Financial hardship, socio-economic position and depression: Results from the PATH Through Life Survey

Abstract

There is a strong association between financial hardship and the experience of depression. Previous longitudinal research differs in whether this association is viewed as a contemporaneous relationship between depression and hardship or whether hardship has a role in the maintenance of existing depression. In this study we investigate the association between depression and hardship over time and seek to resolve these contradictory perspectives. We also investigate the consistency of the association across the lifecourse. This study reports analysis of two waves of data from a large community survey conducted in the city of Canberra and the surrounding region in south-east Australia. The PATH Through Life Study used a narrow-cohort design, with 6715 respondents representing three birth cohorts (1975–1979; 1956–1960; and 1937–1941) assessed on the two measurement occasions (4 years apart). Depression was measured using the Goldberg Depression Scale and hardship assessed by items measuring aspects of deprivation due to lack of resources. A range of measures of socio-economic circumstance and demographic characteristics were included in logistic regression models to predict wave 2 depression. The results showed that current financial hardship was strongly and independently associated with depression, above the effects of other measures of socio-economic position and demographic characteristics. In contrast, the effect of prior financial difficulty was explained by baseline depression symptoms. There were no reliable cohort differences in the association between hardship and depression having controlled for socio-demographic characteristics. There was some evidence that current hardship was more strongly associated with depression for those who were not classified as depressed at baseline than for those identified with depression at baseline. The evidence of the contemporaneous association between hardship and depression suggests that addressing deprivation may be an effective strategy to moderate socio-economic inequalities in mental health.

Introduction

There is considerable evidence of a social gradient in the prevalence of common mental disorders including depression: lower socio-economic position is associated with increased risk (Fryers et al., 2003, Kessler and Cleary, 1980, Lewis et al., 1998, Lorant et al., 2003, Muntaner et al., 2004, Power et al., 2002, Rodgers, 1991, Skapinakis et al., 2006, Stansfeld et al., 2003, Weich and Lewis, 1998b, Weich and Lewis, 1998a, Whelan, 1994). The focus of this paper is on financial hardship. Measures of hardship or deprivation assess whether people are excluded from minimally accepted ways of life in society due to a lack of resources (Whelan, Layte, Maitre, & Nolan, 2001). In contrast to income or poverty measures which infer exclusion from a lack of resources, financial hardship directly assesses the extent to which individuals or households lack goods, facilities or services or are unable to engage in activities (Whelan, 1993). Financial hardship can focus on absolute need, with reference to food, shelter, clothing and medical care (Krieger et al., 1997, Mayer and Jencks, 1989, Mirowsky and Ross, 1999) or consider deprivation relative to social norms (Townsend, 1979, Whelan et al., 2001). Within the psychiatric literature, indicators of financial hardship have included access to a car, household overcrowding, ownership of household appliances, difficulty paying bills, difficulty purchasing food or clothing, having services/utilities disconnected, and structural housing problems (Lewis et al., 1998, Lorant et al., 2007, Mirowsky and Ross, 2001, Skapinakis et al., 2006, Weich and Lewis, 1998b, Weich and Lewis, 1998a, Whelan, 1993).

Across the different approaches to the measurement of financial hardship there is consistent evidence that hardship is associated with common mental disorders and psychological distress (Butterworth et al., 2004, Fryers et al., 2003, Lahelma et al., 2006, Lewis et al., 1998, Lorant et al., 2007, Mirowsky and Ross, 1999, Mirowsky and Ross, 2001, Pudrovska et al., 2005, Rodgers, 1991, Skapinakis et al., 2006, Weich and Lewis, 1998b, Whelan, 1993, Whelan, 1994). Hardship has been shown to be robustly and independently associated with depression, and to mediate the relationship between other measures of socio-economic position and depression (Kessler et al., 1987, Lewis et al., 1998, Mirowsky and Ross, 1999, Rodgers, 1991, Thomas et al., 2007, Weich and Lewis, 1998b). Difficulties satisfying the basic requirements of daily living because of limited financial resources, such as having problems paying bills, providing food and clothing, or having inadequate housing, may directly impact on mental health, being a source of ongoing worry and stress, causing feelings of demoralisation, entrapment and lack of control, limiting social and educational opportunities and leading to uncertainty about the future (e.g., Brown, 2002, Brown and Moran, 1997, Desjarlais et al., 1995, Kahn and Pearlin, 2006, Mirowsky and Ross, 1999, Mirowsky and Ross, 2001, Reading and Reynolds, 2001, Ross and Huber, 1985, WHO, 2001).

