Providing effective treatment and support for mental distress is a stated government aim. Within low-income communities, use of antidepressant medication is relatively high, but current strategies tend to frame mental distress as an individual psychological problem, rather than addressing the factors that are often the root causes of suffering.
This research is examining how moralising narratives relating to individual responsibility and welfare entitlements influence the medicalisation of mental distress caused by material deprivation and social disadvantage. In so doing, the research will inform a stated aim of the British Government’s No Health Without Mental Health strategy to effectively reduce health inequalities amongst vulnerable groups (HM Government 2011), and respond to recent calls to prioritise research examining the social determinants of mental distress (Mental Health Taskforce 2015).
Working in two low-income communities, the interdisciplinary research team are using a range of qualitative methods to gain in-depth and applied understanding of the role moral narratives play in:
- influencing individuals’ decisions to seek and accept medical support for mental distress;
- influencing healthcare consultation and prescribing practice.
This will provide an informed and nuanced contextualisation of data often missing from mental health research, and from low-income groups in particular.
Against a background of health-service cuts and on-going welfare reform, this interdisciplinary research project examines:
- why and how people’s ability to cope with poverty-related issues e.g. social isolation, unemployment, poor housing, has become increasingly pathologised;
- how high levels of antidepressant prescribing and use are impacting on people’s health and wellbeing in low-income communities in South West England;
- good healthcare practice and the potential for alternative responses to mental distress in potentially vulnerable populations.
This 30 month programme of research consists of two linked stages.
Firstly, 96 people from two targeted low-income areas will participate in focus groups to explore how moral narratives are defined and used/resisted in people’s daily lives.
Then, secondary analysis of 60 video-recorded consultations will enable insight into the contexts in which GPs and low-income patients discuss mental distress. Through in-depth analysis of 30 consultations we will identify how GP-patient interaction influences decision-making to prescribe/accept or withhold/reject treatment.
Further insights will be gained through interviews with 10 GPs in the study sites and repeat interviews with 40 people from low-income communities who have attended a GP consultation for mental distress.
The research programme will inform policy and practice regarding the development of effective, meaningful and non-stigmatising responses to mental distress in low-income communities.
Identification of GP practice (relating to mental distress) that enhances patient wellbeing will be developed into guidelines on good practice for health professionals working in low-income communities. These will be refined at a Regional Practitioner workshop, where a dissemination strategy that maximizes their utility for the health sector will be agreed. Participation in the workshop by local authorities charged with health provision will ensure findings feed in to local health plans e.g. Devon Joint Health and Wellbeing Strategy.
NIHR ARC BITEs (Brokering Innovation Through Evidence) are short summaries, which aim to break ARC research into accessible, bite-sized pieces. These summaries highlight the main findings and impact of our research on practice, providing links and references for more in-depth information and further reading.
Read the DE-STRESS BITE Poverty-related distress is on the rise, but is medical intervention the answer?
- C2 – Connecting Communities learning and delivery programme, which seeks to promote healthful behaviours and reduce inequalities in disadvantaged neighbourhoods.
- PARTNERS2: an NIHR-funded programme to help primary care and community based mental health services work more closely together to support people with schizophrenia and bipolar disorder.
- The Engager collaboration, focusing on mental health care for prisoners.
- The University of Bristol’s One in a Million study.
Hansford L, Thomas F, Wyatt K.The impact of the Work Capability Assessment on mental health: claimants’ lived experiences and GP perspectives in low-income communities. Journal of Poverty and Social Justice. 2019; 27(3):351-368
Kuyken W, Hayes R, Barrett B, Byng R, Dalgleish T, Kessler D, Lewis G, Watkins E, Brejcha C, Cardy J, Causley A, Cowderoy S, Evans A, Gradinger F, Kaur S, Lanham P, Morant N, Richards J, Shahb P, Sutton H, Vicary R, Weaver A, Wilks J, Williams M, Taylor RS, Byford S. Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. Lancet 2015; 386 (9988): 63–73
Thomas, F., Hansford, L., Ford, J., Wyatt, K., McCabe, R., and Byng, R. (2018) Moral narratives and mental health: rethinking understandings of distress and healthcare support in contexts of austerity and welfare reform, Palgrave Communications, 4:39
Thomas, F. and Hansford, L. (in press) Supporting mental health in low-income communities: implications for justice and equity, in Aggleton, P., Broom, A. and Moss, J. (eds) Practical Justice: Principles, Practice and Social Change, London: Routledge
Thomas, F., Hansford, L., Wyatt, K., et al. (in press) An engaged approach to exploring issues around poverty and mental health: a reflective evaluation of the research process from researchers and community partners involved in the DeStress study, Health Expectations
Ford, J., Thomas, F. McCabe, R. and Byng, R. (in press) How is the Patient Health Questionnaire (PHQ-9) used in practice? Qualitative Health Research
Thomas, F., Hansford, L., and Wyatt, K. (2020) The violence of narrative: embodying responsibility for poverty-related distress, Sociology of Health and Illness, https://doi.org/10.1111/1467-9566.13084
Thomas, F., Hansford, L., Ford, J., Wyatt, K., McCabe, R., Byng, R. (2019) How accessible and acceptable are current GP referral mechanisms for IAPT for low-income patients? Lay and primary care perspectives, Journal of Mental Health, https://doi.org/10.1080/09638237.2019.1677876
Ford, J., Thomas, F., McCabe, R. and Byng, R. (2019) How do patients respond to GP recommendations for mental health treatment? British Journal of General Practice Open, DOI: https://doi.org/10.3399/bjgpopen19X101670
Hansford, L., Thomas, F. and Wyatt, K. (2019) The impact of the Work Capability Assessment on mental health: claimants’ lived experience and GP perspectives in low-income communities, Journal of Poverty and Social Justice
Thomas, F. and Hansford, L. (2019) Supporting mental health in low-income communities: implications for justice and equity, in Aggleton, P., Broom, A. and Moss, J. (eds) Practical Justice: Principles, Practice and Social Change, London: Routledge
Thomas, F., Hansford, L., Ford, J., Wyatt, K., McCabe, R. and Byng, R. (2018) Moral narratives and mental health: rethinking understandings of distress and healthcare support in contexts of austerity and welfare reform, Palgrave Communications, 4: 39
For more videos of the team discussing the project, please visit the DE – STRESS project page.
Links and downloads
- Professor Rose McCabe
- Lorraine Hansford
- Susanne Hughes
- Dr Joseph Ford