Recession and Mental Health in Scotland: Do Personal or Community Factors promote Resilience to Labour Market Change?

Lead Research Organisation: University of Edinburgh
Department Name: Sch of Geosciences

Abstract

This project will examine how, over time, between 2001 and 2014, mental health outcomes and mental health care use in Scotland have related to changes in local labour markets, particularly changing levels of employment during the recent recession. The study will examine mental health outcomes for individuals (including self-reported mental illness and death due to mental illness) and use of NHS care for mental illnesses (including hospital care, outpatient services and prescribed medicines). The study population include about 150,000 people in the Scottish Longitudinal Study and we are able to examine information collected over time for this large group, which makes the study particularly powerful. This project will analyse a new and innovative dataset made up of secondary data from several different sources which have not been combined in this way before. We have permission from the data guardians to use these data in a secure data centre, so that no identifiable information about any individual will be released. Our focus will be especially on patterns of change that we can observe for large groups of people living in different parts of Scotland.

The public benefits of this research project will be primarily in providing evidence to inform policy makers and organizations contributing to policies for those affected by mental health issues. When our findings are approved for public release, we anticipate that public interest will focus on the following aspects of our findings:
- Relationships between local trends in employment levels during the recession, and mental health and health care outcomes for different social groups in the population. This is of relevance for policy makers in NHS Scotland, and for other agencies, such as Support in Mind, Scotland, and Centre for Welfare Reform, which are concerned to address, and advocate for the needs of those at risk of mental health problems in different parts of the country.
- A more complete picture of mental health outcomes for populations in different types of localities, and how these change over time. These findings have potential to contribute to the design of population mental health indicators for localities, relevant for performance monitoring and needs assessment by NHS Scotland.

This research project also provides an excellent opportunity to further develop a growing collaboration between two leading research centres concerned with inequalities in health and wellbeing and how we can address these inequalities through policy and action in social and economic sectors as well as through the medical system. It also focuses specifically on one of the research priorities for ESRC relating to mental health in the population.

As well as senior academics (Pearce, Dibben and Bambra) our multi-disciplinary team includes two 'Early Career' Academic colleagues (Cunningham, as a Co-I with expertise in application of Geographical Information Systems to explore change in social inequalities and divisions over time and Cherrie as a PDRA with postgraduate and postdoctoral experience in Environmental Epidemiology and Geography and in complex data management and analysis).
The project will be supported by an advisory group, including Prof Sarah Curtis, Professor Emeritus, Durham University (internationally recognized for her research in health geography and has been directly involved in helping to develop this project and to prepare the linked dataset on which it will draw), Dr Mylene Riva (Associate Professor, McGill University, Canada, expert in health geography and geospatial analysis and has published research in collaboration with Prof Curtis on employment conditions and health in England), Dr Lynne Friedli (independent mental health specialist and advocate) and Dr Simon John Duffy (Director Centre for Welfare Reform), Dr Andrew Millard and Dr Stuart McTaggart, NHS Health Scotland, Frances Simpson, Chief Executive of Support in Mind Scotland.

Planned Impact

Our findings will be of interest to a range of research users including: policymakers with responsibilities in the areas of public health, health care and health inequalities; advocacy groups with concerns for mental health, welfare and local infrastructure; and beneficiaries including the wider public. Our insights into how mental health outcomes respond to large-scale shocks such economic recession and austerity measures, as well as the factors promoting resilience to such episodes, will be used to inform policy and practice debates in Scotland and beyond.

Our ambition is to ensure that the opportunities for improving mental health and reducing inequalities are widely recognised and adopted across the areas of health, environment and social policy. This will require us to raise public awareness about the connections between economic recessions and health as well as inform policymakers across a range of sectors. Building on our existing networks, and in collaboration with our non-academic partners, we will have access to, and be able to influence, the key policy and practice arenas to ensure long-term use of our research findings.

Our impact strategy has been developed to influence policy and practice, and challenge public assumptions about the determinants of mental health. The strategy is designed to ensure that our translation and communication plans are robust, and to make sure that we develop outputs that are of the greatest value to our intended beneficiaries and other key audiences. To assist with this, we have already involved some key beneficiaries early in our work to refine our research questions and help us develop our research design.

