The effects of inequalities and socioeconomic factors on health are well established, and considerable evidence is emerging of the impact of inequalities on mental health. However the relationship between these factors is less understood. Whilst certain social circumstances may lead to mental health problems, it is also likely that experiences of long-term and severe forms of mental health may impact on the socio-economic status of individuals (see the Social Exclusion Unit's report on mental health). The London Health Observatory is developing a basket of indicators for health inequalities which includes mental health.

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Differences in sex are reported in the following sections.

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London is recognised as the most diverse city in Europe. Almost half (46%) of all non-white ethnic minority groups in England and Wales live in the capital. Overall nearly 30% of adult London residents and approximately 40% of children under 15 years belong to a non-White British ethnic group, approximately 2.9 million residents (1). (For more information see the Ethnic Minorities pages, and the Health in London report).

Prevalence of mental health problems appears to vary across ethnic groups. The Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) project (2) found that for common mental health problems:

Estimates of annual prevalence rates of psychotic disorders ranged from six per 1,000 in the Bangladeshi population, to 16 per 1,000 for the Black Caribbean population. The prevalence of psychosis amongst the Black Caribbean population was twice that of the rate for the White population (8 per 1,000). Rates were largely similar for men and women except for the White population (10 per 1,000 men, 7 per 1,000 women). The reverse trend was found amongst the Indian population (9 per 1,000 men, 13 per 1,000 women). None of these differences were statistically significant.

Evidence shows that black and minority ethnic (BME) groups are more likely to be diagnosed with schizophrenia and detained and treated compulsorily under the Mental Health Act (1983) (3), and Black ethnic groups are over-represented in London inpatient and forensic mental health services.

A summary of findings on ethnicity and mental health can be found in the LHO's report Ethnic Disparities in Health and Healthcare on this page.

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Migration is an important determinant of health outcomes and psychological wellbeing. Some studies have shown that migration can have a negative affect on health, exposing individuals to considerable pressure and stress. Other studies have shown that the offspring of migrated parents have a higher risk of mental health problems than their parents or other members of the general public (1-4). Over 60% of London's ethnic minorities (not including White British) were born outside the UK (5).

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In the week ending 16 April 2004, there were reported to be 29,134 asylum seekers in London, 12.4% being single adults, 74.7% being children and adults in families, and 12.9% being unaccompanied children (aged 0-to-17 years) (6). Further there were approximately 2,400 unaccompanied asylum seeking children being looked after at 31 March 2003 in England (excluding those being looked after under an agreed series of short-term placements), about 71% of which were in London (7).

Refugees and asylum seekers, by definition, experience some form of personal crises or severe and potentially damaging traumatic event (2). Because of these experiences and the effects of migration, resettlement and isolation, mental health problems amongst refugees are prevalent, including depression, suicide and post-traumatic stress (8). For example, about two-thirds of refugees will have experienced anxiety or depression. It is important to note that refugees and asylum seekers are at high risk of a range of socio-economic inequalities such as poverty, homelessness and social exclusion, which all impact on physical and mental health (9).

For further information see the Health of Londoners Project's report Refugee Health in London.

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The 2001 Census showed that London had the highest unemployment rate (6.7%) of all regions in England and Wales except for the North East (the rate for England and Wales was 5.2%). For further information on employment and unemployment in London see Employment & Unemployment page.

Unemployment and being economically inactive (unemployed and not seeking work) are associated with increased risks of developing mental health problems. The ONS surveys found that 72% of those with psychotic disorders were unemployed or economically inactive compared with 33% of the total sample. The comparable figure for those with a common mental health problem was 43%. Those with a mental health problem (including drug and alcohol dependency) were more likely to be from the manual classes compared with those without a mental disorder. Again, those with a probable psychotic disorder fared worse than those with current neurotic disorders. After controlling for issues related to employment and social class it was found that the probability of those with a psychotic disorder not working was four times that of the rest of the sample (i.e. someone without a psychotic disorder). For someone with a depressive episode this probability was twice that of the rest of the sample (10).

Children without a parent working in the family were twice as likely to have a mental health problem than those with one or both parents working. Further children from families in social class V (unskilled occupations) were approximately three times more likely to have a mental disorder than those in social class I (professionals). However it was noted that "more specific indicators of family difficulties and disturbance have been regarded as more important risk factors for children's psychological well-being than family social position per se" (11,12).

The ONS psychiatric morbidity survey found that those with probable psychotic disorder were more likely to be in a household with an income less than £300 per week, compared with those with a common mental health problem and those with no mental health problem (60%, 37% and 28% respectively: in this survey mental health problems included alcohol and drug dependency). Those with a psychotic disorder were also more likely to be receiving state benefits (income support or incapacity benefit) than those with common mental health problems and those with no mental health problem (two thirds, less than one third, 10%).

Overall those with a mental health problem were at least three times as likely to have had their telephone, gas, electricity or water disconnected compared with those without a mental health problem (10% compared with 3%) (10). For further information on income and benefits in London see Determinants of health.

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The ONS psychiatric morbidity survey amongst adults found almost half of those with a psychotic disorder (49%) were living in accommodation rented from a housing association or local authority compared with 15% of those without a mental health problem. Those with a mental health problem were more likely to be living in rented accommodation (38% compared with 24%).

People with mental health problems were also more likely to report lack of security in their accommodation. Eleven percent of those with mental health problems thought that they might have to leave their accommodation before they would wish to leave, the most common specific reason for this was financial problems. For those without mental health problems, 5% thought they might have to leave their accommodation, the most common reasons being for expiration of the lease or contract (10). Differences in housing tenure were also noticed in the survey on the mental health of children and adolescents (see Datasets).

