Society and mental health
There is abundant evidence of a social gradient in mental health, ie that levels of distress increase in line with levels of inequality, disadvantage, and adversity. Risk is highest, for example, in countries with high levels of inequality, in regions and neighbourhoods with high levels of poverty, among those who grow up in low-income households, among those exposed to discrimination, abuse, and violence. Our feelings, thoughts, moods, perceptions – that is, our emotional worlds – are intimately interwoven with our daily lives, with our experiences, relationships, and aspirations, and with the places we live, work, and socialise. Conditions and experiences of adversity – the daily grind of poverty and uncertainty, the unremitting dread of chronic exposure to violence and threat, the sudden shock and lasting effects of trauma – all cause distress and leave traces that, over time, can crystalise into persistent feelings of sadness, anxiety, suspiciousness, ie into what we currently recognise as mental health problems. Of course, individuals vary in how they respond to these challenges and in access to social resources (ie, in families, social networks, and wider communities) that can mitigate the effects of the most challenging circumstances and experiences. However, the persistent social patterning of mental distress attests to the pervasive negative impacts of adverse social conditions and experiences.
Social change, COVID-19, and mental health
The COVID-19 pandemic has starkly exposed and further exacerbated social and economic inequalities. Those most affected are individuals and communities with the fewest resources to tolerate and mitigate the consequences of social restrictions to contain the spread of COVID-19, including those in insecure jobs, on low incomes, and in insecure accommodation; those in marginalised communities, including minority ethnic communities, migrants, and refugees; those in violent and abusive households; and those with existing mental health problems. And it is among those most directly affected, particularly where impacts co-occur and compound historic and structural disadvantages, that there is so far the clearest evidence of an increase in mental distress. For example, a recent analysis of data from the UK COVID-19 Mental Health and Wellbeing study, that has followed around 3,000 adults at 3 time points during the pandemic, found that mental health outcomes were worst for the most socially disadvantaged, those with pre-existing mental health problems, women, and young people (aged 18 –29 years). At present, there is limited data on impacts on mental health among minority ethnic populations. This is urgently needed, given these populations are more exposed to the impacts of COVID-19 due to longstanding inequalities and structural racism. It is at these intersections – of racism and poverty – that the impacts of the pandemic on mental distress are likely to be most acute. Finally, there is particular concern about impacts on the mental health of children and adolescents, given the disruptions to education, exams, and peer relationships; the evidence to date suggests mental distress has increased most among children and adolescents from disadvantaged backgrounds.
Mental health, distress, and social suffering
To feel anxious and sad, to have trouble sleeping, to be afraid for the future – all are perfectly understandable responses to such a profound rupture in our social worlds. However, framing this distress in terms of mental health – as we have done so far, following the currently dominant narrative – is potentially problematic. This approach, at the very least implicitly, locates distress and mental health problems in individuals and, in effect, severs experiences like sadness and anxiety from the social conditions in which they arise, making them problems of psychology or even of biology. It is this narrative that underpins the predominant responses to date, which centre around calls for an expansion of individual interventions, of mental health services, and, in settings such as schools and workplaces, of myriad therapies such as mental health first aid, various forms of supportive counselling, and mindfulness. This is taken to its extreme in Amazon’s recently reported mindfulness pod, a portable cubicle with space for a single worker to step out of the workplace, isolate themselves, and practice being in the moment as a means to reduce stress. Better, it seems, that workers clear their minds than reflect too much on the excessively long working hours, lack of autonomy, pitiable wages, and the Dickensian working conditions they are forced to endure to further enrich the billionaire, Jeff Bezos. By stripping suffering and distress from their social origins in this way we add insult to injury. We might, then, more usefully think about the distress that arises primarily as a consequence of poverty, precarity, violence, and trauma – including much of the distress stemming from the pandemic, social restrictions, and economic impacts – as a form of social suffering. That is, suffering and distress that is inseparable from the conditions and sets of experiences in which it arises and through which it is sustained. Viewed from this perspective, levels of mental distress in populations become a barometer of the health of society. This draws our attention away from the individual and individual interventions to the impacts of socially structured disadvantage – amplified by the pandemic – and the need to address historic and structural inequalities and to strengthen and harness the social and economic resources that individuals draw from to cope with and navigate challenging and changing social worlds. If, as Nancy Schepper-Hughes argues, mental distress is the transformation of social ills into private troubles, our response should be to address the social ills.
Reimagining society
As we emerge from the pandemic – as we step through Arundhati Roy’s metaphorical portal – and contemplate how to build a fairer, healthier society, that enables all to flourish, we need to consider and address the structural inequalities that underpin the injustices, racism, violence, and disadvantages that are the fundamental drivers of mental distress. At a broad level, this implies the need for a set of principles (eg, equity, justice, community) and goals (eg, reducing inequalities, increasing security in employment, income, and housing, providing robust social and health services for those most in need) that can guide specific public and social policies in a post-pandemic world. To illustrate this, here we highlight four policies that encompass these principles and goals, that focus on key areas – income security, education, communities, and social and health services – and that would signify a fundamental shift toward building a society that prioritises and promotes health and well-being and that enables individuals, families, and communities to thrive. First, a universal basic income scheme to mitigate the uncertainty and insecurity of rapidly changing economic conditions. Second, a package of measures to support young people in disadvantaged households, including extended provision of free school meals, breakfast clubs, free internet access, and resources for digital education. Third, rapid investment to support local services (eg, libraries), mutual aid and community groups, and the voluntary sector with an emphasis on women's refuges, homeless charities, youth groups, and community-based supports for black and minority ethnic populations. Finally, re-investment in local public health and community mental health teams,
in particular child and adolescent mental health teams, to support local strategies to promote mental health and to provide professional support for those most in need. These are not isolated proposals. They are indicative examples that should form part of a multi-sector, systems approach. It is difficult to contemplate, but further crises (for eg, linked to climate change) are sure to follow the current pandemic. We were ill-equipped to deal with COVID-19 and it was those living in the most disadvantaged, marginalised, and vulnerable circumstances who were most exposed, who suffered the most, in large part because of long-term trends that have prioritised efficiency and profit and that have eroded – in many cases, dismantled – public and health services. As we emerge from the current crisis, there is a will for change, a will to reimagine a better, fairer, healthier society – as Roy’s quote at the head of this essay attests. To achieve this, to promote well-being and enable people to thrive, we need to broaden and deepen our gaze to addressthe historic and structural inequalities that underpin so much personal distress.