Poverty and Mental Health – Let’s Talk About It

Janette, aged 46, attends for a medication review. Her records show a diagnosis of chronic low back pain and mixed anxiety and depressive disorder. She’s been taking analgesics and sertraline for over a year with little improvement. What’s the next step? Increase the dose of sertraline? Switch to another antidepressant? Refer her for more physiotherapy? Or should we dig a little deeper?

A social history reveals Janette works part-time as an events coordinator and is the primary carer for her elderly mother who has dementia. While her situation involves multiple potential contributory factors to depression including chronic pain, a key issue often overlooked is poverty. Defined by the Joseph Rowntree Foundation as having “resources well below minimum needs,” poverty has a significant and bidirectional relationship with both mental and physical health. Those in the lowest income brackets are twice as likely to develop mental health problems compared to those with average incomes and 86% of people with mental health challenges report that financial struggles worsen their condition (PHE, 2019). Yet, despite its clear impact on health, poverty is rarely discussed in consultations.

 A recent BJGP Open study examined communication about poverty and mental distress in primary care. It found that clinicians often lacked confidence in discussing socio-economic issues. Patients rarely disclosed financial difficulties unless explicitly asked, and clinicians worried that asking these questions may offend patients. However, the research showed that sensitively asking about poverty-related stressors improved understanding of patients’ mental distress, reduced inappropriate antidepressant prescribing and helped patients to access more coordinated and appropriate support from practice teams.

Why can it be hard to talk about poverty and mental health? In research from MIND 2021 people discussed the barrier of stigma, on both an individual and societal level. There was a view that although talking about mental health is ‘easier’ than in the past, this did not extend to mental health symptoms related to poverty and the ‘spiral of adversity’ between the two. In other words: ‘it’s ok not to be ok, but it’s not ok to be poor’. 

So, returning to Janette you decide to broaden the discussion beyond her medication and you sensitively ask if she is struggling financially. She appears relieved to discuss it and shares with you that she relies on food banks, struggles to heat her home and constantly worries about rent. She has stopped socialising as she cannot afford to go out and has become very isolated. She says that she’s never discussed this with a health professional before because she didn’t think they could help. You listen, acknowledge, and together explore options. You agree a referral to the social prescribing team for holistic support with finances, social isolation and mental health. In the interim you signpost to the money and mental health resources from MIND.

The key takeaway here is the potential power of primary care’s holistic approach with the patient at the centre and thinking beyond the traditional medical model. With expanding multidisciplinary teams we now have more options for supporting patients. There is also evidence that even where we cannot offer practical support, ‘feeling heard’ will still make a real difference to patients, meaning that we should not shy away from asking difficult but questions for fear of not having the solution (BJGP Open).

This case and research remind us to step back, reassess and explore potential underlying root causes of mental distress such as financial hardship, because sometimes asking the difficult questions is the most powerful intervention that we can offer.