The European Journal of Public Health Advance Access published December 23, 2013 European Journal of Public Health, 1–4 ß The Author 2013. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/ckt208
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Short Report
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The evolution of mental health in Spain during the economic crisis Xavier Bartoll1,2,3, Laia Pale`ncia1,2,3, Davide Malmusi1,2,3, Marc Suhrcke4,5, Carme Borrell1,2,3,6 1 2 3 4 5 6
Age`ncia de Salut Pu´blica de Barcelona, Barcelona, Spain CIBER Epidemiologı´a y Salud Pu´blica (CIBERESP), Spain Institute of Biomedical Research (IIB-Sant Pau), Barcelona, Spain Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK UKCRC Centre for Diet and Activity Research (CEDAR), Institute of Public Health, Cambridge, UK Universitat Pompeu Fabra, Barcelona, Spain
Correspondence: Xavier Bartoll Roca, Pl. Lesseps 1, 08023 Barcelona, Spain, Tel: +34 93 238 45 45, Fax: +34 93 368 69 43, e-mail: [email protected]
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Introduction ost European countries have been in recession since 2008, with
MSpain standing out as one of the most seriously hit in economic
terms, especially with regard to unemployment, which is a wellknown 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.
Results Descriptive statistics suggests an increase in the prevalence of poor mental health among men (from 14.7 to 16.9% between 2006/2007
Downloaded from http://eurpub.oxfordjournals.org/ at Aston University on January 13, 2014
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.
2 of 4
European Journal of Public Health
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
Men Total Age in years 16–24 25–34 35–44 45–54 55–64
2006/2007
2011/2012
2011/2012 vs. 2006/2007: PR
Column % % with poor mental health
Column % % with poor mental health
Model 1a
N = 12.019 100.0
N = 8.355 100.0
14.7
16.9
1.15 (1.04–1.26)**
Model 2b
0.99 (0.90–1.08)
11.3 15.2 15.0 14.8 16.9
13.9 22.6 25.7 21.5 16.2
11.2 16.1 18.7 19.1 17.3
0.98 1.05 1.24 1.29 1.02
(0.72–1.34) (0.85–1.31) (1.04–1.47)* (1.07–1.55)** (0.83–1.25)
n/a n/a n/a n/a n/a
74.8 7.7 0.1 17.4
12.3 27.9 35.4 18.9
61.2 20.6 0.5 17.6
12.0 28.6 31.5 19.9
0.97 1.02 0.89 1.05
(0.85–1.10) (0.83–1.25) (0.27–2.87) (0.86–1.27)
n/a n/a n/a n/a
10.3 10.4 22.4 42.7 14.2
11.8 14.6 15.9 14.8 15.3 1.02 (0.99–1.04) 2.4 ( 0.2–5.1)
10.9 7.8 17.0 50.7 13.6
12.2 15.4 15.4 18.2 18.6 1.08 (1.05–1.11)*** 8.8 (5.4–12.2)***
1.04 1.06 0.97 1.23 1.21
(0.75–1.44) (0.78–1.43) (0.78–1.21) (1.07–1.40)** (0.94–1.56)
1.00 (0.73–1.38) 0.95 (0.70–1.29) 0.90 (0.73–1.11) 1.00 (0.88–1.15) 1.06 (0.83–1.36) (0.000)c
19.5 26.9 22.6 26.2 4.8
12.9 13.6 15.2 17.1 14.5 1.05 (1.02–1.07)*** 5.3 (2.7–8.0)***
16.6 22.2 48.3 8.4 4.5
13.3 12.2 19.3 22.0 18.6 1.13 (1.10–1.17)*** 14.2 (10.7–17.5)***
1.02 0.89 1.27 1.29 1.28
(0.80–1.31) (0.73–1.10) (1.07–1.49)** (1.02–1.62)* (0.86–1.90)
0.97 (0.76–1.24) 0.80 (0.65–0.98)* 0.98 (0.83–1.15) 1.09 (0.87–1.37) 1.18 (0.80–1.76) (0.000)c
Country of birth Spain Not Spain
86.3 13.7
14.7 14.5
83.9 16.1
16.4 19.3
1.11 (1.01–1.22)* 1.33 (1.00–1.77)*
0.97 (0.88–1.07) 1.13 (0.86–1.49)
Main breadwinner Yes No
64.3 35.7
14.1 15.8
61.0 39.0
16.2 18.0
1.15 (1.03–1.28)* 1.13 (0.96–1.34)
1.03 (0.92–1.15) 0.92 (0.78–1.08)
(N = 8.261) 100.0 22.7
0.92 (0.87–0.98)*
0.89 (0.84–0.95)***
Working status Employed Unemployed Homemaker Others Social class I Managers with >10 workers II Managers with 10 workers II Managers with
.........................................................................................................
