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The evolution of mental health in Spain during the economic crisis

Xavier Bartoll, Laia Palència, Davide Malmusi, Marc Suhrcke, Carme Borrell
DOI: http://dx.doi.org/10.1093/eurpub/ckt208 ckt208 First published online: 23 December 2013

Abstract

We analyse how mental health and socioeconomic inequalities in the Spanish population aged 16–64 years have changed between 2006–2007 and 2011–2012. We observed an increase in the prevalence of poor mental health among men (prevalence ratio = 1.15, 95% CI 1.04–1.26], especially among those aged 35–54 years, those with primary and secondary education, those from semi-qualified social classes and among breadwinners. None of these associations remained after adjusting for working status. The relative index of inequality by social class increased for men from 1.02 to 1.08 (P = 0.001). We observed a slight decrease in the prevalence of poor mental health among women (prevalence ratio = 0.92, 95% CI 0.87–0.98), without any significant change in health inequality.

Introduction

Most European countries have been in recession since 2008, with Spain standing out as one of the most seriously hit in economic terms, especially with regard to unemployment, which is a well-known risk factor for psychological morbidity.1 A small number of studies, several of which were based in other Mediterranean countries, have investigated the health effects of the recession. For example, Greece appears to have suffered an increase in suicide rates and a deterioration in self-perceived health status.2 In Spain, the evidence on this issue to date is limited to one study that highlighted an increase in suicide rates in working-age men3 and a second study that indicated a substantial increase in the prevalence of most types of mental health disorders among primary care attendees between 2006–2007 and 2010–2011, with unemployment, mortgage payment difficulties and evictions emerging as major risk factors, especially for depression.4 In the present study, we add to evidence of the recession’s effects on mental health outcomes in Spain. Importantly, we present evidence not only on average health effects in the population but also on changes in socioeconomic inequalities in health, an aspect of research on economic fluctuations and health that has largely been neglected to date.5

More specifically, we analyse how mental health and socioeconomic inequalities in mental health changed in the Spanish population between 2006–2007 and 2011–2012, and we also analyse the role that working status has played in these changes.

Methods

We undertook a before-and-after study with control variables, using data from the 2006–2007 and 2011–2012 rounds of the Spanish National Health Survey, a representative cross-sectional survey of the non-institutionalized Spanish population. Data were collected through face-to-face interviews at participants’ homes between June 2006 and June 2007 (2006–2007 survey), and between July 2011 and June 2012 (2011–2012 survey).6 Our analysis was restricted to people aged 16–64 years (n = 23 760 for 2006–2007, and 16 616 for 2011–2012).

The dependent variable was mental health, which was measured using the 12-item version of the General Health Questionnaire (GHQ-12), a widely used tool for detecting risk of current, diagnosable anxious and depressive symptoms, and which has been validated in the Spanish population.7 We used a two-point scoring method, rating a problem as absent (0) or present (1). Participants with a score ≥3 were classified as having poor mental health.

The main independent variable was the survey edition, represented by a dichotomous dummy variable (1 = 2011/2012; 0 = 2006/2007). Other variables were two socioeconomic variables (social class and level of education), working status, main breadwinner and country of birth. Social class was assigned according to the current or previous occupation of the interviewee or, if he or she has never worked, the occupation of the head of the household.8 Interviewees who were the person who contributed most to their household budget were referred to as the ‘main breadwinner’.

To measure socioeconomic inequalities in mental health, we calculated two different measures for each survey year using either social class or education as a socioeconomic indicator: (i) the relative index of inequality (RII), a measure of relative health inequalities; and (ii) the slope index of inequality (SII), a measure of absolute health inequalities.

We fitted two Poisson regression models with robust error variance to test for association [PR and 95% confidence interval (95% CI)] between poor mental health and the survey year (2011–2012 vs. 2006–2007) for each sex and for each of the categories of the other independent variables described above. In Model 1 we estimate crude prevalence ratios, and in Model 2 our estimates were adjusted for age and working status.

View this table:
Table 1

Description of the sample (column %); prevalence of poor mental health and prevalence ratio (PR) of poor mental health in 2011/2012 vs. 2006/2007. Relative and absolute indexes of inequality of poor mental health by social class and educational level (in italics). Men and women, the Spanish National Health Survey 2006/2007 and 2011/2012

