A multi-level, prevention-oriented approach that addresses poverty.
SIGNIFICANCE FOR PRACTICING PSYCHIATRISTS
Figure. Age-adjusted percentage of adults with serious psychological distress, by income relative to federal poverty level and by race and ethnicity: United States, 2009–2013
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.
Take the quiz: Poverty, Inequality, and Mental Illness
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.
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]
In the clinic, at the individual level, mental health providers are well placed to start with a thorough social history, to understand whether clients are accessing all the financial, housing, and support resources they are eligible for, to elicit client strengths, and to listen to what each person says that they need.
The health care and social welfare systems are often challenging to navigate, and it is important to validate the systemic difficulties clients experience. Resources such as Poverty-A Clinical Tool for Primary Care Providers,12 developed for use within different Canadian cities, can support clinicians and organizations in helping clients to maximize their income. There are similar screening tools including The EveryOne Project endorsed by the American Academy of Family Physicians. And yet, clinicians may not feel confident that their clients can follow through and access support services. For clients with multiple vulnerabilities, enhanced care coordination and case management support, such as social workers, Intensive Case Management, and Assertive Community Treatment (ACT) teams, can assist clients in addressing the social determinants of mental health, along with improving access to medical and behavioral health care.
CASE VIGNETTE (cont'd)
Susan has “always been anxious,” particularly since the death of her son, and has been unable to work for the past 3 years. However, her anxiety worsened after her eviction. Susan reports insomnia and spends most of the day worrying about many things, including her debt, safety, and when an imprisoned son will be on parole. After first providing her with a drink of water, you find out that she has never applied for any income or housing support. She agrees to restart an antidepressant, and accepts a referral to a local community agency, which helps her apply for unemployment and disability benefits, thereby allowing her to obtain housing. They also ensure that her health care coverage is active. Her anxiety and insomnia subsequently improve.
While assisting individual patients can have a significant impact, the repeated occurrence of poverty in the lives of our clients calls for community-level interventions. Addressing the social determinants of mental health through the health care system is only part of the answer, and creative solutions are needed. At the meso-level, which includes community engagement and education, training, and continuing professional development, mental health professionals can advocate for improved health. For example, they can develop outreach programs that targeted specific populations, they can contact local elected officials about the need for enhanced funding of social services, and they can provide continuing education sessions for their fellow health care professionals.
Systemic barriers are equally challenging and call for macro-level advocacy in solidarity with affected communities. To create upstream change, we need systems-based solutions that go beyond simply encouraging individual clinicians to address social needs. The past decades have seen declining taxes on the wealthy with cuts in social benefits, which restricts the resources available to address social needs effectively. Using a variety of advocacy skills, including everything from writing letters and opinion pieces to protesting on the streets, clinicians can bring an evidence-based lens to efforts to advocate for better housing, more income equality, better access to care, fairer immigration policies, and a stronger social safety net to improve mental health for everyone.
In working with people experiencing poverty, clinicians need to be mindful of the privilege that comes with the role of health care professional. There is a long history of professionals telling people in poverty what they need, without carefully listening to the creative ideas and strengths present in poor communities. Whether in the clinic, at the community-level, or when advocating for policy change, the voices of those directly impacted need to be at the front and center. For psychiatrists, this can mean listening closely in clinical encounters, asking for community input and partnership for any new local programs, and ensuring that all advocacy efforts involve the leadership of people with lived experience, with clinicians as allies.
To break the complex links between economic inequality, poverty, and poor mental health, providers need to take a multi-level, prevention-oriented approach that addresses upstream causes. Through careful screening, clinical care, referral to social services and psychosocial programs, and community- and population-level advocacy, mental health professionals can work collaboratively with clients, in a strengths-based manner, to improve health for all.
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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