Across all the questions in this paper, we are seeking your views on how the mental health and wellbeing plan can address mental health disparities. To inform your responses, this annex provides detailed evidence on key disparities and provides links to sources where you can find out more. This annex presents an overview of evidence on disparities in mental health. The evidence was purposefully selected by topic experts to include available evidence from academic research, published data and grey literature. The overview is based primarily on an internal Public Health England rapid review of evidence on the determinants of mental health and vulnerable groups from 2020. It also draws on internal technical reports, expert opinion and a search of key sources from 2000 to February 2022 including the Adult Psychiatric Morbidity survey (2014) and the Office for Health Improvement and Disparities’ public health profiles. Note that the list of mental health disparities presented below is not exhaustive; there is variability in the strength of the evidence and critical appraisal has not been undertaken; there is a lack of evidence for certain groups. Introduction We know there is an uneven distribution of mental ill-health and determinants of mental health across society for both adults and children. People facing socio-economic disadvantage and other forms of social exclusion are at a much higher risk of developing mental health conditions. There are notable disparities by ethnicity, sex, age, sexual orientation and gender identity, learning disability and neurodiversity, for people with multiple and other long-term conditions. Risks of mental ill-health are also higher for people who are unemployed, people in problem debt, people who have experienced displacement, including refugees and asylum seekers, people who have experienced violence or abuse, people in contact with the criminal justice system (both as victims and as offenders), children in care and care leavers, people who are homeless or who face housing instability, people with substance misuse or gambling problems, people who live alone, and unpaid carers. These disparities can intersect to create different exposures and vulnerabilities to the social determinants of health. This means that some people face a range of difficult circumstances that compound risk, with childhood being a time of increased vulnerability. Our evidence shows that many of the disparities listed below increase the risk of mental ill-health when experienced together and especially alongside socio-economic disadvantage. Additionally, by worsening risks and outcomes for the most vulnerable, the impact of the COVID-19 pandemic has widened mental health disparities. Socio-economic disadvantage Socio-economic disadvantage includes a range of measures, such as occupation, educational attainment, income and living standards[footnote 46], influencing health across the life course. Certain population subgroups are at higher risk of mental disorders because of greater exposure and vulnerability to unfavourable social and economic circumstances[footnote 47] that are interrelated with sex. Less advantaged socio-economic position is associated with lower levels of wellbeing[footnote 48] and increased rates of depression[footnote 49]. There is well-established evidence that disparities in income[footnote 50] negatively affect mental health and many studies suggest a gradient of increasing ill-health with increasing disadvantaged position[footnote 51]. A number of studies show that socio-economic disadvantage has a detrimental effect on children’s mental health.  For example, data from the Millennium cohort study shows that children from the poorest 20% of households are 4 times more likely to have serious mental health difficulties by the age of 11 years compared to those from the wealthiest backgrounds[footnote 52]. Living in a low-income household or with a parent in receipt of income-related benefits is associated with higher rates of mental health conditions in children[footnote 53]. The Adult Psychiatric Morbidity Survey found that socioeconomic factors were strongly linked with psychotic disorder, for example, it was more common in those who were economically inactive and there was some evidence of associations with benefit status[footnote 54]. The prevalence of severe mental illness is also associated with area-level deprivation and urban environments[footnote 55]. Data from the Improving Access to Psychological Therapies initiative (IAPT)[footnote 56] shows that people living in the most deprived areas of England are more likely to be referred to IAPT services than those from the least deprived areas. However, the data also shows that people from the most deprived populations are less likely to use IAPT services and less likely to have recovered by the end of treatment compared to those living in the least deprived areas. An academic analysis of service data found similar patterns in 2014[footnote 57]. Ethnicity There is an established link between ethnic minority backgrounds and diagnosis of psychoses such as schizophrenia and major depression. There is strong evidence that severe mental health conditions are particularly elevated for people from black ethnic backgrounds and that people from South Asian, white other and mixed ethnicity groups are also at increased risk[footnote 58]. There is a need for further work on explanatory factors including urban environments, socio-economic status, migration and racial disparities. Findings on the prevalence of common mental health conditions for ethnic minority groups