An important feature of hardship from a methodological perspective is that, unlike many other measures of social position that are relatively stable across the lifecourse, the experience of hardship may fluctuate. Thus, researchers studying hardship are able to evaluate the dynamic effect of changes in socio-economic circumstances over time and potentially differentiate social causation and social selection (Lorant et al., 2007, Skapinakis, 2007). Despite this, few studies have examined the relationship between hardship and depression over time (see Lorant et al., 2003), and most of the existing research has only analysed two waves of data. For example, Weich and Lewis (1998a) reported that baseline hardship (poverty index) was associated with the maintenance of common mental disorders across two measurement occasions (12 months apart), but not with the onset of disorder for those respondents without disorder at baseline. In analysis of the British Psychiatric Morbidity Survey (with follow-up at 18 months), Skapinakis et al. (2006) found that baseline hardship (financial difficulty) was not associated with the onset or maintenance of “any common mental disorder” at wave 2 after controlling for baseline psychiatric symptoms. However analysis restricted to major depression found that baseline hardship was significantly associated with both onset and maintenance (though the maintenance effect was much stronger). A limitation of these two studies, however, is that while they did assess mental health/depression at two points in time, there was no consideration of change in hardship. Rather, they considered the association between hardship at wave 1 and subsequent mental health. Nonetheless, a meta-analysis by Lorant et al. (2003) reached the same conclusion: that socio-economic status generally has a greater effect on depression maintenance than onset.

A different conclusion has been reached by studies using other analytic approaches. Mirowsky and Ross (2001) also analysed data from two time points, but considered hardship at both measurement occasions. They found that persistent hardship (evident in both waves) or recent hardship (only at wave 2) was associated with depression at wave 2 after controlling for depression scores at wave 1 (approximately three years earlier) but that resolved hardship (only at wave 1) was not. Lorant et al. (2007) analysed eight waves of the Belgian Households Panel Survey using fixed-effect models and showed that an increase in hardship (deprivation in their terminology) was associated with increased risk of depression. Importantly, Lorant et al. found no significant independent effect of lagged (previous) depression. The findings of these later two studies suggest that hardship has an impact on current mental health, that prior hardship is not associated with depression above the effect of current hardship (Lorant et al., 2007), and that the effect of hardship lessens with time (i.e., resolved hardship: Mirowsky & Ross, 2001). The somewhat contradictory findings about hardship being associated with either the maintenance or the contemporaneous experience of depression may simply be a consequence of the different analytic approaches used across studies. Therefore, the major goal of the current study is to examine the relationship between hardship and depression using two waves of data and contrast these different analytic models.

Another topic on which there is mixed evidence in the literature concerns the association between hardship and depression across the lifecourse. Mirowsky and Ross (2001) reported that the relationship between hardship and depression differed across age, and that the association was weaker for older respondents. However, other researchers (e.g., Weich & Lewis, 1998b) have found a consistent effect of hardship across age. A secondary aim of this study, therefore, is to evaluate whether the association between hardship and depression differs across the lifecourse.

In summary, the purpose of this paper is to use data from a large community survey and the methods used in previous research to resolve somewhat anomalous findings in the existing literature about the nature of the association between financial hardship and depression. The specific aims are to i) contrast the contemporaneous association between hardship and depression and the role of prior hardship in the maintenance of depression after controlling for covariates and other measures of social position; and ii) assess the consistency of the relationship between hardship and depression across three birth cohorts.