Is low individual socioeconomic status (SES) in high-SES areas the same as low individual SES in low-SES areas: a 10-year follow-up schizophrenia study

The Role of Socioeconomic Position in the Association Between Mental Disorders and Mortality: A Systematic Review and Meta-Analysis

Importance

Studies are lacking summarizing how the association between mental disorders and mortality varies by socioeconomic position (SEP), particularly considering different aspects of SEP, specific types of mental disorders, and causes of death.

Objective

To investigate the role of SEP in the association between mental disorders and mortality and the association between SEP and mortality among people with mental disorders.

Data Sources

MEDLINE, Embase, PsycINFO, and Web of Science were searched from January 1, 1980, through April 3, 2023, and a snowball search of reference and citation lists was conducted.

Study Selection

Inclusion criteria were observational studies estimating the associations between different types of mental disorders and mortality, stratified by SEP and between SEP and mortality in people with mental disorders.

Data Extraction and Synthesis

Pairs of reviewers independently extracted data using a predefined data extraction form and assessed the risk of bias using the adapted Newcastle-Ottawa scale. Graphical analyses of the dose-response associations and random-effects meta-analyses were performed. Heterogeneity was explored through meta-regressions and sensitivity analyses.

Main Outcomes and Measures

All-cause and cause-specific mortality.

Results

Of 28 274 articles screened, 71 including more than 4 million people with mental disorders met the inclusion criteria (most of which were conducted in high-income countries). The relative associations between mental disorders and mortality were similar across SEP levels. Among people with mental disorders, belonging to the highest rather than the lowest SEP group was associated with lower all-cause mortality (pooled relative risk [RR], 0.79; 95% CI, 0.73-0.86) and mortality from natural causes (RR, 0.73; 95% CI, 0.62-0.85) and higher mortality from external causes (RR, 1.18; 95% CI, 0.99-1.41). Heterogeneity was high (I2 = 83% to 99%). Results from subgroup, sensitivity, and meta-regression analyses were consistent with those from the main analyses. Evidence on absolute scales, specific diagnoses, and specific causes of death was scarce.

Conclusion and Relevance

This study did not find a sufficient body of evidence that SEP moderated the relative association between mental disorders and mortality, but the underlying mortality rates may differ by SEP group, despite having scarcely been reported. This information gap, together with our findings related to SEP and a possible differential risk between natural and external causes of death in individuals with specific types of mental disorders, warrants further research.

Generating data to facilitate more equitable distribution of health resources: an illustration of how local health surveys can identify probable need in mixed socio-economic regions

OBJECTIVES

This study aimed to (1) encourage allocation of governmental and grant funds to the administration of local area health surveys and (2) illustrate the predictive impact of socio-economic resources on adult health status at the local area level to provide an example of how health surveys can identify residents with the greatest health needs.

STUDY DESIGN

Randomly sampled and weight-adjusted regional household health survey (7501 respondents) analyzed with categorical bivariate and multivariate statistics, combined with Census data. Survey sample consists of the lowest, highest, and near highest ranked counties in the County Health Rankings and Roadmaps for Pennsylvania.

METHODS

Socio-economic status (SES) is measured regionally with Census data consisting of seven indicators and individually with Health Survey data consisting of five indicators based on poverty level, overall household income, and education. Both of these composite measures are examined jointly for their predictive effects on a validated health status measure using binary logistic regression.

RESULTS

Once county-level measures of SES and health status are broken down into smaller areas, better identification of pockets of health need is possible. This was most strongly revealed in an urban county, Philadelphia, which is ranked lowest of 67 counties on health measures in the state of Pennsylvania, yet when broken down into 'neighborhood clusters' contained both the highest- and lowest-ranked local area in a five-county region. Overall, regardless of the SES level of the County subdivision one lives in, a low-SES adult has close to six times greater odds of reporting 'fair or poor health status' than does a high-SES adult.

