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Chapter 8 Disability and Mental Health

Introduction

According to recently published data just under one in five adults in Scotland have a disability and/or a long-term illness (Scottish Executive, 2004i). Against this background this chapter has a two-fold purpose: to explore the social and economic consequences of having a mental health problem; and to map out the implications for mental health inequalities of physical disabilities, including sensory impairments.

To include people with mental health problems in a section on disability may seem, in some respects, idiosyncratic. The concept of disability is often associated with physical impairments, and people with mental health problems may not see themselves, or may choose not to see themselves as 'disabled' (Beresford et al, 2002; McFarlane, c2000; SEU, 2004). However, for the purposes of the Disability Discrimination Act (1995) ( DDA) 'A person has a disability if he has a physical or mental impairment which has substantial and long-term adverse affect on his ability to carry out normal day to day activities' (emphasis added). Although issues have been raised relating to awareness, interpretation and application of the legislation to people with mental impairments (Durie, nd; Cullen, 2004), it nonetheless provides important protections against discrimination toward people with a 'clinically well-recognised' mental illness, in relation to, for example, employment and access to goods and services. It is within this legislative context that people with mental health problems are included in this section.

In terms of the causes and consequences of mental health inequality the focus therefore needs to be on the experiences of three groups of people:

• People with mental health problems for whom the experience of mental distress may be compounded by the socio-economic disadvantage, stigma and discrimination associated with mental illness;
• People with mental health problems and physical disabilities who may be multiply disadvantaged;
• People with physical disabilities, whose experience of socio-economic disadvantage, discrimination and stigma due to their physical impairment may impact on their mental health and well being.

Reflecting the readily available evidence this chapter focuses largely on the first group: people with mental health problems. A key finding and implication is the need for
further research and analysis of the associations between physical disability and mental health inequalities.

People with Mental Health Problems: Some Indicators

Along a number of dimensions people with mental health problems are disadvantaged. For example:

Poverty and employment

• UK-wide only 24% of adults with long-term mental health problems are in work - the lowest employment rate for any of the main groups of disabled people ( SEU, 2004).
• In one study, 60% of the sample of people assessed as having a psychotic disorder had a gross weekly household income of less than £300 per week, compared with 37% of people assessed as having a neurotic disorder, and 28% of the sample with no disorder (Melzer et al, 2002).
• In the same study, two-thirds of those with a psychotic disorder were on welfare benefits, compared with one-third of those with a neurotic disorder and 10% of those with no disorder (Melzer et al, 2002).
• 35% of people coming onto Incapacity Benefit cite mental health problems as their main disability ( SEU, 2004).
• People with mental health problems are nearly three times more likely to be in debt; and one in four tenants with mental health problems has serious rent arrears and is at risk of losing their home (Melzer et al, 2002).
• Of over 550 people with mental health problems surveyed in one study, 72% of respondents defined themselves as being on a low income and half felt excluded from their local community because of their financial situation (Focus on Mental Health, 2001).
• The same study also found that 66% of respondents had difficulties making their income last all week (Focus on Mental Health, 2001). This sets in context the findings from another study that adults with mental health problems are more likely to cut down on use of the telephone, gas, electricity and water than the general population (Melzer et al, 2002).
• Less than 2% of people receiving Direct Payments in Scotland in the financial year 2003 - 2004 were people with mental health problems (Scottish Executive, 2004o; Ridley and Jones, 2002).

Housing and Homelessness

• People with a mental disorder are more likely to be living in rented accommodation (Melzer et al, 2002).
• Mental health problems are four times as common among homeless people as within the general population. At least one in five homeless people have severe mental health problems which are likely to have contributed to the person becoming homeless (Dean and Craig, 1999). Young homeless people in particular may be vulnerable to both mental health and physical health problems (Stephens, 2002).

