Life and death under austerity
When Mark Wood was found dead in his home in August 2013 it could have been just another tragic, but private, event for one family. But it wasn't. His death came a few months after his disability benefits had been cut because he had been declared "fit for work" by the assessors appointed by the government to implement its "back-to-work" strategy. When his body was discovered he weighed just 5 st 8 lbs.
His sister Cathie said that 44-year-old Mark had struggled to live on just £40 a week after his disability and housing benefits were cut. She says that his ongoing mental health problems, including anxiety, obsessive traits and an eating disorder, were seriously aggravated by the extra stress. A letter to the Jobcentre written by Mark's GP at the time his benefits were being cut was presented at the inquest into his death. In it, his doctor cautioned that Mark was "absolutely unfit for any work whatsoever". At the inquest, the GP told the coroner that, in his view, the loss of benefits was an "accelerating factor" in Mark's decline and eventual death.
The circumstances surrounding Mark's death hit the UK headlines after his family launched a campaign calling on the government to rethink its cuts and other austerity-driven policy reforms. Yet his case is far from isolated. People have died from physical illnesses that have got worse after being subject to a Work Capability Assessment or having their benefits cut, and some have even taken their own lives.
In August 2015, after a number of Freedom of Information requests, the government released mortality statistics on people who had died after being declared fit for work. The data did not cover how they died, and the government warned against any causal links being made between the deaths and the assessments, but the episode prompted calls for ministers to commission analysis so that any potential connections could be understood.
In the UK, suicide rates rose in 2011 and 2012 (the most recent data available). Men especially seem to be at risk: the male suicide rate is the highest it's been since 2001 and, for men between the ages of 45 and 59, the highest since 1981. After five years of austerity in the UK – and with billions of pounds more of budget cuts on the way – families, charities, mental health professionals, campaigners and researchers have been highlighting what they regard as the profound effects of austerity on mental health. In May this year, the chief executive of one of the biggest mental health charities in Britain warned that cuts to service provision along with welfare reforms tied to austerity were "driving people to the edge".
But what evidence is there for a link between economic difficulties and mental ill health? What is it about UK austerity measures – namely cuts and changes to public services put in place to reduce government borrowing – that is raising so many alarm bells when it comes to mental wellbeing? And what lies in store if the direction of travel stays the same?
Above a row of shops in a bustling high street in south London are the offices of CoolTan Arts, a grassroots mental health charity. Inside is a small group of men and women, sipping tea and eating biscuits around the kitchen table.
Everyone here has first-hand experience of living with mental health problems and some have multiple disabilities. When we meet, the UK's general election has just taken place and everyone present is anxious about what will happen. The new Conservative majority government has pledged to shrink social security spending by an additional £12 billion – on top of the billions already cut since 2010. In July 2015, the Chancellor's second Budget in four months outlined plans for a raft of new reforms, including a freeze on working-age benefits for four years and cuts to Employment and Support Allowance for new claimants deemed capable of "work-related activity".
People living with mental health problems are among the vulnerable groups that have found themselves at the sharp end of austerity measures introduced after the biggest recession and worst recovery in almost a century.
The cuts to mental health budgets and changes to the benefits system, including tough "back-to-work" policies ushered in by the coalition government formed in 2010, are never far from the minds of those at CoolTan. Punitive financial sanctions, where proportions of benefits are withheld (sometimes for years if people can't comply with strict rules for finding a job), have been adding to ever-greater anxiety.
"My worst enemy is the postman," Adam says, describing what it's like waiting to hear if he has been sanctioned. "When I hear the letterbox go, I tell you it's just like earthquakes. I can't bear it." Often, Adam says, he doesn't open the envelopes when alone because he is terrified of having a panic attack. "What they don't realise is they keep putting you through the mill."
With fewer places to turn for help, George says he fears for the future. The others around the table nod. They agree that, in a climate of continual cuts and political rhetoric that classifies people who don't work as outcasts, they would be "lost" without the help of CoolTan, collateral damage in a society that no longer values them.
The experiences of the people at this one small charity are far from an anomaly. Research published in September by Mind, the UK's largest mental health charity, reported that for people with mental health problems the government's flagship back-to-work scheme, the Work Programme, made their distress worse in 83 per cent of cases.
My own research interviewing hundreds of people across the UK during the first wave of austerity produced consistently similar insights. I encountered people, usually but not always in more deprived areas, living in daily dread of losing their benefits, homes, livelihoods and, in some cases, their ability to cope as the mental strain overwhelmed them.
