Do social programmes contribute to mental well-being? The long-term impact of unemployment on depression in the United States

Eunice Rodrigueza, Edward A Frongillob and Pinky Chandrac

a Department of Policy Analysis and Management,
b College of Human Ecology and
c Cornell Institute for Social and Economic Research, Cornell University, Ithaca, NY, USA.

Reprint requests to: Eunice Rodriguez, 140 MVR Hall, Cornell University, Ithaca, NY 14850, USA. E-mail: er23{at}Cornell.edu

Abstract

Background Important evidence about the mental health effects of unemployment exist; however, little is known about the possible protective effects of various social interventions or about their long-term impact. This study examines the long-term consequences that different types of social programmes, i.e. entitlement and means-tested benefits, might have as regards ameliorating a negative mental health impact of unemployment among women and men.

Methods Multiple regression models were used to analyse panel data collected in the National Survey of Families and Households in 1987 and 1992. In all 8029 individuals interviewed in both 1987 and 1992 were included in the analysis. A depression index was created from the responses to 15 items from the Center for Epidemiological Studies' Depression Scale-D (CES-D) which were included in the survey.

Results The receipt of government entitlement benefits by unemployed women is associated with a reduction of depression symptoms in the long term. Men and women not working and receiving means-tested or welfare benefits are more likely to report depression in both the short and long term.

Conclusions The study underscores the need for monitoring the impact of welfare reform on mental health.

Keywords Depression, unemployment, social programmes, mental health, social support

Accepted 10 January 2000

The US has been very successful in lowering the overall unemployment rate to <5.3%,1 but the context of unemployment has changed considerably within the last 15 years, and this adjustment can have long-term consequences. Of the full-time workers who lost their jobs and found new employment in the US, about a third suffered earning losses of >20% and took up jobs without health insurance benefits.2

The health effects of economic insecurity have been widely analysed, and we have important evidence on the mental and overall health effects of unemployment.39 An increase in depression symptoms, substance abuse, admissions to psychiatric hospitals, death by suicide, and violence are among the most salient outcomes associated with unemployment.1014 The evidence is inconclusive regarding other health outcomes. In addition, people in poorer health are more likely to lose their jobs and people in better health are more likely to be re-employed.1517 Comprehensive reviews discussing these findings are readily available.18,19

There is also an extensive literature on the impact of adverse working conditions on health; while most of the research in this area of inquiry started by focusing on men's work,20,21 a growing number of studies are now including women.22,23 It has been noted that that for women combining paid work with responsibilities related to home and family reduces the well-being benefits of employment.24,25

There has been some work on the impact of the interactions between unemployment levels and job conditions on the psychological distress of workers,26 but very rarely are different working situations and unemployment studied simultaneously using individual level data. In addition, the impact of public assistance in ameliorating the effects of unemployment on perceived physical illness has rarely been addressed.2729

Objectives

Our objective is to assess the long-term effects of unemployment on depression symptoms. What is unique about this study is that we explore the possible impact that different social programmes, such as entitlement unemployment benefits or means-tested welfare schemes could have with respect to ameliorating a possible negative mental health impact among the unemployed, as well as the fact that we are able to look at different employment arrangements simultaneously.

Our hypothesis is that economic hardship is only one of the effects associated with being without a job.30 Unemployment may have additional psychological and sociological costs that could be mitigated by different activities and programmes of social support in addition to the provision of economic relief. We argue that in order to have a protective effect on mental health, social support should not only consist of adequate economic assistance, but should simultaneously seek to alleviate the additional sociological and psychological impact of unemployment.

The importance of social support in protecting health has been widely documented since the publication of a comprehensive review by Cassel in 1976.31 In addition, recent research indicates that ‘the actual social environment is not the source of some protective factors for mental health; instead, what may be more important is how the environment is perceived’ (p.395),32 and that the effect of perceived support is not always mediated by actual supportive behaviours.33 While the social environment can be the source of adverse health outcomes, the way social support is perceived could be a key factor in benefiting from its health protective effects.

In a previous study it was found that the type of unemployment benefits received played a role in modifying the impact of unemployment on symptoms of depression,12 but the nature of the cross-sectional analysis carried out precluded the possibility of assessing whether the observed differences were due to the impact of the different benefit programmes or to a selection process. By using longitudinal data, we are able to further explore the possible differences between unemployed groups in relation to full-time employed, and to better understand how men and women are affected in different ways.

