Introduction
The city of Glasgow is the most populated in Scotland and is considered a cultural and creative hub due its world-class museums and lively music scene. However, you don’t need to look too far into this vibrant city to discover the disparities that exist within its boundaries. Between the prosperous West end to the adverse East end, or from one side of the Clyde tunnel to the other, it is clear that socio-economic inequalities prevail even within an arm’s reach of one another. These socio-economic disparities determine health inequalities that exist in Glasgow, one specific example that emphasises this is that the difference of life expectancy in Calton (a deprived area) compared to Lenzie (an affluent area) is a massive 28 years (Vacarella et al., 2019). This shows that low income, marginalised communities in Glasgow do not receive adequate health support, at least not up to the standard of more affluent communities. This report is going to look specifically at mental health disparities within Glasgow and resources that are available to communities that have a lower socio-economic status, as well as the stigma those with mental health illnesses face.
I would also like to outline my positionality before moving on to the main body of this community briefing. I have lived in Glasgow for the majority of my life, therefore I have grown up in this same system that appears to be failing many people. However I had been oblivious to this gap in mental health services as I have never experienced any mental health conditions myself, and only as I have become more aware of these issues have I started to pay more attention to them. I only started to become more conscious of this issue when the covid-19 pandemic hit in 2020 and I became a support worker at a mental health care home for people that require more support. This really opened my eyes into the challenges and stigmas that those with mental health needs face. Thus, although I have not experienced any of these challenges first hand, I have observed them. It should also be noted that the purpose of this report is to provide a greater insight into the issues addressed for anyone who might be interested, from those who are affected by these inequalities to policy makers who want to make a positive change. The report will conclude by offering two recommendations that I believe could help to improve the Scottish health care system in supporting those with mental health illnesses in Glasgow.
Current Situation
Every year, one third of all people in Scotland are affected by mental illness (Gov.scot, 2023). The Scottish Government’s mental health and wellbeing strategy acknowledges that some societal groups have poorer mental health than others due to the unequal distribution of wealth (Mental health and wellbeing strategy 2023), hence these inequalities are not something that is overlooked. However, this strategy focuses on Scotland’s nation as a whole and fails to account for the differences between Scottish cities. There is a clear differentiation between the mean mental health scores in Glasgow compared to other Scottish cities and especially to Scotland as a whole (Gov.scot, 2023). This emphasises the fact that there needs to be greater attention placed on Glasgow, as clearly the strategies that are working for the rest of the country aren’t working for Glasgow and perhaps a more refined and individual approach is needed.
Researchers that have studied the inequalities faced in Glasgow compared to the rest of Scotland and the UK have come up with a theory called the ‘Glasgow Effect’. The term ‘Glasgow Effect’ first surfaced when people started researching why cities in the UK with similar deprivation levels were experiencing different health outcomes (Walsh, 2010). Glasgow, Liverpool and Manchester all experience virtually identical levels of deprivation, educational attainment and single parent households, however ill health in Glasgow (measured by premature mortality rates) was overall found to be over 30% higher in Glasgow than either Liverpool and Manchester (Walsh, 2010). This has not always been the case however. One hundred years ago, health outcomes in these three cities were much more alike. It has only been in the past 40 years that the gap in health outcomes has widened between Glasgow and the other English cities (Walsh, 2010). This shows that there have been positive developments put in place in Liverpool and Manchester that are improving health outcomes at a faster pace than in Glasgow. Many assume that the Glasgow Effect is only applied to physical health, however it has previously been proven to apply for mental health as well (Gray, 2007). A meaningful figure found in the study carried out by David Walsh in 2010 is that death rates by suicide in Glasgow are 70% higher than the rates in Liverpool and Manchester, highlighting that the consequences of ill mental health are much greater in Glasgow. This shows that although deprivation is a key component of health outcomes, there are many more components that must be considered, otherwise the health outcomes in Glasgow wouldn’t be so dissimilar to two other almost identical UK cities. One of these components that perhaps should be considered more is the use of alcohol and drugs in Glasgow, because although the levels of alcohol consumption, smoking and estimated drug use in these three cities are much the same, deaths caused by drugs and alcohol in Glasgow were more than double that of Manchester and Liverpool (Walsh, 2010).
