The association between Health and Social Class is discussed in a separate article.
There is a growing contribution of mental health problems to the global disease burden - neuropsychiatric disorders now account for about 13% of the total.
The link between poverty and mental health is well known. Arguments regarding the causality of the relationship continue but it seems likely that it is bi-directional:
- Those with low incomes are more likely to suffer from poor mental health and poverty effectively causing or contributing to poor mental health. Observationally, both individual and neighbourhood deprivation increase the risk of poor general and mental health. The rates of admission for acute psychiatric care tend to be higher in deprived areas. Conversely, a study of older people in Hertfordshire, UK, who had a strong sense of cohesion within their neighbourhood and reported fewer neighbourhood problems, had higher levels of mental well-being. Whilst this suggests more serious mental illness in deprived areas, it does not mean that poverty causes mental illness. Do urban, deprived areas lead to mental health problems or do individuals with those problems gravitate towards them?
- Those with mental health problems are more likely to experience poverty: once incapacitated, an individual's socio-economic status is likely to fall further ('selective social drift'). One study, for example, showed a decline in social position and financial circumstances over time in people who were depressed. In another study, the GHQ-28 (a general health questionnaire used for the detection of psychiatric conditions) was employed to assess a cohort of people born in 1947. Poorer reported mental health in men (although not in women) was associated with downward socio-economic trajectory over the whole life course.
Consider potential confounding variables:
Having mental illness has a number of adverse effects on the ability to earn:
- When unwell, It is more difficult to study and to achieve qualifications.
- It is more difficult to get a job - mental illness carries a heavy social stigma. Surveys have shown a widespread reluctance amongst employers to take on employees with a disability at any level, and that applies especially to those with a mental disability.
- Of people actively seeking employment, the rate of unemployment is much lower amongst those without any medical problems than it is amongst those with physical disability. Those with mental disability face even greater difficulty.
- It is more difficult to hold down a job - a person with mental illness may need intermittent and unpredictable time off when the illness needs more intense treatment. Employers may perceive this, whether due to mental or physical ill health, as 'unreliability'. They may also have concerns that there could be risk involved in the individual working whilst unwell.
- Even once employed, individuals may feel unsupported both by employers and colleagues. They may suffer disparaging remarks at work. There is often a lack of sympathy and understanding, symptomatic of society's general unease with mental illness.
The Disability Discrimination Act (1995) makes it unlawful to discriminate against employees with a disability. Those with mental illness that has a substantial, adverse and long-term (>12 months) effect on their ability to carry out normal day-to-day activities are considered to have a disability under the Act. It is intended to offer protection but attitudinal changes towards disability and mental health lag behind legislation.
- A report of Mental Health and Social Exclusion, published by the Social Exclusion Unit in 2004, showed that amongst those with long-term mental health problems, only 24% were employed.
- It should be recognised that not everyone with mental health problems is capable of working and the nature of mental illness means that this capacity may fluctuate. Welfare benefits, therefore, are the major source of financial support for many working-age adults with significant mental health problems. The Employment and Support Allowance replaced Incapacity Benefit, Severe Disablement Allowance and Income Support in 2008. People who wish to claim such an allowance are expected to undertake a work-related assessment and are then put into either a Work Related Activity Group in which support is provided to find work, or into a Support Group in which the person is recognised as being unfit to work and provided with appropriate support.
- Employment levels have been stable over many years but have risen steadily since the credit crunch and reached 2.49 million in the UK in June 2011. Many have concerns about the mental ill health that previous generations have encountered under such conditions.
- Unemployment has a complex relationship with suicide rates. Studies suggest that during a recession, suicide rates increase in the employed but decrease in the unemployed.
- One UK study found that the risk of common mental health disorders increased in those who had been out of work for three years or more.
When people using mental health services are asked about the major issues that concern them in their daily lives, personal finances are consistently identified as a major source of difficulty and distress. 1 in 3 people with a serious mental health condition is thought to be in debt. Concerns and anxieties regarding finance constitute a significant stressor.
- Financial strain is thought by some to be a better predictor of future psychiatric morbidity than either poverty or unemployment, although the nature of this risk factor and its relationship with poverty and unemployment remain unclear.
- One UK study suggested that the relationship between poverty and mental illness was mediated largely by debt - a cross-sectional design showed that those with low income were more likely to have mental disorder but that this relationship was significantly attenuated after adjustment for debt. People with six or more separate debts had a six-fold increase in mental disorder after adjustment for income.
- As with physical ill health, common mental disorders are associated with poorer material standards of living ('relative poverty'), independent of occupational social class. The gulf between those living affluent lifestyles and those living in poverty in the UK has widened over the last few decades and the concern is that this poses an increased threat to health as well as raising issues of social justice.
- One UK study looking at evidence on a population basis supported the hypothesis that greater income inequality was associated with lower standards of population health.
