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Original Investigation
December 2014

Associations Between Subjective Social Status and DSM-IV Mental Disorders: Results From the World Mental Health Surveys

Author Affiliations
  • 1Department of Psychological Medicine, University of Otago, Dunedin, New Zealand
  • 2Department of Medicine, College of Medicine, Al-Qadisia University, Diwania, Iraq
  • 3Section of Psychiatric Epidemiology–LIM 23 Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
  • 4Division of Epidemiological and Psychosocial Research, Department of Intervention Models, National Institute of Psychiatry, Mexico City, Mexico
  • 5Department of Health Services, Metropolitan Autonomous University, Mexico City, Mexico
  • 6Chronic Diseases Research Center and Department of Mental Health, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
  • 7National Institute of Health of Peru, Evidence Generation Research Unit, Lima, Peru
  • 8World Health Organization Collaborating Centre for Research and Training in Mental Health, Neurosciences, and Drug and Alcohol Abuse, Ibadan, Nigeria
  • 9Department of Psychiatry, College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
  • 10Shenzhen Institute of Mental Health and Shenzhen Kangning Hospital, Guangdong Province, PR China
  • 11St George Hospital University Medical Center, Balamand University, Institute for Development, Research, Advocacy, Beirut, Lebanon
  • 12Applied Care, Medical Institute for Neuropsychological Disorders, Beirut, Lebanon
  • 13School of Public Health, University of Tokyo, Tokyo, Japan
  • 14Department of Psychiatry, The Chinese University of Hong Kong, Shatin, Hong Kong
  • 15Mental Health Services, Ministry of Health, Jerusalem, Israel
  • 16Subdirección General de Salud Mental y Asistencia Psiquiátrica, Servicio Murciano de Salud, El Palmar, Murcia, Spain
  • 17National Centre of Public Health and Analyses, Ministry of Health, Sofia, Bulgaria
  • 18Colegio Mayor de Cundinamarca University, Bogota, DC, Colombia
  • 19Salud Mental, Universidad CES, Medellín, Colombia
  • 20Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, Massachusetts
  • 21Kiev International Institute of Sociology, Kiev, Ukraine
  • 22Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
JAMA Psychiatry. 2014;71(12):1400-1408. doi:10.1001/jamapsychiatry.2014.1337

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.