The evidence is strong for a causal relationship between poverty and mental health.3 However, findings suggest that poverty leads to mental health and developmental problems that in turn prevent individuals and families from leaving poverty, creating a vicious, intergenerational cycle of poverty and poor health.4
Economic inequality affects mental health independently of poverty. Both internationally and within countries including the US, area-level income inequality has been associated with mental health outcomes including more depression, poor self-reported mental health, drug overdose deaths, incidence of schizophrenia, child mental health problems, juvenile homicides, and adverse child educational outcomes.5–8
Findings indicate that geographically concentrated poverty—often in urban areas—is particularly toxic to psychiatric well-being. Signs of social and physical disorder often characterize poor neighborhoods, which can cause stress, undermine health-promoting social ties, and affect the mental health of people who live there. Neighborhood deprivation has been associated with many of the same mental health outcomes as poverty, even while controlling for individual poverty.9,10 Institutional and structural mediators include the quality of local services and schools, as well as physical distance between residents and social isolation. Community-level mediators include collective efficacy, socialization by adults, peer influences, social networks, exposure to crime and violence, and safety fears. Individual-level poverty moderates the relationship between neighborhood deprivation and mental health, with poorer families affected more adversely by area-level poverty.
Clinical challenges and practical solutions
The link between increased rates of physical and mental illness and poverty has been well established. And yet, many psychiatrists receive little training in assessing and intervening in poverty. To address risk factors, we must first screen for them. A validated screening question, such as “Do you ever have difficulty making ends meet at the end of the month?” that has a 98% sensitivity and 40% specificity for people living below the poverty line, allows clinicians to identify those who may need further support.11 To intervene effectively, we also need to ask our clients about other social determinants of mental health, including housing, education, immigration status, and legal concerns.
Psychiatrists may be hesitant to screen for poverty if they do not have ready access to interventions or referrals. Screening should not occur in isolation, especially because most of the remedies for poverty and other social determinants of health or social determinants of mental health lie beyond the health sector. To address the complex effects of poverty on mental health, a 3-level approach to socially accountable care can be used. Psychiatrists can assist patients living in poverty at the micro- (individual, clinical) level, at the meso- (local community) level, and at the macro- (policy and population) level. There have been numerous validated screening tools for poverty created for research purposes. For clinical use, such tools should always be interpreted in the context of what is known about the patient and family. The Table provides an example of a clinical tool that highlights questions psychiatrists can ask when screening for poverty that address different levels of intervention [Erratum: no table appeared in the June issue. -Eds]
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.
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