How do macro-level structural determinants affect inequalities in mental health? - a systematic review of the literature

Rejected sickness cash benefit claims after 180 days of sick leave in the Swedish rehabilitation chain: A nationwide register-based study

AIM

Since a lack of financial security among vulnerable groups could further hamper health and well-being, this study scrutinises factors predicting rejected prolonged sickness cash benefit claims among people on compensated sick leave of more than 180 days with a rejection between days 181 and 365.

METHODS

All 246,872 claims for employed people on sick leave recorded in the Swedish official statistics register between January 2018 and June 2021 were analysed. Claim outcome was evaluated using logistic regression with odds ratios recalculated to relative risks (RR) with 95% confidence intervals (CI), mutually adjusted for sociodemographic, work and health-related factors.

RESULTS

Overall, 46,611 (19%) of the claims were rejected, with slightly lower rates among women (RR=0.97; 95% CI 0.95-0.99). Musculoskeletal diseases had the highest rejection rates (RR=1.84; 95% CI 1.75-1.94) followed by injuries (RR=1.57; 95% CI 1.50-1.64) and symptoms (RR=1.51; 95% CI 1.46-1.56). Mental disorders also had above-average rates (RR=1.14; 95% CI 1.09-1.19), whereas the lowest rates were found among pregnancy-related diagnoses (RR=0.13; 95% CI 0.12-0.14) and neoplasms (RR=0.18; 95% CI 0.18-0.18). Higher rates were found among immigrants (RR=1.37; 95% CI 1.34-1.40), those with only primary education (RR=1.09; 95% CI 1.06-1.12) and among blue-collar workers. The regional variation was substantial (RR range 0.41-1.72).

CONCLUSIONS

High rejection rates were found for complex diagnoses and diagnoses with presupposed work ability in physically lighter occupations and among groups with assumed precarious positions at the labour market. Systematic differences in rates were identified between geographic regions. More studies are warranted to conclude if the differences found could be justified by other factors.

Using latent class analysis to investigate enduring effects of intersectional social disadvantage on long-term vocational and financial outcomes in the 20-year prospective Chicago Longitudinal Study

BACKGROUND

Class and social disadvantage have long been identified as significant factors in the etiology and epidemiology of psychosis. Few studies have explicitly examined the impact of intersecting social disadvantage on long-term employment and financial independence.

METHODS

We applied latent class analysis (LCA) to 20-year longitudinal data from participants with affective and non-affective psychosis (n = 256) within the Chicago Longitudinal Research. LCA groups were modeled using multiple indicators of pre-morbid disadvantage (parental social class, educational attainment, race, gender, and work and social functioning prior to psychosis onset). The comparative longitudinal work and financial functioning of LCA groups were then examined.

RESULTS

We identified three distinct latent classes: one comprised entirely of White participants, with the highest parental class and highest levels of educational attainment; a second predominantly working-class group, with equal numbers of Black and White participants; and a third with the lowest parental social class, lowest levels of education and a mix of Black and White participants. The latter, our highest social disadvantage group experienced significantly poorer employment and financial outcomes at all time-points, controlling for diagnosis, symptoms, and hospitalizations prior to baseline. Contrary to our hypotheses, on most measures, the two less disadvantaged groups did not significantly differ from each other.

CONCLUSIONS

Our analyses add to a growing literature on the impact of multiple forms of social disadvantage on long-term functional trajectories, underscoring the importance of proactive attention to sociostructural disadvantage early in treatment, and the development and evaluation of interventions designed to mitigate ongoing social stratification.

Methods used to conceptualize dimensions of health equity impacts of public health interventions in systematic reviews

OBJECTIVES

Our aims were to, first, identify and summarize the use of methods, frameworks, and tools as a conceptual basis for investigating dimensions of equity impacts of public health interventions in systematic reviews including an equity focus. These include PROGRESS-Plus, which identifies key sociodemographic characteristics that determine health outcomes. Second, we aimed to document challenges and opportunities encountered in the application of such methods, as reported in systematic reviews.

STUDY DESIGN AND SETTING

We conducted a methodological study, comprising an overview of systematic reviews with a focus on, or that aimed to assess, the equity impacts of public health interventions. We used electronic searches of the Cochrane Database of Systematic Reviews, the Database of Promoting Health Effectiveness Reviews (DoPHER), and the Finding Accessible Inequalities Research in Public Health Database, supplemented with automated searches of the OpenAlex dataset. An active learning algorithm was used to prioritize title-abstract records for manual screening against eligibility criteria. We extracted and analyzed a core dataset from a purposively selected sample of reviews, to summarize key characteristics and approaches to conceptualizing investigations of equity.

RESULTS

We assessed 322 full-text reports for eligibility, from which we included 120 reports of systematic reviews. PROGRESS-Plus was the only formalized framework used to conceptualize dimensions of equity impacts. Most reviews were able to apply their intended methods to at least some degree. Where intended methods were unable to be applied fully, this was usually because primary research studies did not report the necessary information. A general rationale for focusing on equity impacts was often included, but few reviews explicitly justified their focus on (or exclusion of) specific dimensions. In addition to practical challenges such as data not being available, authors highlighted significant measurement and conceptual issues with applying these methods which may impair the ability to investigate and interpret differential impacts within and between studies. These issues included investigating constructs that lack standardized operationalization and measurement, and the complex nature of differential impacts, with dimensions that may interact with one another, as well as with particular temporal, personal, social or geographic contexts.