Further and Higher Education

• In 1999-2000 only 4.5% of 1.6 million students in higher education in the UK declared a disability and only 0.12% declared a mental health disability (Royal College of Psychiatrists, 2003) ⁷

Physical Health

• People with mental health problems are at increased risk of experiencing a range
  of physical health problems. People with mental health problems are nearly twice
  as likely to die from coronary heart disease as the general population and four
  times as likely to die from respiratory diseases (Friedli and Dardis, 2002).

Suicide

• Figures reproduced by Rogers and Pilgrim suggest that the risk of suicide is 14 times greater for both men and women with a diagnosis of schizophrenia, and 12 times greater for men with a diagnosis of a major affective disorder and 16 times greater for women (Baxter and Appleby, 1999 in Rogers and Pilgrim, 2003).
• The National Inquiry into suicide and homicide by people with a mental illness found that nearly one quarter of suicides or probable suicides in Scotland over the three-year period April 1997-2000 had been in contact with mental health services one year before death. Of this group of mental health service users, 12% were psychiatric in-patients at the time of death ( DH, 2001).

Stigma and prejudice

• One study found that almost one half of a sample of people with current or past experience of mental distress had been abused or harassed in public. One-quarter felt at risk of attack inside their own homes (Read and Baker, 1996, in Mind 2004)

People with Mental Health Problems: Risk Factors

Socio-economic disadvantage

Clearly, people with mental health problems are at risk of experiencing serious socio-economic disadvantage and social exclusion. Mental health problems and exclusion can become mutually reinforcing: mental health problems can lead to unemployment, debt, homelessness, and a breakdown in social relationships, which can contribute to worsening mental and physical health ( SEU, 2004).

Studies such as that by Payne (1999) and Focus on Mental Health (2001), illustrate the compounding effects of socio-economic disadvantage and the perceived 'degrading experience' of being on a very low income.

Discrimination and stigma

For people with mental health problems, a fundamental source of socio-economic disadvantage, inequality and social isolation is the stigma and associated discrimination with which they have to deal on a day to day basis. The personal impact is illustrated by the findings from a recent Mind survey of people with mental health problems and a complementary NOP study of the general population. The Mind study found that 84% of people with mental health problems have felt isolated compared to 29% of the general population (Mind, 2004). In the same survey nearly 60% of people with mental health problems felt that isolation was linked to discrimination on the grounds of mental health. People in rural and remote areas can be even more isolated (Mind, 2004; Philo, Parr and Burns, 2003).

Taking as a framework two of the areas covered by the Disability Discrimination Act: employment and the provision of goods, facilities, services and premises and education, helps to understand just how pervasive the impact of this discrimination and stigma
can be.

Employment

The Disability Discrimination Act prohibits discrimination against disabled people in relation both to recruitment and in the course of employment, yet the picture that emerges consistently from the research is of the barriers experienced by people with mental health problems in retaining and/or gaining access to employment (Robbie and Pressland, 2003). The inter-related barriers identified include:

• Individual: for example people may lack the confidence or skills to seek employment; or are concerned about the impact of employment on their mental health. In one study, for example, nearly three-quarters of respondents felt that their mental health had affected their work prospects, some even felt it made obtaining employment virtually impossible (De Ponte, 2000; Focus on Mental Health, 2001).
• Attitudinal: Consistently people with mental health problems report being turned down for jobs because of their mental health problem (De Ponte, 2000; Warner, 2002; Read and Baker 1996, in Dunn, 1999; SEU, 2004); have experienced discrimination, stigma and prejudice on the part of employers and colleagues within the workplace, including being passed over for promotion, or bullying, isolation and derision (De Ponte, 2000; Warner, 2002; Robbie and Pressland, 2003; Cullen, 2004) or have been dismissed or forced to resign as a result of their mental health status (Mind, 2001). One study of psychiatric patients found that 80% of those employed at the time of diagnosis had lost their jobs following admission to hospital (Butterworth, 2001, in Thomas, 2002) The disadvantage is compounded by the reduced likelihood of returning to work the longer people are out of employment ( BSRM, 2000).

