How to Make Societies Thrive? Coordinating Approaches to Promote Well-being and Mental Health

Report

17 October 2023

4. Risk and resilience factors for mental health and well-being: Community relations

Abstract

The quality of people’s relationships with each other, their community and their public institutions can influence, and in some cases be influenced by, their mental health. Well-being deprivations in these areas – including feeling and being unsafe in one’s neighbourhood, home or society; an inadequate work-life balance; loneliness and social isolation; and poor motivation to participate in civic engagement – are all linked to an elevated risk for mental ill-health and lower positive mental health. Conversely, doing well in these areas can promote good mental health. Examples of interventions available to policy makers to make improvements in these areas include integrating safety and social connectedness considerations into urban design, making better social connectedness an explicit policy priority, tackling the gender gap in unpaid work, and expanding the representation of those with lived experience of mental ill-health in politics.

Community relations encompass how safe people are and feel, with whom and how people spend their time, and how they relate to one another and their institutions. These factors are intrinsically vital for fulfilled and connected lives and can contribute to achieving other material and quality-of-life aspirations as well. There is a strong, and in some cases bidirectional, link between good mental health and good community relations.

4.1. Safety

Being safe is about being free from harm – whether that comes in the form of crime, conflict, violence or natural disasters. This section focuses on people’s safety and its effect on mental health in the spaces where they spend most of their time (their neighbourhoods and homes, including violence committed by intimate partners), as well as on experiences of discrimination. The impact of natural disasters on mental health in the context of climate change is discussed in Chapter 3.

Crime in one’s community is an important contextual predictor of residents’ mental health. Associations between neighborhood-level crime and self-reported symptoms of mental ill-health (such as psychological distress, depression and anxiety) as well as the use of mental health services (including for conditions such as psychosis, schizophrenia and PTSD) have been confirmed in ecological, cross-sectional and longitudinal studies (Bhavsar et al., 2014[1]; Weisburd et al., 2018[2]; Beck et al., 2017[3]; Astell-Burt et al., 2015[4]; Dustmann and Fasani, 2016[5]; Baranyi et al., 2020[6]; Baranyi et al., 2021[7]). For instance, longitudinal evidence using administrative crime records from Scotland shows that increases in local area crime are associated with a higher risk of self-reported mental health conditions as well as with rising antidepressant and antipsychotic prescriptions, among both people who remained in the area and those who moved out (Baranyi et al., 2020[8]). Exposure to neighborhood crime, particularly to violent offenses, is also linked to lower positive mental health. Based on police records from 1994-2012 in Germany, a 1% increase in local area crime frequency resulted in a 0.04 standard deviation decrease in life satisfaction and made residents both worry more frequently and be more concerned about crime in general. This effect was driven almost exclusively by violent crimes: property and other crimes had no significant impact on life satisfaction (Krekel and Poprawe, 2014[9]). Similarly, in Australia, while both self-reported experiences of physical violence and property crimes negatively affected the positive mental health of respondents (as measured by the SF-36 mental well-being scale), the decline in well-being associated with physical violence was ten times larger (Mahuteau and Zhu, 2016[10]).

In most OECD countries, violent crime occurs relatively rarely (OECD, 2020[11]). However, beyond officially recorded crime in one’s neighborhood, an individual’s perceived risk of crime and being vulnerable to it also matter for mental health. Fear of crime has been linked to increased anxiety, somatisation, psychological distress and depressive symptoms (Wilson-Genderson and Pruchno, 2013[12]; Pietsch and Aarons, 2012[13]; Morrall et al., 2010[14]; White et al., 1987[15]; Green, 2002[16]). A systematic review of 63 studies on the links between neighborhood crime and mental health found stronger associations between mental ill-health and perceived rather than reported crime, and data from New Zealand pointed to a significant effect of increased fear of crime, but not of actually recorded crime rates, on mental well-being (Pearson and Breetzke, 2014[17]; Baranyi et al., 2021[7]). The links between feeling safe and mental health are illustrated in Figure 4.1 below, which shows the share of those reporting feeling unsafe in a range of situations for people at risk of poor mental health compared to both those not at risk and the general population. People experiencing mental distress (Panel A) and low levels of positive mental health (Panel B) are more likely to feel unsafe at night and to believe that their neighbourhoods are more affected by crime, violence and vandalism.

Figure 4.1. Living in neighbourhoods perceived as unsafe is associated with a higher risk for mental distress and with lower levels of positive mental health

The physical and social features of living spaces impact mental health both directly and indirectly

Multiple pathways explain the link between neighbourhood safety and mental health. Most directly, becoming a victim of and witnessing crime – first- or second-hand – increases the risk of developing mental disorders, particularly PTSD and depression (Fowler et al., 2009[20]; Lorenc et al., 2012[21]; Meyer, Castro-Schilo and Aguilar-Gaxiola, 2014[22]). An Australian study found that the mean impact of experiencing physical violence on mental well-being is well over that of losing one’s job, though smaller than experiencing the death of a spouse or sustaining a serious personal illness (however, past the median of the mental well-being distribution, the impact of violent crimes is very close to that of these two negative life events) (Mahuteau and Zhu, 2016[10]). The effect of violence extends across the whole life course, with well-established connections between experiences of abuse in childhood and lifelong (mental and physical) health outcomes (Moffitt, 2013[23]; Metzler et al., 2017[24]). More broadly, constantly feeling vulnerable and being afraid for one’s safety can be considered a chronic environmental stressor with substantial cumulative effects on mental health (Lorenc et al., 2012[21]).

Neighborhood safety also affects mental health indirectly. Individuals with fear of crime experience greater “time-space” inequalities, or variation in the ability to use the neighborhood space fully and at all times for mental health protecting activities such as sport and socialising (Pearson and Breetzke, 2014[17]; Stafford, Chandola and Marmot, 2007[25]; Won et al., 2016[26]). Fearful residents are more likely to exercise less, see friends less often and participate in fewer social activities compared with less fearful ones (Loukaitou-Sideris and Eck, 2007[27]; Carver, Timperio and Crawford, 2008[28]). In addition, fear of crime can decrease community trust and cohesion and lead to individual withdrawal, contributing to a progressive decline in the social and physical environments, which further impacts on mental health and general well-being (Skogan, 1986[29]; Vanderveen, 2006[30]).

