Introduction

What are the key equity issues and who is at risk?

• Socioeconomic disadvantage – The National Survey of Mental Health and Wellbeing identified that ‘the proportion of people who reported having mental problems increased as levels of socioeconomic disadvantage increased’. In 2007–08, 16% of people living in the most disadvantaged areas had a mental or behavioural problem, compared with 11% of people living in the least disadvantaged areas. The likelihood of depression among low socioeconomic status (SES) persons is almost double that of SES persons (most marked for persistent depression). ^3,5,7 Anxiety and affective disorders are more common in unemployed people. ^8,9 In patients with chronic disease and disability, lower educational level and unemployment are predictive of depression. ^10,11
  • Practices in disadvantaged areas have a higher prevalence of depression to identify and manage. Mental health services overall are used at lower rates by the socioeconomically disadvantaged, possibly related to low health literacy and stigma.^12–14
  • Suicide and attempted suicide are consistently associated with markers of SES disadvantage including limited educational achievement and homelessness.^15,16
• Aboriginal and Torres Strait Islander peoples – Aboriginal and Torres Strait Islander peoples are known to be at greater risk of morbidity and mortality from mental health–related conditions affecting social and emotional wellbeing. Aboriginal and Torres Strait Islander peoples are hospitalised for mental health problems at twice the rate of non-Indigenous Australians and experience twice the rate of suicide, rising to five times the rate in the 15–19 years age group.¹⁷ Very high psychological distress in Aboriginal and Torres Strait Islander communities may be related to the risk factors of chronic stress and exposure to violence, racism (including within the health system¹⁸ where all concerned have a role to ensure this does not happen), and marginalisation and dispossession.¹⁹
• Culturally and linguistically diverse patients (CALD) – Differences in the way depression is understood and presented may create barriers to accessing effective depression care for patients from non–English-speaking and culturally diverse backgrounds.²⁰
• Age – Income-related inequalities in the prevalence of psychological distress and common mental health conditions are particularly common in midlife.²¹ With advancing age, socioeconomic inequities lead to an increase in anxiety and depression. Young people with a low level of education have the greatest likelihood of experiencing chronic depression and progression from anxiety to depression. Socioeconomic disadvantage is associated with both the incidence and chronic nature of depression and anxiety symptoms in older adults.²²
• Childbirth – Postpartum depression and poor childbirth outcomes are associated with socioeconomic disadvantage.²³ Postpartum depression is more common in women from CALD backgrounds and these women are less likely to receive help.²⁴ Immigrant women experience many barriers to accessing high-quality, equitable care and are especially vulnerable to stress in the postpartum period, which may result in postnatal depression.^25,26

What can GPs do?

• Refer to the general principles of providing patient education and supporting health literacy in disadvantaged groups (refer to preamble).
• Be aware of the associated stigma of mental illness if offering opportunistic screening for depression to disadvantaged groups.
• Refer to The Royal Australian College of General Practitioners’ (RACGP) National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people for important information on offering mental health care to Aboriginal and Torres Strait Islander patients.²⁷
• Assist women to achieve optimal postpartum health by linking them into social and medical supports, improving their health literacy and self-efficacy, and promoting positive coping strategies and realistic expectations.²⁸ Early screening and treatment of women with perinatal mental illness can alleviate symptoms and decrease comorbid disease risk.²⁹ Culturally appropriate, individual-level interventions may be important.³⁰