Department of Psychological Medicine, University of Otago, Dunedin, New Zealand.
Department of Medicine, College of Medicine, Al-Qadisia University, Diwania, Iraq.
JAMA Psychiatry. 2014 Dec 1;71(12):1400-8. doi: 10.1001/jamapsychiatry.2014.1337.
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.
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.
The Composite International Diagnostic Interview assessed the 12-month prevalence of 16 DSM-IV mood, anxiety, and impulse control disorders.
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.
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.
精神障碍的逆社会梯度是一个既定的研究发现，对因果模型和政策具有重要意义。这项研究使用了传统的客观社会地位（OSS）指标，如教育水平、收入和职业。最近，主观社会地位（SSS）的测量已被提倡用来捕捉相对社会地位的感知，但据我们所知，还没有研究 SSS 与精神障碍之间的关联。
在多个国家估计 SSS 与 DSM-IV 精神障碍之间的关联，并调查在全面调整 OSS 后，这些关联是否仍然存在。
设计、地点和参与者：对来自亚洲、南太平洋、美洲、欧洲和中东 18 个国家的社区居住成年人进行面对面的横断面家庭调查（N=56085）。主观社会地位采用自我锚定量表进行评估，反映了受访者对其在国家社会阶层中的收入、教育水平和职业的评价。SSS 量表的 1 到 10 分得分分为 4 类：低（得分 1-3）、低-中（得分 4-5）、中-高（得分 6-7）和高（得分 8-10）。客观社会地位采用广泛的精细收入、教育水平和职业客观指标进行评估。
综合国际诊断访谈评估了 16 种 DSM-IV 情绪、焦虑和冲动控制障碍的 12 个月患病率。
加权平均调查回复率为 75.2%（范围为 55.1%-97.2%）。SSS 与所有 16 种精神障碍呈梯度反比关系。在调整 OSS 指标后，所有 16 种疾病的最低 SSS 类别与最高 SSS 类别的总比值（OR）（1.8-9.0）均有所降低，但仍具有统计学意义（OR，1.4-4.9）。这种 SSS 与精神障碍之间的反比关系在 18 个国家中的 14 个国家以及低收入、中等收入和高收入国家组中均有显著意义，但在高收入与低收入国家之间差异更为显著。
即使在全面调整 OSS 后，SSS 与许多 DSM-IV 精神障碍之间仍存在显著的反比关系，这种关系存在于广泛的国家范围内。尽管尚不清楚这些关联是社会选择、社会因果关系还是两者的综合结果，但这些结果清楚地表明，仅依赖标准 OSS 测量的研究低估了精神障碍社会梯度的陡峭程度。
