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Inequality: an underacknowledged source of mental illness and distress

  • Kate E. Pickett (a1) and Richard G. Wilkinson (a2)
Summary

Greater income inequality is associated with higher prevalence of mental illness and drug misuse in rich societies. There are threefold differences in the proportion of the population suffering from mental illness between more and less equal countries. This relationship is most likely mediated by the impact of inequality on the quality of social relationships and the scale of status differentiation in different societies.

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Corresponding author
Kate E. Pickett, Department of Health Sciences, University of York, Seebohm Rowntree Building, Area 2, Heslington, York YO10 5DD, UK. Email: kp6@york.ac.uk
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Declaration of interest

None.

Footnotes
References
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1 Wilkinson, RG, Pickett, KE. Income inequality and population health: a review and explanation of the evidence. Soc Sci Med 2006; 62: 1768–84.
2 Kondo, N, Sembajwe, G, Kawachi, I, van Dam, RM, Subramanian, SV, Yamagata, Z. Income inequality, mortality and self-rated health: a meta-analysis of multilevel studies with 60 million subjects. BMJ 2009; 339: b4471.
3 Subramanian, SV, Kawachi, I. Income inequality and health: what have we learned so far? Epidemiol Rev 2004; 26: 7891.
4 Wolfson, M, Kaplan, G, Lynch, J, Ross, N, Backlund, E. Relation between income inequality and mortality: empirical demonstration. BMJ 1999; 319: 953–5.
5 Weich, S, Lewis, G, Jenkins, SP. Income inequality and the prevalence of common mental disorders in Britain. Br J Psychiatry 2001; 178: 222–7.
6 Wilkinson, R, Pickett, K. The Spirit Level: Why Equality is Better for Everyone. Penguin, 2010.
7 Wilkinson, R, Pickett, KE. The problems of relative deprivation: why some societies do better than others. Soc Sci Med 2007; 65: 1965–78.
8 Wilkinson, R, Pickett, KE. Income inequality and social dysfunction. Ann Rev Sociol 2009; 35: 493511.
9 Donnellan, C. Mental Wellbeing. Independence Educational Publishers, 2004.
10 Office for National Statistics, Psychiatric Morbidity among Adults Living in Private Households, 2000. TSO (The Stationery Office), 2001.
11 Demyttenaere, K, Bruffaerts, R, Posada-Villa, J, Gasquet, I, Kovess, V, Lepine, JP, et al. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA 2004; 291: 2581–90.
12 Wells, JE, Oakely-Brown, MA, Scott, KM, Mcgee, MA, Baxter, J, Kokaua, J, et al. Te Rau Hinengaro: the New Zealand Mental Health Survey: overview of methods and findings. Aust N Z J Psychiatry 2006; 40: 835–44.
13 Australian Bureau of Statistics. National Health Survey, Mental Health, 2001. Australian Bureau of Statistics, 2003.
14 WHO International Consortium in Psychiatric Epidemiology. Cross-national comparisons of the prevalences and correlates of mental disorders. Bull World Health Organ 2000; 78: 413–26.
15 Zahran, HS, Kobau, R, Moriarty, DG, Zack, MM, Holt, J, Donehoo, R, et al. Health-related quality of life surveillance–United States, 1993–2002. MMWR Surveill Summ 2005; 54: 135.
16 Child and Adolescent Health Measurement Initiative. National Survey of Children's Health, Data Resource Center on Child and Adolescent Health. Child and Adolescent Health Measurement Initiative. CAHMI, 2006 (http://www.childhealthdata.org).
17 Fiscella, K, Franks, P. Individual income, income inequality, health, and mortality: what are the relationships? Health Serv Res 2000; 35:307–18.
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19 Shi, L, Starfield, B, Politzer, R, Regan, J. Primary care, self-rated health, and reductions in social disparities in health. Health Serv Res 2002; 37: 529–50.
20 Henderson, C, Liu, X, Diez Roux, AV, Link, BG, Hasin, D. The effects of US state income inequality and alcohol policies on symptoms of depression and alcohol dependence. Soc Sci Med 2004; 58: 565–75.
21 James, O. Affluenza. Vermilion, 2007.
22 de Botton, A. Status Anxiety. Hamish Hamilton, 2004.
23 Frank, RH. Luxury Fever. Free Press, 1999.
24 Layard, R. Happiness: Lessons from a New Science. Allen Lane, 2005.
25 United Nations Office on Drugs and Crime. World Drug Report. UN Office on Drugs and Crime, 2007.
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27 Morgan, D, Grant, KA, Gage, HD, Mach, RH, Kaplan, JR, Prioleau, O, et al. Social dominance in monkeys: dopamine D2 receptors and cocaine self-administration. Nat Neurosci 2002; 5: 169–74.
28 Friedli, L. Mental Health, Resilience and Inequalities. WHO Regional Office for Europe, 2009.
29 The Marmot Review. Fair Society, Healthy Lives. The Marmot Review, 2010.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
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Inequality: an underacknowledged source of mental illness and distress