are complex due to variations in socio-economic status and migration experiences[footnote 59] [footnote 60] and have also been associated with experiences of racial disparities and discrimination[footnote 61]. Overall, findings for common mental health conditions are limited by poor quality data and small sample sizes, with no statistically significant findings available from the Adult Psychiatric Morbidity survey. There is less evidence for smaller ethnic groups, for example, people who are gypsy and Romany travellers and from Chinese ethnic backgrounds. The recent rapid review of the evidence on Ethnic Inequalities in Healthcare[footnote 62] undertaken for the NHS Race and Health Observatory found a number of mainly qualitative studies identifying barriers to help seeking by ethnic minorities. These were rooted in a distrust of both primary care and mental health care providers, as well as a fear of being discriminated against in healthcare. Evidence from qualitative research suggests that the lack of appropriate interpreting services acted as a deterrent to seeking help. The review also found a number of cross-sectional studies showing that ethnic minority groups face greater barriers in accessing Improving Access to Psychological Therapies (IAPT) compared to the white British group and are less likely to self-refer, be referred by a GP, be assessed or receive treatment[footnote 63]. In terms of IAPT treatment outcomes, recent data shows that white British service users show more improvement compared to ethnic minority groups[footnote 64]. Evidence was identified for disparities in the receipt of cognitive behavioural therapy (CBT) with ethnic minority people with psychosis less likely to be referred for CBT, and less likely to attend as many sessions as their white counterparts[footnote 65]. The review confirmed very large and persisting disparities in access to secondary mental health services for people from all ethnic minority backgrounds with severe mental illness[footnote 66] [footnote 67].  In particular, people from black Caribbean, black African and black British backgrounds with severe mental illness experience higher rates of contact with the police and criminal justice system (both as victims and as offenders), more admission to psychiatric hospitals, more compulsory inpatient care and fewer primary care interventions[footnote 68].  A number of small studies have found worse recovery outcomes for these groups[footnote 69]. In 2020 to 2021, rates of detention under the Mental Health Act were 4 times higher for the black British group compared to the white group, with use of Community Treatment Orders 10 times higher[footnote 70]. There is also evidence of harsher treatment with more frequent use of restraint of people from mixed ethnicity backgrounds and black backgrounds in mental health inpatient units compared to people from white backgrounds[footnote 71] and greater use of the prone position and seclusion[footnote 72]. The review also found 2 large national studies showing that ethnic minority children were more likely to be referred to Children and Adolescent Mental Health Services (CAMHS) via social services, education or criminal justice pathways. This was particularly stark for black children who were 10 times more likely to be referred to CAMHS via social services (rather than through the GP) relative to white British children[footnote 73]. Sex Pre-existing mental health problems are not distributed equally by sex. Women are more likely to experience common mental health conditions than men[footnote 74]: 20.7% of women and 13.2% of men aged 16 and over have been identified as having common mental health conditions such as anxiety or depression. Whilst rates remain relatively stable for men, prevalence of common mental health conditions is growing in women[footnote 75]. Young women (aged 16 to 24 years) are at particularly high risk, with 26% of young women experiencing a common mental health condition – almost 3 times more than young men, at 9.1%[footnote 76]. Women experience higher rates of PTSD, self-harm, suicidal ideation[footnote 77] and eating disorders[footnote 78] and can also face additional vulnerabilities during the perinatal period. Men report lower levels of overall life satisfaction, happiness and feeling as though their life is worthwhile[footnote 79]. Men tend to seek help less than women[footnote 80]. Men may also present their mental and emotional distress differently, for example through aggression or substance misuse. This means that when they do present to services, diagnosis can be missed, placing individuals at higher risk of deterioration[footnote 81]. For some severe mental health conditions, such as bipolar disorder, prevalence is slightly higher for men[footnote 82]. Over three-quarters of people who die by suicide are men[footnote 83] although the rates of suicide are growing in women, particularly young women[footnote 84]. There are long standing disparities in access to services. For example, men are less likely to be referred for, and access, Improving Access to Psychological Therapies (IAPT) than women[footnote 85]. Comparably, higher rates of men than women are detained under the Mental Health Act[footnote 86]. In terms of treatment outcomes, data shows that men and women experience similar rates of recovery following IAPT treatment[footnote 87] [footnote 88]. However, there can be sex-related differences in mental illness and the experience of mental health services. Many women face additional challenges such as lack of consideration to their roles as mothers and carers and