The relationship between drug use, alcohol consumption and mental health is a complicated one that has been researched extensively, with some researchers suggesting that alcohol and drug use is the driving factor of mental health illnesses, while some researchers argue for the reversed order, that ill mental health is the driving factor of alcohol and drug use (Bell & Britton, 2014). There are multiple common risk factors that apply to both the use of drugs and alcohol and mental health illness, such as genetic vulnerabilities, environmental influences, stress and childhood experiences and trauma (NIDA, 2021). Therefore, once these risk factors that apply to both substance abuse and mental health are considered, the comorbidity of the two should not come as a surprise. Alcohol consumption is one of the primary causal factors of major depression and anxiety (Fergusson et al., 2009), and drug use has more of a direct association with mental illnesses such as bipolar disorder and schizophrenia (NIDA, 2021). People suffering from ill mental health may begin using substances such as alcohol and drugs in an attempt to self-medicate, however once this fails to be the case, they are likely to continue (ab)using these substances in an effort to relieve the symptoms of their mental illnesses (Mitchell et al., 2007). All this research supports the opinion that a vicious and dynamic cycle is the best way to summarise the relationship between drug use, alcohol consumption and mental health, for example alcohol consumption leads to deteriorated mental health, which in turn leads to increased alcohol consumption and drug use, which only leads to further deterioration of one’s mental health (Bell & Britton, 2014). In Glasgow’s case, due to the high levels of alcohol consumption and drug use, it is key that health care systems consider this direct relationship in order to provide simultaneous treatment for mental illnesses and substance misuse disorders (Jane-Llopis & Matytsina, 2006). In terms of why there are worsened outcomes in Glasgow, despite there being similar levels of alcohol and drug consumption as Manchester and Liverpool, this is perhaps down to Glaswegians using substances at a more excessive rate and more extreme levels which is not recognised by routine health surveys (Walsh 2010).
Mental Health Services and Support
Before proceeding to the recommendations section of this report, I think it is necessary to first discuss the services and support that is available in Glasgow. The NHS Greater Glasgow and Clyde (NHSGGC) has a website called Heads Up which provides advice on how to access the most suitable support for your needs. This website recommends that the first step in getting help for mental health is to make an appointment to talk to a GP. Although it fails to mention the fact that wait times to get an appointment at a GP can be quite lengthy at times, due to staffing shortages or general unorganisation (Carey & Spratt, 2009) which could be off putting to someone seeking help for their mental health, it does highlight the benefit that GPs will have good knowledge of mental health services in the local area. The Heads Up website also details two free helpline services for anyone struggling with their mental health to get professional and confidential support. This is very beneficial information for the NHSGGC to provide, as the helplines are available to anyone who has access to a phone, to receive a safe space to talk to a professional without fear of discrimination due to their socio-economic status.
There are multiple reasons why someone might choose private healthcare over the NHS to treat their mental health, some of these being the long wait times to receive an appointment, not being able to get an appointment outwith working hours, GPs not being able to provide the treatment or support one needs, or needing more intensive and long term support (Mind, 2017). In terms of specialist treatment for more severe mental health illnesses, turning to private healthcare is a much more expensive option. The cost of a one hour counselling session through a private therapist can range anywhere from £40 – £100 (NHS inform, 2023), and the cost of a private mental health live-in care home in Glasgow can be anywhere around £500 per night (Rehab Guide, 2023). Of course, the care these private institutions can provide will be exceptional and they will also be able to offer a wider range treatments depending on the service users individual needs, however the cost itself makes clear that this treatment option is inaccessible for anyone on a lower income salary, or who is unemployed, which is very likely for someone who struggles with their mental health due to the stigma they face when it comes to employment. This, once again, highlights the inequalities that deprived communities face in terms of receiving mental health care. It should never be the case that someone doesn’t receive adequate health care based on how much money they have to pay for it.
