Poverty and mental health

The mental health of individuals is shaped by the social, environmental and economic conditions in which they are born, grow, work and age.^{4–Reference Shim, Koplan, Langheim, Manseau, Powers and Compton7} Poverty and deprivation are key determinants of children's social and behavioural development^{Reference Cooper and Stewart8,Reference Cooper and Stewart9} and adult mental health.^{Reference Cooper and Stewart10} In Scotland, individuals living in the most deprived areas report higher levels of mental ill health and lower levels of well-being than those living in the most affluent areas. In 2018 for example, 23% of men and 26% of women living in the most deprived areas of Scotland reported levels of mental distress indicative of a possible psychiatric disorder, compared with 12 and 16% of men and women living in the least deprived areas.^{Reference Cheong, Dean, Dougall, Hinchliffe, Mirani and Vosnaki11} There is also a clear relationship between area deprivation and suicide in Scotland, with suicides three times more likely in the least than in the most deprived areas.¹²

Inequalities in mental health emerge early in life and become more pronounced throughout childhood. In one cohort study, 7.3% of 4-year-olds in the most deprived areas of Glasgow were rated by their teacher as displaying ‘abnormal’ social, behavioural and emotional difficulties, compared with only 4.1% in the least deprived areas. By age 7, the gap between these groups had widened substantially: 14.7% of children in the most deprived areas were rated as having ‘abnormal’ difficulties, compared with 3.6% of children in the least deprived.^{Reference Marryat, Thompson, Minnis and Wilson13} National data from parental ratings of children's behaviour show a similar pattern: at around 4 years of age, 20% of children living in the most deprived areas of Scotland are rated as having ‘borderline’ or ‘abnormal’ levels of difficulties, compared with only 7% living in the least deprived areas.^{Reference Bromley and Cunningham-Burley14}

These findings reflect a broader pattern of socioeconomic inequalities in health that is observed internationally.^{Reference Mackenbach, Stirbu, Roskam, Schaap, Menvielle and Leinsalu15} The primary causes of these inequalities are structural differences in socioeconomic groups’ access to economic, social and political resources, which in turn affect health through a range of more immediate environmental, psychological and behavioural processes.^{Reference Adler and Stewart16,Reference McCartney, Collins and Mackenzie17} A wide range of risk factors are more prevalent among low income groups for example, including low levels of perceived control^{Reference Orton, Pennington, Nayak, Sowden, Petticrew and White18} and unhealthy behaviours such as smoking and low levels of physical activity,^{Reference Cheong, Dean, Dougall, Hinchliffe, Mirani and Vosnaki11} although these are best understood as mechanisms that link the structural causes of inequality to health outcomes.^{Reference McCartney, Collins and Mackenzie17}

Excess mortality and mental health in Glasgow

Glasgow has some of the highest Scottish rates of income deprivation, working-age adults claiming out of work benefits, and children living in low-income families.¹⁹ Moreover, the city also reports poor mental health, relative to the Scottish average, on a host of indicators, including lower mental well-being and life satisfaction, and higher rates of common mental health problems, prescriptions for anxiety, depression or psychosis, and greater numbers of patients with hospital admissions for psychiatric conditions.¹⁹

These statistics are consistent with Glasgow's overall health profile and high rates of mortality. Life expectancy in Glasgow is the lowest in Scotland. For example, men and women born in Glasgow in 2016–2018 can expect to live 3.6 and 2.7 fewer years respectively than the Scottish average.²⁰ Within Glasgow, men and women living in the most deprived areas of the city can expect to live 13.5 and 10.7 fewer years respectively than those living in the least deprived areas.^{Reference Whyte21}

The high level of mortality in Glasgow can largely be attributed to the effects of deprivation and poverty in the city, although high levels of excess mortality have also been recorded in Glasgow, meaning a significant level of mortality in excess of that which can be explained by deprivation. For example, premature mortality (deaths under 65 years of age) is 30% higher in Glasgow compared with Liverpool and Manchester, despite the similar levels of deprivation between these cities.^{Reference Walsh, Bendel, Jones and Hanlon22} Crucially, this excess premature mortality is in large part driven by higher rates of ‘deaths of despair’^{Reference Case and Deaton23} in Glasgow, namely deaths from suicide and alcohol- and drug-related causes.^{Reference Walsh, Bendel, Jones and Hanlon22}