Methods

We analysed panel data collected in the National Survey of Families and Households (NSFH) 1987–1992. The 1987 NSFH study consisted of interviews with 13 014 respondents, of whom 10 008 were re-interviewed in 1992–1993. This represents an attrition rate of 23%. We analysed possible differences between respondents to the 1992 survey and those who were lost to follow-up after the 1987 interview. There were no significant differences in attrition rates by gender, age, ethnic group, and marital status between those who were re-interviewed and those lost to follow-up.

We limited our analysis to those respondents who were aged between 17 and 65 in 1987 and who were re-interviewed in 1992–1993. The total number of respondents included in the analysis was 7536.

As the outcome measure, we used a depression index created from the responses to 15 items from the Center for Epidemiological Studies' Depression Scale (CES-D) which were included in the survey. The 15 CES-D items are described in Appendix 1. The index of depression ranged from 0 to 105, and we transformed it to log (depression + 0.05) to better fit the assumptions of multiple regression analyses. The mean (and standard deviation) of the untransformed and transformed index were 16.89 (18.52) and 2.23 (1.29), respectively. The transformation changed the skewness from 1.84 to –0.69, and made the distribution symmetric with the mean in the middle of the range of –0.693 and 4.66. An advantage of the log transformation is that the regression coefficients that result from the analysis can be back-transformed to yield an interpretation of how many times higher or lower is the depression index for one group compared to another.

An employment situation variable was constructed from several variables asking about the respondents' employment. Employed respondents in 1987 were divided into full- and part-time employed, depending on whether they worked >=30, or <=29 h a week. For the 1992 interviews, we divided the employed population into two additional categories according to whether or not they were satisfied with their jobs. Satisfaction with 1992 employment reflects the perception of the individual, and could be due to a variety of both structural and personal factors (e.g. level of benefits, schedule, friendliness of supervisors of co-workers).

In addition, we differentiated those working people who were simultaneously receiving welfare benefits (i.e. means-tested or public assistance), and followed the same strategy. Males working and receiving welfare could not be included in the analysis because of the insignificant number involved.

Non-employed individuals looking for work during the 4 weeks prior to the interview, and those not actively looking for work were separated into two categories. These two groups were then further divided into three categories: (1) people receiving public assistance in the form of welfare or means-tested benefits; (2) people receiving income from government entitlement benefit programmes (including veterans' benefits, unemployment compensation, and worker's compensation), and (3) people not receiving any type of income or economic assistance. This last group of non-working people is difficult to interpret; it could include both people out of the labour force by choice, and unemployed people who have given up looking for work. Of these, we do not know how many are housewives by choice, students, or simply discouraged unemployed not eligible for any kind of benefits. There was no question included in the survey that allowed us to differentiate between these three groups of people included in the same category of non-employed and not looking for work without receiving any benefits.

Those who were fully retired in 1992 were grouped in a separate category. The typology of employment situation was operationalized as dummy variables.

Statistical analysis
We ran three different multiple regression models to explain depression. First, we analysed the possible impact of 1987 employment status and receipt of benefits on 1992 depression, while controlling for age, race, 1987 years of education, 1987 index of depression, and two measures of social support (number of social contacts, and having someone to call in an emergency in 1987).

Second, we added other 1992 factors to the model, including years of education in 1992, marital status, family income, assets and debts, having a physical or mental limitation that would restrict the ability to work, number of weeks unemployed during the year before the second interview (i.e. 1991), frequency of social contacts, satisfaction with personal relations, and environmental variables such as unemployment rate in the State of residence and amount of unemployment benefit available per unemployed person in the relevant State. Third, we added employment situation in 1992 to create a full model that allowed us to assess the impact of current employment status on depression while controlling for 1987 employment.

We used a Box-Cox transformation of the income, assets and debts variables to reduce skewness of these variables. The optimal transformations were found by doing a grid search over possible values of the Box-Cox shape parameter. The appropriate regression diagnostic tests were performed to assess the fit of the model. We did not impute any missing values in the dependent variable. For the categorical independent variables, we added an option of ‘no response’ where necessary. The income, assets and debts variables were complex, comprised of many components. If a component was missing, we imputed the values deterministically with the predicted values estimated for the age, sex, ethnic, marital and occupational group of the respondent. Preliminary analyses indicated that results were not sensitive to the inclusion of these imputed values.

To control for a possible reverse causation effect, we included in our model previous measures of depression and employment history.

