Poverty & Mental Disorder: Breaking the Cycle Vikram Patel, PhD Professor of International Mental Health London School of Hygiene & Tropical Medicine Sangath Public Health Foundation of India April 2014

Intended Audience & Learning Objectives This lecture will be most informative for someone with a beginning level knowledge of the topic. By the end of this lecture, users will be able to: State why a focus on social determinants is important to global health Describe evidence of the relationship between poverty and mental health Describe evidence on breaking the cycle of poverty and mental health

Plan Why social determinants? The evidence on the relationship of poverty and mental health The evidence on breaking the cycle of poverty and mental ill-health

Plan Why social determinants? Click book cover For more information (in slide show view only) http://www.who.int/social_determinants/thecommission/finalreport/en/

Why social determinants? “Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness and their risk of premature death” --WHO Commission on Social Determinants of Health, 2008

The charge “We are at a crucial juncture….action on social determinants of health is not only vital for health equity but has other highly desirable societal outcomes including social cohesion, reduction of crime and civil unrest, a more educated workforce and the freedom for people to lead lives they have reason to value. (Marmot, Bull WHO 2011)

Poverty: a key social determinant Lack of adequate material resources to meet basic needs such as food, shelter and health care “Structural determinant” rooted in unequal power relationships in society

Myths about the relationship between poverty and mental health Mental illness is the result of materialism and fast-paced lifestyles Mental health is a luxury item for poor people or for developing countries Isn’t misery the obvious result of poverty?

This cartoon illustrates the myth that not feeling content (a metaphor for low mood) is an experience of the wealthy who have much time on hand and scarcity of nothing.

Plan Why social determinants? The evidence on the relationship of poverty and mental health

A systematic review (click title for access in slide show view only) http://www.ncbi.nlm.nih.gov/pubmed/20621748

Indicators of “absolute” poverty Low educational status Low income Hunger Low material possessions

Is there an association between depression and absolute poverty? 115 studies Most studies showed statistically significant association* between indicators of poverty and depression Poverty strongly associated with higher rates of depression across age ranges in rural and urban areas Poverty associated with: Increased prevalence Increased severity Longer course and worse outcome * (p<.05; OR with 95%CI>1)

Other mental disorders Similarly strong associations between absolute poverty and a range of other mental disorders and disabilities, notably: Chronic psychoses Substance use disorders Developmental disabilities

Beyond absolute poverty….

“Relative poverty” or inequality (Wilkinson, The Spirit Level, 2010)

How living in poverty can lead to mental ill-health Material stressors, e.g. hunger, indebtedness Noisy, crowded, polluted and unsafe living conditions Higher burden of physical ill-health Inadequate access to good health care Impairment of early child development due to malnutrition Insecurity and humiliation of living in poverty

The humiliation of living in poverty “There’s nothing to eat. We’re constantly hungry. There’s nothing to wear. There’s no money to buy the child boots, or notebooks, pens or book bag. My life is just grief. I gave birth to these kids and I have to raise them. But if I didn’t I would have put a rope around my neck and hung myself a long time ago.” (woman, Ukraine) -from: Narayan et al, Voices of the Poor, OUP 2000

The insecurity of the poor “…the employer can keep you up to three months on a temporary contract without signing a permanent contract. At the end of the third month, he just says ‘go away’ without explaining how and why... If you say anything he says there are thousands like you waiting for your position.” (a man, Plovdiv, Bulgaria) (from ‘Voices of the Poor’, OUP 2000)

How mental ill-health can lead to poverty (Click cover for full story in slide show view only) http://www.tehelka.com/issue-wise-archive/?volume=7&issue=19&magid=124634

Excerpt from the story.

Cycle of poverty and mental ill-health Social exclusion High stressors Reduced access to social capital/safety net Malnutrition Obstetric risks Violence and trauma Mental Ill Health Higher prevalence Poor/lack of care More severe course Poverty Economic deprivation Indebtedness Low education Unemployment Lack of basic amenities Inadequate housing Overcrowding Increased health expenditure Loss of employment Reduced Productivity Social drift

Plan Why social determinants? The evidence on the relationship of poverty and mental health The evidence on breaking the cycle of poverty and mental ill-health

(Click title of article in slide show view only) http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60754-X/abstract

Interventions identified Poverty Mental ill-health Conditional Cash transfers Unconditional Cash transfers Loans Asset promotion Group or individual psycho- therapy Family psycho- education Psychiatric medication Community rehabilitation programme Residential drug rehab. Epilepsy surgery Review 1 Social causation Review 2 Social drift

Results: Review 1 4 studies (5 articles), all RCTs Mexico, Ecuador, South Africa and Uganda Mixed results Conditional cash transfers and asset promotion most clearly associated with mental health benefits Difficult to draw clear conclusions

Results: Review 2 9 studies: China (3), India (2), Iran (1), Nigeria (1), Thailand (1), Uganda (1) Of 19 associations tested: 10 showed a significant positive effect on economic status 9 showed a non-significant yet positive effect Benefits for individuals and households/families Improvements in economic status go hand-in-hand with clinical improvements: all studies

What probably works but is very difficult to evaluate? Poverty alleviation, promoting gender equity, and promoting fairer income distribution may be the most powerful interventions to promote mental ill-health