Claire L. Niedzwiedz

Trends in population mental health before and after the 2008 recession: a repeat cross-sectional analysis of the 1991–2010 Health Surveys of England

Objective To assess short-term differences in population mental health before and after the 2008 recession and explore how and why these changes differ by gender, age and socio-economic position. Design Repeat cross-sectional analysis of survey data. Setting England. Participants Representative samples of the working age (25–64 years) general population participating in the Health Survey for England between 1991 and 2010 inclusive. Main outcome measures Prevalence of poor mental health (caseness) as measured by the general health questionnaire-12 (GHQ). Results Age–sex standardised prevalence of GHQ caseness increased from 13.7% (95% CI 12.9% to 14.5%) in 2008 to 16.4% (95% CI 14.9% to 17.9%) in 2009 and 15.5% (95% CI 14.4% to 16.7%) in 2010. Women had a consistently greater prevalence since 1991 until the current recession. However, compared to 2008, men experienced an increase in age-adjusted caseness of 5.1% (95% CI 2.6% to 7.6%, p<0.001) in 2009 and 3% (95% CI 1.2% to 4.9%, p=0.001) in 2010, while no statistically significant changes were seen in women. Adjustment for differences in employment status and education level did not account for the observed increase in men nor did they explain the differential gender patterning. Over the last decade, socio-economic inequalities showed a tendency to increase but no clear evidence for an increase in inequalities associated with the recession was found. Similarly, no evidence was found for a differential effect between age groups. Conclusions Population mental health in men has deteriorated within 2 years of the onset of the current recession. These changes, and their patterning by gender, could not be accounted for by differences in employment status. Further work is needed to monitor recessionary impacts on health inequalities in response to ongoing labour market and social policy changes.

Suicide Clusters: A Review of Risk Factors and Mechanisms

Suicide clusters, although uncommon, cause great concern in the communities in which they occur. We searched the world literature on suicide clusters and describe the risk factors and proposed psychological mechanisms underlying the spatio-temporal clustering of suicides (point clusters). Potential risk factors include male gender, being an adolescent or young adult, drug or alcohol abuse, and past history of self-harm. However, the majority of studies lack methodological rigor. Many different psychological mechanisms are described, including contagion, imitation, suggestion, learning, and assortative relating, but supporting empirical evidence is generally lacking. More scientifically rigorous studies are needed to improve understanding of suicide clusters.

Life course socio-economic position and quality of life in adulthood: a systematic review of life course models

BackgroundA relationship between current socio-economic position and subjective quality of life has been demonstrated, using wellbeing, life and needs satisfaction approaches. Less is known regarding the influence of different life course socio-economic trajectories on later quality of life. Several conceptual models have been proposed to help explain potential life course effects on health, including accumulation, latent, pathway and social mobility models. This systematic review aimed to assess whether evidence supported an overall relationship between life course socio-economic position and quality of life during adulthood and if so, whether there was support for one or more life course models.MethodsA review protocol was developed detailing explicit inclusion and exclusion criteria, search terms, data extraction items and quality appraisal procedures. Literature searches were performed in 12 electronic databases during January 2012 and the references and citations of included articles were checked for additional relevant articles. Narrative synthesis was used to analyze extracted data and studies were categorized based on the life course model analyzed.ResultsTwelve studies met the eligibility criteria and used data from 10 datasets and five countries. Study quality varied and heterogeneity between studies was high. Seven studies assessed social mobility models, five assessed the latent model, two assessed the pathway model and three tested the accumulation model. Evidence indicated an overall relationship, but mixed results were found for each life course model. Some evidence was found to support the latent model among women, but not men. Social mobility models were supported in some studies, but overall evidence suggested little to no effect. Few studies addressed accumulation and pathway effects and study heterogeneity limited synthesis.ConclusionsTo improve potential for synthesis in this area, future research should aim to increase study comparability. Recommendations include testing all life course models within individual studies and the use of multiple measures of socio-economic position and quality of life. Comparable cross-national data would be beneficial to enable investigation of between-country differences.

The definition and epidemiology of clusters of suicidal behavior: a systematic review.