Results

Table 1Go presents a description of our sample according to employment status and reported level of depression in 1992. Consistent with the literature, women report higher levels of depression symptoms than men. The main similarities between men and women are the lower levels of depression indicators among respondents who are full- or part-time employed and satisfied with their jobs, and those who are fully retired. All respondents report higher indices of depression if they were unemployed and receiving welfare (i.e. means-tested) benefits.


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Table 1 Means and standard deviations (SD) of depression index for different employment status groups in 1992 (range: 0–105)
 
Table 2Go presents the results of our multiple regression analysis to assess the impact of 1987 employment status on 1992 symptoms of depression. As observed in Table 2Go, the important factors in explaining less symptoms of depression include age and years of education. Index of depression previously reported in 1987 is strongly related to depression in 1992. Differences between men and women include frequency of social contacts being negatively associated with depression only among men. Race other than white or African American is associated with the depression outcome only among women.


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Table 2 Parameter estimates and 95% CI from regression model (model 1) to assess impact of 1987 employment status on 1992 symptoms of depressiona
 
In comparison with full-time workers, women not working, not looking for work, and not receiving any social benefits in 1987 (i.e. mostly housewives) report a lower index of depression in 1992; their index of depression is 1.1 times (i.e. 10%) lower. A similar association is observed among unemployed women who were looking for work while receiving government (entitlement) benefits in 1987, although the confidence interval for the effect is relatively large; these women have a depression index that is 2.2 times lower than that of the reference group. In contrast, women who were not working while receiving welfare (means-tested) benefits in 1987 are significantly more likely to report depression in 1992; they have an index of depression that is 1.3 times higher.

Men have a different pattern than women with regard to the association of employment status and depression. Only those who were working part-time in 1987 report less symptoms of depression in 1992 than full-time workers. No other important differences are observed among the other employment groups.

When the 1992 explanatory variables are added to the regression model for women (Table 3Go, column 2), the only 1987 employment categories that remain inversely associated with 1992 depression are those of unemployed people receiving government benefits. In addition, an inverse association is observed among unemployed women who were not looking for work while receiving government benefits in 1987. For men (Table 3Go, column 2), we observe the same association as in our reduced model: those who were working part-time in 1987 report less symptoms of depression in 1992. The same effects remain when we add 1992 employment status to the model (Table 3Go, Columns 3 and 4).


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Table 3 Parameter estimates and 95% CI from regression models including 1992 factors to assess impact of 1987 employment status on 1992 symptoms of depressiona
 
Women who were not satisfied with their job in 1992 report more symptoms of depression than those who were satisfied. Among non-working women, only those who were unemployed, not looking for work, and receiving welfare benefits are more likely to report depression than the comparison group. Men working full-time but not satisfied with their jobs are more depressed than those who were satisfied, and among the unemployed men only those looking for work while receiving government benefits report more depression.

Factors strongly related to depression in 1992, for men and women alike, are having a physical or mental condition that could limit ability to work in 1992, and the respondents' baseline 1987 index of depression (Table 3Go). Total family assets, satisfaction with personal relationships (family, friends, etc.), and age are associated with lower depression for both groups. In contrast, greater frequency of social contacts is associated with more symptoms of depression.

Some of the most notable differences between men and women include the impact of debts, and marital status. While being divorced, widowed or separated is significantly related to depression among females, never having been married is what is significantly related to depression among men. Once we control for 1992 employment status in our model, the impact of years of education is no longer significant among women. In addition to total family assets, for women the amount of accumulated debt is also significantly related to depression. In addition, the number of weeks that respondents were unemployed and looking for work during the previous year (i.e. 1991) is significantly related to depression among men only.

Discussion

Limitations
For researchers concerned with the dynamics at work between social issues and health, going beyond the modelling of complex relationships among risk factors and focusing on an understanding of their origins and implications are significant challenges. Our study confirms the need to look at men and women separately.

We attenuated the effects of reverse causation by using prospective longitudinal data. We controlled both for having any physical or mental condition that would limit the ability to work for pay in 1992, and the previous index of depression. However, unemployed people receiving benefits differ in many ways from people not receiving benefits, and these differences may not be fully controlled for by the background covariates used in our analysis. Our exclusion criteria and the factors controlled for in our models should have eliminated most of the differences between the various groups of unemployed people, but uncontrolled variables determining both unemployment resources and health outcomes may still have existed.

