By Elise Craig
California Health Report
Judith Baer is worried about how poor people, especially poor mothers, are labeled with diagnoses of mental health problems. Once a teenage mother, today she is a professor who understands the anxiety that comes with poverty— and she wants the diagnostic manual to reflect that kind of understanding, too.
“I was one of those people we study,” says Baer, an associate professor of social work at Rutgers University and an adjunct professor of psychiatry at New York University’s School of Medicine.
When Baer was growing up in Texas, her first couple of decades were fraught with challenges. Her father left her mother when she was only 3, and Baer never saw him again. At 19, she gave birth to her first child, a son. Eleven months later, she had her daughter. By age 22, she was a single mother with two toddlers, no money—and a passionate desire to get to college.
She graduated from the University of Houston, funding her education by working at a psychological institute called the Jung Center, pulling her kids around in a red wagon while she worked a paper route as a side job, and finding subsidized child care. Eventually she earned her Ph.D., also from UH.
Baer’s memory of that experience—balancing her kids, her jobs and her schoolwork, and desperately trying to make something of herself—has driven her to research risk and resiliency, and the factors that help people to overcome long odds like the ones she faced. It’s also led her to question how we define mental illnesses like anxiety disorder among the poor.
“We ate cereal two meals every day,” she says. “I used to look at people drinking a Coca-Cola and I would want one so bad, but didn’t have the money. Anxiety and distress about survival was an everyday phenomenon. Any life event beyond the ordinary, such as an ill child, was overwhelming.
Anxiety isn’t always necessarily mental illness. Sometimes it is a normal reaction to life’s challenges, such as the level of poverty Baer experienced.
In the 1960s, Baer and her children were living on $300 a month. Making the money stretch to cover their needs was no easy feat. She was stressed. But she wasn’t mentally ill. “The last thing I needed, on top of everything else, was to be called disordered,” she says. “I was very anxious—yes, but not disordered.”
Recently, Baer and colleagues at the Rutgers School of Social Work examined the relationship between poverty and generalized anxiety disorder (GAD), a psychological disorder characterized by “excessive anxiety and worry” that lasts for at least six months. According to the Diagnostic Statistical Manual of Mental Disorders IV (DSM), a set of diagnostic criteria published by the American Psychiatric Association, symptoms of the disorder cause “clinically significant distress or impairment in social, occupational or other important areas of functioning.”
But the symptoms associated with the disorder could also be caused by normal reactions to the stressors of life. Failing to account for factors like significant financial stress may lead to the overdiagnosis of the disorder in the low-income population. Environmental and social conditions are often overlooked, Baer and her co-authors wrote in the August 2012 “Child and Adolescent Social Work Journal.”
She worries that other young mothers now in her shoes might be diagnosed with a disorder, when their anxiety could really stem from a very natural reaction to financial stress. “I’m concerned about this disease narrative,” Baer says. “If as a poor woman, you are concerned about feeding your children or getting a job or all those things embodied in that situation, and you’re told have a disease, how is that helpful?”
The lowest-income mothers have a greater chance of reporting symptoms associated with the disorder, Baer and her co-authors found. Mothers who were the recipients of free food, for instance, were 2.5 times as likely to exhibit symptoms of general anxiety disorder as outlined by the DSM, while mothers who had problems paying utilities were 2.44 times as likely, and those who had to move in with others were 1.9 times as likely.
Ignoring those factors could have serious consequences be- yond the misdiagnosis of a single patient, says Kim Jaffee, an associate professor who coordinates the master’s in social work program at Wayne State University. “What particularly concerns me is that this overdiagnosis of GAD, without adequately assessing the social environmental factors, contributes to the racial and ethnic disparities in mental health.”
“People with mental illness are overrepresented in high-poverty neighborhoods,” she says, “where a disproportionate share of minorities live.” The environmental factors in those areas lead to social conditions that “exacerbate the impact of personal vulnerabilities.”
For Baer, fighting for changes in the next version of the DSM, which will come out in May of next year, is a necessity.
