The World Health Organisation (2014) has defined mental health as:

‘a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community’

Feelings of well-being and life satisfaction are linked with good health. Positive feelings about one’s life (self-esteem, control, resilience and a sense of purpose) influence levels of mental well-being, which in turn impact on physical and mental health. Being in good mental health (especially early in life) can reduce inequalities, improve physical health, reduce health-risk behaviour and increase life expectancy (one study^[1] found by 7.5 years), economic productivity, social functioning and quality of life.^[2] Positive mental health reduces the incidence and impact of mental illness. Good mental health and personal resilience protect against self-harm and suicide.

Mental health problems range from the worries we all experience as part of everyday life to serious long term conditions. They can start early in life, often as a result of deprivation including poverty, insecure attachments, trauma, loss or abuse.^[3] Risk factors for poor mental health in adulthood include unemployment; lower income; debt; violence; stressful life events; and inadequate housing.

Risk factors for poor mental health disproportionately affect people from higher risk and marginalised groups. Higher risk groups include looked-after children; children who experienced abuse; black and ethnic minority individuals; those with intellectual disability; homeless people; new mothers; lesbian, gay, bisexual and transgender people; refugees and asylum seekers and prisoners.^[4]

An estimated 1 in 4 people in the UK will experience a mental health problem each year (Mind, 2016), which could include anxiety or depression. In the National Survey for Wales, 9% of respondents living in North Wales reported being treated for a mental illness (2018-19 & 2019-20).

The mental component summary score is a self-reported estimate of a person’s own mental health, where higher scores indicate better health. During this period people in Conwy reported higher than average mental health and Denbighshire reported average mental health, when compared to the rest of Wales.^[5] The percentage of adults (16 years and over) reported being currently treated for a mental illness, during 2018-19 and 2019-20 combined was 7% in Conwy County Borough and 11% in Denbighshire. The average for North Wales and Wales was 9% and 10% respectively.^[6]

The number of admissions to mental health facilities has been reducing. There has been an overall decline in the number of admissions in North Wales. It is not possible to tell from this data whether that decline is due to a reduction in demand or a reduction in the availability of acute mental health beds. The model for mental health care has changed in recent years and there are more alternative to bed based care particularly for older persons. Admissions have been reducing but it should be caveated that demand is not reducing but is being directed elsewhere such as in the community.^[7]

Children and young people’s mental health

Mental health problems can begin in childhood and can have lifelong impacts, such as poor educational attainment, a greater risk of suicide and substance misuse; antisocial behaviour and offending.

Risk factors include parental alcohol, tobacco and drug use during pregnancy; maternal stress during pregnancy; poor parental mental health; a parent in prison and parental unemployment. Children who experience child abuse; looked-after children; young offenders; children with intellectual disability; 16-18 year olds not in employment, education or training (NEET); young carers and young people with a physical illness are also at higher risk of mental illness (Royal College of Psychiatrists, 2010).

Predictions from Daffodil show the number of children and young people with mental disorders in Conwy County Borough was around 1,445 in 2020. In Denbighshire it was around 1,300. The number is predicted to decrease over the next 20 years to around 1,325 in Conwy County Borough and 1,175 in Denbighshire in 2040.^[8] This is due to a decrease in the number of children and young people, and not due to an expected decrease in mental health disorders.

Prior to the Covid-19 pandemic, one in five (19%) of young people in Wales reported mental health symptoms. The pandemic has exacerbated mental health and well-being issues for children and young people.  Research undertaken by Public Health Wales found that the pandemic had an overwhelmingly negative impact on all aspects of mental well-being among children and young people. A key area of concern identified by the Welsh Government Children, Young People and Education (CYPE) Committee is that there is a gap in provision for what it calls ‘the missing middle’. This refers to children and young people who require mental health support, but may not be unwell enough to meet the criteria for services. More information is available in the North Wales Population Needs Assessment.

Early experiences may have long-term consequences for the mental health and social development of children and young people (Public Health Wales, 2016b).

Mental health and well-being

People with mental health problems can enjoy good mental well-being, while some people without a diagnosed mental health problem may have poor mental well-being. However, people with mental health problems are more likely to have poor physical health. Mental ill health is associated with physical ill health, reduced life expectancy and vice versa (Royal College of Psychiatrists, 2010). Poor mental health is also associated with increased risk-taking behaviour and unhealthy life-style behaviours such as smoking, hazardous alcohol consumption, drug misuse and lower levels of physical activity (Welsh Government, 2012).