Experiences and perceptions of neighborhood safety do not affect everyone in a society equally. People with lower-economic status are more likely to live in degraded neighborhoods and are disproportionately affected by violence (CDC, 2021[31]). In addition, women more generally, particularly low-income mothers, older people and people with mental health disorders are more likely to experience time-space inequalities and hence are more vulnerable to the mental health consequences of feeling unsafe (Pain, 2000[32]; Campbell, 2005[33]; Whitley and Prince, 2005[34]). And, specific features of the environment, such as sidewalk quality, especially matter for the safety perceptions of (older) adults with functional limitations (Velasquez et al., 2021[35]).

Experiencing mental ill-health itself can also influence exposure to crime

In the opposite causal direction, people’s mental health can also impact exposure to crime. People with mental health conditions, particularly serious ones, are at greater risk of being victimised (Choe, Teplin and Abram, 2008[36]; Maniglio, 2009[37]; Teplin et al., 2005[38]; Dean et al., 2018[39]). For instance, a study of Londoners found that nearly 45% of people with severe mental ill-health reported experiencing crime in the past year, and, compared to those without, people with severe mental ill-health were three times more likely to be a victim of any crime and five times more likely to be a victim of an assault. Compared to the general population, they were also significantly more likely to report that the police had been unfair or disrespectful (Pettitt et al., 2013[40]). Experiencing mental ill-health can additionally increase perceived vulnerability and hence fuel a disproportionate fear of crime (Whitley and Prince, 2005[34]). Lastly, there is evidence that having a diagnosis of substance use disorder, schizophrenia spectrum disorder, bipolar disorder or personality disorder increases the risk of perpetrating violence more generally (Fazel et al., 2018[41]). It is important to note that the vast majority of people with mental health conditions are not violent (and are more likely to experience than to commit violence), and the odds of people with mental health conditions perpetrating offences such as intimate partner violence are lower than those for people without but with other historical drivers (e.g. having experienced violence in childhood) (Oram et al., 2022[42]; Varshney et al., 2016[43]; Desmarais et al., 2014[44]).

Deep dive: Intimate partner violence and mental health

Intimate partner violence (IPV), the most common form of violence worldwide, is a specific risk to personal safety, with substantial mental health consequences. IPV includes any behaviour perpetrated against a current or former intimate partner that causes physical, psychological or sexual harm, including physical violence, emotional abuse, sexual violence, and controlling and coercive behaviours (Oram et al., 2022[42]). The vast majority of victims are women, although high rates of IPV are also experienced by sexual and gender minorities, people with disabilities, migrants and people from marginalised ethnic or racial groups (Oram et al., 2022[42]; Peitzmeier et al., 2020[45]; Brownridge, 2008[46]; Terrazas and Blitchtein, 2022[47]).1 Accordingly, 21 out of 37 OECD countries adhering to the OECD Gender Recommendation list violence against women as one of the three most urgent gender equality issues in their country (OECD, 2020[48]). Indeed, a 2014 survey of European countries found that around 13 million women had experienced physical violence in the 12 months prior to being surveyed, and 33% had experienced physical and/or sexual violence since they were 15 years old (European Union Agency for Fundamental Rights, 2014[49]). Concerningly, only 14% of victims surveyed reported their abuse to the police (European Union Agency for Fundamental Rights, 2014[49]).

Although women can be violent towards their partners (of any gender), and sexual and gender minorities, as mentioned above, also experience high rates of IPV, the majority of IPV worldwide, as estimated by police records and surveys, is committed by men against women (Sardinha et al., 2022[50]; Oram et al., 2022[42]; Scott-Storey et al., 2023[51]). The effects of gender inequality and heteropatriarchy on social norms and behaviour are thus key to understand and address IPV (Oram et al., 2022[42]). Alongside other structural factors such as poverty and educational outcomes, these can affect the individual-level risk factors (e.g. mental ill-health, substance abuse, adverse childhood experiences due to parental stress, poor conflict responses) that make experiencing and perpetrating IPV more likely (Figure 4.2).2 Conflict and post-conflict periods can further intensify these drivers. Indeed, rates of intimate partner violence in complex emergency settings and among refugee populations are estimated to be higher than among the general population (Stark and Ager, 2011[52]); intimate partner violence also intensified in 2020 during the COVID-19 pandemic (OECD, 2021[53]).

Figure 4.2. A complex set of risk factors can lead to intimate partner violence

Exposure to IPV, whether in adulthood or in childhood (and even in utero), increases the likelihood of developing a range of mental health conditions. Anxiety, depression, substance use disorder, PTSD, personality disorders, psychosis, self-harm and suicidality are all more common among people who have experienced IPV than among those who have not (Dillon et al., 2013[54]). These associations exist across the lifespan, up until old age, and last long after abuse has stopped, and there is evidence that IPV experience is related to more persistent mental health challenges (Exner-Cortens, Eckenrode and Rothman, 2013[55]; Warmling, Lindner and Coelho, 2017[56]; Brown et al., 1994[57]). While all forms of IPV are damaging to mental health (including technology-enabled IPV), chronic exposure and combined abuse – in particular involving sexual violence – is associated with the highest levels of harm (Potter et al., 2021[58]). Children who are exposed to IPV (either themselves or by witnessing it) also face increased risks of anxiety, depression, and worse behavioural and educational outcomes (Vu et al., 2016[59]; Flach et al., 2011[60]; Fry et al., 2018[61]). For example, a nationally representative study of German children aged 0-3, conducted by the National Centre for Early Prevention (NZFH) as part of the Federal Initiative for Early Childhood Intervention Networks and Family Midwives, found that socio-emotional problems in children were twice as likely to be reported by parents from families affected by intra-family violence, compared to families not experiencing it (Liel et al., 2020[62]). The same study also estimated that a child had been threatened or injured by a parent as a result of IPV in up to 3% of interviewed families (Liel et al., 2020[62]).3

Pathways for the link between IPV exposure and mental ill-health include biological stress responses, self-medication with substances to cope with the consequences of abuse, and restricted help-seeking and decision-making options (Oram et al., 2022[42]). In children in particular, experiencing or exposure to IPV can lead to difficulties coping with other stressors throughout life, such as neurodevelopmental impairments, and these children run a high risk for revictimisation in adulthood due to a lower sense of self-worth and not knowing what a healthy relationship looks like (Oram et al., 2022[42]; Anderson et al., 2016[63]).