CONCLUSION

PROGRESS-Plus is the predominant framework used in systematic reviews to conceptualize differential impacts of public health interventions by dimensions of equity. It appears sufficiently broad to encompass dimensions of equity examined in most investigations of this kind. However, PROGRESS-Plus does not necessarily ensure or guide critical thinking about more complex pathways, including interactions between dimensions of equity, and with wider contextual factors, and important practical, measurement and conceptual challenges remain. The findings from investigations of equity impacts in systematic reviews could be made more useful through more explicitly rationalized and considered approaches to the design, conduct and reporting of both primary research and the reviews themselves.

Systematic review of individual-level, community-level, and healthcare system-level factors contributing to socioeconomic differences in healthcare utilisation in OECD countries with universal health coverage

OBJECTIVES

Countries with universal health coverage (UHC) strive for equal access for equal needs without users getting into financial distress. However, differences in healthcare utilisation (HCU) between socioeconomic groups have been reported in countries with UHC. This systematic review provides an overview individual-level, community-level, and system-level factors contributing to socioeconomic status-related differences in HCU (SES differences in HCU).

DESIGN

Systematic review following the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines. The review protocol was published in advance.

DATA SOURCES

Embase, PubMed, Web of Science, Scopus, Econlit, and PsycInfo were searched on 9 March 2021 and 9 November 2022.

ELIGIBILITY CRITERIA

Studies that quantified the contribution of one or more factors to SES difference in HCU in OECD countries with UHC.

DATA EXTRACTION AND SYNTHESIS

Studies were screened for eligibility by two independent reviewers. Data were extracted using a predeveloped data-extraction form. Risk of bias (ROB) was assessed using a tailored version of Hoy's ROB-tool. Findings were categorised according to level and a framework describing the pathway of HCU.

RESULTS

Of the 7172 articles screened, 314 were included in the review. 64% of the studies adjusted for differences in health needs between socioeconomic groups. The contribution of sex (53%), age (48%), financial situation (25%), and education (22%) to SES differences in HCU were studied most frequently. For most factors, mixed results were found regarding the direction of the contribution to SES differences in HCU.

CONCLUSIONS

SES differences in HCU extensively correlated to factors besides health needs, suggesting that equal access for equal needs is not consistently accomplished. The contribution of factors seemed highly context dependent as no unequivocal patterns were found of how they contributed to SES differences in HCU. Most studies examined the contribution of individual-level factors to SES differences in HCU, leaving the influence of healthcare system-level characteristics relatively unexplored.

The social determinants of mental health and disorder: evidence, prevention and recommendations

People exposed to more unfavourable social circumstances are more vulnerable to poor mental health over their life course, in ways that are often determined by structural factors which generate and perpetuate intergenerational cycles of disadvantage and poor health. Addressing these challenges is an imperative matter of social justice. In this paper we provide a roadmap to address the social determinants that cause mental ill health. Relying as far as possible on high-quality evidence, we first map out the literature that supports a causal link between social determinants and later mental health outcomes. Given the breadth of this topic, we focus on the most pervasive social determinants across the life course, and those that are common across major mental disorders. We draw primarily on the available evidence from the Global North, acknowledging that other global contexts will face both similar and unique sets of social determinants that will require equitable attention. Much of our evidence focuses on mental health in groups who are marginalized, and thus often exposed to a multitude of intersecting social risk factors. These groups include refugees, asylum seekers and displaced persons, as well as ethnoracial minoritized groups; lesbian, gay, bisexual, transgender and queer (LGBTQ+) groups; and those living in poverty. We then introduce a preventive framework for conceptualizing the link between social determinants and mental health and disorder, which can guide much needed primary prevention strategies capable of reducing inequalities and improving population mental health. Following this, we provide a review of the evidence concerning candidate preventive strategies to intervene on social determinants of mental health. These interventions fall broadly within the scope of universal, selected and indicated primary prevention strategies, but we also briefly review important secondary and tertiary strategies to promote recovery in those with existing mental disorders. Finally, we provide seven key recommendations, framed around social justice, which constitute a roadmap for action in research, policy and public health. Adoption of these recommendations would provide an opportunity to advance efforts to intervene on modifiable social determinants that affect population mental health.

Public perspectives on inequality and mental health: A peer research study

INTRODUCTION

Associations between structural inequalities and health are well established. However, there is limited work examining this link in relation to mental health, or that centres public perspectives. This study explores people's experience and sense-making of inequality in their daily lives, with particular consideration of impacts on mental health.

METHODS

We conducted a peer research study. Participants had to live in one of two London Boroughs and have an interest in inequalities and mental health. Using social media, newsletters, local organisations and our peer researchers' contacts, we recruited 30 participants who took photos representing their experience of inequality and discussed them during semi-structured interviews. Data were analysed using reflexive thematic analysis.