  • Kate E. Pickett (a1) and Richard G. Wilkinson (a2)
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eLetters

Inequality, mental health and research

David Harper, Reader in Clinical Psychology
09 February 2011

Pickett and Wilkinson (2010) are to be congratulated for directing our attention to the pervasive effects of social inequality on mental health and suggesting interventions targeted at the global, national and community level - rather than solely at the individual therapy level, as health professionals are inclined to do.

Whilst we agree that there is much evidence to link inequality and mental health we would like to offer some suggestions for future research in this area. One of the problems with psychiatric epidemiology, as Rogersand Pilgrim (2003) have noted, is that it draws on heterogeneous, contested categories which often have considerable problems of reliabilityand validity (Boyle, 2002). For researchers to make clearer links betweeninequality and mental distress it will be important to conduct studies which gather information on particular kinds of problematic experience -- what some authors refer to as complaints (Bentall, 2004) or symptoms.

We also need to re-conceptualise mental health as not simply a categorical variable which is either absent or present, but something thatexists along a continuum, across a number of dimensions, which is influenced by context, and has a particular set of individual and culturalmeanings. Obviously, given the increasing globalised medicalisation of distress the thresholds need to be set much higher than they are currentlyso that only clinically significant distress is captured. There is also a need to draw on systematic qualitative investigations that enable the context and meaning of distress and inequality to be understood (e.g. Charlesworth, 1999). This might also be extended to examine how those who are wealthy live with the privileges that wealth brings.

Lastly, as Pickett and Wilkinson note, there are a number of candidate causal hypotheseses. However, there is remarkably little research into models that link inequality and distress. One of the problems with the explanations Pickett and Wilkinson cite is that they tend to over-emphasise psychological variables, potentially obscuring the significant contribution of actual social and material conditions. Research needs to be guided by rigorous psychosocial models that do not dualistically separate the psychological from other influences.

David Harper, Reader in Clinical Psychology, University of East London

John Cromby, Senior Lecturer, Loughborough University

References

Bentall, R.P. (2004). Madness Explained: Psychosis And Human Nature Allen Lane/Penguin: London.

Boyle, M. (2002). Schizophrenia: A Scientific Delusion? Second edition. London: Routledge.

Charlesworth, S.J. (1999). A Phenomenology Of Working-Class Experience. London: Cambridge University Press.

Pickett, K.E. & Wilkinson, R.G. (2010). Inequality: an underacknowledged source of mental illness and distress. British Journal of Psychiatry, 197, 426–428.

Rogers, A. & Pilgrim, D. (2003). Mental Health and Inequality. Basingstoke: Palgrave MacMillan.
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Conflict of interest: None Declared

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"Income inequality and mental health problems"

derek a summerfield, consultant psychiatrist/Hon Sen Lect
26 January 2011

I thank Prof Pickett for her response to my letter. My quarrel is indeed not with her and her co-author but with the WHO-backed epidemiologythat has produced frankly incredible population prevalences for mental disorder like 1 in 4. My quarrel is also with a biomedically driven psychiatric academe and with profession leaders like the Royal College of Psychiatrists who self-aggrandisingly endorse such figures. From what ProfPickett says, the correlations she is identifying apply whether the comparison is with “distress”, “mental health problems” or “mental illness”, but for the psychiatric profession maintaining such distinctionsis crucial for its very credibility. (Not long ago I asked Sir David Goldberg, originator of perhaps the most widely used screening instrument the GHQ, what he had intended to capture with it. “Distress”, he replied. But distress” is not “mental illness”.) These concepts are increasingly blurred by cultural trends towards medicalisation of everyday life, endorsing a view of the average citizen as ever less robust and more vulnerable. Psychiatry seems uncritically to support this process, which will do no one any good in the longer run across society.

My reflections were not intended to question the thrust of the work on income inequality and health, which as I said has built up a near unassailable body of evidence, merely to query how much the slope of the graph might have been steepened by apparently stronger trends towards the medicalisation of nonspecific distress in the English speaking world by comparison with other cultures.

