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Table of Contents
PERSPECTIVE/VIEWPOINT
Year : 2019  |  Volume : 1  |  Issue : 1  |  Page : 36-38

Inequity in mental health: An issue of increasing public health concern


Treasurer, World Association of Social Psychiatry; Free Lance with Own Firm, Frederiksberg, Denmark

Date of Submission20-May-2019
Date of Decision16-Jun-2019
Date of Acceptance26-Jun-2019
Date of Web Publication27-Sep-2019

Correspondence Address:
Dr. Marianne C Kastrup
Amalievej 23, DK-1875 Frederiksberg
Denmark
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/WSP.WSP_3_19

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  Abstract 


The WHO Alma-Ata Declaration of 1978 aimed to include social and economic sectors within the scope of attaining health. Health is seen as a human right, and a goal was to reduce disparities in health in 2000. Forty years later, we are far from having reached these goals, and inequity in health both between and within countries is still a major problem that receives too little public and political attention. This article discusses the social determinants of mental health and reasons for disparities thereof. To achieve equity is a goal that is beyond reach, but there are many strategies how to reduce the inequity in health, and examples thereof will also be discussed.

Keywords: Human rights, mental health, social determinants


How to cite this article:
Kastrup MC. Inequity in mental health: An issue of increasing public health concern. World Soc Psychiatry 2019;1:36-8

How to cite this URL:
Kastrup MC. Inequity in mental health: An issue of increasing public health concern. World Soc Psychiatry [serial online] 2019 [cited 2019 Nov 18];1:36-8. Available from: http://www.worldsocpsychiatry.org/text.asp?2019/1/1/36/267969




  Introduction Top


Equity and equality are frequently used interchangeably when applied in analyses of health. According to the Oxford Dictionary, equity comprises the quality of being fair and impartial and equality comprises the state of being equal, especially in status, rights, or opportunities.

When dealing with determinants of health, it is important to distinguish what are controllable and what uncontrollable factors,[1] and in this paper, the term equity is used to refer to an absence of controllable disparities in aspects of mental health. It does not include factors beyond control and usually implies a degree of social injustice. In mental health inequity, the focus is generally on the various factors that influence the differences in quality of mental health and available mental health care for different individuals and populations. It is well documented that differences in mental health equity are huge on a global, a national, as well as a local level.

Already in the Alma-Ata Declaration of 1978,[2] economic and social development as necessary prerequisites were called for to attain health for all. Over the years, the Alma-Ata Declaration has received numerous criticisms accused of being too ambitious and without clear targets. Nevertheless, the declaration with its urge toward governments, international organizations, and the world community to focus on inequity in fighting for social justice is as valid as ever-also in social psychiatry. This point was supported by the Lancet Series on Global Mental Health from 2007,[3] which aimed to change the way policymakers and other stakeholders thought about mental health. However, we have, in no way, reached the goals pointed out in 2007,[4] and equity is still far away.


  Factors Underlying Inequity in Mental Health Top


Socioeconomic status is a highly significant factor underlying inequities in mental health. Low socioeconomic status is related to limitations in financial and social capital,[1],[5] and poverty may be a causal factor or a consequence of mental illness. Research has documented that lower socioeconomic status is related to higher levels of almost any mental illness, from schizophrenia to more common mental illnesses such as depression, and having to deal with severe life stressors related to, for example, unemployment, may lead to common mental disorders or suicide.

The stressors related to lower socioeconomic status may in itself be a mechanism, leading to mental distress, and evidence suggests the idea of a gradient between different socioeconomic indicators and depression symptoms.[6] Those with more social capital have better access to the resources provided by the surrounding community, and resources are required to maintain good mental health. Thus, having a low socioeconomic status contributes to inequity.

Ethnic and racial factors

In many Western countries, in particular, the US ethnic and racial minorities experience inequity in access to mental health care. In fact, being non-White is a significant determinant in access to mental healthcare and may be closely related to the increased use of coercive psychiatric measures, and the inequity cannot be explained by differences in social status. Indigenous populations represent other groups that are reported in many settings at risk for self-harm and substance abuse and may also experience inequity in access to mental healthcare; however, ethnic minorities may experience the inequity in other ways, for example, limited possibility to get a qualified interpreter when required, and they are reported to have a higher burden of disability due to the mental disorder.

Urban life

Urban areas usually have poverty-stricken neighborhoods housing minorities, socially deprived populations, etc., and the social drift to such urban areas endangers those that are predisposed to mental illness.[7] If you live in a deprived area, you are also more likely to be subject to health hazards or other stressful life events endangering your mental health. Further, persons with mental disorders are often faced with the negative aspects of city life, such as homelessness and criminality, and a large proportion of the homeless population suffers from various psychotic disorders and substance abuse. Such groups are likely to have insufficient access to appropriate mental healthcare, thereby depriving care to those in need.