At the same time, people who are experiencing mental health conditions may be more vulnerable to IPV in the first place. When it comes to victimisation, estimates from interviews with psychiatric patients suggest that the frequency of IPV exposure is up to three times higher among people with mental health disorders than among the general population (Khalifeh et al., 2015[64]). Moreover, a systematic review of longitudinal evidence points to an increased risk of first-time IPV exposure for women going through depressive symptoms compared to those who are not – possibly because abusers assume they are less able to protect themselves, particularly during active episodes (Devries et al., 2013[65]).

In some cases, mental ill-health can also be associated with a higher relative risk of perpetrating IPV. According to a systematic review of cross-sectional studies, the odds of having ever been physically violent to a partner were two to three times higher for individuals diagnosed with depression, generalised anxiety disorder, panic disorder and substance use disorder than in those without such diagnoses (Oram et al., 2014[66]).4 Substance use, of alcohol in particular, increases the risk of being violent more generally as well as towards intimate partners, potentially by affecting neurochemical systems that lead to aggressive behaviour or by alcohol itself preventing effective communication (Yu et al., 2019[67]; Pihl and NS Hoaken, 2004[68]). Regardless, the vast majority of people experiencing mental ill-health are not violent, and they are more likely to be victims than perpetrators of IPV. Moreover, other environmental and historical drivers (e.g. problems in a partnership, or having experienced IPV in the past) are stronger explanatory factors for IPV than mental disorders (Oram et al., 2022[42]).

Deep dive: Discrimination and mental health

Part of feeling safe also includes freedom from discrimination, and there is well-documented evidence of the negative mental health consequences associated with discrimination. Experiencing discrimination has been linked particularly to depression, but also to anxiety, lower positive mental health and adverse changes in personality (e.g. neuroticism) for women, older adults, LBTQI individuals and people belonging to racial and ethnic minority groups (Williams and Williams-Morris, 2000[69]; Hnilica, 2011[70]; Kelaher, Ferdinand and Paradies, 2014[71]; Conlin, Douglass and Ouch, 2019[72]; Priest et al., 2017[73]; Vargas, Huey and Miranda, 2020[74]; Marx, 2021[75]; Williams and Etkins, 2021[76]; Wallace, Nazroo and Bécares, 2016[77]). Indeed, a study in 12 OECD countries showed that people who said they experienced discrimination in the past year were also more likely to report having mental health conditions and worse social and subjective well-being outcomes (Figure 4.3). The same study also suggests that one in four people overall, and one in two of those who self-identify as being part of a minority, had been subject to discrimination.

The frequency of individuals’ experience of discrimination matters for how their mental health is impacted. According to a systematic review, being exposed to multiple forms of discrimination (e.g. racism and heterosexism) is associated with a higher risk for depression symptoms (Vargas, Huey and Miranda, 2020[74]). Evidence on racial and ethnic minority groups in Australia also suggests the volume of discrimination experienced, rather than the type of incident, matters most for mental health (Ferdinand, Paradies and Kelaher, 2015[78]). However, discrimination in some contexts (shops, employment, interactions with government – each of which are critical settings for guaranteeing social inclusion, income opportunities and access to services) was particularly associated with high psychological stress (Ferdinand, Paradies and Kelaher, 2015[78]).

Figure 4.3. Experiencing discrimination is linked to worse mental health outcomes

The pathways through which discrimination impacts mental health are immediately biological and operate through larger social structures. The majority of evidence thus far has focused on racial discrimination. A growing body of literature, including lab studies, shows that experiencing racial discrimination causes neurobiological stress responses (e.g. chronically elevated cortisol levels, elevated heart rate and blood pressure). These in turn can affect a person’s immune system and metabolism, but also mood and cognitive functioning (Berger and Sarnyai, 2015[80]). Taking a broader view, structural racism that is embedded in institutions and policies also strongly affects the determinants of mental health inequalities (Williams and Etkins, 2021[76]). First, cultural racism in media and societal norms can lead to the internalisation of stereotypes (which has been associated with increased distress and substance use), stereotype threat5 (which can cause anxiety and impaired decision-making), and unconscious bias by service providers (which can affect the quality of services received). Stigma and discrimination in health-care settings specifically can lead to affected individuals having less access to or receiving worse quality care (e.g. improper diagnoses6 and treatment7), contributing to further disengagement and to people not seeking treatment until their conditions have further deteriorated (MIND UK, 2019[81]; Medina-Martínez et al., 2021[82]; Rivenbark and Ichou, 2020[83]). Second, residential segregation based on race can lead to limited access to opportunities and resources, higher exposure to environmental stressors in one’s neighborhood, and truncated social mobility – all of which, as highlighted in the various sections in this report, are well-being drivers of mental health. Lastly, exclusionary immigration policies and discrimination in the criminal justice system, including racialised incarceration, have direct negative effects on the mental health of affected individuals (Williams and Etkins, 2021[76]).