Typical comments people made in interviews between 2012 and 2015 include this from Dec, a single parent in Luton who was struggling to find work. "There's people who are suicidal," he told me, holding back tears. "There's people with mental health problems – and if they didn't have mental issues before, they have them now because they are being so degraded."
And this from Maria, a severely disabled young woman from London who required 24-hour support: "There were many occasions when I wanted to stop existing and didn't know how I would get through the day," she said, explaining how she felt after being told by her local council that funds were being cut and that she had to be reassessed for care.
Both the coalition government of the Conservatives and Liberal Democrats formed in 2010 and the Conservative government in power since the 2015 election have defended cuts in a number of areas, including welfare, as being necessary in order to tackle government borrowing.
They have also said that the most vulnerable are offered protection. Responding to concerns raised about the mental stress associated with changes to welfare, a spokesperson for the Department of Work and Pensions said: "It's important we don't simply write off people who have a health condition to a life on benefits, which is something that has happened in the past.
"We provide unconditional support to those who can't work, and jobs support to those who can – for example through the £40 million we're investing in Jobcentres for people with mental health conditions. Our reforms are fixing the welfare system to ensure it promotes work, helps people lift themselves out of poverty and puts public spending on a more sustainable footing."
The price of austerity
No matter where in the world you are, look at the research and the evidence is clear: economic strain contributes to mental health difficulties – especially during recessions, when unemployment and poverty tend to jump.
What's more, people already living with mental health difficulties are likely to suffer disproportionately in times of recession – not just because funding for services might be cut, but also because they are at higher risk of losing their jobs.
The so-called Great Recession showed just how serious and widespread the impact of economic turmoil on mental health could be. One US study found a "significant and sustained" increase in major depression among adults between 2005–06 and 2011–12, during which time millions of Americans lost their jobs and their homes.
Another study exploring the effects of the 2008 financial crash reached some stark conclusions. Analysing data from 24 EU countries, the USA and Canada, the researchers reported that, by 2011, the economic crisis had already led to over 10,000 more suicides than would have been expected – which they called a "conservative estimate". The downward trend in suicide rates seen in the EU before 2007 went into reverse when the financial crisis hit, rising 6.5 per cent by 2009. In the US the rate increased by 4.8 per cent over the same period.
Yet the study also showed that the trends were not uniform: many countries did not see any increase in suicide rates. The researchers suggested that a range of interventions – from back-to-work programmes to prescriptions for antidepressants – may reduce the risk of suicide during future economic downtowns.
What of the specific effects of large-scale government cuts? In The Body Economic, Sanjay Basu and David Stuckler examined health and economic data over decades, concluding that austerity was bad for both physical and mental health. "If austerity were tested like a medication in a clinical trial, it would have been stopped long ago, given its deadly side effects… One need not be an economic ideologue – we certainly aren't – to recognize that the price of austerity can be calculated in human lives," they wrote in the New York Times.
They went on to argue that countries that have chosen stimulus over austerity, such as Germany, Sweden and Iceland, have had better health outcomes than countries such as Greece, Italy and Spain, where austerity measures have been used. "If suicides were an unavoidable consequence of economic downturns this would just be another story about the human toll of the Great Recession," they concluded. "But it isn't so."
Greece – a country with traditionally lower suicide rates than other European nations – has felt the impact of austerity more than most. A landmark study led by Professor Charles Branas of the University of Pennsylvania incorporated a 30-year month-by-month analysis of suicides in Greece, ending in 2012. The researchers looked at possible links between suicide data and particular prosperity- and austerity-related events over the three decades, including the acceptance of Greece into the EU, the 2004 Athens Olympic Games, and the passing of austerity measures by the government.
While cautious not to link the cause directly to austerity, the researchers found "a significant, abrupt and sustained increase" in suicides following austerity-related events like announcements of spending cuts and violent protests against them. Across the decades studied, 2012 was the peak year for suicides in Greece.
From as early as 2011, the charities Sane and the Depression Alliance were reporting concerns about links between financial woes, austerity policies and rising stress and depression.
Many organisations, including one run by disability activists, began flagging up how a plethora of local government cuts and welfare reforms such as the Work Capability Assessment were creating unnecessary and sometimes intolerable stress for both physically disabled and mentally ill people.
