On average, countries dedicate less than 2% of their healthcare budgets to mental health (WHO 2021), despite the substantial number of people (i.e. one person in every eight [WHO 2021]) around the world living with a mental disorder.
Out of the meagre 2% of the healthcare budget allocated to mental healthcare in these countries, 70% of this goes straight to the running of psychiatric hospitals (WHO 2021). Such hospitals typically serve people with secondary mental health conditions, rather than to
populations suffering with depression (or anxiety).
Half of the world’s population reside in countries where there is just one psychiatrist to serve 200,000 people or more (WHO 2021). Therefore the budget afforded to low and middle income countries (LMICs) pays for very few trained staff who are able to prescribe psychopharmacological medicines. This is also compounded by diminished supplies of such medications, especially at less common doses.
The macro factors that affect the mental health treatment gap between high and low income countries are compound. It is not simply down to economic barriers such as poverty, the cost of care, and limited funding for resources. There may be poorly administered legislation and
policies around mental health, as well as a lack of national-ethics frameworks or a lack of adherence to global-ethics frameworks.
Unfortunately, a consequence of this could be an infraction of human rights (WHO 2023). Other potential issues may include inadequate
training of staff, variability in the quality of care, and a disjointed approach to mental healthcare and well-being.
There are also cultural concerns with some LMICs that inhibit help seeking behaviours for mental health. There is often increased stigma, and with it, self-stigma. Some cultures do not see mental illness as natural, or as having at least in part, a medical nature. People may choose to suffer with their depression rather than disclose their suffering and become ostracised by their family and/or community.
Moreover, sufferers of depression may also experience reluctance to seek help if there is a financial burden for themselves or for their families, especially if there is inadequate health insurance available, or worse, none at all.
Much of these issues are self-perpetuating. As healthcare budgets are decided, more “critical” issues will always be prioritised over mental health, especially whenever there is a public health crisis. This underinvestment worsens the lack of adequate staffing, training and services, creating a feedback loop which in turn diminishes the perceived importance of addressing mental health problems. In turn, with a lack of research in these countries, policymakers may not recognize the full economic cost of neglecting mental health care, and the cycle continues. Furthermore, the policy and governance issues precipitate a lack of accountability, ensuring that such issues remain a problem for far too long.
Cultural, social and self-stigma issues also self-perpetuate. Cultural and social beliefs and taboos may cause those who are struggling to suffer in silence, which means that mental health is not openly discussed, thus causing low demand at the psychiatric hospitals, which also in turn leads to less dedicated funding for mental health while sufferers continue to deteriorate.
Meanwhile, these same beliefs and taboos make mental health campaigns such as raising mental health literacy very difficult to implement, especially given the low budget for doing so. In turn this lack of awareness around mental health means that fewer sufferers will seek the help they need, even if the right staff and medications were available to them.
Depression faced by working age people in the UK
In the UK, many populations are affected by income inequality and socioeconomic disadvantage. Among the people of working age, there is a substantial difference in income between those who find themselves out of work, and those who are employed full time, even
if they are on national minimum wage. With the rise of zero-hour working contracts, there is also “working poverty”.
Kirkbridge et al (2024) describe socioeconomic disadvantage as a fundamental determinant of mental health. This is not surprising given that socioeconomic disadvantage affects not only living standards, but also education, occupation, and social status. Meanwhile, Patel etal (2018) cite several papers that found a connection between income inequality and risk of depression, corroborating their own findings in their meta-analysis.
The substantial gap between the need for treatment for depression and its availability and timely accessibility leads to unwanted consequences for employers and the economy, through reduced productivity and workforce participation (Chislholm et al 2016).
People often find themselves out of work through no fault of their own, for example due to changes in industry, or through disability or mental ill health, such as depression.
What is being done to address these matters?
In the UK, there is legislation and country-wide policy in place for mental health services. This includes free treatment available at the point of service from the National Health Service (NHS). This treatment is spread into community populations and is not limited to psychiatric institutions or hospital wards. Also, both England and Wales are currently commissioning for greater numbers of mental health nursing degrees, which will do more to help with this.
One way of preventing depression in the future UK workforce is being implemented through targeting secondary schools. They have Health and Wellbeing days, whereby they spend an entire school day learning about mental health and wellbeing. This is universal and
primordial prevention. According to a systematic review and meta analysis by Conejo-Ceron et al (2017), psychological and educational interventions to prevent depression can have a modest though statistically significant preventative effect.
Psychopharmacological therapies are widely available in the UK, and in some circumstances this is at no cost to the service user.
In recent times, talking therapies for depression have become easier to access in the UK, with the advent of telemedicine. This is headed by qualified professionals and is accessible around the clock.
Stigma surrounding depression may be less of an issue in the UK compared with certain other countries, but it still remains a critical issue. Stigma discourages help-seeking behaviour which means that sufferers may not always choose to access the help available to
them.
The UK relies heavily on charities to address stigma, through charities aimed at suicide prevention, or those aimed specifically at reducing stigma, such as Time to Change England and Time to Change Wales.
The work by the Time to Change organisations is commendable. They have ‘Champions’ who are people with lived experience who provide anti-stigma talks in person and online. This can be considered contact-based education. There’s a growing literature confirming the effectiveness of contact-based education for stigma reduction in health profession trainees (Patten et al 2012). It is conceivable that this benefits the wider community in the same way.