to their experiences of violence and trauma which they are more likely to experience compared to men[footnote 89]. Age Mental health conditions are not distributed equally across all age groups. In children and young people (CYP), 16% of children aged 5 to 16 years were identified as having a probable mental health condition[footnote 90]. Estimates from the Adult Psychiatric Morbidity Survey (2014) found that 1 in 6 (17%) adults aged 16 and over have a common mental health condition at any one time[footnote 91]. The age group with the highest prevalence is 35 to 44 (19.3%). This decreases in older age groups, with an estimated prevalence of common mental health conditions in age 65 and older of 10.2%, using 2017 data[footnote 92]. A number of mental health conditions are known to have different age trajectories. For example, post-traumatic stress disorder (PTSD) peaks in young adulthood (16 to 24) and decreases with age[footnote 93].  Psychotic disorders are most prevalent in working-age adults (16 to 64), and lowest in older adults[footnote 94]. In terms of suicide, people aged 45 to 49 have the highest age-specific suicide rates[footnote 95]. The evidence on the prevalence of mental health conditions in older age is disputed, with a 2018 report by the Royal College of Psychiatrists[footnote 96] suggesting that older people are no less prone to mental ill health than younger adults, with difficulties manifesting differently in older age. Mental health conditions may be under-identified by healthcare professionals and older people themselves;[footnote 97] and research studies may exclude the growing care home population. In terms of access to care, those who are in mid-life (35 to 54) are more likely than others to receive treatment, and younger people (especially those from deprived backgrounds) are more likely to have unmet treatment requests [footnote 98].  Of all age groups 18- to 24-year-olds are the least likely to seek care for a mental health problem[footnote 99]. In terms of older people, there are lower proportions of people aged 65 and over entering IAPT treatment (204 per 100,000) compared to those aged 18 and over (659 per 100,000); there are also lower levels of treatment completion compared to the average[footnote 100]. One study of primary care found that the oldest age groups with new depression diagnoses and symptoms have fewer recorded referrals to psychological therapies and higher psychotropic drug treatment rates in primary care[footnote 101]. Sexual orientation and gender identity In the UK there is a higher prevalence of poor mental health and low wellbeing in people who identify as lesbian, gay and bisexual (LGB)[footnote 102] [footnote 103]. Previous studies have shown that there is an increased risk of mental ill-health symptoms in LGB adults, compared to heterosexual adults. These disparities are highlighted by Stonewall’s 2018 survey[footnote 104] which found that 50% of respondents said they had experienced depression in the previous year. Prevalence of mental ill-health symptoms is greatest for LGB adults over 55 and those under 35 years. In terms of children and young people, studies using data from the Millennium Cohort Study have found that LGB adolescents are 5 times more likely to be depressed and almost 6 times more likely to have self-harmed in the previous year compared to heterosexual teens[footnote 105]. An assessment of transgender disparities is hampered by a lack of routine data collection and small sample sizes[footnote 106] [footnote 107] with evidence collected predominantly by voluntary sector bodies. An evidence review by the Scottish Government[footnote 108] reported much higher prevalence of depression, stress and anxiety among transgender people and an Equality and Human Rights Commission report found evidence of high rates of self-harm and attempted suicide. Stonewall’s survey found that almost half of transgender respondents had considered suicide in the previous year[footnote 109]. Those who identify as LGBT (lesbian, gay, bisexual, transgender, queer and non-cisgender) are more likely than heterosexual people to experience multiple risk factors such as discrimination, homophobia, transphobia and social isolation[footnote 110] [footnote 111]. In terms of access to services, the Stonewall survey reported that 1 in 8 LGBT people had experienced some form of unequal treatment by healthcare staff such as discrimination or lack of understanding of their specific health needs; 1 in 7 had avoided seeking healthcare services due to a fear of discrimination[footnote 112]. Psychological treatment outcomes across LGB groups show smaller reductions in depression and anxiety compared to heterosexual groups[footnote 113]. For transgender groups, there is some evidence from the voluntary sector showing that around 40% of transgender people report barriers accessing healthcare due to a lack of understanding of specific transgender health needs[footnote 114]. This is supported by government research, which also suggests that mental health services are the most often perceived to be discriminatory. In particular, there is evidence of a lack of mental health inpatient provision for transgender people and a tendency to attribute mental health problems to an individual’s transgender status[footnote 115]. Within mental health services for young people, a study has shown that the gender identity of transgender individuals can be dismissed[footnote 116]. People with a learning disability and/or neurodiversity Both adults[footnote 117] and children and adolescents[footnote 118] with a learning disability