Evidence
Alert

Breast cancer screening: women with poor mental health are less likely to attend appointments

Women with poor mental health are less likely than others to come forward for breast screening, new research has found. Not attending cancer screening could partly explain why people with mental health conditions die younger than the general population. It means that cancer is more likely to be diagnosed later when it is less treatable.  

The research was carried out in Northern Ireland and included nearly 60,000 women. They were all eligible for routine NHS screening for breast cancer. One in ten reported poor mental health. This group was substantially less likely to attend breast screening than women without mental health problems (23% less likely).  

The authors suggest that health services should explore targeted interventions, such as more frequent appointment reminders. This could encourage women with mental illness to attend screening appointments. 

What’s the issue?

If cancer is diagnosed early, treatment is more likely to be successful. That is the rationale behind screening programmes for those at highest risk. In the UK, women aged between 50 and 70 are invited for breast cancer screening; they are offered X-rays (mammography) once every three years.  But not everyone who is asked to attend an appointment does so. 

Over the last ten years, research has found that some groups are less likely to accept screening invitations. Women who live in less affluent or urban areas, and those who are not married, are less likely to attend. 

Previous work from the US has suggested that poor mental health may be another reason. Unlike in the UK, where NHS screening is free of charge, women in the US pay for screening (either directly or through insurance). Researchers wanted to know whether mental health would have a similar effect on screening here.  

People with mental illness are known to have a reduced life expectancy and are more likely to die from many health conditions, including cancer, than the general population. Lower rates of screening may contribute to avoidable cancer deaths and could explain the higher rates of death in people with mental illness. 

Deprivation, urban-living and not being married are all linked with poor mental health. Researchers at Queen’s University Belfast wanted to tease out these factors. They explored how far mental illness can explain lower rates of breast screening.   

What’s new?

The Northern Ireland Longitudinal Study includes data on one in four (28%) of the Northern Ireland population. It includes women’s responses to questions on mental health in the 2011 Northern Ireland Census. The authors linked this information to women’s records on breast cancer screening. 

Nearly 60,000 women aged between 50-70 were included in this study. One in ten had reported a mental health condition. 

The study found that: 

    • women with mental illness were less likely to attend screening than women who did not report mental health conditions (23% less likely)
    • not being married or living in an urban area were each linked to a similar reduction (23% less) in attendance
    • the effect of social deprivation was greater, and women in this group were 34% less likely to attend breast screening
    • mental health had an impact across all groups of women, regardless of social deprivation, urban living or marital status.

Why is this important?

The findings show that women with mental illness are less likely to attend breast screening. This is concerning, say the authors, as poor mental health was common among the women eligible for screening. 

The effect of mental health on screening was seen across all groups. Women with mental health problems were less likely to attend screening, regardless of deprivation, marital status or urban living.  

The authors conclude that the NHS should explore strategies to encourage women with mental health conditions to attend screening appointments. These women may be less motivated than others to accept screening, they may be more likely to neglect themselves and not to prioritise prevention.

What’s next?

The authors suggest interventions such as more frequent reminders of the screening appointment. Text messages, phone calls and even home visits could make a difference. Increasing awareness of this study among GPs could also help. Some women might benefit from a visit to the screening clinic in advance of their appointment, or from a longer appointment, to help address anxiety about the screening procedure. 

As yet, no studies explore the direct impact of such interventions on participation in health screening. This would be an interesting area for further research. 

This study provides convincing evidence of inequality in uptake of breast screening for women with mental illness. But the underlying reasons for these inequalities are not fully understood. Further research could explore specific barriers to attending breast screening among those with mental health problems. 

This study was carried out in Northern Ireland; further work is needed to establish whether the same would be found in other parts of the UK. 

You may be interested to read

The full paper: Ross E, and others. Does poor mental health explain socio-demographic gradients in breast cancer screening uptake? A population-based study. European Journal of Public Health 2020;30:3 

Another study by the same team looking at the influence of mental illness, as assessed by the uptake of psychotropic medications, on breast screening uptake: Ross E, and others. Disparities in Breast Cancer Screening Uptake for Women With Mental Illness in the United Kingdom. American Journal of Preventative Medicine. 2021;60:3

Pooled literature comparing breast screening uptake in women with mental illness and those without mental ill health: Mitchell AJ, and others. Breast cancer screening in women with mental illness: comparative meta-analysis of mammography uptake. The British Journal of Psychiatry. 2014;205:6 

Breast Cancer Now's free helpline on 0808 800 6000 offers information and support.

Funding

The funding was provided by the Northern Ireland Department for Employment and Learning (DEL) Northern Ireland and supported by its Public Health Agency.

Commentaries

Study author

A body of evidence already demonstrates inequalities in healthcare provision for people with mental illness. It was likely to extend to breast cancer screening, but we were surprised to see that the effect in the UK was comparable to that in the US. The UK’s universal healthcare system is free at the point of delivery, so UK women do not face the same financial barriers to accessing screening, or indeed mental healthcare services. But those with mental illnesses are as likely not to attend here as in the US.

The extent to which women of eligible screening age were affected by chronic poor mental health was also striking. More than one in ten reported a mental health condition lasting at least 12 months.

Emma Ross, Research Fellow, Queen’s University Belfast 

Breast Cancer Now 

Screening plays a vital role in detecting breast cancer early and helping prevent women dying from the disease.

The findings of this research therefore highlight the need for greater understanding around the direct relationship between poor mental health in women and breast screening uptake. With the number of people reporting mental health problems rising, and the impacts of the pandemic adding to the issue, it’s crucial we identify and address any barriers that poor mental health might present to women attending breast screening.

Improving uptake amongst women who are less likely to attend breast screening is vital to ensuring all eligible women have the best chance of an early breast cancer diagnosis, giving them the best chance of survival. The significant disruption to breast screening caused by the pandemic also brings into sharp focus the need for UK Governments to invest in the chronically under-resourced imaging and diagnostic workforce so screening can recover quickly and be sustainable.

Screening comes with some risks, but we encourage women to attend their breast screening appointments and to contact their GP with any new or unusual breast changes.” 

Baroness Delyth Morgan, Chief Executive, Breast Cancer Now 

Psychiatrist

The findings are a stark reminder of shortened life expectancy in people with poor mental health. The study might encourage more assertive efforts to ensure those with poor mental health are offered screening, and followed up, and that screening pathways are more accessible and supportive.

The findings are relevant to Northern Ireland, but replication is needed in the rest of the UK. I would be delighted to be involved in an analysis by ethnicity.

Kamaldeep Bhui, Professor of Psychiatry, University of Oxford 

Public contributor 

As someone living with long-term mental illness, I recognise that mental illness could reduce uptake of breast screening. I would suggest that mental health treatment needs to be built into breast screening programmes. People with mental health conditions who are reluctant to respond to breast screening invitations will perhaps be more likely to go if their mental health is also examined and treated. The two need to go hand in hand.

For that to happen, mental health professionals will need to be part of breast screening programmes. Or screening staff will need to be sufficiently schooled in mental health to recognise when mental health interventions are needed. This could also have a positive impact on stigma and discrimination.

People with long-term mental health conditions and on anti-depressive and/or anti-psychotic medication are likely to be offered at least annual health checks (bloods, blood pressure, weight etc). These checks could include consideration of cancer screening.

There are wider health concerns for those within the mental health system. Engaging people with lived experience of mental illness will be essential for turning important research findings like these into definitive practical actions.

Julian Harrison, Public Contributor, Wigston, Leicestershire 

Conflicts of Interest

None declared.