Because of the expected and actual experience of discrimination or stigma whether from employers or colleagues, people are reluctant to disclose their mental health status either at the stage of applying for a job or subsequently. Judgmental attitudes or lack of understanding or insight on the part of employers and colleagues can also make it difficult for employees with mental health problems to approach them if they are experiencing difficulties (McCollam, Mclean and Durie, 2003). People with mental health problems may therefore be on the horns of a dilemma. On the one hand, if they reveal that they have experienced a mental health problem, a lack of awareness among employers of the legal requirements of the Disability Discrimination Act may mean that they may not get a job, may be overlooked for promotion, experience negative attitudes within the workplace, or be asked to resign. On the other hand,
if they do not disclose their mental health history to employers they may not receive the help and support that would enable them to retain their job. More specifically, those who would qualify would lose out on the protections of the Disability Discrimination Act. Under the legislation an employer has no duty to make reasonable adjustments until the disclosure is made.

• Structural: Both the financial disincentives built into the operation of the welfare benefits system and a lack of support services to enable people to remain in, or re-enter employment act as further barriers (Durie, 1999; Robbie and Pressland, 2003; Cullen, 2004; SEU, 2004).

Provision of goods and services

Across a range of goods and services studies have found people with mental health problems to be disadvantaged. For example:

• Difficulties in accessing insurance (Read and Baker, 1996 in Dunn, 1999; Cullen, 2004; SEU, 2004; www.mind.org.uk/Information/Factsheets/Insurance.htm accessed 27 September 2004).
• Difficulties in accessing welfare benefits such as housing benefit, increasing the risk of rent arrears and eviction (Cullen, 2004).
• 'Residential sorting' with people with mental health problems being located in the same few local neighbourhoods and estates ( SEU, 2004).
• Barriers to access to education (Learning and Skills Council, 2002; SEU, 2004). According to the Learning and Skills Council 'the main barrier to learning for people with mental ill health is the widespread ignorance and prejudice about mental health' (Learning and Skills Council, 2002).
• Difficulties paying for the costs of transport (Focus on Mental Health, 2001; SEU, 2004).
• Experiencing discrimination from GPs or other health care providers (Dunn, 1999;
  De Ponte, 2000; www.mhe-sme.org/en/projects_harrassment.htm). In one study, 44% of respondents reported discrimination from GPs, 32% from other health services (De Ponte, 2000). In both cases the reported discrimination took the form of physical illnesses not being taken seriously or attributed to mental distress.

Physical ill-health

The reported discrimination by health care providers takes on particular significance given the very real physical health risks faced by people with mental health problems.

Reasons for the poor physical health of people with mental health problems include the impact on physical health of deprivation and poverty, but also associated lifestyle behaviours. Friedli and Dardis (2002) refer to data indicating that poor nutrition, obesity, higher levels of smoking, heavy alcohol use and lack of exercise contribute to higher rates of morbidity and life expectancy among people with mental health problems. This is reflected in the findings from a recent study comparing health perceptions in Gloucester. This found that people with severe mental illness had poorer self-reported health, undertook less physical activity, had poorer diets, higher body mass index and higher levels of smoking compared with the general population (Crone et al, 2004).

Mental health service users in one study in London reported that they were rarely provided with health promotion information and given little information about or offered physical health checks in a primary care setting. Further, health promotion information and services were not seen as open to people with mental health problems. Specifically in relation to smoking cessation, respondents reported little in the way of support to help them quit. The study concludes that, from the point of view of users, a key barrier to more equitable access to health promotion information, services and support was the perceived attitude of primary health care staff toward people with mental health problems (Friedli and Dardis, 2002).

