Mental Health in Bradford

This research was commissioned by Alan Turing Institue through the Centre for Applied Education Research. The research was motivated by the hypothesis that there’re mental health inequalities across the Bradford District.

Maike Gatzlaff (LIDA, University of Leeds) , Dr Ning Lu (Data Science, Bradford Teaching Hospitals NHS) , Professor Mark Mon-Williams (Cognitive Psychology, University of Leeds) , Mallory Morehead (Bradford Teaching Hospitals NHS)
04-19-2021

Background

Mental ill health epidemic in Bradford

Mental health issues are prevalent within the Bradford District, with a mental ill health epidemic affecting children and young people (CYP). Mental health support has been identified as a top priority by community stakeholders in the Holme Wood area of the District. These stakeholders report a range of issues, including problems with accessibility to support, fragmented and poorly coordinated services, and insufficient resources. Stakeholders suggest the focus is on crisis management rather than early intervention. There is general recognition across the system that tackling these issues will result in better outcomes at the individual and community level, and could potentially offer savings in health, social care and policing costs. Thus, long-term solutions are needed in order to improve mental health support.

Mental health

(…) mental health is more than just the absence of mental disorders or disabilities. Mental health is a state of well-being which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community. Mental health is fundamental to our collective and individual ability as humans to think, emote, interact with each other, earn a living and enjoy life. (World Health Organization 2018)

Mental health disorders amongst children aged 5 to 16 in England have increased from one in nine (10.8%) in 2017 to one in six (16%) in 2020 (NHS Digital 2020). The presence of mental health disorders is even higher among young people (17 to 22 years), with 27.2% of young women and 13.3% of young men having a probable mental disorder (NHS Digital 2020). Most mental health conditions develop during childhood and youth (Table 1), with 50% of mental health conditions having started by age 14 years, rising to 75% by age 24 years (Kessler et al. 2005; United Nations 2020).


Table 1: A selection of mental health disorder onset

Data source: Kessler et al. (2005)



“Children’s mental health care has historically been a ‘Cinderella service’ within the NHS, with high numbers of children not accepted into treatment and long waits for those who can get on the waiting list.” (Lennon 2021, 5)

In 2019 only 1 out of 4 children and young people estimated to need treatment accessed mental health support (Lennon 2021). While the number of children and young people increased by 35% compared to 2018/19 (and nearly 60% compared to 2017/19), the number of children and young people receiving treatment has only risen by 4% (Lennon 2021).
A range of socioeconomic, biological and environmental factors determine mental health risk (World Health Organization 2018):

Though mental health support is one of the most neglected areas of health - on a global level, there is less than one mental health professional for every 10,000 people (United Nations 2020).

Holme Wood in Bradford

Bradford, West Yorkshire’s District with the highest population, has a larger proportion of children than England, Leeds, Sheffield, or Manchester (City of Bradford Metropolitan District Council 2018). Holme Wood is located in the south-east of Bradford in postcode district BD4 (Figure 1).

Holme Wood in Bradford District

Figure 1: Holme Wood in Bradford District

Children and young people, which account for nearly 30% of Bradford’s population (City of Bradford Metropolitan District Council 2018), are at risk of adverse childhood experiences due to high deprivation levels (Stevens 2019). According to the 2019 English Indices of Deprivation, Bradford ranks 13th most deprived of 317 local authorities (Table 2). 14 Bradford wards are amongst the 10% most deprived wards of England (Bradford Metropolitan District Council n.d.); Tong ward, where Holme Wood is located, being one of these. In 2015, 64% of the residents struggled to manage on their income (Booth, Croucher, and Bryant 2020). The neighbourhood (LSOA) of Holme Wood was ranked 83 out of 32,844 LSOAs in England – 1 being the most deprived (Ministry of Housing, Communities & Local Government 2019).


Table 2: Indices of Deprivation

Data source: Bradford Metropolitan District Council (n.d.)



COVID-19 pandemic

What is COVID-19? COVID-19 is a disease caused by a new coronavirus called SARS-CoV-2. WHO first learned of this new virus on 31 December 2019, following a report of a cluster of cases of ‘viral pneumonia’ in Wuhan, People’s Republic of China. (WHO 2020)

WHO has characterised COVID-19 as a pandemic on 11 March 2020, with Europe being the pandemic’s epicentre on 13 March 2020.
On 16 March 2020, the Prime Minister announced that people should work from home and avoid social venues to limit the spread of COVID-19. Further restrictions, including closing schools, have followed since, with the first national lockdown coming into force on March 26.

