Mental health as a reason for claiming incapacity benefit a comparison of national and local trends

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1 Journal of Public Health Vol. 31, No. 1, pp doi: /pubmed/fdn098 Advance Access Publication 30 October 2008 Mental health as a reason for claiming incapacity benefit a comparison of national and local trends Judith Brown 1, Phil Hanlon 1, Ivan Turok 2, David Webster 3, James Arnott 3, Ewan B. Macdonald 1 1 Public Health and Health Policy Section, University of, G12 8RZ, UK 2 Department of Urban Studies, University of, G12 8RS, UK 3 Development and Regeneration Services, City Council, G1 1QU, UK Address correspondence to Judith Brown, j.brown@clinmed.gla.ac.uk ABSTRACT Background Getting incapacity benefit (IB) claimants into work has become a focus for policy makers. Strategies to help this depend on an understanding of the reasons for claiming benefit at a local level where variations from a national strategy may be needed. Methods Data supplied by the Department for Work and Pensions (DWP) was analysed to establish reasons for claiming benefit in and between 2000 and Results There has been a continuing rise in mental health diagnosis and a corresponding fall in musculoskeletal diagnosis during this period. More people were claiming because of mental health problems in than in. Also those with a poor employment history (creditsonly claimants) are more likely to claim IB because of a mental health problem. This study has shown a breakdown into 25 categories those claiming IB because of a mental health problem. Conclusion DWP data can be used to provide important insights into the trends in reasons for claiming IB, in particular those claiming because of mental health problems. This study also highlighted the growing importance of problems caused by alcohol and drug-abuse claimants, a subset of the mental health category. DWP data should be used at a local as well as a national level to guide and evaluate interventions to help this vulnerable. Keywords incapacity benefit, mental health Introduction Incapacity benefit (IB) is the key contributory benefit for people who are incapable of work because of illness or disability. In order to qualify for IB, claimants must be incapable of work, not entitled to Statutory Sick Pay and have sufficient National Insurance (NI) contributions. Several reports have provided general information on IB claimants. 1 4 These show important UK trends (e.g. falling total IB claimants after many years of increase, movement from musculoskeletal to mental health problems), but provide insufficient details about the characteristics of the claimants in any city or region to be truly useful for monitoring the local impact of policy initiatives. From the 1960s to the 1990s, musculoskeletal disorders were the main reason for claiming sickness benefits in the UK. 5 However, since then there has been a dramatic shift in the reason for claiming IB to mental health disorders. 6 The reduction in musculoskeletal disorders as a cause of morbidity has accompanied changes in the medical management of low back pain to one of encouraging continuing activity rather than rest. 7 is an IB hot spot and has the largest single population of IB claimants in the UK. 8 also has some of the highest rates in the UK of alcohol-related harm, drug misuse and mental health disorders. 9 Therefore, there may be important differences in local trends that could Judith Brown, Research Fellow Healthy Working Lives Group Phil Hanlon, Professor of Public Health Ivan Turok, Professor of Urban Economic Development David Webster, Housing Strategy Manager James Arnott, Senior Policy Development Officer Ewan B. Macdonald, Head of Healthy Working Lives Group 74 # The Author 2008, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved.

2 MENTAL HEALTH AND INCAPACITY BENEFIT 75 inform interventions. In this study, data for and were analysed to characterize the reasons for claiming IB and to understand more about the mental-health claiming, particularly the alcohol and drug abuse. Six main questions were addressed in the study: (1) How many mental-health claiming IB claimants are there in and compared with those claiming because of musculoskeletal problems? (2) How has this changed over the 7-year time period? (3) Are there differences between payment and credits-only (distinction explained in methods) IB claimants, in terms of claiming IB because of a mental health problem? (4) What is the breakdown of the mental health (in terms of mental health category, sex, age and length of time on benefit)? (5) How does the mental health profile compare with the profile of total IB claimants? (6) In particular, what are the characteristics of those claiming IB because of alcoholism and drug abuse? Methods The study team received comprehensive data (100% sample of IB claimants) for and from the Department for Work and Pensions (DWP) Work and Pensions Longitudinal Study (WPLS) for the period The WPLS was introduced in January 2004 and contains benefit and