Social determinants and Adolescent Mental Social determinants and Adolescent Mental HealthHealth

Stephen Stansfeld

Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts & the London School of Medicine and Dentistry, London UK UK

Addressing young people’s health inequalities

Association for Young People’s Health and Young People’s Health Special Interest Group, Royal College of Paediatrics and Child

Health

Coin Street Conference Centre LondonCoin Street Conference Centre London

October 17-18October 17-18thth 2013 2013

Outline

• Pathways of influences on adolescent mental health

• Effects of socioeconomic status

• Neighbourhood and cultural factors

• Parental and peer social support

• Exposure to adversity

• Conclusions

Hypothetical pathways linking income inequality and health

(Kondo, 2012)

Intermediate factors between social disadvantage and health

Material factorsLow incomePoor housing

Psychosocial factorsStress levelsCoping mechanismsLow social support

LifestylePoor dietSmokingObesity

Environmental factorsNoiseAir pollutionPoor water qualityExposure to toxic

chemicals

Environment

Physical Social Cultural

Intervening variables

Nervous system

Intervening variables

Psychiatric Physical Illness illness

Health inequalities begin before birth

Generation R Study: 9778 mothers from multi-ethnic sample in Rotterdam

Low socioeconomic status associated with:

Greater risk of eclampsia, raised maternal blood pressure

slower foetal growth, lower birth weight, more pre-term births

Infants had more respiratory infections (2 years) and more difficult temperaments (6 months) measured on a standard scale

(Raat et al, 2011)

Cross-sectional associations between Father’s Social Class and childhood mental health: 1958 Birth Cohort

Father’s SEP OR (95% CI)

RGSC Internalising Externalising

7yNon-manual

Manual1.01.86 (1.7-2.1)

1.01.58 (1.4-1.8)

11yNon-manual

Manual1.02.01 (1.8-2.3)

1.01.86 (1.7-2.1)

16yNon-manual

Manual1.01.46 (1.3-1.6)

1.02.28 (2.0-2.6)

(adjusted for gender)

Association of childhood SEP (cumulative) and CIS-R diagnoses in adulthood: 1958 Birth Cohort

No of occasions in manual RGSC

% with any Diagnosis

OR (95% CI)

0 4.6 1.0

1 3.8 0.8 (0.5-1.3)

2 7.2 1.57 (1.1-2.3)

3 7.2 1.57 (1.1-2.2)

4 6.4 1.39 (1.1-1.8)

RELACHS Study: Risk and Protective factors for mental health

• 2790 pupils from 29 schools, 11-14 years at baseline

• 68% of all secondary school age children in ELCHA are non-White (64% Hackney; 70% Newham; 71% Tower Hamlets) (DfEE 1999)

• Main groups: Bangladeshi; Black African/Caribbean; Indian and Pakistani

• Questionnaire administered in English as most respondents are fluent in English

• Multilingual research workers recruited

Proportion with High Strengths and Difficulties score by age and sex compared with national data

% High SDQ score

11-12 years RELACHS HSE

Female 11.3% 7%Male 10.5% 11%

13-15 years Female 11.4% 6%Male 8% 9%

Proportion of High scorers on the Strengths and Difficulties Questionnaire by socioeconomic status and sex

SES Male Female % %

Parental employmentOne/both working 9.2 11.3Neither working 9.4 11.4

Car ownership0 10.6 9.41+ 7.9 11.92 10.4 11.9

Eligibility forFree School Meals

No 8.4 11.7Yes 9.9 10.9

(Stansfeld et al, 2004)

Odds ratios for poor mental health by socioeconomic status

Eligibility for SDQ SDQFree School Adjusted for SexAdjusted

Meals and Year Groupsfor Ethnicity

No 1 1

Yes 1.03 (0.8-1.4) 1.10 (0.8-1.5)

Mean WEMWBS score by socioeconomic Indicator: ORIEL Study Mean 95% CI

Overcrowded housingNot overcrowdedn

51.250.8

2688

[50.9, 51.6][50.1, 51.5]

Free school mealsNo free school mealsn

51.350.8

2887

[50.9, 51.7][50.2, 51.3]

Both unemployedAl least one parent employedBoth parents employedn

50.850.851.6

2569

[49.6, 51.8][50.3 51.3][51.0. 52.1]

Low FAS scoreMiddle FAS scoreHigh FAS scoren

50.250.751.8

2819

[49.0, 51.3[50.2, 51.2][51.3, 52.4]

(Smith et al, in preparation)

Significantly different to low FAS

Proportion with depressive symptoms by socioeconomic indicator: ORIEL Study% Odds of having depressive symptoms by socioeconomic indicators OR 95% CI

Not overcrowdedOvercrowded housingn

22.322.6 1.01

2546[0.81, 1.27]

1

Free school mealsNo free school mealsn

21.623.4 1.11

2732[0.92, 1.33]

1

Both unemployedAl least one parent employedBoth parents employedn

25.822.5 0.8421.1 0.77

2429

[0.61, 1.14][0.56, 1.06]

1

Low FAS scoreMiddle FAS scoreHigh FAS scoren

25.422.6 0.86 21.3 0.80

2659

[0.64, 1.16][0.58, 1.09]