Box 4.1. Policy focus: Safety interventions that also improve mental health outcomes

Improving neighbourhood safety and time-space inequalities

Place-based interventions that address the safety of residents could be integrated into urban design and community development strategies. In particular, there is evidence that interventions tackling some of the features of the built environment that are negatively associated with safety, such as renovating abandoned buildings, greening vacant lots, and improving street connectivity and lighting, can successfully decrease actual crime rates and improve feelings of security (Garvin, Cannuscio and Branas, 2013[84]; Hohl et al., 2019[85]; Kondo et al., 2018[86]). The Centre for Urban Design and Mental Health’s principles of crime prevention through environmental design (CPTED) include (The Centre for Urban Design and Mental Health, 2022[87]):

Natural access control: Design that makes public routes clear and includes features that discourage access to private spaces, such as placement of entrances, fences and hedges, etc.
Natural surveillance: Design that increases the visibility of the location, so that people feel like they can be seen, and victims would be able to call for help, such as ensuring that windows overlook pedestrian areas, using appropriately angled lighting to illuminate faces (as opposed to bright light that causes glare and shadows) and avoiding sight-limiting features
Territorial reinforcement: Design that clearly demarcates public and private spaces
Balance: Design choices that are safe but do not reduce action opportunities and residents’ sense of agency

In addition to crime prevention, providing comprehensive public transport that incorporates considerations for traffic safety, including for residents who want to walk and cycle, can encourage spatial and temporal movement for all, especially older people. Another form of safety is navigational safety, particularly for people with dementia, which can be supported by including design features that maintain clear landmarks as environmental cues for navigation (World Resources Institute, 2015[88]).

Lastly, a well-being approach to preventing violence would not only involve urban design principles, but also invest in community social capital to address some of the risk factors that increase susceptibility to violence in the first place. Relevant areas of intervention here include increasing neighbourhood access to services, such as health care, substance use support and child protective services, and community-first public safety approaches that pair law enforcement with social workers and trained civilians in cases related to mental health, substance use and homelessness (Sebastian et al., 2022[89]).

Address intimate partner violence (IPV) and improve support for survivors

The recent OECD report Supporting Lives Free from Intimate Partner Violence, building on the outcomes of the 2020 OECD High-Level Conference on Ending Violence Against Women, has identified priority actions to address IPV effectively (OECD, 2020[48]; OECD, 2023[90]), including:

Improving integrated services, including mental health support, for both survivors and perpetrators of IPV. This involves coordination of service providers such as health, justice, housing and social protection across governmental and non-governmental providers
Creating survivor-centric justice pathways that are open, consistent and effectively monitored
Shifting heteropatriarchy norms for both women and men by investing in early-age education, conducting information campaigns that emphasise positive masculinity, and examining patriarchal norms that also underpin law enforcement and the justice system
Improving data collection on IPV prevalence

Tackle the roots of discrimination and racism

Research indicates that interventions designed to prevent the occurrence of discrimination in the first place, particularly in interactions with government services and in employment settings, have more potential to improve mental health in affected communities than do interventions that work with individuals in response to their experience, after the fact (Ferdinand, Paradies and Kelaher, 2015[78]). For example, studies have shown that LGBTI+ populations in the United States have higher self-reported health, lower levels of mental distress and lower prevalence rates for psychiatric conditions in states have that have extended protections to the LGBTI+ community (Raifman et al., 2018[91]; Hatzenbuehler, Keyes and Hasin, 2009[92]; Gonzales and Ehrenfeld, 2018[93]).

Tackling discrimination and racism, including in its structural forms, is a complex endeavour that will involve interventions across all levels of government service provision, including criminal justice, (mental) health care and medical education, and that might also include the exploration of relevant restorative justice models (WHO, 2017[94]; Paradies et al., 2009[95]; Williams and Etkins, 2021[76]). An example of efforts already underway in OECD countries is Canada’s Building a Foundation for Change: Anti-Racism Strategy (2019-22) (Government of Canada, 2019[96]). The Federal Anti-Racism Secretariat, within the Department of Canadian Heritage, coordinates efforts across Canadian governments and civil society to implement the Strategy, focusing on:

Improving coordination and sharing innovative approaches across governments to improve outcomes for minority groups and to identify policy gaps.
Implementing an Anti-Racism Action Plan, which provides funding to local, regional and national initiatives that reduce employment barriers, promote social participation and improve access to justice for ethnic and religious minorities and Indigenous people. In addition, funding was increased for existing capacity-building programmes and public awareness campaigns.
Building the evidence base: the Secretariat works with Statistics Canada and the Centre for Gender, Diversity and Inclusion Statistics to enhance the collection of disaggregated data on people’s ethnic identities, impact measurement and performance reporting. This includes oversampling ethnic minorities in the General Social Survey to enable more detailed analysis of well-being.

Upcoming work of the OECD Observatory on Social Mobility and Equal Opportunity will explore policy options and good practices to address discrimination in member countries (OECD, 2022[97]).

4.2. Work-life balance

Work-life balance is about being able to combine family commitments, leisure and work, including both paid and unpaid work. People need time to access support services, build close relationships, exercise, work, play, care and consume – all activities that are fundamental to (mental) health.

An inadequate work-life balance tends to go hand in hand with worse mental health outcomes. Compared to those in good mental health, people at risk of mental distress are three times more likely to be dissatisfied with how their time is spent (Figure 4.4, Panel A), and people with low positive mental health are almost twice as likely to report conflict between work demands and social/family commitments (Figure 4.4, Panel B). They are also more likely to report being unhappy with their commuting time, wish they would have more time for things they enjoy, are more tired after work, and find it more difficult to combine work requirements with care, family and social obligations. In terms of care obligations, people with low positive mental health are also more likely to spend long hours in unpaid work and to spend more time on childcare than their partners (Figure 4.4). These findings point to the direct impacts of (paid and unpaid) work demands on stress and time-poverty.

Figure 4.4. People experiencing mental distress and those with low positive mental health are more dissatisfied with how they (have to) spend their time

Time is a resource that people need for good mental health

Time scarcity can be considered as one of the social determinants of health inequalities, and it has been linked to worse mental health outcomes both directly and indirectly. First, the experience of time pressure itself is associated with emotional exhaustion, as an acute affective response, which for some individuals can then translate into more chronic symptoms of depression and lower life satisfaction. This evidence is often drawn from studies using experience sampling or day reconstruction methods, where participants record their thoughts, feelings and behaviours during different activities throughout their days, as well as from cross-sectional and longitudinal research (Kahneman et al., 2004[98]). For instance, a small-sample study of accountants in the United States found that mood and emotional exhaustion fluctuated with periods of high work demand (Teuchmann, Totterdell and Parker, 1999[99]). In a nationally representative survey of workers, also in the United States, self-reported time pressure was significantly associated with symptoms of depression, particularly for women who were also facing housework, while income and supportive co-worker relationships acted as protective factors for mental health even in times of pressure (Roxburgh, 2004[100]). Importantly, though, too much free time is also not desirable from a mental health perspective: a recent large-scale study of Americans indicated that having too little time was indeed linked to lower positive mental health, due to stress. The benefits of free time for positive mental health started to level off at about two hours per day, and began to decline after five, because of a declining sense of productivity (Sharif, Mogilner and Hershfield, 2021[101]). This suggests that in cases where people find themselves with excessive amounts of free time (e.g. retirement, or having left or lost a job), individuals may benefit from spending their days with purposeful activities and new routines.

