Definitions of poverty vary with social, cultural, and political systems. Attempts to understand poverty from poor people’s perspectives reveal that poverty is a multidimensional social phenomenon.1,2 From an epidemiological perspective, poverty can mean low socio-economic status (measured by social or income class), unemployment, and/or low levels of education
Economic inequality and poverty as social determinants of mental health
Sitting in the waiting room talking to herself, Susan looked exhausted and disheveled. Surrounded by her belongings, she waited for her psychiatrist. Since her last visit, Susan has become homeless following a rent increase, she has chronic medical conditions that have gotten worse, she stopped taking her prescribed psychotropic medications, and she has lost contact with the clinic. Thankfully, she has returned for care.
Poverty is one of the most significant social determinants of health and mental health, intersecting with all other determinants, including education, local social and community conditions, race/ethnicity, gender, immigration status, health and access to health care, neighborhood factors, and the built environment (eg, homes, buildings, streets, parks infrastructure). The mental health effects of poverty are wide ranging and reach across the lifespan. Individuals who experience poverty, particularly early in life or for an extended period, are at risk of a host of adverse health and developmental outcomes through their life. Poverty in childhood is associated with lower school achievement; worse cognitive, behavioral, and attention-related outcomes; higher rates of delinquency, depressive and anxiety disorders; and higher rates of almost every psychiatric disorder in adulthood. Poverty in adulthood is linked to depressive disorders, anxiety disorders, psychological distress, and suicide.
Poverty affects mental health through an array of social and biological mechanisms acting at multiple levels, including individuals, families, local communities, and nations. Individual-level mediators in the relationship between poverty and mental health include financial stress, chronic and acute stressful life events exposure, hypothalamic-pituitary-adrenal (HPA) axis changes, other brain circuit changes (eg, language processing, executive functioning), poor prenatal health and birth outcomes, inadequate nutrition, and toxin exposure (eg, lead). Family-level mediators include parental relationship stress, parental psychopathology (especially depression), low parental warmth or investment, hostile and inconsistent parenting, low-stimulation home environments, and child abuse and neglect.
Dr. Simon is a General Psychiatry Resident, Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine, Atlanta, GA; Dr. Beder is Lecturer, Psychiatry, University of Toronto; Dr. Manseau is Clinical Assistant Professor of Psychiatry, New York University School of Medicine.
1. Naraya D, Patel R, Schafft K, et al. Voices of the Poor: Can Anyone Hear Us? New York: Oxford University Press; 2000.
2. Compton MT, Shim RS. The social determinants of mental health. Focus. 2015;13:419-425.
3. Leventhal T, Brooks-Gunn J. Moving to opportunity: an experimental study of neighborhood effects on mental health. Am J Public Health. 2003;93:1576-1582.
4. McLoyd VC. Socioeconomic disadvantage and child development. Am Psychol. 1998;53:185-204.
5. Yoshikawa H, Aber JL, Beardslee WR. The effects of poverty on the mental, emotional, and behavioral health of children and youth: implications for prevention. Am Psychol. 2012;67:272-84.
6. Pickett KE, Wilkinson RG. Child wellbeing and income inequality in rich societies: ecological cross sectional study. BMJ. 2007;335:1080.
7. Messias E, Eaton WW, Grooms AN. Economic grand rounds: Income inequality and depression prevalence across the United States: an ecological study. Psychiatr Serv. 2011;62:710-712.
8. Zimmerman FJ, Bell JF. Income inequality and physical and mental health: testing associations consistent with proposed causal pathways. J Epidemiol Commun Health. 2006:513-521.
9. Chow JC, Johnson MA, Austin MJ. The status of low-income neighborhoods in the post-welfare reform environment: mapping the relationship between poverty and place. J Health Soc Pol. 2005;21:1-32.
10. Chung HL, Steinberg L. Relations between neighborhood factors, parenting behaviors, peer deviance, and delinquency among serious juvenile offenders. Devel Psychol. 2006;42:319-331.
11. Brcic V, Eberdt C, Kaczorowski J. Corrigendum to “Development of a Tool to Identify Poverty in a Family Practice Setting: A Pilot Study.” Int J Family Med. 2015;2015.
12. Bloch G. Poverty: A Clinical Tool for Primary Care Providers. Toronto: Centre for Effective Practice; 2016.