For further information on the impact of housing and homelessness on physical and mental health see the Housing section.

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The ONS survey into mental health of children and adolescents (aged 5-to-15 years) found that the children of lone parents (single parents not cohabiting with a partner) were approximately twice as likely to have a mental health problems as those living with married or cohabiting couples (16% compared with 8%). Further, children living with a cohabiting couple rather than a married couple were again twice as likely to have a mental health problem (8% compared with 4%). However, caution needs to be used in interpreting these data as other factors need to be considered such as socioeconomic and social functioning background.

Further analysis showed that likelihood of mental health problems increased when children were in families with step-children (15% compare with 9% for those without step-children), and increased family size: 13% and 18% of children in families of four or five children respectively had mental health problems compared with 8% of two children households (11).

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The term 'looked after children' refers to all children and young people looked after by local authorities, either in foster homes or children's homes. London had almost one fifth (19.3%) of all children being looked after in England at 31 March 2003 (excluding those under an agreed series of short term placements). Overall there were 11,750 children being looked after in London on this date (13).

Data from the ONS survey on the mental health of looked after children aged 5-to-17 years found that 45% of those interviewed (1,039) were assessed as having mental health problems and 37% had symptoms that warranted a clinical diagnosis. Those in care were five times more likely to have a mental disorder (42% compared with 8%), with particularly notable differences in conduct disorder. Gender differences and variation by type of care establishment were noted (14).

Date	Title	Format	View
16 Mar 2012	Community Mental Health Profiles Tool
11 Nov 2010	Celebrating a decade of public health intelligence. London key fact 9: mental health
28 Mar 2007	Commissioning for equity. Equal access, equal care? Can London deliver the race equality action plan for mental health? Executive summary
28 Mar 2007	Commissioning for equity. Equal access, equal care? Main report
1 Nov 2005	Mental Health In London: What are the Special Issues
13 Jun 2005	Ethnic diversity and mental health in London: recent developments
13 Jun 2005	Ethnic Minority Psychiatric Illness Rates in the Community
13 Jun 2005	Mental Health and Social Exclusion: Social Exclusion Report
13 Jun 2005	Mental Health and Social Exclusion: Social Exclusion Report Summary
13 Jun 2005	The Mental Health of children and adolescents in Great Britain
13 Jun 2005	The mental health of young people looked after by local authorities in England
13 Jun 2005	The social and economic circumstances of adults with mental disorders
19 May 2005	Prevalence of mental health problems amongst children and young people aged 5-to-15 years
19 May 2005	Social and Economic Circumstances of Adults with Mental Health Problems
18 May 2005	Mental health problems amongst children and young people - family factors and socio-economic background
18 May 2005	Prevalence of Mental Health Problems by Ethnicity
3 Aug 2004	Ethnic disparities in health and health care: a focused review of the evidence and selected examples of good practice. Full report
25 Mar 2004	Between worlds: interpreting conflict between black patients and their clinicians
30 Jun 1999	Refugee health in London: key issues for public health

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1. London Health Commission (2004) Health in London: Review of the London Health Strategy high level indicators London Health Commission: London.
2. Sproston K and Nazroo J (Eds) (2002) Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) - Quantitative Report HMSO: London.
3. Keating F, Robertson D and Kotecha N (2003) Ethnic diversity and mental health in London: recent developments King's Fund: London.
4. Nazroo, JY (2001) 'Ethnicity and mental health, findings from a national community survey' in London Health Commission (2004) Health in London: Review of the London Health Strategy high level indicators London Health Commission: London
5. ONS census, 2001.
6. Data taken from the London Asylum Seekers Association website.
7. Children Looked After in England: 2002-2003, Table 6 Unaccompanied Asylum Seeking children who are looked after at 31 March 2003 by region and age Data taken from statistics produced by the Department for Education and Skills. See also - http://www.dfes.gov.uk/rsgateway/DB/SBU/b000424/table6.xls
8. Johnson et al (1997) 'London's Mental Health: The report to the King's Fund London Commission' in Keating F, Robertson D and Kotecha N (2003) Ethnic diversity and mental health in London: recent developments King's Fund: London.
9. London Health Commission (2004) Health in London: Review of the London Health Strategy high level indicators London Health Commission: London
10. Meltzer H, Singleton N, Lee A, Bebbington P, Brugha T, Jenkins R (2002) The social and economic circumstances of adults with mental disorders Her Majesty's Stationery Office (HMSO): London.
11. Meltzer H, Gatward R, Goodman R, Ford T (2000) The mental health of children and adolescents in Great Britain HMSO: London.
12. Children Looked After by Local Authorities Ending 31 March 2003. Table 1 Data taken from statistics produced by the Department for Education and Skills.
13. Meltzer H, Corbin T, Gatward R, Goodman R, Ford T (2003) The mental health of young people looked after by local authorities in England HMSO: London.

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• The Social Exclusion Unit, the Office of the Deputy Prime Minister (ODPM)
  The mental health pages of the Social Exclusion Unit, including access to publications.
• London Health Commission
  Produces the annual Health in London reports - City Hall, The Queen's Walk, London SE1 2AA Tel: 020 7983 4120
• London Asylum Seekers Consortium
  Association of London Government, 59½ Southwark Street, London SE1 0AL
• Health for Asylum seekers and Refugees Portal (HARP)
  HARP's mental health and wellbeing resource pages for professionals working with asylum seekers and refugees
• Department for Education and Skills
  Statistics page

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