Poverty and Mental Health

The association between health and social class has been discussed in a separate article.

There is a link between poverty and mental health problems but this can work in two directions.

• Those with low incomes are more likely to suffer from poor mental health.
• Those with mental health problems are more likely to experience poverty.

Both these statements appear to be true.

People with schizophrenia tend to come from the lower social classes. This might be interpreted as suggesting that being of low social class predisposes to developing schizophrenia. However, if the social class of the father, rather than the individual is examined, there is a much more normal distribution. This suggests that schizophrenia does not have a predilection to strike at low social classes but that those with the disease tend to drift down the social scale.¹ However, a more recent review of schizophrenia has concluded that poverty may be a contributory factor.²

Employment

Having mental illness has a number of adverse effects on ability to earn. It is more difficult to study and to achieve qualifications. It is more difficult to hold down a responsible job. A person with mental illness may need to take time out occasionally, when the illness needs more intense treatment, whether this means time in hospital or not. Employers like reliability and do not take kindly to employees who frequently take time off. This applies whether the problem is mental or physical illness. The Disability Discrimination Act is supposed to offer protection but legislation can change laws much more easily than it changes attitudes. Mental illness carries a heavy social stigma and employers are also worried about what the sufferer may do when still working but unwell.

It is not only in highly responsible jobs that people with mental health problems face discrimination. Employers like reliability in the workforce at all levels and surveys have shown a reluctance to take on anyone with a disability at any level, especially a mental disability. They may suffer disparaging remarks at work. There is a lack of sympathy and understanding.

Not everyone with mental health problems is capable of working. 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 more difficulty in getting work.

Just because two things are associated, does not mean that one causes the other. It is not fair to assume that because the mentally ill are more likely to face poverty that poverty causes mental illness. It is necessary to look at the evidence.

Mental illness is multifactorial and the tendency to descend the social scale complicates the proposition of post hoc ergo propter hoc (which came first, the chicken or the egg?). A paper from Bristol concluded that mental health differences in Wales are partly explained by the level of regional social deprivation.³
A group from Newcastle used the GHQ-28 to assess a cohort of people born in 1947. Poorer reported mental health in men was associated with downward socioeconomic trajectory over the whole lifecourse.⁴ This was not found for women. Again, it suggests social decline with poor mental health rather than poor mental health resulting from social disadvantage.

Both individual and neighbourhood deprivation increase the risk of poor general and mental health.⁵ The rate of compulsory admission under the Mental Health Act tends to be higher in deprived areas.⁶ This suggests more serious mental illness in such areas but it does not mean that poverty causes mental illness.

Poverty and unemployment increase the duration of episodes of common mental disorders but not the likelihood of their onset. Financial strain is a better predictor of future psychiatric morbidity than either of these more objective risk factors though the nature of this risk factor and its relation with poverty and unemployment remain unclear.⁷ Like mortality and physical morbidity, common mental disorders are associated with a poor material standard of living, independent of occupational social class. These findings support the view that recent widening of inequalities in material standards of living in the United Kingdom pose a substantial threat to health.⁸ 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

Young People

Because of the social decline with mental illness, it may be more useful to examine mental health in young people who are still dependent upon their parents for their economic position. A paper from the Institute of Psychiatry in London¹⁰ 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, while conduct disorders were most closely associated with family variables, and ADHD was only related to child characteristics. They concluded that disadvantaged schools, deprived neighbourhoods, low socioeconomic status, 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.

Early adverse circumstances were strongly associated with lower cognitive ability in childhood and adolescence, and were detectable on measures of verbal ability, memory, and speed and concentration in midlife.¹¹ However, these long term effects were mostly explained by the effects of adversity on childhood or adolescent cognitive ability or by differences in educational attainment and adult social class. This still does not properly test the proposition that a poor start to life leads to low intellect and educational achievement. A great deal of intellect, as measured by IQ, is inherited and those with parents of low intellect are more likely to be brought up in poverty.

Financial difficulties as a student and incurring debt are associated with poor mental health.¹²

Abuse of drugs or alcohol is likely to lead to social decline. It takes money, it makes the individual more unemployable and it is liable to lead to 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 begs the question of whether the substance abuse has caused the mental illness or if the mental illness has led to "self-medication" with alcohol or illicit drugs. Probably both are true. What is plain is that if a person with incipient mental illness decides to "self-medicate" in this way, that he does himself no good.

In the 1960s and 1970s the large Victorian lunatic asylums were closed and the patients discharged to care in the community. Many saw this as a cost-cutting device. It is generally true that care in the community is cheaper than in hospital and this is a basic tenet of the shift from secondary to primary care as facilitated by Practice Based Commissioning. However, psychiatric care in the community should be seen as a humanitarian aim rather than a financial expedient. It has not always proved adequate and too often those with mental health problems have broken the law and been incarcerated in prison. In addition, a major cause of crime is substance abuse and the demands on the prison medical services are enormous. There are substance abusers, there are the mentally ill, there are problems of dual diagnosis and the psychological stresses of being incarcerated as well as physical problems such as hepatitis B, hepatitis C and HIV infection. According to the Mental Health Foundation, only 1 in 10 prisoners, does not have a mental health problem. 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.

"Prison works" is a sound-bite much loved by politicians despite the transparent absurdity in that if it did, the prison population would be falling, not rising. In overcrowded prisons it is impossible to offer proper treatment and rehabilitation but until society sees the folly of its ways, little is likely to change and offenders will be demonised rather than helped to become useful members of society.

There seems to be no doubt that people with mental illness are more likely to live in poverty. They are more likely to slide down the social scale. They are less likely to find employment of any sort and they are very likely to face discrimination in all fields of the job market.

People with poor mental health are more likely to suffer from poor physical health. They are more likely to smoke and abuse drugs or alcohol. They may also fall foul of the criminal justice system.

This is a far more difficult question, not least because of the problem of association and causation and the question of genetics and environment. The papers cited here are mostly based on surveys of British citizens as findings from abroad, especially from developing nations, may not be applicable. They often appear to be contradictory.

The aetiology of mental illness is multifactorial with genetics, upbringing and substance abuse all being possible confounding factors. A child brought up in financial hardship may also be deprived of affection, but not necessarily. One factor that is difficult to quantify but does tend to be a recurrent theme in causes of mental illness is stress. Living in poverty with poor living conditions or even being homeless and struggling financially, is certainly a very severe stress.On balance, it seems likely that living in poverty does predispose to mental illness.

A society may be judged on how it treats its most disadvantaged. The problems of poverty as described in Charles Dickens' David Copperfield and other works or the rehabilitation of offenders, or lack of it, as portrayed by Victor Hugo in Les Misérables are still visible today. If the Ancient Greeks were to look at our society, they would not be very impressed.