2006/20072011/20122011/2012 vs. 2006/2007: PR
Column %% with poor mental healthColumn %% with poor mental healthModel 1aModel 2b
MenN = 12.019N = 8.355
Total100.014.7100.016.91.15 (1.04–1.26)**0.99 (0.90–1.08)
Age in years
    16–2415.711.313.911.20.98 (0.72–1.34)n/a
    25–3425.815.222.616.11.05 (0.85–1.31)n/a
    35–4424.115.025.718.71.24 (1.04–1.47)*n/a
    45–5419.214.821.519.11.29 (1.07–1.55)**n/a
    55–6415.216.916.217.31.02 (0.83–1.25)n/a
Working status
    Employed74.812.361.212.00.97 (0.85–1.10)n/a
    Unemployed7.727.920.628.61.02 (0.83–1.25)n/a
    Homemaker0.135.40.531.50.89 (0.27–2.87)n/a
    Others17.418.917.619.91.05 (0.86–1.27)n/a
Social class
    I Managers with >10 workers10.311.810.912.21.04 (0.75–1.44)1.00 (0.73–1.38)
    II Managers with <10 workers10.414.67.815.41.06 (0.78–1.43)0.95 (0.70–1.29)
    III Intermediary and self-employed22.415.917.015.40.97 (0.78–1.21)0.90 (0.73–1.11)
    IV Supervisors, qualified and semi-qualified42.714.850.718.21.23 (1.07–1.40)**1.00 (0.88–1.15)
    V Non-qualified14.215.313.618.61.21 (0.94–1.56)1.06 (0.83–1.36)
    RII1.02 (0.99–1.04)1.08 (1.05–1.11)***(0.000)c
    SII2.4 (−0.2–5.1)8.8 (5.4–12.2)***
Education
    University19.512.916.613.31.02 (0.80–1.31)0.97 (0.76–1.24)
    Higher secondary26.913.622.212.20.89 (0.73–1.10)0.80 (0.65–0.98)*
    Secondary22.615.248.319.31.27 (1.07–1.49)**0.98 (0.83–1.15)
    Primary26.217.18.422.01.29 (1.02–1.62)*1.09 (0.87–1.37)
    Incomplete primary and illiterate4.814.54.518.61.28 (0.86–1.90)1.18 (0.80–1.76)
    RII1.05 (1.02–1.07)***1.13 (1.10–1.17)***(0.000)c
    SII5.3 (2.7–8.0)***14.2 (10.7–17.5)***
Country of birth
    Spain86.314.783.916.41.11 (1.01–1.22)*0.97 (0.88–1.07)
    Not Spain13.714.516.119.31.33 (1.00–1.77)*1.13 (0.86–1.49)
Main breadwinner
    Yes64.314.161.016.21.15 (1.03–1.28)*1.03 (0.92–1.15)
    No35.715.839.018.01.13 (0.96–1.34)0.92 (0.78–1.08)
Women(N = 11.741)(N = 8.261)
Total100.024.6100.022.70.92 (0.87–0.98)*0.89 (0.84–0.95)***
Age in years
    16–2415.222.213.514.50.65 (0.51–0.82)***n/a
    25–3424.721.022.119.30.91 (0.78–1.07)n/a
    35–4424.024.224.924.31.01 (0.89–1.14)n/a
    45–5419.727.722.125.60.92 (0.81–1.05)n/a
    55–6416.329.017.427.30.94 (0.83–1.06)n/a
Working status
    Employed52.322.351.118.80.84 (0.76–0.93)***n/a
    Unemployed10.130.216.130.51.01 (0.86–1.18)n/a
    Homemaker24.325.217.226.31.04 (0.91–1.19)n/a
    Others13.328.115.623.60.84 (0.71–0.99)*n/a
Social class
    I Managers with >10 workers7.416.19.118.81.17 (0.89–1.52)1.17 (0.89–1.53)
    II Managers with <10 workers9.421.48.617.30.81 (0.64–1.03)0.79 (0.62–1.01)
    III Intermediary and self-employed22.522.123.220.40.92 (0.80–1.06)0.89 (0.77–1.03)
    IV Supervisors, qualified and semi-qualified40.024.836.622.80.92 (0.83–1.02)0.88 (0.79–0.98)*
    V Non-qualified20.731.122.528.00.90 (0.79–1.02)0.86 (0.76–0.98)*
    RII1.14 (1.11–1.17)***1.14 (1.11–1.18)***(0.414)c
    SII16.8 (13.1–20.4)***15.6 (11.9–19.3)***
Education
    University19.718.020.116.60.92 (0.77–1.09)0.91 (0.76–1.08)
    Higher Secondary25.121.123.121.01.00 (0.86–1.16)0.96 (0.83–1.12)
    Secondary21.928.044.224.30.86 (0.78–0.97)*0.79 (0.71–0.89)***
    Primary27.927.28.126.80.98 (0.83–1.16)0.97 (0.82–1.14)
    Incomplete primary and illiterate5.438.94.536.20.93 (0.75–1.14)0.85 (0.70–1.05)
    RII1.16 (1.12–1.19)***1.15 (1.11–1.19)***(0.264)c
    SII18.6 (14.7–22.5)***15.9 (11.9–19.8)***
Country of birth
    Spain85.224.082.022.30.93 (0.87–0.99)*0.90 (0.84–0.96)**
    Not Spain14.828.018.024.50.87 (0.72–1.04)0.82 (0.68–0.99)*
Main breadwinner
    Yes19.927.630.026.80.97 (0.87–1.08)0.93 (0.84–1.03)
    No80.123.870.021.00.88 (0.81–0.95)**0.85 (0.78–0.92)***
  • All data with weights applied.

