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Urban Suffering Studies Center



The association Poverty - Mental Disorders and its implications for outcome and care provision

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Benedetto Saraceno



"Mental or psychological well-being is influenced not only by individual characteristics or attributes, but also by the socioeconomic circumstances in which persons find themselves and the broader environment in which they live" (WHO, 2012)

Poverty, from an epidemiological perspective, means essentially low Social Economic Status (SES) namely, exceedingly low income, unemployment and low levels of education and family standing.
Over the last 25 years, several studies have shown the close links between poverty, mental disorders and mental ill-health.
As clearly shown by Patel and Araya (1999) and Patel and Kleinman (2003), the so-called common mental disorders are about twice as frequent among the poor as among the rich; Depression is 1,5 to 2 times more prevalent among the low income group of any given population.
Hunger, Poor, Crowded Housing or Debts represent all significant risk factors for common mental disorders.
Education and Employment are also factors which play a key role in the association between poverty and mental disorders: low levels of education and unemployment are well-established risk factors for mental ill-health (Araya and Lewis, 2003); unemployment is also associated with greater health care use and higher death rates. This association also works in the opposite direction, which means that mental ill-health is a significant predictor of unemployment (WHO, 2012).


As shown in the critical review of Saraceno, Levav and Kohn (Saraceno et al, 2005) people with the lowest socioeconomic status (SES) have 8 times more relative risk for schizophrenia than those of the highest SES (Holzer et al, 1986). People with Schizophrenia, in comparison with people without mental disorders, are 4 times more likely to be unemployed (Robins et al, 1991), one-third more likely not to have graduated from high school, and 3 times more likely to be divorced (Cohen, 1993).
Since the beginning of the seventies, Bruce Dohrenwed was able to make evident that SES was inversely related to the prevalence rates of psychiatric disorders such as schizophrenia and major depression (Dohrenwed et al, 1969, 1974). The finding of higher rates of mental disorders among people with the lowest SES suggested that low SES might be a significant risk factor for developing mental disorders due to the association between low SES and greater environmental adversity. This explanation was the so-called "social causation explanation". Nevertheless, this explanation was seriously challenged by the argument which states that the rates of mental illnesses are higher in lower SES groups simply because people with these disorders drift into lower SES groups. This explanation was the so-called "social selection explanation". However, some studies have provided evidence that, at least for schizophrenia, people with this psychiatric disorder may drift down to or fail to rise out of lower SES. As stated by Dohrenwend, Levav et al.: "although this evidence needs to be confirmed in different settings with different ethnic groups, it provides preliminary support for the social selection explanation" (Dohrenwed, Levav et al, 1992). Community-based epidemiological studies across countries and over time have consistently identified an inverse relationship between SES and prevalence rates of schizophrenia (Dohrenwed, 1993).

Major Depression

SES is also associated with Major Depression (Kohn et al, 1998) and the social causation hypothesis is supported by most but not all surveys. This association has been found also in low income countries as shown by a review of studies conducted in several African and Asian countries; this review of studies has identified low SES-related variables as a risk factor for mental disorders (Husain et al, 2002).
In other words, it seems that the social selection explanation applies to schizophrenia while the social causation explanation applies to depression.

Broadening the concept of "poverty"

More recent studies have clearly shown that the concept of "poverty" cannot be confined to the narrow variable of "income". A comprehensive review of English-language journals published since 1990 and three global mental health reports identified 11 community studies on the association between poverty and common mental disorders in six low- and middle-income countries (Patel and Kleinman, 2003). Most studies showed an association between indicators of poverty and the risk of mental disorders, the most consistent association being with low levels of education. According to Patel and Kleinman, the review of articles exploring the mechanism of the relationship between poverty and mental disorders suggested weak evidence to support a specific association just with income levels. "Factors such as the experience of insecurity and hopelessness, rapid social change and the risks of violence and physical ill-health may explain the greater vulnerability of the poor to common mental disorders" (Patel and Kleinman, 2003). On one hand, studies in industrialized countries have shown an association of low income with depression in women (Kahn et al, 2000) but these findings have been contradicted by studies demonstrating a weak relationship between income inequality and common mental disorders (Sturm and Gresenz, 2002).
Indeed, things are much more complex and there is also evidence of other types of associations with increased rates of mental disorders such as insecurity, shame, humiliation, illiteracy, gender and social change.
Some studies have proved that common mental disorders could be significantly associated with financial insecurity and dramatic decrease of income: Araya et al. found a strong relationship between acute income drop in the previous six months and the risk of mental disorders (Araya et al, 2003). Sundar (Sundar, 1999) has studied the suicide of Indian farmers and this phenomenon (also studied in other countries like Chile, Sri Lanka and some Central American countries) could be seen as an additional evidence of the impact of financial insecurity on mental health. As noted by Patel and Kleinman (2003), the psychological impact of living in poverty is often mediated by shame, stigma and the humiliation of poverty (Narayan et al, 2000).
Furthemore, illiteracy or low levels of education are also significant risk factors for common mental disorders and some studies have even demonstrated a dose-response relationship between educational level and the risk of common mental disorders (Araya et al, 2001). There is no doubt that the lack of education may represents a serious obstacle for people to access job market and consequently financial resources (Husain et al, 2002).
Finally, as stated by Patel and Kleinman, "epidemiological investigations in many developing countries have attributed the high rates of common mental disorders to factors such as discrimination, unemployment and living through a period of rapid and unpredictable social change" (Rumble et al, 1996). In conclusion, all social inequalities, low levels of education and, more in general, all conditions of exclusion and social suffering can be considered as part of a broader concept of poverty and its association with mental disorders.

