RCPsych in Wales

Baltic House, Mount Stuart Square, Cardiff, CF10 5FH

Tel: 029 2048 9006 Fax: 029 2048 9385

Response to the Inquiry into Poverty in Wales by the Communities, Equality and Local Government Committee of the National Assembly for Wales

The Royal College of Psychiatrists in Wales (RCPsych in Wales) is pleased to make a contribution to this Inquiry. There is an intimate relationship between poverty and mental illness. Wales has made a bold innovation in implementing the Mental Health (Wales) Measure, which is concerned with services. It is timely that there is now an examination of poverty, which is the single most important public health factor influencing the incidence and outcome of mental illness.

Consultees are asked to comment on the following:

‘To consider:

· how effectively the Tackling Poverty Action Plan, Strategic Equality Plan and other government strategies work together;

· the impacts of poverty, particularly destitution and extreme poverty, on different groups of people;

· how legislation, policy and budgets targeted at tackling poverty and reducing inequality are co-ordinated and prioritised across the Welsh Government’

We shall restrict our response to the second point. RCPsych in Wales does not have the evidence or expertise to comment on the first or third points.

Inequality and poverty as causes of mental ill health

1. It is well established that inequality and poverty have adverse effects on health and well-being¹. It might seem self-evident that poverty causes mental illness. However, there are important complexities. Schizophrenia is far commoner in deprived inner city areas than elsewhere. In the past this association has not been regarded as causal. However, the current evidence suggests that growing up in urban poverty is one of the two major non-genetic factors leading to later schizophrenic illnesses². The other factor is growing up in Britain in a family of Caribbean origin. It is more or less certain that the latter is mediated by social adversity; broadly speaking, by racism. These two factors have a large effect on the likelihood of developing a psychotic illness in adulthood. Childhood abuse experiences also have an independent adverse effect.

2. It is likely that a permanent structural change towards greater equality would have the long-term effect of reducing rates of psychosis.

3. Surprisingly, the impact of childhood poverty in causing affective (mood) disorders is less well established. However, it is known that social and financial stress influence suicide rates. Periods of high unemployment are associated with increased rates of male suicide. Rural populations are at greater risk of suicide than urban populations, and this is important for Wales. There are new patterns of poverty emerging, particularly amongst people who are partially employed on zero hours contracts. Little is known about the specific effects of this at present.

4. Childhood mental ill health has a strong relationship with current deprivation.

5. Poverty underlies a wide range of public health problems, and this includes mental illness in all age groups.

Inequality and poverty inhibit recovery from mental illness

6. Poverty and attendant social exclusion are major factors that inhibit recovery from mental illness. In part this is due to a vicious cycle, whereby poverty causes mental illness and mental illness worsens poverty and social exclusion.

7. At present, ‘welfare reform’ is having a serious effect on people with mental illness. Many people with serious mental illness are dependent upon benefits and cannot compete in the job market, despite employment being their preferred option. Hostile reviews of benefit entitlements, reduction of benefits (often restored in appeal) and the ‘bedroom tax’ are all having a significant impact in causing people to relapse. Although the evidence for this is largely anecdotal, the observation is widespread and is, in our opinion, likely to be accurate.

8. This is compounded by reductions in legal aid and advice services, which make it more difficult for people with mental health problems to respond to their social and financial problems.

Destitution and extreme poverty

9. Destitution affects two groups in particular: homeless people and refugees/asylum seekers.

10. Homeless people in the UK rarely sleep rough in the long term. Their problem is more often one of extremely unstable accommodation. Most research in the UK shows that about 70% of homeless people have alcohol or drug problems, and about 30% have a major mental health problem. Although there are people who are homeless as a consequence of, for example, a chronic psychotic illness, more often they have multiple problems. Homeless people tend to be young, with a background in local authority care, prison and the armed forces. Their homelessness is a reflection of multiple complex problems that lead to antisocial behaviour and exclusion. Homeless people benefit from specialist mental health services that work on an outreach basis. There are few in Wales.

11. Asylum seekers often have mental health problems as a consequence of their experience prior to arrival in the UK. However, their biggest problem is an inability to improve their situation. Even when treated, they return to social circumstances where they are destitute and insecure. Outcomes of treatment are therefore often poor.

Conclusions

12. Poverty is a major issue in mental health care. It would require major changes in domestic economic policy to reduce poverty. Even prior to 2008, the poorest 10% of the UK population had been becoming poorer in absolute terms for more than a decade. There are some measures that could ameliorate the impact of poverty on mental health:

· Provision of free financial, housing and social problem advice to everyone under treatment for a mental health problem

· Development of outreach mental health services for destitute populations such as homeless people and asylum seekers

References

1. Wilkinson R, Pickett K (2009) The Spirit Level: Why More Equal Societies Almost Always Do Better. London: Allen Lane.

2. Poole R, Higgo R, Robinson CA (2014) Mental Health and Poverty. Cambridge: Cambridge University Press