- Both income and income inequality affect infant health outcomes in the USA. The health of the poorest infants was affected more by absolute wealth than relative wealth.
Because of the social decline associated with mental illness, research has looked at mental health of young people who are still dependent upon their parents for their economic position:
- Most surveys suggest an increased rate of mental health problems in children in families with low incomes compared to those in better-off households (1 in 6, compared to 1 in 20). This difference is most exaggerated in boys, with double the risk. Attention deficit hyperactivity disorder (ADHD), bedwetting and self-harming behaviours show strong social patterns, whilst autistic spectrum disorders show no social difference.
- However, a paper from the Institute of Psychiatry in London found that none of the variables they examined was associated with all types of disorder:
- Poor general health and life events were related to emotional disorders.
- Conduct disorders were most closely associated with family variables.
- ADHD was only related to child characteristics.
- Evidence from the 1958 and 1970 British prospective birth cohort studies cited socio-economic deprivation as one of the issues which affected childhood mental well-being.
- Do interventions work? A Cochrane Review found no benefits to child mental health from studies looking at the use of financial support to poor families. However, they also comment that the studies were limited given the small increases in total household income, the lack of conditions as to the use of the money and strict conditions for receipt of payments.
- Adults who have grown up in financial hardship are more likely to experience mental health problems (and adult poverty). A Swedish cohort study showed that the risk of developing psychoses increased with an increasing exposure to measures of social adversity in childhood (based upon rented accommodation, low socio-economic status, single-parent households, unemployment and households receiving social welfare benefits) suggestive of a dose-response relationship.
Mental illness itself is a significant contributory factor to child poverty. An estimated 1.25 million children in England and Wales live with parents or carers with a mental health problem. Given the huge over-representation of unemployment and benefits' dependence amongst those with mental illness, a conservative estimate is that at least 370,000 will live in financial hardship.
- The findings from the East London First Episode Psychosis Study confirmed a higher risk of psychosis in first- and second-generation immigrants to the UK, in comparison to white British people.
- The excess risk is not specific to Afro-Caribbean immigrants; it is also present among African-born black immigrants to the UK and, to a lesser extent, among Asian immigrants.
- Incidence rates of schizophrenia in Caribbean countries are similar to those found in the indigenous UK population and much lower than reported rates among immigrants from the region. The rate for schizophrenia in second-generation Afro-Caribbean people born in the UK is higher than in the first generation.
- There is no evidence for selective immigration as part of a pre-psychotic drift process. The economic conditions of the 1950s and 1960s would have been more selective for upwardly mobile individuals from the West Indies.
- Immigrant populations are disadvantaged in terms of socio-economic status, educational attainment, employment and housing standards, as well as subject to racial discrimination.
- Typically, immigrants suffer delay in seeking professional help, a lower probability of medical referral, more frequent involvement of the police and emergency services and higher proportions of compulsory and secure unit admissions.
- High incidence rates are also found amongst the lowest social class in the indigenous white population.
The association has been seen in several immigrant groups across Europe. It is clear that a personal or family history of immigration is a risk factor for schizophrenia and there is an increasing interest in how chronic social stressors may interact with other factors to cause the development of schizophrenia.
- Studies have shown higher risk of mental disorder among persons living in urban versus rural areas. Epidemiological research has documented that associations between particular features of the urban environment, such as concentrated disadvantage, residential segregation and social norms, contribute to the risk of mental illness. Some studies have suggested a link between urban environmental factors and a higher risk of mental illness, particularly schizophrenia.
- As ever, there is the question as to whether this is causation (urbanity causing psychosis) rather than selection (high-risk individuals move into urban areas, often as part of the social drift accompanied by onset of illness). Some consider the effect of the urban environment to be conditional on genetic risk (a gene-environment interaction).
- There are important within-city variations in the incidence of schizophrenia associated with different neighbourhood social characteristics. For example, the incidence of non-affective psychoses varies widely across South East London and this is is not adequately explained by looking at individual-level risks. The cause of these neighbourhood variations is unknown but may be a reflection of social fragmentation.
- Abuse of drugs or alcohol is likely to lead to social decline: it is a financial drain, makes the individual more unemployable and often is associated with criminal behaviour.
- Although substance abuse should not be seen as a mental illness, it is not uncommon to find that there is a dual diagnosis of both substance abuse and mental illness.
- This leads to the question of primacy: has the substance abuse caused the mental illness or has the mental illness led to 'self-medication' with alcohol or illicit drugs? Probably both are true. Genetic factors may also play a part.
- Closure of the 'asylums' and the ascendance of 'care in the community' radically changed mental healthcare provision in the UK. Many saw this as a cost-cutting device and, whilst it is generally true that care in the community is cheaper than in hospital, psychiatric care in the community should be seen as a humanitarian aim rather than a financial expedience. There is a view that asylums should not have been abolished but reformed. 'Care in the community' has not always proved adequate and too often those with mental health problems have broken the law and been incarcerated in prison.
