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Inequalities in Mental Health in the Spanish Autonomous Communities: A Multilevel Study

  • Kátia B. Rocha (a1), Katherine Perez (a2), Maica Rodriguez-Sanz (a2), Carles Muntaner (a3), Jordi Alonso (a4) and Carme Borrell (a2)...


The aim of this study was to analyze inequalities in the prevalence of poor mental health and their association with socioeconomic variables and with the care network in the Autonomous Communities in Spain. A cross-sectional multilevel study was performed, which analyzed individual data from the National Health Survey in Spain (ENS), in 2006 (n = 29,476 people over the age of 16). The prevalence of poor mental health was the dependent variable, measured by the General Health Questionnaire (GHQ-12 > = 3). Individual and contextual socioeconomic variables, along with mental health services in the Autonomous Communities, were included as independent variables. Models of multilevel logistic regression were used, and odds ratios (OR) were obtained, with confidence intervals (CI) of 95%. The results showed that there are inequalities in the prevalence of poor mental health in Spain, associated to contextual variables, such as unemployment rate (men OR 1.04 CI 1.01–1.07; women OR 1.02 CI 1.00–1.05). On the other hand, it was observed that inequalities in the mental health care resources in the Autonomous Communities also have an impact on poor mental health.


Corresponding author

*Correspondence concerning this article should be addressed to Kátia B. Rocha. Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS). Porto Alegre (Brazil). Av. Ipiranga, 6681. Prédio 11. Sala 931 90619–900. E-mail:


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Alonso, J., & Lepine, J. P. (2007). Overview of key data from the European Study of the Epidemiology of Mental Disorders (ESEMeD). Journal of Clinical Psychology, 68, 39.
Artazcoz, L., Benach, J., Borrell, C., & Cortes, I. (2004). Unemployment and mental health: Understanding the interactions among gender, family roles and social class. American Journal of Public Health, 94, 8288.
Artazcoz, L., Borrell, C., & Benach, J. (2001). Gender inequalities in health among workers: The relation with family demands. Journal of Epidemiology and Community Health, 55, 639647.
Barbaglia, G., Duran, N., Vilagut, G., Forero, C. G., Haro, J. M., & Alonso, J. (2013). Discapacidad funcional Atribuible a trastornos mentales y Físicos Frecuentes en España [Effects of common mental disorders and physical conditions on role functioning in Spain]. Gaceta Sanitária, 27, 480486.
Buss, P. M., & Pellegrini, A. (2007). A saúde e seus determinantes sociais. [Health and social determinants]. Physis: Revista Saúde Coletiva, 17, 7793.
Cowell, F. A., & Kuga, K. (1981). Inequality measurement: An axiomatic approach. Journal of Economic Theory, 25, 287305.
Domingo-Salvany, A., Regidor, E., Alonso, J., & Alvarez-Dardet, C. (2000). Propuesta de medida de clase social. Grupo de Trabajo de la Sociedad Española de Epidemiología y la Sociedad Española de Medicina Familiar y Comunitaria. [Proposal for a social class measure. Working group of the Spanish Society of epidemiology and the Spanish Society of family and community medicine]. Atencion Primaria, 25, 350363.
Fone, D., Dunstan, F., Williams, G., Lloyd, K., & Palmer, S. (2007). Places, people and mental health: A multilevel analysis of economic inactivity. Social Science & Medicine, 64, 633645.
Fryers, T., Melzer, D., & Jenkins, R. (2003). Social inequalities and the common mental disorders: A systematic review of the evidence. Social Psychiatric and Psychiatric Epidemiology, 38, 229237.
Gispert, M. R., Puig, O. X., Palomera, F. E., Autonell, C. J., Gine, J. M., & Ribas, S. G. (2006). Los factores individuales y ecológicos relacionados con la variabilidad geográfica de los trastornos psicológicos entre áreas pequeñas: un análisis multinivel en Cataluña, España [Individual and ecological factors related to the geographical variability of psychological distress among small areas: A multilevel analysis in Catalonia, Spain]. Revista Española de Salud Pública, 80, 335347.
Goldberg, D. P., Gater, R., Sartorius, N., Ustun, T. B., Piccinelli, M., Gureje, O., & Rutter, C. (1997). The validity of two versions of the GHQ in the WHO study of mental health illness in general health care. Psychological Medicine, 27, 191197.
Haro, J. M., Palacin, C., Vilagut, G., Martínez, M., Bernal, M., Luque, I., … Alonso, J. (2006). Prevalencia de los trastornos mentales y factores asociados: resultados del estudio ESEMeD. [Prevalence of mental disorders and associated factors: Results from the ESEMeD-Spain study]. Medicina Clínica, 126, 445451.
Harrison, J., Barrow, S., & Creed, F. (1998). Mental health in the North West region of England: Associations with deprivation. Social Psychiatry and Psychiatric Epidemiology, 33, 124128.
Hatch, S. L., & Dohrenwend, B. P. (2007). Distribution of traumatic and other stressful life events by race/ethnicity, gender, SES and age: A review of the research. American Journal of Community Psychology, 40, 313332.
Hsiao, W. C., & Liu, Y. (2001). Health care financing: Assessing its relationship to health equity. In Evans, T., Whitehead, M., Diderichsen, F., Bhuiya, A., & Wirth, M. (Ed.), Challenging inequities in health. From ethics to action. Oxford, UK: Oxford University Press.
INE Instituto Nacional de Estadística (2013). Estadísticas del mercado laboral [Labour market statistics]. Madrid, Spain: Retrieved from
Kawachi, I., & Kennedy, B. P. (1997). Health and social cohesion: Why care about income inequality? BMJ, 314, 10371040.
Legido-Quigley, H., Otero-Garcia, L., la Parra, D., Alvarez-Dardet, C., Martin-Moreno, J. M., & McKee, M. (2013). Will austerity cuts dismantle the Spanish health care system? BMJ, 346. http://dx.10.1136/bmj.f2363
Medel, A., & Sarria, A. (2009). Indicadores hospitalarios por Comunidades Autónomas, 1980-2004 (Análisis longitudinal de indicadores de morbilidad y dotación hospitalaria en salud mental). [Hospital indicators by Regional Communities, 1980–2004 (Longitudinal analysis of morbidity indicators and hospital staffing in mental health)]. Actas Españolas de Psiquiatría 37, 8293.
Ministerio de, Sanidad, y, Consumo. (2006). Encuesta Nacional de Salud en España. [Spain National Health Survey]. Madrid, Spain: Author. Retrieved from
Montilla, J. F., Gonzáles, C., Retolaza, Duenas, C., & Alameda, J. (2002). Uso de servicios ambulatorios de salud mental en España. Consumo de recursos en el primer año de asistencia a pacientes nuevos. [Use of mental health services in Spain: Resource consumption in the first year of assistance to new patients]. Revista de la Asociación Española de Neuropsiquiatría 84, 2547.
Muntaner, C., Li, Y., Xue, X., Thompson, T., O'Campo, P., Chung, H., & Eaton, W. W. (2006). County level socioeconomic position, work organization and depression disorder: A repeated measures cross-classified multilevel analysis of low-income nursing home workers. Health Place, 12, 688700.
Observatorio de Salud Mental de la Asociación Española de Neuropsiquiatría (2009). Statistical data. Madrid, Spain. Ministerio de Sanidad y Consumo. Retrieved from
Observatorio Social de España (2006). Wage Structure Survey. Barcelona, Spain: Ministerio de Trabajo e Inmigración. Retrieved from
Reverte-Cejudo, D., & Sanchez-Bayle, M. (1999). Devolving health services to Spain’s autonomous regions. BMJ, 318, 12041205.
Ricci-Cabello, I., Ruiz-Perez, I., Plazaola-Castano, J., & Montero-Pinar, I. (2010). Morbilidad psíquica, existencia de diagnóstico y consumo de psicofármacos. Diferencias por comunidades autónomas según la Encuesta Nacional de Salud de 2006. [Mental disease, existence of diagnostic, use of psychotropic medication. Differences by Autonomous Communities under the National Health Survey 2006]. Revista Española de Salud Publica, 84, 2941.
Rocha, K. B., Pérez, K., Rodríguez-Sanz, M., Borrell, C., & Obiols, C. (2011). Propiedades psicométricas y valores normativos del General Health Questionnaire (GHQ-12) en población general española. [Psychometric properties and normative values of the General Health Questionnaire (GHQ-12) in the Spanish general population]. International Journal of Clinical and Health Psychology, 11, 125139.
Rocha, K., Pérez, K., Rodríguez-Sanz, M., Alonso, J., Muntaner, C., & Borrell, C. (2013). Inequalities in the use of services provided by psychiatrists in Spain: A Multilevel Study. Psychiatric Online, 64, 901907.
Rocha, K. B., Rodríguez-Sanz, M., Pérez, K., Obiols, J. E., & Borrell, C. (2013). Inequalities in the utilization of psychiatric and psychological services in Catalonia: A multilevel approach. Administration and Policy in Mental Health and Mental Health Services Research, 40, 355363.
Rocha, K. B., Pérez, K., Rodríguez-Sanz, M., Borrell, C., & Obiols, J. E. (2010). Prevalence of mental health problems and their association with socioeconomic, work and health variables: Findings from the Spain National Health Survey. Psicothema, 22, 389395.
Salvador-Carulla, L., Costa-Font, J., Cabases, J., McDaid, D., & Alonso, J. (2010). Evaluating mental health care and policy in Spain. Journal of Mental Health Policy and Economics, 13, 7386.
Salvador-Carulla, L., Garrido, M., McDaid, D., & Haro, J. M. (2006). Financing mental health care in Spain. European Journal of Psychiatry, 20, 2934.
Salvador-Carulla, L., Saldivia, S., Martinez-Leal, R., Benjamin, V., Garcia-Alonso, C., Grandon, P., & Haro, J. M. (2008). Meso-level comparison of mental health service availability and use in Chile and Spain. Psychiatric Services, 59, 421428.
Weich, S., Blanchard, M., Prince, M., Burton, E., Erens, B., & Sproston, K. (2002). Mental health and the built environment: Cross-sectional survey of individual and contextual risk factors for depression. The British Journal of Psychiatry, 180, 428433.
Wilkinson, R., & Pickett, K. (2009). The spirit level: Why more equal societies almost always do better. London, UK: Allen Lane.
World Health Organization – WHO. (2003). Investing in Mental Health. Geneva, Switzerland: WHO Department of Mental Health and Substance Abuse.
World Health Organization – WHO. (2005). Mental Health Atlas 2005. Geneva, Switzerland: WHO.
Word Health Organization – WHO. (2008). The global burden of disease – 2004 update. Geneva, Switzerland: WHO. Retrieved from
Word Health Organization – WHO. (2011). Mental Health Atlas. Geneva, Switzerland: WHO. Retrieved from


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Inequalities in Mental Health in the Spanish Autonomous Communities: A Multilevel Study

  • Kátia B. Rocha (a1), Katherine Perez (a2), Maica Rodriguez-Sanz (a2), Carles Muntaner (a3), Jordi Alonso (a4) and Carme Borrell (a2)...


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