The Time to Change organisations also provide videos and blog posts from these Champions which are available on their website and on several social media platforms aimed at reducing stigma and promoting mental health.
In 2007, Mental Health First Aid (MHFA) was launched in England (Davies 2021) and later made its way to Wales. Its aim was to train people in the workplace to identify, understand and respond to signs of mental illnesses and substance use disorders. This was to enable
individuals to reach out and provide initial help and support to someone in their workplace who may be developing a mental health problem or experiencing a crisis.
Another organisation aimed at workplace wellbeing, Improving Access to Psychological Therapies, was rolled out in the UK in 2006 (Davies 2021). Dr M. Scott looked into its effectiveness in 2010, and deemed it as no more effective than no treatment at all (Davies
2021). IAPT has since been rebranded and is now available in a different form.
Davies (2021) makes the point that while this training may do some good, it doesn’t address workforce distress, and proposes that MHFA may be colluding with workplace distress. He argues that low mood is often the result of a dissatisfied and disengaged workforce, and that many people find their jobs unfulfilling. A way to improve this will be discussed shortly.
Improvements proposed
Following the principles of social marketing, the ‘costs’ experienced (i.e. money, effort etc.) should be lower than the value that it’s perceived to bring (Chriss, cited in Wilderink et al 2022).
Chislholm et al (2016) presented a return on investment analysis of the scaling up of the treatment of depression and anxiety, which found a benefit to cost ratio of 2.3 – 3.0. This ratio is better again when the value of health returns is also included. This in itself makes a compelling case for further financial investment in mental health promotion.
Patel et al (2018) propose that a basic universal income be established to address income inequality. While there is a universal welfare income available for those out of work in the UK, this is widely considered insufficient – during the Covid-19 pandemic there was a temporary but substantial increase in this benefit. This increased benefit amount should be reinstated and set to rise in line with UK inflation.
Free prescriptions for health conditions should be made available in all UK nations regardless of population age. It’s unethical and poor economics not to include people of working age in this, especially for those out of work, as is the current situation.
While telemedicine helps sufferers to access talking therapies, there is still a lack of in-person talking therapies that are readily available due to the long waiting lists across the UK. This is of particular concern because a meta-analytic review by McHugh et al (2013)
concluded that there’s a significant three-fold preference for psychological treatment compared with medication.
A further issue is the time it takes for people to be trained in mental health in the UK. Mental health nursing degrees take a minimum of three years to complete, while training to become a professional counsellor in the UK typically takes at least three years.
For these reasons, I propose that there be greater focus for other types of mental health care training in the UK to address the rapidly increasing demand.
In the UK, there’s a clear disconnect between mental health care, and advice and guidance relating to work and careers. This needs to be rectified. Mental health practitioners typically avoid giving tangible career advice, while careers advisors can sometimes omit a more holistic practice when it’s mental ill health that’s holding someone back from their ideal life circumstances.
Helping someone find the right employment for them should be in synchrony with helping people out of “walking” depression or any other form of depression. This is why I propose the rebranding of the careers advice services of the four nations, so that they are aimed firstly at improving mental health and wellbeing, while also covering all the careers advice, and support to get people into employment, that they have always done. This service could also
cover the same services that are currently provided by the UK’s Citizens Advice Bureau.
The people providing these services should be trained in various matters. This includes Mental Health First Aid, so that they can spot urgent mental health needs, and provide referrals to in-person talking therapies on a fast-track waiting list. There should also be
mental health questionnaires completed, presented as a mere formality that everyone has to fill out (on their phone). Due to UK GDPR legislation all data provided will be confidential, unless a person conveys that they (or others) are in immediate danger.
People receiving this service would work with their advisor to form an action plan and have regular contact with their advisor in the same vein as Problem Management Plus (PM+) (Dawson et al 2015). There could be self-referral to this service as well as referral from other organisations. It would begin with a transdiagnostic approach, since this would be beneficial in instances where there may be comorbidity.
The problem-management approach will empower service users, putting the service user in control, by determining what is important to them and investing primarily in the areas of greatest significance to them.
This in-person service is particularly valuable, not only because people tend to prefer psychological therapies over pharmacological ones (McHugh et al 2013), but also because person-centred experiential therapy is on par with cognitive behavioural therapy for
short-term outcomes (Barkham et al 2021).
Training advisors to carry out this service would take weeks rather than years (Dawson et al 2015). This reduces the barriers of prolonged training time, and also reduces the waiting times on referrals to formal counselling due to the fast-track referral scheme.
Crucially, any available therapy is only helpful when it is accessed, which means there’s a strong argument for greater efforts to reduce stigma, and to encourage help seeking behaviours.
Therefore, I suggest that charities aimed at increasing the conversation around mental health, depression, and suicide prevention should receive funding from both the central and
the devolved governments.
Conclusion
Further investment of time and money is undeniably imperative for the mental health of working age people in the UK, both for the mental health benefits and for the economy. A sufficiently funded, combined mental health and life advice service is an improvement worthy of consideration by policymakers.
Cari Mayhew healthcare content Writer 
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