The mental health impact of the COVID-19 pandemic

“The pandemic is also a mental health risk for our society.” (Young Minds 2020a)

Caused by the COVID-19 pandemic, a parallel pandemic of fear, anxiety, and depression has developed (Yao, Chen, and Xu 2020). Various countries have recorded higher-than-usual levels of depression and anxiety (United Nations 2020). These might be caused by widespread misinformation causing distress, media coverage of severely ill people, dead bodies, and coffins causing fear of losing loved ones without being able to say goodbye or hold funerals (United Nations 2020).
Findings from recent research:


Why are children and young people mentally affected by the pandemic?

A survey by NHS Digital (2020) has found that 50.2% of children with a probable mental disorder are worried about family and friends getting infected with COVID-19, 36.1% are worried about catching COVID-19 themselves, 23.8% are concerned about transmitting the virus, and 18.0% are worried about leaving their house. However, Child & Adolescent Mental Health Services (CAMHS) already had long waiting lists before the pandemic, and these waiting lists are now longer than before the lockdown (Danese and Smith 2020). Pre-pandemic, in 2019-2020, only 20% of children and young people referred to NHS mental health support services started treatment within a month (Lennon 2021).


Why are people with pre-existing mental health conditions more affected by the pandemic?

Many people coping well with their mental health before the pandemic now cope less well due to increased stress levels (United Nations 2020). It is expected that more people will require mental health support once the restrictions of daily life have sunken in (Young Minds 2020a). A survey by NHS Digital (2020) shows that pre-existing mental health conditions affect children and young people’s lockdown experiences – with 54.1% of 11 to 16-year-olds and 59.0% of 17 to 22-year-olds with a probable mental disorder, compared to 39.2% and 37.3% respectively. Simultaneously, access to mental health support has been disrupted. For example, mental health support for six in ten (62.6%) English children and young people with a probable mental disorder is provided by school or college (NHS Digital 2020). Due to lockdown measures, it was more challenging to reach out to these services. In their second survey, three months after the first lockdown, Young Minds (2020b) have found that almost a third (31.0%) of young people previously receiving mental health support are no longer accessing it.


What are the reasons disrupting access to mental health services? (United Nations 2020)

Therefore, as the pandemic has reached everyone, many call for proactive population-level interventions in mental health promotion and suicide prevention (e.g. Danese and Smith (2020); Leske et al. (2021); Mohsen (2020)). The United Nations (2020) suggest:

  1. To apply a whole-of-society approach to promoting mental health;

  2. Ensuring widespread availability of mental health support;

  3. Extending mental health services for the future to minimise the mental health consequences of the pandemic on future generations.

COVID-19 pandemic in Bradford

Bradford has been characterised by the Joint Biosecurity Centre as showing a stubborn transmission of COVID-19, with elevated transmission rates typically superseding the national level (City of Bradford Metropolitan District Council 2021). These high transmission rates are likely to be linked to a range of interconnected factors, including deprivation, employment, demographics and household composition (City of Bradford Metropolitan District Council 2021). Bradford recorded 1,000 deaths due to COVID-19 by 27 January 2021 (City of Bradford Metropolitan District Council 2021).
To give information and tips on how to cope during the pandemic, Community Action Bradford & District have produced a booklet with valuable advice on mental health and well-being.

Mental health A&E visits at Bradford Royal Infirmary

“Some of the youngsters had accessed alcohol or drugs, with others trying to escape lockdown at home by jumping out of windows.” (“Covid Lockdown: Children as Young as Eight Self-Harming, Doctor Says” 2021)