programme information held by DWP on its customers. It can be used to perform a range of statistical and research analyses. Data for IB claimants were provided quarterly from December 1999 until February To illustrate the change over the 7 years of analysis, a breakdown by reason for those claiming IB is shown for the first and last quarter, i.e. December 1999 February 2000 and December 2006 February 2007, but this was only chosen as the approach once it had been established that changes had been gradual and constant over the period of analysis. For simplicity, the quarter ending February 2000 will be referred to as 2000 and quarter ending February 2007 will be referred to as Data on the mental-health claiming of IB claimants were further analysed by mental health category, sex, age and length of time on benefit. DWP data on the reason for claiming IB is routinely broken down into six broad categories (mental and behavioural disorders; diseases of the nervous system; diseases of the circulatory or respiratory system; diseases of the musculoskeletal system and connective tissue; injury, poisoning and certain other consequences of external causes and other). We requested a further breakdown of the mental-health claiming. The s claiming because of alcoholism and drug abuse were investigated further. IB claimants can be divided into two s payment IB claimants and credits-only IB claimants. Together these two categories make up what is commonly understood to be a single IB claiming population, however, there are clear distinctions between the two s. Definitions are complex and the benefit system as a whole tries to ensure that individuals receive broadly equivalent amounts from the State, but the source may vary. Payment IB claimants must be incapable of work, not entitled to Statutory Sick Pay, and have sufficient NI contributions to receive IB payment. Payment IB claimants therefore have a good recent work history. Credits-only claimants will not have made sufficient NI contributions but fulfil all the other qualifying conditions for IB and so receive financial support from other sources. They are credited with pension contributions and gain access to other benefits such as income support with a disability premium. These claimants have less good recent work histories. In this study, the total claimants can be broken down into payment and credits-only claimants and where differences have been found between the two s this is highlighted. Results Main reason for claiming IB in and The most common reason for claiming IB in 2000 and 2007 in both and was mental and behavioural disorders. In 2000, there were IB claimants in of which (33.6% of total) were claiming because of mental and behavioural disorders. By 2007, the number of total IB claimants had decreased to , however the number claiming because of mental and behavioural disorders had increased to (44.2% of total) (Table 1). In 2000, there were IB claimants in of which (40.1% of total) were claiming because of mental and behavioural disorders. By 2007, the number of total IB claimants had decreased to , however the number claiming because of mental and behavioural disorders had increased to (51.3% of total) (Table 1). There has been a decrease in the number receiving IB because of diseases of the musculoskeletal system in

3 76 JOURNAL OF PUBLIC HEALTH Table 1 Per cent of total IB claimants with mental health problem or musculoskeletal problem in and Quarter ending Mental and behavioural disorders Diseases of the musculoskeletal system Mental and behavioural disorders Diseases of the musculoskeletal system February February Claiming because of alcoholism and drug abuse has increased, but only modestly, from 2000 to 2007 (alcohol %; drug abuse %). In, the main reason for claiming IB due to a mental and behavioural problem in 2000 was other neurotic disorders (47.3%) (Table 3). There has been a decrease in the number of people claiming for this reason in 2007 (35.2%) but other neurotic disorders was still the main reason for claiming IB due to a mental health problem. Claiming because of a depressive episode, alcoholism and drug abuse have increased from 2000 to 2007 (depressive episode %; alcohol % and drug abuse %). Depression has been the biggest category of increase. (from 19.9 to 15.4%) and (from 16.8 to 12.5%) (Table 1). Mental health IB claimants in and : payment versus credits-only claimants Table 2 shows total IB claimants claiming because of a mental health problem split into payment and credits-only claimants. The percentage of payment and credits-only claimants claiming because of a mental health problem has increased from 2000 to 2007 in and. There are more mental-health claiming credits-only claimants than payment claimants in both and (in 2007, 37.8% payment claimants, 56.2% credits in ; 43.8% payment, 60.0% credits-only in ). Breakdown of mental-health IB claiming in and The mental-health claiming was broken down into 25 categories. In, the main reason for claiming IB due to a mental and behavioural disorder in 2000 was