1

(Smith et al, in preparation)

Malaise symptoms (mean in past month) by social class at ages 11, 13 and 15West of Scotland 11-16 Study I II III-NM III-M IV Linear sig

Malaise symptoms

Males

11 1.6 1.6 1.7 1.5 1.5 1.4 0.161

13 1.9 1.6 1.4 1.4 1.4 1.7 0.026

15 2.3 1.7 1.5 1.5 1.7 1.8 0.093

Females

11 1.6 1.7 1.5 1.5 1.5 1.4 0.029

13 2.1 2.2 2.1 1.8 1.8 1.7 0.000

15 2.6 2.6 2.4 2.3 2.2 2.0 0.000(West & Sweeting, 2004)

SHaW Study

• Questionnaire study of Grade 8 learners (14-15 yrs) in 7 schools from Cape Town Metro Central Educational District

• All co-educational schools from one administrative district stratified according to fees

• Total sample size for main study =1034

• Response rate = 88%

• Coloured 60%, Black 25%, White 10%, Indian 2%

Risk of mental ill-health by financial difficulties

Depressive Symptoms

OR (95% CI)

Anxiety symptoms

OR (95% CI)

Most financial difficulties 4.70 2.13-10.4 3.82 1.68-8.94

Receiving household grants

1.55 1.01-2.37

Neighbourhood Quality

• Moving to higher quality neighbourhoods associated with

less anxiety/depression for boys

(Leventhal & Brooks Gunn, 2003)

• Ambient hazards related to conduct disorder, depression and

anxiety

(Aneshensel & Sucoff, 1996; Curtis et al, 2004)

Neighbourhood deprivation and adolescent mental health8 Studies from North America and 2 from other parts of Europe

show associations between neighbourhood deprivation and

externalising and internalising problems controlling for individual

and family risk factors

Recent UK studies do not show significant associations

(Curtis et al 2013)

Area characteristics and psychological distress

• Social and economic conditions at level of ‘Middle Layer Super Output Areas’, (Census, 2001) linked with SDQ

• Lower SDQ among Asian, Black groups, families with social support and no financial stress

• High SDQ among those with special educational needs, long standing illness, reconstituted families

• Area differences associated with 6% of variation in SDQ score Material deprivation, social fragmentation, crime did not show effects on SDQ

• Better mental health for South Asians in medium rather than high or low ethnic density areas

(Fagg et al, 2006)

Odds ratios for high SDQ scores by ethnic group and socioeconomic status

Adjusted* for + Adjusted for

Ethnicity sex and year group SES

OR (95%CI) OR (95%CI)

White (UK) 1 1White (Other) 1.39 (0.8-2.3) 1.36 (0.8-2.3)Bangladeshi 0.64 (0.4-0.9) 0.63 (0.4-0.9)Pakistani 0.92 (0.4-2.1) 0.91 (0.4-2.1)Indian 1.02 (0.7-1.6) 1.03 (0.7-1.6)Black 0.89 (0.6-1.3) 0.89 (0.6-1.3)Mixed 1.16 (0.7-2.0) 1.15 (0.7-1.9)Other 0.71 (0.4-1.2) 0.71 (0.4-1.2)*Adjusted for sex, year group, and interaction sex x year

group

(Stansfeld et al, 2004)

RELACHS Study: Odds ratios for Mood and Feelings Questionnaire caseness by ethnic group and socioeconomic status

Adjusted* for + Adjusted forEthnicity sex and year group SES

OR (95%CI) OR (95%CI) White (UK) 1

White (Other) 1.53 (1.1-2.2) 1.54 (1.1-2.2)Bangladeshi 0.92 (0.7-1.3) 0.92 (0.7-1.3)Pakistani 0.97 (0.6-1.6) 0.97 (0.6-1.6)Indian 1.01 (0.7-1.5) 1.01 (0.7-1.5)Black 0.94 (0.7-1.2) 0.94 (0.7-1.3)Mixed 1.25 (0.8-1.9) 1.25 (0.8-1.9)Other 1.26 (0.8-1.9) 1.27 (0.8-1.9)

*Adjusted for sex, year group, and interaction sex x year group

(Stansfeld et al, 2004)

Risk for psychological distress and depressive symptoms: adjustment for recent migration

Non-UK born White pupils

Adjustment for sex, age and SES OR (95% CI)

Adjustment for recent migration OR (95% CI)

SDQ 1.36 (0.8-2.3) 1.19 (0.7-2.0)

MFQ 1.54 (1.1-2.2) 1.25 (0.9-1.8)

Cultural Identity and Psychological Distress

•Integrated friendship choices (OR= 0.6, 95% CI 0.4-0.9) boys (OR= 0.5, 95% CI 0.2-0.9) and Bangladeshi pupils (OR= 0.15, 95% CI 0.04-0.6) protective of psychological distress relative to marginalised identity

(Bhui et al, 2005)

•In longitudinal analysis traditional identity based on clothing choice was protective for Bangladeshi girls

(Bhui et al, 2008)

Area social fragmentation, social support and mental healthHigh levels of social cohesion are beneficial for mental health

