Call for evidence outcome

Mental health and wellbeing plan: discussion paper

Updated 17 May 2023

Applies to England

Ministerial foreword

As Secretary of State for Health and Social Care, I believe it is vital that all parts of society promote good mental health and wellbeing, and provide effective, timely support to people with mental health conditions. Prioritising the nation’s mental health isn’t just the ‘right thing to do’. Shifting the way that we think about and invest in mental health, and tackling entrenched disparities, will level up the country and help our citizens, our communities, and our economy to thrive. That is why the government’s Levelling Up white paper committed to improve wellbeing in every area of the UK by 2030, while closing the gap between the top performing areas and others.

I am proud to say that we’ve come a long way in the last 10 years. Across the country, we’re talking more about our mental health and wellbeing than ever before. Thanks to the trailblazing courage of campaigners in the public eye, and thousands of quiet conversations in homes, schools and workplaces, more and more people now feel comfortable being open about their mental health. Over 4 million people have used our Every Mind Matters resources to make a tailored Mind Plan to help them take active steps to look after their wellbeing. Initiatives like Thriving at Work have driven improvements to workplace wellbeing. The NHS is offering care and support to more people with mental health conditions than ever before, backed by record levels of investment, workforce expansion and delivery of the Advancing Mental Health Equalities Strategy. We are also investing in world-class research and bringing forward once in a generation reforms to the Mental Health Act to improve care for those who are most acutely unwell.

Since March 2020, the wide-ranging effects of the pandemic and the impacts on mental health have been felt across the country, but they have also fostered a strong spirit of innovation in the NHS and collaboration across government. We invested an additional £500 million in mental health and developed a one-year cross-government action plan to support recovery.

But I know there is much more to do. Too many people, particularly our children and young people, still do not have the right tools and support to look after their wellbeing or get the early help that they need to prevent mental health problems from escalating. Too many people’s daily practical, social and emotional needs are not being met. This can put people, especially groups that face entrenched disparities, at much greater risk of developing a mental health condition or jeopardise their recovery. We have further to go in understanding and delivering ‘what works’ to treat mental health conditions, and crucially we are often intervening too late when people have reached crisis point. Tragically, too many people are dying by suicide.

I’ve heard concerns about these challenges loud and clear from members of the public in my constituency surgeries, from leaders I’ve met in the mental health sector and from colleagues in departments across government.

I believe that now is the right time to think about bold, long-term action to build the mentally healthy society that we want to see in 10 years’ time. That is why I want your help to develop a new long-term mental health plan to transform the way that individuals, families, communities, the public, the private and voluntary and community sectors, and local and national government support the mental health of the nation. Given that mental ill-health is the second most common cause of years lived with disability in England^{[footnote 1]}, a new plan for mental health will contribute to delivering the government’s levelling up mission to increase healthy life expectancy by 5 years by 2035, and narrow the gap in healthy life expectancy between local areas where it is highest and lowest by 2030.

I recognise that preventing suicides requires specific attention and focused action, nationally and locally. I am therefore planning to develop a separate suicide prevention plan that will refresh our strategy from 2012 and complement an ambitious mental health plan.

We want to build a strong foundation for robust new plans for wellbeing, mental health and suicide prevention, based on the latest evidence and the perspectives of people with lived experience of mental health conditions and suicidality. Therefore, I, along with my colleagues across government, want to start a national conversation about the questions that we have set out in this discussion document. 

These questions have been developed in partnership with stakeholders and people with lived experience of mental health conditions. We want to build consensus on the priority actions we need to collectively take to reduce the number of people who go on to develop mental health conditions, especially for our children and young people and for communities at greatest risk. We want to develop plans to make sure that people at risk of developing a mental health condition or taking their life receive help at an earlier stage, and that people who are unwell are treated with compassion and get the support they need from the NHS, social care, and beyond. We also want your advice on how to fully harness the potential of technology and data to support better mental health, and how to incentivise the private sector to play its part. We want to hear about the best, innovative practice that is transforming lives and tackling disparities across the country, and how to make this the norm everywhere.

I urge you to challenge us to be ambitious in your responses and think beyond the status quo, and to spread the word about this opportunity to have your say. Your input will support us to develop the right plans for wellbeing, mental health, and suicide prevention in England, and to make them a reality.

Statement from the Lived Experience Advisory Network at NHS England and Improvement

This statement was co-developed in consultation with the Lived Experience Advisory Network at NHS England and Improvement. It seeks to provide a sense of direction for the plan which is rooted in the voices and perspectives of people who live with a mental health condition. The Lived Experience Advisory Network is a group of individuals with lived experience of mental-ill health, who provide advice and direction on NHS policy decisions, using their unique perspectives and expertise. This statement is our starting point and has informed the priorities and themes we are exploring as part of this discussion paper. We will build upon this as we develop a vision for the new mental health plan.

This plan needs to get us to a place where anyone struggling with their mental health, including those who live with a mental health condition, can expect to lead a good, healthy and fulfilled life. This means having meaningful and fulfilling relationships, achieving our potential, and being understood and respected by our communities.

A new mental health plan needs to shift how we approach the subject of ‘mental health’. Plans in recent years to invest in, grow and build up NHS services have been welcome, and vitally needed. But if we are going to truly change things for the better, we need to think about people as a whole - what makes up their lives, and their needs, wants and ambitions.

As individuals, we face different life experiences and circumstances which make us who we are. The things which enable us to stay well, both physically and mentally, are just as multifaceted and unique as we are.

This starts with our basic needs, to feel safe and financially secure. But equally significant is having a strong sense of purpose and identity - feeling connection, loving relationships, and to know we are valued members of society.  

Meaningful change must be driven by all parts of society and government. We need to transform attitudes and awareness, and de-stigmatise mental health conditions - in our families, communities, places of worship, workplaces, and health and social care services. 

We need compassionate employers who are able to meet us where we are at, and can support us to meet our full potential. People who understand and can meet our physical and mental needs in the workplace and enable us to thrive at work. We essentially need our society and public services to play a role in protecting and promoting our positive mental wellbeing instead of contributing to or exacerbating negative symptoms of mental health conditions.

These varied and personal needs must be reflected in the support and treatment we receive from public services too. Here we should be striving for needs based, not diagnosis-based, care and treatment. We need an NHS and social care system which is focused on and curious about a whole person and their needs for recovery, considering both their strengths, as well as the wide range of factors which might impact their mental wellbeing, including their physical health. We need a consistent and seamless service there at the time when its needed, and we need to build trust and see the same faces, and not be moved around different parts of the system, and fear falling through the cracks.

For many people, medication will be an important tool to manage mental health conditions. But it is only one component of care. We need a broader range of tools. And crucially we need more immediate access to those tools to help keep us well and support us to recover when we are struggling.

We need more therapies, more peer support workers, and the right medication for the correct diagnosis. But we also need to empower and enable clinicians to work with us to understand our needs as a whole person before agreeing a course of action to keep us well. We need choice and to practise shared decision-making. We also need easily accessible support for families and carers who are closest to us and support us to stay well.

Perhaps most significantly, we need the plan to elevate the voices and perspectives of people with lived experience. We need to see lived experience leadership on a par with clinical leadership and to move towards co-production, co-delivery and co-evaluation. People with lived experience need to be part of the decision-making at all levels - from inside the patient consultation room, right up to the board table. Positive change will come when things are done with people, not to people.’

Building on this statement, we are particularly keen that people of all ages with lived experience of mental health conditions and suicide respond to the questions set out in this discussion paper. We will be engaging widely with people with lived experience over the coming months. We will use their feedback to shape the mental health and wellbeing plan’s 10-year vision statement and our new suicide prevention plan.

Introduction

A table of definitions can be found towards the end of the document.

What follows is the scale of the problem, and why we need to act.

Poor mental health and poor wellbeing have an impact on every part of society, and every part of society has a role to play in supporting positive mental health and wellbeing.

Over the past decade, government investment has driven a welcome transformation of NHS mental health service provision. However, historical underinvestment in our mental health services means we have been building from a low base. Despite progress, significant numbers of people of all ages who would benefit from access to NHS services do not get the care they need. We estimate that more than 60% of children and young people who have diagnosable mental health conditions do not currently receive NHS care.^{[footnote 2]}

Approximately 1 in 6 people aged 16 and over in England were identified as having a common mental health condition in 2014, according to survey data.^{[footnote 3]} In 2020 to 2021, there were around half a million people with more severe mental illness such as schizophrenia or bipolar disorder.^{[footnote 4]} We have seen worrying trends for children and young people, with rates of probable mental health disorders in 6 to 16-year-olds rising from 11.6% in 2017 to 17.4% in 2021.^{[footnote 5]} More people than ever are receiving support for a mental health crisis and, tragically, the numbers of those ending their life through suicide have broadly increased over the past decade.^{[footnote 6]} We know that two-thirds of people who end their life by suicide are not in contact with NHS mental health services.^{[footnote 7]}

For many of us, the experience of the coronavirus (COVID-19) pandemic - and its wide-ranging impacts on individuals, families, society and the economy - have brought these issues into sharper focus. Around 1 in 5 adults in Britain experienced some form of depression in the first 3 months of 2021, over double pre-pandemic figures.^{[footnote 8]}

These problems aren’t felt equally by all of us. We know there is an uneven distribution of mental ill-health across society. People facing social and economic disadvantage are at a much higher risk of developing mental health conditions. They are also more likely to receive care and support much later as their conditions escalate to crisis point. In 2020 to 2021, people living in the most deprived areas of England were twice as likely to be in contact with mental health services than those living in the least deprived areas.^{[footnote 9]}

There are also disparities by ethnicity, age, sexuality, and sex, and for people with learning disabilities, neurodiversity, and long-term physical health conditions. Risks of mental ill-health are also higher for people who are unemployed, people in problem debt, people who have experienced displacement, including refugees and asylum seekers, people who have experienced trauma as the result of violence or abuse, children in care and care leavers, people in contact with the criminal justice system (both victims and offenders), people who sleep rough or are homeless, people with substance misuse or gambling problems, people who live alone, and unpaid carers. People may belong to several disadvantaged groups at once, which is likely to compound the risk of experiencing mental ill-health. Addressing these disparities is critical to deliver the government’s ambition to level up the country and tackle disparities in health. We will set out more detail on our plans to reduce the gap in health outcomes between different places and communities across the country in our forthcoming health disparities white paper. See Annex A below on mental health disparities for more detail, which can be used as a point of reference when responding to our questions.

The impacts of mental ill-health on individuals, communities, society and the economy are substantial. Children and young people’s mental health conditions incur annual short-term costs estimated at £1.58 billion and annual long-term costs estimated at £2.35 billion.^{[footnote 10]} Around 50% of mental health conditions are established by the time a child reaches the age of 14, and 75% by age 24.^{[footnote 11]} Adults with mental health conditions are much more likely to be out of work, to have lower incomes,^{[footnote 12]}] increased problems with their physical health,^{[footnote 13][footnote 14]} and increased involvement in the criminal justice system, both as victims and perpetrators.^{[footnote 15][footnote 16]} The total annual cost of mental ill-health in the workplace to government has been estimated at between £24 billion and £27 billion. The overall annual loss to the economy has been estimated at between £70 billion and £100 billion.^{[footnote 17]} Losses are greater in places and among groups that experience mental health disparities.

Health is essential to a stable and functioning economy. Our strong economic foundation going into the pandemic and the support provided throughout means we have made good economic progress. However, we must continue to build back better as we begin to rebuild the economy. By improving mental health across the country, we can improve lives and livelihoods whilst reducing the demand on the NHS and pressure on other public services, and at the same time supporting economic growth. A healthier and happier population is also more likely to access employment opportunities,^{[footnote 18]} which will reduce inactivity and improve productivity. Reducing disparities in mental health between local areas is therefore critical to ensuring more equal access to opportunities and supporting the government’s Levelling Up agenda.

The ability to socialise has been dramatically reduced by the pandemic. As we emerge from the pandemic, we need to encourage and support people to integrate back into their local communities. Systematic reviews show interventions (such as peer support and group activities) to reduce loneliness and social isolation are effective in improving mental health.^{[footnote 19][footnote 20][footnote 21]} Healthier people are more likely to engage in social and leisure activities, therefore by improving mental health within the population, people will be better connected with one another and we can further boost the economy through increased activity and demand for goods and services.

Significantly, mental ill-health is the second most common cause of years lived with disability in England.^{[footnote 20]} That is why a new plan for mental health building on the NHS Long Term Plan, alongside the wide-ranging cross-government policy programme set out in the Levelling Up white paper, is needed to deliver the government’s levelling up mission to increase healthy life expectancy by 5 years by 2035, and narrow the gap in healthy life expectancy between local areas where it is highest and lowest by 2030.

Poor wellbeing is distinct from mental illness, and we do not want to ‘medicalise’ the normal worries and stresses of life, but over the long term it can have detrimental effects on our life satisfaction, productivity at school and work, and on our physical health. This government has also set a levelling up mission that by 2030, wellbeing will have improved in every area of the UK, with the gap between top performing and other areas closing.

Continuing to grow our NHS mental health services to meet the mental health needs of more people is vital. But the scale of the challenge over the coming decade - and the size of the potential rewards for individuals, society and the economy - are vast. Simply expanding services is not the answer. We need to take a radical new, truly cross-society approach to promoting wellbeing, preventing mental health conditions, intervening earlier, improving treatment, supporting people with mental health conditions to live well and preventing suicide. We need to set a vision for change that can be ‘made real’ in each local area, transform lives and livelihoods and level up the country.

Our questions for you

We need your support and ideas to develop a comprehensive plan that will help set and achieve our vision for mental health in 2035. We have chosen, in consultation with stakeholders and people with lived experience, to focus our questions on 6 key areas. These are:

1. How can we all promote positive mental wellbeing?
2. How can we all prevent the onset of mental health conditions?
3. How can we all intervene earlier when people need support with their mental health?
4. How can we improve the quality and effectiveness of treatment for mental health?
5. How can we all support people with mental health conditions to live well?
6. How can we all improve support for people in crisis?

The chapters in this paper provide more context for why we have focused on these areas, and set out the key challenges that will need to be addressed through a 10-year plan. For each area, we are seeking your views on a range of questions which stakeholders and people with lived experience of mental health conditions have identified as priorities. We are keen to hear about examples of best practice and innovation, including uses of digital technology and data.

Building on progress to date: where are we now

As we look towards what action is needed over the coming decade, we are not at a standing start. We remain committed to our ambitious plans to expand and transform NHS mental health services to reach an additional 2 million people, backed by £2.3 billion more in real terms per year by 2023 to 2024 - with a planned update to the NHS Long Term Plan later this year considering the impact of the pandemic on the delivery of wider NHS commitments to transforming mental health services. Many parts of national and local government, the private and the voluntary sector are also already working tirelessly to improve the nation’s mental health and wellbeing. The UK also invests in world-class research on mental health through our major funders, the National Institute for Health Research (NIHR) and UK Research and Innovation (UKRI). 

To support your responses, a summary of our progress to date can be found below. Note that, due to the wide range of activity, this list is not comprehensive. You can read more about what happened from 2021 to 2022 in the COVID-19 mental health and wellbeing recovery action plan.

How can we all promote positive mental wellbeing?

Key action to date includes:

• the Office for Health Improvement and Disparities (OHID) runs Every Mind Matters, a digital resource which contains advice and tools to equip people to look after their wellbeing. Over 4 million Mind Plans have been created since October 2019^{[footnote 23]}

• OHID Prevention Concordat programme has provided guidance, advice and support on best practice on promoting wellbeing, backed by funding from the Public Health Grant

• the Office for National Statistics measures population wellbeing on a quarterly basis

• the Department for Education (DfE) has introduced compulsory Relationships, Sex and Health Education (RSHE) to ensure that all children get a good quality education about mental health and a range of other factors that may affect their wellbeing. All state schools will have had the opportunity to train a senior mental health lead by 2025 in how to lead a ‘whole school’ approach to promoting positive mental health and wellbeing

• the Department for Environment, Food and Rural Affairs (DEFRA) is improving access to nature, including through the ‘Preventing and Tackling of Mental Ill Health through Green Social Prescribing’ project, a £5.77 million cross-government project which is testing how to increase the use and connectivity to green social prescribing services in England in order to improve mental health outcomes

• the Department for Digital, Culture, Media and Sport (DCMS) is boosting access to the arts and sport, supporting the voluntary sector and investing in youth provision. The National Youth Guarantee, backed by £560 million worth of investment, means that every young person in England will have access to regular clubs and activities, adventures away from home and volunteering opportunities by 2025

• the Ministry of Justice (MoJ) is improving wellbeing support in prisons through its Prisons Strategy white paper

• building on the Care Act (2014), the Department of Health and Social Care’s adult social care reform white paper, People at the Heart of Care, sets out a 10-year vision to embed personalised care and promote wellbeing for people drawing on care and support, including those with a mental health condition

• DfE’s Opportunity for all: strong schools with great teachers for your child sets out how our education system can deliver on the government’s priority to level up across the country

How can we all prevent the onset of mental health conditions?

Key action to date includes:

• DCMS is leading work to address loneliness through its Tackling Loneliness Strategy. It is also tackling online harms through the Online Safety Bill. This legislation will help tackle misleading and dangerous online content that encourages and facilitates eating disorders, self-harm and suicide

• the Department for Work and Pensions (DWP) has developed and rolled-out guidance and training for its frontline staff on mental health, and is supporting people to gain and retain employment, for example through the Kickstart scheme

• the Department for Levelling Up, Housing and Communities (DLUHC) is working to provide safe and secure housing, and tackle rough sleeping

• to deliver the mission to improve housing conditions and security, DLUHC will publish a landmark white paper in the spring to consult on introducing a legally binding Decent Homes Standard in the Private Rented Sector for the first time ever, explore proposals for a privately rented property portal and bring forward other measures to reset the relationship between landlords and tenants, including through ending section 21 ‘no fault evictions’. This is in addition to commitments made in the social housing white paper to review the Decent Homes Standard in the Social Rented Sector, and consider whether it needs to be updated to ensure it is delivering what is needed for safety and decency now and consider how improvements to communal space around social homes could make places more liveable, safe and comfortable.