Recommendations
1. Making higher quality green spaces more widely available
The first action that I would recommend taking in the step towards reducing mental health inequalities for low income communities in Glasgow is creating green spaces that are not only more widely accessible, but also of better quality as a means to create more positive mental health outcomes. The term green spaces is used in this recommendation to define gardens, parks, outdoor sports facilities and open spaces that are available to the public, free of charge and for the exclusive use of pedestrians and cyclists for their leisure. In recent years, there has been a vast number of studies undertaken that exhibit the impact that having access to green spaces in an urban area can have on one’s mental (and physical) health. Some of the wider benefits of having access to green space are outlined by Callaghan et al, (2020), and include a greater amount of physical activity, better physical health, and a greater sense of community cohesion. In terms of mental health, benefits of having access to green spaces while living in a busy urban environment include reduced cortisol levels (the stress hormone), an ‘escape’ from the mental fatigue of the busy setting of an urban area, and a general improvement of psychological health (Callaghan et al., 2020). The United Nations have committed to providing “universal access to safe, inclusive and accessible green and public spaces” especially for minority groups and marginalised communities as part of the sustainable development goals (World Health organisation, 2016), which shows that this is an initiative that can be beneficial globally if implemented correctly.
A study that has been carried out on the relationship between greenspace and levels of deprivation in Glasgow has found that there is a strong correlation between the two (Baka & Mabon, 2022). However, this study was important in highlighting that there isn’t necessarily a lack of green spaces in more deprived areas for lower income communities, rather a stark difference in the quality of green spaces available for them. It was found that green spaces available in areas where there is a greater level of low-income communities were significantly less well-kept, less safe and had less perceived greenness (Baka & Mabon, 2022). This deduces that mental health inequalities between higher and lower income communities can be attributed to the unequal distribution of quality green space between affluent and deprived areas in Glasgow.
Enhancing green spaces and making them more widely available would be a preventative measure as it is reducing wider mental health needs, which could be regarded as more effective than creating solutions as a consequence of ill mental health (World Health Organisation, 2016). Therefore, I would recommend to the city of Glasgow council to consider a wider range of green spaces that are accessible and available to all communities. I would recommend that in order to do this, engagement with local stakeholders, environmental organisations and health providers is key to producing the most successful outcomes, as well as the local communities as they will be the main users of the green spaces.
Anti-stigma Projects and Local Support
The second recommendation that I would like to offer is in the hopes of reducing the stigma surrounding mental health illnesses and in turn encouraging people to not be intimidated about seeking professional help. The examples of anti-stigma projects and support groups that this report will move on to discuss aim to tackle public stigma, which is the negative and prejudiced attitudes of others; and self stigma, which is the internalised negative attitudes and humiliation that people with ill mental health have about themselves and their own condition (American psychiatric association). Those who face stigma due to their mental health face social exclusion in their daily lives, when it comes to employment, education and relationships (Quinn & Knifton, 2005).
Students are amongst one of the groups that experience the highest levels of self stigma towards their mental health (Quinn et al., 2009). Studies have found that there is still reluctance from students to open up about their struggles with mental health while studying at university or any higher education institution (Quinn et al., 2009). This is due to both internal and external factors, stigma being a main component of both. In a study funded by the Scottish Government’s National Programme for Mental Health, Quinn et al (2009) found that the first main barrier that students are faced with is accepting themselves that they need help, and the second barrier is knowing how to to get help, and what this will even involve. It was found that many students were reluctant to seek help due to the fear that it could affect their future job opportunities (Fuller et al., 2004), which is definitely not the case due to disclosure laws. Therefore, I believe that implementing anti-stigma projects in higher education institutions in Glasgow is one effective way of reducing the stigma surrounding mental health illnesses from an early stage in life. This could involve running campaigns and raising awareness of the true facts about mental health and debunking stereotypes. Anti-stigma projects in higher education institutions should also make clear the student services that are available to students, so that anyone who wants to seek help knows exactly where to go and what options are available to them, whether this is to a counsellor, a peer group or a professor.