A person’s mental health can impact on physical well-being. For example, current research suggests that smoking 20 cigarettes a day can decrease life expectancy by an average of ten years. While the prevalence of smoking in the total population is about 25 to 30 percent, the prevalence among people with schizophrenia is approximately three times as high – or almost 90%, and approximately 60% to 70% for people who have bipolar disorder. Mortality rates for people with Schizophrenia and bipolar disorder show a decrease in life expectancy of 25 years, largely because of physical health problems.^[9]  Obesity, poor diet and an inactive lifestyle are also contributory factors associated with severe mental illness and poor physical health.

Some types of behaviour arising from poor mental health can specifically increase the risk of fire and decrease the person’s ability to escape safely. Compulsive behaviours such as hoarding and or blocking up doors and windows cause fire hazards for example. The social isolation that can be associated with poor mental health increases the risk of a fire starting or spreading unnoticed, and also reduces the person’s chances of escaping unharmed.

Poor mental health has been reported as an amplifying factor in a range of areas of public sector work that have been discussed whilst consulting with service providers across North Wales during the preparation of our previous well-being assessment. It was and continues to be an area of key concern for all partner agencies. These include helping families in difficulty, supporting learners with their education, homelessness presentations, incidents of domestic violence, substance misuse cases (including alcohol), reports of anti-social behaviour, dealing with poor parenting skills, and supporting people into work. A lack of co-ordination between health, social care and other welfare providers (e.g. social housing) can cause compound problems for sufferers, their family, friends and the community they live in, and for the service providers.

The mental health and well-being of individuals can be improved by increasing emotional resilience through interventions designed to promote self-esteem and life coping skills across all stage of life, from infancy to old age.^[10] Understanding how services and community assets can promote and strengthen these core protective factors is crucial to optimising population mental well-being. Another concept which brings together evidence based actions to promote mental well-being is the ‘5 Ways to Well-being’. It describes five daily actions that individuals, families, and communities can take to maintain and improve their well-being. They can also be built into the design and delivery of existing services and interventions:

1. Take notice.
2. Connect.
3. Be active.
4. Keep learning.
5. Give.

Suicide and self-harm

Self-harm is when somebody intentionally damages or injures their body. It’s usually a way of coping with or expressing overwhelming emotional distress. It is an area of growing concern, particularly amongst children and young people. The different ways people can intentionally harm themselves include cutting or burning their skin; punching or hitting themselves; poisoning themselves with tablets or toxic chemicals; misusing alcohol or drugs; deliberately starving themselves (anorexia nervosa) or binge eating (bulimia nervosa); excessively exercising.

It is difficult to draw conclusions from the available data on suicide in North Wales due to the small number of cases and other caveats. None of the local council areas in North Wales have suicide rates for those aged 10 years and over which are statistically significantly higher than the Wales average (Jones et al., 2021). Around three-quarters of registered suicide deaths in 2020 were for men, which follows a consistent trend back to the mid-1990’s (Office for National Statistics, 2020).

The causes of suicide are complex (Jones et al., 2021). There are a number of factors associated with an increased risk of suicide including gender (male); age (15 to 44 year olds); socio-economic deprivation; psychiatric illness including major depression; bipolar disorder; anxiety disorders; physical illness such as cancer; a history of self-harm and family history of suicide.^[11] There are a number of ways in which mental health care is safer for patients, and services can reduce risk with: safer wards; early follow-up on discharge, no out-of-area admissions; 24 hour crisis teams; dual diagnosis service; family involvement in ‘learning lessons’; guidance on depression; personalised risk management; low staff turnover (Centre for Mental Health and Safety, 2016). Many people who die by suicide have a history of drug or alcohol misuse, but few were in contact with specialist substance misuse services. Access to these specialist services should be more widely available, and they should work closely with mental health services (Centre for Mental Health and Safety, 2016).

Farmers are identified as a high risk occupational group, with increased knowledge of and ready access to means (also doctors, nurses and other agricultural workers). Certain factors have been identified as particularly creating risk and stress to people living in rural areas over and above the suicide risk factors affecting general populations: isolation, declining incomes, being different within the rural context; heightened stigma associated with mental health issues; barriers to accessing appropriate care (culture of self-reliance, poor service provision) poor social networks; social fragmentation; availability of some means of suicide (firearm ownership); and high risk occupational groups such as farmers and vets (Welsh Government, 2015a). Specific support for farmers has been launched, more information can be found via this link – Mental health support available to young farmers – Farmers Weekly (fwi.co.uk)

The Welsh Government suicide and self-harm prevention strategy is Talk to me 2 and there is the North Wales Suicide and Self-harm Working Group that coordinates work on suicide prevention for the region.

Covid-19 impact

It is now clear that the pandemic has had a significant impact on the population’s mental health as a whole. For those with existing mental health conditions, they are more likely to have experienced a deterioration in well-being. A survey by Mind Cymru^[12] stated that more than half of adults and three quarters of young people reported that their mental health had worsened during lockdown periods.

