Depression is one of the leading causes of disability and poor health worldwide, and comes with common symptoms such as low mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, feelings of tiredness, and poor concentration (National Institute for Health and Care Excellence, 2022).
Depression is highly prevalent in healthcare workers (HCWs), with most data showing above national averages. Not only does depression impact care quality and productivity, but experiencing depression presents the risk of financial and personal costs to HCWs themselves due to sickness and loss of earnings (NHS Digital, 2022). The Office for National Statistics (2022) showed 20-30% of sick days in the UK National Health Service (NHS) were because of mental health problems. The ongoing pressures of the COVID-19 pandemic have only worsened this.
We have known for a long time that low household incomes are generally associated with an increased risk of mental health problems (Sareen et al., 2011) but, interestingly, the evidence concerning the relationship between financial concerns and depression among HCWs is limited. However, from what we do know, HCWs are at risk of developing depression when they experience income loss, and depression can be higher among HCWs with low monthly income in comparison to those in higher wage brackets (Mohammedi et al., 2023; Sarfraz et al., 2022).
In the context of ongoing industrial action from HCWs protesting real-term salary cuts during a cost-of-living crisis and persistent post-pandemic pressures on services and staff, this timely paper by McBride and colleagues (2023) helpfully sets out to examine such a link to add to the evidence base.
Longitudinal survey data involving a large sample (N = 3,521) was taken from a UK-wide cohort of employed HCWs (UK-REACH) to determine whether financial concerns at baseline (December 2020 to March 2021) were associated with depression (measured with the Public Health Questionnaire-2) at follow-up (June to October 2022). The collection points cover the height of the pandemic.
The effects of the UK’s cost-of-living crisis on the prevalence of financial concerns was also explored.
Data from an impressive 15,199 HCWs was received for the baseline, with 3,521 providing follow-up and allowing inclusion in the analysis. The implications regarding those who didn’t follow-up are noted later.
Of those included, the median age was 48 (interquartile range 37-56), with 74.8% identifying as female and 22.8% identifying as ethnic minorities. This is reasonably in line with NHS services, though one might argue the sample is a little older, and (depending where one works) has fewer people from ethnic minorities. Further, only 21.5% were nurses, despite this group clearly make up the largest part of the NHS.
HCWs who were concerned about their financial situation at baseline (including ‘a little’, ‘moderately’, ‘quite a bit’, and ‘extremely’) had significantly higher chances of developing depressive symptoms at follow-up. Alarming, individuals classified as being ‘extremely’ concerned about their finances at baseline were shown to subsequently have seven times the odds of meeting criteria for depression, in comparison to those who were ‘not at all’ concerned (OR = 7.85, 95% CI [4.52 to 13.60], p < .001).
There were variations between professions, with those working in nursing roles having over twice the odds of developing financial concerns (adjusted OR = 2.28, 95% CI [1.84 to 2.82], p < .001) and meeting the criteria for depression (adjusted OR = 2.28, 95% CI [1.59 to 3.28], p < .001) compared with those in medical roles at follow-up.
Worryingly, there were growing concerns about finances in general across time-points, with 43.8% reporting an increased level of financial concerns. This might reflect the generally increasing cost-of-living issues in the wider economy over this time.
A large sample of HCWs within the UK reported having concerns about their financial situation, and this was significantly associated with developing symptoms of depression.
Those in nursing, midwifery and other nursing allied roles were particularly at risk of developing financial concerns and depression. Such worries are likely to continue in the face of the cost-of-living crisis, causing additional consequences for individuals, services, and the economy.
Strengths and limitations
As well as its large sample size, this study was the first to use longitudinal data to examine the effects of financial concerns and the risk of health care workers (HCWs) developing symptoms of depression within the UK. The piece is incredibly timely: as well as the noted workforce recruitment and retention problems, the cost-of-living crisis continues to bite, and we face ongoing industrial action from healthcare staff. These findings help inform current debates and policy.
Although the existing literature is limited, these findings support research reporting a link between financial concerns and depression among HCWs.
Participant drop out is common among longitudinal studies, which the researchers acknowledged as a limitation for their study. Of notable importance, participants who met the criteria for depression and who had financial concerns at baseline were less likely to respond to the follow-up questionnaires. One can sympathise and imagine reasons why this might be the case but, of course, this would have been a key group to explore and understand. Unfortunately, such drop out might have led to a bias within the overall findings, as well as underestimations of the prevalence of depression and financial concern among HCWs. The sample was reasonably representative of the NHS, with some caveats noted earlier.