  • RII: Relative index of inequality; SII: Absolute index of inequality.

  • a: Model 1: crude prevalence ratio.

  • b: Model 2: prevalence ratio adjusted by age and working status.

  • c: P value for the significance of change in RII 2011/2012 vs. 2006/2007.

  • *P < 0.05, **P < 0.01, **P < 0.001.

Results

Descriptive statistics suggests an increase in the prevalence of poor mental health among men (from 14.7 to 16.9% between 2006/2007 and 2011/2012) but not among women, whose poor mental health prevalance has decreased (from 24.6 to 22.7%). Both absolute and relative inequalities in poor mental health increased among men (RII = 1.02, 95%CI 0.99–1.04; and 1.08, 95%CI 1.05–1.11, for 2006–2007 and 2011–2012, respectively; P-value for change <0.001; using social class as the socioeconomic indicator), but remained stable among women between the two survey rounds (although absolute inequalities were greater among women than among men, according to both measures).

The change in prevalence of poor mental health among men is confirmed by the results of regression Model I, which showed a 15% increase in 2011–2012 compared with that in 2006–2007 (PR = 1.15, 95%CI 1.04–1.26). This increase was relatively larger in men in the 35–44 (PR = 1.24, 95%CI 1.04–1.47) and 45–54 years age groups (PR = 1.29, 95%CI 1.07–1.55), those in social class IV (PR = 1.23, 95%CI 1.07–1.40), those with primary or secondary education (PR = 1.29, 95 %CI 1.02–1.62; PR = 1.27, 95%CI 1.07–1.49, respectively), foreigners (PR = 1.33, 95%CI 1.00–1.77) and breadwinners (PR = 1.15, 95%CI 1.03–1.28). These associations were not markedly affected by adjustment for age (data not shown), whereas, importantly, none of these associations were maintained after additional adjustment for working status (Model 2). Among women, the prevalence of poor mental health decreased overall (PR = 0.92, 95%CI 0.87–0.98), with the decrease concentrated among those younger than 24 years, the employed and non-breadwinners.

Discussion

In this study, we observed an increase in the prevalence of poor mental health among men and a slight decrease among women between 2006–2007 and 2011–2012. Among men, this increase is attributed to employment status. Socioeconomic inequalities in the prevalence of mental health increased among men, but remained stable among women.

The greater impact of unemployment on the mental health of men and less advantaged socioeconomic groups observed in our study is similar to that reported by a previous meta-analysis (which, however, did not focus specifically on times of recession).1 Moreover, as mentioned above, suicide rates also increased among working age men, but not among women, during the economic crisis in Spain3; this supports our findings because suicide can be considered a proxy for mental health problems. Recently, a study using a similar approach in the UK also found a trend of increasing inequalities in poor mental health during the period 1991–2010; inequalities worsened among men (and did not vary significantly among women), but contrary to our study, employment status did not play an important role.9

The differences in the trend of the mental health effects among men compared with women, which is most noticeable among individuals with a secondary level education, have been attributed to the notion that work is strongly related to the social role of men as the main household breadwinner, while women find psychological compensation in their family role as substitute for employment.10 While a full dissection of the various causal pathways behind our results is beyond the scope of this article, our data (not shown) suggest that the improvement in mental health is concentrated among employed women, who may experience additional recognition and greater self-esteem in a new breadwinner role.

With regard to other changes that could modify the effects of socioeconomic factors on mental health, it is worth mentioning that public health care coverage in Spain was still universal until 2012, and that a sensitivity analysis with additional adjustment for social support did not significantly affect our results (data not shown).

This is the first study to analyse mental health outcomes at the population level before and during the Spanish crisis. As the 2006–2007 survey was the first to introduce GHQ-12, we cannot assess preceding trends. However, the increase in mental distress is consistent with the aforementioned study on suicide rates, which was not disaggregated by socioeconomic position3, and the study on general practitioner users, which was not disaggregated by sex.4 Moreover, evidence that increasing unemployment accounts for deteriorating mental health in men supports the plausibility of the role of the crisis.

Funding

This research was supported by the European Community’s Seventh Framework Programme (FP7/2007–2013), under, grant agreement number 278173: “Evaluating the impact of structural policies on health inequalities and their social determinants and fostering change” (Sophie) project.

Conflicts of interest: None declared.

Key points

  • This study shows a deterioration in mental health among men during the economic crisis in Spain, especially among those from low socioeconomic position.

  • Among women, we noted a slight improvement in mental health, driven by younger individuals, employed and non-breadwinners.

  • Socioeconomic inequalities in mental health became more pronounced among men but not among women.

  • Social protection policies need to be reinforced, especially among individuals from a disadvantaged socioeconomic position.

References

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