depressive episode (32.8%) (Table 3). There was an increase in the number of people claiming for this reason in 2007 (37.9%). Breakdown of mental-health claiming by sex, age and length of time on benefit We can breakdown all the mental health categories by sex, age and length of time on benefit. Table 4 shows the breakdown of the mental health and total IB claiming s in and in 2000 and The ratio of males to females claiming because of a mental health problem is similar to total IB claimants in both and (Tables 4), with slightly more males claiming than females. The age profile of the mental-health claiming is younger than total IB claimants. For example, in 2007, the percentage of total claimants in the age category was 21.9% in and 24.5% in (Table 4). In the same quarter, the percentage claiming because of a mental health problem was 27.3% in and 29.7% in (Table 4). There have been decreases in all the duration of claim categories between 2000 and 2007 except for the greater than 5 years category where there have been increases (for %; for %, Table 4). This is similar to total IB claimants (Table 4). This seems to be the where people are most trapped. Table 2 Per cent of total, payment and credits-only IB claimants claiming because of a mental health problem in and Quarter ending Total claimants Payment Credits-only Total claimants Payment Credits-only February February

4 MENTAL HEALTH AND INCAPACITY BENEFIT 77 Table 3 Breakdown of mental-health IB claiming in and All mental and behavioural disorders Depressive episode (32.8) (37.9) 6060 (22.4) 8510 (28.9) Other neurotic disorders (25.4) (17.6) (47.3) (35.2) Other anxiety disorders (11.1) (10.4) 2740 (10.1) 3000 (10.2) Alcoholism 6940 (6.2) 9380 (6.9) 1710 (6.3) 2270 (7.7) Unspecified mental retardation 6480 (5.8) 5590 (4.1) 540 (2.0) 520 (1.8) Drug abuse 4930 (4.4) 8030 (5.9) 1170 (4.3) 1410 (4.8) Schizophrenia 3430 (3.1) 3870 (2.8) 470 (1.7) 570 (1.9) Reaction to severe stress 2930 (2.6) 5950 (4.4) 390 (1.4) 920 (3.1) Specific development disorders of scholastic 2490 (2.2) 5360 (3.9) 220 (0.8) 610 (2.1) skills Mental disorder not otherwise specified 2100 (1.9) 2910 (2.1) 180 (0.7) 380 (1.3) Unspecified non-organic psychosis 1560 (1.4) 1770 (1.3) 200 (0.7) 260 (0.9) Phobic anxiety disorders 880 (0.8) 920 (0.7) 180 (0.7) 200 (0.7) Mental and behavioural disorders associated 770 (0.7) 600 (0.4) 150 (0.6) 90 (0.3) with the puerperium, not elsewhere classified Persistent mood disorder 520 (0.5) 280 (0.2) 70 (0.3) 30 (0.1) Unspecified mood disorder 470 (0.4) 660 (0.5) 70 (0.3) 70 (0.2) Persistant delusional disorder 140 (0.1) 250 (0.2) 20 (0.1) 40 (0.1) Eating disorder 130 (0.1) 180 (0.1) 20 (0.1) 40 (0.1) Specific personality disorders 130 (0.1) 220 (0.2) 10 (0.0) 20 (0.1) Manic episode 120 (0.1) 120 (0.1) 10 (0.0) 10 (0.0) Recurrent depressive disorder 110 (0.1) 190 (0.1) 30 (0.1) 100 (0.3) Unspecified dementia 100 (0.1) 70 (0.1) 10 (0.0) 10 (0.0) Pervasive development disorders 40 (0.0) 290 (0.2) 10 (0.0) 30 (0.1) Dissociative Disorders 10 (0.0) 10 (0.0) 0 (0.0) 0 (0.0) Psychological and behavioural factors associated 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) with disorders or diseases elsewhere classified Somatoform disorders 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) Breakdown of alcoholism claiming by sex, age and length of time on benefit The results for the alcohol claiming IB are shown in Table 4. There are many more men claiming IB because of alcoholism than women in both and (in 2000, 85.4% men, 14.6% women in ; 88.4% men, 11.6% female in ). However there has been an increase in the number of women claiming due to alcoholism over the 7-year period (for 2007 up to 16.7% in ; up to 14.6% in ). The age profile of the alcoholism is younger than the total IB claiming (for the alcoholism age, 30.7% in, 30.4% in 2000, Table 4; for the total IB claiming age, 19.9% in, 22.6% in 2000, Table 4). In 2000, the largest claiming s because of alcoholism were the two categories 2 years and up to 5 years ( 33.9%; 32.2%) and 5 years and over ( 34.4%; 40.4%, Table 4). However by 2007, there had been a shift with the largest being the 5 years and over ( 49.0%; 52.0%, Table 4). Breakdown of drug-abuse claiming by sex, age and length of time on benefit The results for the drug-abuse claiming IB are shown in Table 4. There are more men than women claiming

