Mental health in an unequal world — let’s ask what happened, not what’s wrong

The Covid-19 pandemic has triggered a mental health pandemic that will likely outlive the virus itself.

In Singapore, we may be seeing a worrying spike of infected cases in recent weeks bringing the total infected to roughly 2 per cent of our population.

Yet nine in 10 or 90 per cent of Singaporeans reported a decline in their mental health as a result of the pandemic, according to a nationally representative study by insurer AIA which was released in April 2021.

The long-term consequences of poor mental health among the population can be devastating.

Despite an encouraging groundswell of response efforts across public, private and people sectors to this deepening crisis, we could do well with an urgent and coordinated public mental health strategy that must, among other things, address the effects of inequalities on mental health outcomes and adopt a trauma-informed approach in interventions.

TACKLING SOCIAL INEQUALITIES TO REDUCE MENTAL HEALTH PROBLEMS

We may all experience mental health problems, whatever our background, but the risks of ill-health are not equally distributed.

Not surprisingly, the mental health effects of the pandemic are falling hardest on our vulnerable communities such as low-income households, migrant workers, persons with disabilities and the elderly — the same groups that are disproportionately impacted by Covid-19.

The pandemic has shone a spotlight on the plight of such individuals yet focusing merely on dealing with the poorer mental health of these groups overlooks the inequities that have led to such disparities in the first place.

In a recent episode of the Shades of Love podcast, my guest Zakir Hossein Khokan, a migrant worker, shared how the hefty debt his family incurred to pay the agent fees, the dismal living and working conditions in Singapore he was subjected to and the lack of social connections led him into a state of “mental sickness” in his early days here.

The link between poverty and mental health has been recognised for years and is well-evidenced.

Being poor can bring about mental health problems, most commonly anxiety and depression but mental health problems can also lead people into poverty due to discrimination in employment and a reduced ability to work.

Children growing up in poor households may be exposed to stress from parental neglect (working multiple jobs) or parental conflicts (money troubles) which could lead to anxiety disorders.

A lack of support may lead to low grades which may make these children feel hopeless, lead them to be bullied, or both, and this could trigger depression.

Substance abuse by teens may provide temporary escape but could lead to addiction that then traps them into a vicious circle of poverty and inequality.

It is worth noting that half of all mental health conditions start by 14 years of age but most cases are undetected and untreated. 

ADOPTING A TRAUMA-INFORMED APPROACH WITH MENTAL HEALTH 

One experience common to these vulnerable populations, in fact to human beings in general, is trauma.

Trauma may conjure up images of violence, war and other situations of extreme stress but in fact it refers to an experience that is physically and emotionally harmful or threatening and that has lasting adverse effects on the individual’s physical, social, emotional, or spiritual wellbeing.

In fact, emerging research is suggesting that Covid-19 is also a traumatic stressor that could lead to post-traumatic stress disorder symptomology.

Traumatic stress during childhood increases the risks for mental illness, according to a 2016 study on adverse childhood experiences (ACEs) by the Institute of Mental Health.

The study found that the prevalence of lifetime ACEs in the Singapore adult population was 63.9 per cent.

Nearly one in two (46.5 per cent) of adults experienced the ACE of emotional neglect while nearly one in 16 (5.9 per cent) experienced physical neglect.

“Those who experienced one ACE were more likely to be associated with bipolar disorder, obsessive compulsive disorder and suicidality, while those who experienced three or more ACEs were more likely to be associated with all disorders assessed,” the study said.

It is important to note that having an adverse childhood experience is a risk factor in its own right, no matter what our economic status, though living in poverty raises the likelihood of ACEs and compounds their negative impact.

A trauma-informed approach recognises that the poorer mental health outcomes among the most vulnerable populations are a result of not just individual choices or experiences, but broader social forces.

By connecting biography to structure and history, we better understand what has happened to someone, rather than fixate on what’s wrong with them.

Trauma-informed care for mental health, especially for vulnerable populations, therefore acknowledges the full human experience they have had without stereotypes or prejudice.

It empowers them to reclaim their voice so they can move from self loathing to self compassion in a way that helps foster resilience.

MENTAL HEALTH IN AN UNEQUAL WORLD

Sunday (Oct 10) was World Mental Health Day.

The theme for this year was “Mental health in an unequal world” to highlight how inequalities in mental health have deepened as a result of the pandemic, leaving many behind.

Those who face the greatest disadvantages in life also face the greatest risks to their mental health.

Singapore has made laudable progress in recent times with our mental health efforts, but the public health aspect of mental health has been largely neglected.

Not enough is being done to prevent people, especially from vulnerable communities, from being mentally sick in the first place.  

In the #AreWeOkay public survey conducted by citizen-led initiative SG Mental Health Matters in April this year, lead author and public health researcher Dr Rayner Tan and the team found a high level of consensus around the greater mental health vulnerabilities of low-income households, people living with disabilities, LGBTQ+ individuals and healthcare workers.

In all, 81.8 per cent of the total 561 participants agreed that low-income households are at greater mental health risk and believe that they should be given additional support while 89.6 per cent believe the same applies to people living with disabilities.

Policy interventions relating to mental health must recognise its social determinants and integrate efforts to reduce poverty and social inequality and trauma-informed approaches with policy initiatives in reducing stigma and improving healthcare access.

Community agencies and ground-up initiatives must necessarily include mental health inequities in their intervention, advocacy and awareness efforts.

Employers must adopt job redesign and flexible work arrangements to promote employee mental wellbeing as well as to retain low-wage and special needs workers where possible instead of eliminating their jobs outright as the immediate cost-cutting strategy.

We can all contribute too through our individual actions to reduce the impact of inequalities, make meaningful connections and show up with empathy for each other.

We must act now, and together, because our collective wellbeing depends on enabling every person to lead a life of dignity and opportunity so as to build a resilient society where everyone can thrive and flourish, equally.

ABOUT THE AUTHOR:

Anthea Ong is a former Nominated Member of Parliament, social entrepreneur (Hush TeaBar, WorkWell Leaders, SG Mental Health Matters, A Good Space), leadership coach, author of 50 Shades of Love, and host of Shades of Love podcast.