It has been proposed that excess mortality in Glasgow can be explained by a number of historical processes that have rendered the city especially vulnerable to the hazardous effects of deprivation and poverty. These include the lagged effects of historically high levels of deprivation and overcrowding; regional policies that saw industry and sections of the population moved out of Glasgow; the nature of urban change in Glasgow during the post-war period and its effects on living conditions and social connections; and local government responses to UK policies during the 1980s.^{Reference Walsh, McCartney, Collins, Taulbut and Batty24} On the last point, Walsh and colleagues^{Reference Walsh, McCartney, Collins, Taulbut and Batty24} describe how the UK government introduced a host of neoliberal policies during this period – including rapid deindustrialisation – that had particularly adverse effects in cities such as Glasgow, Manchester and Liverpool. While Manchester and Liverpool were able to mitigate the negative effects of these national policies to some extent by pursuing urban regeneration and mobilising the political participation of citizens, there were fewer such efforts made in Glasgow, which contributed to the diverging health profiles of the cities.

These researchers have also suggested that this excess mortality may partly reflect an inadequate measurement of deprivation.^{Reference Walsh, McCartney, Collins, Taulbut and Batty24} However, that does not capture the reality of living in poverty. One aspect of this lived experience that may be important is the experience of poverty-based stigma and discrimination.^{Reference Inglis, McHardy, Sosu, McAteer and Biggs25} Stigma is a fundamental cause of health inequalities,^{Reference Hatzenbuehler, Phelan and Link26} and international evidence has demonstrated that poverty stigma is associated with poor mental health among low-income groups.^{Reference Mickelson and Williams27} Individuals living in socioeconomically deprived areas may also experience ‘spatial’ stigma, which similarly has a range of adverse health effects for residents^{Reference Halliday, Popay, Anderson de Cuevas and Wheeler28} and, crucially, may be unintentionally exacerbated by media and public health professionals’ reports of regional health inequalities.^{Reference Smith and Anderson29} Given the continued focus on Glasgow's relatively poor health it is possible that the city is more vulnerable to such stigmatising processes. However, we stress that additional research will be required to test whether stigma is an important aspect of the lived reality of poverty, particularly as several psychosocial explanations have already been offered for the excess mortality, with varying levels of supporting evidence.^{Reference Walsh, McCartney, Collins, Taulbut and Batty24} The notion of intersectional stigma is also gaining traction and requires further research.

Understanding the life-course impact of poverty on mental health is also important. Childhood adversity is one mechanism through which poverty and deprivation have an impact on mental health. Adverse childhood experiences, such as exposure to abuse or household dysfunction, are relatively common in the population. Marryat & Frank examined the prevalence of seven adverse childhood experiences among children born in 2004–2005 in Scotland, and found that approximately two-thirds had experienced at least one adverse experience by age 8.^{Reference Marryat and Frank30} Moreover, the prevalence was greatest in low-income households: only 1% of children in the highest-income households had four or more adverse childhood experiences, compared with 10.8% in the lowest-income households. Adverse childhood experiences are also strong predictors of mental health in adulthood: individuals who have experienced at least four are at a considerably greater risk of mental ill health, problematic alcohol use and drug misuse.^{Reference Hughes, Bellis, Hardcastle, Sethi, Butchart and Mikton31} It has also been suggested that experiences of childhood adversity and complex trauma may contribute to Glasgow's – and Scotland's – excess mortality, particularly that which is attributable to violence, suicide and alcohol and drug-related deaths.^{Reference Smith, Williamson, Walsh and McCartney32} The implications are significant for psychiatry. Not only does it offer a broader explanation of causation; it also highlights the importance of supporting early interventions for young people's mental health and supporting the families – including children – of those experiencing mental health problems.

Implications

When faced with the scale of the challenge the response can be daunting. This is especially so at a time when we see increasing poverty and socioeconomic inequalities within our society and challenging political conditions. The complexity and enduring nature of the problems necessitate a multilevel response from psychiatry across practice, policy, advocacy and research, which we explore in this section. We argue that this response should address three broad areas.