The concept of health is more expansive than just an absence of disease, it encompasses physical, mental, and social wellbeing. The World Health Organisation (WHO) defines mental health as ‘a state of wellbeing in which the individual realises his or her abilities, can cope with the normal stresses of life, work productively and fruitfully, and is able to make a contribution to his or her community’¹.  Wellness is a state of living a healthy lifestyle to enhance health and wellbeing². Wellness is a dynamic rather than static process which is conscious and self-directed. There are thought to be eight dimensions of wellness as shown in figure 1.

                         

Figure 1: The eight dimensions of wellness adapted from Swarbrick³

2011 saw the start of a significant cultural shift around mental health in the UK, particularly, the de-stigmatisation of mental health and its introduction into the social lexicon, the beginning of the social discourse. It started quietly in 2007 by a charity known as ‘Time to Change’⁴, which is led by the charities ‘Mind’⁵ and ‘Re-think Mental Illness’⁶.  Their goal was to end mental health discrimination and stigma. A national campaign was launched with the strapline ‘it’s time to talk, it’s time to change’ which included the statistic that one in four people will experience mental health issues at some point in their life⁷. Thus, bringing the prevalence of mental health into the social consciousness. Celebrities shared their experience of mental health, enabling people to relate to their own struggles and providing the realisation that anyone can be affected by mental health issues.

A recent study exploring the impact of celebrity health narratives reported that they served the purpose of educating and inspiring⁸.  The impact of personal narratives has been used regularly in public health campaigns, educating at a population level, and making experiences more relatable⁹. Since the inaugural campaign, there has been an explosion of campaigns around mental health awareness, including body image campaign, the unlock loneliness campaign, kindness campaign, the I’m fine campaign, mental health awareness week, world mental health day, men’s mental health campaign, and the green ribbon campaign, to name a few. In 2020 Public Health England launched its first mental health campaign targeting children and young people. Memoirs about struggles with mental health started to appear, and workplaces trained their staff on mental health issues. As a result, the discourse on mental health and wellbeing became ubiquitous.

More recently the phrase “it’s okay to not be okay” has been used to encourage people to talk about how they are feeling regarding their mental health and wellbeing. Dr Lucy Foulkes, a psychologist who researches mental health, in her book Losing Our Minds: What Mental Illness Really Is – and What It Isn’t¹⁰, discusses the seemingly binary choice of being either okay or not okay when it comes to mental health. Reporting that despite the ubiquity of mental health literature available to the public their understanding of what constitutes a mental illness, what causes them and what treatments are available is still poorly understood. Foulkes discusses the spectrum of mental health (see figure 2), which we all sit on, and move across as we go through life experiences. Describing “healthy” as a state of thriving and flourishing. Foulkes advocates for this spectrum of describing mental health with a shift away from a binary choice of either mentally ill or mentally well. Using anxiety as an example, a common negative emotion that everyone experiences. Foulkes describes how as you move up the spectrum you have people who experience anxiety more often or more severely, making it more difficult to control, and causing increased distress. To differentiate when a ‘disorder’ has begun, i.e., the person has moved into the ‘unwell’ stage, the inability to function in day-to-day life is present.

Figure 2: The spectrum of mental health¹¹

Dr Foulkes also describes concerns around the conflation of symptoms of a disorder with the disorder. Believing it can devalue the language used to describe serious medical problems. A classic example is the often heard “I’m a bit OCD”. However, this aspect of Foulkes’ work is outside the scope of this article.

Could it be that the misnomer of being either ‘healthy’ or ‘unwell’ when it comes to mental health, acts as a barrier to people being able to discuss their feelings? Should, as Foulkes advocates, the narrative change to a spectrum of wellness, to help people better understand and verbalise their experience with mental health? Whilst it was a significant step forward to get people talking about mental health, is it time to think about the language we are using? Foulkes reports “It’s great that the essential first step has been taken, that the conversation has begun, but the public discourse around mental health now needs to go deeper, to recognise more fully what mental illness is”¹⁰.

