- Certain states explicitly exclude mental health conditions from qualifying as a health risk that allows access to abortion.
- Abortion policies can maintain cycles of poverty and mental health conditions that have detrimental effects for individuals and society.
- Policymakers in all states with restricted abortion access should include mental health conditions as a legitimate reason to access abortion.
By A. Alban Foulser, M.A., and Sophie Arkin, M.A., on behalf of the Atlanta Behavioral Health Advocates
The ban on abortions after six weeks following the overturning of Roe v. Wade is an enormous threat to the reproductive freedom and well-being of Americans (Rahman & Fellow, 2022). Many states allow exceptions to abortion restrictions for severe health risks or medical emergencies (Schoenfeld Walker, 2023); however, in states such as Georgia, Nebraska, West Virginia, and Florida, mental health conditions are explicitly excluded from qualifying as such medical emergencies (Tanner, 2022).
This denial of mental illness as a legitimate reason to obtain an abortion is inconsistent with the biopsychosocial model of medicine, which considers the role of mental health, biology, and sociocultural factors such as generational racial trauma, poverty, and food insecurity on physical health (Engel, 1977).
These restrictions are also in direct contrast with other state and federal laws. For example, the LIFE Act (2019) recently reinstated in Georgia contradicts the state’s recent reform bill requiring mental health treatment to be considered on par with physical health treatment (Mental Health Parity Act, 2022), as well as the Affordable Care Act, which included treatment for mental health as an Essential Health Benefit (Beronio et al, 2013).
Failing to recognize the important role of mental health and socioeconomic status (SES) on well-being is considered reductionistic and outdated (McDaniel & deGruy, 2014). These abortion restrictions also ignore that certain mental health conditions (including severe depression, psychosis, mania, and substance use) can rise to the level of psychiatric emergency (Kalb et al., 2019) and contribute to the development of chronic physical health conditions (e.g., cancer, heart disease, asthma, hypertension, stroke; Scott et al., 2016).
Historically, abortion restrictions disproportionately impact low-income women for many reasons, including lack of financial resources to support children, higher rates of unintended and adolescent pregnancy, decreased access to health insurance and family planning resources, and discrimination in the healthcare system (Dehlendorf et al., 2013, Ogbu-Nwobodo et al., 2022, Rahman & Fellow, 2022). The link between financial insecurity and mental illness, including mental health emergencies, is well-documented.
In a study of children from the Children of the National Longitudinal Surveys of Youth dataset, children with early poverty had higher levels of depression, a difference that maintained over a subsequent five-year period regardless of changes in their poverty status (McLeod & Shanahan, 1996). Additionally, lower parent SES is consistently associated with children’s mental health challenges (Vukojević et al., 2017). Another study found that people with lower SES and people experiencing economic hardship (e.g., being under the federal poverty line, unemployment, and housing unaffordability) had higher rates of mental illness (Hudson, 2005).
A review by Kromka and Simpson (2019) identified socioeconomic factors (e.g., homelessness) associated with mental illnesses (e.g., schizophrenia, substance use disorder, current receipt of psychiatric treatment) among the most significant predictors of return visits to a psychiatric emergency department. Food insecurity has also been linked to significantly increased depressive symptoms, including suicidality (Alaimo et al., 2002). Based on this clear relationship between financial insecurity and mental illness, families affected by current state abortion restrictions such as the one in Georgia may be trapped in a cycle of mental illness and poverty for generations to come.
The cost of birthing and raising a child may also worsen this cycle. A Brookings Institute analysis estimated that raising a child born in 2015 would cost a middle-income family a total of $310,605 over the course of 17 years (Welch & Sawhill, 2022), in addition to the estimated average cost of $7,006 for childbirth (Xu et al., 2017).
The impact of this financial strain was documented by Foster et al.’s study (2018) comparing the socioeconomic outcomes of women from the Turnaway Study who obtained an abortion to those who were denied an abortion due to being over the gestational limit of 30 weeks. At a six-month follow-up, women who were denied an abortion were less likely to be working full-time or have health insurance, four times more likely to be living below the federal poverty level, and six times more likely to be receiving public financial and food assistance.
At a five-year follow-up, women who had been denied an abortion were more likely to be single parents without the support of family members or a partner than women who obtained an abortion. Restrictions put into place because of the overturning of Roe v. Wade are therefore likely to compound the significant financial burden for those with mental illnesses who are forced to carry pregnancies to term.
The exacerbation of the cycle of mental illness and poverty because of abortion restrictions has societal consequences beyond the individual level due to the costs of mental illness on taxpayers. Although the direct cost of mental healthcare is reported to account for a low percentage of total healthcare costs in the United States (Mark et al., 2007), findings from the National Comorbidity Survey Replication estimate the 12-month societal-level cost of mental illness totaled $193.2 billion when including the loss of potential earnings and need for resources such as public income support assistance (Kessler et al., 2008).
Despite this substantial societal cost, publicly funded mental health services such as those in Georgia were overburdened and insufficient for addressing current mental health needs prior to the overturning of Roe v. Wade (Sharpe, 2021). The lack of a mental health exception for abortion will very likely further perpetuate mental health disparities, systemic oppression, and burgeoning costs to all Americans.
Given the immediate and downstream costs of mental health conditions on individuals and families, and an already overburdened system of publicly funded hospitals and taxpayers, policymakers should include mental health conditions as a health risk that allows access to abortion. This simple and compassionate step would liberate some of the most vulnerable from a cycle of mental illness and poverty and benefit society more broadly.