Gender

Women have, in many societies, a lower social position, are more prone to poverty and with limited control over their own life. In relation to mental health, there may be barriers receiving adequate help simply due to their sex even though women are more likely to suffer from depression and anxiety disorders. Cultural and traditional factors in many societies prioritize still males' health higher than females that, on the other hand, are more likely to be prescribed psychotropic medication and rarer referred to specialist psychiatric treatment.

Another inequity relates to trafficking and violence against women, both huge global problems with serious mental health consequences, not least posttraumatic disorders, and where the women victimized may have inadequate access to proper care and be reluctant to disclose a history of violence.

Lesbian, gay, bisexual and transgender (LGBT)

In recent years, the inequity related to sexual preference has received increasing public and media attention. The LGBT population – due to discrimination and frequently lack of family support – may develop anxieties, substance abuse, suicidal ideas, or other psychiatric problems. Moreover, despite that whether you are homosexual, bisexual, transgender, or other gender-variant, you are likely in many countries to be met with health discrimination, inequity in access to care if not direct violation of your human rights, which again may lead to traumatic conditions.

Access to care

Several underlying barriers may contribute to the inequity in access to care. Among the most important barriers, we find the financial barriers, leaving mentally ill with few resources deprived of adequate treatment. Barriers may be legal not allowing certain populations, e.g., illegal migrants, access to care, irrespective of their need. Or they may be structural if services, e.g., are not available for certain groups for linguistic or cultural reasons. All these factors may contribute to a detrimental lack of help in adequate diagnosis and treatment of even severe psychiatric disorders.


  Ways Ahead Top


Reduction of inequity in access to care

Many ways may be taken to reduce inequity in mental health. Moreover, it is time to call for an ethical, scientific, and humanistic standpoint and request that responsible authorities show concrete acts of solidarity.

In the Lancet Commission on Global Mental Health from 2018,[8] the agenda is proposed expanded to improving the mental health of entire populations and reducing the global burden of mental disorders. They emphasize that all have a right to mental health and that good mental health can facilitate development and lead to a fairer world.[4]

Strategies may be directed on different levels:

  • On clinical service level: To overcome shortage of resources and review efficiency and practice of health promotion activities, resource-oriented interventions all directed to reduce inequity in access
  • On research level: To implement scientific evidence on the mental health aspects of health inequity and support researchers in implementing “reduction of health inequity” issues in clinical and community research
  • Finally, on an organizational level: To carry out advocacy and encourage psychiatric associations to facilitate awareness on how to reduce inequity in mental health and lobby at the national levels for more resources to and better mental health services to deprived populations.


Hence, to conclude as pointed out in the Lancet editorial A shared future for all,[9] it is high time for decision-makers to step down from their pedestals and recognize that health and well-being for all can only be achieved if those currently at the margins of society are targeted with appropriate interventions and included in all available services. To overcome mental health, addressing inequity is a task that is an essential part of social psychiatry [Box 1].



Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Available from: https://en.wikipedia.org/wiki/Health_equity downloaded. [Last accessed on 2019 May 13].  Back to cited text no. 1
    
2.
World Health Organization Alma Ata Declaration International Conference on Primary Health Care, Alma-Ata, USSR; 6-12 September, 1978. Available from: http://www.who.int/publications/almaata_declaration_en.pdf. [Last accessed on 2019 Jul 05].  Back to cited text no. 2
    
3.
Lancet Series of Global Mental Health. Available from: https://www.thelancet.com/series/global-mental-health. [Last accessed on 2019 Jul 05].  Back to cited text no. 3
    
4.
Frankish H, Boyce N, Horton R. Mental health for all: A global goal. Lancet 2018;392:1493-4.  Back to cited text no. 4
    
5.
Ben-Shlomo Y, White IR, Marmot M. Does the variation in the socioeconomic characteristics of an area affect mortality? BMJ 1996;312:1013-4.  Back to cited text no. 5
    
6.
Maselko J, Bates L, Bhalotra S, Gallis JA, O'Donnell K, Sikander S, et al. Socioeconomic status indicators and common mental disorders: Evidence from a study of prenatal depression in Pakistan. SSM Popul Health 2018;4:1-9.  Back to cited text no. 6
    
7.
Available from: https://www.urbandesignmentalhealth.com/how-the-city-affects-mental-health.html. [Last accessed on 2019 Jul 05].  Back to cited text no. 7
    
8.
Lancet Commission on Global Mental Health; 2018 Available from: https://www.thelancet.com/commissions/global-mental-health. [Last accessed on 2019 Jul 05].  Back to cited text no. 8
    
9.
The Lancet. A shared future for all: Let's talk about homelessness. Lancet 2018;391:179.  Back to cited text no. 9
    




 

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