CONCLUSION

Local health survey analysis can lead to a more precise identification of health needs than surveys attempting to cover broad areas. Low-SES communities within counties, and low-SES individuals, regardless of the community they live in, are substantially more likely to experience fair to poor health. This adds urgency to the need to implement and investigate socio-economic interventions, which can hopefully improve health and save healthcare costs. Novel local area research can identify the impact of intervening variables such as race in addition to SES to add more specificity in identifying populations with the greatest health needs.

The association between community-level socioeconomic status and depressive symptoms among middle-aged and older adults in China

BACKGROUND

There was little evidence concerning the association of community socioeconomic status (SES) and the cross-level interaction between community- and individual-level SES with depressive symptoms in China. This study aimed to investigate the association of community-level SES with depressive symptoms among Chinese middle-aged and older people and to examine whether individual-level SES moderates this relationship.

METHODS

Using data from the China Health and Retirement Longitudinal 2011-2018 Study, the 10-item Center for Epidemiologic Studies Depression Scale (CES-D-10) short form was used to measure depressive symptoms in 35,546 Chinese individuals aged 45 years and older. Community SES was calculated as a sum of z scores of the average years of schooling and household income per capita, which were derived by aggregating the individual measures to the community level. Two-level hierarchical linear regression was used.

RESULTS

Community SES was negatively related to CES-D-10 scores (coef=-0.438). A 1-SD increase in individual SES was associated with lower CES-D-10 scores (coef=-0.490). The cross-level interaction on individual- and community-level SES was significantly associated with depressive symptoms, indicating that with the increase of individual-level SES, the effect of community-level SES on depression decreases. Stratified analyses observed robust associations of community SES with CES-D scores between urban and rural residents.

CONCLUSIONS

This study showed that individuals who live in lower-SES communities had more severe depressive symptoms, particularly individuals with low SES. Additional attention should be given to the community socioeconomic context of middle-aged and older adults with lower SES, which may be helpful to reduce SES inequalities in depressive symptoms in China.

Pre-existing chronic physical morbidity and excess mortality in people with schizophrenia: a population-based cohort study

PURPOSE

Schizophrenia is associated with increased premature mortality and physical morbidity. This study aimed to examine prevalence of pre-existing chronic physical diseases, and association between physical multimorbidity burden and mortality rates among patients with newly diagnosed schizophrenia.

METHODS

This population-based cohort study investigated patients with first-recorded diagnosis of schizophrenia between January 2006 and December 2016, using territory-wide medical-record database of public healthcare service in Hong Kong. Physical morbidities were measured by Charlson Comorbidity Index (CCI), taking into consideration both number and severity of physical diseases, and were grouped into nine broad disease categories for analyses. Physical multimorbidity burden was stratified into three levels according to CCI of 0, 1 or ≥ 2. Cox proportional hazards regression models were used to examine associations of physical multimorbidity with mortality rates.

RESULTS

Of the 13,945 patients, 8.6% (n = 1207) had pre-existing physical morbidity. Patients with physical morbidity exhibited elevated all-cause mortality rate relative to those without physical morbidity [adjusted HR 2.38 (95% CI 2.04-2.77)]. Gastrointestinal/liver diseases, diabetes and cardiovascular diseases constituted the three most frequently diagnosed physical morbidities, whereas cancers displayed the highest all-cause mortality rate. An increase in physical multimorbidity burden was associated with increased all-cause mortality rate [CCI = 1: 1.98 (1.64-2.40); CCI ≥ 2: 3.08 (2.51-3.77), CCI = 0 as reference].

CONCLUSION

Schizophrenia patients with pre-existing physical morbidity had two-fold increased risk of premature mortality compared to those without physical morbidity. Physical multimorbidity confers incremental impact on excess mortality. Early detection and intervention of physical morbidity in the initial phase of schizophrenia is necessary to reduce avoidable mortality.

Individuals at ultra-high risk of psychosis and first-degree relatives of patients with schizophreniaexperience impaired family functionality and social support deficit in comparison to healthy controls

AIM

The present study was designed to assess the role of family function and social support in the context of different phases of schizophrenia.

