An Overlooked Priority: Mental Health
Since May is National Mental Health Awareness Month, this post will discuss the incidence of mental health issues worldwide, focusing especially on mental distress among adolescents and female adults in low- and middle-income countries (LMICs)—two groups I focus my research on—the aggregate costs of mental distress, and the results of a study that has inspired some of my evaluations of psychology-based interventions for caregivers.
A worrisome state of affairs
In 2019, an estimated 970 million people in the world were living with a mental health disorder (of these, 301 million experienced anxiety disorders, and 280 million suffered from depressive disorders). Strikingly, 82% of these individuals were living in LMICs. After the COVID-19 pandemic hit in 2020, these numbers rose significantly: initial estimates show that major depressive and anxiety disorders increased by 28% and 26%, respectively, in just one year! There are important heterogeneities by geography: one in five people in post-conflict settings or affected by humanitarian crises have a mental health condition.
Notably, a greater increase in disorder prevalence occurred among females than among males, which could be due to the fact that females were more likely to be affected by the social and economic consequences of the pandemic. Globally a greater change in prevalence also occurred among younger age groups than among older ones, potentially reflecting the drastic impact that school closures and social restrictions had on the mental health of youth. As of 2022, approximately 20% of children and adolescents around the world had a mental health condition, and suicide was tragically the second leading cause of death among 15-29-year-olds.
Should economists care about mental health?
Unlike most physical conditions, mental disorders can directly affect a person’s cognitive function, preferences, and beliefs in ways that can potentially perpetuate poverty (Ridley et al., 2020). Studies have also shown that mental health conditions are associated with reduced productivity, higher rates of unemployment, and other economic impacts. In a recent study, the World Economic Forum indicated that, based on a broadly defined set of mental health conditions, mental health disorders could cost the world economy approximately US$ 6 trillion by 2030 (2022). (Note: These estimates do not attach monetized value to anyone outside of the paid workforce, including primary [mostly female] caregivers). And, LMICs were predicted to bear 35% of the cost of these conditions, which adds only more pressure to LMICs’ already fragile national budgets. Given these negative economic consequences of mental health, economists, researchers, and policymakers would do well to make this issue a priority.
A promising solution
Perinatal depression is a mental health disorder that has been receiving increased attention in recent years. The incidence of perinatal depression is about twice as high in LMICs, relative to high-income countries (HICs). Since depression can negatively affect decision-making and, consequently, have impacts not only on the mother but also on her children (e.g., through underinvestment), treating perinatal depression can, conversely, have long-term positive impacts by halting intergenerational transmission of poverty.
Baranov, Bhalotra, Biroli, and Maselko (2020) experimentally investigated the hypothesis above by conducting one of the largest psychotherapy trials in the world. Specifically, they studied how depression treatment affects decision-making by offering the low-cost (US$10/person) cognitive behavioral therapy (CBT) program Thinking Healthy to 903 women with perinatal depression (aged 16-45 years) in rural Pakistan. Community-based trained female health service providers (Lady Health Workers) delivered the intervention directly during the course of 16 home visits, which demonstrates that the program has the potential to be implemented at scale.
According to an early study, Thinking Healthy significantly reduced depression in mothers during their first year postpartum. Baranov and coauthors then used the variation in the assignment to treatment and control conditions to study if the reduction in postpartum depression in the short-term placed treated women on a better trajectory seven years later. After contacting 65% of the initial sample of women, Baranov et al. showed that the intervention reduced depression by 5 percentage points (13% of the first-year mark reduction) after seven years and that this reduction had a positive impact on women’s decision-making for themselves and their children. First, women in the treated group scored higher on the financial empowerment index, with improvements driven by greater control over household spending. Second, the program also increased mothers’ time- and money-intensive parental investments. For example, children of mothers in the intervention arm were more likely to attend better quality and private schools and to have more learning materials at home, all of which were measured objectively, compared to children of women in the control arm. Interestingly, the program also seemed to reduce the gender gap in parental investments; only the mothers of females (as opposed to males) had statistically significant and greater control over spending, which is likely why girls received higher parental investments.
With regard to the children, the authors found only small and imprecisely estimated effects on cognitive or socio-emotional development at age 7. The lack of results can be attributed to the fact that the returns to increased parental investments either appeared and then faded, will emerge at a later stage of the life cycle, or required larger sample sizes. Overall, more research is necessary to understand the indirect effects of a caregiver's mental health intervention on children.
What, then, explains these positive results of the Thinking Healthy intervention? After ruling out explanations such as improvements in the women’s physical health, their husbands’ income over time, or the participants’ marital relationship, the authors found that the intervention led to a sustained increase in perceived social support, a measure closely linked with mental health and taken into the recent context, an important factor missing from the lives of so many people who felt socially isolated through lockdowns and distancing during the worldwide pandemic.
Although the few existing studies that test interventions to address mental health show promising results, more evidence on how we can address mental health stigma and make mental health accessible for the most at-risk populations is still needed. Given the striking increase in mental health disorders in LMICs since the pandemic as well as their far-reaching effects, it also would behoove economists, researchers, and policymakers to prioritize this important issue.