Does inequality cause suicide, drug abuse, and mental illness?

Featured in The Economist on 6/14/18

THERE is something peculiarly haunting about the recent suicides of Kate Spade, a well-known designer, and Anthony Bourdain, a chef and author (see Obituary). Evidently success—building brands and businesses, achieving wealth and fame—does not ease the psychic pain that many people suffer. Even at the top of the capitalist pyramid, these deaths insist, there is no escape from inner demons. That sad rule applies to nations as much as celebrities. Nearly 45,000 Americans took their own lives in 2016, an increase of almost 30% since 1999, according to new figures released by the Centres for Disease Control. Another 42,000 died from opioid overdoses, victims of America’s drug epidemic. The world’s richest large country, the city on a hill, sometimes seems to be coming apart. But why?

In “The Sane Society”, published in 1955, Erich Fromm, a German-American psychologist and philosopher, asked whether a society could grow sick—whether conditions within it might so distress the inhabitants as to generate mass mental illness. Fromm’s argument focused on the strains of economic life at the time he was writing, such as the tendency to work long hours in pursuit of ever more consumer goods. In recent decades globalisation and mechanisation have added new kinds of worry. Yet, so far as mental health is concerned, the pain of these trials has not been evenly distributed.

In a paper published in 2010, Kate Pickett and Richard Wilkinson found that about one in ten people in Japan and Germany suffered some form of mental illness in the year they studied, compared with one in five Britons and Australians and one in four Americans. If economic ups and downs are the source of such troubles, they seem to have torn at the minds of citizens in some societies more than others.

The key to the puzzle, Ms Pickett and Mr Wilkinson argue in their new book, “The Inner Level”, is inequality. When the distribution of income spreads apart, a society begins to malfunction, affecting the mental health of everyone living within it.

Curse of the social animal

The pair have addressed the subject before. In “The Spirit Level”, a bestseller released in 2009, they sought to demonstrate a link between high levels of inequality and all manner of social ills, from poor health and obesity, to crime and violence, to educational failure and low social mobility. The more unequal a society, they wrote, the worse it was likely to perform on such measures. Indeed, the social damage wrought by inequality might be severe enough that the rich in less equal societies would benefit from efforts to even things up. The book attracted its share of criticism, as theories of everything tend to, in particular for confusing correlations with causality. Nonetheless, it helped to inspire a burgeoning debate about the costs of widening inequality.

“The Inner Level” seeks to push that debate forward, by linking inequality to a crisis of mental health. This time the authors’ argument focuses on status anxiety: stress related to fears about individuals’ places in social hierarchies. Anxiety declines as incomes rise, they show, but is higher at all levels in more unequal countries—to the extent that the richest 10% of people in high-inequality countries are more socially anxious than all but the bottom 10% in low-inequality countries. Anxiety contributes to a variety of mental-health problems, including depression, narcissism and schizophrenia—rates of which are alarming in the West, the authors say, and rise with inequality.

Manifestations of mental illness, such as self-harm, drug and alcohol abuse and problem gambling, all seem to get worse with income dispersion, too. Such relationships seem to apply within countries as well as between them. Damaging drug use is higher in more unequal neighbourhoods of New York City, in more unequal American states and in more unequal countries. The authors emphasise that it is a person’s relative position rather than absolute income that matters most. A study of 30,000 Britons found that an individual’s place in the income hierarchy predicted the incidence of mental stress more accurately than absolute income did. And in America, relative income is more closely linked to depression than absolute income. It is not enough to lift all boats, their work suggests, if the poshest vessels are always buoyed up more than the humblest.

The fact that relative status matters so much is a result of human beings’ intrinsically social nature, Ms Pickett and Mr Wilkinson argue. Group interaction and co-operation have been an essential component of humanity’s evolutionary success; indeed, the authors say, its social nature helped drive the growth of human brains. Across primates, they write, the size of the neocortex—a part of the brain responsible for higher-level cognitive functions—varies with the typical group size of a species. Living in complex social groups is hard cognitive work. Survival requires an understanding of roles within the social hierarchy, and intuition of what others are thinking. Thus people are necessarily sensitive to their status within groups, and to social developments that threaten it.

Such hierarchies are found in all human societies. But as inequality rises, differences in status become harder to ignore. There is more to be gained or lost by moving from one rung on the ladder to another. And however much some maintain that disparities in pay-cheques do not correspond to differences in human worth, such well-meaning pieties feel hollow when high-rollers earn hundreds or thousands of times what ordinary folk take home. Money cannot buy everything, but it can buy most things. The steeper the income gradient, the less secure everyone becomes, in both their self-respect and their sense of the community’s esteem.