have a higher prevalence of psychiatric disorder and symptoms[footnote 119] and mental ill-health than the general population. People with a learning disability may experience specific challenges around diagnostic overshadowing which complicates the assessment of mental health conditions[footnote 120] and there are well documented barriers to accessing health care[footnote 121]. There is evidence of high levels of psychiatric comorbidity in people with autism[footnote 122] [footnote 123] as well as in people with attention deficit hyperactivity disorder (ADHD)[footnote 124]. Around 21% of those with autism also have ADHD[footnote 125] which can complicate identification and treatment of mental health conditions. People with autism may not access services in line with mental health need[footnote 126]. This has been confirmed by qualitative studies[footnote 127] [footnote 128]. High levels of stigma may also reduce help-seeking[footnote 129]. One study described a gap in available mental health services for adults with autism, together with long waiting lists, a lack of funding for support or treatment, a lack of professionals’ understanding of autism and support and treatment not suited to their needs[footnote 130]. People with multiple and other long-term conditions More than 1 in 4 of the adult population in England lives with 2 or more conditions[footnote 131]. Living with numerous and often complex ill-health is becoming the norm for older people and those from disadvantaged communities. Around 30% of people with a long-term physical health condition also experience mental ill-health[footnote 132].  People with multiple long-term conditions including mental ill-health disproportionately live in deprived areas[footnote 133]. The government’s Rare Disease Action plan has also recently highlighted the specific mental health needs of people with rare diseases and their families and carers, 75% of whom are children[footnote 134]. A review of evidence by the National Institute for Healthcare Research[footnote 135] found that the healthcare system frequently fails to respond to the needs of people with multiple long-term conditions and focuses on individual diseases or issues resulting in complex, uncoordinated pathways. People with multiple long-term conditions feel their mental health and emotional wellbeing is frequently ignored, which often results in a worsening of symptoms. People who are unemployed Unemployment is associated with increased stress, depression, anxiety and increased suicides[footnote 136] [footnote 137]. The Adult Psychiatric Morbidity Survey found unemployed adults had a higher prevalence of common mental health conditions (28.8% respectively) compared to those employed full-time and employed part-time (14.1% and 16.3%). Economically inactive adults also show high levels of prevalence (33.1%) and adults in receipt of benefits were found to have 2.5 to 4 times higher prevalence of mental health conditions than adults not in receipt of benefits[footnote 138]. The 2021 UK Household Longitudinal survey (UKHLS) showed that 43% of unemployed people had mental ill-health, compared to 34% for people on furlough and 27% for those in work[footnote 139]. Furthermore, other studies published since 2020 using data from previous UKHLS have demonstrated an increase in mental ill-health overall since the start of the COVID-19 pandemic. These studies all cite unemployment and job loss as key contributing factors to a decline in mental health[footnote 140] [footnote 141] [footnote 142]. However, good quality work is also important and analysis of data from one longitudinal household survey found some evidence that job quality affects mental health. Negative working conditions linked to increased common mental ill-health include job strain, night shifts, effort-reward imbalance, low job satisfaction and poor work-life balance[footnote 143]. Moderate quality evidence shows that job insecurity has an adverse effect on mental health[footnote 144]. A peer-reviewed 2017 qualitative study showed unemployed people with mental-ill health often do not use mental health services and therefore do not benefit from available therapies. The main barriers include mental health literacy, stigma and discrimination, and healthcare system design[footnote 145].  Evaluation of the Employment Advisers in IAPT Services programme has shown positive outcomes for some clients including: increased confidence, assertiveness and motivation; improved mental health and well-being; a return to work or movement to alternative employment; and progress into or towards work for those that were out of work. Across all client groups, qualitative research indicated that what really seemed to work in delivering EA support was the combination of practical, emotional and motivational support. The results show that individuals who receive Employment Support combined with IAPT therapy are more likely to be in employment when leaving the service (if they were not in employment when joining the service) and have a greater improvement in their mental health than if they just had IAPT therapy. The combination of Employment Support with IAPT therapy addresses individuals needs holistically and enhance each other, creating a “continuous cycle” of support.