Mental Health in a Time of Financial Cholera

The financial tsunami that has hit the United States and most of the rest of the globe is causing unparalleled misery for hundreds of millions. In America, millions of jobs have been lost, and it appears that millions more will be lost. In a nation where home ownership is a cherished expectation and goal, millions are losing their homes. The GNP is shrinking, the value of nearly all investments has plummeted, and the retirement plans of millions have been decimated.

The psychological impact of this economic catastrophe is incalculable. With shocking speed, a job lost can lead to a home lost, a family fractured, the dream of college abandoned, health care insurance lost, savings drained . . . the list goes on and on. Paralyzing fear, depression, loss of self-esteem, and physical illnesses for which there is no apparent cause are frequent. For members of the comfortable middle class who have never experienced such trouble, the assault may be especially damaging psychologically. Just consider the well-dressed, middle-class men and women we see on the evening news visiting food pantries or using food stamps at the supermarket. Many, stunned and bemused, say, “I never dreamed I would be doing this.” Equally vulnerable are the not-long-ago poor, who, having struggled to get out of poverty, suddenly find themselves plunged back into it-usually through no fault of their own.

Severe stress breeds mental health problems in vulnerable individuals, and psychiatrists and other health professionals are seeing the onslaught of such problems arising from the financial crisis.

“The economic crisis is dominating people’s psychological landscape,” says Richard Rubin, MD, who practices psychiatry in Guilford, Conn. “It’s causing nearly everyone to worry and to develop a chronic sense of unease and apprehension that’s permeating our society and country.”

Although there is little quantitative data that indicate a rise in need or demand for mental health services as a result of the financial crisis, there is growing anecdotal evidence attesting to this. Manual Mota-Castillo, MD, who has a private practice in Orange City, Fla, and is a psychiatric consultant to a local community hospital, reports that the number of calls to his office from people seeking help has doubled in recent months. But with an already full patient load, he is able to see very few of them.

According to Mota-Castillo, people with generalized anxiety disorder or obsessive-compulsive disorder are particularly vulnerable to the ubiquitous barrage of bad economic news. “These are people who suffer from anticipatory anxiety: they spend much of their lives playing “What if this or that bad thing happens to me? Now, it’s what if I lose my job or lose my house?” says Mota-Castillo. “Unfortunately, such fears may be justified, which only heightens anxiety and may undercut years of relative stability.”

Both Andres Pumariega, MD, chairman of the department of psychiatry at Reading Hospital and Medical Center in Pennsylvania and professor of psychiatry at Temple Univer­sity Medical School, and Rubin are concerned that the loss of patients’ financial security, combined with cuts in public funding for mental health services, could result in a significant decline in the number of patients who receive psychiatric treatment at a time when the need for it is growing.

In times of economic crisis, pub­lic services-including health ser­vices-are very likely to be re­duced. Many psychiatrists worry about possible cuts in Medicaid mental health programs and in school-based counseling programs for children. Indeed, in financially ravaged families, visits by children to mental health professionals may be sus­pended. Although the Obama administration’s stimulus package provides additional Medicaid money to the states, it is probable that pub­licly funded mental health services as well as those provided by nonprofit hospitals will be constricted.

Pumariega has seen a rise in decompensation and in inpatient care and emergency department use among the severely mentally ill population because of financially driven curtailments in the community-based services that support this population. He believes that because of the severe financial stresses experienced by psychologically vulnerable individuals-especially those without adequate support systems-more patients with a history of serious mental illness will experience a re­lapse. Pumariega believes that rates of clinically significant depression, anxiety disorders and, especially, sub­stance abuse disorders will rise. He also anticipates increasing comorbidity of mental health and substance abuse problems.

Men have been disproportionately affected by job loss in the current economic crisis, and this may have psychological complications for the male “breadwinner,” according to Mota-Castillo. Many unemployed men feel diminished, guilty, and emasculated because they are unable to fulfill the traditional role of supporting the family. The humiliation is intensified when, as is likely, the wife is then obliged to work or take a second job. This situation can give rise to other problems, such as depression, lethargy, rage, and alcohol abuse. Mounting tensions within the family may lead to spousal abuse and domestic violence. In addition, unemployment can inhibit a man’s ability to move on, accept the changes that have occurred, and search for another job or contemplate a new career.