• DfE published the first ever Education Staff Wellbeing Charter in May 2021, which set out the actions the government and other organisations, including Ofsted, will take to improve the wellbeing of staff in schools and colleges. Over 1,200 schools and colleges have now signed up to the charter

• in May 2021, HM Treasury (HMT) launched ‘Breathing Space’, which gives eligible people in problem debt who are receiving professional debt advice access to a 60-day period in which most interest, fees and charges on eligible debts are frozen and enforcement action paused. There is also a Mental Health Crisis Breathing Space, which lasts as long as the person is receiving professional mental health crisis treatment, plus an additional 30 days. Breathing Space gives the struggling with problem debt the space to find a sustainable solution without the worry of creditor or mounting debts

• The Department of Health and Social Care’s (DHSC’s) health disparities white paper is due to be published later this year and will aim to break the link between people’s backgrounds and their prospects for a healthy life. It will explain the government’s overarching approach to tackling disparities across a range of health outcomes and set out new action on factors that drive disparities in both mental and physical health

• DHSC has been working with stakeholders to explore the development of a policy tool which allows policymakers to examine the impact of their proposals on mental health

How can we all intervene earlier when people need support with their mental health?

Key action to date includes:

• Since 2007, Time to Change has helped 5.3 million people improve attitudes to people with mental health problems^{[footnote 24]}

• all government departments have committed to promote OHID’s online Psychological First Aid training to their frontline workers and volunteers

• the government is continuing to take forward the recommendations of the Thriving at Work review to help workplaces provide and signpost people to early support when they are struggling with their mental health

• we are investing £500 million over the next 3 years to transform Start for Life and family help services. This includes £100 million for 75 local authorities to support perinatal mental health and parent-infant relationships during the 1001 critical days from conception to age 2

• liaison and Diversion services operate at police stations and criminal courts to identify and assess people with vulnerabilities, including mental health conditions, and refer them into appropriate services and, where appropriate, away from the justice system altogether

• the Community Sentence Treatment Requirements (CSTR) programme aims to reduce reoffending and short-term custodial sentences by addressing the underlying mental health and substance misuse issues which may be contributing toward the offending behaviours

• the government remains committed to ending the use of prison as a Place of Safety under the Mental Health Act. This is where courts temporarily divert defendants awaiting assessment or treatment in an inpatient setting to prison, because there is no hospital bed available. DHSC and NHS England and Improvement officials have been working closely with MoJ and HMPPS, through a Prison as a Place of Safety Task and Finish Group, to gain a deeper understanding of this issue and to gather data and evidence to support the development of a clear and robust plan for implementation as soon as is safely possible

• building on Future in Mind (2015), the NHS committed that through the NHS Long Term Plan, at least an additional 345,000 children and young people (PDF, 1.17MB) aged 0 to 25 will be able to access support via NHS-funded mental health services by 2023 to 2024, which will help ensure earlier support

• as part of this, NHS Mental Health Support Teams (PDF, 1.17MB) are being rolled out in schools and colleges, complementing the support offered by trained Senior Mental Health Leads. They offer early mental health help to children and young people, covering 15% of pupils in England. We are on target to reach 35% of pupils by 2023

• over a million people are accessing NHS talking therapy services every year and waiting time standards are being met. In the NHS Long Term Plan, the NHS has committed to reach 1.9 million people each year by 2023 to 2024

• we are meeting waiting time standards for NHS Early Intervention in Psychosis (EIP) services. Timely access to EIP is shown to have a significant long-term impact on the lives and livelihoods of individuals with psychosis and their families

• DLUHC has established a review of professional training & development for social housing staff and will also consider training for housing staff to better equip them to support residents with mental health issues which will lead to earlier identification of residents who are in need of support

• The NHS has consulted on introducing new waiting time standards for a wider range of mental health services across all ages. In February 2022, NHS England and NHS Improvement published the outcomes of the consultation. The government will work with the NHS on the next steps for the proposed mental health access and waiting measures

How can we improve the quality and effectiveness of treatment for mental health conditions?

Key action to date includes:

• DHSC is reforming the Mental Health Act to ensure that patients are at the centre of decisions about their own care and are treated with dignity and respect.

• in 2020 to 2021, the government invested £189 million in mental health research through NIHR and UKRI. DHSC and NIHR led the cross-community development of a Framework for mental health and the Mental Health Research Goals, which the major research funders are signed up to^{[footnote 25]}

• the NHS Advancing Mental Health Equalities Strategy sets out actions underway to bridge the gaps for communities fairing worse than others in mental health services

• the Improving Access to Psychological Therapies (IAPT) programme, which began in 2008, has transformed the treatment of adult anxiety disorders and depression in England. It is widely recognised as the most ambitious programme of talking therapies in the world

• in 2015, access to specialist perinatal mental health services was variable and 40% of the country did not have a specialist community team. Teams are now available in every area, and in the Long Term Plan, the NHS has committed that at least 66,000 women will access support in the community by 2023 to 2024

• the NHS Community Mental Health Framework is a new model of care; in the Long Term Plan, the NHS has committed to give 370,000 adults with severe mental illness greater choice and control over their care, with integration between primary and secondary care to provide wraparound support by 2023 to 2024

• the NHS is investing in social prescribing, which is an innovative way to meet people’s practical, social and emotional needs that affect health and wellbeing, including mental health. In 2019, the NHS has committed that at least 900,000 people will be referred to social prescribing by 2023 to 2024

• during the COVID-19 pandemic, many NHS mental health services transitioned to deliver care digitally and the NHS is committed to learn from and build on this period of rapid innovation

• from harm to hope - a 10-year drugs plan to cut crime and save lives was published on 6 December 2021. The government will invest over £2.8 billion over the next 3 years to create a world-class treatment and recovery system. This includes £780 million of additional investment, the largest ever single increase in treatment and recovery funding. Improving the integration of services will include drug treatment being joined up with our investment in NHS mental health services, so that people’s wider needs can be addressed together

• we are investing over £400 million to improve mental health facilities by eradicating dormitories and giving patients the privacy of their own bedroom and an en suite bathroom, ensuring that patients are given the dignity and respect they deserve

How can we all support people living with mental health conditions to live well?

Key action to date includes:

• the NHS Community Mental Health Framework, referenced above, is not just about NHS support. It seeks to build stronger links between health, social care, housing and other services to meet the needs of people with severe mental illness holistically

• the NHS Long Term Plan committed to the delivery of 390,000 physical health checks each year for people living with severe mental illness, by 2023 to 2024

• the NHS Long Term Plan also committed to supporting 55,000 people a year to achieve their goals of finding meaningful employment through the Individual Placement and Support (IPS) programme

• employment Advisers in NHS talking therapy services provide tailored employment support to people with depression and anxiety

• the integration white paper, published in February, builds on and complements the Health and Social Care Bill, as well as the adult social care reform white paper, People at the heart of care, published in December 2021

• the white paper will improve health and care systems for the 21st century, boost the health of local communities, and make it easier to access health and care services, so we can go further and faster in delivering person-centred care thus promoting wellbeing and better population health. It includes new investments in supported housing to enable people who draw on care and support - including those with a mental health condition - to live independently, recover and live well

• the cross-government Changing Futures programme is testing new approaches to improve support for adults facing multiple disadvantages

• the DLUHC Supporting Families programme is helping local areas tackle the multiple and complex challenges that disadvantaged families face, including issues such as domestic abuse, mental ill-health, financial insecurity and children at risk of harm. The programme works to de-escalate these issues through delivering whole-family, multi-agency support. At Spending Review 2021, an additional £200 million announced for Supporting Families over the coming 3 years, bringing the programme’s budget to £695 million

• through its health and disability green paper, DWP is working to improve the health and disability benefits system, increase opportunities for employment and help more people to lead independent lives, including for people with mental health conditions

• DfE has invested over £1 million to pilot new approaches to mental health assessments for children entering care. The pilots generated considerable learning which we will use to inform support for the mental health of looked-after children moving forward, building on our commitment in the NHS Long Term Plan. In addition, all looked-after children benefit from the support of a Virtual School Head, who has a statutory duty to promote the education of all children in their local authority’s care

How can we all improve support for people in crisis?

Key action to date includes

• DHSC published the latest progress report against the National Suicide Prevention Strategy in March 2021, alongside a refreshed cross-government suicide prevention workplan

• all local authorities have a suicide prevention plan in place which addresses key local risk factors

• the NHS is investing £57 million by 2023 to 2024 to support local suicide prevention plans and bereavement services

• every area in England now has a 24 hours a day, 7 days a week mental health crisis service. Rollout of all-age NHS crisis phone lines has been accelerated, taking over 3 million calls in 2020 to 2021. The NHS Long Term Plan committed that this will be integrated with NHS111 by 2023 to 2024

• the Home Office continues to work with the police to help improve the way in which they and other partners respond to people with mental ill-health

• all government departments are encouraging government frontline workers and volunteers to complete suicide prevention awareness training

• DHSC has invested over £5.3 million for voluntary and community sector organisations, via a Suicide Prevention Grant Fund, to support them to continue to deliver vital suicide prevention services in 2021 to 2022

Relationship between the mental health plan and wider plans for the health and care system

Addressing disparities will be a key aim across the whole of the mental health plan - from prevention through to early intervention and treatment. The plan will form part of our wider commitment to break the link between people’s backgrounds and their prospects for a healthy life. It will be closely aligned to the health disparities white paper, which is due to be published later this year. The health disparities white paper will aim to break the link between people’s backgrounds and their prospects for a healthy life. It will explain the government’s overarching approach to tackling disparities across a range of health outcomes and set out new action on factors that drive disparities in both mental and physical health.

The mental health plan will be aligned with the update to the NHS Long Term Plan, which will be published later this year. The NHS Long Term Plan update will set out how the NHS will draw on learning from responding to the pandemic, and how mental health services can benefit from the further development of integrated care systems, expected through the legislation currently being considered by Parliament.

Much of the action we take over the coming decade to support the nation’s mental health will ultimately contribute towards preventing suicide. However, we believe that suicide prevention requires specific, coordinated action, and national and local focus. Through the questions outlined in this paper, we welcome additional input on what more we can do to prevent suicide. We intend to use this feedback to support the development of a separate suicide prevention plan for publication in due course. This will build on our strategy from 2012 and complement the broader mental health and wellbeing plan.

Both the mental health and wellbeing plan and the suicide prevention plan must be underpinned by a robust and comprehensive plan to recruit and retain a world class workforce to deliver our vision for NHS mental health care. We will work with NHS England and Improvement and Health Education England, and engage extensively with the mental health sector, to develop a workforce plan to sit alongside the mental health and wellbeing plan. To improve workforce planning, in July 2021, DHSC has already commissioned Health Education England to work with partners to review long-term strategic trends for the health and regulated workforce, including adult social care professions. This will take a 15-year forward view to guide planning, education and training.

We will also work with the devolved administrations to share best practice and exchange relevant data and evidence to support the development and delivery of mental health and wellbeing strategies across the 4 nations where appropriate.

How to respond

You can respond to any or all questions using the online survey by 11:45pm on 7 July 2022.

If you have any technical problems with using the online survey, log the issue by emailing mhplan@dhsc.gov.uk. Please do not send any personal information to this email.

To drive a step change in mental health outcomes, we need collective action across society. As individuals, friends, family members, carers, co-workers, community leaders and business owners, we all have the power to make a difference. We all have mental health, and all have a part to play in changing things for the better.

We will therefore be engaging widely to develop this plan and build consensus around the priority actions which need to be taken. Written responses will be supplemented by engagement with people with lived experience of mental ill-health, round tables and workshops with stakeholders from the voluntary sector and the clinical, teaching, social care, and business and tech communities. You can find a quick read version of this document and an easy read version.

We understand that engaging with this discussion document may be difficult for people who have experienced or been affected by some of the issues we have highlighted. If you have been affected, you can find:

• advice and tips to help you look after your mental health and wellbeing via the Better Health: Every Mind Matters website 

• information on how to access NHS mental health services on the NHS website

• support from the voluntary and community sector by searching the Hub of Hope

If you or someone you know are experiencing a mental health crisis, you can find details of your local, 24-hour urgent mental health helpline on the NHS website. You can also contact Samaritans for 24-hour support via phone or email.

Chapter 1: how can we all promote positive mental wellbeing?

There is strong evidence that improving wellbeing across every stage of life enables us and future generations to live long, healthy, independent, purposeful, and flourishing lives. Good wellbeing can support effective learning and productive working. It can also help us make healthy lifestyle choices that boost our physical and mental health, such as eating well, doing physical activity, and avoiding smoking and problem drinking.   

In the recently published Levelling Up white paper, this government set a mission that by 2030, wellbeing will have improved in every area of the UK, with the gap between top performing and other areas closing. We want to make sure that we act, nationally and locally, to influence the factors that affect wellbeing in people’s daily lives. We also want to empower people, and give them the right tools and support, to look after their wellbeing.

We have a good sense of ‘what works’ to support positive wellbeing. We know that the foundations for wellbeing include:

• having basic needs met such as food, a home, rest, feeling safe
• experiencing positive social relationships with friends and family and a sense of community
• having the opportunity for a good education, including continued learning through life and to engage in meaningful, quality employment
• being able to make a positive contribution to wider social and community life

We know that providing the right support from preconception, during pregnancy and the early years is vital, and can deliver inter-generational benefits across the life course. We know that helping individuals and families, particularly children and young people, to develop the knowledge and understanding of how to look after their mental health and cope with normal feelings of distress and worry, especially during difficult times, can make a positive difference. There is evidence on effective ways of promoting wellbeing in education settings and workplaces, and that taking part in physical and cultural activities and having access to nature help build and sustain people’s wellbeing.

Where should we be in 10 years’ time?

Over the next 10 years, there are challenges which need to be addressed to support the nation’s wellbeing, including:

• significant and persistent disparities in levels of wellbeing across the country, which are shaped by disparities in society, particularly for the groups identified in Annex A below on mental health disparities. This is why it is important we deliver on our promises to Level Up

• gaps in individuals’, communities’ and organisations’ knowledge about factors that influence wellbeing and the steps they can take to support better wellbeing. People also do not always have the time or resources to improve their wellbeing

• variation in understanding of how policy making, service delivery and practices affect wellbeing and how to ensure that decisions made by organisations at all levels can build in positive actions that support wellbeing (for example, local and national government, education settings, workplaces)

• the need for more comprehensive evaluation of interventions to support wellbeing, further sharing of best practice and better national measurement of wellbeing to help shape policy decisions

Question

How can we help people to improve their own wellbeing?

Your ideas may include actions which can be taken by different types of organisations - such as national and local government, public services such as schools, and the NHS, employers and the private and voluntary sectors. It can also include things that happen between family members and local communities.

Please provide your suggestions in relation to the wellbeing of different groups:

a) Infants and their parents or primary caregivers

b) Children and young people

c) Working age adults

d) Older adults

e) People that are more likely to experience poor wellbeing (see Annex A)

Question

Do you have any suggestions for how we can improve the population’s wellbeing?

This can include ideas about what local people and communities can do together, as well as things you want to see in health services, wider public services such as education settings, places of employment and the private and voluntary sectors.

Please provide your suggestions in relation to the wellbeing of different groups:

a) Infants and their parents or primary caregivers

b) Children and young people

c) Working age adults

d) Older adults

e) People that are more likely to experience poor wellbeing (see Annex A)

Question

How can we support different sectors within local areas to work together, and with people within their local communities, to improve population wellbeing?

This includes a wide range of public services, including education settings, social care, the NHS, voluntary sectors, housing associations and businesses.

Chapter 2: how can we all prevent the onset of mental ill-health?

The causes of mental ill-health are complex. For many people the onset of a mental health condition, and the impacts on their lives and life chances, is not inevitable. We want our plan to set out a radical new cross-government approach to preventing ill-health whenever possible. Our goal is to influence the root causes of mental ill-health and reverse current trends, which have seen increasing numbers of people, particularly children and young people, developing mental health conditions, and a growing number of people ending their life by suicide.

To achieve this goal, we need to influence known ‘risk factors’ for mental ill-health and the multiple, intersectional disparities associated with them.

Lots of factors shape our mental health, such as our personal history (our family, relationships and how we see ourselves) and our social circumstances (including our housing, employment, and education).

Factors with the strongest evidence demonstrating links to the development of mental health conditions include:

• experiences of poverty
• socio-economic disparities
• social exclusion
• problem gambling
• adverse childhood experiences including trauma
• unemployment
• poor quality work
• debt and financial insecurity
• drug and alcohol misuse
• involvement in the criminal justice system (both as a victim or as an offender)
• homelessness
• loneliness, which can be exacerbated by isolating jobs
• relationship breakdown
• violence, including sexual violence
• discrimination, including racism and homophobia
• limited access to or connection with nature and the impact of noise.

People with learning disabilities and autism, and people with disabilities and long-term physical health conditions also experience worse mental health. See Annex A for further details.

In addition to these long-established risk factors, there is emerging evidence that more recent social changes may have harmful impacts on mental health, with potentially disproportionate effects on children and young people. These include exposure to unrealistic body image standards, experience of bullying and discrimination online through social media, and online gambling. We are increasingly concerned about misleading and dangerous online content that encourages and facilitates eating disorders, self-harm and suicide. There is a need for further research, particularly on the negative and positive effects on screen time and social media use on mental ill-health.^{[footnote 26]}

The impact of risk factors can be cumulative across a person’s life. But tackling disparities and risk factors in the early years and childhood are some of the most effective preventative measures we can take. The first 1001 days of life are a crucial period of emotional development. There is also clear evidence that negative experiences throughout childhood (often termed adverse childhood experiences), such as abuse and neglect, or witnessing substance misuse in the home, can have lifelong mental health impacts.

