Poverty and Mental Health

The association between Health and Social Class has been 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 14% 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.¹ The rate of compulsory admission under the Mental Health Act tends to be higher in deprived areas.² Whilst this suggests more serious mental illness in such 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 toward them?
• Those with mental health problems are more likely to experience poverty: once incapacitated, an individual's socio-economic status (SES) is likely to fall further ('selective social drift'). For example, the GHQ-28 was used to assess a cohort of people born in 1947. Poorer reported mental health in men (though not in women) was associated with downward socio-economic trajectory over the whole life course.³

Consider potential confounding variables:

Employment

Having mental illness has a number of adverse effects on the ability to earn:

• It is more difficult to study and to achieve qualifications when unwell.
• 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.

Unemployment

• Amongst those with long-term mental health problems, only 24% are employed. Unemployment is the 'norm'. Those in receipt of sickness and disability benefits currently outnumber the the total number of recipients of Jobseekers' Allowance in England.
• 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 over 75% of working-age adults with significant mental health problems. There is a real need for benefit rules that are sufficiently flexible to accommodate the unpredictable nature of most mental illnesses, combined with welfare-to-work programmes that offer adequate expertise and continuity to support parents with mental health problems back into the work place. The impact of the change from Incapacity Benefit to Employment and Support Allowance remains to be seen.
• Employment levels have been stable over many years, but with the spectre of rising unemployment secondary to the credit crunch and recession, many have concerns about the mental ill health that previous generations have encountered under such conditions.
• Unemployment has been associated with a doubling of the suicide rate. Lack of job security also increases the risk.⁴
• Unemployment seems to increase the duration of episodes of common mental disorders but not the likelihood of their onset.⁵

Debt

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 are 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 though the nature of this risk factor and its relation with poverty and unemployment remain unclear.⁵
• 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.⁶
• Financial difficulties as a student and incurring debt are associated with poor mental health.⁷

Inequality

• As with physical ill health, common mental disorders are associated with poorer material standards of living ('relative poverty'), independent of occupational social class.⁸ 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.
• There is limited evidence of an association between income inequality and worse self-rated health in Britain. As regions with the highest income inequality are also the most urban, these findings may be attributable to characteristics of cities rather than income inequality.⁹
• One US study looking at the 'well-being' of children (based on levels of teenage births, juvenile homicides, infant mortality, low birth weight, educational performance, dropping out of high school, overweight, mental health problems) noted that it negatively correlated with income inequality and percentage of children in relative poverty, but not with average income, suggesting that inequality rather than absolute deprivation was more significant.¹⁰

Child poverty

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).¹¹ This difference is most exaggerated in boys, with double the risk. 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 London¹² found that none of the variables they examined were 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.
  They concluded that disadvantaged schools, deprived neighbourhoods, low SES, parental unemployment, cohabiting, large family size, and poverty were not independently associated with disorder. Individually assessed child and family factors may be more influential than aggregate measures of school and neighbourhood factors.
• 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.¹³ 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 risk of developing psychoses increased with an increasing exposure to measures of social adversity in childhood (based upon rented accommodation, low SES, single-parent households, unemployment and households receiving social welfare benefits) suggestive of a dose-response relationship.¹⁴

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.

Immigration

The link between schizophrenia and immigration to the UK, particularly from the Caribbean, was first made in the 1960s and remains contentious.¹⁵

• 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 SES, educational attainment, employment and housing standards, as well as subject to racial discrimination.
• Typically immigrants suffer delay in 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 elsewhere e.g. among Moroccan immigrants to the Netherlands.¹⁶ It is clear that a personal or family history of immigration is a risk factor for schizophrenia¹⁷ and there is an increasing interest in how chronic social stressors may interact with other factors to cause the development of schizophrenia.

Urban environment

• Studies have suggested that, in the UK, rural residents have slightly better mental health than non-rural counterparts, independent of SES, employment status or household income.¹⁸ Some studies have suggested a link between urban environmental factors and a higher risk of mental illness, particularly schizophrenia.¹⁹
• As ever, is this 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 vary widely across South-East London and this is is not adequately explained by looking at individual-level risks.²⁰ The cause of these neighbourhood variations is unknown but important to understand in terms of social causes of vulnerability and resistance to illness.

Substance abuse

• 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.

Criminality

• Closure of the 'asylums' and the ascendance of 'care in the community' radically changed mental health care 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 expedient. '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 mentally 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

The average life expectancy of individuals with serious mental health problems is 10 years less than that of the general population. Living with schizophrenia and bipolar disorder increases the risk of certain physical diseases (cardiovascular and chronic respiratory disease, diabetes, hepatitis C, HIV). ²¹ Possible reasons for this are multi-fold:

• Poor access to physical healthcare e.g. 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’ - heath care 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 - 70-80% of people with severe mental illness smoke and obesity rates are also high. This may be in part related to low income but also factors exist 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.