In their inaugural edition of the World Health Report titled “Bridging the Gap,” the World Health Organization (WHO) identified poverty as the most lethal global affliction (WHO,1995, p.v). The impact poverty has is evident throughout various phases of human existence. According to a report published by Oxfam in 2023, for the first time in twenty-five years, poverty has increased globally. While millions of people are still overcoming the impact of the pandemic that has killed over twenty million people, these crises have had their winners.
The rich have become richer and the poor poorer, with an ever-widening gap between the two. In a public lecture held at Ohio State University in 2017, esteemed economist and Nobel laureate Amartya Sen asserted that there exists empirical evidence indicating that living in societies characterised by inequality, wherein specific populations experience significantly inferior economic and social conditions, tends to engender deprivations in the overall quality of life that individuals can attain. (Panandiker, 2017)
Poverty and poor mental health are unquestionably linked. However, researchers and policymakers took time to agree on whether and how poverty affects mental health. Establishing this correlation has been challenging for a couple of reasons. First, the oversimplistic, pessimistic, and reductionist “medical model” dominated mental health discourse for decades, keeping socioeconomic factors like poverty undiscussed (Read, 2010). Further, due to the wide range of poverty measures, establishing a link between poverty and mental illness has always been challenging. Inconsistent and inaccurate parameters of poverty and mental illness often interfere (Cooper et al., 2012).
Against the backdrop of evidence that unequivocally supports the significant influence of poverty on mental health (see Butterworth et al., 2009; Funk et al., 2012; Jenkins et al., 2008; Kessler et al., 2005; Patel et al., 1999; Patel & Kleinman, 2003; Weich & Lewis, 1998; WHO, 2007), the discourse in recent years has transitioned to examining the specific elements of poverty and social inequality that serve as the most influential factors (Burns,2015 Poverty as a Causal and Maintenance Factor of Mental Illness.
Researchers hypothesised two major causal pathways from the existing literature in LMICs and high-income countries (Lund, 2012; Read, 2010; Saraceno et al., 2005), the “Social Causation Pathway” and the “Social Drift”.
Social Causation Pathway
According to this hypothesis, poverty and socioeconomic inequality deny equity and equal access to resources in almost every aspect of life. The poor are at an increased risk of violence, trauma, health issues due to malnutrition, and unemployment due to a lack of education. Additionally, individuals in this demographic have access to limited resources, which hinders their ability to safeguard themselves against the negative consequences of these risks. Collectively, these various factors contribute to an increased susceptibility to mental illness in these populations.
Social Drift Hypothesis
The “Social Drift” hypothesis is another potential causal pathway. According to this hypothesis, individuals with mental illness are prone to experiencing a higher likelihood of drifting or persisting into poverty. This can be due to increased expenditures, diminished productivity, and job losses resulting from societal stigmatisation, which subsequently exacerbates their exclusion and marginalisation.
The relationship between poverty and mental illness can be elucidated through the Social Causation Hypothesis, which posits that poverty is a substantial contributing factor to the development of mental illnesses. The Social Drift hypothesis, on the other hand, explains how poverty plays a role in perpetuating and sustaining mental illness (Read, 2010).
The relationship between poverty and mental illness is intricate and multifaceted. It is probable that the causal mechanism operates bidirectionally for most mental disorders. According to Patel (2001), this bi-directional relationship between poverty and mental illness can be most effectively understood as a “vicious cycle” that impacts the lives of numerous individuals experiencing poverty and mental illness throughout their lifespan.
The Medicalization of Poverty
A Reassessment of the Vicious Cycle of Poverty and Mental Illness
When people living in poverty are asked about the lived realities of their experiences, it seems that some talk about despair, pain, being driven mad, and losing the desire to live. People are expressing immense distress in their living conditions. However, how useful is it to understand the distress they speak of as constituting something called a ‘mental illness’ or disorder? Is this distress pathological and in need of psychiatric and/or pharmacological treatments, or might we understand it as a ‘normal’ expression of sadness at living in a harsh environment? (Mills, 2015, p 213)
Mills (2015) critically examines the political aspects of the process of “psychiatrisation” in the context of a socioeconomic crisis such as poverty. The author emphasises the necessity for radical transformations within the field to understand the complex relationship between poverty and “distress”. While a significant portion of the available literature centres on the conceptual framework of the “vicious cycle of poverty and mental illness”, it mostly fails to adequately consider the socio-historical, socio-political, socio-economic, and socio-cultural factors that contribute to the development and perpetuation of poverty and mental illness.
The overemphasis of the medical model on individual-centric and psychopathology-oriented perspectives reduces the understanding of the mental health conditions of individuals living in poverty through disability and clinical lenses. The issue is perceived to be rooted in the individuals themselves, and the proposed resolution involves engaging in treatment and clinical case management within the framework of the medical model.
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In this context, our attention is often directed towards explanations and interventions at the level of individual responsibilities with prevailing “neoliberal trends” rather than critically examining the broader structural and systemic frameworks that generate and perpetuate poverty. It further assumes the universality of Western diagnostic categories and treatments. It fails to consider the social, cultural, and historical factors, as well as the potential for alleviating distress without resorting to “medical” interventions (Bracken et al., 2012; Mills, 2015; Morrow & Weisser, 2012; Summerfield, 2012)
The Danger of Pathologizing Poverty
Adopting an individualised and medicalised approach to poverty contributes to the further exclusion, alienation, and marginalisation of low-income individuals and communities (Schram, 2000, p. 98). Consequently, individuals experiencing poverty and those diagnosed with mental illness (or both) are often perceived as lacking competence and dependent on professionals who act in their best interests (Mills, 2015). Moreover, because of the medicalisation of poverty, numerous initiatives aimed at alleviating poverty have redirected their efforts towards addressing the “symptoms of mental illness” experienced by individuals living in poverty. This approach inadvertently contributes to normalising poverty by framing it within a medical context.
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The Need to Transcend the Medical Paradigm
By transcending the debate surrounding the causal relationship between poverty and illness, we can delve into the socio-politico-economic factors that influence the process of diagnosing diseases. This enables the examination of institutional racism, sexism, and patriarchy within the field of psychiatry (Metzl, 2009; Bullock, 2004) and whether historically marginalised populations might experience an increased likelihood of both living in poverty and being diagnosed with a mental disorder.
It further makes us question the “politics” of medicalising a socio-economical problem like poverty that paves the way for “medical” solutions through “pills and therapy”. Read (2010) rightly observed, “Much of the blame for this imbalance has been focussed on psychiatry’s inability or unwillingness to resist the increasingly pervasive influence of the pharmaceutical industry, which benefits from promulgating a simplistic, reductionist focus on biological causal factors.” (p., 9).
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The medicalisation of poverty creates confusion about cause and effect. While it is acknowledged that poverty can result in psychological distress, it is essential to recognise that solely addressing the “symptoms” of distress will not effectively address the underlying poverty that serves as its root cause. Furthermore, it is imperative to consider the sociopolitical-economic factors that contribute to creating and perpetuating poverty and socioeconomic marginalisation. Hence, medicalisation not only carries the potential to disregard the circumstances of deprivation, social inequality, and poverty that can contribute to psychological distress, but it also can sustain and exacerbate these conditions.