The Work Capability Assessment in particular was generating widespread tension, according to many frontline welfare workers and campaigners. The reasons were complex and multiple. Among them was, as in the case of Mark Wood, the fact that the assessment did not take into account medical evaluations by GPs before decisions were made about a person's fitness for work. The assessments often led to a reduction in benefit payments. So many decisions were being overturned on appeal that campaigners called for a complete overhaul of the system.
Nick Dilworth is a frontline welfare advice worker and longstanding critic of the government's back-to-work strategy who also monitors and analyses welfare statistics. He summed up the reality of dealing with the consequences: "People are coming in with multiple problems. You get grown men crying. What you see are broken lives."
In addition, sanctions, which were causing significant stress, soared after 2010, while Jobcentre workers began speaking out about what they say was an increasingly punitive regime that was adding to the mental stress of both claimants and workers. As Angela Neville, a Jobcentre worker who went on to write a play about it, explained to me in February 2015: "From my own experience, staff are subjected to constant and aggressive pressure to meet and exceed targets. Colleagues would leave team meetings crying." On the fallout after sanctions were applied, she said: "It was very distressing to have customers literally without food, without heat, without resources – and these are unwell [and] disabled customers."
Picking up the pieces
Mental health services in the UK are notoriously underfunded and are often referred to as a "Cinderella service". According to the Centre for Economic Performance, mental health services receive just 13 per cent of the total NHS budget, while mental illness is responsible for 23 per cent of the loss of years of healthy life caused by all illness nationwide. Under the coalition government of 2010–15 there were numerous moves to place mental health at the top of the wider health agenda. A variety of pledges and initiatives were made, many championed in particular by the then Deputy Prime Minister, Nick Clegg. Proposals that included, for the first time, specific waiting-time targets for people seeking treatment from mental health services were widely seen as a step forward. So too was a commitment to invest more in young people's mental health provision.
However, mental health provision was hit hard and early by austerity measures. Despite rising demands for help, including from people in crisis or feeling suicidal who were turning up at A&E departments ill-equipped to deal with them, mental health services and the people relying on them were feeling the impact. Organisations from Oxfam to activist groups such as Disabled People Against Cuts and War on Welfare warned of an unprecedented "perfect storm" of falling incomes, rising costs and the removal of vital safety nets, including for mental health and disability, just when the pressure on individuals and families was skyrocketing.
The numbers back this up. In 2011, three years after the financial crisis, the number of prescriptions for antidepressants rose sharply, up 43 per cent on the previous year. One investigation found that more than 2,000 acute mental health beds were lost in England between 2011 and 2013. This meant that many people in crisis who didn't have a safe place to be had to be transported hundreds of miles to wherever a bed became available. Some patients were even held in police cells.
By 2015, funding for mental health services was estimated to have fallen in real terms by 8.25 per cent over four years. Three-quarters of children and young people with a mental health issue could not access treatment when they needed it. Charities warned that this was also storing up problems for the future because it prevented early intervention, something proven to be crucial for young people's recovery prospects. In June 2015, Liberal Democrat Norman Lamb, who as Minister for Health until the election in May was a key proponent of improving investment in mental health, warned that if the new government failed to stick to pledges to increase funding, mental health would remain "the poor relation" in the health system.
Meanwhile it was reported that calls to mental health helplines from people citing financial problems shot up in line with personal indebtedness. Reports, including a number from the Centre for Welfare Reform, catalogued how policies such as the "bedroom tax" (where benefits can be reduced if someone is deemed to have a "spare" bedroom in their council or housing association home) were "savaging" people's mental health. GPs reported a surge in patients with stress and anxiety due to worsening economic predicaments and joblessness.
On the front line of mental health, the strain of five years of austerity became such that hundreds of health professionals took to writing to newspapers about it. In one highly critical letter to the Guardian on the government's public health record, senior physicians linked austerity policies to rising suicides, concluding that "over the last five years, there have been avoidable deaths and much unnecessary damage to health".
In another letter, published just before the 2015 election, 442 professionals ranging from psychologists to epidemiologists wrote: "The past five years have seen a radical shift in the kinds of issues generating distress in our clients: increasing inequality and outright poverty, families forced to move against their wishes, and, perhaps most important, benefits claimants (including disabled and ill people) and those seeking work being subjected to a quite new, intimidatory kind of disciplinary regime."
