Elsevier

The Lancet

Volume 352, Issue 9128, 22 August 1998, Pages 605-609
The Lancet

Articles
Socioeconomic status, standard of living, and neurotic disorder

https://doi.org/10.1016/S0140-6736(98)04494-8Get rights and content

Summary

Background

Evidence on the association between socioeconomic status and the prevalence of neurotic disorder is contradictory. We studied the association between three elements of socioeconomic status and the prevalence of neurotic psychiatric disorder in a representative sample of adults aged 16–64 living in private households in the UK.

Methods

A cross-sectional survey of 10 108 adults aged 16–65 resident in private households in the UK was selected by a multi-stage, clustered, random-sampling design. Neurotic disorders were defined using a standardised interview, the revised clinical interview schedule (CIS-R). Data for 9570 people were available for this study.

Findings

We used housing tenure and access to cars as measures of standard of living; both were associated with the prevalence of neurotic disorder even after adjustment for other socioeconomic and demographic variables, including Registrar General's Social Class and educational attainment. Those people with no access to a car had an odds ratio for neurotic disorder of 1·4 (95% CI 1·1–1·7), compared with those who had access to two or more cars. People who rented their homes were also at increased risk (1·3 [1·1–1·5]). We estimated that about 10% of the neurotic disorder in the UK could be attributed to the increased prevalence of those without cars who rented their homes. There was a complex interaction between Registrar General's Social Class and sex, and there was no independent association with educational attainment.

Interpretation

There is an independent association between low standard of living and the prevalence of neurotic psychiatric disorder. The UK has experienced one of the largest increases in income inequality within western market economies over the past 20 years, and this inequality may have had adverse consequences for the mental health of the population.

Introduction

The common neurotic psychiatric disorders, mostly depression and anxiety, have a prevalence of about 14% in the UK.1 They are associated with 15–30% of all absence due to sickness2, 3 and lead to as much or more disability than many other chronic medical disorders.4 A study published in 1993 put forward evidence that the prevalence of neurotic disorder is increasing in the UK.5 Neurotic disorder is an important public-health issue meriting investigation of its causes so as to inform preventive action in the future.

Socioeconomic status is a complex concept; we identified at least three related elements that have been used to measure it.6, 7 In the UK the Registrar General's Social Class is a way of grading occupations according to level of skill, but which also reflects their status within the community. A second determinant of socioeconomic status is educational attainment. A third socioeconomic variable is income, wealth, or standard of living—in the UK this can be assessed by whether individuals own or rent their home and have access to a car. These measures of standard of living are inversely related to mortality, independently of social class,8 an important finding since distribution of income is potentially amenable to changes in social and economic policy. A report published in 1995 stated that there has also been a large increase in income inequality in the UK,9 which has coincided with an increase in the prevalence of neurotic psychiatric disorder.5

In the UK, two previous household surveys have found an increase in the prevalence of neurotic disorder in the lower levels of Registrar General's Social Class.10, 11 In both these studies, the general health questionnaire12 was used to assess neurotic disorder, but there are concerns that this particular questionnaire is more biased than more detailed standardised interviews.13, 14, 15 There also seems to be an association between results on the general health questionnaire and income/wealth in the UK11, 16 and this is independent of occupational status.11 Studies in the USA17, 18 have also found higher prevalence in low income groups but occupational status was not measured.

In this study, we examined the association between the prevalence of neurotic disorder and socioeconomic status by identifying the separate contributions made by Registrar General's Social Class, educational qualifications, car access, and housing tenure. We also examined the possibility of an interaction between socioeconomic measures and sex, given the higher prevalence of neurotic disorder among women. Unlike previous studies carried out in the UK, for this study we used a standardised interview to assess neurotic disorder in a representative sample of the population aged 16–64, living in private households.

Section snippets

Participants

This article contains results from the household survey of the UK Office of Population Censuses and Surveys (OPCS) National Surveys of Psychiatric Morbidity undertaken in 1993. The main findings have already been published,1, 19 where further details and the questionnaires used in the survey can be found.

A stratified, clustered, probability sample was drawn from the Small User Postcode Address File for the UK, excluding the Highlands and Islands of Scotland. 200 postal sectors were selected

Results

Of the 9570 participants, 4401 were male and 5169 were female. The association between the socioeconomic variables that were studied is shown in table 1. Respondents in the Registrar General's non-manual Social Classes and who had no qualifications were less likely to rent their homes than those in the normal classes who had no qualifications.

There was a significant interaction between sex and social class, which persisted after adjustment for the other variables (X2 test, p=0·001). The results

Discussion

In this representative cross-sectional study of the household population of the UK aged 16–64 years we found a strong univariate relation between several socioeconomic variables and the prevalence of neurotic disorders. Lower social class, no access to cars, home renting, and low educational attainment were associated with higher prevalence of neurotic disorders. These variables, however, are all associated with each other so statistical adjustment was made for the intercorrelation of these

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