Project Partners: these have been selected to ensure our findings reach the intended audiences; each of the organisations are well rehearsed in engaging with our key audiences. Our project partners are the Centre for Welfare Reform, NHS Scotland, and Support in Mind Scotland. Key representatives from these organisations have agreed to join the project Advisory Group. Their responsibilities will be advising the research team on refining the scope of the research and helping to translate the findings in order to identify opportunities for affecting policy and ensure the outputs are appropriate for the intended audiences.

Influencing decision makers: drawing on the advice of our Advisory Group we will develop a set of tailored and targeted resources for key decision makers working in the realms of health, planning and economic development. This is likely to include: 'policy briefings' (e.g. for politicians in the Scottish Government and local decision makers); talks to key groups including Cross-Party groups in the Scottish Parliament; and a stakeholder workshop for key interest groups including, but not limited to, organisations such as Greenspace Scotland and those involved with delivering the 'Place Standard' in Scotland. The invited organisations will not only be able to learn about the research findings but also contribute to developing the non-academic outputs from the research. In particular participants' advice will sought to help identify what information and in what format(s) will be of the most value to their organisations.

Influencing the public discourse: Given the public misapprehensions and stigma relating to mental health, we will look to influence public understanding of the societal drivers of mental health, as well as the ways in which the places we live, work and play can be better designed to help foster resilience to poor mental health. We will achieve this by involving a wider public at an early stage of the research and by disseminating findings at a later stage. This will be achieved in a number of ways including events at the 2017 and 2018 Edinburgh Science Festivals, blog posts on our (and other) existing blogs, through social media, and dissemination through our existing online and free webmapping tool.
 
Description Using linked administrative data on 86,000 people living in Scotland in the period 2004-2014, we investigated how local economic trends during the financial crisis affected mental health outcomes of people living in different parts of the country. We identified groups of areas in Scotland with distinct trends in labour market conditions during the recession. We found that these geographical economic differences were associated with mental health of individual residents. Regardless of their own employment status, for people living in regions experiencing relatively high and stable levels of employment the odds of reporting a mental illness was significantly lower than for those living in areas with persistently low, or steeply declining employment rates. These findings matter because they show that changes in local economic conditions (e.g. an economic recession) influence people's health and wellbeing independently of their own employment status.

Mental illness is a leading cause of disability worldwide, affecting 1 billion people globally each year, and accounting for 32·4% of years lived with disability. However, to date, studies monitoring changes in mental health have relied mainly on self-reported measures which are strongly affected by differences in propensity to report existing health problems. Our research has developed a novel approach to continuously monitoring population mental health using linked administrative data. NHS prescription data were linked to census information in the Scottish Longitudinal Study, a 5.3% sample of the Scottish population, and, based on individual's place of residence we also included other geographical data on changing socio-economic conditions including employment, loss of welfare benefit income due to austerity measures, social and environmental conditions. This created a large, powerful dataset allowing us to examine determinants of mental health in complex ways.

A technique called sequence analysis was used to classify individuals into groups based on their anti-depressant medication (no prescriptions (76%), occasional prescriptions (10%), continuation of prior use of prescriptions (8%), new course of prescriptions started (4%) or ceased taking prescriptions (3%)). These results are important because they demonstrate the utility of a new resource using routine data to better monitor and understand trends in population mental health. We were able to compare findings using this approach with other analyses we have undertaken as part of this project, using the same dataset to examine self-reported mental health conditions reported in the 2011 census and included in the SLS. Our findings using these different approaches were broadly consistent, while showing that the prescription based analyses provided more complete data on trends in health status and incidence of new cases of mental illness.

Existing international evidence suggests that the 'Great Recession' led to an increase in mental illness, particularly in countries that pursued austerity policies. We also know that in the UK (and other countries), there have been distinct regional differences in the economic impact of (and recovery from) the Great Recession and austerity policies. However, we know less about now local variations in the effects of the Great Recession and austerity have influenced geographical inequalities in mental illness across the country. Our work is novel in the way that regional inequalities economic trends associated with the Great Recession and austerity affected regional inequalities in mental health.