Given the far-reaching nature of the financial crisis, patients with anxiety disorder are in a particularly difficult position. Events may impose drastic changes in their lives, yet the hallmarks of anxiety disorder-rigidity of thinking, difficulty in problem solving, and difficulty in planning for the future-can prevent them from adapting.

The drastic loss of income and savings is not just an accounting ab­straction. It is reflected in real deprivation in many things recently taken for granted-no shopping, no restaurant meals, curtailed vacations, and so forth. These things may not in themselves be very important, but their loss is certainly stressful and a constant reminder of what has happened. Pumariega is concerned that substance abuse (especially alcoholism), depression, and even suicide may occur in elderly patients who have lost much of their income and the status that goes along with a financially comfortable lifestyle. The elderly are generally less likely to seek psychiatric help. Indeed, for any age group, substance abuse can prompt suicidal ideation.

A possible increase in the incidence of suicide as a consequence of the financial crisis is also of major concern. There is a disturbing statistic from the National Suicide Pre­vention Lifeline: between 2007 and 2008, the number of hotline calls rose 38%, from slightly over 400,000 to slightly more than 550,000. Apart from reflecting heightened anxiety in the population, it is difficult to know what these numbers mean. Although they may foreshadow a significant rise in the number of serious suicide attempts and “successful” suicides, this may not be the case. A hotline call usually reflects uncertainty about a resolve to commit suicide; in some cases, the call is not even about suicide.

The psychiatrists with whom Psychiatric Times spoke anticipate that the number of suicides will increase as a result of layering the tensions and anxiety of the economic situation onto whatever underlying problems these individuals are experiencing. Nevertheless, suicide by mentally healthy persons who have been damaged financially and who may never fully recover what they have lost is unlikely.

For psychiatrists and other mental health professionals, the financial health of their patients is a big concern, because it may mean that patients can no longer afford treatment or are no longer insured for it. For these patients, there is virtually no alternative: free mental health clinics are already stretched to the limit.

As is doubtlessly true of most psychiatrists, those consulted by Psychiatric Times do what they can to relieve the financial burden of treatment for beleaguered patients. This includes reduced fees, extended payment schedules, forgiven copays, less frequent visits, brief therapy sessions conducted by phone, and placement (when possible) in free clinics. But such measures are often not enough, and the choices are limited. As one practitioner bluntly put it, “Although I may want to do so, I simply can’t afford to treat my patients for nothing.”

The very nature of the financial crisis-a huge, malignant, external force over which the people affected have little, if any, control-also presents mental health professionals with the enormous challenge of providing comfort and hope to pa­tients in an environment that seems to offer none. Medications and other treatments can help, but clinicians cannot undo the reality of lives turned upside down.

Mota-Castillo tries to get patients to put their situation, no matter how bad, into perspective. He tells them that they can’t give up. I say that “as long as you have energy, you have to keep swimming or you will drown.” He also reminds patients that they aren’t totally without help and that there are practical things they can do.

Pumariega says that clinicians must make patients aware of the practical options that are now available-consulting a credit counseling agency, negotiating new mortgage terms, using food banks and other community safety nets, etc-while emphasizing that there is no shame in using these resources.

For people who have never been in such a situation and never imagined that they could be, shame is a huge obstacle to dealing with this trauma and, indeed, makes it worse. Simply reminding people that they are not alone can be helpful: when bad things happen, there is strength in numbers. For some patients, meeting the challenge of job retraining and changing careers can become a component of psychotherapy.

Rubin agrees but admits that as a therapist, given the present situation, he often has a sense of impotence. “It’s hard to know what to tell people and how to support them when, for example, their incomes have shriveled,” he says. “Saying, in effect, ‘this too will pass,’ which may be comforting in other circumstances, isn’t appropriate here. There’s no end in sight, and no guarantee that their finances will ever rebound. The reality of what’s happening is so difficult that sometimes there is nothing I can say. The only comfort I can offer is empathy.”

On a slightly more hopeful grace note, Pumariega notes that he was struck by the fact that President Obama had said that responding to this crisis will require sacrifice from all Americans. “If Americans can come together in a spirit of common purpose and are willing to make sacrifices for the common good, I think this will be an important factor in reducing mental health problems,” says Pumariega.