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Anyone can experience a mental health problem: one in four of us every year, as we are so often reminded. But our chances of having good or poor mental health are far from equal. And for some, the risk of poor mental health is very much higher than average.

The Commission for Equality in Mental Health was set up by Centre for Mental Health to investigate inequalities in mental health in the UK and produce policy and practice proposals to tackle them.

The Commission is seeking to understand why and how inequalities in mental health happen, what ways they manifest, and most importantly what can be done to prevent or mitigate them. Our first briefing paper focused on the unequal determinants of mental health.

The determinants of mental health can all affect our wellbeing and mental health at different times in our lives. Risk factors make it more likely we will experience poor mental health while protective factors can reduce that likelihood. Evidence from a review of children and young people’s mental health suggests that the more risks a child is exposed to, the more severe they are, and the longer they are exposed to them, the greater the chances are that they will experience significant levels of mental ill health during their lives.

While evidence about the determinants of mental health is still emerging and often contested, it is clear that the environment we live in, from conception onwards, has a major influence on both mental and physical health. The Health Foundation for example has pointed to the importance of ‘allostatic load’: the amount of stress that we are subjected to in our lives – particularly early on – and the way this can erode away our wellbeing.

All of us have multiple layers of identity and belong to communities of geography, gender, ethnicity, social class and many more. And many of us experience forms of disadvantage resulting from poverty, homelessness, exclusion, discrimination or oppression. We have fewer choices, less of a voice, less power and fewer opportunities.

The determinants of mental health interact with these inequalities in ways that put some people at a far higher risk of poor mental health than others. For example:

  • Children from the poorest 20% of households are four times as likely to have serious mental health difficulties by the age of 11 as those from the wealthiest 20%
  • Children and young people with a learning disability are three times more likely than average to have a mental health problem
  • Men and women from African-Caribbean communities in the UK have higher rates of post-traumatic stress disorder and suicide risk and are more likely than average to be diagnosed with schizophrenia
  • 40% or more of people over the age of 85 and those in nursing homes have depression

Mental health inequalities need to be viewed as cumulative during a person’s lifetime. During our lives, risk and protective factors may change but the accumulation of risks from earlier in life and their impact on a person’s mental health build up over time. There is also evidence that these cumulative impacts can perpetuate through generations in families and communities as a form of ‘collective historical trauma’.

We identified a range of suggestions from previous research and from our call for evidence about specific actions and approaches that could help to prevent, reduce or mitigate inequalities in the determinants of mental health. These included:

  • Community-led peer support and social change movements
  • Prioritising early years interventions, including parenting programmes
  • A whole school approach to mental health with a focus on equality and inclusion
  • Action to increase the price and reduce the availability of alcohol
  • Addressing income inequality, work insecurity and working conditions
  • Improving housing quality and security and preventing homelessness

Prioritising inequalities in mental health has profound and wide-ranging implications for policy and practice at every level. It calls into question existing policies and practices, in mental health, the wider health and care system and well beyond, which have been embarked upon without an explicit focus on inequality.

Inequalities in the determinants of our mental health are threaded into the fabric of society. Unpicking them means being prepared to change some of the most deeply rooted inequalities and injustices and shifting the balance of public spending towards very different priorities.

The Commission will produce two further briefing papers, on access to support and on experiences of and outcomes from services, and a final report with recommendations for policy and practice later in 2020.