Want to Improve Mental Health? Reducing Poverty is Key

Family in the Guatemalan highlands

Source: Howard Davies

Early in my career, I spent a year working in two refugee camps in southern Mexico, home to indigenous Guatemalans who had escaped the genocide taking place in their homeland a short walk across the border. I was well-versed in the literature on refugee mental health, which focused almost exclusively on assessing and treating Post-traumatic Stress Disorder (PTSD) related to the violence in whatever country people had escaped from. I assumed that trauma related to the genocide would be the primary mental health concern in the refugee camps.

I was wrong.

There were certainly some people still traumatized by the violence they had experienced. However, far more common than war trauma was despair stemming from the extreme poverty in the camps. Malnutrition was widespread, and most families had lost at least one child to a preventable poverty-related disease. There was a hospital 90 minutes away, but the cost of transportation was prohibitive, and medications were unaffordable. Although the refugees weren’t allowed to own land or work, exploitative black market jobs could sometimes be found. However, they paid terrible wages that left families still unable to meet their basic needs. Men felt shame at being unable to provide for their families; women felt despair at being unable to feed their children adequately, or afford medication to treat their illnesses.

Here’s Catarina, a 48 year old refugee, describing her experience of poverty:

I cry because of what we suffer here. We feel very sad, we had all our lands there. Sometimes we run out of food and our land is so far away. I cry when I want to work and plant crops and we can’t. How are we going to eat? I feel sad because of our poverty. Sometimes I’d rather die because I can’t work. I can’t buy medicine, I can’t earn money to buy medicine.

A focus on war trauma wasn’t wrong, it was simply way too narrow. It overlooked the most powerful source of psychological suffering in the camps.

Years later, I recalled Catarina's words as I listened to a Syrian man express his despair about the impact of falling deeper into poverty as a result of Lebanon's economic collapse, and the reduction of financial support to the refugees:

The financial situation is very hard. My wife and kids are sick. I can't afford the medication. We used to get medical aid for six months, now it's only one month. A person who has a sick wife and children, what can he do? I wish death.

In my work with various refugee communities over the years—Bosnians in Chicago, Syrians in Lebanon, Palestinians in Gaza, Afghans displaced within their own country—I have seen the same thing repeatedly: poverty is a major source of distress, and a contributing factor to a host of other stressors that negatively affect mental health.

But this isn’t just true among refugees. It’s a universal truth, as real in peaceful nations as in war-torn countries. Poverty is causally related to higher rates of anxiety, depression, suicide and severe mental illness. According to a study in the UK, “Children from the poorest 20% of households are four times as likely to have serious mental health difficulties by the age of 11 as those from the wealthiest 20%.” Globally, those with the lowest incomes are far more likely to suffer from anxiety, depression, and suicide than those with the highest incomes (Ridley, Rao, Schilbach, & Patel, 2020).

We can treat these disorders with psychotherapy and medication, but if we limit our response to treating the effects of deprivation without targeting poverty itself, we’ll have an unending wellspring of distress.

Why is poverty so toxic to mental health?

• Families in poverty experience perpetually high levels of stress due to food insecurity, overcrowded and unsafe housing, unaffordable and poor quality healthcare, inferior schools, exposure to crime and community violence, and greater exposure to environmental hazards such as toxic waste and lead paint (Ridley et al., 2020).
• Low-paying jobs often come with the least job security, and are most likely to be lost during economic downturns and other crises, such as the COVID-19 pandemic. Job loss, in turn, is strongly linked to anxiety, depression, and substance abuse. Areas in the US heavily affected by job loss due to technology changes and globalization have seen heavy job losses and a concurrent rise in opioid addiction and overdoses.
• Poverty often leads to high levels of stress among parents and spouses, which in turn may lead to an increase in family violence, including intimate partner violence (“domestic violence”), lower parental warmth, harsh parenting, and child abuse (Masarik & Conger, 2017). These forms of violence result in both short and long-term trauma for women and children, and threaten children’s emotional, cognitive, and social development. In fact, family violence has lasting effects on young children’s brains, in ways that put them at risk for a host of psychological and physical health problems later in life (Yoshikawa, Aber, & Beardslee, 2012).
• Poorer families have a much harder time accessing and affording healthy food. Low-income families in the United States often have limited access to markets selling healthy groceries, leading to a reliance on cheap and unhealthy processed foods that contribute to high rates of obesity and other health problems. Poor health, in turn, is linked to poor mental health. Simply put, it’s stressful and depressing to be sick.

Poverty reduction is good for mental health

There is clear evidence that reducing poverty improves mental health. This has been demonstrated in numerous studies in diverse settings, from deeply impoverished communities in low-income countries, to poor families in the United States and Europe. Here are a few examples:

• Increases in the US minimum wage are associated with a decrease in suicide. In one study, just a one dollar increase was associated with a 3-5% drop in suicide. Imagine what the impact on mental health might be of increasing the US federal minimum wage from $7.25 to $15, as many have proposed.
• A guaranteed minimum income experiment in Finland resulted in improved mental health, including lower stress and greater life satisfaction. According to the researchers, participants “were more satisfied with their lives and experienced less mental strain, depression, sadness and loneliness. They also had a more positive perception of their cognitive abilities, i.e. memory, learning and ability to concentrate.” Interestingly, people receiving the basic income actually worked more days annually than those in the control group, suggesting that a basic income did not discourage people from working.
• Providing uninsured adults in Oregon with free health insurance led to improved mental health, including lower rates of depression, compared with a control group, a finding not attributable to greater use of mental health services by the newly insured. Knowing they could afford healthcare should they need it seemed to significantly reduce people's uncertainty and fear of a health-related financial crisis.
• Cash transfer programs, which provide poor families with infusions of cash, have led to improvements in mental health in numerous low-income countries. In settings where environmental disasters have harmed food crops, cash transfers have reduced depression and suicide (Ridley et al., 2020).
• Anti-poverty programs, which include cash transfers combined with other resources such as job training and increased access to health care, have not only improved participants’ economic wellbeing, but also increased their happiness and lowered their distress (Ridley et al., 2020).
• There is evidence that poverty reduction programs may reduce intimate partner violence, which is generally more prevalent in low-income families.
• Head Start and other early childhood education programs give kids an educational boost, and have also shown powerful long-term benefits in greater educational achievement, lower criminality, and lower teen pregnancy, all factors linked to greater economic wellbeing, which in turn is strongly related to better mental health.

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Does poor mental health lead to poverty?

The relationship between poverty and mental health cuts both ways. Just as poverty is bad for mental health, so too does poor mental health make it difficult to work, increasing the risk of job loss and subsequently falling into or getting stuck in poverty. Clearly, there is an important role for mental health interventions in helping alleviate psychological suffering and enabling people to function well and remain productive.

The danger lies in our current practice of largely ignoring the psychological impact of poverty on mental health, and viewing psychological difficulties as caused exclusively by internal factors—our genes, our thoughts, our behavior, our early childhood traumas and conflicts. These are all real and important causes of poor mental health, but such a view ignores the elephant in the room: the stressful conditions of everyday life in poverty and the suffering to which it gives rise.