- According to the Mental Health Foundation, only 1 in 10 prisoners does not have a mental health problem, counting substance abusers (and those with dual diagnosis), those with a primary mental illness and others who become unwell under the psychological stresses of imprisonment.
- Despite the Rehabilitation of Offenders Act, it is very difficult for anyone with a criminal record to get work and hence they are more likely to re-offend.
Poor physical health
A study by the South London and Maudsley Trust found that people diagnosed with serious mental illness had significantly reduced life expectancy (8.0 to 14.6 life years for men and 9.8 to 17.5 life years for women). Highest reductions were found for men with schizophrenia (14.6 years lost) and women with schizoaffective disorders (17.5 years lost). Living with schizophrenia and bipolar disorder increases the risk of certain physical diseases (cardiovascular and chronic respiratory disease, diabetes, hepatitis C, HIV). Possible reasons for this are multi-fold:
- Poor access to physical healthcare, eg lack of primary healthcare attached to mental health inpatient wards. People with severe mental health problems may not feel empowered to take the initiative with their physical health and to demand good healthcare.
- 'Diagnostic overshadowing' - healthcare workers focus on anxiety and mental health problems and may not attend to physical symptoms preventing early treatment.
- Lack of communication/interplay between physical and mental health systems.
- Lifestyle - people with severe mental illness have a high incidence of smoking and obesity. This may be in part related to low income but also factors such as decreased responsiveness to public health campaigns and messages.
- Medication - some medication used for severe mental health problems may increase the risk of certain conditions, such as diabetes.
The aetiology of mental illness is undoubtedly multifactorial and, although arguments relating its development to poverty are strong, genetics, upbringing and subsequent lifestyle are possible major confounders. Poverty is neither sufficient nor necessary to cause mental illness and the impact of social disadvantage may also be different for different mental illnesses.
Living in poverty causes chronic stress and struggle and this may have an ultimate biological impact on brain function, particularly if experienced at certain critical points in development. According to one hypothesis, schizophrenia is the result of chronic experience of social defeat disturbing dopaminergic function in the brain.
Regardless, a society may be judged on how it treats its most disadvantaged. The problems of poverty, as described in Charles Dickens' David Copperfield, and social rehabilitation, or lack of it, as portrayed by Victor Hugo in Les Misérables, remain as pressing today.
Further reading & references
- Morgan C, Charalambides M, Hutchinson G, et al; Migration, ethnicity, and psychosis: toward a sociodevelopmental model. Schizophr Bull. 2010 Jul;36(4):655-64. Epub 2010 May 30.
- Overview, 2010, Grand Challenges in Global Mental Health
- Stafford M, Marmot M; Neighbourhood deprivation and health: does it affect us all equally? Int J Epidemiol. 2003 Jun;32(3):357-66.
- Curtis S, Copeland A, Fagg J, et al; The ecological relationship between deprivation, social isolation and rates of Health Place. 2006 Mar;12(1):19-37. Epub 2004 Oct 27.
- Gale CR, Dennison EM, Cooper C, et al; Neighbourhood environment and positive mental health in older people: the Health Place. 2011 Jul;17(4):867-74. Epub 2011 May 13.
- Butterworth P, Rodgers B, Windsor TD; Financial hardship, socio-economic position and depression: results from the PATH Soc Sci Med. 2009 Jul;69(2):229-37. Epub 2009 Jun 6.
- Tiffin PA, Pearce MS, Parker L; Social mobility over the lifecourse and self reported mental health at age 50: prospective cohort study. J Epidemiol Community Health. 2005 Oct;59(10):870-2.
- Mental Health and Work, 2011, Directgov
- Social Exclusion Unit Report, Mental Health and Social Exclusion, 2004
- Benefits if you are ill or disabled, 2011, Directgov
- Unemployment, 2011; Office for National Statistics
- Yip PS, Caine ED; Employment status and suicide: the complex relationships between changing J Epidemiol Community Health. 2011 Aug;65(8):733-6. Epub 2010 Nov 28.
- Ford E, Clark C, McManus S, et al; Common mental disorders, unemployment and welfare benefits in England. Public Health. 2010 Dec;124(12):675-81. Epub 2010 Oct 29.
- In the red: debt and mental health, Mind, 2010
- Weich S, Lewis G; Poverty, unemployment, and common mental disorders: population based cohort study. BMJ. 1998 Jul 11;317(7151):115-9.
- Jenkins R, Bhugra D, Bebbington P, et al; Debt, income and mental disorder in the general population. Psychol Med. 2008 Oct;38(10):1485-93. Epub 2008 Jan 10.