We also know that, across the life course, certain events may increase people’s risk of experiencing mental ill-health or suicidal thoughts, particularly if people do not have good support systems. These events include inevitable transitions, such as moving between primary and secondary school, from school to higher education or leaving education to employment, moving jobs, or entering retirement. Some people will experience specific, particularly stressful life changes, such as leaving the care system, bereavement, job loss, eviction, or social exclusion.

We want our plan to draw on the best evidence on ‘what works’ and develop a whole-society approach to prevent and mitigate the impacts of these risk factors on mental health and suicide, particularly for groups who experience disparities. 

The creation of the new Office for Health Improvement and Disparities presents an opportunity to think radically about how to tackle key challenges and prevent the onset of mental ill-health, with a particular focus on those people and communities at greatest risk.

Where should we be in 10 years’ time?

We know that there is much more to do to reduce the number of people who experience mental ill-health and develop mental health conditions, and to tackle disparities. Challenges include:

• entrenched disparities, which may have been widened by the pandemic, that make it more likely some groups (see Annex A on mental health disparities) will be exposed to risk factors for mental ill-health and suicidality. For example, we know that children in low-income households are 2 to 3 times more likely to develop mental health conditions^{[footnote 27]}

• the need for better coordination across government to protect the nation’s mental health. For example, impacts on mental health are not always factored into decision-making on relevant national and local government policy areas

• gaps in our understanding of ‘what works’ to mitigate risk factors for mental ill-health, especially robust evaluation of interventions

• the need for a clearer role for the private sector, including businesses, employers, and online platforms, in preventing the onset of mental health conditions and mental ill-health, and wider implementation of workplace interventions to support mental health, as identified in Thriving at Work. There is a strong evidence base showing that work is generally good for physical and mental health and wellbeing^{[footnote 27]}

Question

What is the most important thing we need to address in order to reduce the numbers of people who experience mental ill-health?

This might include actions which can be taken by national and local government, public services such as education settings, social care, the NHS, and the private and voluntary sectors.

Please provide your suggestions in relation to different groups:

a) Infants and their parents or primary caregivers

b) Children and young people

c) Working age adults

d) Older adults

e) People that are more likely to experience mental ill-health (see Annex A)

Question

Do you have ideas for how employers can support and protect the mental health of their employees?

Question

What is the most important thing we need to address in order to prevent suicide?

This might include actions which can be taken by national and local government, public services such as education settings, social care, the NHS, and private and voluntary sectors.

Please provide your suggestions in relation to different groups:

a) Children and young people

b) Working age adults

c) Older adults

d) People that are at greater risk of suicide (see Annex A)

Chapter 3: how can we all intervene earlier when people need support with their mental health?

We know that the sooner someone receives support when they are struggling with their mental health, the more likely it is they will recover. Early intervention can reduce a person’s symptoms and make it less likely that they will need more intensive intervention at a later stage. Intervening earlier can prevent people from experiencing a ‘mental health crisis’ which could lead to hospital admission or, in some tragic cases, result in death by suicide. Early intervention can also help keep people in work, or engaged in education, and prevent wider negative impacts on people’s lives and relationships, which can in turn compound the risk that their mental health and wellbeing will deteriorate.

We also know that access to early support can prevent infants, children and young adults from developing enduring conditions that can have long-term impacts on their lives and life chances. Around 50% of mental health conditions are established by the time a child reaches the age of 14, and 75% by age 24.^{[footnote 29]}

Early intervention can take many forms. The support that someone needs won’t always be ‘clinical’, and it’s important that we don’t over-medicalise people’s experience of distress. The ‘right’ support will depend on someone’s individual needs, how those needs affect them, the severity of their symptoms, their individual strengths, and their wider circumstances. Sometimes the most appropriate intervention will include providing support and information to important people in a person’s life, such as parents, unpaid carers, teachers, families or employers. In some cases, interventions to tackle the triggers of a person’s distress, or encouraging them to access activities which improve mood and wellbeing such as the arts, physical activity, or nature, may be most effective.

While all parts of the NHS play an important role in identifying, diagnosing, treating, and supporting people with mental health conditions, there are a broad range of bodies and organisations across society which have an equally important role to play in supporting someone early. Parents, families and friends are often the first people to notice that someone they care about needs support. And a whole range of public, private and voluntary and community sector services, such as education settings, housing associations, social care, victim support organisations, youth centres, libraries, sports clubs, workplaces and job centres, are ideally placed to identify people who may be struggling and offer support early. They can also signpost them to NHS services to determine if specialist provision might be needed.

For people who do need ‘clinical’ support, access to early support from the NHS can help them recover or manage their mental health. However, despite progress in recent years (see the ‘progress to date’ section above), many people who would benefit from early support from their GP or NHS mental health services do not receive support at the right time, or in some cases at all. There are not enough joined-up approaches across physical and mental health care to ensure that we meet the mental health needs of people with physical health problems. Too many people only get support from services when they are severely unwell or have reached crisis point, or they face long waits or high thresholds to access NHS care. We are committed to existing plans to expand services further, backed by additional investment of £2.3 billion in real terms from 2023 to 2024, to enable an additional 2 million people to access NHS support and to meet our waiting time standards for access to talking therapies, early intervention in psychosis and children and young people’s eating disorder care. But there is much more to do over the coming decade to ensure that early mental health help from the NHS is available and accessible to all who need it, especially against the backdrop of COVID-19 recovery.

Where should we be in 10 years’ time?

We want our plan to build upon the work to date to improve the availability of early support for mental health across all age groups, both within and beyond the NHS. Key challenges include:

• stigma around mental ill-health or mental health conditions, as well as fear and mistrust of sources of support, including NHS services. This support may not always be culturally appropriate

• gaps in the level and quality of early mental health support and signposting provided in settings where the right staff training and interventions can make a critical difference. This includes schools and colleges, universities, housing associations, social care, NHS physical health services, youth centres, sports clubs, workplaces and job centres

• inconsistency in the way that local places plan and deliver early, joined-up mental health support through collaboration across different services, despite clear examples of good practice in some areas

• current high levels of unmet ‘clinical’ need in NHS services and long waiting times, and the scale of the workforce growth and transformation required to meet demand

• persistent, intersectional disparities in access to early help, with some individuals facing significant barriers to support. This includes people with other support needs beyond but linked to their mental health, such as co-occurring substance misuse

In your responses to our questions, we are interested in priority actions which will address these challenges. We are interested in hearing about your experiences of all mental health conditions, from common mental health conditions like anxiety and depression to severe mental health conditions like bipolar disorder and schizophrenia.

Question

Where would you prefer to get early support for your mental health if you were struggling? Please tick all that apply.

• from family and friends
• from the NHS
• from your local authority
• from an education setting
• from a social care provider
• in your community
• from the voluntary and community sector
• from your workplace
• from digital-based support or advice
• from the private sector, for example by paying for counselling
• don’t mind - as long as the support is high-quality
• other - please specify

Question

What more can the NHS do to help people struggling with their mental health to access support early?

Please provide your suggestions in relation to different groups:

a) Infants and their parents or primary caregivers

b) Children and young people

c) Working age adults

d) Older adults

e) Groups who face additional barriers to accessing support for their mental health

Question

Do you have any suggestions for how the rest of society can better identify and respond to signs of mental ill-health?

• yes
• no

If yes, please share your ideas.

You might want to consider community bodies, public services and private and community sectors. We are particularly interested in how society and different sectors can work together to get people support early.

Please provide your suggestions in relation to different groups:

a) Infants and their parents or primary caregivers

b) Children and young people

c) Working age adults

d) Older adults

e) Groups who face additional barriers to accessing support

Question

How can we ensure that people with wider health problems get appropriate mental health support at an early stage if they are struggling?

You might want to consider barriers faced by individuals, as well as how health and social care services engage with those people.

Chapter 4: how can we improve the quality and effectiveness of treatment for mental health conditions?

For people experiencing a mental health condition at any age, the treatment and support they receive from the NHS plays an important part in supporting them to manage their condition, alleviate their symptoms, and can significantly improve their quality of life.^{[footnote 30]} Over the past 10 years, the range of treatment options available on the NHS has expanded rapidly. For example, adults experiencing a common mental health condition or severe mental illness should now be offered a range of treatment options, combining psychiatric medication with talking therapies like cognitive behavioural therapy (CBT) or counselling.

But we know there are limitations to the current treatment offer. More needs to be done to ensure that existing NICE guidelines can be delivered, and to diversify the range of treatments available. Our understanding of people’s experiences of NHS treatment, the quality of care they receive, and the efficacy of different treatment approaches is rapidly evolving. We want our new plan to ensure we have a diverse and wide-ranging support offer which meets the needs of our diverse population, with improved options and choice for treatment, including access to digital support to enhance care pathways and access to support outside the NHS. Given that mental ill-health is the second most common cause of years lived with disability in England,^{[footnote 31]} our ambition to improve to the quality and effectiveness of treatment options available for people living with mental illnesses is key to achieving the government’s levelling up mission to increase healthy life expectancy by 5 years by 2035.

In particular, as set out in the NHS’s Advancing Mental Health Equalities Strategy, we want to tackle the unacceptable disparities faced by groups who have worse experiences of and outcomes from mental health services.

To achieve this, we need to build on our understanding of ‘what works’ for different groups to treat different conditions. This includes medicines, therapies, social prescribing interventions and more holistic approaches that involve collaboration with education, social care, housing provision and employment support (see ‘Chapter 5: how can we all support people living with mental health conditions to live well?’). It is important to take a multidisciplinary approach and ensure systems of support are connected for people with multiple disadvantages or specific needs. In 2020 to 2021, the government invested £189 million in mental health research through NIHR and UKRI.^{[footnote 32]} But there is much further to go to achieve a level of parity with investment in research on physical health conditions.

Innovative approaches to collecting, sharing and using rich data on services are vital. For example patient outcome measurements, including existing measures such as ‘recovery rates’ in talking therapies, provide valuable insights into the effectiveness of different treatments. These can also be used to inform the approaches services take and to improve patient outcomes in the future. We need to ensure data collection on patient outcomes is as informative as possible, particularly for groups that face disparities, and consider whether new measures such as patient experience and satisfaction would help services to tailor their treatment offer. To provide the best care possible for our patients and to encourage data-driven innovations, we need to make appropriate sharing of data the norm and not the exception across our services - and link datasets in innovative ways to help us tackle policy challenges, and better integrate services to provide holistic support.

Digital innovation, including blended digital and face-to-face interventions, offer the opportunity to improve patient choice, access to treatment and quality of treatment throughout the entire patient journey. Interoperability between settings can reduce therapeutic time lost to administrative activities and improve safety by ensuring that clinicians have access to the right information. They can also empower patients by putting information about their care in their hands and allow for more personalised services to be delivered. Alongside efforts to support digitally enabled care, it is critical that steps are taken to address risks of increasing disparities for people who are not able to or do not want to access digital services. Patient choice must always be at the core of any digital offer.

For care provided in inpatient settings, our work to reform the Mental Health Act is laying strong foundations to ensure that patients of all ages are put at the centre of decisions about their own care and are treated with dignity and respect. We are acting now on the insights that service users have shared with us in previous consultations. We are changing legislation, investing in the inpatient estate and piloting culturally appropriate advocacy for people of all ethnic backgrounds and communities, in particular for black men who were more than 4 times more likely to be detained under the Mental Health Act in 2020 to 2021 than their white counterparts.^{[footnote 33]} But we want our new plan to build on this progress to make sure that hospital-based mental health care, where it is required, is always healing, trauma-informed, high-quality and safe. In your responses, we want to hear how, over the next decade, we can make this a reality and learn from the best international practice to reduce our reliance on inpatient care and support people in less restrictive, community environments.

Where should we be in 10 years’ time?

We want our new plan to boost our evidence base on ‘what works’ and ensure that the NHS can provide world-class treatment that reflects best practice. Key challenges include:

• the current capacity and capability of the mental health and suicide prevention research sector

• the need to improve the quality, availability and use of data throughout all stages of the patient journey; from facilitating easy access to electronic patient records, to capturing the availability of treatment, to measuring outcomes in a meaningful way centred on service user experience

• the capacity and capability of the NHS workforce to turn the latest evidence on what works, as set out in NICE guidelines, into practice while treating service-users with compassion and dignity

Question

What needs to happen to ensure the best care and treatment is more widely available within the NHS?

We want to hear about the most important issues to address in order to improve NHS mental health care and treatment over the next 10 years.

We would be grateful for views on:

a) Infants and their parents or primary caregivers

b) Children and young people

c) Working age adults

d) Older adults

e) Groups who report worse experiences and outcomes from NHS mental health services (see Annex A)

Question

What is the NHS currently doing well and should continue to support people with their mental health?

Question

What should be our priorities for future research, innovation and data improvements over the coming decade to drive better treatment outcomes?

We would be grateful for views on priorities for research across the life course, including:

a) Infants and their parents or primary caregivers

b) Children and young people

c) Working age adults

d) Older adults

e) Groups who have worse experiences in NHS mental health services, and/or often do not experience good outcomes (see Annex A)

Question

What should inpatient mental health care look like in 10 years’ time, and what needs to change in order to realise that vision?

Note that our continued focus on improving community support for people with mental health conditions, including outside of the NHS, is considered in the next chapter.

Chapter 5: how can we all support people living with mental health conditions to live well?

Our ultimate objective for this plan is to improve the lives of children and young people, working age adults and older adults living with both common mental health conditions and severe mental illnesses. This is reflected in our current ambitions to reform the Mental Health Act, support people to live well in the community and reduce the risk of detention.

While NHS treatment can play an important part in helping people to recover and live well (see ‘Chapter 4: how can we improve the quality and effectiveness of treatment for mental health conditions?’), social circumstances have an equal role in shaping a person’s overall health and wellbeing across the life course. This includes suitable housing, education and employment opportunities and remaining in work, social care and voluntary and community sector provision, appropriate support through the benefits system, access to and opportunities to connect with green space, family support, good social relationships, and physical health.

Living with mental health conditions can also mean experiencing worse outcomes than the general population across many of these areas of life. Children and young people with mental health conditions are more likely to experience increased disruption to their education, through time off school and exclusions, than children with no mental health conditions.^{[footnote 34][footnote 35]}

For some people with mental health conditions, life-long impacts of trauma or abuse, experiences of discrimination, including racism, alcohol or drug misuse, homelessness or contact with the criminal justice system (both as victims and as offenders) can also compound negative health and wellbeing outcomes.^{[footnote 36]}

Employed adults are half as likely to have a common mental disorder compared to their unemployed or economically inactive counterparts.^{[footnote 37]} Individuals who receive Employment Support combined with an NHS talking therapy for their anxiety or depression, are more likely to be in employment when leaving the service, as well as having a greater improvement on their mental health, compared to those who receive talking therapy alone. The combination of Employment Support with talking therapies addresses individuals needs holistically and each enhances the other, creating a ‘continuous cycle’ of support. Adults being supported by secondary mental health services are 65% less likely to be in employment compared with the general population,^{[footnote 38]} although there is evidence that the majority want to work and would like more help to get back into employment.^{[footnote 39]} Individual Placement and Support helps people with severe mental illness who want to find or retain employment. If the individual is supported into meaningful work of their choice, there is evidence that employment enables recovery and contributes to health outcomes.^{[footnote 40]}

Good work is important for people’s physical and mental health and there is some evidence that job quality determines whether or not employment has benefits for mental health.^{[footnote 41]} Moving from unemployment into a high-quality job led to improved mental health, however the transition from unemployment to a poor-quality job was more detrimental to mental health than remaining unemployed. £1.3 billion is being provided over the Spending Review 2021 period for employment support for disabled people and people with health conditions. It will extend the Work and Health Programme, expand the Intensive Personalised Employment Support programme, and expand employment support in NHS Improving Access to Psychological Therapy services across England.

The physical health disparities faced by people with severe mental illness in particular, are stark. On average, people with severe mental illnesses in England die 15 to 20 years earlier than the general population,^{[footnote 42]} and two-thirds of deaths are from preventable physical illnesses.^{[footnote 43]} Evidence suggests that this ‘mortality gap’ is widening,^{[footnote 44]} and that socio-economic deprivation compounds these disparities further.

Positive steps have been taken to improve the lives of people living with mental health conditions. These include the Department for Levelling Up, Housing and Communities’ ‘Supporting Families’ programme’s support for vulnerable families, including those with mental health needs; employment advisors in talking therapy services for adults; the government’s ‘Changing Futures’ programme focussed on multiple disadvantages; and the Community Mental Health Framework. The Community Mental Health Framework aims to build stronger links between mental and physical health, social care, housing, employment, and other services to meet people’s needs holistically.

The DHSC integration white paper, published in February 2022, will improve health and care systems for the 21st century, boost the health of local communities, and make it easier to access health and care services. This white paper builds on the Health and Social Care Bill and social care reform white paper, People at the Heart of Care, published in December 2021. This includes new investment in supported housing to enable people who draw on care and support - including those with a mental health condition - to live independently, recover and live well.

But to truly shift the dial, our new plan must drive concerted effort across a range of sectors and in wider society to improve the factors which make up a person’s quality of life, and experience of treatment, across the life course. We also need to ensure that support is trauma-informed and is provided in a joined-up way in each local area, with continuity of care, true integration between the NHS and social care, and no ‘wrong front door’ or barriers to access.

Where should we be in 10 years’ time?