Suicide clusters are a rare and underresearched phenomenon which attract wide media attention and result in heightened concern in the communities where they occur. We conducted a systematic literature review covering the definition and epidemiology of the time-space clustering of suicidal behavior. Of the 890 articles identified by electronic searching, 82 were selected for inclusion and the extracted data were analyzed by narrative synthesis. Less than a third of studies included a definition of a suicide cluster, and definitions varied considerably. Clusters occurred in various settings, including psychiatric hospitals, schools, prisons, indigenous communities, and among the general population. Most clusters involved young people. The proportion of all episodes that occurred in clusters varied considerably between studies and partly depended on study methodology (e.g., a larger proportion was found in studies of specific clusters compared with general population studies). Future studies should aim to combine the statistical analysis of time-space clustering with a case study of events, which examines potential links between individuals and the wider environmental context.

Socioeconomic inequalities in the quality of life of older Europeans in different welfare regimes.

Background: Whether socioeconomic inequalities in health and well-being persist into old age and are narrower in more generous welfare states is debated. We investigated the magnitude of socioeconomic inequality in the quality of life of Europeans in early old age and the influence of the welfare regime type on these relationships. Methods: Data from individuals aged 50–75 years (n = 16 074) residing in 13 European countries were derived from Waves 2 and 3 of the Survey of Health, Ageing and Retirement in Europe. Slope indices of inequality (SIIs) were calculated for the association between socioeconomic position and CASP-12, a measure of positive quality of life. Multilevel linear regression was used to assess the overall relationship between socioeconomic position and quality of life, using interaction terms to investigate the influence of the type of welfare regime (Southern, Scandinavian, Post-communist or Bismarckian). Results: Socioeconomic inequalities in quality of life were narrowest in the Scandinavian and Bismarckian regimes, and were largest by measures of current wealth. Compared with the Scandinavian welfare regime, where narrow inequalities in quality of life by education level were found in both men (SII = 0.02, 95% CI: −1.09 to 1.13) and women (SII = 1.11, 95% CI: 0.05–2.17), the difference in quality of life between the least and most educated was particularly wide in Southern and Post-communist regimes. Conclusion: Individuals in more generous welfare regimes experienced higher levels of quality of life, as well as narrower socioeconomic inequalities in quality of life.

The association between life course socioeconomic position and life satisfaction in different welfare states: European comparative study of individuals in early old age

Background: whether socioeconomic position over the life course influences the wellbeing of older people similarly in different societies is not known. Objective: to investigate the magnitude of socioeconomic inequalities in life satisfaction among individuals in early old age and the influence of the welfare state regime on the associations. Design: comparative study using data from Wave 2 and SHARELIFE, the retrospective Wave of the Survey of Health, Ageing, and Retirement in Europe (SHARE), collected during 2006–07 and 2008–09, respectively. Setting: thirteen European countries representing four welfare regimes (Southern, Scandinavian, Post-communist and Bismarckian). Subjects: a total of 17,697 individuals aged 50–75 years. Methods: slope indices of inequality (SIIs) were calculated for the association between life course socioeconomic position (measured by the number of books in childhood, education level and current wealth) and life satisfaction. Single level linear regression models stratified by welfare regime and multilevel regression models, containing interaction terms between socioeconomic position and welfare regime type, were calculated. Results: socioeconomic inequalities in life satisfaction were present in all welfare regimes. Educational inequalities in life satisfaction were narrowest in Scandinavian and Bismarckian regimes among both genders. Post-communist and Southern countries experienced both lower life satisfaction and larger socioeconomic inequalities in life satisfaction, using most measures of socioeconomic position. Current wealth was associated with large inequalities in life satisfaction across all regimes. Conclusions: Scandinavian and Bismarckian countries exhibited narrower socioeconomic inequalities in life satisfaction. This suggests that more generous welfare states help to produce a more equitable distribution of wellbeing among older people.

The relationship between wealth and loneliness among older people across Europe: Is social participation protective?

OBJECTIVE 1. Examine the relationship between household wealth, social participation and loneliness among older people across Europe. 2. Investigate whether relationships vary by type of social participation (charity/volunteer work, sports/social clubs, educational/training course, and political/community organisations) and gender. 3. Examine whether social participation moderates the association between wealth and loneliness. METHODS Data (N=29,795) were taken from the fifth wave of the Survey of Health, Ageing and Retirement in Europe (SHARE), which was collected during 2013 from 14 European countries. Loneliness was measured using the short version of the Revised-University of California, Los Angeles (R-UCLA) Loneliness Scale. We used multilevel logistic models stratified by gender to examine the relationships between variables, with individuals nested within countries. RESULTS The risk of loneliness was highest in the least wealthy groups and lowest in the wealthiest groups. Frequent social participation was associated with a lower risk of loneliness and moderated the association between household wealth and loneliness, particularly among men. Compared to the wealthiest men who often took part in formal social activities, the least wealthy men who did not participate had greater risk of loneliness (OR=1.91, 95% CI: 1.44 to 2.51). This increased risk was not observed among the least wealthy men who reported frequent participation in formal social activities (OR=1.12, 95% CI: 0.76 to 1.67). CONCLUSION Participation in external social activities may help to reduce loneliness among older adults and potentially acts as a buffer against the adverse effects of socioeconomic disadvantage.

