Understanding the Links Between Poverty and Mental Health

An essay by?Maria E. Yurgel, Ph.D.

In recent years, the rise in mental health disorders has become a global concern, affecting millions. The COVID-19 pandemic has intensified this issue, emphasizing the urgent need to prioritize mental health. While the contribution of genetics and, to a larger extent, environmental factors have been recognized in the onset of common mental health disorders like major depression and generalized anxiety, an increasingly compelling body of evidence is revealing the influence of economic factors, notably poverty, on mental well-being. When mood and anxiety disorders are left unaddressed, they can further contribute to the worsening of economic outcomes, creating a never-ending cycle. The development and support of initiatives specifically targeting poverty, coupled with collaborative efforts between government agencies and departments to maximize the benefits of such programs, offer a critical pathway for addressing the ongoing mental health crisis.

Definition of Poverty

Poverty, a global issue, is traditionally defined as the inability to meet basic survival needs due to inadequate income. Extreme poverty is often quantified as living on less than $2.15 per day. However, the concept of poverty varies globally, influenced by local cost of living, leading to the notion of relative poverty. In the United States, the poverty line benchmark was initially established in the 1960s by Mollie Orshansky, an analyst at the Social Security Administration, based on the minimum income necessary to purchase a nutritionally adequate diet. Over time, this measurement has been refined and updated for greater accuracy. Poverty, however, is a multidimensional issue. Factors such as limited access to education, health care, housing, and transportation are important indicators in defining poverty. This complexity is recognized by initiatives like the Multidimensional Poverty Index, supported by the United Nations Development Program. This index incorporates dimensions such as health, education, and standard of living, providing a comprehensive assessment of poverty.

Impact of wealth on mental health

Globally, around 700 million people live in extreme poverty, with 37.9 million individuals in the U.S. falling below the country’s poverty line. This economic disparity is particularly concerning as lower incomes in the U.S. show disproportionate rates of suicide. Various studies have consistently established a negative correlation between income, employment, and the prevalence of major depression, anxiety disorders, and suicide. Research from low- and middle-income countries indicates that individuals who earn less are 1.5 to 3 times more likely to develop common mental illnesses. However, as mentioned in the “Definition of Poverty” section, poverty is a multidimensional issue. Many studies approach this subject through a narrow lens, primarily focusing on income as the sole metric for poverty. Moreover, a significant limitation in studies linking mental health and poverty lies in the cross-sectional or longitudinal nature of the evidence, making causal claims challenging. The observed correlations could result from poverty itself, the impact of poor mental health leading to low income, or other factors.

To address these challenges, evaluations of anti-poverty programs have been conducted globally and within the U.S., encompassing initiatives such as cash transfers to families. In low- and middle-income countries, this intervention has proven effective in reducing poverty and mitigating its detrimental effects on mental health. In the U.S., the results have been mixed, but comprehensive antipoverty programs that directly or indirectly provide a combination of assets have demonstrated an improvement in psychological well-being. As an example, a study assessing mental health outcomes in children from families in western North Carolina who experienced an uplift from poverty after receiving income from a gambling casino that opened on the reservation, along with job opportunities, revealed a significant decrease in psychiatric symptoms. Interestingly, this positive impact did not extend to the caretakers in the study. These findings not only provide robust evidence for the causal link between mental health and poverty but also underscore the multidimensional effects of poverty and wealth on mental well-being.

Mechanisms Linking Poverty and Mental Health

Poverty can impact mental health through various potential mechanisms. For example, worries and insecurities associated with economic hardship can lead to prolonged stress, known to disrupt brain circuits responsible for emotion and motivation. This disruption increases the likelihood of developing major depression and anxiety disorders. Additionally, individuals in poverty are more exposed to environmental stressors, such as pollution and extreme living conditions, which have direct links to mental illness. Sleep deprivation, a common consequence of living in poverty, further contributes to the development of psychiatric disorders. Lower income is also associated with poorer physical health and limited access to healthcare, which in turn contributes to mental health challenges.

To further our understanding of the links between poverty and mental health and to design effective initiatives, a more robust approach to data collection, research, and the integration of mental health measurements into existing programs is needed. Standardized and integrated data collection on demographics and mental health throughout the healthcare system is crucial for extracting comprehensive information. This facilitates post-hoc analysis, aiding in understanding the intersection between mental health and poverty.

Experts in the mental health field also emphasize the need for well-designed projects, including creating theoretical models. Theory driven designed experiments allow researchers to elucidate the mechanisms through which economic determinants contribute to improved mental health. Similar to the establishment of a common repository for hospitals and clinics, pooling data and fostering interdisciplinary collaboration among scientists are indispensable for meaningful advancements in the field. Ongoing projects like the CHANCES-6 study and ALIVE have been developed with these considerations in mind.

Beyond investigating mechanisms, comparative studies examining low-income populations that develop mental health issues versus those that do not, present a valuable opportunity to identify factors providing protection against mental health challenges in adverse circumstances. Finally, incorporating mental health measurements into anti-poverty policies, coupled with their integration into existing programs, is crucial. This approach is essential for gaining insights into the effectiveness of these policies on the mental well-being of vulnerable populations.

Towards a Solution

To improve mental health outcomes in low- and middle- income countries, researchers have suggested implementing initiatives that promote cash transfers, basic income grants, address income inequality, and enhance employment opportunities based on existing data. In high-income countries, particularly in the U.S., recommended strategies include macro and microeconomic policy changes, such as implementing a basic income system to eradicate poverty and reinstating recurring payments to households with children. Additionally, investments in education and neighborhoods are crucial for improving mental health. Collaborative efforts between government agencies and departments are essential to ensure comprehensive support for anti-poverty programs and maximize their benefits. An example is the establishment of New Zealand's new Mental Health and Wellbeing Commission, which oversees the impact of all government policies on mental health. Addressing poverty and mental health in the global south and north may require both overlapping and distinct strategies. Regardless of the approach, there is a pressing need for improvement in these efforts.

The importance of addressing mental health has risen to a paramount global concern, attracting significant attention from various organizations and initiatives. Notably, it holds a central position in the objectives outlined by Healthy People 2020, the World Health Organization (WHO), and the United Nations' Sustainable Development Goals (SDGs). The White House recently introduced the inaugural U.S. Playbook to Address Social Determinants of Health in the United States. Furthermore, the Department of Health and Human Services (HHS) has issued a Call to Action to Address Health-Related Social Needs, accompanied by a Medicaid and CHIP Health-Related Social Needs Framework.

While these initiatives are a great starting point for addressing the mental health crisis in the U.S., there remains a pressing need for more targeted efforts since they broadly focus on social determinants of health. Concentrating on mental health and anti-poverty programs shows promise given its indirect impact on other factors important for mental well-being, i.e. food insecurity. Therefore, to effectively address the mental health crisis, investment in improving people's living conditions is crucial; otherwise, we risk echoing the sentiment expressed in the WHO’s 2008 Commission on Social Determinants of Health final report: "Why treat people only to send them back to the conditions that made them sick in the first place?"