COVID-19 mitigation measures are affecting Bradford’s children and young people. In a recent newspaper article by the BBC “Covid Lockdown: Children as Young as Eight Self-Harming, Doctor Says” (2021), Consultant Dave Greenhorn from the Bradford Royal Infirmary reported that “we’ve seen all sorts of tragic things that we haven’t seen before.” The number of monthly A&E visits for children’s mental ill health and young people pre-pandemic is now seen weekly (“Covid Lockdown: Children as Young as Eight Self-Harming, Doctor Says” 2021). “Extremely unusual” before the pandemic, the A&E is now treating children as young as eight years for self-harm (“Covid Lockdown: Children as Young as Eight Self-Harming, Doctor Says” 2021). Children and young people are regularly in A&E for attempted suicide or having taken an overdose (“Covid Lockdown: Children as Young as Eight Self-Harming, Doctor Says” 2021). Additionally, an increased number of A&E visits are due to palpitations and headaches, symptoms of psychological stress (“Covid Lockdown: Children as Young as Eight Self-Harming, Doctor Says” 2021).



Bradford’s mental health referrals

Wordcloud of mental health referral reasons and sources

Figure 2: Wordcloud of mental health referral reasons and sources

Mental health referral is controlled by Healthy Minds Youth in Mind Services and processed by MYMUP. Data is available since 1998; however, 2017 is the first year where referral data is available monthly. The number of yearly referrals reported increased significantly in 2019 (Figure 3). Even though data for 2021 is only available until early February (08-02-2021), the number of referrals is already higher than the total of 2018.

Bradford's mental health referrals since 2017

Figure 3: Bradford’s mental health referrals since 2017

Some referral records are missing the referral date, or the client’s age was incorrectly entered into the database. Out of the 6725 records of mental health referrals of 5964 different clients, 6546 records (97.34%) of 5884 clients (98.66%) include a valid referral date and age.
This analysis, therefore, focuses on the 6068 mental health referrals (90.23%) of 5506 clients (92.32%) with referral dates starting from 2019, when the platform was used actively (Figure 3). The following analysis is based on the 4744 referrals (70.54%) of 4227 children and young people (CYP) (70.88%) since 2019, following NHS England’s definition of CYP as 0-25.



Age distribution of mental health clients (since 2019)

Figure 4: Age distribution of mental health clients (since 2019)



Mental health referral reasons

Self-care issues are the most frequent referral reason in Bradford. In Bradford’s BD4 postcode district, where Holme Wood is located, the proportion of self-care issues is about 9% higher than in Bradford overall (Table 3). Furthermore, whilst the proportion of post-traumatic stress disorder is nearly the same in Bradford and the BD4 area, BD4 has significantly fewer mental health referrals due to anxiety (Table 3).


Table 3: Top mental health referral reasons in CYP



Mental health referral sources

Clients are mainly referred from educational services and school nurses (Table 4). However, referrals from CAMHS are split into three categories: Core/Step Down, Crisis Team (Hospital Urgents), and Waiting List. Combined, CAMHS refers 9.61% of mental health clients in Bradford, making them the third most frequent referral source.
In the BD4 postcode district, CAMHS refers 10.31% of all mental health referrals. The proportion of mental health referrals by school nurses is nearly double as high for clients from the BD4 area than for Bradford overall.


Table 4: Top five mental health referral sources for CYP



Examining spatial and temporal characteristics of mental health referrals

BD4, Holme Wood’s postcode district, is with 8% Bradford’s postcode district with the second-highest mental health referral rates in children and young people (Figure 5).

Spatial distribution of all mental health referrals, 2019-2021

Figure 5: Spatial distribution of all mental health referrals, 2019-2021



Mental health referrals are increasing, with referral rates from 2020 generally higher than in 2019 (Figure 6). The monthly referral rate fell at the end of March 2020, when the first lockdown was established as a non-pharmaceutical intervention to control the spread of COIVID-19. Comparing weekly mental health referral rates by year shows that while the number of referrals was higher from mid-March to mid-April 2019 than for the same period in 2020, mental health referrals still decreased in April (Figure 6). Possible trends and seasonality in weekly mental health referrals will be tested in the main analysis.

Comparing weekly mental health referrals by year

Figure 6: Comparing weekly mental health referrals by year

Impact of the offsetting COVID-19 pandemic and the first UK lockdown on mental health referrals

Have mental health referral reasons changed in or after lockdown? Figure 7 shows that self-care issues are a permanent mental health referral reason in Bradford. After the first lockdown came into force on 26 March 2020 an increased number of daily mental health referrals due to post-traumatic stress disorder, depression, and anxiety has been recorded.

