Benefits and employment

There has been considerable debate about the significance of increasing levels of sickness benefit claims. Research from the UK indicates a 10-fold variation in rates of claims between regions and districts, with highest rates being found in the areas of the north of England, Scotland and Wales, which have seen the greatest levels of industrial decline. ^{Reference Beatty and Fothergill4,Reference Beatty, Fothergill and Gore5,Reference Green and Owen14} This evidence has led some authors to suggest that sickness benefit claims represent disguised unemployment in some areas and some groups. ^{Reference Beatty, Fothergill and Macmillan15} In other words, despite their health problems, some claimants may be willing and able to perform some sort of work, but suitable work is not available. The fall in demand for low-skilled labour has affected lower socioeconomic groups more than others, ^{Reference Nickell and Quintini16} and disability is also associated with lower socioeconomic status. ^{Reference Adamson, Ebrahim and Hunt17,Reference Gannon and Nolan18} In most countries, disability benefits are more generous than unemployment benefits, even with recent changes. Evidence from the USA suggests that disability benefit rates have risen in relation to incomes for unskilled workers, making dropping out of work more attractive, especially for workers living in low-wage states. ^{Reference Autor and Duggan19}

Claims for common mental disorders may be particularly sensitive to labour market conditions, since these disorders are more prevalent in lower socioeconomic groups, ^{Reference Scott, Al-Hamzawi, Andrade, Borges, Caldas-de-Almeida and Fiestas20} the groups most affected by job losses. Some mental disorders, like less severe musculoskeletal disorders, may be manageable in the right work environment, with accommodating employers and security of employment, but intolerable in less secure workplaces. The greater work intensity demanded in the post-industrial economy has also been suggested to be a source of stress. ^{Reference Kemp, Sunden and Bakker Tauritz1} Hence as employment options contract, workers may opt to claim disability benefits rather than compete for work that would be difficult for them to sustain.

We did not, however, find greater proportions of mental disorder claims in regions of high unemployment and economic inactivity (excepting Scotland), or changes suggestive of greater proportional increases in these areas between 1995 and 2014. Moreover, the overall and relative trends in mental disorder claims were not obviously affected by the recent economic recession.

Mental disorder trends

There are, therefore, likely to be other drivers for the dramatic divergence in claims for mental disorders compared with other conditions in recent years. The decline in claims among older people is likely to account for some of this pattern. Incapacity benefit and the new ESA are not available to people over the state pension age (in contrast to Severe Disablement Allowance), and claimants with other medical conditions are older than those claiming benefits for mental disorders. However, numbers of people on Severe Disablement Allowance were small, since it was discontinued in 2001. Moreover, the divergent trends were visible in every age category, and claims for mental disorders among older people rose regardless.

Evidence from the UK suggests a modest increase in the reported prevalence of common mental disorders since the early 1990s, but this is not large enough to account for the increase in disability claims, and may represent increasing recognition and identification of such disorders as much as their actual occurrence. ^{Reference Maybin and Thorlby21}

It seems likely that the decreasing stigma associated with mental health problems following media campaigns is significant. Individuals who might previously have been diagnosed as having other conditions, such as back pain, for example, may now be more readily classified as depressed. Indeed, evidence suggests that back and neck pain are often associated with mental disorders such as depression and anxiety. ^{Reference Demyttenaere, Bruffaerts, Lee, Posada-Villa, Kovess and Angermeyer22} Moreover, changing approaches to the treatment of back pain, with an emphasis on recovery and activity, may have discouraged long-term claims for this condition, facilitating the relative rise in mental disorder claims. ^{Reference Cattrell, Harris, Palmer, Kim, Aylward and Coggon23,Reference Buchbinder, Jolley and Wyatt24} This thesis is supported in the current data by the fact that the distribution of mental disorders across age groups and gender became more similar to the distribution of other disorders over the period examined. Our data also support a previous suggestion that the cultural changes that influenced the change from musculoskeletal disorders to mental disorders started in London and the South, and subsequently spread to other regions. ^{Reference Cattrell, Harris, Palmer, Kim, Aylward and Coggon23} Further research is needed, however, to explore the contrasting trends in claims for mental disorders and claims for other common medical conditions.