RESULTS

Three themes were identified in this study: (1) inequalities are unjust, multilayered and intertwined with mental health. Accounts demonstrated a deep understanding of inequalities and their link to mental health outcomes, describing inequalities as 'suffering' and 'not good for anyone'. Financial, housing, immigration and healthcare problems exacerbated poor mental health, with racism, gender-based violence and job loss also contributing factors for both poor mental health and experiences of inequality; (2) inequalities exclude and have far-reaching mental health consequences, impacting personal sense of belonging and perceived societal value and (3) moving forwards-addressing long-standing inequality and poor public mental health necessitated coping and resilience strategies that are often unacknowledged and undervalued by support systems.

CONCLUSION

Lived experience expertise was central in this study, creating an innovative methodological approach. To improve public mental health, we must address the everyday, painful structural inequalities experienced by many as commonplace and unfair. New policies and strategies must be found that involve communities, redistributing resources and power, building on a collective knowledge base, to coproduce actions combatting inequalities and improving population mental health.

PATIENT OR PUBLIC CONTRIBUTION

This study was peer-led, designed and carried out by researchers who had experiences of poor mental health. Six authors of the paper worked as peer researchers on this study.

Nordic region suicide trends 2000-2018; sex and age groups

BACKGROUND AND AIM

Overall, suicide rates in the Nordic region, Denmark, Finland, Iceland, Norway and Sweden, have declined in the past 40 years. The aim of this study was to determine trends in suicide mortality from 2000 to 2018.

METHODS

Data were obtained from official suicide statistics for men and women, 15 years and older. Gender and age groups in four calendar periods were analyzed using Joinpoint Estimated Regression Coefficient.

RESULTS

The crude regional suicide rate was 17.1, 2000-2004, decreased to 14.1 per 100,000 inhabitants in 2015-2018. Age-standardized rates are 13.6-11.3. The crude rate decreased by 19.5% (16.3% age-standardized), 19.3% for males and 20.5% for females. The largest decrease was found in Finland (34.9%), the smallest in Norway (1.4%). In males, the exception was an increased suicide rate among all Icelandic except 15-24-year olds, and in 45-64 year-old Norwegians. Among females, an increase was seen among 15-24-year olds in all countries except Iceland, in all age groups in Norway, and in 25-44-year olds in Sweden. In males, a decline of the suicide rated lower than 10% was noted in 25-44 olds in Norway and in 15-64 year-olds in Sweden.

DISCUSSION

A robust decrease was observed in the overall regional suicide rate in recent years. Exceptions are rising rates in Icelandic males, in Norwegian females, and the youngest female groups in all except Iceland. The small decline among middle-aged males in Norway and Sweden is of concern.

Tracking of depressed mood from adolescence into adulthood and the role of peer and parental support: A partial test of the Adolescent Pathway Model

•Adolescent depressed mood predicts adult depressed mood.•Peer acceptance during adolescence is not associated with adult depressed mood.•Household income moderates the effect of parental closeness on adult depressed mood.

The Effect of Welfare State Policy Spending on the Equalization of Socioeconomic Status Disparities in Mental Health

This article examines whether and how the relationship between socioeconomic status (SES) and depression is modified by welfare state spending using the 2006, 2012, and 2014 survey rounds of the European Social Survey (ESS) merged with macroeconomic data from the World Bank, Eurostat, and SOCX database (N = 87,466). Welfare state spending effort divided between social investment and social protection spending modifies the classic inverse relationship between SES and depression. Distinguishing policy areas in both social investment and social protection spending demonstrates that policy programs devoted to education, early childhood education and care, active labor market policies, old age care, and incapacity account for differences in the effect of SES across countries. Our analysis finds that social investment policies better explain cross-national differences in the effect of SES on depression, implying policies focused earlier in the life course matter more for understanding social disparities in the mental health of populations.

A multi-country survey of the socio-demographic factors associated with adherence to COVID-19 preventive measures during the first wave of the COVID-19 pandemic

BACKGROUND

Health behaviours are influenced by individual characteristics including age, gender, education and economic level. This study aimed to assess the associations between individual-level determinants and adherence to COVID-19 preventive measures.

METHODS

We performed secondary analyses of international data collected using an online survey during the first wave of the COVID-19 pandemic between June and December 2020. The dependent variables were self-reported adherence to COVID-19 preventive measures (wearing of face masks, frequent washing/sanitizing of hands, physical distancing, working remotely). The independent variables were age, sex at birth (female vs male), having a chronic disease related elevated risk for severe COVID-19 (none/little, might be at increased risk, at increased risk), educational level completed (no formal education, primary, secondary vs college/university) and employment status (retiree, students, not employed vs employed). Four multivariate logistic regression analyses were conducted to determine the associations between the dependent variables and independent variables. Interaction terms with country-income level were tested in regressions to explore its moderating effect.

RESULTS

Out of 16,866 respondents, 12,634 (74.9%) wore masks or face coverings, 12,336 (73.1%) washed or sanitized their hands frequently, 11,464 (68.0%) reported adherence to physical distancing and 5,646 (33.5%) worked remotely. In adjusted analyses, increased age, college/university education, employment, and having risks for severe COVID-19 were associated with significantly higher odds of adhering to COVID-19 preventive measures. Retirees and students had lower odds of adhering to COVID-19 prevention measures than employed individuals. Males had significantly lower odds of wearing face masks (AOR: 0.901), frequent washing/sanitizing hands (AOR: 0.774) and working remotely (AOR: 0.875) compared to females. Country-income level generally moderated the above relationships such that the associations disappeared in lower income countries.