We want to build upon the progress to date to improve the lives of people living with mental health conditions, and ensure people are supported to live well in the community. Key challenges include:

• a need for better integration between different local services that support people living with mental health conditions, including social care, housing, education, employment, the voluntary and community sector and the NHS

• gaps in the provision and quality of supported housing to meet the needs of people with severe mental illness in the community and help avoid admissions to hospital

• the scale of the unacceptable gap in life expectancy between people with severe mental illness and the general population

In your responses to our questions, we are interested in all mental health conditions, from common mental health conditions like anxiety and depression to severe mental health conditions like bipolar disorder and schizophrenia. Please indicate if your response covers a particular condition or group.

Question

What do we (as a society) need to do or change in order to improve the lives of people living with mental health conditions?

You might want to consider priorities at national and local government, wider public services such as social care and education settings, and the private and voluntary and community sectors

We would be grateful for input relating to:

a) Infants and their parents or primary caregivers

b) Children and young people

c) Working age adults

d) Older adults

e) Groups who face additional barriers to accessing support

Question

What things have the biggest influence on your mental health and influence your quality of life?

• housing
• provision of social care
• employment and job security
• money and debt management
• social and family relationships
• physical health
• connection to your community
• other - please specify

Question

What more can we do to improve the physical health of people living with mental health conditions?

This will support our ambition to reduce the gap in life expectancy between people with severe mental illness and the general population.

Question

How can we support sectors to work together to improve the quality of life of people living with mental health conditions?

We would be grateful for input relating to:

a) Infants and their parents or primary caregivers

b) Children and young people

c) Working age adults

d) Older adults

e) Groups who face additional barriers to accessing support

Question

What can we change at a system level to ensure that individuals with co-occurring mental health and drug and alcohol issues encounter ‘no wrong door’ in their access to all relevant treatment and support?

This includes people in contact with the criminal justice system.

Chapter 6: how can we all improve support for people in crisis?

Previous sections have set out our ambition that our new plan will support people who are struggling with their mental health at the earliest possible stage, to prevent them from reaching the point of crisis. However, sadly there will be people of all ages who do experience a mental health crisis and require more intensive support. The number of people presenting to services in crisis has been increasing in recent years, particularly during the pandemic. We want our plan to improve the availability, accessibility, and quality of support for people in crisis, and ultimately, to save lives.

Each person’s experience of a mental health crisis is unique and personal. All crises are different in their cause, presentation, and progression. Very often, there is no single cause. People can be in crisis because of a complex combination of mental ill-health and social factors such as relationship breakdown, bullying, isolation, trauma, alcohol or drug misuse, financial insecurity, bereavement, or job loss.

We know that two-thirds of people who end their life by suicide are not in contact with NHS mental health services.^{[footnote 45]} Given the diverse potential reasons for a person’s crisis, and variation in whether, when and how they will seek help, it is vital that different types of support are available. Many sectors have a role to play in identifying someone who may be in crisis and providing the care they need.

For many people in crisis, the NHS can, and does, provide lifesaving, life-changing care. Due to historical underinvestment, we are building from a low base in mental health care. Therefore, delivering transformation in crisis care services will be vital over the coming decade. This change has already begun. In recent years, the NHS has worked to ensure that more people in crisis who may not be in direct contact with NHS mental health services, are identified and supported. For example, through rolling out mental health liaison services in A&E and investing in alternatives to admission such as crisis resolution home treatment teams, crisis houses and crisis cafes. Similarly, people in crisis may seek support through the phone, as was often the case during the pandemic. The delivery of all-age NHS crisis phone lines has therefore also been accelerated, taking over 3 million calls in 2020 to 2021. These lines will ultimately be integrated with NHS111 to provide a more joined-up service.

Although our ultimate aim is to prevent crises from occurring in the first place, we also need to focus on growing the number of services that offer earlier intervention and proactive support (see ‘Chapter 3: how can we all intervene earlier when people need support with their mental health?’). In addition, we need to increase the number of people who are trained to spot signs of crisis and compassionately meet the needs of those in crisis. For example, it is important to appropriately train a range of NHS staff who are not already trained as mental health specialists, including GPs, paramedics, and staff in A&E who care for the physical health of people who have self-harmed. Public messaging is also important - encouraging people in crisis to reach out when they need support from the NHS, from other sectors, or for someone they know.

However, not everyone will reach out to the NHS when they or someone they know is in crisis. This may be because they do not believe that services will be available, because of the stigma associated with self-harm, suicide and seeking mental health support, or due to fear or mistrust of services. Sometimes this mistrust is driven by previous poor experiences or culturally inappropriate care. For some people, emergency mental health care or talking therapies are not the answer, or are only part of the picture; their most urgent needs are for support to resolve social factors that contribute to their crisis, such as problem debt, addiction, or housing. And some people may simply prefer to access support from a different sector, such as voluntary services.

The voluntary and community sector plays, and will continue to play, a critical role in supporting people in crisis who may not otherwise seek help. In recent years, but particularly during the pandemic, there has been a significant increase in pressures on voluntary sector helplines and crisis lines services. In 2020, PAPYRUS, the national charity for the prevention of young suicide, saw a 20% increase in contacts for support compared to the year before. A broadly similar trend has been seen by organisations across the suicide prevention voluntary and community sector. Alongside support and signposting to wider social support by phone via national organisations, smaller, community-based VCS organisations across the country continue to provide vital hands-on help to people in or at immediate risk of crisis, often in partnership with the NHS and social care.

There are also other professionals across the wider public sector who support people in crisis. The police are sometimes the ‘first responders’ who keep people in crisis safe and get them to a ‘place of safety’. A range of other public services, including social workers, schools, college and university staff, housing and benefits officers and debt advisors also identify and respond to people in crisis, and have a vital part to play in providing holistic assessment and support after a crisis to help address underlying social issues.

Because there can be diverse triggers for a crisis, each person’s experience of crisis is unique. What is considered to be the ‘most helpful’ response for each person in crisis will differ. It is important that a wide range of age-appropriate support is available and accessible everywhere in the country. We also need to make sure that the wide range of organisations who may be involved in responding to a crisis - across the NHS, the voluntary and community sector and wider public services - coordinate effectively and have the right skills to ensure a person in crisis gets the best possible care and aftercare.

Where should we be in 10 years’ time?

We want our plan to ensure that people in crisis always have somewhere to turn to for high-quality support that resolves their immediate distress and ensures that - wherever possible - they do not experience a crisis again. Key challenges include:

• rising demand for crisis services

• variation and gaps in provision of crisis support and post-crisis support across the country. Best practice is not the norm everywhere

• variation in the training, capacity and capability of the range of professionals who work with people in crisis. Although most professionals respond with compassion, people with lived experience still report examples of dismissive or discriminatory responses

• a need for better coordination across sectors that provide crisis response services. For example, some people who frequently use crisis services do not have safety plans in place, or no action is taken to address the causes of their crisis, which could otherwise support them to recover and stay well

Question

What can we do to improve the immediate help available to people in crisis?

We want to hear from people who have experienced a mental health crisis, to understand what help you need.

We also want to hear from those who work or have worked within services who support people experiencing a mental health crisis.

We are interested in ways to embed ‘best practice’ of multi-agency working, considering the role of the NHS, social work and social care, the voluntary and community sector, local government, education settings and the police.

Please consider:

a) Children and young people

b) Working age adults

c) Older adults

d) Groups who face additional barriers to accessing support

Question

How can we improve the support offer for people after they experience a mental health crisis?

We want to hear from people who have experienced a mental health crisis, to understand what help you need.

We also want to hear from those who work or have worked within services who support people experiencing a mental health crisis.

Please consider:

a) Children and young people

b) Working age adults

c) Older adults

d) Groups who face additional barriers to accessing support

Question

What would enable local services to work together better to improve support for people during and after an experience of mental health crisis?

We would like you to consider the range of public services involved in crisis support, including the police and NHS services, as well as voluntary and community sector and businesses.

Next steps and implementation

Developing a national mental health plan

Our vision for the future is to turn the tide on the rising number of people who are struggling with their mental health, and to support people living with mental ill-health or a mental health condition to live well and recover. Improving the population’s wellbeing will enable us and future generations to live long, healthy, purposeful, productive and flourishing lives. This in turn will strengthen the nation’s ‘human capital’ - an important asset needed to successfully deliver the Levelling Up agenda.

Our success will be determined by the collective actions we can all take - as citizens, families, employers, and service providers. We all have mental health, and all have a part to play in changing things for the better. We have asked a series of wide-ranging questions to help build a new long-term mental health plan to realise this vision, building on the expansion and transformation of mental health services already underway through the NHS Long Term Plan. The evidence gathered will inform the priorities and commitments within the new plan, with action spanning prevention through to acute mental health care.

We want to hear from people from all walks of life about the changes you want to see. The perspectives of people with lived experience of mental ill-health are key in this context and will form a core part of our plans for engagement.

A focus on redressing disparities will sit at the heart of this plan, with targeted commitments to reduce differences in prevalence, and improve equity in service access and life outcomes. We will therefore be supplementing public discussion with targeted engagement with groups who face significant disparities in mental health outcomes.

This plan must be underpinned by a robust and comprehensive plan to attract, recruit and retain a world class workforce to deliver our vision for NHS mental health care. Therefore, we will be working with NHS England and Improvement and Health Education England, and engaging extensively with the mental health sector, to develop a comprehensive workforce plan to sit alongside the mental health and wellbeing plan. To improve workforce planning, in July 2021, DHSC has already commissioned Health Education England to work with partners to review long-term strategic trends for the health and regulated workforce, including adult social care professions. This will take a 15-year forward view to guide planning, education and training.

To support us in developing the plan, we would like to hear:

Question

What do you think are the most important issues that a new, 10-year national mental health plan needs to address?

• wellbeing and health promotion
• prevention
• early intervention and service access
• treatment quality and safety
• quality of life for those living with mental health conditions
• crisis care and support
• stigma
• other - please specify

Question

Please explain your choice.

Question

What ‘values’ or ‘principles’ should underpin the plan as a whole?

‘Principles’ and ‘values’ can help us to agree what the purpose of a plan should be, and what it should be seeking to achieve for people.

For example, the NHS is underpinned by the principle that access to the NHS is based on clinical need, not an individual’s ability to pay.

Locally owned and driven mental health plans

While a national plan will set government’s priorities to realise our vision for mental health, its principles must be implemented in partnership with local systems, non-government organisations and other sectors in order to succeed.

The Health and Care Act will establish Integrated Care Systems which bring together health, local government and patients to improve services in every part of the country. Integrated Care Systems are required to set out local plans for the next 5 years, and mental health must be a central part of those plans. To inform this planning at system level, we have asked questions throughout this paper to seek views on what would help each local area’s public services, NHS services, voluntary and community sector and businesses to work together to improve mental health and wellbeing.

If you have anything additional to tell us that you’ve not covered in your previous answers, we would be grateful for views on:

Question

How can we support local systems to develop and implement effective mental health plans for their local populations?

You might want to consider barriers local systems currently face, as well as enablers which would support more effective ways of working.

Cross-cutting data priorities

We want to consider how improvements to data sources and systems can support more effective planning and implementation of mental health plans at local and national level.

We are aware that more needs to be done over the coming decade to improve the timeliness of data, interoperability between systems and services, and the range and quality of metrics collected - especially for routine outcome monitoring. We also want to improve the availability and quality of data on protected characteristics and other vulnerable groups, and ensure that we have appropriate granular detail on regional and socio-demographic differences. These changes need to be underpinned by efforts to improve data literacy at the frontline, for managers and for policy-makers to ensure that we make the most of data’s potential to improve the population’s mental health and wellbeing.

Question

How can we improve data collection and sharing to help plan, implement and monitor improvements to mental health and wellbeing?

Developing a refreshed suicide prevention plan

Much of the action we take over the coming decade to support the nation’s mental health will ultimately contribute towards preventing suicide. However, we believe that suicide prevention requires specific, coordinated action, and national and local focus. Through the questions outlined in this paper, we welcome additional input on what more we can do to prevent suicide. We intend to use this feedback to support the development of a separate suicide prevention plan for publication in due course. This will build on our strategy from 2012 and complement the broader mental health and wellbeing plan.

Table of definitions

Term	Definition
Mental health	Mental health is a state of wellbeing in which an individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and is able to contribute to their community.
Mental wellbeing	Mental wellbeing is about thoughts, feelings, and how people cope with the ups and downs of everyday life. Having positive wellbeing means that every individual realises their own potential, can cope with the normal stresses of life, help engage in work productively, and can contribute to their community.
Mental ill-health	Mental ill-health is a negative state of wellbeing.
Mental health condition	Conditions that affect your mood, thinking and behaviour. Examples of mental health conditions include depression, anxiety, eating disorders, schizophrenia, and bipolar disorder. More detail is available on the NHS website.
Mental health crisis	Mental health ‘crisis’ refers to someone experiencing extreme distress. This may lead to self-harm or suicidal ideation. Someone may experience a crisis for a range of reasons, such as a big life change, or because an existing mental health condition is getting worse. All crises will be different in their cause, presentation and progression.
Babies, infants, children and young people	Babies, children and young people are defined as anyone between the age of 0 and 25. When referring to infants, we are typically referring to those 2 years of age or under.
Community Mental Health Framework for England	The Community Mental Health Framework accompanies the NHS Long Term Plan and sets out the changes it expects to see in community mental health services by 2023 to 2024. It describes how the Long Term Plan’s vision for a community mental health model can be realised, and how community services should modernise to offer whole-person, whole-population health approaches.
Crisis Care Concordat	The Crisis Care Concordat is a national agreement between services and agencies involved in the care and support of people in crisis. It sets out how organisations will work together better to make sure that people get the help they need when they are having a mental health crisis.
Early intervention	Early interventions are actions which can prevent a person from developing a ‘clinical’ mental health condition, and/or prevent symptoms from getting worse or reaching crisis point.
Parents or primary caregivers	‘Parent’ includes all biological parents, whether they are married or not. A parent may not be a biological parent but have parental responsibility for a child or young person - this could be an adoptive parent, a stepparent, guardian or other relative, or any person who has care of a child or young person (even if they do not have parental responsibility). Primary caregiver means a person who assumes the principal role of providing care and attention to an infant.
National Institute for Health and Care Excellence (NICE)	NICE is a public organisation which produces evidence-based guidance and advice for health, public health and social care practitioners.
Older adults	Those who are aged 60 or over.
Prevention	Prevention in mental health aims to reduce the prevalence, incidence, and recurrence of mental ill-health.
Promotion	The process of enabling people to increase control over, and to improve their health. It includes any action taken to maximize mental health and wellbeing among populations and individuals.
Protective factor	A characteristic at the biological, psychological, family or community level that is associated with a lower likelihood of problem outcomes or that reduces the negative impact of mental ill-health or a mental health condition.
Recovery rates	There is no widely accepted definition of recovery as it means different things to different people. People often see recovery in terms of clinical and personal recovery. Recovery within the NHS mental health system is often referred to as the “recovery model”. This model highlights the importance of building the resilience and self-esteem of people with mental health conditions.
Risk factor	A characteristic at the biological, psychological, family, community or cultural level that precedes and is associated with a higher likelihood of mental ill-health or developing a mental health condition.
Social prescribing	Social prescribing is a way for people to be connected with activities, groups and services in their local community to meet practical, social and emotional needs that affect health and wellbeing, including mental health.
Stigma	Stigma refers to the negative or discriminatory attitudes that people have about mental ill-health or mental health conditions.
Treatment gap	The treatment gap represents the difference between the true prevalence of a mental health condition and the treated proportion of individuals affected by the condition.
Working age adults	People of working age between 18 and 64 years.

Annex A: mental health disparities

Across all the questions in this paper, we are seeking your views on how the mental health and wellbeing plan can address mental health disparities. To inform your responses, this annex provides detailed evidence on key disparities and provides links to sources where you can find out more.

This annex presents an overview of evidence on disparities in mental health. The evidence was purposefully selected by topic experts to include available evidence from academic research, published data and grey literature. The overview is based primarily on an internal Public Health England rapid review of evidence on the determinants of mental health and vulnerable groups from 2020. It also draws on internal technical reports, expert opinion and a search of key sources from 2000 to February 2022 including the Adult Psychiatric Morbidity survey (2014) and the Office for Health Improvement and Disparities’ public health profiles.

Note that the list of mental health disparities presented below is not exhaustive; there is variability in the strength of the evidence and critical appraisal has not been undertaken; there is a lack of evidence for certain groups.

Introduction

We know there is an uneven distribution of mental ill-health and determinants of mental health across society for both adults and children. People facing socio-economic disadvantage and other forms of social exclusion are at a much higher risk of developing mental health conditions. There are notable disparities by ethnicity, sex, age, sexual orientation and gender identity, learning disability and neurodiversity, for people with multiple and other long-term conditions.

Risks of mental ill-health are also higher for people who are unemployed, people in problem debt, people who have experienced displacement, including refugees and asylum seekers, people who have experienced violence or abuse, people in contact with the criminal justice system (both as victims and as offenders), children in care and care leavers, people who are homeless or who face housing instability, people with substance misuse or gambling problems, people who live alone, and unpaid carers.

These disparities can intersect to create different exposures and vulnerabilities to the social determinants of health. This means that some people face a range of difficult circumstances that compound risk, with childhood being a time of increased vulnerability. Our evidence shows that many of the disparities listed below increase the risk of mental ill-health when experienced together and especially alongside socio-economic disadvantage. Additionally, by worsening risks and outcomes for the most vulnerable, the impact of the COVID-19 pandemic has widened mental health disparities.

Socio-economic disadvantage

Socio-economic disadvantage includes a range of measures, such as occupation, educational attainment, income and living standards^{[footnote 46]}, influencing health across the life course.

Certain population subgroups are at higher risk of mental disorders because of greater exposure and vulnerability to unfavourable social and economic circumstances^{[footnote 47]} that are interrelated with sex. Less advantaged socio-economic position is associated with lower levels of wellbeing^{[footnote 48]} and increased rates of depression^{[footnote 49]}. There is well-established evidence that disparities in income^{[footnote 50]} negatively affect mental health and many studies suggest a gradient of increasing ill-health with increasing disadvantaged position^{[footnote 51]}.