In the final phase of our study, and in response to suggestions from participants from NHS Scotland and related agencies attending a seminar organised under this project, as part of the ESRC Science Festival, we were interested to identify which characteristics of the places people live in Scotland foster resilience against the mental health impacts of the Great Recession, and whether this may also be an opportunity to reduce health inequalities. Using the linked administrative data sets described above, we found that neighbourhood greenspace buffered against the impacts of the Great Recession and austerity on mental illness amongst employed Scottish adults. Further, greenspace-derived mental health resilience is greatest for people living in the most disadvantaged areas, suggesting improving green space availability may help to address mental health inequalities.
Exploitation Route We are currently developing our impact messages with the project Advisory Group but our initial findings indicate the importance of regional approaches to mental health policy that include consideration of what may be sub-regional variability and perhaps rather different processes determining mental health in different parts of the country.
Sectors Environment,Healthcare

 
Description The diverse range of activities undertaken by members of the team mean that this project has started to deliver impact across academic, public and policy and practice sectors. The policy impact of the research has been underpinned in the co-production of knowledge between the project team and health specialists and practitioners and is exemplified in the publication of an article on the sequence analysis of NHS prescription data involving NHS Scotland's Stuart McTaggart in indicative of the direct impact of the research on our public health bodies. These insights are leading NHS Scotland towards new approaches aimed at modelling the incidence of new cases of drug anti-psychotic and psychotropic drug prescription in the population, rather than merely understanding prevalence in a group exposed to the effects of the great recession. The policy audience for the research has also been effectively targeted in a presentation by Cherrie on 'Recession, Austerity and Mental Health in Scotland' to the Scottish Government's Health and Social Care Research Group at Holyrood on January 29th. Here, a Scottish NHS health economist was keen to develop the cost analysis element of the inequality trends presented in the talk.
First Year Of Impact 2019
Sector Environment,Healthcare
Impact Types Societal

 
Title Linked population-mental health datsaset 
Description Over the course of the study we have created a large (N=151,418) new dataset linking population records with NHS prescription data for the period 2009-14. This enabled us to develop a measure of depression (using antidepressant prescription status over the previous six months). This new dataset is an important dataset because it provides a large individual-level data on mental health status that does not suffer from the biases of self-reporting. 
Type Of Material Database/Collection of data 
Year Produced 2019 
Provided To Others? Yes  
Impact To date, the dataset creasted through our study has been utilised by two PhD students (both based at the University of edinburgh) and the analyses are central to the development of their theses. 
 
Description Changing labour market conditions during the 'great recession' & mental health in Scotland 2007-2011: an example using the Scottish Longitudinal Study & data for local areas in Scotland 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Around 30 policymakers, academics and practitioners attended a workshop arranged during the Public Health Association Conference in Ljubljana, which sparked a wide-ranging discussion and further request for information
Year(s) Of Engagement Activity 2018
 
Description Collaborative meetings with NHS Scotland relating to use of pharmacological data 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Through this project a collaborative partnership was built with Stuart McTaggart, Principal Pharmacist, Public Health and Intelligence, NHS National Services Scotland, and with Dr Kirsty Licence, Clinical lead for Mental Health Information, NHS National Services Scotland. They are joint authors on one of the papers produced and have provided helpful advice on how to interpret the indicators of change in mental health that we have produced using analysis of prescribing sequences. The methods we have developed through this work are likely to inform the ways in which the NHS in Scotland generates public health information in future.
Year(s) Of Engagement Activity 2018,2019,2020
 
Description Conference paper at RGS 2019 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Postgraduate students
Results and Impact 25 people attended a session organised by the project team at the Royal Geographical Society Annual Conference, which sparked questions and discussion afterwards, and helped shape future research directions in this area for the research team
Year(s) Of Engagement Activity 2019
URL http://conference.rgs.org/AC2019/369
 
Description Conference plenary: Health and place over the life course: implications for health equity 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Around 150 people attended this invited plenary session at a conference in Changsha, Chine aimed at policymaker, practitioners and academics, which sparked questions and discussion afterwards, and resulted in a number of new collaborative links between UK and China based teams
Year(s) Of Engagement Activity 2020
 
Description Employment trends in relation to reported long term illness in England & Wales 2001-2011 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact This paper was presented by Sarah Curtis, on behalf of the research team, at in a session convened at the 2019 Annual Conference of the Royal Geographical Society and Institute of British Geographers by Niall Cunningham as part of his communication and engagement work on this project. The research presented presented some preliminary research undertaken using the LS (England and Wales) which helped to lay the foundations for research in this project focus using the SLS to examine mental health outcomes in Scotland of recession by conducting a parallel analysis on self-reported mental illness based on data drawn from the Understanding Society Survey and linked to other geographical data. The research has subsequently been published in Journal of Health and Place.
Year(s) Of Engagement Activity 2019
 