CONCLUSION

The study findings suggest that the individual socio-demographic factors-age, sex, employment status, education status and having a chronic disease - influence adherence to COVID-19 preventive measures. Findings further reiterate the need for health education and health promotion campaigns on preventive health measures to focus on subpopulations, such as younger males, students and retirees, that require targeted or unique messaging.

The Social Determinants of Mental Illness: A Rapid Review of Systematic Reviews

Previous research agendas have prioritised the role of biological determinants in mental illness aetiology. This is of particular concern, as endorsing biological determinants has been shown to promote negative attitudes towards people with mental illness. The aim of this review was to provide an overview of high-quality evidence of the social determinants of mental illness. A rapid review of systematic reviews was conducted. Five databases were searched: Embase, Medline, Academic Search Complete, CINAHL Plus, and PsycINFO. Systematic reviews or meta-analyses that described any social determinant of mental illness, were published in peer-review journals in English, and focussed on human participants were included. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were applied for the selection procedure. Thirty-seven systematic reviews were deemed eligible for review and narrative synthesis. Determinants identified included conflict, violence and maltreatment, life events and experiences, racism and discrimination, culture and migration, social interaction and support, structural policies and inequality, financial factors, employment factors, housing and living conditions, and demographic factors. We recommend that mental health nurses ensure adequate support be provided to those affected by the evidenced social determinants of mental illness.

Social Isolation, Healthy Habits, Inequality and Mental Health in the United States

The objective of this work is to deepen the analysis of the socioeconomic determinants of mental health, paying special attention to the impact of inequality, not only in income distribution but also in gender, racial, health and education inequality, social isolation, including new variables to measure loneliness, and healthy habits, on the mental health status. For this purpose, a cross-sectional model for a sample of 2735 counties in the United States is estimated using Ordinary Least Squares in its robust version to solve the detected heteroscedasticity problems. The results obtained show that inequality, social isolation and certain lifestyles, such as smoking or insomnia, are detrimental to mental health, while sexual activity prevents mental distress. On the other hand, poor counties suffer more cases of suicide, with food insecurity being the main problem for mental health. Finally, we found detrimental effects of pollution on mental health.

Living with obesity is related to peer problems in children: A national cross-sectional study

AIM

To assess the association between obesity and problems in peer relations in children (4-15 years) in a large (n = 11 279), nationally representative data set.

METHODS

The chi-square test was used to compare differences in numbers of children with and without obesity and with and without abnormal peer problem scores. Then multivariable logistic regression was used to determine any association between obesity and peer problems after accounting for deprivation and life-style factors.

RESULTS

The results of the chi-square test were statistically significant (P < 0.05) for all groups except older girls. The multivariable logistic regression identified a small but significant association between children living with obesity and abnormal peer problems, odds ratio (OR) 1.06 (95% confidence interval, CI: 1.04-1.08, P = 0.001). When explored by subsets of children using sex and age, this association was strongest for girls aged 4-10 years, OR 1.12 (95% CI: 1.07-1.16, P = 0.001).

CONCLUSION

This is the first nationally representative study of children to identify this association in younger children. Whilst further research is needed to corroborate this finding, as a precautionary measure solutions to improve peer relationships and reduce stigma for school-aged children living with obesity are indicated.

The clustering of physical health conditions and associations with co-occurring mental health problems and problematic alcohol use: a cross-sectional study

BACKGROUND

There is strong evidence for the co-occurrence of mental health conditions and alcohol problems, yet physical health outcomes among this group are not well characterised. This study aimed to identify clusters of physical health conditions and their associations with mental health and problematic alcohol use in England's general population.

METHODS

Cross-sectional analysis of the 2014 Adult Psychiatric Morbidity Survey (N = 7546) was conducted. The survey used standardised measures of problematic alcohol use and mental health conditions, including the Alcohol Use Disorders Identification Test (AUDIT) and the Clinical Interview Schedule-Revised. Participants self-reported any lifetime physical health conditions. Latent class analysis considered 12 common physical illnesses to identify clusters of multimorbidity. Multinomial logistic regression (adjusting for age, gender, ethnicity, education, and occupational grade) was used to explore associations between mental health, hazardous drinking (AUDIT 8 +), and co-occurring physical illnesses.

RESULTS

Five clusters were identified with statistically distinct and clinically meaningful disease patterns: 'Physically Healthy' (76.62%), 'Emerging Multimorbidity' (3.12%), 'Hypertension & Arthritis' (14.28%), 'Digestive & Bowel Problems'' (3.17%), and 'Complex Multimorbidity' (2.8%). Having a mental health problem was associated with increased odds of 'Digestive & Bowel Problems' (adjusted multinomial odds ratio (AMOR) = 1.58; 95% CI [1.15-2.17]) and 'Complex Multimorbidity' (AMOR = 2.02; 95% CI [1.49-2.74]). Individuals with co-occurring mental health conditions and problematic alcohol use also had higher odds of 'Digestive & Bowel Problems' (AMOR = 2.64; 95% CI [1.68-4.15]) and 'Complex Multimorbidity' (AMOR = 2.62; 95% CI [1.61-4.23]).

