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People who are unemployed or who live in insecure housing (staying with friends, in hostels, or homeless) respond less well to treatment for depression than others. Research found that people in unfavourable social circumstances were more likely to have poor treatment outcomes than those in secure employment or homeowners. This applied regardless of the type of treatment, whether medicines (antidepressants), talking therapy or structured exercise.

The review pooled data from 9 studies, including 4,864 people who had been treated for depression at GP practices in the UK. It found that, 3 to 4 months after starting treatment, people who were unemployed had substantially higher scores of depression symptoms than those who were employed. At the same time point, those in insecure housing had more symptoms than homeowners. This was after the severity and duration of depression, and other important factors, had been taken into account.

Unemployment and insecure housing had as much impact on treatment success as the severity of depression, the researchers say. Financial difficulty and educational level did not have this effect.

The findings imply that interventions to help people find employment or stable housing could improve their recovery from depression. Healthcare professionals could assess people’s social circumstances before starting their treatment for depression, the researchers suggest. This information could inform how someone’s depression is managed and treated.

What’s the issue?

Between 2 and 4 million adults in the UK have depression. Many treatments are effective, but 1 in 2 people do not recover with the first treatment they receive. This can prompt them to disengage from services and increase the chance of poor long-term outcomes.

The more severe and long-term the depression is, the harder it is to treat. Anxiety, marital status, social support, and other factors, also have an impact on people’s recovery.

People whose social circumstances (income, housing or education, for example) are less favourable are more likely to develop mental health problems like depression. However, before this study, it was not known how these circumstances affect people’s response to treatment. It was also not known whether the type of treatment offered (medicines or talking therapies) made a difference.

The researchers wanted to learn more about the impact of these socioeconomic factors on people’s recovery from depression. Understanding this link could help health and care professionals tailor the support and treatment they offer.

What’s new?

This review included data from 9 high-quality studies. In all, they included 4,864 people who had been treated for depression at GP practices in the UK. Treatment was with medicines, talking therapies and/or structured exercise. Participants were 42 years old on average, and more than half (67%) were women.

Each individuals’ recovery was assessed 3 to 4 months after treatment started. The researchers considered 4 socioeconomic factors: employment status, housing, financial wellbeing and education. They adjusted results for other factors that might influence recovery (depression severity and duration, anxiety, age, sex, and marital status).

The study found that, 3 to 4 months after treatment started:

  • people who were unemployed had worse treatment outcomes than people in employment (depression symptom scores were 28% higher)
  • people living with family or friends, in hostels, or homeless had worse treatment outcomes than homeowners (depression symptom scores were 18% higher)
  • people who were struggling financially and had no qualification beyond school appeared to have a poorer recovery, but the link was less strong when other factors were taken into account.

Employment and secure housing on recovery from depression continued to have an effect. The researchers saw similar patterns 6 to 8 months, and 9 to 12 months, after treatment.

Why is this important?

The authors believe this is the first review to consider the link between socioeconomic factors and recovery from depression across different types of treatment.

The study found poorer outcomes after treatment for depression among people who are unemployed, struggling financially, not homeowners, and have educational qualifications beyond school. The research concluded that housing and employment status are likely to have a clinically meaningful effect on recovery, independent of the severity of depression, age, marital status or other factors.

These findings can help tailor treatment for depression. In the initial assessment, GPs and other clinicians could ask people with depression about their employment status and housing. GPs might consider increasing the number of appointments offered, or the intensity or duration of treatment. Signposting to other local services able to support people with housing and employment issues, could help.

Interventions to help people secure stable housing or employment have been shown to improve symptoms of depression and quality of life. This research suggests that, for people with these difficulties, practical support may be as effective as standard treatments for depression. People who receive this support may be more able to engage with treatments, and may benefit more quickly.

What’s next?

Future research is needed to explore what types of support would best help people at risk of poor recovery. Studies could investigate the optimal order in which to offer help. It may be that medicines or therapy are more effective for people with unfavourable social circumstances, once they have received help with employment or housing, for example. In addition, this group of people might routinely need more intensive treatment strategies, and more regular reviews to adjust their treatment plan according to their progress. They may need a longer follow-up period.

This research did not include people with bipolar depression, other psychotic or personality disorders, neurological conditions, or children under age 16. In addition, some communities were not well represented, for example, people who are homeless or from marginalised backgrounds. Further research in all of these groups is needed.

The findings are relevant at a public health level. They may encourage government and local authorities to increase their efforts to tackle socioeconomic inequalities.

