Christopher G. Hudson, Ph.D.
Christopher G. Hudson, Ph.D., conducted a large-scale study on poverty and mental illness. Hudson is chairman of the School of Social Work at Salem State College. (photo by Andrew Gallagher)

By Ami Albernaz

For decades, researchers have known that poverty and mental illness are correlated; the lower a person’s socioeconomic status, the greater his or her chances are of having some sort of mental disorder. Yet determining if one comes first – if being poor renders a person more susceptible to mental illness, or if mental illness pulls a person into poverty – is decidedly difficult and the relationship between poverty and mental health has long been assumed to be interactive.

Yet a recently published large-scale, seven-year study suggests that poverty, acting through economic stressors such as unemployment and lack of affordable housing, is more likely to precede mental illness than the reverse. Christopher G. Hudson, Ph.D., chairperson of the School of Social Work at Salem State College, examined the records of more than 34,000 patients who had been hospitalized because of mental illness at least twice between 1994 and 2000. He looked at whether or not these patients had “drifted down” to less affluent ZIP codes following their first hospitalization.

Except for patients with schizophrenia, though, Hudson found little evidence of this downward drift. Hudson says his data suggests that poverty impacts mental illness “both directly and indirectly.”

“Much of the impact comes through economic conditions such as housing and unemployment,” he says. Other hypotheses Hudson tested, including the “downward drift” and the idea that lack of family support acts as a mediator between poverty and mental illness, received little support in his data.

Hudson’s study follows a long line of research into the poverty-mental illness link that has been conducted since the late 1930s. These studies have repeatedly found higher rates of mental illness in low-income communities. Hudson’s data shows mental illness to be three times as prevalent in low-income communities as in higher income ones; other studies have shown the rate to be anywhere from two to nine times higher in poor communities. Research into causes of mental illness began much later; levels of fatalism among poor people, levels of family and community support and unemployment were all examined as possible factors.

The relationship is still regarded by mental health professionals as a complex one. Elizabeth Childs, M.D., commissioner of the Massachusetts Department of Mental Health (DMH), says while it is not surprising that Hudson’s study shows a correlation between serious mental illness and low socio-economic status, she does not infer that poverty leads to mental illness. “Poverty presents risk factors that may exacerbate mental illness,” she says, and “can impede access to services that are necessary for early intervention and treatment. The evidence is increasingly clear that there are biological roots to serious mental illness, and as with many other medical illnesses, environmental factors, such as socio-economic status, can play a major role in the course of the disease,” she says.

Kelly Anthony, Ph.D., a visiting assistant professor of social psychology at Wesleyan University who has researched poverty and homelessness, says that particularly in the United States, “relative poverty” – dissatisfaction with one’s lot in life compared to that of others – seems to correlate with mental illness. “All of these issues [surrounding poverty and mental health] are complex when you lump them all together,” she says. Cases of psychological disturbance for which biological evidence is not so strong, mild depression and anxiety, for instance, might be more influenced by social conditions such as poverty, she adds.

Debates on the connection aside, however, the undeniably higher prevalence of mental illness in poor communities has implications for public policy, some say.

Mental health resources should be distributed according to need, rather than on previous usage or on a per capita basis, Hudson says. In states where the latter happens, poor residents are underserved.

“If the rate of mental illness in poor areas is two to nine times what it is in rich areas, then you need two to nine times the levels of servicing and funding in [poor] areas, which rarely happens,” he says.

Psychological services for the most vulnerable, Hudson says, should be linked to “concrete services,” supported unemployment and assisted housing, for example. “It used to be that mental health workers didn’t want to concern themselves with housing and unemployment,” he says. “But this is starting to change.”

In Massachusetts, where some DMH clients earn 10 to 15 percent of the average yearly income and are often in great need of affordable housing, according to Childs, “a primary goal of our community service system is focused on assisting our clients to obtain housing and employment, through direct housing assistance, linkages with state and federal housing subsidy programs and community programs that foster and develop employment skills,” she says.

Bernice Lott, Ph.D., a professor emerita of psychology and women’s studies at the University of Rhode Island who has written on social class and health, argues that a stronger social service net is needed to prevent people from sliding into poverty and poor health in the first place.

“To prevent illness and provide the conditions for optimal health, we need structural changes,” she says. These changes, she adds, include allotting resources for job creation; increasing the minimum wage; improving public education and increasing access to higher education; providing job training; and offering financial supports for low-income families.

What is ultimately needed, Hudson and Lott suggest, is a leveling of the playing field.

“I find it amazing that so many people will claim that mental illness is equal opportunity. It’s true that anyone can breakdown [acknowledged biological factors], but class differentials are often overlooked,” Hudson says. “When it comes to mental illness, some people are more equal than others.”