Short Report
.........................................................................................................
The evolution of mental health in Spain during the economic crisis Xavier Bartoll1,2,3, Laia Pale`ncia1,2,3, Davide Malmusi1,2,3, Marc Suhrcke4,5, Carme Borrell1,2,3,6 1 2 3 4 5 6
Age`ncia de Salut Pu´blica de Barcelona, Barcelona, Spain CIBER Epidemiologı´a y Salud Pu´blica (CIBERESP), Spain Institute of Biomedical Research (IIB-Sant Pau), Barcelona, Spain Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK UKCRC Centre for Diet and Activity Research (CEDAR), Institute of Public Health, Cambridge, UK Universitat Pompeu Fabra, Barcelona, Spain
Correspondence: Xavier Bartoll Roca, Pl. Lesseps 1, 08023 Barcelona, Spain, Tel: +34 93 238 45 45, Fax: +34 93 368 69 43, e-mail: [email protected]
.........................................................................................................
Introduction ost European countries have been in recession since 2008, with
MSpain standing out as one of the most seriously hit in economic
terms, especially with regard to unemployment, which is a wellknown 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.
Results Descriptive statistics suggests an increase in the prevalence of poor mental health among men (from 14.7 to 16.9% between 2006/2007
Downloaded from http://eurpub.oxfordjournals.org/ at Aston University on January 13, 2014
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.
2 of 4
European Journal of Public Health
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
Men Total Age in years 16–24 25–34 35–44 45–54 55–64
2006/2007
2011/2012
2011/2012 vs. 2006/2007: PR
Column % % with poor mental health
Column % % with poor mental health
Model 1a
N = 12.019 100.0
N = 8.355 100.0
14.7
16.9
1.15 (1.04–1.26)**
Model 2b
0.99 (0.90–1.08)
11.3 15.2 15.0 14.8 16.9
13.9 22.6 25.7 21.5 16.2
11.2 16.1 18.7 19.1 17.3
0.98 1.05 1.24 1.29 1.02
(0.72–1.34) (0.85–1.31) (1.04–1.47)* (1.07–1.55)** (0.83–1.25)
n/a n/a n/a n/a n/a
74.8 7.7 0.1 17.4
12.3 27.9 35.4 18.9
61.2 20.6 0.5 17.6
12.0 28.6 31.5 19.9
0.97 1.02 0.89 1.05
(0.85–1.10) (0.83–1.25) (0.27–2.87) (0.86–1.27)
n/a n/a n/a n/a
10.3 10.4 22.4 42.7 14.2
11.8 14.6 15.9 14.8 15.3 1.02 (0.99–1.04) 2.4 ( 0.2–5.1)
10.9 7.8 17.0 50.7 13.6
12.2 15.4 15.4 18.2 18.6 1.08 (1.05–1.11)*** 8.8 (5.4–12.2)***
1.04 1.06 0.97 1.23 1.21
(0.75–1.44) (0.78–1.43) (0.78–1.21) (1.07–1.40)** (0.94–1.56)
1.00 (0.73–1.38) 0.95 (0.70–1.29) 0.90 (0.73–1.11) 1.00 (0.88–1.15) 1.06 (0.83–1.36) (0.000)c
19.5 26.9 22.6 26.2 4.8
12.9 13.6 15.2 17.1 14.5 1.05 (1.02–1.07)*** 5.3 (2.7–8.0)***
16.6 22.2 48.3 8.4 4.5
13.3 12.2 19.3 22.0 18.6 1.13 (1.10–1.17)*** 14.2 (10.7–17.5)***
1.02 0.89 1.27 1.29 1.28
(0.80–1.31) (0.73–1.10) (1.07–1.49)** (1.02–1.62)* (0.86–1.90)
0.97 (0.76–1.24) 0.80 (0.65–0.98)* 0.98 (0.83–1.15) 1.09 (0.87–1.37) 1.18 (0.80–1.76) (0.000)c
Country of birth Spain Not Spain
86.3 13.7
14.7 14.5
83.9 16.1
16.4 19.3
1.11 (1.01–1.22)* 1.33 (1.00–1.77)*
0.97 (0.88–1.07) 1.13 (0.86–1.49)
Main breadwinner Yes No
64.3 35.7
14.1 15.8
61.0 39.0
16.2 18.0
1.15 (1.03–1.28)* 1.13 (0.96–1.34)
1.03 (0.92–1.15) 0.92 (0.78–1.08)
(N = 8.261) 100.0 22.7
0.92 (0.87–0.98)*
0.89 (0.84–0.95)***
Working status Employed Unemployed Homemaker Others Social class I Managers with >10 workers II Managers with 10 workers II Managers with