Focusing again on lack of time, the more indirect pathway through which time scarcity affects mental health functions via the prevention of beneficial activities and behaviours. These include less time available for socialising, active leisure, self-care and adequate sleep and an increase of unhealthy behaviours, such as eating poorly and not exercising in response to stress (Strazdins et al., 2011[102]; Lathia et al., 2017[103]; Banwell et al., 2005[104]; Morin et al., 2021[105]; Pigeon, Pinquart and Conner, 2012[106]). For instance, poor quality sleep is both a symptom of and a risk factor for poor mental health. Sleep disruption is a common feature of conditions that include depression, PTSD, bipolar disorder and schizophrenia (Khurshid, 2018[107]; Harvey, Talbot and Gershon, 2009[108]; Nutt, Wilson and Paterson, 2008[109]). At the same time, sleeping six hours or less a night has been associated with significantly increased odds of frequent mental distress; and systematic reviews have found that individuals with insomnia were two to five times more likely to develop depression than those without (Blackwelder, Hoskins and Huber, 2021[110]; Baglioni et al., 2011[111]).

Spending extensive time working can have mental health consequences

Work is one of the main activities people spend their time on, and there are many mental health benefits that can come with employment, particularly with high-quality jobs (see Chapter 2). One of the components of job quality with direct impacts on work-life balance is working time. In the OECD’s Well-being Dashboard, workers routinely working more than 50 hours per week are considered to face long hours, since they are likely to be left with very few hours (one or two per day) for other activities after commuting, unpaid work and basic needs (such as sleeping and eating) are taken into account (OECD, 2020[11]).8 Most studies that have examined the relationship between long working hours and mental health also typically apply a range of 40-60+ hours per week.

Spending excessive hours at work has implications for people’s recovery, depletion and self-regulation, and it has been linked to fatigue, stress, impaired sleep and even suicidal ideation (Choi, 2018[112]; Yoon et al., 2015[113]; Tsuno et al., 2019[114]). For instance, several large-scale epidemiological studies found significant adverse effects of long working hours on depression, anxiety, sleep conditions and coronary heart disease (The Lancet Regional Health - Western Pacific, 2021[115]; Ganster, Rosen and Fisher, 2018[116]; Weston et al., 2019[117]). Workers’ socio-economic status plays a suppressing role in this relationship: on the one hand, people with higher levels of education tend to work comparatively longer (paid) hours and face higher rates of time poverty (OECD, 2020[11]; Strazdins et al., 2016[118]). On the other hand, they are more likely to have access to mental health-protecting features of work, including job autonomy and time flexibility, opportunities for learning and higher earnings (Ng and Feldman, 2008[119]; Virtanen et al., 2012[120]; Valcour, 2007[121]). Indeed, several studies find that the health consequences of long hours are worse for workers from lower socio-economic backgrounds (Kivimäki et al., 2015[122]; Yoon et al., 2015[113]).

The mental health impacts of unpaid work in particular are highly gendered

Paid work is not the only aspect of work that matters for mental health – unpaid work, including domestic tasks and care work for children and adults, has equally been linked to negative outcomes, including insomnia, exhaustion, lower life satisfaction, anxiety and depression (Ganster, Rosen and Fisher, 2018[116]). This particularly applies to individuals who face a double burden of paid and unpaid work, which leaves little time for recovery and can increase role conflict and role overload (Janzen and Kelly, 2012[123]).

Unpaid work is a gendered issue not only in terms who “does the work”, but also in terms of through which pathways mental health is impacted. Women carry the main burden of unpaid work to begin with: in OECD countries, they work on average 25 minutes/day more than men, with long hours in unpaid work driving most of the gender differences in total working hours (Figure 4.5). In addition, among employed adults, unpaid labour is negatively associated with women’s mental health, but not necessarily with men’s (McEwen, 2008[124]; Honda et al., 2014[125]; Peristera, Westerlund and Magnusson Hanson, 2018[126]; Seedat and Rondon, 2021[127]; Ervin et al., 2022[128]). Moreover, the burden of employment and unpaid work, having children at home, and inequity in couple relationships have been identified as risk factors for women’s mental health, whereas fatherhood can be protective for men’s (Cabezas-Rodríguez, Utzet and Bacigalupe, 2021[129]).

Figure 4.5. The main burden of unpaid work in OECD countries is carried by women

The nature of specific domestic and care tasks, their distribution among household members, and unequal social norms can help explain why women’s mental health is disproportionally affected by unpaid work. First, task distribution is unequal: men often do less time-sensitive, high-schedule-control household jobs, such as outdoor or maintenance tasks, which might be more enjoyable and possibly protective; while women (particularly those without financial resources to outsource) are more likely to have to engage in repetitive, time-consuming and physically-demanding work (Ervin et al., 2022[128]; Seedat and Rondon, 2021[127]). Second, women carry the greater mental load of household labour, for instance when it comes to scheduling and distributing tasks among other household members; one hour of unpaid work can hence be considered cognitively denser for women and might not be directly comparable to one hour of men’s time (Tao, Janzen and Abonyi, 2010[130]; Milkie, Wray and Boeckmann, 2021[131]). Third, in terms of broader social norms, there tend to be fewer expectations on men when it comes to unpaid labour, so that men who contribute more than the norm tend to be highly praised (Carlson et al., 2016[132]). Relatedly, higher levels of objective stress for women may translate into higher levels of perceived stress compared with men – findings from the Canadian General Social Survey, which included time diaries, indicate that housework time for women was associated with feeling stressed, and was associated with feeling unaccomplished in one's daily goals for men (Milkie, Wray and Boeckmann, 2021[131]). Lastly, in the long term, a gendered unpaid workload can impact other risk and resilience factors for mental ill-health, such as women’s financial resources (due to lower social security contributions and less wealth-building) (OECD, 2022[133]).

