawing away at people’s self respect and security bound up with the way work is organised. All advanced economies are predominantly service sector. Thomas Piketty has pointed out that improvements in productivity are relatively straightforward in manufacturing. Invest in more modern and effective machinery and the production per worker increases. This is not so straightforward in services.
In education, for instance, it has been argued that, although the quality of learning has gone up, the scale of input needed to squeeze each additional measurable point in performance from students gets greater and greater. So a class of 30 kids with one teacher in 1990 would get to a level lower than a comparable class in 2020. But that has required a massive investment in IT – whiteboards etc – and additional personnel, Teaching Assistants; which is positive and gives children a richer experience. But it has also come with a bunch of people in the Senior Management Team whose role in life is to walk round with clip boards measuring everyone’s performance.
This application of Taylorism to teaching has made it increasingly mechanical, squeezed the life out of pauses and reflection, put enormous pressure both on educators and students, both of whom have been disempowered by the process; as appraisal is constant for the staff and testing constant for the children. UK children are the most tested in Europe. Tests for 4 year olds (imagine trying to do one – have Ministers ever met any four year olds?) and a return of Key Stage 3 SATs are the latest wheezes. Is it any wonder that children in the UK come 29th out of 30 in life satisfaction in the OECD. To put it another way, we are a world leader in the unhappiness of our children.
At the same time there is an equally relentless pressure – and this is common to the entire service sector – for compulsory happiness. What might be called a “smile though your heart is breaking” policy.
I stress this point about education because another reference in Starmer’s speech was to a return to the formulas of the Blair years; that squeezing additional performance out of the education system would underpin the programme of any future Labour government. If this is to be done in the same way, what might be summarised as OFSTED, OFSTED, OFSTED; this will compound the problem.
Particularly when you consider that what comes to the front of Starmer’s mind when considering curriculum review is that students should get “life skills” training, like how to fill out a mortgage application – indicating an imaginative horizon bounded more by Moneybox Live than IPCC Reports. The need to review the whole education system, so that our society can rise to the challenge of climate change, passed him by.
But this loss of control is widespread and counterproductive. Even noting that working from home, which gives workers more control over pace, timing, cutting themselves a bit of slack when they need to, working intensely when in the zone, has led to an increase in productivity of around 15%; companies are investing in software that enables supervisors to check up minute by minute on what their workers are doing; thereby killing the autonomy and (accidental) sense of trust that has generated the productivity increase in the first place. Its as if they are afraid that people will notice that this sort of role isn’t needed.
Its even worse for workers in warehouses denied union representation, controlled by wrist monitors dictating a pace of work that has them peeing in bottles, who are not in much condition to generate a sense of well being and fulfillment from their work.
So, the mental health crisis is being driven by the dynamics of the system we live in.
What is being done?
Driven by the economic costs – estimated to be £105 billion a year – and the need to keep the show on the road, the approach is to aim to patch up the people who crack up under the strain enough to make them once more functional, productive members of it – or at least not out of control and a danger to themselves and others; like the nearly 60,000 that were sectioned in 2019-20. This might be described as the Craiglockhart method; after the centre that treated victims of shell shock (PTSD) in the First World War; so they could be sent back to the front line and shelled again. The problem is individualised and the task is to make the patient fit back neatly into the systems that caused them distress in the first place. Starmer’s pledge is an indication of how far this inadequate framework is under resourced and under strain.
According to the Mental Health Foundation in 2014;
“The proportion of people with a common mental health problem using mental health treatment has significantly increased…. It is estimated that 75% of people with mental health problems in England may not get access to the treatment they need.”
There are two main methods. Tablets or talk. Sometimes both.
Prescribing tablets is the first reflex.
This report from NatCen in 2019 shows that
- The number of antidepressant prescriptions dispensed each year in England doubled between 2008 and 2018
- Survey data show that the proportion of adults reporting use of antidepressants in the past year increased in the 1990s, and again between 2007 and 2014
- The average length of time that antidepressants are continuously prescribed to people for has increased over time.
Public Health England reported “that, in 2017 to 2018, 11.5 million adults in England (26% of the adult population) received, and had dispensed, one or more prescriptions for ….antidepressants, “.
Confirming the analysis above they continue “Prescribing rates for opioid pain medicines and gabapentinoids had a strong association with deprivation, being higher in areas of greater deprivation. Antidepressant prescribing had a weaker association with deprivation. For benzodiazepines and z-drugs, prescribing rates slightly decreased with higher deprivation. For all medicine classes the proportion of patients who had at least a year of prescriptions increased with higher deprivation.“
The questions that arise are obvious;
-if a quarter of your population has to be prescribed drugs to be able to cope with everyday life, what’s wrong with the system and what changes need to be made?
At the same time, 1.4 million people were referred to talking therapies in 2017 and just under a million started treatment. The most common form of this is Cognitive Behaviour Therapy. These are time limited sessions, geared to teaching mental techniques to help people cope with pressures that might otherwise prove overwhelming. Its not the same as psychoanalysis and doesn’t seek to cure anything deep seated; more to train the brain in mindfulness and relaxation methods to make the otherwise unbearable bearable. While this is often essential so that a lot of people can cope with everyday life as it is currently lived – and preferable to old fashioned coping strategies like getting drunk – which never worked but had a massive negative knock on effect on personal health and domestic violence – its role is to enable people to get by, not to remove the source of their problem.
So, the approach to mental health is the same as the approach to COVID. Find ways to live with it.
What else might we do?
“We need to stop pulling people out of the river. We need to go upstream and find out why they are falling in”. Archbishop Desmond Tutu.
We might add, many of them are being pushed.
If the underlying sources of anxiety and depression are primarily social, so are the solutions. Poverty, inequality, sexism, racism, disempowerment of people at the bottom of the heap (and the individualisation of their problems) are built into capitalism and daily regenerated by it. So, we can’t expect a top down solution.
However, societies with a shared collective purpose at times of danger have lower levels of mental illness. We are at such a time of danger now with climate breakdown. Anxiety is the only sane response to it. Taking collective action to transform our world is the only way to stay sane while it is happening.
And that applies to every other form of oppression and exploitation. We need to reach out and join up. Humans become more human, creative, empowered, respected when acting in solidarity. Acting together to put things right gets us out of the black box of solitude.
Avoid the tabs, organise!