Psychologists Against Austerity, a new alliance of mental health professionals, had formed with the aim of directly challenging the cuts and welfare changes that they said were adding to mental distress. The group produced a briefing paper that includes five "austerity ailments" it believes contribute to worsening mental despair. These are: humiliation and shame, instability and insecurity, isolation and loneliness, being trapped or feeling powerless, and fear and distrust. The authors conclude: "Mental health problems are being created in the present, and further problems are being stored for the future."
One group of researchers believes that a serious political-cultural shift is taking place within the welfare system, and that it is having serious ramifications for mental health. In a paper published in 2015, Dr Lynne Friedli and colleagues documented their findings on the impact of back-to-work policies, notably psychological assessments of unemployed individuals' fitness for work.
"Psychological explanations for unemployment… isolate, blame, and stigmatise unemployed people. They reinforce myths about 'cultures of worklessness'," Frieldli wrote. "They obscure the realities of the UK labour market and the political choices that underpin it."
Life and death
When the impacts of austerity are discussed in the UK, deaths feature prominently. Like Mark Wood, some of the people who have died had a history of mental health problems. Others didn't. And there are many, many stories. In one case, a man doused himself in petrol outside a Jobcentre after being declared fit for work and experiencing benefits delays. Police arrived in time to save him.
A woman died two days after trying to take her own life. Her doctor told the inquest that a letter stating that her incapacity benefits were to be withdrawn had precipitated the suicide attempt.
A pensioner in his 70s was believed to have killed himself due to fears about the "bedroom tax". Witnesses testified to the inquest that he was frightened by news reports that said people might lose their homes if they couldn't pay it.
The issue of deaths related to welfare reform and austerity, be they a result of suicide or otherwise, is complex and controversial. There have been escalating calls from families and campaigners for a full public investigation into deaths that followed cuts to benefits or the implementation of sanctions in order to find out what connections there may be. And when, in September this year, a coroner in north London concluded that the suicide in 2013 of 60-year-old disabled man Michael O'Sullivan was a direct result of having been wrongly found fit for work, there were yet more calls for the Department for Work and Pensions to overhaul fitness-for-work assessments. The coroner said: "[His] anxiety and depression were long-term problems but the intense anxiety that triggered his suicide was caused by his recent assessment… as being fit for work, and his view of the likely consequences of that."
Journalist John Pring, who lives with a mental illness and runs the website Disability News Service, has been one of those labouring for full disclosure of "internal peer reviews" conducted by the Department for Work and Pensions into deaths (49 cases had been reviewed by June 2015). Some details have been released, he says, but not full reports, which would facilitate a better understanding of the circumstances and, he argues, how to prevent future deaths.
More research and better data are needed to ascertain fully the connections between recessions and austerity and suicide, but mental health strains are clearly exacerbated by economic factors, according to Joe Ferns, Director of Policy and Research at Samaritans.
Part of the problem, he says, is that stresses such as financial pressures or losing a job make people feel "disempowered" and "less able to cope". But people can be affected by the community around them too. "What the research does show," says Ferns, "is that people living in deprived areas are about ten times more likely to die by suicide… I think it's fair to say that an economic recession creates ripples. The social impacts spread far wider and last far longer than the economic ripples."
However, more research will take time and, as epidemiologist Sanjay Basu has pointed out, there is already considerable evidence of serious and deleterious effects, which, as a matter of urgency, require robust policy responses, not least because people's lives are on the line. Basu says his work has persuaded him that the stakes of austerity for mental health are very high indeed. "I think the real decision for us is whether we want to pay now or pay later. I think we can either pay now in terms of creating the social safety nets in order to avoid a real dismantling of some of the key parts of our communities or we'll face the consequence for many years."
Charities, healthcare professionals, academics and those on the front line agree: act now, or suffer more later. The Department of Health told me that they are tackling "historic underfunding" in mental health, increasing investment in the area by £300 million last year. They mentioned that "more people than ever before" are receiving talking therapies and that the government's Suicide Prevention Strategy is backed by £1.5 million funding for research.
But will this be enough to stop people dying because, at least in part, of the UK's austerity measures? At CoolTan Arts, one woman makes a point that's hard to ignore. "I think it's going to get much worse," says Jane. "This government has got another full term and you don't know what their plans are."
Back in Oxford, Mark Wood's sister Cathie says there is only one thing to do: keep fighting. "We are now trying to get answers and just keep the pressure up so people know the human cost of the cuts, and that we are becoming a crueller, more backward society in terms of how we treat our most vulnerable people."
This story first appeared on Mosaic and is republished here under a Creative Commons licence.