Please Stop Making Reductive Claims About Economic Hardship and Mental Health
it doesn't help poor people and it doesn't help the mentally ill
Every social network has its cliches and commonplaces, and on Substack Notes, this is one of the most prominent:
55,000 likes is about as viral as it gets, for a Substack Note. (Also, UNPOPULAR OPINION followed by what might be the most likes in the history of the network… lol.) I’m afraid that, despite all this adulation, this note and the many like it are deeply irresponsible and helps neither the poor nor the mentally ill. The claim that there’s a strong association between rates of poverty, inequality, or economic instability and mental illness is far less certain than this attitude would make it seem. In order to be fair, and to not attack a strawman, I’ll restrict myself today to anxiety and depression, which are the conditions most often cited as being driven by economic insecurity. So I won’t demonstrate that schizophrenia is a disease that afflicts people of all income levels, for example. (Yes, there’s an association between schizophrenia and poverty, but then schizophrenia has a way of causing poverty.) Even so restricted, I’ll demonstrate that richer countries are often more depressed countries, that anxiety often grows as poverty and inequality improve, and that in general, the simplistic claims of the type expressed in this Note are not empirically defensible. Mental health is just much, much more complicated than that.
And to be clear, that argument (that as economic insecurity rises, so do depression and anxiety) is seductive and politically convenient, if you have my politics; it provides more justification for what I already want society to do. Let’s get some redistribution going! More progressive tax rates, more redistribution, fewer billionaires. That all sounds great to me. Fix inequality and you’ll fix the mental health crisis.
Or is it the other way around? Do rising rates of mental illness drive up poverty rates, instead of the other way around? Maybe all the crazies are making us poor. I know that sounds glib, but then this is the problem with “X went up and Y went up, therefore X caused Y”: that is always an equally-strong argument that Y caused X. You can insist that common sense tells us which direction causation must go, and I would agree with you. My point is that this sort of thing is profoundly lacking in rigor, in care, and these are issues that we should be achingly careful about. Of course this narrative has become something close to orthodoxy in progressive public health discourse, repeated in op-eds, policy papers, and social media with the confidence of established fact. But then, that’s when skepticism is most important, when we’re facing the seduction of an oversimplified version of the truth that reinforces our priors. I’m afraid that, as an account of mental illness - its origins, its distribution, its history - this claim is at best a dangerous oversimplification. At worst, it actively impedes progress on both fronts: the effort to combat poverty and inequality and the effort to treat, heal, and cure mental illness.
Let me be tediously clear about what I’m saying and not saying. Economic stress, precarity, housing instability, childhood poverty, social marginalization… these are of course genuine contributors to psychic suffering. The empirical evidence for this is real and should not be dismissed, and of course personal experience tells us the same thing. People who are under chronic material strain, on average, suffer more than those who aren’t; many of the specific stressors that make life so much harder can be addressed with money. And of course we should endeavor to eliminate poverty, in this era of abundance, because poverty is painful and difficult even if it doesn’t result in psychiatric disorders as conventionally defined. I’m on board. But part of what drives me crazy about this narrative is the way that it leads to a slippage between mental health defined very broadly (in terms of mood or mentality or stress level) and mental health as in referring to medical conditions that need to be discussed specifically and with diagnostic care. This is precisely the least helpful way to discuss mental illness, by blurring the boundary between bad feelings and pathological disorders of the brain and mind. Perhaps my many years of fighting against antipsychiatry cultists have left me triggered, I don’t know. But we don’t need that kind of imprecision.
The claim that socioeconomic conditions are the primary cause of mental illness, or that rising rates of depression and anxiety are chiefly explained by economic hardship, runs into serious, well-documented empirical trouble. The story of human mental illness, psychiatric anguish, and emotional suffering is far older, far stranger, and far more biologically rooted than this narrative allows.