Box 4.2. Policy focus: Work-life balance interventions that also improve mental health outcomes

Promote a work-life balance for all groups

Policy makers can promote working arrangements that have been found to improve the work-life balance, such as remote work options, flexible working hours and legal ceilings to working hours (OECD, 2019[134]; Eurofound, 2015[135]; Cazes, Hijzen and Saint-Martin, 2015[136]; Bouzol-Broitman et al., 2016[137]):

At the company level, providing guidance for employers
Through legal frameworks with social partners
Including new categories of (vulnerable) workers such as gig workers

In addition, commuting time to work represents a significant aspect of the work-life balance – on average, before the rise of hybrid and teleworking induced by the COVID-19 pandemic, people in OECD countries spent 30 minutes per day travelling to work or study, and will likely continue to do so at least in some form (OECD, 2021[138]). Given that longer commute times are associated with lower job and leisure time satisfaction, increased strain and poorer mental health (Clark et al., 2020[139]), the experience of commuting – and environmental targets regarding lowering transport emissions – could be improved by expanding the public transport infrastructure to outer city areas, including WiFi connectivity en route, opportunities for sitting, and frequent and high-speed travel.

Reduce the unpaid work gender gap and recognise the value of unpaid work

There are several policy options to address the large gender gap in unpaid work present in OECD countries, including:

Expanding access to timely, affordable and long-term early childhood education and care, which has also been associated with improvements in maternal mental health (Richardson et al., 2018[140])
Designing parental leave policies with gender equality in mind, including allowances that balance the needs for female labour market re-entry, gender parity and mental health; and increase up-take of parental leave by fathers (e.g. by bonus payments or father’s quotas) (OECD, 2017[141])
Continuously assessing existing policies (including taxation) for unintended negative consequences on gender equality and women’s unpaid work burden (OECD, 2022[133]).

In addition, efforts that will increase the recognition of the value of unpaid work, both economic and in terms of social norms, include:

Including unpaid household labour in macroeconomic aggregates and conducting frequent time-use surveys to do so (van de Ven, Zwijnenburg and De Queljoe, 2018[142])
Recognising unpaid care in pension schemes (e.g. carer credits) (OECD, 2021[143])
Conducting awareness campaigns and supporting the work of civil society (including both women’s and men’s groups) that challenge current gender norms around expected roles (OECD, 2017[141]).

4.3. Social connections

Social connections encompass the time spent and relationships with other people. This includes both quantity of time (i.e. frequency of social contact with friends and family, or how socially isolated a person is) and aspects of quality (i.e. whether people feel supported, and whether they feel lonely – which can occur even if a person is not physically socially isolated from other people but perceives a mismatch between their existing and desired social relationships) (OECD, 2020[11]).9

People’s social relationships and their mental health are closely associated. From a clinical perspective, social connectedness is often operationalised as social functioning, or the degree to which a person is able to fulfil various roles in social environments, and one of the key diagnostic criteria of depression is withdrawal from social situations, as well as a lack of interest or engagement in important social roles, such as work or close relationships (American Psychiatric Association, 2022[144]). Reduced connectedness here is then both a risk factor for and an outcome of mental ill-health (i.e. an early symptom of onset, a symptom of ongoing episodes, a criterion for recovery) (Zimmerman et al., 2006[145]; Saeri et al., 2018[146]). Indeed, people experiencing poor mental health tend to consistently experience worse social connection outcomes. For instance, those at risk of mental distress are ten times more likely to report feeling lonely and two times more likely to say they do not trust other people than those not at risk of distress (Figure 4.6, Panel A). Both people at risk of mental distress and those with low positive mental health are also more than twice as likely to have infrequent contact with friends and family, compared to people in good mental health (Figure 4.6, Panels A and B) (Richardson et al., 2018[140]).

Figure 4.6. People experiencing mental distress or low positive mental health are more likely to distrust others, feel lonely and have infrequent contact with family and friends

Social connectedness and good mental health mutually reinforce one another

There is widespread consensus and longitudinal evidence that social connectedness can protect and promote mental health (and health more generally) (Kawachi, 2001[147]; Perkins, Subramanian and Christakis, 2015[148]). Lack of contact with local friends has been linked to common mental disorders, particularly for individuals facing material deprivation, and frequency of social contact in the year prior is associated with higher emotional well-being, regardless of an individual’s initial mental well-being (Lorber et al., 2023[149]; Ding, Berry and O’Brien, 2015[150]; Luo et al., 2012[151]). In addition, poor perceived social support and loneliness predict lower life satisfaction and worse depression outcomes in terms of symptoms, recovery and social functioning, with similar preliminary evidence for anxiety, schizophrenia and bipolar disorder (Wang et al., 2018[152]; Cruwys et al., 2013[153]; Cacioppo et al., 2008[154]). Overall, evidence suggests that subjective appraisals of the quality of social relationships (e.g. loneliness, perceived social support) are more strongly associated with psychological health than objective measures of its quantity (e.g. frequency of social contact, whether a person lives alone) (Holt-Lunstad, Smith and Layton, 2010[155]).

Multiple longitudinal studies have tried to disentangle the complex relationship between different aspects of social connectedness and mental health further, often relying on structural equation models to examine bidirectionality. Overall, it is clear that the relationship is reciprocal (Figure 4.7). For instance, while loneliness is associated with early mortality due to increased risks of behaviours such as substance use, the behaviours associated with substance abuse disorder can then contribute to further social isolation (Patterson and Veenstra, 2010[156]; Hosseinbor et al., 2014[157]). However, there is also increasing evidence that social connectedness is a comparatively stronger predictor of mental health than the converse: loneliness has predicted subsequent changes in depressive symptomatology and perceived mental health, but not vice versa, in British adults and older American adults (Cacioppo, Hawkley and Thisted, 2010[158]; Yu et al., 2015[159]); and perceived lack of being accepted by others was found to be a stronger and more consistent predictor of mental distress year-on-year than the reverse in New Zealand (Saeri et al., 2018[160]). The causal association between social connectedness and health more generally is also supported by recent studies using causal epidemiology and experimental evidence in animals (Office of the U.S. Surgeon General, 2023[161]).

