Depression and Low-Income Women
Challenges for TANF and Welfare-to-Work Policies and Programs

Executive Summary

This report reviews the literature on the prevalence, treatment, and consequences of depression in low-income women, highlighting the relationship of depression to welfare and employment. Depression is a debilitating illness characterized by profound feelings of sadness, low mood, and loss of interest in usual activities that can have severe adverse effects, not only on the individual woman but also on her job and family life.

Recent changes in welfare policy in the United States, including the five-year lifetime limit on assistance and the requirement that recipients obtain jobs after two years of continuous support, have increased concern about depression and other problems facing many women on welfare. The research findings reviewed here have a range of implications for research and for TANF and welfare-to-work policies and programs that are outlined in this report.

Prevalence of Depression Nationally

Data from large-scale national and community surveys reveal that:

• In any given year, approximately 4 percent to 10 percent of adults suffer from major depression.
• Rates of depression among women are 1.5 to 3 times that of men.
• Women from low-income groups are about twice as likely as those from higher-income groups to be depressed.

These results suggest that low-income women and women on welfare are at particularly high risk for developing depressive disorder.

Prevalence of Depression in Women on Welfare

Studies of women on public assistance that have used comparable and reliable measures of Major Depressive Disorder (MDD) to evaluate high levels of depressive symptoms find:

• Twelve-month prevalence rates of MDD range from 12 percent to 36 percent (median: 22 percent).
• High levels of depressive symptoms exist in 25 percent to 57 percent of the women (median: 47 percent).

While variation in rates across studies may reflect differences in local caseload characteristics, in timing of the studies, or in assessment strategies, levels of depression and its symptoms are quite high in welfare samples as compared to community samples of women.

Relationship of Employment and Depression

Researchers generally focus on depression as an obstacle to employment among welfare recipients, but other explanations of the association between depression and employment have empirical support in the literature. This report summarizes research on the following possible causes and consequences of depression:

• Depression as a barrier to employment
• Depression as limiting the capacity to retain employment
• Depression as a consequence of poor-quality jobs
• Depression triggered by job loss

Because these possibilities are not mutually exclusive, it is important to better understand the conditions under which they emerge.

Consequences of Maternal Depression for Children

In mothers, major depression compromises their ability to respond to their children and places children at considerable risk for psychopathology and developmental difficulties. The problems found in children of depressed mothers include: increased rates of clinical diagnoses, impairments in psychological functioning, difficulties in meeting social and academic demands, more internalizing and externalizing behaviors, and substantial risk for psychiatric diagnoses later in life. Thus, any intervention aimed at mothers should consider strategies for reaching at-risk children.

Treatment Effectiveness

A large number of studies document the effectiveness of various treatment and prevention options for depression. Research findings from experimental assignment to treatment show:

• Equal effectiveness of psychopharmacological and psychotherapeutic treatments, as compared with placebo, for mild to moderately severe depression
• Possibly greater effectiveness when drugs and psychotherapy are combined to treat recurrent severe depression

Few studies have focused specifically on low-income populations or women. While little attention has been given to rigorous evaluations of nonmedical or nonpsychotherapeutic interventions in this population, two promising approaches are reviewed:

• Incorporating attention to mental health problems in job search programs
• Offering welfare recipients financial incentives to work

Research suggests that each of these strategies may both reduce depressive symptoms and increase self-sufficiency.

Treatment Availability

Despite the availability of effective therapies, depression in the general population remains largely mistreated or altogether untreated. Moreover, income, health insurance type, ethnicity, and gender affect treatment rates and the type of treatment received. A number of disparities are found in the literature, including:

• Individuals with low incomes are less likely to receive treatment from mental health specialists, such as psychiatrists and psychotherapists.
• Medicaid recipients are less likely to receive newer forms of antidepressants, such as Prozac.
• Medicaid recipients are less likely to obtain psychotherapy than are individuals with private insurance.

Additionally, racial disparities are apparent in the treatment of depressed Medicaid recipients, with nonwhite patients receiving less optimal treatment than white patients.

Care Received Once Access Has Been Achieved

Unfortunately, adequate treatment of depression is not guaranteed by access to health care. In fact, studies consistently reveal:

• High patient attrition rates
• Poor treatment adherence rates
• Subtherapeutic dosing patterns in the management of depression

Many of these problems are exacerbated among individuals with low incomes.

Barriers to Treatment

Barriers to effective treatment for depression abound in the low-income population, including:

• High costs
• Lack of medical insurance
• Stigma
• Poor recognition of depression by physicians
• Patient barriers, such as language barriers or mistrust of strangers

Screening and Assessment—Implications for TANF and Welfare-to-Work Programs

Identifying and treating those in need of mental health services will require screening individuals to determine whether or not they have symptoms that warrant further (diagnostic) assessment. Currently, screening adults for depression, other mental disorders, or co-morbidity is not standard practice at welfare agencies or in welfare-to-work programs. This raises a number of issues for  policymakers, including:

• What (if any) screening tools are available?
• How willing are welfare recipients to reveal information about depression?
• How can the confidentiality of results be insured?
• What system changes may be required to deliver adequate mental health services?

Implications for Research and Policy

This literature review uncovered a number of areas for future policy-relevant research and for policy and program development. Researchers need to:

• Evaluate the adequacy of the current diagnostic system for depression.
• Develop longitudinal, nationally representative samples of low-income women to study the onset, causes, and consequences of depression.
• Understand the sources of disparities in treatment.
• Evaluate how treatment of depressed mothers affects their children.
• Compare the costs and benefits of treating depression, including savings for welfare systems.

To ensure that there is timely and effective treatment and preventive intervention for depression faced by low-income women, policymakers and program administrators will want to:

• Ensure access to health insurance.
• Institute adequate coverage for mental health treatment and intervention.
• Develop screening tools and procedures.
• Utilize multiple points of entry to identify at-risk women and children.
• Ensure adequate income support.