- Weich S, Lewis G; Material standard of living, social class, and the prevalence of the common mental disorders in Great Britain. J Epidemiol Community Health. 1998 Jan;52(1):8-14.
- Eibner C, Sturm R, Gresenz CR; Does Relative Poverty Predict the Need for Mental Health Care? AcademyHealth Meet. 2004; 21: abstract no. 1112.
- Wilkinson RG, Pickett KE; Income inequality and population health: a review and explanation of the Soc Sci Med. 2006 Apr;62(7):1768-84. Epub 2005 Oct 13.
- Olson ME, Diekema D, Elliott BA, et al; Impact of income and income inequality on infant health outcomes in the United Pediatrics. 2010 Dec;126(6):1165-73. Epub 2010 Nov 15.
- End Child Poverty Unhealthy Lives, 2008
- Ford T, Goodman R, Meltzer H; The relative importance of child, family, school and neighbourhood correlates of childhood psychiatric disorder. Soc Psychiatry Psychiatr Epidemiol. 2004 Jun;39(6):487-96.
- Mensah FK, Hobcraft J; Childhood deprivation, health and development: associations with adult health in J Epidemiol Community Health. 2008 Jul;62(7):599-606.
- Lucas PJ, McIntosh K, Petticrew M, et al; Financial benefits for child health and well-being in low income or socially disadvantaged families in developed world countries. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD006358.
- Wicks S, Hjern A, Gunnell D, et al; Social adversity in childhood and the risk of developing psychosis: a national cohort study. Am J Psychiatry. 2005 Sep;162(9):1652-7.
- Gould N; Mental Health and Child Poverty, Joseph Rowntree Foundation
- Coid JW, Kirkbride JB, Barker D, et al; Raised incidence rates of all psychoses among migrant groups: findings from the Arch Gen Psychiatry. 2008 Nov;65(11):1250-8.
- Veling W, Susser E; Migration and psychotic disorders. Expert Rev Neurother. 2011 Jan;11(1):65-76.
- Selten JP, Cantor-Graae E, Kahn RS; Migration and schizophrenia. Curr Opin Psychiatry. 2007 Mar;20(2):111-5.
- Cheng F, Kirkbride JB, Lennox BR, et al; Administrative incidence of psychosis assessed in an early intervention service Psychol Med. 2011 May;41(5):949-58. Epub 2010 Dec 23.
- Galea S, Uddin M, Koenen K; The urban environment and mental disorders: Epigenetic links. Epigenetics. 2011 Apr;6(4):400-4. Epub 2011 Apr 1.
- van Os J, Kenis G, Rutten BP; The environment and schizophrenia. Nature. 2010 Nov 11;468(7321):203-12.
- Kirkbride JB, Fearon P, Morgan C, et al; Neighbourhood variation in the incidence of psychotic disorders in Southeast London. Soc Psychiatry Psychiatr Epidemiol. 2007 Jun;42(6):438-45. Epub 2007 Apr 30.
- Zammit S, Lewis G, Rasbash J, et al; Individuals, schools, and neighborhood: a multilevel longitudinal study of Arch Gen Psychiatry. 2010 Sep;67(9):914-22.
- Najt P, Fusar-Poli P, Brambilla P; Co-occurring mental and substance abuse disorders: a review on the potential Psychiatry Res. 2011 Apr 30;186(2-3):159-64. Epub 2010 Aug 21.
- Cerda M, Sagdeo A, Johnson J, et al; Genetic and environmental influences on psychiatric comorbidity: a systematic J Affect Disord. 2010 Oct;126(1-2):14-38. Epub 2009 Dec 11.
- Munro A; The crime of mental illness. CMAJ. 2010 Dec 14;182(18):2007.
- Mental Health Statistics, 2011, Mental Health Foundation
- Rehabilitation of Offenders Act 1974, legislation.gov.uk
- Chang CK, Hayes RD, Perera G, et al; Life expectancy at birth for people with serious mental illness and other major PLoS One. 2011;6(5):e19590. Epub 2011 May 18.
- Dyer JG, McGuinness TM; Reducing HIV risk among people with serious mental illness. J Psychosoc Nurs Ment Health Serv. 2008 Apr;46(4):26-34.
- Goldberg RW, Seth P; Hepatitis C services and individuals with serious mental illness. Community Ment Health J. 2008 Oct;44(5):381-4. Epub 2008 May 9.
- Sajatovic M, Dawson NV, Perzynski AT, et al; Best practices: optimizing care for people with serious mental illness and Psychiatr Serv. 2011 Sep;62(9):1001-3.
|Original Author: Dr Chloe Borton||Current Version: Dr Laurence Knott||Peer Reviewer: Dr John Cox|
|Last Checked: 28/09/2011||Document ID: 2647 Version: 22||© EMIS|
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.