A number of studies show that socio-economic disadvantage has a detrimental effect on children’s mental health.  For example, data from the Millennium cohort study shows that children from the poorest 20% of households are 4 times more likely to have serious mental health difficulties by the age of 11 years compared to those from the wealthiest backgrounds^{[footnote 52]}. Living in a low-income household or with a parent in receipt of income-related benefits is associated with higher rates of mental health conditions in children^{[footnote 53]}.

The Adult Psychiatric Morbidity Survey found that socioeconomic factors were strongly linked with psychotic disorder, for example, it was more common in those who were economically inactive and there was some evidence of associations with benefit status^{[footnote 54]}. The prevalence of severe mental illness is also associated with area-level deprivation and urban environments^{[footnote 55]}.

Data from the Improving Access to Psychological Therapies initiative (IAPT)^{[footnote 56]} shows that people living in the most deprived areas of England are more likely to be referred to IAPT services than those from the least deprived areas. However, the data also shows that people from the most deprived populations are less likely to use IAPT services and less likely to have recovered by the end of treatment compared to those living in the least deprived areas. An academic analysis of service data found similar patterns in 2014^{[footnote 57]}.

Ethnicity

There is an established link between ethnic minority backgrounds and diagnosis of psychoses such as schizophrenia and major depression. There is strong evidence that severe mental health conditions are particularly elevated for people from black ethnic backgrounds and that people from South Asian, white other and mixed ethnicity groups are also at increased risk^{[footnote 58]}. There is a need for further work on explanatory factors including urban environments, socio-economic status, migration and racial disparities.

Findings on the prevalence of common mental health conditions for ethnic minority groups are complex due to variations in socio-economic status and migration experiences^{[footnote 59] [footnote 60]} and have also been associated with experiences of racial disparities and discrimination^{[footnote 61]}. Overall, findings for common mental health conditions are limited by poor quality data and small sample sizes, with no statistically significant findings available from the Adult Psychiatric Morbidity survey. There is less evidence for smaller ethnic groups, for example, people who are gypsy and Romany travellers and from Chinese ethnic backgrounds.

The recent rapid review of the evidence on Ethnic Inequalities in Healthcare^{[footnote 62]} undertaken for the NHS Race and Health Observatory found a number of mainly qualitative studies identifying barriers to help seeking by ethnic minorities. These were rooted in a distrust of both primary care and mental health care providers, as well as a fear of being discriminated against in healthcare. Evidence from qualitative research suggests that the lack of appropriate interpreting services acted as a deterrent to seeking help.

The review also found a number of cross-sectional studies showing that ethnic minority groups face greater barriers in accessing Improving Access to Psychological Therapies (IAPT) compared to the white British group and are less likely to self-refer, be referred by a GP, be assessed or receive treatment^{[footnote 63]}. In terms of IAPT treatment outcomes, recent data shows that white British service users show more improvement compared to ethnic minority groups^{[footnote 64]}.

Evidence was identified for disparities in the receipt of cognitive behavioural therapy (CBT) with ethnic minority people with psychosis less likely to be referred for CBT, and less likely to attend as many sessions as their white counterparts^{[footnote 65]}.

The review confirmed very large and persisting disparities in access to secondary mental health services for people from all ethnic minority backgrounds with severe mental illness^{[footnote 66] [footnote 67]}.  In particular, people from black Caribbean, black African and black British backgrounds with severe mental illness experience higher rates of contact with the police and criminal justice system (both as victims and as offenders), more admission to psychiatric hospitals, more compulsory inpatient care and fewer primary care interventions^{[footnote 68]}.  A number of small studies have found worse recovery outcomes for these groups^{[footnote 69]}.

In 2020 to 2021, rates of detention under the Mental Health Act were 4 times higher for the black British group compared to the white group, with use of Community Treatment Orders 10 times higher^{[footnote 70]}. There is also evidence of harsher treatment with more frequent use of restraint of people from mixed ethnicity backgrounds and black backgrounds in mental health inpatient units compared to people from white backgrounds^{[footnote 71]} and greater use of the prone position and seclusion^{[footnote 72]}.

The review also found 2 large national studies showing that ethnic minority children were more likely to be referred to Children and Adolescent Mental Health Services (CAMHS) via social services, education or criminal justice pathways. This was particularly stark for black children who were 10 times more likely to be referred to CAMHS via social services (rather than through the GP) relative to white British children^{[footnote 73]}.

Sex

Pre-existing mental health problems are not distributed equally by sex. Women are more likely to experience common mental health conditions than men^{[footnote 74]}: 20.7% of women and 13.2% of men aged 16 and over have been identified as having common mental health conditions such as anxiety or depression. Whilst rates remain relatively stable for men, prevalence of common mental health conditions is growing in women^{[footnote 75]}. Young women (aged 16 to 24 years) are at particularly high risk, with 26% of young women experiencing a common mental health condition - almost 3 times more than young men, at 9.1%^{[footnote 76]}. Women experience higher rates of PTSD, self-harm, suicidal ideation^{[footnote 77]} and eating disorders^{[footnote 78]} and can also face additional vulnerabilities during the perinatal period.

Men report lower levels of overall life satisfaction, happiness and feeling as though their life is worthwhile^{[footnote 79]}. Men tend to seek help less than women^{[footnote 80]}. Men may also present their mental and emotional distress differently, for example through aggression or substance misuse. This means that when they do present to services, diagnosis can be missed, placing individuals at higher risk of deterioration^{[footnote 81]}. For some severe mental health conditions, such as bipolar disorder, prevalence is slightly higher for men^{[footnote 82]}. Over three-quarters of people who die by suicide are men^{[footnote 83]} although the rates of suicide are growing in women, particularly young women^{[footnote 84]}.

There are long standing disparities in access to services. For example, men are less likely to be referred for, and access, Improving Access to Psychological Therapies (IAPT) than women^{[footnote 85]}. Comparably, higher rates of men than women are detained under the Mental Health Act^{[footnote 86]}.

In terms of treatment outcomes, data shows that men and women experience similar rates of recovery following IAPT treatment^{[footnote 87] [footnote 88]}. However, there can be sex-related differences in mental illness and the experience of mental health services. Many women face additional challenges such as lack of consideration to their roles as mothers and carers and to their experiences of violence and trauma which they are more likely to experience compared to men^{[footnote 89]}.

Age

Mental health conditions are not distributed equally across all age groups. In children and young people (CYP), 16% of children aged 5 to 16 years were identified as having a probable mental health condition^{[footnote 90]}. Estimates from the Adult Psychiatric Morbidity Survey (2014) found that 1 in 6 (17%) adults aged 16 and over have a common mental health condition at any one time^{[footnote 91]}. The age group with the highest prevalence is 35 to 44 (19.3%). This decreases in older age groups, with an estimated prevalence of common mental health conditions in age 65 and older of 10.2%, using 2017 data^{[footnote 92]}.

A number of mental health conditions are known to have different age trajectories. For example, post-traumatic stress disorder (PTSD) peaks in young adulthood (16 to 24) and decreases with age^{[footnote 93]}.  Psychotic disorders are most prevalent in working-age adults (16 to 64), and lowest in older adults^{[footnote 94]}. In terms of suicide, people aged 45 to 49 have the highest age-specific suicide rates^{[footnote 95]}.

The evidence on the prevalence of mental health conditions in older age is disputed, with a 2018 report by the Royal College of Psychiatrists^{[footnote 96]} suggesting that older people are no less prone to mental ill health than younger adults, with difficulties manifesting differently in older age. Mental health conditions may be under-identified by healthcare professionals and older people themselves;^{[footnote 97]} and research studies may exclude the growing care home population.

In terms of access to care, those who are in mid-life (35 to 54) are more likely than others to receive treatment, and younger people (especially those from deprived backgrounds) are more likely to have unmet treatment requests ^{[footnote 98]}.  Of all age groups 18- to 24-year-olds are the least likely to seek care for a mental health problem^{[footnote 99]}.

In terms of older people, there are lower proportions of people aged 65 and over entering IAPT treatment (204 per 100,000) compared to those aged 18 and over (659 per 100,000); there are also lower levels of treatment completion compared to the average^{[footnote 100]}. One study of primary care found that the oldest age groups with new depression diagnoses and symptoms have fewer recorded referrals to psychological therapies and higher psychotropic drug treatment rates in primary care^{[footnote 101]}.

Sexual orientation and gender identity

In the UK there is a higher prevalence of poor mental health and low wellbeing in people who identify as lesbian, gay and bisexual (LGB)^{[footnote 102] [footnote 103]}. Previous studies have shown that there is an increased risk of mental ill-health symptoms in LGB adults, compared to heterosexual adults. These disparities are highlighted by Stonewall’s 2018 survey^{[footnote 104]} which found that 50% of respondents said they had experienced depression in the previous year.

Prevalence of mental ill-health symptoms is greatest for LGB adults over 55 and those under 35 years. In terms of children and young people, studies using data from the Millennium Cohort Study have found that LGB adolescents are 5 times more likely to be depressed and almost 6 times more likely to have self-harmed in the previous year compared to heterosexual teens^{[footnote 105]}.

An assessment of transgender disparities is hampered by a lack of routine data collection and small sample sizes^{[footnote 106] [footnote 107]} with evidence collected predominantly by voluntary sector bodies. An evidence review by the Scottish Government^{[footnote 108]} reported much higher prevalence of depression, stress and anxiety among transgender people and an Equality and Human Rights Commission report found evidence of high rates of self-harm and attempted suicide. Stonewall’s survey found that almost half of transgender respondents had considered suicide in the previous year^{[footnote 109]}.

Those who identify as LGBT (lesbian, gay, bisexual, transgender, queer and non-cisgender) are more likely than heterosexual people to experience multiple risk factors such as discrimination, homophobia, transphobia and social isolation^{[footnote 110] [footnote 111]}.

In terms of access to services, the Stonewall survey reported that 1 in 8 LGBT people had experienced some form of unequal treatment by healthcare staff such as discrimination or lack of understanding of their specific health needs; 1 in 7 had avoided seeking healthcare services due to a fear of discrimination^{[footnote 112]}. Psychological treatment outcomes across LGB groups show smaller reductions in depression and anxiety compared to heterosexual groups^{[footnote 113]}.

For transgender groups, there is some evidence from the voluntary sector showing that around 40% of transgender people report barriers accessing healthcare due to a lack of understanding of specific transgender health needs^{[footnote 114]}. This is supported by government research, which also suggests that mental health services are the most often perceived to be discriminatory. In particular, there is evidence of a lack of mental health inpatient provision for transgender people and a tendency to attribute mental health problems to an individual’s transgender status^{[footnote 115]}. Within mental health services for young people, a study has shown that the gender identity of transgender individuals can be dismissed^{[footnote 116]}.

People with a learning disability and/or neurodiversity

Both adults^{[footnote 117]} and children and adolescents^{[footnote 118]} with a learning disability have a higher prevalence of psychiatric disorder and symptoms^{[footnote 119]} and mental ill-health than the general population. People with a learning disability may experience specific challenges around diagnostic overshadowing which complicates the assessment of mental health conditions^{[footnote 120]} and there are well documented barriers to accessing health care^{[footnote 121]}.

There is evidence of high levels of psychiatric comorbidity in people with autism^{[footnote 122] [footnote 123]} as well as in people with attention deficit hyperactivity disorder (ADHD)^{[footnote 124]}. Around 21% of those with autism also have ADHD^{[footnote 125]} which can complicate identification and treatment of mental health conditions.

People with autism may not access services in line with mental health need^{[footnote 126]}. This has been confirmed by qualitative studies^{[footnote 127] [footnote 128]}. High levels of stigma may also reduce help-seeking^{[footnote 129]}. One study described a gap in available mental health services for adults with autism, together with long waiting lists, a lack of funding for support or treatment, a lack of professionals’ understanding of autism and support and treatment not suited to their needs^{[footnote 130]}.

People with multiple and other long-term conditions

More than 1 in 4 of the adult population in England lives with 2 or more conditions^{[footnote 131]}. Living with numerous and often complex ill-health is becoming the norm for older people and those from disadvantaged communities. Around 30% of people with a long-term physical health condition also experience mental ill-health^{[footnote 132]}.  People with multiple long-term conditions including mental ill-health disproportionately live in deprived areas^{[footnote 133]}. The government’s Rare Disease Action plan has also recently highlighted the specific mental health needs of people with rare diseases and their families and carers, 75% of whom are children^{[footnote 134]}.

A review of evidence by the National Institute for Healthcare Research^{[footnote 135]} found that the healthcare system frequently fails to respond to the needs of people with multiple long-term conditions and focuses on individual diseases or issues resulting in complex, uncoordinated pathways. People with multiple long-term conditions feel their mental health and emotional wellbeing is frequently ignored, which often results in a worsening of symptoms.

People who are unemployed

Unemployment is associated with increased stress, depression, anxiety and increased suicides^{[footnote 136] [footnote 137]}.

The Adult Psychiatric Morbidity Survey found unemployed adults had a higher prevalence of common mental health conditions (28.8% respectively) compared to those employed full-time and employed part-time (14.1% and 16.3%). Economically inactive adults also show high levels of prevalence (33.1%) and adults in receipt of benefits were found to have 2.5 to 4 times higher prevalence of mental health conditions than adults not in receipt of benefits^{[footnote 138]}.

The 2021 UK Household Longitudinal survey (UKHLS) showed that 43% of unemployed people had mental ill-health, compared to 34% for people on furlough and 27% for those in work^{[footnote 139]}. Furthermore, other studies published since 2020 using data from previous UKHLS have demonstrated an increase in mental ill-health overall since the start of the COVID-19 pandemic. These studies all cite unemployment and job loss as key contributing factors to a decline in mental health^{[footnote 140] [footnote 141] [footnote 142]}.

However, good quality work is also important and analysis of data from one longitudinal household survey found some evidence that job quality affects mental health. Negative working conditions linked to increased common mental ill-health include job strain, night shifts, effort-reward imbalance, low job satisfaction and poor work-life balance^{[footnote 143]}. Moderate quality evidence shows that job insecurity has an adverse effect on mental health^{[footnote 144]}.

A peer-reviewed 2017 qualitative study showed unemployed people with mental-ill health often do not use mental health services and therefore do not benefit from available therapies. The main barriers include mental health literacy, stigma and discrimination, and healthcare system design^{[footnote 145]}. 

Evaluation of the Employment Advisers in IAPT Services programme has shown positive outcomes for some clients including: increased confidence, assertiveness and motivation; improved mental health and well-being; a return to work or movement to alternative employment; and progress into or towards work for those that were out of work. Across all client groups, qualitative research indicated that what really seemed to work in delivering EA support was the combination of practical, emotional and motivational support. The results show that individuals who receive Employment Support combined with IAPT therapy are more likely to be in employment when leaving the service (if they were not in employment when joining the service) and have a greater improvement in their mental health than if they just had IAPT therapy. The combination of Employment Support with IAPT therapy addresses individuals needs holistically and enhance each other, creating a “continuous cycle” of support.^{[footnote 146]}

People with severe mental illness are far less likely to be in employment. In 2020, 9.1% of adults receiving secondary mental health services and on Care Programme approach were in employment^{[footnote 147]}.

There is strong evidence that Individual Placement Support and Housing First models for people with severe mental illness improves employment and housing stability/homelessness^{[footnote 148]}.

People in problem debt

There is a clear relationship between debt and mental health. People who are in debt have higher odds of mental ill-health, even after controlling for low income^{[footnote 149]}.

A study based on the 2007 national survey of psychiatric morbidity among adults in England shows people in debt were 3 times more likely than those not in debt to have a common mental health condition^{[footnote 150]}.

Providing debt advice in primary care has been identified as a cost-effective intervention to protect mental health^{[footnote 151]}.

People who have experienced displacement, including refugees and asylum seekers

Refugees and asylum seekers are more likely to experience mental ill-health than the general population, including higher rates of serious mental disorder^{[footnote 152]}, depression, PTSD and other anxiety disorders^{[footnote 153]}. Traumatic events pre-departure, life-threating circumstances on their journeys, and difficulties integrating into host countries related to immigration policies, social isolation, poor living conditions, and unemployment are thought to increase risk^{[footnote 154]}. 

Data collection on refugee and asylum seekers’ health service usage is limited^{[footnote 155]}.  However, there are well documented barriers to accessing health services for these groups compiled by voluntary sector organisations^{[footnote 156]}. A recent scoping review^{[footnote 157]} of mental health care policies, barriers and enablers found that there is a gap in the literature regarding UK-wide assessment of access and delivery of mental healthcare for asylum seekers and refugees in the UK.

People who have experienced violence or abuse

There is cross sectional evidence of an association between victims of violent crime and low personal wellbeing, in particular domestic violence^{[footnote 158]}.

Intimate partner violence is associated with higher levels of mental ill-health and exposure to multiple types of abuse increases the risk. Women are twice as likely than men to experience interpersonal violence, with 1 in 4 women reporting experiencing interpersonal violence since the age of 16^{[footnote 159]}.  54% of women with experience of physical and sexual violence have a common mental health condition, and 36% had attempted suicide^{[footnote 160]}.

Child abuse and maltreatment is also associated with mental ill-health, and those who experienced 3 or more types of maltreatment had the highest risk of all mental health conditions^{[footnote 161]}. Elder abuse was associated with common mental health conditions such as depression and anxiety, and a higher level of psychological distress^{[footnote 162]}.

People with higher levels of neighbourhood violence are at higher risk of common mental health conditions, and lifetime exposure to 2 or more types of violence is associated with increased risk for all mental health outcomes^{[footnote 163]}.