Finally, I wish I could share Prof Pickett's apparent optimism that greater equality is achievable. To reverse the income inequality that has been deepening in UK since the late 1970s would take more than mere governmental tinkering, since we are all anchored to an economic system whose intrinsic thrust runs implacably the other way, particularly in its neoliberal form. To alter this will take a revolution!
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Conflict of interest: None Declared

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Inequality, deprivation and psychosis

Rob Poole, Professor of Mental Health
24 January 2011

Pickett and Wilkinson’s editorial on the public health impact of income inequality1 is a timely reminder that there are preventative measures that can be taken to improve the mental health of the UK population, and that these need not involve the daunting, and perhaps impossible , task of mass individual intervention to attempt to induce change at a population level. Like their excellent book, The Spirit Level,2 their article does not explore the relationship between psychosis and social deprivation, perhaps because the association is complex.

There is strong evidence that the prevalence of psychosis is especially high amongst deprived inner city populations. Despite the fact that psychiatrists generally regard psychosis as a genetic or biological disorder, the association between prevalence and deprivation may be at least as strong (if not stronger) for psychosis as for depression3. Although older studies have suggested that this may be due to social drift, more recent studies of place of birth4, and of the mental health ofthe offspring of migrants5, strongly suggest that environmental factors related to social deprivation play a major aetiological role.

At present it is not clear whether social inequality or specific types of deprivation are the relevant factor. People who have grown up in rural deprivation appear to have a lower risk of becoming psychotic than their urban compatriots6, which suggests that specific types of deprivation might be more relevant. The psychological mechanisms linking social inequality (rather than wealth) in childhood to mental health are also poorly understood. Presumably the feeling of being relatively socially disadvantaged must involve some kind of negative comparison against a reference group. As Pickett and Wilkinson’s work finds effects over large geographical areas, rather than locally, it seems likely that beliefs about one’s status in society as a whole are important.

These are complications, but not necessarily contradictions, with regard to Pickett and Wilkinson’s central contention that inequality is the important factor. In any case, the current state of knowledge leads usto the same conclusion: the nation’s mental health would be likely to improve if our society was more equal than it is at present.

Rob Poole, Professor of Mental Health, Glyndwr University, Wrexham.

Richard Bentall, Professor of Clinical Psychology, University of Liverpool.

Declaration of interests: none

References

1.Pickett K, Wilkinson R. (2010), Inequality: an underacknowledged source of mental illness and distress. British Journal of Psychiatry 197,426-428.

2.Wilkinson R, Pickett K. (2009) The Spirit Level: Why More Equal Societies Almost Always Do Better. London: Allen Lane.

3.Sundquist K, Gõlin F, Sundquist J. (2004) Urbanisation and incidence of psychosis and depression. British Journal of Psychiatry. 184,293-298.

4.Harrison G, Gunnell D, Glazebrook C, Page K, Kwiecinski R. (2001) Association between schizophrenia and social inequality at birth: case-control study. British Journal of Psychiatry. 179, 346-350.

5.Hutchinson G, Takei N, Fahy TA, Bhugra D, Gilvarry C, Moran P, Mallett R, Sham P, Leff J, Murray RM. (1996) Morbid risk of schizophrenia in first degree relatives of White and African-Caribbean patients with psychosis. British Journal of Psychiatry. 169, 776-780.

6.Lewis G, David A, Andréasson S, Allebeck P. (1992) Schizophreniaand city life. Lancet. 340, 137-140.
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Conflict of interest: None Declared

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Preventing the inequality gap widening: the role of the General Practitioner

Trisha Sivaraman, Medical Student
22 December 2010

Dear Editor,

Pickett and Wilkinson discuss how mental health and drug use is more prevalent in countries with higher income inequalities [1]. They suggest a possible solution to this problem, by redistributing income through taxes and benefits, and finding ways to reduce income differences in market incomes before taxes [1]. However, how practical and feasible this solution is in the near future is debatable. The inequality gap continues to widen, and it is important that all is done in our power as asociety to bring this to a halt.

At any one time, one in six people of working age have a mental health problem, most often anxiety or depression. About a third of all GP consultations involve a major element of mental health [2]. Primary care therefore plays a crucial role in mental health, especially since there are likely to be a number of people with mental health problems that remain undiagnosed.

In order to tackle health inequalities most effectively, the government has used the Spearhead approach, where most effort is directed at the most disadvantaged areas [3]. A study carried out this year used data from the Quality and Outcomes Framework (QOF) for 2004/05 and 2005/06and found that practices in Spearhead PCTs performed worse than practices in non-Spearhead PCTs in England between 2004-2006 but showed greater improvement [4]. The narrowing in performance between practices in Spearhead and non-Spearhead PCTs may have indirectly contributed to a reduction in area-based health inequalities but the differences are small.

