Breaking the chains of mental illness that bind those in poverty

For several centuries, the more astute have periodically warned us that those who are poor die earlier than those who are more affluent. More recently, they also have alerted us that the poor have much higher rates of mental illness, which then entraps them in poverty. This fundamental fact should cause us to pause and then to revolutionize the practice of mental health care.

What is the evidence? More than half a century ago, research pioneers Auguste Hollingshead and Frederick Redlich (1958), followed shortly thereafter by Thomas Langner and Stanley Michael (1963), documented that poverty leads directly to high rates of mental illness. Three decades later, Richard Mollica and Mladen Milic (1986) observed a similar relationship, with slight modifications.   Just recently, Christopher Hudson (2005) reaffirmed these earlier findings and also added that downward social drift due to prior mental illness is only a minor factor in the observed relationship between poverty and mental illness.

The power of this relationship has been documented through a 1995 survey in the United Kingdom by Rachel Jenkins and others (1997). Compared to those from the highest social class, those from the lowest social class had the following prevalence for specific disorders: alcohol dependence (times 2); depressive disorder (times 4); functional psychosis (times 4); phobia (times 7); and drug dependence (times 7).

These relationships are to be expected. Those who are poor are subjected to physical and sexual abuse, psychological trauma, fear and danger, unhealthy lifestyles and neighborhoods, and the personal consequences of high risk behaviors. They also have less accessible healthcare, and the available healthcare frequently is of low quality.

We also know that women are more likely than are men to be poor (16% vs. 13%, in the United States). Thus, it is not really surprising to learn that up to half of all poor women may have one or more mental illnesses.

Mental illness entraps people in poverty. Not only does it rob one of the vision, motivation, and drive needed to move out of poverty, but it also leads to debilitating social isolation, so that one is not even aware of opportunities when they infrequently do arise. These reasons alone are sufficient to dictate that we take action to mitigate these dire effects.

If we are to reduce these major effects of poverty, then it becomes essential that we focus our efforts upstream to mitigate some of the key causal factors that generate the negative effects of poverty. Two stand out: First, the lifestyle of poverty causes frequent trauma, and trauma causes mental illness and related substance use conditions. Second, poverty also causes social isolation, which can make mental illness much more severe.

The negative effects of trauma can be mitigated. The famous Adverse Childhood Experiences Study (ACES) by Vincent Felitti and others (1998) shows clearly that the number of traumatic events is very important in predicting later behavioral health problems. Hence, a preferred intervention is to reduce the prevalence of traumatic events. Thus, we should ask ourselves how we can teach those who are poor to avoid such events to the extent possible. Further, since it also is obvious that not all traumatic events can actually be avoided, we should ask ourselves how we can increase personal resilience to confront traumatic events.

The negative effects of social isolation also can be reduced. Appropriate interventions could take the form of one-on-one mentor relationships, local social support groups, and community-wide social inclusion initiatives. We should ask ourselves how we can build appropriate partnerships with local communities to undertake these endeavors.

The poverty trap can be fully defeated only if we also can create reasonable career trajectories with appropriate training at key intervals to permit advancement out of poverty. Although this work will be difficult, especially at the present time, it will not be impossible. We need to ask ourselves how we can take the first steps in this direction.

It is very important to note that all of the actions discussed here are far upstream from and actually prior to traditional mental health or substance use services. Hence, this work has tremendous implications not only for those who are poor, but also for our own revolutionary efforts to reposition mental health as a core public health field.

An Important Consideration

Unfortunately, some would argue that because poverty is a primary factor that leads to mental illness among those who are poor, then our responsibility as a mental health field is somehow diminished, i.e., “It is not really mental illness, but rather just poverty.” This is a perverse argument intended to minimize the problem and our involvement in it. In fact, we must step forward, acknowledge the linkage between poverty and mental illness, and engage appropriate solutions. To do less is to fail to accept our responsibility for wellbeing of the whole person, a basic requirement of social justice.