Multiple identities: Multiple disadvantage

As has been described in a number of earlier chapters, the stigma and discrimination that attaches to mental illness compounds, or is compounded by other sources of disadvantage. For example,

• Women with mental health problems (see Chapter 5)
• People from black and minority ethnic communities (See Chapter 6)
• People who are lesbian, gay, bisexual or transgender (See Chapter 7)
• Older people (See for example: Wood and Bain, 2001; Scottish Executive, 2002e; NHSHealth Scotland, 2003; Joint inquiry led by Age Concern and the Mental Health Foundation into Mental Health and Well-Being in Later Life www.mhilli.org.org/inquiry)
• Children and young people (See for example: Kay, 1999; Melzer et al, 2000; Scottish Executive, 2001c; PHIS, 2003 Melzer et al, 2004; Mind, 2004)
• Men and women with mental health problems in prison or secure in-patient accommodation (Singleton, N. et al, 1998; DH, 2002)
• People with mental health problems in rural and remote areas (Philo, Parr and Burns (2003); ( RARARI/ NHS Scotland, 2003).
• People with mental health and learning disabilities (See for example: Scottish Executive, 2000c; Foundation for People with Learning Disabilities, 2002; Scottish Executive, 2002f; NHSHealth Scotland, 2004).

People with Mental Health Problems: Resilience Factors

The resilience factors that enable people to recover from mental distress and to resist the disabling effects of discrimination and stigma are the same as for everyone else (see Chapter 4): self-determination, hope, confiding relationships, access to social networks, having meaningful activity and roles, financial security and feeling safe. This implies, however, not just individual reserves, but also support services which enable individual recovery, socially inclusive 'accepting communities' (Dunn, 1999) and a legal infrastructure which enables people to participate fully as citizens.

Participants at a Scottish workshop on Recovery talked about the sorts of things that facilitated their own development including support, relationships, being enabled to make informed choices and finding a new life ( SDC, 2002).

People with Mental Health Problems: Preventing and Responding to Risk

Tackling stigma and discrimination, supporting inclusion

The Disability Discrimination Act 1995 provides the legal framework for tackling discrimination experienced by people who meet the criteria of the Act, that is, someone who has 'a physical or mental impairment which has a substantial or long-term adverse effect on his or her ability to carry out normal day-to day activities'. As noted earlier, criticisms have been made of the application and interpretation of the legislation (Cullen, 2004; Durie, nd). In December 2003 the UK Government published a Disability Discrimination Bill which includes a duty for public bodies to promote equality of opportunity for disabled people. In responding to the Draft Bill the Disability Rights Commission and the Joint Scrutiny Committee have made recommendations for changes to the legislation relating to mental health ( SEU, 2004).

Strategically, in Scotland the National Programme for Improving Mental Health and
Well-Being, encompasses, but extends beyond, people with mental health problems. Among the initiatives it supports are Choose Life, the suicide prevention strategy and See me… the anti-stigma campaign. The programme is also supporting the development of a National Recovery Network. In addition, its broader based initiatives, for example in support of community well-being have the potential to impact on the social inclusion of people with mental health problems.

Another dimension to this 'mainstreaming' approach is the inclusion within other policy areas of initiatives targeted at people with mental health problems. For example, the Healthy Working Lives Action Plan (Scottish Executive, 2004b), which aims both to improve workplace physical and mental health, and enhance individual employability. The Action Plan includes proposals for pilot job retention projects for people with mental health problems. The National Programme will fund the pilot projects.

A project to provide money advice for people with mental health problems is in development in North Lanarkshire with a view to becoming operational in 2005. This is one of a number of pilot projects supported as part of the Scottish Executive's financial inclusion strategy ( http://www.scotland.gov.uk/about/DD/SI/00017413/page82906061.aspx).

In England, the Social Exclusion Unit has published its report on Mental Health and Social Exclusion. This includes a 27-point Action Plan aimed at tackling stigma and discrimination, supporting the role of health and social care in addressing social exclusion, overcoming barriers to employment, supporting families and community participation, and ensuring access to goods and services such as housing, financial advice and transport ( SEU, 2004). A sister paper, From Here to Equality, has been produced by the National Institute for Mental Health in England ( NIMHE) setting out a five-year strategic plan to tackle stigma and discrimination on mental health grounds ( NIMHE, 2004).