Employment status and income as potential mediators of educational inequalities in population mental health

We assessed whether educational inequalities in mental health may be mediated by employment status and household income. Poor mental health was assessed using General Health Questionnaire ‘caseness’ in working age adult participants (N = 48 654) of the Health Survey for England (2001–10). Relative indices of inequality by education level were calculated. Substantial inequalities were apparent, with adjustment for employment status and household income markedly reducing their magnitude. Educational inequalities in mental health were attenuated by employment status. Policy responses to economic recession (such as active labour market interventions) might reduce mental health inequalities but longitudinal research is needed to exclude reverse causation.

The relationship between financial distress and life-course socioeconomic inequalities in well-being: cross-national analysis of European Welfare States

OBJECTIVES We investigated to what extent current financial distress explains the relationship between life-course socioeconomic position and well-being in Southern, Scandinavian, Postcommunist, and Bismarckian welfare regimes. METHODS We analyzed individuals (n = 18 324) aged 50 to 75 years in the Survey of Health, Ageing, and Retirement in Europe, 2006-2009. Well-being was measured with CASP-12 (which stands for control, autonomy, self-realization, and pleasure) and life satisfaction. We generated a life-course socioeconomic index from 8 variables and calculated multilevel regression models (containing individuals nested within 13 countries), as well as stratified single-level models by welfare regime. RESULTS Life-course socioeconomic advantage was related to higher well-being; the difference in life satisfaction between the most and least advantaged was 2.09 (95% confidence interval = 1.87, 2.31) among women and 1.65 (95% confidence interval = 1.43, 1.87) among men. The weakest associations were found among Scandinavian countries. Financial distress was associated with lower well-being and attenuated the relationship between life-course socioeconomic position and well-being in all regimes (ranging from 34.26% in Postcommunist to 72.22% in Scandinavian countries). CONCLUSIONS We found narrower inequalities in well-being in the Scandinavian regime. Reducing financial distress may help improve well-being and reduce inequalities.

Trends in gender and socioeconomic inequalities in mental health following the Great Recession and subsequent austerity policies: a repeat cross-sectional analysis of the Health Surveys for England

Objective It is known that mental health deteriorated following the 2008 global financial crisis, and that subsequent UK austerity policies post-2010 disproportionately impacted women and those in deprived areas. We aimed to assess whether gender and socioeconomic inequalities in poor mental health have changed since the onset of austerity policies. Design Repeat cross-sectional analysis of survey data. Setting England. Participants Nationally and regionally representative samples of the working-age population (25–64 years) from the Health Survey for England (1991–2014). Outcome measures Population-level poor mental health was measured by General Health Questionnaire-12 (GHQ) caseness, stratified by gender and socioeconomic position (area-level deprivation and highest educational attainment). Results The prevalence of age-adjusted male GHQ caseness increased by 5.9% (95% CI 3.2% to 8.5%, p<0.001) from 2008 to 2009 in the immediate postrecession period, but recovered to prerecession levels after 2010. In women, there was little change in 2009 or 2010, but an increase of 3.0% (95% CI 1.0% to 5.1%, p=0.004) in 2012 compared with 2008 following the onset of austerity. Estimates were largely unchanged after further adjustment for socioeconomic position, employment status and household income as potential mediators. Relative socioeconomic inequalities in GHQ caseness narrowed from 2008 to 2010 immediately following the recession, with Relative Index of Inequality falling from 2.28 (95% CI 1.89 to 2.76, p<0.001) to 1.85 (95% CI 1.43 to 2.38, p<0.001), but returned to prerecession levels during austerity. Conclusions Gender inequalities in poor mental health narrowed following the Great Recession but widened during austerity, creating the widest gender gap since 1994. Socioeconomic inequalities in poor mental health narrowed immediately postrecession, but this trend may now be reversing. Austerity policies could contribute to widening mental health inequalities.