Description Event at Inverness Science Festival, 1/05/2019. Title Recession and Mental Health in Scotland: Do personal or community factors promote resilience to Labour Market Change? 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact This event titled: Recession and Mental Health in Scotland: Do personal or community factors promote resilience to Labour Market Change?
Inverness Science Festival, was Chaired by Jamie Pearce, with presentations by Mark Cherrie and Sarah Curtis. It was given at University of Highlands and Islands, Inverness Campus, as part of the 2019 Inverness Science Festival.

The event focussed on variations in the way the recession impacted different areas across Scotland in terms of employment and wages, and how these different experiences may be associated with different levels of mental illness across the country. The meeting included audience participation, drawing out the views of the audience about the issues covered and aspects that might be explored in more depth. In feedback collected by the festival organizers, the event was rated as 'good' (highest grade) by all those attending and appreciation was expressed for the participative aspects of the event. The participants found the topic interesting and engaged very actively in the debate. Useful point were raised in discussion concerning the need to consider variation across the highlands and islands and issues of varying public access to greenspaces in their area, and these ideas have been fed back into the subsequent research development.
Year(s) Of Engagement Activity 2019
 
Description HARD TIMES: MENTAL HEALTH UNDER AUSTERITY 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact The event was part of the ESRC Festival of Social Science. The description for the events was "How important for mental health are the changing social, economic and environmental conditions in the places where we live? Our research, funded by ESRC, addresses this question through a new and innovative study of mental health of people living in different parts of Scotland. We are focussing especially on the period since 2007 when economic recession and austerity have impacted to a varying extent across the country. This event will use interactive data visualisations to present our research findings, showing how audience polling techniques allow the participants to select topics of special interest for them, to help determine in 'real time' the focus of the results presented. This will be combined with an opportunity for group discussion and exchange of ideas among diverse participants, many of whom will be involved in mental health care and promotion of better mental health. We will be sharing new evidence and discussing the implications for policy and practice in different parts of Scotland. The event is also intended to help shape the future research agenda."
Year(s) Of Engagement Activity 2018
URL https://cresh.org.uk/2018/09/17/festival-of-social-science-economy-mental-health-registration/
 
Description Invited seminar: Great recession, austerity and mental health in Scotland: moderating roles of green space and social cohesion 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact 60 participants attended an invited session at the GeoMed 2019 conference, which sparked questions and discussion afterwards, and led to the development of new research proposals and dissemination events.
Year(s) Of Engagement Activity 2019
URL https://www.gla.ac.uk/media/Media_651605_smxx.pdf
 
Description Lifecourse of place: a longitudinal approach to understanding health, place & inequalities 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact Around 50 students, academics and public attended this research seminar at University of Wuhan, China which sparked questions and discussions afterwards, and results in new collaborations between the Chinese and UK research groups
Year(s) Of Engagement Activity 2019
 
Description Mental Health Prescription Use in Scotland: Exploring relationships with macroeconomic and individual socioeconomic circumstances. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact This presentation was made by team member Mark Cherrie, in a session convened at the 2019 Annual Conference of the Royal Geographical Society and Institute of British Geographers by Niall Cunningham as part of his communication and engagement work on this project. It summarized research he had undertaken as part of this project, using innovative methods to analyse NHS prescription data linked to SLS data and area variables. The ensuing discussion considered methodological issues and policy relevance of the research.