Health inequalities and mental health

According to the WHO, the factors whose variations exert a major effect on health include social, economic, and physical environments and systems of care, in addition to an individual’s characteristics and behaviours¹².  Mental health inequalities mean that although anyone can experience mental ill-health, the risks are much higher for certain populations who experience structural discrimination and disadvantage¹³. We know there is an uneven distribution of mental ill-health across society. Health inequalities are avoidable and unfair differences in health status and determinants between groups of people due to demographic, socioeconomic, geographical, and other factors. These differences include prevalence, access to, experience and quality of care and support, opportunities, and outcomes. Resulting in reduced quality of life, poorer health outcomes and premature death¹⁴.  The association between LGBTQ+ and poorer mental health persists regardless of positive changes in social attitudes and legislation.

The Minority Stress Model was a theory that originated through research related to the mental health of LGBTQ+ individuals. The theory posits that increased social stresses such as homophobia and discrimination, lead to increased risks for negative mental health outcomes, such as depressive symptoms, suicide ideation, and substance abuse¹⁵.  Research shows that LGBTQ+ communities are disproportionally affected by mental health issues. Young people who identify as LGBTQ+ are 1.5 times more likely to develop depression and anxiety compared to the rest of the population, with 55% of trans people in Britain being diagnosed with depression at some point¹⁶.

Almost half of transgender people (46 per cent) and 31 per cent of lesbian, gay and bisexual people had thoughts about taking their own life in the last year¹³.  The rate increases for younger people. Nine in ten transgender young people (92 per cent) and seven in ten (70 per cent) lesbian, gay and bisexual young people have thought about taking their life¹⁷. This is significantly higher than for young people in general (25 per cent).

Minority stress can also be experienced by other minorities of underrepresented or stigmatised groups, who experience stressors that relate to their minority identity, including ethnic minority communities, non-majority religions and people with disabilities. Evidence suggests that ethnic minority communities are disproportionately impacted by social determinants associated with mental illness. Poverty and exposure to racism are some factors suggested to influence the prevalence of mental illness among ethnic minority communities¹⁸. When accessing mental health services, ethnic minority communities are more likely to experience poorer outcomes¹⁸.

Children living in households in the lowest 20% income bracket in the UK are four times more likely to develop mental health problems compared to those in higher income brackets¹⁹. People who are homeless have 40–50 times higher rates of mental health issues than the general population²⁰.

People with long-term physical illnesses are at least twice as likely to have mental health difficulties as those without¹³.  Awareness of the socioeconomic and environmental impacts on an individual’s health and wellness can help us to understand some of the barriers that are faced, enabling us to work together to overcome them.

LGBTQ+ and the Royal Wolverhampton NHS Trust

Those who identify as LBGTQ+ are subject to health inequalities throughout their lives and these are made worse by the barriers to accessing the health services that they need. This could be due to a fear of disclosing their sexuality due to discrimination based on their sexuality or trans status. A lack of understanding and training on LGBTQ+ issues and how to treat and care for people is considered a barrier. Here at the Royal Wolverhampton NHS Trust (RWT), we aim to tackle these issues and support our LGBTQ+ colleagues and patients.

The LGBTQ+ Employee Voice Group: The Trust runs an employee voice group; this group aims to support LGBTQ+ employees and raise awareness of issues within the workplace and promote LGBTQ+ interests and equality within the workplace. It is an inclusive, non-judgmental, understanding and accepting group and is led by Carl Marshall. The group welcomes staff who do not identify as LGBTQ+ to become an ally too. The group works with the Trust to create an inclusive and diverse working environment and its goal is to educate staff about LGBTQ+ issues and best practice. The group are currently drafting a “Transgender Working Guidance” document, and this is due to be publicised shortly. This document will provide support to staff, patients, and carers.

The Trust’s Occupational Health department supports all staff and can provide counselling to staff who identify as LGBTQ+. It is a confidential service whereby staff can self-refer. Other services can be found on the following intranet link Services Provided (xrwh.nhs.uk).