METHODS

First-episode patients with experiences of schizophrenia (FEP), ultra-high risk for psychosis (UHR), first-degree relatives (FDR) of patients with experiences of schizophrenia, and healthy controls (HC) (40 per group) were subjected to in-person clinical interviews. The results of these interviews were then used to gauge social support and family function using the Perceived Social Support Scale (PSSS) and the Family Adaptability and Cohesion Scales (FACESII-CV). Data were analyzed through ANCOVA, correlation analysis and logistic regression analyses.

RESULTS

We found that family function and social support showed a approximately gradual downward trend through the HC, FDR, UHR, and FEP groups but no significant differences were found in the family function of the FDR, UHR and FDR group. Logistic regression analyses indicated that UHR group patients exhibited decreased family support and family cohesion relative to members of the HC group, but had greater perceived social support than did members of the FEP group. Results for members of the FDR group were in line with those of members of the UHR group.

CONCLUSIONS

These findings suggested that both UHR and FDR individuals experience impaired family functionality and social support which expanded the understanding of the psychological characteristics of the prodromal period of schizophrenia. Further explorations are warranted to develop optimal psychosocial interventions.

Excess mortality in patients with schizophrenia spectrum disorders in Malaga (Spain): A cohort study

AIMS

There is evidence that patients with schizophrenia spectrum disorders present higher mortality in comparison with the general population. The aim of this study was to analyse the causes of mortality and sociodemographic factors associated with mortality, standardised mortality ratios (SMRs), life expectancy and potential years of life lost (YLL) in patients with schizophrenia spectrum disorders in Spain.

METHODS

The study included a cohort of patients from the Malaga Schizophrenia Case Register (1418 patients; 907 males; average age 42.31 years) who were followed up for a minimum of 10 years (median = 13.43). The factors associated with mortality were analysed with a survival analysis using Cox's proportional hazards regression model.

RESULTS

The main causes of mortality in the cohort were circulatory disease (21.45%), cancer (17.09%) and suicide (13.09%). The SMR of the cohort was more than threefold that of the population of Malaga (3.19). The life expectancy at birth was 67.11 years old, which is more than 13 years shorter than that of the population of Malaga. The YLL was 20.74. The variables associated with a higher risk of mortality were age [adjusted hazard ratio (AHR) = 1.069, p < 0.001], male gender (AHR = 1.751, p < 0.001) and type of area of residence (p = 0.028; deprived urban zone v. non-deprived urban area, AHR = 1.460, p = 0.028). In addition, receiving welfare benefit status in comparison with employed status (AHR = 1.940, p = 0.008) was associated with increased mortality.

CONCLUSIONS

There is excess mortality in patients with schizophrenia spectrum disorders and also an association with age, gender, socioeconomic inequalities and receiving welfare benefits. Efforts directed towards improved living conditions could have a positive effect on reducing mortality.

Effects of Socioeconomic Status on Alzheimer Disease Mortality in Taiwan

OBJECTIVE

The combined effects of individual and neighborhood socioeconomic status (SES) on survival rates of patients with Alzheimer's disease (AD) remain unclear.

DESIGN

Retrospective cohort study.

SETTING

National Health Insurance Bureau of Taiwan data (2003-2012).

PARTICIPANTS

Patients with AD.

MEASUREMENTS

The authors aimed to analyze the effects of neighborhood and individual SES on the 5-year survival rates of patients with AD. The author defined individual and neighborhood SES based on income-related insurance payment amounts and residence in advantaged versus disadvantaged areas and compared survival rates using the Cox proportional hazards model after adjusting for risk factors.