CONCLUSIONS

Individuals with a mental health condition concurrent with problematic alcohol use experience a greater burden of physical illnesses, highlighting the need for timely treatment which is likely to include better integration of alcohol and mental health services.

Association between migration status and subsequent labour market marginalisation among individuals with posttraumatic stress disorder: a Swedish nationwide register-based cohort study

PURPOSE

The high prevalence of posttraumatic stress disorder (PTSD) among migrants in Europe is widely reported. Our research aimed to investigate the association between migration status and subsequent labour market marginalisation (LMM) events, i.e., long-term unemployment (LTU), long-term sickness absence (LTSA), and disability pension (DP) among individuals with PTSD, and to elucidate how the sociodemographic factors and the pre-existing health conditions influence such association.

METHODS

We established a cohort of 36,714 individuals born between 1960 and 1995, living in Sweden during 2004-2009, aged 19 years or above, with PTSD diagnosis during 2006-2009. Migration status, categorized as refugees, non-refugees, second-generation migrants, and Swedish-born with Swedish-born parents (reference group) was considered as exposure and LMM events as outcome. The cohort was followed from 01-Jan-2010 until LMM, death, or end of follow-up (31-Dec-2016). Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated by Cox regression with a seven-year follow-up.

RESULTS

Refugees (HR 2.07, 95% CI 1.86-2.30), and non-refugees (HR 1.96, 95% CI 1.85-2.07) had almost doubled relative risk of long-term unemployment, compared with the Swedish-born. The hazards of long-term sickness absence were similar across the groups. Refugees (HR 1.49, 95% CI 1.24-1.77), and non-refugees (HR 1.42, 95% CI 1.30-1.56) also had elevated relative risk of disability pension, whereas second-generation migrants had moderately increased relative risks for all three labour market marginalisation events compared with the Swedish-born.

CONCLUSION

Among the individuals with PTSD, being a migrant increases the risk of LMM, refugees being the foremost among migrants. Further research may benefit from including more recent migrant population, pre-migration information and measuring PTSD clinical severity.

Work-family conflict and depressive symptoms among dual-earner couples in Germany: A dyadic and longitudinal analysis

This study contributes to the existing literature by testing the longitudinal effects of both types of work-family conflict (i.e., work-to-family conflict [WTFC] and family-to-work conflict [FTWC]) on depressive symptoms, using data from three waves of the German Family Panel (pairfam) survey collected over a four-year period. Using responses from 631 married or cohabiting heterosexual couples, the analyses are estimated using dyadic data analysis and auto-regressive and cross-lagged panel models. This analytical approach tests direct causation, reverse causation, and reciprocal relationships among WTFC, FTWC and depressive symptoms. The results suggest a reciprocal relationship with significant cross-lagged actor effects between WTFC (and FTWC) and depressive symptoms. However, there were no gender differences in the cross-lagged actor effects between men and women, and no significant partner effects. These results highlight the bidirectional nature of the relationship between work-family conflict and depressive symptoms, which has several implications for research and practice.

Integrating Evolutionary, Cultural, and Computational Psychiatry: A Multilevel Systemic Approach

This paper proposes an integrative perspective on evolutionary, cultural and computational approaches to psychiatry. These three approaches attempt to frame mental disorders as multiscale entities and offer modes of explanations and modeling strategies that can inform clinical practice. Although each of these perspectives involves systemic thinking, each is limited in its ability to address the complex developmental trajectories and larger social systemic interactions that lead to mental disorders. Inspired by computational modeling in theoretical biology, this paper aims to integrate the modes of explanation offered by evolutionary, cultural and computational psychiatry in a multilevel systemic perspective. We apply the resulting Evolutionary, Cultural and Computational (ECC) model to Major Depressive Disorder (MDD) to illustrate how this integrative approach can guide research and practice in psychiatry.

National or population level interventions addressing the social determinants of mental health - an umbrella review

BACKGROUND

Social circumstances in which people live and work impact the population's mental health. We aimed to synthesise evidence identifying effective interventions and policies that influence the social determinants of mental health at national or scaled population level. We searched five databases (Cochrane Library, Global Health, MEDLINE, EMBASE and PsycINFO) between Jan 1st 2000 and July 23rd 2019 to identify systematic reviews of population-level interventions or policies addressing a recognised social determinant of mental health and collected mental health outcomes. There were no restrictions on country, sub-population or age. A narrative overview of results is provided. Quality assessment was conducted using Assessment of Multiple Systematic Reviews (AMSTAR 2). This study was registered on PROSPERO (CRD42019140198).

RESULTS

We identified 20 reviews for inclusion. Most reviews were of low or critically low quality. Primary studies were mostly observational and from higher income settings. Higher quality evidence indicates more generous welfare benefits may reduce socioeconomic inequalities in mental health outcomes. Lower quality evidence suggests unemployment insurance, warm housing interventions, neighbourhood renewal, paid parental leave, gender equality policies, community-based parenting programmes, and less restrictive migration policies are associated with improved mental health outcomes. Low quality evidence suggests restriction of access to lethal means and multi-component suicide prevention programmes are associated with reduced suicide risk.