Mental health referral reasons over time

Figure 7: Mental health referral reasons over time

Interrupted time series analysis of mental health referrals

Poisson and negative binomial regression models are often applied to investigate the effect of an event on a time series (see, for example, Schuengel et al. (2020), Chen et al. (2020), Mansfield et al. (2021), Leske et al. (2021), or Odd et al. (2020)). In a study covering 13% of the UK population, Mansfield et al. (2021) found a rapid and sustained decrease in GP contacts due to diabetic emergencies, depression, and self-harm in the first lockdown period between March and July 2020. In Cambridgeshire and Peterborough Chen et al. (2020) also found that there was a sharp reduction in referrals to care mental health services. Building on Chen et al. (2020) and Schuengel et al. (2020), a Poisson regression model to estimate the absolute effects of the COVID-19 pandemic on the number of weekly mental health referrals in Bradford is developed. Predictions are based on:

The week commencing 23 March 2020, where the first lockdown was announced and enforced, marks the start of the COVID-19 phase. As part of a sensitivity analysis, the COVID-19 phase is also defined as the week of 16 March 2020, when the Prime Minister asked everyone to stop non-essential contact and travel, and the week of 11 March 2020, when COVID-19 was declared a pandemic by the WHO.
A total of all weekly mental health referrals and those particularly relevant in the context of non-pharmaceutical interventions such as social distancing, i.e. anxiety and depression, are investigated. Additionally, it is investigated how the COVID-19 pandemic affected mental health referral reasons especially prominent in Bradford’s BD4 postcode district (including Holme Wood): with 7 out of 10 referrals self-care issues and post-traumatic stress disorder with 1 out of 10 referrals.

The effects of the COVID-19 pandemic on Bradford’s mental health referrals

In the 110 weeks between January 2019 and the beginning of February 2021, on average 43.12 children and young people have been referred to mental health support services weekly (SD = 21.02). After detrending the data no seasonal pattern in mental health referrals has been found. As seen in Figure 8, the recorded mental health referrals and estimated regression line dropped in the week of the first UK lockdown. Poisson regression analysis of weekly mental health referrals pre-COVID-19 and during COVID-19 characterises this drop in mental health referrals as significant (b= -0.697, SE= 0.170, t=-4.087, p < 0.001). However, the overall number of weekly mental health referrals has increased significantly since 2019 (b= 0.011, SE= 0.003, t= 3.679, p< 0.001).

All mental health referral reasons and estimated regression line for pre-COVID-19 and COVID-19 phase

Figure 8: All mental health referral reasons and estimated regression line for pre-COVID-19 and COVID-19 phase

All selected mental health referral reasons – exempt post-traumatic stress disorders, which experienced a highly significant increase after the first lockdown (b= 1.186, SE= 0.308, t=3.853, p < 0.001) - experienced a significant decrease in weekly referrals compared to the pre-lockdown phase. The largest reductions are linked to depression (b= -1.764, SE= 0.335, t=-2.544, p < 0.001), followed by anxiety (b= -0.853, SE= 0.170, t=-4.087, p < 0.01) and self-care issues (b= -0.679, SE= 0.212, t=-3.209, p < 0.01). The sensitivity analysis confirmed the statistical significance of observed increases and decreases.



Where do we go from here?

Mental health referrals: a measurement problem

Mental health support has been a critical issue in Bradford even before the pandemic. Local stakeholders, for example, report problems with accessibility to support. Many mental health disorders develop at a young age; hence early intervention is crucial. Deprivation is one of many risk factors for mental health, therefore children and young people living in Bradford, one of England’s most deprived areas, are especially vulnerable to the development of mental health issues.
Understanding the effects of the COVID-19 pandemic on mental health referrals will benefit local stakeholders in informed decision making and resource allocation. Whilst weekly mental health referrals have significantly decreased in the first national lockdown, it is questionable what proportion of children and young people experiencing mental health issues actively seek or accept mental health support.

Next steps

Building on this initial research, the aim is to better understand mental health support availability and acceptance in Bradford and especially Holme Wood. Focus groups of mental health professionals, children and young people accessing mental health support, and children and young people experiencing but not getting mental health support are planned to understand the community’s mental health experiences.


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References