The impact of recession is far-reaching, affecting not only those made redundant but also their partners and children.
Even those who keep their jobs may struggle to pay bills as companies introduce shorter working weeks, pay freezes and pay cuts to avoid redundancies.
Many families have debts as a result of over-dependence on credit and loans. A stagnant housing market means some are unable to move and competition for school places increases.
At a time when financial problems are so prevalent, GPs need to be even more vigilant for depression and anxiety, drug and alcohol abuse, relationship problems and domestic violence.
GPs have a responsibility to direct patients to reputable sources of advice when suffering financial hardship. Failing to do so will result in increasing physical and mental health problems.
Credit crunch case study
A 57-year-old woman presented to her GP with insomnia. She explained that she would lie awake for hours worrying. She had also had some panic attacks in supermarkets.
Further questioning revealed some depressive symptoms with anhedonia, poor motivation and a lack of energy and appetite. Her Patient Health Questionnaire 9 score and Generalised Anxiety Disorder Assessment 7 were consistent with moderate depression and anxiety.
She had no previous history of mental health problems. When asked about any recent life events she disclosed that she had been made redundant one month previously and had mounting debts.
She felt she had been treated unfairly by her work; a small engineering firm where she had been a secretary for many years. She had used credit cards for a long time and was struggling to meet her mortgage payments.
The woman was tearful as she explained that she had received default notices from creditors and was expecting bailiffs to come knocking on the door.
Stress, depression and anxiety were discussed. She agreed to see the practice counsellor and was referred to the local gym for an exercise programme.
She declined antidepressants but agreed to have her FBC and TFTs checked and was given leaflets about anxiety and depression and sleep hygiene. Eliciting ideas, concerns and expectations, her GP found that she really wanted to know who to turn to for debt advice.
The Citizens Advice Bureau (CAB) website provided some practical steps she could take at home before visiting the local CAB office the next day.
She agreed she would write a CV and visit the job centre before the end of the week. The patient left feeling a lot more positive and agreed to return for a review and her test results in two weeks.
At her follow-up appointment she was still having anxiety symptoms but felt that the exercise was helping with her insomnia.
The CAB had told her about the government-backed, home owners support scheme that is open to those made redundant, or with reduced hours or wages. It enables homeowners to defer mortgage payments temporarily so preventing arrears.
The CAB adviser had told her she was entitled to a redundancy payment and had put her in touch with The Advisory, Conciliation and Arbitration Service which gives free and impartial support in employment disputes.
She had also been given advice about optimising her income (applying for job seekers allowance, selling unwanted items etc), contacting her creditors and reducing her spending. They had discussed bankruptcy and she now realised that it was very much a last resort.
She was feeling more confident about her chances of finding another job. The GP directed her to some self-help resources for depression and anxiety available at the local library and gave her the number for the Depression Alliance helpline.
The medical student sitting in on the consultation questioned whether this was anything to do with medicine but agreed that the practical support seemed to have helped the patient more than antidepressants would have. The student realised that if the patient's debts had continued to increase she could have become homeless and developed other health problems secondary to her stress.
The counsellor had a waiting list for appointments but, importantly, he recognised that the patient was helping herself, setting herself goals and deciding what to do.
A separate case saw three-year-old Henry. He was constipated for three to four days at a time and was having lots of tantrums.
He had previously been fit and well, with no past medical history. Discussing the onset of the problems his mother became tearful and explained that it had started two weeks ago when her husband had failed to return home from work.
Previously an attentive and loving husband and father he had worked long hours in the City. The husband had suffered a 'breakdown' due to the stress of threatened redundancy but he had been in touch with his wife since.
Henry watched his mother intently as she cried and recounted the story. Henry's examination was normal. The mother was given diet, fibre and fluid adviceand reminded of the power of 'positive parenting'.
She was advised to book to see the supportive health visitor and given the website for Relate for couple and family counselling. She agreed that she would try to conceal her distress in front of the children. She also agreed to try to discuss Henry's problems with her husband and ask him to spend some time with the children who were missing him.
Recession can have far-reaching effects on both the physical and mental health of affected adults and children. GPs need to be alert to psychosocial effects of financial hardship and be aware of both local and national resources for affected patients.
- Dr Miller is a freelance GP, mentor for the London deanery and medical student tutor at Imperial College, London
The Advisory, Conciliation and Arbitration Service www.acas.org.uk
Depression Alliance helpline 0845 123 2320
No Panic 0808 808 0545