Various studies have suggested that there is a relationship between poverty, and social exclusion, and mental health problems. But this is complex, both in terms of how we might measure poor mental health, and in how we might assess the direction of causality: does poverty, or social exclusion, cause poor mental health, or does poor mental health lead to poverty and social exclusion?

This is a shortened version of a blog by Professor Sarah Payne, University of Bristol that first appeared on the PSE website. 

The answers to the question above are not straightforward. Firstly it is likely that the interaction between poverty, social exclusion and experiences of poor mental health is two way rather than one causing the other. Secondly, issues of timing are important – mental health problems are often chronic and persistent, and the ways in which they impact on experiences of poverty or exclusion can vary over time for individuals, in association with their employment status for example, or with household characteristics and circumstances.

The association between poverty and social exclusion and mental health

Poverty
Poverty impacts on mental well-being in various ways. Research focusing on individual experiences has found associations between symptoms of common mental health disorders such as depression and anxiety and poverty (Weich and Lewis, 1998a; Butterworth et al. 2009; Jenkins et al. 2008).

Other studies have used area level analysis to explore the association between poverty and mental health. These analyses have found higher levels of hospital admissions, out-patient use for mental health services and suicide and parasuicide in poorer areas (Gunnell et al. 1995; Rehkopf and Buka 2006).

With area level studies a degree of caution is needed, for two reasons. The first is the question of the direction of causality and ‘drift’: are people who are experiencing poor mental health more likely to live in impoverished areas, perhaps moving to these localities after becoming ill due to loss of income and housing, for example? The second caution – often referred to as the ‘ecological fallacy’ – reflects the uncertainty around the association. While rates of treated mental illness or suicide may be higher in poorer areas, these are rates per head of population rather than descriptions of individual circumstances. We cannot tell, from ecological studies, if the people who were diagnosed as having poor mental health, or those who committed suicide, were themselves poor, we only know that they live or lived in a poor area.

Why might there be a relationship between poverty and poor mental health.

A range of factors are involved, including the effects of illness on income and living circumstances. For example, if poor mental health means an individual’s earning capacity is reduced, through the loss of paid work or a reduction in the level of work, then poverty may be a consequence of mental illness (Lorant et al. 2007). However, poor mental health may in turn arise out of the effects of being poor – the stress of managing on a low income, for example, or of living in poor quality housing, or trying to provide for children. Other effects of poverty which might lead to a deterioration in mental well-being include low self-esteem because of employment status, and decreased opportunities for positive self-esteem without a formal work role, or the stigma associated with welfare receipt and discrimination. Again, timing of the association is complex: one study by Weich and Lewis (1998b), for example, found that poverty and unemployment were both associated with the persistence of poor mental health, but not the onset of illness.

These influences can also be inter-related – for example stigma associated with being unemployed or claiming benefit may be exacerbated for those also affected by the stigma which often attaches to mental illness (Sayce 1998).

Social exclusion

Until relatively recently there have been fewer studies of the relationship between social exclusion and mental health difficulties (Morgan et al. 2007; Mezey et al. 2012)  However, new research reveals an increased risk of poor mental health and suicide among groups experiencing different forms of social exclusion, including for example unemployment and poor social capital (Morgan et al. 2007; Whitley et al. 1999). Mental health policy under the Labour government between1997 and 2010 focused on social exclusion as a consequence of mental health difficulties rather than as a cause (SEU 2004) and this association is borne out by research on the impact of discrimination, unfair detention, stigma and constructions of ‘difference’ (Morgan et al. 2007). Sayce and Curran (2007) for example argue that people with mental health problems are excluded from consuming health services, such as health promotion and health improvement programmes that are available to others, leading to unequal health outcomes and increased mortality among these populations. Similarly people with mental health problems experience exclusion as a result of their low employment rates and inequalities in the ‘chance to contribute’ (Sayce and Curran 2007:40).

However, social exclusion can also lead to an increase in the risk of poor mental health through isolation, loneliness and low levels of self-esteem, for example, while social capital can act as a protective factor (Mezey et al. 2012; Stafford et al. 2008).

For a podcast on the importance of social capital for mental health, you can also listen to our podcast What makes us healthy?