Poverty & Mental Disorder: Breaking the Cycle Vikram Patel, PhD Professor of International Mental Health London School of Hygiene & Tropical Medicine Sangath.

Poverty & Mental Disorder:Breaking the Cycle

Vikram Patel, PhDProfessor of International Mental Health

London School of Hygiene & Tropical MedicineSangath

Public Health Foundation of IndiaApril 2014

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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

1. Why social determinants?

2. The evidence on the relationship of poverty and mental health

3. The evidence on breaking the cycle of poverty and mental ill-health

Plan

1. Why social determinants?

Click book coverFor more information(in slide show view only)

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

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“We are at a crucial juncture….action on social determinants of health is not only vitalfor 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)

The charge

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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

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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?

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Plan

1. Why social determinants?2. The evidence on the relationship of

poverty and mental health

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A systematic review(click title for access in slide show view only)

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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)

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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

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Beyond absolute poverty….

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“Relative poverty” or inequality

(Wilkinson, The Spirit Level, 2010)

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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

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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

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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)

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Cycle of poverty and mental ill-health

Poverty

• Economic deprivation

• Indebtedness• Low education• Unemployment• Lack of basic

amenities• Inadequate housing• Overcrowding

Mental Ill Health

• Higher prevalence

• Poor/lack of care

• More severe course

Social exclusionHigh stressorsReduced access to social capital/safety netMalnutritionObstetric risksViolence and trauma

Increased health expenditureLoss of employmentReduced ProductivitySocial drift

Plan

1. Why social determinants?2. The evidence on the relationship of

poverty and mental health3. The evidence on breaking the cycle of

poverty and mental ill-health

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(Click title of article in slide show view only)

PovertyPoverty Mental ill-healthMental ill-health

Conditional Cash transfers

Conditional Cash transfers

Unconditional Cash transfersUnconditional Cash transfers

LoansLoans Asset promotionAsset promotion

Group or individual psycho-therapy

Group or individual psycho-therapy

Family psycho-education

Family psycho-education Psychiatric

medicationPsychiatric medication

Community rehabilitation programme

Community rehabilitation programme

Residential drug rehab.Residential drug rehab.

Epilepsy surgeryEpilepsy surgery

Review 1Review 1

Review 2Review 2

Social causation

Social drift

Interventions identified

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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

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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

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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