RESULTS

A total of 1,754 patients with AD were identified. Each patient was followed for 5 years or censored. The 5-year overall survival rates were worst for those with a low individual SES in a disadvantaged area. After adjustment for sex, age, and comorbidities, patients with a low individual SES living in disadvantaged areas had the worse survival rate than those with a high SES (hazard ratio: 2.19; 95% confidence interval [CI]: 1.53-3.13). In contrast, after the adjustment for characteristics, patients with a high individual SES in disadvantaged areas had a similar mortality rate to those with a high individual SES in advantaged areas (hazard ratio: 0.93; 95% CI: 0.64-1.35).

CONCLUSION

Despite universal health coverage, patients with AD and a low individual SES in disadvantaged areas exhibited the worst survival rate. The socioeconomic survival gradient among patients with AD in Taiwan may result from differences in major attributes of individual and neighborhood SES.

Socioeconomic deprivation and blood lipids in first-episode psychosis patients with minimal antipsychotic exposure: Implications for cardiovascular risk

BACKGROUND

The influence of socioeconomic deprivation on the cardiovascular health of patients with psychosis-spectrum disorders (PSD) has not been investigated despite the growing recognition of social factors as determinants of health, and the disproportionate rates of cardiovascular mortality observed in PSD. Discordant results have been documented when studying dyslipidemia -a core cardiovascular risk factor- in first-episode psychosis (FEP), before chronic exposure to antipsychotic medications. The objective of the present study is to determine the extent to which socioeconomic deprivation affects blood lipids in patients with FEP, and examine its implications for cardiovascular risk in PSD.

METHODS

Linear regression models, controlling for age, sex, exposure to pharmacotherapy, and physical anergia, were used to test the association between area-based measures of material and social deprivation and blood lipid levels in a sample of FEP patients (n = 208).

RESULTS

Social, but not material deprivation, was associated with lower levels of total and HDL cholesterol. This effect was statistically significant in patients with affective psychoses, but not in schizophrenia-spectrum disorders.

CONCLUSIONS

Contrary to other reports from the literature, the relationship between socioeconomic disadvantage and blood lipid levels was contingent on the social rather than the material aspects of deprivation. Furthermore, this association also depended on the main diagnostic category of psychosis, suggesting a complex interaction between the environment, psychopathology, and physical health. Future studies exploring health issues in psychosis might benefit from taking these associations into consideration. A better understanding of the biology of blood lipids in this context is necessary.

Individual-level and area-level socioeconomic status (SES) and schizophrenia: cross-sectional analyses using the evidence from 1.9 million Chinese adults

OBJECTIVES

Health disparities in schizophrenia are well established. However, it is less understood whether area-level socioeconomic status (SES) is differentially associated with schizophrenia depending on individual-level SES. Therefore, using a nationally large representative data, this study investigated the association between individual-level SES, area-level SES and their interaction with schizophrenia in Chinese adults from a multilevel perspective.

SETTING

Household interviews in 734 counties (districts), 2980 towns (streets) and 5964 communities (villages) from 31 provinces, People's Republic of China, as part of the cross-sectional survey of Second China National Sample Survey on Disability.

PARTICIPANTS

1 909 205 men and women aged 18 years old and above.

PRIMARY AND SECONDARY OUTCOME MEASURES

A screen followed by clinical diagnosis was used to identify schizophrenia, and schizophrenia was ascertained according to the International Statistical Classification of Diseases, 10th Revision (code F20).

RESULTS

1-SD increase in individual SES was associated with decreased risk of schizophrenia (OR=0.45, 95% CI 0.43 to 0.46). 1-SD increase in area-level SES was associated with increased risk of schizophrenia (OR=1.30, 95% CI 1.24 to 1.37). The interaction of individual SES and area-level SES was statistically significant (OR=1.05, 95% CI 1.02 to 1.08); as the level of area SES increased, schizophrenia risk of lower SES people grew faster than the risk of higher SES people.

CONCLUSIONS

Area-level SES is particularly important to mental health of low SES individuals, with low SES people in high SES counties having the highest risk of schizophrenia than other groups. Action to reduce SES disparities in schizophrenia will require attention to the area-level context of low SES adults.