CONCLUSION

This umbrella review has identified a small and overall low-quality evidence base for population level interventions addressing the social determinants of mental health. There are significant gaps in the evidence base for key policy areas, which limit ability of national policymakers to understand how to effectively improve population mental health.

Gender differences in trajectories of mental health symptoms among Chinese earthquake survivors

BACKGROUND

Posttraumatic stress symptoms and depressive symptoms are prevalent after natural disasters. However, in a Chinese trauma context, little research examined the long-term trajectories of these two symptoms with a gender perspective.

METHODS

Data came from an 8-year longitudinal survey of 3522 Wenchuan earthquake adult survivors. We used multilevel growth-curve models to investigate the trajectories of PTSS and depressive symptoms; adopted conditional growth-curve models to explore the gender differences in trajectories together with gendered factors associated with mental health symptoms; conducted Chow tests to examine the significance of gender differences. Standardized coefficients, P values, and effect sizes were reported.

RESULTS

With covariates controlled, both linear (β = -1.33, p < 0.001, Cohen's d = 0.79) and quadratic effects (β = 1.03, p < 0.001, Cohen's d = 0.59) of time were significant in PTSS trajectory, whereas quadratic effect (β = 0.27, p < 0.001, Cohen's d = 0.14) in the declining depressive trajectory was clinically nonsignificant. Compared with men, women are at higher risk of PTSS (β = 0.12, p < 0.001, Cohen's d = 0.21) and depressive symptoms (β = 0.10, p < 0.001, Cohen's d = 0.20), but also with a faster-declining rate in PTSS within first five years after the disaster. No gender difference was found regarding depressive trajectory. Additionally, poor education and income associate with more PTSS in women, while sickness predicts severer depression in women and more PTSS in men.

CONCLUSIONS

This study proposes a gendered U-shape trajectory for PTSS and a declining depressive trajectory without gender difference. The findings of this study shed light on mental health intervention in future natural disasters.

Unhealthy environments are associated with adverse mental health and psychological distress: Cross-sectional evidence from nationally representative data in New Zealand

This study combines data on the location of health-constraining 'bads' (i: fast-food outlets, ii: takeaway outlets, iii: dairy outlets and convenience stores, iv: alcohol outlets, and v: gaming venues) and health-promoting 'goods' (i: green spaces, ii: blue spaces, iii: physical activity facilities, and iv: fruit and vegetable outlets) into a nationwide Healthy Living Index. This was applied to pooled (2015/16-2017/18) nationally representative New Zealand Health Survey data, with mental health conditions (depression, bipolar, and anxiety) and psychological distress as population-level outcomes. Mental health was associated with proximity to environmental 'goods' and 'bads'. Compared to those individuals who reside within the unhealthiest environments, there was a steady reduction in the odds of adverse mental health outcomes and psychological distress as the environment became more health-promoting.

Effects of social security policy reforms on mental health and inequalities: A systematic review of observational studies in high-income countries

Evidence increasingly shows that changes to social security policies can affect population mental health. Thus, in the context of rising burden of mental illness, it is of major importance to better understand how expansions and contractions to the social security system may impact on mental health of both adults and children. The aim of this systematic review is to provide a synthesis of observational literature on the effects on mental health and inequalities in mental health of social security reforms. We conducted a systematic review of quantitative observational studies of specific national and regional social security policy changes in high-income countries and summarised the mental health effects of these policies. We searched seven electronic databases, including Medline, PsychInfo, Embase, CINAHL, ASSIA (Proquest), Scopus and Research Papers in Economics from January 1979 to June 2020. We included both objective and subjective mental health and wellbeing measures. The study quality was assessed using the Validity Assessment tool for econometric studies. We identified 13,403 original records, thirty-eight of which were included in the final review. Twenty-one studies evaluated expansionary social security policies and seventeen studies evaluated contractionary policies. Overall, we found that policies that improve social security benefit eligibility/generosity are associated with improvements in mental health, as reported by fourteen of the included studies. Social security policies that reduce eligibility/generosity were related to worse mental health, as reported by eleven studies. Ten studies found no effect for either policies contracting or expanding welfare support. Fourteen studies also evaluated the impact on mental health inequalities and found that contractionary policies tend to increase inequalities whereas expansionary policies have the opposite effect. Changes in social security policies can have significant effects on mental health and health inequalities across different recipient groups. Such health effects should be taken into account when designing future social policy reforms.

Childhood Socioeconomic Status and Depressive Symptom Trajectories in the Transition to Adulthood in the United States and Canada

PURPOSE

We examined whether young people in the U.S. and Canada exhibit similar depressive symptom trajectories in the transition to adulthood and compared the effect of childhood socioeconomic status on trajectory membership.

METHODS

We used the American National Longitudinal Survey of Youth 1979 Child/Young Adult (n = 6,315) and the Canadian National Longitudinal Survey of Children and Youth (n = 3,666). Depressive symptoms were measured using five items from the Center for Epidemiological Studies on Depression scale. Latent trajectories of depressive symptoms from ages 16-25 years were identified using growth mixture models. We estimated the effect of childhood family income, parental education, and parental unemployment on trajectory membership using multivariable Poisson regression models with robust variances.