Groups that experienced a disproportionate effect include:

• People with existing needs for mental health support.
• People on low incomes, people who have seen their employment status change or are self-employed.
• NHS and care workers, and other front line staff.
• Black, Asian and minority ethnic communities.
• Older adults.
• Children and young people.

A report by the Senedd in December 2021 stated that the long term impact of planning to meet a potential increase in demand for mental health services is difficult to predict. The Centre for Mental Health has predicted that around 20% of the population (analysis in relation to England, but likely to be applicable to Wales) will require new or additional mental health support.

Although mental health services were categorised as essential during the pandemic, many have reported that they were unable to access services or that there was a delay in seeking help and support.

Key drivers of worsening mental health and well-being as a result of the pandemic have been:

• Job and financial loss
• Social isolation
• Housing insecurity and quality
• Working in a front-line service
• Loss of coping mechanisms
• Reduced access to mental health services^[13]

The ONS reported that prior to COVID-19 (in the year ending June 2019), the average rating for anxiety was 4.3 out of 10 for disabled people. Disabled people’s average anxiety rating increased following the outbreak of the Covid-19 pandemic to 5.5 out of 10 in April 2020, before decreasing to 4.7 out of 10 in May 2020. 41.6% of disabled people, compared with 29.2% of non-disabled people, continued to report a high level (a score of 6 to 10) of anxiety in May 2020.

Impact on older people

One in three older people agree that their anxiety is now worse or much worse than before the start of the pandemic. The proportion of over 70’s experiencing depression has doubled since the start of the pandemic.

Equality and mental health: “Inequality is one of the key drivers of mental health and mental ill health leads to further inequality”

The core protective factors that influence mental well-being include promotion of social inclusion. It is known that groups who share the protected characteristics are more likely to experience social exclusion and this will need to be factored into the assessments for individuals. Mental health has a huge amount of intersectionality with other protected characteristics. For example, people from Minority Ethnic groups are more likely to be sectioned under the Mental Health Act (Race and Mental Health – Tipping the Scale, Mind, 2019). Around 30% of people with a long-term physical health condition also have a mental health condition, most commonly depression or anxiety (Kings Fund, 2020).

Mental health problems can start early in life, often as a result of deprivation, poverty, insecure attachments, trauma, loss or abuse (Welsh Government, 2012). Risk factors for poor mental health in adulthood include unemployment, lower income, debt, violence, stressful life events and inadequate housing (Royal College of Psychiatrists, 2010).

In Wales, 24% of those who are long-term unemployed or have never worked report a mental health condition, compared with 9% of adults in managerial and professional groups. A recent study found more patients who died by suicide were reported as having economic problems, including homelessness, unemployment and debt (Centre for Mental Health and Safety, 2016).

Risk factors for poor mental health disproportionately affect people from higher risk and marginalised groups. Higher risk groups include, looked-after children; children who experienced abuse; black and ethnic minority individuals; those with intellectual disability; homeless people; new mothers; lesbian, gay, bisexual and transgender people; refugees and asylum seekers and prisoners (Joint commissioning panel for mental health, 2013).

Having a wide support network, good housing, high standard of living, good schools, opportunities for valued social roles and a range of sport and leisure activities can protect people’s mental health (Department of Education, 2016).

[1] Danner D D, Snowdon D A, Friesen W V (2001) Positive emotions in early life and longevity: findings from the nun study. Journal of Personality and Social Psychology, 80:804–813.

[2] Royal College of Psychiatrists Position statement PS4 (2010) No health without public mental health: the case for action. http://www.rcpsych.ac.uk/PDF/Position%20Statement%204%20website.pdf

[3] Royal College of Psychiatrists (2010) ‘No health without public mental health, the case for action’. London: Royal College of Psychiatrists.

[4] Guidance for commissioning public mental health services’ Joint commissioning panel for mental health 2013

[5] Source: StatsWales table hlth5012, National Survey for Wales, Welsh Government

[6] Source: StatsWales table hlth5052, National Survey for Wales, Welsh Government

[7] Source: Welsh Government, admissions, changes in status and detentions under the Mental Health Act 1983 data collection (KP90), StatsWales table HLTH0712

[8] Source: Daffodil – Estimated number of children (age 5-16), with any mental health problem, 2020

[9] Together for mental health: a strategy for mental health and well-being in Wales’, Welsh Government 2012

[10] K. Tudor, ‘Mental Health Promotion: Paradigms and Practice’, 1996

[11] Price, S., Weightman, A., Morgan, H., Mann, M. and Thomas, S. (2010) ‘Suicide prevention: update of the summary of evidence’. Public Health Wales

[12] Mind, June 2020 – A Mental Health Emergency: How has the coronavirus pandemic impacted our mental health?

[13] BCUHB Covid-19 infographic North Wales Population Needs Assessment.