[footnote 146] People with severe mental illness are far less likely to be in employment. In 2020, 9.1% of adults receiving secondary mental health services and on Care Programme approach were in employment[footnote 147]. There is strong evidence that Individual Placement Support and Housing First models for people with severe mental illness improves employment and housing stability/homelessness[footnote 148]. People in problem debt There is a clear relationship between debt and mental health. People who are in debt have higher odds of mental ill-health, even after controlling for low income[footnote 149]. A study based on the 2007 national survey of psychiatric morbidity among adults in England shows people in debt were 3 times more likely than those not in debt to have a common mental health condition[footnote 150]. Providing debt advice in primary care has been identified as a cost-effective intervention to protect mental health[footnote 151]. People who have experienced displacement, including refugees and asylum seekers Refugees and asylum seekers are more likely to experience mental ill-health than the general population, including higher rates of serious mental disorder[footnote 152], depression, PTSD and other anxiety disorders[footnote 153]. Traumatic events pre-departure, life-threating circumstances on their journeys, and difficulties integrating into host countries related to immigration policies, social isolation, poor living conditions, and unemployment are thought to increase risk[footnote 154].  Data collection on refugee and asylum seekers’ health service usage is limited[footnote 155].  However, there are well documented barriers to accessing health services for these groups compiled by voluntary sector organisations[footnote 156]. A recent scoping review[footnote 157] of mental health care policies, barriers and enablers found that there is a gap in the literature regarding UK-wide assessment of access and delivery of mental healthcare for asylum seekers and refugees in the UK. People who have experienced violence or abuse There is cross sectional evidence of an association between victims of violent crime and low personal wellbeing, in particular domestic violence[footnote 158]. Intimate partner violence is associated with higher levels of mental ill-health and exposure to multiple types of abuse increases the risk. Women are twice as likely than men to experience interpersonal violence, with 1 in 4 women reporting experiencing interpersonal violence since the age of 16[footnote 159].  54% of women with experience of physical and sexual violence have a common mental health condition, and 36% had attempted suicide[footnote 160]. Child abuse and maltreatment is also associated with mental ill-health, and those who experienced 3 or more types of maltreatment had the highest risk of all mental health conditions[footnote 161]. Elder abuse was associated with common mental health conditions such as depression and anxiety, and a higher level of psychological distress[footnote 162]. People with higher levels of neighbourhood violence are at higher risk of common mental health conditions, and lifetime exposure to 2 or more types of violence is associated with increased risk for all mental health outcomes[footnote 163]. People in contact with the criminal justice system (offenders) Around a third of people in police custody have mental ill-health, as do 38% of people on probation, and 48% of men and 70% of women in prison[footnote 164]. 12% of men and 28% of women in prison self-harm[footnote 165], and rates of suicide among people in prison are greater compared to people of similar age in the community[footnote 166].  There are limitations to the data on service access, as contact with the criminal justice system is not routinely captured by NHS services. However, a recent major inspection, including reviews of process documents and interviews with a range of staff and individuals, found that many people in the criminal justice system do not have their mental health needs met or experience delays in accessing treatment[footnote 167]. In 2016 to 2017, two-thirds of people in prison with an acute mental health condition waited longer than the standard waiting time to be admitted to a secure hospital, with 7% waiting more than 140 days[footnote 168]. There is some evidence that ethnic minority prisoners, who are over-represented in the prisoner population, are more likely to access mental health services via the criminal justice system than white people[footnote 169]. In first-time youth offenders, three-quarters meet the criteria for a mood, anxiety or behavioural disorder. Despite this, only around 20% were accessing mental health services[footnote 170]. People who sleep rough, are homeless or are in unstable housing People who sleep rough or are homeless have a particularly high prevalence of mental ill-health compared to the general population. 82% of people who had slept rough in the previous year report a mental health need[footnote 171]. In households considered to be legally homeless by a local authority, mental ill-health was the most common support need identified, in 25.2% or 1 in 4 of households[footnote 172], compared to 1 in 5 in the general population. The prevalence of psychosis is between 4 and 15 times higher in the homeless population compared to the general population, and around two-thirds of clients of homelessness services are estimated to have symptoms of personality disorder, although many were undiagnosed[footnote 173]. There are a number of reports from voluntary sector agencies on service provision. These are based on interviews with people experiencing homelessness and service providers. These show that people who are homeless experience additional and specific barriers to accessing preventative or primary health services[footnote 174] and an estimated one-third of people are not receiving the mental health support they