5 78 JOURNAL OF PUBLIC HEALTH Table 4 Breakdown of mental health (MH), alcoholism, drug abuse and total IB claiming s by sex, age and reason on benefit in and Sex MH Female (46.1) (45.3) (43.6) (42.8) Male (53.9) (54.7) (56.4) (57.2) Alcoholism Female 1010 (14.6) 1570 (16.7) 200 (11.6) 330 (14.6) Male 5930 (85.4) 7810 (83.3) 1520 (88.4) 1930 (85.4) Drug abuse Female 1130 (22.9) 1830 (22.8) 310 (26.5) 320 (22.5) Male 3800 (77.1) 6200 (77.2) 860 (73.5) 1100 (77.5) Total Female (42.1) (44.0) (40.5) (41.7) claimants Male (57.9) (56.0) (59.5) (58.3) Age MH (25.9) (27.3) 7530 (27.8) 8730 (29.7) Alcoholism (30.7) 2600 (27.7) 520 (30.4) 590 (26.0) Drug abuse (52.1) 3900 (48.6) 650 (55.6) 540 (38.3) (15.8) 2630 (32.8) 230 (19.7) 650 (46.1) Total (14.2) (12.6) (16.6) 7420 (12.9) claimants (19.9) (21.9) (22.6) (24.5) Length of time on benefit MH 5 years and over (39.1) (53.0) (41.2) (56.3) Alcoholism 2 years and up to 2350 (33.9) 2160 (23.0) 550 (32.2) 510 (22.5) 5 years 5 years and over 2390 (34.4) 4600 (49.0) 690 (40.4) 1180 (52.0) Drug abuse 2 years and up to 1500 (30.4) 2250 (28.0) 360 (30.8) 340 (24.1) 5 years 5 years and over 760 (15.4) 2970 (37.0) 250 (21.4) 660 (46.8) Total claimants 5 years and over (44.0) (56.8) (46.3) (59.5) because of drug abuse (in 2000, 77.1% men, 22.9% women in ; 73.5% men, 26.5% female in ). The ratio of men-to-women claiming because of drug abuse is less than alcoholism. Figures remain largely unchanged for in In, there is an increase in the number of males claiming because of drug abuse (in 2007 up to 77.5%). The age profile of the drug-abuse claiming population is younger compared with total IB claimants (for the drug abuse age, 52.1% in, 55.6% in 2000, Table 4; for the total IB claiming age, 14.2% in, 16.6% in 2000, Table 4). The decrease between 2000 and 2007 in the age category is likely to be due to this getting older and moving into the next age category (35 44 age category increases from 15.8 to 32.8% in from 2000 to 2007; age category increases from 19.7 to 46.1% in from 2000 to 2007, Table 4). The number of people claiming because of drug abuse shows a more recent increase. In 2000, there are more drug abusers in the shorter duration of claims compared with total claimants. In 2000, the highest claiming

6 MENTAL HEALTH AND INCAPACITY BENEFIT 79 because of drug abuse was the 2 years and up to 5 years in both (30.4%) and (30.8%). By 2007, the largest category was the 5 years and over category ( 37.0%; 46.8%) (Table 4). Discussion Main findings of this study This study provides an analysis of the IB population who had a mental health diagnosis as a reason for claiming IB in and in 2000 and This paper has been able to show for the first time the breakdown of the mental health by mental health category, sex, age and length of time on benefit. Further, those claiming because of alcoholism and drug abuse have been characterized. There has been a continuing rise in mental health diagnosis and a corresponding fall in musculoskeletal diagnosis during this period. More people were claiming because of mental health problems in than in. Also more credits-only claimants are claiming IB because of a mental health problem which suggests that those with a mental health diagnosis are more likely to have a poor work history. The large number of individuals diagnosed as having a depressive, neurotic or anxiety disorder opens up the possibility that many of these individuals might respond to treatment and may not have permanent disability. Alcoholism and drug abuse as a reason for claiming IB are more common in men than women and increased over the study period in both and causing together 12.8% of mental health problems in and 12.5% in in In 2000, unlike other s there are more people claiming IB for these reasons with shorter duration of claims. However by 2007, the largest claiming was greater than 5 years category. What is already known on this topic In the 1980s, the growth in sickness-related benefits was largely due to musculoskeletal conditions, which outnumbered two to three times the relatively stable numbers with mental health conditions. 10 Since the mid- to late 1990s, there has been a dramatic shift in the main reason for claiming IB from musculoskeletal to mental health diagnoses. A recent figure for the whole of the UK showed that 42% of the stock IB population were claiming IB because of mental health conditions, compared with 16% in The vast majority of this increase is in mild to moderate mental health conditions like depressive symptoms, stress, anxiety or other neuroses, with only a small numbers having serious psychiatric illnesses such as schizophrenia. Interestingly, there was a geographical dimension to this increase in mild/moderate mental health conditions, which started in the south east of England and spread gradually to the rest of the country supporting the augment that it is a social rather than a biological phenomenon. 6 What this study adds This study describes in detail the mental-health claiming IB population in and in 2000 and Other studies have provided only broad medical diagnostic categories for those claiming IB and have not given an insight into those medical reasons for claiming IB because of mental and behavioural disorders. Further this study highlights the alcohol and drug-abuse claiming s. It is known that is an IB hot spot but this study also shows that s IB population has more claimants with mental health problems than and the UK. It also shows the larger proportion of credits-only claimants in this category. Of the different mental health diagnostic categories used in 2000, 69.3% were either depressive, neurotic and anxiety disorders in, compared with 79.8% in suggesting that in