Abstract
The Great Recession of 2008/2009 increased unemployment and reduced living standards, which led to stress and unhealthy behaviours at a community level, due to precarious financial and social circumstances. Individuals living in regions of Scotland that fared better over the recession period were shown have a lower likelihood of reporting mental health problems (Curtis et al., 2018). However, self-reported mental health status is limited by differences in reporting by age, sex, ethnicity and socioeconomic status (Dowd et al., 2011), and provides no information on the development of the illness.
We used data from a population representative sample of participants from the Scottish Longitudinal Study which had been linked to monthly NHS mental health prescription records from 2009-2014. We aimed to determine the relationship between individual socioeconomic and macroeconomic circumstances on the pattern of prescription use, using multilevel logistic regression. A latent class mixed model was used to identify groups of the 32 Scottish local authorities that had similar trajectories for full-time employment from 2004-2014. We analysed the sequences of six month prescription status, and computed sequence dissimilarity using optimal matching (i.e. minimising insertion, deletion, substitution costs). Hierarchical clustering was used to produce five prescription groups. We found a higher likelihood of being in the increasing antidepressant prescription group if the participant had lived in an area of low and declining (post-recession) full-time employment, after adjustment for age, sex, ethnicity, occupational social class, living alone and marital status.
Year(s) Of Engagement Activity 2019
 
Description Poster at Mental Health Policy Event 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact A poster was presented and aided debate with other delegates. There was a panel discussion with politicians and third sector delegates. The final part was an informal discussion, mainly with members of the general public, whereby I was able to stimulate interest for the current research project, in the context of what we had heard in the panel discussion. I was also influenced by the individual lived experiences of the impact of the recession/austerity and this was useful for me in carrying out the research.
Year(s) Of Engagement Activity 2018
URL https://www.blogs.hss.ed.ac.uk/language-mind/2018/03/03/mental-health-policy-social-science-practice...
 
Description Poster at SSM meeting 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact A poster was presented in a chaired session. There were around 15 people that I gave a short synopsis of the research to, followed by some questions on the methods undertaken and implications of the work. I expect that the audience left with an increased awareness and appreciation of the geographical inequality in the effect of the recession on mental health in Scotland.
Year(s) Of Engagement Activity 2018
URL https://socsocmed.org.uk/annual-scientific-meeting/
 
Description Socio-spatial mobility and mental health in a time of austerity 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact This paper was presented by Niall Cunningham at in a session convened at the 2019 Annual Conference of the Royal Geographical Society and Institute of British Geographers also by Niall Cunningham as part of his communication and engagement work on this project. The research presented was an extension of the research on the project, which expanded the project focus on mental health outcomes of recession by conducting a parallel analysis on self-reported mental illness based on data drawn from the Understanding Society Survey and linked to other geographical data.

The ensuing discussion considered the methodological and theoretical issues arising from this analysis, and compared the findings with related research in other countries.

Abstract:
The Great Recession of 2008/2009 has shined a powerful light on increasing inequalities in developed economies and their implications for society. As evidence continues to build up regarding the health impactsof these trends, it becomes increasingly apparent that we need to consider individual's social and geographical trajectories over time, in order to understand these processes. This has led to a growing interest in how social and residential mobility may be important for health outcomes.
Some research has focused on long term, even intergenerational mobility processes and the long-term impact of conditions experienced early in the lifecourse. Population health studies often aim more particularly to 'control' for mobility in order to assess more rigorously how exposures to socio-geographical environments at particular time points relate to subsequent health outcomes. More recently, however, the research literature has been increasingly concerned with the process of social and geographical mobility itself and how it may impact on health and wellbeing. These studies have examined, for example the social mobility experiences of populations living in 'escalator regions', and whether moving to more advantaged areas may have positive (or possibly negative) effects on health.
Year(s) Of Engagement Activity 2019
 
Description Study shows toll financial crisis took on mental health 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Media (as a channel to the public)
Results and Impact Newspaper article appeared in the Scotsman on 30/9/18 based on results from this study
Year(s) Of Engagement Activity 2018
URL https://twitter.com/jamie0pearce/status/1046679796896411648?ref_src=twsrc%5Etfw%22%3EOctober%201,%20...
 
Description University seminar: How did the Great Recession impact mental health in Scotland? 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Other audiences
Results and Impact 40 academic staff from across the University of Edinburgh with interests in mental health came together to discuss new opportunities for research collaboration. The key outcome was a plan for a new cross-university research initiative on mental health.
Year(s) Of Engagement Activity 2019
 
Description Workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Around 120 participants from policy, practice and academia attended our end of project workshop which sparked significant debate about the impact of the global crises on public health. In the formal feedback, participants reported that the workshop had been highly informative, had helped change their views on the connections between labour markets and health, and provided new ideas that they would take back to inform the working of their organisations.
Year(s) Of Engagement Activity 2019