People in contact with the criminal justice system (offenders)

Around a third of people in police custody have mental ill-health, as do 38% of people on probation, and 48% of men and 70% of women in prison^{[footnote 164]}. 12% of men and 28% of women in prison self-harm^{[footnote 165]}, and rates of suicide among people in prison are greater compared to people of similar age in the community^{[footnote 166]}. 

There are limitations to the data on service access, as contact with the criminal justice system is not routinely captured by NHS services. However, a recent major inspection, including reviews of process documents and interviews with a range of staff and individuals, found that many people in the criminal justice system do not have their mental health needs met or experience delays in accessing treatment^{[footnote 167]}. In 2016 to 2017, two-thirds of people in prison with an acute mental health condition waited longer than the standard waiting time to be admitted to a secure hospital, with 7% waiting more than 140 days^{[footnote 168]}. There is some evidence that ethnic minority prisoners, who are over-represented in the prisoner population, are more likely to access mental health services via the criminal justice system than white people^{[footnote 169]}.

In first-time youth offenders, three-quarters meet the criteria for a mood, anxiety or behavioural disorder. Despite this, only around 20% were accessing mental health services^{[footnote 170]}.

People who sleep rough, are homeless or are in unstable housing

People who sleep rough or are homeless have a particularly high prevalence of mental ill-health compared to the general population. 82% of people who had slept rough in the previous year report a mental health need^{[footnote 171]}. In households considered to be legally homeless by a local authority, mental ill-health was the most common support need identified, in 25.2% or 1 in 4 of households^{[footnote 172]}, compared to 1 in 5 in the general population.

The prevalence of psychosis is between 4 and 15 times higher in the homeless population compared to the general population, and around two-thirds of clients of homelessness services are estimated to have symptoms of personality disorder, although many were undiagnosed^{[footnote 173]}.

There are a number of reports from voluntary sector agencies on service provision. These are based on interviews with people experiencing homelessness and service providers. These show that people who are homeless experience additional and specific barriers to accessing preventative or primary health services^{[footnote 174]} and an estimated one-third of people are not receiving the mental health support they need^{[footnote 175]}.

People with drug misuse, alcohol misuse or gambling problems

There is evidence for co-existing mental ill-health and substance misuse^{[footnote 176]}.

Research shows that alcohol and drug issues in mental health treatment populations is common.

The Adult Psychiatric Morbidity Survey found that adults who reported signs of dependence on drugs other than cannabis (50.1%) and a quarter of adults with probable alcohol dependence were receiving treatment and services for mental ill-health or emotional problem^{[footnote 177]}. Nearly half of those in Community Mental Health Treatment services have substance use issues. Also, mental ill-health is experienced by the majority of drug (70%) and alcohol (86%) users in community substance misuse treatment^{[footnote 178]}.

For those who may not be receiving routine treatment through mental health treatment services, a history of alcohol or drug use was recorded in 54% of individuals with identified mental health conditions who died by suicide^{[footnote 179]}. Evidence shows that despite the shared responsibility that NHS and local authority commissioners have to provide treatment, care and support, people with co-occurring conditions such as mental health and drug use are often excluded from services^{[footnote 180] [footnote 181] [footnote 182]}.

A recent evidence review^{[footnote 183]} found a correlation between gambling and mental health. This showed that having mental ill-health makes someone 2 times more likely to participate in harmful gambling than people with no mental ill-health and more likely to be a gambler experiencing gambling-related harms. Depression was found to be a risk factor in children and young people for subsequent harmful gambling. The review also found a higher prevalence of poor health, low life satisfaction and wellbeing among problem gamblers and some weaker evidence of anxiety, depression, and sleep problems.

There is good evidence that deaths from suicide are significantly higher among adults who are problem gamblers compared to the general adult population. The link between gambling, suicide and self-harm is supported by qualitative studies.

There is limited data on mental health service usage by problem gamblers. A YouGov survey^{[footnote 184]} of gamblers found that 5% have sought support from mental health services and around 57% of those using such services found them helpful.

Children in care and care leavers

There is some evidence that looked after children are more at risk of mental health conditions. A British cohort study found that looked-after children and young people were significantly more likely to be depressed, dissatisfied with life and have low self-efficacy^{[footnote 185]}; residential care was associated with an increased odds ratio of 4 for depression^{[footnote 186]}.

People who live alone

The Adult Psychiatric Morbidity Survey shows rates of mental health conditions are higher in single adult households compared to households with more than one adult or child^{[footnote 187]}. For example, 10.8% of lone adults under the age of 60 with no children screened positively for PTSD compared to 4.6% of households with 2 adults under the age of 60 with no children.

There is cross-sectional evidence to support the association between loneliness and a range of psychiatric disorders, including anxiety, depression and psychosis, and to support an association between loneliness and suicidal thoughts and behaviour^{[footnote 188]}. People who reported feeling lonely were almost 10 times more likely to report low feelings of worth (10.5% compared with 1.1%), over 7 times more likely to report low life satisfaction (15.2% compared to 1.9%), over 3 times more likely to report feeling unhappy (18.8% compared to 5.6%) and twice as likely to report feeling anxious (34.8% compared to 15.1%) than those who have low ratings of loneliness^{[footnote 189]}.

Three systematic reviews show interventions (such as peer support and group activities) to reduce loneliness and social isolation are effective^{[footnote 190] [footnote 191] [footnote 192]}. However, social isolation is often a barrier to accessing services and individuals are less likely to seek help.

Unpaid carers

Being a carer is a risk factor for mental ill-health as it has been associated with higher psychological distress in comparison to non-carers^{[footnote 193] [footnote 194]}. In 2021, the Carers UK annual survey^{[footnote 195]} showed that a third of carers reported mental ill-health, with a worse picture for those providing unpaid care for more than 35 hours a week. Compared to the population average, carers were less satisfied with life and more anxious.

Carers on low-income, from particular ethnic minority backgrounds and those caring for people with certain conditions such as psychosis^{[footnote 196]} dementia^{[footnote 197]} and other intellectual disabilities^{[footnote 198]} were more at risk of mental ill-health. COVID-19 increased pressure on carers resulting in a higher risk of carers developing mental health conditions^{[footnote 199]}.

There is strong evidence of barriers to accessing support services especially for ethnic minority carers^{[footnote 200]}. Also, young carers may face barriers to accessing support services, with one study showing that only half of young adult carers with a mental health condition reporting receiving support from school^{[footnote 201]}. The Carers UK survey^{[footnote 202]} found that looking after carer health and wellbeing topped the list of carer priorities for support. However there appears to be little formal research on usage of mental health services by carers and related outcomes.

Annex B: evidence summary

This annex outlines the key evidence sources that underpinned the development of the mental health and wellbeing plan discussion paper. We have also indicated the overall strength of the evidence base and highlighted key gaps.

The evidence shows that overall mental ill-health within the population is increasing and have been for some time. Mental ill-health is unevenly distributed across the population, as are the determinants that contribute to causing mental health conditions. Further, surveillance data shows that COVID-19 has increased the prevalence of mental ill-health and widened disparities. It is crucial to continue to build this evidence.

Prevention and promotion of good mental health

Children and young people

There is good evidence that preventing mental ill-health and promoting wellbeing in children and young people is key to promoting good mental health into adulthood and across the life-course. Rates of probable mental health conditions and mental ill-health in children and young people have increased in recent years. Mental ill-health in children is associated with known risk and protective factors, and CYP experiencing multiple risk factors are more likely to have poorer mental health outcomes.

Child and Maternal Health Fingertips

Mental Health of Children and Young People Surveys - NHS Digital

Changes in children’s mental health symptoms from March 2020 to June 2021

Risk factors

There is strong evidence that outlines the risk factors (outlined in the prevention chapter) associated with mental ill-health in children and young people.

Mental capital and wellbeing: making the most of ourselves in the 21st century Government Office for Science

NHS Digital (2021) Mental Health of Children and Young People in England Surveys (2017 and follow up waves 1 and 2

The mental health of children and young people in England. Public Health England (PDF, 6.75MB)

Children’s mental wellbeing and ill-health: not two sides of the same coin. The Millennium Cohort Study

What works

There is good evidence that preventing mental ill-health and promoting wellbeing in CYP is key to promoting good mental health into adulthood.

No child left behind: a public health informed approach to improving outcomes for vulnerable children (PDF, 1.03MB)

Maternity high impact area 2: Supporting good parental mental health (PDF, 628KB)

Universal approaches to improving children and young people’s mental health and wellbeing (PDF, 2.22MB) (page 39)

Parenting for mental health: what does the evidence say we need to do? Report of the Data project

A systematic review of the effectiveness of mental health promotion interventions for young people in low and middle income countries

Childhood nature connection and constructive hope: A review of research on connecting with nature and coping with environmental loss

Evidence gaps

Aside from the above, further evidence is needed to understand which interventions will work in the UK to address the intergenerational cycle of disadvantage including mental health behaviours and eliminate health disparities. 

More evidence is needed to establish a consensus on a framework for measuring children and young people’s mental health and wellbeing at both a national and local level. This will help to close gaps in availability and quality of data on the impact of preventative services.

Mental wellbeing and common mental health disorders - adults

There is strong evidence that common mental health conditions in adults have been gradually increasing for some time. There is evidence for geographical variation across the country and by age/sex.

Wellbeing - Office for National Statistics (ons.gov.uk)

Common Mental Health Disorders - OHID (phe.org.uk)

Adult Psychiatric Morbidity Survey (PDF, 5.79MB)

There is strong evidence of mental health disparities as a result of area deprivation, income disparity, unemployment, debt, living alone and chronic physical health problems. Common mental health conditions peaks in middle age and is more prevalent among women, with young women at greater risk. There is some evidence for increased risk as a result of discrimination and migration.

Adult Psychiatric Morbidity Survey (PDF, 5.79MB)

Psychosocial pathway and health outcomes: informing action on health inequalities (PDF, 1.36MB)

Build Back Fairer the COVID-19 Marmot Review (PDF, 3.39MB)

COVID-19 mental health and wellbeing surveillance: Spotlights - GOV.UK (www.gov.uk)

Tackling social inequalities to reduce mental health problems

Risk factors

There is strong evidence that the social determinants of health such as poverty, socio-economic disparities, disparities between sexes, unemployment, and discrimination contribute to mental ill-health in adulthood.

The Conceptual framework for public mental health published in 2021 shows the latest evidence on risk and protective factors influencing mental health. The Foresight report Mental Capital and Wellbeing (PDF, 1.31MB) is also important sources of evidence.

The People and Nature Survey gathers evidence and trend data relating to people’s enjoyment, access, understanding of and attitudes to the natural environment, and its contributions to wellbeing.

What works

A significant number of public mental health interventions and approaches exist. A number demonstrating good efficacy and return on investment are outlined in Commissioning Cost-Effective Services for Promotion of Mental Health and Wellbeing and Prevention of Mental Ill-Health . The smaller evidence base for wellbeing interventions is summarised by the What Works Centre for Wellbeing in How to improve wellbeing? - What Works Wellbeing There is evidence that in practice local interventions focusing on broader structural and environmental determinants are uncommon.

Better Mental Health for All (PDF, 747KB)

Public mental health: Evidence, practice and commissioning

What Good Looks Like for Public Mental Health (PDF, 824KB)

Public mental health: required actions to address implementation failure in the context of COVID-19 (PDF, 344KB)

There is evidence that secure, meaningful work is an effective way to improve the wellbeing of individuals, their families and their communities.

Is work good for your health and wellbeing? (PDF, 1.21MB)

Thriving at work - The Stevenson/Farmer review of mental health and employers (PDF, 1.02MB)

Mental wellbeing at work NICE guideline (2022)

Evidence gaps

National or population level interventions addressing the social determinants of mental health identified a small and overall low-quality evidence base for population level interventions addressing the social determinants of mental health with significant gaps in the evidence base for key policy areas. There is also a lack of comprehensive evaluation of locally commissioned services Community interventions for improving adult mental health - mapping policy and practice in England  .

There is a need for an up-to-date summary of prevention and promotion interventions mapped against the determinants of mental health. There is a gap in evidence for interventions appropriate for different cultural groups and contexts.

The Department of Health and Social Care and the NIHR have recently announced the Mental Health Research Initiative which is strengthening research to help tackle the disparity between regional needs and mental health research activity.

Early intervention

There is good evidence which shows that early intervention results in better long-term outcomes with people recovering faster. This is especially important for children and young adults where a study showed 50% of people with lifetime mental ill-health first experience symptoms by the age of 14, and three-quarters before their mid-20s. 

Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication

There is evidence for lack of perceived need, lack of population mental health literacy and discrimination when seeking help. There is also evidence that stigma and anticipated stigma can be a major barrier to accessing mental health support which is more prominent for certain demographic groups.

Mental illness stigma after a decade of Time to Change England

The importance of cultural adaptation in IAPT and CBT (PDF, 1.07MB)

Self-stigma has also been a larger barrier during the pandemic with people not wanting to be a ‘burden’ when the health system is under strain. There is emerging evidence that the pandemic may also have reduced the number of people seeking help for mental ill-health.

Mental Health of Children and Young People in England, 2021: Wave 2 follow up to the 2017 survey

What has the impact of the pandemic been on mental health? (PDF, 1.30MB)

What works

Clinical early intervention at the commencement of illness has been shown to have positive impacts on the development and severity of the illness. There is evidence that early intervention can also address conditions that can contribute to people becoming mentally unwell, reducing the need for specialist services.  

Implementing the Early Intervention In Psychosis Standard and Waiting Time Guidance, NHS England (PDF, 501KB)

Psychosocial and psychological interventions for preventing postpartum depression

There is some evidence for the effectiveness of interventions to increase formal help-seeking including mental health literacy promotion, de-stigmatisation, and motivational enhancement for people with or at risk of common mental health conditions.

Effectiveness of interventions to promote help-seeking for mental health problems

There is evidence that non-clinical intervention, such as teacher support in school settings, can promote positive mental health and provide opportunities for identifying children at risk.

A systematic review of the effectiveness of mental health promotion interventions for young people in low- and middle-income countries

Transforming children and young people’s mental health provision: a green paper

Evidence gaps

More evidence on the effects of interventions which are supported by local partnership working, co-production and different approaches to working with people rather than direct interventions is needed.

Detailed evidence on specific non-clinical intervention programmes and trials would also be beneficial.

Improve the quality of life for people living with mental illness

Common mental Illness

There is strong evidence that adults experiencing symptoms of common mental health conditions such as anxiety and depression is increasing. There is emerging evidence that the pandemic has further increased the prevalence of common mental health conditions.

Adult Psychiatric Morbidity Survey (PDF, 5.79MB)

Public mental health: required actions to address implementation failure in the context of COVID-19 (PDF, 344KB)

Coronavirus and depression in adults, Great Britain: January to March 2021

6 new research projects have been funded by the NIHR and UKRI to investigate and reduce the impact of the Covid-19 pandemic on mental health through the launch of the Rapid Response Rolling Call.

What works

The Improving Access to Psychological Therapies (IAPT) programme is used to treat common mental health conditions with good evidence that people who have a course of treatment showing substantial reductions in their anxiety and depression.

IAPT at 10: Achievements and challenges

As well as NHS Improving Access to Psychological Therapies and prescribed psychotropic medication, there is evidence of referral to community and voluntary sector interventions.

Since people with mental health conditions are more likely to experience poor mental wellbeing, wellbeing promotion is an important intervention to promote recovery from mental health conditions. For example, psychosocial interventions, social skills training, physical activity promotion, supported employment and skills-based training, supported housing, positive psychology interventions, and mindfulness.

Community interventions for improving adult mental health: mapping local policy and practice in England

Public mental health: required actions to address implementation failure in the context of COVID-19

There is evidence that public mental health interventions are relevant for those with mild to moderate common mental health conditions including workplace interventions.

Commissioning Cost-Effective Services for Promotion of Mental Health and Wellbeing and Prevention of Mental Ill-Health .

Better Mental Health for All (PDF, 747KB)

Public mental health: Evidence, practice and commissioning

Public mental health: required actions to address implementation failure in the context of COVID-19 (PDF, 344KB)

Guidelines for how to create the right conditions for mental wellbeing at work have been published by NICE. These guidelines aim to promote supportive and inclusive work environments, including training and support for managers and helping people who have or are at risk of poor mental health.

Mental wellbeing at work, NICE guideline [NG212]

Severe mental illness (SMI)

There is evidence of disparities in prevalence of SMI. Rates are higher in men, minority ethnic groups (particularly those of black ethnicity), the most deprived areas in England and in urban areas (compared to rural).

Severe Mental Illness Fingertips profile

Severe mental illness (SMI) and physical health inequalities: briefing

There is strong evidence that both premature mortality and excess premature mortality rates are higher for those with SMI. For instance, on average, people with SMI in England die 15-20 years earlier than the general population.

Risks of all-cause and suicide mortality in mental disorders: a meta-review

There is evidence that this gap is widening. Since 2015, premature mortality for people with SMI has worsened in England by nearly a 20% increase in deaths.

There is strong evidence that people with SMI are at a greater risk of poor physical health where it is estimated that 2 in 3 deaths are from physical illnesses such as cardiovascular disease, cancer, liver disease and respiratory disease.

The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness

Inequalities in physical comorbidity: a longitudinal comparative cohort study of people with severe mental illness in the UK

Premature mortality among people with severe mental illness - new evidence from linked primary care data

An Urgent Call to Address the Deadly Consequences of Serious Mental Disorders.

What works

There is good evidence that addressing the social determinants of health will help prevent poor physical health and reduce health disparities.

 Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas (nih.gov)

There is some evidence which shows that monitoring of physical health and access to preventative treatment for people with SMI can lead to improvements in patient outcomes.

Bringing together physical and mental health. A new frontier for integrated care (PDF, 1.01MB)

There is evidence that providing support and treatment within the community can be shown to be more effective and prevent the need for inpatient admission for people with SMI. For example, there is some evidence that community schemes such as Peer Support can have a positive impact.