I noticed depression was the only mental health difficulty screened for this study. Anxiety and other psychiatric difficulties are equally prevalent in the NHS workforce, so I was curious to know why these mental health problems were not included. I wonder what influence such issues and other co-morbidities could have had on the relationship between financial concerns and general staff well-being among the sample; this is an area for future research.
Finally, there were low numbers of specific occupational groups which necessitated combining groups. For example, midwives were combined with nurses and pharmacists within allied health professionals to limit exclusions and maximise statistical power. This may have introduced some level of heterogeneity by including a range of occupations. On the flip side, such groupings could have unintentionally led to profession-specific income not being further compared. I presume relatively high and low wage brackets would have existed within the groupings, and such differences in wage could have shed additional insight into which professional group were more at risk of developing depression.
Implications for practice
Financial concerns can significantly impact health care workers (HCWs) mental health and can lead to symptoms of depression.
Despite HCWs occupying crucial roles, they are not immune to the financial pressures any more than the rest of the population. The rising cost of living, stagnant wages, and the burden of student loan debt can create a significant strain on their overall financial well-being. What doesn’t help is that the nature of the HCW work often includes long hours, shift work, and irregular schedules, making it challenging for them to find additional sources of income. Many HCWs earn relatively modest salaries, particularly in the early stages of their careers. It is no wonder this limited financial resource can restrict HCW’s ability to meet basic needs, cover unexpected expenses, or save for the future, contributing to feelings of helplessness and despair.
The mental health of HCWs is crucial not only for their personal well-being but also for the quality of care they provide to patients. Depression resulting from financial concerns can lead to decreased motivation, burnout, and diminished job performance. This, in turn, may compromise the ability to maintain high standards of patient care simply due to the mental and emotional toll of their financial worries.
I always find it interesting when NHS statistics regarding sickness are reported, as, for me, this can be a double-edged sword. It is good to highlight existing issues within the workforce as this may trigger further discussions on a need for positive change; however, it does not make the NHS look like an attractive place to work, and it does not provide the public with reassurance that they are receiving a safe and effective service.
The Government launched and provided funding for 40 NHS mental health and wellbeing hubs to give struggling NHS staff rapid access to mental health support; however, this ended in March 2023. Discussing the impacts and rationale behind this goes beyond the scope of this blog but, this cut has potentially left a workforce without vital mental health support during a time where there is more uncertainty over work, pay and the cost-of-living than ever before. Even if further initiatives are funded, HCWs may still face barriers to accessing them. HCWs work long hours and their teams are often understaffed, and the stigma surrounding mental health issues within the healthcare profession can discourage individuals from seeking help. This lack of support exacerbates the impact of financial concerns on their mental health, as they may feel isolated and unable to find appropriate assistance.
As a clinical psychologist working in the NHS and one who strives to lead with compassion, I advocate for a culture which supports the well-being of NHS staff. With this in mind, this paper offers an opportunity for policymakers to recognise and address these issues faced by HCWs by offering adequate financial support, accessible mental health services, and promoting a culture of open dialogue regarding mental health within the healthcare profession. By doing so, we can support the mental well-being of NHS workers, ultimately benefiting both the individual healthcare professionals and the patients they care for.
Through human history, writers, poets, musicians and philosophers have noted how money cannot buy happiness. That might well be true, but its absence can certainly lead to distress and ill-health.
Statement of interests
McBride, M., Martin, C. A., Teece, L., Irizar, P., Batson, M., Lagrata, S., … & UK-REACH Study Collaborative Group. (2023). Investigating the impact of financial concerns on symptoms of depression in UK healthcare workers: data from the UK-REACH nationwide cohort study. BJPsych Open, 9(4), e124.
Mohammadi, A. Q., Neyazi, A., Rangelova, V., Padhi, B. K., Odey, G. O., Ogbodum, M. U., & Griffiths, M. D. (2023). Depression and quality of life among Afghan healthcare workers: A cross-sectional survey study. BMC Psychology, 11(1), 29.
National Institute for Health and Care Excellence (2022). Overview/Depression in adults: treatment and management/ Guidance/ NICE.
NHS Digital. (n.d.). NHS Sickness Absence Rates, July 2022.
Office for National Statistics (2023). Sickness absence in the UK labour market- Office for National Statistics.
Sareen, J., Afifi, T. O., McMillan, K. A., & Asmundson, G. J. (2011). Relationship between household income and mental disorders: findings from a population-based longitudinal study. Archives of General Psychiatry, 68(4), 419-427.
Sarfraz, M., Ji, X., Asghar, M., Ivascu, L., & Ozturk, I. (2022). Signifying the relationship between fear of COVID-19, psychological concerns, financial concerns and healthcare employees job performance: a mediated model. International Journal of Environmental Research and Public Health, 19(5), 2657.