mental health shows some differences from in total contribution to IB ill health. Also those with a mental health diagnosis tend to be younger in both and compared with the total IB population. The large number of individuals diagnosed as having a depressive, neurotic or anxiety disorder indicates that many of these individuals would be amenable to treatment and may not have permanent disability. Severe mental health problems such as schizophrenia and psychotic disorders and mood disorders were relatively small in numbers and did not change as a proportion of the whole over the study period. This study gives detailed information on the alcohol and drug abuse. Although the majority of these claimants are male there are increasing numbers of females claiming for alcohol-related reasons. These claimants also tend to be younger. The length of time on IB profile shows that claiming because of drug abuse and to a lesser extent alcohol was a relatively new phenomenon in 2000 with relatively short durations of claims. By 2007, the pattern was more like that of total IB claimants with the largest of alcohol/drug-abuse claimants claiming for over 5 years. Limitations of the study There may be limitations associated with the classification of the type of mental health illness. Although this study has for the first time shown the breakdown of the mental-health

7 80 JOURNAL OF PUBLIC HEALTH claiming in, the classification depends on the consistency and interpretation of those doing this (General Practitioners and DWP gate keeping doctors) and the results of personal capability assessment (PCA). A recent review has been undertaken to consider the impact of the changing pattern of mental health problems and treatment options on the effectiveness of the mental health component of the PCA assessment. 11 Also, only one illness is required to be recorded when claimants may actually have a number of conditions. In the year 2000 in other neurotic disorders were the largest category at 47.3% compared with 25.4% in where depressive episode was the largest category at 32.8%. These differences in diagnostic categorization of individuals with mental health continued in There is clearly a difference in diagnostic labelling, or a real difference in psychiatric morbidity in when compared with as a whole with neurosis being more common in, compared with where depression predominated. Conclusions Those with a poor employment history (credits-only claimants) are more likely to claim IB because of a mental health problem. The DWP data can be broken down into 25 mental health diagnoses. This study has highlighted the differences in these categories in 2000 and 2007 in and. This study has also highlighted the growing number of alcohol and drug-abuse claimants. These claimants tend to be younger and male but there are increasing numbers of females claiming for alcohol-related reasons. Having a detailed breakdown of this of claimants could help with policy decisions for this vulnerable population. There is a need for this work to be carried out at a local as well as a national level because local differences should inform strategy. This study also suggests that the routine DWP data, while important, should be supplemented by other studies that provide insight into what is driving these trends. Supplementary data Supplementary data are available at Journal of Public Health online. Acknowledgements The authors acknowledge the help of Gary Gifford, DWP and Dr Richard Mitchell, University of. They also thank Professor Carol Tannahill, Dr Russell Jones and the Centre for Population Health. Funding This study was funded by the Centre for Population Health. References 1 Department for Work and Pensions. Pathways to Work: Helping People into Employment. London: Department for Work and Pensions, Department for Work and Pensions. A New Deal for Welfare: Empowering People to Work. London: Department for Work and Pensions, Blyth B. Incapacity Benefits Reforms Pathways to Work Pilots Performance and Analysis. London: Department for Work and Pensions, Berthoud R. The profile of exits from incapacity-related benefits over time. Department for Work and Pensions, Working Paper No. 17, Waddell G. Preventing incapacity in people with musculoskeletal disorders. Br Med Bull 2006;77 78: Waddell G, Aylward M. The Scientific and Conceptual Basis of Incapacity Benefits. London: The Stationery Office, Waddell G, Burton AK. Occupational health guidelines for the management of low back pain at work: evidence review. Occup Med 2001;51: Brown J, Hanlon P, Turok I et al. Establishing the potential for using routine data on incapacity benefit to assess the local impact of policy initiatives. J Public Health 2008;30: Hanlon P, Walsh D, Whyte B. Let Flourish. : Centre for Population Health, Waddell G, Burton AK. Concepts of Rehabilitation for the Management of Common Health Problems. London: The Stationery Office, Department for Work and Pensions. Transformation of the Personal Capability Assessment. London: Department for Work and Pensions, 2006.