Poverty as a Prognostic Factor for the Outcome of Mental Illness

From an epidemiological as well as a clinical point of view, the question is therefore to understand whether poverty affects also the long-term course and outcome of mental disorders. This is a central point in the debate because an association between SES and outcome would imply that mental disorders cannot be managed without directly taking into account the environment of poverty, including the "poverty of mental health care and related services". Saraceno and Barbui (Saraceno and Barbui, 1997 ) have argued that an association between SES and outcome would imply that mental disorders such as depression and schizophrenia could not be managed without taking into account the environment of poverty and discrimination. Saraceno (Saraceno, 2004) argued that, in parallel to the classical biopsychosocial etiological hypothesis, an identical paradigm for mental health intervention is needed: "The social dimension of mental illness should be an intrinsic component of intervention and not just a concession in etiological modeling". The social dimension of mental illness requires a social dimension of treatment; neurosciences have provided an extraordinary contribution to understanding the brain but very few practical solutions. This statement has dramatic implications, because the emphasis of intervention should be moved from symptoms to functioning and disability.
What we should ask ourselves is why, in spite of all of this, psychiatry seems to be strongly conditioned by the hegemony of a biomedical model. The reason should not be searched for in a theoretical resistance on the part of psychiatrists towards the innovation caused by more holistic approaches but rather in a cultural and social resistance to the consequences that the biopsychosocial approach causes (or rather, would cause if really implemented) in delivering mental health care. In fact, shifting from a biomedical approach to a bio psychosocial one would cause important changes in the formulation of mental health policies, in the daily practice of services and in the social status and role of psychiatrists. Such changes would imply the empowerment of nonmedical professions,
users and their families and, last but not least, the recognition of the role of the community as a partner in care and of the role of cooperation between sectors other than health like social security, social assistance, and the economy in general. In other words, the biopsychosocial dimension demands a much more complex view, oriented towards the community. At this point, it is important to clarify once and for all that the conflict between the biological, psychological and social approaches is in itself a false conflict. Today, in the light of the evolution of knowledge in neurobiology, neuropsychology, psychodynamics, and sociology, it would be senseless to propose a model of health/illness that was not interactive and complex. The true conflict is between the biomedical and the public health paradigms. The biomedical paradigm (apart from its major or minor concessions to the contributions of psychology and of social determinants) pervades all of psychiatry and tries to pervade the mental health culture, as well. This is a paradigm which is strongly influenced by the biological approach even when it admits or accepts some of the claims coming from the psychosocial approaches.
The biomedical paradigm is linear (damage to the central nervous system provokes a condition of illness and the treatment aims to repair this damage), individualistic (health and illness are determined by the individual's resources treatments are aimed exclusively towards the individual) and not contextual (it ignores the interactions between the individual and his or her environment). Indeed, the biomedical model is simple, reassuring and fast. The biomedical model, in addition, looks much more dignified by hard sciences (like neurosciences) than other models. We can understand the historical reasons that make today psychiatrists proud of being part of the scientific discourse because in the past too often they were not. However, all these, in spite of being the possible reasons explaining the hegemony of the biomedical model in psychiatrists' practice are not such good reasons for excluding a more comprehensive and complex approach. Sciences have proven the complex interaction between genes, brain and environment. Probably, the right way to overcome the eternal and academic conflict between separate and self-excluding approaches without, however, proposing purely ritualistic integration of approaches is to address the real conflict, which, as already mentioned, is not between the explicative models of mental illness but rather between two operational paradigms: the medical on the one hand and the public health on the other. In conclusion, there are not two sides, but one complex phenomenon that needs to be understood (Saraceno, 2010).
Researchers now conceptualize mental disorders as polygenic, with additive multiple gene models that include non-genetic influences. As stated by Steve Hyman, the past director of NIMH, "Although genes will provide critically important "bottom-up" tools to investigate mechanisms leading to illness, sophisticated "top-down" tools provided by integrative neurosciences and behavioural sciences will be no less crucial" (Hyman, 2000).


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The study centre wishes to study the phenomenon of urban suffering, in other words the suffering that is specific to the great metropolises. Urban Suffering is a category that describes the meeting of individual suffering with the social fabric that they inhabit. The description, the understanding and the transformation of the psychological and social dynamics that develop from the meeting of ...

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The Urban Suffering Studies Center - SOUQ - arises from Milan, a place of complexity and economic and social contradictions belonged to global world.Tightly linked to Casa della Carità Foundation, which provides assistance and care to unserved populations in Milan (such as immigrants legal and illegal, homeless, vulnerable minorities), the Urban Suffering Studies Center puts attention on ...


Centro studi Souq Management commitee: Laura Arduini, Virginio Colmegna (presidente), Silvia Landra, Simona Sambati, Benedetto Saraceno ; Scientific commitee: Mario Agostinelli, Angelo Barbato, Maurizio Bonati, Adolfo Ceretti, Giacomo Costa, Ota de Leonardis,  Giulio Ernesti, Sergio Escobar, Luca Formenton, Francesco Maisto, Ambrogio Manenti, Claudia Mazzucato, Daniela ...
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