(Aneshesel & Sucoff, 1996)

Health Survey for England 2002 – 5,777, 16-24 years old

•Social fragmentation in geographical areas was a risk factor for mental ill-health•Family social support for the individual was independently protective for mental health•The benefits of social support did not vary by area

(Fagg et al 2008)

Low

49

29

52

33

53

35

0

10

20

30

40

50

60

70

80

90

100

Od

ds

of

dis

tre

ss

Medium High

Social support and odds of distress in HSE respondents from areas of low, medium, high area fragmentation

Prospective Associations between Social Support and Mental Health Outcomes

• Low family social support at baseline was associated with a higher risk of depressive symptoms at follow-up in adjusted models* (OR=2.33, 95% CI: 1.31-4.13)

• A decrease in family social support over time was associated with a higher risk of depressive symptoms at follow-up in adjusted models* (OR=2.14, 95% CI 1.13-4.07)

(Khatib et al, 2013)

*Adjusted for age, gender, an interaction between age and gender, socio-economic status (eligibility for free school meals, parental employment status, parental ownership of vehicle), ethnicity, and country of birth, length of time in the UK

Key Findings: Can Social Support Account for Ethnic Variations in Mental Health Outcomes?

• *Adjusted for age, gender, an interaction between age and gender, socio-economic status (eligibility for free school meals, parental employment status, parental ownership of vehicle), ethnicity and country of birth, length of time in the UK and SOCIAL SUPPORT

Ethnicity OR (95% CI) for Overall

Psychological Distress (SDQ

Caseness)

OR (95% CI) for Depressive

Symptoms (MFQ Caseness)

UnadjustedWhite UK

BangladeshiBlack

10.68 (0.40,1.17)0.26 (0.11,0.59)

11.59 (1.04,2.43)0.69 (0.40,1.17)

Adjusted* White UK

BangladeshiBlack

10.29 (0.09,0.97)0.16 (0.04,0.62)

11.12 (0.58,2.16)0.66 (0.29,1.50)

Multivariate associations with self harm

Factor Adjusted Odds Ratio

95% C.I.

Support from familyModerateLow

1.03.923.53

(1.61-9.53)(1.47-8.46)

Bullying (lifetime)Never been bulliedEver been bullied

1.02.37 (1.38-4.08)

Adverse life events123+

1.762.494.41

(0.68-4.59)(1.02-6.11)

(1.90-10.22)

Peer relationships

• Broadly positive impact of peer support on depressive symptoms

• Association with delinquent peer group may have particularly

negative effects

• Unsupervised peer contact associated with behavioural problems

• Peer rejection associated with depression but not always with

behavioural difficulties

(Stansfeld et al unpublished)

Early lack of care, abuse, neglect and depression

Parental indifference, physical, sexual abuse predict depression

(Brown et al, 1993; Bifulco et al, 1994)

Relationship between childhood neglect and abuse and adult depression ‘explained by’ depression before the age of 20y

(Bifulco et al, 1998)

Experience of childhood abuse and neglect may predict subsequent poor parenting – intergenerational transmission risk

(Andrews et al, 1990)

Neighbourhood Violence and Mental Health

“Exposure” to violence includes:living in a neighbourhood with a high crime rate: witnessing violence: perceptions of the neighbourhood as risky:direct experience of victimisation:

• Strong relationships with post-traumatic stress disorder, psychological distress, internalizing and externalising behaviours, low self esteem, suicidal cognition, depression, anger, sadness, anxiety , aggression, conduct disorders and anti-social behaviour. Energy expended in coping with community violence may be at the cost of school, work and personal relationships

(Cooley-Quille et al, 2001)

Exposure to violence and risk of depressive symptoms: SHaW Study

Unadjusted Fully adjusted

Harvard Trauma OR 95% CI OR 95% CIQuestionnaire

Quartile 1 1 1

2 1.78 (1.05, 2.99) 1.74 (0.98, 3.11)

3 3.28 (1.99, 5.41) 2.69 (1.49, 4.84)

4 5.48 (3.34, 9.00) 4.72 (2.52, 8.84)

*Adjusted for sex, ethnicity, social position, physical health, risk behaviours and social support

Multivariable analysis: odds of PTSD

Case on PTSDOR (95% CI)

Case on PTSDOR (95% CI)

Case on PTSDOR (95% CI)

Levels of exposure to violence

adjusting for sex

Adjusting for sex, ethnicity

adjusting for sex, ethnicity, social support

1 lowest 1 1 1

2 2.14 (0.38, 12.16)

2.04 (0.36, 11.50)

2.08 (0.39, 10.93)

3 2.68 (0.56, 12.81)

2.41 (0.50, 11.55)

2.41 (0.53, 10.88)

4 highest 10.26 (3.01, 35.00)

9.10 (2.70, 30.69)

8.93 (2.93, 27.24)

Conclusions

Less advantaged socioeconomic status is associated with

poorer mental health in some but not all studies

Adverse neighbourhoods and exposure to violence tend to be

associated with poorer mental health

Cultural influences and social support can be important

protective factors

Interventions are needed that span areas, generations and

the lifecourse