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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 individual poverty and mental health is well known.The relationship between poor mental health and health inequality within neighbourhoods is, however, more complex.
- One study found that living in neighbourhoods with the highest levels of income inequality was significantly associated with better mental health. The authors forwarded several explanations for these somewhat surprising findings. These included an increase in social capital (the collective value of social networks) in areas with low deprivation and a reduction in the risk of stress experienced by persons living in deprived areas.
- The 'social capital' concept is supported by a study which found that 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.
- 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 obtain 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 experience 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.The Equality Act 2010 clarifies that 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.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, fewer than a quarter 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.
- Unemployment levels were stable for many years but rose steadily since the recession and reached 2.49 million in the UK in June 2011. There were concerns about the mental health of people exposed to such economic conditions. However, recent years have seen a gradual fall in the number of unemployed, which stood at 1.75 million in the quarter April to June 2015.
- 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 more common in people who are socially disadvantaged.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. A report published by the National Equality Panel in 2010 stated that the richest 10% of the population were more than 100 times as wealthy as the poorest 10%.
- 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 study found that children reared in families with a disadvantaged socio-economic position had an increased risk for psychosis.
Mental illness itself is a significant contributory factor to child poverty. An American study found that 68% of women and 57% of men with a mental illness are parents. In addition, many children live with a parent who has long-term mental health problems, as well as alcohol or drug problems and personality disorders. Given the huge over-representation of unemployment and benefits' dependence amongst those with mental illness, this represents a significant number of children living in financially challenged households.
- 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 black Caribbean, black African and South Asian groups in England was higher than in the white British population. There was no evidence of a change in incidence over time, although a change in diagnosis (away from schizophrenia) was observed.
- 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 experience 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.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 obtain 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).[40, 41, 42]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 and references
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McGovern P; Why should mental health have a place in the post-2015 global health agenda? Int J Ment Health Syst. 2014 Oct 118(1):38. doi: 10.1186/1752-4458-8-38. eCollection 2014.
Fone D, Greene G, Farewell D, et al; Common mental disorders, neighbourhood income inequality and income deprivation: small-area multilevel analysis. Br J Psychiatry. 2013 Apr202(4):286-93. doi: 10.1192/bjp.bp.112.116178. Epub 2013 Mar 7.
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