The results from this study show that there is still much potential for area-based initiatives to have an impact and general practitioners need to tailor their care to the particular community they are working with. A nationally representative cross-sectional study carried out this year found income-related inequalities in the prevalence of psychological distress were greatest in midlife; in women aged 45-54 years the odds ratio of reporting mental illness in the lowest income group compared withthe highest was 10.25 [5]. Therefore a possible strategy is GPs spending more time screening this age group and social class in particular for any signs of mental illness and hence tackle any problems before they progress.

We agree that the suggestions of Pickett and Wilkinson could be effective, but it is important to also aim for goals that can be achieved quickly and reach the people who really need it, and the best place to start is in the community. The primary care setting is invaluable in identifying and managing risk factors in groups most at risk of developingmental disorders. Individuals from lower socio-economic backgrounds are the least assertive and proactive about their health, and general practitioners should make it a point to screen these individuals during routine check-ups and to even invite them for specific check-ups if they are particularly at risk. This may prevent these individuals from sliding further down the social scale, and in this way GPs could play a crucial role in preventing the inequality gap from widening.

Trisha Sivaraman4th Year Medical StudentSt. George’s University of London

Denosshan Sri5th Year Medical StudentUniversity of Cambridge

Correspondence to: Trisha Sivaraman m0600178@sgul.ac.uk

Disclosure of interests:No conflict of interests.

References:

1.Inequality: an underacknowledged source of mental illness and distress. Pickett K, Wilkinson R. Br J Psychiatry 2010;197:426-82.MIND 2010. Treatments and services for people with mental health problems. Available at:http://www.mind.org.uk/help/medical_and_alternative_care/statistics_7_treatments_and_services_for_people_with_mental#contact

3.Great Britain. Department of Health (2008) Health inequalities: progress and next steps: progress and next steps. [Online]. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085307.4.Dixon A, Khachatryan A, Gilmour S. Does general practice reduce health inequalities? Analysis of quality and outcomes framework data. Eur J Public Health. 2010 Dec 8. [Epub ahead of print]5.Lang IA, Llewellyn DJ, Hubbard RE, Langa KM, Melzer D. Income and the midlife peak in common mental disorder prevalence. Psychol Med. 2010 Dec 10:1-8. [Epub ahead of print]
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Conflict of interest: None Declared

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Re: Income inequality and mental health problems

Kate E Pickett, Professor of Epidemiology
17 December 2010

Derek Summerfield suggests that the World Health Organization (1) and other survey data that we use seem ‘preposterous’ to him as a doctor and a citizen. His quarrel is then not with us but with the psychometric testing of the diagnostic interviews used by WHO and other epidemiological surveys of mental illness. But even in terms of our own personal experience, we are not at all surprised at the 23% annual period prevalence of any mental illness in the UK. Many of us have felt incapacitated by depression or anxiety, and among our acquaintances we can count episodes of self harm, eating disorders, addictions, behaviour problems and autistic spectrum disorders. As we mentioned in our paper, episodes of severe mental illness are also strongly correlated with income inequality. (2) Both sets of data suggest that inequality is related to mental health, however we choose to label the symptoms.

It is wrong to suggest that the correlations reflect only the high measured prevalence of mental illness in the English speaking countries. Although the English speaking countries do indeed have higher prevalence of mental illness, and higher levels of income inequality, they are not outliers and do not appear to represent a distinct group: they are simply the countries at one end of the distribution. Indeed if we look only at the sub-sample of the English speaking countries, income inequality remains significantly correlated, and is an important explanatory factor for mental illness just among them (r=0.95, p=0.01).

It would be odd if the relationships we showed with mental illness existed in a vacuum but of course they do not. Our research focuses on problems with social gradients, and we find that more unequal societies also have lower levels of trust and social capital, poorer physical health, higher rates of obesity and teenage pregnancies and births, low child wellbeing, educational achievement and social mobility, and higher levels of violence and imprisonment.(3) Against that background it would be surprising if mental health was not also affected by wider income differences.

Until the rise of neoliberal economic policy in the 1980s, the UK was a much more equal society and it could be so again. We are optimistic that societies can change. There are numerous mechanisms through which governments and institutions can promote greater equality, and a wider recognition of the harm caused by inequality is an essential prerequisite.

The reality is that inequality causes real suffering – regardless of labels. Those of us concerned with the mental health of the public need to address its structural, as well as its individual context.

Declaration of Interest: NONE

1. Demyttenaere K, Bruffaerts R, Posada-Villa J, Gasquet I, Kovess V, Lepine JP, et al. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. Jama 2004;291(21):2581-90.

2. Pickett KE, Wilkinson RG. Inequality: an underacknowledged source of mental illness and distress. Br J Psychiatry 2010;197:426-8.

3. Wilkinson R, Pickett K. The Spirit Level: why more equal societies almost always do better. London: Penguin, 2009.
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Conflict of interest: None Declared

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