Noortje is a Research Fellow in the team at our editorial base in York. In her first Cochrane Common Mental Disorders blog, Noortje reflects on a subject she is passionate about - inequalities in mental health.
Mental health for all?
‘The social, physical and economic environments in which people are born, grow, live, work, and age have important implications for mental health.’1 If this is the case, then why do we focus almost all of our attention and resources in research, healthcare, and public health on the individual?
Almost all societies have a social ladder. Few people are at the top, with a lot of money, power, status and resources. Most people are lower down, with less money, power, social status, and resources. People further down the ladder have usually received less education, they tend to have lower wages and more insecure jobs, and often live in more deprived neighbourhoods. This ladder is steep and difficult to climb. In 2016, the 62 richest people in the world owned as much as the poorest half of the world population.2
People lower down the social ladder, on average, have worse mental health. In a UK survey from 2015, 14% of the richest fifth of adults reported they were experiencing anxiety and/or depression, compared to 21% of the poorest fifth of adults.3
Studies have found inequalities for children, adolescents, UK students, employed adults, in England, and around the world. They have found associations between mental health problems and income, level of education, occupation, family affluence, and area deprivation.
York-based charity Joseph Rowntree Foundation offers an insight into the stressors faced by people in poverty. They highlight the difficulty of making healthy choices, the added burden of physical illness, the stress associated with having a low income, and the importance of the goods and services money can buy.
Even though socioeconomic circumstances are clearly important, most efforts to improve mental health or prevent mental health problems point towards individual responsibility. Employers offer staff resilience training, rather than making the work environment less stressful. Parents are advised to enrol in parenting courses, while many cannot afford sufficient and nutritious food for their family. ‘Time to Talk Day’ and ‘World Mental Health Day’ comes with a flood of well-meant advice, telling us to #exercise, #talk, and #enjoynature.
As a researcher, I would like to do more to reduce mental health inequalities. They are unfair and unnecessary. We can work harder to include people of all socioeconomic groups in studies of mental health, so that findings apply to all of society. I recently worked with colleagues to make literature on inequalities easier to search for, and the Campbell and Cochrane Equity Methods Group promotes assessment of health inequalities in literature reviews.
Finally, I hope that sharing my thoughts will help to change conversations. Instead of focusing on individual responsibility for mental health, can we talk about the role of our circumstances and environment?
Noortje Uphoff, March 2019
Noortje is a Research Fellow in the Centre for Reviews and Dissemination at the University of York. She works on systematic reviews and research projects relating to mental health prevention, treatment, global mental health, and comorbidity of mental and physical health.
Previously, Noortje worked with the Born in Bradford cohort study. She has experience conducting systematic reviews, studies on social and ethnic inequalities in health, and the evaluation of complex interventions.
If you would like to read the studies we linked to, but you do not have access to the journals, please get in touch.
Mental Health Foundation. Better Mental Health for All: A Public Health Approach to Mental Health Improvement.; 2016. https://www.mentalhealth.org.uk/publications/better-mental-health-all-public-health-approach-mental-health-improvement.
Oxfam. 62 people own same as half world. http://oxfamapps.org/media/prhow. Published 2016. Accessed March 9, 2019.
Joseph Rowntree Foundation. Adults experiencing anxiety or depression by income group. https://www.jrf.org.uk/data/adults-experiencing-anxiety-or-depression-income-group. Accessed March 9, 2019.
- Elgar FJ, Pförtner T-K, Moor I, De Clercq B, Stevens GWJM, Currie C. Socioeconomic inequalities in adolescent health 2002–2010: a time-series analysis of 34 countries participating in the Health Behaviour in School-aged Children study. Lancet. 2015;385(9982):2088-2095. doi:https://doi.org/10.1016/S0140-6736(14)61460-4
Fitzsimons E, Goodman A, Kelly E, Smith JP. Poverty dynamics and parental mental health: Determinants of childhood mental health in the UK. Soc Sci Med. 2017;175:43-51. doi:https://doi.org/10.1016/j.socscimed.2016.12.040
Ibrahim AK, Kelly SJ, Glazebrook C. Socioeconomic status and the risk of depression among UK higher education students. Soc Psychiatry Psychiatr Epidemiol. 2013;48(9):1491-1501.
Lopes B, Kamau C, Jaspal R. The Roles of Socioeconomic Status, Occupational Health and Job Rank on the Epidemiology of Different Psychiatric Symptoms in a Sample of UK Workers. Community Ment Health J. 2019;55(2):336-349. doi:10.1007/s10597-018-0259-3
- Ormel J, Cuijpers P, Jorm AF, Schoevers R. Prevention of depression will only succeed when it is structurally embedded and targets big determinants. World Psychiatry. 2019;18(1):111-112. doi:10.1002/wps.20580
Patel V, Burns JK, Dhingra M, Tarver L, Kohrt BA, Lund C. Income inequality and depression: a systematic review and meta-analysis of the association and a scoping review of mechanisms. World Psychiatry. 2018;17(1):76-89. doi:10.1002/wps.20492
Power M, Uphoff E, Kelly B, Pickett KE. Food insecurity and mental health: An analysis of routine primary care data of pregnant women in the Born in Bradford cohort. J Epidemiol Community Health. 2017;71(4). doi:10.1136/jech-2016-207799
Power M, Uphoff EP, Stewart-Knox B, Small N, Doherty B, Pickett KE. Food insecurity and socio-demographic characteristics in two UK ethnic groups: An analysis of women in the Born in Bradford cohort. J Public Heal (United Kingdom). 2018;40(1). doi:10.1093/pubmed/fdx029
Prady SL, Uphoff EP, Power M, Golder S. Development and validation of a search filter to identify equity-focused studies: reducing the number needed to screen. BMC Med Res Methodol. 2018;18(1):106. doi:10.1186/s12874-018-0567-x
Stewart-Brown S, Samaraweera PC, Taggart F, Kandala N-B, Stranges S. Socioeconomic gradients and mental health: implications for public health. Br J Psychiatry. 2015;206(6):461-465. doi:DOI: 10.1192/bjp.bp.114.147280