RESULTS

We identified four similar trajectories in the two countries: (1) low stable; (2) mid-peak; (3) increasing; and (4) decreasing. Relatively more Americans were in the low-stable trajectory group than Canadians (77.6% vs. 64.9%), and fewer Americans were in the decreasing group (7.1% vs. 19.1%). In the U.S., childhood family income in the bottom two quartiles was related to higher rates of increasing trajectory membership compared with income in the top quartile (incidence rate ratios: 1.59-1.79, p < .05), but not in Canada. In the U.S., parental education at a high school level was associated with higher rates of decreasing trajectory membership compared with higher education (incidence rate ratio = 1.45, confidence interval: 1.10-1.91; p = .01), but not in Canada.

CONCLUSIONS

Depressive symptoms may take a similar course in the transition to adulthood within these two countries. Country differences may modify the degree to which childhood socioeconomic status determines trajectory membership.

COVID-19 and Psychological Health of Female Saudi Arabian Population: A Cross-Sectional Study

The influence of the COVID-19 pandemic is unprecedented on physical and mental health. This study aimed to determine the impact of the COVID-19 event on mental health among Saudi Arabian females of Riyadh by a cross-sectional study design. The samples of the study were recruited using convenience and snowball sampling methods. The questionnaire is composed of items related to sociodemographic profile, general mental status, negative attitude scale, impact of event (COVID-19 pandemic) scale (R) and negative health impact. The data obtained were analyzed using multivariate regression analysis. Out of the 797 samples (34.58 ± 12.89 years), 457 (57.34%) belonged to an age group of ≥25 years. The average BMI of the participants was 26.73 (kg/m²). Significantly (p = 0.000), a large proportion of the participants were overweight and unemployed. Age group (>25 years) have more odds for abnormal mental status (OR; 1.592), development of negative attitudes (OR; 1.986), the intense impact of COVID-19 events (OR; 1.444) and susceptibility to attain negative health impacts (OR; 1.574). High body weight is another risk factor for altered mental status, negative attitude and developing impact of COVID-19 quickly. Overall, the COVID-19 pandemic was directly associated with stress (53%), anxiety (63%) and depression (44%) in our sample population. There is an urgent need for psychological counseling for the distressed population.

Low assets and financial stressors associated with higher depression during COVID-19 in a nationally representative sample of US adults

BACKGROUND

COVID-19 and related containment policies have caused or heightened financial stressors for many in the USA. We assessed the relation between assets, financial stressors and probable depression during the COVID-19 pandemic.

METHODS

Between 31 March 2020 and 13 April 2020, we surveyed a probability-based, nationally representative sample of US adults ages 18 and older using the COVID-19 and Life stressors Impact on Mental Health and Well-being survey (n=1441). We calculated the prevalence of probable depression using the Patient Health Questionnaire-9 (cut-off ≥10) and exposure to financial stressors by financial, physical and social assets categories (household income, household savings, home ownership, educational attainment and marital status). We estimated adjusted ORs and predicted probabilities of probable depression across assets categories and COVID-19 financial stressor exposure groups.

RESULTS

We found that (1) 40% of US adults experienced COVID-19-related financial stressors during this time period; (2) low assets (OR: 3.0, 95% CI 2.1 to 4.2) and COVID-19 financial stressor exposure (OR: 2.8, 95% CI 2.1 to 3.9) were each associated with higher odds of probable depression; and (3) among persons with low assets and high COVID-19 financial stressors, 42.7% had probable depression; and among persons with high assets and low COVID-19 financial stressors, 11.1% had probable depression. Persons with high assets and high COVID-19 financial stressors had a similar prevalence of probable depression (33.5%) as persons with low assets and low COVID-19 financial stressors (33.5%). The more assets a person had, the lower the level of probable depression.

CONCLUSION

Populations with low assets are bearing a greater burden of mental illness during the COVID-19 pandemic.

Prevalence of Depression Symptoms in US Adults Before and During the COVID-19 Pandemic

IMPORTANCE

The coronavirus disease 2019 (COVID-19) pandemic and the policies to contain it have been a near ubiquitous exposure in the US with unknown effects on depression symptoms.

OBJECTIVE

To estimate the prevalence of and risk factors associated with depression symptoms among US adults during vs before the COVID-19 pandemic.

DESIGN, SETTING, AND PARTICIPANTS

This nationally representative survey study used 2 population-based surveys of US adults aged 18 or older. During COVID-19, estimates were derived from the COVID-19 and Life Stressors Impact on Mental Health and Well-being study, conducted from March 31, 2020, to April 13, 2020. Before COVID-19 estimates were derived from the National Health and Nutrition Examination Survey, conducted from 2017 to 2018. Data were analyzed from April 15 to 20, 2020.

EXPOSURES

The COVID-19 pandemic and outcomes associated with the measures to mitigate it.

MAIN OUTCOMES AND MEASURES

Depression symptoms, defined using the Patient Health Questionnaire-9 cutoff of 10 or higher. Categories of depression symptoms were defined as none (score, 0-4), mild (score, 5-9), moderate (score, 10-14), moderately severe (score, 15-19), and severe (score, ≥20).