A systematic review and meta-analysis of randomised controlled trials of peer support for people with severe mental illness

Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services

There is evidence that the Individual Placement and Support (IPS) model is effective at supporting competitive employment rates and leads to better vocational outcomes

Individual Placement and Support offers route to employment for people with severe mental health condition

Evidence gaps

Better evidence is needed on large-scale and integrated interventions that target dual risk factors for physical and mental health conditions in at-risk groups which are required to reduce the prevalence of both. This in turn could seek evidence on which approaches work to close the SMI mortality gap.

Evidence on whole system approaches that influence life expectancy that engages partners across all sectors is needed. Strategies for implementation and scaling up of prevention programmes with a strong evidence base are scarce.

Reduce people whose interaction with the system is at crisis point

There is evidence that the COVID-19 pandemic has increased the number of people entering crisis response services where record levels of adults were referred for urgent help.

There is also emerging evidence that the pandemic has affected the availability of care with disruptions to regular support.

NHS Mental Health Crisis Helplines Receive 3 Million Calls

National Confidential Inquiry into Suicide and Safety in Mental Health

People at crisis can also encounter services through non-health agencies, particularly the police. There are disparities within this where evidence shows that black people with SMI are more likely than other groups to present to these services.

Health Matters: reducing health inequalities in mental illness

Mental Health Act Statistics, Annual Figures: 2020 to 2021

Police Mental Health Act detentions in England can relate to suicide prevention with rates continually rising. Suicide rates have also increased since 2010 where around 75% of suicide deaths each year are male and is the biggest cause of death in men under the age of 50.

Suicide Registration in England 2020 (Registered deaths in England and Wales from suicide analysed by sex, age, area of usual residence of the deceased and suicide method)

Responses and interventions

There is evidence that two-thirds of people who end their life by suicide are not in contact with a mental health service. However, there is evidence that primary care and the promotion of NHS services through signposting to sources of advice and support can help suicide prevention.

Suicide Prevention Profile (Fingertips: Public Health Data)

There is emerging evidence that certain preventative strategies may have been affected during the pandemic. A survey by the Care Quality Commission finding people were unable to get the help they needed.

CQC (December 2021) 2021 Community Mental Health Survey

Crisis Care Profile (Fingertips: Public Health Data)

Suicide risk and prevention during the COVID-19 pandemic

Evidence gaps

More evidence is needed to understand the true extent of the short- and long-term effects of the pandemic on mental health and the associated influence on the number and certain groups of people experiencing crises.

More research is needed to develop and test primary care delivered interventions to reduce self-harm and suicide risk in all patients.

Suicide prevention and COVID-19: the role of primary care during the pandemic and beyond

Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic

Looking back to move forward: reflections on the strengths and challenges of the COVID-19 UK mental health research response

1. NHS Digital (2015) ‘Health Survey for England 2014’; NHS Digital (2016) ‘Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2014’. This estimate reflects the balance of evidence across both the Health Survey for England and the Adult Psychiatric Morbidity Survey. ↩

2. Mental health in children and young people, NHS England ↩

3. McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. (viewed 7 February 2022) ↩

4. OHID Fingertips public health data on severe mental illness ↩

5. NHS Digital (2021) Mental Health of Children and Young People in England in 2021 - wave 2 follow up to the 2017 survey ↩

6. ONS (September 2020). Suicides in the England and Wales: 2020 registrations ↩

7. The assessment of clinical risk in mental health services National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH). Manchester: The University of Manchester, 2018. ↩

8. ONS (May 2021). Coronavirus and depression in adults, Great Britain: January to March 2021 ↩

9. NHS Digital (2021) Mental Health Bulletin 2020 to 2021 annual report 2020 to 2021 England Outpatients Reference Tables - Table 4. ↩

10. Department of Health and Social Care (2012). The economic case for a shift to prevention. Annual Report of the Chief Medical Officer 2012 - Our Children Deserve Better: Prevention Pays. ↩

11. Kessler, and others (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey replication Archives of General Psychiatry, 62(6), 593-60.  ↩

12. Goodman and others (2011). The long shadow cast by childhood physical and mental problems on adult life Proceedings of the National Academy of Sciences, 108(15), 6032 to 6037. ↩

13. Odgers and others (2007). Prediction of differential adult health burden by conduct problem subtypes in males Arch Gen Psychiatry, 64(4),476-484. ↩

14. Goodman and others (2011). The long shadow cast by childhood physical and mental problems on adult life Proceedings of the National Academy of Sciences, 108(15), 6032 to 6037. ↩

15. Teplin and others (2005). Crime victimization in adults with severe mental illness: Comparison with the National Crime Victimization Survey. Arch Gen Psychiatry, 62(8), 911 to 921. ↩

16. Centre for Mental Health (2016). Mental Health and Criminal Justice. Views from consultation across England and Wales (PDF, 1.40MB). Centre for Mental Health. ↩

17. Thriving at work. The Stevenson and Farmer review of mental health and employers (2017) ↩

18. Mental health & Work report (PDF, 1.36MB) ↩

19. Franck L and others (2016) Systematic review of interventions addressing social isolation and depression in aged care clients. Qual Life Res. 25(6):1395 to 1407 (viewed on 3 February 2022) ↩

20. Poscia A and others (2018) Interventions targeting loneliness and social isolation among the older people: An update systematic review. ExpGerontol 102:133 to 144 (viewed on 3 February 2022) ↩ ↩²

21. Gardiner C and others (2018) Interventions to reduce social isolation and loneliness among older people: an integrative review. Health & Social Care in the Community 26(2):147 to 157 (viewed on 3 February 2022) ↩

22. Public Health England (2021). Every Mind Matters Campaign ↩

23. Our impact: time to change ↩

24. UKRI spend includes grants which are wholly or partially relevant to mental health. NIHR spend includes grants that are wholly relevant to mental health.  ↩

25. UK CMO commentary on screen time and social media map of reviews ↩

26. Boardman and others (2015). Mental health and poverty in the UK - time for change? BJPsych International, 12(2), 27 to 28. ↩ ↩²

27. Kessler, and others (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey replication. Archives of General Psychiatry, 62(6), 593 to 60.  ↩

28. Note that we fully recognise the important role that support from beyond the NHS, particularly social care, can play in treatment and recovery. This is considered in detail in the next chapter. ↩

29. NHS Digital (2015) ‘Health Survey for England 2014’; NHS Digital (2016) ‘Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2014’ This estimate reflects the balance of evidence across both the Health Survey for England and the Adult Psychiatric Morbidity Survey. ↩

30. UKRI spend includes grants which are wholly or partially relevant to mental health. NIHR spend includes grants that are wholly relevant to mental health.  ↩

31. NHS Digital (2021). Mental Health Act Statistics Annual Figures 2020 to 2021 ↩

32. Caution should be taken here due to small numbers of children excluded ↩

33. Green and others (2004). Mental Health of children and young people in Great Britain Basingstoke: Palgrave MacMillan 2005. ↩

34. Public Health England (2019). Mental Health: population factors ↩

35. Adult Psychiatric Morbidity Survey, 2016. ↩

36. NHS Long Term Plan (2019) ↩

37. Centre for Mental Health (2013). Briefing 47: Barrier to employment (PDF, 559KB) ↩

38. Waddell and Burton (2006) ↩

39. Butterworth et al (2011) ↩

40. Chesney and others (2014). Risks of all-cause and suicide mortality in mental disorders: a meta-review World Psychiatry 13(2), 153 to 160. ↩

41. NHS Digital (2021). Excess under 75 mortality rates in adults with serious mental illness - 2018 to 2020 ↩

42. Hayes and others (2017). Mortality gap for people with bipolar disorder and schizophrenia: UK-based cohort study 2000-2014 The British Journal of Psychiatry, 211, 175 to 181. ↩

43. The assessment of clinical risk in mental health services National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH). Manchester: The University of Manchester, 2018. ↩

44. Public Health England, Social Determinants of Health, 2017 (viewed on 7 February 2022) ↩

45. World Health Organization (‎2014)‎. Social determinants of mental health. World Health Organization. (viewed on 7 February 2022) ↩

46. Stewart-Brown S, Samaraweera PC, Taggart F, Kandala NB, Stranges S. Socioeconomic gradients and mental health: implications for public health. Br J Psychiatry. 2015 Jun;206(6):461-5. doi: 10.1192/bjp.bp.114.147280. Epub 2015 Mar 19. PMID: 25792696. (Viewed on 07 February 2022) ↩

47. Patel V, Lund C, Hatheril S, Plagerson S, Corrigall J, Funk M, et al. Mental disorders: equity and social determinants. In: Blas E, Kurup AS, editors. Equity, social determinants and public health programmes. Geneva: World Health Organization; 2010. p. 115-34 ↩

48. Wagner SR and others, Income inequality and mental illness-related morbidity and resilience: a systematic review and meta-analysis,The Lancet Psychiatry, Volume 4, Issue 7, 2017, pages 554-562 (viewed 3 February 2022) ↩

49. Crick Lund, Stephen Stansfeld and Mary de Silva ‘Social Determinants of Mental Health’ in Vikram Patel, Harry Minas, Alex Cohen, Martin J Prince, Global Mental Health Principles and Practice, Oxford University Press; 2014 p. 116-136 ↩

50. Gutman and others. Children of the new century: mental health findings from the Millenium Cohort Study (2015), Centre for Mental Health and UCL ↩

51. Mental health of children and young people in England (PDF, 999KB) (2017) NHS Digital ↩

52. McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. (viewed 7 February 2022) ↩

53. LEE, S. C. and others. Area deprivation, urbanicity, severe mental illness and social drift - a population-based linkage study using routinely collected primary and secondary care data. Schizophrenia research, v. 220, p. 130-140, 2020. (viewed 7 Feb 2022). ↩

54. Office of Health Improvement and Disparities, Public Health profiles, Common Mental Disorders 2022. (viewed 11 February 2022) ↩

55. Delgadillo J, Farnfield A, North A. Social inequalities in the demand, supply and utilisation of psychological treatment. Couns Psychother Res. 2018. (viewed 7 February 2022) ↩

56. Halvorsrud, K, Nazroo, J, Otis, M, Brown Hajdukova, E & Bhui, K 2019, Ethnic inequalities in the incidence of diagnosis of severe mental illness in England: a systematic review and new meta-analyses for non-affective and affective psychoses, Social psychiatry and psychiatric epidemiology, vol. 54, no. 11, pp. 1311-1323.(Viewed on 4 February 2022) ↩

57. Ibid ↩

58. Bignall and others, 2019, Racial disparities in mental health: literature and evidence review, Race Equality Foundation ↩

59. Hatch S.L. and others Discrimination and common mental disorder among migrant and ethnic groups: findings from a South East London Community sample Soc Psychiatry Epidemiol. 2016; 51: 689-701. (viewed 4 February 2022) ↩

60. Kapadia D, and others Ethnic inequalities in healthcare: a rapid review of the evidence (PDF, 1.27MB) (2022) NHS Race and Health Observatory (viewed 28 February 2022) ↩

61. Kapadia D, and others Ethnic inequalities in healthcare: a rapid review of the evidence (PDF, 1.27MB) (2022) NHS Race and Health Observatory (viewed 28 February 2022) ↩

62. Ethnicity Facts and Figures: outcomes for treatment for anxiety and depression, March 2021 (viewed 4 February 2022) ↩

63. Kapadia D, and others Ethnic inequalities in healthcare: a rapid review of the evidence (PDF, 1.27MB) (2022) NHS Race and Health Observatory (viewed 28 February 2022) ↩

64. Kapadia D, and others Ethnic inequalities in healthcare: a rapid review of the evidence (PDF, 1.27MB) (2022) NHS Race and Health Observatory (viewed on 28 February 2022) ↩

65. Halvorsrud, K., Nazroo, J., Otis, M. and others Ethnic inequalities and pathways to care in psychosis in England: a systematic review and meta-analysis. BMC Med 16, 223 (2018). (viewed 4 February 2022) ↩

66. Kamaldeep Bhui, Kristoffer Halvorsrud, James Nazroo Making a difference: ethnic inequality and severe mental illness BJ Psychiatry 2018 Oct 2013 (4) 574-578 (viewed 4 February 2022) ↩

67. Bignall and others, 2019. Racial disparities in mental health: literature and evidence review, Race Equality Foundation. ↩

68. Mental Health Act Statistics Annual Figures 2020 to 2021, NHS Digital [(viewed 4 February 2022) ↩

69. James Payne-Gill, Corin Whifield, Alison Beck The relationship between ethnic background and the use of restrictive practices to manage incidents of violence or aggression in psychiatric inpatient settings First published: 27 June 2021 Whiley Online Library (viewed 4 February 2022) ↩

70. Kapadia D, and others Ethnic inequalities in healthcare: a rapid review of the evidence (PDF, 1.27MB) (2022) NHS Race and Health Observatory (viewed on 28 February 2022) ↩

71. Kapadia D, and others Ethnic inequalities in healthcare: a rapid review of the evidence (PDF, 1.27MB) (2022) NHS Race and Health Observatory (viewed 28 February 2022) ↩

72. McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. (viewed 2 February 2022) ↩

73. McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. (viewed 2 February 2022) ↩

74. McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. (viewed on 2 February 2022) ↩

75. Abel and Newbigging, Addressing unmet needs in women’s mental health (PDF, 400KB). British Medical Association. 2018. (viewed 8 February 2022) ↩

76. Striegel-Moore RH, Rosselli F, Perrin N, and others. Gender difference in the prevalence of eating disorder symptoms. International Journal of Eating Disorders. 2009;42(5):471-474. doi:10.1002/eat.20625 (viewed 8 February 2022) ↩

77. Office for National Statistics (2018). Personal wellbeing estimates by age and sex. (Accessed 8 February 2022). ↩

78. Fronimos & Brown (2010). Gender Differences in Depression and Male Depression: A Social Psychological Review. Social Psychology Review, 12(1), 3-16. ↩

79. Wylie, C., Platt, S., Brownie, J., & Chandler, A. and others. (2012). Men, suicide and society. London: Samaritans ↩

80. McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. (viewed on 2 February 2022) ↩

81. Office of National Statistics. 2017. Suicides in Great Britain: 2016 registrations. (viewed on 2 February 2022). ↩

82. McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. (viewed on 2 February 2022) ↩

83. NHS Digital, Improving Access to Psychological Therapies data set (viewed on 3 February 2022) ↩

84. NHS Digital, Mental Health Act Annual Figures 2019 to 2020 (viewed on 2 February 2022) ↩

85. NHS Digital, Improving Access to Psychological Therapies (IAPT) data set reports (viewed on 3 February 2022) ↩

86. NHS Digital, Improving Access to Psychological Therapies data set (Viewed on 03 February 2022) ↩

87. Department of Health and Social Care (2018). The Women’s Mental Health Taskforce (PDF, 1.49MB). (viewed on 8 February 2022) ↩

88. NHS Digital (2020) Mental health in children and young people in England 2020: wave 1 follow up to the 2017 survey. ↩

89. McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. (viewed on 2 February 2022) ↩

90. OHID, 2022 Public health profiles [online] (viewed 8 February 2022) ↩

91. McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. (viewed 4 February 2022) ↩

92. McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014). Leeds: NHS Digital. (viewed on 2 February 2022) ↩

93. ONS. Suicides in England and Wales: 2020 registrations. (viewed on 7 February 2022) ↩

94. Suffering in silence: age inequality in older people’s mental health (2018) Royal College of Psychiatrists College Report (viewed 28 February 2022) ↩

95. Mental Health later in life (2021) Royal College of Nursing (viewed 28 February 2022) ↩

96. Wang and others. Delay and failure in treatment seeking after first onset of mental disorders in the World Health Organization’s World Mental Health Survey Initiative’. World Psychiatry. 2007 Oct; 6(3): 177-18 (viewed 3 February 2022) ↩

97. Caroline Mitchell and others. Mental health help-seeking behaviours in young adults. British Journal of General Practice 2017; 67 (654): 8-9. (viewed on 4 February 2022) ↩

98. Office for Health Improvement, Public health profiles: mental health disorders (viewed 8 February 2022) ↩

99. Walters K., and others, Sociodemographic inequalities in the management of depression in adults aged 55 and over: an analysis of English primary care data  Psychological Medicine, Volume 48 , Issue 9, July 2018, pp. 1504-1513 (viewed 28 February 2022) ↩

100. Semlyen, J., King, M., Varney, J. and others. Sexual orientation and symptoms of common mental disorder or low wellbeing: combined meta-analysis of 12 UK population health surveys.’ BMC Psychiatry 16, 67 (2016).(Viewed 4 February 2022) ↩

101. Woodhead, C., Gazard, B., Hotopf, M., Rahman, Q., Rimes, K.A., and Hatch, S.L. (2016). Mental health among UK inner city non-heterosexuals: the role of risk factors, protective factors and place. Epidemiology and Psychiatric Sciences, 25, 450-461.(viewed 4 February 2022) ↩

102. Bachman and Gooch, LGBT in Britain, Health Report, 2018 (viewed 4 February 2022) ↩

103. Rebekah Amos, Eric Julian Manalastas, Ross White, Henny Bos and Praveetha Patalay Mental health, social adversity & health-related outcomes in sexual minority adolescents:  a contemporary national cohort study, The Lancet Child and Adolescent Health. 2019. (viewed 4 February 2022) ↩

104. Nathan Hudson-Sharp and Hilary Metcalf, (2016) Inequality among lesbian gay bisexual and transgender in the UK: a review of the evidence (PDF, 1.69MB) National Institute of Economic and Social Research July 2016. (viewed 15 February 2022) ↩

105. McGowan VJ, Lowther HJ, Meads C. Life under COVID-19 for LGBT+ people in the UK: systematic review of UK research on the impact of COVID-19 on sexual and gender minority populations. BMJ open. 2021;11(7) (viewed 15 February 2022) ↩

