The Economics of Gender and Mental Illness: Volume 15

The past quarter-century has seen research on the economic impacts of mental illness flourish. Innovations in measurement and the release of several community-based and often nationally representative data sets containing valid and reliable diagnostic information have enabled researchers to make substantial advances in understanding the myriad ways that mental illness impacts the economic lives of the ill and their families. Among the most interesting and persistent findings in this literature is that mental illness affects women and men differently. Not only do women and men have very different rates of prevalence for various diseases, but mental illness is also commonly found to have different effects in their economic lives.

The NCS was based on multistage area probability sample of people age 15–54 in the non-institutionalized civilian population of the coterminous U.S., with a supplemental sample of students living in campus group housing (Kessler et al., 1994). The survey was carried out face-to-face in the homes of respondents by professional interviewers employed by the Survey Research Center (SRC) at the University of Michigan. The survey was carried out between September 1990 and February 1992. The response rate was 82.6%, with a total of 8,098 respondents participating in the survey. A supplemental non-response survey was carried out to adjust for non-response bias, with a random sample of initial non-respondents offered a financial incentive to complete a short form of the diagnostic interview. A non-response adjustment weight was constructed for the main survey data to compensate for elevated rates of disorders found among the initial non-respondents in this non-response survey. Significance tests were made using design-based methods because of this weighting and clustering of the data (Kish & Frankel, 1970; Koch & Lemeshow, 1972; Woodruff & Causey, 1976). More details about design and weighting procedures are reported elsewhere (Kessler, Little et al., 1995).

Mental illness, in its various forms, is common in the United States. Tens of millions of Americans are afflicted by an episode of mental illness every year. Estimates of the 12-month prevalence of mental disorders in the U.S. (including alcohol and substance abuse or dependence) indicate that 22–30 persons per 100 in the adult population are afflicted each year.¹ An episode of a psychiatric disorder, like a physical disorder, is debilitating – often disrupting the ability of the afflicted to carry on normal personal, social, and work activities. Mental illness also commonly results in large medical expenses. In addition, a number of recent papers have found that mental illness imposes large labor market losses on the ill, decreasing the likelihood of employment and limiting earnings for the employed.² In particular, research by two of the authors indicates that depressive disorders cause significant reductions in the labor force participation of women and the earnings of both men and women.³

Mental disorders collectively account for 4 of the 10 leading causes of disability and represent more than 15% of the overall burden of disease in the United States (SAMHSA, 1999). The first Surgeon General’s Report on Mental Health reported that in 1999 nearly 20 million American adults (9.5% of the population) were clinically depressed and that, at any one time, 1 in every 20 employees is experiencing depression (SAMHSA, 1999). The indirect costs of mental disorders to the American economy amounted to an estimated $79 billion in 1990, with loss of productivity because of illness accounting for about 80% of these costs ($63 billion) (Rice & Miller, 1996). Additionally, significant costs may accrue from decreased productivity due to symptoms that sap energy, affect work habits, and cause problems with concentration, memory, and decision-making (SAMHSA, 1999).

In a number of recent studies, it has been demonstrated that mental illness imposes real and large costs over and above the direct expenses of care and treatment. Each year in the U.S., 5–6 million workers between 16 and 54 years of age lose, fail to seek or cannot find employment as a consequence of mental illness. Among those who do work, it is estimated that mental illness decreases annual income by an amount between USD 3500 and USD 6000 (Marcotte & Wilcox-Gök, 2001). Similar results have been shown in a number of studies (Ettner et al., 1997).

It is well known that mental health disorders cause substantial functional limitations and disability (Surgeon General, 1999). Less well known is the central role that mental health plays in economic disparities. The prevalence of depressive disorders is almost 3 times as high among individuals in the bottom 20% than among individuals in the top 20% of the income distribution, a much steeper gradient than for hypertension, heart disease, arthritis, chronic pain, or the number of medical problems (Sturm & Gresenz, 2002). In addition, individuals with mental disorders are less likely to have savings than individuals with physical health problems and the disparity widens with advancing age (Gresenz & Sturm, 2000).

Schizophrenia is a profoundly disabling chronic mental disorder with an estimated annual prevalence rate of about 1.3% for the U.S. population age 18 to 54 (USDHHS, 1999). One reason it is so disabling is that onset typically occurs in early adulthood, impacting on a range of life experiences that influence later employment, such as completion of schooling, and early-career experiences at work. For most people, successful navigation of these experiences creates a solid foundation for later career advancement through the development of work skills and social supports.

The role of gender in psychiatric disorders is not well understood, but several broad trends are known: while men and women experience psychiatric symptoms at roughly the same rate, women are more likely to experience depressive symptoms (Kessler et al., 1993) and men are more likely to experience substance use disorders (DHHS, 1999). However, women are more likely to use primary care services for mental health care than are men (Wells et al., 1986). Equally controversial and not well understood has been the differential responses to treatment interventions by gender (Kornstein, 1997). One recent study found that a depression intervention was more cost-effective for women than for men (Pyne et al., in press). Indeed, the study found that the intervention was essentially cost and outcome neutral for men, while women were found to have a cost-effectiveness ratio of over $5000 for each QALY saved.

During the past two decades, there has been a growing awareness of the impact of mental illness on the population (Regier et al., 1988; U.S. Department of Health and Human Services, 1999; World Health Organization, 2001). However, only recently have issues surrounding its effect on the labor force been raised (Berndt et al., 2000; Dewa & Lin, 2000; Kessler et al., 1999; Marcotte et al., 1999; Stewart et al., 2003).

Women are nearly twice as likely as men to suffer a major depressive episode (Kessler et al., 1994). Risk of onset for single mothers is twice that of married mothers and financial hardship also doubles the risk of becoming depressed (Brown & Moran, 1997). If diagnosed, depression can be effectively treated, typically with pharmacotherapy or psychotherapy or some combination of the two (Goldman et al., 1999; Sirey et al., 1999). But a sizable majority of sufferers remain undiagnosed and untreated (Lennon et al., 2001). Such treatment can be prohibitively expensive to patients who lack health insurance, particularly those with few financial resources. Although most low-income women have a safety net in Medicaid, welfare reform’s delinking of Medicaid from welfare cash assistance has left uncovered many who are eligible for the benefits (Garrett & Holahan, 2000).