Alaimo, K., Olson, C. M., & Frongillo, E. A. (2002). Family food insufficiency, but not low family income, is positively associated with dysthymia and suicide symptoms in adolescents. The Journal of Nutrition, 132(4), 719-725. doi: 10.1093/jn/132.4.719
Beronio, K., Po, R., Skopec, L., & Glied, S. (2013). Affordable Care Act expands mental health and substance use disorder benefits and federal parity protections for 62 million Americans. Office of the Assistant Secretary for Planning and Evaluation. https://aspe.hhs.gov/reports/affordable-care-act-expands-mental-health-…
Dehlendorf, C., Harris, L. H., & Weitz, T. A. (2013). Disparities in abortion rates: a public health approach. American Journal of Public Health, 103(10), 1772-1779.
Engel, G. L. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196(4286), 129-136.
Foster, D. G., Biggs, M. A., Ralph, L., Gerdts, C., Roberts, S., & Glymour, M. M. (2022). Socioeconomic outcomes of women who receive and women who are denied wanted abortions in the United States. American Journal of Public Health, 112(9): 1290-1296. doi: 10.2105/AJPH.2017.304247
Hudson, C. G. (2005). Socioeconomic status and mental illness: Tests of the social causation and selection hypotheses. American Journal of Orthopsychiatry, 75(1), 3-18. doi: 10.1037/0002-9422.214.171.124
Insel, T. R. (2008). Assessing the economic costs of serious mental illness. American Journal of Psychiatry, 165(6), 663-665. doi: 10.1176/appi.ajp.2008.08030366
Kalb, L. G., Stapp, E. K., Ballard, E. D., Holingue, C., Keefer, A., & Riley, A. (2019). Trends in psychiatric emergency department visits among youth and young adults in the US. Pediatrics, 143(4). doi: 10.1542/peds.2018-2192
Kessler, R. C., Heeringa, S., Lakoma, M. D., Petukhova, M., Rupp, A. E., Schoenbaum, M., ... & Zaslavsky, A. M. (2008). Individual and societal effects of mental disorders on earnings in the United States: results from the national comorbidity survey replication. American Journal of Psychiatry, 165(6), 703-711. doi: 10.1176/appi.ajp.2008.08010126
Kromka, W., & Simpson, S. (2019). A narrative review of predictors of adult mental health emergency department return visits and interventions to reduce repeated use. The Journal of Emergency Medicine, 57(5), 671-682. doi: 10.1016/j.jemermed.2019.08.005
Living Infants Fairness Equity (LIFE) Act. HB 481. General Assembly of Georgia. (2019). https://www.legis.ga.gov/api/legislation/document/20192020/187013
Mark, T.L., Levit, K.R., Coffey, R.M., McKusick, D.R., Harwood, H.J., King, E.C., Bouchery, E., Genuardi, J.S., Vandivort-Warren, R., Buck, J.A., Ryan, K. (2007) National Expenditures for Mental Health Services and Substance Abuse Treatment, 1993–2003. SAMHSA pub no SMA 07-4227. Rockville, Md, Substance Abuse and Mental Health Services Administration, 2007
McDaniel, S. H., & deGruy III, F. V. (2014). An introduction to primary care and psychology. American Psychologist, 69(4), 325. doi: 10.1037/a0036222
McLeod, J. D., & Shanahan, M. J. (1996). Trajectories of poverty and children's mental health. Journal of Health and Social Behavior, 37(3): 207-220.
Mental Health Parity Act. HB 1013. General Assembly of Georgia (2022). https://www.legis.ga.gov/api/legislation/document/20212022/203990
Ogbu-Nwobodo, L., Shim, R. S., Vinson, S. Y., Fitelson, E. M., Biggs, M. A., McLemore, M. R., ... & Mangurian, C. (2022). Mental health implications of abortion restrictions for historically marginalized populations. New England Journal of Medicine, 387(17), 1613-1617. doi: 10.1056/NEJMms2211124
Rahman, A., & Fellow, S. (2022, February). The economic costs of abortion restrictions. Population Institute. https://www.populationinstitute.org/wp-content/uploads/2022/03/PI-3055-…
Scott, K. M., Lim, C., Al-Hamzawi, A., Alonso, J., Bruffaerts, R., Caldas-de-Almeida, J. M., ... & Kessler, R. C. (2016). Association of mental disorders with subsequent chronic physical conditions: world mental health surveys from 17 countries. JAMA psychiatry, 73(2), 150-158.
Schoenfeld Walker, A. (2023, January 21). Most abortion bans include exceptions. In practice, few are granted. The New York Times. https://www.nytimes.com/interactive/2023/01/21/us/abortion-ban-exceptio…
Sharpe, J. (2021, December 21). Even with beds empty, patients can’t get into Ga. state mental hospitals. The Atlanta Journal-Constitution. https://www.ajc.com/life/health/even-with-beds-empty-patients-cant-get-…
Tanner, L. (2022, November 17). Mental crises excluded from some state abortion exemptions. Associated Press. https://apnews.com/article/abortion-science-health-government-and-polit…
Vukojević, M., Zovko, A., Talić, I., Tanović, M., Rešić, B., Vrdoljak, I., & Splavski, B. (2017). Parental socioeconomic status as a predictor of physical and mental health outcomes in children–literature review. Acta Clinica Croatica, 56(4), 742-748. doi: 10.20471/acc.2017.56.04.23
Welch, M. & Sawhill, I. (2022, August). Future estimated annual expenditures of raising a child, assuming a higher inflation rate of 4 percent after 2020. Brookings. https://www.brookings.edu/wp-content/uploads/2022/08/Brookings_Cost-to-…
Xu, X., Lee, H. C., Lin, H., Lundsberg, L. S., Pettker, C. M., Lipkind, H. S., & Illuzzi, J. L. (2018). Hospital variation in cost of childbirth and contributing factors: a cross‐sectional study. BJOG: An International Journal of Obstetrics & Gynaecology, 125(7), 829-839. doi: 10.1111/1471-0528.15033