The Trust also has an extensive health and wellbeing offer, open to all staff:

• Career wellbeing
• Physical wellbeing
• Mental/emotional wellbeing
• Financial wellbeing
• Community and social wellbeing

In the wider community, there are mental health support groups with an LGBTQ+ focus. Wolverhampton LGBTQ+ is a charity run service and works alongside organisations, businesses, and community groups. They run various events throughout the year, all in a welcoming and inclusive manner. Mermaids are a group who support transgender children and young people²¹.

Wider support

Population level actions have been suggested to help tackle inequalities associated with mental health issues¹³, and the Department of Health and Social Care currently has an open consultation on its proposed mental health and wellbeing plan²². At the individual level the following support is available:

Acute support:

• Samaritans freephone, 116 123, email jo@samaritans.org available 24 hours, available to discuss feelings of suicide as well as other worries, you do not have to be in crisis to ring them. Samaritans also have a Welsh Language Line on 0808 164 0123 (7 pm–11 pm every day).

Information on how to get professional help:

• Mind information line, 0300 123 3393 (open 9 am-6 pm, Monday-Friday)
• Rethink Mental Illness helpline, 0808 801 0525 (open 9.30 am-4 pm, Monday-Friday)
• Contact your GP

Anyone living in the UK aged 18 and over, who is registered with a GP can self-refer for Improving Access to Psychological Therapies (IAPT) services, these include:

• Talking therapies, such as cognitive behavioural therapy (CBT), counselling, other therapies, and guided self-help
• Help for common mental health problems, like anxiety and depression

You visit their website: Find an NHS psychological therapies service (IAPT) – NHS (www.NHS.uk)

NHS support

The NHS has launched its live well support with advice on wellness and healthy living. Live Well – NHS (www.NHS.uk).

The NHS also has extensive information on mental health on the NHS website Mental health – NHS (www.nhs.uk) and mindfulness Mindfulness – NHS (www.nhs.uk)

The NHS has a dedicated ‘every mind matters’ website with information on how to take care of your mental health https://www.nhs.uk/every-mind-matters/

The NHS borders website also signposts wellbeing support.

www.nhsborders.scot.nhs.uk/patients-and-visitors/our-services/children-young-peoples-services-directory/health-improvement-team/mental-health-and-wellbeing/

NHS links for support in the LGBTQ+ community Help for mental health problems if you’re LGBTQ – NHS (www.NHS.uk)  and NHS England » LGBT health

 

Additional support for ethnic minority communities

The Black, African and Asian Therapy Network has a directory of therapists of Black, African, Asian or Caribbean heritage.

Black Minds Matter connects people to free mental health support provided by Black therapists.

Taraki – Mental Health in Punjabi Communities provides mental health support and education for Punjabi communities.

The Health of Irish People in Britain – Race Equality Foundation provides information and signposting for Irish people living in the UK. This demographic of the population has been found to have higher rates of hospital admission for mental health issues, and are at greater risk of alcohol issues, depression, and risk of suicide than some other ethnic groups²³.

 

Additional resources

Disability Resource Centre is a charity that supports people to manage their long-term health conditions.

Groundswell Homelessness Charity UK provides support to those experiencing homelessness.

 

