Title: MENTAL HEALTH AND INEQUALITY
1MENTAL HEALTH AND INEQUALITY
- THE TRIALECTIC OF ENVIRONMENT, SERVICES AND
PROFESSIONAL KNOWLEDGE - Anne Rogers
2Long standing evidence of inequalities
- Social class and mental health Study of
admissions - Higher rates of illness in those
groups from poor areas (Faris and Dunham 1939) - The role of social isolation (social exclusion)
-Dunham (1957) - Labour market optimal mental health correlated
with secure well-paid work with workers having
control over tasks
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4Mental health inequalities a dynamic field..
- Mental health is relatively ignored in health
inequality research (Rogers and Pilgrim, 2004). - Differences in morbidity (the poor recurrently
dying younger), occupational disease, class
differences in cancer, lung and heart disease,
ethnic differences in diabetes - Mediating processes leading to focus more on
mental health depression and premature death
from heart disease
5Relationship one of mental health increasing
inequality a vicious circle
- The consequences of depression
- Effects on family and relationships
- Physical impact (heart disease)
- Loss of income/poverty issues - 11 days lost in 6
months cf. to 2-3 days for people without
depression - 109 million working days are lost each year in
the UK through depression and anxiety (Thomas
Morris, 2003)
63 Basic Questions
- 1 How do socio-economic inequalities affect
mental health status? - 2 What is the range/type of knowledge we should
use about mental health problems to understand
inequalities? - 3 In what way are services and service contact
implicated in generating and sustaining
inequalities?
7The trialectic of services, knowledge and
external influences
Social and environmental influences on mental
health
Knowledge
Mental Health services
8Background to a different approach based on
- Epidemiology is important but limited
- Psychiatric knowledge maybe problematic as well
as useful in health inequalities - The relationship with services is underplayed
- Recursive relationship between external drivers
of inequality and service delivery
9Epidemiology is important Emergence of trends
10When things get better or worse
11Relationship between key variables important and
some are stronger than others
- Socio-economic position strong consistent
relationship - Childhood socio-economic position impacts on
depression in mid-life (Stansfield et al, 2008
British Journal of Psychiatry).
12Other Central Concepts Introduced
- Gender
- Age
- Social Class
- Place
13Increasingly Complex Epidemiology
Meltzer
14Knowledge about inequalities
- Epidemiologists collect evidence about
inequalities mapping illness and health in
large populations- objective variables
(employment housing, living arrangements,
diagnosis).
15But is there still a problem with psychiatric
knowledge?
- Contested conceptually (aetiological specificity,
predictive validity) - Are they sufficiently focussed on issues of
social influence? - Influences of culture
- Ignores service and other types of knowledge
16The bio-psychosocial model
- A conceptual model that assumes that
psychological and social factors must also be
included along with the biological in
understanding a person's medical illness or
disorder. - (05 Mar 2000)
17The Biopredominates?
- The framework does not look at issues such as
poverty, stigma and discrimination due to age,
ethnicity and gender, in preference of
individualised psychosocial experiences which may
be the result of these issues. these specific
factors are usually perceived as part of the
experience of poverty (but) the concept of
poverty is not focused upon in the writings of
epidemiologists in mental health. (Ramon 2007)
18Stigma a social concept
- Labeled persons are set apart in a distinct
category that separates us from them. The
culmination of the stigma process occurs when
designated differences lead to various forms of
disapproval, rejection, exclusion and
discrimination (Bruce Link 2000)
19Appropriating Social Knowledge from a medical
bases -Stigma?
- Stigma, is a social not clinical phenomenon and
yet the campaign re-framed it to claim medical
expertise. It deliberately yoked stigma to
specific medical categories and understated
relevant sociological knowledge ..College authors
started with diagnoses and than mapped stigmas
(plural) onto them, rather than examining stigma
generically and the role psychiatric labelling
may play in its reduction or aggravation.
Psychiatrists as social engineers A study of an
anti-stigma campaign, 61, 12, December 2005,
2546-2556
20Other type of knowledge from a different source
Lay Knowledge
- A different perspective and set of variables
about cause - patients have extensive knowledge of their own
lives and the conditions in which they live. - they can turn themselves into experts in order
to challenge medical hegemony.
21Lay vs Professional knowledge
- GPs encourage patients to view depression as
separate from the self and normal sadness. - Patients question these boundaries rejecting
the notion of a medical cure and emphasise
self-management. - Depression-management strategies wanted to get
out of their depression -focused on getting by
from day to day, - Clash with GP priorities and patient goals,
- Stress the value of listening to elicit . More
options - Johnson O, Kumar S, Kendall K, Peveler R, Gabbay
J, Kendrick T, (2007) British Journal of General
Practice. 57, 544, 872-879.
22Knowledge and Sexuality Problematised
- C19th biological determinism fatalism as
treatment - Psychoanalytical behaviour therapeutic measures
psychiatrists interfered and aspired to cure - Deviation from gender roles assumed to be abnormal
23Does service contact affect the risk of
inequality?
- A role in causing inequalities rather than
separated out from them? - Risk of stigma and social exclusion
- Distinguishing professional from social stigma
- Iatrogenic effects
24The paradox of the inverse care law?
- Access increases with increasing class status
(Tudor Hart) - Those with the least need of health care services
use services more - The same logic applied to mental health?
25Services Gradient of Coercion
- The Inverse Care Law
- Applicable to mental health dubious proposition
- Access does not always meet need in the same way
as physical illness - Gradient of coercion voluntary sector through
to special hospitals
26Access and Services
- Prestige bear consequences for actual priority
setting in healthcare systems - Mental health has low prestige in general
settings - It was demonstrated that active, specialized,
biomedical, and high-technological types of
medicine practised on organs in the upper part of
the bodies of young or middle-aged people were
accorded high levels of prestige Norredam M,
Album D. (2007) Scandinavian Journal of Public
Health 35, 6, 655-661 - Primary care point of equity
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29Conclusions
- Bodies of knowledge exist about
- the causal role of social inequalities in
predicting mental health status - the impact of service contact
- the role of clinical knowledge
- We still need to develop a transdisciplinary
approach to the relationship between these bodies
of knowledge.