Consequences of worklessness

Concerns about the disadvantages associated with worklessness were part of the motivation for the reforms to the benefits system introduced by the British Government in 2008. ³ This coincided with the worldwide economic crash. Neither event appears to have had much impact on long-term trends in total claims for sickness and disability benefits in the UK, which were falling prior to 2008, nor on rates of mental disorder claims, which had long been rising. However, it is likely that numbers of claimants would have risen further over the economic recession in the absence of the new procedures. ^{Reference Beatty, Fothergill and Gore5}

Non-employment among those with mental health problems has individual as well as social costs. Work has been shown to be beneficial for mental health, and people with severe mental disorders who find secure employment show improvements in symptom levels, self-esteem, social disability and quality of life. ^{Reference Burns and Catty25,Reference Schneider, Slade, Secker, Rinaldi, Boyce and Johnson26} Although research with people with severe mental disorders suggests they want to work, the barriers are substantial and include symptoms of the mental condition, effects of treatment, a poor sickness record and lack of confidence. ^{Reference Marwaha and Johnson27,Reference Boycott, Akhtar and Schneider28} There is a complex trade-off between providing security and dignity for people who are mentally incapacitated and unable to work, and creating a ‘disability trap’ that produces a culture of dependence and demoralisation. ^{Reference Drake, Bond, Thornicroft, Knapp and Goldman29} It is a particular concern that individuals with mental disorders show an increasing tendency to be claiming sickness and long-term disability benefits, since it has been shown that such people are unlikely ever to rejoin the workforce. ^{Reference Berthoud30}

Although some argue that the most important intervention to reduce benefit claims is the provision of suitable job opportunities for lower socioeconomic groups, ^{Reference Beatty and Fothergill4} others, including the UK Government, advocate individual-level interventions. Thus, the ESA benefit provides people who are thought to be capable of returning to work with support from an Employment Service Advisor. The success of this approach has not yet been formally evaluated, but more intensive employment support schemes have been trialled for people with severe mental disorders. Their success also depends on the local context of employment rates, economic growth and welfare systems, however, ^{Reference Heslin, Howard, Leese, McCrone, Rice and Jarrett31,Reference Burns, White and Catty32} and they have not so far been offered to people with less severe, but more common, mental health problems.

Limitations

The way that mental disorders are classified by the Department for Work and Pensions does not correspond to official classification systems and the reliability of the classification has not been established. The information on diagnosis comes initially from general practitioners, who may provide only vague descriptions of the reasons for the claim (such as ‘stress’). Whereas this is less likely to affect categorisation of claims into broad medical categories, it may affect the quality of data on different mental disorders. General practitioners may have a tendency, for example, to classify schizophrenia as something less severe to avoid the use of what is perceived as a stigmatising diagnosis. The introduction of more stringent procedures for obtaining benefits may produce the opposite pressure, requiring evidence of more serious problems to justify a claim. Moreover, some diagnoses such as bipolar disorder were not included, so that some people with this diagnosis may have been included in the ‘depressive disorders’ category under the Department's label of ‘chronic mood disorders’. It is notable, however, that the relative contributions of different types of mental disorder, broadly conceived, have not changed substantially since the 1990s.

Despite these issues, the Department for Work and Pensions data are collected nationally, using the same protocols year on year. Since 2000, diagnostic information has been provided for 100% of all claimants nationwide, except for the early years of the introduction of ESA. Prior to this date, detailed information, such as diagnostic category, was only available for a 5% sample of claimants. Overall numbers of claimants and proportions of claimants prior to 2000 therefore represent estimates. Because of the large size of the sample, the estimates are extremely precise, however, as indicated by the narrow confidence intervals. Moreover, unlike some other countries, for example, the USA where there are multiple types of public assistance for people with ill-health, the system of sickness and disability benefits in the UK is relatively simple. Even with the changeover to the new ESA, it is possible to examine long-term trends in the total number of people who receive public welfare payments because of ill-health.

Implications

According to the current analysis, mental disorders constitute a major burden on social resources, and one that is increasing. Moreover, the burden is largely attributable to common mental disorders, such as anxiety and depression, rather than conditions like schizophrenia that are generally regarded as being more severe and persistent. The increasing use of all types of drugs for mental disorders, and especially antidepressants, in England since the 1990s does not appear to have ameliorated the rising trends in disability claims for these conditions. ^{Reference Ilyas and Moncrieff33} Moreover, long-term use of antidepressants is reported to be increasing, ^{Reference Moore, Yuen, Dunn, Mullee, Maskell and Kendrick34} just as long-term disability claims because of mental disorders are rising. These corresponding trends may indicate greater chronicity of depression and other common mental disorders than is usually thought to be the case.

The disguised unemployment hypothesis suggests that socioeconomic changes, not individual-level treatment, are required to reduce sickness benefit claims, particularly the provision of suitable employment opportunities where health and mental health-related limitations are accommodated. Supported employment interventions may complement such measures, but further research is needed to evaluate their effectiveness for people with severe, and less severe, mental health problems in the context of the UK.