The loose definitions presented in the DSM, Baer and her co-authors say, have led to a widening of symptoms that can classify a disorder. One of their biggest concerns was a change between editions of the DSM, which is updated whenever enough new re- search has come out to merit a revision. Diagnostic criteria for GAD once included an evaluation of external factors like the social and financial context of the symptoms, but that piece of the entry was omitted in 1995.
Mark Olfson, a professor of psychiatry at Columbia University Medical Center who directs studies on mental health care in community settings, points out that the study has some flaws. It did not screen for one of the main criteria for making a GAD diagnosis: that the anxiety “causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.” He does, however, agree with the authors’ conclusion that socioeconomic context is important in diagnoses.
Understanding the causes of anxiety is key, Baer says. If clinicians diagnose patients based solely on symptoms and ignore context, they run the risk of diagnosing a false positive. Also, mental health professionals who understand the causes of anxiety can create treatment plans that focus on practicality, self- empowerment and resiliency—helpful tools for low-income patients.
“For something to be a mental disorder, it needs to cause distress, but there also needs to be some breakdown of an internal mechanism that’s not functioning,” Baer says. “That’s a true disorder. We don’t know true disorder from the vicissitudes of life.”
Treating the Whole Person
At the Woman’s Clinic and Family Counseling Center in Los Angeles, the therapists not only focus on patients’ mental health issues such as symptoms of depression and anxiety, but also try to understand and treat their problems in the larger context of their lives. Although clients seek treatment for an array of issues, from anxiety and depression to abuse and addiction, monetary problems are a consistent concern.
“Financial pressures are bigger than ever,” says Carla Becker, director of counseling at the center and a private clinician. She started at the clinic in 1997 and now supervises the 25 volunteer therapists who work at the center.
Some patients who come into the clinic can clearly attribute their anxiety to occupational or economic stressors, says Jennifer Hayes Silvers, a counselor. “In my young career, when I think about GAD, there’s not a client that I have where [the anxiety] is not situational,” Hayes Silvers says. “It’s very much about whatever particular situation they’re dealing with at the time.”
Despite their shared belief in the necessity of considering financial and social factors when treating patients suffering from anxiety, the Women’s Clinic staff members aren’t that concerned by the exclusion of social and environmental context from the definition of GAD in the last version of the DSM. Neither is Columbia’s Mark Olfson.
Any counselor treating patients would have been trained to consider those factors, they say, and the DSM-IV does include general criteria for a multiaxial assessment, where counselors are expected to consider five different factors when treating their patients. The fourth axis is recent psychosocial stressors, like the loss of a job or a loved one.
But the DSM does have limitations. As Kara Hoppe, a fellow counselor, and Becker point out, it only allows six months for bereavement, for instance. “You only get six months to mourn a parent,” Hoppe says. “I don’t think you get more than that if you lose your job, according to the DSM.”
To Becker, the DSM should be used as a tool for understanding the cluster of symptoms associated with a particular disorder—but a clinician needs to think outside the manual and consider a client’s circumstances, too. Even biological issues like thyroid problems can cause anxiety. Clinicians need to consider those as well.
“Does that bug me that it’s not a holistic approach or view of the person? Yes,” she says. “I’ve never liked that.”
There are also dangers to being labeled with a stronger diagnosis. As Baer’s study points out, mental health care is often an entry point into the health-care system for low-income patients, and added social stigma could keep them out of the system. And for patients who do have insurance, Becker says, a diagnosis of GAD, a more severe condition than something like an adjustment disorder (anxiety related to a specific event and lasting for less than six months), could drive up future premiums or prevent coverage, depending, of course, on changes in health-care laws.
But to Baer, the real problem is that the health-care system is pathologizing a normal response to difficult situations.
“Psychology is creeping into what’s obvious and normal,” she says. “People in desperate circumstance feel anxious, as they should. I’m concerned about the narrative that if you’re suffering, you have a disorder.” ￼
This story originally appeared in the California Health Report magazine’s Winter 2012/2013 issue. Read the rest of the magazine here.