Kate M Scott1, Ali Obaid Al-Hamzawi2, Laura H Andrade3, Guilherme Borges4, Jose Miguel Caldas-de-Almeida5, Fabian Fiestas6, Oye Gureje7, Chiyi Hu8, Elie G Karam9, Norito Kawakami10, Sing Lee11, Daphna Levinson12, Carmen C W Lim1, Fernando Navarro-Mateu13, Michail Okoliyski14, Jose Posada-Villa15, Yolanda Torres16, David R Williams17, Victoria Zakhozha18, Ronald C Kessler19. 1. Department of Psychological Medicine, University of Otago, Dunedin, New Zealand. 2. Department of Medicine, College of Medicine, Al-Qadisia University, Diwania, Iraq. 3. Section of Psychiatric Epidemiology-LIM 23 Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil. 4. Division of Epidemiological and Psychosocial Research, Department of Intervention Models, National Institute of Psychiatry, Mexico City, Mexico5Department of Health Services, Metropolitan Autonomous University, Mexico City, Mexico. 5. Chronic Diseases Research Center and Department of Mental Health, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal. 6. National Institute of Health of Peru, Evidence Generation Research Unit, Lima, Peru. 7. World Health Organization Collaborating Centre for Research and Training in Mental Health, Neurosciences, and Drug and Alcohol Abuse, Ibadan, Nigeria9Department of Psychiatry, College of Medicine, University of Ibadan, University College Hospital, Ibadan. 8. Shenzhen Institute of Mental Health and Shenzhen Kangning Hospital, Guangdong Province, PR China. 9. St George Hospital University Medical Center, Balamand University, Institute for Development, Research, Advocacy, Beirut, Lebanon 12Applied Care, Medical Institute for Neuropsychological Disorders, Beirut, Lebanon. 10. School of Public Health, University of Tokyo, Tokyo, Japan. 11. Department of Psychiatry, The Chinese University of Hong Kong, Shatin, Hong Kong. 12. Mental Health Services, Ministry of Health, Jerusalem, Israel. 13. Subdirección General de Salud Mental y Asistencia Psiquiátrica, Servicio Murciano de Salud, El Palmar, Murcia, Spain. 14. National Centre of Public Health and Analyses, Ministry of Health, Sofia, Bulgaria. 15. Colegio Mayor de Cundinamarca University, Bogota, DC, Colombia. 16. Salud Mental, Universidad CES, Medellín, Colombia. 17. Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, Massachusetts. 18. Kiev International Institute of Sociology, Kiev, Ukraine. 19. Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.
Abstract
IMPORTANCE: The inverse social gradient in mental disorders is a well-established research finding with important implications for causal models and policy. This research has used traditional objective social status (OSS) measures, such as educational level, income, and occupation. Recently, subjective social status (SSS) measurement has been advocated to capture the perception of relative social status, but to our knowledge, there have been no studies of associations between SSS and mental disorders. OBJECTIVES: To estimate associations of SSS with DSM-IV mental disorders in multiple countries and to investigate whether the associations persist after comprehensive adjustment of OSS. DESIGN, SETTING, AND PARTICIPANTS: Face-to-face cross-sectional household surveys of community-dwelling adults in 18 countries in Asia, South Pacific, the Americas, Europe, and the Middle East (N=56,085). Subjective social status was assessed with a self-anchoring scale reflecting respondent evaluations of their place in the social hierarchies of their countries in terms of income, educational level, and occupation. Scores on the 1 to 10 SSS scale were categorized into 4 categories: low (scores 1-3), low-mid (scores 4-5), high-mid (scores 6-7), and high (scores 8-10). Objective social status was assessed with a wide range of fine-grained objective indicators of income, educational level, and occupation. MAIN OUTCOMES AND MEASURES: The Composite International Diagnostic Interview assessed the 12-month prevalence of 16 DSM-IV mood, anxiety, and impulse control disorders. RESULTS: The weighted mean survey response rate was 75.2% (range, 55.1%-97.2%). Graded inverse associations were found between SSS and all 16 mental disorders. Gross odds ratios (lowest vs highest SSS categories) in the range of 1.8 to 9.0 were attenuated but remained significant for all 16 disorders (odds ratio, 1.4-4.9) after adjusting for OSS indicators. This pattern of inverse association between SSS and mental disorders was significant in 14 of 18 individual countries, and in low-, middle-, and high-income country groups but was significantly stronger in high- vs lower-income countries. CONCLUSIONS AND RELEVANCE: Significant inverse associations between SSS and numerous DSM-IV mental disorders exist across a wide range of countries even after comprehensive adjustment for OSS. Although it is unclear whether these associations are the result of social selection, social causation, or both, these results document clearly that research relying exclusively on standard OSS measures underestimates the steepness of the social gradient in mental disorders.
IMPORTANCE: The inverse social gradient in mental disorders is a well-established research finding with important implications for causal models and policy. This research has used traditional objective social status (OSS) measures, such as educational level, income, and occupation. Recently, subjective social status (SSS) measurement has been advocated to capture the perception of relative social status, but to our knowledge, there have been no studies of associations between SSS and mental disorders. OBJECTIVES: To estimate associations of SSS with DSM-IV mental disorders in multiple countries and to investigate whether the associations persist after comprehensive adjustment of OSS. DESIGN, SETTING, AND PARTICIPANTS: Face-to-face cross-sectional household surveys of community-dwelling adults in 18 countries in Asia, South Pacific, the Americas, Europe, and the Middle East (N=56,085). Subjective social status was assessed with a self-anchoring scale reflecting respondent evaluations of their place in the social hierarchies of their countries in terms of income, educational level, and occupation. Scores on the 1 to 10 SSS scale were categorized into 4 categories: low (scores 1-3), low-mid (scores 4-5), high-mid (scores 6-7), and high (scores 8-10). Objective social status was assessed with a wide range of fine-grained objective indicators of income, educational level, and occupation. MAIN OUTCOMES AND MEASURES: The Composite International Diagnostic Interview assessed the 12-month prevalence of 16 DSM-IV mood, anxiety, and impulse control disorders. RESULTS: The weighted mean survey response rate was 75.2% (range, 55.1%-97.2%). Graded inverse associations were found between SSS and all 16 mental disorders. Gross odds ratios (lowest vs highest SSS categories) in the range of 1.8 to 9.0 were attenuated but remained significant for all 16 disorders (odds ratio, 1.4-4.9) after adjusting for OSS indicators. This pattern of inverse association between SSS and mental disorders was significant in 14 of 18 individual countries, and in low-, middle-, and high-income country groups but was significantly stronger in high- vs lower-income countries. CONCLUSIONS AND RELEVANCE: Significant inverse associations between SSS and numerous DSM-IV mental disorders exist across a wide range of countries even after comprehensive adjustment for OSS. Although it is unclear whether these associations are the result of social selection, social causation, or both, these results document clearly that research relying exclusively on standard OSS measures underestimates the steepness of the social gradient in mental disorders.
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