Welfare and well-being: towards mental health-promoting welfare systems

Summary

By protecting vulnerable people from poverty and debt, welfare systems can be powerful tools for promoting mental health. However, the details of how welfare systems are implemented determine whether they also cause harm. Here, we review evidence and principles that might guide the development of mental health-promoting welfare systems.

Debt and poverty are toxic to mental health. People in debt are more likely to have a mental illness and to have thought about taking their own life. Causation probably flows both ways: the stress caused by debt and poverty causes mental illness, while mentally ill people face discrimination at work and are more likely to be in poorly paying jobs.

By providing a financial safety net, welfare systems can have a powerful protective effect on population mental health. For example, suicide rates in men in the USA fall sharply when individuals reach the eligibility age for social security retirement benefits, even though only a small proportion of men retire at this age. However, the way that welfare systems are run can harm the mental health of those that rely on them. In England, the introduction of the Work Capability Assessment, a checklist used to assess claimants' eligibility for disability benefits, was associated with increases of 6 suicide attempts, 2700 people reporting mental health problems and 7000 prescriptions of antidepressants for every 10 000 people who went through the assessment.¹ And in his statement on his visit to the UK, Philip Alston, the United Nations Special Rapporteur on Extreme Poverty and Human Rights said that ‘an increasing body of research makes clear that there are far too many instances in which Universal Credit is being implemented in ways that negatively impact many claimants' mental health, finances, and work prospects’ (supplementary references are available online at https://doi.org/10.1192/bjp.2019.242).

What principles should guide a welfare system that promotes mental health?

First, do no harm

As a minimum, a mental health-promoting welfare system would avoid causing further harm to the people who depend on it. Eligibility assessments are a source of considerable stress and anxiety. This is likely to have a greater impact on those already suffering mental illness, making such assessments a form of indirect discrimination. A survey by the UK charity the Money and Mental Health Policy Institute of 455 people with mental health problems who had claimed some form of welfare payment found that 93% said that their mental health had suffered because of the assessment process.² As already noted, the introduction of eligibility checks in the form of the Work Capability Assessment was associated with increases in suicides, rates of mental illness and antidepressant prescriptions. As well as the cost in human suffering, the likely effect of such conditional welfare regimes is to increase demand for mental healthcare. In countries where healthcare is funded from taxation or national insurance contributions, it is likely that savings in welfare payments made by imposing strict conditions and eligibility assessments are eroded by increased costs in the healthcare system.

It should go without saying that a mental health-promoting welfare system would not discriminate against people with mental illness. However, recent experience in the UK suggests that this is not always the case. A recent study of claimants for illness-related welfare payments in the UK found that people with a mental illness were more likely than people with a physical illness to have their payments withdrawn when the Disability Living Allowance (DLA) was replaced by the Personal Independence Payment (PIP).³

As well as these examples of indirect discrimination, direct (i.e. intentional) discrimination can be seen in some welfare policy decisions. For example, in 2017, the UK government announced that mental illness would no longer be considered in eligibility for one of the two criteria by which claims for DLA are judged. The High Court ruled that this change was ‘blatantly discriminatory’.

Simplify processes and introduce easements

In addition to facing discrimination, there is evidence that people with mental illnesses find navigating a complex benefits system particularly difficult. Problems with memory, attention and motivation are common symptoms of mental illness. In a survey by the Money and Mental Health Policy Institute, nearly all of the people with mental illnesses who had claimed welfare payments found the application forms difficult and four-fifths struggled to find the right information to send in support of their claim.² Simplifying processes and introducing easements for those in mental health crisis would help to minimise the extra burden caused by these processes.

Train assessors in mental illness

The use of assessors with professional training in mental illness would also help to make sure that disabilities caused by mental illness are assessed properly. However, this may depend on an adequate supply of trained assessors. In its written evidence to the Parliamentary Work and Pensions Committee, ATOS (one of the companies conducting assessments on behalf of the UK government) said that 17% of its assessors were mental health specialists. UK government data suggest that psychiatric conditions were the ‘main disability’ in 35% of PIP claims (data are not available broken down by each assessment provider, so we do not know whether ATOS's case-load reflects the national picture, although this seems likely). The companies providing assessments maintain that the assessor's clinical background should not prevent them from assessing the full range of possible conditions and that further evidence can be supplied by the claimant's clinicians. However, a number of mental health charities provided evidence to the same enquiry suggesting that in some cases a low level of awareness of mental illness among assessors had resulted in poor assessments and distress to claimants.

But beyond avoiding causing further harm, how can benefits systems realise their potential for improving population mental health?

Introduce an unconditional component to welfare payments

International evidence suggests that unconditional payments can benefit mental health. The introduction of a universal basic income pilot scheme in Canada was associated with improvements in mental health.⁴ However, unconditional income supplements need not be on the scale of a universal basic income to benefit claimants' mental health. A US study found that, when Native American families started receiving an unconditional income supplement of between $500 and $9000 dollars a year, rates of psychiatric illness and substance misuse among children in these families fell relative to non-Native American children experiencing similar levels of deprivation who did not receive the income supplement.⁵ Similarly, a 2016 Swedish study found that, among people with severe mental illness, a supplement of only 500 krona (equivalent to US$73) a month was associated with a decrease in perceived symptoms and an increase in quality of life. Studies of unconditional payments typically find little reduction in hours worked. Taken together, this evidence suggests that introducing an unconditional component of the welfare system is likely to improve claimants' mental health (and consequently their ability to work) without reducing their desire to work.

Adopt a ‘mental health in all policies’ approach

Beyond these specific policies, governments may wish to adopt a ‘mental health in all policies’ approach to welfare policy. Such an approach would assess the likely impact of changes to welfare policies on mental health and would provide a mechanism across government for maximising population mental health. The Mental Well-being Impact Assessment is one framework that can be used to understand the likely impacts of policy changes on mental health, drawing on both quantitative data and qualitative evidence from those affected by the policies. This approach is an example of therapeutic jurisprudence – the idea that the psychological effects of laws and the way that they are implemented should be considered and valued alongside the laws' stated aims.

The recent ‘Breathing Space' campaign in the UK to ease repayments for people with mental illness in debt is an example of how policies can protect rather than harm people with mental illness. The campaign’s success likely reflects a recognition that, as well as increasing distress, punitive measures targeted at people with mental illness are likely to make it harder for them to repay their debts. Similarly, benefits policies that cause or worsen mental illnesses are unlikely to help people to move into work. Mentally ill people frequently report being denied jobs or being forced to resign because they had received psychiatric treatment, and employers were found to be less likely to recommend hiring someone with a mental illness compared with a physical illness. A benefits system that makes people sicker is unlikely to achieve its aim of helping them to gain employment.

Governments are beginning to realise the value of a mentally healthy population. This has been most visible in commitments to ‘parity of esteem’ between mental and physical health services, for example in the UK's 2011 mental health strategy ‘No Health Without Mental Health’. However, as with other areas of health, policies outside of the healthcare system may have more influence over the overall burden of mental illness across a population. Given the close links between poverty, debt and mental illness, the welfare system should be a focus of attention for policymakers who wish to improve population mental health.