Although the Social Exclusion Report remit covers only England, a number of its recommendations could have implications for Scotland including, for example, raising awareness among individuals and employers of the rights of people with mental health problems under the Disability Discrimination Act (Action 3); promoting best practice in the public sector in readiness for the proposed new public sector duty to promote equality of opportunity for all disabled people (Action 4); improving access to employment programmes (Action 12); easing the transition from benefits to work (Action 13). In other areas there may be opportunities for shared learning, for example, support on employment and social issues for people with severe mental illness (Action 5); models for vocational and social support in or linked to primary care (Action 7); strengthening training on vocational and social issues for health and social care professionals (Action 8); tackling inequalities in access to health services (Action 9); effective interventions for young people (action 19); and access to services such as adult learning, housing, transport and financial and legal advice (Actions, 17, 21, 22, 23).

The role of mental health services

The Social Exclusion Report describes the role of health and social care services in tackling social exclusion. In particular it states that 'Effective mental health services will view rehabilitation and support for reintegration into the community as an integral part of their work' ( SEU, 2004, p. 97, para 9). NIMHE has published a social inclusion resource pack for people working in mental health to enable the identification of positive practice in social inclusion in different 'life domains' ( NIMHE, 2003a).

In Scotland, there are a number of different drivers encouraging health and social care services to contribute, with others, to tackling the inequalities and exclusion to which people who experience mental illness are at risk. For example, one of the objectives of the National Programme is to improve the ability of public services to act in support of the promotion of mental health and the prevention of mental illness. Specifically in relation to health services, in 2003 the Minister for Health announced the extension of Fair for All, the Scottish Executive Health Department guidance on developing culturally competent health services, to other groups, including people with disabilities. The Scottish Executive is currently developing an Equality and Diversity Strategy: Fair for All - the Wider Challenge as part of the Patient Focus and Public Involvement Agenda (Scottish Executive, 2004a).

Another potential lever is the principle of reciprocity embedded within the Mental Health (Care and Treatment) (Scotland) Act 2003. This is the requirement to provide appropriate services to people who may be detained under the legislation as well as providing continuing care when an order is no longer in place. The Act also places a duty on local authorities to provide for people who are not in hospital services designed to promote their well being and social development. This includes assistance to people to obtain and undertake employment.

For people in in-patient care, particularly women (see Chapter 5) the Scottish Executive policy of abolishing single-sex wards may have a particular impact on psychiatric services. At present a significant proportion of the remaining 21 mixed sex wards in Scotland are located in one psychiatric hospital.

Beyond the in-patient setting is the contribution of Community Planning and Community Health Partnerships ( CHPs) to population health improvement. It is anticipated that CHPs, for example, will contribute with local authority partners to improving the 'health of local communities, tackling inequalities and promoting policies that address poverty and deprivation' (Scottish Executive, 2004d). Specifically in relation to mental health, recent guidance on CHPs and integrated mental health services, anticipates that local Mental Health Partnerships, to which CHPs will belong will 'give attention to and allocate resources to health promotion and social inclusion priorities'.

People with Mental Health Problems: Implications

Embedding mental health considerations into other policy domains

Clearly, to redress the inequalities to which people who have experienced mental illness are at risk extends beyond the domains of health and mental health, into the heart of the social justice agenda.

Closing the opportunity gap for this group of people implies, for example, consideration of the impact of community regeneration or development on the economic inclusion or exclusion of people who experience mental distress.

Specifically in relation to access to, and retention in, employment a number of reviews have looked at 'what works' (Crowther et al, 2001; NIMHE, 2003; Robbie and Pressland, 2003). Individual Placement and Support ( IPS) models of supported employment, developed in the USA, have been found to be more effective than traditional vocational services in obtaining employment. The key features are the use of open employment, integration with mental health care, responsiveness to user preferences, continuous and comprehensive assessment and time-unlimited support ( NIMHE, 2003b). A number of different models of practice are described in the Social Exclusion Unit's report ( SEU, 2004). Guidance to promote employment and other occupational activity for people with mental health problems is also due to be published by NIMHE.

