According to research, psychological treatments for depression and anxiety are less effective for people living in poverty. For example, studies have found that people who are unemployed and who have a low income are less likely to recover from mental health problems after treatment. Furthermore, even after considering the influence of employment and other individual factors, it seems that living in a poor neighbourhood also adversely impacts on people's psychological treatment outcomes.
In order to maximise the effectiveness of psychological treatments, we need to better understand the influence of neighbourhood poverty.
Poverty can be measured in many different ways. A lot of research on neighbourhood poverty has used a National scale called the Index of Multiple Deprivation (IMD). The IMD combines 7 scores measuring different aspects of neighbourhood poverty: Income, (Un)employment, Health and Disability, Education Skills & Training, Housing & Services, Living Environment, and Crime.
Our project aimed to find out specifically which of these aspects of patients’ neighbourhoods were associated with psychological treatment outcomes. The project was completed by researchers at the University of Sheffield, using anonymised routine clinical data from the Improving Access to Psychological Therapies (IAPT) Practice Research Network.
Anonymous data from 44,805 patients accessing psychological treatment in IAPT services in the North of England were analysed. Our outcomes of interest included patients' depression scores (using the PHQ-9), and anxiety scores (using the GAD-7) at the end of psychological treatment. These measures are used routinely in IAPT services.
After taking into account patients' characteristics such as their initial levels of depression and their employment status, we found that people living in neighbourhoods with lower average income and higher crime rates tended to benefit less from psychological treatment compared to patients living in more affluent and safer neighbourhoods.
Neighbourhood levels of employment, health, education, housing and living environments didn't significantly influence treatment effectiveness.
These findings help us to narrow down the focus of future research, to help us understand how to improve care for people in these neighbourhoods. They also add to the evidence suggesting that there are inequalities in the effectiveness of psychological treatment.
Further research is needed to find out how neighbourhood income and crime are related to treatment outcomes. Current theories suggest that people living in poorer neighbourhoods are deprived of resources and health-enhancing goods, which can lead to a state of demoralisation and stress related to material deprivation and associated social problems (e.g. debt, hunger, precarious employment, discrimination, etc). People living in high crime neighbourhoods are also likely to feel more anxious and less safe, despite the efforts of psychological treatment. Other theorists argue that, even when their basic needs are met, some people living in poor neighbourhoods might negatively compare themselves with others who live in more privileged circumstances, increasing their stress and reducing their sense of control or self-worth.
Our findings also suggested that people living in poorer neighbourhoods can nevertheless benefit from psychological therapy, but tend to require longer and more intensive treatments to attain relief of depression and anxiety symptoms.
Next steps might include considering how to plan or adapt psychological services in order to make them more effective and sensitive to the needs of people living in socioeconomically deprived neighbourhoods.
If you would like more information about this research, you can view the published paper or contact Dr Nick Firth at the Psychotherapy Evaluation and Research Lab @ Sheffield (PEARLS) on firstname.lastname@example.org.
Nick Firth, Jaime Delgadillo and Megan Finegan