Figure 4.7. Previous experience of loneliness predicts current mental health status, and vice versa

In terms of causal pathways, social relationships fulfil a fundamental psychological need for belonging and act as a protective psychological resource, particularly in times of adversity (Baumeister and Leary, 1995[163]; Jetten, Haslam and S. Haslam, 2012[164]; Praharso, Tear and Cruwys, 2017[165]). Social isolation may alter an individual’s cognitive processes and social cognition, leading to lower interpersonal trust and hypervigilance for social threats, which then further contribute to less motivation to connect with others, while strong social connections are linked to higher self-esteem, greater empathy and more cooperative relationships (VanderWeele, Hawkley and Cacioppo, 2012[166]). Loneliness also impacts both biological and behavioural aspects of mental health, in that it can contribute to increased cortisol levels, disrupted sleep patterns, higher risk of substance use to self-medicate, and lower likelihood to engage in protective activities such as exercise (which also has been found to have additional mental health benefits if done in the company of others) (Hawkley, Thisted and Cacioppo, 2009[167]; Hosseinbor et al., 2014[157]; Kanamori et al., 2016[168]; Victorian Government Australia, 2021[169]).

Loneliness among young people is an emerging policy concern

Public awareness of loneliness and social isolation so far has been greatest for older people, with much of the research on loneliness and health, including on which interventions might work to tackle it, relating to people over age 55 (Box 4.3). Indeed, older adults are more likely to face factors such as living alone, the loss of family or friends, chronic illness and hearing loss, and some pre-COVID-19 country-specific estimates considered up to one quarter of people aged 65 or older to be socially isolated and/or lonely (National Academies, 2020[170]; Local Government Association, 2016[171]).

However, during COVID-19 young people have emerged as a new risk group for both loneliness and mental distress: in March 2021, nearly one in five people in European OECD countries felt lonely most or all of the time, and people aged 18-24 felt the loneliest during the pandemic, being twice as likely as those over 65 to feel so, reversing pre-pandemic trends (OECD, 2021[53]). By spring 2022, these numbers still had not recovered to 2020 levels: people aged 18-29 continued to be the loneliest age group, with more than one in three young people affected (Eurofound, 2022[172]). However, the increase in youth loneliness seems to predate COVID-19, with evidence from systematic reviews suggesting that loneliness in young adults has already been on the rise worldwide over the past four decades (Buecker et al., 2021[173]).

Box 4.3. Policy focus: Social connection interventions that also improve mental health outcomes

Make improving social connectedness an explicit policy priority

The topic of social connections, despite its central importance for the well-being of people and societies, often does not have a dedicated policy home. In order to generate the mandate for agencies to address and systematically think of social connectedness in their work, improving it has to be made an explicit policy goal to be monitored and improved, including through:

Including relevant targets in cross-government and local-level strategies.
Creating initiatives and positions with dedicated funding, visibility and convening power, such as dedicated government roles (e.g. the Minister of Loneliness in the United Kingdom and in Japan) or strategies (e.g. the 2018 Loneliness Strategy in the United Kingdom, the 2018 Loneliness Programme of the Netherlands, the 2022 Strategy against Loneliness in Germany and the 2020-30 Municipal Strategy against Loneliness in Barcelona) (Government of the United Kingdom, 2023[174]; BMFSFJ, 2022[175]; Government of the Netherlands, 2023[176]; Ajuntament de Barcelona, 2020[177]). In the United States, the Surgeon General published an advisory report to call attention to the importance of social connections for individual and community-wide health and well-being in May 2023, including recommendations for different stakeholders across government, research, civil society, media, families and individuals (Office of the U.S. Surgeon General, 2023[161]). In addition, the Public Health Agency in Sweden and the Ministry of Social Rights and Agenda 2030 in Spain are currently in the process of developing national loneliness strategies (Swedish Presidency of the Council of the European Union, 2023[178]; EPE, 2022[179]).
Routinely evaluating policies for their impact on social connectedness.

Expand support for existing social connection interventions and infrastructure

Support for existing programmes and structures that tackle the drivers of social connections, and for which evidence of efficacy exists, should be expanded. This includes:

Integrating social connections in existing service structures, for example, through social prescribing, a practice in which health professionals connect patients to non-health-related support provided by community organisations (e.g. debt advice and financial planning workshops, arts and sports activities, walking groups) (OECD, 2021[53]).
Investing in social infrastructure, e.g. public, civic and green spaces that create inclusive opportunities for social contact and improve a sense of belonging. For instance, the German government is currently sponsoring more than 500 multi-generational centres in which people from different ages and backgrounds come together for social and civic engagement as part of its strategy to strengthen local development in all regions (BMFSFJ, 2023[180]).
Supporting community programmes, including recreational and art activities and volunteering groups. For instance, the United Kingdom recently launched a “Know Your Neighbourhood Fund” for local organisations, in order to widen participation in volunteering and tackle loneliness, particularly for people living in disadvantaged areas (Government of the United Kingdom, 2023[181]). Additionally, Germany’s Urban Development Support programme “Social Cohesion – Building Coexistence in the Neighbourhood Together,” implemented jointly by the Federal Ministry for Housing, Urban Development and Building and state and municipal governments, focuses on strengthening cohesion through quality-of-life oriented integrated urban development planning, more diverse housing, and neighbourhood managers who help residents connect with one another and volunteer (Federal Ministry, 2023[182]). The Ministry of Health, Welfare and Sport in the Netherlands also focuses on supporting municipalities in expanding and evaluating local social connectedness programmes (Government of the Netherlands, 2023[176]).
Expanding access to psychological support services, including in education systems, to improve social skills and maladaptive social cognition for people who already feel disconnected (Masi et al., 2011[183]).