References

1. World Health Organization. Promoting Mental Health: Concepts, Emerging Evidence, Practice: Summary Report. Geneva, World Health Organization. Retrieved.; 2004. Accessed June 13, 2022. http://www.who.int/mental_health/evidence/en/promoting_mhh.pdf
2. Johnson C. Health and Wellness. J Manipulative Physiol Ther. 2015;34(6):407. doi:10.1016/j.jmpt.2011.06.004
3. Swarbrick M. A wellness approach. Psychiatr Rehabil J. 2006;29(4):311-314. doi:10.2975/29.2006.311.314
4. About us | Time To Change. Published 2021. Accessed June 13, 2022. https://www.time-to-change.org.uk/about-us
5. Home – Mind. Accessed June 13, 2022. https://www.mind.org.uk/
6. We are Rethink Mental Illness. Published 2022. Accessed June 13, 2022. https://www.rethink.org/
7. McManus S, Bebbington P, Jenkins R, Brugha T. Adult Psychiatric Morbidity in England – 2007, Results of a household survey – NHS Digital. Published 2014. Accessed June 13, 2022. https://digital.nhs.uk/data-and-information/publications/statistical/adult-psychiatric-morbidity-survey/adult-psychiatric-morbidity-in-england-2007-results-of-a-household-survey
8. Beck CS, Aubuchon SM, McKenna TP, Ruhl S, Simmons N. Blurring Personal Health and Public Priorities: An Analysis of Celebrity Health Narratives in the Public Sphere. Health Commun. 2014;29(3):244-256. doi:10.1080/10410236.2012.741668
9. Calhoun AJ, Gold JA. “I Feel Like I Know Them”: the Positive Effect of Celebrity Self-disclosure of Mental Illness. Acad Psychiatry. 2020;44(2):237-241. doi:10.1007/s40596-020-01200-5
10. Foulkes L. Losing Our Minds: What Mental Illness Really Is – and What It Isn’t. Vintage Digital; 2022.
11. Centre for Mental Health. Children and Young People’s Mental Health: The Facts.; 2018. Accessed June 24, 2022. http://www.wsipp.wa.gov/BenefitCost/ProgramPdf/66/Group-cognitive-behavioral-therapy-CBT-
12. The World Health Organisation. Determinants of health. doi:10.1787/g25b6ac16-en
13. Centre for Mental Health. Tackling Mental Health Disparities Ten Evidence-Based Actions That Government Could Take in the Forthcoming White Paper.; 2022.
14. Public Health England. Health Matters: Reducing health inequalities in mental illness – UK Health Security Agency. Published 2018. Accessed June 13, 2022. https://www.gov.uk/government/publications/health-matters-reducing-health-inequalities-in-mental-illness/health-matters-reducing-health-inequalities-in-mental-illness
15. Baams L, Grossman AH, Russell ST. Minority stress and mechanisms of risk for depression and suicidal ideation among lesbian, gay, and bisexual youth. Dev Psychol. 2015;51(5):688-696. doi:10.1037/a0038994
16. Gender, Sexuality & Mental Health – stem4. Accessed August 4, 2022. https://stem4.org.uk/gender-sexuality-mental-health/?gclid=EAIaIQobChMI9MjD4ZCC-QIVjt_tCh35GgXQEAAYASAAEgJEofD_BwE
17. Bradlow J. Bartram F. Guasp A. Jadva V. School Report: The Experiences of Lesbian, Gay, Bi and Trans Young People in Britain’s Schools in 2017. Vol 413.; 2017. doi:10.4324/9781003170808-3
18. Bignall T, Jeraj S, Helsby E, Butt J. Racial disparities in mental health: Literature and evidence review. Race Equal Found Heal Well-being Alliance. Published online 2019:60. Accessed June 13, 2022. https://raceequalityfoundation.org.uk/wp-content/uploads/2020/03/mental-health-report-v5-2.pdf
19. Morrison Gutman L, Joshi H, Parsonage M, Schoon I, Eisenstadt Professor Barbara Maughan Professor Lord Richard Layard N. Mental Health Findings from the Millennium Cohort Study Children of the New Century. Centre for Mental Health.; 2015.
20. HM Government. No Health Without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of All Ages.; 2012. Accessed June 13, 2022. www.dh.gov.uk/mentalhealthstrategy
21. Mermaids. Resources for young people, carers and parents. Accessed August 4, 2022. https://mermaidsuk.org.uk/young-people/resources-for-young-people/
22. Department for Health and Social Care. Mental health and wellbeing plan: discussion paper. Published 2022. Accessed June 28, 2022. https://www.gov.uk/government/consultations/mental-health-and-wellbeing-plan-discussion-paper-and-call-for-evidence/mental-health-and-wellbeing-plan-discussion-paper
23. Delaney L, Fernihough A, Smith JP. Exporting Poor Health: The Irish in England. Demography. 2013;50(6):2013-2035. doi:10.1007/s13524-013-0235-z