And so people compensate. They take pills, to steel their nerves or dull the pain. Some cut themselves. Some adopt a more submissive posture, avoiding contact with others. Yet such withdrawal can feed on itself, depriving recluses of the social interaction that is important to mental health, undermining relationships and careers and contributing to economic hardship.

Others respond in the opposite way, by behaving more aggressively and egotistically. Studies of narcissistic tendencies showed a steep increase between 1982 and 2006, the authors report; 30% more Americans displayed narcissistic characteristics at the end of the period than at the beginning. Scrutiny of successive American cohorts found a progressive rise in those listing wealth and fame as important goals (above fulfilment and community). Over time, more people cited money as the main motivation for attending college (rather than intellectual enrichment).

Domineering responses to anxiety are associated with loss of empathy and delusions of grandeur. Thus highly successful people often display narcissistic or even psychopathic behaviour. In surveys, the rich are generally less empathetic and more likely to think they deserve special treatment than others. Modern capitalism, the authors suggest, selects for assertiveness, for a lack of sentimentality in business and comfort in sacking underlings, and for showy displays of economic strength. From the top to the bottom of the income spectrum, people use conspicuous consumption and other means of enhancing their image to project status.

The least secure are often the most likely to exaggerate their qualities. For example, countries with lower average life-expectancy tend to do better on measures of self-reported health; 54% of Japanese say they are in good health compared with 80% of Americans, though the Japanese live five years longer on average. Whereas 70% of Swedes consider themselves to be above-average drivers, 90% of Americans do. Such figures cast declamations of America’s greatness, and the politicians who make them, in a new light.

“The Inner Level” is not a page-turner in the usual sense. But it holds readers’ attention by elaborating a phenomenon most will already have observed, and by providing an explanation for the dysfunction they see around them, from the brazen disregard for rules among many corporate and political leaders to the nihilism of drug addicts and school-shooters. And yet the idea that inequality alone is responsible for all this, and that reducing inequality will solve it, does not in the end convince.

That is partly because the authors are not always as circumspect with their evidence as they should be. They declare, for instance, that “growth has largely finished its work”, and that “higher average material standards in the rich countries no longer improve well-being”. This is a controversial judgment. Work by another pair of analysts, Betsey Stevenson and Justin Wolfers, concludes that, “If there is a satiation point” beyond which income no longer boosts subjective well-being, “we are yet to reach it.” Moreover, the highly egalitarian policies of the post-war decades were themselves made feasible by rapid economic growth. Slower growth in recent years has strengthened the hands of political leaders looking to trim the safety-net.

So the link between growth and equality is stronger than the authors allow. More important, they aver that inequality causes stress without admitting the possibility that some other factor is contributing to both, or indeed that social breakdown contributes to inequality. They argue, for instance, that “social cohesion is reduced in more unequal societies”, noting that higher inequality is associated with less willingness to help others, diminished levels of trust, and lower participation in civic groups, from recreational clubs to unions. But causation almost certainly runs in the other direction as well. Civic institutions foster solidarity, reminding citizens that there is such a thing as society. Research suggests that higher levels of “social capital” are associated with more support for redistribution and welfare states.

Towards a great awakening

That is not to say that close community ties are an unalloyed good. They constrain individual freedom, increase suspicion of outsiders and discourage mobility, all of which limit a place’s dynamism and inventiveness. But low levels of trust, poor governance and corruption do all that too. The ideal, perhaps, is a world in which strong communities help individuals to thrive—a Nordic model, producing high incomes, low inequality and rosy levels of well-being. Unfortunately, such societies cannot simply be conjured out of a hat.

Which is one reason to be sceptical of the policies proposed by Ms Pickett and Mr Wilkinson, such as an infusion of “economic democracy”. Worker representation on boards is one suggestion; a move towards employee-owned or co-operative-style firms is another. These are not crazy ideas. Worker representation in Germany has probably dampened inequality without making the country an economic backwater. But it is hard to imagine that such schemes alone could put a broken society back together. Reversing the cycle of institutional fraying, gaping inequality and mental distress seems likely to require a much broader civic rejuvenation.

That is not impossible. American history has been punctuated by civic awakenings that yielded social, political and economic reforms. Those movements were generally bottom-up affairs, however, powered by a sense of purpose and moral outrage. Whether America, Britain or other sickly places retain the capacity for such mobilisations is an open question.