Experts Call for More Effective Investment in Mental Health

In the world of mental health, we are increasingly drawing on the expertise of those with lived experience of mental ill-health to understand their journey to recovery and apply the learning to improve services. However, all too often, stigma and social exclusion continue to prevail in the absence of environments and services that protect and support mental health and offer quality care.

Tackling the subject of improved environments at the recent World Congress for the International Association for Suicide Prevention, two important keynote presentations explored why better understanding of the importance of economic policy is needed in mental health and suicide prevention. 

Professor David McDaid from the London School of Economics offered a rationale for assessing the investment in suicide prevention initiatives, and Dr Steven Stack from the Emeritus Academy, Wayne State University in Michigan, shared some tangible examples of government investment that impact people’s decisions to take their own life.

Professor McDaid noted that economic evaluation is routinely used as part of the decision-making process in many areas of public policy, e.g., public health and health care systems, road and other transport safety and violence prevention. However, this is not common in suicide prevention policy. He contends that we need to routinely assess the economic benefits of self-harm and suicide prevention because understanding the costs of suicide is of limited use unless we can do something about it. As such it requires the need to identify effective interventions, determine the costs of implementing interventions and use economic evaluation to make decisions on how best to use resources. 

While research has advanced our understanding of protective factors and the importance of social determinants of health in the prevention of mental ill-health and suicide, Professor McDaid says there are very few economic evaluations of non-health system interventions. “Research is dominated by health system costs, not financial and other economic supports, yet the majority of costs are outside the health system. The medico-legal costs of suicide to the public purse and families amount to millions of dollars annually, yet this is commonly overlooked.”

In a recent article in Nature Mental Health, Sinyor and colleagues state that there is general agreement the world is facing an economic downturn on the back of Covid. The evidence from previous severe economic downturns showed an increase in suicide. This was particularly apparent in countries where economic policy centred on austere fiscal measures, while countries that provided social and financial safety nets did not have a significant increase in suicides.

This is supported in a report published by the Black Dog Institute in Australia What can be done to decrease suicidal behaviour in Australia? Chapter two dives into the impact of social determinants on suicide and how policy settings can help. The report notes that large studies of welfare support and suicide show that countries with more generous welfare payments and active labour market programs experience little or no increase in suicide during economic downturns, whereas countries with less generous welfare see substantial increases in suicide.

Dr Steven Stack reinforced the importance of economic policy supporting both mental health and suicide prevention. According to Dr Stack, many economic policies within the United States have had a positive effect on the rates of suicide and mental ill-health. “The challenge is to ensure those policies are not overturned or even watered down. We have already seen this happen in some policy areas, and this will undoubtedly have a negative impact,” says Dr Stack.

His research identified some important structural supports that reinforce how economic policy impacts the prevention of suicide and mental ill-health. This includes unionised workforces, minimum wages laws and financial and nutritional assistance for those in need.

While the proportion of people who belong to a union has been declining in most OECD nations since 2000, there is still a large gap between the US (9.9%) and the mean for a European sample (33.7%). Dr Stack says that unions continue to provide a voice for economic security, which is an important factor in suicide prevention. “At the state level, they advocate for laws regarding economic security such as minimum wage and anti-union laws such as Right to Work.”

There is also considerable variation in the American minimum hourly wage, ranging from $7.25 to $16.10. An increase in the minimum wage has been shown to be associated with a 2% – 6% decrease in suicide rates. Dr Stack explained that persons with a high school education or less are especially helped through this mechanism. A $1.00 inflation-adjusted increase in the minimum wage is associated with a 5.9% reduction in suicide for this high-risk group. 

Providing federal assistance has also been correlated with decreasing economic stress. The Supplemental Nutrition Assistance Program (SNAP) (formerly food stamps) can help reduce economic stress by reducing food insecurity among people experiencing poverty. It was funded for $55.1 billion and reached 35,700,00 recipients in 2019. A recent analysis of data (Austin, et al., 2023) found that elimination of both the asset test and increases in the income limit for eligibility were associated with an 8% reduction in past year major depression episodes, 9% reduction in serious mental illness and 11% reduction in suicide ideation.

Temporary Assistance to Needy Families (TANF)and/or Aid to Families with Dependent Children, which provides cash transfers to qualified impoverished families, supported 920,000 families in 2019. It was funded by $20.4 billion in federal funds in 2019, about one-third of the federal funding for SNAP ($65.5 billion). 

As shown in the following chart, since the late 1990s, the percentage of a state’s poverty population that received TANF has declined. This decline may be part of what drives the American suicide rate upwards through 2022.

Dr Stack says that although suicide rates have been increasing nationally (45% between 2000-2019), state programs to improve economic security for low-income people have held back suicide rates. “This is particularly apparent in states aggressively adopting such programs (minimum wage, SNAP, EITC, TANF).

In an effort to guide governments in meeting these challenges and ensure that future economic downturns do not result in an increase in mental ill-health and suicide, Sinyor and colleagues identify a set of guiding principles that call for greater focus on understanding what works and at what cost. Among the principles is the need to avoid austerity measures, enhance economic protections and prioritise efforts to foster social cohesion (encouraging people to offer support to others in financial difficulty).

The full raft of the principles are supported by World Health Organisation Director General, Dr Tedros Adhanom Ghebreyesus, in his message in the World Mental Health Report Transforming Mental Health for All. “We need to transform our attitudes, actions and approaches to promote and protect mental health and to provide and care for those in need. We can and should do this by transforming the environments that influence our mental health ….”

Today, governments across the globe are grappling with the ongoing challenge of mental ill-health arising from the COVID-19 epidemic. This will be further exacerbated by the wars in Ukraine and the Middle East. The evidence presented by Dr Stack and Professor McDaid shows that it is timely to examine how assessing investment across social, economic and health systems might help to reduce those impending challenges.