Towards a new conceptual framework for psychopathology: Embodiment, enactivism, and embedment

Psychopathology classification is at a conceptual crossroads. It is becoming increasingly accepted that the flaws of the DSM relate to its struggles to pick out “real” entities as opposed to clusters of symptoms. The Research Domain Criteria (RDoC) was formulated in response to this failure, and attempts to address the concerns confronting the DSM by shifting to a causal and continuous model of psychopathology. Noting key criticisms of neurocentricism and problems with conceptual validity leveled at the RDoC, we argue that they stem from its grounding in the metaphysical position of eliminative materialism, or at least material-reductionism. We propose that 3e cognition (viewing the mind as embodied, embedded, and enactive) offers a superior alternative to eliminative materialism. A 3e-informed framework of mental disorder is sketched out and its advantages as a basis for classifying and conceptualizing mental disorders are considered.

Physiological characteristics of patients with schizophrenia prematurely dying from circulatory diseases

INTRODUCTION

Patients with schizophrenia before reaching geriatric age are at high risk of circulatory mortality. However, investigations are lacking on the characteristics of physiological measurement among these at-risk patients.

METHODS

In this study, we followed acutely inpatients with schizophrenia disorder for cause of death through record linkage to the Death Certification System in Taiwan. Cases of patients who died because of circulatory morbidity (ICD-9 401-443) before turning 65 years old were used. Each schizophrenia case was then matched with two mentally healthy controls for the age and sex, and date of laboratory examination. Clinical data of all subjects were obtained by reviewing medical records.

RESULTS

Totally, 81 patients with schizophrenia who died from circulatory diseases at mean ages of 48.0 ± 10.7 years were investigated. The mean age at the final acute psychiatric hospitalization was 43.0 ± 10.9 years. Multivariate analysis showed that elevated fasting serum glucose levels (95% confidence interval [CI] for odds ratio (OR) = 1.00-1.03), blood leukocyte counts (95% CI for odds ratio (OR) = 1.07-1.55), and heart rates on electrocardiogram (95% CI for OR = 1.04-1.10) in the final psychiatric hospitalization collectively provided the predictive validity for premature circulatory death.

CONCLUSION

Systemic inflammatory activation and autonomic nervous system dysfunction along with dysregulation of glucose metabolism rather than lipids could be the physiological characteristics of schizophrenia patients at risk of premature circulatory mortality.

Socio-economic status and family structure differences in early trajectories of child adjustment: Individual and neighbourhood effects

We examined the effects of single-parent family status and high parental socio-economic status (SES) on the trajectories of children's emotional/behavioural adjustment in early-to-middle childhood (ages 3-7 years). We also assessed whether these family characteristics interact with the equivalent neighbourhood characteristics of shares of single-parent families and high-SES adults in predicting these trajectories. Using data on 9850 children in England participating in the Millennium Cohort Study, we found that family status and parental SES predicted children's trajectories of adjustment. Even after controlling for these family factors and key child and parent characteristics, the neighbourhood shares of high-SES adults and single-parent families were related (negatively and positively, respectively) to child problem behaviour. Importantly, children of low-SES parents in neighbourhoods with a high concentration of high-SES adults had fewer emotional symptoms than their counterparts in areas with fewer high-SES adults. Surprisingly, the adverse effect of single-parent family status on child hyperactivity was attenuated in areas with a higher share of single-parent families.

Survival analysis of the use of first and second generation antipsychotics among patients suffering schizophrenia: A nationwide population-based cohort study

BACKGROUND

Few studies have investigated the relationship between the use of different generations of antipsychotics and mortality with contradictory results. The aim of this study is to compare mortality among patients suffering schizophrenia taking different generations of antipsychotics in a nationwide population-based cohort study in Taiwan.