One of the difficulties in a longitudinal study is that cases are subject to attrition over time.34 Many variables expected to be related to drop-out status were included in the regression model, and the per cent of respondents lost to follow-up in 1992 was similar across employment categories, with the exception of those unemployed actively looking for work and receiving welfare or no benefits at all in 1987. Among those groups, the attrition rate was close to 30%. It is plausible that unemployed people actively looking for work had a higher probability of changing residencies and relocating, and consequently a higher probability of being lost to follow-up.

Main findings and implications
One of the most interesting findings is to see a direct effect of 1987 unemployment on 1992 depression for women who were receiving government, i.e. entitlement, benefits in 1987. Even after incorporating 1992 variables in the regression model, unemployed women who were receiving entitlement benefits in 1987 report less symptoms of depression than those who were full-time employed. This finding gives support to the hypothesis that the receipt of entitlement government assistance may have a long-term protective effect on unemployed women, and confirms previous findings using cross-sectional data.

On the contrary, being unemployed and receiving means-tested benefits in 1987 is strongly related to depression in 1992. However, the effect is reduced when we include 1992 variables in the model. Not working while receiving welfare in 1992 has a direct effect on increasing symptoms of depression among women. One possible explanation is that the amount of welfare benefits provided is insufficient to positively influence mental health. However, given that we control for family income and wealth, other factors are more likely to be responsible for the difference. Social stigma and/or some other factors in the process associated with receiving welfare benefits could add additional stress to the lives of the recipients, which could offset some of the positive impact of welfare or other means-tested benefits. Previous research has shown the importance of perception in mediating the effect of supportive events, and how those perceptions influence the coping processes of individuals. In any case, the 1992 employment situation is more important in having an impact on depression than the fact of having been on welfare 5 years earlier.

Previous research has found an association between length of unemployment periods and depression. In our model the number of weeks unemployed during 1991–1992 does not have a direct effect on depression among women, but it has some effect on decreasing symptoms of depression among men.

In our full regression model unemployed men who were looking for work while receiving government benefits are more likely to report symptoms of depression than the employed. This could be due to the fact that government unemployment benefits are usually short-term subsidies, and depression could be higher during the initial period of the unemployment.

Men on welfare report three times more symptoms of depression than those employed and satisfied with their jobs (Table 1Go), and the lack of a direct impact on depression in our regression model is probably due to a small sample effect.

In this study we have been able to confirm simultaneously the significant impact that both economic and emotional resources of the family have in explaining depression, for men and women alike. Interestingly, total family income is not a significant factor once family assets and debts are included in the model, which suggests that those indicators could be better measures of wealth.

The effects of unemployment on depression depend upon gender and upon participation in governmental assistance programmes in a complex way. Continuing to develop an understanding of these effects will be increasingly important as rapid and substantial changes are made in the structure of employment and governmental assistance for those not employed.

Appendix

Index of depression
The variable index of depression was created by adding the 15 Center for Epidemiological Studies' Depression Scale-D (CES-D) items variables included in the National Survey of Families and Households. These variables represent a list of ways one might have felt or behaved during the past week. The questions ask on how many days during the past week did you:

  1. feel bothered by things that usually don't bother you?
  2. not feeling like eating; appetite was poor?
  3. feel that you could not shake off the blues even with help from family or friends?
  4. have trouble keeping your mind on what you were doing?
  5. feel depressed?
  6. feel that everything you did was an effort?
  7. feel fearful?
  8. feel restlessly?
  9. talk less than usual?
  10. feel lonely?
  11. feel sad?
  12. feel you could not get going?
  13. feel irritable, or likely to fight or argue?
  14. feel like telling someone off?
  15. feel angry or hostile for several hours at a time?

Acknowledgments

We would like to thank Cornell Agricultural Experiment Station for the award of a Hatch Grant that made possible this research effort. The data were generously provided by the Center for Demography and Ecology at the University of Wisconsin-Madison. The National Survey of Families and Households (NSFH) was funded by a grant (HD21009) from the Center for Population Research of the National Institute of Child Health and Human Development. The survey was designed and carried out at the Center for Demography and Ecology at the University of Wisconsin-Madison under the direction of Larry Bumpass and James Sweet. Field work was done by the Institute for Survey Research at Temple University. A previous version of this paper was presented at the European Evaluation Society, Stockholm, Sweden, March 1997.

E Rodriguez conceptualized and designed the study, supervised the analysis and wrote the first draft of the paper. E Frongillo provided statistical expertise and contributed to the writing of the paper. P Chandra analysed the data, prepared the tables and read the final version of the manuscript. All authors participated in the interpretation of the results and can take public responsibility for the content of the paper.

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