need[footnote 175]. People with drug misuse, alcohol misuse or gambling problems There is evidence for co-existing mental ill-health and substance misuse[footnote 176]. Research shows that alcohol and drug issues in mental health treatment populations is common. The Adult Psychiatric Morbidity Survey found that adults who reported signs of dependence on drugs other than cannabis (50.1%) and a quarter of adults with probable alcohol dependence were receiving treatment and services for mental ill-health or emotional problem[footnote 177]. Nearly half of those in Community Mental Health Treatment services have substance use issues. Also, mental ill-health is experienced by the majority of drug (70%) and alcohol (86%) users in community substance misuse treatment[footnote 178]. For those who may not be receiving routine treatment through mental health treatment services, a history of alcohol or drug use was recorded in 54% of individuals with identified mental health conditions who died by suicide[footnote 179]. Evidence shows that despite the shared responsibility that NHS and local authority commissioners have to provide treatment, care and support, people with co-occurring conditions such as mental health and drug use are often excluded from services[footnote 180] [footnote 181] [footnote 182]. A recent evidence review[footnote 183] found a correlation between gambling and mental health. This showed that having mental ill-health makes someone 2 times more likely to participate in harmful gambling than people with no mental ill-health and more likely to be a gambler experiencing gambling-related harms. Depression was found to be a risk factor in children and young people for subsequent harmful gambling. The review also found a higher prevalence of poor health, low life satisfaction and wellbeing among problem gamblers and some weaker evidence of anxiety, depression, and sleep problems. There is good evidence that deaths from suicide are significantly higher among adults who are problem gamblers compared to the general adult population. The link between gambling, suicide and self-harm is supported by qualitative studies. There is limited data on mental health service usage by problem gamblers. A YouGov survey[footnote 184] of gamblers found that 5% have sought support from mental health services and around 57% of those using such services found them helpful. Children in care and care leavers There is some evidence that looked after children are more at risk of mental health conditions. A British cohort study found that looked-after children and young people were significantly more likely to be depressed, dissatisfied with life and have low self-efficacy[footnote 185]; residential care was associated with an increased odds ratio of 4 for depression[footnote 186]. People who live alone The Adult Psychiatric Morbidity Survey shows rates of mental health conditions are higher in single adult households compared to households with more than one adult or child[footnote 187]. For example, 10.8% of lone adults under the age of 60 with no children screened positively for PTSD compared to 4.6% of households with 2 adults under the age of 60 with no children. There is cross-sectional evidence to support the association between loneliness and a range of psychiatric disorders, including anxiety, depression and psychosis, and to support an association between loneliness and suicidal thoughts and behaviour[footnote 188]. People who reported feeling lonely were almost 10 times more likely to report low feelings of worth (10.5% compared with 1.1%), over 7 times more likely to report low life satisfaction (15.2% compared to 1.9%), over 3 times more likely to report feeling unhappy (18.8% compared to 5.6%) and twice as likely to report feeling anxious (34.8% compared to 15.1%) than those who have low ratings of loneliness[footnote 189]. Three systematic reviews show interventions (such as peer support and group activities) to reduce loneliness and social isolation are effective[footnote 190] [footnote 191] [footnote 192]. However, social isolation is often a barrier to accessing services and individuals are less likely to seek help. Unpaid carers Being a carer is a risk factor for mental ill-health as it has been associated with higher psychological distress in comparison to non-carers[footnote 193] [footnote 194]. In 2021, the Carers UK annual survey[footnote 195] showed that a third of carers reported mental ill-health, with a worse picture for those providing unpaid care for more than 35 hours a week. Compared to the population average, carers were less satisfied with life and more anxious. Carers on low-income, from particular ethnic minority backgrounds and those caring for people with certain conditions such as psychosis[footnote 196] dementia[footnote 197] and other intellectual disabilities[footnote 198] were more at risk of mental ill-health. COVID-19 increased pressure on carers resulting in a higher risk of carers developing mental health conditions[footnote 199]. There is strong evidence of barriers to accessing support services especially for ethnic minority carers[footnote 200]. Also, young carers may face barriers to accessing support services, with one study showing that only half of young adult carers with a mental health condition reporting receiving support from school[footnote 201]. The Carers UK survey[footnote 202] found that looking after carer health and wellbeing topped the list of carer priorities for support. However there appears to be little formal research on usage of mental health services by carers and related outcomes.