Strengthen the evidence base on effective and scalable interventions for different population groups

There are still many knowledge gaps on what works best in which context in order to lastingly improve social connectedness, especially when it comes to scalable policy solutions (European Commission, 2023[184]; NWO, 2023[185]). There is a real need to fund further research on the root causes of social connectedness (rather than only on its prevalence) and to share best practices among OECD countries, including for the following areas:

On the different components of social connectedness (including structural, functional and quality aspects), rather than only on loneliness
On the different interventions needed to target children, young adults and the working-age population, rather than only older people, including on group-specific pathways and delivery mechanisms such as digital tools
On the role of the stigma of loneliness
On the medium- and long-term impact of promising interventions, since most have only been evaluated in the short term
On community-level and place-based approaches that tackle social determinants and improve social infrastructure, rather than only individual-level interventions

4.4. Civic engagement

Civic engagement is about whether citizens can and do take part in important civic activities that enable them to shape the society in which they live. Mental health has political consequences in that people’s likelihood to participate in civic engagement can be influenced by their mental states, and perceptions of public institutions can be a risk factor for poor mental health.

Feelings of exclusion from society and alienation from public institutions are associated with worse mental health outcomes. Indeed, compared to their peers with good mental health, people at risk of mental distress and those with low positive mental health are more likely to report distrust in a range of public institutions (e.g. the government, the legal system, the police) and to say they feel left out of society (Figure 4.8).

Figure 4.8. Feeling alienated from society and public institutions is associated with both mental distress and lower positive mental health

Similarly, people who reported having experienced more symptoms of depression in the past year (the mental health condition on which most of the research in this field has focused so far) are less likely to vote and to engage in other forms of political participation, such as contacting a politician, signing a petition or demonstrating. They are also less likely to be interested and confident in politics more generally (Figure 4.9).

Figure 4.9. Depression is associated with citizens being less active, less interested and less confident in politics

Outcomes related to civic engagement and political representation can also affect mental health

Without the participation of people experiencing mental ill-health, their needs (including needs regarding conditions that could help with recovery and promote good mental health) might not be well represented on the political agenda, contributing to further decreasing feelings of political efficacy and motivation (Bevan and Jennings, 2014[187]; Bernardi, 2021[188]). Second, there is tentative evidence from some OECD countries that “political stress” and concerns about polarisation are emerging as new risk factors for mental health. In 2020, 40% of American adults felt significant stress due to politics, between 20% and 30% blamed politics for causing fatigue, lost sleep, feelings of anger and loss of temper and for triggering compulsive behaviours, and 5% reported suicidal ideation as a result (Smith, 2022[189]).

Figure 4.10. A quarter of respondents across OECD countries believe people with a history of mental illness should be excluded from public office

Box 4.4. Policy focus: Civic engagement interventions that also improve mental health outcomes

Ease the participation and representation of those with lived experience of mental ill-health in politics

The particular challenges for political participation and civic engagement that people experiencing mental ill-health face should be taken into account when trying to increase their representation in politics, including by:

Offering less physically-demanding forms of participation in decision-making (e.g. through digital formats) and reducing any potential barriers to voting embedded in regulation more generally. Several of these would also help the participation of other groups, such as the elderly or those working long, inflexible working hours.
Improving trust in public institutions by targeting people with experience of mental ill-health, and particularly young people. The updated OECD Trust Framework has identified government competencies (i.e. responsiveness and reliability) and values (i.e. openness, integrity, fairness) as the drivers of public trust (OECD, 2017[191]; Brezzi et al., 2021[192]). The various recommendations and good governance practices in each area could be adapted for specific population groups, such as people experiencing poor mental health.
Conducting awareness campaigns to decrease stigma, particularly for politicians with lived experience of mental ill-health.
Funding research on the impact of mental ill-health on civic participation beyond depression, and whether the challenges might be different.

Address political stress as an emerging risk factor for mental health

The prevalence of political stress should be monitored further to determine whether this is a growing phenomenon across OECD countries. Individuals already affected could be supported by integrating the management of political stress as well as other risk factors, such as low perceptions of government responsiveness, into clinical practice and education systems. In addition, interventions that enhance social capital, such as investment in civic spaces to connect people from different backgrounds, including political views, could help to bridge divides (Box 4.3).

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Notes

← 1. This also implies that intersectionality between these characteristics increases the risk for being affected by IPV.

← 2. Disability is another individual risk factor for IPV: people with disabilities have been consistently found to be at greater risk of sexual, physical and psychological IPV victimisation, with some estimates suggesting that more than 50% of disabled women experience IPV in their lifetime (Breiding and Armour, 2015[193]).

← 3. These figures are not fully representative for children aged 0-3, however, because children were of different ages at the time their parents were surveyed. The lifetime prevalence of experiencing intimate partner violence was 9.6% for mothers (who represented 90% of the sample) and 2.6% for fathers (who represented 7% of the sample of around 8 000 families).

← 4. Pathways that explain the link between IPV perpetration and mental ill-health might include symptoms leading to violence (e.g. paranoia, hostility, anger), increased likelihood of substance use, and shared genetic and family environmental risks for mental health conditions, substance use and violence (Oram et al., 2022[42]). However, more research into these hypothesised causal mechanisms is needed.

← 5. Stereotype threat refers to expectations and anxieties activated by a stigmatised group when negative stereotypes about their group are made salient.

← 6. For instance, Black Americans with severe depression are more likely than white Americans to be misdiagnosed as having schizophrenia, suggesting that clinicians tend to put more emphasis on psychotic than depressive symptoms for this population group (Gara et al., 2019[194]).

← 7. For instance, in 2014 (the latest available data point), Black people in the United Kingdom were more than twice as likely as white people to be receiving treatment for mental health problems (Government of the United Kingdom, 2017[195]).

← 8. Moreover, in countries where there is a regulation on maximum working time, this is generally limited to 48 hours per week.

← 9. It is important to note that the majority of research on social connectedness more generally and with regards to studies relating to mental health often does not cleanly distinguish between different aspects of the phenomenon. Often very different concepts, such as social isolation, loneliness, social capital, social cohesion and community participation, are either conflated or used interchangeably. Upcoming WISE work on different conceptualisations of relevant aspects of social connectedness will contribute to this field, focusing on more harmonised official data collection on the topic.

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