It must also be acknowledged that socio-economic status is the leading factor of unequal access to higher education in Scotland (The Scottish Government, 2020), therefore to only implement anti-stigma projects in higher education institutions could widen the gap in mental health inequalities. Therefore, it would also be most favourable to implement anti-stigma projects within local communities with an emphasis on communities in deprived areas. An organisation in Maryland, US started up anti-stigma workshops in order for anyone to come along and learn about harmful stigmatising behaviours, attitudes and practices, and create a safe space for participants who do suffer with their mental health (On our own of Maryland, 2022). These take place in a wide variety of communities and multiple different stakeholders have become involved from within the healthcare sector, and participants have reported that benefits of these workshops include decreased stigma, improved attitudes and a greater sense of community (On our own of Maryland, 2022). For this reason, I believe that implementing similar workshops in lower income communities in Glasgow would help to proactively reduce social exclusion towards people with mental health illnesses. Having a wide range of workshops that appeal to different interests will also encourage more people to attend them, for example some people may be more likely to attend a creative, arts based workshop, and some people may prefer workshops that involve physical activity such as football clubs or running groups. In order for these types of projects to work, they must have the support of local organisations, policy makers, NGOs and healthcare providers.
An additional community led initiative, similar to these workshops, that I would encourage communities to get involved in, is the implementation of local support groups. Support groups allow for anyone suffering with their mental health to meet like-minded people and encourage personal growth. Support groups are especially useful for people who suffer from mental illnesses such as depression that can make someone feel isolated from their peers. An organisation in Kenya called the Users and Survivors of psychiatry in Kenya (USP-K) establishes support groups in Nairobi for people with ill mental health to support its members in integrating themselves into their communities (WHO, 2021). USP-K support groups have seeked to reduce social exclusion by educating participants on their human rights and the ways they can apply them to their daily lives. It has been reported that members of the USP-K support groups have reclaimed their voices and become less ashamed of asking for the help that they are entitled to (WHO, 2021). This example from Nairobi highlights how successful support groups can be for people seeking advice for their mental health, and how beneficial it can be to meet people going through or that have previously gone through similar experiences.
Both workshops and support groups are also good opportunities to socialise with people in a positive way, that doesn’t involve harmful substances such as alcohol and drugs that deteriorate mental health. I believe that the implementation of local workshops and support groups in low income communities in Glasgow would not only reduce mental health stigma, but provide an outlet for people to express their emotions in different ways, whether this is through creative projects, physical activity or simply socialising with people who share lived experiences. Sequentially, this could have a positive effect on mental health outcomes and reduce the health inequalities that are found in Glasgow.
Final Conclusions
To conclude this community briefing, I would like to re-emphasise the importance of community led approaches as a means to reduce the effects of mental health disparities across Glasgow. This report has outlined how people with ill mental health face social exclusion, and why communities in deprived areas are at greater risk of mental illness. I have demonstrated the benefits that can come from improving green spaces, implementing anti-stigma workshops and creating local support groups, however these are only some of many initiatives that can be taken to reduce mental health inequalities, and further reading is required to cover all bases of how to create equality for marginalised communities. Emphasis really needs to be put on these in order for Glasgow to not fall any further behind other UK cities in terms of health disparities. Although Glasgow is a modern, vibrant and friendly city, it is important to remember the quote from Mahatma Gandhi, “the true measure of any society can be found in how it treats its most vulnerable members”, and Glasgow needs to start taking action in order to stop failing those living in deprived areas who are suffering with their mental health.
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