106. Scottish Government  (2013) Equality Outcomes: Lesbian, Gay, Bisexual and Transgender (LGBT) Evidence Review (viewed 15 February 2022) ↩

107. Bachman and Gooch, LGBT in Britain, Health Report, 2018 (Viewed 4 February 2022) ↩

108. Mitchel M and Howarth C, (2009) Transgender Research review (PDF, 906KB), Equality and Human Rights Commission research report 27. (Viewed 15 February 2022) ↩

109. Bachman and Gooch, LGBT in Britain, Health Report, 2018 (viewed 4 February 2022) ↩

110. Bachman and Gooch, LGBT in Britain, Health Report, 2018 (viewed 4 February 2022) ↩

111. Rimes, K.A., Broadbent, M., Holden, R., Rahman, Q., Hambrook, D., Hatch, S.L. and Wingrove, J. Comparison of treatment outcomes between lesbian, gay, bisexual and heterosexual individuals receiving a primary care psychological intervention. 2018. Behavioural and Cognitive Psychotherapy, 46(3), pp.332-349. (viewed 4 February 2022) ↩

112. Stonewall. 2017. LGBT in Britain: Trans Report (PDF, 1.47MB). (viewed 15 February 2022). ↩

113. Hudson-Sharp, N and Metcalf, H, 2016. Inequality among lesbian, gay, bisexual and transgender groups in the UK: a review of evidence National Institute of Economic and Social Research. (viewed 15 February 2022). ↩

114. Carlile, A and others. “It’s like my kid came back overnight”: experiences of trans and non-binary young people and their families seeking, finding and engaging with clinical care in England, 2021, International Journal of Transgender Health, vol 22, issue 4. (Viewed on 15 February 2022). ↩

115. Buckles J, Luckasson R, Keefe E. A systematic review of the prevalence of psychiatric disorders in adults with intellectual disability, 2003-2010. Journal of Mental Health Research in Intellectual Disabilities 2013. Volume 6, pages 181-207. (Viewed on 8 February 2022). ↩

116. Glasson E and others. Systematic Review and Meta-Analysis: Mental Health in Children With Neurogenetic Disorders Associated With Intellectual Disability. Journal of the American Academy of Child and Adolescent Psychiatry, 2020. Volume 59(9), pages 1036-1048. (Viewed on 8 February 2022). ↩

117. Cooper S-A, Smiley E, Finlayson J, Jackson A, Allan L, Williamson A, and others. The prevalence, incidence, and factors predictive of mental ill-health in adults with profound intellectual disabilities. Journal of Applied Research in Intellectual Disabilities. 2007. Volume 20, pages 493-501. (Viewed on 8 February 2022). ↩

118. Sheehan R, Hassiotis A, Walters K, Osborn D, Strydom A, Horsfall L. Mental illness, challenging behaviour, and psychotropic drug prescribing in people with intellectual disability: UK population based cohort study. British Medical Journal 2015.351:h4326. (Viewed 8 February 2022). ↩

119. Hanlon, P, MacDonald, S, Wood, K, Allan, L, Cooper, S. Long-term condition management in adults with intellectual disability in primary care: a systematic review. BJGP Open 2018. Volume 2 (1), bjgpopen18X101445. (Viewed 08 February 2022). ↩

120. Cooper, SA., Smiley, E, Morrison, J, Williamson, A., and Allan, L. Mental ill-health in adults with intellectual disabilities: prevalence and associated factors. The British Journal of Psychiatry 2007. Volume 190, pages 27-35 (Viewed on 4 February 2022). ↩

121. Rydzewska, E and others. Prevalence of long-term health conditions in adults with autism: observational study of a whole country population, BMJ Open, 2018; 8(8) ↩

122. Pehlivanidis, A., Papanikolaou, K., Mantas, V. and others Lifetime co-occurring psychiatric disorders in newly diagnosed adults with attention deficit hyperactivity disorder (ADHD) or/and autism spectrum disorder (ASD). BMC Psychiatry 20, 423 (2020). (Viewed 11 February 2022) ↩

123. Hollingdale J, Woodhouse E, Young S, Fridman A, Mandy W. Autistic spectrum disorder symptoms in children and adolescents with attention-deficit/hyperactivity disorder: a meta-analytical review. Psychol Med. 2020 Oct;50(13):2240-2253 (Viewed 11 February 2022) ↩

124. McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. (Viewed on 02 February 2022) ↩

125. Crane, L. and others (2019) Something needs to change: mental health experiences of young autistic adults in England. Autism 2019. Volume 23(2), pages 477-493 (viewed on 4 February 2022) ↩

126. Camm-Crosbie, L and others (2019). People like me don’t get support: autistic adults’ experiences of support and treatment for mental health difficulties, self-injury and suicidality. Autism 2019. Volume 23(6), pages 1431-1441 (viewed on 4 February 2022) ↩

127. Crane, L. and others (2019) Something needs to change: Mental health experiences of young autistic adults in England. Autism 2019. Volume 23(2), pages 477-493 (viewed on 4 February 2022) ↩

128. Camm-Crosbie, L and others (2019). People like me don’t get support: autistic adults’ experiences of support and treatment for mental health difficulties, self-injury and suicidality’. Autism 2019. Volume 23(6), pages 1431-1441 (viewed on 4 February 2022) ↩

129. National Institute of Healthcare Research Multiple long-term conditions (multimorbidity) Making sense of the evidence [online] (Viewed 11 February 2022) ↩

130. NHS England and NHS Improvement (2018) The Improving Access to Psychological Therapies (IAPT) Pathway for People with Long-term Physical Health Conditions and Medically Unexplained Symptoms (PDF, 1.02MB) (2018) (viewed on 4 February 2022) ↩

131. Hoang U, Goldacre MJ, Stewart R. Avoidable mortality in people with schizophrenia or bipolar disorder in England. Acta Psychiatrica Scandinavica, 2013. Volume 127, pages195-201 (viewed on 4 February 2022) ↩

132. Department of Health and Social Care (2022) England rare disease action plan  (viewed 2 March 2022) ↩

133. National Institute of Healthcare Research Multiple long-term conditions (multimorbidity) Making sense of the evidence [online] (Viewed 11 February 2022) ↩

134. Paul, K. I., & Moser, K. (2009). Unemployment Impairs Mental Health: Meta-Analyses. Journal of Vocational Behavior, 74(3), 264-282. (viewed on 4 March 2022) ↩

135. Stuckler, D., Basu, S., Suhrcke, M., Coutts, A., and McKee, M. (2009). The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis. The Lancet, 374(9686), 315-323 (viewed on 4 March 2022) ↩

136. McManus S and others (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014 (PDF, 3.04MB). Leeds: NHS Digital (viewed 3 February 2022) ↩

137. The Health Foundation (2021) Unemployment and mental health (viewed on 3 February 2022) ↩

138. Daly M and others (2020), Longitudinal changes in mental health and the COVID-19 pandemic: evidence from the UK Household Longitudinal Study (viewed on 11 February 2022) ↩

139. Gagne T and others (2021) Time trend analysis of social inequalities in psychological distress among young adults before and during the pandemic: evidence from the UK Household Longitudinal Study COVID-19 waves (PDF, 271KB) (viewed on 11 February 2022) ↩

140. Pierce M and others (2020) Mental health before and during the COVID-19 pandemic: a longitudinal probability sample survey of the UK population (viewed on 11 February 2022) ↩

141. National Institute for Health Research (2021) Public mental health conceptual framework (viewed 7 March 2022) ↩

142. Rönnblad T, Grönholm E, Jonsson J, Koranyi I, Orellana C, Kreshpaj B, Chen L, Stockfelt L, Bodin T. Precarious employment and mental health: a systematic review and meta-analysis of longitudinal studies. Scand J Work Environ Health. 2019 Sep 1;45(5):429-443 (viewed 7 March 2022) ↩

143. Staiger, T and others (2017). Barriers and facilitators of help-seeking among unemployed persons with mental health problems: a qualitative study. BMC Health Services Research 17, 39. (viewed on 3 February 2022) ↩

144. DWP EA in IAPT review in April 2022 ↩

145. OHID, (2022) Fingertips public health data 2022 (viewed 7 March 2022) ↩

146. Killaspy, H and others. 2022. Community-based social interventions for people with severe mental illness: a systematic review and narrative synthesis of recent evidence. World Psychiatry, 21: 96-123.  (viewed on 3 February 2022) ↩

147. McManus S and others (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014 (PDF, 3.04MB). Leeds: NHS Digital (viewed 3 February 2022) ↩

148. Meltzer H and others. (2013) The relationship between personal debt and specific common mental disorders. Eur J Public Health. 2013 Feb;23(1):108-13 (viewed on 3 February 2022) ↩

149. McDaid and others (2017) Commissioning cost-effective services for promotion of mental health and wellbeing and prevention of mental ill health. Public Health England. (viewed on 3 February 2022) ↩

150. Fazel M and others (2005) Prevalence of serious mental disorder in 7,000 refugees resettled in Western countries: A systematic review. The Lancet, 365, 1309-1314. (viewed on 3 February 2022) ↩

151. Tempany M. (2009) What research tells us about the mental health and psychosocial wellbeing of Sudanese refugees: A literature review. Transcultural Psychiatry, 46, 300-315 . (viewed on 3 February 2022) ↩

152. Pollard T, Howard N. (2021) Mental healthcare for asylum-seekers and refugees residing in the United Kingdom: a scoping review of policies, barriers, and enablers. International journal of mental health systems. 2021;15(1):60. (viewed on 3 February 2022) ↩

153. Aspinall, P., and Watters, C. (2010). Refugees and asylum seekers: A review from an equality and human rights perspective (PDF, 1.83MB). Equality and Human Rights Commission Research report 52, University of Kent. (viewed on 3 February 2022) ↩

154. Refugee Council, A note on barriers to people seeking refugee status or asylum, on accessing health services (PDF, 626KB) March 2021. ↩

155. Pollard T, Howard N. (2021) Mental healthcare for asylum-seekers and refugees residing in the United Kingdom: a scoping review of policies, barriers, and enablers. International journal of mental health systems. 2021;15(1):60. (viewed on 3 February 2022) ↩

156. Office for National Statistics Personal wellbeing and crime: crime statistics from the Crime Survey of England and Wales (2015) (viewed on 28 February 2022) ↩

157. Office for National Statistics (2017). Focus on violent crime and sexual offences, England and Wales: year ending March 2016. (viewed on 8 February 2022). ↩

158. Scott, S. and McManus, S. (2016). Hidden hurt: violence, abuse and disadvantage in the lives of women. DMSS Research for Agenda. (viewed on 3 February 2022). ↩

159. Macpherson, J.M and others. Child maltreatment and incident mental disorders in middle and older ages: a retrospective UK Biobank cohort study. The Lancet 2021: volume 11, 100224. (viewed on 3 February 2022). ↩

160. Dong, X and others. Elder abuse and psychological well-being: a systematic review and implications for research and policy - a mini review. Gerontology 2013: volume 59, pages 132-142. (veiwed on 3 February 2022). ↩

161. Kadra, G. and others. Investigating exposure to violence and mental health in a diverse urban community sample: data from the South East London community health (SELCoH) survey. PLoS One 2014. Volume: 4, e93660. (viewed on 3 February 2022) ↩

162. Her Majesty’s Inspectorate of Probation. (2021). A joint thematic inspection of the criminal justice journey for individuals with mental health needs and disorders. (viewed on 3 February 2022). ↩

163. House of Commons. (2017). Mental health in prisons: eighth report of session 2017 to 2019 (PDF, 620KB). (viewed on 3 February 2022) ↩

164. Zhong, S and others. (2021) Risk factors for suicide in prisons: a systematic review and meta-analysis. The Lancet 2021, volume 6, pages E164-E174. (viewed on 3 February 2022) ↩

165. Her Majesty’s Inspectorate of Probation. (2021). A joint thematic inspection of the criminal justice journey for individuals with mental health needs and disorders. (viewed on 3 February 2022) ↩

166. House of Commons. (2017). Mental health in prisons: Eighth report of session 2017-2019 (PDF, 620KB). (viewed on 3 February 2022) ↩

167. Bignall and others, 2019. Racial disparities in mental health: literature and evidence review. Race Equality Foundation. ↩

168. Jeffrey, D, B and others. (2015) Prevalence of mental health problems and service use among first-time juvenile offenders. Journal of Child and Family Studies 2015: volume 12, pages 3774-3781. (viewed on 3 February 2022) ↩

169. Ministry of Housing, Communities and Local Government. (2020). The Rough Sleeping Questionnaire: Initial Findings. (viewed on 3 February 2022) ↩

170. Ministry of Housing, Communities and Local Government. (2021). Statutory Homelessness January to March (Q1) 2021: England (PDF, 3.78MB). (viewed on 3 February 2022) ↩

171. Rees, S. (2009). Mental ill health in the adult single homeless population. London: Crisis UK. (accessed on 3 February 2022). ↩

172. Rees, S. (2009). Mental ill health in the adult single homeless population. London: Crisis UK. (viewed on 3 February 2022). ↩

173. Homeless Link. (2010). The health and wellbeing of people who are homeless: Evidence from a national audit. (viewed on 3 February 2022). ↩

174. Public Health England, 2017 Guidance: People with co-occurring conditions: commission and provide services. (viewed 8 February 2022) ↩

175. McManus S and others (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014 (PDF, 3.04MB). Leeds: NHS Digital (viewed 3 February 2022) ↩

176. Weaver T, and others. Comorbidity of substance misuse and mental illness in community mental health and substance misuse services. The British Journal of Psychiatry. 2003. Volume 183 (4), pages 304-313. (viewed on 4 February 2022) ↩

177. Appleby, L and others (2017) The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Annual Report 2017: England, Northern Ireland, Scotland and Wales October 2017. University of Manchester (viewed on 4 February 2022) ↩

178. Care Quality Commission (2015) Right here, right now (PDF, 4.66MB) (viewed on 4 February 2022) ↩

179. The Recovery Partnership (2015) The Recovery Partnership. State of the Sector 2015 (viewed on 4 February 2022) ↩

180. Department of Health and Social Care. (2021). Review of drugs: phase 2 report  (viewed on 4 February 2022) ↩

181. Public Health England (2021) Gambling related harms evidence review (viewed on 8 February 2022) ↩

182. YouGov (2020) Gambling Treatment and Support (PDF, 1.39MB) 281 (viewed on 4 February 2022) ↩

183. Dregan A, Brown J, Armstrong D. Do adult emotional and behavioural outcomes vary as a function of diverse childhood experiences of the public care system? Psychological medicine. 2011;41(10):2213-20. (viewed on 3 March 2022) ↩

184. Dregan A, Gulliford MC. Foster care, residential care and public care placement patterns are associated with adult life trajectories: population-based cohort study. Social psychiatry and psychiatric epidemiology. 2012;47(9):1517-26 ↩

185. McManus S and others (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014 (PDF, 5.79MB). Leeds: NHS Digital (viewed on 3 February 2022) ↩

186. ‘Tackling Loneliness evidence review’ January 2022 Department of Culture Media and Sport (viewed on 28 February 2022) ↩

187. ONS (2015), Measuring National Well-being: Insights into Loneliness, Older People and Well-being, 2015 (viewed on 3 February 2022) ↩

188. Franck L and others (2016) Systematic review of interventions addressing social isolation and depression in aged care clients. Qual Life Res. 25(6):1395-407 (viewed on 3 February 2022) ↩

189. Poscia A and others (2018) Interventions targeting loneliness and social isolation among the older people: An update systematic review. ExpGerontol 102:133-144 (viewed on 3 February 2022) ↩

190. Gardiner C and others (2018) Interventions to reduce social isolation and loneliness among older people: an integrative review. Health and Social Care in the Community 26(2):147-157 (viewed on 3 February 2022) ↩

191. George ES and others (2020). Psychological distress among carers and the moderating effects of social support. BMC Psychiatry (viewed on 8 February 2022) ↩

192. Shah, A.J. and others (2010). Review Article: Psychological Distress in Carers of People with Mental Disorders. British Journal of Medical Practitioners, 3(3), 327. (viewed on 8 February 2022) ↩

193. Carers UK, State of caring 2021 - a snap shot of unpaid care in the UK (viewed on 8 February 2022) ↩

194. Sin J and others. (2021). Mental health and caregiving experiences of family carers supporting people with psychosis. Epidemiol Psychiatr Sci. 2021 Jan 8;30:e3. (viewed on 8 February 2022) ↩

195. Carbone EA, de Filippis R, Roberti R, Rania M, Destefano L, Russo E, De Sarro G, Segura-Garcia C, De Fazio P. The Mental Health of Caregivers and Their Patients With Dementia During the COVID-19 Pandemic: A Systematic Review. Front Psychol. 2021 Dec 24;12:782833. (viewed on 8 February 2022) ↩

196. Willner P and others (2020). Effect of the COVID‐19 pandemic on the mental health of carers of people with intellectual disabilities. J Appl Res Intellect Disabil [Internet]; (viewed on 8 February 2022) ↩

197. Willner P and others. (2020) Effect of the COVID‐19 pandemic on the mental health of carers of people with intellectual disabilities. J Appl Res Intellect Disabil (viewed on 8 February 2022) ↩

198. Greenwood N, Habibi R, Smith R, Manthorpe J. Barriers to access and minority ethnic carers’ satisfaction with social care services in the community: a systematic review of qualitative and quantitative literature. Health Soc Care Community. 2015;23(1):64-78. ↩

199. Sempik, J., and Becker, S. (2013). Young adult carers at school experiences and perceptions of caring and education (PDF, 1.22MB). Carers Trust (viewed on 8 February 2022) ↩

200. State of Caring 2021: a snapshot of unpaid care in the UK (viewed on 8 February 2022) ↩