determinants of health: income inequality and mental health 8/28/20141 e. jane costello william e....

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Determinants of Health: Income Inequality and Mental Health

8/28/2014

E. Jane CostelloWilliam E. Copeland

Adrian Angold

Center for Developmental EpidemiologyDuke University

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Poverty is not good for children’s present or future mental health.

• Is this true?• If so, Why?

Reduced access to treatmentReduced access to material resourcesPoor children have worse parenting

Does poverty cause problems or do problems cause poverty? (social causation vs. social selection)

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Poverty is not good for children’s present or future mental health.

3-month prevalence of one or more DSM-IV psychiatric disorders in poor/non-poor* children (poverty= low SES)

2 out of 3 of 1)Household is below the federal poverty line; 2) low parental occupational level; 3) parental education less than highschool graduation

10 11 12 13 14 15 160

5

10

15

20

25

30

No poverty Linear (No poverty )Poverty Linear (Poverty)

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Poverty is not good for children’s present or future mental health.

3-month prevalence of one or more DSM-IV psychiatric disorders in poor/non-poor* children (poverty= material hardship)

*Material hardship: No health insurance, Poor financial coverage, Residential instability, No health or MH insurance

10 11 12 13 14 15 160

5

10

15

20

25

30

35

No poverty Linear (No poverty )Poverty Linear (Poverty)

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• Poverty is not good for children’s present or future mental health. Why not? Reduced access to treatmentReduced access to resourcesPoor children have worse parenting

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Reasons: 1. Reduced access to treatment?3-month use of specialty mental health services by poor/non-poor* children with one or more

DSM-IV psychiatric disorders in(poverty= material hardship)*Material hardship: No health insurance, Poor financial coverage, Residential instability, No health or MH insurance

10 11 12 13 14 15 160

5

10

15

20

25

30

35

No poverty Linear (No poverty )Poverty Linear (Poverty)

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Children living in poverty had GREATER access To specialty mental health care than non-poor children

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Reduced access to treatment?

• Poor children had better access to services than non-poor children with a psychiatric disorder.

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Reasons: 1. Reduced access to treatment?3-month use of specialty mental health services by children with one or more DSM-IV

psychiatric disorders by type of insurance

10 11 12 13 14 15 160

10

20

30

40

50

60

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Reduced access to treatment?

• Adolescents with public insurance (Medicaid, SCHIP, IHS) had better access to specialty MH care than adolescents with private insurance

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• Poverty is not good for children’s present or future mental health. Why not? Reduced access to treatmentReduced access to resourcesPoor children have worse parenting

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Impact of material hardship and poverty on rates of psychiatric disorder, age 9-16

Parental education low Parental occupational status low

Parent unemployed0

5

10

15

20

25

30

35

Non-poor, no hardship Non-poor, hardshipPoor, no hardship Poor, hardship

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Impact of material hardship and poverty on rates of psychiatric disorder, age 9-16

Poverty has a greater impact than specific types of material hardship at this age

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• Poverty is not good for children’s present or future mental health. Why not? Reduced access to treatmentReduced access to resourcesPoor children have worse parenting

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Poor children have worse parenting% with one or more DSM-IV psychiatric disorders in children with varying degrees of family stressors, (poverty= material hardship)

*Material hardship: No health insurance, Poor financial coverage, Residential instability, No health or MH insurance

0 1 2 3 4 5 60

10

20

30

40

50

60

No poverty Linear (No poverty )Poverty Linear (Poverty)

Poverty interacts with family stressors to increase the risk of mental illness in children(poverty-by-family stress β=2.0, Z=2.3, p=.0222)

N. Of familystressors

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Poor children have worse parenting

• Interaction: the worse the parenting the more at risk poor children are relative to non-poor children

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Can changing family resources change children’s mental health?

• Hard to be sure because of the chicken and egg problem:– Does poverty cause child mental illness or does

children’s mental illness cause poverty?

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4/25/2012 17

Number of Cherokee families that moved out of poverty, 1996-2000

• Ex-poor: 14.4% • Persistently poor: 53.2% • Never poor: 32.4%

4/25/2012 18

Impact of casino opening on children’s behavioral symptoms; American Indians

1

1.5

2

2.5

3

3.5

4

Before (1993-1996)

After (1997-2000)

Mea

n N

of

psy

chia

tric

sym

pto

ms

ove

r 4

year

s

Never Poor Ex-Poor Persistently Poor4/25/2012 19

Impact of increased income on children’s psychiatric symptoms; Anglo and Indian children

1

2

3

4

5

6

7

8

Before (1993-1996)

After (1997-2000)

Mea

n N

of

psy

chia

tric

sym

pto

ms

ove

r 4

year

s

Anglo: Never Poor

Anglo: Ex-poor

Anglo: Persistently poor

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Impact of increased income on children’s psychiatric symptoms; Anglo and Indian children

1

2

3

4

5

6

7

8

Before (1993-1996)

After (1997-2000)

Mea

n N

of

psy

chia

tric

sym

pto

ms

ove

r 4

year

s

Anglo: Never Poor

Indian: Never Poor

Anglo: Ex-poor

Indian: Ex-poor

Anglo: Persistently poor

Indian: Persistently poor

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4/25/2012 22

Categories Reduction in: Marginal Effects

Recalculated

Annual Cost Associated with Row Activities

in 2013 $:

Marginal Effects x

Annual Costs for Rows with Education:

Marginal Effects x Annual Costs for Rows without Education:

1. Education Not Completing 12th Grade on Time

Costs associated with repeating a grade.

-0.156> 7717^ -1203.85

2. Substance Abuse Substance Use Disorder at Age 19

Societal Cost -0.156$ 4373# -682.19 -682.19

3. Psychological / Behavioral Any Psychiatric Diagnosis Costs for treatment -0.168̀ ` 4712@ -791.62 -791.62 Behavioral Symptoms Costs for treatment -0.0509 Emotional Symptoms Costs for treatment -0.102 4. Criminal Larceny- Shoplifting Victimization costs -0.179>> 642++ -114.92 -114.92 Incarceration Juvenile Justice

Costs -0.179$$ 4278̂ ̂ -765.76 -765.76

Moderate Crime - Burglary Societal costs -0.002 Severe Crime - Assault/Robbery Societal costs 0.002 5. Physical Health Obesity Health Care Costs -0.024\\\

Total Societal and Individual Costs:

-3558.34 -2354.48

Estimation of Reduction in Total Societal and Individual Costs by Categories per Individual

4/25/2012 23

1 2 3 4 5 6 7 8 9 100

5000

10000

15000

20000

25000

30000

Costs and Benefits to 4 Year Income Supplement Program to Households with Adolescents

Benefit with EduCostBenefit without Edu

Years after Program Ends (19+)

Dolla

rs in

201

3

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Take-home message

• Universal (primary) prevention gets over the access-to-care barrier

• Universal prevention avoids “labeling”• Reducing poverty has a long-term effect on

children’s mental health problems• A universal intervention can have effects

beyond the targeted area

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Thank you