Mental health inequalities and cancer

Macmillan have submitted evidence to a new Commission set up by the Center for Mental Health to investigate inequalities in mental health.¹

Inequality is variation in health outcomes and experience that is both avoidable and unjust.² This could be because of someone’s socioeconomic status, race, age, gender, disability, religion or belief, sexual orientation, cancer type or geographical location.³

The inequalities agenda in cancer policy has tended to focus on prevention and survival (such as earlier diagnosis). However, we now know that there are now an estimated 2.5 million people living with cancer in the UK and this is expected to rise to 4 million by 2030.⁴ Additionally 6 in 10 cancers are not preventable. At Macmillan we believe that the health inequalities agenda must be made to reflect this. More must be done to ensure that everyone has access to the information and support they need from the point of diagnosis onward, vitally including access to mental health support.

What do we mean by mental health? It might refer to someone who is dealing with shock, distress and anxiety about what the cancer diagnosis and prognosis means for them and their family. It could refer to an individual with severe depression struggling to put their life back together once treatment has finished, or someone who experiences post-traumatic stress on the anniversary of their cancer diagnosis. It also includes someone with a distinct mental health condition like Schizophrenia who has just been told that they also have cancer.

It doesn’t really matter, so long as that person feels able to talk about their experience and has access to timely, coordinated and effective support that is appropriate to their needs. That is what we are calling for.

The risk of poor mental health has been shown to be higher for people going through cancer compared with the general population, with risk increasing among certain subgroups of the cancer population.⁵ These groups may have more severe needs and experience them more often.

For example, socioeconomic deprivation (i.e. income, employment, education, health, crime, barriers to housing and services, and living environment) can increase the risk of mental health issues in people diagnosed with cancer.⁶

In the UK, people living with cancer and on the lowest income are almost twice as likely to mention a need for more emotional support than those with larger household incomes.⁷ The Improving Access to Psychological Therapies (IAPT) services for moderate depression and anxiety receive more referrals from the most deprived areas of England, compared with the least deprived.⁸

There are likely to be inter-related issues leading to complex needs, particularly linked to socioeconomic deprivation. Mental health conditions are the third most common among people with cancer living with one or more condition other than their cancer.⁹ More deprived cancer populations have both higher prevalence of non-cancer long term conditions and a higher average number per person.¹⁰

Unfortunately, many of these needs go unmet. For instance, analysis by Macmillan shows that low income groups experience heightened unmet need around sadness, depression, confidence, and loneliness and isolation.¹¹

More work is needed to understand the needs and experiences of people who experience socioeconomic deprivation and live with cancer and mental health issues. How might their needs and experiences be different from the general cancer population and are the interventions different? For instance, we don’t know if it’s harder for people living with cancer to access mental health support in more deprived areas.

More evidence is needed to understand the experience of marginalized groups affected by cancer more broadly, and how they might face inequality in accessing mental health support. This includes people with learning difficulties and hard to reach groups like the homeless population.

Where you live might also determine the support you get, creating unacceptable geographical inequality and variation in care. This affects the general cancer population, as well as those who may experience needs more often, or more severely.

National Institute for Health and Care Excellence (NICE) guidance on cancer services for England recommends that psychological support be embedded within the cancer treatment pathway.¹² However, support for mental health is rarely built into cancer services. Too often it’s not addressed at all. There is an estimated 70% shortfall in the levels of psychological care in oncology in England.¹³ Access to mental health services also varies across England and is limited.

Macmillan’s research has highlighted that this separation of care has had an adverse effect on cancer patients’ attitudes towards their own mental well-being and seeking support.¹⁴ Unless cancer services are pro-active in identifying mental health needs, access to support may be more difficult for people who don’t have the health or digital literacy to navigate the system, creating another potential inequality.

Macmillan aims to influence equal access to mental health support in the cancer pathway, as well as improving access and quality in mental health services.

At Macmillan we are working to learn more and understand the needs and experiences of different populations of people living with cancer, including people from socioeconomically deprived backgrounds and black, Asian and minority ethnic people. This will help deepen our understanding of where inequalities in cancer care exist and how those needs should be met, particularly in terms of support for those who experience mental ill health.

We know there’s a lot more to do in this area. If you’re interested in inequalities, cancer and mental health get in touch.

James Thorneycroft is a Policy Officer at Macmillan Cancer Support.

References

1. https://www.centreformentalhealth.org.uk/campaigns/commission-equality-mental-health
2. http://www.healthscotland.scot/health-inequalities/what-are-health-inequalities
3. All Party Parliamentary Group on Cancer. Report of the All Party Parliamentary Group on Cancer’s Inquiry into Inequalities in Cancer. Available from: https://www.macmillan.org.uk/documents/getinvolved/campaigns/appg/britainagainstcancer2009/cancerinequalitiesreport.pdf [Accessed 02 August 2019]
4. https://www.macmillan.org.uk/_images/cancer-statistics-factsheet_tcm9-260514.pdf
5. Macmillan Cancer Support. Worried Sick. The Emotional Impact of Cancer. Available from: https://www.macmillan.org.uk/documents/getinvolved/campaigns/campaigns/impact_of_cancer_english.pdf [Accessed 25 July 2017].
6. Ibid.
7. Macmillan Cancer Support. Inequalities: Time to talk. Available from: https://www.macmillan.org.uk/_images/Health-Inequalities-Paper-April-2019_tcm9-350678.PDF [Accessed 25 July 2019]
8. http://www.pulsetoday.co.uk/clinical/clinical-specialties/mental-health/deprivation-linked-to-poor-recovery-from-mental-illness/20033038.article
9. Macmillan Cancer Support. The burden of cancer and other long-term conditions. Available from: https://www.macmillan.org.uk/documents/press/cancerandotherlong-termconditions.pdf [Accessed 01 February 2019]
10. Macmillan study [unpublished]
11. Research conducted in 2015 via an online survey of 1600 people living with cancer, looking at the needs and concerns of the 2.5m people living with cancer in the UK. Low income recorded as less than £10,000 per annum.
12. The National Institute for Health and Care Excellence (2004). Improving supportive and palliative care for adults with cancer. Available from https://www.nice.org.uk/guidance/csg4 [Accessed 10 May 2019]
13. Macmillan Cancer Support. Mapping Level 3 and 4 Psychological Services for Oncology in England. Dr Julie Highfield Consultant Clinical Psychologist. January 2016 [unpublished].
14. Macmillan internal research including interviews with people living with cancer and clinicians (2019, unpublished)