Poverty and mental health: social causation or social drift

Question 1

What is the recognition of the links between poverty and mental health in LMICs?

Answer 1

It is gaining international recognition, especially since 2010

• United Nations Assembly ‘Commission on Social Determinants of Health’ (2010)
• WHO Commission on Social Determinants of Health and WHO ‘Mental health and development’ (2010)
• WHO ‘Social determinants of mental health’ (2010, 2014)

Question 2

What is the association between poverty and common mental disorders in LMICs (Lund et al., 2010)?

Answer 2

Systematic review: 115 studies, 36 countries:
- association between diverse measures of poverty and increased prevalence of common mental disorders

• association between poverty and increased severity, longer course and worse outcomes for common mental disorders

Question 3

What is the problem with most studies investigating the association between poverty and common mental disorders in LMICs (Lund et al., 2010)?

Answer 3

It was not possible to establish causality

Question 4

What characterises the relationship between poverty and mental illness?

Answer 4

It is cyclical -> Cycle of poverty and mental illness

Question 5

What does the cycle of poverty and mental illness explain?

Answer 5

• Poverty increases mental illness through social causation

- Mental illness increases poverty through social drift

Question 6

How does poverty increase mental illness through a social causation?

Answer 6

• Social exclusion
• High level of stress and worry
• Reduced access to social capital and safety net
• Malnutrition
• Obstetric risks
• Violence and trauma

Question 7

How does mental illness increase poverty through a social drift?

Answer 7

• Increased healthcare expenditure
• Loss of employment
• Reduced productivity
• Stigma

Question 8

What constitutes the debate between social causation and social drift/selection?

Answer 8

> Social causation better explains the relationship between poverty and mental health in the case of depression

> Social drift better explains the relationship between poverty and mental health in the case of schizophrenia

Question 9

What is needed in order to comprehensively answer the questions surrounding the debate between social causation and social drift/selection?

Answer 9

Large well-characterised longitudinal studies in LMICs

Question 10

What is novel about the 2015 United Nations’ sustainable development goals envisaged for 2030?

Answer 10

For the first time, mental health is included
- 3rd Goal: good health and well-being

• Target 3.4: reduce premature mortality from noncommunicable disease by 1/3 ‘through prevention and treatment and promote mental health and well-being’
• Target 3.5: ‘Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol’

Question 11

What is the relevance of the United Nations’ sustainable development targets (2015) concerning noncommunicable diseases and mental health?

Answer 11

The defined targets are critical for the inclusion of mental health in universal health coverage plans

Question 12

What are the challenges of the United Nations’ sustainable development goals (2015) regarding mental health?

Answer 12

All of the remaining SDGs besides ‘good health and well-being’ have a bearing on mental health

• > How do we clarify mechanisms of relationship between each SDG and mental health?
• > Is it possible to harness political momentum from the SDGs to address social determinants of mental health and improve population mental health and well-being?
• > Can we show that providing mental health care yields economic and environmental benefits?
• > Is mental health both a means and an end of development?

Question 13

What is the purpose of the defined social determinants of mental health and sustainable development goals framework (UN, 2015)?

Answer 13

Understand how achieving the SDGs can improve mental health

Question 14

What does the social determinants of mental health and sustainable development goals framework consists of?

Answer 14

> 5 domains of SDGs:

• Neighbourhood
• Economic
• Demographic
• Social
• Environmental events

> Distal factors
Proximal factors

Question 15

Which approach is needed to understand how the social determinants influence mental health at various life stages?

Answer 15

A life course approach

• e.g. socio-economic deprivation in early childhood has profound effects on mental health over the life course

Question 16

What is the current evidence on how to break the cycle of poverty and mental illness in LMICs (Lund et al., 2011)?

Answer 16

Systematic reviews

> Addressing social causation of mental ill health

• conditional and unconditional cash transfers
• loans
• asset promotion
• > Some mental health benefits found, BUT exceptions and equivocal findings

> Addressing social drift of mental ill health towards poverty

• family psycho-education
• group/individual psychotherapy
• psychotropic medication
• community rehab program
• residential drug rehab
• epilepsy surgery
• > clinical improvement AND improved functioning and better individual and household economic circumstances

Question 17

What are the two candidate interventions for mental health and the sustainable development goals?

Answer 17

1. Targeting the cognitive and affective mechanisms of poverty
   - negative affective states (depression, stress, anxiety)
   - habitual behaviours (risk aversion)
2. Cash transfers (e.g. in Kenya)
   - significant reduction in depression symptoms, particularly among young men
   - substantial improvements in psychological wellbeing and reductions in stress following receipt of unconditional cash transfers

Question 18

What is the research agenda to tackle the issues of poverty and mental illness?

Answer 18

> Longitudinal epidemiological studies in LMICs

> Intervention studies targeting specific AND distal mechanisms

• linking cognitive neuroscience with behavioural economics
• e.g. cash transfers combined with psychological interventions

Question 19

What are the potential ‘piggy back’ opportunities in the research agenda?

Answer 19

• Include mental health outcomes in poverty alleviation and violence prevention trials (e.g. JPaL)
• Include economic outcomes in mental health trials

Question 20

What does the initiative EconIPV-MH (2017/2018) consist of?

Answer 20

• Systematic reviews of the economic (Econ) and intimate partner violence (IPV) impact of mental health trials (MH)
• Working with mental health trials in the field to include economic and IPV outcome measures

Question 21

Which institutions have committed to fund and deliver interventions on poverty and mental illness?

Answer 21

• World Bank
• World Health Organisation (WHO)

-> strong commitment made during the ‘Out fo the Shadows’ meeting on mental health and global development in Washington DC (April 2016)

Question 22

What are the findings on the ‘global return on investment analysis’ of scalling-up treatment of depression and anxiety (Chisholm et al., 2016)?

Answer 22

1$ invested in care for depression and anxiety disorders

= 3$ to 5$ return on investment over the period of the SDGs (2015-2030)

Question 23

What is the key approach to address both social causation and social drift pathways?

Answer 23

Comprehensive coordinated multi-sectoral approach