You may be interested to read

This NIHR Alert is based on: Joshua E. J. Buckman, and others. Socioeconomic Indicators of Treatment Prognosis for Adults With Depression: A Systematic Review and Individual Patient Data Meta-analysis. JAMA Psychiatry 2022;79:5

An overview of how socioeconomic factors are associated with mental ill health: Marmot M, Bell R. Fair society, healthy lives (Full report). Public Health 2012;126:S4-S10

Why socioeconomic disadvantage might make treatment less effective: Ridley M, and others. Poverty, depression, and anxiety: Causal evidence and mechanisms. Science (80- ) 2020;370:6522

Emerging evidence to support housing interventions:  Aubry T, Tsemberis S, and others. One-year outcomes of a randomized controlled trial of housing first with act in five Canadian cities. Psychiatric Services 2015;66:5

Emerging evidence to support employment interventions: Bejerholm U, and others. Supported employment adapted for people with affective disorders—A randomized controlled trial. Journal of Affective Disorders 2017;207:212-220

Funding: This research was supported by the NIHR UCL Biomedical Research Centre.

Conflicts of Interest: None declared.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.


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Comments

Study author

“Previously, many clinicians believed treatment outcomes for depression were simply due to severity of symptoms. This study provides evidence that unemployed people have considerably worse outcomes compared to employed people, independent of the severity of their symptoms or which treatment they received.

We also showed that housing status matters. Homeowners had considerably fewer symptoms following treatment than those who were living in hostels, with family and friends, or who were homeless.

We always believed employment status was important, but we didn’t expect it to be of a similar magnitude to severity of symptoms. We were also surprised that educational attainment and financial wellbeing had less impact on the outcomes.

This study suggests that it’s almost as important to support people with employment and housing issues, as it is to provide treatment for their depression, if there’s any hope of them getting better from their depression”

Joshua Buckman, Lecturer in Clinical Psychology and Clinical Director of the UCL University Clinic and Clinical Psychologist, Camden and Islington NHS Foundation Trust

Mind

“We know that social and economic factors affect our mental health, and this study demonstrates just how harmful or beneficial to recovery various factors, such as someone’s housing situation, can be. We’ve long recommended a holistic approach to recovery, and this is increasingly important as the nation has to deal with the financial and psychological toll of the cost-of-living crisis.

While being able to buy a home and being in employment can be good for our mental health, they are not miracle cures and there are many financial and societal barriers to accessing both. Forcing someone into unsuitable or poor quality housing or employment could actually be detrimental to their recovery.

The study also highlights why it is important that mental health is considered when Government creates policy in areas such as employment and housing. This is why we believe it’s essential whoever becomes the next Prime Minister urgently commits to implementing the long-awaited 10 year mental health plan, to make sure that mental health is at the heart of a wide range of policy areas.”

Vicki Nash, Head of Policy, Campaigns and Public Affairs, Mind

Psychologist with lived experience

“I received a diagnosis of major depression as a young adult. After a time, I went on to complete my PhD on the psychological and social aspects of depression.

I have attended a range of therapies over many years because I was not ‘cured’. The most important things I have found, after basic survival needs like a roof over my head, has been social connection, meaning, purpose, and everyday kindness. Medication has often given me short-term relief but hasn’t felt like a long-term solution.

I would like GPs to take a more holistic approach and ask (sensitively) about employment, housing, and any money worries. Someone could make a list of resources such as good debt advice charities and places offering support and advice. The list would have to be kept up to date so that GPs could signpost appropriate help when it’s needed.’’

Sue Holttum, Senior Lecturer in Applied Psychology, Canterbury Christ Church University

Social Prescribing Network

“This interesting and much-needed approach demonstrates the health impact of determinants of health in the context of depression.  Anxiety, depression and low moods are some of the most common concerns raised by people using social prescribing services. And much of the success of social prescribing services is associated with supporting the determinants of health explored in this research (financial issues, debt, housing and unemployment).

Central to the effect of social prescribing is the experience of being able to explain the full situation that is causing the depression. This explanation needs to be received with compassion by a social prescribing link worker so that a person can be supported appropriately. This is known to improve their wellbeing, their mood and in some cases reduce the need for prescription medication.

The results of this study, therefore, provide more understanding as to why social prescribing is beneficial. It further highlights the value of clinicians giving equal weight to considering a social prescribing referral for people with depression, as they do to prescribing depression medication.”

Marie Polley, Co-Chair, Social Prescribing Network

Lived experience

“I have relevant lived experience, and I campaign for more support for people with mental health conditions. I could relate to the results and conclusion of the research. I hope there will be more tailored support for people, if they wish to disclose their employment and housing status at the point of seeking help for depression.

This research adds more evidence to the link between socioeconomic status and outcomes of treatment for mental health. The link has long been suspected. I hope it leads to more national and local consultations to capture the voices of those most affected.”

Stuart, North East England 

Mental Health Foundation

“This is a timely and important reminder that biomedical interventions do not act in isolation from people’s day to day lives. It is a thorough and well-constructed piece of research that adds to the growing evidence base for interventions that address the socio-economic factors contributing to an increased risk of poor mental health, the likelihood of mental ill-health, and that hinder recovery.

We welcome this research and hope that it encourages policy makers and service providers to work in a more integrated and less siloed way that will provide benefits to more individuals, their friends and families, and broader communities. It is becoming ever clearer that we can only provide effective and sustainable mental health services by tackling social inequality alongside direct mental health support.”

David Crepaz-Keay, Head of Applied Learning, Mental Health Foundation

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