Within the workplace, employees with mental health problems interviewed in a study by McCollam et al (2003) described the importance of sensitive and approachable managers and support for structuring and managing workloads to accommodate individual needs.

Whether through specific projects or programmes, or adjustments within the workplace, enabling people with mental health problems to return to or remain in employment has implications individually and jointly, for mental health service providers, primary health care providers, local authorities, other agencies and professionals as well as public, voluntary and private sector employers.

Meeting the learning and skills needs of people with mental health problem requires similarly flexible, supportive and responsive approaches (Learning and Skills Council, 2002; James, 2002; National Bureau for Students with Disabilities, 2004). This applies to young adults ( www.niace.org.uk/information/Briefing_sheets/Young_Adults_MHD.htm) (accessed 23 September 2004; www.lookingforward.org.uk) (accessed 23 September 2004) and people returning to education (James, 2002). One survey of learning provision for young adults aged 16-25 years with mental health problems found that there was a lack of targeted provision for this group of learners and potential learners, with insufficient knowledge and information among providers identified as one of the main barriers ( www.lookingforward.org.uk). Again, this has implications for higher and further/continuing education providers, and for partnership working between education providers and other agencies or services, including mental health services.

Across the board there needs to be greater awareness not just of the needs, but also the rights of people with mental illness who come within the criteria of the DDA, in terms of employment, access to premises and access to goods and services. This includes public services such as housing, transport, education, welfare benefits and advice/financial/debt advice. It also extends to the health service, both as an employer, and as a service provider, including a provider of physical health care and health promotion. Awareness that the provisions cover people with mental health problems may also need to be reinforced among private sector employers, including, since October 2004, those with 15 or fewer employees.

Fundamentally too, there is a need to 'empower' people with mental illness who come within the scope of the Act to ensure that they are aware of their rights under the legislation, and the scope for ensuring that these rights are honoured.

Embedding considerations of inequality within the mental health service system

Although perhaps a difficult concept to grasp, there is a role for mental health improvement in the lives of people who also have a mental illness (Herron and Trent, 2000). The National Programme is supporting a number of initiatives, which directly or indirectly impact on the mental health and well-being of people with mental illness.

The other side of the coin is the role of mental health services in redressing inequalities. Rogers and Pilgrim (2003) draw attention to the 'inequalities created by service provision'. This has at least three dimensions: equality of access to services; negative
or stigmatising experience of mental health service provision; and the longer term impacts for individuals.

The first two dimensions have been touched upon in earlier chapters. As also discussed earlier, there are possible levers for change from a focus on an individual's symptoms to supporting personal recovery. However, if at a basic level, Mental Health Officer, ward staff, primary care staff, do not, for example, ask questions about a person's employment, then the individual may struggle for years to get back to work. Mental health services (in partnership with other agencies) therefore have a key role in closing the opportunity gap for people who experience mental illness. To take on this mantle requires not just the appropriate skills and resources, but for a social justice culture to be part of the warp and weft of the service system.

Mental Health of People with Physical Disabilities

It was suggested at the beginning of this chapter that, in addition to people with mental health problems, consideration has to be given to the mental health inequalities experienced by people with physical disabilities, including people who may have both a mental illness and physical disability.