RESULTS

A total of 1470 participants completed the COVID-19 and Life Stressors Impact on Mental Health and Well-being survey (completion rate, 64.3%), and after removing those with missing data, the final during-COVID-19 sample included 1441 participants (619 participants [43.0%] aged 18-39 years; 723 [50.2%] men; 933 [64.7%] non-Hispanic White). The pre-COVID-19 sample included 5065 participants (1704 participants [37.8%] aged 18-39 years; 2588 [51.4%] women; 1790 [62.9%] non-Hispanic White). Depression symptom prevalence was higher in every category during COVID-19 compared with before (mild: 24.6% [95% CI, 21.8%-27.7%] vs 16.2% [95% CI, 15.1%-17.4%]; moderate: 14.8% [95% CI, 12.6%-17.4%] vs 5.7% [95% CI, 4.8%-6.9%]; moderately severe: 7.9% [95% CI, 6.3%-9.8%] vs 2.1% [95% CI, 1.6%-2.8%]; severe: 5.1% [95% CI, 3.8%-6.9%] vs 0.7% [95% CI, 0.5%-0.9%]). Higher risk of depression symptoms during COVID-19 was associated with having lower income (odds ratio, 2.37 [95% CI, 1.26-4.43]), having less than $5000 in savings (odds ratio, 1.52 [95% CI, 1.02-2.26]), and exposure to more stressors (odds ratio, 3.05 [95% CI, 1.95-4.77]).

CONCLUSIONS AND RELEVANCE

These findings suggest that prevalence of depression symptoms in the US was more than 3-fold higher during COVID-19 compared with before the COVID-19 pandemic. Individuals with lower social resources, lower economic resources, and greater exposure to stressors (eg, job loss) reported a greater burden of depression symptoms. Post-COVID-19 plans should account for the probable increase in mental illness to come, particularly among at-risk populations.

Investigating the relationship between changes in social security benefits and mental health: a protocol for a systematic review

INTRODUCTION

Poor mental health is one of the greatest causes of disability in the world. Evidence increasingly shows that population mental health may be influenced by national social security policies. This systematic review aims to establish the relationship between social security and mental health in order to help inform recommendations for policy-makers, practitioners and future research.

METHODS AND ANALYSIS

A systematic review of quantitative observational studies investigating mental health outcomes related to changes in social security policies will be conducted. Six major databases, including Medline, PsychInfo, Embase, Cumulative Index to Nursing and Allied Health Literature, Applied Social Sciences Index Abstracts and Scopus, as well as Research Papers in Economics will be searched from January 1979 to April 2020. The electronic database searches will be supplemented by reference and citation searches as well as hand-searching of key journals. The outcomes of interest are objective or subjective mental health outcomes, including stress, anxiety, depression, self-reported mental health scores, subjective well-being and suicide. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the quality of the studies will be assessed by the validity assessment framework designed for appraising econometric studies. A narrative synthesis will be conducted for all included studies. If data permit, study findings will be synthesised by conducting a meta-analysis.

ETHICS AND DISSEMINATION

As it will be a systematic review, without primary data collection, there will be no requirement for ethical approval. Findings will be disseminated through peer-reviewed publications and in various media, for example, conferences or symposia.

PROSPERO REGISTRATION NUMBER

CRD42019154733.

Mental disorders in adolescents, youth, and adults in the RPS Birth Cohort Consortium (Ribeirão Preto, Pelotas and São Luís), Brazil

Although depression and anxiety are known to result in disabilities and workplace and health system losses, population-based studies on this problem are rare in Brazil. The current study assessed the prevalence of mental disorders in adolescents, youth, and adults and the relationship to sociodemographic characteristics in five birth cohorts (RPS) in Ribeirão Preto (São Paulo State), Pelotas (Rio Grande do Sul State), and São Luís (Maranhão State), Brazil. Major depressive episode, suicide risk, social phobia, and generalized anxiety disorder were assessed with the Mini International Neuropsychiatric Interview. Bootstrap confidence intervals were estimated and prevalence rates were stratified by sex and socioeconomic status in the R program. The study included 12,350 participants from the cohorts. Current major depressive episode was more prevalent in adolescents in São Luís (15.8%; 95%CI: 14.8-16.8) and adults in Ribeirão Preto (12.9%; 95%CI: 12.0-13.9). The highest prevalence rates for suicide risk were in adults in Ribeirão Preto (13.7%; 95%CI: 12.7-14.7), and the highest rates for social phobia and generalized anxiety were in youth in Pelotas, with 7% (95%CI: 6.3-7.7) and 16.5% (95%CI: 15.4-17.5), respectively. The lowest prevalence rates of suicide risk were in youth in Pelotas (8.8%; 95%CI: 8.0-9.6), social phobia in youth in Ribeirão Preto (1.8%; 95%CI: 1.5-2.2), and generalized anxiety in adolescents in São Luís (3.5%; 95%CI: 3.0-4.0). Mental disorders in general were more prevalent in women and in individuals with lower socioeconomic status, independently of the city and age, emphasizing the need for more investment in mental health in Brazil, including gender and socioeconomic determinants.