METHODS

A total of 812 patients suffering newly diagnosed schizophrenia under monotherapy of second generation antipsychotics (SGAs) comprised the group of cases. The matched controls were under monotherapy of first generation antipsychotics (FGAs). Each case was matched individually with their initial antipsychotics prescription calendar year and month, gender, and age. Cox regression analyses were applied to estimate survival time, adjusting for gender, age, residence, insurance premium, Charlson comorbidity index, hospital admission days, and hospital admission times. An analysis including the number of antipsychotic prescriptions, a proxy indicator of adherence, into the fully adjusted model to reveal the effect of adherence on survival of patients served as a sensitivity analysis.

RESULTS

Subjects receiving SGAs had lower admission times and inpatient days, more antipsychotic prescriptions, and longer follow-up time than FGAs. Compared with the FGAs group, the adjusted hazard ratio of mortality was 0.58 (95% confidence interval =0.34-0.96, p=.034) for SGAs group. After controlling for the number of antipsychotic prescriptions, the difference in mortality between antipsychotic generations was non-significant.

CONCLUSIONS

The results of this study suggest that SGAs were better than FGAs in mortality among patients suffering schizophrenia. The difference in mortality can be explained by the better medication adherence of SGAs.

Parental socioeconomic status and prognosis in individuals with ultra-high risk for psychosis: A 2-year follow-up study

A possible relationship between socioeconomic status (SES) and the development of mental illness has been continuously suggested. Still, less clear is whether the SES has a direct effect on the development of schizophrenia. In this longitudinal study, we test the hypothesis that parental SES is associated with the prognosis of individuals at ultra-high risk (UHR) for psychosis. One hundred and sixteen individuals who were determined as UHR using a Comprehensive Assessment of At-Risk Mental States (CAARMS) were classified into three groups based on the parental SES levels assessed by the Hollingshead-Redlich scale. There were no differences in the Positive and Negative Syndrome Scale (PANSS), the Scale for the Assessment of Positive Symptoms (SAPS), the Scale for the Assessment of Negative Symptoms (SANS) and the Brief Psychiatric Rating Scale (BPRS) at baseline. However, at the 1-year follow-up, the higher versus lower SES group showed significant differences in clinical measures including SAPS, SANS, PANSS positive and negative scales as well as BPRS scores. Most of these clinical differences were attenuated by the second year of follow-up with no sign of an increased rate of conversion to psychosis derived from a socioeconomically disadvantaged status. However, SAPS and PANSS positive scale still revealed sub-threshold positive symptoms within the low SES group at the 2-year follow-up. Moreover, especially for the subjects who continued the follow-ups for 1year and/or 2years, the changes of clinical symptoms between the baseline and follow-ups showed that there were significant symptom changes in higher and middle SES groups within the 1-year period already, but the lower SES group showed significant recovery at the second year. Our findings suggest that low parental SES can be detrimental to the prognosis phase of individuals at UHR. Limited supportive socioeconomic resources may slow the rate of symptom recovery in UHR subjects.

The impact of social deprivation on paranoia, hallucinations, mania and depression: the role of discrimination social support, stress and trust

The negative implications of living in a socially unequal society are now well documented. However, there is poor understanding of the pathways from specific environmental risk to symptoms. Here we examine the associations between social deprivation, depression, and psychotic symptoms using the 2007 Adult Psychiatric Morbidity Survey, a cross-sectional dataset including 7,353 individuals. In addition we looked at the mediating role of stress, discrimination, trust and lack of social support. We found that the participants' neighbourhood index of multiple deprivation (IMD) significantly predicted psychosis and depression. On inspection of specific psychotic symptoms, IMD predicted paranoia, but not hallucinations or hypomania. Stress and trust partially mediated the relationship between IMD and paranoid ideation. Stress, trust and a lack of social support fully mediated the relationship between IMD and depression. Future research should focus on the role deprivation and social inequalities plays in specific manifestations of psychopathology and investigate mechanisms to explain those associations that occur. Targeting the mediating mechanisms through appropriate psychological intervention may go some way to dampen the negative consequences of living in an unjust society; ameliorating economic injustice may improve population mental health.