It is not possible within the scope of this review to address the mental health impact of the socio-economic disadvantage, discrimination and stigma that can be experienced by people with physical disabilities. The need to consider this is, however, underlined by evidence of the poverty and social exclusion faced by this group of people. For example, data reproduced in the Scottish Executive publication Social Focus on Disabilities⁸ (2004i) indicate that people with disabilities:

• Have much lower rates of economic activity than people without disabilities.
• Are more likely to live in households with an income below £10,000.
• Comprise 65% of claimants of at least one key benefit (this includes people who have a long-term illness).
• Are more aware of anti-social behaviour where they live and more likely to consider their neighbourhoods unsafe. This is reflected in the findings from one study in Scotland in which nearly one-half of respondents reported having experienced a hate crime because of their disability ( DRC/Capability Scotland, 2004).

A number of studies also illustrate the multiple sources of discrimination and disadvantage experienced by disabled people (see for example, Molloy, Knight and Woodfield, 2003; Pierce, 2003; Breslin, 2003).

As summarised by Burchardt (2003), 'someone who is socially excluded is at greater risk of becoming disabled, and someone who becomes disabled is at greater risk of being socially excluded'.

The few studies identified suggest the potential multiple exclusions people with physical and mental health problems may experience. One example is a study in England and Wales (Morris, 2004) exploring how people with physical impairments and mental health support needs experience mental health and physical disability services. This found that the majority of respondents had difficulty accessing mental health services because of their physical impairments, and difficulty using physical disability services because of the inadequate recognition of their mental health needs and negative attitudes amongst staff towards mental health issues. This, together with a lack of communication between the two types of service, resulted in the fragmentation of people's needs. As described by one study respondent 'I have to go to one town for my mind, another for my body'.

Specifically in relation to sensory impairment, a Mind factsheet on deafness and mental health cites studies that have found that 38% of people with hearing impairments in the community were experiencing some form of mental distress. People with hearing impairments experience higher rates of depression or anxiety than hearing people, but similar rates of schizophrenia. In terms of risk factors, studies have found that 37% of people with hearing impairments report that they have been sexually abused before the age of 16 years, while one-third of deaf people in touch with mental health services had experienced significant negative attitudes towards deafness from members of their own family (Ridgeway, 1997 in www.mind.org.uk/Information/Factsheets/Sensory+impairment/Deafness+and+Mental+Health.htm , accessed 27 September 2004). The Mind factsheet also cites findings that suggest that hearing impaired people with mental health problems find difficulty accessing services, and that when they do, can experience problems around assessment and diagnosis. It is believed, as a result that that deaf people are over-represented among people in psychiatric hospitals (Timmermans, (1989) in www.mind.org.uk/Information/Factsheets/Sensory+impairment/Deafness+and+Mental+Health.htm). It is suggested that misdiagnosis arises because assessment is undertaken by people with inappropriate communication skills. This may be particularly compounded for people from black and minority ethnic communities.

A further Mind factsheet describes the emotional and psychological impact of developing sight problems ( http://www.mind.org.uk/Information/Factsheets/Sensory+impairment/Visual+Impairment.htm). As at the end of March 2004 there were 37,942 registered blind or partially sighted people in Scotland. Of these 536 (1.4%) registered blind and 242 (0.6%) partially sighted people indicated that they also had a mental health problem. The majority of these people were aged 65 years and over (Scottish Executive, 2004r). Studies exploring the implications for mental health service users who are blind or deaf-blind have not been identified.

In early 2004, the Scottish Executive launched its action plan for community care services for adults with a sensory impairment (Scottish Executive, 2004p). The Scottish Executive is also currently working with the Scottish Council for Deafness to look at the needs of people with mental health problems who also have hearing impairments. Options for 'modernising mental health services for people who are deaf' in England/Wales were set out in a Department of Health consultation document issued in 2002 ( DH, 2002b).

Mental Health and People with Physical Disabilities: Implications

In terms of mental health inequalities as experienced by people with physical disabilities the main implication is the apparently limited evidence to inform policy and practice. For example, how are mental health services in Scotland able to meet the needs of people with both physical and mental health problems, in an holistic way; what are the risk and resilience factors that have the most impact on the mental health and well-being of people with physical disabilities; and fundamentally, what does mental health improvement and promotion mean for people with physical disabilities?

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